Estimated Glomerular Filtration Rate Within the Normal or Mildly Impaired Range and Incident Cardiovascular Disease

Mild renal impairment is associated with increased cardiovascular events and all-cause mortality following cancer diagnosis

BACKGROUND

The association between mildly decreased renal function and cardiovascular (CV) outcomes in cancer patients remains unestablished.

AIMS

We sought to explore this association in asymptomatic self-referred healthy adults.

METHOD

We followed 25, 274 adults, aged 40-79 years, who were screened in preventive healthcare settings. Participants were free of CV disease or cancer at baseline. The estimated glomerular filtration rate (eGFR) was calculated according to the CKD Epidemiology Collaboration equation and categorized into groups [≤59, 60-69, 70-79, 80-89, 90-99, ≥100 (ml/min/1.73 m²)]. The outcome included a composite of death, acute coronary syndrome, or stroke, examined using a Cox model with cancer as a time-dependent variable.

RESULTS

Mean age at baseline was 50 ± 8 years and 7973 (32%) were women. During a median follow-up of 6 years (interquartile range: 3-11), 1879 (7.4%) participants were diagnosed with cancer, of them 504 (27%) develop the composite outcome and 82 (4%) presented with CV events. Multivariable time-dependent analysis showed an increased risk of 1.6, 1.4, and 1.8 for the composite outcome among individuals with eGFR of 90-99 [95% confidence interval (CI): 1.2-2.1 P = 0.01], 80-89 (95% CI: 1.1-1.9, P = 0.01) and 70-79 (95% CI: 1.4-2.3, P < 0.001), respectively. The association between eGFR and the composite outcome was modified by cancer with 2.7-2.9 greater risk among cancer patients with eGFR of 90-99 and 80-89 but not among individuals free from cancer ( Pinteraction < 0.001).

CONCLUSION

Patients with mild renal impairment are at high risk for CV events and all-cause mortality following cancer diagnosis. eGFR evaluation should be considered in the CV risk assessment of cancer patients.

Rate and Risk Factors of Acute Myocardial Infarction after Debut of Chronic Kidney Disease-Results from the KidDiCo

Chronic kidney disease (CKD) is a known risk factor for cardiovascular disease, including acute myocardial infarction. However, whether this risk is only associated with severe kidney disease or is also related to mildly impaired kidney function is still under debate. The incidence rate and risk factors of incident acute myocardial infarction (AMI) in patients with CKD are sparse. Potential differences in risk factor profiles between CKD patients with incident AMI and CKD patients with a prior AMI have not been sufficiently investigated. Furthermore, important factors such as albuminuria and socio-economic factors are often not included. The primary aim of this study was to establish the incidence rate of AMI after CKD debut. Secondly, to evaluate the importance of different CKD stages and the risk of having an AMI. Finally, to identify individuals at risk for AMI after CKD debut adjusted for prevalent AMI. Based on data from the kidney disease cohort of Southern Denmark (KidDiCo), including 66,486 CKD patients, we established incidence rates and characteristics of incident AMI among patients within a 5-year follow-up period after CKD debut. A Cox regression was performed to compute the cause-specific hazard ratios for the different risk factors. The incidence rate for CKD stage G3−5 patients suffering acute myocardial infarction is 2.5 cases/1000 people/year. In patients without a previous myocardial infarction, the risk of suffering a myocardial infarction after CKD debut was only significant in CKD stage G4 (HR = 1.402; (95% CI: 1.08−1.81); p-value = 0.010) and stage G5 (HR = 1.491; (95% CI: 1.01−2.19); p-value = 0.042). This was not the case in patients who had suffered an acute myocardial infarction prior to their CKD debut. In this group, a previous myocardial infarction was the most critical risk factor for an additional myocardial infarction after CKD debut (HR = 2.615; (95% CI: 2.241−3.05); p-value < 0.001). Irrespective of a previous myocardial infarction, age, male sex, hypertension, and a low educational level were significant risk factors associated with an acute myocardial infarction after CKD debut. The incidence rate of AMI in patients with CKD stage G3−5 was 2.5 cases/1000 people/year. Risk factors associated with incident AMI in CKD stage G3−5 patients were CKD stage, age, and hypertension. Female sex and higher educational levels were associated with a lower risk for AMI. Prior AMI was the most significant risk factor in patients with and without previous AMI before fulfilling CKD stage G3−5 criteria. Only age, sex, and a medium-long educational level were significant risk factors in this group.

