Lifetime Risk of ESRD

Transcription

CLINICAL EPIDEMIOLOGY
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Tanvir Chowdhury Turin,* Marcello Tonelli,† Braden J. Manns,*‡ Sofia B. Ahmed*
Pietro Ravani,*‡ Matthew James*‡ and Brenda R. Hemmelgarn*‡
Departments of *Medicine and ‡Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; and
†
Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
ABSTRACT
Lifetime risk is the cumulative risk of experiencing an outcome between a disease-free index age and
death. The lifetime risk of ESRD for a middle-aged individual is a relevant and easy to communicate
measure of disease burden. We estimated lifetime risk of ESRD in a cohort of 2,895,521 adults without
ESRD from 1997 to 2008. To estimate lifetime risk of ESRD by level of baseline kidney function, we
analyzed a cohort of participants who had a serum creatinine measurement. We also estimated the sexand index age-specific lifetime risk of incident ESRD and accounted for the competing risk of death.
Among those individuals without ESRD at age 40 years, the lifetime risk of ESRD was 2.66% for men
and 1.76% for women. The risk was higher in persons with reduced kidney function: for eGFR=44–59
ml/min per 1.73 m2, the lifetime risk of ESRD was 7.51% for men and 3.21% for women, whereas men and
women with relatively preserved kidney function (eGFR=60–89 ml/min per 1.73 m2) had lifetime risks of
ESRD of 1.01% and 0.63%, respectively. The lifetime risk of ESRD was consistently higher for men at all
ages and eGFR strata compared with women. In conclusion, approximately 1 in 40 men and 1 in 60 women
of middle age will develop ESRD during their lifetimes (living into their 90s). These population-based
estimates may assist individuals who make decisions regarding public health policy.
J Am Soc Nephrol 23: ccc–ccc, 2012. doi: 10.1681/ASN.2012020164
ESRD is a chronic condition with significant health
consequences and high-cost treatment options.1–3
Although estimates of incidence and prevalence
provide important information about the burden
of a disease in the community, they do not provide
adequate information to understand risk at the
individual level. Lifetime risk (which expresses
the probability of an individual developing a disease condition during their remaining lifespan)
may be more informative for both the general
population and policy-makers, because it portrays
overall risk burden over the course of a person’s
life, thus allowing comparison of lifetime risks
across diseases of interests. It has been suggested
that lifetime risk estimates are useful for public education, because they are easier to comprehend than
measures such as incidence, prevalence, or relative
risk.4
Although estimates of lifetime risk are available
for several chronic disease conditions, including
coronary heart disease, 5,6 stroke, 7,8 hypertension,9 diabetes,10 breast cancer,11 dementia,12 and
J Am Soc Nephrol 23: ccc–ccc, 2012
fractures,13,14 reports on the lifetime risk of ESRD
are scarce and limited to an early-adult population.15 Furthermore, the lifetime risk of ESRD at
middle age and the lifetime risk of ESRD by level
of kidney function have not been reported. Given
the high morbidity16 and cost17 associated with
ESRD, an estimate of lifetime risk of ESRD would
be important information for patients, health practitioners, and policy-makers.
Using a cohort of adults residing in a single
Canadian province, we estimated the lifetime risk of
ESRD by sex. We also estimated the lifetime risk of
Received February 13, 2012. Accepted June 7, 2012.
Published online ahead of print. Publication date available at
www.jasn.org.
Correspondence: Dr. Brenda R. Hemmelgarn, Division of Nephrology, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB, Canada T2N 2T9. Email: Brenda.hemmelgarn@
albertahealthservices.ca
Copyright © 2012 by the American Society of Nephrology
ISSN : 1046-6673/2309-ccc
1
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ESRD by level of kidney function among a cohort of adults
with a serum creatinine measurement.
RESULTS
During total follow-up of 25,985,361 person-years (see
Figure 1 for cohort creation), 7107 participants experienced
ESRD. The mean duration of follow-up was 8.97 years (SD=3.73).
