Cardiovascular risk in mild to moderately decreased glomerular filtration rate, diabetes and coronary heart disease in a southern European region.

INTRODUCTION AND OBJECTIVES: Individuals with mild to moderately decreased estimated glomerular filtration rate (eGFR=30-59 mL/min/1.73 m2) are considered at high risk of cardiovascular disease (CVD). No studies have compared this risk in eGFR=30-59, diabetes mellitus (DM), and coronary heart disease (CHD) in regions with a low incidence of CHD. METHODS: We performed a retrospective cohort study of 122 443 individuals aged 60-84 years from a region with a low CHD incidence with creatinine measured between January 1, 2010 and December 31, 2011. We identified hospital admissions due to CHD (myocardial infarction, angina) or CVD (CHD, stroke, or transient ischemic attack) from electronic medical records up to December 31, 2013. We estimated incidence rates and Cox regression adjusted subdistribution hazard ratio (sHR) including competing risks in patients with eGFR=30-59, DM and CHD, or combinations, compared with individuals without these diseases. RESULTS: The median follow-up was 38.3 [IQR, 33.8-42.7] months. Adjusted sHR for CHD in individuals with eGFR=30-59, DM, eGFR=30-59 plus DM, previous CHD, CHD plus DM, and CHD plus eGFR=30-59 plus DM, were 1.34 (95%CI, 1.04-1.74), 1.61 (95%CI, 1.36-1.90), 1.96 (95%CI, 1.42-2.70), 4.33 (95%CI, 3.58-5.25), 7.05 (5.80-8.58) and 7.72 (5.72-10.41), respectively. The corresponding sHR for CVD were 1.25 (95%CI, 1.06-1.46), 1.56 (95%CI, 1.41-1.74), 1.83 (95%CI, 1.50-2.23), 2.86 (95%CI, 2.48-3.29), 4.54 (95%CI, 3.93-5.24), and 5.33 (95%CI, 4.31-6.60). CONCLUSIONS: In 60- to 84-year-olds with eGFR=30-59, similarly to DM, the likelihood of being admitted to hospital for CHD and CVD was about half that of individuals with established CHD. Thus, eGFR=30-59 does not appear to be a coronary-risk equivalent. Individuals with CHD and DM, or eGFR=30-59 plus DM, should be prioritized for more intensive risk management.

Estimated Glomerular Filtration Rate, Cardiovascular Events and Mortality Across Age Groups Among Individuals Older Than 60 Years in Southern Europe.

INTRODUCTION AND OBJECTIVES: Individuals with a decreased estimated glomerular filtration rate (eGFR) are at increased risk of all-cause (ACM) and cardiovascular mortality; there is ongoing debate about whether older individuals with eGFR 45 to 59mL/min/1.73 m2 are also at increased risk. We evaluated the association between eGFR and ACM and cardiovascular events (CVE) in people aged 60 to 74 and ≥ 75 years in a population with a low coronary disease incidence. METHODS: We conducted a retrospective cohort study by using primary care and hospital electronic records. We included 130 233 individuals aged ≥ 60 years with creatinine measurement between January 1, 2010 and December 31, 2011; eGFR was estimated by using the Chronic Kidney Disease Epidemiology Collaboration creatinine equation. The independent association between eGFR and the risk of ACM and hospital admission due to CVE were determined with Cox and Fine-Gray regressions, respectively. RESULTS: The median was age 70 years, and 56.1% were women; 13.5% had eGFR < 60 (69.7% eGFR 45-59). During a median follow-up of 38.2 months, 6474 participants died and 3746 had a CVE. For ACM and CVE, the HR in older individuals became significant at eGFR < 60. Fully adjusted HR for ACM in the eGFR 45 to 59 category were 1.61; 95%CI, 1.37-1.89 and 1.19; 95%CI, 1.10-1.28 in 60- to 74-year-olds and ≥ 75-year-olds, respectively; for CVE HR were 1.28; 95%CI, 1.08-1.51 and 1.12; 95%CI, 0.99-1.26. CONCLUSIONS: In a region with low coronary disease incidence, the risk of death and CVE increased with decreasing eGFR. In ≥ 75-year-olds, the eGFR 45 to 59 category, which had borderline risk for CVE, included many individuals without significant additional risk.

