Prevalence of chronic kidney disease and its association with cardio-metabolic risk factors in the adult Romanian population: the PREDATORR study

Differences in the epidemiology, management and outcomes of kidney disease in men and women

Improved understanding of differences in kidney disease epidemiology, management and outcomes in men and women could help nephrologists to better meet the needs of their patients from a sex- and gender-specific perspective. Evidence of sex differences in the risk and outcomes of acute kidney injury is mixed and dependent on aetiology. Women have a higher prevalence of chronic kidney disease (CKD) stages 3-5 than men, whereas men have a higher prevalence of albuminuria and hence CKD stages 1-2. Men show a faster decline in kidney function, progress more frequently to kidney failure and have higher mortality and risk of cardiovascular disease than women. However, the protective effect of female sex is reduced with CKD progression. Women are less likely than men to be aware of, screened for and diagnosed with CKD, started on antiproteinuric medication and referred to nephrologist care. They also consistently report a poorer health-related quality of life and a higher symptom burden than men. Women experience greater barriers than men to access the waiting list for kidney transplantation, particularly with respect to older age and obesity. However, women also have longer survival than men after transplantation, which may partly explain the comparable prevalence of transplantation between the sexes.

Prevalence and Predictors of Renal Disease in a National Representative Sample of the Romanian Adult Population: Data from the SEPHAR IV Survey

Background: The prevalence of chronic kidney disease (CKD) correlates with the prevalence of hypertension (HT). We studied the prevalence and predictors of CKD in a representative sample of the Romanian adult population. Methods: A sample of 1470 subjects were enrolled in the SEPHAR IV (Study for the Evaluation of Prevalence of Hypertension and Cardiovascular Risk) survey. All subjects were evaluated for blood pressure (BP) and extensive evaluations of target organ damage, blood, and urine samples were undertaken. Results: A total of 883 subjects were included in the statistical analysis. Those experiencing CKD with an eGFR < 60 mL/min/1.73 m2 were older at 71.94 ± 7.4 years (n = 19, 2.15%) compared with those without renal impairment at 50.3 ± 16.21 years (n = 864, 97.85%), p < 0.0001. The prevalence of CKD among hypertensives (379 from 883) was 4.49% (17/379), while 17 out of 19 subjects with CKD had HT (89.47%). After adjusting for age, sex, and diabetic status, only serum uric acid (SUR) > 6.9 mg/dL (OR: 6.61; 95% CI: 2.063, 10.83; p = 0.004) was an independent risk factor and a predictor of CKD. Conclusions: The prevalence of CKD in hypertensive Romanian adults was more than ten times higher than in the normotensive population. Levels of SUR > 6.9 mg/dL were predictors of CKD.

Biomarker Utility for Peripheral Artery Disease Diagnosis in Real Clinical Practice: A Prospective Study

Peripheral arterial disease (PAD) is a common manifestation of generalized atherosclerosis, which affects more than 200 million patients worldwide. Currently, there is no ideal biomarker for PAD risk stratification and diagnosis. The goal of this research was to investigate the levels of inflammation biomarkers and cystatin C and to explore their utility for the diagnosis of PAD. The study included 296 participants, distributed in two groups: 216 patients diagnosed with PAD and 80 patients without PAD as controls. All studied biomarker levels (C-reactive protein, CRP; fibrinogen; erythrocyte sedimentation rate, ESR; neopterin; beta 2-microglobulin, B2-MG; and cystatin C) were significantly higher in the PAD group and indirectly correlated with the ankle-brachial index (ABI). The final logistic regression model included an association of neopterin, fibrinogen, and cystatin C as the most efficient markers for the prediction of PAD diagnosis. When comparing the area under the curve (AUC) for all biomarkers, the value for neopterin was significantly higher than those of all the other analyzed biomarkers. In agreement with previous studies, this research shows that markers such as fibrinogen, CRP, ESR, B2-MG, and cystatin C have significant value for the diagnosis of PAD, and also clearly underlines the accuracy of neopterin as a leading biomarker in PAD prediction.

