Risk factors for increased left ventricular hypertrophy in patients with chronic kidney disease: findings from the CKD-JAC study

Global burden of chronic kidney disease due to diabetes mellitus, 1990-2021, and projections to 2050

Introduction

Chronic kidney disease (CKD) is a serious complication of diabetes, and the global burden of the disease is gradually increasing.

Methods

This study systematically analyzed the trends and future projections of the worldwide burden of chronic kidney disease caused by type 1 and type 2 diabetes mellitus based on the Global Burden of Disease Study (GBD) using data from 1990 to 2021. Number of deaths, Age-standardized mortality rates, disability-adjusted life years (DALYs), and age-standardized DALYs rate were used to estimate the disease burden. The study used Estimated Annual Percentage Changes (EAPCs) to calculate trends in the burden of each disease subtype and different regions and assessed the impact of various age groups and metabolic factors on chronic kidney disease due to diabetes. The ARIMA model was further used to predict the burden of Diabetic nephropathy from 2022 to 2050.

Results

The results of the study showed that the burden of Diabetic nephropathy and its EAPCs varied significantly in distribution across different Sociodemographic Index subgroups of countries as well as among 204 countries and regions worldwide. In addition, the influence of different age groups and metabolic factors on the burden of Diabetic nephropathy also showed significant variability. The effects of metabolic factors on the number of deaths and mortality were positively correlated with age. Different metabolic factors have different effects on the mortality of CKD due to type 1 diabetes and CKD due to type 2 diabetes. The ARIMA model predicts that the global burden of Diabetic nephropathy will continue to increase in the absence of interventions.

Conclusions

To effectively manage CKD caused by diabetes, more accurate and cost-effective diagnostic tools and interventions are needed in the future, especially in low - and middle-income countries with poor healthcare resources.

Independent risk factors of left ventricular hypertrophy in non-diabetic individuals in Sierra Leone - a cross-sectional study

BACKGROUND

Left ventricular hypertrophy (LVH) is a critical factor in heart failure and cardiovascular event-related mortality. While the prevalence of LVH in diabetic patients is well-documented, its occurrence and risk factors in non-diabetic populations remain largely unexplored. This study addresses this issue by investigating the independent risk factors of LVH in non-diabetic individuals.

METHODS

This cross-sectional study, conducted meticulously, utilized data from a robust and comprehensive source, DATADRYAD, in the Sierra Leone database, collected between October 2019 and October 2021, including LVH and various variables. All variables were described and screened using univariate analysis, Spearman correlation, and principal component analysis (PCA). The lipid profile, including total cholesterols (TC), triglycerides (TG), high-density lipoprotein (HDL-C), non-high-density lipoprotein (Non-HDL-C), and low-density lipoprotein cholesterol (LDL-C), TC/HDL-C ratio, TG/HDL-C ratio, Non-HDL-C /HDL-C ratio and LDL-C/HDL-C ratio, which quartiles were treated as categorical variables, with the lowest quartile serving as the reference category. Three adjusted models were constructed to mitigate the influence of other variables. To ensure the robustness of the model, receiver operating characteristic (ROC) curves were used to calculate the cutoff values by analyzing the ROC curves. A sensitivity analysis was performed to validate the findings further.

RESULTS

The dataset encompasses information from 2092 individuals. After adjusting for potential factors that could influence the results, we found that TC (OR = 2.773, 95%CI: 1.805-4.26), Non-HDL-C (OR = 2.74, 95%CI: 1.7723-4.236), TC/HDL-C ratio (OR = 2.237, 95%CI: 1.445-3.463), Non-HDL-C/HDL-C ratio (OR = 2.357, 95%CI: 1.548-3.588), TG/HDL-C ratio (OR = 1.513, 95%CI: 1.02-2.245) acts as independent risk factors of LVH. ROC curve analysis revealed the predictive ability of blood lipids for LVH, with Non-HDL-C exhibiting area under the curve (AUC = 0.6109), followed by TC (AUC = 0.6084).

