Cystatin C and risk of vascular and nonvascular mortality: a prospective cohort study of older men

Abstract. Emberson JR, Haynes R, Dasgupta T, Mafham M, Landray MJ, Baigent C, Clarke R (University of Oxford, Oxford, UK). Cystatin C and risk of vascular and nonvascular mortality: a prospective cohort study of older men. J Intern Med 2010; 268 : 145–154. Objective. To assess the relevance of cystatin C, as a marker of mild‐to‐moderate renal impairment, for vascular and nonvascular mortality in older people. Design. Prospective cohort study. Setting. Re‐survey in 1997 to 1998 of survivors in the 1970 Whitehall study of London civil servants. Subjects. Five thousand three hundred and seventy‐one men (mean age at resurvey: 77 years) who took part in the resurvey and had plasma cystatin C concentration measured. Main outcome measures. Cause‐specific mortality over subsequent 11 years (1997 to 2008). Methods. Cox regression was used to estimate the associations of cystatin C with vascular and nonvascular mortality, before and after adjustment for prior disease and other risk factors (including lifetime blood pressure). Results. During an 11.0‐year follow‐up period, there were 1171 deaths from vascular causes [26 per 1000 per year (py)] and 1615 deaths from nonvascular causes (36 per 1000 py). Compared with men with cystatin C in the bottom fifth of the distribution, men in the top 10th had about two‐fold higher mortality rates from vascular and nonvascular mortality (fully adjusted P both <0.001) even after adjustment for prior disease and all measured confounders, including lifetime blood pressure. The fully adjusted relative risks per 50% higher cystatin C concentrations were 1.66 [95% CI 1.48 to 1.85] for vascular mortality, 1.92 [95% CI 1.66 to 2.22] for ischaemic heart disease mortality and 1.46 [95% CI 1.31 to 1.61] for nonvascular mortality. Conclusions. In older men, plasma concentration of cystatin C, probably as a marker of mild renal disease, is a strong independent predictor of both vascular and nonvascular mortality.     

Evidence for the Prevention and Treatment of Stroke in Dialysis Patients

The risks of both ischemic and hemorrhagic stroke are particularly high in dialysis patients of any age and outcomes are poor. It is therefore important to identify strategies that safely minimize stroke risk in this population. Observational studies have been unable to clarify the relative importance of traditional stroke risk factors such as blood pressure and cholesterol in those on dialysis, and are affected by biases that usually make them an inappropriate source of data on which to base therapeutic decisions. Well‐conducted randomized trials are not susceptible to such biases and can reliably investigate the causal nature of the association between a potential risk factor and the outcome of interest. However, dialysis patients have been under‐represented in the cardiovascular trials which have proven net benefit of commonly used preventative treatments (e.g., antihypertensive treatments, low‐dose aspirin, carotid revascularization, and thromboprophylaxis for atrial fibrillation), and there remains uncertainty about safety and efficacy of many of these treatments in this high‐risk population. Moreover, the efficacy of renal‐specific therapies that might reduce cardiovascular risk, such as modulators of mineral and bone disorder, online hemodiafiltration, and daily (nocturnal) hemodialysis, have not been tested in adequately powered trials. Recent trials have also demonstrated how widespread current practices could be causing stroke. Therefore, it is important that reliable information on the prevention and treatment of stroke (and other cardiovascular disease) in dialysis patients is generated by performing large‐scale randomized trials of many current and future treatments.     

Conventional and Genetic Evidence on the Association between Adiposity and CKD

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The challenge of secondary prevention for coronary heart disease in older patients: findings from the British Women's Heart and Health Study and the British Regional Heart Study

BACKGROUND: Secondary prevention of coronary heart disease (CHD) among older individuals is associated with considerable benefit. METHODS: In this study, we have examined the extent of secondary prevention among British women and men aged 60-79 years who were surveyed and examined between 1998 and 2001. RESULTS: Among 483 women (12.1% of the whole sample) and 831 men (19.5%) with CHD, >90% of both sexes had at least one modifiable risk factor, with over two-fifths having high blood pressure and over three-quarters high cholesterol. For total cholesterol and body mass index, mean values in both male and female subjects were above recommended levels, and a large shift in the population distributions would be required for targets to be met. Less than one-quarter of subjects of either sex were on a statin, and whilst the majority of men were taking an antiplatelet medication, only 40% of women were. CONCLUSIONS: Most older women and men in Britain were failing to meet National Service Framework standards for secondary prevention in the period immediately before its implementation. Large shifts in the population distributions of some risk factors would be required in this group to meet these standards.     

英国中年男性的生活方式和心血管疾病：校正个体变异的影响

目的：探讨个体自身变异对英国中年男性吸烟、体力活动极少和体重指数（BMI）增加与心血管疾病（CVD）发生之问预计风险关系的影响。方法和结果：对6452例年龄在40-59岁之间、既往无CVD证据的男性就主要CVD事件（致死性／非致死性心肌梗死或脑卒中）和全因死亡进行了超过20年随访；整个研究过程中定期确定受试者的生活方式特点。观察到1194例男性（18．5％）发生了主要CVD事件。