Normal reference values for glomerular filtration rate: what do we really know?

A Joint Bayesian Model for Change-Points and Heteroskedasticity Applied to the Canadian Longitudinal Study on Aging

Maintaining homeostasis, the regulation of internal physiological parameters, is essential for health and well-being. Deviations from optimal levels, or 'sweet spots,' can lead to health deterioration and disease. Identifying biomarkers with sweet spots requires both change-point detection and variance effect analysis. Traditional approaches involve separate tests for change-points and heteroskedasticity, which can yield inaccurate results if model assumptions are violated. To address these challenges, we propose a unified approach: Bayesian Testing for Heteroskedasticity and Sweet Spots (BTHS). This framework integrates sampling-based parameter estimation and Bayes factor computation to enhance change-point detection, heteroskedasticity quantification, and testing in change-point regression settings, and extends previous Bayesian approaches. BTHS eliminates the need for separate analyses and provides detailed insights into both the magnitude and shape of heteroskedasticity, enabling robust identification of sweet spots without strong assumptions. We applied BTHS to blood elements from the Canadian Longitudinal Study on Aging identifying nine blood elements with significant sweet spot variance effects.

Glomerular filtration rate and comorbidity factors in elderly hospitalizations

BACKGROUND

With an increase in the elderly population, the frequency of hospitalizations in recent years has also risen at a rapid pace. This, in turn, has resulted in poor outcomes and costly treatments. Hospitalization rates increase in elderly patients due to a decline in glomerular filtration rate (GFR).

AIM

To investigate the connection between GFR and comorbidity and reasons for hospitalization in elderly patients.

METHODS

We analyzed patients aged 75 years and over who were admitted to the internal medicine clinic of a tertiary hospital in Eskisehir. At admission, we calculated GFR values using the Modification of Diet in Renal Disease study formula and classified them into six categories: G1, G2, G3a, G3b, G4, and G5. We analyzed associations with hospitalization diagnoses and comorbidity factors.

RESULTS

The average age of the patients was 80.8 years (± 4.5 years). GFR was 57.287 ± 29.5 mL/kg/1.73 m2 in women and 61.3 ± 31.5 mL/kg/1.73 m2 in men (P = 0.106). Most patients were admitted to the hospital at G2 stage (32.8%). The main reasons for hospitalization were anemia (34.4% and 28.6%) and malnutrition (20.9% and 20.8%) in women and men, respectively (P = 0.078). The most frequent comorbidity leading to hospitalization was arterial hypertension (n = 168, 28%), followed by diabetes (n = 166, 27.7%) (P = 0.001).

CONCLUSION

When evaluating geriatric patients, low GFR alone does not provide sufficient information. Patients' comorbid factors should also be taken into account. There is no association between low GFR during hospitalization and hospitalization-related diagnoses. Knowing the GFR value before hospitalization will be more informative in such studies.

Age- and sex-specific reference values of estimated glomerular filtration rate for European adults

Kidney function, often assessed by estimated glomerular filtration rate (eGFR), declines naturally with age. However, there is a lack of eGFR reference values to describe normal and abnormal values for a specific age. The European Chronic Kidney Disease Burden Consortium is comprised of nine participating general population-based studies from seven European countries which provides European age- and sex-specific eGFR reference values in healthy adults using the European Kidney Function Consortium (EKFC) equation. Of 2,572,020 individuals, 1,535,253 (60%) were considered healthy, of which 45% were men. Ages ranged from 18 to 105 years old in men and 18 to 107 years old in women with a median age of 43 years in both sexes. At age 20 in men, the 5th, 50th and 95th eGFR percentiles were 78 ml/min per 1.73 m2, 99 ml/min per 1.73 m2, and 119 ml/min per 1.73 m2. In 20-year-old women this was 81 ml/min per 1.73 m2, 101 ml/min per 1.73 m2, and 121 ml/min per 1.73 m2. Consequently, in men aged 80 years old, the 5th, 50th and 95th eGFR percentiles were 49 ml/min per 1.73 m2, 66 ml/min per 1.73 m2, and 84 ml/min per 1.73 m2. In 80 year old women this was 46 ml/min per 1.73 m2, 63 ml/min per 1.73 m2, and 81 ml/min per 1.73 m2. Overall, our study shows that eGFR is not preserved with ageing in healthy individuals and these eGFR reference values can help determine abnormal and normal kidney function across the age range.

Organic cation transporters 2: Structure, regulation, functions, and clinical implications

The SLC22A2 gene encodes organic cation transporter 2 (OCT2), which is predominantly expressed in renal proximal tubule cells. OCT2 is critical for the active renal excretion of various cationic drugs and endogenous metabolites. OCT2 expression varies across species, with higher levels in mice and monkeys compared with humans and rats. The human OCT2 protein consists of 555 amino acids and contains 12 transmembrane domains. OCT2 functions as a uniporter, facilitating the bidirectional transport of organic cations into renal tubular cells, driven by the inside-negative membrane potential. Its expression is regulated by sex hormones, contributing to potential sex differences in Oct2 activity in rodents. OCT2 has been linked to tissue toxicity, such as cisplatin-induced nephrotoxicity. Factors such as genetic variants, age, disease states, and the coadministration of drugs, including tyrosine kinase inhibitors, contribute to interindividual variability in OCT2 activity. This, in turn, impacts the systemic exposure and elimination of drugs and endogenous substances. Regulatory agencies recommend evaluating the potential of a drug to inhibit OCT2 through in vitro and clinical drug-drug interaction (DDI) studies, often using metformin as a probe substrate. Emerging tools like transporter biomarkers and physiologically based pharmacokinetic modeling hold promise in predicting OCT2-mediated DDIs. While several OCT2 biomarkers, such as N1-methylnicotinamide, have been proposed, their reliability in predicting renal DDIs remains uncertain and requires further study. Ultimately, a better understanding of the factors influencing OCT2 activity is essential for achieving precision medicine and minimizing renal and systemic toxicity. SIGNIFICANCE STATEMENT: Organic cation transporter 2 (OCT2) is essential for the active tubular secretion of xenobiotics and endogenous cationic substances in the kidneys. This article offers a comprehensive overview of the tissue distribution, interspecies differences, and factors affecting its activity-critical for evaluating tissue toxicity and systemic exposure to cationic substances. Using OCT2 biomarkers and integrating OCT2 activity and expression data into physiologically based pharmacokinetic models are valuable tools for predicting OCT2 function and its clinical implications.

Creatine supplementation does not add to resistance training effects in prostate cancer patients under androgen deprivation therapy: A double-blind randomized trial

OBJECTIVES

Androgen deprivation therapy (ADT) leads to loss of lean mass (LM) and reduced strength and physical function. Resistance exercise alone can counteract these changes; however, it is unknown if the addition of creatine supplementation can further protect against these ADT-induced toxicities. We compared the effects of creatine supplementation with resistance exercise versus resistance exercise alone in patients with prostate cancer undergoing ADT on LM, muscle strength, and physical function.

DESIGN

A 12-week randomized trial.

METHODS

Men with prostate cancer receiving ADT (n = 30) were randomized to either resistance exercise + placebo (PLA) or resistance exercise + creatine (SUPP), with both groups undertaking supervised exercise 3 days per week. Outcomes included whole body and appendicular LM and fat mass (FM) assessed by dual-energy X-ray absorptiometry, as well as muscle strength (chest press, seated low, leg press), and physical function (timed up-and-go, chair rise, 400-m walk) assessed at baseline and following the intervention.

RESULTS

Patients were aged 59-84 years with a BMI of 28.6 kg·m-2. PLA completed a mean of 30 sessions (83 %) and SUPP a mean of 33 sessions (92 %). Despite similar within-group improvements (p < 0.05) in whole-body LM (PLA +0.6 kg, SUPP +1.3 kg), appendicular LM (PLA +0.5 kg, SUPP +0.6 kg), muscle strength (PLA +8.8-49.3 kg, SUPP +9.4-40.4 kg) and physical function, there were no between group differences (p = 0.078-0.951). No adverse events were reported due to creatine supplementation or resistance exercise.

CONCLUSIONS

A short-term program of resistance exercise alone results in meaningful improvements in LM, muscle strength and physical function, with no additional effects of creatine supplementation.

Stroke-Induced Renal Dysfunction: Underlying Mechanisms and Challenges of the Brain-Kidney Axis

Stroke, a major neurological disorder and a leading cause of disability and death, often inflicts damage upon other organs, particularly the kidneys. While chronic kidney disease (CKD) has long been established as a significant risk factor for cerebrovascular disease, stroke can induce renal dysfunction, manifesting as acute kidney injury (AKI) or CKD. Mounting clinical and basic research evidence supports the existence of a bidirectional brain-kidney crosstalk following stroke, implicating specific mechanisms and pathways in stroke-related renal dysfunction. This review analyzes pertinent experimental studies, elucidating the underlying mechanisms of this cerebro-renal interaction following stroke. Additionally, we summarize the current landscape of clinical research investigating brain-kidney interplay and discuss potential challenges in the future. By enhancing our understanding of the scientific underpinnings of brain-kidney crosstalk, this review paves the way for improved treatment strategies and outcomes for stroke patients. Recognizing the intricate interplay between the brain and kidneys after stroke holds profound clinical implications.

