1
|
Sullivan VK, Appel LJ, Anderson CAM, Kim H, Unruh ML, Lash JP, Trego M, Sondheimer J, Dobre M, Pradhan N, Rao PS, Chen J, He J, Rebholz CM. Ultraprocessed Foods and Kidney Disease Progression, Mortality, and Cardiovascular Disease Risk in the CRIC Study. Am J Kidney Dis 2023; 82:202-212. [PMID: 37028638 PMCID: PMC10524102 DOI: 10.1053/j.ajkd.2023.01.452] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/22/2023] [Indexed: 04/09/2023]
Abstract
RATIONALE & OBJECTIVE Ultraprocessed foods are widely consumed in the United States and are associated with cardiovascular disease (CVD), mortality, and kidney function decline in the general population. We investigated associations between ultraprocessed food intake and chronic kidney disease (CKD) progression, all-cause mortality, and incident CVD in adults with chronic kidney disease (CKD). STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Chronic Renal Insufficiency Cohort Study participants who completed baseline dietary questionnaires. EXPOSURE Ultraprocessed food intake (in servings per day) classified according to the NOVA system. OUTCOMES CKD progression (≥50% decrease in estimated glomerular filtration rate [eGFR] or initiation of kidney replacement therapy), all-cause mortality, and incident CVD (myocardial infarction, congestive heart failure, or stroke). ANALYTICAL APPROACH Cox proportional hazards models adjusted for demographic, lifestyle, and health covariates. RESULTS There were 1,047 CKD progression events observed during a median follow-up of 7 years. Greater ultraprocessed food intake was associated with higher risk of CKD progression (tertile 3 vs tertile 1, HR, 1.22; 95% CI, 1.04-1.42; P=0.01 for trend). The association differed by baseline kidney function, such that greater intake was associated with higher risk among people with CKD stages 1/2 (eGFR≥60mL/min/1.73m2; tertile 3 vs tertile 1, HR, 2.61; 95% CI, 1.32-5.18) but not stages 3a-5 (eGFR<60mL/min/1.73m2; P=0.003 for interaction). There were 1,104 deaths observed during a median follow-up of 14 years. Greater ultraprocessed food intake was associated with higher risk of mortality (tertile 3 vs tertile 1, HR, 1.21; 95% CI, 1.04-1.40; P=0.004 for trend). LIMITATIONS Self-reported diet. CONCLUSIONS Greater ultraprocessed food intake may be associated with CKD progression in earlier stages of CKD and is associated with higher risk of all-cause mortality in adults with CKD. PLAIN LANGUAGE SUMMARY Ultraprocessed foods are industrial formulations produced using ingredients and processes that are not commonly used in culinary preparations and contain few, if any, intact unprocessed foods. Ultraprocessed foods are widely consumed in the United States, and high intakes of such foods have been linked to cardiovascular disease, kidney disease, and mortality in the general population. In this study, we found that greater intake of ultraprocessed foods was associated with higher risk of kidney disease progression and mortality in adults with chronic kidney disease. Our findings suggest that patients with kidney disease may benefit from greater consumption of fresh, whole, and homemade or hand-prepared foods and fewer highly processed foods.
Collapse
Affiliation(s)
- Valerie K Sullivan
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lawrence J Appel
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cheryl A M Anderson
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California
| | - Hyunju Kim
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark L Unruh
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, NM
| | - James P Lash
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, IL
| | - Marsha Trego
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James Sondheimer
- Division of Nephrology and Hypertension, School of Medicine, Wayne State University, Detroit, MI
| | - Mirela Dobre
- Department of Medicine (Nephrology), Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Nishigandha Pradhan
- Department of Medicine (Nephrology), Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH
| | | | - Jing Chen
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Casey M Rebholz
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| |
Collapse
|
2
|
Muiru A, Hsu J, Zhang X, Appel L, Chen J, Cohen DL, Drawz PE, Freedman BI, Go AS, He J, Horwitz E, Hsu RK, Lash JP, Liu KD, McCoy IE, Porter A, Rao P, Ricardo AC, Rincon-Choles H, Sondheimer J, Taliercio J, Unruh M, Hsu CY. Risk for Chronic Kidney Disease Progression After Acute Kidney Injury: Findings From the Chronic Renal Insufficiency Cohort Study. Ann Intern Med 2023; 176:961-968. [PMID: 37429030 PMCID: PMC10829039 DOI: 10.7326/m22-3617] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Prior studies associating acute kidney injury (AKI) with more rapid subsequent loss of kidney function had methodological limitations, including inadequate control for differences between patients who had AKI and those who did not. OBJECTIVE To determine whether AKI is independently associated with subsequent kidney function trajectory among patients with chronic kidney disease (CKD). DESIGN Multicenter prospective cohort study. SETTING United States. PARTICIPANTS Patients with CKD (n = 3150). MEASUREMENTS Hospitalized AKI was defined by a 50% or greater increase in inpatient serum creatinine (SCr) level from nadir to peak. Kidney function trajectory was assessed using estimated glomerular filtration rate (eGFR) based on SCr level (eGFRcr) or cystatin C level (eGFRcys) measured at annual study visits. RESULTS During a median follow-up of 3.9 years, 433 participants had at least 1 AKI episode. Most episodes (92%) had stage 1 or 2 severity. There were decreases in eGFRcr (-2.30 [95% CI, -3.70 to -0.86] mL/min/1.73 m2) and eGFRcys (-3.61 [CI, -6.39 to -0.82] mL/min/1.73 m2) after AKI. However, in fully adjusted models, the decreases were attenuated to -0.38 (CI, -1.35 to 0.59) mL/min/1.73 m2 for eGFRcr and -0.15 (CI, -2.16 to 1.86) mL/min/1.73 m2 for eGFRcys, and the CI bounds included the possibility of no effect. Estimates of changes in eGFR slope after AKI determined by either SCr level (0.04 [CI, -0.30 to 0.38] mL/min/1.73 m2 per year) or cystatin C level (-0.56 [CI, -1.28 to 0.17] mL/min/1.73 m2 per year) also had CI bounds that included the possibility of no effect. LIMITATIONS Few cases of severe AKI, no adjudication of AKI cause, and lack of information about nephrotoxic exposures after hospital discharge. CONCLUSION After pre-AKI eGFR, proteinuria, and other covariables were accounted for, the association between mild to moderate AKI and worsening subsequent kidney function in patients with CKD was small. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.
