الفهرس 
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Abstract
Chronic kidney disease (CKD) is a challenging issue for healthcare providers and a major burden for healthcare. Cardiovascular disease is a well-recognized and important source of mortality in patients with chronic kidney disease. It accounts for approximately 50 percent of deaths in dialysis patients. Aside from coronary artery disease, other forms of cardiovascular disease are also prevalent in chronic kidney disease.
Despite recent improvement in dialysis process, patients receiving maintenance dialysis still have high hospitalization rates, poor quality of life, and high mortality. The all-cause mortality of this patient group re-mains more than 20% a year and is 10 times greater than that of the gen-eral population.
The characteristics of cardiovascular dysfunction observed in dialy-sis patients are distinct from those noted in the general population. Alt-hough traditional cardiovascular risk factors in patients with end stage renal disease (ESRD) are highly prevalent, they play only a partial role on the excessive cardiovascular morbidity and mortality of this population.
Nephrologists have strived to better understand the pathogenesis, drivers, and predictive factors for Cardiovascular (CV) disease in patients with chronic kidney disease (CKD). Both traditional and new risk factors have been associated with CV disease in this population, but outcomes are still dismal and further research is needed.
YKL-40 (chitinase-3-like protein 1, or human cartilage glycoprotein-39) is a 40-kDa glycoprotein, a member of the mammalian chitinase-like protein family. YKL-40 is produced by macrophages, neutrophils, and cancer cells and regulates vascular endothelial growth factor (VEGF), is involved in inflammation and angiogenesis, remodeling of the extracellular matrix, and fibrosis. Thus YKL-40 has been associated with inflammation disorders, arteriosclerosis, and endothelial dysfunction.
Recently a link between YKL-40 and mortality was reported in he-modialysis patients. However, studies are necessary to evaluate a poten-tial link between YKL-40 and CV events in hemodialysis patients and to identify additional factors potentially associated with serum YKL-40 lev-els.
The aim of this study was to assess the association between YKL-40 and cardiovascular events including (myocardial infarction, congestive heart failure, and stroke) in hemodialysis patients.
The present study was a case-control study that was conducted on 80 subjects, 42 males and 38 females attending the Nephrology Department and Renal Dialysis Unit and laboratory investigations were done at Clinical and Chemical Pathological Department at Benha University Hospital from August 2022 to January 2023.
Subjects in this study were divided into 3 groups:
• group (1): 30 hemodialysis patients with cardiovascular events.
Their mean age was (56.57±9.46) years, and they were 11 males and 19 females.
• group (2): 30 hemodialysis patients without cardiovascular events.
Their mean age was (52.5±11.25) years, and they were 14 males and 16 females.
• group (3): 20 apparently healthy control people.Their mean age was (55.65±11.03) years, and they were 7 males and 13 females.
The Research Ethical Committee of Benha Faculty of Medicine ap-proved this study.
Written informed consent was taken from each patient.
Inclusions criteria: Both genders, clinical stability of hemodialysis patients with no recent hospitalization (in the past 3 months). Age >18 years.
Exclusion criteria include inability to understand the study, recent hospitalization, patients with pacemakers.
All participants were subjected to the following: Complete history taking, including age, sex, CKD, etiology, presence of diabetes mellitus, hypertension, dyslipidemia and a history of prior cardiovascular events, including CHF, myocardial infarction, and stroke.
General and local examination: Physical status assessment, physical examination of heart and chest.
Laboratory investigations: Kidney functions (serum creatinine, urea), serum Na, K, Troponin I, highly sensitive C-reactive protein and serum YKL-40 concentrations were measured by ELISA.
The results of the present study can be summarized as follows:
• This study reveals that comparison HD patients with, without cardiovascular events and control group regarding to socio-demographic data showed that there is statistically non-significant difference regarding sex (p=0.637) and age (p=0.308) between HD patients and control group (i.e., the three groups were age and sex matched. Also, duration of HD showed insignificant difference between HD patients with and without cardiovascular events (p >0.05).
• Most of HD patients were females 63.3% in HD with CV events and 53.3% in HD without CV events
• There was statistically significant increase in urea and creatinine in HD with cardiovascular events when compared with control (p <0.001). Additionally, there is statistically significant increase in urea and creatinine in HD without cardiovascular event when compared with control group (p <0.001).
• There were no statistically significant differences regarding Na level (p=0.901) and K level (p=0.272) between HD patients with CVD events and HD patients without CVD events and control group.
• There was a significant increase in hs-CRP in HD cases with CVD compared to HD patients without CVD and control (p<0.001). There is statistically significant increase in hs-CRP in HD patients without CVD when compared to control (p<0.001).
• Troponin I was statistically significant increased in HD patients with CVD when compared to HD patients without CVD and control (p<0.001).
• As regarding YKL-40, this study showed statistically significant increase in HD patients with CVD when compared to HD patients without CVD ( p<0.001)and control (p<0.001). Also, it was significantly increased in HD patients without CVD compared to control (p<0.001).
• There was significant positive correlation between YKL-40 and Troponin I (r=0.874, p<0.001) in HD patients with and without CVD, while other parameters were not significant (p >0.05).
• YKL-40 showed excellent AUC (=0.923) at best cut off value of >570.8 (ng/ml), sensitivity was 93.33%, specificity was 80%, PPV was 93.3%, NPV WAS 80% and accuracy was 90%.
• The validity of YKL-40 for discrimination between HD with and without CVD shows a highly statistically significant predictor for predicting CVD among HD patients at a cut off value of >928.4, (AUC: 0.918, P<0.001) at a sensitivity and specificity of 93.34% & 83.33%, respectively with PPV was 84.85%, NPV was 92.59% and accuracy was 88.33%.
• Logistic regression analysis was conducted for prediction of HD using gender, age, urea, creatinine, Na, K, hs-CRP, troponin I and YKL-40 as confounder. Urea, hs-CRP and YKL-40 were considered as a predictor of HD in univariate analysis. However, conducting multivariable analysis revealed that hs