Cardiovascular risk among adults with chronic kidney disease, with or without prior myocardial infarction

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.

Chronic kidney disease and statin eligibility

BACKGROUND

Chronic kidney disease (CKD) is a risk factor for atherosclerotic cardiovascular disease (ASCVD). American cardiovascular societies consider CKD a risk-enhancing factor that supports statin therapy in intermediate-risk patients aged 40-75 years. In contrast, European cardiovascular societies recommend statins for all middle-aged adults with CKD. The Kidney Disease: Improving Global Outcomes lipid management guideline for CKD recommends statin therapy for all patients with CKD >50 years. Clinical implications for these differences have not been examined.

OBJECTIVE

This study examines CKD prevalence and statin eligibility in non-ASCVD adults, representative of the US population, at 3 levels of 10-year risk of ASCVD estimated by pooled cohort equations.

METHODS

National Health and Nutrition Examination Surveys 1999-2016 weighted data were evaluated for CKD defined as estimated glomerular filtration rate < 60 mL/min/1.73 m2. Overall prevalence of low, intermediate, and high 10-year risk for ASCVD was determined.

RESULTS

A total of 92.5% of all participants had estimated glomerular filtration rate ≥ 60 mL/min/1.73 m2; 7.5% (confidence interval 6.9%, 8.1%) had CKD. Among participants with CKD, 46.3% had 10-year risk for ASCVD <7.5% (low risk); 31.7% had intermediate risk (7.5-< 20%), and 22.0% had high risk (≥20%). In participants with CKD, 62.5% were women. A total of 19.6% of all participants with CKD had diabetes. A total of 46.3% of participants with CKD at intermediate or high risk reported taking cholesterol-lowering drugs.

CONCLUSION

A total of 46.3% of patients with CKD aged 40-75 years had 10-year risk <7.5% (low risk) and hence were statin eligible by European and Kidney Disease: Improving Global Outcomes (>50 years) guidelines. US cardiovascular guidelines limit statin eligibility to intermediate- and high-risk CKD. Statin eligibility in lower-risk patients may be best determined by measuring coronary artery calcium.

Cardiac Biomarkers and Risk of Mortality in CKD (the CRIC Study)

Introduction

Cardiovascular disease (CVD) is the leading cause of mortality among individuals with chronic kidney disease (CKD). Cardiac biomarkers of myocardial distention, injury, and inflammation may signal unique pathways underlying CVD in CKD. In this analysis, we studied the association of baseline levels and changes in 4 traditional and novel cardiac biomarkers with risk of all-cause, CV, and non-CV mortality in a large cohort of patients with CKD.

Methods

Among 3664 adults with CKD enrolled in the Chronic Renal Insufficiency Cohort Study, we conducted a cohort study to examine the associations of baseline levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), cardiac high-sensitivity troponin T (hsTnT), growth differentiation factor−15 (GDF-15), and soluble ST-2 (sST-2) with risks of all-cause and cardiovascular (CV) mortality. Among a subcohort of 842 participants, we further examined the associations between change in biomarker levels over 2 years with risk of all-cause mortality. We used Cox proportional hazards regression models and adjusted for demographics, kidney function measures, cardiovascular risk factors, and medication use.

Results

After adjustment, elevated baseline levels of each cardiac biomarker were associated with increased risk of all-cause mortality: NT-proBNP (hazard ratio [HR] = 1.92, 95% confidence interval [CI] = 1.73−2.12); hsTnT (HR = 1.62, 95% CI = 1.48, 1.78]); GDF-15 (HR = 1.61, 95% CI = 1.46−1.78]); and sST-2 (HR = 1.26, CI = 1.16−1.37). Higher baseline levels of all 4 cardiac biomarkers were also associated with increased risk of CV. Declines in NT-proBNP (adjusted HR = 0.55, 95% CI = 0.36−0.86) and sST2 (HR = 0.55, 95% CI = 0.36−0.86]) over 2 years were associated with lower risk of all-cause mortality.

Conclusion

In a large cohort of CKD participants, elevations of NT-proBNP, hsTnT, GDF-15, and sST-2 were independently associated with greater risks of all-cause and CV mortality.

[Chronic kidney disease and dyslipidaemia]

Chronic kidney disease (CKD) has to be considered as a high, or even very high risk cardiovascular risk condition, since it leads to an increase in cardiovascular mortality that continues to increase as the disease progresses. An early diagnosis of CKD is required, together with an adequate identification of the risk factors, in order to slow down its progression to more severe states, prevent complications, and to delay, whenever possible, the need for renal replacement therapy. Dyslipidaemia is a factor of the progression of CKD that increases the risk in developing atherosclerosis and its complications. Its proper control contributes to reducing the elevated cardiovascular morbidity and mortality presented by these patients. In this review, an assessment is made of the lipid-lowering therapeutic measures required to achieve to recommended objectives, by adjusting the treatment to the progression of the disease and to the characteristics of the patient. In CKD, it seems that an early and intensive intervention of the dyslipidaemia is a priority before there is a significant decrease in kidney function. Treatment with statins has been shown to be safe and effective in decreasing LDL-Cholesterol, and in the reduction of cardiovascular events in individuals with CKD, or after renal transplant, although there is less evidence in the case of dialysed patients.

OLDER PEOPLE WITH CHRONIC KIDNEY DISEASE: DEFINITION, AND INFLUENCE OF BIOMARKERS AND MEDICATIONS UPON CARDIOVASCULAR AND RENAL OUTCOMES

BACKGROUND

Chronic kidney disease (CKD) is a global problem. With an ageing population the burden on the health services has increased due to the growing number of older people with CKD. This group of individuals is far different to the younger CKD population and their risk of cardiovascular death is far greater than the risk of progressing to end stage kidney disease (ESKD).

OBJECTIVE

In this review we explore the role of certain biomarkers and medications in predicting the risk of progression to ESKD and death in old people with CKD.

METHODS

An electronic literature search of EMBASE and MEDLINE databases was performed using Healthcare Databases Advanced Search (HDAS) in December 2014.

