Fast GFR decline and progression to CKD among primary care patients with preserved GFR

Classification and Regression Trees analysis identifies patients at high risk for kidney function decline following hospitalization

Estimated glomerular filtration rate (eGFR) decline is associated with negative health outcomes, but the use of decision tree algorithms to predict eGFR decline is underreported. Among patients hospitalized during the first year of the COVID-19 pandemic, it remains unclear which individuals are at the greatest risk of eGFR decline after discharge. We conducted a retrospective cohort study on patients hospitalized at Stony Brook University Hospital in 2020 who were followed for 36 months post discharge. Random Forest (RF) identified the top ten features associated with fast eGFR decline. Logistic regression (LR) and Classification and Regression Trees (CART) were then employed to uncover the relative importance of these top features and identify the highest risk patients. In the cohort of 1,747 hospital survivors, 61.6% experienced fast eGFR decline, which was associated with younger age, higher baseline eGFR, and acute kidney injury (AKI). Multivariate LR analysis showed that older age was associated with lower odds of fast eGFR decline whereas length of hospitalization and vasopressor use with greater odds. CART analysis identified length of hospitalization as the most important factor and that patients with AKI and hospitalization of 27 days or more were at highest risk. After grouping by ICU and COVID-19 status and propensity score matching for demographics, these risk factors of fast eGFR decline remained consistent. CART analysis can help identify patient subgroups with the highest risk of post-discharge eGFR decline. Clinicians should consider the length of hospitalization in post-discharge monitoring of kidney function.

Predictors of chronic kidney disease survival in type 2 diabetes: a 12-year retrospective cohort study utilizing estimated glomerular filtration rate

Predicting the course of kidney disease in individuals with both type 1 and type 2 diabetes mellitus (DM) is a significant clinical and policy challenge. In several regions, DM is now the leading cause of end-stage renal disease. The aim of this study to identify both modifiable and non-modifiable risk factors, along with clinical markers and coexisting conditions, that increase the likelihood of stage 3-5 chronic kidney disease (CKD) development in individuals with type 2 DM in the United Arab Emirates (UAE). This was a single-center retrospective cohort study based on data derived from electronic medical records of UAE patients with DM who were registered at outpatient clinics at Tawam Hospital in Al Ain, UAE, between January 2011 and December 2021. Type 2 DM patients aged ≥ 18 years who had serum HbA1c levels ≥ 6.5% were included in the study. Patients with type 1 DM, who had undergone permanent renal replacement therapy, who had under 1 year of follow-up, or who had missing or incomplete data were excluded from the study. Factors associated with diabetic patients developing stage 3-5 CKD were identified through Cox regression analysis and a fine and gray competing risk model to account for competing events that could potentially hinder the development of CKD. A total of 1003 patients were recruited for the study. The mean age of the study cohort at baseline was 70.6 ± 28.2 years. Several factors were found to increase the risk of developing stage 3-5 CKD: advancing age (HR 1.005, 95% CI 1.002-1.009, p = 0.026), a history of hypertension (HR 1.69, 95% CI 1.032-2.8, p = 0.037), a history of heart disease (HR 1.49, 95% CI 1.16-1.92, p = 0.002), elevated levels of serum creatinine (HR 1.006, 95% CI 1.002-1.010, p = 0.003), decreased levels of estimated glomerular filtration rate (eGFR) (HR 0.943, 95% CI, 0.938-0.947; p < 0.001), and the use of beta-blockers (HR 139, 95% CI 112-173, p = 0.003). Implementing preventative measures, initiating early interventions, and developing personalized care plans tailored to address specific risk factors are imperative for reducing the impact of CKD. Additionally, the unforeseen findings related to eGFR highlight the ongoing need for research to deepen our understanding of the complexities of kidney disease.

Polygenic association of glomerular filtration rate decline in world trade center responders

BACKGROUND

The factors associated with estimated glomerular filtrate rate (eGFR) decline in low risk adults remain relatively unknown. We hypothesized that a polygenic risk score (PRS) will be associated with eGFR decline.

