Temporal trends in end-stage renal disease in patients with heart failure with or without diabetes: a nationwide study from 2002 to 2017
Authors: Knigge P , Lundberg S , Wagner A K , Strange J E , Gislason G , Fosboel E , Zahir D , Andersson C , Butt J H , Koeber L , Schou M 
Published: October 2022

Abstract

Background
Advances in treatment of heart failure (HF) have increased survival rates. However, whether the improved life expectancy for HF patients has resulted in an increased risk of a significant comorbidity like end-stage renal disease (ESRD) is less clear. Renal dysfunction is associated with increased morbidity and mortality in HF and constitutes an important prognostic factor for HF. Further, diabetes (DM) is closely related to both HF and ESRD, but it is unknown how DM affects the risk of ESRD in patients with HF.

Purpose
To investigate temporal trends in ESRD in patients with HF and the subsequent risk of mortality stratified by DM.

Methods
Using Danish nationwide registies, we identified patients, aged 18 to 100 years, with incident HF between 2002 and 2017. The outcomes were ESRD (defined as dialysis treatment), worsening of HF (wHF, defined as rehospitalization for HF) and all-cause mortality. Three study periods were investigated 2002–2006, 2007–2011 and 2012–2017. We estimated crude 5-year incidence rates (per 1000/person-years) of the outcomes stratified by DM. Multivariate Cox regression models were performed for all outcomes stratified by DM. Further, we computed the 1-year all-cause mortality risk after diagnosis with ESRD.

Results
Of 124,141 patients with HF, 50,690 (41%) were women and the median age was 74.5 years [95% confidence interval (CI) 64.5–82.8]. At baseline DM was present in 20% of the patients. These patients were older, more often men and more comorbid than HF patients without DM. Over time (2002–2006 to 2012–2017) the incidence rates of ESRD (9.0 to 7.9 and 2.1 to 1.9 per 1000/person-years for DM and no-DM, respectively) and wHF (124.0 to 124.8 and 84.3 to 81.9 per 1000/person-years for DM and no-DM) remained stable, while all-cause mortality rates decreased (217.0 to 170.3 and 172.9 to 127.8 per 1000/person-years for DM and no-DM). The incidence of ESRD was lower compared with the incidence of wHF and all-cause mortality [Figure 1]. HF patients with DM had significantly higher associated rates of all three outcomes (in 2012–2017 the rates for DM vs no-DM of ESRD: 3.99 [3.27–4.86], wHF: 1.42 [1.36–1.49], all-cause mortality: 1.36 [1.31–1.41]) compared with patients without DM. We found no significant interaction between time period and DM on the rates of outcomes (p&gt;0.05 for all) [Figure 2]. One-year all-cause mortality risk after diagnosis with ESRD was high both for HF patients with and without DM through all time periods (identical risks and 95% CI in 2012–2017: 32% [0.25–0.39]).

Conclusions
We did not observe a change over time in the 5-year risk of ESRD for HF patients. The incidence of ESRD remained low compared to wHF and all-cause mortality. DM was associated with increased rates of all three events, not changed over time. Conversely, all-cause mortality after diagnosis with ESRD was markedly high, irrespectively of DM. Our analyses suggest that ESRD is a less common, but fatal event in HF patients.

Funding Acknowledgement
Type of funding sources: None.