RESULTS

Albuminuria is a key biomarker in predicting the risk of death and progression to ESKD. Cystatin C appears to be superior in predicting the risk of cardiovascular and non-cardiovascular death compared to GFR or creatinine. Several inflammatory biomarkers can be used to predict the risk of death and progression to CKD but measuring and monitoring them in routine clinical practice will be expensive and impractical. The effects of long-term RAAS inhibition in older people are not well established. Older people especially those with CKD receive suboptimal secondary preventive measures. Due to multiple comorbidities older people with CKD are usually receiving a number of medications. This can potentially lead to significant adverse drug events (ADE) due to drug interactions.

CONCLUSION

Novel non-traditional risk factors like albuminuria, Cystatin C and inflammatory biomarkers play an important role in predicting their risk of death and progression to ESKD. The efficacy and safety of medications in older people with CKD is not well established and requires more extensive, focused study.

Chronic kidney disease and 10-year risk of cardiovascular death

BACKGROUND

In recent clinical guidelines, individuals with chronic kidney disease are considered to have a similar 10-year absolute risk of cardiovascular death as individuals with diabetes or established cardiovascular disease. There is limited evidence to support this claim.

METHODS

We investigated the 10-year risk for cardiovascular death in individuals with moderate or severe chronic kidney disease (glomerular filtration rate of 30-60 or <30 mL/min/1.73 m(2), respectively) in a cohort of primary care health check-ups in Stockholm, Sweden (n = 295,191, 46% women, 4290 cardiovascular deaths during 10 years follow-up). We also assessed the risk associated with diabetes or cardiovascular disease. The inclusion criteria, exposure, study outcome and follow-up period adhered strictly to the definitions of the European Society of Cardiology guidelines.

RESULTS

The absolute 10-year risk of cardiovascular death was 3.9% and 14.0% in individuals with moderate and severe chronic kidney disease, respectively, but was substantially lower in women and in younger individuals. The risk in individuals with prevalent diabetes and cardiovascular disease was approximately two and three times higher compared to the risk estimate for moderate chronic kidney disease (hazard ratio (HR) 4.1, 95% confidence interval (CI) 3.8-4.5 and HR 6.2, 95% CI 5.7-6.7 vs. HR 2.3 95% CI 2.0-2.6, respectively) while the risk for individuals with severe chronic kidney disease appeared more congruent to that of diabetes and cardiovascular disease (HR 5.5, 95% CI 3.3-8.9).

CONCLUSIONS

Although moderate chronic kidney disease is an independent predictor for an increased 10-year risk of cardiovascular death, only those with severe chronic kidney disease had similar risk to those with diabetes or cardiovascular disease.

Prognostic impact of renal dysfunction in patients with acute coronary syndrome-role beyond the CHA2 DS2 -VASc score: Data from Taiwan acute coronary syndrome full spectrum registry

AIM

CHA2 DS2 -VASc score has been proven to have great prognostic value in patients with acute coronary syndrome (ACS). We aimed to determine whether the addition of renal dysfunction in the CHA2 DS2 -VASc score would improve the prognostic impact of the scoring system to predict prognosis among ACS patients.

METHODS

A total of 3031 ACS patients were prospectively enrolled at 39 hospitals and followed for 1 year. The patients were divided into three groups based on estimated glomerular filtration rate (eGFR) (group 1, eGFR>90; group 2, eGFR between 60 and 90; and group 3, eGFR<60 mL/min per 1.73 m(2) ). The occurrence of subsequent myocardial infarction (MI), stroke, or death was recorded.

RESULTS

As renal function progressively decreased from group 1 to 3, the patients were, respectively older and had higher incidence of comorbidity, worse Killip classification, and less evidence-based medical therapies. The rate of subsequent MI, stroke or death increased from 3.4% in group 1 to 7.4% in group 2 and 17.2% in group 3 (P < 0.001). Renal dysfunction (eGFR<60 mL/min per 1.73 m(2) ) and CHA2 DS2 -VASc scores were both significant predictors of adverse events in multivariable regression analyses. Renal dysfunction can further stratify patients with CHA2 DS2 -VASc score of 0 or 1 into 3 groups with different adverse event rates (group 1, 3.0%; group 2, 4.1%; and group 3, 9.2%, P < 0.001). A new scoring system (R-CHA2 DS2 -VASc score) derived by assigning one more point for eGFR ≤ 60 mL/min per 1.73 m(2) to the CHA2 DS2 -VASc score could improve its predictive accuracy (area under the receiver operating curve, 0.70 vs. 0.66, P < 0.001).

CONCLUSIONS

Renal dysfunction is a significant risk factor of future adverse events in ACS patients and may improve the prognostic impact of the CHA2 DS2 -VASc score.

Genetics of coronary heart disease with reference to ApoAI-CIII-AIV gene region

Cardiovascular diseases are affected by multiple factors like genetic as well as environmental hence they reveal factorial nature. The evidences that genetic factors are susceptible for developing cardiovascular diseases come from twin studies and familial aggregation. Different ethnic populations reveal differences in the prevalence coronary artery disease (CAD) pointing towards the genetic susceptibility. With progression in molecular techniques different developments have been made to comprehend the disease physiology. Molecular markers have also assisted to recognize genes that may provide evidences to evaluate the role of genetic factors in causation of susceptibility towards CAD. Numerous studies suggest the contribution of specific “candidate genes”, which correlate with various roles/pathways that are involved in the coronary heart disease. Different studies have revealed that there are large numbers of genes which are involved towards the predisposition of CAD. However, these reports are not consistent. One of the reasons could be weak contribution of genetic susceptibility of these genes. Genome wide associations show different chromosomal locations which dock, earlier unknown, genes which may attribute to CAD. In the present review different ApoAI-CIII-AIV gene clusters have been discussed.

Age and gender predict OPG level and OPG/sRANKL ratio in maintenance hemodialysis patients

PURPOSE

Cardiovascular disease (CVD) is a major cause of death among chronic hemodialysis (HD) patients. Gender and age belong to its classical risk factors. OPG/RANK/sRANKL (Osteoprotegerin/ Receptor Activator of Nuclear Factor κB/ soluble Receptor Activator of Nuclear Factor κB Ligand) axis constitute a system connecting bone and vascular remodeling.

METHODS

We aimed to evaluate the plasma levels of OPG, sRANKL and OPG/sRANKL ratio in 21 HD patients and 16 healthy volunteers in relation to gender, age and the other clinical parameters.

