Novel Risk Factors for Progression of Diabetic and Nondiabetic CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

Risk stratification of metabolic disorder-associated kidney disease

During the last 20 years, the disease burden attributable to metabolic disorders increased by 49.4%. Metabolic disorders are established risk factors for both chronic kidney disease (CKD) and cardiovascular disease (CVD). A concept of cardiovascular-kidney-metabolic (CKM) syndrome has recently been proposed to underscore the pathophysiological interrelatedness of the metabolic risk factors, CKD, and CVD. Two major adverse outcomes of the metabolic disorder-associated kidney disease are cardiovascular disease and, to a less extent, kidney failure. This review aims to briefly summarize the traditional metabolic risk factors for kidney disease; to introduce the concept of CKM health; to present the methods for risk assessment for CKD progression and CVD, with focus on validated and clinically applicable prediction tools; and to discuss the key gaps in the current tools for the risk stratification. In summary, in general clinical settings, the CKM health and associated risk in patients with the metabolic disorder-associated kidney disease can be assessed by combining the CKM staging model, the CKD Prognosis Consortium equations for CKD progression, and the Predicting Risk of CVD Events (PREVENT) equations for CVD. More efficient risk prediction tools, potentially incorporating multimodal data, are needed for more accurate and early identification of individuals at high risk and better personalized management of the disease.

Advances and challenges in kidney fibrosis therapeutics

Chronic kidney disease (CKD) is a major global health burden that affects more than 10% of the adult population. Current treatments, including dialysis and transplantation, are costly and not curative. Kidney fibrosis, defined as an abnormal accumulation of extracellular matrix in the kidney parenchyma, is a common outcome in CKD, regardless of disease aetiology, and is a major cause of loss of kidney function and kidney failure. For this reason, research efforts have focused on identifying mediators of kidney fibrosis to inform the development of effective anti-fibrotic treatments. Given the prominent role of the transforming growth factor-β (TGFβ) family in fibrosis, efforts have focused on inhibiting TGFβ signalling. Despite hopes raised by the efficacy of this approach in preclinical models, translation into clinical practice has not met expectations. Antihypertensive and antidiabetic drugs slow the decline in kidney function and could slow fibrosis but, owing to the lack of technologies for in vivo renal imaging, their anti-fibrotic effect cannot be truly assessed at present. The emergence of new drugs targeting pro-fibrotic signalling, or enabling cell repair and cell metabolic reprogramming, combined with better stratification of people with CKD and the arrival of nanotechnologies for kidney-specific drug delivery, open up new perspectives for the treatment of this major public health challenge.

Associations between intercurrent events and cardiorenal clinical outcomes in non-diabetic chronic kidney disease: a real-world retrospective cohort study in the United States

BACKGROUND

Chronic kidney disease (CKD) is a global public health concern, with 50-70% of the burden attributed to non-diabetic aetiology. To expand CKD research, there is a need to identify novel surrogate endpoints preceding cardiorenal outcomes that are commonly used in CKD trials. This study explored and quantified associations between intercurrent events and clinical outcomes in patients with non-diabetic CKD to inform potential surrogate endpoints.

METHODS

In this retrospective observational cohort study, adults with non-diabetic, moderate-to-severe CKD (stage 3/4) were identified in the US Optum Clinformatics® Data Mart healthcare claims database. Key outcomes were hospitalization for heart failure, kidney failure/need for dialysis, and worsening of CKD stage from baseline. Intercurrent events were defined as events observed in patient medical or pharmacy claims after the cohort inclusion date that either precluded a clinical outcome of interest or were associated with a modified risk of the respective outcome. Intercurrent events were selected a priori or by a data-driven exploratory approach. Associations between intercurrent events and clinical outcomes were explored and quantified using a Cox proportional hazards regression model.

RESULTS

The study cohort included 504,924 patients. An outpatient heart failure diagnosis code was associated with an increased risk of consequent hospitalization for heart failure (hazard ratio [HR]: 12.92, 95% confidence interval [CI]: 12.67-13.17). CKD stage 4 diagnosis code was associated with an increased risk of kidney failure/need for dialysis (HR: 3.75, 95% CI: 3.69-3.81). Dispensation of potassium-removing resins and potassium-binding agents as an intercurrent event was associated with an increased risk of consequent worsening of CKD stage (HR: 4.83, 95% CI: 4.51-5.17). The estimated glomerular filtration rate decline in 295,174 patients with available laboratory data was associated with progressively increased risk of hospitalization for heart failure and kidney failure/need for dialysis.

CONCLUSIONS

Associations between intercurrent events and clinical outcomes in patients with non-diabetic CKD were investigated, quantified, and ranked using a large set of routinely collected data from a US claims database. Our approach may help identify novel surrogate endpoints that occur earlier in the disease course and could be leveraged as indicators of clinical outcomes in CKD research.

Association between high-sensitivity troponin T levels below the ninety-ninth percentile and diabetic kidney disease: A cross-sectional study

BACKGROUND

Identification of myocardial injury has traditionally relied on high-sensitivity troponin T (hs-TnT) levels exceeding the 99th percentile threshold. However, patients with detectable hs-TnT levels below this threshold represent a heterogeneous group with an inadequately characterized risk profile.

AIM

To investigate the association between hs-TnT levels below the 99th percentile and the presence of diabetic kidney disease (DKD) in patients with diabetes mellitus.

METHODS

This study analyzed data from the National Health and Nutrition Examination Survey obtained between 1999 and 2004, focusing on adults with type 2 diabetes mellitus. Serum hs-TnT concentrations were evaluated. DKD was defined as impaired glomerular filtration rate (< 60 mL/minute/1.73 m²), proteinuria (urinary albumin-to-creatinine ratio of ≥ 30 mg/g), or both conditions in patients with diabetes mellitus. Weighted multivariable logistic regression analysis and restricted cubic spline analyses were employed to examine the independent association between hs-TnT and DKD, with the likelihood ratio test being used to evaluate nonlinearity.

RESULTS

The study included 2505 patients with a mean age of 55.02 (standard error: 0.72) years, of whom 44.87% were females. Among the participants, 909 (32.34%) were diagnosed with DKD. Multivariable logistic regression analysis indicated that, compared to the lowest tertile of hs-TnT (< 5.93 ng/L), tertile 2 (5.94-9.79 ng/L) had an odds ratio of 1.25 (95% confidence interval: 0.77-2.02, P = 0.350), while tertile 3 (9.80-21.88 ng/L) had an odds ratio of 2.07 (95% confidence interval: 1.13-3.80, P = 0.022), with a significant trend (P for trend = 0.022). Smoothed curve fitting demonstrated a linear association between hs-TnT levels and DKD in the overall population (P = 0.061 for nonlinearity) and in male (P = 0.136 for nonlinearity) and female (P = 0.067 for nonlinearity) subgroups. Further stratification and sensitivity analyses yielded consistent conclusions.

CONCLUSION

Our study findings suggest that in individuals with type 2 diabetes, detectable hs-TnT levels below the 99th percentile are associated with DKD.

Identifying subgroups benefiting from intensive glycaemic treatment to improve renal outcomes in type 2 diabetes: Insights from the ACCORD trial

AIMS

The ACCORD trial showed that intensive glucose-lowering therapy has a limited impact on renal function decline. We aimed to identify subgroups in the ACCORD population that might derive renal benefits from intensive glucose-lowering therapy.

MATERIALS AND METHODS

The primary renal outcome included a ≥50% decline in baseline estimated glomerular filtration rate or end-stage renal disease (ESRD). Using the causal tree model, we employed internal cross-validation to identify five pivotal variables influencing the renal efficacy of intensive glycaemic control. These variables were integrated into the model-based recursive partitioning approach, yielding a visualizable tree model that depicted benefitting subgroups.

RESULTS

Node 4, characterized by no cardiovascular history, systolic blood pressure (SBP) ≤142.67 mm Hg, and triglycerides ≤172 mg/dL, showed significantly reduced hazards of the composite renal outcome (fully adjusted hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.49-0.89; p = 0.006) and doubling of serum creatinine (fully adjusted HR 0.59, 95% CI 0.36-0.98; p = 0.041). Node 7 (no cardiovascular history and SBP 142.67-154 mm Hg) showed reduced hazards of the primary renal outcome (fully adjusted HR 0.67, 95% CI 0.49-0.93; p = 0.016) and ESRD (fully adjusted HR 0.35, 95% CI 0.17-0.74; p = 0.0057). Encouragingly, neither node 4 nor node 7 displayed elevated cardiovascular risk or hypoglycaemic events.

CONCLUSIONS

Through innovative machine learning, we identified ACCORD subgroups benefitting significantly from intensive glycaemic therapy for renal outcomes, without increased cardiovascular or hypoglycaemic risks.

Advances in kidney disease: pathogenesis and therapeutic targets

Chronic kidney disease (CKD) is a global public health issue characterized by progressive loss of kidney function, of which end-stage kidney disease (ESKD) is the last stage. The global increase in the prevalence of CKD is linked to the increasing prevalence of traditional risk factors, including obesity, hypertension, and diabetes mellitus, as well as metabolic factors, particularly insulin resistance, dyslipidemia, and hyperuricemia. Mortality and comorbidities, such as cardiovascular complications, rise steadily as kidney function deteriorates. Patients who progress to ESKD require long-term kidney replacement therapy, such as transplantation or hemodialysis/peritoneal dialysis. It is currently understood that a crucial aspect of CKD involves persistent, low-grade inflammation. In addition, increased oxidative and metabolic stress, endothelial dysfunction, vascular calcification from poor calcium and phosphate metabolism, and difficulties with coagulation are some of the complex molecular pathways underlying CKD-related and ESKD-related issues. Novel mechanisms, such as microbiome dysbiosis and apolipoprotein L1 gene mutation, have improved our understanding of kidney disease mechanisms. High kidney disease risk of Africa has been linked to APOL1 high-risk alleles. The 3-fold increased risk of ESKD in African Americans compared to European Americans is currently mainly attributed to variants in the APOL1 gene in the chromosome 22q12 locus. Additionally, the role of new therapies such as SGLT2 inhibitors, mineralocorticoid receptor antagonists, and APOL1 channel function inhibitors offers new therapeutic targets in slowing down the progression of chronic kidney disease. This review describes recent molecular mechanisms underlying CKD and emerging therapeutic targets.

Clinical significance of hyperuricaemia in biopsy-proven diabetic kidney disease ━ a single-centre retrospective study

Aims

Hyperuricaemia is associated with the development of Diabetic kidney disease (DKD). However, the mechanism of hyperuricaemia causing the progression of DKD remain unclear.

