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Risks of Adverse Events in Advanced CKD: The Chronic Renal Insufficiency Cohort (CRIC) Study
Morgan E Grams1, Wei Yang2, Casey M Rebholz3
1Division of Nephrology, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology & Clinical Research, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Insights
Outcomes for advanced chronic kidney disease (CKD) patients vary. Risk factors like age and blood pressure influence the timing of end-stage renal disease (ESRD), cardiovascular disease (CVD), and death, aiding personalized CKD management.
Area of Science:
- Nephrology
- Cardiology
- Public Health
Background:
- Advanced chronic kidney disease (CKD) patients face high risks for end-stage renal disease (ESRD), cardiovascular disease (CVD) events, and mortality.
- Understanding prognostic variability is crucial for patient counseling and medical decision-making.
Purpose of the Study:
- To identify risk factors influencing the prognosis and timing of adverse outcomes in patients with advanced CKD.
- To analyze the variability in progression to ESRD, CVD, and death.
Main Methods:
- Prospective cohort study of 1,798 participants with estimated glomerular filtration rates (eGFRs) < 30 mL/min/1.73 m² in the CRIC Study.
- Follow-up for a median of 5.5 years, assessing predictors including age, race, sex, eGFR, proteinuria, diabetes, BMI, ejection fraction, blood pressure, CVD history, and smoking history.
- Outcomes included ESRD, CVD events (heart failure, stroke, myocardial infarction, peripheral artery disease), and death.
Main Results:
- The cohort's average age was 60, with 46% women and 46% African American. Over half (52.3%) progressed to ESRD.
- Individual 1-year probabilities for CVD, ESRD, and death varied significantly based on patient characteristics (e.g., age, blood pressure, diabetes, CVD history).
- Development of ESRD or CVD independently increased subsequent mortality risk, irrespective of patient race or BMI.
Conclusions:
- Prognosis and outcome timing in advanced CKD are highly variable and influenced by individual patient characteristics.
- These findings support the development of personalized management strategies for advanced CKD patients.
- The CRIC cohort, recruited for kidney disease, predominantly saw nephrologists, highlighting a focused clinical context.
Background:
People with advanced chronic kidney disease are at risk for the development of end-stage renal disease (ESRD), but also many other adverse outcomes, including cardiovascular disease (CVD) events and death. Determination of risk factors that explain the variability in prognosis and timing of these adverse outcomes can aid patient counseling and medical decision making.
Study Design:
Prospective research cohort.
Setting & Participants:
1,798 participants with estimated glomerular filtration rates (eGFRs)<30mL/min/1.73m2 in the CRIC Study were followed up for a median of 5.5 years.
Predictors:
Age, race, sex, eGFR, proteinuria, diabetes mellitus, body mass index, ejection fraction, systolic blood pressure, history of CVD, and smoking history.
Outcomes:
ESRD, CVD (congestive heart failure, stroke, myocardial infarction, and peripheral artery disease), and death.
Results:
Baseline age of the cohort was 60 years, 46% were women, and 46% were African American. Although 52.3% of participants progressed to ESRD during follow-up, the path by which this occurred was variable. For example, predicted 1-year probabilities for a hypothetical 60-year-old white woman with eGFR of 30mL/min/1.73m2, urine protein excretion of 1.8g/d, and no diabetes or CVD (risk characteristics similar to the average participant) were 3.3%, 4.1%, and 0.3%, for first developing CVD, ESRD, and death, respectively. For a 40-year-old African American man with similar characteristics but higher systolic blood pressure, the corresponding 1-year probabilities were 2.4%, 13.2%, and 0.1%. For all participants, the development of ESRD or CVD increased the risk for subsequent mortality, with no differences by patient race or body mass index.
Limitations:
The CRIC population was specifically recruited for kidney disease, and the vast majority had seen a nephrologist.
Conclusions:
The prognosis and timing of adverse outcomes in chronic kidney disease vary by patient characteristics. These results may help guide the development of personalized approaches for managing patients with advanced CKD.