METHODS

We analyzed genetic data from 1,601 adult participants with European ancestry in the World Trade Center Health Program (baseline age 49.68 ± 8.79 years, 93% male, 23% hypertensive, 7% diabetic and 1% with cardiovascular disease) with ≥ three serial measures of serum creatinine. PRSs were calculated from an aggregation of single nucleotide polymorphisms (SNPs) from a recent, large-scale genome-wide association study (GWAS) of rapid eGFR decline. Generalized linear models were used to evaluate the association of PRS with renal outcomes: baseline eGFR and CKD stage, rate of change in eGFR, stable versus declining eGFR over a 3-5-year observation period. eGFR decline was defined in separate analyses as "clinical" (> -1.0 ml/min/1.73 m2/year) or "empirical" (lower most quartile of eGFR slopes).

RESULTS

The mean baseline eGFR was ~ 86 ml/min/1.73 m2. Subjects with decline in eGFR were more likely to be diabetic. PRS was significantly associated with lower baseline eGFR (B = -0.96, p = 0.002), higher CKD stage (OR = 1.17, p = 0.010), decline in eGFR (OR = 1.14, p = 0.036) relative to stable eGFR, and the lower quartile of eGFR slopes (OR = 1.21, p = 0.008), after adjusting for established risk factors for CKD.

CONCLUSION

Common genetic variants are associated with eGFR decline in middle-aged adults with relatively low comorbidity burdens.

Usefulness of metabolic score for insulin resistance index in estimating the risk of mildly reduced estimate glomerular filtration rate: a cross-sectional study of rural population in China

OBJECTIVES

This study aimed to reveal the association between metabolic score for insulin resistance (MetS-IR) and the risk of mildly decreased estimated glomerular filtration rate (eGFR), and explore the evaluation effect of MetS-IR on the progress of eGFR decline.

STUDY DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

A total of 11 956 rural participants (aged ≥35 years) from northeastern China were enrolled in the study. After excluding the subjects whose data were not integrated or who met the exclusion criteria, we finally obtained 11 042 participants in the present study.

MAIN OUTCOME MEASURES

Mildly decreased eGFR was defined as 60-90 mL/min/1.73 m².

RESULTS

The prevalence of mildly decreased eGFR in the general population was 36.9%. After adjustment of covariates, each SD increment of MetS-IR could bring 26.3% additional risk of mildly decreased eGFR (OR: 1.263, 95% CI: 1.066 to 1.497, p=0.007). When MetS-IR was classified into four levels by quartile, we observed participants in the top level had 3.032-fold risk of mildly decreased eGFR (OR: 3.032, 95% CI: 1.841 to 4.991, p<0.001) compared with those from the bottom level. Further, we found the participants with higher MetS-IR score were more likely to aggravate into a worse renal state which presented as higher risk of accelerated decline of eGFR, by additional 28.3% risk in whole participants (OR: 1.283, 95% CI: 1.150 to 1.430, p<0.001) and 41.9% in men (OR: 1.419, 95% CI: 1.183 to 1.701, p<0.001).

CONCLUSION

High MetS-IR was associated with high risk of mildly reduced eGFR and often accompanied by a high risk of accelerated decline in eGFR. Hence, we believed MetS-IR was a suitable indicator to evaluate the risk of early-stage renal dysfunction.

Renal involvement in sarcoidosis: histological patterns and prognosis, an Italian survey

Background

Granulomatous interstitial nephritis in sarcoidosis (sGIN) is generally clinically silent, but in <1% causes acute kidney injury (AKI).

Methods

This Italian multicentric retrospective study included 39 sarcoidosis-patients with renal involvement at renal biopsy: 31 sGIN-AKI, 5 with other patterns (No-sGIN-AKI), 3 with nephrotic proteinuria. We investigate the predictive value of clinical features, laboratory, radiological parameters and histological patterns regarding steroid response. Primary endpoint: incident chronic kidney disease (CKD) beyond the 1°follow-up (FU) year; secondary endpoint: response at 1°line steroid therapy; combined endpoint: the association of initial steroid response and outcome at the end of FU.