Table 1 presents the 10-, 20-, 30-, and 40-year risks of ESRD as
well as the lifetime risk of ESRD for men and women by index
ages of 40, 50, 60, and 70 years in Alberta, Canada (percentage). Adjustment for the competing risk of death attenuated
the estimate of cumulative incidence for ESRD. Lifetime risk of
ESRD for 40-year-old men was 4.14% when death was treated
as a censoring event and 2.66% when the death was treated as
a competing event. The lifetime risk of ESRD for 40-year-old
women, without and with adjustment for the competing risk of
death, was 2.28% and 1.76%, respectively. Similar differences
between the two methods were observed for all strata defined
by age and sex. As expected, there was a graded increase in the
risk of ESRD over longer time horizons for all age and sex
strata. For example, the risk of ESRD in a 40-year-old man
was 0.15%, 0.46%, 1.08%, and 1.98% over 10-, 20-, 30-, and
40-year time horizons, respectively (Figure 2).
In the cohort of participants who had at least one estimated
GFR (eGFR) measurement during 2002–2008, there were
996,249 participants (416,576 men and 579,673 women)
with baseline eGFR$90 ml/min per 1.73 m 2 , 689,603
participants (335,387 men and 354,216 women) with baseline
eGFR=60–89 ml/min per 1.73 m2, 89,662 participants (37,389
men and 52,273 women) with baseline eGFR=45–59 ml/min
per 1.73 m2, and 31,755 participants (12,190 men and 19,565
women) with baseline eGFR=30–44 ml/min per 1.73 m2.
During 7,504,339 person-years of follow-up, there were 2212 incident cases of ESRD. Table 2 shows the person-year of followup, incidence of ESRD, and mortality across age groups.
Table 3 presents the risk of ESRD in men and women over
different time intervals by index ages and level of eGFR. After
adjustment for the competing risk of death, the lifetime risk
of ESRD for 40-year-old men with eGFR$90 ml/min per
1.73 m2 was 0.72%, eGFR=60–89 ml/min per 1.73 m2 was
1.01%, eGFR=45–59 ml/min per 1.73 m2 was 7.51%, and
eGFR=30–44 ml/min per 1.73 m2 was 55.54%. For women aged
40 years, the lifetime risk was 0.67% for those individuals
with eGFR$90 ml/min per 1.73 m 2 , 0.73% for those
individuals with eGFR=60–89 ml/min per 1.73 m2, 3.21%
for those individuals with eGFR=45–59 ml/min per 1.73 m2,
and 28.81% for those individuals with eGFR=30–44 ml/min
per 1.73 m2 (Figure 3). Differential trends were observed for
the short-term risk estimates for the impaired and relatively
preserved kidney function groups. The short-term risks for
ESRD increased with higher index age for participants with
eGFR.90 and 60–89 ml/min per 1.73 m2. However, shortterm risks for ESRD decreased with higher index age for participants with eGFR=30–44 and 45–59 ml/min per 1.73 m2
(Table 3). A graded increase in the risk of ESRD over longer
time horizons was observed for all age and sex strata across all
Figure 1. Overview of cohort creation. (A) The primary study cohort consisted of Alberta residents aged 18 years or older registered
with Alberta Health and Wellness from April 1, 1997 to March 31, 2008. (B) Cohort of participants who had at least one outpatient
serum creatinine measurement from May 1, 2002 to March 31, 2008.