RESULTS

OPG and OPG/sRANKL ratio were significantly higher in HD patients than in controls whereas sRANKL was similar in both groups. Adjusted for gender, in controls OPG were higher in women whereas sRANKL did not differ between men and women. In HD group OPG and sRANKL were higher in women whereas OPG/sRANKL ratio was similar in both genders. Female patients compared to healthy women revealed 56% higher OPG concentration and 54% higher OPG/ sRANKL ratio. Comparison of male patients and controls revealed 61% higher level of OPG and 75% higher OPG/sRANKL ratio in HD group. Interestingly, OPG and OPG/sRANKL ratio positively correlated with age only in male patients. Contrary, the association between OPG/sRANKL ratio and age was negative in HD women.

CONCLUSION

Higher OPG levels in HD women comparing to age matched HD men indicate the necessity of more careful screening towards the presence of CVD and bone-mineral disorders. The negative association between age and OPG/ sRANKL ratio in HD women warrant in-depth study for thorough understanding of this complex interrelationship.

Management of coronary atherosclerosis and acute coronary syndromes in patients with chronic kidney disease

Atherosclerosis of the coronary arteries is common, extensive, and more unstable among patients with chronic renal impairment or chronic kidney disease (CKD). The initial presentation of coronary disease is often acute coronary syndrome (ACS) that tends to be more complicated and has a higher risk of death in this population. Medical treatment of ACS includes antianginal agents, antiplatelet therapy, anticoagulants, and pharmacotherapies that modify the natural history of ventricular remodeling after injury. Revascularization, primarily with percutaneous coronary intervention and stenting, is critical for optimal outcomes in those at moderate and high risk for reinfarction, the development of heart failure, and death in predialysis patients with CKD. The benefit of revascularization in ACS may not extend to those with end-stage renal disease because of competing sources of all-cause mortality. In stable patients with CKD and multivessel coronary artery disease, observational studies have found that bypass surgery is associated with a reduced mortality as compared with percutaneous coronary intervention when patients are followed for several years. This article will review the guidelines-recommended therapeutic armamentarium for the treatment of stable coronary atherosclerosis and ACS and give specific guidance on benefits, hazards, dose adjustments, and caveats concerning patients with baseline CKD.

Cardiovascular risk assessment: addition of CKD and race to the Framingham equation

BACKGROUND/AIMS

The value of the Framingham equation in predicting cardiovascular risk in African Americans and patients with chronic kidney disease (CKD) is unclear. The purpose of the study was to evaluate whether the addition of CKD and race to the Framingham equation improves risk stratification in hypertensive patients.

METHODS

Participants in the ALLHAT were studied. Those randomized to doxazosin, older than 74 years, and those with a history of coronary heart disease were excluded. Two risk stratification models were developed using Cox proportional hazards models in a two-thirds developmental sample. The first model included the traditional Framingham risk factors. The second model included the traditional risk factors plus CKD, defined by estimated glomerular filtration rate categories, and stratification by race (black vs non-black). The primary outcome was a composite of fatal coronary heart disease, nonfatal myocardial infarction, coronary revascularization, and hospitalized angina.

RESULTS

There were a total of 19,811 eligible subjects. In the validation cohort, there was no difference in C-statistics between the Framingham equation and the ALLHAT model including CKD and race. This was consistent across subgroups by race and sex and among those with CKD. One exception was among Non-Black women where the C-statistic was higher for the Framingham equation (0.68 vs 0.65, P = .02). In addition, net reclassification improvement was not significant for any subgroup based on race and sex, ranging from -5.5% to 4.4%.

CONCLUSION

The addition of CKD status and stratification by race does not improve risk prediction in high-risk hypertensive patients.

Mathematical modeling the neuroregulation of blood pressure using a cognitive top-down approach

Background:

The body′s physiological stability is maintained by the influence of the autonomic nervous system upon the dynamic interaction of multiple systems. These physiological systems, their nature and structure, and the factors which influence their function have been poorly defined. A greater understanding of such physiological systems leads to an understanding of the synchronised function of organs in each neural network i.e. there is a fundamental relationship involving sensory input and/or sense perception, neural function and neural networks, and cellular and molecular biology. Such an approach compares with the bottom-up systems biology approach in which there may be an almost infinite degree of biochemical complexity to be taken into account.

Aims:

The purpose of this article is to discuss a novel cognitive, top-down, mathematical model of the physiological systems, in particular its application to the neuroregulation of blood pressure.

Results:

This article highlights the influence of sensori-visual input upon the function of the autonomic nervous system and the coherent function of the various organ networks i.e. the relationship which exists between visual perception and pathology.

Conclusions:

The application of Grakov′s model may lead to a greater understanding of the fundamental role played by light e.g. regulating acidity, levels of Magnesium, activation of enzymes, and the various factors which contribute to the regulation of blood pressure. It indicates that the body′s regulation of blood pressure does not reside in any one neural or visceral component but instead is a measure of the brain′s best efforts to maintain its physiological stability.

Risk of coronary events in people with chronic kidney disease compared with those with diabetes: a population-level cohort study

BACKGROUND

Diabetes is regarded as a coronary heart disease risk equivalent-ie, people with the disorder have a risk of coronary events similar to those with previous myocardial infarction. We assessed whether chronic kidney disease should be regarded as a coronary heart disease risk equivalent.

METHODS

We studied a population-based cohort with measures of estimated glomerular filtration rate (eGFR) and proteinuria from Alberta, Canada. We used validated algorithms based on hospital admission and medical-claim data to classify participants with baseline history of myocardial infarction or diabetes and to ascertain which patients were admitted to hospital for myocardial infarction during follow-up (the primary outcome). For our primary analysis, we defined baseline chronic kidney disease as eGFR 15-59·9 mL/min per 1·73 m(2) (stage 3 or 4 disease). We used Poisson regression to calculate unadjusted rates and relative rates of myocardial infarction during follow-up for five risk groups: people with previous myocardial infarction (with or without diabetes or chronic kidney disease), and (of those without previous myocardial infarction), four mutually exclusive groups defined by the presence or absence of diabetes and chronic kidney disease.