Risk factors for sexual dysfunction in Romanian women with type 1 diabetes mellitus and chronic autoimmune thyroiditis: a comparative cross-sectional study

BACKGROUND

Female sexual dysfunction (FSD) is one of the chronic complications of diabetes as is male sexual dysfunction, but the former is less studied. Therefore, the aim of this study was to assess of the prevalence and risk factors associated with FSD in Romanian women with type 1 diabetes mellitus (T1DM) and chronic autoimmune thyroiditis (CAT).

METHODS

The study sample included 104 Romanian women with both T1DM and CAT, and 101 Romanian matched controls with only T1DM. The presence of FSD was established using two validated tests: The Female Sexual Function Index and the Female Sexual Distress Scale-revised. The presence of depression was assessed using Beck's Depression Inventory-II.

RESULTS

We found that almost half of the women in the group with T1DM and CAT presented with sexual dysfunction (49 vs. 33.7% in the control group; p = 0.025): 27.9 vs. 8.9 (p < 0.001)-desire, 23.1 vs. 7.9% (p = 0.003)-orgasm, 21.2 vs. 5.9% (p = 0.002)-lubrication, 17.3 vs. 6.9% (p = 0.023)-arousal, 9.6 vs. 1% (p = 0.006)-pain, and 20.2 vs. 9.9% (p = 0.040)-satisfaction problems. Multivariate regression analysis revealed that age was a significant risk factor for FSD, along with DM and body mass index. Coexisting CAT, polyneuropathy, depression, and the use of insulin pumps were significant risk factors for FSD.

CONCLUSIONS

Women with T1DM and CAT are more likely to present with FSD than those without. It is important for patients to address depression, if present, and exercise caution while using insulin pumps. Moreover, DM complications such as polyneuropathy are significant risk factors for FSD; thus, it is crucial to ensure satisfactory glycemic control and optimal DM management.

Preclinical and clinical results regarding the effects of a plant-based antidiabetic formulation versus well established antidiabetic molecules

Diabetes mellitus (DM) is a complex syndrome with debilitating long-term complications, comprising alterations of carbohydrate, protein and lipid metabolisms, along increased oxidative stress and chronic low-grade inflammation. Diet management and plant-based formulations can improve the metabolic status of patients, being used as adjuvants of classic antidiabetic therapy. The purpose of our study was to evaluate the impact of a plant-based antidiabetic formulation (PBAF), containing Vaccinium myrtillus, Ribes nigrum, Rosa canina and Capsicum annuum, on the increased oxidative burden found in diabetes mellitus, comparing it with the effects of metformin and gliclazide. Firstly, we characterized the individual plant-derived components of this formulation and also assessed their in vitro radical scavenging capacity. We devised a preclinical study protocol to examine the impact of the PBAF, along metformin and gliclazide, on tissue histology as well as on the redox status of tissue, mitochondria, serum and serum lipoproteins of alloxan-induced diabetic Wistar rats. Subsequently, we assessed their long-term impact on the redox status of serum and isolated serum lipoproteins of type 2 DM (T2DM) patients, taking into consideration their cardiometabolic profile. In the preclinical stage, we found that PBAF was able to enhance total serum antioxidant defense, while metformin yielded the best results regarding the advanced glycation and protein/lipid oxidation of serum and of serum lipoproteins. The latter also improved overall serum redox status and HDL redox function. Also, antidiabetic treatment seemed to increase mitochondrial redox activity, without overturning overall tissue redox balance. Histologically, liver and brain tissues of treated diabetic rats were fairly similar to those of non-diabetic rats. In T2DM patients, the most striking results involved the effects on serum lipoproteins. The tested PBAF exerted protective antioxidant effects on low-density and, especially, on high density lipoproteins. We conclude that this formulation might constitute a good addition to the well-established pharmacological approach of DM, contributing to the reduction of overall oxidative burden.

