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Kim JS, Hwang HS. Vascular Calcification in Chronic Kidney Disease: Distinct Features of Pathogenesis and Clinical Implication. Korean Circ J 2021; 51:961-982. [PMID: 34854578 PMCID: PMC8636761 DOI: 10.4070/kcj.2021.0995] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/27/2021] [Accepted: 10/13/2021] [Indexed: 01/10/2023] Open
Abstract
Vascular calcification (VC) is highly prevalent in patients with chronic kidney disease (CKD) and leads to increased cardiovascular morbidity and mortality. In patients with CKD, traditional factors do not fully explain the high prevalence of VC. This suggests that a CKD-specific pathobiology is involved in the development of VC and mounting evidence indicates that VC in CKD patients has distinct features of clinical presentation and that clinical implications are changed compared to those in the general population. In this review, we discuss the mechanism, diagnostic imaging modalities, clinical features and implications, and management of VC in patients with CKD. Chronic kidney disease (CKD) is associated with a higher prevalence of vascular calcification (VC) and cardiovascular disease. VC in CKD patients showed different pathophysiological features from those of the general population. The pathogenesis of VC in CKD is a highly organized process, and prior studies have suggested that patients with CKD have their own specific contributors to the phenotypic change of vascular smooth muscle cells (VSMCs), including uremic toxins, CKD-mineral and bone disease (CKD-MBD), inflammation, and oxidative stress. For the diagnosis and monitoring of VC in CKD, several imaging modalities, including plain radiography, ultrasound, and computed tomography have been utilized. VC in CKD patients has distinct clinical features and implications. CKD patients revealed a more intense and more prevalent calcification on the intimal and medial layers, whereas intimal calcification is predominantly observed in the general population. While a higher VC score is clearly associated with a higher risk of all-cause mortality and cardiovascular events, a greater VC score in CKD patients does not fully reflect the burden of atherosclerosis, because they have more calcification at equal volumes of atheromatous plaques. The primary goal of VC treatment in CKD is the prevention of VC progression, and the main management is to control the biochemical components of CKD-MBD. Cinacalcet and non-calcium-containing phosphate binders are the mainstay of VC prevention in CKD-MBD management. VC in patients with CKD is an ongoing area of research and is expected to advance soon.
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Affiliation(s)
- Jin Sug Kim
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea
| | - Hyeon Seok Hwang
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea.
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Hong J, Surapaneni A, Daya N, Selvin E, Coresh J, Grams ME, Ballew SH. Retinopathy and Risk of Kidney Disease in Persons With Diabetes. Kidney Med 2021; 3:808-815.e1. [PMID: 34693260 PMCID: PMC8515075 DOI: 10.1016/j.xkme.2021.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Rationale & Objective Retinopathy and chronic kidney disease (CKD) are typically considered microvascular complications of diabetes, and cardiovascular and cerebrovascular diseases are considered macrovascular complications; however, all may share common pathological mechanisms. This study quantified the association of retinopathy with risk of kidney disease and compared with the association with cardiovascular disease in persons with diabetes. Study Design Retrospective cohort study. Setting & Participants 1,759 participants in the ARIC study who had diabetes at visit 4 and underwent retinal examination at visit 3. Exposure Retinopathy. Outcome Prevalent CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2), prevalent albuminuria (urinary albumin-creatinine ratio [UACR] > 30 mg/g), incident CKD, incident end-stage kidney disease (ESKD), incident coronary heart disease (CHD), and incident stroke. Analytical Approach The cross-sectional association of retinopathy with prevalent CKD and albuminuria was assessed by logistic regression. The associations between retinopathy, incident CKD, incident ESKD, incident CHD, and incident stroke were examined using Cox proportional hazards models. Seemingly unrelated regression was used to compare the strength of association between retinopathy and outcomes. Results During the median follow-up period of 14.2 years, 723 participants developed CKD, and there were 109 ESKD events, 399 CHD events, and 196 stroke events. Compared with the participants without retinopathy, participants with retinopathy were more likely to have reduced eGFR (OR, 1.56 [95% CI, 1.09-2.23]) and UACR > 30 mg/g (OR, 1.61 [95% CI, 1.24-2.10]). Retinopathy was associated with risk of incident CKD (HR, 1.22 [95% CI, 1.02-1.46]), ESKD (HR, 1.69 [95% CI, 1.11-2.58]), CHD (HR, 1.46 [95% CI, 1.15-1.84]), and stroke (HR, 1.43 [95% CI, 1.03-1.97]). A stronger relationship was found between retinopathy and CHD when compared with retinopathy and CKD (P = 0.03); all other associations were similar. Limitations Retinal examination and kidney measurements were taken at different visits. Conclusions The presence of retinopathy was associated with higher prevalence of kidney disease and higher risk of incident CKD, ESKD, and CHD. These results may suggest that a similar mechanism underlies the development of retinopathy and other adverse outcomes in diabetes.