FINDINGS

During a median follow-up of 48 months (IQR 25-65), 11,340 of 1,268,029 participants (1%) were admitted to hospital with myocardial infarction. The unadjusted rate of myocardial infarction was highest in people with previous myocardial infarction (18·5 per 1000 person-years, 95% CI 17·4-19·8). In people without previous myocardial infarction, the rate of myocardial infarction was lower in those with diabetes (without chronic kidney disease) than in those with chronic kidney disease (without diabetes; 5·4 per 1000 person-years, 5·2-5·7, vs 6·9 per 1000 person-years, 6·6-7·2; p<0·0001). The rate of incident myocardial infarction in people with diabetes was substantially lower than for those with chronic kidney disease when defined by eGFR of less than 45 mL/min per 1·73 m(2) and severely increased proteinuria (6·6 per 1000 person-years, 6·4-6·9 vs 12·4 per 1000 person-years, 9·7-15·9).

INTERPRETATION

Our findings suggest that chronic kidney disease could be added to the list of criteria defining people at highest risk of future coronary events.

FUNDING

Alberta Heritage Foundation for Medical Research.

Inclusion of stroke in cardiovascular risk prediction instruments: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Current US guideline statements regarding primary and secondary cardiovascular risk prediction and prevention use absolute risk estimates to identify patients who are at high risk for vascular disease events and who may benefit from specific preventive interventions. These guidelines do not explicitly include patients with stroke, however. This statement provides an overview of evidence and arguments supporting (1) the inclusion of patients with stroke, and atherosclerotic stroke in particular, among those considered to be at high absolute risk of cardiovascular disease and (2) the inclusion of stroke as part of the outcome cluster in risk prediction instruments for vascular disease.

METHODS AND RESULTS

Writing group members were nominated by the committee co-chairs on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee and the AHA Manuscript Oversight Committee. The writers used systematic literature reviews (covering the period from January 1980 to March 2010), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and, when appropriate, formulate recommendations using standard AHA criteria. All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive AHA internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. There are several reasons to consider stroke patients, and particularly patients with atherosclerotic stroke, among the groups of patients at high absolute risk of coronary and cardiovascular disease. First, evidence suggests that patients with ischemic stroke are at high absolute risk of fatal or nonfatal myocardial infarction or sudden death, approximating the ≥20% absolute risk over 10 years that has been used in some guidelines to define coronary risk equivalents. Second, inclusion of atherosclerotic stroke would be consistent with the reasons for inclusion of diabetes mellitus, peripheral vascular disease, chronic kidney disease, and other atherosclerotic disorders despite an absence of uniformity of evidence of elevated risks across all populations or patients. Third, the large-vessel atherosclerotic subtype of ischemic stroke shares pathophysiological mechanisms with these other disorders. Inclusion of stroke as a high-risk condition could result in an expansion of ≈10% in the number of patients considered to be at high risk. However, because of the heterogeneity of stroke, it is uncertain whether other stroke subtypes, including hemorrhagic and nonatherosclerotic ischemic stroke subtypes, should be considered to be at the same high levels of risk, and further research is needed. Inclusion of stroke with myocardial infarction and sudden death among the outcome cluster of cardiovascular events in risk prediction instruments, moreover, is appropriate because of the impact of stroke on morbidity and mortality, the similarity of many approaches to prevention of stroke and these other forms of vascular disease, and the importance of stroke relative to coronary disease in some subpopulations. Non-US guidelines often include stroke patients among others at high cardiovascular risk and include stroke as a relevant outcome along with cardiac end points.

CONCLUSIONS

Patients with atherosclerotic stroke should be included among those deemed to be at high risk (≥20% over 10 years) of further atherosclerotic coronary events. Inclusion of nonatherosclerotic stroke subtypes remains less certain. For the purposes of primary prevention, ischemic stroke should be included among cardiovascular disease outcomes in absolute risk assessment algorithms. The inclusion of atherosclerotic ischemic stroke as a high-risk condition and the inclusion of ischemic stroke more broadly as an outcome will likely have important implications for prevention of cardiovascular disease, because the number of patients considered to be at high risk would grow substantially.

Should eGFR and albuminuria be added to the Framingham risk score? Chronic kidney disease and cardiovascular disease risk prediction

Presence of chronic kidney disease (CKD) defined as decreased glomerular filtration rate (GFR) and/or increased urine albumin excretion is associated with heightened risk of cardiovascular disease (CVD) and all-cause as well as CVD mortality. Although CKD is strongly linked with CVD, it remains undetermined whether this strong association is simply due to shared CVD risk factors or unique traits consequential to CKD. The probability of future CVD events can be estimated with reasonable accuracy using the Framingham equation which was derived from the Framingham study, a community-based cohort of 5,209 white adults aged 30-62 years who were first examined in 1948. Efforts to capture excess CVD risk associated with CKD have been evaluated by adding estimated GFR, cystatin C, serum creatinine and measures of urinary albumin excretion to the Framingham equation which is based on traditional cardiovascular risk factors. Although decreased GFR and increased urine albumin excretion are consistently associated with cardiovascular outcomes, the addition of these factors to the Framingham equation has not been shown to substantially improve overall CVD risk prediction in populations not enriched with CKD. Moreover, the Framingham equation itself underpredicts cardiovascular events among adults with stage 3 and 4 CKD without clinical CVD. Given the poor performance of the Framingham equation in adults with CKD, future studies should explore risk equations which include traditional CVD risk factors and the unique comorbidities associated with CKD for prediction of cardiovascular events in adults with CKD.