Collapse
Affiliation(s)
- Anthony Muiru
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco, CA
| | - Jesse Hsu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Xiaoming Zhang
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Larry Appel
- Division of General Internal Medicine, The Johns Hopkins University, Baltimore, MD
| | - Jing Chen
- Section of Nephrology & Hypertension, Tulane University School of Medicine, New Orleans, LA
| | - Debbie L. Cohen
- Division of Nephrology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Paul E. Drawz
- Division of Nephrology and Hypertension, University of Minnesota Medical School, Minneapolis, MN
| | - Barry I. Freedman
- Section on Nephrology, Wake Forest University, Winston-Salem, North Carolina
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jiang He
- Tulane University School of Public Health & Tropical Medicine, New Orleans, LA
| | - Ed Horwitz
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Raymond K. Hsu
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco, CA
| | - James P. Lash
- Division of Nephrology, University of Illinois Health, Chicago, IL
| | - Kathleen D. Liu
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco, CA
| | - Ian E. McCoy
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco, CA
| | - Anna Porter
- Division of Nephrology, University of Illinois Health, Chicago, IL
| | - Panduranga Rao
- Division of Nephrology, University of Michigan Health, Ann Arbor, MI
| | - Ana C. Ricardo
- Division of Nephrology, University of Illinois Health, Chicago, IL
| | | | - James Sondheimer
- Division of Nephrology and Hypertension, Wayne State University School of Medicine, Detroit, MI
| | | | - Mark Unruh
- University of New Mexico Health Sciences, Albuquerque, NM
| | - Chi-yuan Hsu
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco, CA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | |
Collapse
|
3
|
Sullivan VK, Appel LJ, Anderson CAM, Tan TC, Brown J, Ricardo AC, Schrauben SJ, Hsu CY, Shah VO, Unruh M, Nelson RG, Sondheimer J, Chen J, He J, Charleston J, Rebholz CM. Changes in Diet Quality, Risk of CKD Progression, and All-Cause Mortality in the CRIC Study. Am J Kidney Dis 2023; 81:621-624. [PMID: 36455682 PMCID: PMC10228419 DOI: 10.1053/j.ajkd.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 09/30/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Valerie K Sullivan
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lawrence J Appel
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cheryl A M Anderson
- Herbert Wertheim School of Public Health and Human Longevity Science, UC San Diego, La Jolla, California
| | - Thida C Tan
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Julia Brown
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, Illinois
| | - Ana C Ricardo
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, Illinois
| | - Sarah J Schrauben
- Department of Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California San Francisco, San Francisco, California; Kaiser Permanente Division of Nephrology, Oakland, California
| | - Vallabh O Shah
- Departments of Internal Medicine and Biochemistry and Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Mark Unruh
- Departments of Internal Medicine and Biochemistry and Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Robert G Nelson
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, Arizona
| | - James Sondheimer
- Division of Nephrology and Hypertension, School of Medicine, Wayne State University, Detroit, Michigan
| | - Jing Chen
- Department of Medicine, Tulane School of Medicine, New Orleans, Louisiana
| | - Jiang He
- Department of Epidemiology, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Jeanne Charleston
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Casey M Rebholz
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| |
Collapse
|
4
|
Estrella ML, Allen-Meares P, Ricardo AC, Fischer MJ, Gordon EJ, Carmona-Powell E, Sondheimer J, Chen J, Horwitz E, Wang X, Hsu JY, Lash JP, Lora C. Prospective associations of health literacy with clinical outcomes in adults with CKD: findings from the CRIC study. Nephrol Dial Transplant 2023; 38:904-912. [PMID: 35746879 PMCID: PMC10064835 DOI: 10.1093/ndt/gfac201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Limited health literacy is associated with significant morbidity and mortality in the general population but the relation of health literacy with long-term clinical outcomes among adults with chronic kidney disease (CKD) is less clear. METHODS Prospective data from the Chronic Renal Insufficiency Cohort (CRIC) Study (n = 3715) were used. Health literacy was assessed with the Short Test of Functional Health Literacy in Adults (dichotomized as limited/adequate). Cox proportional hazards models were used to separately examine the relations of health literacy with CKD progression, cardiovascular event (any of the following: myocardial infarction, congestive heart failure, stroke or peripheral artery disease), and all-cause, cardiovascular and non-cardiovascular mortality. Poisson regression was used to assess the health literacy-hospitalization association. Models were sequentially adjusted: Model 1 adjusted for potential confounders (sociodemographic factors), while Model 2 additionally adjusted for potential mediators (clinical and lifestyle factors) of the associations of interest. RESULTS In confounder-adjusted models, participants with limited (vs adequate) health literacy [555 (15%)] had an increased risk of CKD progression [hazard ratio (HR) 1.34; 95% confidence interval (CI) 1.06-1.71], cardiovascular event (HR 1.67; 95% CI 1.39-2.00), hospitalization (rate ratio 1.33; 95% CI 1.26-1.40), and all-cause (HR 1.54; 95% CI 1.27-1.86), cardiovascular (HR 2.39; 95% CI 1.69-3.38) and non-cardiovascular (HR 1.27; 95% CI 1.01-1.60) mortality. Additional adjustments for potential mediators (Model 2) showed similar results except that the relations of health literacy with CKD progression and non-cardiovascular mortality were no longer statistically significant. CONCLUSIONS In the CRIC Study, adults with limited (vs adequate) health literacy had a higher risk for CKD progression, cardiovascular event, hospitalization and mortality-regardless of adjustment for potential confounders.
Collapse
Affiliation(s)
- Mayra L Estrella
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Brownsville, TX, USA
- Institute for Minority Health Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Paula Allen-Meares
- Institute for Minority Health Research, University of Illinois at Chicago, Chicago, IL, USA
- Office of Health Literacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael J Fischer
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
- Medicine/Nephrology, Jesse Brown VA Medical Center, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, IL, USA
| | - Elisa J Gordon
- Division of Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eunice Carmona-Powell
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - James Sondheimer
- Department of Medicine, Wayne State University, Detroit, MI, USA
| | - Jing Chen
- Department of Medicine, Tulane University, New Orleans, LA, USA
| | - Edward Horwitz
- Case Western Reserve University, School of Medicine, MetroHealth Medical Center, Cleveland, OH, USA
| | - Xue Wang
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - James P Lash
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Claudia Lora
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Brownsville, TX, USA
| |
Collapse
|
5
|
Ghandour M, Thimmisetty RK, Sondheimer J, Imran N, Bhat ZY, Osman-Malik YM. Conversion from Intermittent Hemodialysis to Peritoneal Dialysis in Metastatic Catheter-Related Bloodstream Infection. Case Rep Nephrol Dial 2023; 13:97-103. [PMID: 37900928 PMCID: PMC10601878 DOI: 10.1159/000531094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 05/09/2023] [Indexed: 10/31/2023] Open
Abstract
Of all complications from central venous catheters (CVC) in end-stage renal disease (ESRD) patients, catheter-related bloodstream infection (CRBSI) is one of the most devastating consequences. The option of catheter salvage is not an effective measure with metastatic infections. However, in patients with severe vasculopathy and/or near end-stage vascular disease, preservation of the venous access should be given utmost importance as the luxury of utilizing another vascular site is markedly limited. Providing adequate renal replacement therapy in this group of patients can be remarkably challenging for nephrologists. We are presenting an ESRD patient with advanced vascular disease who developed metastatic CRBSI with worsening uremia who was successfully converted from intermittent hemodialysis (IHD) to peritoneal dialysis (PD). Our rationale was to minimize repeated intravascular procedures coupled with the presence of another intravascular device. This has led to a complete resolution of persistent bacteremia, with a steady improvement in the uremic state. Conversion from IHD to PD for persistent bacteremia with metastatic complications was seldom addressed in literature. In the absence of a significant contraindication to PD, it can be considered as a valid alternative possibility in order to interrupt this viscous cycle, especially in vasculopathic patients.
Collapse
Affiliation(s)
- Mohamedanwar Ghandour
- Division of Nephrology and Hypertension, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ravi K Thimmisetty
- Division of Nephrology and Hypertension, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - James Sondheimer
- Division of Nephrology and Hypertension, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nashat Imran
- Division of Nephrology and Hypertension, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Zeenat Y Bhat
- Division of Nephrology and Hypertension, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yahya Mohamed Osman-Malik
- Division of Nephrology and Hypertension, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| |
Collapse
|
6
|
Wen D, Zheng Z, Surapaneni A, Yu B, Zhou L, Zhou W, Xie D, Shou H, Avila-Pacheco J, Kalim S, He J, Hsu CY, Parsa A, Rao P, Sondheimer J, Townsend R, Waikar SS, Rebholz CM, Denburg MR, Kimmel PL, Vasan RS, Clish CB, Coresh J, Feldman HI, Grams ME, Rhee EP. Metabolite profiling of CKD progression in the chronic renal insufficiency cohort study. JCI Insight 2022; 7:e161696. [PMID: 36048534 PMCID: PMC9714776 DOI: 10.1172/jci.insight.161696] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUNDMetabolomic profiling in individuals with chronic kidney disease (CKD) has the potential to identify novel biomarkers and provide insight into disease pathogenesis.METHODSWe examined the association between blood metabolites and CKD progression, defined as the subsequent development of end-stage renal disease (ESRD) or estimated glomerular filtrate rate (eGFR) halving, in 1,773 participants of the Chronic Renal Insufficiency Cohort (CRIC) study, 962 participants of the African-American Study of Kidney Disease and Hypertension (AASK), and 5,305 participants of the Atherosclerosis Risk in Communities (ARIC) study.RESULTSIn CRIC, more than half of the measured metabolites were associated with CKD progression in minimally adjusted Cox proportional hazards models, but the number and strength of associations were markedly attenuated by serial adjustment for covariates, particularly eGFR. Ten metabolites were significantly associated with CKD progression in fully adjusted models in CRIC; 3 of these metabolites were also significant in fully adjusted models in AASK and ARIC, highlighting potential markers of glomerular filtration (pseudouridine), histamine metabolism (methylimidazoleacetate), and azotemia (homocitrulline). Our findings also highlight N-acetylserine as a potential marker of kidney tubular function, with significant associations with CKD progression observed in CRIC and ARIC.CONCLUSIONOur findings demonstrate the application of metabolomics to identify potential biomarkers and causal pathways in CKD progression.FUNDINGThis study was supported by the NIH (U01 DK106981, U01 DK106982, U01 DK085689, R01 DK108803, and R01 DK124399).