2
Journal of the American Society of Nephrology
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Table 1. Age- and sex-specific 10-, 20-, 30-, and 40-year and lifetime risk estimates (in percentages) for ESRD in Alberta,
Canada
Sex
Unadjusted for competing risk of death
men
men
men
men
women
women
women
women
Adjusted for competing risk of death
men
men
men
men
women
women
women
women
Index Age
(Years)
Short- and Intermediate-Term Risk (Years)
10
40
50
60
70
40
50
60
70
0.16 (0.14–0.17)
0.32 (0.30–0.34)
0.70 (0.65–0.74)
1.23 (1.15–1.31)
0.12 (0.10–0.13)
0.21 (0.19–0.23)
0.46 (0.43–0.50)
0.74 (0.69–0.79)
0.48 (0.45–0.50) 1.17 (1.12–1.22) 2.39 (2.30–2.48) 4.14 (3.93–4.35)
1.02 (0.96–1.07) 2.24 (2.15–2.33)
3.99 (3.78–4.20)
1.92 (1.84–2.01)
3.68 (3.47–3.89)
3.00 (2.79–3.21)
0.33 (0.31–0.35) 0.79 (0.75–0.83) 1.52 (1.45–1.59) 2.28 (2.16–2.39)
0.67 (0.63–0.72) 1.41 (1.34–1.48)
2.16 (2.05–2.28)
1.20 (1.13–1.26)
1.95 (1.83–2.07)
1.50 (1.39–1.61)
40
50
60
70
40
50
60
70
0.15 (0.14–0.17)
0.31 (0.29–0.34)
0.66 (0.62–0.71)
1.09 (1.02–1.15)
0.11 (0.10–0.13)
0.21 (0.19–0.23)
0.45 (0.41–0.48)
0.69 (0.64–0.74)
0.46 (0.44–0.49) 1.08 (1.03–1.13) 1.98 (1.91–2.05) 2.66 (2.57–2.75)
0.94 (0.90–1.00) 1.86 (1.79–1.93)
2.56 (2.46–2.59)
1.62 (1.55–1.70)
2.35 (2.26–2.45)
1.91 (1.82–2.01)
0.32 (0.30–0.34) 0.75 (0.71–0.79) 1.36 (1.30–1.42) 1.76 (1.69–1.83)
0.64 (0.61–0.68) 1.26 (1.20–1.32)
1.67 (1.60–1.74)
1.09 (1.03–1.14)
1.51 (1.43–1.54)
1.14 (1.08–1.21)
levels of kidney function (Figure 3). Men had a consistently
higher risk of ESRD compared with women in all analyses.
DISCUSSION
We estimated the lifetime risk of ESRD in a community-based
cohort of nearly 3 million people from a provincial health
registry. Lifetime risk is a measure of the cumulative risk
of experiencing an outcome during the remainder of an
individual’s life from a disease-free index age. Theoretical
advantages of reporting lifetime risk include ease of comparison between studies and overall risk of an adverse outcome
may be easier to understand than other commonly used epidemiologic measures of risk. The observed probabilities suggest that approximately 1 in 40 men and 1 in 60 women of
middle age will develop ESRD over their remaining life (with
the assumption that they will live to the age of 90 years). This
risk was higher in persons with reduced kidney function compared with those individuals with preserved kidney function.
The magnitude of the lifetime risks for ESRD may seem
higher than expected. However, a few key issues must be considered when interpreting our results. First, our estimates by
levels of kidney function are based on people who obtained a
serum creatinine measurement as part of clinical care. Because
physicians may be less likely to measure serum creatinine in
healthy individuals with no risk factors for ESRD, our estimates by levels of kidney function may be most relevant to
people accessing medical care with a perceived clinical need
rather than the general population. Second, given the average
age of our cohort, the lifetime risks predominantly reflect the
20
30
40
Lifetime Risk
risks in people who have survived to middle age, and they exclude individuals dying because of causes that disproportionately affect young individuals, such as childhood illnesses or
trauma. With these caveats in mind, our results are consistent
with prior reports. A simulation study based on the US
population reported the lifetime risk of ESRD to be 1 in 40 for
white men and nearly 1 in 50 for white women.15
Our estimates take into account all-cause mortality and the
competing risk of death in a community-based population.