A minimal physiologically based pharmacokinetic model to study the combined effect of antibody size, charge, and binding affinity to FcRn/antigen on antibody pharmacokinetics

Protein therapeutics have revolutionized the treatment of a wide range of diseases. While they have distinct physicochemical characteristics that influence their absorption, distribution, metabolism, and excretion (ADME) properties, the relationship between the physicochemical properties and PK is still largely unknown. In this work we present a minimal physiologically-based pharmacokinetic (mPBPK) model that incorporates a multivariate quantitative relation between a therapeutic's physicochemical parameters and its corresponding ADME properties. The model's compound-specific input includes molecular weight, molecular size (Stoke's radius), molecular charge, binding affinity to FcRn, and specific antigen affinity. Through derived and fitted empirical relationships, the model demonstrates the effect of these compound-specific properties on antibody disposition in both plasma and peripheral tissues using observed PK data in mice and humans. The mPBPK model applies the two-pore hypothesis to predict size-based clearance and exposure of full-length antibodies (150 kDa) and antibody fragments (50-100 kDa) within a onefold error. We quantitatively relate antibody charge and PK parameters like uptake rate, non-specific binding affinity, and volume of distribution to capture the relatively faster clearance of positively charged mAb as compared to negatively charged mAb. The model predicts the terminal plasma clearance of slightly positively and negatively charged antibody in humans within a onefold error. The mPBPK model presented in this work can be used to predict the target-mediated disposition of a drug when compound-specific and target-specific properties are known. To our knowledge, a combined effect of antibody weight, size, charge, FcRn, and antigen has not been incorporated and studied in a single mPBPK model previously. By conclusively incorporating and relating a multitude of protein's physicochemical properties to observed PK, our mPBPK model aims to contribute as a platform approach in the early stages of drug development where many of these properties can be optimized to improve a molecule's PK and ultimately its efficacy.

Development and Validation of an Accurate Creatinine-Based Equation to Estimate Glomerular Filtration Rate for the Adult Indian Population: Design and Methods

Background

Existing creatinine-based equations to estimate glomerular filtration rate (GFR), developed primarily in populations of European and African American ancestry, do not accurately reflect the GFR in the Indian population due to differences in body composition, diet, and other factors. This manuscript describes the rationale and methodology for developing a creatinine-based equation for more accurate GFR estimation in Indian subjects.

Materials and Methods

This cross-sectional study will be conducted in India's two geographically and demographically diverse locations: Chandigarh (north) and Puducherry (south). Participants will include a representative sample from the general population and subjects with chronic kidney disease (CKD), with the latter being recruited from outpatient clinics. A total of 1558 subjects will be enrolled in the discovery and cross-validation cohort and 620 subjects in the external validation cohort. The reference standard for measured GFR (mGFR) will be the plasma clearance of iohexol. Stepwise multiple regression on log-transformed data will determine a set of variables that jointly predict mGFR and identify factors influencing mGFR and estimated (eGFR) in the study population. This study will also explore the performance of mGFR by iohexol measurement from dried blood spots against mGFR from plasma clearance of iohexol.

Conclusion

Developing a more reliable and accurate creatinine-based GFR estimating equation will improve CKD diagnosis, classification, and management. The findings will have substantial implications for CKD research in India and other regions with similar populations.

Data mining of reference intervals for serum creatinine: an improvement in glomerular filtration rate estimating equations based on Q-values

OBJECTIVES

Glomerular filtration rate (GFR) estimating equations based on rescaled serum creatinine (SCr/Q) have shown better performance, where Q represents the median SCr for age- and sex-specific healthy populations. However, there remains a scarcity of investigations in China to determine this value. We aimed to develop Chinese age- and sex-specific reference intervals (RIs) and Q-values for SCr and to validate the equations incorporating new Q-values.

METHODS

We included 117,345 adults from five centers for establishing RIs and Q-values, and 3,692 participants with reference GFR (rGFR, 99mTc-DTPA renal dynamic imaging measurement) for validation. Appropriate age partitioning was determined using the decision tree method. Lower and upper reference limits and medians were calculated using the refineR algorithm, and Q-values were determined accordingly. We evaluated the full age spectrum (FAS) and European Kidney Function Consortium (EKFC) equations incorporating different Q-values considering bias, precision (interquartile range, IQR), and accuracy (percentage of estimates within ±20 % [P20] and ±30 % [P30] of rGFR).

RESULTS

RIs for males were: 18-79 years, 55.53-92.50 μmol/L; ≥80 years, 54.41-96.43 μmol/L. RIs for females were: 18-59 years, 40.42-69.73 μmol/L; 60-79 years, 41.16-73.69 μmol/L; ≥80 years, 46.50-73.20 μmol/L. Q-values were set at 73.82 μmol/L (0.84 mg/dL) for males and 53.80 μmol/L (0.61 mg/dL) for females. After validation, we found that the adjusted equations exhibit less bias, improved precision and accuracy, and increased agreement of GFR categories.

CONCLUSIONS

We determined Chinese age- and sex-specific RIs and Q-values for SCr. The adjustable Q-values provide an effective alternative to obtain valid equations for estimating GFR.

Cross species extrapolation of the disruption of thyroid hormone synthesis by oxyfluorfen using in vitro data, physiologically based pharmacokinetic (PBPK), and thyroid hormone kinetics models

The thyroid hormones play key roles in physiological processes such as regulation of the metabolic and cardiac systems as well as the development of the brain and surrounding sympathetic nervous system. Recent efforts to screen environmental chemicals for their ability to alter thyroid hormone synthesis, transport, metabolism and/or function have identified novel chemicals that target key processes in the thyroid pathway. One newly identified chemical, oxyfluorfen, is a diphenyl-ether herbicide used for control of annual broadleaf and grassy weeds in a variety of tree fruit, nut, vine, and field crops. Using in vitro high-throughput screening (HTS) assays, oxyfluorofen was identified to be a potent inhibitor of the thyroidal sodium-iodide symporter (NIS). To quantitatively assess this inhibition mechanism in vivo, we extrapolated in vitro NIS inhibition data to in vivo disruption of thyroid hormones synthesis in rats using physiologically based pharmacokinetic (PBPK) and thyroid hormone kinetics models. The overall computational model (chemical PBPK and THs kinetic sub-models) was calibrated against in vivo data for the levels of oxyfluorfen in thyroid tissue and serum and against serum levels of thyroid hormones triiodothyronine (T3) and thyroxine (T4) in rats. The rat thyroid model was then extrapolated to humans using human in vitro HTS data for NIS inhibition and the chemical specific hepatic clearance rate in humans. The overall species extrapolated PBPK-thyroid kinetics model can be used to predict dose-response (% drop in thyroid serum levels compared to homeostasis) relationships in humans. These relationships can be used to estimate points of departure for health risks related to a drop in serum levels of TH hormones based on HTS assays in vitro to in vivo extrapolation (IVIVE), toxicokinetics, and physiological principles.

Comparison of glomerular filtration rate estimating equations in older adults: A systematic review and meta-analysis

BACKGROUND

Debates persist regarding the performance of existing glomerular filtration rate (GFR) estimating equations in older individuals. We performed this meta-analysis to assess the accuracy and bias of six commonly used equations, including the Chronic Kidney Disease Epidemiology Collaboration creatinine equation (CKD-EPICr) and its combination with cystatin C (CKD-EPICr-Cys), with the corresponding pair of the Berlin Initiative Study equations (BIS1 and BIS2) and the Full Age Spectrum equations (FASCr and FASCr-Cys).

METHODS

PubMed and the Cochrane Library were searched for studies comparing estimated GFR (eGFR) with measured GFR (mGFR). We analyzed the difference in P30 and bias among the six equations and investigated subgroups based on the area (Asian and non-Asian), mean age (60-74 years and ≥75 years), and levels of mean mGFR (<45 mL/min/1.73m2 and ≥45 mL/min/1.73m2).

RESULTS

27 studies with 18,112 participants were included, all reporting P30 and bias. BIS1 and FASCr exhibited significantly higher P30 than CKD-EPICr. While no significant differences were observed between FASCr and BIS1, or among the three combined equations in terms of either P30 or bias. Subgroup analyses revealed FASCr and FASCr-Cys achieved better results in most situations. However, in the subgroup of mGFR<45 mL/min/1.73m2, CKD-EPICr-Cys had relatively higher P30 and significantly smaller bias.

CONCLUSIONS

Overall, BIS and FAS provided relatively more accurate estimates of GFR than CKD-EPI in older adults. FASCr and FASCr-Cys may be better suited for various conditions, while CKD-EPICr-Cys would be a better option for older individuals with impaired renal function.

Update on persistent acute kidney injury in critical illnesses

Acute kidney injury (AKI) affects about half of patients admitted to the intensive care unit (ICU), and worsens their short- and long-term outcomes. Apparently self-limiting AKI episodes initiate a progression toward chronic kidney disease (CKD) through cellular and molecular mechanisms that are yet to be explained. In particular, persistent AKI, defined in 2016 by the Acute Dialysis Quality Initiative as an AKI which lasts more than 48 h from its onset, has been correlated with higher morbidity and mortality, and with a higher progression to acute kidney disease (AKD) and CKD than transient AKI (i.e. AKI with a reversal within 48 h). This classification has been also used in the setting of solid organ transplantation, demonstrating similar outcomes. Due to its incidence and poor prognosis and because prompt interventions seem to change its course, persistent AKI should be recognized early and followed-up also after its recovery. However, while AKI and CKD are well-described syndromes, persistent AKI and AKD are relatively new entities. The purpose of this review is to highlight the key phases of persistent AKI in ICU patients in terms of both clinical and mechanistic features in order to offer to clinicians and researchers an updated basis from which to start improving patients' care and direct future research.

