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Buchalter RB, Mohan S, Schold JD. Geospatial Modeling Methods in Epidemiological Kidney Research: An Overview and Practical Example. Kidney Int Rep 2024; 9:807-816. [PMID: 38765574 PMCID: PMC11101776 DOI: 10.1016/j.ekir.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/19/2023] [Accepted: 01/08/2024] [Indexed: 05/22/2024] Open
Abstract
Geospatial modeling methods in population-level kidney research have not been used to full potential because few studies have completed associative spatial analyses between risk factors and exposures and kidney conditions and outcomes. Spatial modeling has several advantages over traditional modeling, including improved estimation of statistical variation and more accurate and unbiased estimation of coefficient effect direction or magnitudes by accounting for spatial data structure. Because most population-level kidney research data are geographically referenced, there is a need for better understanding of geospatial modeling for evaluating associations of individual geolocation with processes of care and clinical outcomes. In this review, we describe common spatial models, provide details to execute these analyses, and perform a case-study to display how results differ when integrating geographic structure. In our case-study, we used U.S. nationwide 2019 chronic kidney disease (CKD) data from Centers for Disease Control and Prevention's Kidney Disease Surveillance System and 2006 to 2010 U.S. Environmental Protection Agency environmental quality index (EQI) data and fit a nonspatial count model along with global spatial models (spatially lagged model [SLM]/pseudo-spatial error model [PSEM]) and a local spatial model (geographically weighted quasi-Poisson regression [GWQPR]). We found the SLM, PSEM, and GWQPR improved model fit in comparison to the nonspatial regression, and the PSEM model decreased the positive relationship between EQI and CKD prevalence. The GWQPR also revealed spatial heterogeneity in the EQI-CKD relationship. To summarize, spatial modeling has promise as a clinical and public health translational tool, and our case-study example is an exhibition of how these analyses may be performed to improve the accuracy and utility of findings.
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Affiliation(s)
- R. Blake Buchalter
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
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Su CC, Lee KJ, Yen CT, Wu LH, Huang CH, Lu MZ, Cheng CL. Use of spatial panel-data models to investigate factors related to incidence of end-stage renal disease: a nationwide longitudinal study in Taiwan. BMC Public Health 2023; 23:247. [PMID: 36747222 PMCID: PMC9901115 DOI: 10.1186/s12889-023-15189-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/19/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The assumptions of conventional spatial models cannot estimate the responses across space and over time. Here we propose new spatial panel data models to investigate the association between the risk factors and incidence of end-stage renal disease (ESRD). METHODS A longitudinal (panel data) study was conducted using data from the National Health Insurance Database in Taiwan. We developed an algorithm to identify the patient's residence and estimate the ESRD rate in each township. Corresponding covariates, including patient comorbidities, history of medication use, and socio-environmental factors, were collected. Local Indicators of Spatial Association were used to describe local spatial clustering around an individual location. Moreover, a spatial panel data model was proposed to investigate the association between ESRD incidence and risk factors. RESULTS In total, 73,995 patients with ESRD were included in this study. The western region had a higher proportion of high incidence rates than the eastern region. The proportion of high incidence rates in the eastern areas increased over the years. We found that most "social environmental factors," except average income and air pollution (PM 2.5 and PM10), had a significant influence on the incidence rate of ESRD when considering spatial dependences of response and explanatory variables. Receiving non-steroidal anti-inflammatory drugs and aminoglycosides within 90 days prior to ESRD had a significant positive effect on the ESRD incidence rate. CONCLUSION Future comprehensive studies on townships located in higher-risk clusters of ESRD will help in designing healthcare policies for suitable action.
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Affiliation(s)
- Chien-Chou Su
- grid.412040.30000 0004 0639 0054Clinical Innovation and Research Center, National Cheng Kung University Hospital, Tainan City, Taiwan
| | - Kuo-Jung Lee
- grid.64523.360000 0004 0532 3255Department of Statistics, Institute of Data Science, National Cheng Kung University, No.1, University Road, 701 Tainan City, Taiwan
| | - Chi-Tai Yen
- grid.410770.50000 0004 0639 1057Department of Nephrology , Tainan Hospital, Ministry of Health and Welfare , Tainan City, Taiwan
| | - Lu-Hsuan Wu
- grid.412040.30000 0004 0639 0054Department of Pharmacy, National Cheng Kung University Hospital, Tainan City, Taiwan ,grid.64523.360000 0004 0532 3255School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, No. 1 University Road, 701 Tainan city, Taiwan
| | - Chien-Huei Huang
- grid.412040.30000 0004 0639 0054Department of Pharmacy, National Cheng Kung University Hospital, Tainan City, Taiwan
| | - Meng-Zhan Lu
- grid.64523.360000 0004 0532 3255School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, No. 1 University Road, 701 Tainan city, Taiwan
| | - Ching-Lan Cheng
- Department of Pharmacy, National Cheng Kung University Hospital, Tainan City, Taiwan. .,School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, No. 1 University Road, 701, Tainan city, Taiwan.
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Xu E, Xie Y, Al-Aly Z. Risks and burdens of incident dyslipidaemia in long COVID: a cohort study. Lancet Diabetes Endocrinol 2023; 11:120-128. [PMID: 36623520 PMCID: PMC9873268 DOI: 10.1016/s2213-8587(22)00355-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/14/2022] [Accepted: 11/25/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Non-clinical evidence and a few human studies with short follow-ups suggest increased risk of dyslipidaemia in the post-acute phase of COVID-19 (ie, >30 days after SARS-CoV-2 infection). However, detailed large-scale controlled studies with longer follow-ups and in-depth assessment of the risks and burdens of incident dyslipidaemia in the post-acute phase of COVID-19 are not yet available. We, therefore, aimed to examine the risks and 1-year burdens of incident dyslipidaemia in the post-acute phase of COVID-19 among people who survive the first 30 days of SARS-CoV-2 infection. METHODS In this cohort study, we used the national health-care databases of the US Department of Veterans Affairs to build a cohort of 51 919 participants who had a positive COVID-19 test and survived the first 30 days of infection between March 1, 2020, and Jan 15, 2021; a non-infected contemporary control group (n=2 647 654) that enrolled patients between March 1, 2020, and Jan 15, 2021; and a historical control group (n=2 539 941) that enrolled patients between March 1, 2018, and Jan 15, 2019. Control groups had no evidence of SARS-CoV-2 infection, and participants in all three cohorts were free of dyslipidaemia before cohort enrolment. We then used inverse probability weighting using predefined and algorithmically-selected high dimensional variables to estimate the risks and 1-year burdens of incident dyslipidaemia, lipid-lowering medications use, and a composite of these outcomes. We reported two measures of risk: hazard ratios (HRs) and burden per 1000 people at 12 months. Additionally, we estimated the risks and burdens of incident dyslipidaemia outcomes in mutually exclusive groups based on the care setting of the acute infection (ie, participants who were non-hospitalised, hospitalised, or admitted to intensive care during the acute phase of SARS-CoV-2 infection). FINDINGS In the post-acute phase of the SARS-CoV-2 infection, compared with the non-infected contemporary control group, those in the COVID-19 group had higher risks and burdens of incident dyslipidaemia, including total cholesterol greater than 200 mg/dL (hazard ratio [HR] 1·26, 95% CI 1·22-1·29; burden 22·46, 95% CI 19·14-25·87 per 1000 people at 1 year), triglycerides greater than 150 mg/dL (1·27, 1·23-1·31; 22·03, 18·85-25·30), LDL cholesterol greater than 130 mg/dL (1·24, 1·20-1·29; 18·00, 14·98-21·11), and HDL cholesterol lower than 40 mg/dL (1·20, 1·16-1·25; 15·58, 12·52-18·73). The risk and burden of a composite of these abnormal lipid laboratory outcomes were 1·24 (95% CI 1·21-1·27) and 39·19 (95% CI 34·71-43·73), respectively. There was also increased risk and burden of incident lipid-lowering medications use (HR 1·54, 95% CI 1·48-1·61; burden 25·50, 95% CI 22·61-28·50). A composite of any dyslipidaemia outcome (laboratory abnormality or lipid-lowering medications use) yielded an HR of 1·31 (95% CI 1·28-1·34) and a burden of 54·03 (95% CI 49·21-58·92). The risks and burdens of these post-acute outcomes increased in a graded fashion corresponding to the severity of the acute phase of COVID-19 infection (ie, whether patients were non-hospitalised, hospitalised, or admitted to intensive care). The results were consistent in analyses comparing the COVID-19 group to the non-infected historical control group. INTERPRETATION Our findings suggest increased risks and 1-year burdens of incident dyslipidaemia and incident lipid-lowering medications use in the post-acute phase of COVID-19 infection. Post-acute care for those with COVID-19 should involve attention to dyslipidaemia as a potential post-acute sequela of SARS-CoV-2 infection. FUNDING US Department of Veterans Affairs.
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Affiliation(s)
- Evan Xu
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA
| | - Yan Xie
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA; Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA; Institute for Public Health, Washington University in Saint Louis, Saint Louis, MO, USA.
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Luo C, Ouyang Y, Shi S, Li G, Zhao Z, Luo H, Xu F, Shao L, Chen Z, Yu S, Jin Y, Xu J, Du W, Fang Z, Jafar Hussain HM, Zhang W, Wang W, Cui Y, Zhang H, Chen N, Yu Z, Xie J. Particulate matter of air pollution may increase risk of kidney failure in IgA nephropathy. Kidney Int 2022; 102:1382-1391. [PMID: 36087808 DOI: 10.1016/j.kint.2022.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/16/2022] [Accepted: 08/01/2022] [Indexed: 01/12/2023]
Abstract
IgA nephropathy (IgAN) is characterized by deposition of galactose-deficient IgA1 (Gd-IgA1) in glomerular mesangium associated with mucosal immune disorders. Since environmental pollution has been associated with the progression of chronic kidney disease in the general population, we specifically investigated the influence of exposure to fine particulate matter less than 2.5 μm in diameter (PM2.5) on IgAN progression. Patients with biopsy-proven primary IgAN were recruited from seven Chinese kidney centers. PM2.5 exposure from 1998 to 2016 was derived from satellite aerosol optical depth data and a total of 1,979 patients with IgAN, including 994 males were enrolled. The PM2.5 exposure levels for patients from different provinces varied but, in general, the PM2.5 exposure levels among patients from the north were higher than those among patients from the south. The severity of PM2.5 exposure in different regions was correlated with regional kidney failure burden. In addition, each 10 μg/m3 increase in annual average concentration of PM2.5 exposure before study entry (Hazard Ratio, 1.14; 95% confidence interval, 1.06-1.22) or time-varying PM2.5 exposure after study entry (1.10; 1.01-1.18) were associated with increased kidney failure risk after adjustment for age, gender, estimated glomerular filtration rate, urine protein, uric acid, hemoglobin, mean arterial pressure, Oxford classification, glucocorticoid and renin-angiotensin system blocker therapy. The associations were robust when the time period, risk factors of cardiovascular diseases or city size were further adjusted on the basis of the above model. Thus, our results suggest that PM2.5 is an independent risk factor for kidney failure in patients with IgAN, but these findings will require validation in more diverse populations and other geographic regions.