Could Repeated Cardio-Renal Injury Trigger Late Cardiovascular Sequelae in Extreme Endurance Athletes?

Regular exercise confers multifaceted and well-established health benefits. Yet, transient and asymptomatic increases in markers of cardio-renal injury are commonly observed in ultra-endurance athletes during and after competition. This has raised concerns that chronic recurring insults could cause long-term cardiac and/or renal damage. Indeed, extreme endurance exercise (EEE) over decades has sometimes been linked with untoward cardiac effects, but a causal relation with acute injury markers has not yet been established. Here, we summarize the current knowledge on markers of cardiac and/or renal injury in EEE athletes, outline the possible interplay between cardiac and kidney damage, and explore the roles of various factors in the development of potential exercise-related cardiac damage, including underlying diseases, medication, sex, training, competition, regeneration, mitochondrial dysfunction, oxidative stress, and inflammation. In conclusion, despite the undisputed health benefits of regular exercise, we speculate, based on the intimate link between heart and kidney diseases, that in rare cases excessive endurance sport may induce adverse cardio-renal interactions that under specific, hitherto undefined conditions could result in persistent cardiac damage. We highlight future research priorities and provide decision support for athletes and clinical consultants who are seeking safe strategies for participation in EEE training and competition.

Renal function and outcome of patients with non-valvular atrial fibrillation

AIMS

Atrial fibrillation and renal dysfunction are associated with increased cardiovascular risk. We examined the association between renal function and incident ischaemic stroke or myocardial infarction in patients with atrial fibrillation treated with direct oral anticoagulants (DOACs).

METHODS AND RESULTS

This study was conducted using a large health record database. Included were 19 713 patients with first time diagnosis of non-valvular atrial fibrillation treated with DOACs between 2010 and 2018. Patients were categorized into four groups according to the estimated glomerular filtration rate (eGFR) (<30, 30-59, 60-89, and ≥90 mL/min/1.73 m2). Ischaemic stroke and acute myocardial infarction rates were compared between the groups. During 55 086 person-years of follow-up, there were 2295 (11.6%) cases of ischaemic stroke and 1158 (5.9%) cases of acute myocardial infarction. There was a significant inverse association between eGFR and the risk of myocardial infarction. A multivariate analysis using the group with eGFR ≥90 mL/min/1.73 m2 as a reference demonstrated an increased risk of myocardial infarction with lower eGFR [hazard ratio (HR) = 1.2 95% confidence interval (CI) 0.9-1.4, HR = 1.4, 95% CI 1.2-1.7, and HR = 2.5, 95% CI 1.8-3.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P < 0.001]. Each 10 mL decrease in eGFR was associated with an 8% increase in the risk of myocardial infarction. There was no association between eGFR and the risk of ischaemic stroke (HR = 0.9 95% CI 0.8-1.1, HR = 0.93, 95% CI 0.8-1.1, and HR = 1.1, 95% CI 0.8-1.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P = 0.325).

CONCLUSIONS

Renal dysfunction is associated with an increased risk of myocardial infarction but not of ischaemic stroke among patients with atrial fibrillation treated with DOACs.

