Identification and outcomes of KDIGO-defined chronic kidney disease in 1.4 million U.S. Veterans with heart failure

Abstract: Aims: According to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline, the definition of chronic kidney disease (CKD) requires the presence of abnormal kidney structure or function for >3 months with implications for health. CKD in patients with heart failure (HF) has not been defined using this definition, and less is known about the true health implications of CKD in these patients. The objective of the current study was to identify patients with HF who met KDIGO criteria for CKD and examine their outcomes. Methods and Results: Of the 1 419 729 Veterans with HF not receiving kidney replacement therapy, 828 744 had data on ≥2 ambulatory serum creatinine >90 days apart. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 (n = 185 821) or urinary albumin‐to‐creatinine ratio (uACR) >30 mg/g (n = 32 730) present twice >3 months apart. Normal kidney function (NKF) was defined as eGFR ≥60 ml/min/1.73 m2, present for >3 months, without any uACR >30 mg/g (n = 365 963). Patients with eGFR <60 ml/min/1.73 m2 were categorized into four stages: 45–59 (n = 72 606), 30–44 (n = 74 812), 15–29 (n = 32 077), and <15 (n = 6326) ml/min/1.73 m2. Five‐year all‐cause mortality occurred in 40.4%, 57.8%, 65.6%, 73.3%, 69.7%, and 47.5% of patients with NKF, four eGFR stages, and uACR >30mg/g (albuminuria), respectively. Compared with NKF, hazard ratios (HR) (95% confidence intervals [CI]) for all‐cause mortality associated with the four eGFR stages and albuminuria were 1.63 (1.62–1.65), 2.00 (1.98–2.02), 2.49 (2.45–2.52), 2.28 (2.21–2.35), and 1.22 (1.20–1.24), respectively. Respective age‐adjusted HRs (95% CIs) were 1.13 (1.12–1.14), 1.36 (1.34–1.37), 1.87 (1.84–1.89), 2.24 (2.18–2.31) and 1.19 (1.17–1.21), and multivariable‐adjusted HRs (95% CIs) were 1.11 (1.10–1.12), 1.24 (1.22–1.25), 1.46 (1.43–1.48), 1.42 (1.38–1.47), and 1.13 (1.11–1.16). Similar patterns were observed for associations with hospitalizations. Conclusion: Data needed to define CKD using KDIGO criteria were available in six out of ten patients, and CKD could be defined in seven out of ten patients with data. HF patients with KDIGO‐defined CKD had higher risks for poor outcomes, most of which was not explained by abnormal kidney structure or function. Future studies need to examine whether CKD defined using a single eGFR is characteristically and prognostically different from CKD defined using KDIGO criteria.

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