Body-mass index and the risk of albuminuria in hypertensive patients with a poor estimated glomerular filtration rate and the potential role of diabetes mellitus

BACKGROUND

Obesity-related to metabolic syndrome was associated with a greater risk for development of chronic kidney disease (CKD). We aimed to assess the association between obesity and micro/macroalbuminuria in hypertensive patients with a poor estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m².

METHODS

One hundred old patients (median age 79 years ± inter-quartile range 68-84.7) with manifested hypertension (systolic blood pressure ≥ 130 mmHg and/or diastolic blood pressure ≥ 85 mmHg) and a permanently poor eGFR for a duration time more than 3 months were enclosed. Albuminuria was defined as urinary albumin-to-creatinine ratio (ACR) ≥ 30 mg/gr and it was classified according to KDIGO 2012. The obesity was defined by a high body mass index (BMI>30 kg/m²). The waist circumference, HDL-C, triglycerides and serum glucose were measured. Chi-square tests and an adjusted model were performed.

RESULTS

Chi-square tests showed significant association between classified albuminuria and both obesity and high serum triglycerides (x² = 7.2, p = 0.02 and x² = 8.3, p = 0.01 respectively). However, the adjusted model for the prediction of albuminuria showed that the presence of a high BMI was a non-significant risk factor, although diabetes mellitus and eGFR value were found to be significant risk factors (p = 0.03, OR = 4.3, 1.2-22.07 and p = 0.04, OR = 0.9, 0.9-1.007 respectively) adjusting to covariates including the high waist circumference.

CONCLUSION

Obesity defined by a high BMI was not found to be a significant risk factor for micro/macroalbuminuria in hypertensive patients with a poor estimated glomerular filtration rate, when diabetes mellitus and the low eGFR value act as confounders.

Prevalence of dyslipidemia and its association with cardiometabolic factors and kidney function in the adult Romanian population: The PREDATORR study

The aims were to assess the prevalence and characteristics of dyslipidemia phenotypes in a Romanian population-based sample from the PREDATORR study.

METHODS

PREDATORR was an epidemiological study with a cross-sectional, cluster random sampling design. Participants were classified into four dyslipidemia phenotypes based on the NCEP ATP III criteria: isolated hypertrigliceridemia, isolated hypoHDL-C, isolated hyperLDL-C and mixed dyslipidemia (≥2 standard lipid abnormalities). Overall, 2656 were included in the analysis by dyslipidemia phenotypes.

RESULTS

An estimated 67.1% of Romanian adults have at least one lipid abnormality: 27.5% (95%CI26.0-28.9%) have elevated TG, 29.4% (95%CI27.9-30.8%) have low HDL-C and 47.8% (95%CI46.3-49.2%) have elevated LDL-C (26.2% had LDL-C levels ≥2.58 mmol/l associated with CHD or CHD risk equivalent). Also, 30% Romanian adults have mixed dyslipidemia with 7.6% (95%CI6.1-9.0%) having all three lipid abnormalities. THE AGE: and sex-adjusted prevalence of isolated dyslipidemia phenotypes in Romanian adult population was 23.7% (95%CI22.2-25.1%) for hyperLDL-Cholesterolemia, 9.3% (95%CI7.8-10.7%) for hypoHDL-Cholesterolemia and 4.1% (95%CI2.6-5.5%) for hypertriglyceridemia. Among participants with triglycerides ≥2.25 mmol/l, 15.2% (95%CI13.7-16.6%) of Romanian adults have non-HDL-C levels ≥3.36 mmol/l.

CONCLUSIONS

The PREDATORR survey indicated a high prevalence of dyslipidemia phenotypes in the Romanian population aged 20-79 years, providing data on its association with several cardiometabolic risk factors.

LONG-TERM IMPROVEMENT OF GLUCOSE HOMEOSTASIS AND BODY COMPOSITION IN PATIENTS UNDERGOING LAPAROSCOPIC SLEEVE GASTRECTOMY

CONTEXT

Laparoscopic sleeve gastrectomy (SG) has gained popularity as a metabolic procedure, but its long-term effectiveness for Romanian patients remains unclear.

