Rate of Change in Kidney Function and the Risk of Death: The Case for Incorporating the Rate of Kidney Function Decline into the CKD Staging System

Al‐Aly, Ziyad; Cepeda, Oscar A.

doi:10.1159/000324768

Cited by 8 publications

(5 citation statements)

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“…Most of the patients with CKD—even with grade 3a, 3b or 4—remain stable for many years. As such, the results of our study support the proposition of Al Aly and Cepeda that CKD should be defined in a dynamic way, taking into account the CKD grade and the decline of kidney function 21. More specifically, age and gender interact with CKD in their effect on severe decline: in patients with CKD, but not in patients without CKD, severe decline is more prevalent in younger patients and in men.…”

Section: Discussionsupporting

confidence: 85%

Long-term evolution of renal function in patients with type 2 diabetes mellitus: a registry-based retrospective cohort study

et al. 2013

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ObjectivesTo picture the 10-year evolution of renal function in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) and to describe the risk factors for severe decline.SettingPrimary registration network with 97 general practitioners working in 55 practices sending routinely collected patient data.ParticipantsFrom the database, we selected all patients aged 40 years or older with T2DM and at least two creatinine measurements in two different years with an interval of at least 3 months. Based on the last available value of estimated glomerular filtration rate calculated by the modification of diet in renal disease (MDRD) equation, patients were divided into grades of CKD. Severe decline (decline of >4 mL/min/year) and ‘certain drop’ (CD, year-to-year decline >10 mL/min) were determined in patients with CKD. Determinants of severe decline and CD were investigated with logistic regression and longitudinal logistic regression analysis, respectively.Primary outcome measureKidney function (MDRD).Results4041 patients, 1980 women, were included. The mean age was 71 years, mean diabetes duration was 7.7 years; 1514 (38%) suffered from CKD, 231 (15%) presented with severe decline and 18% of the patients with CKD presented with two or more CDs. Younger age, male gender, mean glycated haemoglobin and a higher number of CDs were significantly associated with the presence of severe decline (p<0.05); statins and higher diastolic blood pressure were significantly associated with the absence of severe decline (p<0.001). ACE inhibitors, other antihypertensive drugs and antidiabetic drugs including insulin therapy were specific determinants of CD.ConclusionsCKD is highly prevalent in patients with T2DM; a minority of patients evolve into severe decline that is associated with younger age, male gender, ‘CD’ and manageable factors such as blood pressure, blood glucose, associated drugs prescriptions and statin therapy. Further prospective observational and experimental research is needed to clarify the nature of those associations.

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Section: Discussionsupporting

confidence: 85%

Long-term evolution of renal function in patients with type 2 diabetes mellitus: a registry-based retrospective cohort study

et al. 2013

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“…eGFR variability may be difficult to compute; however, similar to the automation of eGFR reporting that is now part of numerous electronic health records software, longitudinal measures of kidney function (eGFR slope and eGFR variability) may also be automated. 16 This study has the following limitations. The cohort included mostly white men, and thus the results may not be generalizable to less narrowly defined populations.…”

Section: Discussionmentioning

confidence: 96%

Greater variability in kidney function is associated with an increased risk of death

Al‐Aly¹,

Balasubramanian²,

McDonald

et al. 2012

Kidney International

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Intra-individual variability in kidney function is a common phenomenon; however, predictors of kidney function variability and its prognostic significance are not known. To examine this question, we assembled a cohort of 51,304 US veterans with an estimated glomerular filtration rate (eGFR) <60 ml/min at the end of the study period and who had at least two eGFR measurements during the previous 3 years. Variability in kidney function was defined for each patient as the coefficient of variation of the regression line fitted to all outpatient measures of eGFR during this time frame. In adjusted analyses, blacks, women, and those with Current Procedural Terminology and ICD-9-CM diagnostic codes for hypertension, diabetes, cardiovascular disease, peripheral artery disease, chronic lung disease, hepatitis C, dementia, acute kidney injury, and those with a greater number of hospitalizations had greater variability in eGFR. After a median follow-up of 4.9 years, there were 23.66%, 25.68%, and 31.23% deaths among patients in the lowest, intermediate, and highest tertiles of eGFR variability, respectively. Compared with the referent (those in the lowest tertile), patients in the highest tertile had a significantly increased risk of death with a hazard ratio of 1.34 (1.28-1.40), an association consistently present in all sensitivity analyses. Thus, our results demonstrate that greater variability in kidney function is independently associated with increased risk of death.

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“…The rate of eGFR decline varies at the individual patient level, and much is known about individual risk factors associated with rapid kidney function decline. 14 , 15 The prevalence of rapid eGFR decline might also vary by geography; however, the spatial epidemiology of longitudinal changes in kidney function including rate of eGFR decline and of particular interest rapid eGFR decline has not been characterized. Furthermore, although geographic attributes of pre-ESRD nephrology care have been described, data on the relationship between geographic attributes, social, economic, physical and environmental conditions of communities, and rate of kidney function decline are lacking.…”

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confidence: 99%

Geographic Variation and US County Characteristics Associated With Rapid Kidney Function Decline

Bowe

Xie

Xian

et al. 2017

Kidney International Reports

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IntroductionGeographic variation in the prevalence of chronic kidney disease and incidence of end-stage renal disease has been previously reported. However, the geographic epidemiology of rapid estimated glomerular filtration rate (eGFR) decline has not been examined.MethodsWe built a longitudinal cohort of 2,107,570 US veterans to characterize the spatial epidemiology of and examine the associations between US county characteristics and rapid eGFR decline.ResultsThere were 169,029 (8.02%) with rapid eGFR decline (defined as eGFR slope < –5 ml/min per 1.73 m2/year). The prevalence of rapid eGFR decline adjusted for age, race, gender, diabetes, and hypertension varied by county from 4.10%–6.72% in the lowest prevalence quintile to 8.41%–22.04% in the highest prevalence quintile (P for heterogeneity < 0.001). Examination of adjusted prevalence showed substantial geographic variation in those with and without diabetes and those with and without hypertension (P for heterogeneity < 0.001). Cohort participants had higher odds of rapid eGFR decline when living in counties with unfavorable characteristics in domains including health outcomes (odds ratio [OR] = 1.15; confidence interval [CI] = 1.09–1.22), health behaviors (OR = 1.08; CI = 1.03–1.13), clinical care (OR = 1.11; CI = 1.06–1.16), socioeconomic conditions (OR = 1.15; CI = 1.09–1.22), and physical environment (OR = 1.15; CI = 1.01–1.20); living in counties with high percentage of minorities and immigrants was associated with rapid eGFR decline (OR = 1.25; CI = 1.20–1.31). Spatial analyses suggest the presence of cluster of counties with high prevalence of rapid eGFR decline.DiscussionOur findings show substantial geographic variation in rapid eGFR decline among US veterans; the variation persists in analyses stratified by diabetes and hypertension status; results show associations between US county characteristics in domains capturing health, socioeconomic, environmental, and diversity conditions, and rapid eGFR decline.

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Rate of Change in Kidney Function and the Risk of Death: The Case for Incorporating the Rate of Kidney Function Decline into the CKD Staging System

Cited by 8 publications

References 93 publications

Long-term evolution of renal function in patients with type 2 diabetes mellitus: a registry-based retrospective cohort study

Long-term evolution of renal function in patients with type 2 diabetes mellitus: a registry-based retrospective cohort study

Greater variability in kidney function is associated with an increased risk of death

Geographic Variation and US County Characteristics Associated With Rapid Kidney Function Decline

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