Methods

This is a single-centre retrospective study. 155 biopsy-proven DKD patients were grouped into hyperuricaemia and non-hyperuricaemia groups. Kaplan-Meier analysis and landmark curves were performed to explore predictors of end-stage renal disease (ESRD), Cox regression analysis was used to screen for factors, a nomogram was constructed to predict the renal prognosis of DKD.

Results

Patients in hyperuricaemia group had higher serum creatinine (Scr), degree of mesangial expansion and IFTA score and lower GFR, haemoglobin. SUA level was positively correlated with IFTA scores. The Kaplan-Meier curve and landmark analysis revealed worse survival in hyperuricaemia group, especially after 12 months. 11 variables, including age, sex, haemoglobin, Scr, SUA, and pathological score were collected to make a nomogram model. In the testing and training sets, the AUCs at 1, 3, and 5 years were 0.888, 0.939, and 0.886 and 0.947, 0.867, and 0.905, respectively.

Conclusion

The clinicopathologic manifestation of DKD patients with hyperuricaemia was much more severe, and hyperuricaemia predicted a worse renal prognosis. A new renal prognosis prediction model including SUA was constructed for DKD with higher accuracy.

Genetic Variants Related to Increased CKD Progression-A Systematic Review

The incidence and prevalence of chronic kidney disease (CKD) are increasing worldwide. CKD is associated with high morbidity, premature mortality, and high healthcare costs. Genetic variants may influence CKD development and progression. This study aimed to identify the associations between allelic variants and CKD progression. We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PubMed, Embase, and Cochrane Central databases were used for data collection. Hereditary causes of CKD were excluded from the analysis. A total of 38 reports were included. The selected studies included cohort studies, case-control studies, and genome-wide association studies (GWASs). The studies involved patients of different ethnicities and with comorbid diseases. Several genetic variants were identified in genes that encode proteins related to metabolic processes, oxidative stress, immune regulation, the renin-angiotensin-aldosterone pathway, and epigenetics, among others. These genetic alterations can affect protein function and lead to renal damage, impacting CKD development and progression. Gene polymorphisms can influence CKD progression. Many of these are population-specific, and their relevance may be influenced by the presence of other diseases and environmental factors. Larger studies are needed to confirm the associations described here.

The DPP-4 inhibitor sitagliptin improves glycaemic control and early-stage diabetic nephropathy in adolescents with type 1 diabetes using the MiniMed 780G advanced hybrid closed-loop system: a randomised controlled trial

AIMS/HYPOTHESIS

Dipeptidyl peptidase-4 (DPP-4) inhibition has beneficial effects on various metabolic indicators in diabetes. Stromal cell-derived factor-1 (SDF-1) is expressed in diverse organs including the kidneys and is cleaved and inactivated by DPP-4 enzyme. The aim of this study was to conduct a randomised controlled trial to assess the effect of sitagliptin on diabetic nephropathy when used as an add-on therapy to the advanced hybrid closed-loop (AHCL) system in adolescents with type 1 diabetes and nephropathy.

METHODS

This open-label, parallel-group, randomised controlled trial took place at the Pediatric Diabetes Clinic, Ain Shams University, Egypt. Forty-six adolescents aged 14.13 ± 2.43 years on the MiniMed 780G system for at least 6 months before study, with HbA1c ≤69 mmol/mol (8.5%) and diabetic nephropathy in the form of microalbuminuria, were randomly assigned to two groups (n=23 for each) based on a computer-generated randomisation sequence. The intervention group received oral sitagliptin 50 mg for 3 months. The other group used AHCL only and served as a control group. The primary outcome measure was the change in urinary albumin/creatinine ratio (UACR) after 3 months of administration of sitagliptin. The key secondary outcome measure was the change from baseline in SDF-1 levels after treatment.

RESULTS

Data for all participants were analysed. No significant difference was found between the groups as regards baseline clinical and laboratory characteristics as well as AHCL system settings (p>0.05). Serum SDF-1 levels were higher in all individuals with type 1 diabetes vs healthy control individuals (p<0.001). After 3 months, sitagliptin resulted in a significant decrease of SDF-1 levels from 3.58 ± 0.73 to 1.99 ± 0.76 ng/ml (p<0.001), together with improvement of UACR from 7.27 ± 2.41 to 1.32 ± 0.31 mg/mmol (p<0.001). In addition, sitagliptin reduced postprandial glucose, sensor glucose, coefficient of variation and total daily dose of insulin, while time in range 3.9-10.0 mmol/l (70-180 mg/dl) and insulin-to-carbohydrate ratio were significantly increased. Sitagliptin was safe and well-tolerated without severe hypoglycaemia or diabetic ketoacidosis.

CONCLUSIONS/INTERPRETATION

Sitagliptin as an add-on therapy to AHCL had a reno-protective effect for individuals with type 1 diabetes and diabetic nephropathy, in addition to the improvement of time in range while reducing glycaemic variability and without compromising safety.

FUNDING

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06115460.

Diabetic kidney disease: the kidney disease relevant to individuals with diabetes

In individuals with diabetes, chronic kidney disease (CKD) is a major comorbidity. However, it appears that there is worldwide confusion regarding which term should be used to describe CKD complicated with diabetes: diabetic nephropathy, diabetic kidney disease (DKD), CKD with diabetes, diabetes and CKD, etc. Similar confusion has also been reported in Japan. Therefore, to provide clarification, the Japanese Diabetes Society and the Japanese Society of Nephrology collaborated to update the corresponding Japanese term to describe DKD and clearly define the concept of DKD. In this review, we briefly described the history of kidney complications in individuals with diabetes and the Japanese definition of the DKD concept and provided our rationale for these changes.

Comparison of value of 640-slice CT kidney scan and kidney ultrasound in the diagnosis of chronic kidney disease

To explore the value of 640-slice CT kidney scan and kidney ultrasound (KUS) in the diagnosis of chronic kidney disease (CKD). The data of 120 CKD patients at our institution between June 2019 and September 2020 were analyzed, and they were randomly divided into ultrasound (US) group (n = 40, KUS), CT group (n = 40) first receiving a plane CT scan to determine the scope of dynamic volume scan, which was performed for scans in cortical, parenchymal, and delayed phases with bolus injection of contrast medium, and combined group (n = 40, KUS and 640-slice CT kidney scan), with the images obtained read and analyzed. The subjective scores and effective radiation doses of 640-layer CT kidney scan were counted to calculate the detection rates. The subjective scores of 640-slice CT kidney scan in plane scan, cortical phase, parenchymal phase, and delayed phase were (1.23 ± 0.42), (1.80 ± 0.40), (2.08 ± 0.26), (2.18 ± 0.38) in the CT group and (1.18 ± 0.38), (1.85 ± 0.36), (2.08 ± 0.26), (2.20 ± 0.40) in the combined group. The effective radiation doses in the CT and combined groups were (1.92 ± 0.32) mSv and (1.95 ± 0.35) mSv. The reading results showed that 26 cases (65.0%), 30 cases (75.0%), and 38 cases (95.0%) were detected in the US, CT and combined groups, respectively, with remarkably higher detection rate in the combined group than the US and CT groups (P < 0.05). 640-slice CT kidney scan and KUS can be adopted for the diagnosis of CKD; with low radiation dose, good image quality, and higher detection rate in the former, their combination can improve the clinical detection rate of CKD and is worth promoting.

External validation and calibration of risk equations for prediction of diabetic kidney diseases among patients with type 2 diabetes in Taiwan

BACKGROUND

Most existing risk equations for predicting/stratifying individual diabetic kidney disease (DKD) risks were developed using relatively dated data from selective and homogeneous trial populations comprising predominately Caucasian type 2 diabetes (T2D) patients. We seek to adapt risk equations for prediction of DKD progression (microalbuminuria, macroalbuminuria, and renal failure) using empiric data from a real-world population with T2D in Taiwan.

METHODS

Risk equations from three well-known simulation models: UKPDS-OM2, RECODe, and CHIME models, were adapted. Discrimination and calibration were determined using the area under the receiver operating characteristic curve (AUROC), a calibration plot (slope and intercept), and the Greenwood-Nam-D'Agostino (GND) test. Recalibration was performed for unsatisfactory calibration (p-value of GND test < 0.05) by adjusting the baseline hazards of risk equations to address risk variations among patients.

RESULTS

The RECODe equations for microalbuminuria and macroalbuminuria showed moderate discrimination (AUROC: 0.62 and 0.76) but underestimated the event risks (calibration slope > 1). The CHIME equation had the best discrimination for renal failure (AUROCs from CHIME, UKPDS-OM2 and RECODe: 0.77, 0.60 and 0.64, respectively). All three equations overestimated renal failure risk (calibration slope < 1). After rigorous updating, the calibration slope/intercept of the recalibrated RECODe for predicting microalbuminuria (0.87/0.0459) and macroalbuminuria (1.10/0.0004) risks as well as the recalibrated CHIME equation for predicting renal failure risk (0.95/-0.0014) were improved.

CONCLUSIONS

Risk equations for prediction of DKD progression in real-world Taiwanese T2D patients were established, which can be incorporated into a multi-state simulation model to project and differentiate individual DKD risks for supporting timely interventions and health economic research.

N-terminal pro-B-type natriuretic peptide, eGFR, and progression of kidney disease in chronic kidney disease patients without heart failure

Background

Cardiorenal syndrome highlights the bidirectional relationship between kidney and heart dysfunction. N-terminal pro-B-type natriuretic peptide (NT-proBNP), which is the gold standard biomarker in heart failure (HF), may be an important biomarker for chronic kidney disease (CKD) progression. However, NT-proBNP is negatively related with estimated glomerular filtration rate (eGFR). In this study, we investigated the association of NT-proBNP, eGFR, and progression of kidney disease in CKD patients without HF.

Methods

This multicentric retrospective cohort study recruited 23 860 CKD patients without HF, who had at least one NT-proBNP record from China Renal Data System database. Linear regression model evaluated the relationship between eGFR and NT-proBNP. Cox regression analysis assessed the association between NT-proBNP and CKD progression. Sensitivity analysis examined the robustness of the main findings.

