Increased end-stage renal disease risk in patients with inflammatory bowel disease: A nationwide population-based study

Estimated Glomerular Filtration Rate and the Risk of Inflammatory Bowel Disease in Adults: A Swedish Population-Based Study

BACKGROUND

Kidney complications are common in patients with long-standing inflammatory bowel disease (IBD). Whether kidney complications, defined as low estimated glomerular filtration rate (eGFR), may predispose to later IBD is unknown.

METHODS

We analyzed the association between eGFR and the risk of being subsequently diagnosed with IBD among 1 612 160 adults from Stockholm. The exposure was categories of eGFR, with 90 to 104 mL/min/1.73 m2 as the reference. Cox regression models were used to investigate the association between eGFR, IBD, and IBD subtypes. Subgroup analyses included age strata, sex, education, and comorbidities. To explore the possibility of detection bias or reverse causation, we estimated IBD hazard ratios (HRs) after excluding cases and individuals censored during early years of follow-up.

RESULTS

During a median of 9 years of follow-up, we detected 9663 cases of IBD (3299 Crohn's disease, 5072 ulcerative colitis, 1292 IBD unclassified). Lower eGFR levels were associated with higher IBD risk (for eGFR 30-59 mL/min/1.73 m2: adjusted HR, 1.15; 95% confidence interval [CI], 1.01-1.33; and for eGFR <30 mL/min/1.73 m2: adjusted HR, 1.65; 95% CI, 1.16-2.37). This association was stronger in magnitude for Crohn's disease (for eGFR 30-59 mL/min/1.73 m2: HR, 1.33, 95% CI, 1.04-1.72; and for eGFR <30 mL/min/1.73 m2: HR, 2.25; 95% CI, 1.26-3.99). Results were consistent across strata of age, comorbidities, and attained education but suggested the association between eGFR and IBD to be stronger in women (P for interaction <.05). Results attenuated but were robust to exclusion of early IBD cases.

CONCLUSIONS

We observed an association between reduced eGFR and the risk of developing IBD, which was stronger in magnitude for Crohn's disease.

Association of Inflammatory Bowel Disease with Incident IgA Nephropathy

Key Points

Background

There have been scarce epidemiologic data on the relationship between inflammatory bowel disease and the incidence of IgA nephropathy. In this study, we assessed whether inflammatory bowel disease was associated with a higher risk of developing IgA nephropathy using a large-scale epidemiologic cohort.

Methods

We retrospectively analyzed 4,311,393 adults enrolled in the JMDC Claims Database (previously known as the Japan Medical Data Center database), a nationwide epidemiologic database in Japan. The definitions of IgA nephropathy and inflammatory bowel disease (ulcerative colitis or Crohn disease) were based on International Classification of Diseases, 10th Revision codes. Individuals who had a history of IgA nephropathy were excluded. Study participants were categorized into two groups according to the presence of inflammatory bowel disease. Clinical outcomes were collected between January 2005 and May 2022. The primary outcome was incident IgA nephropathy.

Results

Median (interquartile range) age was 44 (36–53) years, and 2,497,313 (58%) were men. Inflammatory bowel disease was observed in 18,623 individuals (0.4%). Over a median follow-up of 1089 (532–1797) days, there were 2631 incidences of IgA nephropathy and 22 incidences in individuals without and with inflammatory bowel disease, yielding incident ratios with 95% confidence intervals of 1.74 (1.68–1.81) and 3.43 (2.26–5.21), respectively. Kaplan–Meier curves and the log-rank test showed that a cumulative incidence of IgA was higher in individuals with inflammatory bowel disease compared with those without (log-rank P = 0.0028). Multivariable Cox regression analysis demonstrated that individuals with inflammatory bowel disease were at higher risk of incident IgA nephropathy (hazard ratio, 1.96; 95% confidence interval, 1.29 to 2.99).

Conclusions

We demonstrated the potential association of inflammatory bowel disease with higher risk of developing IgA nephropathy in a general population.

Anti-Tumor Necrosis Factor Therapy and Risk of Kidney Function Decline and Mortality in Inflammatory Bowel Disease

Importance

Inflammatory bowel disease (IBD) is associated with adverse clinical outcomes, including chronic kidney disease and mortality, due in part to chronic inflammation. Little is known about the effects of anti-tumor necrosis factor (TNF) therapy on kidney disease progression and mortality among patients with new-onset IBD.

Objective

To examine the association of incident use of TNF inhibitors with subsequent decline in kidney function and risk of all-cause mortality.

Design, Setting, and Participants

This retrospective cohort study used data from the US Department of Veterans Affairs health care system. Participants were US veterans with new-onset IBD enrolled from October 1, 2004, through September 30, 2019. Data were analyzed from December 2022 to February 2024.

Exposures

Incident use of TNF inhibitors.

Main Outcomes and Measures

The main outcomes were at least 30% decline in estimated glomerular filtration rate (eGFR) and all-cause mortality.

Results

Among 10 689 patients (mean [SD] age, 67.4 [12.3] years; 9999 [93.5%] male) with incident IBD, 3353 (31.4%) had diabetes, the mean (SD) baseline eGFR was 77.2 (19.2) mL/min/1.73 m2, and 1515 (14.2%) were newly initiated on anti-TNF therapy. During a median (IQR) follow-up of 4.1 (1.9-7.0) years, 3367 patients experienced at least 30% decline in eGFR, and over a median (IQR) follow-up of 5.0 (2.5-8.0) years, 2502 patients died. After multivariable adjustments, incident use (vs nonuse) of TNF inhibitors was significantly associated with higher risk of decline in eGFR (adjusted hazard ratio [HR], 1.34 [95% CI, 1.18-1.52]) but was not associated with risk of all-cause mortality (adjusted HR, 1.02 [95% CI, 0.86-1.21]). Similar results were observed in sensitivity analyses.

Conclusions and Relevance

In this cohort study of US veterans with incident IBD, incident use (vs nonuse) of TNF inhibitors was independently associated with higher risk of progressive eGFR decline but was not associated with risk of all-cause mortality. Further studies are needed to elucidate potentially distinct pathophysiologic contributions of TNF inhibitor use to kidney and nonkidney outcomes in patients with IBD.

Absolute and Relative Risks of Kidney and Urological Complications in Patients With Inflammatory Bowel Disease

INTRODUCTION

The burden of kidney and urological complications in patients with inflammatory bowel disease (IBD) remains poorly characterized.

METHODS

We analyzed association between developing IBD (as a time-varying exposure) and relative risks of receiving diagnoses of chronic kidney disease (CKD), acute kidney injury (AKI), or kidney stones, and experiencing a clinically-relevant decline in estimated glomerular filtration rate (eGFR) (CKD progression; composite of kidney failure or an eGFR decline ≥30%) in 1,682,795 individuals seeking healthcare in Stockholm, Sweden, during 2006-2018. We quantified 5- and 10-year absolute risks of these complications in a parallel matched cohort of IBD cases and random controls matched (1:5) on sex, age, and eGFR.

RESULTS

During median 9 years, 10,117 participants developed IBD. Incident IBD was associated with higher risks of kidney-related complications compared with non-IBD periods: hazard ratio (HR) (95% confidence interval) was 1.24 (1.10-1.40) for receiving a CKD diagnosis and 1.11 (1.00-1.24) for CKD progression. For absolute risks, 11.8% IBD cases had a CKD event within 10-year. Of these, 6.4% received a CKD diagnosis, and 7.9% reached CKD progression. The risks of AKI (HR 1.97 [1.70-2.29]; 10-year absolute risk 3.6%) and kidney stones (HR 1.69 [1.48-1.93]; 10-year absolute risk 5.6%) were also elevated. Risks were similar in Crohn's disease and ulcerative colitis.

DISCUSSION

More than 10% of patients with IBD developed CKD within 10-year from diagnosis, with many not being identified through diagnostic codes. This, together with their elevated AKI and kidney stone risks, highlights the need of established protocols for kidney function monitoring and referral to nephrological/urological care for patients with IBD.

Inflammatory Bowel Disease With Chronic Kidney Disease and Acute Kidney Injury

INTRODUCTION

It remains unclear whether inflammatory bowel disease is associated with long-term risk of chronic kidney disease (CKD) and acute kidney injury (AKI) in the general population.

METHODS

A total of 417,302 participants, including 2,940 patients with ulcerative colitis and 1,261 patients with Crohn's disease, without previous CKD and AKI at baseline (2006-2010) from the UK Biobank were included. The study outcomes included incident CKD and AKI, ascertained by self-report data and data linkage with primary care, hospital admissions, and death registry records. Analysis was conducted in 2022.

