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      Chronic Kidney Disease and the Risk of End-Stage Renal Disease versus Death

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          ABSTRACT

          BACKGROUND

          Among older adults with chronic kidney disease (CKD), the comparative event rates of end-stage renal disease (ESRD) and cause-specific death are unknown.

          OBJECTIVE

          To compare the rates of ESRD, cardiovascular and non-cardiovascular death and examine risk factors for ESRD and all-cause mortality in Cardiovascular Health Study (CHS) participants.

          Design

          The CHS is a longitudinal cohort study of community-dwelling adults aged 65 years and older.

          PARTICIPANTS

          1,268 participants with an estimated glomerular filtration rate (eGFR) < 60 ml/min per 1.73 m 2 were followed until the time of first event (ESRD, cardiovascular or non-cardiovascular death) or until March 31, 2003.

          MAIN MEASURES

          The outcomes were ESRD, cardiovascular- and non-cardiovascular death. Rates of each event were calculated, and a Cox Proportional Hazards Model with a competing risk framework was used to examine risk factors for ESRD as compared with death. Predictors included age, gender, race, BMI, hypertension, diabetes, cardiovascular disease, heart failure, tobacco use, eGFR, and total cholesterol.

          KEY RESULTS

          During 9.7 years of follow-up, 5% of the cohort progressed to ESRD, and 61% of the cohort died. The rate (per 100 person-years) was 0.5 for ESRD and 6.8 for all-cause mortality (3.0 for cardiovascular and 3.8 for non-cardiovascular mortality). In the competing risk framework, lower eGFR, male gender, African-American race, and higher BMI were associated with an increased risk of ESRD.

          CONCLUSIONS

          Older adults with CKD are 13-fold more likely to die from any cause than progress to ESRD and are 6-fold more likely to die from cardiovascular causes than develop ESRD.

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          Most cited references17

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          Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies.

          Chronic kidney disease (CKD) is a major public health problem. Conflicting evidence exists among community-based studies as to whether CKD is an independent risk factor for adverse cardiovascular outcomes. After subjects with a baseline history of cardiovascular disease were excluded, data from four publicly available, community-based longitudinal studies were pooled: Atherosclerosis Risk in Communities Study, Cardiovascular Health Study, Framingham Heart Study, and Framingham Offspring Study. Serum creatinine levels were indirectly calibrated across studies. CKD was defined by a GFR between 15 and 60 ml/min per 1.73 m(2). A composite of myocardial infarction, fatal coronary heart disease, stroke, and death was the primary study outcome. Cox proportional hazards models were used to adjust for study, demographic variables, educational status, and other cardiovascular risk factors. The total population included 22,634 subjects; 18.4% of the population was black, and 7.4% had CKD. There were 3262 events. In adjusted analyses, CKD was an independent risk factor for the composite study outcome (hazard ratio [HR], 1.19; 95% confidence interval [CI], 1.07-1.32), and there was a significant interaction between kidney function and race. Black individuals with CKD had an adjusted HR of 1.76 (95% CI, 1.35-2.31), whereas whites had an adjusted HR of 1.13 (95% CI, 1.02-1.26). CKD is a risk factor for the composite outcome of all-cause mortality and cardiovascular disease in the general population and a more pronounced risk factor in blacks than in whites. It is hypothesized that this effect may be due to more frequent or more severe subclinical vascular disease secondary to hypertension or diabetes in black individuals.
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            Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999.

            Knowledge of the excess risk posed by specific cardiovascular syndromes could help in the development of strategies to reduce premature mortality among patients with chronic kidney disease (CKD). The rates of atherosclerotic vascular disease, congestive heart failure, renal replacement therapy, and death were compared in a 5% sample of the United States Medicare population in 1998 and 1999 (n = 1,091,201). Patients were divided into the following groups: 1, no diabetes, no CKD (79.7%); 2, diabetes, no CKD (16.5%); 3, CKD, no diabetes (2.2%); and 4, both CKD and diabetes (1.6%). During the 2 yr of follow-up, the rates (per 100 patient-years) in the four groups were as follows: atherosclerotic vascular disease, 14.1, 25.3, 35.7, and 49.1; congestive heart failure, 8.6, 18.5, 30.7, and 52.3; renal replacement therapy, 0.04, 0.2, 1.6, and 3.4; and death, 5.5, 8.1, 17.7, and 19.9, respectively (P < 0.0001). With use of Cox regression, the corresponding adjusted hazards ratios were as follows: atherosclerotic vascular disease, 1, 1.30, 1.16, and 1.41 (P < 0.0001); congestive heart failure, 1, 1.44, 1.28, and 1.79 (P < 0.0001); renal replacement therapy, 1, 2.52, 23.1, and 38.9 (P < 0.0001); and death, 1, 1.21, 1.38, and 1.56 (P < 0.0001). On a relative basis, patients with CKD were at a much greater risk for the least frequent study outcome, renal replacement therapy. On an absolute basis, however, the high death rates of patients with CKD may reflect accelerated rates of atherosclerotic vascular disease and congestive heart failure.
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              A Proportional Hazards Model for the Subdistribution of a Competing Risk

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                Author and article information

                Contributors
                +1-916-7343774 , +1-916-7347920 , lorien.dalrymple@ucdmc.ucdavis.edu
                Journal
                J Gen Intern Med
                Journal of General Internal Medicine
                Springer-Verlag (New York )
                0884-8734
                1525-1497
                19 September 2010
                19 September 2010
                April 2011
                : 26
                : 4
                : 379-385
                Affiliations
                [1 ]Department of Medicine, University of California Davis, 4150 V Street, #3500 PSSB, Sacramento, CA 95817 USA
                [2 ]Department of Biostatistics, University of Washington, Seattle, WA USA
                [3 ]Department of Medicine, University of Washington, Seattle, WA USA
                [4 ]General Internal Medicine Section, Medical Service, Veterans Affairs Medical Center, San Francisco, CA USA
                [5 ]Department of Medicine, University of California, San Francisco, CA USA
                [6 ]Department of Medicine, Tufts Medical Center, Boston, MA USA
                [7 ]Amgen Inc., Thousand Oaks, CA USA
                [8 ]Department of Medicine, University of Maryland School of Medicine, Baltimore, MD USA
                [9 ]Department of Epidemiology, University of Washington, Seattle, WA USA
                [10 ]Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
                [11 ]Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
                [12 ]Renal Section, VA Pittsburgh Health Care System, Pittsburgh, PA USA
                Article
                1511
                10.1007/s11606-010-1511-x
                3055978
                20853156
                b5a59778-bc3c-48ae-a406-0268006db88a
                © The Author(s) 2010
                History
                : 15 April 2010
                : 17 August 2010
                : 26 August 2010
                Categories
                Original Research
                Custom metadata
                © Society of General Internal Medicine 2011

                Internal medicine
                cardiovascular disease,clinical epidemiology,renal disease
                Internal medicine
                cardiovascular disease, clinical epidemiology, renal disease

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