Healthy Lifestyle May Lower Death, MACE Risk in Chronic Kidney Disease – Renal and Urology News

Patients with chronic kidney disease (CKD) have a 10-fold higher risk of cardiovascular disease compared with the general population. Now a new study published in the Journal of the American Society of Nephrology finds that adhering to generally recommended healthy lifestyle behaviors also reduces the risks for death and some major adverse cardiovascular events (MACE) in individuals with reduced kidney function.

Investigators led by Sarah J. Schrauben, MD, of the University of Pennsylvania in Philadelphia, Pennsylvania, pooled data from 3 cardiovascular cohort studies in the United States (ARIC, MESA, and CHS) involving 27,271 participants. Kidney function categories were 60 or higher, 45 to less than 60, and less than 45 mL/min/1.73 m2, according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation for estimating glomerular filtration rate (eGFR).


Adhering to recommended lifestyle behaviors was associated with lower risks for all-cause mortality, regardless of eGFR. Death risk was 54% lower for former or never smokers compared with current smokers (reference). Compared with a body mass index (BMI) of 30 kg/m2 or higher (reference), a BMI of at least 18.5 but less than 30 kg/m2 was significantly associated with a 16% decreased risk of death. Moderate or no daily alcohol intake was significantly associated with a 13% decreased risk of death compared with excessive intake (reference). A diet score of 2 or higher was significantly associated with a 7% decreased risk of death compared with a score of 0-1 (reference). Any moderate to vigorous physical activity, compared with none (reference), was significantly associated with a 20% lower death risk. Adhering to all 5 lifestyle behaviors reduced the risk for death by a significant 52% compared with adopting none.

For the diet score, 1 point was given for each of the following components recommended for the general population: fruits and vegetables (4.5 cups or servings/d or more), fish (3.5 oz or 2 servings/wk or more), whole grains (3 one-oz servings/d), sodium (less than 1500 mg/d), and sugar-sweetened beverages (36 oz or 4 glasses/wk or less). Moderate alcohol intake was defined as up to 2 drinks for men or 1 drink for women per day.

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Cardiovascular Events

Cardiovascular endpoints included a composite of major coronary events (myocardial infarction, fatal coronary heart disease, or revascularization procedure such as coronary angioplasty), as well as ischemic stroke, and heart failure events.

Regardless of eGFR, not smoking currently and any moderate to vigorous physical activity were significantly associated with a 38% and 15% reduced risk of major coronary events and a 52% and 14% reduced risk of heart failure events, respectively, compared with reference values. Any moderate to vigorous physical activity, compared with none, also correlated with a 20% decreased risk of ischemic stroke among those with an eGFR of 60 mL/min/1.73 m2 or higher.

A healthy BMI of at least 18.5 but less than 30 kg/m2 was associated with a 13% decreased risk of heart failure events, regardless of eGFR.

Remarkably, moderate to no daily alcohol (versus excessive consumption) was significantly associated with a 29% increased risk of major coronary events, regardless of eGFR.

The investigators found no significant associations between adherence to the American Heart Association’s dietary pattern and lower cardiovascular risks possibly because they merged the intermediate and ideal categories to define a healthy diet (a score of 2 or higher rather than a score of higher than 4).

Cardiovascular risks decreased as the number of healthy behaviors increased. Adherence to all 5 healthy behaviors was significantly associated with 27%, 38%, and 44% reduced risks for major coronary events, ischemic stroke, and heart failure, respectively, compared with adopting none of the behaviors.

That benefits of a healthy lifestyle did not vary by kidney function may reflect improvement in traditional cardiovascular disease risk factors, such as hypertension, obesity, insulin resistance, and hyperlipidemia, according to the investigators. However, healthy behaviors may also mitigate cardiovascular risk factors unique to kidney disease, such as albuminuria and mediators of inflammation and oxidative stress, they stated.

“Our study supports the importance of lifestyle as a potentially modifiable risk factor for individuals with and without kidney disease,” Dr Schrauben’s team concluded.

Clinicians may want to prioritize counseling patients with CKD about healthy behaviors with appropriate referrals. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) provides helpful information on Heart Disease & Kidney Disease.


Schrauben SJ, Hsu JY, Amaral S, Anderson AH, Feldman HI, Dember LM. Effect of kidney function on relationships between lifestyle behaviors and mortality or cardiovascular outcomes: a pooled cohort analysis. Published online February 5, 2021.  J Am Soc Nephrol. doi:10.1681/ASN.2020040394

Heart Disease & Kidney Disease. National Institute of Diabetes and Digestive and Kidney Diseases. Accessed February 25, 2021.