Association of Mildly Reduced Kidney Function With Cardiovascular Disease: The Framingham Heart Study

Background Data are limited on the association of mildly reduced estimated glomerular filtration rate (eGFR 60-89 mL/min per 1.73 m²) with cardiovascular disease (CVD) in the community. Methods and Results We evaluated 3066 Framingham Offspring Study participants (55% women, mean age 58 years), without clinical CVD. Using multivariable regression, we related categories of mildly reduced eGFR (80-89, 70-79, or 60-69 versus ≥90 mL/min per 1.73 m² [referent]) to prevalent coronary artery calcium, carotid intima media thickness, and left ventricular hypertrophy, and to circulating concentrations of cardiac stress biomarkers. We related eGFR categories to CVD incidence and to progression to ≥Stage 3 chronic kidney disease (eGFR <60 mL/min per 1.73 m²) using Cox regression. Individuals with eGFR 60-69 mL/min per 1.73 m² (n=320) had higher coronary artery calcium score (odds ratio 1.69; 95% CI 1.02-2.80) compared with the referent group. Individuals with eGFR 60-69 and 70-79 mL/min per 1.73 m² had higher blood growth differentiating factor-15 concentrations (β=0.131 and 0.058 per unit-increase in log-biomarker, respectively). Participants with eGFR 60-69 and 80-89 mL/min per 1.73 m² had higher blood B-type natriuretic peptide concentrations (β=0.119 and 0.116, respectively). On follow-up (median 16 years; 691 incident CVD and 252 chronic kidney disease events), individuals with eGFR 60-69 and 70-79 mL/min per 1.73 m² experienced higher CVD incidence (hazard ratio [HR], 1.40; 95% CI, 1.02-1.93 and 1.45, 95% CI, 1.05-2.00, respectively, versus referent). Participants with eGFR 60-69 mL/min per 1.73 m² experienced higher chronic kidney disease incidence (HR, 2.94; 95% CI, 1.80-4.78 versus referent). Conclusions Individuals with mildly reduced eGFR 60-69 mL/min per 1.73 m² have a higher burden of subclinical atherosclerosis cross-sectionally, and a greater risk of CVD and chronic kidney disease progression prospectively. Additional studies are warranted to confirm our findings.

Relationship between mild renal dysfunction and coronary artery disease in young patients with stable angina pectoris

Aim: We investigated the relationship between mild renal dysfunction (MRD) and the presence of coronary artery disease (CAD) in people under 60 years of age. Materials & methods: A total of 634 (317 patients with vessel stenosis ≥50% and 317 with normal angiography) individuals diagnosed with stable angina pectoris and estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m² were included in the present study. Results: The mean eGFR was lower (95.3 ± 23.7 vs 109.7 ± 22.3, respectively, p = 0.002) and the number of patients with MRD was higher in patients with CAD (137, 43.2%) than in the control group (52, 16.4%, p < 0.001). The multivariate analysis showed that lower eGFR is an independent risk factor for presence of CAD in people under 60 years of age with stable angina pectoris. Conclusion: According to our retrospective study, the risk of developing CAD appears to be slightly increased in individuals under 60 years of age with MRD.

Estimated Glomerular Filtration Rate, Activation of Cardiac Biomarkers and Long-Term Cardiovascular Outcomes: A Population-Based Cohort

OBJECTIVE

To classify subjects in a general population per their renal function and characterize the cardiac biomarker levels, left ventricular function and cardiovascular outcomes over a 10.2 year follow-up period (interquartile range, 5.1-11.4 years).

METHODS

This was a retrospective review of a population-based random sample of residents aged ≥45 years. Data were collected between January 1, 1997, and December 31, 2000. One thousand nine hundred eighty-one individuals were classified based on estimated glomerular filtration rate (eGFR) into group I (>90 mL/min/1.73 m²), group II (60 to 89 mL/min/1.73 m²) and group III (<60 mL/min/1.73 m²; chronic kidney disease [CKD]). Age/sex-adjusted baseline characteristics, tertiles of N-terminal pro B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hs-TnT) and their interactions with eGFR were examined. Outcomes measured included incident myocardial infarction (MI), congestive heart failure, stroke, and all-cause mortality.

