Journal Article

Long-term retinal, renal and cardiovascular outcomes in diabetic chronic kidney disease without proteinuria

Rajiv Agarwal, Yalew T. Debella, Habtamu D. Giduma and Robert P. Light

in Nephrology Dialysis Transplantation

Published on behalf of European Renal Association - European Dialysis and Transplant Assoc

Volume 27, issue 1, pages 310-317
Published in print January 2012 | ISSN: 0931-0509
Published online June 2011 | e-ISSN: 1460-2385 | DOI: http://dx.doi.org/10.1093/ndt/gfr320
Long-term retinal, renal and cardiovascular outcomes in diabetic chronic kidney disease without proteinuria

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Background.

Patients with diabetes mellitus (DM) with chronic kidney disease (CKD) often have no proteinuria.

Methods.

To compare the characteristics that differ between DM + CKD patients with and without proteinuria, we conducted a cross-sectional study followed by surveillance over a decade for ‘hard’ cardiovascular, renal and retinal outcomes. Groups were stratified by presence (n = 129) and absence (n = 284) of DM. Each stratum had three groups: no CKD, CKD without proteinuria and CKD with proteinuria.

Results.

Compared to DM + CKD + proteinuria patients, those with DM + CKD but without proteinuria had similar clinical characteristics including estimated glomerular filtration rate. However, they had lower 24-h ambulatory systolic and diastolic blood pressure. Crude all-cause mortality rates per 1000 patient-years in the nondiabetic group with no CKD, CKD with no proteinuria and CKD with overt proteinuria were 29.3, 68.5 and 111.1, respectively. Respective rates in the diabetic group were 50.1, 105.7 and 136.8. Diabetes increased the risk of coronary (P = 0.01) and end-stage renal disease (ESRD) events (P = 0.05) even after multivariate adjustments. Proteinuria aggravated the risk of cardiovascular events, ESRD, death and time to first of these events similarly among diabetics with CKD compared to nondiabetics with CKD. Diabetic patients with CKD but no overt proteinuria were much more likely than nondiabetics to progress to overt proteinuria [adjusted hazard ratio 5.28 (95% confidence interval 1.64–17.02), P < 0.01). CKD was a risk factor for prevalent retinopathy and proteinuria was a risk factor for incident diabetic retinopathy.

Conclusions.

To protect sight, those with proteinuria and DM need regular retinal examinations. Since diabetic CKD patients without proteinuria are more likely to develop overt proteinuria, close follow-up and risk factor management among these patients appear to be more important than among nondiabetic patients with CKD and no proteinuria.

Keywords: CKD; cohort study; diabetes mellitus; myocardial infarction; proteinuria

Journal Article.  4534 words.  Illustrated.

Subjects: Nephrology

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