Adjustment for the competing risk of death clearly attenuated
the estimate of cumulative ESRD incidence, especially over
longer time horizons, for those individuals with relatively
preserved kidney function. Adjusting for the competing risk of
death did not have any marked effect among the participants
with impaired kidney function. Attenuation of lifetime risk
estimates after adjusting for the competing risk of death has also
been reported in studies of cardiovascular disease.5,7
Sex differences in studies of CKD progression have been
reported, with higher rates of progression for men.18–20 We also
observed that women had a lower lifetime risk of ESRD compared with men of similar age strata. Our results are consistent
with prior reports, with lifetime risk of ESRD for 20-year-old
white men reported to be higher than white women.15 Interestingly, the lifetime risk of ESRD was reported to be the same for
black men and women at approximately 1 in 12.15
The cumulative risk of ESRD increased across the time horizons for all age strata for both men and women and reflects
the contribution of the age time scale, which has also been
reported for cardiovascular disease.5–8 We also observed that
the lifetime risk of ESRD decreased for increasing age strata,
which is also consistent with other reports of similar
3
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Figure 2. Cumulative risk of ESRD (in percentage) with advancing age for men and women at the index age of 40 years.
estimation for other chronic disease conditions.5–8 The decrease in lifetime risk of ESRD with older age reflects the
shorter life expectancy and period at risk for older participants. Also at older ages, competing causes of death will increase in importance, because older people may not live long
enough to develop ESRD, and people susceptible to ESRD
would have developed ESRD at an earlier age.
Adjustment of competing risk of death led to attenuation
for lifetime risk of ESRD in the overall estimates. Similar attenuation was observed regarding competing risk adjustment for the
estimates reported for other chronic disease conditions.5–8 Not
accounting for mortality (i.e., competing risk) during risk estimation in studies with prospective capturing of incidence may
introduce bias in risk estimates.21 Thus, adjusting for competing
risk of death will provide more robust lifetime risk estimates.
The lifetime risk estimates are useful for public education,
because they are easier to comprehend than measures such as
incidence, prevalence, or relative risk. 4 These estimates
provide a more coherent approach to health education, because low statistical numeracy and/or quantitative literacy are
common.22 A study with the objective to elicit patient preferences for the presentation and framing of risk information
concluded that patients preferred health risks to be framed
in absolute terms and lifetime estimates with a scale of x of
100.23 The benefits of reporting lifetime risk estimates have
4
also been observed. The widely publicized lifetime risk of
breast cancer, estimated to be one in eight (12.6%) for women
in the United States,11 is believed to have contributed to the
increase in screening mammogram for early disease detection.24 Although lifetime risk lacks the detail and precision
required for clinical consultation, the lifetime estimates presented here provide a useful and understandable summary of
risk in a population that will be useful for researchers and
policy-makers in envisaging the population burden of ESRD.
Strengths of our study include the use of a population-based
cohort and the completeness of ESRD and mortality ascertainment. We were also able to analyze a cohort stratified by
level of kidney function to estimate the lifetime risk of ESRD
by stage of kidney function.
This study examines the lifetime risk of ESRD among the
general population and by level of kidney function. However,
our estimates reported should be interpreted within the
context of the study limitations common to this type of
methodology—including an inability to directly validate the
results.5–7,11–13 Lifetime risks estimates are population-based
results, and therefore they have limited prognostic use at the
patient level, where the lifetime risk would also depend on
individual risk factors for ESRD. Furthermore, lifetime risk
estimates are based on assumptions of a fixed age and demographic structure for the general population as well as stable
262
8587
6264
4971
0
14
15
23
1150.4
88,928.2
62,163.0
36,640.4
972
5902
2746
1507
Total person-year, ESRD (n), and death (n) occurred in the age group during the study follow-up. Age is considered in timescale (attained age method).