D-Serine as a sensor and effector of the kidney

D-Serine, a rare enantiomer of serine, is a biomarker of kidney disease and function. The level of D-serine in the human body is precisely regulated through the urinary clearance of the kidney, and its clearance serves as a new measure of glomerular filtration rate with a lower bias than creatinine clearance. D-Serine also has a direct effect on the kidneys and mediates the cellular proliferation of tubular cells via mTOR signaling and induces kidney remodeling as a compensatory reaction to the loss of kidney mass. In living kidney donors, the removal of the kidney results in an increase in blood D-serine level, which in turn accelerates kidney remodeling and augments kidney clearance, thus reducing blood levels of D-serine. This feedback system strictly controls D-serine levels in the body. The function of D-serine as a biomarker and modulator of kidney function will be the basis of precision medicine for kidney diseases.

Evaluation of glomerular filtration rate estimation equations based on serum creatinine in healthy Chinese children and adolescents: a nationwide cross-sectional study

BACKGROUND

Several equations for glomerular filtration rate (GFR) estimation based on serum creatinine (SCr) have been proposed for children, but most were developed among patients with kidney disease. The association between SCr and GFR may be distorted by kidney dysfunction and thus not applicable to healthy children. This study aimed to evaluate the applicability of existing SCr-based GFR estimation equations in healthy Chinese children.

METHODS

GFR estimation equations that developed in healthy children were mainly analysed, including the Flanders Metadata (FM), simple height-independent (Simple), full age spectrum (FAS) and FAS-height equations. The FM equation assumed that GFR is proportional to the ratio of height to SCr. The Simple, FAS and FAS-height equations assumed that the ratio of GFR to population mean is equal to the reciprocal ratio of SCr to population mean (denoted by Q). Estimated GFR were calculated using data of SCr, age, sex and height collected from 12 208 healthy Chinese children aged 3 months to <20 years. The performance of GFR estimation equations was evaluated by the sex and age distribution of the estimated GFR and the deviation from the measured GFR reported by other literatures.

RESULTS

The FM and Simple equations performed well in their applicable age of 1 month to 14 years, but presented undesirable sex difference after adolescence. The FAS and FAS-height equations showed reasonable development trend of estimated GFR throughout childhood, and the FAS equation had higher consistency than the FAS-height equation compared with measured GFR in healthy children. The GFR estimated by the FAS equation increased with age before 2 years, and reached the adult level thereafter without important sex difference.

CONCLUSIONS

The FAS equation is applicable to healthy Chinese children.

Validation of the European Kidney Function Consortium Equation in Chinese Adult Population: An Equation Standing on the Shoulders of Predecessors

BACKGROUND

Equations based on serum creatinine (SCr) have been extensively applied to estimate glomerular filtration rate (GFR), but their performance is debatable. In 2021, the European Kidney Function Consortium (EKFC) published one novel SCr-based formula, which combined the feature of Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and full age spectrum (FAS) equations, but its potential applications remain unknown. We seek to assess the appropriateness of the three equations in Chinese adults.

METHODS

A total of 3,692 participants (median age, 54 years) were included. Reference GFR (rGFR) was measured by the 99mTc-DTPA renal dynamic imaging method. Estimated GFR (eGFR) was calculated by the CKD-EPI, FAS, and EKFC equations. Correlation coefficients and Bland-Altman analysis were adopted to evaluate their validity. The performance was assessed in subgroups according to age, sex, rGFR, and SCr, considering the bias, accuracy, and precision.

RESULTS

The average rGFR was 74.2 mL/min/1.73 m2. eGFR by EKFC showed a relatively stronger correlation with rGFR (R = 0.749) and a larger area under the receiver operating characteristic curve (0.902). EKFC was significantly less biased and exhibited the highest P30 in the entire population (bias = 3.61, P30 = 73.3%). It also performed well in all analyzed subgroups, especially in participants with normal or slightly impaired renal function (rGFR≥60 mL/min/1.73 m2), and low SCr.

CONCLUSIONS

Compared to the other two SCr-based formulas, EKFC performed better in the Chinese. Thus, it might serve as a good alternative, until a more suitable formula is developed for the Chinese population.

Age of Onset and Disease Course in Biopsy-Proven Minimal Change Disease: An Analysis From the Cure Glomerulonephropathy Network

RATIONALE & OBJECTIVE

Adolescent- and adult-onset minimal change disease (MCD) may have a clinical course distinct from childhood-onset disease. We characterized the course of children and adults with MCD in the Cure Glomerulonephropathy Network (CureGN) and assessed predictors of rituximab response.

STUDY DESIGN

Prospective, multicenter, observational study.

STUDY PARTICIPANTS

CureGN participants with proven MCD on biopsy.

EXPOSURE

Age at disease onset, initiation of renin-angiotensin-aldosterone system (RAAS) blockade, and immunosuppression including rituximab during the study period.

OUTCOME

Relapse and remission, change in estimated glomerular filtration rate (eGFR), and kidney failure.

ANALYTICAL APPROACH

Remission and relapse probabilities were estimated using Kaplan-Meier curves and gap time recurrent event models. Linear regression models were used for the outcome of change in eGFR. Cox proportional hazards models were used to estimate the association between rituximab administration and remission.

RESULTS

The study included 304 childhood- (≤12 years old), 49 adolescent- (13-17 years old), and 201 adult- (≥18 years) onset participants with 2.7-3.2 years of follow-up after enrollment. Children had a longer time to biopsy (238 vs 23 and 36 days in adolescent- and adult-onset participants, respectively; P<0.001) and were more likely to have received therapy before biopsy. Children were more likely to be treated with immunosuppression but not RAAS blockade. The rate of relapse was higher in childhood- versus adult-onset participants (HR, 1.69 [95% CI, 1.29-2.21]). The probability of remission was also higher in childhood-onset disease (HR, 1.33 [95%CI, 1.02-1.72]). In all groups eGFR loss was minimal. Children were more likely to remit after rituximab than those with adolescent- or adult-onset disease (adjusted HR, 2.1; P=0.003). Across all groups, glucocorticoid sensitivity was associated with a greater likelihood of achieving complete remission after rituximab (adjusted HR, 2.62; P=0.002).

LIMITATIONS

CureGN was limited to biopsy-proven disease. Comparisons of childhood to nonchildhood cases of MCD may be subject to selection bias, given that childhood cases who undergo a biopsy may be limited to patients who are least responsive to initial therapy.

CONCLUSIONS

Among patients with MCD who underwent kidney biopsy, there were differences in the course (relapse and remission) of childhood-onset compared with adolescent- and adult-onset disease, as well as rituximab response.

PLAIN-LANGUAGE SUMMARY

Minimal change disease is a biopsy diagnosis for nephrotic syndrome. It is diagnosed in childhood, adolescence, or adulthood. Patients and clinicians often have questions about what to expect in the disease course and how to plan therapies. We analyzed a group of patients followed longitudinally as part of the Cure Glomerulonephropathy Network (CureGN) and describe the differences in disease (relapse and remission) based on the age of onset. We also analyzed rituximab response. We found that those with childhood-onset disease had a higher rate of relapse but also have a higher probability of reaching remission when compared with adolescent- or adult-onset disease. Children and all steroid-responsive patients are more likely to achieve remission after rituximab.

Cystatin C for kidney function assessment in patients with facioscapulohumeral muscular dystrophy

BACKGROUND AND AIMS

Muscle mass (MM) impairment observed in facioscapulohumeral muscular dystrophy (FSHD) may bias estimated glomerular filtration rate (eGFR) based on creatinine (eGFRcreat). eGFR based on cystatin C (eGFRcys), produced by all nucleated cells, should be an interesting alternative. Main objectives were to compare eGFRcreat and eGRFcys for chronic kidney disease (CKD) staging and for annual eGFR evolution. Secondary objective was to analyse creatinine, cystatin C with measured MM.

MATERIAL AND METHODS

During 4 years, 159 FSHD patients having one or more creatinine and cystatin C measurements (total samples: n=379), with MM determination by bio-impedancemetry during their follow-up were included. eGFR were determined with CKD-Epi and EKFC equations.

RESULTS

On first examination samples, mean eGFRcys was significantly lower than mean eGFRcreat of 25.5 and 17.9 ml/min/1.73m² using CKD-Epi and EKFC equations, respectively. 53.5% (CKD-Epi) and 59.1% (EKFC) of agreement were obtained when using eGFRcys instead of eGFRcreat with reclassifications occurring mainly towards more severe stages. Age was correlated with cystatin C but not with creatinine, MM was correlated with creatinine but not with cystatin C. eGFR decreases >1 ml/min/1.73m² were more important when using eGFRcys instead of eGFRcreat (CKD-Epi: 37.5 vs 15.4%, p<0.001; EKFC: 34.6 vs 20.2%, p<0.01).

CONCLUSION

Cystatin C which is independent of MM appears as a promising candidate biomarker for CKD diagnosis and follow-up in FSHD patient.

Recommendations for living donor kidney transplantation

This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.

