title: Impact of Educational Attainment on Health Outcomes in Moderate to Severe CKD.
abstract: BACKGROUND
  The inverse association between educational attainment and mortality is well established, but its relevance to vascular events and renal progression in a population with chronic kidney disease (CKD) is less clear. This study aims to determine the association between highest educational attainment and risk of vascular events, cause-specific mortality, and CKD progression.
  
  
  METHODS
  Prospective epidemiologic analysis among participants in the Study of Heart and Renal Protection (SHARP), a randomized controlled trial.
  
  
  METHODS
  9,270 adults with moderate to severe CKD (6,245 not receiving dialysis at baseline) and no history of myocardial infarction or coronary revascularization recruited in Europe, North America, Asia, Australia, and New Zealand.
  
  
  METHODS
  Highest educational attainment measured at study entry using 6 levels that ranged from "no formal education" to "tertiary education."
  
  
  RESULTS
  Any vascular event (any fatal or nonfatal cardiac, cerebrovascular, or peripheral vascular event), cause-specific mortality, and CKD progression during 4.9 years' median follow-up.
  
  
  RESULTS
  There was a significant trend (P<0.001) toward increased vascular risk with decreasing levels of education. Participants with no formal education were at a 46% higher risk of vascular events (relative risk [RR], 1.46; 95% CI, 1.14-1.86) compared with participants with tertiary education. The trend for mortality across education levels was also significant (P<0.001): all-cause mortality was twice as high among those with no formal education compared with tertiary-educated individuals (RR, 2.05; 95% CI, 1.62-2.58), and significant increases were seen for both vascular (RR, 1.84; 95% CI, 1.21-2.81) and nonvascular (RR, 2.15; 95% CI, 1.60-2.89) deaths. Lifestyle factors and prior disease explain most of the excess mortality risk. Among 6,245 participants not receiving dialysis at baseline, education level was not significantly associated with progression to end-stage renal disease or doubling of creatinine level (P for trend = 0.4).
  
  
  CONCLUSIONS
  No data for employment or health insurance coverage.
  
  
  CONCLUSIONS
  Lower educational attainment is associated with increased risk of adverse health outcomes in individuals with CKD.
authors.affiliation: NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia; Health Economics Research Centre, University of Oxford, Oxford, United Kingdom.
authors.forename: Rachael L
authors.initials: RL
authors.lastname: Morton
authors.affiliation: Health Economics Research Centre, University of Oxford, Oxford, United Kingdom.
authors.forename: Iryna
authors.initials: I
authors.lastname: Schlackow
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
authors.forename: Natalie
authors.initials: N
authors.lastname: Staplin
authors.affiliation: Health Economics Research Centre, University of Oxford, Oxford, United Kingdom.
authors.forename: Alastair
authors.initials: A
authors.lastname: Gray
authors.affiliation: Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
authors.forename: Alan
authors.initials: A
authors.lastname: Cass
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
authors.forename: Richard
authors.initials: R
authors.lastname: Haynes
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Emberson
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
authors.forename: William
authors.initials: W
authors.lastname: Herrington
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
authors.forename: Martin J
authors.initials: MJ
authors.lastname: Landray
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
authors.forename: Colin
authors.initials: C
authors.lastname: Baigent
authors.affiliation: Health Economics Research Centre, University of Oxford, Oxford, United Kingdom. Electronic address: boby.mihaylova@dph.ox.ac.uk.
authors.forename: Borislava
authors.initials: B
authors.lastname: Mihaylova
mesh_terms: D000368:Aged; D000924:Anticholesteremic Agents / Q000627:therapeutic use*; D018450:Disease Progression; D004522:Educational Status; D000069438:Ezetimibe / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000401:mortality / Q000517:prevention & control*; D012720:Severity of Illness Index; D019821:Simvastatin / Q000627:therapeutic use*; D014652:Vascular Diseases / Q000209:etiology
chemical_list: D000924:Anticholesteremic Agents; D019821:Simvastatin; D000069438:Ezetimibe
keywords: Chronic kidney failure; Study of Heart and Renal Protection (SHARP); chronic kidney disease (CKD); disease progression; education; educational attainment; end-stage renal disease (ESRD); health behavior; inequalities; mortality; renal dialysis; risk factor; socioeconomic factors; vascular event