Cardiovascular Risk Based on ASCVD and KDIGO Categories in Chinese Adults: A Nationwide, Population-Based, Prospective Cohort Study

Abstract

Background: The Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline used eGFR and urinary albumin-creatinine ratio (ACR) to categorize risks for CKD prognosis. The utility of KDIGO's stratification of major CVD risks and predictive ability beyond traditional CVD risk prediction scores are unknown.

Methods: To evaluate CVD risks on the basis of ACR and eGFR (individually, together, and in combination using the KDIGO risk categories) and with the atherosclerotic cardiovascular disease (ASCVD) score, we studied 115,366 participants in the China Cardiometabolic Disease and Cancer Cohort study. Participants (aged ≥40 years and without a history of cardiovascular disease) were examined prospectively for major CVD events, including nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death.

Results: During 415,111 person-years of follow-up, 2866 major CVD events occurred. Incidence rates and multivariable-adjusted hazard ratios of CVD events increased significantly across the KDIGO risk categories in ASCVD risk strata (all P values for log-rank test and most P values for trend in Cox regression analysis <0.01). Increases in c statistic for CVD risk prediction were 0.01 (0.01 to 0.02) in the overall study population and 0.03 (0.01 to 0.04) in participants with diabetes, after adding eGFR and log(ACR) to a model including the ASCVD risk score. In addition, adding eGFR and log(ACR) to a model with the ASCVD score resulted in significantly improved reclassification of CVD risks (net reclassification improvements, 4.78%; 95% confidence interval, 3.03% to 6.41%).

Conclusions: Urinary ACR and eGFR (individually, together, and in combination using KDIGO risk categories) may be important nontraditional risk factors in stratifying and predicting major CVD events in the Chinese population.

Keywords: atherosclerotic cardiovascular disease; estimated glomerular filtration rate; urinary albumin-to-creatinine ratio.

Graphical abstract

Figure 1.

The Kaplan–Meier curves and the log-rank tests revealed significantly increased possibilities of developing major CVD events across the low, intermediate, and high or very high KDIGO risk categories in each ASCVD risk stratum (all P values <0.01). (A) ASCVD risk score <5.0%. (B) ASCVD risk score 5.0% to <7.5%. (C) ASCVD risk score 7.5% to <10.0%. (D) ASCVD risk score 10.0% to <15.0%. (E) ASCVD risk score 15.0% to <20.0%. (F) ASCVD risk score ≥20.0%.

Figure 2.

Risks of major CVD events increased significantly across the ASCVD risk groups and the KDIGO risk categories. The low KDIGO risk category in each ASCVD risk stratum was used as the reference (left panel). The low KDIGO risk and an ASCVD risk score <5.0% was used as the only reference (right panel). The analysis was adjusted for age, sex, education, body mass index, current drinking, fruit and vegetable intake, and physical activity. Risks increased significantly across the low, intermediate, and high or very high KDIGO risk categories in most ASCVD risk groups. Risks were even higher with both increasing KDIGO risk categories and increasing ASCVD risk groups.