RESULTS

Eight hundred nineteen patients were classified as group I, 1036 as group II, and 126 of 1981 (6.4%) as group III or CKD. Subjects in group III were older and had a higher incidence of hypertension, diabetes, and MI at baseline. Over a 10.2-year follow-up period, CKD was associated with an increased risk of MI (hazard ratio, 1.95; 95% CI, 1.2-3.14; P=.006) and composite cardiovascular outcomes including MI, congestive heart failure, stroke, and all-cause mortality (hazard ratio, 1.38; 95% CI, 1.05-1.83 ;P=.02). Subjects with NT-proBNP or hs-TnT in the third tertile were at greater risk of cardiovascular events without significant interactions between eGFR and levels of NT-proBNP and hs-TnT.

CONCLUSION

Subjects with CKD had significantly elevated cardiac biomarkers and were at an increased risk of MI and adverse cardiovascular events. This warrants future studies to investigate whether these cardiac biomarkers could identify high-risk CKD patients for aggressive management of cardiovascular risk factors.

Risk factors for coronary artery disease in young patients with stable angina pectoris

Background/aim

We aimed to investigate the relationship between risk factors and the presence of coronary artery disease (CAD) in a young population with stable angina pectoris (SAP).

Materials and methods

A total of571 individuals younger than 60 years old, admitted to the outpatient clinic with chest pain and referred for coronary angiography between January 2015 and December 2017, were included in the study. All clinical and biochemical parameters were documented in the hospital records. Coronary angiography of patients was monitored from records. The individuals were divided into two groups. The patient group consisted of 363 individuals with at least one-vessel stenosis of ≥70%, and the control group consisted of 208 individuals with normal coronary angiography. We compared the traditional and nontraditional risk factors of these two groups in terms of the presence of CAD.

Results

Prevalence of male sex and smoking were higher in the patient group, and the prevalence of hypertension and diabetes were similar in the two groups. In the patient group, mean age, blood cholesterols, serum gamma-glutamyltransferase, hemoglobin, and white blood cell and lymphocyte levels were higher, while estimated glomerular filtration rate (eGFR), high-density lipoprotein cholesterol (HDL-C), platelets, and neutrophil/lymphocyte and platelet/lymphocyte ratios were lower. Low eGFR and HDL-C levels, older age, male sex, smoking, and high levels of low-density lipoprotein cholesterol and lymphocytes were independent risk factors for the presence of CAD in young patients.

Conclusion

Contrary to studies performed in the elderly, traditional and nontraditional risk factors could not exactly predict the presence of CAD in a young population with SAP.

Predicting of the risk of major cardiovascular events developing in patients with chronic obstructive pulmonary disease in combination with renal dysfunction

Aim.To identify the independent predictors of major cardiovascular events (MCVE) in patients with chronic obstructive pulmonary disease (COPD) in combination with the early stages of chronic kidney disease (CKD).

Material and methods.The study included 279 patients with GOLD 2014 2-4 severity COPD. At the first stage, we surveyed the potential risk factors for MCVE and the level of 25-OH vitamin D. After 12 months, all patients had a history of MCVE. Patients were divided into 2 groups: those who had MCVE during the previous 12 months, and without them. The risk factors for the development of MCVE, significantly differing between the two groups according to the results of a univariate analysis, were included in the logistic regression to determine reliable independent predictors of MCVE. We also studied ROC curve to identify the prognostic cut-off point.

Results.The group of patients who had MCVE consisted of 37 people with 40 MCVE cases. In patients with COPD in combination with the early stage of CKD, the level of vitamin D, the frequency of exacerbations in the preceding 12 months, the glomerular filtration rate (GFR), the score of PROCAM scale significantly influence to the development of MCVE. For the constructed regression equation, the determination coefficient is defined as R2=0,76, Hosmer-Lemeshov criterion =0,8. The area under the curve for the model =0,95. According to the results of the ROC analysis, it was found that independent predictors of MCVE in a 12-month period in patients with COPD and CKD (early stages) are: the sum of PROCAM scale points >56, the frequency of COPD exacerbations for the previous 12 months >2, GFR <80 ml/min/1,73 m2, the level of vitamin D <34,3 ng/ml.

