Assessing Renal Risk in Type 2 Diabetes: NZ Diabetes Cohort Study

Size: px

Start display at page:

Download "Assessing Renal Risk in Type 2 Diabetes: NZ Diabetes Cohort Study"

Jack Short
7 years ago
Views:

1 Assessing Renal Risk in Type 2 Diabetes: NZ Diabetes Cohort Study C Raina Elley, Tom Robinson, Simon Moyes, Tim Kenealy, Elizabeth Robinson, John Collins, Brandon Orr-Walker and Paul Drury School of Population Health, University of Auckland, PHOs, Diabetes Trusts and DHBs from around NZ

2 Renal disease and type 2 diabetes Diabetes is the number one cause of end stage renal disease (ESRD) around the world Costs of dialysis, renal transplantation and death from renal failure are high Disparities in ESRD exist

3 Background European Maori Pacific Renal replacement therapy by ethnicity in New Zealand (patients/million) re: J. Collins, 2009

4 Background Few effective treatments to prevent ESRD other than BP control, ACEi/ARBs and Glc control Early detection and treatment do better At present we use egfr as measure of deterioration and risk of ESRD Does not include albuminuria or other risk factors Tangri s ESRD risk score for advanced CKD Appropriateness for 1 o care? Tangri JAMA 2011; 305:1553-9

5 Aims: NZ Diabetes Cohort Study: Renal risk equation development To derive a renal risk equation for primary care Methods ( ): Derivation cohort: NZ Diabetes Cohort Study (DCS) Validation cohort: Auckland Diabetes Care Support Services (DCSS) Outcome: End Stage Renal Disease (ESRD): Peritoneal dialysis or haemodialysis for ESRD Renal transplantation or Death (CRF or ESRD as contributing cause)

6 East Health Health West Mangere Comm. Health Trust Total Healthcare Otara South Seas health Counties Manukau CCM Rotorua GP Group Wellington Regional Diabetes Trust 6 Northland PHOs North Harbour Tamaki Healthcare Procare Ngati Porou Hauora Pinnacle Western BOP PHO Eastern BOP PHO Manawatu, Horowhenua, Tararua Diabetes Trust Pegasus 24/26 organisations agreed to participate

7 Model derivation: Flow diagram DCS patients with type 2 diabetes and complete data at baseline n= 26,924 Previous renal event (Dialysis or transplant prior to baseline): n = 104 (0.3%) CKD stage 4-5 egfr <30: n = 1,084 (4%) Study sample n = 25,736 (96%) (Follow-up 4-11 years; mean: 7 years) Other deaths: n = 4,744 (18%) Surviving and no renal event: n = 20,355 (79%) First renal event n = 637 (2.5%): Death with ESRD as contributing cause n =369 Renal transplant n = 33 Dialysis n = 235

8 Adjusted Hazard Ratios for first ESRD event Model 4: Adjusted HR 7: Adjusted HR Female Serum Cr, per 10umol/L 1.36 egfr (MDRD) 0.96 Albuminuria No albuminuria 1 1 Microalbuminuria Macroalbuminuria Advanced albuminuria Systolic BP, per 10mmHg HbA1c, per 10 mmol/mol Smoking status Non-smoker 1 1 Current smoker Past smoker History of CVD Age, per year Age of onset, per year Duration, per year C-statistic:

9 Adjusted Hazard Ratios for first end-stage renal event Model 4: Adjusted HR 7: Adjusted HR Ethnicity α European 1 1 Māori Pacific East Asian 0.87* 0.84* Indo Asian 0.96* 0.95* Other ethnicity 0.80* 0.77* Ethnicity as a whole was statistically significant; *not statistically significant and small numbers

10 Discrimination in validation cohort (n=5,877) Sensitivity Specificity Model 3 Model 4 Model 5 Model 6 Area under the ROC = 0.92 for DCS models on DCSS cohort