Increased risk of cardiovascular events and mortality among non-diabetic chronic kidney disease patients with hypertensive nephropathy: the Gonryo study

To examine the clinical significance of hypertensive nephropathy (HN) among non-diabetic chronic kidney disease (CKD) patients. The study comprised 2692 CKD patients recruited from 11 outpatient nephrology clinics; these included 1306 patients with primary renal disease (PRD), 458 patients with HN, 283 patients with diabetic nephropathy (DN) and 645 patients with other nephropathies (ONs). All patients fulfilled the criteria of CKD, with a persistent low estimated glomerular filtration rate (eGFR) <60 ml min(-1) per 1.73 m(2) or proteinuria as determined by a urine dipstick test. The risk factors for cardiovascular disease (CVD), such as ischemic heart disease, congestive heart failure and stroke; all-cause mortality; and progression to end-stage renal failure (dialysis induction) were analyzed using a Cox proportional hazards model in each group. During a mean follow-up period of 22.6 months from recruitment, 100 patients were lost to follow-up and 192 patients began chronic dialysis therapy. A total of 115 CVD events occurred (stroke in 37 cases), and 44 patients died. Regarding CVD events and death, there were significant differences in the hazard ratios (HRs) for the groups of patients with different underlying renal diseases as determined by both univariate and multivariate analysis adjusted for confounding factors including estimated glomerular filtration rate: PRD, 1.0 (reference); HN, 3.33 (95% confidence interval, 1.82-6.09); DN, 5.93 (2.80-12.52); and ON, 2.22 (1.22-4.05). However, there were no differences in the hazard ratio for dialysis induction for the groups of patients with different underlying renal diseases. HN is associated with an increased risk of CVD events and death among non-diabetic CKD patients, which highlights the clinical significance of HN.

Blood pressure level and kidney disease progression: do we really need to go to 130/80 mm Hg?

Current guidelines recommend a blood pressure goal of less than 130/80 mm Hg in patients with chronic kidney disease. Considerable epidemiologic observational data, post hoc analyses of clinical trials, and meta-analyses support this goal, particularly in patients with proteinuria. Although prospective clinical trials have not shown a clear benefit, recent data indicate that a longer duration of follow-up may be needed to assess the effects of different blood pressure goals. While we await the results of several ongoing and planned studies in this area, the current recommendations of a blood pressure goal less than 130/80 mm Hg appear reasonable.

Genetic contribution and associated pathophysiology in end-stage renal disease

End-stage renal disease (ESRD) or chronic kidney disease (CKD) is the terminal state of the kidney when its function has been permanently and irreversibly damaged. A wide variety of etiologies and pathological processes culminate in ESRD, and both environmental and genetic factors contribute to its development and progression. Various reports suggest that susceptibility to develop ESRD has a significant genetic component. These studies include familial aggregation studies, comparisons of incidence rates between different racial or ethnic populations, and segregation analysis. Genetic approaches have been used to identify genes that contribute to genetic susceptibility. Many studies have now been carried out assessing the contribution of specific “candidate genes”, which correlate with different functions that are involved in the renal pathogenesis. Independent studies for specific associated genes have frequently provided contradictory results. This may be due, in part, to the modest contribution to genetic susceptibility which these genes impart. With the availability of different genomewide association studies, chromosomal regions harboring novel, previously unrecognized, genes that may contribute to renal diseases have been recently reported. We have focused on different genetic studies conducted on ESRD and have discussed the strength and weaknesses of these studies. The nonmuscle myosin heavy chain 9 gene (MYH9) and renin–angiotensin system (RAS) have been discussed in detail.

Acute kidney injury following coronary angiography is associated with a long-term decline in kidney function

To determine whether acute kidney injury results in later long-term decline in kidney function we measured changes in kidney function over a 3-year period in adults undergoing coronary angiography who had serum creatinine measurements as part of their clinical care. Acute kidney injury was categorized by the magnitude of increase in serum creatinine (mild (50-99% or >or=0.3 mg/dl) and moderate or severe (>or=100%)) within 7 days of coronary angiography. Compared to patients without acute kidney injury, the adjusted odds of a sustained decline in kidney function at 3 months following angiography increased more than 4-fold for patients with mild to more than 17-fold for those with moderate or severe acute kidney injury. Among those with an estimated glomerular filtration rate after angiography less than 90 ml/min per 1.73 m(2), the subsequent adjusted mean rate of decline in estimated glomerular filtration rate during long-term follow-up (all normalized to 1.73 m(2) per year) was 0.2 ml/min in patients without acute kidney injury, 0.8 ml/min following mild injury, and 2.8 ml/min following moderate to severe acute kidney injury. Thus, acute kidney injury following coronary angiography is associated with a sustained loss and a larger rate of future decline in kidney function.

The association of low selenium and renal insufficiency with coronary heart disease and all-cause mortality: NHANES III follow-up study

Although prospective studies suggest that low selenium is a risk factor for cardiovascular disease, most clinical trials of selenium supplementation have not shown this benefit. Prospective studies of renal insufficiency show that it is associated with low-selenium levels, and increased cardiovascular disease risk. We hypothesized that low selenium and renal insufficiency might show biologically important interactions warranting a future trial of selenium supplementation in this high-risk group of patients with both renal insufficiency and low selenium. We evaluated the prospective association of low selenium and renal insufficiency with coronary heart disease and all-cause mortality. A cohort of 10,531 NHANES III participants aged 35 years or older with serum selenium measurements and creatinine were followed longitudinally and linked to the National Death Index. In multivariable-adjusted analysis, low-selenium levels were associated with an increased risk of CHD mortality (HR=1.26; 95% CI: 0.94-1.69) and an increased risk for all-cause mortality (HR=1.41; 95% CI: 1.18-1.68). Renal insufficiency was also associated with increased risk of CHD mortality (HR=1.64; 95% CI: 1.29-2.08) and all-cause mortality (HR=1.51; 95% CI: 1.31-1.74). Despite the findings that adults with impaired renal function and low selenium had an increased risk for CHD mortality (HR=2.06; 95% CI: 1.13-3.75), there was no evidence of supra-additivity between low selenium and renal insufficiency on rate of CHD mortality (relative excess risk due to the interaction [RERI=0.16; 95% CI: -1.34 to 1.65] or all-cause mortality (RERI=-0.85; 95% CI: -1.50 to -0.20). This analysis suggests that the combination of renal insufficiency and low selenium does not represent an extremely high-risk group where a randomized trial of selenium supplementation would be of greater value than focusing on all adults with low-serum selenium.

Genetic polymorphisms and the risk of accelerated renal function decline in women

Background

Reduced glomerular filtration rate is an important predictor of cardiovascular disease and death. Genetic polymorphisms, particularly in genes involved in the renin-angiotensin system (RAS), may influence the rate of renal function decline.

Methodology/Principal Findings

We examined the relation between specific single nucleotide polymorphisms (SNPs), including those in the RAS, apolipoprotein E and alpha-adducin, and renal function decline assessed by estimated glomerular filtration rate (eGFR) over an 11-year period in 2578 Caucasian participants of the Nurses' Health Study. Logistic regression was used to examine the associations between genotype and risk of eGFR decline of ≥25%.

