Diabetes and End-Stage Renal Disease Synergistically Contribute to Increased Incidence of Cardiovascular Events: A Nationwide Follow-up Study During 1998–2009

Abstract

OBJECTIVE This study aimed to investigate the effect of interaction of diabetes and end-stage renal disease (ESRD) on the risks of cardiovascular (CV) events. RESEARCH DESIGN AND METHODS By using two representative national cohorts, we determined the age- and sex-specific incidences and 20-year risks of incident CV events, including acute myocardial infarction (AMI), stroke, and congestive heart failure (CHF), stratified by the presence of diabetes, de novo diabetes after ESRD, or ESRD. Individuals were excluded if age <18 years or if previous CV events or malignancies were present before enrollment. Cox proportional hazards models were also constructed with adjustments for competing risk of mortality. RESULTS A total 648,851 non-ESRD individuals and 71,397 ESRD patients, including 53,342 and 34,754 diabetic patients, respectively, were followed up during 1998–2009. A monotonic risk pattern of CV-related incidences was noted with the presence of diabetes, ESRD, or both, respectively, after stratification by age and sex. De novo diabetes showed similar increased risks for CV incidences, especially AMI and stroke. There is a multiplicatively synergistic effect of diabetes and ESRD for CV-related risks, especially for AMI and stroke, of which the adjusted hazard ratios (aHRs) were 5.24 (95% CI 4.83–5.68) and 2.43 (2.32–2.55), respectively, in comparison with people without diabetes or ESRD; de novo diabetes after ESRD had similar effects with aHRs of 4.12 (3.49–4.87) and 1.75 (1.57–1.95), respectively. CONCLUSIONS Diabetes and ESRD synergistically increase risks of CV events. Proactive screening and control for diabetes in patients with ESRD should be built into our daily practice.