Beyond Traditional Risk Factors: Estimated Glomerular Filtration Rate and Albuminuria | Journal Scan

Study Questions:

What is the role of estimated glomerular filtration rate (eGFR) and albuminuria for prediction of cardiovascular outcomes?

Methods:

This was a meta-analysis of individual-level data. Data were analyzed from 24 cohorts, all with data about fatal and nonfatal cardiovascular outcomes and median follow-up longer than 4 years. Cohorts were eligible if there was baseline measurement of eGFR and albuminuria, at least 1,000 participants, and at least 50 cardiovascular events. Urine albumin-to-creatinine ratio (ACR) was the preferred measure of albuminuria. The outcomes that were studied as prespecified primary endpoints were cardiovascular mortality, coronary heart disease, stroke, and heart failure. The authors determined the difference in C statistic between prediction models that included or excluded measures of kidney disease; the categorical net reclassification improvement was also determined.

Results:

The analytic sample included 637,315 individuals from 24 cohorts with no history of cardiovascular disease (mean age, 47 years; mean follow-up, 8.9 years). The addition of eGFR and ACR significantly improved the discrimination of cardiovascular outcomes beyond that of traditional risk factors. The improvement was greater with ACR than with eGFR, and was more evident for cardiovascular mortality and heart failure. Improvements in discrimination with eGFR and ACR were more evident among individuals with diabetes or hypertension. In the chronic kidney disease population, the combination of eGFR and ACR outperformed any single modifiable traditional risk factor for prediction of coronary heart disease.

Conclusions:

eGFR and ACR independently improved the prediction of incident cardiovascular events beyond that conferred by traditional risk factors.

Perspective:

This is an important study that draws attention to the ability of eGFR and urinary ACR to significantly and independently improve the discrimination of cardiovascular outcomes beyond traditional risk factors. As discussed in an accompanying editorial (Ortiz A and Fernandez-Fernandez B), perhaps the most valuable finding is the demonstration of the central role that urinary ACR may play in risk prediction. Even though urinary ACR is currently not routinely assessed in clinical practice, perhaps it should be incorporated into algorithms used for risk prediction. As Ortiz and Fernandez-Fernandez summarize, the authors of this meta-analysis have ‘[settled] the debate on the predictive value of urinary ACR, [but] reignite the questions of the pathophysiological pathways involved and the therapeutic implications.’

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Hypertension

Keywords: Albumins, Albuminuria, Coronary Artery Disease, Coronary Disease, Creatinine, Diabetes Mellitus, Follow-Up Studies, Glomerular Filtration Rate, Heart Failure, Hypertension, Metabolic Syndrome X, Renal Insufficiency, Chronic, Risk Factors, Stroke


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