Outcomes associated with microalbuminuria: Effect modification by chronic kidney disease

Csaba Kovesdy, Evan H. Lott, Jun Ling Lu, Sandra M. Malakauskas, Jennie Z. Ma, Miklos Z. Molnar, Kamyar Kalantar-Zadeh

Research output: Contribution to journalArticle

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Abstract

Objectives: This study sought to compare the association of microalbuminuria with outcomes in patients with different comorbidities. Background: The risk of adverse outcomes associated with lower levels proteinuria has been found to be linearly decreasing with even low-normal levels of microalbuminuria. It is unclear whether comorbid conditions change these associations. Methods: We examined the association of urine microalbumin- creatinine ratio (UACR) with mortality and the slopes of estimated glomerular filtration rate (eGFR) in a nationally representative cohort of 298,875 U.S. veterans. Associations of UACR with all-cause mortality overall and in subgroups of patients with and without diabetes mellitus, hypertension, cardiovascular disease, congestive heart failure, and advanced chronic kidney disease (CKD) were examined in Cox models, and with the slopes of eGFR in linear and logistic regression models. Results: Very low levels of UACR were linearly associated with decreased mortality and less progression of CKD overall: adjusted mortality hazard ratio and estimated glomerular filtration rate slope (95% confidence interval [CI]) associated with UACR ≥200 μg/mg, compared to <5 μg/mg were 1.53 (95% CI: 1.38 to 1.69, p < 0.001) and -1.59 (95% CI: -1.83 to -1.35, p < 0.001). Similar linearity was present in all examined subgroups, except in patients with CKD in whom a U-shaped association was present and in whom a UACR of 10 to 19 was associated with the best outcomes. Conclusions: The association of UACR with mortality and with progressive CKD is modified in patients with CKD, who experience higher mortality and worse progression of CKD with the lowest levels of UACR. Proteinuria-lowering interventions in patients with advanced CKD should be implemented cautiously, considering the potential for adverse outcomes.

Original languageEnglish (US)
Pages (from-to)1626-1633
Number of pages8
JournalJournal of the American College of Cardiology
Volume61
Issue number15
DOIs
StatePublished - Apr 16 2013

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Chronic Renal Insufficiency
Creatinine
Urine
Mortality
Glomerular Filtration Rate
Confidence Intervals
Proteinuria
Logistic Models
Veterans
Proportional Hazards Models
Comorbidity
Linear Models
Diabetes Mellitus
Cardiovascular Diseases
Heart Failure
Hypertension

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine

Cite this

Kovesdy, C., Lott, E. H., Lu, J. L., Malakauskas, S. M., Ma, J. Z., Molnar, M. Z., & Kalantar-Zadeh, K. (2013). Outcomes associated with microalbuminuria: Effect modification by chronic kidney disease. Journal of the American College of Cardiology, 61(15), 1626-1633. https://doi.org/10.1016/j.jacc.2012.11.071

Outcomes associated with microalbuminuria : Effect modification by chronic kidney disease. / Kovesdy, Csaba; Lott, Evan H.; Lu, Jun Ling; Malakauskas, Sandra M.; Ma, Jennie Z.; Molnar, Miklos Z.; Kalantar-Zadeh, Kamyar.

In: Journal of the American College of Cardiology, Vol. 61, No. 15, 16.04.2013, p. 1626-1633.

Research output: Contribution to journalArticle

Kovesdy, Csaba ; Lott, Evan H. ; Lu, Jun Ling ; Malakauskas, Sandra M. ; Ma, Jennie Z. ; Molnar, Miklos Z. ; Kalantar-Zadeh, Kamyar. / Outcomes associated with microalbuminuria : Effect modification by chronic kidney disease. In: Journal of the American College of Cardiology. 2013 ; Vol. 61, No. 15. pp. 1626-1633.
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abstract = "Objectives: This study sought to compare the association of microalbuminuria with outcomes in patients with different comorbidities. Background: The risk of adverse outcomes associated with lower levels proteinuria has been found to be linearly decreasing with even low-normal levels of microalbuminuria. It is unclear whether comorbid conditions change these associations. Methods: We examined the association of urine microalbumin- creatinine ratio (UACR) with mortality and the slopes of estimated glomerular filtration rate (eGFR) in a nationally representative cohort of 298,875 U.S. veterans. Associations of UACR with all-cause mortality overall and in subgroups of patients with and without diabetes mellitus, hypertension, cardiovascular disease, congestive heart failure, and advanced chronic kidney disease (CKD) were examined in Cox models, and with the slopes of eGFR in linear and logistic regression models. Results: Very low levels of UACR were linearly associated with decreased mortality and less progression of CKD overall: adjusted mortality hazard ratio and estimated glomerular filtration rate slope (95{\%} confidence interval [CI]) associated with UACR ≥200 μg/mg, compared to <5 μg/mg were 1.53 (95{\%} CI: 1.38 to 1.69, p < 0.001) and -1.59 (95{\%} CI: -1.83 to -1.35, p < 0.001). Similar linearity was present in all examined subgroups, except in patients with CKD in whom a U-shaped association was present and in whom a UACR of 10 to 19 was associated with the best outcomes. Conclusions: The association of UACR with mortality and with progressive CKD is modified in patients with CKD, who experience higher mortality and worse progression of CKD with the lowest levels of UACR. Proteinuria-lowering interventions in patients with advanced CKD should be implemented cautiously, considering the potential for adverse outcomes.",
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AU - Lott, Evan H.

AU - Lu, Jun Ling

AU - Malakauskas, Sandra M.

AU - Ma, Jennie Z.

AU - Molnar, Miklos Z.

AU - Kalantar-Zadeh, Kamyar

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N2 - Objectives: This study sought to compare the association of microalbuminuria with outcomes in patients with different comorbidities. Background: The risk of adverse outcomes associated with lower levels proteinuria has been found to be linearly decreasing with even low-normal levels of microalbuminuria. It is unclear whether comorbid conditions change these associations. Methods: We examined the association of urine microalbumin- creatinine ratio (UACR) with mortality and the slopes of estimated glomerular filtration rate (eGFR) in a nationally representative cohort of 298,875 U.S. veterans. Associations of UACR with all-cause mortality overall and in subgroups of patients with and without diabetes mellitus, hypertension, cardiovascular disease, congestive heart failure, and advanced chronic kidney disease (CKD) were examined in Cox models, and with the slopes of eGFR in linear and logistic regression models. Results: Very low levels of UACR were linearly associated with decreased mortality and less progression of CKD overall: adjusted mortality hazard ratio and estimated glomerular filtration rate slope (95% confidence interval [CI]) associated with UACR ≥200 μg/mg, compared to <5 μg/mg were 1.53 (95% CI: 1.38 to 1.69, p < 0.001) and -1.59 (95% CI: -1.83 to -1.35, p < 0.001). Similar linearity was present in all examined subgroups, except in patients with CKD in whom a U-shaped association was present and in whom a UACR of 10 to 19 was associated with the best outcomes. Conclusions: The association of UACR with mortality and with progressive CKD is modified in patients with CKD, who experience higher mortality and worse progression of CKD with the lowest levels of UACR. Proteinuria-lowering interventions in patients with advanced CKD should be implemented cautiously, considering the potential for adverse outcomes.

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