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Affiliation(s)
- Chengwen Luo
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Bioinformatics and Biostatistics, School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, China; Evidence-based Medicine Center, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Zhejiang, China
| | - Yan Ouyang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sufang Shi
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Guisen Li
- Department of Nephrology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Zhanzheng Zhao
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huimin Luo
- Department of Nephrology, the First People's Hospital of Yunnan Province, Kunming, China
| | - Feifei Xu
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Leping Shao
- Department of Nephrology, Qingdao Municipal Hospital, Qingdao, China
| | - Zijin Chen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuwen Yu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanmeng Jin
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Xu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen Du
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhengying Fang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hafiz Muhammad Jafar Hussain
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen Zhang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiming Wang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yidan Cui
- Department of Bioinformatics and Biostatistics, School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Nan Chen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhangsheng Yu
- Department of Bioinformatics and Biostatistics, School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, China; Shanghai Jiaotong University School of Medicine Clinical Research Center, Shanghai, China.
| | - Jingyuan Xie
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Squires A, Thompson R, Sadarangani T, Amburg P, Sliwinski K, Curtis C, Wu B. International migration and its influence on health. Res Nurs Health 2022; 45:503-511. [DOI: 10.1002/nur.22262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Allison Squires
- Rory Meyers College of Nursing New York University New York New York USA
- Grossman School of Medicine New York University New York New York USA
| | - Roy Thompson
- Sinclair School of Nursing University of Missouri Columbia Missouri USA
| | - Tina Sadarangani
- Rory Meyers College of Nursing New York University New York New York USA
| | - Polina Amburg
- School of Nursing Monmouth University Long Branch New Jersey USA
| | - Kathy Sliwinski
- School of Nursing, Center for Health Outcomes and Policy Research University of Pennsylvania Philadelphia Pennsylvania USA
| | - Cedonnie Curtis
- School of Nursing La Salle University Philadelphia Pennsylvania USA
| | - Bei Wu
- P50 Center for Asian Health Promotion and Equity, Rory Meyers College of Nursing New York University New York New York USA
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Shen YS. Multiple pathways and mediation effects of built environment on kidney disease rate via mitigation of atmospheric threats. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 833:155177. [PMID: 35421457 DOI: 10.1016/j.scitotenv.2022.155177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 06/14/2023]
Abstract
Air pollution and high temperatures can increase kidney disease rate, especially under climate change. A well-designed urban environment has mediating effects on atmospheric environmental threats and promoting human health, but previous studies have overlooked these effects. This study used partial least squares modeling and urban-scale data from Taiwan to identify the crucial effects (i.e., direct, indirect, and total effects) and pathways of urban form (i.e., urban development intensity, land-use mix, and urban sprawl), urban greening (i.e., green coverage), urban industrial status (e.g., industrial level), atmospheric environment (i.e., high temperature and air pollution), and socioeconomic status (i.e., elderly ratio, medical resources, and economic status) on kidney disease rate. Maximizing land-use mix and green coverage and minimizing urban development intensity, urban sprawl, and industrial levels could help reduce kidney disease rate. Air pollution and high temperature had a mediation effect of built environment on kidney disease rate; with the mediation effect of air pollution was greater than that of high temperature. Furthermore, air pollution, high temperature, and elderly ratio increased kidney disease rate, whereas medical resources decreased kidney disease rate. This study is the first to consider the impact (i.e., direct, indirect, and total effects) and pathways of built environment characteristics on kidney disease rate. The findings revealed that an appropriate urban policy might be a practical strategy and lower kidney disease rate for a healthy city development. Moreover, this study provides a new approach for clarifying complex relationships and identifying crucial factors.
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Affiliation(s)
- Yu-Sheng Shen
- Key Lab of Urban Environment and Health, Institute of Urban Environment, Chinese Academy of Sciences, Xiamen, China; Xiamen Key Lab of Urban Metabolism, Institute of Urban Environment, Chinese Academy of Sciences, Xiamen, China; University of Chinese Academy of Sciences, Beijing, China.
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Ghazi L, Drawz PE, Berman JD. The association between fine particulate matter (PM 2.5) and chronic kidney disease using electronic health record data in urban Minnesota. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2022; 32:583-589. [PMID: 34127789 PMCID: PMC8202050 DOI: 10.1038/s41370-021-00351-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 05/28/2021] [Accepted: 06/03/2021] [Indexed: 05/31/2023]
Abstract
BACKGROUND Recent evidence has shown that fine particulate matter (PM2.5) may be an important environmental risk factor for chronic kidney disease (CKD), but few studies have examined this association for individual patients using fine spatial data. OBJECTIVE To investigate the association between PM2.5 and CKD (estimated glomerular filtration rate [eGFR]<45 ml/min/1.73 m2) in the Twin-Cities area in Minnesota using a large electronic health care database (2012-2019). METHODS We estimated the previous 1-year average PM2.5 from the first eGFR (measured with the CKD Epidemiology Collaboration equation using the first available creatinine measure during the baseline period [2012-2014]) using Environmental Protection Agency downscaler modeling data at the census tract level. We evaluated the spatial relative risk and clustering of CKD prevalence using a K-function test statistic. We assessed the prevalence ratio of the PM2.5 association with CKD incidence using a mixed effect Cox model, respectively. RESULTS Patients (n = 20,289) in the fourth (PM2.5 > 10.4), third (10.3 < PM2.5 < 10.8) and second quartile (9.9 < PM2.5 < 10.3) vs. the first quartile (<9.9 μg/m3) had a 2.52[2.21, 2.87], 2.18[1.95, 2.45], and 1.72[1.52, 1.97] hazard rate of developing CKD in the fully adjusted models, respectively. We identified spatial heterogeneities and evidence of CKD clustering across our study region, but this spatial variation was accounted for by air pollution and individual covariates. SIGNIFICANCE Exposure to higher PM2.5 is associated with a greater risk for incident CKD. Improvements in air quality, specifically at hotspots, may reduce CKD.
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Affiliation(s)
- Lama Ghazi
- Clinical and Translational Research Accelerator, Department of Medicine, Section of Nephrology, Yale University, New Haven, CT, USA.
| | - Paul E Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN, USA
| | - Jesse D Berman
- Division of Environmental Health Science, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Xie Y, Al-Aly Z. Risks and burdens of incident diabetes in long COVID: a cohort study. Lancet Diabetes Endocrinol 2022; 10:311-321. [PMID: 35325624 PMCID: PMC8937253 DOI: 10.1016/s2213-8587(22)00044-4] [Citation(s) in RCA: 262] [Impact Index Per Article: 131.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/07/2022] [Accepted: 01/28/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is growing evidence suggesting that beyond the acute phase of SARS-CoV-2 infection, people with COVID-19 could experience a wide range of post-acute sequelae, including diabetes. However, the risks and burdens of diabetes in the post-acute phase of the disease have not yet been comprehensively characterised. To address this knowledge gap, we aimed to examine the post-acute risk and burden of incident diabetes in people who survived the first 30 days of SARS-CoV-2 infection. METHODS In this cohort study, we used the national databases of the US Department of Veterans Affairs to build a cohort of 181 280 participants who had a positive COVID-19 test between March 1, 2020, and Sept 30, 2021, and survived the first 30 days of COVID-19; a contemporary control (n=4 118 441) that enrolled participants between March 1, 2020, and Sept 30, 2021; and a historical control (n=4 286 911) that enrolled participants between March 1, 2018, and Sept 30, 2019. Both control groups had no evidence of SARS-CoV-2 infection. Participants in all three comparison groups were free of diabetes before cohort entry and were followed up for a median of 352 days (IQR 245-406). We used inverse probability weighted survival analyses, including predefined and algorithmically selected high dimensional variables, to estimate post-acute COVID-19 risks of incident diabetes, antihyperglycaemic use, and a composite of the two outcomes. We reported two measures of risk: hazard ratio (HR) and burden per 1000 people at 12 months. FINDINGS In the post-acute phase of the disease, compared with the contemporary control group, people with COVID-19 exhibited an increased risk (HR 1·40, 95% CI 1·36-1·44) and excess burden (13·46, 95% CI 12·11-14·84, per 1000 people at 12 months) of incident diabetes; and an increased risk (1·85, 1·78-1·92) and excess burden (12·35, 11·36-13·38) of incident antihyperglycaemic use. Additionally, analyses to estimate the risk of a composite endpoint of incident diabetes or antihyperglycaemic use yielded a HR of 1·46 (95% CI 1·43-1·50) and an excess burden of 18·03 (95% CI 16·59-19·51) per 1000 people at 12 months. Risks and burdens of post-acute outcomes increased in a graded fashion according to the severity of the acute phase of COVID-19 (whether patients were non-hospitalised, hospitalised, or admitted to intensive care). All the results were consistent in analyses using the historical control as the reference category. INTERPRETATION In the post-acute phase, we report increased risks and 12-month burdens of incident diabetes and antihyperglycaemic use in people with COVID-19 compared with a contemporary control group of people who were enrolled during the same period and had not contracted SARS-CoV-2, and a historical control group from a pre-pandemic era. Post-acute COVID-19 care should involve identification and management of diabetes. FUNDING US Department of Veterans Affairs and the American Society of Nephrology.
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Affiliation(s)
- Yan Xie
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Development Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO, USA; Veterans Research and Education Foundation of Saint Louis, Saint Louis, MO, USA; Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA; Institute for Public Health, Washington University in Saint Louis, Saint Louis, MO, USA.
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Mahbub MH, Yamaguchi N, Nakagami Y, Hase R, Takahashi H, Ishimaru Y, Watanabe R, Saito H, Shimokawa J, Yamamoto H, Kikuchi S, Tanabe T. Association of Plasma Branched-Chain and Aromatic Amino Acids with Reduction in Kidney Function Evaluated in Apparently Healthy Adults. J Clin Med 2021; 10:jcm10225234. [PMID: 34830517 PMCID: PMC8625145 DOI: 10.3390/jcm10225234] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 01/09/2023] Open
Abstract
The published literature on the association of circulatory branched-chain amino acids (BCAAs) and aromatic amino acids (AAAs) with reduced kidney function is inconsistent or conflicting. Clarification of it might help to better understand the underlying pathophysiology and to determine potential biomarkers for early detection and evaluation of kidney function decline. Our main purpose was to explore and clarify the potential relationships of individual BCAAs and AAAs with estimated glomerular filtration rate (eGFR) decline. We included the data from 2804 healthy subjects and categorized them into three groups based on eGFR tertiles. The associations between individual amino acids and eGFR were explored by covariate-adjusted logistic regression models. There was a progressive increase in the concentrations of BCAAs and AAAs from the upper to the lower tertiles. We revealed significant positive associations of isoleucine, leucine, and phenylalanine with lower tertiles of eGFR in the adjusted models (p < 0.01-0.001). The findings hold a promising potential of using plasma isoleucine, leucine, and phenylalanine levels for evaluation of kidney function decline. Future longitudinal studies should investigate the causal association between altered levels of these amino acids and impaired kidney function and also the utility of the former as potential biomarkers for evaluating the risk and early detection of the latter.
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Affiliation(s)
- MH Mahbub
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
- Correspondence: ; Tel.: +81-836-22-2231
| | - Natsu Yamaguchi
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Yuki Nakagami
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Ryosuke Hase
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Hidekazu Takahashi
- Department of Public Health, Faculty of Veterinary Medicine, Okayama University of Science, Imabari 794-8555, Japan;
| | - Yasutaka Ishimaru
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Rie Watanabe
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Hiroyuki Saito
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Junki Shimokawa
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
| | - Hiroshi Yamamoto
- Institute for Innovation, Ajinomoto Co., Inc., Kawasaki 210-8681, Japan; (H.Y.); (S.K.)
| | - Shinya Kikuchi
- Institute for Innovation, Ajinomoto Co., Inc., Kawasaki 210-8681, Japan; (H.Y.); (S.K.)
| | - Tsuyoshi Tanabe
- Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube 755-8505, Japan; (N.Y.); (Y.N.); (R.H.); (Y.I.); (R.W.); (H.S.); (J.S.); (T.T.)
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Liang Z, Wang W, Wang Y, Ma L, Liang C, Li P, Yang C, Wei F, Li S, Zhang L. Urbanization, ambient air pollution, and prevalence of chronic kidney disease: A nationwide cross-sectional study. ENVIRONMENT INTERNATIONAL 2021; 156:106752. [PMID: 34256301 DOI: 10.1016/j.envint.2021.106752] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/23/2021] [Accepted: 07/01/2021] [Indexed: 06/13/2023]
Abstract
An increasing number of studies have linked ambient air pollution to chronic kidney disease (CKD) prevalence. However, its potential effect modification by urbanization has not been investigated. Based on data of 47,204 adults from the China National Survey of Chronic Kidney Disease (CKSCKD) dataset, night light satellite remote sensing data and high-resolution air pollution inversion products, the present cross-sectional study investigated the association between fine particulate matter <2.5 mm in diameter (PM2.5), nitrogen dioxide (NO2), night light index (NLI) and CKD prevalence in China, and the effect modification by urbanization characterized by administrative classification and NLI on the pollutant-health associations. Our results showed that a 10-μg/m3 increase in PM2.5 at 3-year moving average, a 10-μg/m3 increase in NO2 at 5-year moving average, and a 10-U increase in NLI at 5-year moving average were significantly associated with increased odds of CKD prevalence [OR = 1.24 (95 %CI:1.14, 1.35); OR = 1.12 (95 %CI:1.09, 1.15); OR = 1.05 (95 %CI:1.02, 1.07)]. Meanwhile, the pollutant-health associations were more apparent in medium-urbanized areas compared to low- and high-urbanized areas. For instance, a 10-μg/m3 increase in PM2.5 concentration at 2-year moving average was associated with increased odds of CKD in the areas with NLI level in the second [OR = 2.78 (95 %CI:1.77, 4.36)] and third quartiles [OR = 1.49 (95 %CI:1.14, 1.95)], compared to the lowest [OR = 0.96 (95% CI: 0.73, 1.26)] and highest [OR = 0.63 (95% CI: 0.39-1.02)] quartiles. PM2.5 and NO2 were associated with increased odds of CKD prevalence, especially in areas with medium NLI levels, suggesting the necessity of strengthening environmental management in medium-urbanized regions.
