Elsevier

The Lancet

Volume 380, Issue 9844, 1–7 September 2012, Pages 807-814
The Lancet

Articles
Risk of coronary events in people with chronic kidney disease compared with those with diabetes: a population-level cohort study

https://doi.org/10.1016/S0140-6736(12)60572-8Get rights and content

Summary

Background

Diabetes is regarded as a coronary heart disease risk equivalent—ie, people with the disorder have a risk of coronary events similar to those with previous myocardial infarction. We assessed whether chronic kidney disease should be regarded as a coronary heart disease risk equivalent.

Methods

We studied a population-based cohort with measures of estimated glomerular filtration rate (eGFR) and proteinuria from Alberta, Canada. We used validated algorithms based on hospital admission and medical-claim data to classify participants with baseline history of myocardial infarction or diabetes and to ascertain which patients were admitted to hospital for myocardial infarction during follow-up (the primary outcome). For our primary analysis, we defined baseline chronic kidney disease as eGFR 15–59·9 mL/min per 1·73 m2 (stage 3 or 4 disease). We used Poisson regression to calculate unadjusted rates and relative rates of myocardial infarction during follow-up for five risk groups: people with previous myocardial infarction (with or without diabetes or chronic kidney disease), and (of those without previous myocardial infarction), four mutually exclusive groups defined by the presence or absence of diabetes and chronic kidney disease.

Findings

During a median follow-up of 48 months (IQR 25–65), 11 340 of 1 268 029 participants (1%) were admitted to hospital with myocardial infarction. The unadjusted rate of myocardial infarction was highest in people with previous myocardial infarction (18·5 per 1000 person-years, 95% CI 17·4–19·8). In people without previous myocardial infarction, the rate of myocardial infarction was lower in those with diabetes (without chronic kidney disease) than in those with chronic kidney disease (without diabetes; 5·4 per 1000 person-years, 5·2–5·7, vs 6·9 per 1000 person-years, 6·6–7·2; p<0·0001). The rate of incident myocardial infarction in people with diabetes was substantially lower than for those with chronic kidney disease when defined by eGFR of less than 45 mL/min per 1·73 m2 and severely increased proteinuria (6·6 per 1000 person-years, 6·4–6·9 vs 12·4 per 1000 person-years, 9·7–15·9).

Interpretation

Our findings suggest that chronic kidney disease could be added to the list of criteria defining people at highest risk of future coronary events.

Funding

Alberta Heritage Foundation for Medical Research.

Introduction

Guidelines for lipid-lowering treatment mainly base initiation of treatment and therapeutic goals for LDL cholesterol on projected risk of coronary heart disease events. The US National Cholesterol Education Program Adult Treatment Panel III (ATP III) recommends that LDL cholesterol be reduced to lower than 2·6 mmol/L in patients with coronary heart disease or an equivalent disorder.1 The term coronary heart disease risk equivalent refers to a characteristic that leads to a 10-year risk of coronary death or myocardial infarction that is equivalent to the risk associated with previous myocardial infarction (generally >20% risk).2

ATP III guidelines classify diabetes as a coronary heart disease risk equivalent, partly because data show that people with diabetes are at very high risk of cardiovascular events.3 An expert panel has suggested that chronic kidney disease should also be regarded as a coronary heart disease risk equivalent.4 People with chronic kidney disease have high rates of cardiovascular events, particularly when proteinuria is present.5, 6 However, whether chronic kidney disease constitutes a coronary heart disease risk equivalent (compared with accepted criteria such as diabetes)—especially when proteinuria is included in the definition of chronic kidney disease—is unknown.

We used data from a large population-based cohort to examine the risk of hospital admission for myocardial infarction in people with previous myocardial infarction, diabetes mellitus, or chronic kidney disease compared with people without these disorders. We aimed to assess the merits of chronic kidney disease (with and without proteinuria) as a coronary heart disease risk equivalent.

Section snippets

Data sources and cohort

We did this study using two datasets: the Alberta Kidney Disease Network (AKDN) database7 and the National Health and Nutrition Examination Survey (NHANES) 2003–068 (appendix). We used the AKDN database7—a selection of routine laboratory data from all patients in Alberta, Canada—to estimate risk of hospital admission for myocardial infarction, and a secondary outcome of all-cause death in individuals with previous myocardial infarction, diabetes, or chronic kidney disease. We identified adults

Results

Table 1 shows baseline characteristics of the 1 268 029 participants who met the inclusion criteria in each risk group. Participants with previous myocardial infarction or chronic kidney disease were substantially older than were those with diabetes (table 1). During median follow-up of 48 months (IQR 25–65), 11 340 (1%) participants were admitted to hospital with myocardial infarction, and 47 712 (4%) died.

The unadjusted rate of myocardial infarction during follow-up was higher in people with

Discussion

In this population-based cohort of nearly 1·3 million people, the unadjusted rate of hospital admission for myocardial infarction during follow-up was substantially lower for people with diabetes or chronic kidney disease than for those with a history of myocardial infarction. However, the rate of first myocardial infarction during follow-up was slightly higher in those with chronic kidney disease (but without diabetes) than in those with diabetes (without chronic kidney disease), especially

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