Collapse
Affiliation(s)
- Donghai Wen
- Nephrology Division and
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zihe Zheng
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aditya Surapaneni
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - Bing Yu
- Department of Epidemiology, Human Genetics & Environmental Sciences, University of Texas Health Sciences Center at Houston School of Public Health, Houston, Texas, USA
| | - Linda Zhou
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - Wen Zhou
- Nephrology Division and
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dawei Xie
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Haochang Shou
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California San Francisco School of Medicine, San Francisco, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Afshin Parsa
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, Maryland, USA
| | - Panduranga Rao
- Division of Nephrology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James Sondheimer
- Division of Nephrology and Hypertension, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Raymond Townsend
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sushrut S. Waikar
- Section of Nephrology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Casey M. Rebholz
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - Michelle R. Denburg
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pediatric Nephrology, Children’s Hospital of Philadelphia, and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul L. Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, Maryland, USA
| | - Ramachandran S. Vasan
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Sections of Preventive Medicine and Epidemiology and Cardiology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Clary B. Clish
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - Harold I. Feldman
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, New York University, New York, New York, USA
| | - Eugene P. Rhee
- Nephrology Division and
- Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
7
|
Lidgard B, Bansal N, Zelnick LR, Hoofnagle A, Chen J, Colaizzo D, Dobre M, Mills KT, Porter AC, Rosas SE, Sarnak MJ, Seliger S, Sondheimer J, Tamura MK, Yaffe K, Kestenbaum B. Association of Proximal Tubular Secretory Clearance with Long-Term Decline in Cognitive Function. J Am Soc Nephrol 2022; 33:1391-1401. [PMID: 35444055 PMCID: PMC9257801 DOI: 10.1681/asn.2021111435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 04/05/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND People with chronic kidney disease (CKD) are at high risk for cognitive impairment and progressive cognitive decline. Retention of protein-bound organic solutes that are normally removed by tubular secretion is hypothesized to contribute to cognitive impairment in CKD. METHODS We followed 2362 participants who were initially free of cognitive impairment and stroke in the prospective Chronic Renal Insufficiency Cohort (CRIC) Study. We estimated tubular secretory clearance by the 24-hour kidney clearances of eight endogenous solutes that are primarily eliminated by tubular secretion. CRIC study investigators assessed participants' cognitive function annually using the Modified Mini-Mental State (3MS) Examination. Cognitive decline was defined as a sustained decrease of more than five points in the 3MS score from baseline. Using Cox regression models adjusted for potential confounders, we analyzed associations between secretory solute clearances, serum solute concentrations, and cognitive decline. RESULTS The median number of follow-up 3MS examinations was six per participant. There were 247 incident cognitive decline events over a median of 9.1 years of follow-up. Lower kidney clearances of five of the eight secretory solutes (cinnamoylglycine, isovalerylglycine, kynurenic acid, pyridoxic acid, and tiglylglycine) were associated with cognitive decline after adjustment for baseline eGFR, proteinuria, and other confounding variables. Effect sizes ranged from a 17% to a 34% higher risk of cognitive decline per 50% lower clearance. In contrast, serum concentrations of the solutes were not associated with cognitive decline. CONCLUSIONS Lower kidney clearances of secreted solutes are associated with incident global cognitive decline in a prospective study of CKD, independent of eGFR. Further work is needed to determine the domains of cognition most affected by decreased secretory clearance and the mechanisms of these associations.
Collapse
Affiliation(s)
- Benjamin Lidgard
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Nisha Bansal
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Leila R. Zelnick
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Andrew Hoofnagle
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Jing Chen
- Department of Medicine, Tulane University, New Orleans, Louisiana
| | | | - Mirela Dobre
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Anna C. Porter
- Department of Medicine, Section of Nephrology, University of Illinois at Chicago, Chicago, Illinois
| | - Sylvia E. Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mark J. Sarnak
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Stephen Seliger
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - James Sondheimer
- Department of Medicine, Division of Nephrology, Wayne State University, Detroit, Michigan
| | - Manjula Kurella Tamura
- Department of Medicine, Stanford University and VA Palo Alto Health Care System, Palo Alto, California
| | - Kristine Yaffe
- Departments of Psychiatry, Neurology, Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, California
| | - Bryan Kestenbaum
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | | |
Collapse
|
8
|
Kalim S, Berg AH, Karumanchi SA, Thadhani R, Allegretti AS, Nigwekar S, Zhao S, Srivastava A, Raj D, Deo R, Frydrych A, Chen J, Sondheimer J, Shafi T, Weir M, Lash JP. Protein carbamylation and chronic kidney disease progression in the Chronic Renal Insufficiency Cohort Study. Nephrol Dial Transplant 2021; 37:139-147. [PMID: 33661286 PMCID: PMC8719615 DOI: 10.1093/ndt/gfaa347] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Protein carbamylation is a post-translational protein modification caused, in part, by exposure to urea's dissociation product cyanate. Carbamylation is linked to cardiovascular outcomes and mortality in dialysis-dependent end-stage kidney disease (ESKD), but its effects in earlier pre-dialysis stages of chronic kidney disease (CKD) are not established. METHODS We conducted two nested case-control studies within the Chronic Renal Insufficiency Cohort Study. First, we matched 75 cases demonstrating CKD progression [50% estimated glomerular filtration rate (eGFR) reduction or reaching ESKD] to 75 controls (matched on baseline eGFR, 24-h proteinuria, age, sex and race). In the second study, we similarly matched 75 subjects who died during follow-up (cases) to 75 surviving controls. Baseline carbamylated albumin levels (C-Alb, a validated carbamylation assay) were compared between cases and controls in each study. RESULTS At baseline, in the CKD progression study, other than blood urea nitrogen (BUN) and smoking status, there were no significant differences in any matched or other parameter. In the mortality group, the only baseline difference was smoking status. Adjusting for baseline differences, the top tertile of C-Alb was associated with an increased risk of CKD progression [odds ratio (OR) = 7.9; 95% confidence interval (CI) 1.9-32.8; P = 0.004] and mortality (OR = 3.4; 95% CI 1.0-11.4; P = 0.05) when compared with the bottom tertile. C-Alb correlated with eGFR but was more strongly correlated with BUN. CONCLUSIONS Our data suggest that protein carbamylation is a predictor of CKD progression, beyond traditional risks including eGFR and proteinuria. Carbamylation's association with mortality was smaller in this limited sample size.
Collapse
Affiliation(s)
- Sahir Kalim
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Anders H Berg
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Ravi Thadhani
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew S Allegretti
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sagar Nigwekar
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sophia Zhao
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Anand Srivastava
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dominic Raj
- Department of Medicine, Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC, USA
| | - Rajat Deo
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania Philadelphia, PA, USA
| | - Anne Frydrych
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Jing Chen
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - James Sondheimer
- Department of Medicine, Wayne State University, Detroit, MI, USA
| | - Tariq Shafi
- Department of Medicine, Johns Hopkins University Baltimore, MD, USA
| | - Matthew Weir
- Department of Medicine, Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - James P Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
9
|
Grams ME, Surapaneni A, Appel LJ, Lash JP, Hsu J, Diamantidis CJ, Rosas SE, Fink JC, Scialla JJ, Sondheimer J, Hsu CY, Cheung AK, Jaar BG, Navaneethan S, Cohen DL, Schrauben S, Xie D, Rao P, Feldman HI. Clinical events and patient-reported outcome measures during CKD progression: findings from the Chronic Renal Insufficiency Cohort Study. Nephrol Dial Transplant 2021; 36:1685-1693. [PMID: 33326030 PMCID: PMC8396398 DOI: 10.1093/ndt/gfaa364] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) face risks of not only end-stage kidney disease (ESKD), cardiovascular disease (CVD) and death, but also decline in kidney function, quality of life (QOL) and mental and physical well-being. This study describes the multidimensional trajectories of CKD using clinical events, kidney function and patient-reported outcome measures (PROMs). We hypothesized that more advanced CKD stages would associate with more rapid decline in each outcome. METHODS Among 3939 participants enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study, we evaluated multidimensional disease trajectories by G- and A-stages of enrollment estimated glomerular filtration rate (eGFR) and albuminuria, respectively. These trajectories included clinical events (ESKD, CVD, heart failure and death), eGFR decline and PROMs [kidney disease QOL (KDQOL) burden, effects and symptoms questionnaires, as well as the 12-item short form mental and physical component summaries]. We also evaluated a group-based multitrajectory model to group participants on the basis of longitudinal PROMs and compared group assignments by enrollment G- and A-stage. RESULTS The mean participant age was 58 years, 45% were women, mean baseline eGFR was 44 mL/min/1.73 m2 and median urine albumin:creatinine ratio was 52 mg/g. The incidence of all clinical events was greater and eGFR decline was faster with more advanced G- and A-stages. While baseline KDQOL and physical component measures were lower with more advanced G- and A-stage of CKD, changes in PROMs were inconsistently related to the baseline CKD stage. Groups formed on PROM trajectories were fairly distinct from existing CKD staging (observed agreement 60.6%) and were associated with the risk of ESKD, CVD, heart failure and death. CONCLUSIONS More advanced baseline CKD stage was associated with a higher risk of clinical events and faster eGFR decline, and was only weakly related to changes in patient-reported metrics over time.