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Affiliation(s)
- Ze Liang
- Key Laboratory for Earth Surface Processes of the Ministry of Education, College of Urban and Environmental Sciences, Peking University, Beijing 100871, China
| | - Wanzhou Wang
- School of Public Health, Peking University, Beijing 100191, China
| | - Yueyao Wang
- Key Laboratory for Earth Surface Processes of the Ministry of Education, College of Urban and Environmental Sciences, Peking University, Beijing 100871, China
| | - Lin Ma
- Key Laboratory for Earth Surface Processes of the Ministry of Education, College of Urban and Environmental Sciences, Peking University, Beijing 100871, China
| | - Chenyu Liang
- Key Laboratory for Earth Surface Processes of the Ministry of Education, College of Urban and Environmental Sciences, Peking University, Beijing 100871, China
| | - Pengfei Li
- Advanced Institute of Information Technology, Peking University, Hangzhou 311215, China
| | - Chao Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing 100034, China
| | - Feili Wei
- Key Laboratory for Earth Surface Processes of the Ministry of Education, College of Urban and Environmental Sciences, Peking University, Beijing 100871, China
| | - Shuangcheng Li
- Key Laboratory for Earth Surface Processes of the Ministry of Education, College of Urban and Environmental Sciences, Peking University, Beijing 100871, China.
| | - Luxia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing 100034, China; National Institutes of Health Data Science at Peking University, Beijing 100191, China.
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11
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Bowe B, Xie Y, Xu E, Al-Aly Z. Kidney Outcomes in Long COVID. J Am Soc Nephrol 2021; 32:2851-2862. [PMID: 34470828 PMCID: PMC8806085 DOI: 10.1681/asn.2021060734] [Citation(s) in RCA: 183] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/07/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND COVID-19 is associated with increased risk of post-acute sequelae involving pulmonary and extrapulmonary organ systems-referred to as long COVID. However, a detailed assessment of kidney outcomes in long COVID is not yet available. METHODS We built a cohort of 1,726,683 US Veterans identified from March 1, 2020 to March 15, 2021, including 89,216 patients who were 30-day survivors of COVID-19 and 1,637,467 non-infected controls. We examined risks of AKI, eGFR decline, ESKD, and major adverse kidney events (MAKE). MAKE was defined as eGFR decline ≥50%, ESKD, or all-cause mortality. We used inverse probability-weighted survival regression, adjusting for predefined demographic and health characteristics, and algorithmically selected high-dimensional covariates, including diagnoses, medications, and laboratory tests. Linear mixed models characterized intra-individual eGFR trajectory. RESULTS Beyond the acute illness, 30-day survivors of COVID-19 exhibited a higher risk of AKI (aHR, 1.94; 95% CI, 1.86 to 2.04), eGFR decline ≥30% (aHR, 1.25; 95% CI, 1.14 to 1.37), eGFR decline ≥40% (aHR, 1.44; 95% CI, 1.37 to 1.51), eGFR decline ≥50% (aHR, 1.62; 95% CI, 1.51 to 1.74), ESKD (aHR, 2.96; 95% CI, 2.49 to 3.51), and MAKE (aHR, 1.66; 95% CI, 1.58 to 1.74). Increase in risks of post-acute kidney outcomes was graded according to the severity of the acute infection (whether patients were non-hospitalized, hospitalized, or admitted to intensive care). Compared with non-infected controls, 30-day survivors of COVID-19 exhibited excess eGFR decline (95% CI) of -3.26 (-3.58 to -2.94), -5.20 (-6.24 to -4.16), and -7.69 (-8.27 to -7.12) ml/min per 1.73 m2 per year, respectively, in non-hospitalized, hospitalized, and those admitted to intensive care during the acute phase of COVID-19 infection. CONCLUSIONS Patients who survived COVID-19 exhibited increased risk of kidney outcomes in the post-acute phase of the disease. Post-acute COVID-19 care should include attention to kidney disease.
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Affiliation(s)
- Benjamin Bowe
- Clinical Epidemiology Center, Research and Development Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, Missouri,Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri,Veterans Research and Education Foundation of Saint Louis, Saint Louis, Missouri
| | - Yan Xie
- Clinical Epidemiology Center, Research and Development Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, Missouri,Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri,Veterans Research and Education Foundation of Saint Louis, Saint Louis, Missouri
| | - Evan Xu
- Clinical Epidemiology Center, Research and Development Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, Missouri,Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Development Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, Missouri,Veterans Research and Education Foundation of Saint Louis, Saint Louis, Missouri,Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri,Nephrology Section, Medicine Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, Missouri,Institute for Public Health, Washington University in Saint Louis, Saint Louis, Missouri
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12
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Hirsch AG, Nordberg CM, Chang A, Poulsen MN, Moon KA, Siegel KR, Rolka DB, Schwartz BS. Association of community socioeconomic deprivation with evidence of reduced kidney function at time of type 2 diabetes diagnosis. SSM Popul Health 2021; 15:100876. [PMID: 34377762 PMCID: PMC8327153 DOI: 10.1016/j.ssmph.2021.100876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/09/2021] [Accepted: 07/15/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND While there are known individual-level risk factors for kidney disease at time of type 2 diabetes diagnosis, little is known regarding the role of community context. We evaluated the association of community socioeconomic deprivation (CSD) and community type with estimated glomerular filtration rate (eGFR) when type 2 diabetes is diagnosed. METHODS This was a retrospective cohort study of 13,144 adults with newly diagnosed type 2 diabetes in Pennsylvania. The outcome was the closest eGFR measurement within one year prior to and two weeks after type 2 diabetes diagnosis, calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-Epi) equation. We used adjusted multinomial regression models to estimate associations of CSD (quartile 1, least deprivation) and community type (township, borough, city) with eGFR and used adjusted generalized estimating equation models to evaluate whether community features were associated with the absence of diabetes screening in the years prior to type 2 diabetes diagnosis. RESULTS Of the participants, 1279 (9.7%) had hyperfiltration and 1377 (10.5%) had reduced eGFR. Women were less likely to have hyperfiltration and more likely to have reduced eGFR. Black (versus White) race was positively associated with hyperfiltration when the eGFR calculation was corrected for race but inversely associated without the correction. Medical Assistance (ever versus never) was positively associated with reduced eGFR. Higher CSD and living in a city were each positively associated (odds ratio [95% confidence interval]) with reduced eGFR (CSD quartiles 3 and 4 versus quartile 1, 1.23 [1.04, 1.46], 1.32 [1.11, 1.58], respectively; city versus township, 1.38 [1.15, 1.65]). These features were also positively associated with the absence of a type 2 diabetes screening measure. CONCLUSIONS In a population-based sample, more than twenty percent had hyperfiltration or reduced eGFR at time of type 2 diabetes diagnosis. Individual- and community-level factors were associated with these outcomes.
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Affiliation(s)
- Annemarie G. Hirsch
- Department of Population Health Sciences, Geisinger, Danville, PA, USA
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cara M. Nordberg
- Department of Population Health Sciences, Geisinger, Danville, PA, USA
| | - Alexander Chang
- Department of Population Health Sciences, Geisinger, Danville, PA, USA
| | | | - Katherine A. Moon
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Karen R. Siegel
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Deborah B. Rolka
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brian S. Schwartz
- Department of Population Health Sciences, Geisinger, Danville, PA, USA
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Cai M, Bowe B, Xie Y, Al-Aly Z. Temporal trends of COVID-19 mortality and hospitalisation rates: an observational cohort study from the US Department of Veterans Affairs. BMJ Open 2021; 11:e047369. [PMID: 34400452 PMCID: PMC8370839 DOI: 10.1136/bmjopen-2020-047369] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To investigate the temporal trends of 30-day mortality and hospitalisation in US Veterans with COVID-19 and 30-day mortality in hospitalised veterans with COVID-19 and to decompose the contribution of changes in the underlying characteristics of affected populations to these temporal changes. DESIGN Observational cohort study. SETTING US Department of Veterans Affairs. PARTICIPANTS 49 238 US veterans with a positive COVID-19 test between 20 March 2020 and 19 September 2020; and 9428 US veterans hospitalised with a positive COVID-19 test during the same period. OUTCOME MEASURES 30-day mortality rate and hospitalisation rate. RESULTS Between 20 March 2020 and 19 September 2020 and in COVID-19 positive individuals, 30-day mortality rate dropped by 9.2% from 13.6% to 4.4%; hospitalisation rate dropped by 16.8% from 33.8% to 17.0%. In hospitalised COVID-19 individuals, 30-day mortality rate dropped by 12.7% from 23.5% to 10.8%. Among COVID-19 positive individuals, decomposition analyses suggested that changes in demographic, health and contextual characteristics, COVID-19 testing capacity, and hospital occupancy rates accounted for 40.2% and 33.3% of the decline in 30-day mortality and hospitalisation, respectively. Changes in the underlying characteristics of hospitalised COVID-19 individuals accounted for 29.9% of the decline in 30-day mortality. CONCLUSION Between March and September 2020, changes in demographic and health characteristics of people infected with COVID-19 contributed measurably to the substantial decline in 30-day mortality and hospitalisation.
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Affiliation(s)
- Miao Cai
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Veterans Research and Education Foundation of Saint Louis, Saint Louis, Missouri, USA
| | - Benjamin Bowe
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Veterans Research and Education Foundation of Saint Louis, Saint Louis, Missouri, USA
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, USA
| | - Yan Xie
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Veterans Research and Education Foundation of Saint Louis, Saint Louis, Missouri, USA
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Veterans Research and Education Foundation of Saint Louis, Saint Louis, Missouri, USA
- Institute for Public Health, Washington University in Saint Louis, Saint Louis, Missouri, USA
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
- Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
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14
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Ghazi L, Oakes JM, MacLehose RF, Luepker RV, Osypuk TL, Drawz PE. Neighborhood Socioeconomic Status and Identification of Patients With CKD Using Electronic Health Records. Am J Kidney Dis 2021; 78:57-65.e1. [PMID: 33359151 PMCID: PMC10156131 DOI: 10.1053/j.ajkd.2020.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 10/24/2020] [Indexed: 01/29/2023]
Abstract
RATIONALE & OBJECTIVE Screening for chronic kidney disease (CKD) is recommended for patients with diabetes and hypertension as stated by the respective professional societies. However, CKD, a silent disease usually detected at later stages, is associated with low socioeconomic status (SES). We assessed whether adding census tract SES status to the standard screening approach improves our ability to identify patients with CKD. STUDY DESIGN Screening test analysis. SETTINGS & PARTICIPANTS Electronic health records (EHR) of 256,162 patients seen at a health care system in the 7-county Minneapolis/St. Paul area and linked census tract data. EXPOSURE The first quartile of census tract SES (median value of owner-occupied housing units <$165,200; average household income <$35,935; percentage of residents >25 years of age with a bachelor's degree or higher <20.4%), hypertension, and diabetes. OUTCOMES CKD (eGFR <60 mL/min/1.73 m2, or urinary albumin-creatinine ratio >30mg/g, or urinary protein-creatinine ratio >150mg/g, or urinary analysis [albuminuria] >30 mg/d). ANALYTICAL APPROACH Sensitivity, specificity, and number needed to screen (NNS) to detect CKD if we screened patients who had hypertension and/or diabetes and/or who lived in low-SES tracts (belonging to the first quartile of any of the 3 measures of tract SES) versus the standard approach. RESULTS CKD was prevalent in 13% of our cohort. Sensitivity, specificity, and NNS of detecting CKD after adding tract SES to the screening approach were 67% (95% CI, 66.2%-67.2%), 61% (95% CI, 61.1%-61.5%), and 5, respectively. With the standard approach, sensitivity of detecting CKD was 60% (95% CI, 59.4%-60.4%), specificity was 73% (95% CI, 72.4%-72.7%), and NNS was 4. LIMITATIONS One health care system and selection bias. CONCLUSIONS Leveraging patients' addresses from the EHR and adding tract-level SES to the standard screening approach modestly increases the sensitivity of detecting patients with CKD at a cost of decreased specificity. Identifying further factors that improve CKD detection at an early stage are needed to slow the progression of CKD and prevent cardiovascular complications.
