Introduction Few population-based data exist in the U.S. about adults with IgA nephropathy (IgAN) and risks of kidney, cardiovascular, and mortality outcomes versus those with non-glomerular CKD or no CKD. Methods We applied natural language processing (NLP) algorithms to electronic health record data within a large integrated healthcare delivery system to identify adults with biopsy-proven IgAN between 2010-2020. We next identified two comparison cohorts of adults with non-glomerular CKD and adults without CKD matched on age and sex, and compared rates of ESKD, worsening CKD, acute kidney injury, cardiovascular outcomes, and death through 2021 using multivariable Cox proportional hazards models. Results We identified 1651 adults with biopsy-confirmed IgAN who had a mean age of 43 years and 48% women, 41% Asian or Pacific Islander and 3.3% Black. Compared to matched adults with non-glomerular CKD (N=9863), those with IgAN had higher adjusted rates of ESKD (adjusted hazard ratio [aHR]: 2.79, 95%CI:2.16-3.62), worsening CKD (aHR: 3.05, 95%CI:2.68-3.46), and AKI (aHR: 1.45, 95%CI:1.22-1.73) but no significant adjusted differences in cardiovascular events and death. Compared to matched adults without CKD (N=16,510), patients with IgAN had substantially higher adjusted rates of adverse kidney outcomes as well as higher adjusted rates of hospitalization for heart failure (aHR: 8.06, 95%CI:2.90-22.37) and death (aHR: 2.90, 95%CI:2.08-4.02) but not acute myocardial infarction or stroke/transient ischemic attack. Conclusions Adults with IgAN are at greater risk of adverse kidney outcomes versus non-glomerular CKD and substantially higher risks of heart failure and death compared with no CKD.
Background Cognitive decline has been reported after coronary artery revascularization, but whether it reflects procedure-specific effects or the burden of underlying vascular disease remains uncertain. Objectives To determine whether incident dementia risk differs according to coronary revascularization strategy among older adults with acute coronary syndrome (ACS). Methods We conducted a longitudinal cohort study among adults aged ≥65 years hospitalized for ACS between 2010 and 2020 (n = 25,176). Patients underwent percutaneous coronary intervention (n = 8,043), coronary artery bypass grafting (n = 797), or received no revascularization (n = 16,336). A second comparator cohort included patients with stable coronary artery disease (CAD) without revascularization (n = 154,299). The primary outcome was incident dementia identified using validated International Classification of Diseases codes after a 1-year washout. Propensity-matched analyses used Cox models accounting for the competing risk of death. Results Revascularized patients were younger (74.8 ± 6.9 vs 77.1 ± 8.2 years), more often male (66.2% vs 54.0%), and had lower Elixhauser multimorbidity scores (4.6 ± 2.8 vs 5.4 ± 3.0, all P < 0.001). Over a median 4.8 years of follow-up, 9.0% of ACS patients developed dementia. Revascularization was not associated with increased dementia risk compared with ACS without revascularization (sub-hazard ratio: 1.05; 95% CI: 0.95-1.17) or stable CAD. Dementia risk was also similar between percutaneous coronary intervention and coronary artery bypass grafting. Conclusions We found that among older adults with ACS, coronary revascularization was not statistically significantly associated with increased dementia risk compared with no revascularization or stable CAD. These findings reflect the hypothesis that the majority of dementia risk is potentially driven more by cumulative vascular and systemic factors than by procedure-specific neurotoxicity.
BACKGROUND AND AIMS:HF incidence increases with age. Novel treatments have led to more patients recovering LVEF, now classified as HF with improved ejection fraction (HFimpEF). However, the age-related epidemiology and prognosis of HFimpEF remain unclear. METHODS AND RESULTS:We identified adults ≥18 years with incident HFrEF (LVEF ≤40%) between 2013 and 2022 within Kaiser Permanente Northern California (KPNC), a healthcare delivery system serving 4.5 million members. HFimpEF was defined as baseline LVEF ≤40% with improvement to ≥40%. HFimpEF incidence was assessed by baseline age categories (<50, 50-64, 65-79, ≥80 years [yrs]). Rates of worsening HF (WHF) events (i.e. HF-related hospitalization, ED, or outpatient visits) were compared between HFimpEF and persistent HFrEF patients across age using Cox proportional hazards models adjusted for sex, race, and EF at the time of incident HFrEF, including evaluation of a potential interaction by age. DATA:Among 28 292 adults with incident HFrEF, 35% experienced HFimpEF, with lower rates at older ages: 43% (<50 yrs), 42% (50-64 yrs), 39% (65-79 yrs), and 21% (≥80 yrs) (P < .001 for trend). WHF incidence rates (per 100 person-years) increased with age: 10.6 [95% CI, 9.5-11.7] (<50 yrs), 14.5 [13.7-15.3] (50-64 yrs), 20.8 [20.0-21.6] (65-79 yrs), and 31.7 [29.9-33.5] (≥80 yrs). Patients with HFimpEF, compared to those with persistent HFrEF, had lower adjusted rates of WHF, a finding more prominent at lower ages (pinteraction by age <0.001). CONCLUSIONS:HFimpEF is common within a year of incident HFrEF, more prevalent in younger patients, and is associated with continued residual risk. Compared to persistent HFrEF, improvements in LVEF are associated with lower risk of WHF or death across the age spectrum. Additional research is needed to understand HF symptom burden and medical therapy use in this population to inform shared decision-making.
