Coexisting diabetes and end-stage renal disease (ESRD) synergistically boosted the risk of cardiovascular events as much as five-fold compared with patients who had neither condition, according to long-term follow-up in two large cohorts.
The hazard ratio for myocardial infarction (MI) increased to 5.24 and the stroke risk more than doubled among patients who had both diabetes and ESRD. The risk was almost 12 times greater in certain age groups.
Risks were similar for patients who had ESRD and developed diabetes during follow-up.
The findings emphasize the importance of screening for and control of diabetes in patients with ESRD, Junne-Ming Sung, MD, of the National Cheng-Kung University Hospital in Tainan, Taiwan, and co-authors reported online in Diabetes Care.
“When we summarized all cardiovascular events (MI, stroke, and congestive heart failure) together, the same trend appears to be consistently present,” the authors reported. “Furthermore, a monotonic increment of CV risk pattern could also be observed with the presence of diabetes, ESRD, or both, even after adjusting for multiple confounding factors, including mortality.”
“Twenty-year risks for any CV events are around 13% to 50% in diabetes populations and 30% to 87% in ESRD patients,” they added. “De novo diabetes carries similar CV-related 20-year risks as prevalent diabetes in ESRD patients, while the risks were attenuated after accounting for the effect of death. Thus, the ongoing efforts to reduce the traditional or unique CV risk factors in diabetes and/or ESRD populations should never be over-emphasized.”
ESRD and diabetes both confer a high risk of cardiovascular disease and mortality. Studies of CV events in patients with ESRD have focused primarily on mortality rather than incidence of CV events, which leads to underestimation of event rates because of coding for a single cause of death, the authors noted in their introduction.
Additionally, few studies have examined the excess risk associated with the combination of diabetes and ESRD or occurrence of de novo diabetes in patients with ESRD. Knowing the magnitude of the combined effects could guide development of more effective primary prevention strategies, the authors continued.
In an effort to inform decision making about management of patients with diabetes and ESRD, the investigators analyzed data on two large cohorts identified through Taiwan’s National Health Insurance Research Database. They calculated age and sex-specific incidence and hazard ratios for MI, stroke, CHF, and the composite of the three clinical events, and compared results for patients who had diabetes and those who didn’t, those with de novo diabetes after ESRD, or ESRD and no history of CV events.
The study encompassed the years 1998 through 2009. The analysis included 648,851 patients without ESRD and 71,397 patients with ESRD. Additionally, 53,342 patients had diabetes at enrollment, and 34,754 developed (de novo) diabetes during follow-up.
Sung and colleagues separated the patients into five groups according to diabetes and ESRD status and determined the incidence and 20-year risk of CV events. Median follow-up was 12 years for patients without ESRD or diabetes, 4.9 years for those with diabetes but not ESRD, 3.7 years for patients with ESRD but not diabetes, 2.4 years for patients with diabetes and ESRD, and 1.7 years for patients with ESRD and de novo diabetes.
As compared with patients who had neither diabetes nor ESRD, those with either of the conditions had significantly higher rates (P0.0001 for all comparisons) of total CV events and of the individual events (expressed as mortality-adjusted hazard ratios):
- Diabetes/no ESRD – 1.60 (composite), 1.67 (MI), 1.60 (stroke), 1.52 (CHF)
- No diabetes/ESRD – 2.27, 2.72, 1.63, 3.72
- Diabetes/ESRD – 3.25, 5.24, 2.43, 4.12
- De novo diabetes/ESRD – 2.19, 4.12, 1.75, 2.25
Results were similar across all age groups and for men and women.
On the basis of the results, the authors recommend that “proactive screening and control for diabetes in patients with ESRD should be built into our daily practice.”
The study did not yield any new evidence, but the large study population provided “tremendous statistical power and makes the outcome so much more convincing,” said Robert Eckel, MD, of the University of Colorado in Denver, who was not involved in the study.
“I find of interest that the presence of ESRD/diabetes appeared to be more important for [stroke] and CHF than MI,” Eckel told MedPage Today in an email. “The male-versus-female risk difference was also interesting.”
Analysis of various risk factors showed that hypertension remained a risk for all outcomes, but the data could not provide insight into the adequacy of blood pressure control or the treatments used, he added.
The study was supported by the National Cheng-Kung University Hospital.
The authors had no relevant disclosures.
Primary source: Diabetes Care
Source reference: Sung JM, et al “Diabetes and end-stage renal disease synergistically contribute to increased incidence of cardiovascular events: A nationwide follow-up study during 1998-2009” Diabetes Care 2013; DOI: 10.2337/dc13-078.
open bio Working from Houston, home to one of the world’s largest medical complexes, Charles Bankhead has more than 20 years of experience as a medical writer and editor. His career began as a science and medical writer at an academic medical center. He later spent almost a decade as a writer and editor for Medical World News, one of the leading medical trade magazines of its era. His byline has appeared in medical publications that have included Cardio, Cosmetic Surgery Times, Dermatology Times, Diagnostic Imaging, Family Practice, Journal of the National Cancer Institute, Medscape, Oncology News International, Oncology Times, Ophthalmology Times, Patient Care, Renal and Urology News, The Medical Post, Urology Times, and the International Medical News Group newspapers. He has a BA in journalism and MA in mass communications, both from Texas Tech University.