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Affiliation(s)
- Lama Ghazi
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN; Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN.
| | - J Michael Oakes
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Russell V Luepker
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Theresa L Osypuk
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Paul E Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN
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15
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Ghazi L, Osypuk TL, MacLehose RF, Luepker RV, Drawz PE. Neighborhood Socioeconomic Status, Health Insurance, and CKD Prevalence: Findings From a Large Health Care System. Kidney Med 2021; 3:555-564.e1. [PMID: 34401723 PMCID: PMC8350830 DOI: 10.1016/j.xkme.2021.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONAL & OBJECTIVE Neighborhood socioeconomic status (SES) and health insurance status may be important upstream social determinants of chronic kidney disease (CKD), but their relationship remains unclear. The aim of this study was to determine whether neighborhood SES and individual-level health insurance status were independently associated with CKD prevalence. STUDY DESIGN Observational study using electronic health records (EHRs). SETTING & PARTICIPANTS EHRs of patients (n = 185,269) seen at a health care system in the 7-county Minneapolis/St Paul area (2017-2018). EXPOSURES Census tract neighborhood SES measures (median value of owner-occupied housing units [wealth], percentage of residents aged >25 years with bachelor's degree or higher [education]) and individual-level health insurance status (aged <65 years: Medicaid vs other insurance; ≥65 years: Medicare vs Medicare and supplemental insurance plan) were obtained from the American Community Survey and EHR data. Neighborhood SES was operationalized into quartiles, comparing low (first quartile) versus high (fourth quartile) neighborhood SES. OUTCOMES CKD prevalence: estimated glomerular filtration rate < 60 mL/min/1.73 m2 or proteinuria. ANALYTIC APPROACH Multilevel Poisson regression with robust error variance with a random intercept at the census-tract level, adjusted for demographic and clinical covariates, was used to estimate the association between neighborhood SES, insurance, and CKD. RESULTS Neighborhood SES and insurance were independently associated with CKD prevalence. In covariate-adjusted models, patients living in low versus high neighborhood SES had a higher CKD prevalence among both younger and older patients. For example, the prevalence ratios of CKD in low versus high neighborhood SES as defined by education among patients younger than 65 and 65 years and older were 1.11 (95% CI, 1.05-1.18) and 1.08 (95% CI, 1.04-1.12), respectively. Patients younger than 65 years receiving Medicaid had higher CKD prevalence versus those with other insurance (1.51 [95% CI, 1.43-1.6]). For patients 65 years and older, insurance was not associated with prevalence of CKD in the fully adjusted model. LIMITATIONS One health care system and selection bias. CONCLUSIONS Living in low neighborhood SES as defined by wealth and education and having Medicaid for patients younger than 65 years were associated with higher CKD prevalence.
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Affiliation(s)
- Lama Ghazi
- Clinical and Translational Research Accelerator, Yale University, School of Medicine, New Haven, CT
| | - Theresa L. Osypuk
- Division of Epidemiology and Community Health, School of Public Health, Minneapolis, MN
| | - Richard F. MacLehose
- Division of Epidemiology and Community Health, School of Public Health, Minneapolis, MN
| | - Russell V. Luepker
- Division of Epidemiology and Community Health, School of Public Health, Minneapolis, MN
| | - Paul E. Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN
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Clark-Cutaia MN, Rivera E, Iroegbu C, Squires A. Disparities in chronic kidney disease-the state of the evidence. Curr Opin Nephrol Hypertens 2021; 30:208-214. [PMID: 33464006 DOI: 10.1097/mnh.0000000000000688] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review was to assess the prevalence of United States chronic kidney disease (CKD) health disparities, focusing on racial/ethnic groups, immigrants and refugees, sex or gender, and older adults. RECENT FINDINGS There are major racial/ethnic disparities in CKD, with possible contributions from the social determinants of health, socioeconomics, and racial discrimination. Racial/ethnic minority patients experience faster progression to end-stage kidney disease (ESKD) and higher mortality predialysis, however, once on dialysis, appear to live longer. Similarly, men are quicker to progress to ESKD than women, with potential biological, behavioral, and measurement error factors. There is a lack of substantial evidence for intersex, nonbinary, or transgender patients. There are also strikingly few studies about US immigrants or older adults with CKD despite the fact that they are at high risk for CKD due to a variety of factors. SUMMARY As providers and scientists, we must combat both conscious and unconscious biases, advocate for minority patient populations, and be inclusive and diverse in our treatment regimens and provision of care. We need to acknowledge that sufficient evidence exists to change treatment guidelines, and that more is required to support the diversity of our patient population.
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Affiliation(s)
| | - Eleanor Rivera
- Assistant Professor, University of Illinois Chicago College of Nursing, Chicago, Illinois
| | - Christin Iroegbu
- Doctoral Student, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Allison Squires
- Associate Professor, NYU Meyers College of Nursing, New York, New York, USA
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17
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Xie Y, Bowe B, Yan Y, Cai M, Al-Aly Z. County-Level Contextual Characteristics and Disparities in Life Expectancy. Mayo Clin Proc 2021; 96:92-104. [PMID: 33413839 DOI: 10.1016/j.mayocp.2020.04.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 03/05/2020] [Accepted: 04/06/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To estimate the contribution of county-level contextual factors to differences in life expectancy in the United States. METHODS We used a counterfactual approach to estimate the years of life expectancy lost associated with 45 potentially modifiable county-level contextual characteristics in the United States in the year 2016. Contextual data and life expectancy data were obtained from the County Health Ranking Project and the U.S. Small-Area Life Expectancy Estimates Project, respectively. RESULTS Median census-tract-level life expectancy was 78.90 (interquartile range, 76.30-81.00) years, and the range across census tracts spanned 41.20 years. Large variations in life expectancy existed within and between states and within and between counties; the gap between counties was 20.30 years and gaps within counties ranged from 0 to 34.60 years. An array of 45 county-level factors was associated with 4.30 years of life expectancy loss. County-level adult smoking, food insecurity, adult obesity, physical inactivity, college education, and median household income were associated with 1.24-, 0.89-, 0.58-, 0.35-, 0.33-, and 0.14-year losses in life expectancy, respectively; and altogether were associated with a 3.53-year loss in life expectancy. The contribution of contextual factors to years of life expectancy lost varied among states and was more pronounced in states with lower life expectancy and in areas of increased socioeconomic deprivation and increased percentage of Black race. CONCLUSION Substantial geographic variation in life expectancy was observed. Six county-level contextual factors were associated with a 3.53-year loss in life expectancy. The findings may inform and help prioritize approaches to reduce inequalities in life expectancy in the United States.
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Affiliation(s)
- Yan Xie
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Veterans Research & Education Foundation of Saint Louis, Saint Louis, MO; Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO
| | - Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Veterans Research & Education Foundation of Saint Louis, Saint Louis, MO; Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO
| | - Yan Yan
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Miao Cai
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO; Veterans Research & Education Foundation of Saint Louis, Saint Louis, MO; Department of Medicine, Washington University School of Medicine, Saint Louis, MO; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, MO; Institute for Public Health, Washington University in Saint Louis, Saint Louis, MO.
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18
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Bowe B, Cai M, Xie Y, Gibson AK, Maddukuri G, Al-Aly Z. Acute Kidney Injury in a National Cohort of Hospitalized US Veterans with COVID-19. Clin J Am Soc Nephrol 2020; 16:14-25. [PMID: 33199414 PMCID: PMC7792643 DOI: 10.2215/cjn.09610620] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 10/15/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Coronavirus disease 2019 (COVID-19) is associated with higher risk of AKI. We aimed to describe rates and characterize predictors and health outcomes associated with AKI in a national cohort of US veterans hospitalized with COVID-19. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a cohort of 5216 US veterans hospitalized with COVID-19 identified through July 23, 2020, we described changes in serum creatinine and examined predictors of AKI and the associations between AKI, health resource utilization, and death, utilizing logistic regressions. We characterized geographic and temporal variations in AKI rates and estimated variance explained by key variables utilizing Poisson regressions. RESULTS In total, 1655 (32%) participants had AKI; 961 (58%), 223 (13%), and 270 (16%) met Kidney Disease Improving Global Outcomes definitions of stage 1, 2, and 3 AKI, respectively, and 201 (12%) received KRT. Eight percent of participants had AKI within 1 day of hospitalization, and 47% did not recover to baseline serum creatinine by discharge. Older age, Black race, male gender, obesity, diabetes, hypertension, and lower eGFR were significant predictors of AKI during hospitalization with COVID-19. AKI was associated with higher mechanical ventilation use (odds ratio, 6.46; 95% confidence interval, 5.52 to 7.57) and longer hospital stay (5.56 additional days; 95% confidence interval, 4.78 to 6.34). AKI was also associated with higher risk of death (odds ratio, 6.71; 95% confidence interval, 5.62 to 8.04); this association was stronger in Blacks (P value of interaction <0.001). Hospital-level rates of AKI exhibited substantial geographic variability, ranging from 10% to 56%. Between March and July 2020, AKI rates declined from 40% to 27%; proportions of AKI stage 3 and AKI requiring KRT decreased from 44% to 17%. Both geographic and temporal variabilities were predominately explained by percentages of Blacks (31% and 49%, respectively). CONCLUSIONS AKI is common during hospitalization with COVID-19 and associated with higher risk of health care resource utilization and death. Nearly half of patients with AKI did not recover to baseline by discharge. Substantial geographic variation and temporal decline in rates and severity of AKI were observed. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_11_16_CJN09610620_final.mp3.
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Affiliation(s)
- Benjamin Bowe
- Clinical Epidemiology Center, Research and Development Service, Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, St. Louis University, St. Louis, Missouri
- Veterans Research and Education Foundation of St. Louis, St. Louis, Missouri
| | - Miao Cai
- Clinical Epidemiology Center, Research and Development Service, Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
- Veterans Research and Education Foundation of St. Louis, St. Louis, Missouri
| | - Yan Xie
- Clinical Epidemiology Center, Research and Development Service, Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, St. Louis University, St. Louis, Missouri
- Veterans Research and Education Foundation of St. Louis, St. Louis, Missouri
| | - Andrew K. Gibson
- Clinical Epidemiology Center, Research and Development Service, Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
- Veterans Research and Education Foundation of St. Louis, St. Louis, Missouri
| | - Geetha Maddukuri
- Nephrology Section, Medicine Service, Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Development Service, Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
- Veterans Research and Education Foundation of St. Louis, St. Louis, Missouri
- Nephrology Section, Medicine Service, Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
- Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri
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Boyle SM, Zhao Y, Chou E, Moore K, Harhay MN. Neighborhood context and kidney disease in Philadelphia. SSM Popul Health 2020; 12:100646. [PMID: 32939392 PMCID: PMC7476869 DOI: 10.1016/j.ssmph.2020.100646] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 01/10/2023] Open
Abstract
Neighborhood context might influence the risk of chronic kidney disease (CKD), a condition that impacts approximately 10% of the United States population and is associated with significant morbidity, mortality, and costs. We included a sample of 23,692 individuals in Philadelphia, Pennsylvania, who were seen in a large academic primary care practice between January 1, 2016 and December 31, 2017. We used generalized linear equations to estimate the associations between indicators of neighborhood context (e.g., proximity to healthy foods stores, neighborhood walkability, social capital, crime rate, socioeconomic status) and CKD, adjusted for age, sex, race/ethnicity, and insurance coverage. Among those with CKD, secondary outcomes were poor glycemic control (hemoglobin A1c ≥ 6.5%) and uncontrolled blood pressure (systolic ≥ 140 mm Hg and/or diastolic ≥ 90 mm Hg). The cohort represented residents from 97% of Philadelphia census tracts. CKD prevalence was 10%. When all neighborhood context metrics were considered collectively, only lower neighborhood socioeconomic index (a composite assessment of neighborhood income, educational attainment, and occupation) was associated with a higher risk of CKD (lowest tertile vs. highest tertile: adjusted relative risk [aRR] 1.46 [1.25, 1.69]; mid-tertile vs. highest-tertile: aRR 1.35 [1.25, 1.52]). Among those with CKD, compared to residence in the most walkable neighborhoods (i.e., where most essential resources are accessible by foot), residence in neighborhoods with mid-level WalkScore® (i.e., where only some essential neighborhood resources are accessible by foot) was independently associated with poor glycemic control (aRR 1.20, 95% CI 1.01-1.42). These findings suggest a potential role for measures of neighborhood socioeconomic status in identifying communities that would benefit from screening and treatment for CKD. Studies are also needed to determine mechanisms to explain why residence in neighborhoods not easily navigated by foot or car might hinder glycemic control among people with CKD.
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Affiliation(s)
- Suzanne M. Boyle
- Department of Medicine, Section of Nephrology, Hypertension and Kidney Transplantation, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Yuzhe Zhao
- Urban Health Collaborative, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | - Edgar Chou
- Department of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kari Moore
- Urban Health Collaborative, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | - Meera N. Harhay
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
- Tower Health Transplant Institute, Tower Health System, West Reading, Pennsylvania, USA
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Lapedis CJ, Mariani LH, Jang BJ, Hodgin J, Hicken MT. Understanding the Link between Neighborhoods and Kidney Disease. ACTA ACUST UNITED AC 2020; 1:845-854. [PMID: 33367284 DOI: 10.34067/kid.0001202019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Neighborhoods are where we live, learn, work, pray, and play. Growing evidence indicates that neighborhoods are an important determinant of health. The built features of our neighborhoods, such as the ways in which the streets are designed and connected and the availability of green spaces and transit stops, as well as the social features, such as the trust among neighbors and the perceptions of safety, may influence health through multiple pathways, such as access to important resources, psychosocial stress, and health behaviors. In particular, the extant literature consistently documents an association between neighborhood features and renal-associated conditions, such as cardiovascular disease, hypertension, diabetes, and obesity. There is also some evidence suggesting an association between neighborhood poverty and ESKD. The link between neighborhood and earlier stages of CKD, however, has been less clear, with most studies documenting no association. It may be that the neighborhood measures used in previous studies do not capture features of the neighborhood important for earlier stages of disease development and progression. It may also be that our current biomarkers (e.g., eGFR) and urine protein are not able to pick up very early forms of renal damage because of the kidney's overall high reserve capacity. This paper critically reviews the state of the literature on neighborhood and renal disease, with recommendations for neighborhood measures in future research. Neighborhoods are designed, built, and informed by policy, and thus, they are amenable to intervention, making them a potentially powerful way to improve renal health and reduce health inequalities at the population level.