CONCLUSIONS

TC, non-HDL-C, TC/HDL-C ratio, Non-HDL-C/HDL-C ratio, and TG/HDL-C ratio were independent risk factors of LVH in non-diabetic people. Non-HDL-C and TC were found to be essential indicators for predicting the prevalence of LVH.

The mediating role of the left ventricular mass index on the relationship between the fluid balance and left ventricular diastolic function in patients with chronic kidney disease

BACKGROUND

The pathophysiological mechanism of cardiovascular disease in patients with chronic kidney disease (CKD) is complicated. Mediation analysis is an important statistical tool for gaining insight into the complex mechanisms of exposure-outcome effects. We investigated the potential mediating role of the left ventricular mass index (LVMI) on the association between fluid balance (overhydration/extracellular water, OH/ECW) and left ventricular diastolic function (E/e´ ratio) in patients with CKD not yet on dialysis.

METHODS

Bioimpedance spectroscopy, echocardiography, and laboratory evaluations were performed on 425 consecutive patients on the same day. The patients were classified into two groups according to the estimated glomerular filtration rate corresponding to CKD stages 3 and 5. Mediation analysis was performed using the PROCESS macro and bootstrapping methods.

RESULTS

OH/ECW and LVMI were positively correlated with the E/e´ ratio in both the CKD stages 3 and five groups. In CKD stage 5, there was a statistically significant association between OH/ECW and LVMI, whereas no correlation was observed in CKD stage 3. In the mediation analysis, LVMI positively mediated the relationship between OH/ECW and E/e´ ratio when controlling for confounders in patients with CKD stage 5 (B = 2.602; Boot 95% confidence interval, 1.313-4.076).

CONCLUSION

In our analysis, the indirect effect of mediators was significant in patients with advanced CKD. Therefore, our study suggests that further research on several other risk factors may be needed to determine the underlying mechanisms of association between the associated factors in all CKD stages.

The cardio-renal-metabolic connection: a review of the evidence

Type 2 diabetes (T2D), cardiovascular disease (CVD) and chronic kidney disease (CKD), are recognized among the most disruptive public health issues of the current century. A large body of evidence from epidemiological and clinical research supports the existence of a strong interconnection between these conditions, such that the unifying term cardio-metabolic-renal (CMR) disease has been defined. This coexistence has remarkable epidemiological, pathophysiologic, and prognostic implications. The mechanisms of hyperglycemia-induced damage to the cardio-renal system are well validated, as are those that tie cardiac and renal disease together. Yet, it remains controversial how and to what extent CVD and CKD can promote metabolic dysregulation. The aim of this review is to recapitulate the epidemiology of the CMR connections; to discuss the well-established, as well as the putative and emerging mechanisms implicated in the interplay among these three entities; and to provide a pathophysiological background for an integrated therapeutic intervention aiming at interrupting this vicious crosstalks.

Excess risk of cardiovascular events in patients in the United States vs. Japan with chronic kidney disease is mediated mainly by left ventricular structure and function

While patients receiving dialysis therapy in the United States are more likely to develop cardiovascular disease (CVD) than those in Japan, direct comparisons of patients with predialysis chronic kidney disease (CKD) are rare. To study this, we compared various outcomes in patients with predialysis CKD using data from the Chronic Renal Insufficiency Cohort (CRIC) and CKD Japan Cohort (CKD-JAC) studies and determined mediators of any differences. Candidate mediators included left ventricular (LV) indices assessed by echocardiography. Among 3125 CRIC and 1097 CKD-JAC participants, the mean LV mass index (LVMI) and ejection fraction (EF) were 55.7 and 46.6 g/m2 and 54% and 65%, respectively (both significant). The difference in body mass index (32 and 24 kg/m2, respectively) largely accounted for the differences in LVMI and C-reactive protein levels across cohorts. Low EF and high LVMI were significantly associated with subsequent CVD in both cohorts. During a median follow-up of five years, CRIC participants were at higher risk for CVD (adjusted hazard ratio [95% confidence interval]: 3.66 [2.74-4.89]) and death (4.69 [3.05-7.19]). A three-fold higher C-reactive protein concentration and higher phosphate levels in the United States cohort were moderately strong mediators of the differences in CVD. However, echocardiographic parameters were stronger mediators than these laboratory measures. LVMI, EF and their combination mediated the observed difference in CVD (27%, 50%, and 57%, respectively) and congestive heart failure (33%, 62%, and 70%, respectively). Thus, higher LV mass and lower EF, even in the normal range, were found to be predictive of CVD in CKD.

