Risk of Coronary Events in People With Chronic Kidney Disease Compared With Those With Diabetes: A Population-Level Cohort Study

Study Questions:

What is the evidence that chronic kidney disease should be regarded as a coronary heart disease risk equivalent?

Methods:

The investigators studied a population-based cohort with measures of estimated glomerular filtration rate (eGFR) and proteinuria from Alberta, Canada. The authors used validated algorithms based on hospital admission and medical-claim data to classify participants with baseline history of myocardial infarction (MI) or diabetes, and to ascertain which patients were admitted to the hospital for MI during follow-up (the primary outcome). For the primary analysis, they defined baseline chronic kidney disease as eGFR 15-59.9 ml/min per 1.73 m2 (stage 3 or 4 disease). They used Poisson regression to calculate unadjusted rates and relative rates of MI during follow-up for five risk groups: people with previous MI (with or without diabetes or chronic kidney disease), and (of those without previous MI) four mutually exclusive groups defined by the presence or absence of diabetes and chronic kidney disease.

Results:

During a median follow-up of 48 months (interquartile range, 25-65), 11,340 of 1,268,029 participants (1%) were admitted to the hospital with MI. The unadjusted rate of MI was highest in people with previous MI (18.5 per 1,000 person-years, 95% confidence interval [CI], 17.4-19.8). In people without previous MI, the rate of MI was lower in those with diabetes (without chronic kidney disease) than in those with chronic kidney disease (without diabetes; 5.4 per 1,000 person-years, 5.2-5.7, vs. 6.9 per 1,000 person-years, 6.6-7.2; p < 0.0001). The rate of incident MI in people with diabetes was substantially lower than for those with chronic kidney disease when defined by eGFR of <45 ml/min per 1.73 m2 and severely increased proteinuria (6.6 per 1,000 person-years, 6.4-6.9 vs. 12.4 per 1,000 person-years, 9.7-15.9).

Conclusions:

The authors concluded that chronic kidney disease could be added to the list of criteria defining people at highest risk of future coronary events.

Perspective:

In this population-based cohort of nearly 1.3 million people, the unadjusted rate of hospital admission for MI during follow-up was substantially lower for people with diabetes or chronic kidney disease than for those with a history of MI. The rates of hospital admission for MI and the risk of death after such an event in people with chronic kidney disease without diabetes were similar to or higher than rates in those with diabetes (without chronic kidney disease). These findings would suggest that chronic kidney disease may be added to the list of criteria defining people at highest risk of future coronary events since Adult Treatment Panel III guidelines include diabetes as a coronary heart disease risk equivalent.

Clinical Topics: Arrhythmias and Clinical EP, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Risk, Myocardial Infarction, Follow-Up Studies, Canada, Coronary Disease, Transcription Factors, Proteinuria, Renal Insufficiency, Cardiovascular Diseases, Atrial Fibrillation, Glomerular Filtration Rate, Confidence Intervals, Diabetes Mellitus, Atrial Flutter


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