Collapse
Affiliation(s)
- Morgan E Grams
- Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Aditya Surapaneni
- Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Lawrence J Appel
- Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - James P Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Jesse Hsu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Sylvia E Rosas
- Joslin Diabetes Center, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Jeffrey C Fink
- Department of Medicine, University of Maryland, Baltimore, MD, USA
| | - Julia J Scialla
- School of Medicine, Duke University, Durham, NC, USA
- Department of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - James Sondheimer
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA
| | - Chi-Yuan Hsu
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Alfred K Cheung
- Veterans Affairs Salt Lake City Health Care System, University of Utah, Salt Lake City, UT, USA
| | - Bernard G Jaar
- Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | | | - Debbie L Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah Schrauben
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dawei Xie
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pandu Rao
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Harold I Feldman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
10
|
Ishigami J, Taliercio JT, Feldman HI, Srivastava A, Townsend RR, Cohen DL, Horwitz EJ, Rao P, Charleston J, Fink JC, Ricardo AC, Sondheimer J, Chen TK, Wolf M, Isakova T, Appel LJ, Matsushita K. Fibroblast Growth Factor 23 and Risk of Hospitalization with Infection in Chronic Kidney Disease: The Chronic Renal Insufficiency Cohort (CRIC) Study. J Am Soc Nephrol 2020; 31:1836-1846. [PMID: 32576601 DOI: 10.1681/asn.2019101106] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 04/14/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Risk of infectious disease is increased among individuals with CKD. Fibroblast growth factor 23 (FGF23) is often elevated in CKD, and may impair immune function directly or indirectly through proinflammatory and vitamin D-suppressing pathways. Whether FGF23 is associated with risk of infection has not been evaluated in a CKD population. METHODS In 3655 participants of the Chronic Renal Insufficiency Cohort study, we evaluated the association of baseline plasma levels of C-terminal FGF23 with time to first hospitalization with major infection, defined by hospital discharge with a diagnosis code for urinary tract infection, pneumonia, cellulitis/osteomyelitis, or bacteremia/septicemia. Multivariable Cox models were used to estimate hazard ratios (HRs) and adjust for confounding. RESULTS During a median follow-up of 6.5 years, 1051 individuals (29%) were hospitalized with major infection. Multivariable Cox analysis indicated a graded increase in the risk of infection with higher levels of FGF23 (HR, 1.51; 95% CI, 1.23 to 1.85 with the highest quartile [≥235.9 RU/ml] versus lowest quartile [<95.3 RU/ml]; HR, 1.26; 95% CI, 1.18 to 1.35 per SD increment in log FGF23). The association was consistent across infection subtypes and demographic and clinical subgroups, and remained significant after additional adjustment for biomarkers of inflammation (IL-6, TNF-α, high-sensitivity C-reactive protein, fibrinogen, and albumin), and bone mineral metabolism (25-hydroxyvitamin D, phosphorus, calcium, and parathyroid hormone). The association was consistent across infection subtypes of urinary tract infection (482 cases), cellulitis/osteomyelitis (422 cases), pneumonia (399 cases), and bacteremia/septicemia (280 cases). CONCLUSIONS Among individuals with CKD, higher FGF23 levels were independently and monotonically associated with an increased risk of hospitalization with infection.
Collapse
Affiliation(s)
- Junichi Ishigami
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland .,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jonathan T Taliercio
- Department of Nephrology and Hypertension, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Harold I Feldman
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anand Srivastava
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raymond R Townsend
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debbie L Cohen
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward J Horwitz
- Division of Nephrology, MetroHealth Medical Center, Cleveland, Ohio
| | - Panduranga Rao
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Jeanne Charleston
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeffrey C Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ana C Ricardo
- Division of Nephrology, University of Illinois, Chicago, Illinois
| | - James Sondheimer
- Division of Nephrology and Hypertension, Wayne State University School of Medicine, Detroit, Michigan
| | - Teresa K Chen
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lawrence J Appel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | |
Collapse
|
11
|
Saraf SL, Hsu JY, Ricardo AC, Mehta R, Chen J, Chen TK, Fischer MJ, Hamm L, Sondheimer J, Weir MR, Zhang X, Wolf M, Lash JP. Anemia and Incident End-Stage Kidney Disease. ACTA ACUST UNITED AC 2020; 1:623-630. [PMID: 33117990 DOI: 10.34067/kid.0000852020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Chronic kidney disease (CKD) progression can be a cause and potentially a consequence of anemia. Previous studies suggesting that anemia is associated with CKD progression have not utilized methodologic approaches to address time-dependent confounding. Methods We evaluated the association of anemia (defined using World Health Organization criteria of hemoglobin <12 g/dL in women and <13 g/dL in men) with incident ESRD and all-cause death in individuals with CKD using data from the Chronic Renal Insufficiency Cohort Study. Marginal structural models were used to account for time-dependent confounding. Results Among 3919 participants, 1859 (47.4%) had anemia at baseline. Over median follow up of 7.8 years, we observed 1,010 ESRD events and 994 deaths. In multivariable analyses, individuals with anemia had higher risk for ESRD compared to those without (HR 1.62, 95% CI 1.24-2.11). In stratified analyses, the increased risk for incident ESRD with anemia was observed in males (HR 2.15, 95% CI: 1.53-3.02) but not females (HR 1.20, 95% CI 0.82-1.78. The association between anemia and ESRD was significant among all racial/ethnic groups except non-Hispanic blacks (non-Hispanic white, HR 2.16, 95% CI 1.53-3.06; Hispanic, HR 1.92, 1.04-3.51; others, HR 2.94; 95% CI 1.16-7.44; non-Hispanic black, HR 1.39; 95% CI 0.95-2.02). There was no association between anemia and all-cause death. Conclusions In this cohort, anemia was independently associated with increased risk for incident ESRD. Future work is needed to evaluate the mechanisms by which anemia leads to CKD progression as well as the impact of novel therapeutic agents to treat anemia.