Results

After 11 years between creatinine measurements, the eGFR declined by ≥25% in 423 of 2578 (16%) women. The angiotensinogen (AGT) A-20C polymorphism was associated with a higher risk of renal function decline when two risk alleles were present than if one or no alleles were present (CC vs AA and AC) OR 1.83 (95% CI 1.02–3.26; p = 0.04). The angiotensin II type 1 receptor (AT₁R) A1166C polymorphism was marginally associated with a higher risk of renal function decline when two risk alleles were present (CC vs AA, OR = 1.41; 95% CI 0.98–2.01; p = 0.06). The alpha-adducin G460W polymorphism was associated with a lower risk of renal function decline when any number of risk alleles were present (WG vs GG, OR = 0.78, 95% CI 0.61–0.99, p = 0.04; WW vs GG, OR = 0.46; 95% CI 0.20–1.07, p = 0.07). Linear regression analysis with change in eGFR as the outcome showed a larger decline of 3.5 (95% CI 0.5 to 6.4, p = 0.02) ml/min/1.73 m² in AGT A-20C CC homozygotes. No other polymorphisms were significantly associated with renal function decline or absolute change in eGFR over the study period.

Conclusions

Genetic variants in the angiotensinogen, angiotensin II type 1 receptor and alpha-adducin genes may contribute to loss of renal function in the general female Caucasian population.

Poor glycemic control in diabetes and the risk of incident chronic kidney disease even in the absence of albuminuria and retinopathy: Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

Diabetic nephropathy is the leading cause of kidney failure in the United States. The extent to which an elevated glycated hemoglobin (HbA(1c)) concentration is associated with increased risk of chronic kidney disease (CKD) in the absence of albuminuria and retinopathy, the hallmarks of diabetic nephropathy, is uncertain.

METHODS

Glycated hemoglobin concentration was measured in 1871 adults with diabetes mellitus followed up for 11 years in the Atherosclerosis Risk in Communities (ARIC) Study. Incident CKD was defined as an estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) after 6 years of follow-up or a kidney disease-related hospitalization. We categorized HbA(1c) concentrations into 4 clinically relevant categories. Albuminuria and retinopathy were measured midway through follow-up.

RESULTS

Higher HbA(1c) concentrations were strongly associated with risk of CKD in models adjusted for demographic data, baseline glomerular filtration rate, and cardiovascular risk factors. Compared with HbA(1c) concentrations less than 6%, HbA(1c) concentrations of 6% to 7%, 7% to 8%, and greater than 8% were associated with adjusted relative hazard ratios (95% confidence intervals) of 1.4 (0.97-1.91), 2.5 (1.70-3.66), and 3.7 (2.76-4.90), respectively. Risk of CKD was higher in individuals with albuminuria and retinopathy, and the association between HbA(1c) concentration and incident CKD was observed even in participants without either abnormality: adjusted relative hazards, 1.46 (95% confidence intervals, 0.80-2.65), 1.17 (0.43-3.19), and 3.51 (1.67-7.40), respectively; P(trend) = .004.

CONCLUSIONS

We observed a positive association between HbA(1c) concentration and incident CKD that was strong, graded, independent of traditional risk factors, and present even in the absence of albuminuria and retinopathy. Hyperglycemia is an important indicator of risk of both diabetic nephropathy with albuminuria or retinopathy and of less specific forms of CKD.

High prevalence of stage 3 chronic kidney disease in older adults despite normal serum creatinine

BACKGROUND

Serum creatinine is commonly used to diagnose chronic kidney disease (CKD), but may underestimate CKD in older adults when compared with using glomerular filtration rates (eGFR). The magnitude of this underestimation is not clearly defined.

OBJECTIVE

Using the Modification of Diet in Renal Disease (MDRD) equation, to describe both the prevalence and the magnitude of underestimation of stage 3 CKD (GFR 30-59 ml/min/1.73 m(2)), as well as ideal serum creatinine cutoff values to diagnose stage 3 CKD among Americans > or =65 years of age.

DESIGN

Cross-sectional.

PARTICIPANTS

A total of 3,406 participants > or =65 years of age from the 1999-2004 National Health and Nutrition Examination Surveys (NHANES).

MEASUREMENTS

Serum creatinine levels were used to determine eGFR from the MDRD equation. Information on clinical conditions was self-reported.

RESULTS

Overall, 36.1% of older adults in the US have stage 3 or greater CKD as defined by eGFR values. Among older adults with stage 3 CKD, 80.6% had creatinine values < or =1.5 mg/dl, and 38.6% had creatinine values < or =1.2 mg/dl. Optimal cutoff values for serum creatinine in the diagnosis of stage 3 CKD in older adults were > or =1.3 mg/dl for men and > or =1.0 mg/dl for women, regardless of the presence or absence of hypertension, diabetes, or congestive heart failure.

CONCLUSION

Use of serum creatinine underestimates the presence of advanced (stage 3 or greater) CKD among older adults in the US. Automated eGFR reporting may improve the accuracy of risk stratification for older adults with CKD.

The case for chronic kidney disease, diabetes mellitus, and myocardial infarction being equivalent risk factors for cardiovascular mortality in patients older than 65 years

The objective of the study was to determine whether chronic kidney disease (CKD) is as important a risk as either diabetes mellitus (DM) or previous myocardial infarction (MI). CKD and DM are important coronary artery disease risk factors. We hypothesized that the risk of cardiovascular mortality in elderly patients with CKD is equivalent to that for patients with either DM or previous MI. The CHS limited-access database was used to identify a cohort of patients with a baseline history of MI, DM, or CKD (estimated glomerular filtration rate <60 ml/min). Subjects were categorized in 1 of 3 groups as group 1, patients with DM (no CKD or MI); group 2, patients with previous MI (no DM or CKD); and group 3, patients with CKD (no DM or MI). Patients were followed up for a mean of 8.6 years, and rates of cardiovascular mortality were compared using proportional hazards regression. There were 789, 443, and 667 people in the MI, DM, and CKD groups, respectively. During follow-up, 124 patients (15.7%) died of cardiovascular causes in the MI group, and 69 (15.8%) and 87 (13%), in the DM and CKD groups, respectively. After adjusting for age, race, gender, smoking, hypertension, and total, high-density lipoprotein, and low-density lipoprotein cholesterol, the hazard ratio (HR) for cardiovascular mortality was similar between the DM (HR 1.0, 95% confidence interval 0.8 to 1.4)) and CKD cohorts (HR 0.8, 95% confidence interval 0.6 to 1.1) compared with the MI group. In conclusion, the risk of cardiovascular mortality in patients with moderate CKD was as high as that in patients with a history of MI or DM. Designation of CKD as a cardiovascular risk equivalent in patients >65 years of age appears justified.