Results

This study involved 23 860 CKD patients without HF, distributed across different CKD stages: 10 526 in stages G1-2, 4665 in G3a, 3702 in G3b, 2704 in G4, and 2263 in G5. NT-proBNP was negatively correlated with eGFR, particularly in stages 4-5 CKD. A 15-unit decrease in eGFR was associated with increases in log (NT-proBNP) levels by 1.04-fold, 1.27-fold, 1.29-fold, 1.80-fold, and 3.50-fold for stages 1-2, 3a, 3b, 4, and 5, respectively. After excluding patients who developed CKD progression within 1 year, the Cox regression analysis revealed that the relationship between NT-proBNP and CKD progression was not significant in stages 4 and 5. However, for stages 1-3, each standard deviation increase in log (NT-proBNP) was associated with a 26%, 36%, and 28% higher risk of CKD progression, with P interaction ≤.001. The hazard ratios were 1.26 (95% confidence intervals (CI), 1.18 to 1.35), 1.36 (95% CI, 1.22 to 1.51), and 1.28 (95% CI, 1.14 to 1.43) for stages 1-2, stage 3a, and stage 3b, respectively.

Conclusions

Despite its strong inverse association with eGFR, NT-proBNP was positively associated with the risk of progression of kidney disease in CKD patients with stages 1-3 without HF. Future studies should investigate the effectiveness of NT-proBNP as a predictive biomarker for the progression of kidney disease across diverse racial groups and healthcare settings.

Targeted and untargeted serum NMR metabolomics to reveal initial kidney disease in diabetes mellitus

Serum 1H NMR metabolomics has been used as a diagnostic tool for screening type 2 diabetes (T2D) with chronic kidney disease (CKD) as comorbidity. This work aimed to evaluate 1H NMR data to detect the initial kidney damage and CKD in T2D subjects, through multivariate statistical analysis. Clinical data and biochemical parameters were obtained for classifying five experimental groups using KDIGO guidelines: Control (healthy subjects), T2D, T2D-CKD-mild, T2D-CKD-moderate, and T2D-CKD-severe. Serum 1H NMR spectra were recorded to follow two strategies: one based on metabolite-to-creatinine (Met/Cr) ratios as targeted metabolomics, and the second one based on untargeted metabolomics from the 1H NMR profile. A prospective biomarkers panel of the early stage of T2D-CKD based in metabolite-to-creatinine ratio (ornithine/Cr, serine/Cr, mannose/Cr, acetate/Cr, acetoacetate/Cr, formate/Cr, and glutamate/Cr) was proposed. Later, a statistical model based on non-targeted metabolomics was used to predict initial CKD, and its metabolic pathway analysis allowed identifying the most affected pathways: phenylalanine, tyrosine, and tryptophan biosynthesis; valine, leucine, and isoleucine degradation; glyoxylate and dicarboxylate metabolism; glycine, serine, and threonine metabolism; and histidine metabolism. Nonetheless, further studies with a larger cohort are advised to precise ranges in metabolite-to-creatinine ratios and evaluate the prediction pertinency to detect initial CKD in T2D patients in both statistical models proposed.

Urine complement proteins are associated with kidney disease progression of type 2 diabetes in Korean and American cohorts

Background

Mechanisms of progression of diabetic kidney disease (DKD) are not completely understood. This study uses untargeted and targeted mass spectrometry-based proteomics in two independent cohorts on two continents to decipher the mechanisms of DKD in patients with type 2 diabetes.

Methods

We conducted untargeted mass spectrometry on urine samples collected at the time of kidney biopsy from Korean patients with type 2 diabetes and biopsy-proven diabetic nephropathy at Seoul National University Hospital (SNUH-DN cohort; n = 64). These findings were validated using targeted mass spectrometry in urine samples from a Chronic Renal Insufficiency Cohort subgroup with type 2 diabetes and DKD (CRIC-T2D; n = 282). Urinary biomarkers/pathways associated with kidney disease progression (doubling of serum creatinine, ≥50% decrease in estimated glomerular filtration rates, or the development of end-stage kidney disease) were identified.

Results

SNUH-DN patients had an estimated glomerular filtration rate (eGFR) of 55 mL/min/1.73 m 2 (interquartile range [IQR], 44-75) and random urine protein-to-creatinine ratio of 3.1 g/g (IQR, 1.7-7.0). Urine proteins clustered into two groups, with cluster 2 having a 4.6-fold greater hazard (95% confidence interval [CI], 1.9-11.5) of disease progression than cluster 1 in multivariable-adjusted, time-to-event analyses. Proteins in cluster 2 mapped to 10 pathways, four of the top five of which were complement or complement-related. A high complement score, constructed from urine complement protein abundance, was strongly correlated to 4 of 5 histopathologic DN features and was associated with a 2.4-fold greater hazard (95% CI, 1.0-5.4) of disease progression than a low complement score. Targeted mass spectrometry of the CRIC-T2D participants, who had an eGFR of 42 mL/min/1.73 m 2 (IQR, 37-49) and 24-hr urine protein of 0.48 g (IQR, 0.10-1.87), showed that the complement score similarly segregated them into rapid and slow DKD progression groups. In both cohorts, the complement score had a linear association with disease progression.

Conclusions

Urinary proteomic profiling confirms the association between the complement pathway and rapid DKD progression in two independent cohorts. These results suggest a need to further investigate complement pathway inhibition as a novel treatment for DKD.

Serum biomarkers for predicting microvascular complications of diabetes mellitus

INTRODUCTION

Diabetic microvascular complications such as retinopathy, nephropathy, and neuropathy are primary causes of blindness, terminal renal failure, and neuropathic disorders in type 2 diabetes mellitus patients. Identifying reliable biomarkers promptly is pivotal for early detection and intervention in these severe complications.

AREAS COVERED

This review offers a thorough examination of the latest research concerning serum biomarkers for the prediction and assessment of diabetic microvascular complications. It encompasses biomarkers associated with glycation, oxidative stress, inflammation, endothelial dysfunction, basement membrane thickening, angiogenesis, and thrombosis. The review also highlights the potential of emerging biomarkers, such as microRNAs and long non-coding RNAs.

EXPERT OPINION

Serum biomarkers are emerging as valuable tools for the early assessment and therapeutic guidance of diabetic microvascular complications. The biomarkers identified not only reflect the underlying pathophysiology but also align with the extent of the disease. However, further validation across diverse populations and improvement of the practicality of these biomarkers in routine clinical practice are necessary. Pursuing these objectives is essential to advance early diagnosis, risk assessment, and individualized treatment regimens for those affected by diabetes.

Immediate drop of urine osmolality upon tolvaptan initiation predicts impact on renal prognosis in patients with ADPKD

BACKGROUND

Tolvaptan, a vasopressin V2 receptor antagonist, is used for treating autosomal dominant polycystic kidney disease (ADPKD). We focused on changes in urinary osmolality (U-Osm) after tolvaptan initiation to determine whether they were associated with the therapeutic response to tolvaptan.

METHODS

This was a single-centre, prospective, observational cohort study. Seventy-two patients with ADPKD who received tolvaptan were recruited. We analysed the relationship between changes in U-Osm and annual estimated glomerular filtration rate (eGFR) in terms of renal prognostic value using univariable and multivariable linear regression analyses.

RESULTS

The mean value of U-Osm immediately before tolvaptan initiation was 351.8 ± 142.2 mOsm/kg H2O, which decreased to 97.6 ± 23.8 mOsm/kg H2O in the evening. The decrease in U-Osm was maintained in the outpatient clinic 1 month later. However, the 1-month values of U-Osm showed higher variability (160.2 ± 83.8 mOsm/kg H2O) than did those in the first evening of tolvaptan administration. Multivariate analysis revealed that the baseline eGFR, baseline urinary protein and U-Osm change in the evening of the day of admission (initial U-Osm drop) were significantly correlated with the subsequent annual change in eGFR.

CONCLUSIONS

U-Osm can be measured easily and rapidly, and U-Osm change within a short time after tolvaptan initiation may be a useful index for the renal prognosis in actual clinical practice.

Preventing CXCL12 elevation helps to reduce acute exacerbation of COPD in individuals co-existing type-2 diabetes: A bioinformatics and clinical pharmacology study

AIMS

To investigate the immunology shared mechanisms underlying chronic obstructive pulmonary disease (COPD) and type 2 diabetes mellitus (T2DM) and examine the impact of anti-diabetic drugs on acute exacerbation of COPD (AECOPD).

METHODS

We analyzed GSE76925, GSE76894, GSE37768, and GSE25724 to identify differentially expressed genes. Hub-genes were identified through protein-protein interaction network analysis and evaluated by the receiver operating characteristic curve. CXCL12 emerged as a robust biomarker, and its correlation with lung function and CD8+ T cells were further quantified and validated. The activated signaling pathways were inferred through Gene set enrichment analysis (GSEA). The retrospective clinical analysis was executed to identify the influence of dipeptidyl peptidase-4 inhibitors (DPP-4i) on CXCL12 and evaluate the drug's efficacy in AECOPD.

RESULTS

The significant up-regulation of CXCL12 expression in patients with two diseases were revealed. CXCL12 exhibited a negative correlation with pulmonary function (r = -0.551, p < 0.05). Consistent with analysis in GSE76925 and GSE76894, the positive correlation between the proportion of CD8+ T cells was demonstrated(r=0.469, p<0.05). GSEA identified "cytokines interaction" as an activated signaling pathway, and the clinical study revealed the correlation between CXCL12 and IL-6 (r=0.668, p<0.05). In patients with COPD and T2DM, DDP-4i treatment exhibited significantly higher serum CXCL12, compared to GLP-1RA. Analysis of 187 COPD patients with T2DM indicated that the DPP-4i group had a higher frequency of AECOPD compared to the GLP-1RA group (OR 1.287, 95%CI [1.018-2.136]).

CONCLUSIONS

CXCL12 may represent a therapeutic target for COPD and T2DM. GLP-1RA treatment may be associated with lower CXCL12 levels and a lower risk of AECOPD compared to DPP-4i treatment.

CLINICAL TRIAL REGISTRATION

China Clinical Trial Registration Center（ChiCTR2200055611）.

Salvianolic acid B attenuates diabetic nephropathy through alleviating ADORA2B, NALP3 in flammasome, and NFκB activity

Diabetic nephropathy is one of the microvascular complications of diabetes. This study is aimed at investigating the role and mechanisms of salvianolic acid B (Sal B) in diabetic nephropathy. High glucose (HG)-induced human renal tubular epithelial HK-2 cells were treated with Sal B, BAY-60-6583 (agonist of adenosine 2B receptor), or PSB-603 (antagonist of adenosine 2B receptor) for 24 h. Adenosine A2b receptor (ADORA2B), NACHT, leucine-rich repeat (LRR), and pyrin (PYD) domains-containing protein 3 (NALP3), and nuclear factor Kappa B (NFκB) expressions, mitochondrial membrane potential (MMP), and reactive oxygen species (ROS) levels were examined. Following 6 weeks of Sal B treatment, db/db mice blood and kidney tissue were harvested for biochemical detection with hematoxylin-eosin (H&E), Masson's, periodic acid schiff (PAS), and Sirius red staining and detection of ADORA2B, NALP3, NFκB, interleukin 1β (IL-1β), and toll-like receptor 4 (TLR4) activity. NFκB, NALP3, and ADORA2B were found to be downregulated in Sal B treated HK-2 cells exposed to high glucose (HG), accompanied by elevated levels of MMPs and reduced intracellular ROS production. Sal B-treated diabetic mice had the improvement in body weight, water intake, hyperglycemia, hyperlipidemia, and liver and kidney function. Altogether, Sal B attenuates HG-induced kidney tubule cell injury and diabetic nephropathy in diabetic mice, providing clues to other novel mechanisms by which Sal B is beneficial in diabetic nephropathy.

