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ESRD After Heart Failure, Myocardial Infarction, or Stroke in Type 2 Diabetic Patients With CKD
David M Charytan1, Scott D Solomon2, Peter Ivanovich3
1Renal Division, Department of Medicine, Brigham & Women's Hospital, Boston, MA.
Insights
Cardiovascular events, especially heart failure, significantly increase the risk of end-stage renal disease (ESRD) in patients with type 2 diabetes. However, most ESRD cases occur without preceding cardiovascular events, with similar post-ESRD mortality.
Area of Science:
- Nephrology
- Cardiology
- Diabetology
Background:
- The impact of cardiovascular (CV) events on the progression to end-stage renal disease (ESRD) in type 2 diabetes patients is not fully understood.
- Understanding this relationship is crucial for developing targeted interventions.
Purpose of the Study:
- To investigate the association between postrandomization cardiovascular events and the risk of developing ESRD.
- To analyze the characteristics of patients who develop ESRD following a cardiovascular event.
Main Methods:
- An observational study analyzing data from 4,022 patients with type 2 diabetes, anemia, and chronic kidney disease from the TREAT trial.
- Examined the incidence of ESRD and post-ESRD mortality following intercurrent cardiovascular events (e.g., heart failure, myocardial infarction, stroke).
Main Results:
- 23.8% of ESRD cases occurred after a cardiovascular event, with heart failure being the most common preceding event (16.9%).
- The ESRD rate was significantly higher within 30 days following a CV event (HR, 22.2).
- Patients developing ESRD post-CV event were older, had more prior CV disease, and higher baseline estimated glomerular filtration rates (eGFRs).
Conclusions:
- Intercurrent cardiovascular events, particularly heart failure, are strongly linked to an increased risk of ESRD in this population.
- Despite this association, most ESRD cases occurred in patients without preceding CV events.
- The findings highlight the need for kidney-specific therapies alongside cardiovascular risk factor management to reduce ESRD incidence in diabetes.
Background:
How cardiovascular (CV) events affect progression to end-stage renal disease (ESRD), particularly in the setting of type 2 diabetes, remains uncertain.
Study Design:
Observational study.
Setting & Participants:
4,022 patients with type 2 diabetes, anemia, and chronic kidney disease from the Trial to Reduce Cardiovascular Events With Aranesp Therapy (TREAT).
Predictor:
Postrandomization CV events.
Outcomes:
ESRD (defined as initiation of dialysis for >30 days, kidney transplantation, or refusal or nonavailability of renal replacement therapy) and post-ESRD mortality within 30 days and during overall follow-up after an intercurrent CV event.
Limitations:
Population limited to clinical trial participants with diabetes and anemia.
Results:
155 of 652 (23.8%) ESRD cases occurred after an intercurrent CV event; 110 (16.9%) cases followed heart failure, 28 (4.3%) followed myocardial infarction, 12 (1.84%) followed stroke, and 5 (0.77%) followed multiple CV events. ESRD rate was higher within 30 days in individuals with an intercurrent CV event compared with those without an intercurrent event (HR, 22.2; 95% CI, 17.0-29.0). Compared to no intercurrent CV events, relative risks for ESRD were higher after the occurrence of heart failure overall (HR, 3.4; 95% CI, 2.7-4.2) and at 30 days (HR, 20.1; 95% CI, 14.5-27.9) than after myocardial infarction or stroke (P<0.001). Compared with individuals without pre-ESRD events, those with ESRD following intercurrent CV events were older, were more likely to have prior CV disease, and had higher (24.4 vs 23.1mL/min/1.73m2; P=0.01) baseline estimated glomerular filtration rates (eGFRs) and higher eGFRs at last measurement before ESRD (18.6 vs 15.2mL/min/1.73m2; P<0.001), whereas race, sex, and medication use were similar. Post-ESRD mortality was similar (P=0.3) with and without preceding CV events.
Conclusions:
Most ESRD cases occurred in individuals without intercurrent CV events who had lower eGFRs than individuals with intercurrent CV events, but similar post-ESRD mortality. Nevertheless, intercurrent CV events, particularly heart failure, are strongly associated with risk for ESRD. These findings underscore the need for kidney-specific therapies in addition to treatment of CV risk factors to lower ESRD incidence in diabetes.
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