Specific impact of past and new major cardiovascular events on acute kidney injury and end-stage renal disease risks in diabetes: a dynamic view

Background. Interconnections between major cardiovascular events (MCVE5) and renal events are recognized in diabetes, however, the specific impact of atrial fibrillation (AF), heart failure (HF) and acute coronary syndrome (ACS) on the risk of end-stage renal disease (ESRD) on top of established renal risk factors is unclear in type 2 diabetes mellitus. Methods. We conducted a retrospective study in 861 consecutive patients followed in a nephrology setting during the 2000-13 period. Results. The mean age was 70 +/- 10 years, 65.1% were men and the estimated glomerular filtration rate (eGFR) was 42.4 +/- 21.0 mL/min/1.73 m(2). During follow-up (median 59 months), 194 patients reached ESRD. A history of AF, HF or ACS was associated with an increased risk of reduced baseline eGFR. In turn, reduced baseline eGFR resulted in a greater risk of new MCVE (especially HF) during follow-up. Finally, all new MCVE5 were risk factors for subsequent acute kidney injury (AKI) {HF: hazard ratio [HR] 8.99 [95% confidence interval (CI) 7.06-11.4]; AF: HR 5.42 (3.91-7.52); ACS: HR 8.82 (6.24-12.5); all P < 0.0001) and ESRD [HF: HR 5.52 (95% CI 4.01-7.60), P < 0.0001; AF: HR 3.48 (2.30-5.21), P < 0.0001; ACS: HR 2.31 (1.43-3.73), P = 0.0006]. The AF- and HF-associated risks of ESRD were significant after adjustments on all renal risks of ESRD (gender, blood pressure, eGFR, albuminuria, renin-angiotensin blockers, retinopathy and AKI), but the association was less strong for ACS. Importantly, no association was noted between other major events such as stroke or infections and the risk of ESRD. Conclusions. Past and new cardiovascular events (more HF and AF than ACS) have a strong, independent impact on the development of ESRD above and beyond established risk factors in diabetes.