Elsevier

Atherosclerosis

Volume 211, Issue 1, July 2010, Pages 342-347
Atherosclerosis

Prognostic value of chronic kidney disease in patients with coronary heart disease: Role of estimating equations

https://doi.org/10.1016/j.atherosclerosis.2010.02.028Get rights and content

Abstract

Objective

Chronic kidney disease (CKD) increases risk of coronary heart disease (CHD), but the impact of using different equations for estimating kidney function on CHD is not clear yet. This study described the prognostic value of CKD as defined by various creatinine- (Cr-eGFR) and cystatin C-based estimating (Cys-eGFR) equations and their combinations on subsequent cardiovascular disease (CVD) events in patients with CHD.

Setting

Patients with coronary heart disease in in-patient rehabilitation and long-term follow-up (mean 63.4 months).

Subjects

1050 patients with coronary heart disease aged 30–70 years at baseline.

Methods

CKD was defined as eGFR < 60 mL/min/1.73 m2 (CKD stages 3–5) estimated by three Cr-eGFR equations (Cockroft–Gault equation adjusted for body surface area (CG/BSA), Modification of Diet in Renal Disease Study (MDRD) equation, CKD-EPIcrea) and by two Cys-eGFR equations (Arnal-Dade equation, CKD-EPIcys) and a combination. The primary endpoint of our study was subsequent CVD events.

Results

During follow-up 118 patients (11.2%) experienced the outcome of our study. CKD assessed by the CG/BSA, MDRD, and CKD-EPIcrea equations showed no statistically significant association with subsequent CVD events after adjustment for multiple covariates (hazard ratio (HR) 1.45 [95% CI, 0.81–2.59], HR 1.47 [95% CI, 0.84–2.60], and HR 1.31 [95% CI, 0.72–2.83], respectively). By contrast, the Cys-eGFR equations were much stronger associated with subsequent CVD endpoints (Arnal-Dade: HR, 2.01 [95% CI, 1.34–3.04]; CKD-EPIcys HR, 2.22 [95% CI, 1.46–3.37]). The CKD-EPIcys also provided the highest area under the curve value.

Conclusion

Our study shows that prevalent CKD is an independent risk factor for subsequent CVD in patients with prevalent CHD and implies that Cys-eGFR equations show a better clinical utility compared to the Cr-eGFR equations.

Introduction

Chronic kidney disease (CKD) is an independent risk factor for coronary heart disease (CHD) and CHD is a major cause of mortality in patients with CKD [1]. The development or progression of CKD might be the consequence of CVD risk factors and vice versa. Accurate assessment of kidney function by estimated glomerular filtration rate (eGFR) is important in early detecting subjects with CKD and subsequently preventing complications of decreased kidney function. The complications include not only progression to end-stage renal disease (ESRD), but also complications such as hypertension, anemia, bone-metabolic disorders, and an increased risk for infections and cancer [2].

Performance of serum creatinine-based equations for eGFR (Cr-eGFR equations), especially the Cockroft–Gault equation adjusted for body surface area (CG/BSA) and the simplified Modification of Diet in Renal Disease Study (MDRD) equation [3], has been widely used and discussed in the literature, but their validity among patients with CHD remains unclear [4]. Cystatin C (CysC) is emerging as a promising biomarker for the assessment of kidney function [5]. In an earlier work, CysC levels in serum have been found as a useful clinical marker providing complementary prognostic information in patients with CHD [6]. Although several cystatin C-based equations for eGFR (Cys-eGFR equations) have been suggested for eGFR [7], current evidence is too limited to favor one estimating equation. In addition, data comparing the clinical utility to Cr-eGFR equations in high risk groups are rare.

The objective of this analysis was to compare the prevalence of CKD by means of Cr-eGFR and Cys-eGFR equations and to evaluate their prognostic value in a high risk group of patients with prevalent CHD at baseline.

Section snippets

Study population

All patients with CHD (International Classification of Disease, 9th revision [ICD-9], codes 410-414), aged 30–70 years and participating in an in-hospital rehabilitation program between January 1999 and May 2000 in two cooperating hospitals (Schwabenland-Klinik, Isny, and Klinik im Südpark, Bad Nauheim, Germany) were enrolled in the study (initial response 58%). In Germany, all patients after acute coronary syndrome (ACS) or coronary artery revascularization are offered a comprehensive

Results

Overall, 1206 patients with a diagnosis of CHD within the past 3 months were included at baseline during the in-hospital rehabilitation program. Six-year follow-up information was complete for 1050 patients (87.1%).

The main characteristics of the study population are shown in Table 1. The mean age of the study population was 58.9 years, most of the patients were male (85.0%). A history of high blood pressure and diabetes was reported by 55.4% and 17.2%, respectively. Mean Cr was 0.97 mg/dL (SD

Discussion

In this prospective cohort study comprising 1050 patients with prevalent CHD, we found a strong association of prevalent CKD with subsequent CVD during follow-up when using the Cys-eGFR based equations which was strongest with the cystatin C-based CKD-EPIcys equation. Therefore, compared to the Cr-eGFR equations, the Cys-eGFR based equations seem to have better clinical utility for identifying patients at high risk for subsequent CVD and might therefore be more helpful in improving risk

Acknowledgements

Dade Behring provided the reagents for cystatin C measurement. We thank Gerlinde Trischler for excellent technical assistance. We also thank Dr. Lutz Philipp Breitling for his helpful comments and advice. The graduation program (Graduiertenkolleg 793) of the German Research Foundation (DFG) funded the writing of this paper. All authors have no financial conflict of interest. This cohort study was supported by grants from the German Ministry of Education and Research (Grant 01GD9820/0), the

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