Association of estimated glomerular filtration rate and urine albumin-to-creatinine ratio with incidence of cardiovascular diseases and mortality in Chinese patients with type 2 diabetes mellitus - A population-based retrospective cohort study

Abstract

Background: Estimated glomerular filtration rate (EGFR) and urine albumin-to-creatinine ratio (UACR) are renal markers associated with risks of cardiovascular diseases (CVD) and all-cause mortality in diabetic patients. This study aims to quantify such risks in Chinese diabetic patients based on EGFR and UACR. Methods: This was a territory-wide retrospective cohort study on primary care diabetic patients with documented EGFR and UACR but without baseline CVD in 2008/2009. They were followed up till 2013 on CVD events and mortality. Associations between EGFR/UACR and incidence of CVD/mortality were evaluated by multivariable Cox proportional models adjusted with socio-demographic and clinical characteristics. Results: The data of 66,311 patients who had valid baseline EGFR and UACR values were analysed. The risks of CVD events and mortality increased exponentially with the decrease in EGFR, with a hazard ratio (HR) increasing from 1.63 to 4.55 for CVD, and from 1.70 to 9.49 for mortality, associated with Stage 3 to 5 CKD, compared to Stage 1 CKD. UACR showed a positive linear association with CVD events and mortality. Microalbuminuria was associated with a HR of 1.58 and 2.08 for CVD and mortality in male (1.48 and 1.79 for female), respectively, compared to no microalbuminuria. Male patients with UACR 1-1.4 mg/mmol and EGFR ≥90 ml/min/1.73 m2 (60-89 ml/min/1.73 m2) had a HR of 1.25 (1.43) for CVD. Female patients with UACR 2.5-3.4 mg/ml and EGFR ≥90 ml/min/1.73 m2 (60-89 ml/min/1.73 m2) had a HR of 1.45 (1.65) for CVD. Conclusions: Risks of CVD events and mortality increased exponentially with EGFR drop, while UACR showed positive predictive linear relationships, and the risks started even in high-normal albuminuria. UACR-based HR was further modified according to EGFR level, with risk progressed with CKD stage. Combining EGFR and UACR level was more accurate in predicting risk of CVD/mortality. The findings call for more aggressive screening and intervention of microalbuminuria in diabetic patients.