Pulmonary hypertension (PH) is associated with poor outcomes in the dialysis and general populations, but its effect in CKD is unclear. We evaluated the prevalence and predictors of PH measures and their associations with long-term clinical outcomes in patients with nondialysis-dependent CKD. Chronic Renal Insufficiency Cohort (CRIC) Study participants who had Doppler echocardiography performed were considered for inclusion. PH was defined as the presence of estimated pulmonary artery systolic pressure (PASP) .35 mmHg and/or tricuspid regurgitant velocity (TRV) .2.5 m/s. Associations between PH, PASP, and TRV and cardiovascular events, renal events, and all-cause mortality were examined using Cox proportional hazards models. Of 2959 eligible participants, 21% (n=625) had PH, with higher rates among those with lower levels of kidney function. In the multivariate model, older age, anemia, lower left ventricular ejection fraction, and presence of left ventricular hypertrophy were associated with greater odds of having PH. After adjusting for relevant confounding variables, PH was independently associated with higher risk for death (hazard ratio, 1.38; 95% confidence interval, 1.10 to 1.72) and cardiovascular events (hazard ratio, 1.23; 95% confidence interval, 1.00 to 1.52) but not renal events. Similarly, TRV and PASP were associated with death and cardiovascular events but not renal events. In this study of patients with CKD and preserved left ventricular systolic function, we report a high prevalence of PH. PH and higher TRV and PASP (echocardiographic measures of PH) are associated with adverse outcomes in CKD. Future studies may explain the mechanisms that underlie these findings.

Background and objectives Atrial fibrillation frequently complicates CKD and is associated with adverse outcomes. Progression to ESRD is a major complication of CKD, but the link with atrial fibrillation has not been fully delineated. In this study, we examined the association of incident atrial fibrillation with the risk of ESRD in patients with CKD.Design, setting, participants, & measurements We studied participants in the prospective Chronic Renal Insufficiency Cohort Study without atrial fibrillation at entry. Incident atrial fibrillation was identified by study visit ECGs, self-report, and hospital discharge diagnostic codes, with confirmation by physician adjudication. ESRD through 2012 was ascertained by participant self-report, medical records, and linkage to the US Renal Data System. Data on potential confounders were obtained from self-report, study visits, and laboratory tests. Marginal structural models were used to study the potential association of incident atrial fibrillation with risk of ESRD after adjustment for time-dependent confounding.Results Among 3091 participants, 172 (5.6%) developed incident atrial fibrillation during follow-up. During mean follow-up of 5.9 years, 43 patients had ESRD that occurred after development of incident atrial fibrillation (11.8/ 100 person-years) compared with 581 patients without incident atrial fibrillation (3.4/100 person-years). In marginal structural models with inverse probability weighting, incident atrial fibrillation was associated with a substantially higher rate of ESRD (hazard ratio, 3.2; 95% confidence interval, 1.9 to 5.2). This association was consistent across important subgroups by age, sex, race, diabetes status, and baseline eGFR.Conclusions Incident atrial fibrillation was associated with higher risk of developing ESRD in CKD. Additional study is needed to identify potentially modifiable pathways through which atrial fibrillation was associated with a higher risk of progression to ESRD. More aggressive monitoring and treatment of patients with CKD and atrial fibrillation may improve outcomes in this high-risk population.

Introduction: Chronic kidney disease (CKD) increases the risk for adverse cardiovascular events including heart failure (HF) and death. Left atrial size is an easily quantified metric that provides prognostic information in non-CKD populations. Hypothesis: We hypothesized that left atrial size would be an independent risk marker for incident HF and death in individuals with CKD. Methods: The Chronic Renal Insufficiency Cohort (CRIC) is a large, multicenter, multiracial cohort study established to understand the progression of cardiovascular and renal disease among individuals with CKD. We evaluated echocardiograms among participants without a history of heart failure. The left atrial area was measured in the apical 4-chamber view and indexed to body surface area (LAAI). Cox proportional hazards models were constructed to assess the risk between left atrial size and incident HF and death. Results: Among the 2960 CKD participants without known heart failure, higher tertiles of LAAI were associated with older age, Hispanic ethnicity, a history of stroke, myocardial infarction, atrial fibrillation, higher systolic blood pressure, hypertension, diabetes, and lower eGFR (P<0.005 for all). The median left ventricular ejection fraction was 55% across LAAI tertiles. Over a median [IQR] follow-up of 6.6 [5.7-7.6] years, 344 participants developed HF and 472 died. An increase in LAAI was a strong risk marker for the development of heart failure after multivariable adjustment (Table 1). LAAI was modestly associated with all-cause death after controlling for demographics and clinical variables; however, additional adjustment for echocardiographic variables and cardiac biomarkers rendered the association non-significant. There was no significant interaction between LAAI and sex or race for either outcome. Conclusion: Among adults with CKD, LAAI is a stronger marker of risk for incident HF than death.