Background A low rate of blood pressure control has been reported among patients with chronic kidney disease (CKD). These data were derived from population-based samples with a low rate of CKD awareness. Study Design Cross-sectional Setting & Participants Data from the baseline visit of the Chronic Renal Insufficiency Cohort (CRIC) study (n=3612) were analyzed. Participants with an estimated glomerular filtration rate of 20 to 70 ml/min/1.73m2 were identified from physician offices and review of laboratory databases. Outcomes Prevalence and awareness of hypertension, treatment patterns, control rates and factors associated with hypertension control. Measurements Following a standardized protocol, blood pressure was measured three times by trained staff and hypertension was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg and/or self-reported antihypertensive medication use. Patients’ awareness and treatment of hypertension were defined using self-report and two levels of hypertension control were evaluated: systolic/diastolic blood pressure <140/90 mmHg and <130/80 mmHg. Results The prevalence of hypertension was 85.7%, and 98.9% of CRIC participants were aware of this diagnosis, 98.3% were treated with medications while 67.1% and 46.1% had their hypertension controlled to <140/90 mmHg and <130/80 mmHg, respectively. Of CRIC participants with hypertension, 15%, 25%, 26% and 32% were taking one, two, three and four or more antihypertensive medications, respectively. After multivariable adjustment, older patients, blacks, those with higher urinary albumin excretion were less likely while participants taking ACE-inhibitors and angiotensin receptor blockers were more likely to have controlled their hypertension to <140/90 mmHg and <130/80 mmHg. Limitations Data were derived from a single study visit. Conclusions Despite almost universal hypertension awareness and treatment in this cohort of patients with CKD, rates of hypertension control were sub-optimal.

Importance Coronary artery calcification (CAC) is highly prevalent in patients with pre-dialysis chronic kidney disease (CKD). However, there are sparse data on the association of CAC with subsequent risk of cardiovascular disease (CVD) and all-cause mortality in this population. Objectives To study the prospective association of CAC with risk of CVD and all-cause mortality among patients with pre-dialysis CKD. Design, Setting, and Participants Chronic Renal Insufficiency Cohort study recruited adults aged 21–74 years with an estimated-glomerular filtration rate (eGFR) of 20–70 mL/min/1.73 m2 from seven clinical centers in the US. Of them, 1,541 participants without CVD at baseline who had CAC measures were included in current analyses. Exposure CAC was assessed by electron-beam computed tomography or multi-detector computed tomography. Main Outcomes and Measures Incidence of CVD (including myocardial infarction, heart failure, and stroke) and all-cause mortality were reported every six months and confirmed by medical record adjudication. Results During an average of 5.9 years of follow-up, we observed 188 CVD (60 myocardial infarction, 120 heart failure, and 27 stroke) and 137 deaths. In Cox proportional hazards models adjusted for age, gender, race, clinical site, education, physical activity, total cholesterol, HDL-cholesterol, systolic blood pressure, antihypertensive treatment, current cigarette smoking, diabetes, body-mass index, C-reactive protein, hemoglobin A1c, phosphate, troponin T, log-N-terminal pro-B-type natriuretic peptide, fibroblast growth factor-23, eGFR, and proteinuria, the hazard ratios (95% confidence interval [CI]) associated with one standard deviation of CAC were 1.40 (1.16 to 1.69, p<.001) for CVD, 1.44 (1.02 to 2.02, p=.04) for myocardial infarction, 1.39 (1.10 to 1.76, p=.006) for heart failure, and 1.19 (0.94 to 1.51, p=.15) for all-cause mortality. In addition, inclusion of CAC score led to significant increase in c-statistic 0.02 (95% CI 0.00 to 0.09, p<.001) for predicting CVD over all above-mentioned established and novel CVD risk factors. Conclusion and Relevance CAC is independently and significantly related to the risks of CVD, myocardial infarction, and heart failure in CKD patients. In addition, CAC improves risk prediction for CVD, myocardial infarction, and heart failure over established and novel CVD risk factors among CKD patients, although the change in c-statistics is small.

