Foundation's Kidney Early Evaluation Research Articles

Chronic kidney disease from screening, detection, and awareness, to prevention.

Chronic kidney disease from screening, detection, and awareness, to prevention.

Risk Factors for ESRD in Individuals With Preserved Estimated GFR With and Without Albuminuria: Results From the Kidney Early Evaluation Program (KEEP)

Given the increasing costs and poor outcomes of end-stage renal disease (ESRD), we sought to identify risk factors for ESRD in people with preserved estimated glomerular filtration rate (eGFR), with or without albuminuria, who were at high risk of ESRD. This cohort study included participants in the National Kidney Foundation's Kidney Early Evaluation Program (KEEP) with eGFR ≥ 60 mL/min/1.73 m(2) at baseline stratified by the presence or absence of albuminuria. The Chronic Kidney Disease Epidemiology Collaboration equation was used to calculate eGFR. Urine was tested for albuminuria by semiquantitative dipstick. The outcome was the development of treated chronic kidney failure, defined as initiation of maintenance dialysis therapy or kidney transplantation, determined by linkage to the US Renal Data System. We used a Cox model with the Fine-Gray method to assess risk factors for treated chronic kidney failure while accounting for the competing risk of death. During a median follow-up of 4.8 years, 126 of 13,923 participants with albuminuria (16/10,000 patient-years) and 56 of 109,135 participants without albuminuria (1.1/10,000 patient-years) developed treated chronic kidney failure. Diabetes was a strong risk factor for developing treated chronic kidney failure in participants with and without albuminuria (adjusted HRs of 9.3 [95% CI, 5.7-15.3] and 7.8 [95% CI, 4.1-14.8], respectively). Black race, lower eGFR, and higher systolic blood pressure also were associated with higher adjusted risks of developing treated chronic kidney failure. In a diverse high-risk cohort of KEEP participants with preserved eGFR, we showed that diabetes, higher systolic blood pressure, lower eGFR, and black race were risk factors for developing treated chronic kidney failure irrespective of albuminuria status, although the absolute risk of kidney failure in participants without albuminuria was very low. Our findings support testing for kidney disease in high-risk populations, which often have otherwise unrecognized kidney disease.

Association Between Lack of Health Insurance and Risk of Death and ESRD: Results From the Kidney Early Evaluation Program (KEEP)

Uninsured adults in the United States have poor access to health care services and worse health outcomes than insured adults. Little is known about the association between lack of insurance and chronic kidney disease (CKD) progression to end-stage renal disease (ESRD) or death in patients at high risk of kidney disease. We used 2000-2011 data from the National Kidney Foundation's Kidney Early Evaluation Program (KEEP) to examine this association. The study population included KEEP participants younger than 65 years. Outcomes were time to ESRD (chronic kidney failure treated by renal replacement therapy) and time to death. Incident ESRD was ascertained by linkage to the US Renal Data System, and vital status, by linkage to the Social Security Administration Death Master File. We used Cox proportional hazard regression to examine the association between insurance and risk of death or ESRD after adjusting for demographic variables. Of 86,588 participants, 27.8% had no form of insurance, 10.3% had public insurance, and 61.9% had private insurance; 15.0% had CKD (defined as estimated glomerular filtration rate <60 mL/min/1.73 m(2) or urine albumin-creatinine ratio ≥ 30 mg/g), 63.3% had hypertension, and 27.7% had diabetes. Of participants with CKD, 29.3% had no health insurance. Participants without insurance were younger, more likely to be Hispanic and to have 12 or fewer years of education, and less likely to have seen a physician in the past year. After adjustment for demographic characteristics, uninsured KEEP participants were 82% more likely than privately insured participants to die (HR, 1.82; 95% CI, 1.56-2.12; P < 0.001) and 72% more likely to develop ESRD (HR, 1.72; 95% CI, 1.33-2.22; P < 0.001). The association between insurance and outcomes varied by CKD stage. Lack of insurance is an independent risk factor for early death and ESRD in this population at high risk of kidney disease. Considering the high morbidity and mortality and increasing cost associated with ESRD, access to appropriate health insurance coverage is warranted.

