American Journal of Kidney Diseases

Heart Failure–Type Symptom Score Trajectories in CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

  • Carl P. Walther
    Corresponding author: Carl P. Walther, MD, MS, One Baylor Plaza, Houston, TX 77030,
    Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX
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  • Julia S. Benoit
    Texas Institute for Measurement, Evaluation, and Statistics, University of Houston, Houston, TX
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  • Nisha Bansal
    Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, WA
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  • Vijay Nambi
    Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX

    Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX
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  • Sankar D. Navaneethan
    Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX

    Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX

    Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, TX
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  • on behalf of theCRIC Study Investigators
    Author Footnotes
    CRIC Study Investigators: Harold I. Feldman, MD, MSCE, Lawrence J. Appel, MD, MPH, Jing Chen, MD, MMSc, MSc, Debbie L. Cohen, MD, Alan S. Go, MD, James P. Lash, MD, Robert G. Nelson, MD, PhD, MS, Mahboob Rahman, MD, Panduranga S. Rao, MD, Vallabh O Shah, PhD, MS, Mark L. Unruh, MD, MS.
  • Author Footnotes
    CRIC Study Investigators: Harold I. Feldman, MD, MSCE, Lawrence J. Appel, MD, MPH, Jing Chen, MD, MMSc, MSc, Debbie L. Cohen, MD, Alan S. Go, MD, James P. Lash, MD, Robert G. Nelson, MD, PhD, MS, Mahboob Rahman, MD, Panduranga S. Rao, MD, Vallabh O Shah, PhD, MS, Mark L. Unruh, MD, MS.
Published:November 17, 2022DOI:


      Rationale & Objective

      Quality of life in chronic kidney disease (CKD) is impaired by a large burden of symptoms including some that overlap with the symptoms of heart failure (HF). We studied a group of individual with CKD to understand the patterns and trajectories of HF-type symptoms in this setting.

      Study Design

      Prospective cohort study.

      Setting & Participants

      3,044 participants in the Chronic Renal Insufficiency Cohort (CRIC) without prior diagnosis of HF.


      Sociodemographics, medical history, medications, vital signs, laboratory values, echocardiographic and EKG parameters.


      Trajectory over 5.5 years of a HF-type symptom score (modified Kansas City Cardiomyopathy Questionnaire [KCCQ] Overall Summary Score with a range of 0-100 where <75 reflects clinically significant symptoms).

      Analytical Approach

      Latent class mixed models were used to model trajectories. Multinomial logistic regression was used to model relationships of predictors with trajectory group membership.


      Five trajectories of KCCQ score were identified in the cohort of 3,044 adults, 45% of whom were female, and whose median age was 61 years. Group 1 (41.7%) had a stable high score (minimal symptoms, average score of 96); Groups 2 (35.6%) and 3 (15.6%) had stable but lower scores (mild symptoms, average 81, and clinically significant symptoms, average 52, respectively). Group 4 (4.9%) had a substantial worsening in symptoms over time (mean 31-point decline) and Group 5 (2.2%) had a substantial improvement (mean 33-point increase) in KCCQ score. A majority of Group 1 was male, non-diabetic, non-obese, and had higher baseline kidney function. A majority of Groups 2 and 3 had diabetes and obesity. A majority of Group 4 was male and had substantial proteinuria. Group 5 had the highest proportion of baseline cardiovascular disease (CVD).


      No validation cohort available, CKD management changes in recent years may alter trajectories, and latent class models depend on the missing at random assumption.


      Distinct HF-type symptom burden trajectories were identified in the setting of CKD, corresponding to different baseline characteristics. These results highlight the diversity of HF-type symptom experiences in individuals with CKD.

      Key words

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