RESULTS

During a median follow-up of 12.5 years, 13,564 and 14,331 participants developed CKD and AKI, respectively. Compared with the hazard ratio for non-inflammatory bowel diseases, the hazard ratios for CKD and AKI related to inflammatory bowel diseases were 1.57 (95% CI=1.37, 1.79) and 1.96 (95% CI=1.74, 2.20) after adjustments for age, sex, and race and were 1.32 (95% CI=1.15, 1.51) and 1.70 (95% CI=1.51, 1.91) after further adjustments for biological, behavioral, and socioeconomic factors in addition to mental health and self-rated health. Similar results were found for patients with Crohn's disease (adjusted hazard ratio=1.38 (95% CI=1.09, 1.75) for CKD and 1.62 [95% CI=1.30, 2.02] for AKI) and those with ulcerative colitis (adjusted hazard ratio=1.29 (95% CI=1.09, 1.51) for CKD and 1.71 [95% CI=1.49, 1.97] for AKI) in the fully adjusted models. Genetic risks of kidney diseases did not significantly affect the association of inflammatory bowel disease with incident CKD and AKI (both p-interactions>0.05). The association between inflammatory bowel disease and the risk of incident CKD (p-interaction=0.010) and AKI (p-interaction<0.001) were stronger in younger participants than in older participants.

CONCLUSIONS

Inflammatory bowel disease was associated with higher risks for CKD and AKI, independent of genetic risks of kidney diseases.

Association between inflammatory bowel disease, nephrolithiasis, tubulointerstitial nephritis, and chronic kidney disease: A propensity score-matched analysis of US nationwide inpatient sample 2016-2018

OBJECTIVES

The incidence and prevalence of inflammatory bowel disease (IBD), mainly including ulcerative colitis (UC) and Crohn's disease (CD), are increasing globally. We aimed to evaluate the potential association between IBD and nephrolithiasis, tubulointerstitial nephritis, and chronic kidney disease (CKD).

METHODS

Data of hospitalized adults ≥20 years of age were extracted from the U.S. National Inpatient Sample (NIS) during 2016-2018. Patients with UC, CD, or CKD were identified through the International Classification of Diseases, Tenth Revision (ICD-10) codes. Propensity score matching (PSM) analysis (1:1) was conducted to balance the characteristics between groups. Logistic regression analyses were performed to determine the relationships between UC or CD and kidney conditions.

RESULTS

Three cohorts were included for analysis after PSM analysis. Cohorts 1, 2 and 3 contained 235 262 subjects (117 631 with CD or without IBD), 140 856 subjects (70 428 with UC or without IBD), and 139 098 subjects (69 549 with CD or UC), respectively. Multivariate analysis revealed that compared to non-IBD individuals, CD patients were significantly associated with greater odds for nephrolithiasis (adjusted odds ratio [aOR] 2.25, 95% confidence interval [CI] 2.08-2.43), tubulointerstitial nephritis (aOR 1.31, 95% CI 1.24-1.38), CKD at any stage (aOR 1.28, 95% CI 1.24-1.32), and moderate-to-severe CKD (aOR 1.22, 95% CI 1.17-1.26), while UC was associated with a higher rate of nephrolithiasis. Compared to UC, CD was associated with higher odds for all such kidney conditions.

CONCLUSIONS

Patients with CD are more likely to have nephrolithiasis, tubulointerstitial nephritis, CKD at any stage, and moderate-to-severe CKD compared to non-IBD individuals.

Enteroendocrine cells and gut hormones as potential targets in the crossroad of the gut-kidney axis communication

Recent studies suggest that disruptions in intestinal homeostasis, such as changes in gut microbiota composition, infection, and inflammatory-related gut diseases, can be associated with kidney diseases. For instance, genomic investigations highlight how susceptibility genes linked to IgA nephropathy are also correlated with the risk of inflammatory bowel disease. Conversely, investigations demonstrate that the use of short-chain fatty acids, produced through fermentation by intestinal bacteria, protects kidney function in models of acute and chronic kidney diseases. Thus, the dialogue between the gut and kidney seems to be crucial in maintaining their proper function, although the factors governing this crosstalk are still emerging as the field evolves. In recent years, a series of studies have highlighted the significance of enteroendocrine cells (EECs) which are part of the secretory lineage of the gut epithelial cells, as important components in gut-kidney crosstalk. EECs are distributed throughout the epithelial layer and release more than 20 hormones in response to microenvironment stimuli. Interestingly, some of these hormones and/or their pathways such as Glucagon-Like Peptide 1 (GLP-1), GLP-2, gastrin, and somatostatin have been shown to exert renoprotective effects. Therefore, the present review explores the role of EECs and their hormones as regulators of gut-kidney crosstalk and their potential impact on kidney diseases. This comprehensive exploration underscores the substantial contribution of EEC hormones in mediating gut-kidney communication and their promising potential for the treatment of kidney diseases.

Inflammatory bowel disease increases the levels of albuminuria and the risk of urolithiasis: a two-sample Mendelian randomization study

BACKGROUND

Alterations in kidney function and increased risk of kidney diseases in patients with inflammatory bowel disease (IBD) have been reported, but the causal relationship remains unclear. Herein, Mendelian randomization was employed to identify the causal effect of inflammatory bowel disease on kidney function and the risk of chronic kidney disease (CKD), urolithiasis, and IgA nephropathy.

METHODS

The International Inflammatory Bowel Disease Genetics Consortium provided the summary-level genome-wide association study (GWAS) data that correlates with Crohn's disease (CD) and ulcerative colitis (UC). GWAS data for estimated glomerular filtration rate from serum creatinine (eGFRcrea), urine albumin-creatinine ratio (uACR), and CKD were obtained from the CKDGen Consortium, and GWAS data for urolithiasis were obtained from the FinnGen consortium. The summary-level GWAS data for IgA nephropathy were obtained from the meta-analysis of UK-biobank, FinnGen, and Biobank Japan. Inverse-variance weighted was used as the primary estimate. Furthermore, the Steiger test was used to validate the direction of causality.

RESULTS

The inverse-variance weighted data revealed that genetically predicted UC significantly increased uACR levels, while genetically predicted CD significantly increased the risk of urolithiasis.

CONCLUSIONS

UC increases the levels of uACR, and CD increases the risk of urolithiasis.

Depression and anxiety are associated with poor outcomes in patients with inflammatory bowel disease: A nationwide population-based cohort study in South Korea

BACKGROUND

Prevalence of depression and anxiety are known to be increased in patients with inflammatory bowel disease (IBD), but it is unclear whether such elevations adversely affect IBD outcomes.

OBJECTIVE

We aimed to investigate the association between depression or anxiety and clinical outcomes of IBD.

METHOD

Using claims data from the South Korean National Health Insurance Service (NHIS), patients with IBD were identified by codes of the International Classification of Disease, 10th Revision (ICD-10) and the Rare/Intractable Disease (RID) registration program for years 2010 to 2017. ICD-10 codes were also used to identify depression and anxiety in this population. Primary study endpoints were IBD-related outcomes, including emergency room (ER) visits, hospitalizations, and surgeries during the follow-up period.

RESULTS

Our cohort included 32,867 patients with IBD, of whom 3794 (11.5%) experienced depression and anxiety during the 6-year median follow-up period. In multivariate analysis, comorbid depression and anxiety were associated with increased risks of ER visits (hazard ratio [HR] = 1.34, 95% confidence interval [CI]: 1.19-1.51) and hospitalizations (HR = 1.24, 95% CI: 1.12-1.37), whereas surgical risk was not different for IBD patients with and without depression and anxiety. There was no differential effect of depression and anxiety on outcomes in IBD patients, but depression was more closely associated with outcomes in CD patients and anxiety in UC patients.

CONCLUSION

In patients with IBD, comorbid depression and anxiety are associated with increased risks of ER visits and hospitalizations, but not surgery. These associations are more pronounced for depression in CD patients and for anxiety in UC patients.