The Synergistic Relationship Between Estimated GFR and Microalbuminuria in Predicting Long-term Progression to ESRD or Death in Patients With Diabetes: Results From the Kidney Early Evaluation Program (KEEP)

Chronic kidney disease may complicate diabetes, often manifesting with reduced glomerular filtration rate (GFR), albuminuria, or both. Although greater albuminuria and lower estimated GFR both predict adverse prognosis, whether a synergistic prognostic interaction occurs in patients with diabetes has not been defined in a large national cohort study. We used 2000-2011 data from the National Kidney Foundation's Kidney Early Evaluation Program (KEEP) for 42,761 participants with diabetes. Kaplan-Meier survival analysis and multivariable Cox regression were used to ascertain the association of estimated GFR, albumin-creatinine ratio (ACR), and their interaction on all-cause mortality and progression to end-stage renal disease (ESRD) at a median 4 years of follow-up. Of 42,761 participants with diabetes, 8,618 (20.2%) had estimated GFR <60 mL/min/1.73 m(2), 7,715 (18.0%) had ACR >30 mg/g, and 2,641 (6.2%) had both. The unadjusted incidence (per 1,000 person-years) of all-cause mortality increased from 3.1 (95% CI, 2.4-3.8) in participants with estimated GFR ≥ 105 mL/min/1.73 m(2) and no albuminuria to 73.7 (95% CI, 54.9-92.5) in participants with estimated GFR <30 mL/min/1.73 m(2) and macroalbuminuria (P < 0.001). Progression to ESRD likewise increased from 0.2 (95% CI, 0-0.4) to 220.4 (95% CI, 177.2-263.6) per 1,000 person-years (P < 0.001). After adjustment for confounders, both estimated GFR and albuminuria were associated independently with mortality and progression to ESRD, with a strong synergistic interaction (P for interaction < 0.001); estimated GFR <30 mL/min/1.73 m(2) and macroalbuminuria together were associated with a 5-fold higher risk of mortality and a more than 1,000-fold higher risk of progression to ESRD (compared with patients with estimated GFR >60 mL/min/1.73 m(2) and ACR <30 mg/g; P < 0.001 for both outcomes). In this large cohort of diabetic KEEP participants with more than 170,000 person-years of follow-up, both estimated GFR and albuminuria were associated independently with mortality and progression to ESRD, with a strong synergistic interaction.

Awareness of Kidney Disease and Relationship to End-stage Renal Disease and Mortality

BackgroundOften, patients with chronic kidney disease are reported to be unaware of it. We prospectively evaluated the association between awareness of kidney disease to end-stage renal disease and mortality. MethodsWe utilized 2000-2009 data from the National Kidney Foundation's Kidney Early Evaluation Program. Mortality was determined by cross reference to the Social Security Administration Death Master File and development of end stage by cross reference with the United States Renal Data System. ResultsOf 109,285 participants, 28,244 (26%) had chronic kidney disease defined by albuminuria or estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Only 9% (n=2660) reported being aware of kidney disease. Compared with those who were not aware, participants aware of chronic kidney disease had lower eGFR (49 vs 62 mL/min/1.73 m2) and a higher prevalence of albuminuria (52% vs. 46%), diabetes (47% vs 42%), cardiovascular disease (43% vs 28%), and cancer (23% vs 14%). Over 8.5 years of follow-up, aware participants compared with those unaware had a lower rate of survival for end stage (83% and 96%) and mortality (78% vs 81%), P <.001. After adjustment for demographics, socioeconomic factors, comorbidity, and severity of kidney disease, aware participants continued to demonstrate an increased risk for end-stage renal disease (hazard ratio 1.37; 95% confidence interval, 1.07-1.75; P <.0123) and mortality (hazard ratio 1.27; 95% confidence interval, 1.07-1.52; P <.0077) relative to unaware participants with chronic kidney disease. ConclusionsAmong patients identified as having chronic kidney disease at a health screening, only a small proportion had been made aware of their diagnosis previously by clinicians. This subgroup was at a disproportionately high risk for mortality and end-stage renal disease.

