title: The Risk of Major Hemorrhage with CKD.
abstract: New staging systems for CKD account for both reduced eGFR and albuminuria; whether each measure associates with greater risk of hemorrhage is unclear. In this retrospective cohort study (2002-2010), we grouped 516,197 adults ≥40 years old by eGFR (≥90, 60 to <90, 45 to <60, 30 to <45, 15 to <30, or <15 ml/min per 1.73 m(2)) and urine albumin-to-creatinine ratio (ACR; >300, 30-300, or <30 mg/g) to examine incidence of hemorrhage. The 3-year cumulative incidence of hemorrhage increased 20-fold across declining eGFR and increasing urine ACR groupings (highest eGFR/lowest ACR: 0.5%; lowest eGFR/highest ACR: 10.1%). Urine ACR altered the association of eGFR with hemorrhage (P<0.001). In adjusted models using the highest eGFR/lowest ACR grouping as the referent, patients with eGFR=15 to <30 ml/min per 1.73 m(2) had adjusted relative risks of hemorrhage of 1.9 (95% confidence interval [95% CI], 1.5 to 2.4) with the lowest ACR and 3.7 (95% CI, 3.0 to 4.5) with the highest ACR. Patients with the highest eGFR/highest ACR had an adjusted relative risk of hemorrhage of 2.3 (95% CI, 1.8 to 2.9), comparable with the risk for patients with the lowest eGFR/lowest ACR. The associations attenuated but remained significant after adjustment for anticoagulant and antiplatelet use in patients ≥66 years old. The risk of hemorrhage differed by urine ACR in high risk subgroups. Our data show that declining eGFR and increasing albuminuria each independently increase hemorrhage risk. Strategies to reduce hemorrhage events among patients with CKD are warranted.
authors.affiliation: Division of Nephrology, McMaster University, Hamilton, Ontario, Canada; Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada;
authors.forename: Amber O
authors.initials: AO
authors.lastname: Molnar
authors.affiliation: Institute for Clinical Evaluative Sciences, Ontario, Canada; Department of Epidemiology and Biostatistics and.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Bota
authors.affiliation: Institute for Clinical Evaluative Sciences, Ontario, Canada; Department of Epidemiology and Biostatistics and Division of Nephrology, Western University, London, Ontario, Canada;
authors.forename: Amit X
authors.initials: AX
authors.lastname: Garg
authors.affiliation: Institute for Clinical Evaluative Sciences, Ontario, Canada; Division of Nephrology, Western University, London, Ontario, Canada; Division of Nephrology, University of Toronto, Ontario, Canada;
authors.forename: Ziv
authors.initials: Z
authors.lastname: Harel
authors.affiliation: Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada; and.
authors.forename: Ngan
authors.initials: N
authors.lastname: Lam
authors.affiliation: Institute for Clinical Evaluative Sciences, Ontario, Canada;
authors.forename: Eric
authors.initials: E
authors.lastname: McArthur
authors.affiliation: Division of Nephrology, Humber River Hospital, Toronto, Ontario, Canada.
authors.forename: Gihad
authors.initials: G
authors.lastname: Nesrallah
authors.affiliation: Division of Nephrology, University of Toronto, Ontario, Canada;
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Perl
authors.affiliation: Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, Ontario, Canada; Msood@toh.on.ca.
authors.forename: Manish M
authors.initials: MM
authors.lastname: Sood
mesh_terms: D000419:Albuminuria / Q000209:etiology; D015331:Cohort Studies; D005260:Female; D005919:Glomerular Filtration Rate; D006470:Hemorrhage / Q000453:epidemiology* / Q000209:etiology*; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index
keywords: albuminuria; bleeding risk; chronic kidney disease; clinical epidemiology; hemorrhage; vascular disease
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