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Affiliation(s)
- Cathryn J Lapedis
- Department of Veterans Affairs, Ann Arbor Health System, Ann Arbor, Michigan.,National Clinical Scholar Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.,Department of Pathology, Michigan Medicine, Ann Arbor, Michigan
| | - Laura H Mariani
- Division of Nephrology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Bohyun Joy Jang
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey Hodgin
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan
| | - Margaret T Hicken
- Division of Nephrology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan.,Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan
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Liu B, Fan D, Huang F. Relationship of chronic kidney disease with major air pollutants - A systematic review and meta-analysis of observational studies. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2020; 76:103355. [PMID: 32143119 DOI: 10.1016/j.etap.2020.103355] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/15/2020] [Accepted: 02/21/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Articles concerning the correlation of the risk of chronic kidney disease (CKD) with air contaminant exposure present inconsistent findings and the magnitude of the link is still unclear. Therefore, we planned to systematically and quantitatively investigate the overall strength of proofs in this field. METHODS Relevant articles on Cochrane, EMBASE, Medline, Web of Science, and CINHAL were searched as per relevant strategies. Only observational studies that disclosed the link of CKD risk with major air pollutants were enrolled, including PM10 and PM2.5, which were particulate matter less than 10 um and less than 2.5 um in erodynamic diameter respectively. Pooled relative risk (RR) and 95 % confidence interval (CI) were determined using random--effects models, regardless of the heterogeneity quantified by I2 statistic. RESULTS Finally, 7 studies involving 5,812,381 participants were included. The incidence of CKD was increased by long-term exposure to PM10 (including solely estimated exposure to PM10 from studies using PM2.5) (RR 1.08, 95 %CI 1.04-1.11) with considerable heterogeneity (I2 = 79 %), and the risk of CKD was raised by 8% when the long-time exposure to PM10 increased by 10 ug/m3. The pooled RR (95 %CI) with a 10 μg/m3 increase in PM2.5 for risk of CKD was 1.09 (1.03-1.17). Stratified analysis also verified the general negative effects. CONCLUSIONS Chronic subjection to major air contaminants (PM10 and PM2.5) is more likely to cause CKD. Thus, developing global approaches of air pollution elimination to prevent CKD is urgent.
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Affiliation(s)
- Bo Liu
- Department of Nephrology, Huzhou Central Hospital, Affiliated central hospital Huzhou University, Huzhou, Zhejiang, PR China
| | - Deyong Fan
- Department of Nephrology, Huzhou Central Hospital, Affiliated central hospital Huzhou University, Huzhou, Zhejiang, PR China
| | - Fuhan Huang
- Department of Nephrology, Huzhou Central Hospital, Affiliated central hospital Huzhou University, Huzhou, Zhejiang, PR China.
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Bowe B, Artimovich E, Xie Y, Yan Y, Cai M, Al-Aly Z. The global and national burden of chronic kidney disease attributable to ambient fine particulate matter air pollution: a modelling study. BMJ Glob Health 2020; 5:e002063. [PMID: 32341805 PMCID: PMC7173767 DOI: 10.1136/bmjgh-2019-002063] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/10/2020] [Accepted: 02/15/2020] [Indexed: 12/31/2022] Open
Abstract
Introduction We aimed to integrate all available epidemiological evidence to characterise an exposure-response model of ambient fine particulate matter (PM2.5) and the risk of chronic kidney disease (CKD) across the spectrum of PM2.5 concentrations experienced by humans. We then estimated the global and national burden of CKD attributable to PM2.5. Methods We collected data from prior studies on the association of PM2.5 with CKD and used an integrative meta-regression approach to build non-linear exposure-response models of the risk of CKD associated with PM2.5 exposure. We then estimated the 2017 global and national incidence, prevalence, disability-adjusted life-years (DALYs) and deaths due to CKD attributable to PM2.5 in 194 countries and territories. Burden estimates were generated by linkage of risk estimates to Global Burden of Disease study datasets. Results The exposure-response function exhibited evidence of an increase in risk with increasing PM2.5 concentrations, where the rate of risk increase gradually attenuated at higher PM2.5 concentrations. Globally, in 2017, there were 3 284 358.2 (95% UI 2 800 710.5 to 3 747 046.1) incident and 122 409 460.2 (108 142 312.2 to 136 424 137.9) prevalent cases of CKD attributable to PM2.5, and 6 593 134.6 (5 705 180.4 to 7 479 818.4) DALYs and 211 019.2 (184 292.5 to 236 520.4) deaths due to CKD attributable to PM2.5. The burden was disproportionately borne by low income and lower middle income countries and exhibited substantial geographic variability, even among countries with similar levels of sociodemographic development. Globally, 72.8% of prevalent cases of CKD attributable to PM2.5 and 74.2% of DALYs due to CKD attributable to PM2.5 were due to concentrations above 10 µg/m3, the WHO air quality guidelines. Conclusion The global burden of CKD attributable to PM2.5 is substantial, varies by geography and is disproportionally borne by disadvantaged countries. Most of the burden is associated with PM2.5 levels above the WHO guidelines, suggesting that achieving those targets may yield reduction in CKD burden.
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Affiliation(s)
- Benjamin Bowe
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, USA
| | - Elena Artimovich
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
| | - Yan Xie
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, USA
| | - Yan Yan
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Division of Public Health Sciences, Department of Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Miao Cai
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
- Nephrology Section, Medicine Service, VA Saint Louis Helath Care System, Saint Louis, Missouri, USA
- Institute for Public Health, Washington University in Saint Louis, Saint Louis, Missouri, USA
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Diabetes Minimally Mediated the Association Between PM 2.5 Air Pollution and Kidney Outcomes. Sci Rep 2020; 10:4586. [PMID: 32165691 PMCID: PMC7067761 DOI: 10.1038/s41598-020-61115-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 02/05/2020] [Indexed: 12/22/2022] Open
Abstract
Epidemiologic observations suggest that exposure to ambient fine particulate matter (PM2.5) is associated with increased risk of chronic kidney disease (CKD) and diabetes, a causal driver of CKD. We evaluated whether diabetes mediates the association between PM2.5 and CKD. A cohort of 2,444,157 United States veterans were followed over a median 8.5 years. Environmental Protection Agency data provided PM2.5 exposure levels. Regression models assessed associations and their proportion mediated. A 10 µg/m3 increase in PM2.5 was associated with increased odds of having a diabetes diagnosis (odds ratio: 1.18, 95% CI: 1.06–1.32), use of diabetes medication (1.22, 1.07–1.39), and increased risk of incident eGFR <60 ml/min/1.73 m2 (hazard ratio:1.20, 95% CI: 1.13–1.29), incident CKD (1.28, 1.18–1.39), ≥30% decline in eGFR (1.23, 1.15–1.33), and end-stage renal disease (ESRD) or ≥50% decline in eGFR (1.17, 1.05–1.30). Diabetes mediated 4.7% (4.3–5.7%) of the association of PM2.5 with incident eGFR <60 ml/min/1.73 m2, 4.8% (4.2–5.8%) with incident CKD, 5.8% (5.0–7.0%) with ≥30% decline in eGFR, and 17.0% (13.1–20.4%) with ESRD or ≥50% decline in eGFR. Diabetes minimally mediated the association between PM2.5 and kidney outcomes. The findings will help inform more accurate estimates of the burden of diabetes and burden of kidney disease attributable to PM2.5 pollution.
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Bowe B, Xie Y, Yan Y, Al-Aly Z. Burden of Cause-Specific Mortality Associated With PM2.5 Air Pollution in the United States. JAMA Netw Open 2019; 2:e1915834. [PMID: 31747037 PMCID: PMC6902821 DOI: 10.1001/jamanetworkopen.2019.15834] [Citation(s) in RCA: 165] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Ambient fine particulate matter (PM2.5) air pollution is associated with increased risk of several causes of death. However, epidemiologic evidence suggests that current knowledge does not comprehensively capture all causes of death associated with PM2.5 exposure. OBJECTIVE To systematically identify causes of death associated with PM2.5 pollution and estimate the burden of death for each cause in the United States. DESIGN, SETTING, AND PARTICIPANTS In a cohort study of US veterans followed up between 2006 and 2016, ensemble modeling was used to identify and characterize morphology of the association between PM2.5 and causes of death. Burden of death associated with PM2.5 exposure in the contiguous United States and for each state was then estimated by application of estimated risk functions to county-level PM2.5 estimates from the US Environmental Protection Agency and cause-specific death rate data from the Centers for Disease Control and Prevention. MAIN OUTCOMES AND MEASURES Nonlinear exposure-response functions of the association between PM2.5 and causes of death and burden of death associated with PM2.5. EXPOSURES Annual mean PM2.5 levels. RESULTS A cohort of 4 522 160 US veterans (4 243 462 [93.8%] male; median [interquartile range] age, 64.1 [55.7-75.5] years; 3 702 942 [82.0%] white, 667 550 [14.8%] black, and 145 593 [3.2%] other race) was followed up for a median (interquartile range) of 10.0 (6.8-10.2) years. In the contiguous United States, PM2.5 exposure was associated with excess burden of death due to cardiovascular disease (56 070.1 deaths [95% uncertainty interval {UI}, 51 940.2-60 318.3 deaths]), cerebrovascular disease (40 466.1 deaths [95% UI, 21 770.1-46 487.9 deaths]), chronic kidney disease (7175.2 deaths [95% UI, 5910.2-8371.9 deaths]), chronic obstructive pulmonary disease (645.7 deaths [95% UI, 300.2-2490.9 deaths]), dementia (19 851.5 deaths [95% UI, 14 420.6-31 621.4 deaths]), type 2 diabetes (501.3 deaths [95% UI, 447.5-561.1 deaths]), hypertension (30 696.9 deaths [95% UI, 27 518.1-33 881.9 deaths]), lung cancer (17 545.3 deaths [95% UI, 15 055.3-20 464.5 deaths]), and pneumonia (8854.9 deaths [95% UI, 7696.2-10 710.6 deaths]). Burden exhibited substantial geographic variation. Estimated burden of death due to nonaccidental causes was 197 905.1 deaths (95% UI, 183 463.3-213 644.9 deaths); mean age-standardized death rates (per 100 000) due to nonaccidental causes were higher among black individuals (55.2 [95% UI, 50.5-60.6]) than nonblack individuals (51.0 [95% UI, 46.4-56.1]) and higher among those living in counties with high (65.3 [95% UI, 56.2-75.4]) vs low (46.1 [95% UI, 42.3-50.4]) socioeconomic deprivation; 99.0% of the burden of death due to nonaccidental causes was associated with PM2.5 levels below standards set by the US Environmental Protection Agency. CONCLUSIONS AND RELEVANCE In this study, 9 causes of death were associated with PM2.5 exposure. The burden of death associated with PM2.5 was disproportionally borne by black individuals and socioeconomically disadvantaged communities. Effort toward cleaner air might reduce the burden of PM2.5-associated deaths.