Glomerulonephritis and inflammatory bowel disease: A tale of gut-kidney axis dysfunction

The incidence and prevalence of Inflammatory Bowel Disease (IBD) has increased over the past decades, imposing a growing socioeconomic burden on healthcare systems globally. Most of the morbidity and mortality related to IBD is typically attributed to gut inflammation and its complications; yet the disease is characterized by various extraintestinal manifestations that can be severe. Glomerulonephritis (GN) is of particular interest since a significant proportion of patients evolve into end-stage kidney disease, requiring kidney replacement therapy and associated with high morbidity and mortality. Herein, we review the GN landscape in IBD and define the clinical and pathogenic associations reported to date in the literature. Underlying pathogenic mechanisms suggest either the initiation of antigen-specific immune responses in the inflamed gut that cross react with non-intestinal sites, such as the glomerulus, or that extraintestinal manifestations are gut-independent events that occur due to an interaction between common genetic and environmental risk factors. We present data associating GN with IBD either as a bona fide extraintestinal manifestation or reporting it as an extraneous co-existing entity, involving various histological subtypes, such as focal segmental glomerulosclerosis, proliferative GN, minimal change disease, crescentic GN, but most emphatically IgA nephropathy. Supporting the pathogenic interplay between gut inflammation and intrinsic glomerular processes, enteric targeting the intestinal mucosa with budesonide reduced IgA nephropathy-mediated proteinuria. Elucidating the mechanisms at play would provide insight not only into IBD pathogenesis but also into the gut's role in the development of extraintestinal diseases, such as glomerular diseases.

Kidney Biopsy Findings and Clinical Outcomes of US Veterans with Inflammatory Bowel Disease

Introduction

Patients with inflammatory bowel disease (IBD; ulcerative colitis [UC] and Crohn's disease [CD]) may have unique patterns of kidney injury related to their underlying or coexisting disease or to medications. We present the kidney biopsy findings and clinical outcomes of veterans with UC or CD from the US Department of Veteran's Affairs (VA) health system.

Methods

Histopathologic and clinical data were extracted by retrospective review of the VA electronic health record of patients with IBD and a kidney biopsy between 2000 and 2018. Incident end-stage kidney disease (ESKD) was defined as requirement of kidney replacement therapy. Statistical analyses were performed using SAS.

Results

A total of 140 patients (UC: 91 and CD: 49) underwent kidney biopsy. The three most common diagnoses were IgA nephropathy (17.1%), diabetic nephropathy (14.3%), and acute interstitial nephritis (9.3%). Significant interstitial fibrosis, tubular atrophy, and arteriosclerosis were present in 45% of biopsies. Twenty-six percent of patients with UC and 20% of those with CD progressed to ESKD, with a mean time from kidney biopsy of 3.1 and 1.9 years, respectively. Forty-five percent of patients with UC and 34% of those with CD died, with a mean time from kidney biopsy of 4.3 and 4.6 years, respectively.

Conclusion

Among US veterans with IBD who underwent a kidney biopsy, IgA nephropathy, diabetic nephropathy, and interstitial nephritis were among the most common findings. Additionally, features of advanced kidney disease with rapid clinical progression to ESKD or death were observed. These findings suggest a delay and possibly a low rate of diagnosis.

Association of immune-mediated inflammatory diseases with depression and anxiety in patients with type 2 diabetes: A nationwide population-based study

Objective

Patients with type 2 diabetes (T2DM) are at a high risk of developing depression and anxiety. To better stratify the risk, we aimed to assess whether the presence of immune-mediated inflammatory diseases (IMIDs) confers a higher risk of depression and anxiety in these patients.

Methods

Patients with T2DM without prior depression or anxiety who underwent national health examination between 2009 and 2012 (n = 1,612,705) were enrolled from the nationwide health check-up data from Korean National Health Insurance Service. The outcome events were incident depression and anxiety, defined as International Classification of Diseases, 10th Revision codes F32-F33 and F40-F41, respectively. Multivariable Cox proportional hazard regression analyses were conducted to estimate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) according to the existence of IMIDs.

Results

Over an average follow-up time of 6.4 years, existence of gut IMIDs was associated with a higher risk of depression (aHR: 1.28 [95% CI: 1.08-1.53]) and anxiety (1.22 [1.06-1.42]). Existence of joint IMIDs was associated with a higher risk of depression (1.34 [1.31-1.37]) and anxiety (1.31 [1.29-1.34]). Existence of skin IMID was associated with a higher risk of depression (1.18 [1.14-1.23]) and anxiety (1.13 [1.09-1.16]). The effect sizes of IMIDs on depression and anxiety were larger in those with ≥ 2 IMIDs (1.42 [1.19-1.69] and 1.49 [1.29-1.72], respectively) than in those with one IMID (1.30 [1.27-1.32] and 1.26 [1.24-1.28], respectively).

Conclusion

In patients with T2DM, presence of IMIDs was associated with a higher risk of depression and anxiety. More stringent attention and screening for anxiety and depression should be encouraged in patients with T2DM and comorbid IMIDs due to clinical implications of psychological distress on patient-reported outcomes and prognosis.

Spectrum and prognosis of renal histopathological lesions in patients with inflammatory bowel disease: a cross-sectional study from a single center in China

To explore the spectrum, clinicopathological features and prognosis of patients with inflammatory bowel disease (IBD) including Crohn's disease (CD) and ulcerative colitis (UC) with renal involvement. Included in this cross-sectional study were 36 IBD patients, in whom renal biopsy was performed to analyze the histological pattern and prognosis. Renal histopathology was examined by light microscopy and immunofluorescence using the standard procedures. Renal function decline was defined as a twofold increase in serum creatinine (SCr) after biopsy, initiation of dialysis and transplantation. Of the 36 IBD patients (22 UC and 14 CD), renal biopsy was performed in 33 cases. Compared with UC patients, CD patients were significantly younger at presentation and had a higher proportion of chronic renal insufficiency (CRI). The most common renal histological pattern in the 33 biopsy cases was IgA nephropathy (66.6%), followed by membrane nephropathy (9.1%), amyloidosis (9.1%), tubulointerstitial nephritis (9.1%), and membranoproliferative glomerulonephritis (6.1%). Renal function decline occurred in 4 patients (1 with amyloidosis, 1 with TIN and 2 with CRI). Factors associated with renal function decline included CD and a higher SCr level at presentation. Urinalysis and renal function test should be routinely examined in IBD patients. Renal biopsy can provide useful information about the histological patterns and therefore should be considered in IBD patients with renal lesions.

Renal manifestations in inflammatory bowel disease: a systematic review

As extra-intestinal manifestations (EIMs) are frequent in inflammatory bowel disease (IBD) and affect morbidity and sometimes even mortality, vigilance in the surveillance of EIMs and installing the appropriate treatment are essential. Data on renal manifestations in patients with IBD are however rare. Nevertheless, up to 5-15% of adult patients with IBD will develop chronic kidney disease over time. The pathophysiology of renal involvement in patients with IBD is complex and poorly understood, with a wide range of renal disorders affecting the glomeruli and/or the tubular structure. Furthermore, medication used to treat IBD can be potentially nephrotoxic and metabolic complication due to the disease itself can furthermore cause renal damage. The aim of this systematic review is to provide an overview of the existing data in literature on these renal manifestations and complications in patients with IBD.

The pathological and outcome characteristics of renal lesions in Crohn's disease

Background

The inflammatory bowel disease, containing Crohn’s disease and ulcerative colitis, was rare in the population, especially in the complication of kidney disease. A few studies had found proteinuria played a potential indicator of inflammatory bowel disease occurrence and activity. This study aimed to better define the histopathologic spectrum and study the outcome of renal disease in Crohn’s disease.

Methods

A retrospective study of 3557 Crohn's disease from January 1^st, 2016 to July 1^st, 2021 in the Sixth Affiliated Hospital of Sun Yat-sen University identified 20 (0.56% [20/3557]) patients who underwent kidney biopsy. All biopsy specimens were examined by standard procedures containing light microscopy, immunofluorescence, and electron microscopy.

Results

Twenty cases were shown in this review study. Subnephrotic proteinuria (30% [6 of 20]), persistent hematuria and proteinuria (25% [5 of 20]), and isolated hematuria with acanthocytes (25% [5 of 20]) were the main indications for kidney biopsy. The most common diagnosis was IgA nephropathy (70% [14/20]), followed by minimal change disease (10% [2/20]), acute interstitial nephritis (5% [1/20]), granulomatous interstitial nephritis (5% [1/20]), non-IgA mesangial proliferative nephritis (5% [1/20]) and thin basement membrane nephropathy (5% [1/20]). The Lee classification of IgA nephropathy was mostly II or III level. Glomerular mesangial hyperplasia was the most common pathologic manifestation according to the MEST-C Sore. After twelve-month treatment, the majority of patients turned to complete remission of renal disease by measuring proteinuria, while 3 patients still stayed in the relapse stage and 6 patients turned to partial remission by measuring hematuria.