Changes in Natriuretic Peptide Levels and Subsequent Kidney Function Decline in SPRINT

RATIONALE & OBJECTIVE

Novel approaches to the assessment of kidney disease risk during hypertension treatment are needed because of the uncertainty of how intensive blood pressure (BP) lowering impacts kidney outcomes. We determined whether longitudinal N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements during hypertension treatment are associated with kidney function decline.

STUDY DESIGN

Prospective observational study.

SETTING & PARTICIPANTS

8,005 SPRINT (Systolic Blood Pressure Intervention Trial) participants with NT-proBNP measurements at baseline and 1 year.

EXPOSURE

1-year change in NT-proBNP categorized as a ≥25% decrease, ≥25% increase, or <25% change (stable).

OUTCOME

Annualized change in estimated glomerular filtration rate (eGFR) and ≥30% decrease in eGFR.

ANALYTICAL APPROACH

Linear mixed-effect and logistic regression models were used to evaluate the association of changes in NT-proBNP with subsequent annualized change in eGFR and ≥30% decrease in eGFR, respectively. Analyses were stratified by baseline chronic kidney disease (CKD) status.

RESULTS

Compared with stable 1-year NT-proBNP levels, a ≥25% decrease in NT-proBNP was associated with a slower decrease in eGFR in participants with CKD (adjusted difference, 1.09%/y; 95% CI, 0.35-1.83) and without CKD (adjusted difference, 0.51%/y; 95% CI, 0.21-0.81; P = 0.4 for interaction). Meanwhile, a ≥25% increase in NT-proBNP in participants with CKD was associated with a faster decrease in eGFR (adjusted difference, -1.04%/y; 95% CI, -1.72 to -0.36) and risk of a ≥30% decrease in eGFR (adjusted odds ratio, 1.44; 95% CI, 1.06-1.96); associations were stronger in participants with CKD than in participants without CKD (P = 0.01 and P < 0.001 for interaction, respectively). Relationships were similar irrespective of the randomized BP arm in SPRINT (P > 0.2 for interactions).

LIMITATIONS

Persons with diabetes and proteinuria >1 g/d were excluded.

CONCLUSIONS

Changes in NT-proBNP during BP treatment are independently associated with subsequent kidney function decline, particularly in people with CKD. Future studies should assess whether routine NT-proBNP measurements may be useful in monitoring kidney risk during hypertension treatment.

PLAIN-LANGUAGE SUMMARY

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a biomarker in the blood that reflects mechanical stress on the heart. Measuring NT-proBNP may be helpful in assessing the risk of long-term losses of kidney function. In this study, we investigated the association of changes in NT-proBNP with subsequent kidney function among individuals with and without chronic kidney disease. We found that increases in NT-proBNP are associated with a faster rate of decline of kidney function, independent of baseline kidney measures. The associations were more pronounced in individuals with chronic kidney disease. Our results advance the notion of considering NT-proBNP as a dynamic tool for assessing kidney disease risk.

Predicting chronic kidney disease progression with artificial intelligence

BACKGROUND

The use of tools that allow estimation of the probability of progression of chronic kidney disease (CKD) to advanced stages has not yet achieved significant practical importance in clinical setting. This study aimed to develop and validate a machine learning-based model for predicting the need for renal replacement therapy (RRT) and disease progression for patients with stage 3-5 CKD.

METHODS

This was a retrospective, closed cohort, observational study. Patients with CKD affiliated with a private insurer with five-year follow-up data were selected. Demographic, clinical, and laboratory variables were included, and the models were developed based on machine learning methods. The outcomes were CKD progression, a significant decrease in the estimated glomerular filtration rate (eGFR), and the need for RRT.

RESULTS

Three prediction models were developed-Model 1 (risk at 4.5 years, n = 1446) with a F1 of 0.82, 0.53, and 0.55 for RRT, stage progression, and reduction in the eGFR, respectively,- Model 2 (time- to-event, n = 2143) with a C-index of 0.89, 0.67, and 0.67 for RRT, stage progression, reduction in the eGFR, respectively, and Model 3 (reduced Model 2) with C-index = 0.68, 0.68 and 0.88, for RRT, stage progression, reduction in the eGFR, respectively.

CONCLUSION

The time-to-event model performed well in predicting the three outcomes of CKD progression at five years. This model can be useful for predicting the onset and time of occurrence of the outcomes of interest in the population with established CKD.

Relationship of hemoglobin levels with outcomes in deceased donor kidney transplant: a retrospective cohort study

INTRODUCTION

Anemia is frequent in patients undergoing replacement therapy for kidney failure. Anemia in the pre- and post-transplantation period might be related to kidney transplant outcomes. The current study therefore sought to assess the relationship between anemia, delayed allograft function (DGF), chronic kidney allograft dysfunction (CAD), and death from any cause following kidney transplantation from a deceased donor.

METHODS

This was a retrospective study with 206 kidney transplant patients of deceased donors. We analyzed deceased donors' and kidney transplant patients' demographic data. Moreover, we compared biochemical parameters, anemia status, and medicines between DGF and non-DGF groups. Afterward, we performed a multivariate analysis. We also evaluated outcomes, such as CAD within one year and death in ten years.

RESULTS

We observed a lower frequency of pre-transplant hemoglobin concentration (Hb) but higher frequency of donor-serum creatinine and red blood transfusion within one week after transplantation in the group with DGF. In addition, there was an independent association between Hb concentration before transplantation and DGF [OR 0.252, 95%CI: 0.159-0.401; p < 0.001]. There was also an association between Hb concentration after six months of kidney transplantation and both CAD [OR 0.798, 95% CI: 0.687-0.926; p = 0.003] and death from any cause.

CONCLUSION

An association was found between pre-transplantation anemia and DGF and between anemia six months after transplantation and both CAD and death by any cause. Thus, anemia before or after transplantation affects the outcomes for patients who have undergone kidney transplantation from a deceased donor.

Non-Invasive Biomarkers for Diagnosis, Risk Prediction, and Therapy Guidance of Glomerular Kidney Diseases: A Comprehensive Review

Effective management of glomerular kidney disease, one of the main categories of chronic kidney disease (CKD), requires accurate diagnosis, prognosis of progression, assessment of therapeutic efficacy, and, ideally, prediction of drug response. Multiple biomarkers and algorithms for the assessment of specific aspects of glomerular diseases have been reported in the literature. Though, the vast majority of these have not been implemented in clinical practice or are not available on a global scale due to limited access, missing medical infrastructure, or economical as well as political reasons. The aim of this review is to compile all currently available information on the diagnostic, prognostic, and predictive biomarkers currently available for the management of glomerular diseases, and provide guidance on the application of these biomarkers. As a result of the compiled evidence for the different biomarkers available, we present a decision tree for a non-invasive, biomarker-guided diagnostic path. The data currently available demonstrate that for the large majority of patients with glomerular diseases, valid biomarkers are available. However, despite the obvious disadvantages of kidney biopsy, being invasive and not applicable for monitoring, especially in the context of rare CKD etiologies, kidney biopsy still cannot be replaced by non-invasive strategies.

In emergency hypertension, could biomarkers change the guidelines?

BACKGROUND

Hypertension may cause target organ damage (TOD). Target blood pressure (BP) management may not be appropriate in some conditions.

AIM

We aim to assess the impact of targeted BP management in severe hypertension on renal TOD.

PATIENTS & METHODS

This is a prospective cohort study involving patients admitted due to severe hypertension (BP > 180/120) associated with any symptoms. The study involved patients referred to the ICU in our tertiary center during the period between August 2017 and February 2018. All patients underwent target BP treatment according to recent guidelines. Hs-Troponin T (hs-TNT) and serum creatinine (s.creat) were measured in all patients on admission and 24 h later. Patients were divided into Group A (with initial normal hs-TNT) and Group B (with initial high hs-TNT). The main outcome was in-hospital renal-related morbidity (including renal failure).

RESULTS

Four hundred seventy consecutive patients with hypertensive crises were involved in the study. Group B had a significantly higher incidence of in-hospital mortality (4 patients) and renal TOD (acute renal dysfunction) than Group A (P value = 0.001 and 0.000 respectively). There was a significant difference between initial s.creat on admission and follow-up s.creat values in Group B with significant elevation of their s.creat on the following 24 h (P = 0.002), while this difference is insignificant in Group A (P = 0.34). There was a significant positive correlation between hs-TNT and the follow-up s.creat (P = 0.004).

CONCLUSION

In severe HTN, hs-TNT may be elevated due to marked afterload. Patients with severe HTN and high hs-TNT have higher s.creat values, which are associated with an increased risk of renal failure and in-hospital mortality if their BP decreases acutely to the guideline-target BP. Using biomarkers during the management of emergency HTN should be considered before following clinical guidelines. However, our findings do underscore the potential utility of hs-TNT as an indicator for risk stratification in patients with severe or emergency HTN.

Association between pulmonary function and rapid kidney function decline: a longitudinal cohort study from CHARLS

BACKGROUND

Pulmonary function has been reported to be associated with chronic kidney disease. However, the relationship between lung function and rapid kidney function decline remains unclear.

METHODS

Participants aged ≥45 years with complete data from the 2011 and 2015 interviews of the China Health and Retirement Longitudinal Study (CHARLS) were included. Lung function, assessed by peak expiratory flow (PEF), and kidney function, assessed by estimated glomerular filtration rate (eGFR), were tested at the baseline and endpoint surveys. Rapid kidney function decline was defined as a decrease in eGFR ≥3 mL/min/1.73 m²/year, and ΔeGFR represented the difference between baseline and endpoint eGFR. Multivariate logistic regression models and linear regression models were employed to evaluate the association between PEF and the risk of rapid eGFR decline, as well as the correlation between PEF and ΔeGFR.

