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Peschard VG, Scherzer R, Estrella MM, Sarnak MJ, Ascher SB, Lash J, Bonventre JV, Greenberg JH, Gutierrez OM, Schelling JR, Katz R, Cheung KL, Levitan EB, Schrauben SJ, Cushman M, Ilori TO, Parikh CR, Kimmel PL, Rao PS, Taliercio JJ, Sondheimer J, Shulman R, Coca SG, Chen J, Ramachandran VS, Ix JH, Shlipak MG. Defining Kidney Health Dimensions and Their Associations with Adverse Outcomes in Persons with Diabetes and CKD. Clin J Am Soc Nephrol 2025; 20:665-675. [PMID: 40085155 PMCID: PMC12097179 DOI: 10.2215/cjn.0000000676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Collaborators] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Accepted: 03/11/2025] [Indexed: 03/16/2025]
Abstract
Key Points We identified three kidney health dimensions using 17 urine and plasma biomarkers across two cohorts of persons with diabetes and CKD. Worse scores for tubule injury, tubule function, and systemic inflammation/filtration were associated with a higher risk of CKD progression and death. A multibiomarker approach could help capture tubulointerstitial health in persons with diabetes and CKD. Background Individual kidney tubule biomarkers are associated with risks of CKD progression and mortality in persons with diabetes. Integrating multiple kidney biomarkers using a latent variable method of exploratory factor analysis could define distinct dimensions of kidney health and their associations with adverse outcomes. Methods We conducted a factor analysis of 17 candidate urine and plasma biomarkers in 1256 participants with diabetes and eGFR <60 ml/min per 1.73 m2 from the Chronic Renal Insufficiency Cohort (CRIC; N =701) and the REasons for Geographic And Racial Differences in Stroke (REGARDS; N =555) studies. We used Cox proportional hazards models to evaluate the associations of identified factors with CKD progression and mortality, adjusting for baseline clinical risk factors, eGFR, and albuminuria. Results Three factor scores comprising ten biomarkers were identified: systemic inflammation and filtration (plasma TNF receptor-1 and TNF receptor-2, plasma soluble urokinase plasminogen activator receptor, and plasma symmetric dimethylarginine), tubular function (urine EGF, urine asymmetric dimethylarginine, and urine symmetric dimethylarginine), and tubular damage (urine α -1 microglobulin, urine kidney injury molecule-1, and urine monocyte chemoattractant protein-1). In CRIC, there were 244 incident ESKD events, 102 with ≥40% eGFR decline from baseline, and 259 deaths; in REGARDS, there were 121 incident ESKD events and 462 deaths. In CRIC, lower tubular function (hazard ratio per 1-SD, 0.36; 95% confidence interval, 0.25 to 0.52) and higher tubular damage (1.45; 1.18 to 1.78) scores were independently associated with higher CKD progression risk. Associations in REGARDS were weaker but directionally consistent (tubular function score [0.81; 0.47 to 1.39] and tubular damage score [1.12; 0.73 to 1.72]). Higher tubular damage (1.47; 1.15 to 1.87) scores were associated with higher mortality risk in CRIC, but not REGARDS (1.15; 0.96 to 1.38). Higher systemic inflammation and filtration factor scores were associated with higher mortality risk in both cohorts (CRIC: 1.35; 1.07 to 1.71; REGARDS: 1.41; 1.20 to 1.65). Conclusions Three distinct kidney health dimensions were identified, and each associated with CKD progression and/or all-cause mortality in persons with diabetes and CKD.
