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The relationship between shrunken pore syndrome and all-cause mortality in people with type 2 diabetes and normal
David G Bruce1, Wendy A Davis1, S A Paul Chubb1
1Medical School, University of Western Australia, Fremantle, WA, Australia.
Aims/Hypothesis:
Estimated GFRs utilising creatinine- (eGFRcreat) or cystatin C-based (eGFRcyst) equations can generate discrepant results that are associated with clinical outcomes. A low eGFRcyst/eGFRcreat ratio (<0.60), reflecting a pathological glomerular state termed shrunken pore syndrome (SPS), has been associated with excess mortality in some clinical situations including diabetes. The aim of the present study was to explore this association in a longitudinal observational study of type 2 diabetes with special reference to participants with normal renal function.
Methods:
Of 1481 Fremantle Diabetes Study Phase II participants with type 2 diabetes, aged ≥17 years, 1466 had eGFRcreat and eGFRcyst assessed as part of the baseline assessment and were followed for 10 years or until death, whichever came first. Cox regression modelling was used to determine independent associates of death excluding eGFR; eGFRcyst/eGFRcreat ratio was then added to this model separately as a categorical or continuous variable. These analyses were also conducted in a subgroup (n=754) of participants with normal renal function (eGFRcreat ≥60 ml/min per 1.73 m2 and urinary albumin/creatinine ratio <3 mg/mmol) at baseline.
Results:
At entry, the participants had a mean age of 65.9 years, 51.8% were male, the median diabetes duration was 9.0 years and 10.4% had eGFRcyst/eGFRcreat ratio <0.60 (the definition of SPS). There were 384 deaths (26.2%) during follow-up. The eGFRcyst/eGFRcreat ratio was independently, significantly and negatively associated with death (adjusted HR [95% CI] 0.91 [0.85, 0.97] for an increase of 0.1, p=0.004). Of eGFRcyst/eGFRcreat ratio categories, only <0.60 added significantly to the most parsimonious Cox model of time to death (HR [95% CI] 1.56 [1.07, 2.29], p=0.021). In those with normal renal function, 123 (16.3%) died during follow-up. An eGFRcyst/eGFRcreat ratio <0.60, observed in 57 (7.6%), was also independently associated with mortality (HR [95% CI] 2.55 [1.34, 4.84], p=0.004).
Conclusions/Interpretation:
A low eGFRcyst/eGFRcreat ratio is independently associated with mortality in type 2 diabetes, including in people without conventional markers of diabetic kidney disease. The presence of SPS may add clinical value to the risk assessment of people with type 2 diabetes regardless of renal status.
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