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Affiliation(s)
- Jingyao Hong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Aditya Surapaneni
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Natalie Daya
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Aronov M, Allon R, Stave D, Belkin M, Margalit E, Fabian ID, Rosenzweig B. Retinal Vascular Signs as Screening and Prognostic Factors for Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Current Evidence. J Pers Med 2021; 11:jpm11070665. [PMID: 34357132 PMCID: PMC8307097 DOI: 10.3390/jpm11070665] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The substantial burden of kidney disease fosters interest in new ways of screening for early disease diagnosis, especially by non-invasive imaging. Increasing evidence for an association between retinal microvascular signs and kidney disease prompted us to investigate the relevant current literature on such an association systematically by performing a meta-analysis of our findings. METHODS We scrutinized the current literature by searching PubMed and Embase databases from for clinical studies of the association between retinal microvascular signs and prevalent or incident kidney disease. After excluding cases that did not meet our criteria, we extracted relevant data from 42 published studies (9 prospective, 32 cross-sectional, and 1 retrospective). RESULTS Our investigation yielded significant associations between retinal vascular changes (including retinopathy and retinal vascular diameter) and kidney dysfunction (including chronic kidney disease (CKD), end-stage renal disease (ESRD), albuminuria, and estimated glomerular filtration rate (eGFR) decline). According to our meta-analysis, retinopathy was associated with ESRD (hazard ratio (HR) 2.12 (95% confidence interval CI; 1.39-3.22)) and with CKD prevalence in the general population (odds ratio (OR) 1.31 (95% CI; 1.14-1.50)), and specifically in type 2 diabetic patients (OR 1.68 (95% CI; 1.68-2.16)). CRAE was associated with prevalent CKD (OR 1.41 (95% CI; 1.09-1.82)). CONCLUSIONS Our findings suggest that the retinal microvasculature can provide essential data about concurrent kidney disease status and predict future risk for kidney disease development and progression.
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Affiliation(s)
- Michael Aronov
- SPRING Biomed Vision Ltd. 8, Haneviim St., Haifa 3350109, Israel; (R.A.); (D.S.); (E.M.)
- Correspondence: ; Tel.: +972-77-2009796
| | - Raviv Allon
- SPRING Biomed Vision Ltd. 8, Haneviim St., Haifa 3350109, Israel; (R.A.); (D.S.); (E.M.)
| | - Danielle Stave
- SPRING Biomed Vision Ltd. 8, Haneviim St., Haifa 3350109, Israel; (R.A.); (D.S.); (E.M.)
| | - Michael Belkin
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer 5262000, Israel; (M.B.); (I.D.F.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Eyal Margalit
- SPRING Biomed Vision Ltd. 8, Haneviim St., Haifa 3350109, Israel; (R.A.); (D.S.); (E.M.)
| | - Ido Didi Fabian
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer 5262000, Israel; (M.B.); (I.D.F.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Barak Rosenzweig
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Department of Urology, Sheba Medical Center, Tel Hashomer 5262000, Israel;
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Bover J, Aguilar A, Arana C, Molina P, Lloret MJ, Ochoa J, Berná G, Gutiérrez-Maza YG, Rodrigues N, D'Marco L, Górriz JL. Clinical Approach to Vascular Calcification in Patients With Non-dialysis Dependent Chronic Kidney Disease: Mineral-Bone Disorder-Related Aspects. Front Med (Lausanne) 2021; 8:642718. [PMID: 34095165 PMCID: PMC8171667 DOI: 10.3389/fmed.2021.642718] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/12/2021] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is associated with a very high morbimortality, mainly from cardiovascular origin, and CKD is currently considered in the high- or very high risk- cardiovascular risk category. CKD-mineral and bone disorders (CKD-MBDs), including vascular and/or valvular calcifications, are also associated with these poor outcomes. Vascular calcification (VC) is very prevalent (both intimal and medial), even in non-dialysis dependent patients, with a greater severity and more rapid progression. Simple X-ray based-scores such as Adragão's (AS) are useful prognostic tools and AS (even AS based on hand-X-ray only) may be superior to the classic Kauppila's score when evaluating non-dialysis CKD patients. Thus, in this mini-review, we briefly review CKD-MBD-related aspects of VC and its complex pathophysiology including the vast array of contributors and inhibitors. Furthermore, although VC is a surrogate marker and is not yet considered a treatment target, we consider that the presence of VC may be relevant in guiding therapeutic interventions, unless all patients are treated with the mindset of reducing the incidence or progression of VC with the currently available armamentarium. Avoiding phosphate loading, restricting calcium-based phosphate binders and high doses of vitamin D, and avoiding normalizing (within the normal limits for the assay) parathyroid hormone levels seem logical approaches. The availability of new drugs and future studies, including patients in early stages of CKD, may lead to significant improvements not only in patient risk stratification but also in attenuating the accelerated progression of VC in CKD.