Collapse
Affiliation(s)
- Santosh L Saraf
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Ana C Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Rupal Mehta
- Department of Medicine, Northwestern University, Chicago, IL.,Medical Service, Jesse Brown VA Medical Center, Chicago, Illinois
| | - Jing Chen
- Department of Medicine, Tulane University, New Orleans, LA
| | - Teresa K Chen
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Michael J Fischer
- Department of Medicine, University of Illinois at Chicago, Chicago, IL.,Medical Service, Jesse Brown VA Medical Center, Chicago, Illinois.,Research Service, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, Illinois
| | - Lee Hamm
- Department of Medicine, Tulane University, New Orleans, LA
| | | | - Matthew R Weir
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Xiaoming Zhang
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - James P Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| |
Collapse
|
12
|
Ishigami J, Taliercio J, I Feldman H, Srivastava A, Townsend R, L Cohen D, Horwitz E, Rao P, Charleston J, Fink JC, Ricardo AC, Sondheimer J, Chen TK, Wolf M, Isakova T, Appel LJ, Matsushita K. Inflammatory Markers and Incidence of Hospitalization With Infection in Chronic Kidney Disease. Am J Epidemiol 2020; 189:433-444. [PMID: 31673705 DOI: 10.1093/aje/kwz246] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 10/09/2019] [Accepted: 10/11/2019] [Indexed: 12/20/2022] Open
Abstract
Persons with chronic kidney disease (CKD) are at high risk of infection. While low-grade inflammation could impair immune response, it is unknown whether inflammatory markers are associated with infection risk in this clinical population. Using 2003-2013 data from the Chronic Renal Insufficiency Cohort Study (3,597 participants with CKD), we assessed the association of baseline plasma levels of 4 inflammatory markers (interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), interleukin-1 receptor antagonist (IL-1RA), and transforming growth factor-β (TGF-β)) with incident hospitalization with major infection (pneumonia, urinary tract infection, cellulitis and osteomyelitis, and bacteremia and sepsis). During follow-up (median 7.5 years), 36% (n = 1,290) had incident hospitalization with major infection. In multivariable Cox analyses with each inflammatory marker modeled as a restricted cubic spline, higher levels of IL-6 and TNF-α were monotonically associated with increased risk of hospitalization with major infection (for 95th vs. 5th percentile, hazard ratio = 2.11 (95% confidence interval: 1.68, 2.66) for IL-6 and 1.88 (95% confidence interval: 1.51, 2.33) for TNF-α), while corresponding associations for IL-1RA or TGF-β were nonsignificant. Thus, higher plasma levels of IL-6 and TNF-α, but not IL-1RA or TGF-β, were significantly associated with increased risk of hospitalization with major infection. Future studies should investigate whether inflammatory pathways that involve IL-6 and TNF-α increase susceptibility to infection among individuals with CKD.
Collapse
|
13
|
Zhan M, Doerfler RM, Xie D, Chen J, Chen HY, Diamantidis CJ, Rahman M, Ricardo AC, Sondheimer J, Strauss L, Wagner LA, Weir MR, Fink JC. Association of Opioids and Nonsteroidal Anti-inflammatory Drugs With Outcomes in CKD: Findings From the CRIC (Chronic Renal Insufficiency Cohort) Study. Am J Kidney Dis 2020; 76:184-193. [PMID: 32317121 DOI: 10.1053/j.ajkd.2019.12.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 12/11/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Safe analgesic choices are limited in chronic kidney disease (CKD). We conducted a comparative analysis of harm from opioids versus nonsteroidal anti-inflammatory drugs (NSAIDs) in CKD. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 3,939 patients with CKD in the Chronic Renal Insufficiency Cohort (CRIC) Study. EXPOSURES 30-day analgesic use reported at annual visits. OUTCOMES A composite outcome of 50% glomerular filtration rate reduction and kidney failure requiring kidney replacement therapy (KRT), as well as the outcomes of kidney failure requiring KRT, hospitalization, and pre-kidney failure death. ANALYTICAL APPROACH Marginal structural models with time-updated exposures. RESULTS Participants were followed up for a median of 6.84 years, with 391 (9.9%) and 612 (15.5%) reporting baseline opioid and NSAID use, respectively. Time-updated opioid use was associated with the kidney disease composite outcome, kidney failure with KRT, death (HRs of 1.4 [95% CI, 1.2-1.7], 1.4 [95% CI, 1.1-1.7], and 1.5 [95% CI, 1.2-2.0], respectively), and hospitalization (rate ratio [RR], 1.7; 95% CI, 1.6-1.9) versus opioid nonusers. Similar results were found in an analysis restricted to a subcohort of participants reporting ever using other (nonopioid and non-NSAID) analgesics or tramadol. Time-updated NSAID use was associated with increased risk for the kidney disease composite (HR, 1.2; 95% CI, 1.0-1.5) and hospitalization (RR, 1.1; 95% CI, 1.0-1.3); however, these associations were not significant in the subcohort. The association of NSAID use with the kidney disease composite outcome varied by race, with a significant risk in blacks (HR, 1.3; 95% CI, 1.0-1.7). NSAID use was associated with lower risk for kidney failure with KRT in women and individuals with glomerular filtration rate<45mL/min/1.73m2 (HRs of 0.63 [95% CI, 0.45-0.88] and 0.77 [95% CI, 0.59-0.99], respectively). LIMITATIONS Limited periods of recall of analgesic use and potential confounding by indication. CONCLUSIONS Opioid use had a stronger association with adverse events than NSAIDs, with the latter's association with kidney disease outcomes limited to specific subgroups, notably those of black race.
Collapse
Affiliation(s)
- Min Zhan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Rebecca M Doerfler
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jing Chen
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Hsiang-Yu Chen
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Mahboob Rahman
- Department of Medicine, Case Western University, Cleveland, OH
| | - Ana C Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - James Sondheimer
- Department of Medicine, Wayne State University School of Medicine, Detroit, MI
| | - Louise Strauss
- Department of Medicine, Case Western University, Cleveland, OH
| | - Lee-Ann Wagner
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Jeffrey C Fink
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.
| | | |
Collapse
|
14
|
Ku E, Yang W, McCulloch CE, Feldman HI, Go AS, Lash J, Bansal N, He J, Horwitz E, Ricardo AC, Shafi T, Sondheimer J, Townsend RR, Waikar SS, Hsu CY. Race and Mortality in CKD and Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2019; 75:394-403. [PMID: 31732235 DOI: 10.1053/j.ajkd.2019.08.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/02/2019] [Indexed: 01/13/2023]
Abstract
RATIONALE & OBJECTIVES Few studies have investigated racial disparities in survival among dialysis patients in a manner that considers risk factors and mortality during the phase of kidney disease before maintenance dialysis. Our objective was to explore racial variations in survival among dialysis patients and relate them to racial differences in comorbid conditions and rates of death in the setting of kidney disease not yet requiring dialysis therapy. STUDY DESIGN Retrospective cohort study. SETTINGS & PARTICIPANTS 3,288 black and white participants in the Chronic Renal Insufficiency Cohort (CRIC), none of whom were receiving dialysis at enrollment. EXPOSURE Race. OUTCOME Mortality. ANALYTIC APPROACH Cox proportional hazards regression was used to examine the association between race and mortality starting at: (1) time of dialysis initiation and (2) entry into the CRIC. RESULTS During 7.1 years of median follow-up, 678 CRIC participants started dialysis. Starting from the time of dialysis initiation, blacks had lower risk for death (unadjusted HR, 0.67; 95% CI, 0.51-0.87) compared with whites. Starting from baseline CRIC enrollment, the strength of the association between some risk factors and dialysis was notably stronger for whites than blacks. For example, the HR for dialysis onset in the presence (vs absence) of heart failure at CRIC enrollment was 1.30 (95% CI, 1.01-1.68) for blacks versus 2.78 (95% CI, 1.90-4.50) for whites, suggesting differential severity of these risk factors by race. When we included deaths occurring both before and after dialysis, risk for death was higher among blacks (vs whites) starting from CRIC enrollment (HR, 1.41; 95% CI, 1.22-1.64), but this finding was attenuated in adjusted models (HR, 1.08; 95% CI, 0.91-1.28). LIMITATIONS Residual confounding. CONCLUSIONS The apparent survival advantage among blacks over whites treated with dialysis may be attributed to selected transition of a subset of whites with more severe comorbid conditions onto dialysis.
Collapse
Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA; Division of Pediatric Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, CA.