Interconnection between cardiovascular, renal and metabolic disorders: A narrative review with a focus on Japan

Insights from epidemiological, clinical and basic research are illuminating the interplay between metabolic disorders, cardiovascular disease (CVD) and kidney dysfunction, termed cardio-renal-metabolic (CRM) disease. Broadly defined, CRM disease involves multidirectional interactions between metabolic diseases such as type 2 diabetes (T2D), various types of CVD and chronic kidney disease (CKD). T2D confers increased risk for heart failure, which-although well known-has only recently come into focus for treatment, and may differ by ethnicity, whereas atherosclerotic heart disease is a well-established complication of T2D. Many people with T2D also have CKD, with a higher risk in Asians than their Western counterparts. Furthermore, CVD increases the risk of CKD and vice versa, with heart failure, notably, present in approximately half of CKD patients. Molecular mechanisms involved in CRM disease include hyperglycaemia, insulin resistance, hyperactivity of the renin-angiotensin-aldosterone system, production of advanced glycation end-products, oxidative stress, lipotoxicity, endoplasmic reticulum stress, calcium-handling abnormalities, mitochondrial malfunction and deficient energy production, and chronic inflammation. Pathophysiological manifestations of these processes include diabetic cardiomyopathy, vascular endothelial dysfunction, cardiac and renal fibrosis, glomerular hyperfiltration, renal hypoperfusion and venous congestion, reduced exercise tolerance leading to metabolic dysfunction, and calcification of atherosclerotic plaque. Importantly, recognition of the interaction between CRM diseases would enable a more holistic approach to CRM care, rather than isolated treatment of individual conditions, which may improve patient outcomes. Finally, aspects of CRM diseases may differ between Western and East Asian countries such as Japan, a super-ageing country, with potential differences in epidemiology, complications and prognosis that represent an important avenue for future research.

Chronic Kidney Disease and Its Clinical Correlates in a Rural Community in Southwestern Nigeria

Chronic kidney disease (CKD) is a burgeoning problem globally, and more than a billion adults were affected as of 2016, with 1.2 million people dying from renal failure in 2017. To arrest the seemingly relentless progression of CKD to renal failure, there is a need to detect CKD early in the community. A community-based study was carried out to look at the prevalence and risk factors of CKD. Anthropometric and other clinical variables were measured. Blood samples were taken for determining creatinine, uric acid, urea, and lipids. CKD was defined as an estimated glomerular filtration rate of ≤60 mL/min/1.73 m2. Electrocardiograms and renal ultrasound scans were performed. In total, 201 people were recruited. Those with CKD had a male:female ratio of 1:3.9 and were older. The prevalence of autosomal-dominant polycystic kidney disease and CKD was 531.9 persons/100,000 population and 46.3%, respectively. Systolic blood pressure, pulse pressure, total cholesterol, triglycerides, high-density lipoprotein (HDL), uric acid, QTc interval, and electrocardiographic left ventricular hypertrophy were higher in those with CKD. Age, female sex, and HDL were independently associated with CKD. There was a steep rise in CKD at the community level. Increased awareness of CKD and prompt interventions are therefore imperative.

Associations between Albuminuria, Estimated GFR and Cardiac Phenotype in a Cohort with Chronic Kidney Disease - The CPH-CKD ECHO Study

OBJECTIVE

Echocardiographic findings in chronic kidney disease (CKD) vary. We sought to estimate the prevalence of abnormal cardiac structure and function in patients with CKD and their association to estimated glomerular filtration rate (eGFR) and urine albumin/creatinine ratio (UACR).