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Affiliation(s)
- Jordi Bover
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Armando Aguilar
- Department of Nephrology, Instituto Mexicano del Seguro Social, Hospital General de Zona No. 2, Tuxtla Gutiérrez, Mexico
| | - Carolt Arana
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Pablo Molina
- Department of Nephrology, Hospital Universitario Dr Peset, Universidad de Valencia, REDinREN, Valencia, Spain
| | - María Jesús Lloret
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Jackson Ochoa
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Gerson Berná
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Yessica G Gutiérrez-Maza
- Department of Nephrology, Instituto Mexicano del Seguro Social, Hospital General de Zona No. 2, Tuxtla Gutiérrez, Mexico
| | - Natacha Rodrigues
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, Lisboa, Portugal
| | - Luis D'Marco
- Servicio de Nefrología, Hospital Clínico Universitario, INCLIVA, Universidad de Valencia, Valencia, Spain
| | - José L Górriz
- Servicio de Nefrología, Hospital Clínico Universitario, INCLIVA, Universidad de Valencia, Valencia, Spain
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Could aortic arch calcification help in detection of hypertensive retinopathy? Blood Press Monit 2021; 26:118-123. [PMID: 33234808 DOI: 10.1097/mbp.0000000000000498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Hypertension-induced end-organ damage is one of the important determinants of morbidity and mortality in patients with hypertension. All types of hypertension-induced end-organ damages start with vascular damage. Vascular calcification is a marker of vascular damage and aortic arch calcification (AAC) is one of the easily identifiable types of vascular calcification. We hypothesized that AAC predicts retinopathy in hypertensive patients. METHODS Consecutive hypertensive patients without diabetes mellitus were included. Chest radiography in the posterior-anterior was used to assess the presence of AAC. All patients underwent ophthalmologic examination for retinopathy. RESULTS We included 495 hypertensive patients in this study. Of these, 306 (62%) had hypertensive retinopathy. Patients with hypertensive retinopathy had significantly higher prevalence of AAC as compared to the patients without hypertensive retinopathy (88% vs. 22%, P < 0.001). We found a strong and positive correlation between hypertensive retinopathy and AAC grades (r = 639, P < 0.001). Receiver operator characteristics curve analysis yielded a strong predictive ability of AAC for the presence of hypertensive retinopathy [area under curve = 0.814, 95% confidence interval (CI): 0.775-0.853, P < 0.0001]. In multivariate logistic regression analysis, presence of AAC [odds ratio (OR) 13.128; CI: 7.894-21.832] and serum glucose levels (OR 1.020; CI: 1.003-1.037) were strongly and independently associated with hypertensive retinopathy. CONCLUSION Presence of AAC on chest radiograph is strongly and independently associated with retinopathy in nondiabetic hypertensive patients. This simple, inexpensive and widely available tool may help in early detection of retinopathy in patients with hypertension.
