A policy model of cardiovascular disease in moderate-to-advanced chronic kidney disease

Abstract

Objective: To present a long-term policy model of cardiovascular disease (CVD) in moderate-to-advanced chronic kidney disease (CKD).

Methods: A Markov model with transitions between CKD stages (3B, 4, 5, on dialysis, with kidney transplant) and cardiovascular events (major atherosclerotic events, haemorrhagic stroke, vascular death) was developed with individualised CKD and CVD risks estimated using the 5 years' follow-up data of the 9270 patients with moderate-to-severe CKD in the Study of Heart and Renal Protection (SHARP) and multivariate parametric survival analysis. The model was assessed in three further CKD cohorts and compared with currently used risk scores.

Results: Higher age, previous cardiovascular events and advanced CKD were the main contributors to increased individual disease risks. CKD and CVD risks predicted by the state-transition model corresponded well to risks observed in SHARP and external cohorts. The model's predictions of vascular risk and progression to end-stage renal disease were better than, or comparable to, those produced by other risk scores. As an illustration, at age 60-69 years, projected survival for SHARP participants in CKD stage 3B was 13.5 years (10.6 quality-adjusted life years (QALYs)) in men and 14.8 years (10.7 QALYs) in women. Corresponding projections for participants on dialysis were 7.5 (5.6 QALYs) and 7.8 years (5.4 QALYs). A non-fatal major atherosclerotic event reduced life expectancy by about 2 years in stage 3B and by 1 year in dialysis.

Conclusions: The SHARP CKD-CVD model is a novel resource for evaluating health outcomes and cost-effectiveness of interventions in CKD.

Trial registration number: NCT00125593 and ISRCTN54137607; Post-results.

Keywords: CKD progression; cardiovascular risk; chronic kidney disease; life expectancy; markov model.

Conflict of interest statement

Competing interests: None declared.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Figures

Figure 1

Schematic of the SHARP CKD-CVD lifetime health outcomes model. 1A small number of participants had estimated glomerular filtration rate ≥45 mL/min/1.73 m2 at entry into the study; 2Cox proportional hazards model derived from SHARP data used in internal validation. UK population data used to derive annual non-vascular mortality rates in the model. CKD, chronic kidney disease; CVD, cardiovascular disease; MAE, major atherosclerotic event; RRT, renal replacement therapy; SHARP, Study of Heart and Renal Protection.

Figure 2

Predicted and observed Kaplan-Meier cumulative risks in SHARP (internal validity). For the progression to renal replacement therapy (RRT) endpoint, only participants in pre-RRT stages at baseline were included. Lipid-lowering treatment use was simulated as the percentage of participants using any lipid-lowering medication in the respective treatment arm and year of follow-up in SHARP. CKD, chronic kidney disease; CVD, cardiovascular disease; SHARP, Study of Heart and Renal Protection.

Figure 3

Predicted and observed Kaplan-Meier cumulative risks in CRIB, 4D and AURORA (external validity). The predictions were simulated in the absence of study lipid-lowering treatments in 4D and AURORA; information on non-coronary revascularisation was not available in 4D. Transplantation rates calibrated to correspond to rates in 4D and AURORA; no other calibration was performed. AURORA, A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Hemodialysis: An Assessment of Survival and Cardiovascular Events; CKD, chronic kidney disease; CRIB, Chronic Renal Impairment in Birmingham; CVD, cardiovascular disease; RRT, renal replacement therapy; 4D, Der Deutsche Diabetes Dialyse.

Figure 4

Predicted life expectancy (years) and quality-adjusted life-years for participants in SHARP. The predictions are for SHARP participants in the absence of lipid-lowering treatment. *Major atherosclerotic event is assumed to occur in year prior to entry in the model. CKD, chronic kidney disease; QALYs, quality-adjusted life years; RRT, renal replacement therapy; SHARP, Study of Heart and Renal Protection.