Elsevier

The Lancet

Volume 380, Issue 9854, 10–16 November 2012, Pages 1662-1673
The Lancet

Articles
Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis

https://doi.org/10.1016/S0140-6736(12)61350-6Get rights and content

Summary

Background

Chronic kidney disease is characterised by low estimated glomerular filtration rate (eGFR) and high albuminuria, and is associated with adverse outcomes. Whether these risks are modified by diabetes is unknown.

Methods

We did a meta-analysis of studies selected according to Chronic Kidney Disease Prognosis Consortium criteria. Data transfer and analyses were done between March, 2011, and June, 2012. We used Cox proportional hazards models to estimate the hazard ratios (HR) of mortality and end-stage renal disease (ESRD) associated with eGFR and albuminuria in individuals with and without diabetes.

Findings

We analysed data for 1 024 977 participants (128 505 with diabetes) from 30 general population and high-risk cardiovascular cohorts and 13 chronic kidney disease cohorts. In the combined general population and high-risk cohorts with data for all-cause mortality, 75 306 deaths occurred during a mean follow-up of 8·5 years (SD 5·0). In the 23 studies with data for cardiovascular mortality, 21 237 deaths occurred from cardiovascular disease during a mean follow-up of 9·2 years (SD 4·9). In the general and high-risk cohorts, mortality risks were 1·2–1·9 times higher for participants with diabetes than for those without diabetes across the ranges of eGFR and albumin-to-creatinine ratio (ACR). With fixed eGFR and ACR reference points in the diabetes and no diabetes groups, HR of mortality outcomes according to lower eGFR and higher ACR were much the same in participants with and without diabetes (eg, for all-cause mortality at eGFR 45 mL/min per 1·73 m2 [vs 95 mL/min per 1·73 m2], HR 1·35; 95% CI 1·18–1·55; vs 1·33; 1·19–1·48 and at ACR 30 mg/g [vs 5 mg/g], 1·50; 1·35–1·65 vs 1·52; 1·38–1·67). The overall interactions were not significant. We identified much the same findings for ESRD in the chronic kidney disease cohorts.

Interpretation

Despite higher risks for mortality and ESRD in diabetes, the relative risks of these outcomes by eGFR and ACR are much the same irrespective of the presence or absence of diabetes, emphasising the importance of kidney disease as a predictor of clinical outcomes.

Funding

US National Kidney Foundation.

Introduction

Chronic kidney disease is a global public health problem,1, 2 affecting 10–16% of the adult population worldwide.3, 4, 5, 6, 7, 8 Decreased estimated glomerular filtration rate (eGFR) and increased urinary albumin excretion predict the major health outcomes of this disorder, including end-stage renal disease (ESRD) and death, across a wide range of settings.9, 10, 11, 12, 13 Whether these associations are consistent across diseases or are differentially modified by the presence or absence of a particular disease or condition is uncertain.

Diabetes is the leading cause of chronic kidney disease in the developed world,14, 15 and people with diabetes and chronic kidney disease have a greatly increased risk of all-cause mortality, cardiovascular mortality, and kidney failure. We did a meta-analysis to assess whether the associations between eGFR, albuminuria, and mortality and kidney outcomes are the same in individuals with and without diabetes.

Section snippets

Study selection criteria

Sources of data for the Chronic Kidney Disease Prognosis Consortium are described elsewhere.9, 10, 11, 12, 16 Briefly, we included studies that had at least 1000 participants (not applied to studies that predominantly included patients with chronic kidney disease), baseline information about eGFR and albuminuria, and at least 50 events for each outcome of interest. We restricted our analyses to participants aged at least 18 years. Sample size varies slightly compared with our accompanying

Results

Table 1 and appendix pp 1–3 show baseline characteristics from individual studies. 1 024 977 participants were included, of whom 128 505 (13%) had diabetes. Participants with diabetes were generally older than those without diabetes and had a higher prevalence of hypertension, hypercholesterolaemia, and cardiovascular disease.

In the 30 combined general population and high-risk cohorts with data for all-cause mortality, 75 306 deaths occurred during a mean follow-up of 8·5 years (SD 5·0). In the

Discussion

Individuals with diabetes have a higher risk of all-cause and cardiovascular mortality than do those without diabetes across the range of eGFR and ACR. However, relative risks of these health outcomes according to measures of kidney disease are much the same in individuals with and without diabetes. The use of clinically relevant cutoff points showed the importance of both eGFR and ACR with respect to each of these outcomes. When we did similar analyses for ESRD in chronic kidney disease

References (34)

  • SJ Chadban et al.

    Prevalence of kidney damage in Australian adults: the AusDiab kidney study

    J Am Soc Nephrol

    (2003)
  • J Coresh et al.

    Prevalence of chronic kidney disease in the United States

    JAMA

    (2007)
  • K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification

    Am J Kidney Dis

    (2002)
  • K Matsushita et al.

    Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis

    Lancet

    (2010)
  • M Tonelli et al.

    Using proteinuria and estimated glomerular filtration rate to classify risk in patients with chronic kidney disease: a cohort study

    Ann Intern Med

    (2011)
  • CS Fox et al.

    Predictors of new-onset kidney disease in a community-based population

    JAMA

    (2004)
  • USRDS 2011 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States

    (2011)
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