METHODS

We prospectively enrolled 825 outpatients with non-dialysis-dependent CKD, mean age 58± 13 yrs, and 175 matched healthy controls, mean age 60±12 yrs. Echocardiography included assessment of left ventricular (LV) hypertrophy, LV ejection fraction (LVEF), global longitudinal strain (GLS) and diastolic dysfunction according to ASE/EACVI guidelines.

RESULTS

LV hypertrophy was found in 9% of patients vs. 1.7% of controls (p=0.005) was independently associated with UACR (p=0.002). Median LVEF was 59.4% (IQR 55.2, 62.8) in patients vs. 60.8% (57.7, 64.1) in controls (p=0.002). GLS was decreased in patients with eGFR <60ml/min/1.73m² (-17.6%±3.1%) vs. patients with higher eGFR (19.0%±2.2%, p<0.001), who were similar to controls. . Diastolic dysfunction was detected in 55% of patients and in 34% of controls.

LIMITATIONS

Non-random sampling, cross-sectional analysis.

CONCLUSIONS

We report lower prevalence of hypertrophy than previous studies, but similar measurements of systolic and diastolic function. Cardiac remodeling in CKD may be influenced by treatment modalities, demographics, comorbidities and renal pathology.

Blood Pressure Control and its Determinants among Patients with Chronic Kidney Disease in a Nigerian Tertiary Hospital: A Cross-Sectional Study

Background

Hypertension is a common cardiovascular risk factor associated with adverse renal and cardiovascular outcomes in chronic kidney disease patients. Significant reduction in these adverse outcomes could be achieved through adequate blood pressure control in those with hypertension. This study aimed to determine the prevalence of poor blood pressure control and associated factors among chronic kidney disease patients with hypertension in a Nigerian tertiary hospital.

Methodology

This was a cross-sectional study that determined the prevalence of poor blood pressure control and its associated factors among chronic kidney disease patients with hypertension. Poor blood pressure control was defined as blood pressure ≥ 140/90mmHg. Factors associated with blood pressure control were determined on multivariate analysis. P-value less than 0.05 was considered significant.

Results

A total of 494 chronic kidney disease patients with hypertension were studied. The mean age of patients was 48.77+13.06 with a range of 17-95 years. There were 303 (61.3%) males and 191 (38.7%) females. A total of 44.5% of the patients had end-stage renal disease while all patients were on antihypertensive medications. The common causes of chronic kidney disease were hypertension (35%), diabetes mellitus (26.5%), and chronic glomerulonephritis (12.1%).Poor blood pressure control was found in 74.4% of chronic kidney disease patients. The predictors of poor blood pressure control were age (AOR: 0.65; CI: 0.45-0.94; p=0.02), use of multiple anti-hypertensives (AOR: 1.99; CI: 1.36-2.90; p=<0.001) and the presence of significant proteinuria (AOR: 1.47; CI: 1.02-2.14; p=0.04).

Conclusion

The majority of patients with chronic kidney disease had poor blood pressure control. Those who were young had significant proteinuria, and those who used≥ 3 antihypertensive medications were more likely to have poor blood control. There is a need to optimize BP management in chronic kidney disease patients in order to reduce adverse outcomes.

Left ventricular myocardial mass index associated with cardiovascular and renal prognosis in IgA nephropathy

Introduction

In chronic kidney disease (CKD), like in IgA nephropathy (IgAN), cardiovascular (CV) mortality and morbidity are many times higher than in the general population, and left ventricular hypertrophy (LVH) is an independent risk factor for CV disease. This follow-up study investigated the association between left ventricular mass index (LVMI) and renal or cardiovascular outcomes.

Methods

We examined 118 IgAN patients prospectively. LVMI and LV geometry was investigated using echocardiography. The primary combined endpoints were total mortality, major CV events, and end-stage renal disease. Secondary endpoints, i.e.—cardiovascular or renal endpoints,—were also examined separately.