Glomerular filtration in the aging population

In the last decades, improvements in the average life expectancy in the world population have been associated with a significant increase in the proportion of elderly people, in parallel with a higher prevalence of non-communicable diseases, such as hypertension and diabetes. As the kidney is a common target organ of a variety of diseases, an adequate evaluation of renal function in the approach of this population is of special relevance. It is also known that the kidneys undergo aging-related changes expressed by a decline in the glomerular filtration rate (GFR), reflecting the loss of kidney function, either by a natural senescence process associated with healthy aging or by the length of exposure to diseases with potential kidney damage. Accurate assessment of renal function in the older population is of particular importance to evaluate the degree of kidney function loss, enabling tailored therapeutic interventions. The present review addresses a relevant topic, which is the effects of aging on renal function. In order to do that, we analyze and discuss age-related structural and functional changes. The text also examines the different options for evaluating GFR, from the use of direct methods to the implementation of several estimating equations. Finally, this manuscript supports clinicians in the interpretation of GFR changes associated with age and the management of the older patients with decreased kidney function.

Association between exposure to fine particulate matter and kidney function: Results from the Korea National Health and Nutrition Examination Survey

BACKGROUND

The incidence and prevalence of chronic kidney disease (CKD) are increasing worldwide. Recent studies have shown that air pollution is associated with poorer kidney function. We evaluated the association of long-term exposure to air pollutants with kidney function, and with risk of CKD using data from the seventh Korean National Health and Nutrition Examination Survey (KNHANES).

METHODS

KNHANES data from 2016 through 2018 and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation were used to calculate estimated glomerular filtration rates (eGFRs) and define the CKD patients with eGFRs <60 mL/min/1.73 m². After applying the sampling weights based on the complex survey design, we conducted multivariate linear regression and logistic regression analyses to examine the association of air pollutant exposure with kidney function and CKD risk, after adjusting for covariates, including gender, body mass index, education level, household income, smoking status, alcohol consumption, comorbidities, and serum triglyceride.

RESULTS

A total of 15,983 adults aged ≥20 years were included in the analysis. Long-term exposure to PM_2.5, PM₁₀, NO₂, and CO was associated with decreases in eGFR levels (PM_2.5: -4.67, 95% confidence interval (CI): -6.16, -3.18; PM₁₀: -2.19, 95% CI: -2.84, -1.54; NO₂: -1.56, 95% CI: -2.16, -0.97; CO: -1.34, 95% CI: -1.96, -0.71). Long-term exposure to PM_2.5 (odds ratio (OR): 1.97, 95% CI: 1.14, 3.42) and PM₁₀ (OR: 1.45, 95% CI: 1.10, 1.91) was associated with an increased the risk of CKD.

CONCLUSIONS

Annual exposure to PM_2.5, PM₁₀, NO₂, and CO was significantly associated with decreased eGFR. Long-term exposure to PM_2.5 and PM₁₀ was associated with an increased risk of CKD.

Age and the Course of GFR in Persons Aged 70 and Above

BACKGROUND AND OBJECTIVES

In older adults, data on the age-related course of GFR are scarce, which might lead to misjudgment of the clinical relevance of reduced GFR in old age.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

To describe the course of eGFR in older adults and derive reference values in population-based individuals, we used the longitudinal design of the Berlin Initiative Study (BIS) with a repeated estimation of GFR over a median of 6.1 years of follow-up. In 2069 community-dwelling older individuals (mean inclusion age 80 years, range 70-99), GFR was estimated biennially with the BIS-2 equation, including standardized creatinine and cystatin C levels, sex, and age. We described the crude and adjusted course using a mixed-effects model and analyzed the influence of death on the GFR course applying joint models. GFR slopes were compared using GFR equations on the basis of creatinine and/or cystatin C.

RESULTS

We observed a decreasing, thus nonlinear, eGFR decline with increasing age in a population of old adults. The estimated 1-year slope for ages 75 and 90 diminished for men from -1.67 to -0.99 and for women from -1.52 to -0.97. The modeled mean eGFR for men aged ≥79 and women ≥78 was below 60 ml/min per 1.73 m². Multivariable adjustment attenuated slopes only minimally. Taking death into account by applying joint models did not alter the nonlinear eGFR decline. Using eGFR equations on the basis of creatinine only showed linear slope patterns in contrast to nonlinear patterns for equations including cystatin C.

CONCLUSIONS

The eGFR decline depended on sex and age and changed only marginally after multivariable adjustment but decelerated with increasing age. Equations including cystatin C demonstrated a nonlinear slope challenging the previously assumed linearity of the decline of eGFR in old age.

The association between fine particulate matter (PM2.5) and chronic kidney disease using electronic health record data in urban Minnesota

BACKGROUND

Recent evidence has shown that fine particulate matter (PM_2.5) may be an important environmental risk factor for chronic kidney disease (CKD), but few studies have examined this association for individual patients using fine spatial data.

OBJECTIVE

To investigate the association between PM_2.5 and CKD (estimated glomerular filtration rate [eGFR]<45 ml/min/1.73 m²) in the Twin-Cities area in Minnesota using a large electronic health care database (2012-2019).

METHODS

We estimated the previous 1-year average PM_2.5 from the first eGFR (measured with the CKD Epidemiology Collaboration equation using the first available creatinine measure during the baseline period [2012-2014]) using Environmental Protection Agency downscaler modeling data at the census tract level. We evaluated the spatial relative risk and clustering of CKD prevalence using a K-function test statistic. We assessed the prevalence ratio of the PM_2.5 association with CKD incidence using a mixed effect Cox model, respectively.

RESULTS

Patients (n = 20,289) in the fourth (PM_2.5 > 10.4), third (10.3 < PM_2.5 < 10.8) and second quartile (9.9 < PM_2.5 < 10.3) vs. the first quartile (<9.9 μg/m³) had a 2.52[2.21, 2.87], 2.18[1.95, 2.45], and 1.72[1.52, 1.97] hazard rate of developing CKD in the fully adjusted models, respectively. We identified spatial heterogeneities and evidence of CKD clustering across our study region, but this spatial variation was accounted for by air pollution and individual covariates.

SIGNIFICANCE

Exposure to higher PM_2.5 is associated with a greater risk for incident CKD. Improvements in air quality, specifically at hotspots, may reduce CKD.

Real-world experience of angiotensin receptor neprilysin inhibitor on the glucose-lowering effect

We investigated the effect of angiotensin receptor neprilysin inhibitor (ARNI) on glycemic control in Korean patients. This retrospective cohort study was conducted at a single tertiary hospital. We compared the HbA_1c level reduction between the ARNI and angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) in chronic heart failure patients with diabetes. We also examined whether the target HbA_1c level was reached and the time to start insulin between the two groups. Over the study period, ARNI did not significantly lower the HbA_1c level after adjusting confounding factors compared to ACEIs or ARBs. However, as a result of a simple comparison using Mann–Whitney U test, ARNI group showed significant decrease in HbA_1c at 6, 12, and 24 months compared to ACEIs or ARBs group (p = 0.003, 0.009, and 0.026, respectively). The initiation of insulin was delayed in the ARNI group, but this difference was not significant based on the result of hazard ratio, but cumulative incidence was significantly lower in the ARNI group. In the real world, the blood glucose-control effects of ARNI were not superior to those of ACEIs or ARBs. However, long-term studies are needed as ARNI use increases to obtain more statistically significant results.

Glomerular Biomechanical Stress and Lipid Mediators during Cellular Changes Leading to Chronic Kidney Disease

Hyperfiltration is an important underlying cause of glomerular dysfunction associated with several systemic and intrinsic glomerular conditions leading to chronic kidney disease (CKD). These include obesity, diabetes, hypertension, focal segmental glomerulosclerosis (FSGS), congenital abnormalities and reduced renal mass (low nephron number). Hyperfiltration-associated biomechanical forces directly impact the cell membrane, generating tensile and fluid flow shear stresses in multiple segments of the nephron. Ongoing research suggests these biomechanical forces as the initial mediators of hyperfiltration-induced deterioration of podocyte structure and function leading to their detachment and irreplaceable loss from the glomerular filtration barrier. Membrane lipid-derived polyunsaturated fatty acids (PUFA) and their metabolites are potent transducers of biomechanical stress from the cell surface to intracellular compartments. Omega-6 and ω-3 long-chain PUFA from membrane phospholipids generate many versatile and autacoid oxylipins that modulate pro-inflammatory as well as anti-inflammatory autocrine and paracrine signaling. We advance the idea that lipid signaling molecules, related enzymes, metabolites and receptors are not just mediators of cellular stress but also potential targets for developing novel interventions. With the growing emphasis on lifestyle changes for wellness, dietary fatty acids are potential adjunct-therapeutics to minimize/treat hyperfiltration-induced progressive glomerular damage and CKD.

Prevalence and determinants of anemia among Iranian population aged ≥35 years: A PERSIAN cohort-based cross-sectional study

BACKGROUND

So far, no comprehensive studies have been performed to assess burden and determinants of anemia in Iran. In the present study, we aimed to answer this query using the data obtained from the Prospective Epidemiological Research Studies in IrAN (PERSIAN).

METHODS

In this cross-sectional study, we included 161,686 adult participants (aged 35 years and older) from 16 provinces of Iran. Anemia was defined as a hemoglobin concentration of <13 g/dL in males and <12 g/dL in females. To evaluate the association between anemia and different factors, we used the multivariable Poisson regression analysis with robust variance by applying adjusted prevalence ratio (PR) with 95% confidence interval (CI).