Conclusions

IgA nephropathy is the most common kidney biopsy diagnosis in Crohn's disease. Renal damage in Crohn's disease mainly involves the glomerulus, especially the mesangial matrix. After the treatment, proteinuria might be in remission, but hematuria remains.

Fecal microbiota transplantation in the metabolic diseases: Current status and perspectives

With the development of microbiology and metabolomics, the relationship between the intestinal microbiome and intestinal diseases has been revealed. Fecal microbiota transplantation (FMT), as a new treatment method, can affect the course of many chronic diseases such as metabolic syndrome, malignant tumor, autoimmune disease and nervous system disease. Although the mechanism of action of FMT is now well understood, there is some controversy in metabolic diseases, so its clinical application may be limited. Microflora transplantation is recommended by clinical medical guidelines and consensus for the treatment of recurrent or refractory Clostridium difficile infection, and has been gradually promoted for the treatment of other intestinal and extraintestinal diseases. However, the initial results are varied, suggesting that the heterogeneity of the donor stools may affect the efficacy of FMT. The success of FMT depends on the microbial diversity and composition of donor feces. Therefore, clinical trials may fail due to the selection of ineffective donors, and not to faulty indication selection for FMT. A new understanding is that FMT not only improves insulin sensitivity, but may also alter the natural course of type 1 diabetes by modulating autoimmunity. In this review, we focus on the main mechanisms and deficiencies of FMT, and explore the optimal design of FMT research, especially in the field of cardiometabolic diseases.

Lack of Monitoring Is Associated with Risk of Acute Kidney Events among Patients with Inflammatory Bowel Disease

Background: Although the iatrogenic risk of kidney failure is infrequent with treatment for inflammatory bowel disease (IBD), the repercussions for the patient could be major. The aim of this study was to assess the incidence of kidney events in IBD and to examine the protective effect of kidney function monitoring. Methods: In the French National Health Insurance database, 94,363 patients had a diagnosis of IBD between January 2010 and December 2016. By using a survival model with time-dependent covariates, we analyzed the time from inclusion in this IBD cohort to the first hospitalization for acute kidney impairment (AKI) according to patient characteristics, comorbidities, IBD phenotype and presence of monitoring. Results: A total of 693 patients were hospitalized for AKI, with an incidence of 1.36/1000 person−years (95% confidence interval [CI] 1.26−1.47). The incidence of AKI was lower than those without 5-aminosalicylic acid (5-ASA) use. Patients with 5-ASA use rarely had any lack of monitoring as compared with those not under 5-ASA use (3% vs. 17%). On multivariate analysis, lack of monitoring was associated with a substantial risk of AKI (hazard ratio 3.96, 95% CI [3.20−4.90], p < 0.0001). Conclusions: Increased frequency of monitoring is essential to identify nephropathy at an early stage and avoid the progression to chronic kidney disease.

Phenotypic Presentations of Heart Failure Among Patients With Chronic Inflammatory Diseases

Objective

Characterize incident heart failure (HF) phenotypes among patients with various chronic inflammatory diseases (CIDs).

Background

Several CIDs are associated with increased HF risk, but differences in HF phenotypes across CIDs are incompletely understood. No prior studies to our knowledge have manually adjudicated HF phenotypes across a CID spectrum.

Methods

We screened for patients with—and controls without—CIDs who had possible HF, then hand-adjudicated HF endpoints. Possible HF resulted from a single HF administrative code; HF was deemed definite/probable vs. absent using standardized, validated criteria. We queried adjudicated HF patients' charts to define specific HF phenotypes, then compared clinical, demographic, and HF phenotypic characteristics for HF patients with specific CIDs vs. non-CID controls using Fisher's exact test.

Results

Out of 415 possible HF patients, 192 had definite/probable HF. Significant differences in HF phenotypes existed across CIDs. Isolated right-sided HF was present in 27.8% of patients with SSc and adjudicated HF, which is more than twice as common as it was in any other CID. Left ventricular systolic dysfunction was most common in patients with HIV and lupus (SLE); mean LVEF was 45.0% ± 18.6% for HIV and 41.3% ± 17.1% for SLE, but was 57.7% ± 10.7% for SSc. Those with HIV and multiple CIDs were most likely to have coronary artery disease.

Conclusions

Different CIDs present with different phenotypes of physician-adjudicated HF, potentially reflecting different underlying inflammatory pathophysiologies. Larger studies are needed to confirm these findings, as are mechanistic studies focused on understanding specific immunoregulatory contributors to HF.

Immunosuppressive regimens and outcomes of inflammatory bowel disease patients requiring kidney transplantation

Patients with inflammatory bowel disease (IBD) can develop extra-renal complications and as a result, suffer from end stage renal failure requiring kidney transplantation (KT). A brief review of available literature revealed that IBD patients undergoing KT have shorter overall survival rates compared to their controls. Literature reporting steroid regimens and survival outcomes specific to IBD and post kidney transplant are scarce and these studies have small sample sizes thus making it difficult to draw accurate conclusions. Further research is required in the form of a randomized controlled study to clarify the effect and mechanism of steroid immunosuppression on the prognosis of renal transplant recipients and explore new treatment schemes.

Role of gut-kidney axis in renal diseases and IgA nephropathy

PURPOSE OF REVIEW

Growing evidence show the importance of gut/kidney axis in renal diseases. Advances in gut microbiome sequencing, associated metabolites, detection of gut permeability and inflammation provide new therapeutic strategies targeting gut for kidney diseases and particularly for Immunoglobulin A (IgA) nephropathy (IgAN).

RECENT FINDINGS

The diversity and composition of gut flora have been recently deeply explored in kidney diseases. Modulation and depletion of microbiota in animal models allowed the understanding of molecular mechanisms involved in the crosstalk between gut, immune system and kidney. New clinical trials in order to positively modulate microbiota result in improvement of gastrointestinal disorders and inflammation in patients suffering with kidney diseases.

SUMMARY

The investigation of gut alterations in kidney diseases open new therapeutic strategies. In IgAN, targeted treatments for intestinal inflammation and modifications of gut microbiota seem promising.

Comorbidity before and after a diagnosis of inflammatory bowel disease

BACKGROUND

Comorbidity is an important predictor of how disease course in inflammatory bowel (IBD) evolves.

AIMS

To determine pre-diagnosis relative rates (RR) and post-diagnosis hazard ratios (HR) of component diseases of the Charlson Comorbidity Index (CCI) in a cohort study of persons with IBD.

METHODS

The University of Manitoba IBD Epidemiology Database includes all Manitobans with IBD from 1 April 1984 through 31 March 2018 and matched controls. All outpatient physician claims and hospital discharge abstracts were searched for diagnostic codes for CCI component diseases. Some diseases were collapsed into one group such that we assessed 12 conditions. We report the RR of these conditions prior to IBD and the incidence of these diagnoses after IBD. Using Cox proportional hazards regression we report post-diagnosis HR. Confidence intervals were adjusted for Bonferroni correction.

RESULTS

The RR of cardiovascular diseases, peripheral vascular diseases, chronic pulmonary diseases, connective tissue disease/rheumatic diseases, renal disease, liver diseases, peptic ulcer disease, and cancer were all increased prior to diagnoses of IBD compared to controls. All comorbidities were increased post IBD diagnosis. The increased HR for dementia in persons with Crohn's disease was a concerning novel finding. The increased association with paraplegia/hemiplegia was unexpected. For all comorbidities, except diabetes, the age at diagnosis was younger in IBD than controls.

CONCLUSIONS

Persons with IBD have a higher comorbidity burden than persons without IBD. Optimal care plans for persons with IBD should include an assessment for other comorbidities that include just about every other organ system.

Prevalence of Renal Stones Among Patients With Inflammatory Bowel Disease in Saudi Arabia

INTRODUCTION

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBD) that affect the gastrointestinal tract with no identified etiology. IBD has been associated with several extraintestinal manifestations (EIMs), including renal involvement such as renal stones (nephrolithiasis), resulting in significant morbidity. This study aims to estimate the prevalence of renal stones among IBD patients in Saudi Arabia.

METHODS

This is a retrospective study conducted at King Abdulaziz University Hospital between January 2019 and December 2020. All IBD patients with abdominal imaging studies were included in the study regardless of their age. Data were collected from the electronic hospital information system and analyzed.