Access to Health Care Among Adults Evaluated for CKD: Findings From the Kidney Early Evaluation Program (KEEP)

Data are scant regarding access to health care in patients with chronic kidney disease (CKD). We performed descriptive analyses using data from the National Kidney Foundation's Kidney Early Evaluation Program (KEEP), a nationwide health screening program for adults at high risk of CKD. From 2000-2010, a total of 122,502 adults without end-stage renal disease completed KEEP screenings; 27,927 (22.8%) met criteria for CKD (10,082, stages 1-2; 16,684, stage 3; and 1,161, stages 4-5). CKD awareness, self-rated health status, frequency of physician visits, difficulty obtaining medical care, types of caregivers, insurance status, and medication coverage and estimated costs were assessed. Participants with CKD were more likely to report fair/poor health status than those without CKD. Health care utilization increased at later CKD stages; ~95% of participants at stages 3-5 had visited a physician during the preceding year compared with 83.7% of participants without CKD. More Hispanic and African American than white participants at all CKD stages reported not having a physician. Approximately 40% of participants younger than 65 years reported fair/poor health status at stages 4-5 compared with ~30% who were 65 years and older. Younger participants at all stages were more likely to report extreme or somewhat/moderate difficulty obtaining medical care. Comorbid conditions (diabetes, hypertension, and prior cardiovascular events) were associated with increased utilization of care. Utilization of nephrology care was poor at all CKD stages; <6% of participants at stage 3 and <30% at stages 4-5 reported ever seeing a nephrologist. Lack of health insurance and perceived difficulty obtaining medical care with lower health care utilization, both of which are consistent with inadequate access to health care, are more likely for KEEP participants who are younger than 65 years, nonwhite, and without previously diagnosed comorbid conditions. Nephrology care is infrequent in elderly participants with advanced CKD who are nonwhite, have comorbid disease, and have high-risk states for cardiovascular disease.

Associations Between Access to Care and Awareness of CKD

Most individuals with chronic kidney disease (CKD) in the United States are unaware of their condition, creating challenges in implementing early interventions to delay disease progression. Whether characteristics expected to enhance health care access are associated with greater CKD awareness has not been studied adequately. Data from volunteer participants in the National Kidney Foundation's Kidney Early Evaluation Program (KEEP), 2000-2010, with presumed CKD (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m(2) or albumin-creatinine ratio >30 mg/g) were analyzed. Given that the diagnosis of CKD was based on a single measurement of kidney function, the diagnosis is presumed, but not confirmed. Associations of CKD awareness with measures of access to care (health insurance coverage, type of health insurance, prescription drug coverage, and self-reported level of difficulty obtaining care) were examined using logistic regression. Of 29,144 participants with CKD, 6,751 (23%) reported CKD awareness. No significant association was found between availability of health insurance or prescription drug coverage and CKD awareness; results did not vary by diabetic status or in analyses restricted to participants with eGFR <60 mL/min/1.73 m(2). Participants reporting extreme or some difficulty obtaining medical care were more likely than those reporting no difficulty to be aware of CKD (adjusted OR, 1.25; 95% CI, 1.05-1.50). Most KEEP participants with CKD are unaware of the condition, results that are not modified by the availability of health insurance or prescription drug coverage. The mechanisms underlying the association of perceived difficulty in access to care with greater CKD awareness require further study.

