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The Risk of Major Hemorrhage with CKD
Amber O Molnar1, Sarah E Bota2, Amit X Garg3
1Division of Nephrology, McMaster University, Hamilton, Ontario, Canada; Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada;
Insights
Declining kidney function (eGFR) and increased albuminuria independently raise hemorrhage risk in adults over 40. Higher albuminuria significantly amplifies this risk, especially in advanced chronic kidney disease (CKD).
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Clinical Epidemiology
Background:
- Chronic kidney disease (CKD) staging incorporates estimated glomerular filtration rate (eGFR) and albuminuria.
- The independent association of eGFR and albuminuria with hemorrhage risk is not well-defined.
Purpose of the Study:
- To investigate the independent and combined associations of eGFR and urine albumin-to-creatinine ratio (ACR) with hemorrhage risk in adults.
Main Methods:
- Retrospective cohort study of 516,197 adults (≥40 years) from 2002-2010.
- Patients were grouped by eGFR and ACR levels to assess 3-year cumulative incidence of hemorrhage.
- Adjusted models examined relative risks, considering anticoagulant and antiplatelet use in older adults.
Main Results:
- Hemorrhage incidence increased 20-fold across declining eGFR and increasing ACR categories.
- Higher ACR significantly amplified hemorrhage risk associated with reduced eGFR.
- Even with high eGFR, elevated ACR was linked to increased hemorrhage risk.
Conclusions:
- Both reduced eGFR and increased albuminuria are independent risk factors for hemorrhage.
- Urine ACR modifies the association between eGFR and hemorrhage risk.
- Strategies to mitigate hemorrhage events in CKD patients are essential.
Abstract:
New staging systems for CKD account for both reduced eGFR and albuminuria; whether each measure associates with greater risk of hemorrhage is unclear. In this retrospective cohort study (2002-2010), we grouped 516,197 adults ≥40 years old by eGFR (≥90, 60 to <90, 45 to <60, 30 to <45, 15 to <30, or <15 ml/min per 1.73 m(2)) and urine albumin-to-creatinine ratio (ACR; >300, 30-300, or <30 mg/g) to examine incidence of hemorrhage. The 3-year cumulative incidence of hemorrhage increased 20-fold across declining eGFR and increasing urine ACR groupings (highest eGFR/lowest ACR: 0.5%; lowest eGFR/highest ACR: 10.1%). Urine ACR altered the association of eGFR with hemorrhage (P<0.001). In adjusted models using the highest eGFR/lowest ACR grouping as the referent, patients with eGFR=15 to <30 ml/min per 1.73 m(2) had adjusted relative risks of hemorrhage of 1.9 (95% confidence interval [95% CI], 1.5 to 2.4) with the lowest ACR and 3.7 (95% CI, 3.0 to 4.5) with the highest ACR. Patients with the highest eGFR/highest ACR had an adjusted relative risk of hemorrhage of 2.3 (95% CI, 1.8 to 2.9), comparable with the risk for patients with the lowest eGFR/lowest ACR. The associations attenuated but remained significant after adjustment for anticoagulant and antiplatelet use in patients ≥66 years old. The risk of hemorrhage differed by urine ACR in high risk subgroups. Our data show that declining eGFR and increasing albuminuria each independently increase hemorrhage risk. Strategies to reduce hemorrhage events among patients with CKD are warranted.
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