Background Chronic kidney disease (CKD) is associated with an increased risk of heart failure (HF). We aimed to evaluate the role of large artery stiffness, brachial and central blood pressure as predictors of incident hospitalized HF in the Chronic Renal Insufficiency Cohort (CRIC), a multi-ethnic multi-center prospective observational study of patients with CKD. Methods and Results We studied 2602 participants who were free of HF at baseline. Carotid-femoral pulse wave velocity (CF-PWV, the gold-standard index of large artery stiffness), brachial and central pressures (estimated via radial tonometry and a generalized transfer function) were assessed at baseline. Participants were prospectively followed to assess the development of new-onset hospitalized HF. During 3.5 years of follow-up, 154 participants had a first hospital admission for HF. CF-PWV was a significant independent predictor of incident hospitalized HF. Compared to the lowest tertile, the HR among subjects in the middle and top CF-PWV tertiles were 2.33 (95%CI=1.37-3.97; P=0.002) and 5.24 (95%CI=3.22-8.53; P<0.0001), respectively. After adjustment for multiple confounders, the HR for the middle and top CF-PWV tertiles were 1.95 (95%CI=0.92-4.13; P=0.079) and 3.01 (95%CI=1.45-6.26; P=0.003), respectively. Brachial systolic and pulse pressure were also independently associated with incident hospitalized HF, whereas central pressures were less consistently associated with this endpoint. The association between CF-PWV and incident HF persisted after adjustment for systolic blood pressure. Conclusions Large artery stiffness is an independent predictor of incident HF in CKD, an association with strong biologic plausibility given the known effects of large artery stiffening of left ventricular pulsatile load.

Background: Low health literacy in the general population is associated with increased risk of death and hospitalization. The evaluation of health literacy in individuals with predialysis chronic kidney disease (CKD) is limited. Methods: We conducted a cross-sectional study to evaluate the associations of limited health literacy with kidney function and cardiovascular disease (CVD) risk factors in 2,340 non-Hispanic (NH) Whites and Blacks aged 21 – 74 years with mild-to-moderate CKD. Limited health literacy was defined as a Short Test of Functional Health Literacy in Adults (STOFHLA) score ≤ 22. Outcomes evaluated included estimated glomerular filtration rate (eGFR), 24-hour urine protein excretion, and CVD risk factors. Results: The prevalence of limited health literacy was 28% in NH-Blacks and 5% in NH-Whites. Compared with participants with adequate health literacy, those with limited health literacy were more likely to have lower eGFR (34 vs. 42 mL/min/1.73 m2); higher urine protein/24-hours (0.31 vs. 0.15 g); and higher self-reported CVD (61 vs. 37%); and were less likely to have BP < 130/80 mmHg (51 vs. 58%); p ≤ 0.01 for each comparison. After adjustment, limited health literacy was associated with self-reported CVD (OR 1.51, 95% CI 1.13 – 2.03) and lower eGFR (β –2.47, p = 0.03). Conclusion: In this CKD cohort, limited health literacy was highly prevalent, especially among NH-Blacks, and it was associated with lower eGFR and a less favorable CVD risk factor profile. Further studies are needed to better understand these associations and inform the development of health literacy interventions among individuals with CKD.

Background Depressive symptoms are correlated with poor health outcomes in adults with chronic kidney disease (CKD). The prevalence, severity, and treatment of depressive symptoms and potential risk factors, including level of kidney function, in diverse populations with CKD have not been well studied. Study Design Cross-sectional analysis Settings and Participants Participants at enrollment into the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC (H-CRIC) Studies. CRIC enrolled Hispanics and non-Hispanics at seven centers from 2003-2007, and H-CRIC enrolled Hispanics at the University of Illinois from 2005-2008. Measurement Depressive symptoms measured by Beck Depression Inventory (BDI) Predictors Demographic and clinical factors Outcomes Elevated depressive symptoms (BDI >= 11) and antidepressant medication use Results Among 3853 participants, 28.5% had evidence of elevated depressive symptoms and 18.2% were using antidepressant medications; 30.8% of persons with elevated depressive symptoms were using antidepressants. The prevalence of elevated depressive symptoms varied by level of kidney function: 25.2% among participants with eGFR ≥ 60 ml/min/1.73m2, and 35.1% of those with eGFR < 30 ml/min/1.73m2. Lower eGFR (OR per 10 ml/min/1.73m2 decrease, 1.09; 95% CI, 1.03-1.16), Hispanic ethnicity (OR, 1.65; 95% CI, 1.12-2.45), and non-Hispanic black race (OR, 1.43; 95% CI, 1.17-1.74) were each associated with increased odds of elevated depressive symptoms after controlling for other factors. In regression analyses incorporating BDI score, while female sex was associated with a greater odds of antidepressant use, Hispanic ethnicity, non-Hispanic black race, and higher levels of urine albumin were associated with decreased odds of antidepressant use (p<0.05 for each). Limitations Absence of clinical diagnosis of depression and use of non-pharmacologic treatments Conclusions Although elevated depressive symptoms were common in individuals with CKD, use of antidepressant medications is low. African Americans, Hispanics, and individuals with more advanced CKD had higher odds of elevated depressive symptoms and lower odds of antidepressant medication use.