Association of Physician Care With Mortality in Kidney Early Evaluation Program (KEEP) Participants

People with or at high risk of chronic kidney disease (CKD) are at increased risk of premature morbidity and mortality. We sought to examine the effect of care provided by a primary care physician (PCP) on survival for all participants in the National Kidney Foundation's Kidney Early Evaluation Program (KEEP) and the effect of care provided by a nephrologist on survival for KEEP participants with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2). Provision of care by a PCP (n = 138,331) or nephrologist (n = 10,797) was defined using self-report of seeing that provider within the past year. Survival was ascertained by linking KEEP data to the Social Security Administration Death Master File. Multivariable Cox proportional hazards models examining the relationship between primary care and nephrologist provider status adjusted for age, sex, race, smoking status, education, health insurance, diabetes, cardiovascular disease, hypertension, cancer, albuminuria, body mass index, baseline eGFR, and hemoglobin level, with nephrology models further adjusting for calcium, phosphorus, and parathyroid hormone levels. Of all participants, 70.9% (98,050 of 138,331) reported receiving PCP care; older age and female sex were associated with this care. During a median follow-up of 4.2 years, 4,836 deaths occurred. After multivariable adjustment, receiving PCP care and mortality were not associated (HR, 0.94; 95% CI, 0.86-1.03; P = 0.2). Of participants with eGFR <60 mL/min/1.73 m(2), 10.1% (1,095 of 10,797) reported receiving nephrology care; younger age and male sex were associated with receipt of nephrology care. During a mean follow-up of 2.2 years, 558 deaths occurred. After multivariable adjustment, nephrologist care was not associated with mortality (HR, 1.01; 95% CI, 0.75-1.36; P = 0.9). These associations were not modified by other specialist care (endocrinologist or cardiologist). For all KEEP participants, neither PCP nor nephrology care was associated with improved survival. These results highlight the need to explore the connection between access to health care and outcomes in persons at high risk of or with CKD.

National Kidney Foundation's Kidney Early Evaluation Program (KEEP) Annual Data Report 2011: Executive Summary

KEEP is the world’s only sustained chronic disease screening and awareness program. Its success is partially attributable to the continued dedication and commitment of stakeholders (the National Kidney Foundation, local affiliates, and the academic community), but also to a unique set of methods that balance detail with simplicity and place efficiency and patient care at a premium. Early access to health care through primary care or nephrology referral is critical to improving CKD-related outcomes. However, our understanding of barriers to such care is limited. KEEP participants appear to experience lack of adequate health care access and nephrology care. This finding may be influenced by the nature of a large-scale screening program dedicated to providing some level of access to participants who are concerned about the personal possibility of CKD. Not surprisingly, we observed a low rate of CKD awareness among participants with CKD newly recognized through the KEEP screening, findings not modified by insurance or prescription drug coverage. However, the strongest association occurred between perceived difficulty obtaining access to care and greater CKD awareness. These findings may partially explain the findings of high-level cardiovascular risk factors and mortality in patients receiving nephrologist care. The KEEP Steering Committee continues to work to expand understanding of barriers to care, awareness of CKD, and measures to improve cardiovascular and renal risk (Figure 1). We anticipate that future findings from our longitudinal program will continue to shape our understanding of CKD and the complex interface between recognition of the disease, navigation of the health care system, and related consequences. Open in a separate window Figure 1 Factors that impact KEEP screening and nephrology care. CKD, chronic kidney disease; KEEP, Kidney Early Evaluation Program. Source of kidney image: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

Physician Utilization, Risk-Factor Control, and CKD Progression Among Participants in the Kidney Early Evaluation Program (KEEP)

