PEDIATRICS Vol. 122 No. 1 July 2008, pp. 223-224 (doi:10.1542/peds.2008-0943)
LETTER TO THE EDITOR |
Myocardial Infarction in Chronic Kidney Disease
Tracy E. Hunley, MDValentina Kon, MD
Kathy Jabs, MD
Division of Pediatric Nephrology
Monroe Carell Jr Children's Hospital
Vanderbilt University
Nashville, TN 37232-2584
To the Editor.—
Lane and Ben-Shachar1 recently reported myocardial infarction (MI) in adolescents with normal cardiac anatomy. Here we describe a patient with childhood-onset chronic kidney disease (CKD) who suffered MI at 22 years of age. The patient's CKD resulted from meningococcemia at 6 years of age. Renal transplantation at the age of 9 years resulted in primary nonfunction, the kidney was removed, and peritoneal dialysis was continued. At 17 years, a computed tomography scan incidentally revealed aortic calcification, indicating vascular disease (Fig 1). At 19 years, he received a deceased-donor renal transplant and was immunosuppressed with tacrolimus, mycophenolate mofetil, and 4 months of prednisone. He has maintained good graft function (creatinine: 0.96 mg/dL).The most recent lipid panel showed a total cholesterol level of 134 mg/dL, low-density lipoprotein level of 70 mg/dL, high-density lipoprotein level of 28 mg/dL, and triglyceride level of 182 mg/dL.
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One day before admission, the patient developed chest pain. At a local emergency department, electrocardiogram and cardiac enzyme testing results were normal; the diagnosis given was gastrointestinal pain. His chest pain (described as crushing substernal pain with radiation to the jaw, associated with dyspnea and diaphoresis) intensified hours later. An electrocardiogram showed borderline ST elevation in inferior and anterior leads, ST depression in lateral leads, and peaked T waves in precordial leads that progressed to loss of anterior forces. His troponin level was elevated at 1.24 ng/mL (reference: <0.05 ng/mL), peaking at 5.96 ng/mL, and his creatinine kinase MB level was 17.7 ng/mL (reference: <8 ng/mL), peaking at 70.8 ng/mL. Cardiac catheterization revealed 90% stenosis of the mid–left anterior descending artery with thrombus. A sirolimus-eluting stent was placed across the lesion. The patient was discharged 2 days later without chest pain.
Patients with CKD are now recognized to be in the highest risk group for cardiovascular disease (CVD).2 Increased risk of CVD prevails at every stage of CKD; even a subtle decrease in the glomerular filtration rate imparts independent risks of acute events and death.3 It is important to note that vascular lesions begin in childhood and are accelerated in children with CKD. Thus, carotid intima media thickness is increased among young adults with childhood-onset CKD.4 In 1 study, internal iliac atherosclerosis was seen in 58% of adolescents at renal transplantation, with the plaque severity correlating with duration of renal insufficiency.5 Coronary artery calcification (also linked to carotid thickness/arterial stiffness) is far above normal in young adults who survive childhood CKD and evidences an advanced calcifying arteriopathy.4,6 Nontraditional cardiovascular risk factors in CKD include hyperphosphatemia, hyperparathyroidism, hyperhomocystinemia, and inflammation. Remarkably, Parekh et al demonstrated that children/young adults with renal failure in childhood have a cardiac death rate that is 1000 times that of the general pediatric population,7 which suggests that renal damage in childhood dramatically hastens CVD, warranting heightened suspicion for cardiovascular events in adolescents/young adults with a history of renal dysfunction.
REFERENCES
- Lane JR, Ben-Shachar G. Myocardial infarction in healthy adolescents. Pediatrics.2007; 120 (4). Available at: www.pediatrics.org/cgi/content/full/120/4/e938
- Sarnak MJ, Levey AS, Schoolwerth AC, et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention.
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[Abstract/Free Full Text] - Oh J, Wunsch R, Turzer M, et al. Advanced coronary and carotid arteriopathy in young adults with childhood-onset chronic renal failure.
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[Abstract/Free Full Text] - Nayir A, Bilge I, Kilicaslan I, Ander H, Emre S, Sirin A. Arterial changes in paediatric haemodialysis patients undergoing renal transplantation.
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[Abstract/Free Full Text] - Goodman WG, Goldin J, Kuizon BD, et al. Coronary-artery calcification in young adults with end-stage renal disease who are undergoing dialysis.
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[Abstract/Free Full Text] - Parekh RS, Carroll CE, Wolfe RA, Port FK. Cardiovascular mortality in children and young adults with end-stage kidney disease. J Pediatr.2002; 141 (2):191 –197[CrossRef][Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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