RESULTS

A total of 6159 participants were included, with 1157 (18.78%) individuals experiencing a rapid decline in eGFR. After adjusting for potential covariates, higher baseline PEF (Quartile 4 vs Quartile 1, OR=0.95, 95% CI 0.92 to 0.98) and elevated PEF % predicted (OR=0.96, 95% CI 0.94 to 0.99) were found to be associated with a lower risk of rapid eGFR decline. ΔeGFR decreased by 0.217 and 0.124 mL/min/1.73 m² for every 1 L/s increase in baseline PEF (β (95% CI): -0.217 (-0.393 to -0.042)) and 10% increase in PEF % predicted (β (95% CI): -0.124 (-0.237 to -0.011)), respectively. During the follow-up period, ΔeGFR decreased as PEF increased over time among participants in Quartile 1 (β per 1 L/s increase in ΔPEF=-0.581, 95% CI -1.003 to -0.158; β per 10% increase in ΔPEF % predicted=-0.279, 95% CI -0.515 to -0.043).

CONCLUSIONS

Higher PEF was associated with a slower longitudinal eGFR decline in middle-aged and older adults.

A retrospective cohort study of clinical characteristics and outcomes of type 2 diabetic patients with kidney disease

Background

Type 2 diabetes mellitus (T2DM) with chronic kidney disease (CKD) poses a serious health threat and becomes a new challenge. T2DM patients with CKD fall into three categories, diabetic nephropathy (DN), non-diabetic kidney disease (NDKD), and diabetic nephropathy plus non-diabetic kidney disease (DN + NDKD), according to kidney biopsy. The purpose of our study was to compare the clinical characteristics and kidney outcomes of DN, NDKD, and DN + NDKD patients.

Methods

Data on clinical characteristics, pathological findings, and prognosis were collected from June 2016 to July 2022 in patients with previously diagnosed T2DM and confirmed DN and or NDKD by kidney biopsy at Tongji Hospital in Wuhan, China. The endpoint was defined as kidney transplantation, dialysis, or a twofold increase in serum creatinine.

Results

In our 6-year retrospective cohort research, a total of 268 diabetic patients were admitted and categorized into three groups by kidney biopsy. The 268 patients were assigned to DN (n = 74), NDKD (n = 109), and DN + NDKD (n = 85) groups. The most frequent NDKD was membranous nephropathy (MN) (n = 45,41.28%). Hypertensive nephropathy was the most common subtype in the DN+NDKD group (n = 34,40%). A total of 34 patients (12.7%) reached the endpoint. The difference between the Kaplan-Meier survival curves of the DN, NDKD, and DN + NDKD groups was significant (p < 0.05). Multifactorial analysis showed that increased SBP [HR (95% CI): 1.018(1.002-1.035), p = 0.025], lower Hb [HR(95% CI): 0.979(0.961-0.997), p = 0.023], higher glycosylated hemoglobin [HR(95% CI): 1.338(1.080-1.658), p = 0.008] and reduced serum ALB [HR(95% CI): 0.952(0.910-0.996), p = 0.032] were risk factors for outcomes in the T2DM patients with CKD.

Conclusions

This research based on a Chinese cohort demonstrated that the risk of endpoint events differed among DN, NDKD, and DN+NDKD patients. In T2DM patients with CKD, DN patients displayed worse kidney prognosis than those with NDKD or DN + NDKD. Increased SBP, higher glycosylated hemoglobin, lower Hb, and decreased serum ALB may be correlated with adverse kidney outcomes in T2DM patients.

Clinical validation of the terminological subset for people with chronic kidney disease undergoing conservative treatment

OBJECTIVE

To clinically validate a terminological subset of the International Classification for Nursing Practice (ICNP®) to care for people with chronic kidney disease undergoing conservative treatment.

METHOD

Prospective study of clinical validation assessment of 117 nursing diagnoses/outcomes statements and 199 nursing intervention statements. It was operationalized through the following steps: implementation of the Nursing Process in an outpatient clinic in Southeast Brazil; preparation of case studies; analysis of agreement between specialist nurses. The Kappa. Kruskal-Wallis coefficient of agreement and intraclass correlation coefficient (ICC) were used.

RESULTS

The sample consisted of 50 people with chronic kidney disease. Diagnoses/outcomes and interventions were evaluated with almost perfect/perfect agreement and excellent ICC. The Kruskal-Wallis test showed that there was no significant difference between the assessments. The study allowed the clinical validation of a subset with 110 nursing diagnoses/outcomes and 195 nursing interventions.

CONCLUSION

Care for people with chronic kidney disease undergoing conservative treatment based on the proposed subset has become applicable to clinical practice.

Utility of Cardiac Troponins in Patients With Chronic Kidney Disease

Cardiovascular disease is a major cause of death worldwide especially in patients with chronic kidney disease (CKD). Troponin T and troponin I are cardiac biomarkers used not only to diagnose acute myocardial infarction (AMI) but also to prognosticate cardiovascular and all-cause mortality. The diagnosis of AMI in the CKD population is challenging because of their elevated troponins at baseline. The development of high-sensitivity cardiac troponins shortens the time needed to rule in and rule out AMI in patients with normal renal function. While the sensitivity of high-sensitivity cardiac troponins is preserved in the CKD population, the specificity of these tests is compromised. Hence, diagnosing AMI in CKD remains problematic even with the introduction of high-sensitivity assays. The prognostic significance of troponins did not differ whether it is detected with standard or high-sensitivity assays. The elevation of both troponin T and troponin I in CKD patients remains strongly correlated with adverse cardiovascular and all-cause mortality, and the prognosis becomes poorer with advanced CKD stages. Interestingly, the degree of troponin elevation appears to be predictive of the rate of renal decline via unclear mechanisms though activation of the renin-angiotensin and other hormonal/oxidative stress systems remain suspect. In this review, we present the latest evidence of the use of cardiac troponins in both the diagnosis of AMI and the prognosis of cardiovascular and all-cause mortality. We also suggest strategies to improve on the diagnostic capability of these troponins in the CKD/end-stage kidney disease population.

The association of plasma NT-proBNP level and progression of diabetic kidney disease

AIMS

Diabetic kidney disease (DKD) is the most common cause of end-stage kidney disease (ESKD). The identification of risk factors involved in the progression of DKD to ESKD is expected to result in early detection and appropriate intervention and improve prognosis. This study aimed to explore whether plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) was associated with kidney outcomes in patients with type 2 diabetes mellitus (T2DM) and biopsy-proven DKD.

METHODS

Patients with biopsy-proven DKD who were followed up at West China Hospital over 12 months were enrolled. The kidney outcome was defined as progression to ESKD. The cutoff value of plasma NT-proBNP concentration was calculated by using receiver operating characteristic (ROC) curve analysis. The influence of NT-proBNP levels on kidney outcome in patients with DKD was assessed using Cox regression analysis.

RESULTS

A total of 30 (24.5%) patients reached ESKD during a median follow-up of 24.1 months. The baseline serum NT-proBNP level had a significant correlation with baseline proteinuria, kidney function, glomerular lesions, interstitial fibrosis tubular atrophy (IFTA), and arteriolar hyalinosis. Multivariate Cox regression analysis indicated that increased NT-proBNP level was significantly associated with a higher risk of progression to ESKD (HR 6.43; 95% CI (1.65-25.10, p = 0.007), and each 1 SD increase in LG (NT-proBNP) was also associated with a higher risk (HR 2.43; 95% CI 1.94-5.29, p = 0.047) of an adverse kidney outcome after adjusting for confounding factors.

CONCLUSIONS

A higher level of plasma NT-proBNP predicts kidney prognosis in patients with biopsy-proven DKD. This warrants further investigation into the potential mechanisms.

Trends and perspectives for improving quality of chronic kidney disease care: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Chronic kidney disease (CKD) affects over 850 million people globally, and the need to prevent its development and progression is urgent. During the past decade, new perspectives have arisen related to the quality and precision of care for CKD, owing to the development of new tools and interventions for CKD diagnosis and management. New biomarkers, imaging methods, artificial intelligence techniques, and approaches to organizing and delivering healthcare may help clinicians recognize CKD, determine its etiology, assess the dominant mechanisms at given time points, and identify patients at high risk for progression or related events. As opportunities to apply the concepts of precision medicine for CKD identification and management continue to be developed, an ongoing discussion of the potential implications for care delivery is required. The 2022 KDIGO Controversies Conference on Improving CKD Quality of Care: Trends and Perspectives examined and discussed best practices for improving the precision of CKD diagnosis and prognosis, managing the complications of CKD, enhancing the safety of care, and maximizing patient quality of life. Existing tools and interventions currently available for the diagnosis and treatment of CKD were identified, with discussion of current barriers to their implementation and strategies for improving the quality of care delivered for CKD. Key knowledge gaps and areas for research were also identified.

Association of Longitudinal B-Type Natriuretic Peptide Monitoring With Kidney Failure in Patients With CKD: A Cohort Study

RATIONALE & OBJECTIVE

Both hypervolemia and hypovolemia are associated with chronic kidney disease (CKD) progression. Although longitudinal monitoring of B-type natriuretic peptide (BNP) may aid physicians' decision making about the optimization of volume status, its clinical benefit remains uncertain in CKD. This study assessed the association between BNP monitoring and the risk of incident kidney replacement therapy (KRT).

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

A total of 2,998 outpatients with stages 3-5 of nondialyzed CKD referred to the department of nephrology at an academic hospital.

EXPOSURE

BNP monitoring.

OUTCOME

KRT, acute kidney injury (AKI), and heart failure hospitalization.

ANALYTICAL APPROACH

Marginal structural models, which create a balanced pseudo population at each time point, were applied to account for potential time-dependent confounders. Inverse probability weighted pooled logistic regression models were employed to estimate hazard ratios.

RESULTS

At baseline, the median age and estimated glomerular filtration rate were 66 years and 38.1mL/min/1.73m2, respectively. During the follow-up period (median, 5.9 [IQR, 2.8-9.9] years), 449 patients required KRT, 765 had AKI, and 236 were hospitalized for heart failure. After adjustment for time-updated clinical characteristics and physician-specific practice styles, BNP monitoring was associated with lower risks of KRT (HR, 0.44 [95% CI, 0.21-0.92]), AKI (HR, 0.36 [95% CI, 0.18-0.72]), and heart failure hospitalization (HR, 0.37 [95% CI, 0.14-0.95]). The association between BNP monitoring and KRT was attenuated after additional adjustment for AKI or heart failure hospitalization as a time-varying covariate.

LIMITATIONS

Residual confounding by measured and unmeasured variables or indications for BNP measurements.

