Microalbuminuria y proteinuria clínica como principales predictores de morbimortalidad cardiovascular en pacientes con diabetes tipo 2

doi:10.1016/S0014-2565(03)71346-0

Revista Clínica Española

Volume 203, Issue 11, 2003, Pages 526-531

https://doi.org/10.1016/S0014-2565(03)71346-0 Get rights and content

Fundamento

El objetivo principal fue evaluar la contribución independiente de la microalbuminuria y de la proteinuria clínica a la morbimortalidad cardiovascular de pacientes con diabetes tipo 2.

Métodos

Estudio de cohortes prospectivo con selección de pacientes con diabetes tipo 2 atendidos en consultas externas hospitalarias. Mediante modelo de riesgos proporcionales de Cox se analizó la importancia predictiva de la presencia de microalbuminuria y de proteinuria clínica sobre la aparición de eventos cardiovasculares fatales y no fatales (ángor de inicio, infarto de miocardio fatal y no fatal, muerte súbita, accidente isquémico transitorio, accidente cerebrovascular fatal y no fatal o amputación de extremidades inferiores).

Resultados

Se siguieron 463 pacientes durante una duración media de 4,64 años (desviación estándar [DE]: 1,56). Hubo 330 (71,3%) con normoalbuminuria, 106 (22,9%) con microalbuminuria y 27 (5,8%) con proteinuria. La tasa de morbimortalidad cardiovascular global fue del 3,7% anual (2,46% anual para los normoalbuminúricos, 5,6% para los microalbuminúricos y 14,42% para los proteinúricos; p<0,0001). Tras ajuste múltiple, tanto la microalbuminuria (RR: 1,91; IC 95%: 1,05-3,48; p=0,032) como la proteinuria (riesgo relativo [RR]: 4,15; IC 95%: 1,77-9,75; p=0,0011) fueron los principales predictores independientes de aparición de eventos cardiovasculares. Otras variables predictivas fueron la edad (RR: 1,06; IC 95%: 1,02-1,10; p=0,0014), el colesterol ligado a lipoproteínas de alta densidad (HDL) (RR: 0,96; IC 95%: 0,93-0,98; p=0,001), el colesterol ligado a lipoproteínas de baja densidad (LDL) (RR: 1,01; IC 95%: 1,002-1,02; p=0,016) y la presencia inicial de cardiopatía isquémica (RR: 1,97; IC 95%: 1,03-3,76; p=0,041).

Conclusiones

El incremento de la tasa de excreción de albúmina urinaria es el principal predictor independiente de morbimortalidad cardiovascular en pacientes con diabetes tipo 2.

Contex

The principal objective was that of evaluating the independent contribution of microalbuminuria and clinical proteinuria to the cardiovascular morbidity and mortality in patients with type 2 diabetes.

Methods

A prospective cohort study with selection of patients with type 2 diabetes evaluated in hospital outpatient consultations. Through the Cox proportional risks model the predictive importance of the presence of microalbuminuria and clinical proteinuria on the appearance of fatal and nonfatal cardiovascular complications (angina, fatal and non-fatal myocardial infarction, sudden death, transitory ischemic attack, fatal and non-fatal stroke, or amputation of lower limbs) was analyzed.

Results

The monitoring of 463 patients was done during an average period of 4.64 years (SD: 1.56). There were 330 patients (71.3%) with normoalbuminuria, 106 (22.9%) with microalbuminuria and 27 (5.8%) with proteinuria. The global cardiovascular morbidity and mortality rate was 3.7% annual (2.46% annual for the patients with normoalbuminuria, 5.6% for the patients with microalbuminuria and 14.42% for the patients with proteinuria; p < 0.0001). After multiple adjustment, both microalbuminuria (RR: 1.91; 95% CI: 1.05-3.48; p = 0.032) and proteinuria (RR: 4.15; 95% CI: 1.77-9.75; p = 0.0011) were the main independent predictive factores of appearance of cardiovascular complications. Other predictive variables were age (RR: 1.06; 95% CI: 1.02-1.10; p = 0.0014), HDL cholesterol (RR = 0.96; 95% CI: 0.93-0.98; p = 0.001), LDL cholesterol (RR: 1.01; 95% CI: 1.002-1.02; p = 0.016) and initial presence of ischemic cardiopathy (RR: 1.97; 95% CI: 1.03-3.76; p = 0.041).

Conclusions

The increase in the rate of excretion of urinary albumin is the main independent predictive factor of cardiovascular morbidity and mortality in patiens with type 2 diabetes.