RESULTS

Of the total number of subjects, 72,387 (44.77%) were male and others were female. Mean age was 49.39±9.15 years old. The overall age- and sex-standardized prevalence of anemia was 8.83% (95% CI: 8.70-8.96%) in the included population. The highest and the lowest age- and sex-standardized prevalence of anemia pertained to Hormozgan (37.41%, 95% CI: 35.97-38.85%) and Kurdistan (4.57%, 95% CI: 3.87-5.27%) provinces, respectively. Being female (PR = 2.97), rural residence (PR = 1.24), being retired (PR = 1.53) and housewife (PR = 1.11), third and fourth wealth status quartiles (PR = 1.09 and PR = 1.11, respectively), being underweight (PR = 1.49), drug user (PR = 1.35), inadequate sleep (PR = 1.16), poor physical activity (PR = 1.15), diabetes (PR = 1.09), renal failure (PR = 2.24), and cancer (PR = 1.35) were associated with increased risk of anemia. On the other hand, illiteracy (PR = 0.79) and abdominal obesity (PR = 0.77) decreased the risk of anemia.

CONCLUSIONS

According to the results, a variable prevalence of anemia was observed across the included provinces. We tried to provide an informative report on anemia prevalence for health professionals and authorities to take measures for identification and management of the cases of anemia in high-prevalence areas.

Measurement of glomerular filtration rate using endogenous d-serine clearance in living kidney transplant donors and recipients

BACKGROUND

Endogenous molecules that provide an unbiased and a precise evaluation of kidney function are still necessary. We explored the potential of clearance of d-serine, a rare enantiomer of serine and a biomarker of kidney function, as a measure of glomerular filtration rate (GFR).

METHODS

This was a cross-sectional observational study of 200 living kidney transplant donors and recipients enrolled between July 2019 and December 2020 in a single Japanese center, for whom GFR was measured by clearance of inulin (C-in). Clearance of d-serine (C-dSer) was calculated based on blood and urine levels of d-serine, as measured by two-dimensional high-performance liquid chromatography. Analytical performance was assessed by calculating biases. Utilizing data from 129 participants, we developed equations for C-in based on C-dSer and C-cre using a linear regression model, and the performance was validated in 68 participants.

FINDINGS

The means of C-in and C-dSer were 66.7 and 55.7 mL/min/1.73 m2 of body surface area, respectively, in the entire cohort. C-dSer underestimated C-in with a proportional bias of 22.0% (95% confidence interval, 14.2-29.8%) and a constant bias of -1.24 (-5.78-3.31), whereas the proportional bias was minor to that of C-cre (34.6% [31.1-38.2%] and 2.47 (-1.18-6.13) for proportional and constant bias, respectively). Combination of C-dSer and C-cre measured C-in with an equation of 0.391 × C-dSer + 0.418 × C-cre + 3.852, which reduced the proportional bias (6.5% [-0.2-13.1%] and -4.30 [-8.87-0.28] for proportional and constant bias, respectively). In the validation dataset, this equation performed well with median absolute residual of 3.5 [2.3-4.8], and high ratio of agreement (ratios of 30% and 15% different from C-in [P30 and P15] of 98.5 [91.4-100] and 89.7 [80.0-95.2], respectively).

INTERPRETATION

The smaller proportional bias compared to that of C-cre is an advantage of C-dSer as a measure of C-in. Combinational measurement of d-serine and creatinine, two endogenous molecules, has the potential to serve as a measure of GFR with precision and minor biases and can support important clinical decisions.

FUNDING

Japan Society for the Promotion of Science (JSPS, grant number 17H04188), Japan Agency of Medical Research and Development (AMED, JP20gm5010001), Osaka Kidney Bank (OKF19-0010), Shiseido Co., Ltd and KAGAMI Inc.

Minimal Physiologically Based Pharmacokinetic-Pharmacodynamic (mPBPK-PD) Model of N-Acetylgalactosamine-Conjugated Small Interfering RNA Disposition and Gene Silencing in Preclinical Species and Humans

Conjugation of small interfering RNA (siRNA) to tris N-acetylgalactosamine [(GalNAc)3] can enable highly selective, potent, and durable knockdown of targeted proteins in the liver. However, potential knowledge gaps between in vitro experiments, preclinical species, and clinical scenarios remain. A minimal physiologically based pharmacokinetic-pharmacodynamic model for GalNAc-conjugated siRNA (GalNAc-siRNA) was developed using published data for fitusiran (ALN-AT3), an investigational compound targeting liver antithrombin (AT), to delineate putative determinants governing the whole-body-to-cellular pharmacokinetic (PK) and pharmacodynamic (PD) properties of GalNAc-siRNA and facilitate preclinical-to-clinical translation. The model mathematically linked relevant mechanisms: 1) hepatic biodistribution, 2) tris-GalNAc binding to asialoglycoprotein receptors (ASGPRs) on hepatocytes, 3) ASGPR endocytosis and recycling, 4) endosomal transport and escape of siRNA, 5) cytoplasmic RNA-induced silencing complex (RISC) loading, 6) degradation of target mRNA by bound RISC, and 7) knockdown of protein. Physiologic values for 36 out of 48 model parameters were obtained from the literature. Kinetic parameters governing (GalNAc)3-ASGPR binding and internalization were derived from published studies of uptake in hepatocytes. The proposed model well characterized reported pharmacokinetics, RISC dynamics, and knockdown of AT mRNA and protein by ALN-AT3 in mice. The model bridged multiple PK-PD data sets in preclinical species (mice, rat, monkey) and successfully captured reported plasma pharmacokinetics and AT knockdown in a phase I ascending-dose study. Estimates of in vivo potency were similar (∼2-fold) across species. Subcutaneous absorption and serum AT degradation rate constants scaled across species by body weight with allometric exponents of -0.29 and -0.22. The proposed mechanistic modeling framework characterizes the unique PK-PD properties of GalNAc-siRNA. SIGNIFICANCE STATEMENT: Tris N-acetylgalactosamine (GalNAc)3-conjugated small interfering RNA (siRNA) therapeutics enable liver-targeted gene therapy and precision medicine. Using a translational and systems-based minimal physiologically based pharmacokinetic-pharmacodynamic (mPBPK-PD) modeling approach, putative determinants influencing GalNAc-conjugated siRNA (GalNAc-siRNA) functionality in three preclinical species and humans were investigated. The developed model successfully integrated and characterized relevant published in vitro-derived biomeasures, mechanistic PK-PD profiles in animals, and observed clinical PK-PD responses for an investigational GalNAc-siRNA (fitusiran). This modeling effort delineates the disposition and liver-targeted pharmacodynamics of GalNAc-siRNA.

Age-specific normal reference ranges for 99mTc-DTPA glomerular filtration rate to use with two-sample slope-intercept method and Jodal Brochner-Mortensen correction

Glomerular filtration rate (GFR) varies with age, the calculation method, and the correction factor for slope-intercept overestimation. Hence, any normal reference range accompanying the results should be suitably adapted to the method used. For Nuclear Medicine Departments using a two-sample slope-intercept method, the lack of appropriate age-specific normal reference range has been a hindrance to adopting the recently updated Jodal Brochner-Mortensen (JBM) correction over other older and more widely used methods. A retrospective analysis of the routine GFR calculation and clinical reports generated locally from 2006 to 2020 was carried out. GFR was calculated with ^99mTc-DTPA plasma clearance using a two-sample slope-intercept method with JBM correction. Age-specific normal range equations were developed from normal healthy subjects. Published normal reference ranges were modified with appropriate correction reversal and compared with the locally developed reference ranges. Age-specific normal GFR reference ranges for ^99mTc-DTPA with slope-intercept method and JBM correction were developed and validated with current literature. Normal reference range (Mean ± 2SD) for Normalised GFR (ml min^-1 (1.73m²)^-1) within 95% confidence limits suitable for use with JBM correction is 100.6 ± 35.2 for children above 2 years and 102.9 - 0.00629 × (Age)² ± 19.4 for adults. Availability of age-specific normal GFR reference ranges applicable to the target population and appropriately tailored to the calculation method and correction factor enables Nuclear Medicine Departments to update their calculation methods in line with the current literature and also facilitates accurate reporting and evaluation of the calculated GFR results.

Age-adapted percentiles of measured glomerular filtration in healthy individuals: extrapolation to living kidney donors over 65 years

OBJECTIVES

Most data on glomerular filtration rate (GFR) originate from subjects <65 years old, complicating decision-making in elderly living kidney donors. In this retrospective multi-center study, we calculated percentiles of measured GFR (mGFR) in donors <65 years old and extrapolated these to donors ≥65 years old.

METHODS

mGFR percentiles were calculated from a development cohort of French/Belgian living kidney donors <65 years (n=1,983), using quantiles modeled as cubic splines (two linear parts joining at 40 years). Percentiles were extrapolated and validated in an internal cohort of donors ≥65 years (n=147, France) and external cohort of donors and healthy subjects ≥65 years (n=329, Germany, Sweden, Norway, France, The Netherlands) by calculating percentages within the extrapolated 5th-95th percentile (P5-P95).

RESULTS

Individuals in the development cohort had a higher mGFR (99.9 ± 16.4 vs. 86.4 ± 14 and 82.7 ± 15.5 mL/min/1.73 m²) compared to the individuals in the validation cohorts. In the internal validation cohort, none (0%) had mGFR below the extrapolated P5, 12 (8.2%) above P95 and 135 (91.8%) between P5-P95. In the external validation cohort, five subjects had mGFR below the extrapolated P5 (1.5%), 25 above P95 (7.6%) and 299 (90.9%) between P5-P95.