7
48
42
60
18,611.5
234,192.0
82,292.6
27,717.2
1838
2979
809
359
121,663.4
309,650.3
50162.7
10,239.3
1973
1653
258
130
58
45
16
29
635,645.4
331,199.0
8908.4
1534.1
1667
684
65
32
347,532.7
398,113.4
25,838.2
4048.6
54
55
21
39
28
72
47
62
193
6230
4182
2955
0
21
18
34
657.9
50,614.4
30,522.4
15,438.2
1287
8565
3061
5
91
85
104
14,339.7
208,738.2
59,865.6
17,867.0
2749
4535
946
109,600.9
308,060.0
40,747.3
8338.7
3193
2111
280
54
52
29
38
467,722.3
304,511.1
7565.0
1259.2
2180
798
84
28
314,757.5
384,119.9
19,727.6
3256.3
76
92
44
76
34
116
72
119
ESRD
Person-year
Death
ESRD
Person-year
Person-year
Death
ESRD
Person-year
Death
Person-year
ESRD
ESRD
Death
70–79
Age Group (Years)
60–69
50–59
40–49
Baseline Kidney Function
Table 2. Person-years of follow-up and number of events (ESRD and death) by sex and baseline kidney function across age groups
Men
eGFR$90
eGFR=60–89
eGFR=45–59
eGFR=30–44
Women
eGFR$90
eGFR=60–89
eGFR=45–59
eGFR=30–44
‡80
Death
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ESRD incidence rates and mortality. As in our study, lifetime
risks are estimated from a defined study period (rather than
the full lifespan), with the assumption that the incidence and
mortality rates of the older age groups will be applicable to the
participants from the younger age when they reach the corresponding older age groups (for example, the mortality or incidence rate at age 70 years will be applicable when participants
of age 40 years reach age 70 years). Thus, time period and birth
cohort effects of our study population, therefore, could limit the
external validity of our results. Also, severity of the measure of
exposure was categorized based on a single point in time (baseline kidney function). Consequently, temporal trends in the
prevalence of risk factors and the sensitivity of diagnostic tests
could also alter the lifetime risk of ESRD. Finally, our estimates
describe the risk of ESRD treated with renal replacement therapy
but do not address the risk of untreated renal failure. Therefore,
the ESRD risks that we report are likely to be conservative estimates of the true population burden.
In conclusion, the observed probabilities indicate that
approximately 1 in 40 men and 1 in 60 women of middle
age will develop ESRD in their lifetime in Alberta, Canada. The
risk was higher in those individuals with reduced kidney
function compared with those individuals with relatively
preserved kidney function (eGFR.60 ml/min per 1.73 m2).
These measures can be used in both assisting healthcare planners and decision-makers in setting priorities and increasing
public awareness and interest in prevention of kidney disease.
CONCISE METHODS
Study Sample
The primary study cohort consisted of 2,895,521 (1,459,937 men and
1,435,584 women) Alberta residents ages 18 years or older registered
with Alberta Health and Wellness from April 1, 1997 to March
31, 2008 (Figure 1A). All Alberta residents are eligible for insurance
coverage by Alberta Health and Wellness, and .99% participate in
this coverage. Participants with ESRD (dialysis or transplantation)
were excluded. To estimate the lifetime risk of ESRD by level of baseline kidney function, we included a cohort of participants (Figure 1B)
who had at least one outpatient creatinine measurement from May 1,
2002 to March 31 200825 and used their first serum creatinine measurement of eGFR using the CKD Epidemiology Collaboration equation.26 Participants with eGFR,30 ml/min per 1.73 m2 at the time of
the first creatinine measurement were excluded. We estimated the
lifetime risk of ESRD for people with baseline eGFR categorized as
$90, 60–89, 45–59, and 30–44 ml/min per 1.73 m2.
Outcome Ascertainment
The primary outcome was development of ESRD, which was defined
as the date of registration for chronic dialysis or renal transplantation
as determined from the databases of Northern Alberta and Southern
Alberta Renal Programs and administrative data using a validated
algorithm.27,28 Death was identified using Vital Statistics data from
the Alberta Health and Wellness Registry file.