CONCLUSIONS

BNP monitoring was associated with a lower risk of KRT among patients with CKD that did not require dialysis. This association is potentially mediated through a reduced risk of AKI or heart failure hospitalization.

PLAIN-LANGUAGE SUMMARY

Both volume overload and volume depletion are deleterious to kidney function. B-type natriuretic peptide (BNP) is a biomarker that reflects volume status not only in heart failure but also in nondialysis chronic kidney disease (CKD). Although longitudinal BNP monitoring may aid physicians' decision making about the optimization of volume status, its clinical benefit remains uncertain in CKD. In this cohort study analyzing 2,998 patients with nondialyzed CKD, BNP monitoring was associated with a lower risk of kidney replacement therapy, acute kidney injury, and heart failure hospitalization over the follow-up period. The association with kidney replacement therapy may be mediated through a reduced risk of acute kidney injury or heart failure hospitalization. BNP monitoring may aid physicians in optimal fluid management, potentially conferring better kidney outcomes.

The potential of cardiac biomarkers, NT-ProBNP and troponin T, in predicting the progression of nephropathy in diabetic patients: A meta-analysis of prospective cohort studies

AIMS

A meta-analysis was done to investigate the association of two cardiac biomarkers of N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) and circulating troponin T (TnT) with the progression of diabetic nephropathy (DN).

METHODS

A thorough search of the PubMed, Scopus, and Web of Science databases was done until June 2022. The outcome (progression of DN) was described as either of the followings: a) eGFR decline, b) albuminuria, c) end-stage renal disease, or d) mortality. A pooled analysis of eligible studies was performed using random-effect models to compensate for the differences in measurement standards between the studies. We further carried out subgroup analyses to examine our results' robustness and find the source of heterogeneity. A sensitivity analysis was performed to assess the influence of individual studies on the pooled result and the funnel plot and Egger's test were used to assess publication bias.

RESULTS

For NT-proBNP, 8741 participants from 14 prospective cohorts, and for TnT, 7292 participants from 9 prospective cohorts were included in the meta-analysis. Higher NT-proBNP levels in diabetic patients were associated with a higher probability of DN progression (relative risk [RR]: 1.67, 95% confidence interval [CI]: 1.44 to 1.92). Likewise, elevated levels of TnT were associated with an increased likelihood of DN (RR: 1.57, 95% CI: 1.34 to 1.83). The predictive power of both biomarkers for DN remained significant when the subgroup analyses were performed. The risk estimates were sensitive to none of the studies. The funnel plot and Egger's tests indicated publication bias for both biomarkers. Hence, trim and fill analysis was performed to compensate for this putative bias and the results remained significant both for NT-proBNP (RR: 1.50, 95% CI: 1.31 to 1.79) and TnT (RR: 1.35, 95% CI 1.15 to 1.60).

CONCLUSIONS

The increased blood levels of TnT and NT-proBNP can be considered as predictors of DN progression in diabetic individuals. PROSPERO registration code: CRD42022350491.

Genome-Wide Association Study of CKD Progression

SIGNIFICANCE STATEMENT

Rapid progression of CKD is associated with poor clinical outcomes. Most previous studies looking for genetic factors associated with low eGFR have used cross-sectional data. The authors conducted a meta-analysis of genome-wide association studies of eGFR decline among 116,870 participants with CKD, focusing on longitudinal data. They identified three loci (two of them novel) associated with longitudinal eGFR decline. In addition to the known UMOD/PDILT locus, variants within BICC1 were associated with significant differences in longitudinal eGFR slope. Variants within HEATR4 also were associated with differences in eGFR decline, but only among Black/African American individuals without diabetes. These findings help characterize molecular mechanisms of eGFR decline in CKD and may inform new therapeutic approaches for progressive kidney disease.

BACKGROUND

Rapid progression of CKD is associated with poor clinical outcomes. Despite extensive study of the genetics of cross-sectional eGFR, only a few loci associated with eGFR decline over time have been identified.

METHODS

We performed a meta-analysis of genome-wide association studies of eGFR decline among 116,870 participants with CKD-defined by two outpatient eGFR measurements of <60 ml/min per 1.73 m 2 , obtained 90-365 days apart-from the Million Veteran Program and Vanderbilt University Medical Center's DNA biobank. The primary outcome was the annualized relative slope in outpatient eGFR. Analyses were stratified by ethnicity and diabetes status and meta-analyzed thereafter.

RESULTS

In cross-ancestry meta-analysis, the strongest association was rs77924615, near UMOD / PDILT ; each copy of the G allele was associated with a 0.30%/yr faster eGFR decline ( P = 4.9×10 -27 ). We also observed an association within BICC1 (rs11592748), where every additional minor allele was associated with a 0.13%/yr slower eGFR decline ( P = 5.6×10 -9 ). Among participants without diabetes, the strongest association was the UMOD/PDILT variant rs36060036, associated with a 0.27%/yr faster eGFR decline per copy of the C allele ( P = 1.9×10 -17 ). Among Black participants, a significantly faster eGFR decline was associated with variant rs16996674 near APOL1 (R 2 =0.29 with the G1 high-risk genotype); among Black participants with diabetes, lead variant rs11624911 near HEATR4 also was associated with a significantly faster eGFR decline. We also nominally replicated loci with known associations with eGFR decline, near PRKAG2, FGF5, and C15ORF54.

CONCLUSIONS

Three loci were significantly associated with longitudinal eGFR change at genome-wide significance. These findings help characterize molecular mechanisms of eGFR decline and may contribute to the development of new therapeutic approaches for progressive CKD.

Risk factor mining and prediction of urine protein progression in chronic kidney disease: a machine learning- based study

BACKGROUND

Chronic kidney disease (CKD) is a global public health concern. Therefore, to provide timely intervention for non-hospitalized high-risk patients and rationally allocate limited clinical resources is important to mine the key factors when designing a CKD prediction model.

METHODS

This study included data from 1,358 patients with CKD pathologically confirmed during the period from December 2017 to September 2020 at Zhongshan Hospital. A CKD prediction interpretation framework based on machine learning was proposed. From among 100 variables, 17 were selected for the model construction through a recursive feature elimination with logistic regression feature screening. Several machine learning classifiers, including extreme gradient boosting, gaussian-based naive bayes, a neural network, ridge regression, and linear model logistic regression (LR), were trained, and an ensemble model was developed to predict 24-hour urine protein. The detailed relationship between the risk of CKD progression and these predictors was determined using a global interpretation. A patient-specific analysis was conducted using a local interpretation.

RESULTS

The results showed that LR achieved the best performance, with an area under the curve (AUC) of 0.850 in a single machine learning model. The ensemble model constructed using the voting integration method further improved the AUC to 0.856. The major predictors of moderate-to-severe severity included lower levels of 25-OH-vitamin, albumin, transferrin in males, and higher levels of cystatin C.

CONCLUSIONS

Compared with the clinical single kidney function evaluation indicators (eGFR, Scr), the machine learning model proposed in this study improved the prediction accuracy of CKD progression by 17.6% and 24.6%, respectively, and the AUC was improved by 0.250 and 0.236, respectively. Our framework can achieve a good predictive interpretation and provide effective clinical decision support.

Kidney and Cardiovascular Effects of Canagliflozin According to Age and Sex: A Post Hoc Analysis of the CREDENCE Randomized Clinical Trial

RATIONALE & OBJECTIVE

It is unclear whether the effect of canagliflozin on adverse kidney and cardiovascular events in those with diabetic kidney disease varies by age and sex. We assessed the effects of canagliflozin among age group categories and between sexes in the Canagliflozin and Renal Endpoints in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) study.

STUDY DESIGN

Secondary analysis of a randomized controlled trial.

SETTING & PARTICIPANTS

Participants in the CREDENCE trial.

INTERVENTION

Participants were randomly assigned to receive canagliflozin 100mg/d or placebo.

OUTCOMES

Primary composite outcome of kidney failure, doubling of serum creatinine concentration, or death due to kidney or cardiovascular disease. Prespecified secondary and safety outcomes were also analyzed. Outcomes were evaluated by age at baseline (<60, 60-69, and≥70 years) and sex in the intention-to-treat population using Cox regression models.

RESULTS

The mean age of the cohort was 63.0±9.2 years, and 34% were female. Older age and female sex were independently associated with a lower risk of the composite of adverse kidney outcomes. There was no evidence that the effect of canagliflozin on the primary outcome (a composite of kidney failure, a doubling of serum creatinine concentration, or death from kidney or cardiovascular causes) differed between age groups (HRs, 0.67 [95% CI, 0.52-0.87], 0.63 [0.48-0.82], and 0.89 [0.61-1.29] for ages<60, 60-69, and≥70 years, respectively; P=0.3for interaction) or sexes (HRs, 0.71 [95% CI, 0.54-0.95] and 0.69 [0.56-0.84] in women and men, respectively; P=0.8for interaction). No differences in safety outcomes by age group or sex were observed.

LIMITATIONS

This was a post hoc analysis with multiple comparisons.

CONCLUSIONS

Canagliflozin consistently reduced the relative risk of kidney events in people with diabetic kidney disease in both sexes and across age subgroups. As a result of greater background risk, the absolute reduction in adverse kidney outcomes was greater in younger participants.

FUNDING

This post hoc analysis of the CREDENCE trial was not funded. The CREDENCE study was sponsored by Janssen Research and Development and was conducted collaboratively by the sponsor, an academic-led steering committee, and an academic research organization, George Clinical.

TRIAL REGISTRATION

The original CREDENCE trial was registered at ClinicalTrials.gov with study number NCT02065791.

Metabolic dysfunction-associated fatty liver disease increases risk of chronic kidney disease: a systematic review and meta-analysis

BACKGROUND AND AIM

Metabolic dysfunction-associated fatty liver disease (MAFLD) is an alternative description and classification of non-alcoholic fatty liver disease (NAFLD) that may have better utility than NAFLD in clinical practice. We performed a meta-analysis to quantify the magnitude of the association between MAFLD and risk of both prevalent and incident chronic kidney disease (CKD).

METHODS

We systematically searched PubMed, Medline (OVID), Embase (OVID), Web of Science and Cochrane Library from database inception until 29 May 2022. We included observational studies examining the association between MAFLD and risk of CKD, defined by estimated glomerular filtration rate ≤60 mL/min/1.73 m2 or presence of abnormal albuminuria. Meta-analysis was performed using random-effects models to obtain summary HRs or ORs with 95% CIs.

RESULTS

Seventeen observational studies with aggregate data on 845 753 participants were included in meta-analysis. In the 7 cohort studies, the pooled random-effects HR for incident CKD in patients with MAFLD was 1.29 (95% CI 1.17 to 1.41, I2=87.0%). In the 10 cross-sectional studies, the pooled random-effects OR for prevalent CKD in patients with MAFLD was 1.35 (95% CI 1.11 to 1.64, I2=92.6%).

