Why is chronic kidney disease the “spoiler” for cardiovascular outcomes?**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology (original) (raw)
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Nature Medicine, 2019
Chronic kidney disease is common in the general population and associated with excess cardiovascular disease (CVD), but kidney function does not feature in current CVD risk prediction models. We tested three formulae for estimated glomerular filtration rate (eGFR) to determine the most clinically informative for predicting CVD and mortality. Using data from 440,526 participants from UK Biobank, eGFR was calculated using serum creatinine, cystatin C (eGFRcys) and creatinine-cystatin C. Associations of each eGFR with CVD outcome and mortality were compared using Cox models adjusting for atherosclerotic risk factors (per relevant risk scores), and predictive utility was determined by the C-statistic and categorical Net Reclassification Index. We show that eGFRcys is most strongly associated with CVD and mortality, and along with albuminuria adds predictive discrimination to current CVD risk scores, whilst traditional creatinine-based measures are weakly associated with risk. Clinicians should consider measuring eGFRcys as part of cardiovascular risk assessment. Users may view, print, copy, and download text and data-mine the content in such documents, for the purposes of academic research, subject always to the full Conditions of use:
Nefrología : publicación oficial de la Sociedad Española Nefrologia, 2013
Although the prevalence of chronic kidney disease (CKD) is 10–14%, several prospective studies note a low rate of progression to end-stage renal disease (ESRD) in stages 3 and 4. A correct classification of risk of progression, based on demonstrated predictive factors, would allow better management of CKD. Recent studies have demonstrated the high predictive value of a classification that combines estimated (e) glomerular filtration rate (GFR) and urine albumin–creatinine ratio (ACR). We estimated the clinical risk of progression to ESRD and cardiovascular mortality predicted by the combined variable of eGFR and ACR in the Spanish general population. This study was a cross-sectional evaluation in the Epirce sample, representative of Spanish population older than 20 years. GFR was estimated using MDRD and CKD-EPI formulas; microalbuminuria was considered to be an ACR 20–200 mg/g (men) or 30–300 mg/g (women) and macroalbuminuria was indicated beyond these limits. Population-weighted p...
Nephrology Dialysis Transplantation, 2011
Background. Little is known about normal kidney function level and the prognostic significance of low estimated glomerular filtration rate (eGFR) in the elderly. Methods. We determined age and sex distribution of eGFR with both the Modification of Diet in Renal Disease (MDRD) study and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations in 8705 community-dwelling elderly aged !65 years and studied its relation to 6-year mortality. In a subsample of 1298 subjects examined at 4 years, we assessed annual eGFR decline and clinically relevant markers including microalbuminuria (3-30 mg/mmol creatinine) with diabetes, proteinuria !50 mg/mmol, haemoglobin <11 g/L or resistant hypertension despite three drugs. Results. Median (interquartile range) MDRD eGFR was 78 (68-89) mL/min/1.73m 2 in men and 74 (65-83) in women; http://ndt.oxfordjournals.org/ Downloaded from there were 79 (68-87) and 77 (67-85) for CKD-EPI eGFR, respectively. Prevalence of MDRD eGFR <60 mL/min/ 1.73m 2 was 13.7% and of CKD-EPI eGFR was 12.9%. After adjustment for several confounders, only those with an eGFR <45 mL/min/1.73m 2 had significantly higher allcause and cardiovascular mortality than those with an eGFR of 75-89 mL/min/1.73m 2 whatever the equation. In the subsample men and women with an MDRD eGFR of 45-59 mL/min/1.73m 2 , 15 and 13% had at least one clinical marker and 15 and 3% had microalbuminuria without diabetes, respectively; these percentages were 41 and 21% and 23 and 10% in men and women with eGFR <45, respectively. Mean MDRD eGFR decline rate was steeper in men than in women, 1.75 versus 1.41 mL/min/1.73m 2 /year. Conclusions. Moderately decreased eGFR is more often associated with clinical markers in men than in women. In both sexes, eGFR <45 mL/min/1.73m 2 is related to poor outcomes. The CKD-EPI and the MDRD equations provide very similar prevalence and long-term risk estimates in this elderly population.
Editorial: Glomerular filtration rate in Chronic Kidney Disease
Frontiers in Medicine, 2023
Editorial on the Research Topic Glomerular filtration rate in Chronic Kidney Disease Chronic Kidney Disease (CKD) is defined as "abnormalities of kidney structure or function, present for more than 3 months, with health implications" and is classified according to the cause, the glomerular filtration rate (GFR) category, and the magnitude of albuminuria (1). So, the diagnosis of CKD progression is based on two key parameters: GFR and the presence and extent of albuminuria. GFR is considered the best global index of renal function since its decrease usually correlates with functional renal mass. GFR can be easily estimated (eGFR) through equations that include endogenous analytes such as creatinine or cystatin C, alone or combined, and anthropometric and demographic factors. At the individual level, the accuracy of an eGFR equation is defined as (p30), which means that around 85% of GFR determinations are within ±30% of mGFR. eGFR should not be used when extreme body composition is present, such as patients with anorexia nervosa, cirrhosis, debilitated elderly, severe obesity, or when there is a need to administer nephrotoxic drugs with a narrow therapeutic option. When necessary, mGFR can be measured using radioisotopes or contrast media. The understanding that a reliable and consistent GFR estimation (which means reproducibility under the same conditions) is central for the practice of nephrology in particular and medicine in general. Taking into account its limitations, at present, eGFR is not only a powerful tool for identifying CKD, but it has become fundamental for physicians for early detection, clinical diagnosis, monitoring of progression, indication for admission to replacement therapy, calculation of the dose of drugs excreted by the kidney, and in preparation for invasive diagnostic or therapeutic procedures. As an epidemiological tool, eGFR is not only a simple method to estimate the global burden of CKD, but an instrument for identifying risk factors for progression, understanding the epidemiology of kidney disease concerning different social groups (particularly vulnerable ones), and establishing public policies that intend to reduce CKD at the population level. In kidney disease investigation, it is necessary to determine the risks and benefits of new drugs over CKD progression.