Chronic kidney disease (CKD) is a well-known risk factor for cardiovascular mortality, but little is known about the association between physician utilization and cardiovascular disease risk-factor control in patients with CKD. We used 2005-2010 data from the National Kidney Foundation's Kidney Early Evaluation Program (KEEP) to examine this association at first and subsequent screenings. Control of risk factors was defined as control of blood pressure, glycemia, and cholesterol levels. We used multinomial logistic regression to examine the association between participant characteristics and seeing a nephrologist after adjusting for kidney function and paired t tests or McNemar tests to compare characteristics at first and second screenings. Of 90,009 participants, 61.3% had a primary care physician only, 2.9% had seen a nephrologist, and 15.3% had seen another specialist. The presence of 3 risk factors (hypertension, diabetes, and hypercholesterolemia) increased from 26.8% in participants with CKD stages 1-2 to 31.9% in those with stages 4-5. Target levels of all risk factors were achieved in 7.2% of participants without a physician, 8.3% of those with a primary care physician only, 9.9% of those with a nephrologist, and 10.3% of those with another specialist. Of up to 7,025 participants who met at least one criterion for nephrology consultation at first screening, only 12.3% reported seeing a nephrologist. Insurance coverage was associated strongly with seeing a nephrologist. Of participants who met criteria for nephrology consultation, 406 (5.8%) returned for a second screening, of whom 19.7% saw a nephrologist. The percentage of participants with all risk factors controlled was higher at the second screening (20.9% vs 13.3%). Control of cardiovascular risk factors is poor in the KEEP population. The percentage of participants seeing a nephrologist is low, although better after the first screening. Identifying communication barriers between nephrologists and primary care physicians may be a new focus for KEEP.

Association of Educational Attainment With Chronic Disease and Mortality: The Kidney Early Evaluation Program (KEEP)

Recent reports have suggested a close relationship between education and health, including mortality, in the United States. Observational cohort. We studied 61,457 participants enrolled in a national health screening initiative, the National Kidney Foundation's Kidney Early Evaluation Program (KEEP). Self-reported educational attainment. Chronic diseases (hypertension, diabetes, cardiovascular disease, reduced kidney function, and albuminuria) and mortality. We evaluated cross-sectional associations between self-reported educational attainment with the chronic diseases listed using logistic regression models adjusted for demographics, access to care, behaviors, and comorbid conditions. The association of educational attainment with survival was determined using multivariable Cox proportional hazards regression. Higher educational attainment was associated with a lower prevalence of each of the chronic conditions listed. In multivariable models, compared with persons not completing high school, college graduates had a lower risk of each chronic condition, ranging from 11% lower odds of decreased kidney function to 37% lower odds of cardiovascular disease. During a mean follow-up of 3.9 (median, 3.7) years, 2,384 (4%) deaths occurred. In the fully adjusted Cox model, those who had completed college had 24% lower mortality compared with participants who had completed at least some high school. Lack of income data does not allow us to disentangle the independent effects of education from income. In this diverse contemporary cohort, higher educational attainment was associated independently with a lower prevalence of chronic diseases and short-term mortality in all age and race/ethnicity groups.

Sustainable Community-Based CKD Screening Methods Employed by the National Kidney Foundation's Kidney Early Evaluation Program (KEEP)

This year, 2011, the National Kidney Foundation’s (NKF) Kidney Early Evaluation Program (KEEP) celebrates its 11th anniversary, approaching 3,500 cumulative screening events conducted by 48 affiliates and reaching more than 165,000 people in communities across the country. KEEP serves as the largest and most comprehensive and sustained multicenter community-based chronic kidney disease (CKD) screening program in the United States. While focused on CKD, KEEP also functions as a unique means of screening for and discovering obesity, diabetes, hypertension, and cardiovascular disease. The NKF’s approach to social marketing (Fig 1), patient education, and advocacy combined with KEEP’s data capabilities, longitudinal tracking, and feedback to clinicians have made the program the nation’s leading effort to screen for and intervene in chronic diseases. KEEP’s structure as an outreach effort, coupled with a sense of activism in recent years regarding primary prevention of chronic disease, has enabled sustained growth and international expansion.