5
6
Unadjusted for competing risk of death
eGFR$90
eGFR$90
eGFR$90
eGFR$90
eGFR$90
eGFR$90
eGFR$90
eGFR$90
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR 30–44
eGFR=30–44
eGFR=30–44
eGFR=30–44
eGFR=30–44
eGFR=30–44
eGFR=30–44
eGFR=30–44
Adjusted for competing risk of death
eGFR$90
eGFR$90
eGFR$90
eGFR$90
eGFR$90
eGFR$90
eGFR$90
Kidney Function
40
50
60
70
40
50
60
70
40
50
60
70
40
50
60
70
40
50
60
70
40
50
60
70
40
50
60
70
40
50
60
70
40
50
60
70
40
50
60
Men
Men
Men
Men
Women
Women
Women
Index Age (Years)
Men
Men
Men
Men
Women
Women
Women
Women
Men
Men
Men
Men
Women
Women
Women
Women
Men
Men
Men
Men
Women
Women
Women
Women
Men
Men
Men
Men
Women
Women
Women
Women
Sex
0.09 (0.06–0.11)
0.16 (0.12–0.19)
0.28 (0.20–0.35)
0.29 (0.08–0.49)
0.07 (0.05–0.09)
0.11 (0.08–0.14)
0.16 (0.11–0.22)
0.09 (0.06–0.11)
0.16 (0.12–0.19)
0.29 (0.21–0.38)
0.39 (0.09–0.68)
0.07 (0.05–0.09)
0.11 (0.08–0.14)
0.17 (0.11–0.22)
0.31 (0.11–0.51)
0.12 (0.08–0.16)
0.17 (0.13–0.21)
0.25 (0.20–0.30)
0.40 (0.33–0.47)
0.09 (0.06–0.13)
0.11 (0.08–0.14)
0.17 (0.13–0.21)
0.20 (0.15–0.25)
3.39 (1.91–4.87)
2.05 (1.42–2.69)
1.47 (1.09–1.86)
1.18 (0.92–1.43)
1.24 (0.46–2.02)
0.78 (0.37–1.16)
0.76 (0.51–1.01)
0.61 (0.45–0.77)
24.57 (16.95–32.19)
20.55 (15.99–25.11)
13.05 (10.59–15.52)
6.34 (5.21–7.46)
13.58 (7.72–19.43)
10.80 (7.35–14.24)
6.31 (4.68–7.94)
2.83 (2.14–3.52)
10
6.77 (5.18–8.36)
4.63 (3.87–5.39)
2.75 (1.85–3.64)
2.12 (1.64–2.61)
47.90 (41.66–54.13)
35.30 (31.08–39.51)
27.77 (21.99–33.54)
18.79 (15.30–22.28)
5.37 (3.80–6.94)
3.50 (2.77–4.23)
2.63 (2.18–3.08)
2.00 (1.13–2.87)
1.52 (1.06–1.98)
1.37 (1.07–1.66)
40.07 (33.11–47.04)
30.92 (26.50–35.34)
18.56 (16.06–21.07)
22.91 (16.89–28.92)
16.42 (12.88–19.96)
8.96 (7.25–10.67)
0.33 (0.27–0.39)
0.50 (0.34–0.66)
0.38 (0.32–0.44)
0.48 (0.41–0.55)
0.21 (0.16–0.25)
0.28 (0.23–0.33)
0.37 (0.31–0.43)
0.18 (0.15–0.21)
0.26 (0.20–0.32)
0.41 (0.24–0.57)
0.54 (0.47–0.61)
0.82 (0.73–0.91)
0.29 (0.23–0.34)
0.42 (0.36–0.48)
0.65 (0.57–0.74)
0.49 (0.41–0.57)
0.64 (0.46–0.82)
0.35 (0.28–0.42)
0.58 (0.38–0.79)
0.18 (0.15–0.22)
0.28 (0.21–0.34)
0.47 (0.27–0.68)
0.24 (0.19–0.28)
0.41 (0.33–0.50)
0.52 (0.33–0.71)
0.54 (0.45–0.64)
0.84 (0.54–1.15)
30
0.24 (0.20–0.29)
0.46 (0.37–0.55)
0.68 (0.38–0.99)
20
0.56 (0.41–0.72)
0.71 (0.53–0.89)
29.81 (24.18–35.45)
51.20 (45.33–57.06)
3.34 (2.44–4.24)
7.86 (6.27–9.45)
0.57 (0.50–0.65)
0.94 (0.84–1.04)
0.66 (0.45–0.87)
0.93 (0.62–1.24)
40
Table 3. Age- and sex-specific 10-, 20-, 30-, and 40-year and lifetime risk estimates (in percentage) for ESRD by level of kidney function
0.72 (0.54–0.89)
0.65 (0.47–0.83)