Chronic kidney disease as a predictor of cardiovascular disease (from the Framingham Heart Study)

Chronic kidney disease (CKD) is a risk factor for cardiovascular disease (CVD), although shared risk factors may mediate much of the association. CKD and CVD were related in the setting of specific CVD risk factors, and whether more advanced CKD was a CVD risk equivalent was determined. The Framingham Heart Study original cohort (n = 2,471, mean age 68 years, 58.9% women) was studied. Glomerular filtration rate was estimated (eGFR) using the simplified Modification of Diet in Renal Disease Study equation. CKD was defined as eGFR <59 (women) and <64 ml/min/1.73 m(2) (men), and stage 3b CKD was defined as eGFR of 30 to 44 (women) and 30 to 50 ml/min/1.73 m(2) (men). Cox proportional hazard models adjusting for CVD risk factors were used to relate CKD to CVD. Effect modification by CVD risk factors was tested for. Overall, 23.2% of the study sample had CKD (n = 574, mean eGFR 50 ml/min/1.73 m(2)) and 5.3% had stage 3b CKD (n = 131, mean eGFR 42 ml/min/1.73 m(2)). In multivariable models (mean follow-up 16 years), stage 3 CKD was marginally associated with CVD (hazard ratio [HR] 1.17, 95% confidence interval [CI] 0.99 to 1.38, p = 0.06), whereas stage 3b CKD was associated with CVD (HR 1.41, 95% CI 1.05 to 1.91, p = 0.02). Testing CVD risk equivalency, the risk of CVD for stage 3b CKD in subjects with previous CVD was significantly lower compared with subjects with previous CVD and no stage 3b CKD (age- and sex-adjusted HR for CVD 0.66, 95% CI 0.47 to 0.91, p = 0.01). Low high-density lipoprotein cholesterol modified the association between CKD and CVD (p = 0.004 for interaction). Stage 3b CKD was associated with CVD, but was not a CVD risk equivalent. In conclusion, CVD risk in the setting of CKD is higher in the setting of low high-density lipoprotein cholesterol.

Development of end stage renal disease following an acute cardiac event

We determined the rate and risk factors for end-stage renal disease (ESRD) in consecutive patients discharged after a cardiac event in a large, unbiased Canadian cohort that receives universal health coverage. A total of 8236 adults hospitalized over a 2 year period were followed for up to 7.5 years and the incidence of ESRD and mortality determined. Of these, 113 reached ESRD (stage 5). Patients with moderate (stage 3) and severe (stage 4) renal insufficiency were more likely to develop ESRD than those patients at stage 1 or 2. However, patients with moderate renal insufficiency were 78.6 times more likely to die than to develop ESRD. Absolute rates of progression to ESRD per 100-patient years were 0.08 at stages 1 and 2, 0.17 at stage 3 and 4.27 at stage 4. Age, diabetes, hypertension and congestive heart failure also predicted ESRD. We found that patients with stage 4 disease are at high risk of ESRD after a cardiac admission while those at stage 3 are far more likely to die than to develop ESRD.

N-terminal prohormone brain natriuretic peptide as a predictor of cardiovascular disease and mortality in blacks with hypertensive kidney disease: the African American Study of Kidney Disease and Hypertension (AASK)

BACKGROUND

Higher levels of N-terminal prohormone brain-type natriuretic peptide (NT-proBNP) predict cardiovascular disease (CVD) in several disease states, but few data are available in patients with chronic kidney disease or in blacks.

METHODS AND RESULTS

The African American Study of Kidney Disease and Hypertension trial enrolled hypertensive blacks with a glomerular filtration rate of 20 to 65 mL x min(-1) x 1.73 m(-2) and no other identified cause of kidney disease. NT-proBNP was measured with a sandwich chemiluminescence immunoassay (coefficient of variation 2.9%) in 994 African American Study of Kidney Disease and Hypertension participants. NT-proBNP was categorized as undetectable, low, moderate, or high. Proteinuria was defined as 24-hour urinary protein-creatinine ratio >0.22. A total of 134 first CVD events (CVD death or hospitalization for coronary artery disease, heart failure, or stroke) occurred over a median of 4.3 years. Participants with high NT-proBNP were much more likely to have a CVD event than participants with undetectable NT-proBNP after adjustment (relative hazard 4.0 [95% confidence interval [CI] 2.1 to 7.6]). A doubling of NT-proBNP was associated with a relative hazard of 1.3 (95% CI 1.0 to 1.6) for coronary artery disease, 1.7 (95% CI 1.4 to 2.2) for heart failure, 1.1 (95% CI 0.9 to 1.4) for stroke, and 1.8 (95% CI 1.4 to 2.4) for CVD death. The association of NT-proBNP with CVD events was significantly stronger (P(interaction)=0.05) in participants with than in those without proteinuria. Higher NT-proBNP was not associated with renal disease progression.

CONCLUSIONS

These results suggest that elevated NT-proBNP levels are associated with higher CVD risk among blacks with hypertensive kidney disease. This association may be stronger in individuals with significant proteinuria.

[A case-control study of health benefits in patients with moderate renal failure]

In order to evaluate medical management in patients with renal failure before dialysis, we conducted a case-control study to analyze the health benefits in 914 moderate renal failure patients with Cockcroft clearance between 30 and 60 ml/min. Health benefits reimbursed by the Social Security in this population were compared with those in 1828 controls randomly chosen in the Social Security files but matched by age and gender. Mean age of the participants was 73+/-11 year-old, 67% were women, Cockcroft clearance was 48+/-8 ml/min. Number of hospitalizations and hospitalization durations were not different between the two populations. Conversely, cases had more specialized outpatients' clinics in cardiology but not in nephrology or urology. Cases had more biological tests and radiological exams and had taken more medicines. For biology, cases had more often renal function tests and markers of renal dysfunction tests than controls. Cases had taken more medicines than controls for erythropoietin, diuretics, renin-angiotensin blockers, hypoglycemic drugs, and anticoagulants. Patients with mild renal failure had higher health benefits than controls for outpatients' clinics in cardiology, for biological tests, for radiological exams, and for some medicines.

