A synergistic effect of variability in estimated glomerular filtration rate with chronic kidney disease on all-cause mortality prediction in patients with type 2 diabetes: a retrospective cohort study

I-Te Lee,Yu-Hsuan Li,Yu-Shan Chang

doi:10.1186/s12933-021-01399-z

Abstract

BackgroundThe combination of diabetes mellitus (DM) and chronic kidney disease (CKD) is associated with a high risk of mortality. Annual assessment of the estimated glomerular filtration rate (eGFR) is recommended for patients with DM. We investigated the effect of variability in annual eGFR values on all-cause mortality in patients with type 2 DM.MethodsIn this retrospective cohort study, we enrolled patients with eGFR data between 01 Aug 2017 and 31 July 2018. We defined the index eGFR as the first available eGFR value within the enrollment year and collected additional annual eGFR data from the previous three years. A total of 3592 patients with type 2 DM were enrolled, including 959 patients with CKD (index eGFR < 60 mL/min/1.73 m2) and 2633 patients without CKD. We assessed eGFR variability by using the standard deviation (SD) of the three annual eGFR and index eGFR values. We divided patients into subgroups according to the median SD of their annual eGFR (7.62 mL/min/1.73 m2). The primary endpoint was all-cause mortality after the index eGFR was assessed.ResultsDuring a median follow-up of 19 months (interquartile range: 18‒20 months), 127 (3.5%) deaths occurred among all 3592 enrolled patients. The highest mortality risk was observed in the high SD with CKD group, with a hazard ratio (HR) of 2.382 [95% confidence interval (CI) 1.346‒4.215] in comparison to the low SD without CKD group after adjusting for the associated factors. In patients without CKD, a high SD was an independent risk factor for mortality (HR = 2.105, 95% CI 1.256‒3.528). According to the C-index, the mortality prediction ability was better for the index eGFR + SD model than for the index eGFR alone model (0.671 vs. 0.629, P < 0.001).ConclusionThere was a synergistic effect of eGFR variability with single-measured eGFR for the prediction of mortality in patients with type 2 DM. The SD of the annual eGFR values was also an independent predictor of mortality in patients with an eGFR > 60 mL/min/1.73 m2.

Highlights

The combination of diabetes mellitus (DM) and chronic kidney disease (CKD) is associated with a high risk of mortality
It is not sufficient to predict mortality using a single-measurement of estimated glomerular filtration rate (eGFR) in patients with eGFR ≥ 60 mL/min/1.73 m2, and other associated risk factors for mortality should be assessed in patients with type 2 DM without hypofiltration [17]
The strength of our study is that we demonstrated that variability in eGFR has a synergistic effect with CKD on the prediction of the primary endpoint of all-cause mortality in patients with type 2 DM

Summary

Introduction

The combination of diabetes mellitus (DM) and chronic kidney disease (CKD) is associated with a high risk of mortality. Annual assessment of the estimated glomerular filtration rate (eGFR) is recommended for patients with DM. We investigated the effect of variability in annual eGFR values on all-cause mortality in patients with type 2 DM. The global prevalence of CKD between stages 3 and 5 was reported to be approximately 10.6%, and diabetes mellitus (DM) is a major risk factor for CKD [3]. It is not sufficient to predict mortality using a single-measurement of eGFR in patients with eGFR ≥ 60 mL/min/1.73 m2, and other associated risk factors for mortality should be assessed in patients with type 2 DM without hypofiltration [17]

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Discussion

Conclusion