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Affiliation(s)
- Benjamin Bowe
- Research and Education Service, Clinical Epidemiology Center, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- College for Public Health and Social Justice, Department of Epidemiology and Biostatistics, St Louis University, St Louis, Missouri
| | - Yan Xie
- Research and Education Service, Clinical Epidemiology Center, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- College for Public Health and Social Justice, Department of Epidemiology and Biostatistics, St Louis University, St Louis, Missouri
- Veterans Research & Education Foundation of St Louis, St Louis, Missouri
| | - Yan Yan
- Research and Education Service, Clinical Epidemiology Center, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ziyad Al-Aly
- Research and Education Service, Clinical Epidemiology Center, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Veterans Research & Education Foundation of St Louis, St Louis, Missouri
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
- Nephrology Section, Medicine Service, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Institute for Public Health, Washington University School of Medicine in St Louis, St Louis, Missouri
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Intraregional differences in renal function in the Northern Netherlands: The Lifelines Cohort Study. PLoS One 2019; 14:e0223908. [PMID: 31613916 PMCID: PMC6793867 DOI: 10.1371/journal.pone.0223908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/01/2019] [Indexed: 11/24/2022] Open
Abstract
Background Although the interregional disparity in chronic kidney disease (CKD) prevalence has been reported globally, little is known about differences in CKD prevalence within a region. We aimed to study the intraregional distribution of renal function in the Northern Netherlands and identify determinants of geographical differences in renal function. Methods We included 143,735 participants from the Lifelines population-based cohort in the Northern Netherlands. Spatial analysis was performed to identify regional clusters of lower eGFR (cold spots) and higher eGFR (hot spots) at the postal code level, without and with adjustment for clinical risk factors. Multivariate logistic regression was used to identify the contribution of neighborhood-level health-related behaviors, socioeconomic status, and environmental factors (air pollution parameters, urbanity) to regional clustering of lower eGFR. Results Significant spatial clustering of renal function was found for eGFR as well as for early stage renal function impairment (eGFR<90 ml/min/1.73 m2), (p<0.001). Spatial clustering persisted after adjustment of eGFR for clinical risk factors. In adjusted cold spots, the aggregate eGFR was lower (mean ± SD: 96.5±4.8 vs. 98.5±4.0 ml/min/1.73 m2, p = 0.001), and the prevalence of early stage renal function impairment (35.8±10.9 vs. 28.7±9.8%, p<0.001) and CKD stages 3–5 was higher (median (interquartile range): 1.2(0.1–2.4) vs 0(0–1.4)%, p<0.001) than in hot spots. In multivariable logistic regression, exposure to NO2 (Odd ratio [OR], 1.45; 95% confidence interval [95% CI], 1.19 to 1.75, p<0.001) was associated with cold spots (lower renal function), whereas proportion of fat intake in the diet (OR, 0.68; 95%CI, 0.48–0.97, P = 0.031) and income (OR, 0.91; 95%CI, 0.86–0.96, p<0.001) for median level income) were inversely related. Conclusions Significant intraregional clustering of renal function, early renal function impairment and CKD were observed in the Northern Netherlands even after adjustment for renal function-related clinical risk factors. Environmental (air pollution), neighborhood-level socioeconomic factors and diet are determinants of intraregional renal function distribution. Spatial analysis might be a useful adjunct to guide public health strategies for the prevention of CKD.
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Bilgel F. Spatial distribution of inequalities in end-stage renal disease in the United States. Spat Spatiotemporal Epidemiol 2019; 30:100282. [DOI: 10.1016/j.sste.2019.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/15/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
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Xie Y, Bowe B, Yan Y, Xian H, Li T, Al-Aly Z. Estimates of all cause mortality and cause specific mortality associated with proton pump inhibitors among US veterans: cohort study. BMJ 2019; 365:l1580. [PMID: 31147311 PMCID: PMC6538974 DOI: 10.1136/bmj.l1580] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To estimate all cause mortality and cause specific mortality among patients taking proton pump inhibitors (PPIs). DESIGN Longitudinal observational cohort study. SETTING US Department of Veterans Affairs. PARTICIPANTS New users of PPIs (n=157 625) or H2 blockers (n=56 842). MAIN OUTCOME MEASURES All cause mortality and cause specific mortality associated with taking PPIs (values reported as number of attributable deaths per 1000 patients taking PPIs). RESULTS There were 45.20 excess deaths (95% confidence interval 28.20 to 61.40) per 1000 patients taking PPIs. Circulatory system diseases (number of attributable deaths per 1000 patients taking PPIs 17.47, 95% confidence interval 5.47 to 28.80), neoplasms (12.94, 1.24 to 24.28), infectious and parasitic diseases (4.20, 1.57 to 7.02), and genitourinary system diseases (6.25, 3.22 to 9.24) were associated with taking PPIs. There was a graded relation between cumulative duration of PPI exposure and the risk of all cause mortality and death due to circulatory system diseases, neoplasms, and genitourinary system diseases. Analyses of subcauses of death suggested that taking PPIs was associated with an excess mortality due to cardiovascular disease (15.48, 5.02 to 25.19) and chronic kidney disease (4.19, 1.56 to 6.58). Among patients without documented indication for acid suppression drugs (n=116 377), taking PPIs was associated with an excess mortality due to cardiovascular disease (22.91, 11.89 to 33.57), chronic kidney disease (4.74, 1.53 to 8.05), and upper gastrointestinal cancer (3.12, 0.91 to 5.44). Formal interaction analyses suggested that the risk of death due to these subcauses was not modified by a history of cardiovascular disease, chronic kidney disease, or upper gastrointestinal cancer. Taking PPIs was not associated with an excess burden of transportation related mortality and death due to peptic ulcer disease (as negative outcome controls). CONCLUSIONS Taking PPIs is associated with a small excess of cause specific mortality including death due to cardiovascular disease, chronic kidney disease, and upper gastrointestinal cancer. The burden was also observed in patients without an indication for PPI use. Heightened vigilance in the use of PPI may be warranted.
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Affiliation(s)
- Yan Xie
- Clinical Epidemiology Center, Department of Veterans Affairs St Louis Health Care System, 915 North Grand Boulevard, St Louis, MO 63106, USA
- Veterans Research and Education Foundation of St Louis, St Louis, MO, USA
| | - Benjamin Bowe
- Clinical Epidemiology Center, Department of Veterans Affairs St Louis Health Care System, 915 North Grand Boulevard, St Louis, MO 63106, USA
- Department of Biostatistics, College for Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Yan Yan
- Clinical Epidemiology Center, Department of Veterans Affairs St Louis Health Care System, 915 North Grand Boulevard, St Louis, MO 63106, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Hong Xian
- Clinical Epidemiology Center, Department of Veterans Affairs St Louis Health Care System, 915 North Grand Boulevard, St Louis, MO 63106, USA
- Department of Biostatistics, College for Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Tingting Li
- Clinical Epidemiology Center, Department of Veterans Affairs St Louis Health Care System, 915 North Grand Boulevard, St Louis, MO 63106, USA
- Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Department of Veterans Affairs St Louis Health Care System, 915 North Grand Boulevard, St Louis, MO 63106, USA
- Veterans Research and Education Foundation of St Louis, St Louis, MO, USA
- Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
- Renal Section, Medicine Service, Department of Veterans Affairs Saint Louis Health Care System, St Louis, MO, USA
- Institute for Public Health, Washington University School of Medicine, St Louis, MO, USA
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Bowe B, Xie Y, Li T, Yan Y, Xian H, Al-Aly Z. Estimates of the 2016 global burden of kidney disease attributable to ambient fine particulate matter air pollution. BMJ Open 2019; 9:e022450. [PMID: 31072847 PMCID: PMC6528010 DOI: 10.1136/bmjopen-2018-022450] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To quantitate the 2016 global and national burden of chronic kidney disease (CKD) attributable to ambient fine particulate matter air pollution ≤ 2.5 μm in aerodynamic diameter (PM2.5). DESIGN We used the Global Burden of Disease (GBD) study data and methodologies to estimate the 2016 burden of CKD attributable to PM2.5 in 194 countries and territories. Population-weighted PM2.5 levels and incident rates of CKD for each country were curated from the GBD study publicly available data sources. SETTING GBD global and national data on PM2.5 and CKD. PARTICIPANTS 194 countries and territories. MAIN OUTCOME MEASURES We estimated the attributable burden of disease (ABD), years living with disability (YLD), years of life lost (YLL) and disability-adjusted life-years (DALYs). RESULTS The 2016 global burden of incident CKD attributable to PM2.5 was 6 950 514 (95% uncertainty interval: 5 061 533-8 914 745). Global YLD, YLL and DALYs of CKD attributable to PM2.5 were 2 849 311 (1 875 219-3 983 941), 8 587 735 (6 355 784-10 772 239) and 11 445 397 (8 380 246-14 554 091), respectively. Age-standardised ABD, YLL, YLD and DALY rates varied substantially among geographies. Populations in Mesoamerica, Northern Africa, several countries in the Eastern Mediterranean region, Afghanistan, Pakistan, India and several countries in Southeast Asia were among those with highest age-standardised DALY rates. For example, age-standardised DALYs per 100 000 were 543.35 (391.16-707.96) in El Salvador, 455.29 (332.51-577.97) in Mexico, 408.41 (283.82-551.84) in Guatemala, 238.25 (173.90-303.98) in India and 178.26 (125.31-238.47) in Sri Lanka, compared with 5.52 (0.82-11.48) in Sweden, 6.46 (0.00-14.49) in Australia and 12.13 (4.95-21.82) in Canada. Frontier analyses showed that Mesoamerican countries had significantly higher CKD DALY rates relative to other countries with comparable sociodemographic development. CONCLUSIONS Our results demonstrate that the global toll of CKD attributable to ambient air pollution is significant and identify several endemic geographies where air pollution may be a significant driver of CKD burden. Air pollution may need to be considered in the discussion of the global epidemiology of CKD.
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Affiliation(s)
- Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
| | - Yan Xie
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
| | - Tingting Li
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Yan Yan
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Hong Xian
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
- Nephrology Section, Medicine Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA
- Institute for Public Health, Washington University in Saint Louis, Saint Louis, Missouri, USA
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Califf RM. Improving Clinical Outcomes in the Era of Information Ubiquity. J Am Soc Nephrol 2019; 30:7-12. [DOI: 10.1681/asn.2018111128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Bowe B, Xie Y, Li T, Mokdad AH, Xian H, Yan Y, Maddukuri G, Al-Aly Z. Changes in the US Burden of Chronic Kidney Disease From 2002 to 2016: An Analysis of the Global Burden of Disease Study. JAMA Netw Open 2018; 1:e184412. [PMID: 30646390 PMCID: PMC6324659 DOI: 10.1001/jamanetworkopen.2018.4412] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Over the past 15 years, changes in demographic, social, and epidemiologic trends occurred in the United States. These changes likely contributed to changes in chronic kidney disease (CKD) epidemiology. OBJECTIVE To describe the change in burden of CKD at the US state level from 2002 to 2016. DESIGN, SETTING, AND PARTICIPANTS This systematic analysis used data and methodologies from the 2016 Global Burden of Disease study in the United States. Data on CKD from 2002 to 2016 were examined at the state level. MAIN OUTCOMES AND MEASURES Disability-adjusted life years (DALYs) and death due to CKD. RESULTS In this analysis of data from individuals in the United States, from 2002 to 2016, CKD DALYs increased by 52.6%, from 1 269 049 DALYs (95% uncertainty interval [UI], 1 154 521-1 387 008) to 1 935 954 DALYs (95% UI, 1 747 356-2 124 795). Death due to CKD increased by 58.3%, from 52 127 deaths (95% UI, 51 082-53 076) to 82 539 deaths (95% UI, 80 298-84 652). All states exhibited increases in CKD burden, but the rate of change (2002-2016) and the burden in 2016 varied by state. States in the southern United States (including Mississippi and Louisiana) exhibited more than twice the burden seen in other states (eg, the age-standardized CKD DALY rate in Vermont was 321 [95% UI, 281-363] per 100 000 population, whereas the rate in Mississippi was 697 [95% UI, 620-779] per 100 000 population). In the United States, the increase in CKD DALYs was attributable to increased risk exposure (40.3%), aging (32.3%), and population growth (27.4%). Age-standardized CKD DALY rates increased by 18.6% where increases in metabolic, and to a lesser extent dietary, risk factors contributed 93.8% and 5.3% of this change, respectively. Chronic kidney disease due to diabetes was the primary contributor for the 26.8% increased probability of death due to CKD among the population aged 20 to 54 years; among the population aged 55 to 89 years, the probability of death due to CKD increased by 25.6% and was driven by CKD due to diabetes and decreased probability of death from causes other than CKD. Improvement in sociodemographic development was coupled with an increase in age-standardized CKD DALY rates that occurred at a faster pace than that of other noncommunicable diseases in the United States. CONCLUSIONS AND RELEVANCE Our findings revealed that between 2002 and 2016, the burden of CKD in the United States appeared to be increasing and variable among states. These changes may be associated with increased risk exposure and demographic expansion leading to increased probability of death due to CKD, especially among young adults. The findings suggest that an effort to target the reduction of CKD through greater attention to metabolic and dietary risks, especially among younger adults, is necessary.