Elevated cystatin C concentration and progression to pre-diabetes: the Western New York study

OBJECTIVE

We conducted a nested case-control investigation to examine whether elevated baseline concentrations of cystatin C predicted progression from normoglycemia to pre-diabetes over 6 years of follow-up from the Western New York Health Study.

RESEARCH DESIGN AND METHODS

In 2002-2004, 1,455 participants from the Western New York Health Study, who were free of type 2 diabetes and known cardiovascular disease at baseline (1996-2001), were reexamined. An incident case of pre-diabetes was defined as an individual with fasting glucose < 100 mg/dl at the baseline examination and > or = 100 and < or = 125 mg/dl at the follow-up examination, thereby eliminating individuals with prevalent pre-diabetics. All case patients (n = 91) were matched 1:3 to control participants based on sex, race/ethnicity, and year of study enrollment. All control subjects had fasting glucose levels < 100 mg/dl at both baseline and follow-up examinations. Cystatin C concentrations and the urinary albumin-to-creatinine ratio were measured from frozen (-196 degrees C) baseline blood and urine samples. Serum creatinine concentrations were available from the baseline examination only.

RESULTS

Multivariate conditional logistic regression analyses adjusted for age, baseline glucose level, homeostasis model assessment of insulin resistance, BMI, hypertension, estimated glomerular filtration rate, cigarette smoking, and alcohol use revealed a significantly increased risk of progression to pre-diabetes among those with elevated baseline concentrations of cystatin C (odds ratio 3.28 [95% CI 1.43-7.54]) (upper quintile versus the remainder). Results of secondary analyses that considered high-sensitivity C-reactive protein, interleukin-6, E-selectin, or soluble intercellular adhesion molecule-1 did not alter these results.

CONCLUSIONS

These results suggest that cystatin C was associated with a threefold excess risk of progression to pre-diabetes in this population.

Carotid intima media thickness predicts cardiovascular diseases in Chinese predialysis patients with chronic kidney disease

Patients with chronic kidney disease (CKD) have a high risk for cardiovascular disease. Ultrasound measurements of the intima media thickness (IMT) in the carotid arteries is a strong predictor for cardiovascular events in the general population and dialysis patients. However, it is unclear whether carotid IMT is useful for the prediction of cardiovascular events in predialysis patients with CKD. The prediction power of carotid ultrasonography for cardiovascular event, rate of renal function decline, and all-cause mortality was tested in a cohort of 203 Chinese patients with stages 3 to 4 CKD. The average IMT was 0.808 +/- 0.196 mm; 121 (59.6%) patients had atherosclerotic plaques visualized. IMT correlated with patient age (r = 0.373, P < 0.001), serum LDL level (r = 0.164, P = 0.021), Charlson's comorbidity score (r = 0.260, P < 0.001), and serum C-reactive protein (r = 0.279, P < 0.001). Carotid IMT was significantly higher in patients with diabetes than in those without diabetes (0.930 +/- 0.254 versus 0.794 +/- 0.184; P = 0.002). At 48 mo, the cardiovascular event-free survival was 94.4, 89.8, 77.7, and 65.9% for IMT quartiles I, II, III, and IV, respectively (log rank test, P = 0.006). By multivariate analysis with the Cox proportional hazard model, each higher quartile of IMT conferred 41.6% (95% confidence interval 6.4 to 88.4%; P = 0.017) excess hazard for developing cardiovascular event. The actuarial survival at 48 mo was 96.3, 98.0, 95.7, and 85.7% for IMT quartiles I, II, III and IV, respectively (log rank test, P = 0.127), and the difference was not statistically significant after Cox proportional hazard model to adjust for confounders. Carotid IMT did not correlate with the rate of renal function decline in these patients. Carotid IMT is a strong predictor of cardiovascular disease in Chinese predialysis patients and may be usefully applied for risk stratification in this group of patients.

The Impact of Reclassifying Moderate CKD as a Coronary Heart Disease Risk Equivalent on the Number of US Adults Recommended Lipid-Lowering Treatment

BACKGROUND

The Third National Cholesterol Education Program Adult Treatment Panel (ATP-III) guidelines recommend consideration of lipid-lowering therapy at lower low-density lipoprotein cholesterol levels (>or=100 mg/dL [>or=2.59 mmol/L]) for adults with coronary heart disease risk equivalents. Chronic kidney disease is associated with increased coronary heart disease risk but is not included as a risk equivalent in these guidelines.

METHODS

The impact of including moderate chronic kidney disease (estimated glomerular filtration rate, 30 to 59 mL/min/1.73 m(2) [0.50 to 0.98 mL/s]) as a coronary heart disease risk equivalent on the percentage and number of US adults with chronic kidney disease recommended lipid-lowering therapy was estimated by using data from the Third National Health and Nutrition Examination Survey.

RESULTS

Of adults with moderate chronic kidney disease, 53.0% had a history of coronary heart disease or a risk equivalent, 24.7% reported a history of myocardial infarction or stroke, 17.7% had diabetes, 9.6% had angina, and 26.9% had a 10-year coronary heart disease risk greater than 20%. Using current ATP-III guidelines, lipid-lowering therapy is recommended for 61.4% of adults with moderate chronic kidney disease. If moderate chronic kidney disease was reclassified as a coronary heart disease risk equivalent, this percentage would increase to 87.7%, representing an increase in number of adults with moderate chronic kidney disease recommended lipid-lowering treatment from 4.5 to 6.5 million adults.

CONCLUSION

This analysis shows that a majority of adults with moderate chronic kidney disease have coronary heart disease or risk equivalents. Nonetheless, a substantially greater proportion of US adults with moderate chronic kidney disease would be recommended lipid-lowering therapy through its reclassification as a coronary heart disease risk equivalent.