OBJECTIVES

To assess the long-term efficacy of SG for Romanian patients and to evaluate the differences between 5 years and 1 year follow-up.

DESIGN

A longitudinal, prospective analysis of collected data from 68 patients undergoing SG between 2009 and 2014 was performed. Long-term outcomes at 5 years were analyzed in terms of total weight loss (%TWL), excess weight loss (%EWL), body composition and glucose homeostasis.

SUBJECTS AND METHODS

All patients meeting the standard criteria for SG before inclusion were prospectively enrolled in the study. Of the 68 patients, eight were lost to follow-up, therefore, 60 patients (41.7±12.5 years, baseline body mass index [BMI] 44.6±9.9Kg/m2) were analyzed.

RESULTS

The BMI decreased at 12 months with 30.7% from the preoperative BMI (p<0.001) and subsequently stabilized at 5 years.TWL and EWL were 30.6% and 83.1%, respectively at 1 year, with a slightly increase at 5 years.Therapeutic success rate (%EWL≥50) and diabetes remission rate (Buchwald criteria) were 93.3% and respectively 63.6% at 5 years. Insulin sensitivity index and metabolic clearance rate of glucose increased with 92.5% and 60.1% respectively, in the third month from baseline (p<0.001), while estimated second phase of insulin secretion decreased with 7.9% in the first month postoperatively (p=0.04), remaining stable afterwards.

CONCLUSIONS

SG was effective in terms of %EWL, body composition and glucose homeostasis improvement for Romanian patients, the outcomes stabilizing after 1 year follow-up.

Metabolic syndrome and its components are associated with increased chronic kidney disease risk: Evidence from a meta-analysis on 11 109 003 participants from 66 studies

BACKGROUND & AIMS

Observational studies examining the relationship between metabolic syndrome and the risk of chronic kidney disease (CKD) have reported inconclusive results. This meta-analysis was performed to resolve these controversies.

METHODS

The MEDLINE, EMBASE, and PubMed databases were systematically searched from their inception until March 2016 to identify all relevant studies. Risk estimates and their corresponding 95% confidence intervals (CIs) for the associations of MetS and its components with CKD risk were extracted and pooled using a random-effects model.

RESULTS

A total of 66 studies, including 18 prospective cohorts and 48 cross-sectional studies, with 699 065 CKD patients and 11 109 003 participants were included in the meta-analysis. When all definitions were pooled, the presence of MetS was associated with a significant 50% increase of CKD risk (OR = 1.50, 95% CI = 1.43-1.56), with evidence of moderate heterogeneity (I2  = 72.3%, P < .001). The risk of CKD associated with MetS was higher in studies using the American Heart Association/National Heart, Lung, and Blood Institute criteria (OR = 1.68, 95% CI = 1.25-2.10) compared with those using the Adult Treatment Panel III (OR = 1.49, 95% CI = 1.42-1.56) and the International Diabetes Federation (OR = 1.32, 95% CI = 1.22-1.41) definitions. This relationship was independent of diabetes status. Moreover, all individual components of the MetS were significantly associated with CKD, and their coexistence resulted in an escalating dose-response relationship. The sensitivity and subgroup analyses established the stability of the findings.

CONCLUSIONS

This meta-analysis strongly suggests that the metabolic syndrome and its components are independently associated with the increased risk of CKD.

Metabolic Syndrome and Chronic Renal Disease

Background: The influence of metabolic syndrome (MetS) on kidneys is related to many complications. We aimed to assess the association between MetS and chronic renal disease defined by a poor estimated glomerular filtration rate (eGFR) and/or the presence of microalbuminuria/macroalbuminuria.

