Abstract Body (Do not enter title and authors here): Background
Previous studies have shown that chronic kidney disease (CKD) is associated with
increased cardiovascular disease (CVD) burden, but few studies have investigated
trends in CVD deaths in CKD. We evaluated the temporal changes in the CVD-related
age-adjusted mortality rate (AAMR) in CKD based on sex, race, rural-urban status, and
census region from 1999-2020.

Methods
This was a retrospective repeated cross-sectional analysis of national death certificate
data from the CDC WONDER from 1999 to 2020. We included persons aged ≥25 years
of age with CKD (ICD-10 code N18) as the underlying cause of death. We used ICD-10
codes I10-I178 to identify CVD-related deaths from the multiple cause-of-death dataset.
We calculated the CVD-related AAMR in CKD per 100,000 population. The exposure
variable was the year of death, and the outcome was the changes over time in CVD-
related AAMR in CKD, stratified by sex, race, rural-urban status, and census region.
We used the Mann-Whitney test and ANOVA for group comparisons as appropriate.
Racial disparities were assessed with the Black-White AAMR ratio. Trends were
evaluated with Joinpoint regression and expressed as average annual percentage
change (AAPC) with 95% confidence interval (CI). P<0.05 defined statistical
significance.

Results
Of the 4.4 billion people, 260,679 with CKD had CVD-related deaths (AAMR 5.5). The
AAMR was higher in males (7 vs 4.4 in females; P<0.001), Black people (12.6 vs 4.7 in White; P<0.001), and the Northeast and South census regions (AAMR 5.8). The AAMR did not differ by rural-urban status. From 1999 to 2020, the overall AAMR increased from 4.7 to 6.5 (AAPC 1.6%; CI: 1.4-1.8). Similarly, the AAMR increased significantly in males (AAPC 1.5%; CI: 1.2-1.7), females (AAPC 1.4%; CI: 1.1-1.6), rural areas (AAPC 2%; CI: 1.6-2.3), urban areas (AAPC 1.4%; CI: 1.1-1.7), White race (AAPC 1.9%; CI: 1.7-2.2) and across each of the four census regions. There was no significant change in Black race (AAPC 0.2%; CI: -0.04-0.5). The overall Black-White AAMR ratio was 2.8 and it declined from 3.4 to 2.4 (AAPC -1.7%; CI, -1.9, -1.5).


Conclusion
CVD-related deaths increased in CKD patients over the last two decades. While racial
disparities in CVD-related deaths persisted, they narrowed during the study period.
These findings underscore the need to intensify CVD screening and multidisciplinary
management in CKD patients. The reasons for the persistence of the racial disparity
require further study.