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Chillo P, Ismail A, Sanyiwa A, Ruggajo P, Kamuhabwa A. Hypertensive retinopathy and associated factors among nondiabetic chronic kidney disease patients seen at a tertiary hospital in Tanzania: a cross-sectional study. Int J Nephrol Renovasc Dis 2019; 12:79-86. [PMID: 31118738 PMCID: PMC6503192 DOI: 10.2147/ijnrd.s196841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 03/26/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Hypertensive retinopathy is a known marker of cardiovascular disease, and among unselected patients with chronic kidney disease (CKD) more severe retinopathy has been associated with lower estimated glomerular filtration rate (eGFR). This association has, however, not been widely studied among nondiabetic hypertensive patients with CKD, especially in sub-Saharan Africa. We aimed to determine the prevalence and severity of hypertensive retinopathy and its relationship with eGFR among nondiabetic CKD patients seen at Muhimbili National Hospital in Dar es Salaam, Tanzania. Methods: A hospital-based cross-sectional study was conducted among nondiabetic CKD adult (≥18 years) patients with hypertension. A structured questionnaire was used to record patients' demographic characteristics and their cardiovascular risk profile. eGFR was calculated using the Modification of Diet in the Renal Disease (MDRD) equation and only patients with CKD stage 3 or more were enrolled in the study. Grading of retinopathy was done using the Keith-Wagener classification. Results: In total, 224 patients fulfilled the inclusion criteria and were enrolled. Their mean age was 45.8±14.1 years, and 59.4% were men. The proportions of patients with stage 3, 4, and 5 CKD were 21.4%, 19.6%, and 58.9%, respectively. Hypertensive retinopathy was present in 157 (70.1%) patients and the proportions with grade I, grade II, grade III, and grade IV retinopathy were 17.9%, 18.8%, 19.6%, and 13.8%, respectively. The severity of retinopathy increased with decreasing levels of eGFR, and in multivariate logistic regression analysis, factors found to be independently associated with ≥grade II hypertensive retinopathy were more severe CKD, higher hypertension grades, and alcohol use, all p<0.05. Conclusion: The prevalence of hypertensive retinopathy is high among nondiabetic CKD patients seen at a tertiary hospital in Tanzania and is independently associated with CKD severity. Retinopathy grade can be used as a marker of CKD severity among these patients.
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Affiliation(s)
- Pilly Chillo
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ame Ismail
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anna Sanyiwa
- Department of Ophthalmology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Paschal Ruggajo
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Appolinary Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Kim Y, Cho JS, Cho WK, Yoon HE, Hong YA, Chang YK, Yang CW, Kim SY, Hwang HS. Retinopathy and left ventricular hypertrophy in patients with chronic kidney disease: Interrelationship and impact on clinical outcomes. Int J Cardiol 2017; 249:372-376. [DOI: 10.1016/j.ijcard.2017.06.123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/12/2017] [Accepted: 06/29/2017] [Indexed: 10/18/2022]
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Ahmed MH, Elwali ES, Awadalla H, Almobarak AO. The relationship between diabetic retinopathy and nephropathy in Sudanese adult with diabetes: population based study. Diabetes Metab Syndr 2017; 11 Suppl 1:S333-S336. [PMID: 28325541 DOI: 10.1016/j.dsx.2017.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/03/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Diabetic nephropathy is responsible for nearly third of the world cases of end stage renal disease; it becomes a major public health problem with social and economic burden. The aim of this study is to explore if there is an association between retinopathy and nephropathy. MATERIAL AND METHODS In a cross sectional hospital based study a total of 316 individuals with diabetes were recruited from Makkah eye complex retina clinic. Demographic data, medical history and life style characteristics were taken through standard questionnaire. In addition, urine samples were collected to check for presence of albuminuria, blood samples were taken to measure HbA1c, lipid profile and renal function test. RESULTS The mean age of participants was 58±10 years old. Only 39.8 and 40.2% of females were diagnosed with retinopathy and nephropathy, respectively. In addition, 60.2 and 59.8% of males were diagnosed with retinopathy and nephropathy, respectively. Hypertension was identified as risk factors for both retinopathy and nephropathy (P<0.001 and P<0.07). Serum creatinine and blood urea are significantly associated with retinopathy (P<0.01 and P<0.01). Body mass index (BMI) and HbA1c are not significantly associated with retinopathy and nephropathy. The prevalence of nephropathy among individuals with retinopathy was 35.6%. There was significant association between nephropathy and development of retinopathy (P<0.01). Logistic regression showed that two absolute risk factors are: nephropathy and having hypertension with P value of 0.009 and 0.003, respectively. CONCLUSIONS Almost third of diabetic patients developed nephropathy, significant association between nephropathy and development of retinopathy was found.
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Affiliation(s)
- Mohamed H Ahmed
- Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire, UK.
| | - Einas S Elwali
- Public and Tropical Heath Program, Graduate College, University of Medical Sciences and Technology, Khartoum, Sudan
| | - Heitham Awadalla
- Department of Community Medicine, University of Khartoum, Khartoum, Sudan.
| | - Ahmed O Almobarak
- Department of Pathology, Faculty of Medicine, University of Medical Sciences and Technology, Khartoum, Sudan.
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