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Harold I Feldman
- Division of Nephrology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alan S Go
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, San Francisco, CA
| | - James Lash
- Division of Nephrology, Department of Medicine, University of Illinois, Chicago, IL
| | - Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Ed Horwitz
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland OH
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois, Chicago, IL
| | - Tariq Shafi
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | | | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sushrut S Waikar
- Division of Nephrology, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | | |
Collapse
|
15
|
Hsu CY, Hsu RK, Liu KD, Yang J, Anderson A, Chen J, Chinchilli VM, Feldman HI, Garg AX, Hamm L, Himmelfarb J, Kaufman JS, Kusek JW, Parikh CR, Ricardo AC, Rosas SE, Saab G, Sha D, Siew ED, Sondheimer J, Taliercio JJ, Yang W, Go AS. Impact of AKI on Urinary Protein Excretion: Analysis of Two Prospective Cohorts. J Am Soc Nephrol 2019; 30:1271-1281. [PMID: 31235617 PMCID: PMC6622423 DOI: 10.1681/asn.2018101036] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 03/30/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Prior studies of adverse renal consequences of AKI have almost exclusively focused on eGFR changes. Less is known about potential effects of AKI on proteinuria, although proteinuria is perhaps the strongest risk factor for future loss of renal function. METHODS We studied enrollees from the Assessment, Serial Evaluation, and Subsequent Sequelae of AKI (ASSESS-AKI) study and the subset of the Chronic Renal Insufficiency Cohort (CRIC) study enrollees recruited from Kaiser Permanente Northern California. Both prospective cohort studies included annual ascertainment of urine protein-to-creatinine ratio, eGFR, BP, and medication use. For hospitalized participants, we used inpatient serum creatinine measurements obtained as part of clinical care to define an episode of AKI (i.e., peak/nadir inpatient serum creatinine ≥1.5). We performed mixed effects regression to examine change in log-transformed urine protein-to-creatinine ratio after AKI, controlling for time-updated covariates. RESULTS At cohort entry, median eGFR was 62.9 ml/min per 1.73 m2 (interquartile range [IQR], 46.9-84.6) among 2048 eligible participants, and median urine protein-to-creatinine ratio was 0.12 g/g (IQR, 0.07-0.25). After enrollment, 324 participants experienced at least one episode of hospitalized AKI during 9271 person-years of follow-up; 50.3% of first AKI episodes were Kidney Disease Improving Global Outcomes stage 1 in severity, 23.8% were stage 2, and 25.9% were stage 3. In multivariable analysis, an episode of hospitalized AKI was independently associated with a 9% increase in the urine protein-to-creatinine ratio. CONCLUSIONS Our analysis of data from two prospective cohort studies found that hospitalization for an AKI episode was independently associated with subsequent worsening of proteinuria.
Collapse
Affiliation(s)
- Chi-yuan Hsu
- Department of Medicine, University of California, San Francisco, San Francisco, California;,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Raymond K. Hsu
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Kathleen D. Liu
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Jingrong Yang
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Jing Chen
- Medicine, Tulane University, New Orleans, Louisiana
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | | | - Amit X. Garg
- Department of Medicine, Western University, London, Ontario, Canada
| | - Lee Hamm
- Medicine, Tulane University, New Orleans, Louisiana
| | | | - James S. Kaufman
- Veterans Affairs New York Harbor Healthcare System, New York, New York;,Department of Medicine, New York University School of Medicine, New York, New York
| | | | - Chirag R. Parikh
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois, Chicago, Illinois
| | - Sylvia E. Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Georges Saab
- Case Western Reserve University and Metrohealth Medical Center, Cleveland, Ohio
| | - Daohang Sha
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward D. Siew
- Vanderbilt University Medical Center and Nashville Veterans Affairs Hospital, Nashville, Tennessee
| | - James Sondheimer
- Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan; and
| | | | - Wei Yang
- Department of Biostatistics and Epidemiology, and
| | - Alan S. Go
- Department of Medicine, University of California, San Francisco, San Francisco, California;,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | |
Collapse
|
16
|
Brown L, Luciano A, Pendergast J, Khairallah P, Anderson CAM, Sondheimer J, Hamm LL, Ricardo AC, Rao P, Rahman M, Miller ER, Sha D, Xie D, Feldman HI, Asplin J, Wolf M, Scialla JJ. Predictors of Net Acid Excretion in the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2019; 74:203-212. [PMID: 30910373 DOI: 10.1053/j.ajkd.2018.12.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 12/28/2018] [Indexed: 12/18/2022]
Abstract
RATIONALE & OBJECTIVE Higher urine net acid excretion (NAE) is associated with slower chronic kidney disease progression, particularly in patients with diabetes mellitus. To better understand potential mechanisms and assess modifiable components, we explored independent predictors of NAE in the CRIC (Chronic Renal Insufficiency Cohort) Study. STUDY DESIGN Cross-sectional. SETTING & PARTICIPANTS A randomly selected subcohort of adults with chronic kidney disease enrolled in the CRIC Study with NAE measurements. PREDICTORS A comprehensive set of variables across prespecified domains including demographics, comorbid conditions, medications, laboratory values, diet, physical activity, and body composition. OUTCOME 24-hour urine NAE. ANALYTICAL APPROACH NAE was defined as the sum of urine ammonium and calculated titratable acidity in a subset of CRIC participants. 22 individuals were excluded for urine pH < 4 (n = 1) or ≥7.4 (n = 19) or extreme outliers of NAE values (n = 2). From an analytic sample of 978, we identified the association of individual variables with NAE in the selected domains using linear regression. We estimated the percent variance explained by each domain using the adjusted R2 from a domain-specific model. RESULTS Mean NAE was 33.2 ± 17.4 (SD) mEq/d. Multiple variables were associated with NAE in models adjusted for age, sex, estimated glomerular filtration rate (eGFR), race/ethnicity, and body surface area, including insulin resistance, dietary potential renal acid load, and a variety of metabolically active medications (eg, metformin, allopurinol, and nonstatin lipid agents). Body size, as indicated by body surface area, body mass index, or fat-free mass; race/ethnicity; and eGFR also were independently associated with NAE. By domains, more variance was explained by demographics, body composition, and laboratory values, which included eGFR and serum bicarbonate level. LIMITATIONS Cross-sectional; use of stored biological samples. CONCLUSIONS NAE relates to several clinical domains including body composition, kidney function, and diet, but also to metabolic factors such as insulin resistance and the use of metabolically active medications.
Collapse
Affiliation(s)
- Landon Brown
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Alison Luciano
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC
| | - Jane Pendergast
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Pascale Khairallah
- Department of Medicine, Duke University School of Medicine, Durham, NC; Department of Medicine, Columbia University School of Medicine, New York, NY
| | - Cheryl A M Anderson
- Department of Family and Medicine and Public Health, University of California San Diego School of Medicine, San Diego, CA
| | - James Sondheimer
- Department of Medicine, Wayne State University School of Medicine, Detroit, MI
| | - L Lee Hamm
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Ana C Ricardo
- Department of Medicine, University of Illinois College of Medicine, Chicago, IL
| | - Panduranga Rao
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Mahboob Rahman
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Edgar R Miller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daohang Sha
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Harold I Feldman
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - John Asplin
- Litholink Corporation, Laboratory Corporation of America Holdings, Chicago, IL
| | - Myles Wolf
- Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
| | | |
Collapse
|
17
|
Cedillo-Couvert EA, Ricardo AC, Chen J, Cohan J, Fischer MJ, Krousel-Wood M, Kusek JW, Lederer S, Lustigova E, Ojo A, Porter AC, Sharp LK, Sondheimer J, Diamantidis C, Wang X, Roy J, Lash JP. Self-reported Medication Adherence and CKD Progression. Kidney Int Rep 2018; 3:645-651. [PMID: 29854972 PMCID: PMC5976857 DOI: 10.1016/j.ekir.2018.01.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 01/16/2018] [Accepted: 01/25/2018] [Indexed: 02/01/2023] Open
Abstract
Introduction In the general population, medication nonadherence contributes to poorer outcomes. However, little is known about medication adherence among adults with chronic kidney disease (CKD). We evaluated the association of self-reported medication adherence with CKD progression and all-cause death in patients with CKD. Methods In this prospective observational study of 3305 adults with mild-to-moderate CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study, the baseline self-reported medication adherence was assessed by responses to 3 questions and categorized as high, medium, and low. CKD progression (50% decline in eGFR or incident end-stage renal disease) and all-cause death were measured using multivariable Cox proportional hazards. Results Of the patients, 68% were categorized as high adherence, 17% medium adherence, and 15% low adherence. Over a median follow-up of 6 years, there were 969 CKD progression events and 675 deaths. Compared with the high-adherence group, the low-adherence group experienced increased risk for CKD progression (hazard ratio = 1.27, 95% confidence interval = 1.05, 1.54) after adjustment for sociodemographic and clinical factors, cardiovascular medications, number of medication types, and depressive symptoms. A similar association existed between low adherence and all-cause death, but did not reach standard statistical significance (hazard ratio = 1.14 95% confidence interval = 0.88, 1.47). Conclusion Baseline self-reported low medication adherence was associated with an increased risk for CKD progression. Future work is needed to better understand the mechanisms underlying this association and to develop interventions to improve adherence.