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Risk of mortality associated to chronic kidney disease in patients with type 2 diabetes mellitus: A 13-year follow-up
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Citation Excerpt :
The greatest strength of our study was the long follow-up of patients, with only few losses, which allowed a reliable estimation of mortality rates during this period of time and reinforced the internal validity. The results are in agreement with those obtained in a previous data analysis with a shorter follow-up.23 Regarding noteworthy weaknesses, we must point out the limited number of subjects, with a low number of events in some categories, which makes the estimations less precise.
Our aim was to assess the usefulness of glomerular filtration rate (GFR) and urinary albumin excretion (UAE) to predict the risk of mortality in patients with type 2 diabetes mellitus.
This is a prospective cohort study in patients with type 2 diabetes mellitus. Clinical end-point was mortality rate. GFR was measured in ml/min/1.73 m² and stratified in 3 categories (≥60; 45–59; <45); UAE was measured in mg/24 h and was also stratified in 3 categories (<30; 30–300; >300). Mortality rates were reported per 1000 patient-years. Cox regression models were used to predict mortality risk associated with combined GFR and UAE. The predictive power was estimated with C-Harrell statistic.
A total of 453 patients (39.3% males), aged 64.9 (SD 9.3) years were included; mean diabetes duration was 10.4 (SD 7.5) years. Median follow-up was 13 years. Total mortality rate was 39.5/1000. The progressive increase in mortality in the successive categories of GFR and UAE was statistically significant (P < .001). In a multivariable analysis, UAE (HR30-300 = 1.02 and HR > 300 = 2.83; χ² = 11.6; P = .003) and GFR (HR45-59 = 1.34 and HR < 45 = 1.84; χ² = 6.4; P = .041) were independent predictors for mortality, with no significant interaction. Simultaneous inclusion of GFR and UAE improved the predictive power of models (C-Harrell 0.741 vs. 0.726; P = .045).
GFR and UAE are independent predictors for mortality in type 2 diabetic patients and do not show a statistically significant interaction.
Nuestro objetivo fue evaluar la influencia de la tasa de filtración glomerular (TFG) y de la excreción de albúmina urinaria (EAU) sobre el riesgo de mortalidad en pacientes con diabetes mellitus tipo 2 (DM2).
Estudio de cohortes prospectivo con inclusión de pacientes con DM2. El punto final clínico fue mortalidad total. La TFG se midió en ml/min/1,73 m² con estratificación en 3 categorías (≥60; 45-59; <45) y la EAU en mg/24 h con estratificación también en 3 categorías (<30; 30-300; >300).
Se evaluaron las tasas de mortalidad por cada 1.000 pacientes/año y, mediante regresión de Cox, el riesgo de mortalidad asociado con las categorías de TFG y EAU. El poder predictivo se midió con el estadístico C de Harrell.
Se incluyó a 453 pacientes (39,3% varones, edad 64,9 [DE 9,3] años y evolución de DM2 10,4 [DE 7,5] años). Durante una mediana de 13 años de seguimiento, la tasa de mortalidad total fue de 39,5/1.000, con incremento progresivo ante descenso de la TFG y aumento de la EAU (p < 0,001). En análisis multivariante la EAU (HR_30-300 = 1,02 y HR_>300 = 2,83; chi² = 11,6; p = 0,003) y la TFG (HR_45-59 = 1,34 y HR_<45= 1,84; chi² = 6,4; p = 0,041) fueron predictores independientes de mortalidad sin interacción significativa. La inclusión de TFG y EAU mejoró la capacidad predictiva de los modelos (C de Harrell 0,741 vs. 0,726; p = 0,045).
La TFG y la EAU son predictores independientes de mortalidad en pacientes con DM2, sin interacción significativa.
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Microalbuminuria y proteinuria clínica como principales predictores de morbimortalidad cardiovascular en pacientes con diabetes tipo 2Microalbuminuria and clinical proteinuria as the main predictive factors of cardiovascular morbidity and mortality in patients with type 2 diabetes

Fundamento

Métodos

Resultados

Conclusiones

Contex

Methods

Results

Conclusions

Metabolism

Lancet

Am J Med

Diabetes Res Clin Pract

Diabetes Res Clin Pract

Keen H and the WHO Multinational Study Group. Mortality and causes of death in the WHO multinational study of vascular disease in diabetes

Diabetologia

Lee E and the WHO Multinational Study Group. Proteinuria and mortality in diabetes: the WHO multinational study of vascular disease in diabetes

Diabet Med

Microalbuminuria predicts clinical proteinuria and early mortality in maturity onset diabetes

N Engl J Med

Microalbuminuria predicts mortality in non insulin dependent diabetes

Diabet Med

The association of microalbuminuria and mortality in non insulin dependent diabetes mellitus. A systematic overview of the literature

Arch Intern Med

Microalbuminuria is strongly associated with NIDDM and hypertension, but not with the insulin resistance syndrome: the Hoorn Study

Diabetologia

Technical report series 727