Trends in Major Cardiovascular Events and Bleeding Among Patients With Advanced CKD: A Nationwide Swedish Study.

Overview

abstract

RATIONALE & OBJECTIVE: Patients with advanced chronic kidney disease (CKD) have an excess risk of cardiovascular and bleeding events, but trends in the rates of these events have yet to be fully investigated. This study focused on characterizing them in Sweden. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: All patients with advanced CKD enrolled by nephrologists in a nationwide Swedish Renal Registry between 2011 and 2021. EXPOSURE: Stage G4 CKD (N = 25,591), nondialysis stage G5 CKD (ND-CKD, N = 13,968), supported by hemodialysis (N = 10,635), or supported by peritoneal dialysis (N = 4,511). OUTCOME: Major adverse cardiovascular events (MACE), arterial and venous thromboembolic events, major and non-major clinically-relevant bleeding. ANALYTICAL APPROACH: Patients were followed until an outcome event, death, or progression to a more severe CKD-stage/change of dialysis modality. Poisson models to estimate unadjusted incidence rates and standardized incidence rate ratios were computed using indirect standardization based on the observed rates in the age- and sex- matched general population. RESULTS: The rates of all study outcomes were greater with more severe stages of CKD; by 2021, the rates of these outcomes were 1.4 to 13.6 times higher than in the general population. Between 2011 and 2021, patients with advanced CKD experienced important reductions in the rates of MACE and arterial and venous thromboembolic events (as much as 39%, 28%, and 57%, respectively), with larger declines than those observed for the general population. Major bleeding rates also decreased (up to 12%), but non-major bleeding markedly increased, especially in ND-CKD (from 42% to 69%). The decreases in MACE as well as arterial and venous events were comparable for men and women (except for a greater reduction in arterial events in men than in women, P = 0.03). The increase in non-major bleeding rates was greater in women than in men (P = 0.02). LIMITATIONS: Outcomes based on diagnostic codes; unknown generalizability to other countries. CONCLUSIONS: Although there have been important reductions in the rates of cardiovascular events and major bleeding events in patients with advanced CKD, the event rates remain substantially higher than in the general population, indicating a need for additional strategies to minimize these risks. PLAIN-LANGUAGE SUMMARY: We explored rates and trends of cardiovascular and bleeding events in Swedish patients with advanced CKD between 2011 and 2021. Cardiovascular and bleeding events were 1.5 to 11.1 times more common in patients with CKD than in the general population. However, over time there has been a significant reduction in the rates of both types of events. The decline in these events over time was larger than that observed in the general population. These findings document improvements in cardiovascular and bleeding risks for patients with advanced CKD, but their continued occurrence at a rate greater than in the general population indicates the need for additional strategies to further reduce the burden of these health conditions.