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Affiliation(s)
- Vanessa-Giselle Peschard
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System, University of California, San Francisco, San Francisco, California
| | - Rebecca Scherzer
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System, University of California, San Francisco, San Francisco, California
| | - Michelle M. Estrella
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System, University of California, San Francisco, San Francisco, California
| | - Mark J. Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Washington
| | - Simon B. Ascher
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System, University of California, San Francisco, San Francisco, California
| | - James Lash
- Division of Nephrology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Joseph V. Bonventre
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Washington
| | - Jason H. Greenberg
- Section of Nephrology, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Orlando M. Gutierrez
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey R. Schelling
- Department of Physiology and Biophysics and Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Ronit Katz
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Katharine L. Cheung
- Division of Nephrology, Department of Medicine, Larner College of Medicine, The University of Vermont, Burlington, Vermont
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sarah J. Schrauben
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Titilayo O. Ilori
- Nephrology Division, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Chirag R. Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paul L. Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Panduranga S. Rao
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jonathan J. Taliercio
- Department of Kidney Medicine; Medical Subspecialty Institute, Cleveland Clinic, Cleveland, Ohio
| | - James Sondheimer
- Division of Nephrology and Hypertension, Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan
| | - Rachel Shulman
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven G. Coca
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jing Chen
- Department of Medicine, Tulane University, New Orleans, Louisiana
| | | | - Joachim H. Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Michael G. Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System, University of California, San Francisco, San Francisco, California
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Collaborators
Vasan S Ramachandran, Joseph Massaro, Clary Clish, Jeffrey Schelling, Tom Hostetter, Michelle Denburg, Susan Furth, Bradley Warady, Joseph Bonventre, Sushrut Waikar, Gearoid McMahon, Venkata Sabbisetti, Josef Coresh, Morgan Grams, Casey Rebholz, Alison Abraham, Adriene Tin, Jon Klein, Steven Coca, Bart S Ferket, Girish N Nadkarni, Eugene Rhee, Paul L Kimmel, John W Kusek, Robert Nelson, Caroline Fox, Brad Rovin, Andrew S Levey, Lesley A Inker, Meredith Foster, Andrew S Levey, Lesley A Inker, Meredith Foster, Harold I Feldman, Amanda Anderson, Theodore Mifflin, Dawei Xie, Haochang Shou, Shawn Ballard, Krista Whitehead, Kellie Ryan, Chirag Parikh, Vasan S Ramachandran, Joseph Bonventre, Sushrut Waikar, Venkata Sabbisetti, Jennifer Van Eyk, Dawn Chen, Qin Fu, Hermine Brunner, Vivette D'Agati, Jonathan Barasch, Josef Coresh, Casey Rebholz, Alan S Go, Erwin Bottinger, Avelino Teixeira, Ilse Daehn, Mark Molitch, Daniel Batlle, Brad Rovin, Haifeng Wu, Andrew S Levey, Lesley A Inker, Meredith Foster, Chi-Yuan Hsu, Kathleen Liu, Jon Klein, Michael Mauer, Paola Fioretto, Gary Nelsestuen, John H Eckfeldt, Amy Karger, Paola Fioretto, Harold I Feldman, Shawn Ballard, Krista Whitehead, Dawei Xie, Haochang Shou, Xiaoming Zhang, Kellie Ryan, Theodore E Mifflin, Tom Greene, Robert G Nelson, Paul L Kimmel, John W Kusek,
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Wang X, Ren L, Huang Y, Feng Z, Zhang G, Dai H. The Role of Tubulointerstitial Markers in Differential Diagnosis and Prognosis in Patients with Type 2 Diabetes and Biopsy Proven Diabetic Kidney Disease. Clin Chim Acta 2023:117448. [PMID: 37331550 DOI: 10.1016/j.cca.2023.117448] [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: 11/25/2022] [Revised: 05/15/2023] [Accepted: 06/13/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVE To evaluate the potential application of tubularinterstitial biomarkers in the differential diagnosis of diabetic kidney disease (DKD) from non-diabetic kidney disease (NDKD), as well as investigate key clinical and pathological parameters to help improve the stratification of patients according to end-stage renal disease risk. METHODS 132 type 2 diabetic patients with chronic kidney disease were enrolled. Patients were categorized into 2 groups according to the renal biopsy results: DKD (n=61) and NDKD (n=71).The independent factors of the occurrence of DKD and the diagnostic implications of tubular biomarkers were explored by logistic regression and receiver-operating characteristic curve analysis. Furthermore, predictors were analyzed by least absolute shrinkage and selection operator regression, and constructed a new model for predicting the unfavorable renal outcomes through Cox proportional hazard regression analysis. RESULTS Serum neutrophil gelatinase-associated lipocalin (sNGAL) (OR= 1.007; 95%CI = [1.003, 1.012], p = 0.001) was identified as an independent risk factor for the occurrence of DKD in diabetic patients with CKD. Tubular biomarkers including sNGAL, N-acetyl-β-D-glucosaminidase and β2 microglobulin (β2-MG) could complement albuminuria for DKD detection (AUC = 0.926, specificity = 90.14%, sensitivity = 80.33%).Moreover, among of the 47 variables, 4 predictors such as sNGAL, interstitial fibrosis and tubular atrophy (IFTA)score, β2-MG and estimated glomerular filtration rate were selected to construct a new model for predicting the unfavorable renal outcomes through regression analysis. sNGAL (HR = 1.004; 95%CI = [1.001, 1.007], p = 0.013), IFTA score of 2 (HR = 4.283; 95%CI = [1.086, 16.881], p = 0.038), and IFTA score of 3 (HR = 6.855; 95%CI = [1.766, 26.610], p = 0.005) were considered to be independent risk factors for unfavorable renal outcomes. CONCLUSIONS Tubulointerstitial injury in DKD is independently associated with renal function decline and routinely detected tubular biomarkers are able to enhance the level of non-invasive diagnosis of DKD beyond traditional factors.