Metabolism, 2008
The Cockcroft and Gault (CG) and Modification of Diet in Renal Disease (MDRD) equations underestimate the glomerular filtration rate (GFR) decline in diabetes. Do this decline and the albumin excretion rate (AER) influence their validity ? In 161 diabetic patients, isotopically determined GFR (i-GFR) (51Cr-EDTA) was compared with estimated GFR (e-GFR) by the CG, MDRD, and the new Mayo Clinic Quadratic (MCQ) equations. We searched for a relation between the error in e-GFR and the AER. An influence of the AER outcome on the e-GFR decline was evaluated in 63 subjects followed up over 3 years. The MDRD and the MCQ were more precise and accurate than the CG, but they were biased. The error increased with AER for the CG (r = 0.25, P = .001) and the MDRD (r = 0.20, P = .009), but not for the MCQ. For the 63 patients followed up, the e-GFR declines by the 3 estimations were related to the initial AER, whereas no relation with arterial blood pressure, hemoglobin A 1C , hemoglobin, and blood lipids emerged. The MCQ declines were more pronounced: −10.5% ± 8.9% in the macroalbuminuric group (P b .05 vs both microalbuminuric [−2.6% ± 10.1%] and normoalbuminuric [−0.1% ± 6.6%] groups), and were related to the outcome of the AER (r = 0.33, P b .05). As chronic kidney disease progresses in diabetes, the declining GFR and rising AER influence the estimation of GFR by the CG and MDRD equations, underestimating the GFR decline and the benefit of reducing the AER. The less affected MCQ evidences a slower e-GFR decline with AER control.
Atherosclerosis, 2011
Objective: The chronic kidney disease (CKD)-Epidemiology Collaboration (EPI) equation was shown to be more accurate than the Modification of Diet in Renal Disease (MDRD) Study formula for estimating glomerular filtration rate (GFR) in the general population. This study was aimed at assessing cardiovascular disease (CVD) burden associated with CKD in type 2 diabetes, using these two GFR estimating formulas for CKD definition. Methods: This cohort study examined 15,773 Caucasian patients with type 2 diabetes participating in the Renal Insufficiency And Cardiovascular Events Italian Multicenter Study (NCT00715481) and attending the baseline visit in 19 diabetes clinics in years 2007-2008. Serum creatinine was assessed by the modified Jaffe method. Albuminuria was measured by immunonephelometry or immunoturbidimetry. CKD was defined as an estimated GFR (eGFR) <60 mL/min/1.73 m 2 and/or micro/macroalbuminuria. Results: Prevalence of impaired eGFR and CKD decreased from 18.7% to 17.2% (P = 0.0012) and from 37.5% to 36.3% (P = 0.077), respectively, with the CKD-EPI, as compared with the MDRD Study equation. Subjects with impaired eGFR or CKD with the MDRD Study equation only showed lower CVD prevalence rates and coronary heart disease risk scores, mainly driven by prevailing female sex, younger age and shorter diabetes duration, as compared with those with both formulas, whereas opposite figures were observed in patients falling into these categories with the CKD-EPI equation only.
2007
Epidemiology of CKD 1 vi71 decided to analyze the rate of progression of CKD in a population followed by a multidisciplinary team. Methods: We analyzed data from 209 patients (102 females) referred to the Nephrology Division, after at least 6 months under treatment by a multidisciplinary team (nephrologist, nutritionist, nurse and psychologist) patients were followed from January of 2002 until December of 2005. Glomerular filtration rate was estimated by MDRD equation (eGFR). Patients with eGFR below 15ml/min were excluded, and this value was considered the end-point for calculation of the rate of decline of renal function. Results are mean± SD. Results: Hypertension was the main cause of CKD (31%) followed by Diabetes (26%). Age was 60±15 years, body mass index was 27±5 kg.m 2 for females and 26±4 kg.m 2 for males. Serum calcium, phosphorus and albumin were normal. Urea was 71±36mg/dl, eGFR = 38±20 ml/min. Systolic arterial pressure was 137±20mmHg and diastolic= 80±11mmHg; hematocrit = 37±5%, hemoglobin =12.3±1.7g/dl; cholesterol= 194±42mg/dl, HDL-cholesterol= 36±11mg/dl, LDL-cholesterol= 119±54mg/dl; triglyceride = 167±106 mg/dl; iPTH= 221±221 pg/ml. From the studied population 58% was referred to treatment with eGFR = 45-30 ml/min, and the remaining with eGFR =29 to 15 ml/min. K/DOQUI suggests a decline of 4ml/min/year for CKD patients. As shown in Table1, the rate of decline of eGFR of the present population was below this level, meaning an extra gain of time per year free from dialysis as a consequence of the conservative management with a multidisciplinary team. Table1. Progression of CKD Baseline disease Initial eGFR GFR reduction Time expectancy Time gain/year (ml/min) (ml/min/yr) in conservative in conservative management (yrs) management (yrs) Diabetes 40.48 2.88