Original Investigation
Pathogenesis and Treatment of Kidney Disease
Retinopathy and CKD as Predictors of All-Cause and Cardiovascular Mortality: National Health and Nutrition Examination Survey (NHANES) 1988-1994

https://doi.org/10.1053/j.ajkd.2014.01.437Get rights and content

Background

Retinopathy is associated with increased mortality risk in general populations. We evaluated the joint effect of retinopathy and chronic kidney disease (CKD) on mortality in a representative sample of US adults.

Setting & Participants

7,640 adults from NHANES (National Health and Nutrition Examination Survey) 1988-1994 with mortality linkage through December 31, 2006.

Predictors

CKD, defined as low estimated glomerular filtration rate (<60 mL/min/1.73 m2) or albuminuria (urine protein-creatinine ratio ≥ 30 mg/g), and retinopathy, defined as the presence of microaneurysms, hemorrhages, exudates, microvascular abnormalities, or other evidence of diabetic retinopathy by fundus photograph.

Outcomes

All-cause and cardiovascular mortality.

Measurements

Multivariable-adjusted Cox proportional hazards.

Results

Overall, 4.6% of participants had retinopathy and 15% had CKD. Mean age was 56 years, 53% were women, and 81% were non-Hispanic whites. The prevalence of retinopathy in patients with CKD was 11%. We identified 2,634 deaths during 14.5 years’ follow-up. In multivariable analyses, compared with individuals with neither CKD nor retinopathy, HRs for all-cause mortality were 1.02 (95% CI, 0.75-1.38), 1.52 (95% CI, 1.35-1.72), and 2.39 (95% CI, 1.77-3.22) for individuals with retinopathy only, those with CKD only, and those with both CKD and retinopathy, respectively. Corresponding HRs for cardiovascular mortality were 0.96 (95% CI, 0.50-1.84), 1.72 (95% CI, 1.47-2.00), and 2.96 (95% CI, 2.11-4.15), respectively. There was a significant synergistic interaction between retinopathy and CKD on all-cause mortality (P = 0.04).

Limitations

The presence of retinopathy was evaluated only once. Small sample size of some of the subpopulations studied.

Conclusions

In the presence of CKD, retinopathy is a strong predictor of mortality in this adult population.

Section snippets

Study Population and Baseline Data

NHANES III was conducted by the National Center for Health Statistics (NCHS) between 1988 and 1994 using a stratified clustered multistage probability sample survey design of the civilian noninstitutionalized US population with oversampling of blacks and Mexican Americans. The survey protocol was approved by the NCHS institutional review board. All participants provided informed consent.

There were 9,239 participants 40 years or older who were interviewed at home for sociodemographic and medical

Participant Characteristics

The overall weighted prevalence of retinopathy was 4.6%. The weighted prevalence of retinopathy was 11.0% for participants with CKD (25% and 6% in those with and without diabetes, respectively) and 3.7% in individuals without CKD. The weighted prevalence of CKD was 15%. Demographic and clinical characteristics of participants overall and by CKD and retinopathy status are presented in Table 1. Mean age was 56 years, 53% of participants were women, and 81% were non-Hispanic whites. Among

Discussion

Although previous studies have examined the association of retinopathy and mortality in non-CKD populations, to our knowledge, this study is the first to examine the joint effect of retinopathy and CKD on mortality. Compared with individuals with neither retinopathy nor CKD, the presence of both retinopathy and CKD was associated with a more than 2-fold increase in all-cause and cardiovascular mortality independent of demographic and clinical factors, including smoking, hypertension, and

Acknowledgements

Support: Dr Ricardo is funded by grant 1K23DK094829-01 from the National Institute of Diabetes and Digestive and Kidney Diseases.

Financial Disclosure: The authors declare that they have no other relevant financial interests.

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