Abstract
BackgroundIndividuals with diabetes have remarkably high rates of cardiovascular morbidity and mortality. However, the incremental cardiovascular risk in diabetes is heterogeneous and has often been related to renal involvement. The purpose of this study was to analyse the prognostic value of subclinical atherosclerosis in determining the incidence of first cardiovascular events (CVEs) in individuals with diabetes and chronic kidney disease (CKD) compared to CKD individuals without diabetes.MethodsWe included data from individuals with CKD with and without diabetes, free from pre-existing cardiovascular disease, from the NEFRONA cohort. Participants underwent baseline carotid and femoral ultrasound and were followed up for 4 years. All CVEs during follow-up were registered. Bivariate analysis and Fine–Gray competing risk models were used to perform the statistical analysis.ResultsDuring the mean follow-up time of 48 months, a total of 203 CVE was registered. 107 CVE occurred among participants without diabetes (19.58 per 1000 person-years) and 96 CVE occurred among participants with diabetes (44.44 per 1000 person-years). Following the competing risk analysis, the variables predicting CVEs in CKD individuals without diabetes were the number of territories with plaque at baseline (HR 1.862, 95% CI [1.432;2.240]), age (HR 1.026, 95% CI [1.003;1.049]) and serum concentrations of 25-OH vitamin D (HR 0.963, 95% CI [0.933;0.094]). The only variable predicting CVEs among CKD participants with diabetes was the number of territories with plaque at baseline (HR 1.782, 95% CI [1.393, 2.278]). For both models, concordance (C) index yielded was over 0.7.ConclusionsThe burden of subclinical atherosclerosis is the strongest predictor of future CVEs in diabetic individuals with CKD. Early detection of subclinical atherosclerotic burden by multiterritorial vascular ultrasound could improve CVE prediction in this population.
Highlights
Individuals with diabetes have remarkably high rates of cardiovascular morbidity and mortality
The burden of subclinical atherosclerosis is the strongest predictor of future cardiovascular events (CVEs) in diabetic individuals with chronic kidney disease (CKD)
We observed that among diabetes participants, CVE rates increased with declining renal function: CVE rates were 30.90 per 1000 person-years in CKD-3 versus 41.14 per 1000 person-years in CKD4/5 and 100.67 per 1000 person-years in individuals on renal replacement therapy (RRT) (p-trend < 0.001)
Summary
Individuals with diabetes have remarkably high rates of cardiovascular morbidity and mortality. Some studies have reported that individuals with diabetes show a two to fourfold increased risk of CVD, this risk is not equivalent to that of individuals who have had a cardiovascular event (CVE) [5,6,7,8]. These data support the concept of heterogeneity in cardiovascular risk within the diabetic population and underline the need for cardiovascular risk stratification [9, 10]. It has been reported that in individuals with diabetes, the presence of chronic kidney disease (CKD) is associated with an increased risk of CVD, explaining in part their heightened burden of CVD [16]
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