[Chronic kidney disease in Primary Health Care: prevalence and associated risk factors]. / Enfermedad renal crónica en Atención Primaria: prevalencia y factores de riesgo asociados.

OBJECTIVE: To determine the prevalence of chronic kidney disease and associated risk factors in subjects over 60 years of age, as well as its staging by determining the glomerular filtration rate (GFR). DESIGN: Cross-sectional observational study. SETTING: Primary Health Care. PARTICIPANTS: Patients≥60 years of age who were seen in 40 Primary Health Care centres with serum creatinine measured in a central laboratory between January 1 and December 31, 2010. EXCLUSION CRITERIA: kidney transplant, home care. MAIN MEASURES: Social-demographic and anthropometric data, cardiovascular risk factors, and diseases established according to electronic clinical records. Serum creatinine was measured using standardised Jaffe kinetic method, and GFR estimated with MDRD-4-IDMS and CKD-EPI. RESULTS: A total of 97,665 subjects (57.3% women, median age 70.0 years [Q1: 65.0, Q3: 77.0]). GFR-MDRD prevalence<60=15.1% (16.6% in women, 13.2% in men; P<.001) and increased with age. Multivariate analysis showed a positive association between GFR-MDRD<60 and age (OR=1.74; 95% CI 1.70 to 1.77), hypertension (OR=2.18; 95% CI 2.08 to 2.30), heart failure (OR=2.03; 95% CI 1.83 to 2.25), atrial fibrillation (OR=1.57; 95% CI 1.41 to 1.76), ischaemic heart disease (OR=1.40; 95% CI 1.30 to 1.50), peripheral arterial disease (OR=1.31; 95% CI 1.09 to 1.57), dyslipidaemia (OR=1.28; 95% CI 1.23 to 1.33), diabetes (OR=1.26; 95% CI 1.17 to 1.34), and stroke (OR=1.17; 95% CI 1.09 to 1.25). The GFR-CKD-EPI model showed an increase in OR with age and male sex, that became significant as a chronic kidney disease risk factor. CONCLUSIONS: Chronic kidney disease has considerable prevalence in subjects≥60 years seen in Primary Health Care, more in women, and increasing with age. Hypertension, more than diabetes, was the main associated cardiovascular risk factor.

[Stratification of clinical risk groups in a population over 65 years: features and nursing assessment]. / Estratificación de la población mayor de 65 años en grupos de riesgo clínico: características y valoración enfermera.

OBJECTIVE: To analyze the characteristics of the population over 65 years served in a Basic Health Area, according to the Clinical Risk Group (CRG) classification and geriatric assessment test performed by the nurse in relation to their complexity. METHODS: A descriptive, cross-sectional and observational prevalence study was conducted on the population over 65 years served in a Basic Health Area. The variables collected were: socio-demographic, CRG classification, diseases (ICD-10), healthcare activity, geriatric assessment, and preventive activities. The CRG classification was used as a measurement tool. Data was collected from the Primary Care computerized clinical history (e-CAP). RESULTS: Population over 65 years: 3,219 people; served at home, 130 (4%), and in residential institutions, 92 (2.85%). The population was grouped into: CRG 1-2: 83 (2.5%); CRG 3: 62 (2%); CRG 4: 99 (3%); CRG 5: 537 (17%); CRG 6: 2,077 (64.5%); CRG 7: 276 (8.6%); CRG 8: 61 (2%); CRG 9: 14 (0.4%). Most frequent chronic diseases: 69.12% AHT; 24.94% DM; 19.51% depression; 11.09% kidney failure. The groups 6-7-8 that were analyzed included 2,414 people (75%). Of those within CRG 6-7-8, only 570 (24%) had tests carried out by the geriatric nurse. The mean number of individuals assigned by a nurse for CRG 6-7-8 was 302. CONCLUSIONS: The introduction of classification systems in clinical practice, such as the CRG, along with the use of the new information and communication technologies, helps to incorporate predictive models of health needs. It also promotes proactive actions by nurses and the team to prevent complications of diseases, as well as improving efficiency in the use of services and in care of the complex patients.