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Affiliation(s)
- Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, St Louis University, St Louis, Missouri
| | - Yan Xie
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs St Louis Health Care System, St Louis, Missouri
| | - Tingting Li
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Ali H. Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Hong Xian
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, St Louis University, St Louis, Missouri
| | - Yan Yan
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Geetha Maddukuri
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Nephrology Section, Medicine Service, Veterans Affairs St Louis Health Care System, St Louis, Missouri
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri
- Nephrology Section, Medicine Service, Veterans Affairs St Louis Health Care System, St Louis, Missouri
- Institute for Public Health, Washington University in St Louis, St Louis, Missouri
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Xie Y, Bowe B, Mokdad AH, Xian H, Yan Y, Li T, Maddukuri G, Tsai CY, Floyd T, Al-Aly Z. Analysis of the Global Burden of Disease study highlights the global, regional, and national trends of chronic kidney disease epidemiology from 1990 to 2016. Kidney Int 2018; 94:567-581. [DOI: 10.1016/j.kint.2018.04.011] [Citation(s) in RCA: 354] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/11/2018] [Accepted: 04/12/2018] [Indexed: 12/24/2022]
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Xie Y, Bowe B, Li T, Xian H, Al-Aly Z. Blood urea nitrogen and risk of insulin use among people with diabetes. Diab Vasc Dis Res 2018; 15:409-416. [PMID: 29974791 DOI: 10.1177/1479164118785050] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Laboratory evidence suggests that urea suppresses insulin secretion and sensitivity. Emerging epidemiologic evidence suggests that higher levels of urea are associated with increased risk of incident diabetes mellitus. However, whether elevated levels of blood urea nitrogen are associated with increased risk of insulin use among people with diabetes is unknown. We used the Department of Veterans Affairs databases to assemble a cohort of 197,994 incident users of non-insulin hypoglycaemic agents with an estimated glomerular filtration rate > 60 mL/min per 1.73 m2 and followed them for a median of 4.93 years. Spline analyses suggested that the relationship between blood urea nitrogen and the risk of insulin use was neutral below blood urea nitrogen level of 25 mg/dL and increased exponentially with blood urea nitrogen levels above 25 mg/dL. In survival models, compared to those with blood urea nitrogen ⩽ 25 mg/dL, those with blood urea nitrogen > 25 mg/dL had an increased risk of insulin use (hazard ratio = 1.40; confidence interval = 1.30-1.50). The risk of insulin use was increased in models which accounted for haemoglobin A1c at time zero (hazard ratio = 1.39; confidence interval = 1.28-1.50) and as a time-varying variable (hazard ratio = 1.38; confidence interval = 1.28-1.50). Two-step residual estimation analyses showed that, independent of the impact of estimated glomerular filtration rate, every 10-mg/dL increase in blood urea nitrogen concentration was associated with increased risk of insulin use (hazard ratio = 1.16; confidence interval = 1.12-1.20). Our results suggest that, among people with diabetes, higher levels of blood urea nitrogen are associated with an increased risk of insulin use.
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Affiliation(s)
- Yan Xie
- 1 Clinical Epidemiology Center, Research and Education Service, VA St Louis Health Care System, St Louis, MO, USA
| | - Benjamin Bowe
- 1 Clinical Epidemiology Center, Research and Education Service, VA St Louis Health Care System, St Louis, MO, USA
| | - Tingting Li
- 1 Clinical Epidemiology Center, Research and Education Service, VA St Louis Health Care System, St Louis, MO, USA
- 2 Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Hong Xian
- 1 Clinical Epidemiology Center, Research and Education Service, VA St Louis Health Care System, St Louis, MO, USA
- 3 Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, St Louis, MO, USA
| | - Ziyad Al-Aly
- 1 Clinical Epidemiology Center, Research and Education Service, VA St Louis Health Care System, St Louis, MO, USA
- 2 Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
- 4 Renal Section, Medicine Service, VA St Louis Health Care System, St Louis, MO, USA
- 5 Institute for Public Health, Washington University School of Medicine, St Louis, MO, USA
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Bowe B, Xie Y, Li T, Yan Y, Xian H, Al-Aly Z. The 2016 global and national burden of diabetes mellitus attributable to PM 2·5 air pollution. Lancet Planet Health 2018; 2:e301-e312. [PMID: 30074893 DOI: 10.1016/s2542-5196(18)30140-2] [Citation(s) in RCA: 195] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 05/22/2018] [Accepted: 06/05/2018] [Indexed: 05/22/2023]
Abstract
BACKGROUND PM2·5 air pollution is associated with increased risk of diabetes; however, a knowledge gap exists to further define and quantify the burden of diabetes attributable to PM2·5 air pollution. Therefore, we aimed to define the relationship between PM2·5 and diabetes. We also aimed to characterise an integrated exposure response function and to provide a quantitative estimate of the global and national burden of diabetes attributable to PM2·5. METHODS We did a longitudinal cohort study of the association of PM2·5 with diabetes. We built a cohort of US veterans with no previous history of diabetes from various databases. Participants were followed up for a median of 8·5 years, we and used survival models to examine the association between PM2·5 and the risk of diabetes. All models were adjusted for sociodemographic and health characteristics. We tested a positive outcome control (ie, risk of all-cause mortality), negative exposure control (ie, ambient air sodium concentrations), and a negative outcome control (ie, risk of lower limb fracture). Data for the models were reported as hazard ratios (HRs) and 95% CIs. Additionally, we reviewed studies of PM2·5 and the risk of diabetes, and used the estimates to build a non-linear integrated exposure response function to characterise the relationship across all concentrations of PM2·5 exposure. We included studies into the building of the integrated exposure response function if they scored at least a four on the Newcastle-Ottawa Quality Assessment Scale and were only included if the outcome was type 2 diabetes or all types of diabetes. Finally, we used the Global Burden of Disease study data and methodologies to estimate the attributable burden of disease (ABD) and disability-adjusted life-years (DALYs) of diabetes attributable to PM2·5 air pollution globally and in 194 countries and territories. FINDINGS We examined the relationship of PM2·5 and the risk of incident diabetes in a longitudinal cohort of 1 729 108 participants followed up for a median of 8·5 years (IQR 8·1-8·8). In adjusted models, a 10 μg/m3 increase in PM2·5 was associated with increased risk of diabetes (HR 1·15, 95% CI 1·08-1·22). PM2·5 was associated with increased risk of death as the positive outcome control (HR 1·08, 95% CI 1·03-1·13), but not with lower limb fracture as the negative outcome control (1·00, 0·91-1·09). An IQR increase (0·045 μg/m3) in ambient air sodium concentration as the negative exposure control exhibited no significant association with the risk of diabetes (HR 1·00, 95% CI 0·99-1·00). An integrated exposure response function showed that the risk of diabetes increased substantially above 2·4 μg/m3, and then exhibited a more moderate increase at concentrations above 10 μg/m3. Globally, ambient PM2·5 contributed to about 3·2 million (95% uncertainty interval [UI] 2·2-3·8) incident cases of diabetes, about 8·2 million (95% UI 5·8-11·0) DALYs caused by diabetes, and 206 105 (95% UI 153 408-259 119) deaths from diabetes attributable to PM2·5 exposure. The burden varied substantially among geographies and was more heavily skewed towards low-income and lower-to-middle-income countries. INTERPRETATION The global toll of diabetes attributable to PM2·5 air pollution is significant. Reduction in exposure will yield substantial health benefits. FUNDING US Department of Veterans Affairs.
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Affiliation(s)
- Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, MO, USA; Department of Epidemiology and Biostatistics, Saint Louis University, Saint Louis, MO, USA
| | - Yan Xie
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, MO, USA
| | - Tingting Li
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, MO, USA; Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Yan Yan
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, MO, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Hong Xian
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, MO, USA; Department of Epidemiology and Biostatistics, Saint Louis University, Saint Louis, MO, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, MO, USA; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, Missouri, MO, USA; Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA; Institute for Public Health, Washington University in Saint Louis, Saint Louis, MO, USA.
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Xie Y, Bowe B, Li T, Xian H, Yan Y, Al-Aly Z. Higher blood urea nitrogen is associated with increased risk of incident diabetes mellitus. Kidney Int 2017; 93:741-752. [PMID: 29241622 DOI: 10.1016/j.kint.2017.08.033] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 08/26/2017] [Accepted: 08/31/2017] [Indexed: 01/05/2023]
Abstract
Experimental evidence suggests that higher levels of urea may increase insulin resistance and suppress insulin secretion. However, whether higher levels of blood urea nitrogen (BUN) are associated with increased risk of incident diabetes mellitus in humans is not known. To study this, we built a national cohort of 1,337,452 United States Veterans without diabetes to characterize the association of BUN and risk of incident diabetes. Over a median follow-up of 4.93 years, there were 172,913 cases of incident diabetes. In joint risk models of estimated glomerular filtration rate (eGFR) and BUN. there was no association between eGFR and the risk of incident diabetes in those with a BUN of 25 mg/dl or less. However, the risk was significantly increased in those with a BUN over 25 mg/dl at all eGFR levels, even in those with an eGFR of 60 ml/min/1.73m2 or more (hazard ratio 1.27; confidence interval 1.24-1.31). The risk of incident diabetes was highest in those with BUN over 25 mg/dL and an eGFR under 15 ml/min/1.73m2 (1.68; 1.51-1.87). Spline analyses of the relationship between BUN and risk of incident diabetes showed that risk was progressively higher as BUN increased. In models where eGFR was included as a continuous covariate, compared to a BUN of 25 mg/dl or less, a BUN over 25 mg/dl was associated with increased risk of incident diabetes (1.23; 1.21-1.25). Every 10 ml/min/1.73m2 decrease in eGFR was not associated with risk of incident diabetes (1.00; 1.00-1.01). Two-stage residual inclusion analyses showed that, independent of the impact of eGFR, every 10 mg/dL increase in BUN concentration was associated with increased risk of incident diabetes (1.15; 1.14-1.16). Thus, higher levels of BUN are associated with increased risk of incident diabetes mellitus.
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Affiliation(s)
- Yan Xie
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA
| | - Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA
| | - Tingting Li
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA; Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hong Xian
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA; Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri, USA
| | - Yan Yan
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA; Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA; Renal Section, Medicine Service, VA St. Louis Health Care System, St. Louis, Missouri, USA; Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, USA.
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Bowe B, Xie Y, Li T, Yan Y, Xian H, Al-Aly Z. Associations of ambient coarse particulate matter, nitrogen dioxide, and carbon monoxide with the risk of kidney disease: a cohort study. Lancet Planet Health 2017; 1:e267-e276. [PMID: 29851625 DOI: 10.1016/s2542-5196(17)30117-1] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 09/02/2017] [Accepted: 09/11/2017] [Indexed: 05/24/2023]
Abstract
BACKGROUND Experimental evidence and preliminary clinical evidence suggest that environmental air pollution adversely effects kidney health. Previous work has examined the association between fine particulate matter and risk of kidney disease; however, the association between ambient coarse particulate matter (PM10; ≤10 μm in aerodynamic diameter), nitrogen dioxide (NO2), and carbon monoxide (CO) and risk of incident chronic kidney disease, chronic kidney disease progression, and end-stage renal disease is not clear. METHODS We merged multiple large databases, including those of the Environmental Protection Agency and the Department of Veterans Affairs, to build a cohort of US veterans, and used survival models to evaluate the association between PM10, NO2, and CO concentrations and risk of incident estimated glomerular filtration rate (eGFR) of less than 60 mL/min per 1·73 m2, incident chronic kidney disease, eGFR decline of 30% or more, and end-stage renal disease. We treated exposure as time-varying when it was updated annually and as cohort participants moved. FINDINGS Between Oct 1, 2003, and Sept 30, 2012, 2 010 398 cohort participants were followed up over a median of 8·52 years (IQR 8·05-8·80). An increased risk of eGFR of less than 60 mL/min per 1·73 m2 was associated with an IQR increase in concentrations of PM10 (hazard ratio 1·07, 95% CI 1·06-1·08), NO2 (1·09, 1·08-1·10), and CO (1·09, 1·08-1·10). An increased risk of incident chronic kidney disease was associated with an IQR increase in concentrations of PM10 (1·07, 1·05-1·08), NO2 (1·09, 1·08-1·11), and CO (1·10, 1·08-1·11). An increased risk of an eGFR decline of 30% or more was associated with an IQR increase in concentrations of PM10 (1·08, 1·07-1·09), NO2 (1·12, 1·10-1·13), and CO (1·09, 1·08-1·10). An increased risk of end-stage renal disease was associated with an IQR increase in concentrations of PM10 (1·09, 1·06-1·12), NO2 (1·09, 1·06-1·12), and CO (1·05, 1·02-1·08). Spline analyses suggested a monotonic increasing association between PM10, NO2, and CO concentrations and risk of kidney outcomes. INTERPRETATION Environmental exposure to higher concentrations of PM10, NO2, and CO is associated with increased risk of incident chronic kidney disease, eGFR decline, and end-stage renal disease. FUNDING US Department of Veterans Affairs.
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Affiliation(s)
- Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, MO, USA
| | - Yan Xie
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, MO, USA
| | - Tingting Li
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, MO, USA; Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Yan Yan
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, MO, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Hong Xian
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, MO, USA; Department of Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, MO, USA; Nephrology Section, Medicine Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, MO, USA; Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA; Institute for Public Health, Washington University School of Medicine, Saint Louis, MO, USA.