Results

Complete recovery in all 5 No-sGIN-AKI-patients, only in 45% (13/29) sGIN-AKI-patients (p=0.046) (one lost in follow-up, for another not available renal function after steroids). Nobody had not response. Primary endpoint of 22 sGIN-AKI subjects: 65% (13/20) starting with normal renal function developed CKD (2/22 had basal CKD; median FU 77 months, 15-300). Combined endpoint: 29% (6/21) had complete recovery and final normal renal function (one with renal relapse), 48% (10/21) had partial recovery and final CKD (3 with renal relapse, of whom one with basal CKD) (p=0.024). Acute onset and hypercalcaemia were associated to milder AKI and better recovery than subacute onset and patients without hypercalcaemia, women had better endpoints than men. Giant cells, severe interstitial infiltrate and interstitial fibrosis seemed negative predictors in terms of endpoints.

Conclusions

sGIN-AKI-patients with no complete recovery at 1°line steroid should be treated with other immunosuppressive to avoid CKD, in particular if males with subacute onset and III stage-not hypercalcaemic AKI.

The Association of Posttraumatic Stress Disorder With Longitudinal Change in Glomerular Filtration Rate in World Trade Center Responders

OBJECTIVE

High levels of psychological distress increase the risk of a wide range of medical diseases. In this study, we investigated the association between posttraumatic stress disorder (PTSD) and kidney disease.

METHODS

World Trade Center (WTC) responders were included if they had two or more measures of estimated glomerular filtration rate (eGFR). The PTSD Checklist (PCL) was used to define no PTSD (PCL < 40), "mild" PTSD (40 ≤ PCL <50), and "severe" PTSD (PCL ≥50). Subtypes of PTSD by symptom clusters were analyzed. Multinomial logistic regression was used to estimate the association of PTSD with two GFR change outcomes (decline or increase) compared with the stable GFR outcome.

RESULTS

In 2266 participants, the mean age was 53.1 years, 8.2% were female, and 89.1% were White. Individuals with PTSD (n = 373; 16.5%) did not differ in mean baseline GFR from individuals without PTSD (89.73 versus 90.56 mL min-1 1.73 m-2; p = .29). During a 2.01-year mean follow-up, a mean GFR decline of -1.51 mL min-1 1.73 m-2 per year was noted. In multivariable-adjusted models, PTSD was associated with GFR decline (adjusted relative risk [aRR] = 1.74 [1.32-2.30], p < .001) compared with stable GFR, with "hyperarousal" symptoms showing the strongest association (aRR =2.11 [1.40-3.19]; p < .001). Dose-response effects were evident when comparing mild with severe PTSD and comparing PTSD with versus without depression. PTSD was also associated with GFR rise (aRR = 1.47 [1.10-1.97], p < .009). The association between PTSD and GFR change was stronger in participants older than 50 years.

CONCLUSIONS

PTSD may be a novel risk factor for exaggerated longitudinal GFR change in young, healthy adults. These findings need to be validated in other cohorts.

Arteriolar hyalinosis is related to rapid GFR decline and long-standing GFR changes observed on renal biopsies in normo-microalbuminuric type 2 diabetic patients

AIMS

Whether or not renal structural changes, especially arteriolar hyalinosis, are related to the rate of renal functional decline and increase in urinary albumin excretion (UAE) at the early stage of diabetic nephropathy in patients with type 2 diabetes is still unknown. Our previous study determined that arteriolar hyalinosis is an independent risk factor for low GFR. We sought to determine whether arteriolar hyalinosis is also a risk factor for rapidly progressive decline in GFR.

METHODS

We evaluated 22 type 2 diabetic patients with normo- or microalbuminuria who took part in the previous study, to clarify which renal histological factors were associated with changes in UAE and the glomerular filtration rate (GFR) during 11.0 ± 3.0 years of follow-up. Light and electron microscopy-based morphometric analyses were performed to quantitatively evaluate the glomerular and interstitial structural changes.

RESULTS

In all 22 patients, the GFR was significantly decreased from baseline to follow-up, while the UAE did not change markedly between the 2 periods. After 11 ± 3 years of follow-up, the GFR was significantly lower in the rapid decliner group (annual rate of GFR decline ≥3.0%) than in the non-rapid decliner group (p = 0.017). The index of arteriolar hyalinosis (IAH) at baseline in the rapid decliners was significantly larger than in the non-rapid decliners (p = 0.015). The IAH showed a significant negative correlation with the GFR at follow-up (r = 0.50, p = 0.018) and the annual rate in the GFR decline (r = 0.47, p = 0.027) and significant positive correlations with UAE at follow-up (r = 0.46, p = 0.034) and the annual rate in the UAE increase (r = 0.57, p = 0.005). The GFR at follow-up in patients with IAH ≥2.0 was significantly decreased from baseline (p = 0.042) and significantly lower than that of the patients with IAH <2.0 (p = 0.026), which did not decrease significantly from baseline. The frequency of rapid decliners was larger in the IAH ≥2.0 than in the IAH <2.0 patients (p = 0.037).

