Impact of type 2 diabetes on the incidence of cardiorenal syndromes and on subsequent clinical outcomes: a propensity-matched nationwide analysis

Background

Type 2 diabetes mellitus (T2DM) is a major risk factor for cardiac diseases and renal dysfunction. Whether T2DM increases the risk of cardiorenal syndromes (CRS) subtypes to a similar extent, and whether the risk of deleterious outcomes after CRS is modified by diabetes are poorly known.

Methods

In a nationwide cohort study including 5,123,193 patients seen in French hospitals in 2012 with at least 5 years of follow-up (or dying earlier), we assessed the incidence of CRS subtypes, and then the impact of T2DM in patients with CRS on the risk of death, cardiovascular death, heart failure (HF), myocardial infarction (MI) and end-stage kidney disease (ESKD) during follow-up (27,735,205 person-years). Patients with history of dialysis, kidney transplantation or type 1 DM were excluded of the analysis. We performed 1:1 propensity matching on baseline characteristics including age, sex, risk factors, cardiovascular and non-cardiovascular comorbidities for patients with T2DM or no T2DM. The model by Fine and Gray was used for analyzing the competing risks for clinical events and all-cause death with sub-distribution hazard ratios (sHR).

Results

Among the 5,123,193 patients, 4,605,236 (91.2%) had neither HF nor CKD baseline. Among them, 391,186 (8.1%) had T2DM and 380,581 of them were matched 1:1 with 380,581patients with no T2DM. During follow-up, CRS occurred in 42,375 patients (incidence 0.98%/year): acute, i.e. type 1,3 or 5 CRS n=9,438, 22%; type 2 (cardiorenal) CRS n=21,075, 50%; type 4 (renocardiac) CRS n=11,862, 28%). In multivariable analysis, T2DM was the most powerful predictor of incident CRS (any type, HR: 2.182, 95% CI 2.150–2.214) among all baseline characteristics. The incidence of all-type CRS was higher in matched patients with T2DM (1.30%/year, 95% CI 1.29–1.32) than in those with no T2DM (0.65%/year, 95% CI 0.64–0.66): sHR 1.905 (95% CI 1.867–1.943). The risk of CRS associated with diabetes (vs no diabetes) was higher for type 4 (sHR 2.182, 95% CI 2.098–2.269) than for type 2 (sHR 1.834, 95% CI 1.783–1.887) and for acute (sHR 1.707, 95% CI 1.637–1.780) CRS.

Among the 451,942 patients with HF or CKD at baseline, 26,396 patients had CRS at baseline, among whom 11,355 (43.0%) had diabetes: 8,314 of them were matched 1:1 with 8,314 with CRS and no T2DM. Compared to CRS patients with no diabetes, matched patients with CRS and T2DM had a greater incidence of all-cause death (sHR 1.085, 95% CI 1.048–1.123), cardiovascular death (sHR 1.145, 95% CI 1.080–1.214), ESKD (sHR 1.319, 95% CI 1.223–1.422), hospitalization for HF (sHR 1.119, 95% CI 1.078–1.162) and MI (sHR 1.294, 95% CI 1.139–1.470) during follow-up.

Conclusions

T2DM is a major risk factor for all CRS subtypes, may differently affect the incidence of type 2, type 4 and acute CRS and aggravates the risk of deleterious outcomes after CRS.

Funding Acknowledgement

Type of funding sources: None.

Effect of cardiorenal syndrome and its different subtypes on incidence of atrial fibrillation in a nationwide analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiorenal syndromes (CRS) are associated with increased risks of all-cause and cardiovascular death, end-stage kidney disease (ESKD), myocardial infarction (MI), heart failure (HF) and ischemic stroke. Whether CRS (and different subtypes of CRS) are more prone to develop atrial fibrillation (AF) is unclear.

Methods

This longitudinal cohort study was based on the national hospitalization database covering hospital care from the entire French population. The analysis focused on those with at least 5 years of complete follow-up (or dead earlier) as described by others. We identified 439,787 consecutive patients hospitalized in France in 2012 who had heart failure (HF), chronic kidney disease (CKD) and/or CRS. We estimated incidences of clinical events (including incident AF) during follow-up. Analysis were adjusted for 1) age and sex and 2) all baseline characteristics except cardiac and renal comorbidities.

Results

Overall, 58.2% were male, 67.7% had hypertension, 31.6% had diabetes mellitus and their mean age was 75.3±13.2; 329,154 had isolated HF, 67,939 had isolated CKD, 15,695 had acute concomitant CRS (which could be type 1, 3 or 5 CRS), 15,699 had type 2 CRS (cardiorenal) and 11,300 had type 4 CRS (renocardiac). History of AF was present in 36.4 % of the patients: 39.9% in those with isolated HF, 13.3% in those with isolated CKD, 43.0% in those with concomitant CRS, 57.2% in those with type 2 CRS, 35.3% in those with type 4 CRS (overall p<0.0001).

Incidence and adjusted hazard ratios for of all-cause death, cardiovascular death and incident AF are in Table 1. CRS was associated with a higher risk of death and patients with type 2 CRS had the highest risk of all-cause and cardiovascular mortality. Isolated HF was associated with a higher risk of incident AF than isolated CKD (Table 1). Patients with CRS had higher risk of incident AF than those with isolated HF or isolated CKD. Among patients with CRS, those with concomitant CRS had the numerically highest 5-year risk of incident AF, which was not statistically different than those with type 2 or type 4 CRS in adjusted analysis.

Conclusion

The long-term prognosis of CRS subtypes is poor and may vary, some CRS subtypes being more closely associated with risk of all-cause death and cardiovascular mortality than others. Risk of incident AF is higher in CRS than in isolated HF or isolated CKD and is not statistically different among the various subtypes of CRS.