Clinical epidemiology of cardiovascular disease in chronic kidney disease.

The public health importance of chronic kidney disease (CKD) has only come to be appreciated in the last decade. While glomerular filtration rate (GFR) and urinary albumin creatinine levels are highly predictive of mortality, thresholds that may be useful for screening may be much closer to 'normal' than generally recognised. When optimising the balance between true negative and true positive mortality prediction, GFR from creatinine and GFR from cystatin C and albumin creatinine ratios all seem to perform similarly. Among the older population, mortality rates with creatinine-based GFR are lowest for those with levels between 60 and 90 ml/min/1.73 m(2), unlike with GFR from cystatin C, where mortality rates climb monotonically with declining GFR. Thus, the validity of creatinine-based GFR in older community-dwelling individuals is questionable. Nationally, representative data suggest management of modifiable cardiovascular risk factors in adults with CKD is far from optimal. This paper explores the possibility that robust associations between declining kidney function and cardiovascular outcomes could be caused by an unknown, confounding, shared-risk factors and extrapolates findings from renal transplant donor populations to support this hypothesis.