RESULTS

A total of 363 IBD patients fulfilled the study inclusion criteria. Nephrolithiasis was detected radiologically in 3.6% of the cohort (5.1% of UC and 2.7% of CD patients). Patients with renal stones are older (P=0.002) and more likely to be diabetic (P=0.047), have microscopic hematuria (P<0.001), and proteinuria (P=0.002). Binary logistic regression analysis showed that older age at diagnosis (P=0.003) and microscopic hematuria (P=0.02) are independent predictors for renal stones.

CONCLUSION

 The study reported that 3.6% of Saudi IBD patients had renal stones, with a higher prevalence of renal stones formation among UC patients than Crohn's. Older age at diagnosis and the presence of microscopic hematuria may predict the development of renal stones. Future studies should be conducted in a prospective manner at multiple centers across Saudi Arabia for further investigation.

Effects of changes in regular physical activity status on hip fracture: A nationwide population-based cohort study in Korea

Objective

Hip fracture incidence is increasing with rapid aging of the population and regular physical activity (RPA) is an important modifiable protective factor for fracture. However, the association between the risk of hip fractures and changes in RPA status in the general population remains unknown. Thus, we explore the association between the risk of hip fracture and changes in RPA status.

Methods

We studied 4,984,144 individuals without fractures within a year whose data were registered in the Korean National Health Insurance Service database. Baseline physical activity level was assessed using a standardized self-reported questionnaire during two consecutive national health screening surveys performed in Korea from 2009 to 2012. The risk of hip fracture between 2013 and 2016 according to change in RPA was prospectively analyzed. Participants were divided into those who were always inactive, became inactive, became active, and were always active.

Results

Compared to participants who were always inactive, those who became inactive exhibited a 0.12/1,000 person-years (PY) reduction in hip fracture incidence rate (IR) [aHR: 0.865; 95% confidence interval (CI): 0.824–0.908]. Participants who became active, and those who were always active, exhibited a 0.24/1,000 PY reduction in IR (aHR: 0.827; 95% CI: 0.787–0.870) and a 0.39/1,000 PY reduction in IR (aHR: 0.691; 95% CI: 0.646–0.740), respectively.

Conclusion

Changes in RPA status were associated with the risk of hip fracture; consistent RPA was related to the maximum benefit for risk reduction in the general population.

Proteinuria Is Associated with the Development of Crohn's Disease: A Nationwide Population-Based Study

BACKGROUND AND AIMS

The impact of proteinuria and its severity on the incidence of inflammatory bowel disease (IBD) has not yet been studied. We aimed to determine the association between proteinuria measured by urine dipstick tests and the development of IBD.

METHODS

This nationwide population-based study was conducted using the Korean National Health Insurance Service (NHIS) database. A total of 9,917,400 people aged 20 years or older who had undergone a national health examination conducted by the NHIS in 2009 were followed up until 2017. The study population was classified into four groups-negative, trace, 1+, and ≥ 2+-according to the degree of proteinuria measured by the urine dipstick test. The primary endpoint was newly diagnosed IBD, Crohn's disease (CD), or ulcerative colitis (UC) during the follow-up period.

RESULTS

Compared with the dipstick-negative group, the incidence of CD significantly increased according to the degree of proteinuria (adjusted hazard ratio [aHR] with 95% confidence interval [CI], 1.01 [0.703-1.451], 1.515 [1.058-2.162], and 2.053 [1.301-3.24] in the trace, 1+, and ≥ 2+ dipstick groups, respectively; p for trend 0.007). However, there was no significant difference in the incidence of UC according to the degree of proteinuria (aHR with 95% CI, 1.12 [0.949-1.323], 0.947 [0.764-1.174], and 1.009 [0.741-1.373] in the trace, 1+, and ≥ 2+ dipstick groups, respectively; p for trend 0.722). In the subgroup analysis, dipstick-positive proteinuria independently increased the incidence of CD regardless of the subgroup. However, dipstick-positive proteinuria was associated with the risk of UC in those with diabetes mellitus and not in those without diabetes mellitus (aHR, 1.527 vs. 0.846; interaction p-value 0.004). The risk of CD was increased or decreased according to proteinuria changes but not associated with the risk of UC.

CONCLUSION

Proteinuria, measured by the dipstick test, is strongly associated with the development of CD.

Inflammatory Bowel Disease Is More Common in Patients with IgA Nephropathy and Predicts Progression of ESKD: A Swedish Population-Based Cohort Study

BACKGROUND

Case reports suggest an association between inflammatory bowel disease, a chronic autoimmune condition linked to increased circulating IgA levels, and IgA nephropathy, the most common form of primary GN and a leading cause of ESKD.

METHODS

In a Swedish population-based cohort study, we compared 3963 biopsy-verified IgA nephropathy patients with 19,978 matched controls between 1974 and 2011, following up participants until 2015. Inflammatory bowel disease data and ESKD status were obtained through national medical registers. We applied Cox regression to estimate hazard ratios (HRs) for future inflammatory bowel disease in IgA nephropathy and conditional logistic regression to assess risk of earlier inflammatory bowel disease in IgA nephropathy. We also explored whether inflammatory bowel disease affects development of ESKD in IgA nephropathy.

RESULTS

During a median follow-up of 12.6 years, 196 (4.95%) patients with IgA nephropathy and 330 (1.65%) matched controls developed inflammatory bowel disease (adjusted HR, 3.29; 95% confidence interval [95% CI], 2.73 to 3.96). Inflammatory bowel disease also was more common before a confirmed IgA nephropathy diagnosis. Some 103 (2.53%) IgA nephropathy patients had an earlier inflammatory bowel disease diagnosis compared with 220 (1.09%) controls (odds ratio [OR], 2.37; 95% CI, 1.87 to 3.01). Both logistic regression (OR, 2.60; 95% CI, 2.02 to 3.35) and time-varying Cox regression (HR, 1.84; 95% CI, 1.33 to 2.55) demonstrated that inflammatory bowel disease was associated with increased ESKD risk in patients with IgA nephropathy.

CONCLUSIONS

Patients with IgA nephropathy have an increased risk of inflammatory bowel disease both before and after their nephropathy diagnosis. In addition, among patients with IgA nephropathy, comorbid inflammatory bowel disease elevates the risk of progression to ESKD.

Gut microbiota and inflammatory bowel disease: The current status and perspectives

Inflammatory bowel disease (IBD) is a chronic immune-mediated disease that affects the gastrointestinal tract. It is argued that environment, microbiome, and immune-mediated factors interact in a genetically susceptible host to trigger IBD. Recently, there has been increased interest in the development, progression, and treatment of IBD because of our understanding of the microbiome. Researchers have proved that some factors can alter the microbiome and the pathogenesis of IBD. As a result, there has been increasing interest in the application of probiotics, prebiotics, antibiotics, fecal microbiota transplantation, and gene manipulation in treating IBD because of the possible curative effect of microbiome-modulating interventions. In this review, we summarize the findings from human and animal studies and discuss the effect of the gut microbiome in treating patients with IBD.

Changes in Direct Healthcare Costs before and after the Diagnosis of Inflammatory Bowel Disease: A Nationwide Population-Based Study

Background/Aims

We aimed to investigate the differences in direct healthcare costs between patients with and without inflammatory bowel disease (IBD) and changes in direct healthcare costs before and after IBD diagnosis.

Methods

This population-based study identified 34,167 patients with IBD (11,014 patients with Crohn’s disease and 23,153 patients with ulcerative colitis) and 102,501 age-and sex-matched subjects without IBD (the control group) from the National Health Insurance database using the International Classification of Disease, 10th revision codes and the rare intractable disease registration program codes. The mean healthcare costs per patient were analyzed for 3 years before and after IBD diagnosis, with follow-up data available until 2015.

Results

Total direct healthcare costs increased and peaked at $2,396 during the first year after IBD diagnosis, but subsequently dropped sharply to $1,478 during the second year after diagnosis. Total healthcare costs were higher for the IBD patients than for the control group, even in the third year before the diagnosis ($497 vs $402, p<0.001). The costs for biologics for the treatment of IBD increased steeply over time, rising from $720.8 in the first year after diagnosis to $1,249.6 in the third year after diagnosis (p<0.001).

Conclusions

IBD patients incurred the highest direct healthcare costs during the first year after diagnosis. IBD patients had higher costs than the control group even before diagnosis. The cost of biologics increased steeply over time, and it can be assumed that biologics could be the main driver of costs during the early period after IBD diagnosis.