CONCLUSION

MAFLD is significantly associated with an increased prevalence and incidence of CKD.

PROSPERO REGISTRATION NUMBER

CRD42022352366.

Epigenome-wide association study of diabetic chronic kidney disease progression in the Korean population: the KNOW-CKD study

Since the etiology of diabetic chronic kidney disease (CKD) is multifactorial, studies on DNA methylation for kidney function deterioration have rarely been performed despite the need for an epigenetic approach. Therefore, this study aimed to identify epigenetic markers associated with CKD progression based on the decline in the estimated glomerular filtration rate in diabetic CKD in Korea. An epigenome-wide association study was performed using whole blood samples from 180 CKD recruited from the KNOW-CKD cohort. Pyrosequencing was also performed on 133 CKD participants as an external replication analysis. Functional analyses, including the analysis of disease-gene networks, reactome pathways, and protein-protein interaction networks, were conducted to identify the biological mechanisms of CpG sites. A phenome-wide association study was performed to determine the associations between CpG sites and other phenotypes. Two epigenetic markers, cg10297223 on AGTR1 and cg02990553 on KRT28 indicated a potential association with diabetic CKD progression. Based on the functional analyses, other phenotypes (blood pressure and cardiac arrhythmia for AGTR1) and biological pathways (keratinization and cornified envelope for KRT28) related to CKD were also identified. This study suggests a potential association between the cg10297223 and cg02990553 and the progression of diabetic CKD in Koreans. Nevertheless, further validation is needed through additional studies.

Roles of extracellular vesicles in ageing-related chronic kidney disease: demon or angel

Ageing is a universal and unavoidable phenomenon that significantly increases the risk of developing chronic kidney disease (CKD). It has been reported that ageing is associated with functional disruption and structural damage to the kidneys. Extracellular vesicles (EVs), which are nanoscale membranous vesicles containing lipids, proteins, and nucleic acids, are secreted by cells into the extracellular spaces. They have diverse functions such as repairing and regenerating different forms of ageing-related CKD and playing a crucial role in intercellular communication. This paper reviews the etiology of ageing in CKD, with particular attention paid to the roles of EVs as carriers of ageing signals and anti-ageing therapeutic strategies in CKD. In this regard, the double-edged role of EVs in ageing-related CKD is examined, along with the potential for their application in clinical settings.

Novel Genetic Variants Associated with Chronic Kidney Disease Progression

SIGNIFICANCE STATEMENT

eGFR slope has been used as a surrogate outcome for progression of CKD. However, genetic markers associated with eGFR slope among patients with CKD were unknown. We aimed to identify genetic susceptibility loci associated with eGFR slope. A two-phase genome-wide association study identified single nucleotide polymorphisms (SNPs) in TPPP and FAT1-LINC02374 , and 22 of them were used to derive polygenic risk scores that mark the decline of eGFR by disrupting binding of nearby transcription factors. This work is the first to identify the impact of TPPP and FAT1-LINC02374 on CKD progression, providing predictive markers for the decline of eGFR in patients with CKD.

BACKGROUND

The incidence of CKD is associated with genetic factors. However, genetic markers associated with the progression of CKD have not been fully elucidated.

METHODS

We conducted a genome-wide association study among 1738 patients with CKD, mainly from the KoreaN cohort study for Outcomes in patients With CKD. The outcome was eGFR slope. We performed a replication study for discovered single nucleotide polymorphisms (SNPs) with P <10 -6 in 2498 patients with CKD from the Chronic Renal Insufficiency Cohort study. Several expression quantitative trait loci (eQTL) studies, pathway enrichment analyses, exploration of epigenetic architecture, and predicting disruption of transcription factor (TF) binding sites explored potential biological implications of the loci. We developed and evaluated the effect of polygenic risk scores (PRS) on incident CKD outcomes.

RESULTS

SNPs in two novel loci, TPPP and FAT1-LINC02374 , were replicated (rs59402340 in TPPP , Pdiscovery =7.11×10 -7 , PCRIC =8.13×10 -4 , Pmeta =7.23×10 -8 ; rs28629773 in FAT1-LINC02374 , Pdiscovery =6.08×10 -7 , PCRIC =4.33×10 -2 , Pmeta =1.87×10 -7 ). The eQTL studies revealed that the replicated SNPs regulated the expression level of nearby genes associated with kidney function. Furthermore, these SNPs were near gene enhancer regions and predicted to disrupt the binding of TFs. PRS based on the independently significant top 22 SNPs were significantly associated with CKD outcomes.

CONCLUSIONS

This study demonstrates that SNP markers in the TPPP and FAT1-LINC02374 loci could be predictive markers for the decline of eGFR in patients with CKD.

Initiation of hemodialysis at one month following fistulogram in patients with advanced kidney disease

OBJECTIVE

Previous studies have demonstrated that low contrast volume used in access-related interventions had limited effects on the progression of chronic kidney disease (CKD) after fistulography, but studies are limited and heterogeneous. We sought to evaluate the rate of and factors associated with progression to dialysis (HD) within 1 month after fistulography for patients with advanced CKD.

METHODS

A single-institution retrospective cohort analysis of patients with CKD stage IV and V, not yet on HD, undergoing fistulography from 1 January 2014 to 31 December 2018 was performed. The primary outcome was progression to HD within 1 month. Additional variables and the association with the primary outcome such as medical comorbidities, contrast type or volume were assessed.

RESULTS

A total of 34 patients underwent 41 fistulograms prior to HD initiation. Progression to HD within 1 month of fistulogram occurred in seven patients (all CKD V). The mean time between fistulogram and HD was 271 days for 31 of 34 patients who ultimately progressed to HD. Those with CKD IV began HD in 549 days on average, while those with CKD V began HD in 190 days on average. Three patients had not initiated HD at a mean of 539 days of follow-up. The only factors associated with progression to HD within 1 month included use of isovue (p = .005) and elevated contrast volume, with a mean of 40 mL (p = .027).

CONCLUSION

Although none of the patients with CKD IV required HD within 1 month after fistulogram, the use of larger iodinated contrast volume was associated with progression to HD within 1 month of fistulography for patients with CKD V. Further studies should investigate the safety of iodinated and alternative (e.g., carbon dioxide) contrast media in fistulography or duplex-based HD access procedures for CKD patients, especially CKD V, not yet on HD.

Change in albuminuria as a surrogate endpoint for cardiovascular and renal outcomes in patients with diabetes

For the purpose of predicting clinical outcomes in patients with diabetes and chronic kidney disease, change in albuminuria is a good candidate to be a surrogate marker for future cardiovascular events and progression of kidney disease. Spot urine albumin/creatinine ratio is convenient and recognized as a viable alternative to 24-h albumin, with some limitations. Although there is sufficient evidence to validate its use in clinical trials as a surrogate endpoint for renal outcomes, this is not yet the case for cardiovascular outcomes. While change in albuminuria as a primary or secondary endpoint is trial-specific, its use should be encouraged, nonetheless.

Prognosis and risk factors of chronic kidney disease progression in patients with diabetic kidney disease and non-diabetic kidney disease: a prospective cohort CKD-ROUTE study

Diabetic kidney disease (DKD) is emerging rapidly as the leading cause of chronic kidney disease (CKD) worldwide. In this 3-year prospective, multicenter cohort study, a total of 1138 pre-dialysis CKD patients were recruited. Patients were categorized into two groups according to the etiologies of DKD and non-diabetic kidney disease (NDKD). Propensity score matching was performed to adjust for confounding factors, resulting in 197 patients being assigned to DKD and NDKD groups, respectively. The primary endpoints were 50% estimated glomerular filtration rate (eGFR) decline and initiation of kidney replacement therapy (KRT). The secondary endpoints were all-cause death and the development of cardiovascular disease (CVD) events. We found that DKD patients have a higher risk to develop 50% eGFR decline endpoint (HR:2.30, 95%CI [1.48-3.58], p < 0.001) and KRT endpoint (HR:1.64, 95%CI [1.13-2.37], p < 0.05) than NDKD patients. The 3-year cumulative incidence of 50% eGFR decline and KRT endpoint was significantly higher in DKD patients (26.90% vs.13.71% and 35.03% vs. 22.34%, respectively). The Cox regression analyses showed that the increased systolic blood pressure (SBP), DKD, decreased serum albumin (Alb), and higher CKD stages were risk factors for the 50% eGFR decline endpoint; the increased SBP, DKD, decreased serum Alb, serum creatinine (Scr), higher CKD stages, presence of proteinuria and CVD were risk factors for KRT endpoint; the increased age, decreased hemoglobin (Hb), decreased serum Alb were risk factors for all-cause death endpoint; the increased age, decreased serum Alb were risk factors for CVD events endpoint. Appropriate preventive or therapeutic interventions should be taken to control these predictive factors to delay the development of CKD complications, thereby improving the prognosis and reducing the disease burden of the high-risk populations.

New Insights into Molecular Mechanisms of Chronic Kidney Disease

Chronic kidney disease (CKD) is a major public health problem with a developing incidence and prevalence. As a consequence of the growing number of patients diagnosed with renal dysfunction leading to the development of CKD, it is particularly important to explain the mechanisms of its underlying causes. In our paper, we discuss the molecular mechanisms of the development and progression of CKD, focusing on oxidative stress, the role of the immune system, neutrophil gelatinase-associated lipocalin, and matrix metalloproteinases. Moreover, growing evidence shows the importance of the role of the gut-kidney axis in the maintenance of normal homeostasis and of the dysregulation of this axis in CKD. Further, we discuss the therapeutic potential and highlight the future research directions for the therapeutic targeting of CKD. However, additional investigation is crucial to improve our knowledge of CKD progression and, more importantly, accelerate basic research to improve our understanding of the mechanism of pathophysiology.

