Risk of end-stage renal disease and death after cardiovascular events in chronic kidney disease.

BACKGROUND Patients with chronic kidney disease stages 3 to 5 (glomerular filtration rate <60 mL/min/1.73m(2)) are at increased risk of cardiovascular (CV) disease when compared with patients with less severe chronic kidney disease. How CV events modify the subsequent risk of progression to end-stage-renal disease (ESRD) or all-cause mortality (ACM) before ESRD is not well known. METHODS AND RESULTS This retrospective cohort study involved 2964 chronic kidney disease subjects referred between January 2001 and December 2008 to the nephrology clinic at Sunnybrook Health Sciences Center, Toronto, Ontario. Interim CV events (heart failure, myocardial infarction, and stroke), ESRD, and ACM were ascertained from administrative data. Over a median follow-up time of 2.76 years (interquartile range, 1.45-4.62), 447 (15%) subjects had a CV event. In the same time period, 318 (11%) developed ESRD, and 446 (15%) experienced ACM before ESRD (156 [5%] from a CV and 290 [10%] from a non-CV-related cause). When analyzed as a time-dependent variable, an interim CV event was associated with a higher risk of subsequent ESRD (hazard ratio, 5.33; 95% confidence interval, 3.74-7.58) and ACM before ESRD (hazard ratio, 4.15, hazard ratio, 3.30-5.23). The hazard ratio for CV-related death versus non-CV-related death before ESRD was 12.38 (95% confidence interval, 8.30-18.45) versus 2.13 (95% confidence interval, 1.57-2.87). CONCLUSIONS CV events are common in patients with chronic kidney disease stages 3 to 5 and are associated with a substantial increase in the risk of ESRD and ACM before ESRD. Intensive primary and secondary prevention strategies may help attenuate this risk.