[Descriptive study of ambulatory blood pressure monitoring in the Primary Care Nursing clinic]. / Estudio descriptivo de la monitorización ambulatoria de la presión arterial en la consulta de Enfermería de Atención Primaria.

OBJECTIVE: To analyze the clinical characteristics and the circadian patterns of patients who received ambulatory blood pressure monitoring (ABPM) by a Primary Care Team. METHOD: A descriptive, observational, cross-sectional study at community level. People older than 18 years on ABPM (2007-2011). VARIABLES: demographic, cardiovascular disease, diabetes mellitus, cardiovascular risk factors, any type of arterial hypertension and circadian pattern. Intruments of measurement: 2 validated instruments with comparable results were used. PROCEDURE: The instruments for ABPM were placed during the nursing visit. The instruments were then removed after 24h, and the data was retrieved and recorded in the computerized clinical history. RESULTS: A total of 326 people were studied, with a mean age of 60.53±12.96 years, of whom 56.7% were male. According to ABPM the patient results showed that: 38.5% had «white coat¼ arterial hypertension, 36.2% were classified as poorly controlled arterial hypertension, 17.2% had masked hypertension, and 8% with isolated hypertension. Dipper circadian patterns were present in 39.6% of patients and non- dipper in 60.4%. CONCLUSIONS: ABPM allows to Primary Health Care professionals to check the actual situation of the blood pressure over 24h and analyze the circadian pattern. In clinical practice this involves having a comprehensive care strategy on life style, as well as adherence to treatment.

Estimation of glomerular filtration rate by MDRD-4 IDMS and CKD-EPI in individuals of 60 years of age or older in primary care.

OBJECTIVE: To compare the prevalence and classification of chronic kidney disease (CKD) in accordance with the estimated glomerular filtration rate (eGFR) by MDRD-4 IDMS and CKD-EPI in individuals ≥ 60 years of age in primary care. MATERIAL AND METHODS: Cross-sectional descriptive observational study. Subjects ≥ 60 years treated at 40 primary care centres with serum creatinine determination conducted between 1 January and 31 December 2010 at a single centralised laboratory. EXCLUSION CRITERIA: renal transplantation, home care. VARIABLES: socio-demographic, anthropometric, risk factors and cardiovascular disease as recorded in electronic medical records and serum creatinine concentration by a standardised compensated kinetic Jaffe method with IDMS and eGFR by MDRD-4 IDMS and CKD-EPI. Agreement was analysed using the kappa coefficient and the Bland-Altman graphical method. RESULTS: 97,554 individuals (57.3% women, mean age 70.0 [Q1: 65.0, Q3: 77.0]). Median eGFR with MDRD 78.7 [66.7, 91.0] ml/min/1.73m² (77.9 for women, 79.7 for men, P<.001) and 81.8 [68.5, 90.5] ml/min/1.73 m² (P=.311) with CKD-EPI, eFG(MDRD) prevalence <60 15.0% (16.5% women, 13.1% men and 6.5% in ≤ 70 years, 24%> 70 years) with CKD-EPI 14.2% (15.0% female, 13.0% male, 4.7% in ≤ 70 years, 24.1% in> 70 years) . There was an overall agreement of 85.6% (kappa coefficient = 0.75) in women> 70 years of 86.6% (kappa = 0.77), of 83.2% (kappa = 0.69) in men> 70 years, of 82.7% (kappa = 0.68) in women ≤ 70 years and 90% (kappa = 0.81) in men ≤ 70 years. CONCLUSIONS: CKD-EPI decreased the prevalence of CKD especially in women ≤ 70 years; the prevalence increased in men> 70 years. One in eight individuals with stage 3a was reclassified to no disease; reclassified individuals had lower comorbidity.