National Kidney Foundation's Kidney Early Evaluation Program (KEEP) Annual Data Report 2010: Executive Summary

National Kidney Foundation's Kidney Early Evaluation Program (KEEP) Annual Data Report 2010: Executive Summary

The Kidney Early Evaluation Program (KEEP) of Japan: results from the initial screening period

The International Kidney Evaluation Association Japan evaluated chronic kidney disease (CKD) in Japan, using a Japanese version of the US National Kidney Foundation's Kidney Early Evaluation Program (KEEP). The screening criteria for the first 1065 participants were presence of diabetes or hypertension, or family history of diabetes, hypertension, or kidney disease. Mean age was 59.7+/-16.1 years; 501 participants were men, 564 women. Of participants, 26.9% had diabetes, 59.2% had hypertension (with an additional 21.5% diagnosed after the program), 16.9% had history of diabetes and hypertension together, and 30.6% had neither, but had family history of diabetes, hypertension, or kidney disease. CKD (stages 1-4) prevalence was 26.7%, defined by albumin-creatinine ratio and estimated glomerular filtration rate. CKD prevalence was 35.0% among diabetic participants, 34.8% among hypertensive participants, and 37.1% among participants with cardiovascular disease (CVD). The following baseline conditions were significantly associated with discovered CKD: diabetes, odds ratio 1.71 (95% confidence interval 1.28-2.30); hypertension, 3.42 (2.15-5.44); CVD, 1.88 (1.37-2.57). CKD prevalence was high compared with the general Japanese population. KEEP Japan seems to define a high-risk population with evidence of CKD based on the targeted nature of the program.

National Kidney Foundation's Kidney Early Evaluation Program (KEEP) Annual Data Report 2009: Executive Summary

M M R his year, 2010, the National Kidney Foundation’s (NKF) Kidney Early Evaluation Proram (KEEP) marks a decade of data collection s a part of its multicenter screening program for olunteer participants at risk of chronic kidney isease (CKD). During the years, KEEP has ielded important inferences regarding CKD epiemiologic characteristics and risk factors, and elated comorbid conditions, including hypertenion, metabolic syndrome, diabetes, bone and ineral disorder, anemia, and heart disease, have een characterized and reported. This suppleent to the American Journal of Kidney Disases highlights 4 articles: (1) a 10th anniversary ummary of KEEP milestones; (2) a comparison f CKD among elderly KEEP participants, the ational Health and Nutrition and Examination urvey (NHANES), and Medicare recipients; (3) n examination of the cluster of obesity and etabolic syndrome in racial categories; and (4) description of the impact of microalbuminuria n CKD identification.

Racial Differences in Kidney Function Among Individuals With Obesity and Metabolic Syndrome: Results From the Kidney Early Evaluation Program (KEEP)

Obesity and metabolic syndrome may differ by race. For participants in the National Kidney Foundation's Kidney Early Evaluation Program (KEEP), we examined whether African American and white participants with obesity and metabolic syndrome differ regarding albuminuria, estimated glomerular filtration rate (eGFR), anemia, and bone/mineral metabolism derangements in chronic kidney disease (CKD). 3 study cohorts were assembled: (1) eligible African American and white KEEP participants with body mass index > or = 30 kg/m(2), (2) a subgroup meeting criteria for metabolic syndrome, and (3) a subgroup with eGFR < 60 mL/min/1.73 m(2) and laboratory measurements for hemoglobin, parathyroid hormone, calcium, and phosphorus. Patient characteristics and kidney function assessments were compared and tested using chi(2) (categorical variables) and t test (continuous variables). Univariate and multivariate logistic regression analyses were performed to evaluate associations of race with kidney disease measures. Of 37,107 obese participants, 48% were African American and 52% were white. Whites were more likely to have metabolic syndrome components (hypertension, 87.1% vs 84.8%; dyslipidemia, 81.6% vs 66.7%; diabetes, 42.7% vs 34.9%) and more profoundly decreased eGFR than African Americans (CKD stages 3-5 prevalence, 23.6% vs 13.0%; P < 0.001). African Americans were more likely to have abnormal urinary albumin excretion (microalbuminuria, 12.5% vs 10.2%; OR, 1.60 [95% CI, 1.45-1.76]; macroalbuminuria, 1.3% vs 1.2%; OR, 1.61 [95% CI, 1.23-2.12]) and CKD stages 1-2 (10.3% vs 7.1%; OR, 1.54 [95% CI, 1.38-1.72]). For participants with CKD stages 3-5, anemia prevalence was 32.4% in African Americans and 14.1% in whites; corresponding values for secondary hyperparathyroidism were 66.2% and 46.6%, respectively. Obesity and metabolic syndrome may be heterogeneous disease states in African Americans and whites, possibly explaining differences in long-term kidney and cardiovascular outcomes.