INTRODUCTION:To develop and internally validate electronic health record (EHR)-based machine-learning models to predict worsening heart failure (WHF) events across care settings and all-cause mortality among adults with mild-to-moderate chronic kidney disease (CKD). METHODS:We studied adults with mild-to-moderate CKD [estimated glomerular filtration rate (eGFR) 30-59 ml/min/1.73 m² or eGFR ≥60 with albuminuria] receiving care in a large health system from 2012 to 2021; outcomes were ascertained through 31 December 2022. Primary outcomes were (i) WHF events-outpatient encounters, emergency department (ED)/observation stays, and hospitalizations-identified using a validated natural language processing algorithm, and (ii) all-cause mortality. Models [extreme gradient boosting (XGBoost)] used an 80:20 train-test split and >500 EHR-derived covariates. Discrimination [area under the curve (AUC)] and calibration (slope) were evaluated overall and across subgroups by age, sex, race and ethnicity, and CKD stage. RESULTS:Among 375 495 adults (mean age 64 ± 16 years; 54% women; 53% non-Hispanic White; mean eGFR 76 ± 26 ml/min/1.73 m²), the WHF model achieved AUC 0.887 (95% CI 0.879-0.893) with calibration slope 0.955; the mortality model achieved AUC 0.875 (95% CI 0.868-0.883) with calibration slope 0.914 in the test set. Performance was consistent across age, sex, and race and ethnicity, with a slight decrement as CKD stage worsened. CONCLUSIONS:Electronic health record-based machine-learning models accurately predicted WHF and mortality in mild-to-moderate CKD with strong calibration across key subgroups. These models are positioned for EHR deployment to support risk-stratified cardiovascular-kidney-metabolic care-prioritizing guideline-directed therapies and care pathways for those at highest risk.
BACKGROUND:Dementia is increasingly common among older adults (≥ 65 years) and is associated with poor outcomes. However, little is known about its baseline prevalence in patients hospitalized with acute coronary syndrome (ACS), particularly across revascularization strategies. METHODS:The authors conducted a cross-sectional analysis from a current longitudinal cohort study of Kaiser Permanente Northern California members hospitalized with ACS between January 2010 and December 2020. Dementia diagnoses and subtypes were identified using International Classification of Diseases 9/10 codes. Baseline prevalence was compared across revascularization strategies: percutaneous coronary intervention, coronary artery bypass grafting, or no revascularization. RESULTS:Among 26,749 patients with ACS, the mean age was 76.7 ± 8.0 years; patients not revascularized were older than those who were (77.7 ± 8.3 vs 74.9 ± 7.0 years; P < .001). Overall, 57.4% were male, with a higher proportion among revascularized patients. The overall baseline prevalence of dementia was 5.9%, substantially lower among revascularized (1.9%) vs nonrevascularized patients (7.9%; P < .001). Dementia prevalence was 2.0% for percutaneous coronary intervention, 0.6% for coronary artery bypass grafting, and 7.9% for no revascularization. Alzheimer's disease was the most common subtype (85.7%), followed by vascular (5.7%), Lewy body/Parkinson's (3.7%), frontotemporal (1.0%), and unspecified types (3.9%). CONCLUSION:One in 17 older adults hospitalized with ACS had a documented diagnosis of dementia at baseline, with substantial variation by revascularization strategy. These findings highlight the baseline burden of dementia in this high-risk population and support the need for future research on the incidence and progression of cognitive impairment after ACS.