Conclusion.Independent predictors of MCVE in a 12-month period in patients with COPD and the early stages of CKD are: the score of the PROCAM scale >56, the frequency of exacerbations of COPD in the preceding 12 months >2, GFR <80 ml/min/1,73 m2, the level of vitamin D <34,3 ng/ml.

Ambivalence about the selection of cardiovascular risk stratification tools: Evidence in a type 1 diabetes population

BACKGROUND

Cardiovascular disease (CVD) is one of the leading causes of death among people with diabetes, however, despite the increasing incidence of CVD, there are few tools for evaluating Cardiovascular Risk (CVR) in the population of patients with Type 1 Diabetes (T1D), with the existing ones diverging in the stratification of risk and in the suggestions for therapeutic conduct.

METHODS

A cross-sectional study was carried out with 104 participants diagnosed with T1D, aged 18-40, attending specialized services. The Steno Type 1 Risk Engine and the Cardiovascular Risk Stratification Calculator (CRSC) were used to assess the risk of a cardiovascular event over a 10-year period.

FINDINGS

Of the total sample selected, 62% were female, with a median age of 32 years (IQ 24; 43). There was a large difference between the stratification of CVR between the calculators, and 65.82% of the patients classified as low risk for CVD according to the Steno were identified as intermediate (30, 38.00%) and high risk (35.44%) by the CRSC. The analysis also highlighted a great difference in eligibility for statin use according to the risk stratification of the tools.

CONCLUSION

The CRSC and Steno tools evaluated and stratified the CVR of the same population with T1D, with there being divergence of the results. It was found that the CRSC tool classified the majority of the sample as high risk. Due to this result, the eligibility to use statins, which is one of the applications of these tools, showed great differences, with the Steno tool presenting less aggressive provisions regarding the prescription of statins in patients with type 1 DM.

[Predictors for development of major cardiovascular events in elderly patients with severe and extremely severe chronic obstructive pulmonary disease in combination with early stages of chronic kidney disease]

AIM

To study the structure of major cardiovascular events (MCVE) and to identify their independent predictors in elderly patients with severe and extremely severe chronic obstructive pulmonary disease (COPD) in combination with early stages of chronic kidney disease (CKD).

MATERIALS AND METHODS

The study included 172 elderly patients with stage 3-4 COPD associated with stage 1-2 CKD. Initially, risk factors for MCVE were identified and levels of vitamin D (25 (ОН) D) were measured for all patients. In 12 months, MCVE anamnesis was collected, and patients were divided into two groups with and without MCVE during the observation period. The risk factors for MCVE, which were significantly different between the two groups according to results of a one-way analysis, were successively included into a logistic regression for identifying independent predictors of MCVE. A ROC analysis was performed for the identified variables to identify a predictive cut-off point.

RESULTS

21 MCVEs were observed in 8.7% (15) patients. Heart rhythm disorders (HRD) not reversed at the prehospital stage were observed in 38.1% patients; acute cerebrovascular disease and transient ischemic attack - in 23.8%, acute coronary syndrome - in 23.8%, and pulmonary thromboembolism (PTE) - in 14.3%. Two MCVEs, namely, a combination of HRD not reversed at the prehospital stage and PTE, were observed in 3 (20%) patients. The ROC analysis showed that the incidence of COPD exacerbation for the previous 12 months &gt;3 had the highest predictive value for the 12-month risk of MCVE in patients with COPD associated with early CKD (95% CI, 0.823-0.925, р=0.001). A total PROCAM score &lt;50 (95% CI, 0.882-0.964, р=0.001); GFR ≥80 ml/min/1.73 m2 (95% CI, 0.750-0.870, р=0.001); and a level of vitamin D ≥33 ng/ml (95% CI, 0.730-0.855, р=0.001) reduced the risk for MCVE.