CONCLUSIONS

We demonstrate that extrapolation of mGFR from younger donors is possible and might aid with decision-making in elderly donors.

The distribution of eGFR by age in a community-based healthy population: the Japan specific health checkups study (J-SHC study)

BACKGROUND

Renal function gradually declines with age. However, the association between changes in renal function and healthy aging has not been determined. This study examined the distribution of estimated glomerular filtration rate (eGFR) values in healthy subjects by age using large-scale cross-sectional data of health check-up participants in Japan.

METHODS

Among the 394,180 health check-up participants, 75,217 (19.1%) subjects without hypertension, diabetes, hyperlipidemia, obesity, proteinuria, smoking, past history of cardiovascular diseases, and renal failure/not undergoing dialysis were included in the healthy group. The distribution of eGFR values was determined at each age between 39 and 74 years.

RESULTS

in healthy subjects, the mean (± 2 SD range) values of eGFR (mL/min/1.73 m²) at ages 40, 50, 60, and 70 were 88.0 (55.4-121.7), 82.3 (51.2-113.3), 77.8 (48.1-107.6), and 72.9 (44.7-101.1), respectively. The difference in the mean eGFR by age was almost constant across all ages. In the linear regression analysis adjusted for sex, the regression coefficient of mean eGFR for a one-year increase in age was -0.46 mL/min/1.73 m² in healthy subjects (P < 0.001). By sex, the distribution of eGFR and the 1-year change in eGFR showed similar results in both men and women.

CONCLUSIONS

Renal function slowly declined with age in a healthy population; however, it was relatively preserved until the mid 70 s. This result suggests that a decline in renal function often observed in the elderly does not attribute to aging alone, and further examination might be required to clarify the cause of renal impairment.

US deceased kidney transplantation: Estimated GFR, donor age and KDPI association with graft survival

BACKGROUND

Despite a significant shortage of kidneys for transplantation in the US, kidneys from older deceased donors are infrequently transplanted. This is primarily over concern of graft quality and transplant durability.

METHODS

The US national transplant database (2000-2018) was assessed for deceased donor kidney transplant patient and graft survival, graft durability and stratified by donor age (<65 years>), Kidney Donor Profile Index (KDPI) and estimated glomerual filtration rate (GFR) one year post-transplantation (eGFR-1) were calculated.

FINDINGS

Recipients of kidneys transplanted from deceased donors >65 years had a lower eGFR-1, (median 39 ml/min) than recipients of younger donor kidneys (median 54 ml/min). However, death-censored graft survival, stratified by eGFR-1, demonstrated similar survival, irrespective of donor age or KDPI. The durability of kidney survival decreases as the achieved eGFR-1 declines. KDPI has a poor association with eGFR-1 and lesser for graft durability. While recipients of kidneys > 65 years had a higher one year mortality than younger kidney recipients, recipients of kidneys > 65 years and an eGFR-1 <30 ml/min, had a lower survival than an untransplanted waitlist cohort (p<0.001).

INTERPRETATION

The durability of kidney graft survival after transplantation was associated with the amount of kidney function gained through the transplant (eGFR-1) and the rate of graft loss (return to dialysis) was not significantly associated with donor age. 24.9% of recipients of older donor kidneys failed to achieve sufficient eGFR-1 providing a transplant survival benefit. While there is significant benefit from transplanting older kidneys, better decision-making tools are required to avoid transplanting kidneys that provide insufficient renal function.

FUNDING

None.

Renal surgery for kidney cancer: is preoperative proteinuria a predictor of functional and survival outcomes after surgery? A systematic review of the literature

INTRODUCTION

Proteinuria is considered both a known marker for the severity of Chronic Kidney Disease (CKD) and a robust predictor of future renal function and cardiovascular morbidity and mortality in a general population. The urological community has long overlooked proteinuria as a marker of renal function. Recently, the American Urological Association (AUA) clinical practice guideline addressed this issue and suggested introducing proteinuria assessment prior to kidney cancer surgery. The aim of this systematic review was to provide evidence of proteinuria as a predictor of renal function impairment and survival outcomes after kidney surgery for renal tumors.

EVIDENCE ACQUISITION

A systematic search was performed by using three search engines (PubMed, Embase®, and Web of Science) from January 2010 to November 2020. Study selection followed the PRISMA guidelines. After screening, ten articles and abstracts fully compatible with the PICOS were included in this systematic review.

EVIDENCE SYNTHESIS

Overall, a total of 11,705 patients who underwent partial nephrectomy (PN) or radical nephrectomy (RN) were analyzed. When used as a binomial variable, proteinuria prior to surgery was detected from 10% to 33% of patients. Relying on both proteinuria and estimated glomerular filtration rate (eGFR) in the assessment of renal function yielded up to 33% higher rates of patients with preoperative renal impairment. Moreover, proteinuria increased the risk of long-term renal impairment after PN and RN as well as patients with preoperative proteinuria undergoing PN exhibited a greater risk of postoperative acute kidney injury (AKI). Among eligible studies, proteinuria was associated with diabetes, obesity, metabolic syndrome, hypertension and cardiovascular disease. Finally, proteinuria was an independent predictor of overall mortality, but not of cancer-specific mortality.

CONCLUSIONS

Proteinuria yields a prognostic power beyond that provided by estimated glomerular filtration rate (eGFR) among patients undergoing renal cancer surgery, supporting its introduction in the preoperative assessment of renal function. However, well-designed multicentre prospective studies would be necessary to corroborate these results and provided urological community with high-grade recommendation for clinical practice.

Biomarkers Linked with Dynamic Changes of Renal Function in Asymptomatic and Mildly Symptomatic COVID-19 Patients

The catastrophic coronavirus disease 2019 (COVID-19) pandemic is currently a critical global issue. One well-known complication of COVID-19 in severe cases is acute kidney injury, but no research has given a description of its impact on the kidney in patients with mild symptoms. We explore the renal function changes in mild COVID-19 patients. This retrospective, single-center study included 27 participants with laboratory-detected severe acute respiratory syndrome coronavirus two (SARS-CoV-2) infection who were admitted to the Tri-Service General Hospital from 4 February to 26 May 2020 and analyzed their clinical features, radiological findings, and laboratory data. Data collected upon admission and discharge showed a median estimated glomerular filtration rate (eGFR) of 106.7 mL/min/1.732 m2 and 112.2 mL/min/1.732 m2, respectively, with a p-value of 0.044. A correlation between renal function and the severity of infection was also found and was statistically significant upon admission. Patients with a lower lymphocyte count or higher C-reactive protein, neutrophil count, and neutrophil-to-lymphocyte ratio presented with a decreased eGFR during their early infection phase. The biomarkers (CRP and NLR) may be linked with dynamic changes of renal function in COVID-19 patients who are asymptomatic or have mild symptoms.

Serum 24,25-dihydroxyvitamin D level in general Korean population and its relationship with other vitamin D biomarkers

Background

Vitamin D status is presently assessed by measuring total serum concentration of 25-hydroxyvitamin D [25(OH)D]. However, 25(OH)D concentration alone might not accurately reflect vitamin D status owing to its weak relationship with various clinical indices and inconsistency across races. Recently, 24,25-dihydroxyvitamin D [24,25(OH)₂D] and vitamin D metabolite ratio [VMR; ratio of 24,25(OH)₂D to 25(OH)D] have emerged as vitamin D biomarkers. The present study aimed to determine the values of 24,25(OH)₂D and VMR in healthy Koreans and compare them with other vitamin D biomarkers, including 25(OH)D and bioavailable 25(OH)D.

Methods

Serum samples and medical information were collected from 200 individuals (100 females and 100 males) who underwent general health checks without self-reported symptoms. We measured 24,25(OH)₂D concentration using liquid chromatography–tandem mass spectrometry, and concentrations of 25(OH)D and vitamin D binding protein using immunoassays. VMR and bioavailable 25(OH)D concentration were calculated using the above data. Serum parathyroid hormone level, and bone mineral density (BMD) data were collected as clinical outcomes, and the effects of the vitamin D markers on them were tested using multiple linear regression models.

Results

The mean values of 25(OH)D, 24,25(OH)₂D, VMR, and bioavailable 25(OH)D were 24.3 ± 8.5 ng/mL, 1.9 ± 1.1 ng/mL, 7.6 ± 2.5, and 3.2 ± 1.2 ng/mL, respectively. The concentration of 25(OH)D closely correlated with 24,25(OH)₂D (R = 0.868, P < 0.001) and bioavailable 25(OH)D (R = 0.862, P < 0.001). No significant effects of 24,25(OH)₂D, VMR, and bioavailable 25(OH)D were observed on the prediction of PTH and BMD in the multiple linear regression models.

Conclusion

Our study presents the distribution of 24,25(OH)₂D concentration and VMR in Korean population for the first time. Overall, our data reaffirm that 25(OH)D is the primary marker for determining vitamin D status in the general population.

The Role of Renal Functional Reserve in Predicting Acute Kidney Injury

Renal functional reserve (RFR) is described as the difference between a glomerular filtration rate (GFR) measured at baseline and after protein stimulation. The percent change in GFR after a protein load varies based on differences in experimental conditions, with the use of an oral meat protein stimulus and a creatinine clearance method to quantify GFR showing the greatest RFR. A decline in RFR has been found in numerous patient groups. Recent investigations have suggested that a lower RFR may be associated with an increased risk of acute kidney injury and eventual chronic kidney disease.

