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Chronic Kidney Disease and Mortality Risk: A Systematic Review

Marcello Tonelli^*,,,, Natasha Wiebe^*, Bruce Culleton^||, Andrew House^¶, Chris Rabbat, Mei Fok^*, Finlay McAlister^*,, and Amit X. Garg^¶,**

Departments of ^* Medicine, Critical Care, and Public Health Sciences, University of Alberta, and Institute of Health Economics, Edmonton, and ^|| Department of Medicine, University of Calgary, Calgary, Alberta, and Departments of ^¶ Medicine and ^** Epidemiology and Biostatistics, University of Western Ontario, London, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada

Address correspondence to: Dr. Finlay McAlister, University of Alberta, Department of Medicine, 8440 112 Street, Edmonton, Alberta T6B 2B7, Canada. Phone: 780-407-1399; Fax: 780-407-2680; E-mail: finlay.mcalister{at}ualberta.ca

Received for publication October 18, 2005. Accepted for publication April 20, 2006.

Current guidelines identify people with chronic kidney disease (CKD) as being at high risk for cardiovascular and all-cause mortality. Because as many as 19 million Americans may have CKD, a comprehensive summary of this risk would be potentially useful for planning public health policy. A systematic review of the association between non–dialysis-dependent CKD and the risk for all-cause and cardiovascular mortality was conducted. Patient- and study-related characteristics that influenced the magnitude of these associations also were investigated. MEDLINE and EMBASE databases were searched, and reference lists through December 2004 were consulted. Authors of 10 primary studies provided additional data. Cohort studies or cohort analyses of randomized, controlled trials that compared mortality between those with and without chronically reduced kidney function were included. Studies were excluded from review when participants were followed for <1 yr or had ESRD. Two reviewers independently extracted data on study setting, quality, participant and renal function characteristics, and outcomes. Thirty-nine studies that followed a total of 1,371,990 participants were reviewed. The unadjusted relative risk for mortality in participants with reduced kidney function compared with those without ranged from 0.94 to 5.0 and was significantly more than 1.0 in 93% of cohorts. Among the 16 studies that provided suitable data, the absolute risk for death increased exponentially with decreasing renal function. Fourteen cohorts described the risk for mortality from reduced kidney function, after adjustment for other established risk factors. Although adjusted relative hazards were consistently lower than unadjusted relative risks (median reduction 17%), they remained significantly more than 1.0 in 71% of cohorts. This review supports current guidelines that identify individuals with CKD as being at high risk for cardiovascular mortality. Determining which interventions best offset this risk remains a health priority.

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