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Bowe B, Xie Y, Li T, Yan Y, Xian H, Al-Aly Z. Particulate Matter Air Pollution and the Risk of Incident CKD and Progression to ESRD. J Am Soc Nephrol 2017; 29:218-230. [PMID: 28935655 DOI: 10.1681/asn.2017030253] [Citation(s) in RCA: 212] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 06/17/2017] [Indexed: 12/25/2022] Open
Abstract
Elevated levels of fine particulate matter <2.5 µm in aerodynamic diameter (PM2.5) are associated with increased risk of cardiovascular outcomes and death, but their association with risk of CKD and ESRD is unknown. We linked the Environmental Protection Agency and the Department of Veterans Affairs databases to build an observational cohort of 2,482,737 United States veterans, and used survival models to evaluate the association of PM2.5 concentrations and risk of incident eGFR <60 ml/min per 1.73 m2, incident CKD, eGFR decline ≥30%, and ESRD over a median follow-up of 8.52 years. County-level exposure was defined at baseline as the annual average PM2.5 concentrations in 2004, and separately as time-varying where it was updated annually and as cohort participants moved. In analyses of baseline exposure (median, 11.8 [interquartile range, 10.1-13.7] µg/m3), a 10-µg/m3 increase in PM2.5 concentration was associated with increased risk of eGFR<60 ml/min per 1.73 m2 (hazard ratio [HR], 1.21; 95% confidence interval [95% CI], 1.14 to 1.29), CKD (HR, 1.27; 95% CI, 1.17 to 1.38), eGFR decline ≥30% (HR, 1.28; 95% CI, 1.18 to 1.39), and ESRD (HR, 1.26; 95% CI, 1.17 to 1.35). In time-varying analyses, a 10-µg/m3 increase in PM2.5 concentration was associated with similarly increased risk of eGFR<60 ml/min per 1.73 m2, CKD, eGFR decline ≥30%, and ESRD. Spline analyses showed a linear relationship between PM2.5 concentrations and risk of kidney outcomes. Exposure estimates derived from National Aeronautics and Space Administration satellite data yielded consistent results. Our findings demonstrate a significant association between exposure to PM2.5 and risk of incident CKD, eGFR decline, and ESRD.
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Affiliation(s)
- Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service and
| | - Yan Xie
- Clinical Epidemiology Center, Research and Education Service and
| | - Tingting Li
- Clinical Epidemiology Center, Research and Education Service and.,Department of Medicine
| | - Yan Yan
- Clinical Epidemiology Center, Research and Education Service and.,Division of Public Health Sciences, Department of Surgery, and
| | - Hong Xian
- Clinical Epidemiology Center, Research and Education Service and.,Department of Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service and .,Department of Medicine.,Nephrology Section, Medicine Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, Missouri.,Institute for Public Health, Washington University School of Medicine, Saint Louis, Missouri; and
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Xie Y, Bowe B, Li T, Xian H, Yan Y, Al-Aly Z. Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans. BMJ Open 2017; 7:e015735. [PMID: 28676480 PMCID: PMC5642790 DOI: 10.1136/bmjopen-2016-015735] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Proton pump inhibitors (PPIs) are widely used, and their use is associated with increased risk of adverse events. However, whether PPI use is associated with excess risk of death is unknown. We aimed to examine the association between PPI use and risk of all-cause mortality. DESIGN Longitudinal observational cohort study. SETTING US Department of Veterans Affairs. PARTICIPANTS Primary cohort of new users of PPI or histamine H2 receptor antagonists (H2 blockers) (n=349 312); additional cohorts included PPI versus no PPI (n=3 288 092) and PPI versus no PPI and no H2 blockers (n=2 887 030). MAIN OUTCOME MEASURES Risk of death. RESULTS Over a median follow-up of 5.71 years (IQR 5.11-6.37), PPI use was associated with increased risk of death compared with H2 blockers use (HR 1.25, CI 1.23 to 1.28). Risk of death associated with PPI use was higher in analyses adjusted for high-dimensional propensity score (HR 1.16, CI 1.13 to 1.18), in two-stage residual inclusion estimation (HR 1.21, CI 1.16 to 1.26) and in 1:1 time-dependent propensity score-matched cohort (HR 1.34, CI 1.29 to 1.39). The risk of death was increased when considering PPI use versus no PPI (HR 1.15, CI 1.14 to 1.15), and PPI use versus no PPI and no H2 blockers (HR 1.23, CI 1.22 to 1.24). Risk of death associated with PPI use was increased among participants without gastrointestinal conditions: PPI versus H2 blockers (HR 1.24, CI 1.21 to 1.27), PPI use versus no PPI (HR 1.19, CI 1.18 to 1.20) and PPI use versus no PPI and no H2 blockers (HR 1.22, CI 1.21 to 1.23). Among new PPI users, there was a graded association between the duration of exposure and the risk of death. CONCLUSIONS The results suggest excess risk of death among PPI users; risk is also increased among those without gastrointestinal conditions and with prolonged duration of use. Limiting PPI use and duration to instances where it is medically indicated may be warranted.
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Affiliation(s)
- Yan Xie
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
| | - Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
| | - Tingting Li
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Hong Xian
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, USA
| | - Yan Yan
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
- Renal Section, Medicine Service, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Institute for Public Health, Washington University in Saint Louis, Saint Louis, Missouri, USA
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Bowe B, Xie Y, Xian H, Li T, Al-Aly Z. Association between Monocyte Count and Risk of Incident CKD and Progression to ESRD. Clin J Am Soc Nephrol 2017; 12:603-613. [PMID: 28348030 PMCID: PMC5383390 DOI: 10.2215/cjn.09710916] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/18/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Experimental evidence suggests a role for monocytes in the biology of kidney disease progression; however, whether monocyte count is associated with risk of incident CKD, CKD progression, and ESRD has not been examined in large epidemiologic studies. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS We built a longitudinal observational cohort of 1,594,700 United States veterans with at least one eGFR during fiscal year 2004 (date of last eGFR during this period designated time zero) and no prior history of ESRD, dialysis, or kidney transplant. Cohort participants were followed until September 30, 2013 or death. Monocyte count closest to and before time zero was categorized in quartiles: quartile 1, >0.00 to ≤0.40 thousand cells per cubic millimeter (k/cmm); quartile 2, >0.40 to ≤0.55 k/cmm; quartile 3, >0.55 to ≤0.70 k/cmm; and quartile 4, >0.70 k/cmm. Survival models were built to examine the association between monocyte count and risk of incident eGFR<60 ml/min per 1.73 m2, risk of incident CKD, and risk of CKD progression defined as doubling of serum creatinine, eGFR decline ≥30%, or the composite outcome of ESRD, dialysis, or renal transplantation. RESULTS Over a median follow-up of 9.2 years (interquartile range, 8.3-9.4); in adjusted survival models, there was a graded association between monocyte counts and risk of renal outcomes. Compared with quartile 1, quartile 4 was associated with higher risk of incident eGFR<60 ml/min per 1.73 m2 (hazard ratio, 1.13; 95% confidence interval, 1.12 to 1.14) and risk of incident CKD (hazard ratio, 1.15; 95% confidence interval, 1.13 to 1.16). Quartile 4 was associated with higher risk of doubling of serum creatinine (hazard ratio, 1.22; 95% confidence interval, 1.20 to 1.24), ≥30% eGFR decline (hazard ratio, 1.18; 95% confidence interval, 1.17 to 1.19), and the composite renal end point (hazard ratio, 1.19; 95% confidence interval, 1.16 to 1.22). Cubic spline analyses of the relationship between monocyte count levels and renal outcomes showed a linear relationship, in which risk was higher with higher monocyte count. Results were robust to changes in sensitivity analyses. CONCLUSIONS Our results show a significant association between higher monocyte count and risks of incident CKD and CKD progression to ESRD.
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Affiliation(s)
- Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service and
| | - Yan Xie
- Clinical Epidemiology Center, Research and Education Service and
| | - Hong Xian
- Clinical Epidemiology Center, Research and Education Service and
- Department of Biostatistics, College for Public Health and Social Justice, St. Louis University, St. Louis, Missouri; and
| | - Tingting Li
- Clinical Epidemiology Center, Research and Education Service and
- Department of Medicine and
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service and
- Division of Nephrology, Department of Medicine, US Department of Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
- Department of Medicine and
- Institute for Public Health, Washington University School of Medicine, St. Louis, Missouri
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Xie Y, Bowe B, Li T, Xian H, Yan Y, Al-Aly Z. Long-term kidney outcomes among users of proton pump inhibitors without intervening acute kidney injury. Kidney Int 2017; 91:1482-1494. [PMID: 28237709 DOI: 10.1016/j.kint.2016.12.021] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/15/2016] [Accepted: 12/22/2016] [Indexed: 12/13/2022]
Abstract
Proton pump inhibitor (PPI) use is associated with an increased risk of acute kidney injury (AKI), incident chronic kidney disease (CKD), and progression to end-stage renal disease (ESRD). PPI-associated CKD is presumed to be mediated by intervening AKI. However, whether PPI use is associated with an increased risk of chronic renal outcomes in the absence of intervening AKI is unknown. To evaluate this we used the Department of Veterans Affairs national databases to build a cohort of 144,032 incident users of acid suppression therapy that included 125,596 PPI and 18,436 Histamine H2 receptor antagonist (H2 blockers) consumers. Over 5 years of follow-up in survival models, cohort participants were censored at the time of AKI occurrence. Compared with incident users of H2 blockers, incident users of PPIs had an increased risk of an estimated glomerular filtration rate (eGFR) under 60 ml/min/1.73m2 (hazard ratio 1.19; 95% confidence interval 1.15-1.24), incident CKD (1.26; 1.20-1.33), eGFR decline over 30% (1.22; 1.16-1.28), and ESRD or eGFR decline over 50% (1.30; 1.15-1.48). Results were consistent in models that excluded participants with AKI either before chronic renal outcomes, during the time in the cohort, or before cohort entry. The proportion of PPI effect mediated by AKI was 44.7%, 45.47%, 46.00%, and 46.72% for incident eGFR under 60 ml/min/1.73m2, incident CKD, eGFR decline over 30%, and ESRD or over 50% decline in eGFR, respectively. Thus, PPI use is associated with increased risk of chronic renal outcomes in the absence of intervening AKI. Hence, reliance on antecedent AKI as warning sign to guard against the risk of CKD among PPI users is not sufficient as a sole mitigation strategy.
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Affiliation(s)
- Yan Xie
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA
| | - Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA
| | - Tingting Li
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA; Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hong Xian
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA; Department of Biostatistics, College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri, USA
| | - Yan Yan
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA; Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA; Nephrology Section, Medicine Service, VA Saint Louis Health Care System, St. Louis, Missouri, USA; Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, USA.
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Li T, Xie Y, Bowe B, Xian H, Al-Aly Z. Serum phosphorus levels and risk of incident dementia. PLoS One 2017; 12:e0171377. [PMID: 28152028 PMCID: PMC5289565 DOI: 10.1371/journal.pone.0171377] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 01/17/2017] [Indexed: 01/13/2023] Open
Abstract
Higher serum phosphorous is associated with cerebral small vessel disease, an important driver of cognitive decline and dementia. Whether serum phosphorous, a potentially modifiable parameter, associates with risk of incident dementia is not known. We aimed to examine the association between serum phosphorous and risk of incident dementia and to determine if the association is modified by age. We used the United States Department of Veterans Affairs national databases to build a longitudinal observational cohort of US veterans without prior history of dementia and with at least one outpatient serum phosphorus between October 2008 and September 2010 and followed them until September 2014. Serum phosphorus was categorized into quintiles: ≤2.9, >2.9 to ≤3.2, >3.2 to ≤3.5, >3.5 to ≤3.9, >3.9 mg/dL. There were 744,235 participants in the overall cohort. Over a median follow-up of 5.07 years (Interquartile range [IQR]: 4.28, 5.63), adjusted Cox models show that compared to quintile 2, the risk of incident dementia was increased in quintile 4 (Hazard Ratio [HR] = 1.05; CI = 1.01–1.10) and quintile 5 (HR = 1.14; CI = 1.09–1.20). In cohort participants ≤60 years old, the risk of incident dementia was increased in quintile 4 (HR = 1.29; CI = 1.12–1.49) and 5 (HR = 1.45; CI = 1.26–1.68). In participants > 60 years old, the risk was not significant in quintile 4, and was attenuated in quintile 5 (HR = 1.10; CI = 1.05–1.16). Formal interaction analyses showed that the association between phosphorous and dementia was more pronounced in those younger than 60, and attenuated in those older than 60 (P for interaction was 0.004 and <0.0001 in quintiles 4 and 5; respectively). We conclude that higher serum phosphorous is associated with increased risk of incident dementia. This association is stronger in younger cohort participants. The identification of serum phosphorous as a risk factor for incident dementia has public health relevance and might inform the design and implementation of risk reduction strategies.
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Affiliation(s)
- Tingting Li
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, United States of America.,Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Yan Xie
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, United States of America
| | - Benjamin Bowe
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, United States of America
| | - Hong Xian
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, United States of America.,Department of Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Education Service, VA Saint Louis Health Care System, Saint Louis, Missouri, United States of America.,Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, United States of America.,Department of Medicine, Division of Nephrology, VA Saint Louis Health Care System, Saint Louis, Missouri, United States of America
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