Results

Sixty seven percent were males, mean age 53.5 ± 13.5. Mean follow-up time: 184 months. LVMI inversely correlated with eGFR (corr. coefficient: -0.365; p < 0.01). We divided the patients into two groups based on the LVMI cut-off suggested by the literature. The presence of LVH caused a worse prognosis in primary (p < 0.001), renal endpoints (p = 0.01), and also in CV endpoints (p = 0.001). The higher LVMI in men significantly worsened the prognosis in all endpoints. Concentric hypertrophy meant a worse prognosis. Independent predictors of LVMI were gender and eGFR in uni- and multivariate regression and hemoglobin levels only in logistic regression. Independent predictors of the primary endpoint were LVMI, eGFR, gender, obesity, HT, DM, and metabolic syndrome in Cox regression analysis.

Conclusion

Increased LVMI may predict the progression to end-stage renal disease and CV events in IgAN. Determining LVMI may be a useful parameter not only in CV risk but also in the stratification of renal risk in CKD.

Identification of Major Risk Factors and Non-linear Effects to the Development of Left Ventricular Hypertrophy in Chronic Kidney Disease by Constructing and Validation of Nomograms

Background

Left ventricular hypertrophy (LVH) is a common cardiovascular complication among chronic kidney disease (CKD) patients. The present study aimed to identify major independent risk factors and determine their contribution and relationship to LVH development.

Methods

Clinical and echocardiographic data of 2002 pre-dialytic CKD patients were retrospectively collected. Independent risk factors for LVH were identified using univariable and multivariable logistic regression. Nomograms together with restricted cubic splines method were employed to explore the effect size and possible non-linear relationship with regard to LVH. A simplified predictive model was constructed and its predictive ability was validated to demonstrate to which extent the identified risk factors accounted for LVH risk.

Results

Multivariable logistic regression identified age, body mass index (BMI), systolic blood pressure (SBP), eGFR and hemoglobin as independent influencing factors for LVH. Nomogram revealed BMI, SBP and hemoglobin concentration as the most important risk factors. Impaired renal function only showed obvious risk for LVH when eGFR declined below 30 ml/min/1.73 m². Significant threshold effects existed for blood pressure and obesity that the risks for LVH doubled when SBP exceeded 160 mmHg or BMI exceeded 30 kg/m². The predictive model constructed performed well on both the training and validation cohort using calibration curve, ROC curve and AUC value, with AUC above 0.80 for both the training cohort and the validation cohort.

Conclusions

With the help of nomogram model, we identified five independent factors that explain a large proportion of LVH risk in CKD patients. Among them, major contribution to LVH development was resulted from comorbidities and complications of CKD (hypertension, anemia, obesity) rather than eGFR reduction per se. Non-linear relationship and threshold relationship between eGFR, blood pressure, obesity and LVH risk were also identified.

Association of left ventricular hypertrophy and functional impairment with cardiovascular outcomes and mortality among patients with chronic kidney disease, results from the C-STRIDE study

AIM

Left ventricular hypertrophy and impaired systolic and diastolic function are commonly seen in patients with chronic kidney disease (CKD), but relationships between the disorders and cardiovascular outcomes are not well established among the patients.

METHODS

Totally, 2020 patients with CKD Stages 1-4 were used in the analysis. Left ventricular hypertrophy was defined by left ventricular mass index >49.2 g/m^2.7 in men and > 46.7 g/m^2.7 in women. Incident heart failure, non-heart failure cardiovascular events, and all-cause mortality were recorded longitudinally. Cox proportional hazards regression model was used to evaluate the association between the echo parameters and the outcomes, with death treated as the competing risk event for the cardiovascular events.

RESULTS

After a median follow-up of 4.5 years, 53 heart failure, 76 non-heart failure cardiovascular events and 82 deaths occurred. No overall association was found between left ventricular hypertrophy and subsequent heart failure, but the relationship was significant among patients with no diabetes with the multivariable adjusted hazard ratio of 3.66 (95% confidence interval: 1.42-9.46). Ejection fraction<55% was associated with both heart failure and non-heart failure cardiovascular events with hazard ratios of 3.16 (1.28-7.77) and 2.76 (1.08-7.04), respectively. E/A ratio ≤ 0.75 was associated with non-heart failure cardiovascular events [hazard ratio = 2.03 (1.09-3.80)], compared with E/A ratio of 0.76-1.49.

