Factors predicting cardiovascular events in chronic kidney disease patients. Role of subclinical atheromatosis extent assessed by vascular ultrasound.

José M Valdivielso,David Arroyo,Montserrat Martinez-Alonso,Angels Betriu,Marcelino Bermudez-Lopez,Elvira Fernandez,For The Nefrona Investigators

doi:10.1371/journal.pone.0186665

José M Valdivielso, David Arroyo + Show 5 more

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https://doi.org/10.1371/journal.pone.0186665

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Abstract

Patients with chronic kidney disease (CKD) have an increased incidence of cardiovascular events (CVE). The contribution of subclinical atheromatosis extent, including femoral arteries, to CVE in CKD patients has not been investigated. In this paper, we examine the prognostic value of subclinical atheromatosis extent, assessed as the number of arterial territories with plaque, in predicting the incidence of major and minor CVE. The NEFRONA is a multicenter, prospective cohorts study that recruited 2445 CKD subjects and 559 controls, free from previous cardiovascular disease, in 81 medical centers across Spain. The presence of atheroma plaque was assessed by arterial ultrasound in ten arterial territories (carotid and femoral). The predictive power of the presence or absence of atheroma plaque in any territory was compared with the quantification of atheroma extent as the number of territories with plaque. During the median follow up of 48 months, 216 CVE were reported. Factors predicting the incidence of CVE in the whole cohort were being male, CKD patient, lower levels of 25(OH) vitamin D, higher levels of cholesterol and the extent of subclinical atheromatosis, yielding a higher concordance (C) index than the presence or absence of plaque. In stratified analysis including specific factors of CKD patients not on dialysis, the variables predicting CVE were the same as in the whole cohort, plus higher levels of potassium. Again, the inclusion of the information about atheromatosis as number of territories with plaque, presented a higher C index than the presence or absence of plaque. In the dialysis population, significant variables were older age, diabetes, dialysis vintage and higher levels of cholesterol and phosphate. In this case the higher C index was obtained with the information about plaque presence.Subclinical atheromatosis extent, including femoral arteries, influences CVE in CKD and its detection could improve the prediction of cardiovascular events.

Highlights

Cardiovascular disease is the main cause of death in chronic kidney disease (CKD) patients, in which cardiovascular death is a more likely outcome than progression to end-stage renal disease (ESRD).[1]
The NEFRONA is an observational, prospective, multicentric, cohorts study that aimed to assess the role of the detection of subclinical atheromatosis extent by arterial ultrasound in the cardiovascular risk prediction of CKD patients
We demonstrate for the first time that the determination of subclinical atheromatosis in CKD patients not on dialysis strongly predicts the incidence of cardiovascular events

Summary

Introduction

Cardiovascular disease is the main cause of death in chronic kidney disease (CKD) patients, in which cardiovascular death is a more likely outcome than progression to end-stage renal disease (ESRD).[1]. Neither traditional risk factors, risk score charts for general population nor emerging risk biomarkers appear to significantly increase the prediction power in this population.[2,3,4] classical risk prediction equations underestimate cardiovascular disease risk in adults with CKD [5, 6] and new tools for risk prediction in renal patients are urgently needed. The contribution of atheromatous disease in cardiovascular mortality of CKD patients has not been clearly defined. [8, 9] In contrast to dialysis patients, in the CKD population not in dialysis, atherothrombotic deaths are very common,[10] and atherosclerosis prevalence is higher than in the general population.[11] In this case, no studies have evaluated the contribution of atheroma plaque to cardiovascular mortality

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