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Affiliation(s)
- Xijian Wang
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China
| | - Liang Ren
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China
| | - Ying Huang
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China
| | - Zhengang Feng
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China
| | - Guangdi Zhang
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China
| | - Houyong Dai
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China.
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Iida T, Hosojima M, Kabasawa H, Yamamoto-Kabasawa K, Goto S, Tanaka T, Kitamura N, Nakada M, Itoh S, Ogasawara S, Kaseda R, Suzuki Y, Narita I, Saito A. Urinary A- and C-megalin predict progression of diabetic kidney disease: an exploratory retrospective cohort study. J Diabetes Complications 2022; 36:108312. [PMID: 36228564 DOI: 10.1016/j.jdiacomp.2022.108312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/17/2022] [Accepted: 09/17/2022] [Indexed: 11/25/2022]
Abstract
AIMS Megalin, a proximal tubular endocytosis receptor, is excreted in urine in two forms: ectodomain (A-megalin) and full-length (C-megalin). We explored whether urinary megalin levels can be used as independent prognostic biomarkers in the progression of diabetic kidney disease (DKD). METHODS The associations between baseline urinary A-megalin/creatinine (Cr) and/or C-megalin/Cr levels and the subsequent estimated glomerular filtration rate (eGFR) slope were analyzed using a generalized estimating equation. Patients were categorized into higher or lower groups based on the optimal cutoff values, obtained from a receiver operating characteristic curve, of the two forms of urinary megalin. RESULTS We retrospectively analyzed 188 patients with type 2 diabetes. The eGFR slopes of the higher A-megalin/Cr and higher C-megalin/Cr groups were - 0.904 and -0.749 ml/min/1.73 m2/year steeper than those of the lower groups, respectively. Moreover, the eGFR slope was -1.888 ml/min/1.73 m2/year steeper in the group with both higher A- and higher C-megalin/Cr than in the other group. These results remained significant when adjusted for known urinary biomarkers (albumin, α1-microglobulin, β2-microglobulin, and N-acetyl-β-d-glucosaminidase). CONCLUSIONS Urinary A- and C-megalin/Cr levels are likely to be prognostic biomarkers in the progression of DKD independent of other urinary biomarkers.
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Affiliation(s)
- Tomomichi Iida
- Department of Applied Molecular Medicine, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8510, Japan; Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8510, Japan
| | - Michihiro Hosojima
- Department of Clinical Nutrition Science, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8510, Japan.
| | - Hideyuki Kabasawa
- Department of Clinical Nutrition Science, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8510, Japan
| | - Keiko Yamamoto-Kabasawa
- Department of Health Promotion Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8510, Japan
| | - Sawako Goto
- Department of Applied Molecular Medicine, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8510, Japan
| | - Takahiro Tanaka
- Clinical and Translational Research Center, Niigata University Medical and Dental Hospital, 1-754 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8520, Japan
| | - Nobutaka Kitamura
- Clinical and Translational Research Center, Niigata University Medical and Dental Hospital, 1-754 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8520, Japan
| | - Mitsutaka Nakada
- Diagnostics Research Department, Life Innovation Research Institute, DENKA Innovation Center, Denka Co., Ltd., 3-5-1 Asahimachi, Machida, Tokyo 194-8560, Japan
| | - Shino Itoh
- Diagnostics Research Department, Life Innovation Research Institute, DENKA Innovation Center, Denka Co., Ltd., 3-5-1 Asahimachi, Machida, Tokyo 194-8560, Japan
| | - Shinya Ogasawara
- Diagnostics Research Department, Life Innovation Research Institute, DENKA Innovation Center, Denka Co., Ltd., 3-5-1 Asahimachi, Machida, Tokyo 194-8560, Japan
| | - Ryohei Kaseda
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8510, Japan
| | - Yoshiki Suzuki
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8510, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8510, Japan
| | - Akihiko Saito
- Department of Applied Molecular Medicine, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata City, Niigata 951-8510, Japan.
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