CONCLUSION

Associations of reduced left ventricular ejection fraction with both heart failure and non-heart failure cardiovascular events and of impaired left ventricular diastolic function with non-heart failure cardiovascular events were validated in a Chinese cohort of CKD.

Bone Marrow Findings in Renal Patients: A Single Renal Specialist Center Experience

Objective

This study evaluated the importance of bone marrow aspiration and trephine biopsy (BM) for the diagnosis of underlying hematological abnormalities in renal patients.

Methods

This cross-sectional study on BM was carried out between August 2010 and April 2019, in our specialist renal center for various unexplained hematological abnormalities in patients with renal diseases [chronic kidney disease (CKD), end-stage renal disease (ESRD) requiring maintenance hemodialysis (MHD), patients with normal renal function but other nephrology and urology issues like stone disease and nephrotic syndrome].

Results

Out of 176 reported BM examinations, 48 (27.3%) were done on ESRD patients on MHD (CKD-D), and 69 (39.2%) on CKD patients not on MHD (CKD-nD). Fifty-nine (33.5%) BM were done on patients with normal renal function (n-CKD). The indication for BM was pancytopenia 50 (28.4%), unexplained anemia 39 (22.2%), and unexplained thrombocytopenia 43 (24.4%). In 91 (51.7%) patients BM was normal. In 30 (17%) patients multiple myeloma (MM) was diagnosed on BM, out of which 18 (26.1%), nine (18%), three (5.3%) were CKD-nD, CKD-D, and n-CKD patients, respectively. In 11 (6.3%) patients BM was suggestive of myelodysplasia (MD), out of these 11 patients, five (10%) were CKD-D patients.

Conclusion

BM is an underutilized method of diagnosis of hematological abnormalities in renal patients. Our study revealed the importance of BM examination, especially in patients with CKD.

Fibroblast Growth Factor 23 and Left Ventricular Hypertrophy in Chronic Kidney Disease-A Pediatric Perspective

Cardiovascular diseases (CVD) are a hallmark in pediatric patients with chronic kidney disease (CKD) contributing to an enhanced risk of all-cause and CV morbidity and mortality in these patients. The bone-derived phosphaturic hormone fibroblast growth factor (FGF) 23 progressively rises with declining kidney function to maintain phosphate homeostasis, with up to 1,000-fold increase in patients with kidney failure requiring dialysis. FGF23 is associated with the development of left ventricular hypertrophy (LVH) and thereby accounts to be a CVD risk factor in CKD. Experimentally, FGF23 directly induces hypertrophic growth of cardiac myocytes in vitro and LVH in vivo. Further, clinical studies in adult CKD have observed cardiotoxicity associated with FGF23. Data regarding prevalence and determinants of FGF23 excess in children with CKD are limited. This review summarizes current data and discusses whether FGF23 may be a key driver of LVH in pediatric CKD.

Relationship among Left Ventricular Hypertrophy, Cardiovascular Events, and Preferred Blood Pressure Measurement Timing in Hemodialysis Patients

This study aimed to identify the ideal timing and setting for measuring blood pressure (BP) and determine whether the left ventricular mass index (LVMI) is an independent risk factor associated with increased cardiovascular events in hemodialysis (HD) patients. BP and LVMI were measured at baseline and at 6 and 12 months after HD initiation. BP was monitored and recorded at nine different time points, including before and after HD over a one-week period (HDBP). The mean BP measurement was calculated as the weekly averaged BP (WABP). LVMI was significantly correlated with home BP, in-office BP, HDBP, and WABP. Receiver operating characteristic analysis indicated that the cutoff LVMI value for cardiovascular events was 156 g/m2. LVMI and diabetes mellitus were significant influencing factors for cardiovascular events (hazards ratio (95% confidence interval): diabetes mellitus, 2.84 (1.17,7.45); LVMI > 156 g/m2, 2.86 (1.22,6.99)). Pre-HDBP, post-HDBP, and WABP were independently associated with higher LVMI in the follow-up periods. Hemoglobin and human atrial natriuretic peptide (hANP) levels were associated with LVMI beyond 12 months after HD initiation. Treatment of hypertension, overhydration based on hANP, and anemia may reduce the progression of LVMI and help identify HD patients at high risk for cardiovascular events.