Prevalence and factors associated with multimorbidity among primary care patients with decreased renal function

Objectives

To establish the prevalence of multimorbidity in people with chronic kidney disease (CKD) stages 1–5 and transiently impaired renal function and identify factors associated with multimorbidity.

Design and setting

Prospective cohort study in UK primary care.

Participants

861 participants aged 60 and older with decreased renal function of whom, 584 (65.8%) had CKD and 277 (32.2%) did not have CKD.

Interventions

Participants underwent medical history and clinical assessment, and blood and urine sampling.

Primary and secondary outcome measures

Multimorbidity was defined as presence of ≥2 chronic conditions including CKD. Prevalence of each condition, co-existing conditions and multimorbidity were described and logistic regression was used to identify predictors of multimorbidity.

Results

The mean (±SD) age of participants was 74±7 years, 54% were women and 98% were white. After CKD, the next most prevalent condition was hypertension (n = 511, 59.3%), followed by obesity (n = 265, 30.8%) ischemic heart disease (n = 145, 16.8%) and diabetes (n = 133, 15.4%). Having two co-existing conditions was most common (27%), the most common combination of which was hypertension and obesity (29%). One or three conditions was the next most prevalent combination (20% and 21% respectively). The prevalence of multimorbidity was 73.9% (95%CI 70.9–76.8) in all participants and 86.6% (95%CI 83.9–89.3) in those with any-stage CKD. Logistic regression found a significant association between increasing age (OR 1.07, 95%CI 1.04–0.10), increasing BMI (OR 1.15, 95%CI 1.10–1.20) and decreasing eGFR (OR 0.99, 95%CI 0.98–1.00) with multimorbidity.

Conclusions

This analysis is the first to provide an accurate estimate of the prevalence of multimorbidity in a screened older primary care population living with or at risk of CKD across all stages. Hypertension and obesity were the most common combination of conditions other than CKD that people were living with, suggesting that there may be multiple reasons for closely monitoring health status in individuals with CKD.

Diabetes Mellitus and Renal Function: Current Medical Research and Opinion

Diabetes mellitus (DM), which is defined as high blood glucose level, is a major public health issue worldwide. An enormous amount of data has been gathered regarding DM as populations have been living with it for more than a decade; however, continually updating our knowledge of DM remains important. Comorbidities are among the major challenges associated with DM. Poorly controlled DM, especially type 2 DM (T2DM), is considered a risk factor for many diseases, including but not limited to chronic kidney disease (CKD). Complications might appear over time as the aging process changes body functions; moreover, a significant number of antidiabetic medications are eventually cleared by the kidneys, thereby increasing the burden on kidney function and placing diabetic patients at risk. The significantly high number of patients with uncontrolled diabetes resulting from kidney disease shows the impact of this condition on the quality of life of patients. This review presents an overview of the pathophysiology, etiology, and prevalence of CKD and abnormal renal parameters correlated with poorly controlled T2DM, with an emphasis on clinical studies involving the association between vitamin D insufficiency/deficiency and CKD among patients with T2DM.

Infection-Related Acute Care Events among Patients with Glomerular Disease

BACKGROUND AND OBJECTIVES

Infections contribute to patient morbidity and mortality in glomerular disease. We sought to describe the incidence of, and identify risk factors for, infection-related acute care events among Cure Glomerulonephropathy Network (CureGN) study participants.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

CureGN is a prospective, multicenter, cohort study of children and adults with biopsy sample-proven minimal change disease, FSGS, membranous nephropathy, or IgA nephropathy/vasculitis. Risk factors for time to first infection-related acute care events (hospitalization or emergency department visit) were identified using multivariable Cox proportional hazards regression.

RESULTS

Of 1741 participants (43% female, 41% <18 years, 68% White), 163 (9%) experienced infection-related acute care events over a median follow-up of 17 months (interquartile range, 9-26 months). Unadjusted incidence rates of infection-related acute care events were 13.2 and 6.2 events per 100 person-years among pediatric and adult participants, respectively. Among participants with versus without corticosteroid exposure at enrollment, unadjusted incidence rates were 50.6 and 28.6 per 100 person-years, respectively, during the first year of follow-up (adjusted hazard ratio for time to first infection, 1.31; 95% CI, 0.89 to 1.93), and 4.1 and 1.1 per 100 person-years, respectively, after 1 year of follow-up (hazard ratio, 2.99; 95% CI, 1.54 to 5.79). Hypoalbuminemia combined with nephrotic-range proteinuria (serum albumin ≤2.5 g/dl and urinary protein-creatinine ratio >3.5 mg/mg), compared with serum albumin >2.5 g/dl and urinary protein-creatinine ratio ≤3.5 mg/mg, was associated with higher risk of time to first infection (adjusted hazard ratio, 2.49; 95% CI, 1.51 to 4.12).

CONCLUSIONS

Among CureGN participants, infection-related acute care events were common and associated with younger age, corticosteroid exposure, and hypoalbuminemia with proteinuria.

Renal Functional Reserve Is Related to the Nondipping Phenotype and to the Exercise Heart Rate Response in Patients with Essential Hypertension and Preserved Renal Function

BACKGROUND

Renal functional reserve (RFR), defined as the difference between stress and resting glomerular filtration rate (GFR), may constitute a diagnostic tool to identify patients at higher risk of developing acute kidney injury or chronic kidney disease. Blunted RFR has been demonstrated in early stages of hypertension and has been attributed to impaired vascular reactivity due to an overactive sympathetic nervous system (SNS).

OBJECTIVE

The purpose of this study was to investigate whether RFR correlates with other phenotypes expressing overactivity of the SNS in patients with essential hypertension and preserved renal function.

METHODS

Thirty-six patients with untreated essential hypertension and a GFR >60 mL/min/1.73 m2 were enrolled. The following parameters were measured: RFR, 24-h ambulatory blood pressure (BP) profile, a treadmill stress test, and an echocardiographic examination. Urine and venous samples were obtained at specific time points for the determination of clinical parameters, and both resting and stress GFR were calculated by using endogenous creatinine clearance for the measurement of RFR after an acute oral protein load (1 g/kg).

RESULTS

Twenty-one patients had a RFR <30 mL/min/1.73 m2 and 15 had a RFR above this cutoff. A nondipping pattern of 24-h BP was significantly more frequent in patients with low RFR (57.1 vs. 25.0%, p < 0.05 for systolic BP and 52.3 vs. 10.0%, p < 0.02 for diastolic BP). Moreover, patients with lower RFR values showed a blunted heart rate (HR) response to exercise during treadmill test (r = 0.439, p < 0.05). None of the echocardiographic parameters differed between the two groups of patients.

CONCLUSIONS

In hypertensive patients with preserved GFR, reduced RFR is related to nondipping BP phenotype as well as to attenuated exercise HR response. Overactivity of the SNS may be a common pathway. Since loss of RFR may represent a risk factor for acute or chronic kidney injury, hypertensive patients with blunted RFR might need a more careful renal follow-up.

Renal hyperfiltration is independently associated with increased all-cause mortality in individuals with type 2 diabetes: a prospective cohort study

INTRODUCTION

In addition to favoring renal disease progression, renal 'hyperfiltration' has been associated with an increased risk of death, though it is unclear whether and how excess mortality is related to increased renal function. We investigated whether renal hyperfiltration is an independent predictor of death in patients with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events Italian multicenter study.

RESEARCH DESIGN AND METHODS

This observational, prospective cohort study enrolled 15 773 patients with type 2 diabetes consecutively attending 19 Italian diabetes clinics in 2006-2008. Serum creatinine, albuminuria, cardiovascular risk factors, and complications/comorbidities were assessed at baseline. Vital status on 31 October 2015 was retrieved for 15 656 patients (99.26%). Patients were stratified (A) by absolute estimated glomerular filtration rate (eGFR) values in eGFR deciles or Kidney Disease: Improving Global Outcomes (KDIGO) categories and (B) based on age-corrected thresholds or age and gender-specific 95th and 5th percentiles in hyperfiltration, hypofiltration, and normofiltration groups.

RESULTS

The highest eGFR decile/category and the hyperfiltration group included (partly) different individuals with similar clinical features. Age and gender-adjusted death rates were significantly higher in deciles 1, 9, and 10 (≥103.9, 50.9-62.7, and <50.9 mL/min/1.73 m², respectively) versus the reference decile 3 (92.9-97.5 mL/min/1.73 m²). Mortality risk, adjusted for multiple confounders, was also increased in deciles 1 (HR 1.461 (95% CI 1.175 to 1.818), p=0.001), 9 (1.312 (95% CI 1.107 to 1.555), p=0.002), and 10 (1.976 (95% CI 1.673 to 2.333), p<0.0001) versus decile 3. Similar results were obtained by stratifying patients by KDIGO categories. Death rates and adjusted mortality risks were significantly higher in hyperfiltering and particularly hypofiltering versus normofiltering individuals.

CONCLUSIONS

In type 2 diabetes, both high-normal eGFR and hyperfiltration are associated with an increased risk of death from any cause, independent of confounders that may directly impact on mortality and/or affect GFR estimation. Further studies are required to clarify the nature of this relationship.

TRIAL REGISTRATION NUMBER

NCT00715481.

