Long-term cardiovascular outcomes across KDOKI risk categories in a large Asian cohort

Background The Kidney Disease Outcomes Quality Initiative (KDOQI) risk stratification integrates estimated glomerular filtration rate (eGFR) and proteinuria to categorize renal risk. However, long-term outcome data in large Asian populations and the prognostic utility of simple dipstick-determined proteinuria remain limited. We investigated the association between KDOQI risk categories and mortality and heart failure (HF) outcomes in a large ambulatory Asian cohort with extended follow-up. Methods We analyzed 162,946 ambulatory adults (mean age 60.6 ± 17.5 years; 55.1% male). eGFR was calculated using the CKD-EPI equation. Proteinuria was assessed using urine dipstick testing, a widely available and low-cost method. Participants were stratified into KDOQI risk categories (low, moderate, high, and very high). Median follow-up was 117 months (interquartile range 66.9–160.8). Outcomes included all-cause mortality, cardiovascular (CV) death, HF hospitalization, and a composite of HF hospitalization or death. Cox proportional hazards models were constructed using the low-risk group as reference. Results During follow-up, 68,736 patients (42.2%) died, including 14,537 (8.9%) CV deaths, and 25,373 experienced HF hospitalization. Adverse outcomes increased stepwise across KDOQI risk categories (all p<0.0001). After adjustment for age and sex: HF hospitalizationModerate risk: HR 1.88 (95% CI 1.82–1.94)High risk: HR 2.85 (2.74–2.97)Very high risk: HR 5.00 (4.83–5.17) All-cause mortalityModerate risk: HR 1.50 (1.47–1.53)High risk: HR 1.75 (1.70–1.79)Very high risk: HR 2.73 (2.67–2.79) CV deathModerate risk: HR 1.74 (1.66–1.81)High risk: HR 2.38 (2.26–2.50)Very high risk: HR 3.95 (3.78–4.14) The gradient was particularly pronounced for HF hospitalization, with nearly a fivefold increase in risk in the very high KDOQI group. These associations were observed in a real-world ambulatory setting using routine laboratory parameters and dipstick proteinuria. Conclusions In a large Asian cohort with decade-long follow-up, KDOQI renal risk stratification based on eGFR and simple dipstick proteinuria provided powerful and graded prediction of mortality and heart failure hospitalization. The marked escalation in HF risk highlights the clinical relevance of cardiorenal interaction. Pragmatic assessment using dipstick proteinuria offers a scalable and cost-effective strategy for long-term cardiovascular risk stratification in routine practice.