0.53 (0.34–0.71)
0.30 (0.09–0.50)
0.67 (0.41–0.94)
0.60 (0.34–0.88)
0.52 (0.24–0.80)
0.95 (0.63–1.24)
0.85 (0.54–1.15)
0.69 (0.38–0.99)
0.40 (0.10–0.69)
0.88 (0.40–1.36)
0.80 (0.33–1.28)
0.69 (0.22–1.17)
0.53 (0.05–1.00)
1.27 (1.11–1.42)
1.15 (1.00–1.30)
0.99 (0.86–1.18)
0.73 (0.61–0.92)
0.71 (0.62–0.81)
0.62 (0.53–0.71)
0.51 (0.42–0.59)
0.33 (0.26–0.41)
8.63 (7.04–10.22)
5.42 (4.63–6.21)
3.44 (2.94–3.94)
2.00 (1.65–2.34)
3.59 (2.68–4.49)
2.37 (1.87–2.87)
1.62 (1.31–1.92)
0.86 (0.67–1.06)
52.43 (46.71–58.16)
36.94 (32.81–41.06)
20.63 (18.13–23.13)
9.21 (7.87–10.56)
30.40 (24.81–35.99)
19.46 (16.00–22.93)
9.72 (8.00–11.43)
3.64 (2.90–4.37)
Lifetime Risk
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eGFR$90
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=60–89
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR=45–59
eGFR=30–44
eGFR=30–44
eGFR=30–44
eGFR=30–44
eGFR=30–44
eGFR=30–44
eGFR=30–44
eGFR=30–44
Kidney Function
Table 3. Continued
Women
Men
Men
Men
Men
Women
Women
Women
Women
Men
Men
Men
Men
Women
Women
Women
Women
Men
Men
Men
Men
Women
Women
Women
Women
Sex
70
40
50
60
70
40
50
60
70
40
50
60
70
40
50
60
70
40
50
60
70
40
50
60
70
Index Age (Years)
0.27 (0.10–0.44)
0.12 (0.08–0.16)
0.17 (0.13–0.20)
0.25 (0.20–0.29)
0.36 (0.30–0.43)
0.09 (0.06–0.13)
0.11 (0.08–0.14)
0.17 (0.13–0.21)
0.19 (0.15–0.23)
3.35 (1.88–4.81)
1.96 (1.35–2.57)
1.40 (1.04–1.77)
1.06 (0.83–1.29)
1.23 (0.46–2.00)
0.75 (0.36–1.14)
0.73 (0.49–0.98)
0.57 (0.42–0.73)
26.87 (18.43–35.30)
20.57 (15.91–25.23)
11.98 (9.61–14.34)
5.36 (4.36–6.36)
13.68 (7.68–19.67)
10.69 (7.16–14.22)
5.84 (4.30–7.38)
2.58 (1.93–3.23)
10
0.51 (0.44–0.58)
0.73 (0.64–0.81)
0.36 (0.30–0.42)
0.45 (0.38–0.51)
6.38 (4.80–7.95)
4.03 (3.33–4.73)
2.61 (1.73–3.48)
1.92 (1.45–2.39)
52.64 (45.85–59.43)
32.62 (28.19–37.05)
27.13 (21.09–33.16)
17.13 (13.51–20.74)
0.20 (0.16–0.25)
0.27 (0.23–0.32)
0.34 (0.29–0.40)
5.19 (3.64–6.75)
3.21 (2.53–3.90)
2.32 (1.90–2.73)
1.95 (1.10–2.81)
1.44 (0.99–1.89)
1.26 (0.98–1.53)
44.60 (36.98–52.30)
29.82 (25.27–34.38)
15.59 (13.21–17.98)
22.96 (16.74–29.18)
15.49 (11.85–19.13)
7.83 (6.24–9.42)
30
0.28 (0.23–0.33)
0.40 (0.34–0.46)
0.58 (0.50–0.66)
20
28.55 (22.60–34.49)
55.05 (48.58–61.51)
3.07 (2.19–3.95)
7.14 (5.58–8.71)
0.53 (0.46–0.61)
0.83 (0.74–0.92)
40
0.40 (0.10–0.69)
1.01 (0.90–1.11)
0.90 (0.80–1.00)
0.76 (0.67–0.86)
0.58 (0.48–0.66)
0.63 (0.54–0.71)
0.45 (0.38–0.51)
0.44 (0.37–0.51)
0.29 (0.23–0.35)
7.51 (5.95–9.08)
4.42 (3.71–5.13)
2.75 (2.32–3.18)
1.56 (1.29–1.83)
3.21 (2.33–4.09)
2.07 (1.60–2.54)
1.42 (1.13–1.70)
0.75 (0.58–0.92)
55.54 (49.14–61.93)
33.18 (28.78–37.59)