The relationship between intra-parenchymal renal resistive index variation and renal functional reserve in healthy subjects

BACKGROUND

Renal functional reserve can be used as a clinical tool for risk stratification of patients undergoing potentially nephrotoxic procedures. Ultrasound assessment of intra-parenchymal renal resistive index variation-IRRIV test-has been recently proposed as a safe, reproducible, inexpensive and easy to perform technique to identify the presence of renal functional reserve. The present study has been designed to externally validate the IRRIV test in a validation cohort of healthy subjects.

METHODS

We examined data from a group of 47 healthy subjects undergoing protein loading and IRRIV testing. The correlation between IRRIV and renal functional reserve was tested using Pearson correlation analysis. Concordance between presence of renal functional reserve (i.e. a value of renal functional reserve ≥ 15 ml/min/1.73 m²) and IRRIV was evaluated using logistic regression analysis.

RESULTS

We found a significant correlation between IRRIV and renal functional reserve (Pearson correlation coefficient = 0.83 [95% confidence interval (CI) 0.71-0.90; p < 0.01]). Concordance between the presence of renal functional reserve and the IRRIV test was described in 45 (95.7%) subjects. In particular, a negative IRRIV test correctly predicted the absence of renal functional reserve in 5 subjects, while a positive IRRIV test correctly predicted the presence of renal functional reserve in 40 subjects. Only two subjects were incorrectly classified by the IRRIV test. IRRIV predicts renal functional reserve with a ROC-AUC of 0.86 [CI 95% 0.68-1].

CONCLUSIONS

The IRRIV test is an ultrasound technique that significantly predicts the presence and the degree of renal functional reserve in healthy subjects.

GFR in Healthy Aging: an Individual Participant Data Meta-Analysis of Iohexol Clearance in European Population-Based Cohorts

BACKGROUND

Population mean GFR is lower in older age, but it is unknown whether healthy aging is associated with preserved rather than lower GFR in some individuals.

METHODS

We investigated the cross-sectional association between measured GFR, age, and health in persons aged 50-97 years in the general population through a meta-analysis of iohexol clearance measurements in three large European population-based cohorts. We defined a healthy person as having no major chronic disease or risk factors for CKD and all others as unhealthy. We used a generalized additive model to study GFR distribution by age according to health status.

RESULTS

There were 935 (22%) GFR measurements in persons who were healthy and 3274 (78%) in persons who were unhealthy. The mean GFR was lower in older age by -0.72 ml/min per 1.73 m² per year (95% confidence interval [95% CI], -0.96 to -0.48) for men who were healthy versus -1.03 ml/min per 1.73 m² per year (95% CI, -1.25 to -0.80) for men who were unhealthy, and by -0.92 ml/min per 1.73 m² per year (95% CI, -1.14 to -0.70) for women who were healthy versus -1.22 ml/min per 1.73 m² per year (95% CI, -1.43 to -1.02) for women who were unhealthy. For healthy and unhealthy people of both sexes, both the 97.5th and 2.5th GFR percentiles exhibited a negative linear association with age.

CONCLUSIONS

Healthy aging is associated with a higher mean GFR compared with unhealthy aging. However, both the mean and 97.5 percentiles of the GFR distribution are lower in older persons who are healthy than in middle-aged persons who are healthy. This suggests that healthy aging is not associated with preserved GFR in old age.

Length of gestation and birth weight are associated with indices of combined kidney biomarkers in early childhood

Infants born prematurely or with low birth weights are more susceptible to kidney dysfunction throughout their lives. Multiple proteins measured in urine are noninvasive biomarkers of subclinical kidney damage, but few studies have examined the joint effects of multiple biomarkers. We conducted an exploratory study of 103 children in the Programing Research in Obesity, Growth, Environment, and Social Stressors (PROGRESS) longitudinal birth cohort, and measured nine proteins selected a priori in banked spot urine samples collected at ages 4-6. The goal of our study was to explore the combined effects of kidney damage biomarkers previously associated with birth outcomes. To do this, we generated kidney biomarker indices using weighted quantile sum regression and assessed associations with length of gestation or birth weight. A decile increase in each kidney biomarker index was associated with 2-day shorter gestations (β = -2.0, 95% CI: -3.2, -0.9) and 59-gram lower birth weights (β = -58.5, 95% CI: -98.3, -18.7), respectively. Weights highlighting the contributions showed neutrophil gelatinase-associated lipocalin (NGAL) (60%) and osteopontin (19%) contributed most to the index derived for gestational age. NGAL (66%) and beta-2-microglobulin (10%) contributed most to the index derived for birth weight. Joint analyses of multiple kidney biomarkers can provide integrated measures of kidney dysfunction and improved statistical assessments compared to biomarkers assessed individually. Additionally, shorter gestations and lower birth weights may contribute to subclinical kidney damage measurable in childhood.

Urinary cadmium clearance, its relationship to glomerular filtration rate and implications for cadmium epidemiology

Decreasing renal glomerular filtration rate (GFR) in association with increasing blood cadmium levels was reported in epidemiological studies of general populations. Dependence of cadmium clearance on GFR has implications for interpreting causation in these studies. Associations between cadmium clearance and creatinine clearance, a metric of GFR, were evaluated in a sample of the U.S. population. Blood to urine cadmium clearance and serum creatinine clearance were estimated in approximately 6000 individuals included in the National Health and Nutrition Examination Survey (NHANES 2009-2016). Linear regression models explained approximately 45% of variance in cadmium clearance in adults, with 74% of the explained variance attributed to creatinine clearance and 25% explained by age. In adolescents (12-<20 years), linear regression models explained 55% of variance in cadmium clearance with >99% of the explained variance attributed to creatinine clearance. The models predicted that halving creatinine clearance would result in a 40% decrease in cadmium clearance and a 20% rise in blood cadmium. Dependence of cadmium clearance on GFR has implications for assigning causation to studies in which increasing blood cadmium levels have been associated with increasing risk of low GFR. Statistical associations between blood cadmium and low GFR, such as elevated odds ratios in upper percentile strata of populations, may be partially a consequence of lower cadmium clearance in association with low GFR that is reverse causation.

Serum xanthophyll carotenoids are associated with estimated glomerular filtration rate in an aged cohort

Progressive renal decline is associated with increasing oxidative stress. However, the majority of studies have investigated endogenous antioxidants in predominantly advanced stages of kidney disease. Many traditional risk factors associated with renal dysfunction have been linked with cognitive decline as the kidneys and brain share comparable anatomic and haemodynamic characteristics that leave them susceptible to common pathogenic mechanisms. The objective of this study was to examine serum dietary antioxidants and their association with renal function characterised by estimated glomerular filtration rate (eGFR) in a cross-sectional analysis of 570 participants. High performance liquid chromatography quantified serum levels of retinol, α-tocopherol, γ-tocopherol and six carotenoids (α-carotene, β-carotene, β-cryptoxanthin, lutein, lycopene and zeaxanthin) in participants. Multiple regression analyses were used to evaluate associations while adjusting for potential confounders. A sensitivity analysis was performed in cognitively-intact participants only. Serum levels of the xanthophyll carotenoid lutein were positively associated with eGFR in analyses adjusted for age (years), gender, smoking, APOE4 status and Alzheimer’s disease. Retinol was inversely associated with eGFR, although was no longer significant in the smaller sensitivity analysis. Our findings identify significant associations between the xanthophyll carotenoids and eGFR. Further investigations are required to confirm these findings.

CKD: A Call for an Age-Adapted Definition

Current criteria for the diagnosis of CKD in adults include persistent signs of kidney damage, such as increased urine albumin-to-creatinine ratio or a GFR below the threshold of 60 ml/min per 1.73 m2 This threshold has important caveats because it does not separate kidney disease from kidney aging, and therefore does not hold for all ages. In an extensive review of the literature, we found that GFR declines with healthy aging without any overt signs of compensation (such as elevated single-nephron GFR) or kidney damage. Older living kidney donors, who are carefully selected based on good health, have a lower predonation GFR compared with younger donors. Furthermore, the results from the large meta-analyses conducted by the CKD Prognosis Consortium and from numerous other studies indicate that the GFR threshold above which the risk of mortality is increased is not consistent across all ages. Among younger persons, mortality is increased at GFR <75 ml/min per 1.73 m2, whereas in elderly people it is increased at levels <45 ml/min per 1.73 m2 Therefore, we suggest that amending the CKD definition to include age-specific thresholds for GFR. The implications of an updated definition are far reaching. Having fewer healthy elderly individuals diagnosed with CKD could help reduce inappropriate care and its associated adverse effects. Global prevalence estimates for CKD would be substantially reduced. Also, using an age-specific threshold for younger persons might lead to earlier identification of CKD onset for such individuals, at a point when progressive kidney damage may still be preventable.

Influence of Sex on the Progression of Chronic Kidney Disease

The role that sex plays in the development and progression of chronic kidney disease remains a subject of controversy. The lack of clarity in this important area reflects complex interactions between biological factors and cultural and socioeconomic influences that impact the relationship between sex and renal disease. Certainly, additional observational studies are indicated; however, innovative approaches are required to isolate biological processes from cultural influences. Despite these limitations, available data suggest that the progression of renal disease is slower in women than in men and that this sexual dimorphism is primarily due to direct actions of sex hormones on cellular metabolism. The extent to which differences in lifestyle factors between the sexes influence sexual dimorphism in the progression of chronic kidney disease remains to be elucidated.