Periodontitis combined with smoking increases risk of the ulcerative colitis: A national cohort study

BACKGROUND

Periodontitis is a chronic inflammation of periodontal tissues. The effect of periodontitis on the development of inflammatory bowel disease (IBD) remains unclear.

AIM

To assessed the risk of IBD among patients with periodontitis, and the risk factors for IBD related to periodontitis.

METHODS

A nationwide population-based cohort study was performed using claims data from the Korean National Healthcare Insurance Service. In total, 9950548 individuals aged ≥ 20 years who underwent national health screening in 2009 were included. Newly diagnosed IBD [Crohn’s disease (CD), ulcerative colitis (UC)] using the International Classification of Disease 10^th revision and rare intractable disease codes, was compared between the periodontitis and non-periodontitis groups until 2017.

RESULTS

A total of 1092825 individuals (11.0%) had periodontitis. Periodontitis was significantly associated with older age, male gender, higher body mass index, quitting smoking, not drinking alcohol, and regular exercise. The mean age was 51.4 ± 12.9 years in the periodontitis group and 46.6 ± 14.2 years in the non-periodontitis group (P < 0.01), respectively. The mean body mass index was 23.9 ± 3.1 and 23.7 ± 3.2 in the periodontitis and non-periodontitis groups, respectively (P < 0.01). Men were 604307 (55.3%) and 4844383 (54.7%) in the periodontitis and non-periodontitis groups, respectively. The mean follow-up duration was 7.26 years. Individuals with periodontitis had a significantly higher risk of UC than those without periodontitis [adjusted hazard ratio: 1.091; 95% confidence interval (CI): 1.008-1.182], but not CD (adjusted hazard ratio: 0.879; 95% confidence interval: 0.731-1.057). The risks for UC were significant in the subgroups of age ≥ 65 years, male gender, alcohol drinker, current smoker, and reduced physical activity. Current smokers aged ≥ 65 years with periodontitis were at a 1.9-fold increased risk of UC than non-smokers aged ≥ 65 years without periodontitis.

CONCLUSION

Periodontitis was significantly associated with the risk of developing UC, but not CD, particularly in current smokers aged ≥ 65 years.

Changes in physical activity and risk of fracture: a Korean nationwide population-based cohort study

Physical activity (PA) is one of the most important modifiable factors associated with fracture risk. However, the association between interval changes in PA and the risk of fracture remains unknown. We investigated the risk of fracture development according to interval changes in PA in middle aged and older individuals. In this nationwide cohort study of adults aged ≥ 40 years, more than 4.9 million individuals without fractures within the last year who underwent two consecutive national health screenings in Korea from 2009 to 2012 were identified. The risk of fracture between 2013 and 2016 according to interval changes in regular PA was prospectively analyzed. Compared to individuals with a continuous lack of PA, those with a decrease in PA (0.41/1000 person-years (PY) decrease in incidence rate (IR); adjusted hazard ratio (aHR) 0.975; 95% confidence interval (CI) 0.964–0.987), increase in PA (1.8/1000 PY decrease in IR; aHR 0.948; 95% CI 0.937–0.959), and continuous PA (3.58/1000 PY decrease in IR; aHR 0.888; 95% CI 0.875–0.901) had a significantly reduced risk of fracture. Interval changes in regular PA were associated with risk of fracture. Individuals who engaged in continuous regular PA exhibited the maximum protective benefit against fracture.

Anemia is associated with the risk of Crohn's disease, not ulcerative colitis: A nationwide population-based cohort study

Anemia is a common manifestation of inflammatory bowel disease (IBD), but it remains unclear whether anemia is associated with the development of IBD. We assessed the risk of developing IBD in anemic patients, and stratified the results with respect to their hemoglobin concentrations. A population-based study was conducted using the National Healthcare Insurance Service database in South Korea. We included individuals over 20 years’ old who participated in the national health screening program in 2009 (n = 9,962,064). Anemia was defined as a hemoglobin level less than 13 g/dL in men and less than 12 g/dL in women. We compared the rate of newly diagnosed IBD in anemic patients and non-anemic individuals. Newly diagnosed IBD was identified using both the ICD-10 medical code and specialized V codes for rare intractable diseases in South Korea. During the mean follow-up period of 7.3 years, the incidences of CD and UC in anemic patients were 2.89 and 6.88 per 100,000 person-years, respectively. The risk of CD was significantly higher in anemic patients than in non-anemic individuals [adjusted hazard ratio (aHR), 2.084; 95% confidence interval (CI), 1.769–2.455]. The risk of CD development was inversely proportional to the hemoglobin concentration. A J-curve relationship was observed between age and the risk of CD in anemic patients. The risk of CD in male anemic patients was significantly higher than that in female anemic patients (aHR, 1.432 vs. 1.240, respectively). By contrast, there was no statistically significant difference in the risk of developing UC in anemic and non-anemic individuals (aHR, 0.972; 95% CI, 0.880–1.073). This work indicates that anemia is related to the development of CD, and this risk was inversely proportional to the hemoglobin concentration.

Inflammatory Bowel Diseases Are Associated With an Increased Risk for Chronic Kidney Disease, Which Decreases With Age

BACKGROUND & AIMS

It is not clear what factors affect risk of chronic kidney disease (CKD) in patients with inflammatory bowel disease (IBD); increased risk has been inconsistently associated with use of 5-aminosalicylates (5-ASAs). We aimed to calculate the relative hazard of CKD among patients with IBD, adjusted for CKD risk factors, and to determine whether IBD medications are associated with change in estimated glomerular filtration rate (eGFR).

METHODS

We performed a retrospective cohort study of data from The Health Improvement Network. Patients with IBD (n = 17,807) were matched for age, sex, and practice to individuals without IBD (n = 63,466). The relative hazard of CKD, stages 3 through 5D, in patients with IBD was calculated using a Cox proportional hazards model adjusted for common CKD risk factors. We also evaluated the association of 5-ASAs, azathioprine, and methotrexate with change in eGFR using a longitudinal model.

RESULTS

After we controlled for risk factors associated with CKD, we found IBD to be associated with development of CKD in patients 16-77 years old. As patient age increased, the adjusted hazard ratio for CKD decreased monotonically, from 7.88 (95% CI, 2.56-24.19) at age 16 to 1.13 (95% CI, 1.01-1.25) at age 77. In the longitudinal analysis, exposure to 5-ASAs or methotrexate was not associated with change in eGFR, whereas azathioprine was associated with a slightly higher eGFR (0.32 mL/min/1.73 m²; 95% CI, 0.16-0.48).

CONCLUSIONS

In a retrospective study of more than 80,000 persons, we found that IBD is associated with increased risk of CKD, and the hazard ratio is highest among younger patients. Commonly used non-biologic therapeutic agents were not associated with lower eGFR.

The Impact of Korean Medicine Treatment on the Incidence of Parkinson's Disease in Patients with Inflammatory Bowel Disease: A Nationwide Population-Based Cohort Study in South Korea

We aimed to investigate the association between Korean medicine (KM) treatment and the risk of Parkinson's Disease (PD) in patients with inflammatory bowel disease (IBD) in South Korea. This study analyzed data from the National Health Insurance Service-Senior cohort in South Korea. The 1816 IBD patients enrolled in the analysis comprised 411 who received only conventional treatment (monotherapy group) and 1405 who received both conventional and KM treatments (integrative therapy group). The risk of PD in patients with IBD was significantly lower in the integrative therapy group than in the monotherapy group after adjusting for confounding variables (adjusted hazard ratio (HR), 0.56; 95% confidence interval (CI) = 0.34-0.92). In the mild Charlson Comorbidity Index (CCI) group, the risk of PD in patients with IBD in the integrative therapy group was 0.39 times lower (adjusted HR, 95% CI = 0.20-0.77) than that in the monotherapy group. However, there was no significant difference in the risk of PD in patients with IBD between the integrative therapy and monotherapy groups among individuals with severe CCI (adjusted HR, 0.90; 95% CI = 0.41-1.96). IBD patients are at a decreased risk of PD when they receive integrative therapy. KM treatment may prevent PD in IBD patients.

Differential Associations of Chronic Inflammatory Diseases With Incident Heart Failure

OBJECTIVES

The purpose of this study was to compare the risks of incident heart failure (HF) among a variety of chronic inflammatory diseases (CIDs) and to determine whether risks varied by severity of inflammation within each CID.

BACKGROUND

Individuals with CIDs are at elevated risk for cardiovascular diseases, but data are limited regarding risk for HF.

