Haifei Liu,1,2,* Junling Han,3,* Weijie Ni,2 Yuan Lu,2 Xinhui Hu,2 Jing Wang,2 Yan Zhou,2 Ze Wang,4 Jingyuan Cao,1 Hong Liu2 

1Department of Nephrology, The Affiliated Taizhou People’s Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, Jiangsu, 225300, People’s Republic of China; 2Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, 210009, People’s Republic of China; 3Clinical Laboratory, The Affiliated Taizhou People’s Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, Jiangsu, 225300, People’s Republic of China; 4Nanjing University of Chinese Medicine, Nanjing, Jiangsu, 210023, People’s Republic of China

*These authors contributed equally to this work

Correspondence: Hong Liu; Jingyuan Cao, Email jstzliu@sina.com; caojingyuan1989@163.com

Objective: This study evaluated the diagnostic value of plasma Neutrophil extracellular traps (NETs) levels and the index of cardiac electrophysiological balance (iCEB) in identifying silent myocardial ischemia (SMI) in maintenance hemodialysis (MHD) patients.
Methods: This cross-sectional observational study involved patients receiving MHD treatment. Data were collected on coronary angiography performed in our hospital from February 2023 to February 2024. Patients diagnosed with myocardial ischemia via coronary angiography but without obvious symptoms were grouped as the SMI group, while those without SMI were grouped as the control group. Plasma NETs levels were assessed using markers indicative of NETs components including double-stranded DNA (dsDNA), circulating free DNA (cfDNA) and myeloperoxidase, while iCEB (QT/QRS) and electrocardiographic findings were obtained. Additionally, echocardiographic parameters, inflammatory markers, and cardiac biomarkers were analyzed. Receiver operating characteristic (ROC) analysis were employed to evaluate the diagnostic accuracy of plasma NETs levels and iCEB in identifying SMI.
Results: A total of 114 patients were included, with 79 participants in the control group and 35 participants in the SMI group. The SMI group exhibited significantly elevated levels of NETs associated components (dsDNA(37.89± 4.55 vs 31.64± 5.32, P< 0.001), cfDNA(11.27± 2.03 vs 8.91± 1.84, P< 0.001), MPO-DNA(23.69± 4.01 vs 17.52± 3.41, P< 0.001)), as well as higher iCEB compared to the control group(56.45± 7.67 vs 45.89± 6.23, P< 0.001). Furthermore, electrocardiography findings, echocardiographic parameters, inflammatory markers, and cardiac biomarkers showed significant differences between the two groups. The ROC analysis demonstrated the potential diagnostic accuracies of NETs levels and iCEB, with an area under the curve (AUC) of 0.908, sensitivity of 0.987, and specificity of 0.829 for identifying SMI.
Conclusion: The study highlights the combined diagnostic value of plasma NETs levels and iCEB in identifying SMI in MHD patients, providing valuable insights into potential early detection and risk stratification strategies for this population.

Keywords: silent myocardial ischemia, hemodialysis, neutrophil extracellular traps, index of cardiac electrophysiological balance, diagnostic value, cardiovascular complications