Relative overhydration is independently associated with left ventricular hypertrophy in dialysis naïve patients with stage 5 chronic kidney disease

Patients with chronic kidney disease (CKD) have a high prevalence of left ventricular hypertrophy (LVH), which increases as kidney function decreases. LVH pathophysiology is complex, making it difficult to generalise its evolution in CKD. Therefore, early detection and prevention of risk factors are critical. Assessment and management of volume status can minimise cardiovascular complications including LVH. We retrospectively investigated the associations between fluid overload and LVH in patients with stage 5 CKD not undergoing dialysis in prospective cohort of 205 patients (age: 59.34 ± 13.51 years; women: 43.4%). All patients, free of intrinsic heart disease, were assessed for relative overhydration/extracellular water (OH/ECW) by bioimpedance spectroscopy. Our results show that markers reflecting fluid balance were significantly higher in the LVH group and as OH/ECW increased, the left ventricular mass index (LVMI) trended higher. Furthermore, our results show that systolic blood pressure, serum phosphorus levels, and OH/ECW were independently associated with LVMI and that OH/ECW was independently associated with LVH. Structural and functional evaluation of the heart using echocardiography and volume status assessment using bioimpedance should be performed simultaneously in patients with early-stage CKD, even in those without evident cardiovascular disease.

Sleep Quality and Sleep Duration with CKD are Associated with Progression to ESKD

BACKGROUND AND OBJECTIVES

Shorter or longer sleep duration and poor sleep quality are risk factors for numerous cardio-metabolic diseases, cardiovascular disease, and mortality in subjects with normal kidney function. The association of sleep duration and sleep quality with health outcomes in patients with CKD remains uncertain.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A 4-year prospective cohort study in 17 nephrology centers in Japan, the CKD Japan Cohort (CKD-JAC) Study, assessed an association of self-reported sleep duration and sleep quality, on the basis of the Pittsburgh Sleep Quality Index (PSQI) questionnaire, with incidence of ESKD in 1601 patients with eGFR 10-59 ml/min per 1.73 m2 using multivariable-adjusted Cox proportional hazards models.

RESULTS

Baseline sleep duration and PSQI global score for the 1601 patients were mean±SD 7.0±1.3 hours and median 4 (interquartile range, 3-7), respectively. Poor sleep quality (PSQI global score ≥6) was common (n=588 [37%]). During a median of 4.0 (2.6-4.3) years of the follow-up period, 282 (18%) patients progressed to ESKD. After adjusting for age, sex, eGFR, urinary albumin excretion, smoking status, body mass index, history of diabetes and cardiovascular disease, systolic BP, blockade of the renin-angiotensin system, use of hypnotics, and Beck depression inventory score, both shorter (≤5 hour) and longer (>8 hour) sleep duration were associated with ESKD (adjusted hazard ratios [95% confidence intervals] for ≤5.0, 5.1-6.0, 6.1-7.0, 7.1-8.0, and ≥8.0 hours were 2.05 [1.31 to3.21], 0.98 [0.67 to 1.44], 1.00 [reference], 1.22 [0.89 to 1.66], and 1.48 [1.01 to 2.16]), suggesting a U-shaped relationship between sleep duration and ESKD. PSQI global score ≥6 was also associated with incidence of ESKD (adjusted hazard ratios [95% confidence intervals] for PSQI global score ≤5 and ≥6 were 1.00 [reference] and 1.33 [1.03 to 1.71]).

CONCLUSIONS

Shorter (≤5 hour) and longer (>8 hour) sleep duration and poor sleep quality (PSQI global score ≥6) were associated with ESKD in patients with CKD.