METHODS

149 patients (77 males/72 females) were enrolled in the study. Chronic renal disease was defined according to KDIGO 2012 criteria based on eGFR category and classified albuminuria. MetS was studied as a dichotomous variable (0 to 5 components) including hypertension, waist circumference, low HDL-cholesterol, high triglycerides, and high glucose. Results: The association between clustering MetS and both classified eGFR and classified albuminuria (x² = 50.3, p = 0.001 and x² = 26.9, p = 0.003 respectively) was found to be significant. The MetS presence showed an odds 5.3-fold (1.6-17.8) higher for low eGFR and 3.2-fold (1.2-8.8) higher for albuminuria in combination with the presence of diabetes mellitus, which also increased the risk for albuminuria by 3.5-fold (1.1-11.3). Albuminuria was significantly associated with high triglycerides, hypertension, high glucose (x² = 11.8, p = 0.003, x² = 11.4, p = 0.003 and x² = 9.1, p = 0.01 respectively), and it was mildly associated with a low HDL-C (x² = 5.7, p = 0.06). A significant association between classified eGFR and both high triglycerides and hypertension (x² = 9.7, p = 0.04 and x² = 16.1, p = 0.003 respectively) was found. Conclusion: The clustering of MetS was significantly associated with chronic renal disease defined by both classified eGFR and albuminuria. The definition of impaired renal function by classified albuminuria was associated with more MetS components rather than the evaluation of eGFR category. MetS may contribute to the manifestation of albuminuria in patients with diabetes mellitus.

Metabolic Syndrome and Chronic Renal Disease

Background: The influence of metabolic syndrome (MetS) on kidneys is related to many complications. We aimed to assess the association between MetS and chronic renal disease defined by a poor estimated glomerular filtration rate (eGFR) and/or the presence of microalbuminuria/macroalbuminuria.

METHODS

149 patients (77 males/72 females) were enrolled in the study. Chronic renal disease was defined according to KDIGO 2012 criteria based on eGFR category and classified albuminuria. MetS was studied as a dichotomous variable (0 to 5 components) including hypertension, waist circumference, low HDL-cholesterol, high triglycerides, and high glucose. Results: The association between clustering MetS and both classified eGFR and classified albuminuria (x² = 50.3, p = 0.001 and x² = 26.9, p = 0.003 respectively) was found to be significant. The MetS presence showed an odds 5.3-fold (1.6-17.8) higher for low eGFR and 3.2-fold (1.2-8.8) higher for albuminuria in combination with the presence of diabetes mellitus, which also increased the risk for albuminuria by 3.5-fold (1.1-11.3). Albuminuria was significantly associated with high triglycerides, hypertension, high glucose (x² = 11.8, p = 0.003, x² = 11.4, p = 0.003 and x² = 9.1, p = 0.01 respectively), and it was mildly associated with a low HDL-C (x² = 5.7, p = 0.06). A significant association between classified eGFR and both high triglycerides and hypertension (x² = 9.7, p = 0.04 and x² = 16.1, p = 0.003 respectively) was found. Conclusion: The clustering of MetS was significantly associated with chronic renal disease defined by both classified eGFR and albuminuria. The definition of impaired renal function by classified albuminuria was associated with more MetS components rather than the evaluation of eGFR category. MetS may contribute to the manifestation of albuminuria in patients with diabetes mellitus.

Associations of smoking with cardiometabolic profile and renal function in a Romanian population-based sample from the PREDATORR cross-sectional study

BACKGROUND

The impact of smoking on morbidity is well known, but in Romania, limited data are available regarding the smoking prevalence and relationship with cardiometabolic profile and kidney function.

OBJECTIVES

To assess the association of smoking with cardiometabolic traits and kidney function, in a Romanian population-based sample from the PREDATORR study.

METHODS

PREDATORR was an epidemiological cross-sectional study. Between 2012 and 2014, participants were randomly selected from the lists of general practitioners and enrolled if they were aged 20 to 79 years, born and living in the past 10 years in Romania. Sociodemographic and lifestyle characteristics were collected through interviewer-administered questionnaires.