Low birth weight is associated with chronic kidney disease only in men

The association of low birth weight and chronic kidney disease was examined in a screened volunteer population by the National Kidney Foundation's Kidney Early Evaluation Program. This is a free, community-based health program enrolling individuals aged 18 years or older with diabetes, hypertension, or a family history of kidney disease, diabetes, or hypertension. Self-reported birth weight was categorized and chronic kidney disease defined as an estimated glomerular filtration rate less than 60 ml per min per 1.73 m(2) or a urine albumin/creatinine ratio >or=30 mg/g. Among 12 364 participants, 15% reported a birth weight less than 2500 g. In men, significant corresponding odds ratios were found after adjustment for demographic characteristics and health conditions to this low birth weight and chronic kidney disease, but there was no association among women. There was no significant interaction between birth weight and race for either gender. Efforts to clinically understand the etiology of this association and potential means of prevention are essential to improving public health.

Independent Components of Chronic Kidney Disease as a Cardiovascular Risk State

The relationships of anemia, microalbuminuria, and estimated glomerular filtration rate (eGFR) with cardiovascular disease (CVD) and subsequent death are not fully understood. We hypothesized that each of these chronic kidney disease-related measures would have an independent relationship with CVD. A cohort of 37 153 persons screened in the National Kidney Foundation's Kidney Early Evaluation Program were followed up for a median of 16.0 months (range, 0.2-47.5 months). Participants were volunteers who completed surveys regarding past medical events and who underwent blood pressure and laboratory testing. Estimated glomerular filtration rate was computed using a 4-variable equation. Mortality was ascertained by linkage to national data systems. Of 37 153 persons, the mean +/- SD age was 52.9 +/- 15.9 years, and 68.7% were female. A total of 1835 (4.9%) had a self-reported history of myocardial infarction, 1336 (3.6%) had a history of stroke, and 2897 (7.8%) had a history of myocardial infarction or stroke. Multivariate analysis controlling for age demonstrated that the following were independently associated with CVD: male sex (odds ratio [OR], 1.64; P<.001), smoking (OR, 1.73; P<.001), body mass index (OR, 1.01; P = .03), diabetes mellitus (OR, 1.66; P<.001), hypertension (OR, 1.77; P<.001), eGFR of 30 to 59 mL/min per 173 m(3) (OR, 1.37; P = .001), hemoglobin level of 12.8 g/dL or less (OR, 1.45; P<.001), and microalbuminuria of greater than 30 mg/L (OR, 1.28; P = .01). Survival analysis found CVD (OR, 3.02; P = .003), chronic kidney disease (OR, 1.98; P = .05), and the combination (OR, 3.80; P<.001) to be independent predictors of mortality. Persons with a combination of all 3 chronic kidney disease measures (anemia, microalbuminuria, and eGFR of <60 mL/min per 1.73 m(2)) had the lowest survival of about 93% by the end of 30 months. Anemia, eGFR, and microalbuminuria were independently associated with CVD, and when all 3 were present, CVD was common and survival was reduced.