11 ROC egfr for first ESRD event Area under the curve = 0.77

12 Calibration in validation cohort Model 3 Model 4 Model 6 5 year risk percent Observed risk Predicted risk Deciles of risk Deciles of risk Deciles of risk

13 Three Scenarios: A. 60 year-old European woman, 6 year hx of diabetes, exsmoker, BP 130/80, HbA1c 7.0, UACR= 3, scr 65, no meds, no CVD. 5-Year Renal risk = 0.2% B. 60 year-old Māori woman with 6 year hx of diabetes, current smoker, BP 130/80, HbA1c 8.0, UACR=33, scr 95, on ACEI, Prev CVD. 5-Year Renal risk = 10.8% C. 60 year-old Māori woman with 6 year hx of diabetes, current smoker, BP 130/80, HbA1c 8.0, UACR>100mg/mmol, scr 95, on ACEI, Prev CVD. 5-Year Renal risk = 25.8%.

14 Survival Curves for ESRD Event-free probability A B C Years Followup

15 55 year-old man with a systolic blood pressure of 140 mmhg, serum creatinine of 120 µmol/l and diabetes duration of 5 years Ethnicity HbA1c, mmol/mol (%) Albuminuria Previous CVD Smoking status egfr 5-year renal risk α (%) European 53 (7) No No Never European 64 (8) Micro Yes Previous European 75 (9) Macro Yes Current European 86 (10) Advanced Yes Current Pacific 53 (7) No No Never Pacific 64 (8) Micro Yes Previous Pacific 86 (10) Advanced Yes Current Maori 53 (7) No No Never Maori 64 (8) Micro Yes Previous Maori 75 (9) Macro Yes Current Maori 86 (10) Advanced Yes Current Indian 53 (7) No No Never Indian 64 (8) Micro Yes Previous Indian 75 (9) Macro Yes Current Indian 86 (10) Advanced Yes Current East-Asian 53 (7) No No Never East-Asian 64 (8) Micro Yes Previous

16 Conclusion Derivation of ESRD risk model to inform treatment decisions in primary care. More accurate and predictive than using egfr or albuminuria alone Useful way of risk stratifying for early preventive medications and referral Similar risk variables to CVD risk and can be projected at the same time (may raise patient awareness as well as prompting earlier intervention) Elley CR et al Diabetes Care June 25, 2013, doi: /dc

17 Acknowledgements Patients, GPs, PHOs, Maori health organisations and Diabetes trusts who contributed to the study Diabetes Cohort Study team and data managers Diabetes Care Support Services New Zealand Ministry of Health and ANZDATA Funders: NZ Health Research Council and Auckland Medical Research Foundation

18 Diabetes CV risk calculator estimate cf Framingham 5-yr CVD risk of 9%

19 Diabetes CV risk calculator estimate cf Framingham 5-yr CVD risk of 9%

20 Diabetes CV risk calculator estimate cf Framingham 5-yr CVD risk of 9%

21 Estimated 5yr CVD risk of 50 yr-old man, non-smoker, SBP 140, TC:HDL ratio 4.5, diabetes duration 5 yrs compared with estimate using the Framingham risk equation Ethnicity HbA1c Albuminuria Anti-hyp Fram 5 yr risk DCS eq. 5 yr risk European 7 No No 9% 10% European 7 Micro No 9% 12% European 9 Macro Yes 9% 23% Māori 7 No No 9% 14% Māori 9 Micro No 9% 19% Māori 9 Macro Yes 9% 27% Indian 7 No No 9% 15% Indian 9 Macro Yes 9% 29% Pacific 7 No No 9% 12% Pacific 9 Micro No 9% 17% Pacific 9 Macro Yes 9% 24 %

Systolic Blood Pressure Intervention Trial (SPRINT) Principal Results

Systolic Blood Pressure Intervention Trial (SPRINT) Principal Results Paul K. Whelton, MB, MD, MSc Chair, SPRINT Steering Committee Tulane University School of Public Health and Tropical Medicine, and