Collapse
Affiliation(s)
| | - Ana C Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
| | - Jinsong Chen
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
| | - Janet Cohan
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
| | - Michael J Fischer
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA.,Department of Medicine, Jesse Brown VAMC, Chicago, Illinois, USA.,Research Service, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, Illinois, USA
| | - Marie Krousel-Wood
- Department of Medicine and Epidemiology, Tulane University, New Orleans, Louisiana, USA; Research Division, Ochsner Health System, New Orleans, Louisiana, USA
| | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Swati Lederer
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA.,Department of Medicine, Jesse Brown VAMC, Chicago, Illinois, USA.,Research Service, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, Illinois, USA
| | - Eva Lustigova
- Department of Medicine and Epidemiology, Tulane University, New Orleans, Louisiana, USA; Research Division, Ochsner Health System, New Orleans, Louisiana, USA
| | - Akinlolu Ojo
- Department of Medicine, University of Arizona, Phoenix, Arizona, USA
| | - Anna C Porter
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
| | - Lisa K Sharp
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
| | - James Sondheimer
- Department of Internal Medicine, Wayne State University, Detroit, Michigan, USA
| | - Clarissa Diamantidis
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Xue Wang
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Roy
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James P Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, Ilinois, USA
| | | |
Collapse
|
18
|
Mehta R, Cai X, Hodakowski A, Lee J, Leonard M, Ricardo A, Chen J, Hamm L, Sondheimer J, Dobre M, David V, Yang W, Go A, Kusek JW, Feldman H, Wolf M, Isakova T. Fibroblast Growth Factor 23 and Anemia in the Chronic Renal Insufficiency Cohort Study. Clin J Am Soc Nephrol 2017; 12:1795-1803. [PMID: 28784656 PMCID: PMC5672973 DOI: 10.2215/cjn.03950417] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/03/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Anemia is an early complication of CKD that is associated with increased morbidity and mortality. Prior data show associations between abnormal mineral metabolism markers and decreased erythropoiesis. However, few studies have investigated elevated fibroblast growth factor 23 as a risk factor for the development of anemia in patients with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a prospective cohort study of 3869 individuals with mild to severe CKD enrolled in the Chronic Renal Insufficiency Cohort Study between 2003 and 2008 and followed through 2013. We hypothesized that elevated baseline fibroblast growth factor 23 levels are associated with prevalent anemia, decline in hemoglobin over time, and development of incident anemia, defined as serum hemoglobin level <13 g/dl in men, serum hemoglobin level <12 g/dl in women, or use of erythropoietin stimulating agents. RESULTS In the 1872 of 3869 individuals who had prevalent anemia at baseline, mean age was 58 (11) years old, and mean eGFR was 39 (13) ml/min per 1.73 m2. Higher levels of fibroblast growth factor 23 were significantly associated with prevalent anemia (odds ratio per 1-SD increase in natural log-transformed fibroblast growth factor 23, 1.39; 95% confidence interval, 1.26 to 1.52), decline in hemoglobin over 4 years, and risk of incident anemia (hazard ratio per 1-SD increase in natural log-transformed fibroblast growth factor 23, 1.13; 95% confidence interval, 1.04 to 1.24; quartile 4 versus quartile 1: hazard ratio, 1.59; 95% confidence interval, 1.19 to 2.11) independent of demographic characteristics, cardiovascular disease risk factors, CKD-specific factors, and other mineral metabolism markers. The results of our prospective analyses remained unchanged after additional adjustment for time-varying eGFR. CONCLUSIONS Elevated fibroblast growth factor 23 is associated with prevalent anemia, change in hemoglobin over time, and development of anemia. Future studies are needed to elucidate the mechanisms for these associations.
Collapse
Affiliation(s)
- Rupal Mehta
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Inker LA, Tighiouart H, Coresh J, Foster MC, Anderson AH, Beck GJ, Contreras G, Greene T, Karger AB, Kusek JW, Lash J, Lewis J, Schelling JR, Navaneethan SD, Sondheimer J, Shafi T, Levey AS. GFR Estimation Using β-Trace Protein and β2-Microglobulin in CKD. Am J Kidney Dis 2016; 67:40-8. [PMID: 26362696 PMCID: PMC4695294 DOI: 10.1053/j.ajkd.2015.07.025] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 07/14/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND β-Trace protein (BTP) and β2-microglobulin (B2M) are novel glomerular filtration markers that have stronger associations with adverse outcomes than creatinine. Comparisons of BTP and B2M to creatinine and cystatin C are limited by the absence of rigorously developed glomerular filtration rate (GFR) estimating equations for the novel markers. STUDY DESIGN Study of diagnostic test accuracy. SETTING & PARTICIPANTS Pooled database of 3 populations with chronic kidney disease (CKD) with mean measured GFR of 48 mL/min/1.73 m2 (N=3,551; MDRD [Modification of Diet in Renal Disease] Study, AASK [African American Study of Kidney Disease and Hypertension], and CRIC [Chronic Renal Insufficiency Cohort] Study). INDEX TESTS GFR estimated using creatinine, cystatin C, BTP, or B2M level. REFERENCE TEST GFR measured as the urinary clearance of iothalamate. RESULTS For BTP and B2M, coefficients for age, sex, and race were smaller than for creatinine and were similar or smaller than for cystatin C. For B2M, coefficients for sex, age, and race were smaller than for creatinine and were similar (age and race) or smaller (sex) than for cystatin C. The final equations with BTP (BTP, age, and sex) or B2M (B2M alone) were less accurate than either the CKD-EPI (CKD Epidemiology Collaboration) creatinine or cystatin C equations. The combined BTP-B2M equation (BTP and B2M alone) had similar accuracy to the CKD-EPI creatinine or cystatin C equation. The average of the BTP-B2M equation and the CKD-EPI creatinine-cystatin C equation was not more accurate than the CKD-EPI creatinine-cystatin C equation. LIMITATIONS No external validation population, study population was restricted to CKD, few participants older than 65 years, or nonblack nonwhite race. CONCLUSIONS BTP and B2M are less influenced by age, sex, and race than creatinine and less influenced by race than cystatin C, but provide less accurate GFR estimates than the CKD-EPI creatinine and cystatin C equations. The CKD-EPI BTP and B2M equation provides a methodological advance for their study as filtration markers and in their associations with risk and adverse outcomes, but further study is required before clinical use.
Collapse
Affiliation(s)
| | - Hocine Tighiouart
- Tufts Medical Center, Boston, MA; Research Design Center/Biostatistics Research Center, Tufts CTSI and Institute for Clinical Research and Health Policy Studies, Boston, MA
| | - Josef Coresh
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Amanda H Anderson
- Perelman School of Medicine at the University of Pennsylvania. Philadelphia, PA
| | | | | | | | | | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - James Lash
- University of Illinois at Chicago, Chicago, IL
| | | | | | | | | | - Tariq Shafi
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | |
Collapse
|
20
|
Pillai U, Kahlon R, Sondheimer J, Cadnapaphorncai P, Bhat Z. A rare case of hyperammonemia complication of high-protein parenteral nutrition. JPEN J Parenter Enteral Nutr 2012; 37:134-7. [PMID: 22610979 DOI: 10.1177/0148607112447815] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Hyperammonemia is a metabolic derangement that can be potentially fatal. Primary hyperammonemia due to urea cycle enzyme deficiency is usually discovered in neonates but rarely can present in adulthood. Late-onset manifestations of urea cycle disorders can go unnoticed, until they become life threatening. The authors report a 28-year-old man who developed hyperammonemia in the hospital following parenteral nutrition (PN), leading to cerebral edema, which was fatal despite resolution of the hyperammonemia with cessation of PN and the use of continuous renal replacement therapy.