METHODS

An electronic health records database from a large urban medical system was examined, comparing individuals with CIDs with frequency-matched controls without CIDs, all of whom were receiving regular outpatient care. Rates of incident HF were determined by using the Kaplan-Meier method and subsequently used multivariate-adjusted proportional hazards models to compare HF risks for each CID. Exploratory analyses determined HF risks by proxy measurement of CID severity.

RESULTS

Of 37,636 patients (n = 18,278 patients with CIDs; and n = 19,358 controls without CIDs) there were 960 incident HF cases over a median of 3.6 years. Risks for incident HF were significantly or borderline significantly elevated for patients with systemic sclerosis (hazard ratio [HR]: 7.26; 95% confidence interval [CI]: 5.72 to 9.21; p < 0.01), systemic lupus erythematosus (HR: 3.15; 95% CI: 2.41 to 4.11; p < 0.01), rheumatoid arthritis (HR: 1.39; 95% CI: 1.13 to 1.71; p < 0.01), and human immunodeficiency virus (HR: 1.28; 95% CI: 0.99 to 1.66; p = 0.06). There was no association between psoriasis or inflammatory bowel disease and incident HF, although patients with those CIDs with higher levels of C-reactive protein had higher risks for HF than controls.

CONCLUSIONS

Systemic sclerosis and systemic lupus erythematosus were associated with the highest risks of HF, followed by rheumatoid arthritis and HIV. Measurements of inflammation were associated with HF risk across different CIDs.

Increased risk of idiopathic pulmonary fibrosis in inflammatory bowel disease: A nationwide study

BACKGROUND AND AIM

The relationship between inflammatory bowel disease (IBD) and idiopathic pulmonary fibrosis (IPF) remains unclear. We evaluated the risk for developing IPF in patients with IBD using a nationwide population-based study.

METHODS

Using claims data from the National Health Insurance service in Korea, patients with IBD, including Crohn's disease (CD) and ulcerative colitis (UC), were identified through both the 10th revision of the International Statistical Classification of Diseases and Related Health Problems and rare and intractable disease program codes from January 2010 to December 2013. We compared 38 921 IBD patients with age-matched and sex-matched individuals without IBD in a ratio of 1:3. Patients with newly diagnosed IPF were identified by both the 10th revision of the International Statistical Classification of Diseases and Related Health Problems and rare and intractable disease registration codes.

RESULTS

During a mean 4.9-year follow-up, the incidence of IPF in patients with IBD was 33.21 per 100 000 person-years. The overall risk of IPF was significantly higher in IBD patients than in non-IBD controls (hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.20-2.20; P = 0.003). In patients with CD, the incidence (per 100 000 person-years) of IPF was 26.04; in controls, the incidence was 9.15 (HR, 2.89; 95% CI, 1.46-5.72; P = 0.002). The incidence of IPF in patients with UC tended to be higher than in controls (36.66 vs 26.54 per 100 000 person-years; 95% CI, 0.99-1.99; HR, 1.41; P = 0.066). The risk of developing IPF in patients with IBD was higher in male patients than in female patients (P = 0.093 in CD; P = 0.147 in UC by interaction analysis).

CONCLUSIONS

Patients with IBD, especially CD, have an increased risk of developing IPF.

Crohn's disease and ulcerative colitis are associated with different lipid profile disorders: a nationwide population-based study

BACKGROUND

The relationships between lipid profiles and IBD remain elusive.

AIM

To determine the association of IBD with serum lipid profiles.

METHODS

A nationwide population-based study was performed using claims data from the Korean National Healthcare Insurance service. A total of 9 706 026 subjects undergoing medical check-ups in 2009 were enrolled and followed up until 2016. Individuals who developed Crohn's disease (CD) or ulcerative colitis (UC) were identified during follow-up. Adjusted hazard ratio (aHR) by age, sex, body mass index, cigarette smoking, alcohol drinking, exercise, income and underlying comorbidities was calculated to define the impact of serum lipid profiles on developing IBD.

RESULTS

During a median follow-up of 7.3 years, IBD was detected in 7,058 (0.07%) individuals. Compared with the highest quartile of serum total cholesterol (TC) levels, lower TC levels were associated with higher incidence of CD (aHR: Q1, 2.52; Q2, 1.52; Q3, 1.27), but not UC. Lower serum LDL-C levels were associated with higher incidence of CD (aHR: Q1, 1.92; Q2, 1.47; Q3, 1.22), but not UC. Moreover, lower serum HDL-C levels were associated with higher incidence of CD (aHR: Q1, 2.49; Q2, 1.90; Q3, 1.43), but not UC. In contrast, lower serum triglyceride levels were associated with higher incidence of UC (aHR: Q1, 1.22; Q2, 1.19; Q3, 1.19), but not CD.

CONCLUSIONS

Low serum TC, LDL-C and HDL-C levels were associated with CD. Low serum triglyceride levels were related to UC.

Trends and risk factors of elderly-onset Crohn’s disease: A nationwide cohort study

BACKGROUND

The incidence of inflammatory bowel disease (IBD) is increasing in Asia. Numerous risk factors associated with IBD development have been investigated.

AIM

To investigate trends and environmental risk factors of Crohn’s disease (CD) diagnosed in persons aged ≥ 40 years in South Korea.

METHODS

Using the National Health Insurance Service database, a total of 14060821 persons aged > 40 years who underwent national health screening in 2009 were followed up until December 2017. Patients with newly diagnosed CD were enrolled and compared with non-CD cohort. CD was identified according to the International Classification of Diseases 10th revision and the rare/intractable disease registration program codes from the National Health Insurance Service database. The mean follow-up periods was 7.39 years. Age, sex, diabetes, hypertension, smoking, alcohol consumption, regular exercise, body mass index, anemia, chronic kidney disease (CKD) and dyslipidemia were adjusted for in the multivariate analysis model.

RESULTS

During the follow-up, 1337 (1.33/100000) patients developed CD. Men in the middle-aged group (40-64 years) had a higher risk than women [adjusted hazard ratio (aHR) 1.46, 95% confidence interval (CI): 1.29-1.66]; however, this difference tended to disappear as the age of onset increases. In the middle-aged group, patients with a history of smoking [aHR 1.46, 95%CI: 1.19-1.79) and anemia (aHR 1.85, 95%CI: 1.55-2.20) had a significantly higher CD risk. In the elderly group (age, ≥ 65 years), ex-smoking and anemia also increased the CD risk (aHR 1.68, 95%CI: 1.22-2.30) and 1.84 (95%CI: 1.47-2.30, respectively). Especially in the middle-aged group, those with CKD had a statistically elevated CD risk (aHR 1.37, 95%CI: 1.05-1.79). Alcohol consumption and higher body mass index showed negative association trend with CD incidence in both of the age groups. [Middle-aged: aHR 0.77 (95%CI: 0.66-0.89) and aHR 0.73 (95%CI: 0.63-0.84), respectively] [Elderly-group: aHR 0.57 (95%CI: 0.42-0.78) and aHR 0.84 (95%CI 0.67-1.04), respectively]. For regular physical activity and dyslipidemia, negative correlation between CD incidences was proved only in the middle-aged group [aHR 0.88 (95%CI: 0.77-0.89) and aHR 0.81 (95%CI: 0.68-0.96), respectively].

CONCLUSION

History of cigarette smoking, anemia, underweight and CKD are possible risk factors for CD in Asians aged > 40 years.

Risk of inflammatory bowel disease in patients with chronic obstructive pulmonary disease: A nationwide, population-based study

BACKGROUND

There is a growing evidence regarding an increased risk of inflammatory bowel disease (IBD) among patients with airway diseases.

AIM

To investigate the influence of chronic obstructive pulmonary disease (COPD) on the risk of IBD.

METHODS

A nationwide, population-based study was conducted using data from the National Health Insurance Service database. A total of 1303021 patients with COPD and 6515105 non-COPD controls were identified. The COPD group was divided into the severe and the mild COPD group according to diagnostic criteria. The risk of IBD in patients with COPD compared to controls was analyzed by Cox proportional hazard regression models. The cumulative incidences of IBD were compared between the groups.

RESULTS

The COPD group had higher incidences of IBD compared to non-COPD controls (incidence rate, 9.98 vs 7.18 per 100000 person-years, P < 0.001). The risk of IBD in the COPD group was increased by 1.38 (adjusted hazard ratio (HR); 95%CI: 1.25-1.52). The incidence rate of IBD was higher in the severe COPD group than in the mild COPD group (12.39 vs 9.77 per 100000 person-year, P < 0.001). The severity of COPD was associated with an increased risk of IBD (adjusted HR 1.70 in severe COPD, 95%CI: 1.27-2.21 and adjusted HR 1.35 in mild COPD, 95%CI: 1.22-1.49)

CONCLUSION

The incidences of IBD were significantly increased in COPD patients in South Korea and the risk of developing IBD also increased as the severity of COPD increased.