CONCLUSIONS

Aggravated arteriolar hyalinosis was a risk factor for a rapid GFR decline. This finding might reflect initial changes in early diabetic nephropathy.

Rationale and design of a multicenter Chronic Kidney Disease (CKD) and at-risk for CKD electronic health records-based registry: CURE-CKD

BACKGROUND

Chronic kidney disease (CKD) is a global public health problem, exhibiting sharp increases in incidence, prevalence, and attributable morbidity and mortality. There is a critical need to better understand the demographics, clinical characteristics, and key risk factors for CKD; and to develop platforms for testing novel interventions to improve modifiable risk factors, particularly for the CKD patients with a rapid decline in kidney function.

METHODS

We describe a novel collaboration between two large healthcare systems (Providence St. Joseph Health and University of California, Los Angeles Health) supported by leadership from both institutions, which was created to develop harmonized cohorts of patients with CKD or those at increased risk for CKD (hypertension/HTN, diabetes/DM, pre-diabetes) from electronic health record data.

RESULTS

The combined repository of candidate records included more than 3.3 million patients with at least a single qualifying measure for CKD and/or at-risk for CKD. The CURE-CKD registry includes over 2.6 million patients with and/or at-risk for CKD identified by stricter guide-line based criteria using a combination of administrative encounter codes, physical examinations, laboratory values and medication use. Notably, data based on race/ethnicity and geography in part, will enable robust analyses to study traditionally disadvantaged or marginalized patients not typically included in clinical trials.

DISCUSSION

CURE-CKD project is a unique multidisciplinary collaboration between nephrologists, endocrinologists, primary care physicians with health services research skills, health economists, and those with expertise in statistics, bio-informatics and machine learning. The CURE-CKD registry uses curated observations from real-world settings across two large healthcare systems and has great potential to provide important contributions for healthcare and for improving clinical outcomes in patients with and at-risk for CKD.

Use of estimated glomerular filtration rate to predict incident chronic kidney disease in patients at risk of cardiovascular disease: a retrospective study

Background

Patients with cardiovascular disease are at an increased risk of chronic kidney disease (CKD). However, data on incident CKD in patients with multiple vascular comorbidities are insufficient. In this study, we identified the predictors of CKD stages 3–5 in patients at risk of cardiovascular disease and used their estimated glomerular filtration rate (eGFR) to construct a nomogram to predict the 5-year risk of incident CKD.

Methods

Ambulatory data on 622 adults with preserved kidney function and one or more cardiovascular disease risk factors who attended outpatient clinics at a tertiary care hospital in Al-Ain, United Arab Emirates were obtained retrospectively. eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation and assessed every 3 months from baseline to December 12, 2017. Fine and Gray competing risk regression model was used to identify the independent variables and construct a nomogram to predict incident CKD at 5 years, which is defined as eGFR < 60 mL/min/1.73 m² for ≥3 months. Time-dependent area under the receiver operating characteristic curve (AUC) was used to evaluate the discrimination ability of the model. Calibration curves were applied to determine the calibration ability and adjusted for the competing risk of death. Internal validation of predictive accuracy was performed using K-fold cross-validation.

Results

Of the 622 patients, 71 had newly developed CKD stages 3–5 over a median follow-up of 96 months (interquartile range, 86–103 months). Baseline eGFR, hemoglobin A1c, total cholesterol, and history of diabetes mellitus were identified as significant predictors of CKD stages 3–5. The nomogram had good discrimination in predicting the disease stages, with a time-dependent AUC of 0.918 (95% confidence interval, 0.846–0.964) at 5 years, after internal validation by cross-validation.

Conclusions

This study demonstrated that incident CKD could be predicted with a simple and practical nomogram in patients at risk of cardiovascular disease and with preserved kidney function, which in turn could help clinicians make more informed decisions for CKD management in these patients.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1494-8) contains supplementary material, which is available to authorized users.