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. 2016 Feb;91(2):196-207.
doi: 10.1016/j.mayocp.2015.10.026.

Association of Slopes of Estimated Glomerular Filtration Rate With Post-End-Stage Renal Disease Mortality in Patients With Advanced Chronic Kidney Disease Transitioning to Dialysis

Keiichi Sumida  1 , Miklos Z Molnar  1 , Praveen K Potukuchi  1 , Fridtjof Thomas  1 , Jun Ling Lu  1 , Jennie Jing  2 , Vanessa A Ravel  2 , Melissa Soohoo  2 , Connie M Rhee  2 , Elani Streja  2 , Kamyar Kalantar-Zadeh  3 , Csaba P Kovesdy  4
Affiliations

Association of Slopes of Estimated Glomerular Filtration Rate With Post-End-Stage Renal Disease Mortality in Patients With Advanced Chronic Kidney Disease Transitioning to Dialysis

Keiichi Sumida et al. Mayo Clin Proc. 2016 Feb.

Abstract

Objective: To investigate the association of estimated glomerular filtration rate (eGFR) slopes before dialysis initiation with cause-specific mortality after dialysis initiation.

Patients and methods: In this retrospective cohort study of 18,874 US veterans who had transitioned to dialysis from October 1, 2007, through September 30, 2011, we examined the association of pre-end-stage renal disease (ESRD) eGFR slopes with all-cause, cardiovascular, and infection-related mortality during the post-ESRD period over a median follow-up of 2.0 years (interquartile range, 1.1-3.2 years). Associations were examined using Cox models with adjustment for potential confounders.

Results: Before the 18,874 patients transitioned to dialysis, 4485 (23.8%), 5633 (29.8%), and 7942 (42.1%) experienced fast, moderate, and slow eGFR decline, respectively, and 814 (4.3%) had increasing eGFR (defined as eGFR slopes of less than -10, -10 to less than -5, -5 to <0, and ≥0 mL/min per 1.73 m(2) per year). During the study period, a total of 9744 all-cause, 2702 cardiovascular, and 604 infection-related deaths were observed. Compared with patients with slow eGFR decline, those with moderate and fast eGFR decline had a higher risk of all-cause mortality (adjusted hazard ratio [HR], 1.06; 95% CI, 1.00-1.11; and HR, 1.11; 95% CI, 1.04-1.18, respectively) and cardiovascular mortality (HR, 1.11; 95% CI, 1.01-1.23 and HR, 1.13; 95% CI, 1.00-1.27, respectively). In contrast, increasing eGFR was only associated with higher infection-related mortality (HR, 1.49; 95% CI, 1.03-2.17).

Conclusion: Rapid eGFR decline is associated with higher all-cause and cardiovascular mortality, and increasing eGFR is associated with higher infection-related mortality among incident dialysis cases.

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Conflict of interest statement

Conflict of Interest Disclosure:

None.

Figures

Figure 1
Figure 1
Flow chart of the study population. Abbreviations: eGFR, estimated glomerular filtration rate; VA, Veterans Affairs
Figure 2
Figure 2
Multivariable-adjusted hazard ratios (95% confidence interval) of post-ESRD (A) all-cause, (B) cardiovascular, and (C) infection-related mortality associated with pre-ESRD eGFR slopes in Cox model using restricted cubic splines, adjusted for age, sex, race/ethnicity, marital status, body mass index, diabetes mellitus, hypertension, Charlson comorbidity index, last eGFR, and medications. The bars represent the number of patients with eGFR slope levels grouped in increments of 1 mL/min/1.73 m2/year. Abbreviations: eGFR, estimated glomerular filtration rate
Figure 2
Figure 2
Multivariable-adjusted hazard ratios (95% confidence interval) of post-ESRD (A) all-cause, (B) cardiovascular, and (C) infection-related mortality associated with pre-ESRD eGFR slopes in Cox model using restricted cubic splines, adjusted for age, sex, race/ethnicity, marital status, body mass index, diabetes mellitus, hypertension, Charlson comorbidity index, last eGFR, and medications. The bars represent the number of patients with eGFR slope levels grouped in increments of 1 mL/min/1.73 m2/year. Abbreviations: eGFR, estimated glomerular filtration rate
Figure 2
Figure 2
Multivariable-adjusted hazard ratios (95% confidence interval) of post-ESRD (A) all-cause, (B) cardiovascular, and (C) infection-related mortality associated with pre-ESRD eGFR slopes in Cox model using restricted cubic splines, adjusted for age, sex, race/ethnicity, marital status, body mass index, diabetes mellitus, hypertension, Charlson comorbidity index, last eGFR, and medications. The bars represent the number of patients with eGFR slope levels grouped in increments of 1 mL/min/1.73 m2/year. Abbreviations: eGFR, estimated glomerular filtration rate
Figure 3
Figure 3
Multivariable-adjusted hazard ratios (95% confidence interval) of (A) all-cause and (B) cardiovascular mortality associated with fast eGFR decline and (C) infection-related mortality associated with increasing eGFR, compared respectively to slow eGFR decline, overall and in selected subgroups. Models were adjusted for adjusted for age, sex, race/ethnicity, marital status, body mass index, diabetes mellitus, hypertension, Charlson comorbidity index, last eGFR, and medications. Abbreviations: BMI, body mass index; DM, diabetes mellitus; eGFR, estimated glomerular filtration rate
Figure 3
Figure 3
Multivariable-adjusted hazard ratios (95% confidence interval) of (A) all-cause and (B) cardiovascular mortality associated with fast eGFR decline and (C) infection-related mortality associated with increasing eGFR, compared respectively to slow eGFR decline, overall and in selected subgroups. Models were adjusted for adjusted for age, sex, race/ethnicity, marital status, body mass index, diabetes mellitus, hypertension, Charlson comorbidity index, last eGFR, and medications. Abbreviations: BMI, body mass index; DM, diabetes mellitus; eGFR, estimated glomerular filtration rate
Figure 3
Figure 3
Multivariable-adjusted hazard ratios (95% confidence interval) of (A) all-cause and (B) cardiovascular mortality associated with fast eGFR decline and (C) infection-related mortality associated with increasing eGFR, compared respectively to slow eGFR decline, overall and in selected subgroups. Models were adjusted for adjusted for age, sex, race/ethnicity, marital status, body mass index, diabetes mellitus, hypertension, Charlson comorbidity index, last eGFR, and medications. Abbreviations: BMI, body mass index; DM, diabetes mellitus; eGFR, estimated glomerular filtration rate
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