CONCLUSIONS

In elderly patients with grade 3-4 COPD associated with stage 1-2 CKD, the development of MCVE within 12 months was determined by the incidence of COPD exacerbations for the previous 12 months &gt;3 while a total PROCAM score &lt;50, GFR &gt;80 ml/min/1.73 m3 , and levels of vitamin D &gt;33 ng/ml reduced the risk of MCVE in these patients.

The association between eGFR in the normal or mildly impaired range and incident cadiovascular disease: Age and sex analysis

BACKGROUND

Worse renal function, even in the normal or mildly impaired range, is associated with incident cardiovascular disease (CVD). Whether this association exists in both sexes across all ages is not known.

METHODS

A population based cohort of individuals >22 years with no prior CVD and with an eGFR 60-130 ml/min/1.73 m². eGFR was calculated using the CKD-EPI formula. Incident CVD was defined as either myocardial infarction, unstable angina pectoris, coronary revascularization, or cerebrovascular event. Incident CVD was examined separately in men and women in 3 age-groups (young, 22-40 years; middle-aged, 41-60 years; and elderly, ≥61 years), during a median follow-up of 96.0 months.

RESULTS

Among 1,341,400 individuals (57% women, mean age 49.2 ± 16.6 years), men had more incident CVD as compared to women (34,968 vs. 23,515 total incident CVD) in all age-groups (0.6% vs. 0.2% in young; 6.2% vs. 2.0% in middle-aged; 13.4% vs. 8.4% in elderly, respectively). After adjustment for CVD risk factors, an increment of 10 units in eGFR was independently associated with a decrease of 5.4%, 3.4% and 5.4% in incident CVD in young, middle-aged and elderly men (p < 0.001 for each) and a decrease of 6.3%, 3.4% and 6.8% in the same age-groups in women (p < 0.001 for each). There was no significant age-sex interaction in the association between eGFR and incident CVD.

CONCLUSION

Although incident CVD differs in men and women, as well as in different age-groups, a higher eGFR even in the normal or mildly impaired range is associated with lesser incident CVD in men and women of all ages.

Chronic kidney disease is associated with carotid atherosclerosis and symptomatic ischaemic stroke

Objective We aimed to investigate the relationships among chronic kidney disease (CKD), symptomatic ischaemic stroke, and carotid atherosclerosis. Methods We enrolled 455 patients who underwent carotid ultrasonography in our hospital, including 311 patients with symptomatic ischaemic stroke and 144 patients without symptomatic ischaemic stroke. Carotid intima-media thickness (IMT), the rate of internal carotid artery stenosis, and maximal plaque size were evaluated. Results The mean age of the patients was 68.5 ± 11.0 years and the mean estimated glomerular filtration rate (eGFR) was 68.8 ± 18.2 mL/min/1.73 m². After adjustment for cardiovascular risk factors, the mean IMT was significantly higher in patients with CKD than in those without CKD. The IMT and eGFR were negatively correlated in patients with stroke (r = -0.169). Multiple logistic regression analyses showed that mean IMT, plaque size, and internal carotid artery stenosis were significant determinants of symptomatic ischaemic stroke after adjustment of multivariate risk factors. Furthermore, the eGFR was a negative determinant of symptomatic ischaemic stroke after adjusting for classical risk factors (odds ratio [95% confidence interval] = 0.868 [0.769-0.979]). Conclusion CKD might be associated with the carotid atherosclerosis and symptomatic ischaemic stroke.