Intravitreal Vascular Endothelial Growth Factor Inhibitor Use and Renal Function Decline in Patients with Diabetic Retinopathy

Adverse renal effects of systemic vascular endothelial growth factor (VEGF) inhibitor treatment are well documented. We aimed to identify associations between intravitreal VEGF inhibitor use and renal function decline in patients with diabetic retinopathy. We included 625 patients with diabetic retinopathy for regular renal function follow-ups and grouped them according to intravitreal therapy (67 with and 558 without treatment). We used a generalized estimating equation model to identify renal function decline risk factors. Increased age (p = 0.02), insulin use (p = 0.01), hypertension (p < 0.01), and ischemic heart disease (p < 0.01) were associated with significantly decreased estimated glomerular filtration rates (eGFRs) in patients with diabetic retinopathy after 1-year follow-up. Compared to the control group, patients who received intravitreal VEGF inhibitor injections showed a declining eGFR trend in the repeated measurement model without statistical significance (p = 0.06). In subgroup analysis, patients with initial eGFR ≤ 30 mL/min/1.73 m² who received intravitreal VEGF inhibitors had significantly decreased renal function (p < 0.01) compared to those without treatment. Intravitreal VEGF inhibitor injection was associated with renal function deterioration among patients with diabetic retinopathy and advanced chronic kidney disease. Strategies to monitor renal function after treatment should be considered in these high-risk populations.

Usefulness of urinary tubule injury markers for predicting progression of renal dysfunction in patients with type 2 diabetes and albuminuria: The Fukuoka Diabetes Registry

AIMS

We prospectively investigated the association of urinary tubule injury markers with estimated glomerular filtration rate (eGFR) decline in Japanese patients with type 2 diabetes.

METHODS

Urinary kidney injury molecule 1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), liver-type fatty-acid-binding protein (L-FABP), and urinary albumin-to creatinine ratio (UACR) were measured in 2,685 participants with type 2 diabetes. Renal outcomes were ≥ 30% decline in eGFR from the baseline and annual eGFR decline for 5 years.

RESULTS

In normoalbuminuric participants, no tubular markers were associated with ≥ 30% decline in eGFR or annual eGFR changes. In those with UACR ≥ 30 mg/gCr, hazard ratios for ≥ 30% eGFR decline were 1.37 (95% confident interval (CI) 1.07-1.75) for urinary KIM-1 (>1.5 µg/gCr), 1.46 (95% CI 1.13-1.66) for urinary NGAL (>16.4 µg/gCr), and 1.26 (95% CI 0.94-1.66) for urinary L-FABP (>12.5 µg/gCr), 2.61 (95% CI 1.64-4.17) for the combination of 3 tubular markers above the cutoff after multivariable adjustments including UACR and eGFR.

CONCLUSIONS

The current study demonstrated that urinary tubule injury markers and their combination were significant predictors for the future eGFR decline in those with type 2 diabetes and albuminuria independently of UACR and eGFR. Urinary tubular markers may be useful to identify high-risk patients with albuminuria.

Clinical Effect of Mudan Granule on Peripheral Neuritis Caused by Chronic Renal Insufficiency

Objective

To investigate the clinical effect of Mudan granule on peripheral neuritis caused by chronic renal insufficiency (CRI).

Methods

Sixty patients with peripheral neuritis caused by CRI treated in our hospital were included from February 2018 to April 2021 in this study. The patients were arbitrarily assigned into control group and study group. The former accepted routine treatment, while the latter accepted Mudan granule treatment. The clinical efficacy, traditional Chinese medicine (TCM) clinical symptom score, nerve conduction velocity, hemorheology index, renal function index, and inflammatory factor index were compared.

Results

We firstly compared the clinical efficacy: the study group was clinically cured in 22 cases, obviously effective in 5 cases, effective in 3 cases, and ineffective in 1 case, with a total effective rate of 96.67%. The control group was clinically cured in 9 cases, obviously effective in 8 cases, effective in 7 cases, and ineffective in 6 cases, with a total effective rate of 80.00%. The total effective rate of the study group was higher compared to the control group (P < 0.05). Secondly, we compared the TCM clinical symptom scores; before treatment, there exhibited no significant difference (P > 0.05); after treatment, the TCM clinical symptom scores decreased. The clinical symptom score of TCM in the study group was lower compared to the control group (P < 0.05). Compared with the control group, the nerve conduction velocity of left MCV, right MCV, left SCV, and right SCV in the study group were remarkably higher. In terms of the hemorheological indexes, the high-shear whole blood viscosity, low-shear whole blood viscosity, and plasma viscosity in the study group were lower compared with the control group (P < 0.05). Before treatment, there existed no significant difference in renal function indexes, but after treatment, the renal function indexes decreased, and the levels of serum creatinine (SCr), blood urea nitrogen (BUN), and uric acid (UA) in the study group were lower compared to the control group (P < 0.05). Finally, we compared the indexes of inflammatory factors; there existed no significant difference before treatment, but after treatment, the indexes of inflammatory factors decreased in both groups, and the levels of IL-6 and CRP in the study group were lower compared to the control group (P < 0.05).

Conclusion

For peripheral neuritis caused by CRI, Mudan granule can remarkably promote the clinical symptoms of TCM and reduce the syndrome score of TCM; moreover, it can remarkably increase the nerve conduction velocity of median nerve and common peroneal nerve and reduce blood viscosity, which is worth popularizing and developing in clinic.

Relationship of coffee consumption with a decline in kidney function among patients with type 2 diabetes: the Fukuoka Diabetes Registry

Aims/Introduction

The evidence regarding the effects of coffee consumption on incident chronic kidney disease is inconclusive, and no studies have investigated the relationship in patients with diabetes. We aimed to prospectively investigate the relationship between coffee consumption and the decline in estimated glomerular function rate (eGFR) in patients with type 2 diabetes.

Materials and Methods

A total of 3,805 patients (2,112 men, 1,693 women) with type 2 diabetes (mean age 64.2 years) and eGFR ≥60 mL/min/1.73 m² were followed (completion of follow up, 97.6%; median 5.3 years). Coffee consumption was assessed at baseline. The end‐point was a decline in eGFR to <60 mL/min/1.73 m² during the follow‐up period.

Results

During follow up, 840 participants experienced a decline in eGFR to <60 mL/min/1.73 m². Higher coffee consumption reduced the risk of decline in eGFR. Compared with no coffee consumption, the multivariate‐adjusted hazard ratios (95% confidence intervals) were 0.77 (0.63–0.93) for less than one cup per day, 0.77 (0.62–0.95) for one cup per day and 0.75 (0.62–0.91) for two or more cups per day (P for trend 0.01). This trend was unaffected by further adjustment for baseline eGFR and albuminuria. The mean eGFR change per year was −2.16 mL/min/1.73 m² with no coffee consumption, −1.89 mL/min/1.73 m² with less than one cup per day, −1.80 mL/min/1.73 m² with one cup per day and −1.78 mL/min/1.73 m² with two or more cups per day (P for trend 0.03).

Conclusions

Coffee consumption is significantly associated with a lower risk of decline in eGFR in patients with type 2 diabetes.

Novel biomarkers and therapeutic approaches for diabetic retinopathy and nephropathy: Recent progress and future perspectives

The global burden due to microvascular complications in patients with diabetes mellitus persists and even increases alarmingly, the intervention and management are now encountering many difficulties and challenges. This paper reviews the recent advancement and progress in novel biomarkers, artificial intelligence technology, therapeutic agents and approaches of diabetic retinopathy and nephropathy, providing more insights into the management of microvascular complications.

Regulatory Effects of Quercetin on M1/M2 Macrophage Polarization and Oxidative/Antioxidative Balance

Macrophage polarization plays essential and diverse roles in most diseases, such as atherosclerosis, adipose tissue inflammation, and insulin resistance. Homeostasis dysfunction in M1/M2 macrophage polarization causes pathological conditions and inflammation. Neuroinflammation is characterized by microglial activation and the concomitant production of pro-inflammatory cytokines, leading to numerous neurodegenerative diseases and psychiatric disorders. Decreased neuroinflammation can be obtained by using natural compounds, including flavonoids, which are known to ameliorate inflammatory responses. Among flavonoids, quercetin possesses multiple pharmacological applications and regulates several biological activities. In the present study, we found that quercetin effectively inhibited the expression of lipocalin-2 in both macrophages and microglial cells stimulated by lipopolysaccharides (LPS). The production of nitric oxide (NO) and expression levels of the pro-inflammatory cytokines, inducible nitric oxide synthase (iNOS) and cyclooxygenase (COX)-2, were also attenuated by quercetin treatment. Our results also showed that quercetin significantly reduced the expression levels of the M1 markers, such as interleukin (IL)-6, tumor necrosis factor (TNF)-α, and IL-1β, in the macrophages and microglia. The M1 polarization-associated chemokines, C–C motif chemokine ligand (CCL)-2 and C-X-C motif chemokine ligand (CXCL)-10, were also effectively reduced by the quercetin treatment. In addition, quercetin markedly reduced the production of various reactive oxygen species (ROS) in the microglia. The microglial phagocytic ability induced by the LPS was also effectively reduced by the quercetin treatment. Importantly, the quercetin increased the expression levels of the M2 marker, IL-10, and the endogenous antioxidants, heme oxygenase (HO)-1, glutamate-cysteine ligase catalytic subunit (GCLC), glutamate-cysteine ligase modifier subunit (GCLM), and NAD(P)H quinone oxidoreductase-1 (NQO1). The enhancement of the M2 markers and endogenous antioxidants by quercetin was activated by the AMP-activated protein kinase (AMPK) and Akt signaling pathways. Together, our study reported that the quercetin inhibited the effects of M1 polarization, including neuroinflammatory responses, ROS production, and phagocytosis. Moreover, the quercetin enhanced the M2 macrophage polarization and endogenous antioxidant expression in both macrophages and microglia. Our findings provide valuable information that quercetin may act as a potential drug for the treatment of diseases related to inflammatory disorders in the central nervous system.

Plasma and urine biomarkers in chronic kidney disease: closer to clinical application

PURPOSE OF REVIEW

Chronic kidney disease (CKD) is a silent disease, causing significant health and economic burden worldwide. It is of strong clinical value to identify novel prognostic, predictive, and pharmacodynamic biomarkers of kidney function, as current available measures have limitations. We reviewed the advances in biomarkers in CKD over the preceding year.

RECENT FINDINGS

The most frequently studied prognostic plasma biomarkers during recent year were plasma TNFR1, TNFR2, KIM1 and urinary MCP-1 and EGF. New biomarkers such as plasma WFDC2, MMP-7, EFNA4, EPHA2 may also have potential to serve as prognostic biomarkers. There is a shortage of data on biomarkers that are predictive of response to treatments. Data on novel biomarkers to serve as pharmacodynamic biomarkers are limited, but there are emerging data that plasmaTNFR1, TNFR2, KIM-1 are not only prognostic at baseline, but can also contribute to time-updated response signals in response to therapy.

SUMMARY

Data continue to emerge on applicable biomarkers for prognostic clinical risk stratification, prediction of therapeutic response and assessment of early efficacy of interventions. Although more studies are needed for refinement and specific clinical utility, there seems to be sufficient data to support clinical implementation for some biomarkers.