RESULTS

Overall, 2704 participants were included in the analysis, 18% of them being current smokers and 30.8% former smokers. Current smokers compared to non-smokers had higher total cholesterol (220.6 ± 50.4 versus 213.9 ± 86.8 mg/dl, P = 0.017), LDL-cholesterol (137.8 ± 45.2 versus 130.7 ± 83.7 mg/dl, P = 0.004) and glomerular filtration rate (96.9 ± 16.8 versus 90.7 ± 19.1 ml/min/1.73 m2, P <0.001) in women and higher triglycerides (170.7 ± 129.8 versus 144.3 ± 94.2 mg/dl, P = 0.007), glomerular filtration rate (97.6 ± 17 versus 90.3 ± 18 ml/min/1.73 m2, P < 0.001) and lower HDL-cholesterol (48 ± 15.5 versus 50.4 ± 14.1 mg/dl, P = 0.002) in men. Active smoking was associated with hypercholesterolaemia [OR: 1.40 (95% CI: 1.01-1.96), P = 0.04] and low HDL-cholesterolaemia [OR: 1.39 (95% CI: 1.01-1.91), P = 0.04] and negatively associated with overweight/obesity [OR: 0.67 (95% CI: 0.48-0.94), P = 0.02]. Male former smokers had higher prevalence of abdominal obesity (82.4% versus 76.4%, P = 0.02), hypertriglyceridaemia (43.6% versus 35.6%, P = 0.01), hypertension (64% versus 56.4%, P = 0.01) and ischaemic vascular disease (40.5% versus 30.9%, P = 0.003) than male non-smokers.

CONCLUSION

The PREDATORR study showed a high prevalence of smoking in the adult Romanian population providing data on the association of smoking with cardiometabolic traits.

Establishing the presence or absence of chronic kidney disease: Uses and limitations of formulas estimating the glomerular filtration rate

The development of formulas estimating glomerular filtration rate (eGFR) from serum creatinine and cystatin C and accounting for certain variables affecting the production rate of these biomarkers, including ethnicity, gender and age, has led to the current scheme of diagnosing and staging chronic kidney disease (CKD), which is based on eGFR values and albuminuria. This scheme has been applied extensively in various populations and has led to the current estimates of prevalence of CKD. In addition, this scheme is applied in clinical studies evaluating the risks of CKD and the efficacy of various interventions directed towards improving its course. Disagreements between creatinine-based and cystatin-based eGFR values and between eGFR values and measured GFR have been reported in various cohorts. These disagreements are the consequence of variations in the rate of production and in factors, other than GFR, affecting the rate of removal of creatinine and cystatin C. The disagreements create limitations for all eGFR formulas developed so far. The main limitations are low sensitivity in detecting early CKD in several subjects, e.g., those with hyperfiltration, and poor prediction of the course of CKD. Research efforts in CKD are currently directed towards identification of biomarkers that are better indices of GFR than the current biomarkers and, particularly, biomarkers of early renal tissue injury.

Contribution of monoamine oxidases to vascular oxidative stress in patients with end-stage renal disease requiring hemodialysis

Arteriovenous fistula (AVF) is the "lifeline" for patients with end-stage renal disease (ESRD) undergoing hemodialysis. AVF maturation failure is a poorly understood process, one of the contributors being endothelial dysfunction due to oxidative stress. Monoamine oxidases (MAOs) A and B were recently identified as novel sources of vascular oxidative stress. The aim of the present study was to assess the contribution of MAOs to the endothelial dysfunction in patients with ESDR with indication of hemodialysis. Fragments of brachial artery collaterals were harvested from ESRD patients during the surgical procedure aimed at creating the vascular access in the cubital fossa. The effect of increasing concentrations (10, 30, 100 μmol/L) of the irreversible MAO-A inhibitor, clorgyline, and MAO-B inhibitor, selegiline, on endothelial-dependent relaxation (EDR) in response to cumulative doses of acetylcholine was studied in isolated phenylephrine-preconstricted vascular rings. Hydrogen peroxide (H₂O₂) production was assessed using ferrous oxidation xylenol orange assay. We showed that incubation of brachial rings with MAO inhibitors significantly improved EDR and attenuated H₂O₂ generation in patients with ESRD. MAO-related oxidative stress might contribute to the primary dysfunction/non-maturation of the AVF and MAO inhibitors could improve maturation and long-term patency of the vascular access in dialysis patients.