Effect of adding bezafibrate to standard lipid-lowering therapy on post-fat load lipid levels in patients with familial dysbetalipoproteinemia. A randomized placebo-controlled crossover trial

Familial dysbetalipoproteinemia (FD) is a genetic disorder associated with impaired postprandial lipid clearance. The effect of adding bezafibrate to standard lipid-lowering therapy on postprandial and fasting lipid levels in patients with FD is unknown. In this randomized placebo-controlled double-blind crossover trial, 15 patients with FD received bezafibrate and placebo for 6 weeks in randomized order in addition to standard lipid-lowering therapy (statin, ezetimibe, and/or lifestyle). We assessed post-fat load lipids, expressed as incremental area under the curve (iAUC) and area under the curve (AUC), as well as fasting levels and safety, and found that adding bezafibrate did not reduce post-fat load non-HDL-cholesterol (non-HDL-C) iAUC (1.78 ± 4.49 mmol·h/l vs. 1.03 ± 2.13 mmol·h/l, P = 0.57), but did reduce post-fat load triglyceride (TG) iAUC (8.05 ± 3.32 mmol·h/l vs. 10.61 ± 5.92 mmol·h/l, P = 0.03) and apoB (0.64 ± 0.62 g·h/l vs. 0.93 ± 0.71 g·h/l, P = 0.01). Furthermore, bezafibrate significantly improved AUC and fasting levels of non-HDL-C, TG, total cholesterol, HDL-C, and apoB. Bezafibrate was associated with lower estimated glomerular filtration rate (78.4 ± 11.4 ml/min/1.73 m2 vs. 86.1 ± 5.85 ml/min/1.73 m2, P = 0.002). In conclusion, in patients with FD, the addition of bezafibrate to standard lipid-lowering therapy resulted in improved post-fat load and fasting plasma lipids. Combination therapy of statin/fibrate could be considered as standard lipid-lowering treatment in FD.

Estimated glomerular filtration rate within the normal or mildly impaired range and incident non-valvular atrial fibrillation: Results from a population-based cohort study

Background Lower estimated glomerular filtration rate, in particular in the significant renal impairment range (estimated glomerular filtration rate <60 ml/min/1.73 m²), is associated with incident atrial fibrillation. This association is less established within the normal or mildly impaired estimated glomerular filtration rate range. Methods Using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimated glomerular filtration rate formula, we identified ambulatory adults (>22 years old) without rheumatic heart disease or prosthetic valves and with 60 ml/min/1.73 m²<estimated glomerular filtration rate<130 ml/min/1.73 m² in their index visit, for incident, newly-diagnosed atrial fibrillation. We analyzed cohorts with and without prior cardiovascular disease. Results Over a mean follow-up of 104 months and >10 m patient-years of follow-up (∼75% <60 years old, ∼57% females), >65,000 individuals had ≥1 atrial fibrillation event (incident atrial fibrillation rate 5.1% and 5.8% excluding or including prior cardiovascular disease, or 49 and 55 per 10,000 patient-years, respectively). In both cohorts, individuals with versus without incident atrial fibrillation had lower mean estimated glomerular filtration rate (∼83 versus 95 ml/min/1.73 m²). Adjusting for age, gender, hypertension, and diabetes mellitus, overall a 10 ml/min/1.73 m² decrease in estimated glomerular filtration rate was independently associated with a mean increase in incident atrial fibrillation of 1.5% and 2.4% in the cohorts excluding or including prior cardiovascular disease, respectively ( p < 0.001 for both). However, a graded association between lower estimated glomerular filtration rate and atrial fibrillation was observed in the 90-130 ml/min/1.73 m² range, whereas a blunted association was observed in the 60-90 ml/min/1.73 m² range. Conclusion Within the 60 ml/min/1.73 m²< estimated glomerular filtration rate < 130 ml/min/1.73 m² range, lower estimated glomerular filtration rate is independently associated with incident non-valvular atrial fibrillation in adults without prior atrial fibrillation, mainly attributed to a graded association within the 90-130 ml/min/1.73 m² range.