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Kidney Dysfunction and Risk of Aortic Stenosis
Study Questions:
What is the link between chronic kidney dysfunction (CKD) and development of aortic stenosis (AS) in the general population?
Methods:
This is a report from the SCREAM (Stockholm CREAtinine Measurements) project in which data regarding baseline renal function and development of AS were derived from 1,121,875 Stockholm residents who underwent assessment of serum creatinine between 2006 and 2011. The only exclusion criteria were known diagnosis of AS or pre-existing renal replacement therapy on the index date. Patients with incident AS were identified based on International Classification of Diseases (ICD)-10 codes from the medical record. The index creatinine was used to calculate estimated glomerular filtration rate (eGFR), which was staged as: >90, 90-60, <60-45, <45-30, and <30 ml/min/1.73 m2.
Results:
The median age was 50 years and 54% were female. The most common comorbidities were hypertension (16.2%), treated hyperlipidemia (9.9%), diabetes (5.5%), ischemic heart disease (5.3%), congestive heart failure (3.0%), and cerebrovascular disease (3.0%). Moderate to severe CKD was defined as <60 ml/min 1.73 m2 and was noted in 6% of the population who were more often female, older, and had a higher number of comorbidities. Over a median follow-up of 5.1 years, 5,858 subjects (0.5%) developed clinically recognized AS for a crude incidence rate of 1.13 per 1,000 person-years. There was a linear increase in the crude AS incidence as eGFR declined. The incidence rate per 1,000 person-years was 0.34 in subjects with eGFR >90 compared to 8.27 in subjects with eGFR <30. Adjusted hazard ratios for the five subgroups of renal function noted under methods were 1.0, 1.14, 1.17, 1.22, and 1.56. Subgroup analysis noted that women with CKD had a 20% higher hazard ratio (1.2) of developing AS compared to those without CKD, whereas a similar association was not seen among men.
Conclusions:
Presence of CKD is associated with a stepwise increase in the likelihood of developing clinically recognized AS.
Perspective:
It is well recognized that in patients with dialysis-dependent CKD, there can be substantial progression and/or development of calcific valvular heart disease including AS. This study evaluated the link between a full range of CKD severity and incident AS and finds a linear relationship. Prior similar studies have been inconclusive regarding a similar link, but may have been limited by substantially smaller population sizes and lower numbers of patients with moderate and severe CKD. It should be noted that this is a purely observational study, which is heavily dependent on the electronic medical record for documenting disease states. Of note, a previous study had documented >90% diagnostic accuracy for the diagnosis of AS based on listed ICD codes from the medical record. An additional limitation is the fact that the diagnosis and stratification of CKD was based on a single creatinine measurement. While the adjusted hazard ratios are relatively modest, prior to adjusting for other cardiovascular comorbidities, the crude hazard ratios were substantially greater. For instance, the crude hazard ratio for patients with an eGFR <30 ml/min/1.73 m2 was 23.78, but after adjustment was 1.56, emphasizing shared risk factors for both CKD and cardiovascular comorbidities.
Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Valvular Heart Disease, Acute Heart Failure, Hypertension
Keywords: Aortic Valve Stenosis, Creatinine, Diabetes Mellitus, Electronic Health Records, Glomerular Filtration Rate, Heart Failure, Heart Valve Diseases, Hyperlipidemias, Hypertension, Kidney Function Tests, Kidney Diseases, Metabolic Syndrome, Myocardial Ischemia, Primary Prevention, Renal Dialysis, Renal Insufficiency, Chronic, Risk Factors
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