16.32 (13.94–18.71)
6.44 (5.41–7.47)
28.81 (22.88–34.73)
17.43 (13.81–21.04)
8.19 (6.60–9.78)
3.05 (2.39–3.72)
Lifetime Risk
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7
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Figure 3. Competing risk of death-adjusted cumulative risk of ESRD (in percentage) with advancing age by eGFR category for men and
women at the index ages of 40 and 70 years. eGFR was categorized as $90, 60–89, 45–59, and 30–44 ml/min per 1.73 m2.
8
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Statistical Analyses
Age (in years) was used as the time scale. The index age categories
started at age 40 years and increased by decade to age 70 years. Risk
estimation began at an index age—participants who were below the
index age of interest at the beginning of the study period entered the
analysis when they reached the required age. For example, for risk
estimation at an index age of 40 years, participants ages 40 years and
older were included. Participants who were ,40 years of age at the
beginning of the study period began contributing to the risk estimation at their 40th birthday.
Follow-up ended at ESRD occurrence, death, migration from the
province, or study end (March 31, 2009), whichever came first. We
estimated cumulative ESRD incidence conditional on survival to ages of
50, 60, 70, 80, and 90 years. We estimated lifetime risk of ESRD (conditional on survival to ages of 40, 50, 60, and 70 years) with and without
adjustment for competing risk of death. The estimates were calculated
using a modified technique of survival analysis29 from previously reported analyses.9,30 All statistical analyses were done using SAS version
9.1 (SAS Institute, Cary, NC). The study was approved by the institutional ethics review board of the University of Calgary.
ACKNOWLEDGMENTS
T.C.T. is supported by Fellowship Awards from the Canadian Institutes
of Health Research (CIHR), Canadian Diabetes Association, and the
Interdisciplinary Chronic Disease Collaboration team grant funded by
Alberta Innovates—Health Solutions (AI-HS). M.T., B.J.M., S.B.A., and
B.R.H. are supported by AI-HS Salary Awards. M.J. is supported by
a KRESCENT new investigator award. M.T. is supported by a Canada
Research Chair. S.B.A. is supported by a salary award from CIHR. B.R.
H. is supported by the Roy and Vi Baay Chair in Kidney Research.
The authors declare that they have no relevant financial interests
or any conflicts of interests.
DISCLOSURES
None.
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Lifetime Risk of ESRD

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