Patients with inflammatory bowel disease have an increased risk of myocardial infarction: a nationwide study

BACKGROUND

Inflammatory bowel disease (IBD) is accompanied by various extraintestinal manifestations including systemic inflammation and hypercoagulability, which may increase the risk of atherosclerosis and ischaemic heart disease.

AIM

To investigate whether IBD is associated with an increased risk of myocardial infarction (MI), stroke or death METHODS: The International Classification of Disease, 10th edition codes and the claim codes for rare diseases were used to identify candidates from National Health Insurance Service (NHIS) of South Korea. Patients diagnosed with Crohn's disease (CD) or ulcerative colitis (UC) between 2006 and 2009 were age-matched 1:3 with NHIS enrolees without IBD. The primary outcomes included newly developed MI, stroke and death. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox regression models.

RESULTS

We identified 10 708 patients diagnosed with CD and 26 769 with UC. MI risk was higher in CD patients than in controls (incidence ratio (IR) 1.64 per 1000 person-years, HR, 1.80; 95% CI, 1.47-2.21), and this trend was more prominent among patients aged <40 years (IR 0.69 per 1000 person-years, HR, 2.96; 95% CI, 1.96-4.47) and among female patients (IR 2.35 per 1000 person-years, HR, 2.18; 95% CI, 1.61-2.94). In contrast, only female patients with UC had an increased risk of MI (IR 2.01 per 1000 person-years, HR, 1.33; 95% CI, 1.13-1.56).

CONCLUSIONS

The risk of MI risk is higher in patients with CD than in the general population, and this trend is stronger in female patients and those aged <40 years.

Dose-response relationship between cigarette smoking and risk of ulcerative colitis: a nationwide population-based study

BACKGROUND

Former cigarette smokers are at risk of developing ulcerative colitis (UC). However, the impact of smoking behavior on the occurrence of UC according to the amount smoked remains elusive. We aimed to determine the relationship between smoking behavior and the risk of UC development.

METHODS

We conducted a retrospective population-based cohort study using the National Health Insurance Service database in South Korea. From January 2009 to December 2012, 23,235,771 individuals over 18 years of age who underwent a national health examination were enrolled and followed until 2016. All study participants were divided into the following 3 groups: nonsmokers, former smokers, and current smokers. The primary endpoint was newly developed UC.

RESULTS

Compared with nonsmokers, the risk of UC development was significantly higher in former smokers [adjusted hazard ratio (aHR) 1.83; 95% confidence interval (CI) 1.73-1.95] but significantly lower in current smokers (aHR 0.92; 95% CI 0.87-0.98). Among current smokers, individuals who stopped smoking after the baseline evaluation had a significantly higher risk of UC development than those who continued to smoke (aHR 2.42; 95% CI 2.10-2.80). The risk of UC development among former smokers was significantly associated with smoking amount and duration. Among current smokers, however, the risk of UC development was not correlated with the cumulative lifetime smoking exposure. The preventive effect of current smoking on UC development was observed only in men (aHR 0.90; 95% CI 0.84-0.96).

CONCLUSIONS

Compared with nonsmokers, former smokers have a significantly higher risk of UC development that may be proportional to the cumulative smoking exposure.

Patients with Inflammatory Bowel Disease Are at an Increased Risk of Parkinson's Disease: A South Korean Nationwide Population-Based Study. J Clin Med. 2019;8. [PMID: 31398905 PMCID: PMC6723604 DOI: 10.3390/jcm8081191]

Background and Aims: It is not known whether inflammatory bowel disease (IBD) enhances the risk of Parkinson’s disease (PD) or whether PD diagnosis is the result of increased health care use. We determined the risk of developing PD among patients with IBD in terms of health care and medication use. Methods: A nationwide population-based study was conducted using claims data from the Korean National Health care Insurance service. From 2010 to 2013, patients with Crohn’s disease (CD) and ulcerative colitis (UC) were identified through both International Classification of Disease, Tenth Revision (ICD-10) and national rare intractable disease (RID) registration program codes. We compared 38,861 IBD patients with age and sex-matched non-IBD individuals at a ratio of 1:3. Patients with newly diagnosed PD were identified through both ICD-10 and RID codes. Results: The incidence of PD among patients with IBD was 49 per 100,000 person-years. The risk of developing PD in patients with IBD was significantly higher than controls even after adjustment for health care use (adjusted hazard ratio (aHR), 1.87; P < 0.001). Compared to controls, the risk of PD was significantly higher in patients with CD (aHR, 2.23; P = 0.023) and UC (aHR, 1.85; P < 0.001). Corticosteroid use showed a preventive effect on developing PD in patients with CD (aHR 0.08; P < 0.001), but not UC (aHR, 0.75; P = 0.213). Among 2110 patients receiving anti-tumor necrosis factor (anti-TNF), none of the treated patients experienced PD during 9950 person-years. Conclusion: Patients with IBD are at an increased risk of PD, regardless of health care use. Corticosteroid and anti-TNF use may prevent PD in patients with IBD.

Risk of Anxiety and Depression in Patients with Inflammatory Bowel Disease: A Nationwide, Population-Based Study. J Clin Med. 2019;8. [PMID: 31083476 PMCID: PMC6572298 DOI: 10.3390/jcm8050654]

Background and Aims: Inflammatory bowel disease (IBD) may be associated with anxiety and depression. The aim of this study was to evaluate the incidence of anxiety and depression in patients with IBD compared to the general population. Methods: A nationwide population-based cohort study was conducted using claims data from the National Healthcare Insurance service in Korea. We compared the incidence of anxiety and depression between 15,569 IBD patients and 46,707 non-IBD controls, age and sex matched at a ratio of 1:3. Results: During a mean follow-up of six years, IBD patients experienced significantly more anxiety (12.2% vs. 8.7%; p < 0.001) and depression (8.0% vs. 4.7%; p < 0.001) compared to controls. The curves showing cumulative incidences of anxiety and depression showed a steep rise within one year following a diagnosis of IBD, leading to lines with a constant slope. The hazard ratio (HR) for new onset anxiety following a diagnosis of Crohn’s disease (CD) and ulcerative colitis (UC) was 1.63 and 1.60, respectively, compared to controls (p < 0.001). Compared to controls, the HR for developing depression after a diagnosis of CD and UC was 2.09 and 2.00, respectively (p < 0.001). The risks of anxiety and depression in patients with IBD were higher compared to controls, except in those with diabetes mellitus, hypertension, and dyslipidemia, or who required immunomodulators and biologics within one year of the IBD diagnosis. Conclusions: The risk of anxiety and depression increased after a diagnosis of IBD compared to the general population.

Increased Risk of Diabetes in Inflammatory Bowel Disease Patients: A Nationwide Population-based Study in Korea. J Clin Med. 2019;8. [PMID: 30862129 PMCID: PMC6463263 DOI: 10.3390/jcm8030343]

The association of diabetes with inflammatory bowel disease (IBD) remains unclear. The risk of diabetes in patients with IBD compared with non-IBD controls was investigated. Using the National Health Insurance database of South Korea, 8070 patients with IBD based on the International Classification of Disease 10th revision (ICD-10) codes and rare intractable disease codes for Crohn’s disease (CD) and ulcerative colitis (UC) were compared with 40,350 non-IBD individuals (2010–2014). Newly diagnosed diabetes identified using ICD-10 codes and the prescription of anti-diabetic medication by the end of the follow-up period (2016) was investigated. During a mean follow-up of 5.1 years, the incidence of diabetes in patients with IBD was significantly higher compared with controls after adjusting for serum glucose levels and steroid use (23.19 vs. 22.02 per 1000 person-years; hazard ratio (HR), 1.135; 95% confidence interval (CI), 1.048–1.228). The risk of diabetes was significantly higher in patients with CD (HR, 1.677; 95% CI, 1.408–1.997), but not in UC (HR, 1.061; 95% CI, 0.973–1.156). The effect of IBD on the development of diabetes was significantly more prominent in younger patients (p < 0.001). Patients with CD are at a higher risk of diabetes. Regular monitoring for diabetes is recommended, even in younger CD patients who do not use steroid medication.