Estimated Glomerular Filtration Rate and Albuminuria as Predictors of Outcomes in Patients With High Cardiovascular Risk: A Cohort Study

Study Questions:

What is the contribution of estimated glomerular filtration rate (eGFR) and urinary albumin–creatinine ratio beyond that of traditional cardiovascular risk factors to classification of patient risk for cardiovascular and renal outcomes?

Methods:

This was a prospective cohort study that pooled all patients of ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and TRANSCEND (Telmisartan Randomized Assessment Study in Angiotensin-Converting-Enzyme-Inhibitor Intolerant Subjects with Cardiovascular Disease) trials. A total of 27,620 patients older than 55 years with documented cardiovascular disease were followed for a mean of 4.6 years. Baseline eGFR, urinary albumin–creatinine ratio, and cardiovascular risk factors were measured. Outcomes were all-cause mortality; a composite of cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure; long-term dialysis; and a composite of long-term dialysis and doubling of serum creatinine level.

Results:

Lower eGFRs and higher urinary albumin–creatinine ratios were associated with the primary cardiovascular composite outcome (for example, an adjusted hazard ratio of 2.53 [95% confidence interval, 1.61-3.99] for an eGFR <30 ml/min per 1.73 m2 and a very high urinary albumin–creatinine ratio). However, adding information about eGFR and urinary albumin–creatinine ratio to the risk reclassification analyses led to no meaningful decrease in the proportion of patients assigned to the intermediate-risk category (31% without vs. 32% with renal information). In contrast, eGFR and urinary albumin–creatinine ratio were strongly associated with risk for long-term dialysis, and greatly improved both model calibration and risk stratification capacity when added to traditional cardiovascular risk factors (65% assigned to intermediate-risk categories without renal information vs. 18% with renal information).

Conclusions:

The authors concluded that in patients with high vascular risk, eGFR and urinary albumin–creatinine ratio do not add much to traditional cardiovascular risk factors, but greatly improve risk stratification for renal outcomes.

Perspective:

The study suggests that in patients with high vascular risk, eGFR and urinary albumin–creatinine ratio add little to traditional cardiovascular risk factors in stratification of cardiovascular risk, but greatly improve prediction of renal outcomes. The utility of information on renal function for predicting these outcomes may differ in the general population or in persons with renal disease, however. Further research is needed on which patients at high risk for cardiovascular events might benefit from screening for low eGFR and albuminuria and how their clinical management should be modified on the basis of the results.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Myocardial Infarction, Stroke, Heart Failure, Cardiovascular Diseases, Glomerular Filtration Rate, Creatinine


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