Collapse
|
21
|
Isakova T, Xie H, Yang W, Xie D, Anderson AH, Scialla J, Wahl P, Gutiérrez OM, Steigerwalt S, He J, Schwartz S, Lo J, Ojo A, Sondheimer J, Hsu CY, Lash J, Leonard M, Kusek JW, Feldman HI, Wolf M. Fibroblast growth factor 23 and risks of mortality and end-stage renal disease in patients with chronic kidney disease. JAMA 2011; 305:2432-9. [PMID: 21673295 PMCID: PMC3124770 DOI: 10.1001/jama.2011.826] [Citation(s) in RCA: 766] [Impact Index Per Article: 58.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT A high level of the phosphate-regulating hormone fibroblast growth factor 23 (FGF-23) is associated with mortality in patients with end-stage renal disease, but little is known about its relationship with adverse outcomes in the much larger population of patients with earlier stages of chronic kidney disease. OBJECTIVE To evaluate FGF-23 as a risk factor for adverse outcomes in patients with chronic kidney disease. DESIGN, SETTING, AND PARTICIPANTS A prospective study of 3879 participants with chronic kidney disease stages 2 through 4 who enrolled in the Chronic Renal Insufficiency Cohort between June 2003 and September 2008. MAIN OUTCOME MEASURES All-cause mortality and end-stage renal disease. RESULTS At study enrollment, the mean (SD) estimated glomerular filtration rate (GFR) was 42.8 (13.5) mL/min/1.73 m(2), and the median FGF-23 level was 145.5 RU/mL (interquartile range [IQR], 96-239 reference unit [RU]/mL). During a median follow-up of 3.5 years (IQR, 2.5-4.4 years), 266 participants died (20.3/1000 person-years) and 410 reached end-stage renal disease (33.0/1000 person-years). In adjusted analyses, higher levels of FGF-23 were independently associated with a greater risk of death (hazard ratio [HR], per SD of natural log-transformed FGF-23, 1.5; 95% confidence interval [CI], 1.3-1.7). Mortality risk increased by quartile of FGF-23: the HR was 1.3 (95% CI, 0.8-2.2) for the second quartile, 2.0 (95% CI, 1.2-3.3) for the third quartile, and 3.0 (95% CI, 1.8-5.1) for the fourth quartile. Elevated fibroblast growth factor 23 was independently associated with significantly higher risk of end-stage renal disease among participants with an estimated GFR between 30 and 44 mL/min/1.73 m(2) (HR, 1.3 per SD of FGF-23 natural log-transformed FGF-23; 95% CI, 1.04-1.6) and 45 mL/min/1.73 m(2) or higher (HR, 1.7; 95% CI, 1.1-2.4), but not less than 30 mL/min/1.73 m(2). CONCLUSION Elevated FGF-23 is an independent risk factor for end-stage renal disease in patients with relatively preserved kidney function and for mortality across the spectrum of chronic kidney disease.
Collapse
Affiliation(s)
- Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Huiliang Xie
- Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, Florida
| | - Wei Yang
- The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Dawei Xie
- The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Amanda Hyre Anderson
- The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Julia Scialla
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Patricia Wahl
- Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Orlando M. Gutiérrez
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Jiang He
- Department of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Stanley Schwartz
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Joan Lo
- Kaiser Permanente, Oakland, California
| | - Akinlolu Ojo
- Division of Nephrology, Department of Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - James Sondheimer
- Division of Nephrology, Department of Medicine, Wayne State University School of Medicine
| | - Chi-yuan Hsu
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - James Lash
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Mary Leonard
- Department of Pediatrics, the Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - John W. Kusek
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Harold I. Feldman
- The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Myles Wolf
- Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| |
Collapse
|
22
|
Das A, Puklin JE, Spoor TC, Sondheimer J, Karanes C. Retinopathy due to renovascular hypertension in a patient with non-Hodgkin's lymphoma. Arch Ophthalmol 1992; 110:1052-3. [PMID: 1497514 DOI: 10.1001/archopht.1992.01080200032014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
23
|
Abstract
Alpers disease consists of diffuse cerebral degeneration manifested as developmental delay, seizures, vomiting, and progressive neuromuscular deterioration, with liver disease and death. We report the clinical course of the liver disease, histologic progression of the hepatic lesions, and etiologic investigations in five patients (four girls, three kinships). All had grown and developed normally until seen at 6 to 36 months of age (mean 20 months), with vomiting (n = 5), progressive hypotonia (n = 3), or seizures (n = 2). All had been given anticonvulsants, including valproic acid in three. Liver disease was noted at a mean age of 35 months (range 9 to 67 months), with hepatomegaly (two patients), abnormal hepatic synthetic function (three) or transaminase values (three), and cirrhosis in one. Patients survived for a mean of 4.6 weeks (range 1 to 8 weeks) after the identification of liver disease; all died of hepatic failure. Results of evaluation for infectious and metabolic causes of liver disease and causes of degenerative neuromuscular disease were negative in all patients. Premortem liver biopsy specimens (n = 3) demonstrated an early lesion consisting of lobular disarray, microvesicular steatosis, periportal acute and chronic inflammation, and individual hepatocyte necrosis. Autopsy findings (n = 5) consisted of macrovesicular steatosis, massive hepatocyte dropout, and proliferation of bile ductular elements, with almost complete replacement of hepatocytes by proliferating bile ductular elements in two patients. Brain showed characteristic neuronal degeneration. We conclude that Alpers disease can be a cause of rapidly progressive liver failure in early childhood. Although the cause of this autosomal recessive disease is not known, it does not appear to be related to peroxisomal dysfunction.
Collapse
Affiliation(s)
- M R Narkewicz
- Section of Pediatric Gastroenterology and Nutrition University of Colorado Health Sciences Center, Denver
| | | | | | | | | |
Collapse
|
24
|
Abu-Hamdan DK, Desai H, Sondheimer J, Felicetta J, Mahajan S, McDonald F. Taste acuity and zinc metabolism in captopril-treated hypertensive male patients. Am J Hypertens 1988; 1:303S-308S. [PMID: 3046632 DOI: 10.1093/ajh/1.3.303s] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Hypogeusia is a reported side effect of captopril. Linkage of hypogeusia to zinc deficiency has been suggested. We objectively assessed taste acuity using Henkin's three-drop stimulus technique and measured plasma zinc (PZn) level and urinary zinc excretion in 31 hypertensive patients. Of these, 11 were long-term, high-dose captopril recipients (more than 6 months, 266 +/- 34 mg/day), six were short-term captopril recipients (less than 6 months, 104 +/- 40 mg/daily dose), and the remaining 14 served as noncaptopril controls. Compared to controls, the long-term captopril group had significantly higher taste detection and recognition thresholds, lower PZn (91 +/- 3 vs. 100 +/- 3 micrograms/dl, P less than 0.05) and higher urinary zinc excretion (1017 +/- 89 vs. 609 +/- 76 micrograms/day, P less than 0.005). The short-term captopril group did not differ significantly from the noncaptopril group except for higher taste-recognition thresholds for NaCl and sucrose (P less than 0.05). Discontinuing captopril improved taste acuity and almost normalized zinc parameters in two patients on long-term captopril. These results suggest that abnormalities of taste are commonly associated with captopril therapy and may be related to changes in zinc metabolism. This is especially true in patients on long-term, high-dose captopril therapy.
Collapse
Affiliation(s)
- D K Abu-Hamdan
- Department of Medicine, VA Hospital, Allen Park, MI 48101
| | | | | | | | | | | |
Collapse
|
25
|
Abstract
Over a four-year interval, four cases of Listeria monocytogenes bacteremia were observed among a population of 127 patients undergoing long-term hemodialysis. None had an underlying malignancy or were recently receiving immunosuppressive medications. A search for a predisposing factor suggested a relationship to transfusional iron overload. Although still a rare infection, the possibility of listeriosis must be kept in mind by physicians caring for patients undergoing hemodialysis, particularly those requiring blood transfusions.
Collapse
|
26
|
Crosley CJ, Kim RC, Parisi JE, Collins GH, Sondheimer J. Cerebral capillary telangiectasis in an infant. Coincidental Association with hypsarrhythmia. Arch Pathol Lab Med 1982; 106:79-80. [PMID: 6895831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We studied a case of cerebral capillary telangiectasis in infancy. The patient, who had received treatment with intramuscular corticotropin for hypsarrhythmia, suffered disseminated intravascular coagulation and died on the 66th day of life. Neuropathological examination disclosed the presence of two fresh hemorrhages of moderate size within the cerebral hemispheres, one of which seemed to have originated from a capillary telangiectasis within the left frontoorbital white matter.
Collapse
|
27
|
Glass JD, Silver L, Sondheimer J, Pande CS, Coderre J. 4-Phenoxy-3,5-dinitrobenzoylpolyethyleneglycol: Reversible attachment of cysteine-containing polypeptides to polymers in aqueous solutions. Biopolymers 1979. [DOI: 10.1002/bip.1979.360180214] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
28
|
|