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Robinson-Cohen C, Triozzi JL, Rowan B, He J, Chen HC, Zheng NS, Wei WQ, Wilson OD, Hellwege JN, Tsao PS, Gaziano JM, Bick A, Matheny ME, Chung CP, Lipworth L, Siew ED, Ikizler TA, Tao R, Hung AM. Genome-Wide Association Study of CKD Progression. J Am Soc Nephrol 2023; 34:1547-1559. [PMID: 37261792 PMCID: PMC10482057 DOI: 10.1681/asn.0000000000000170] [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: 05/25/2023] [Accepted: 05/25/2023] [Indexed: 06/02/2023] Open
Abstract
SIGNIFICANCE STATEMENT Rapid progression of CKD is associated with poor clinical outcomes. Most previous studies looking for genetic factors associated with low eGFR have used cross-sectional data. The authors conducted a meta-analysis of genome-wide association studies of eGFR decline among 116,870 participants with CKD, focusing on longitudinal data. They identified three loci (two of them novel) associated with longitudinal eGFR decline. In addition to the known UMOD/PDILT locus, variants within BICC1 were associated with significant differences in longitudinal eGFR slope. Variants within HEATR4 also were associated with differences in eGFR decline, but only among Black/African American individuals without diabetes. These findings help characterize molecular mechanisms of eGFR decline in CKD and may inform new therapeutic approaches for progressive kidney disease. BACKGROUND Rapid progression of CKD is associated with poor clinical outcomes. Despite extensive study of the genetics of cross-sectional eGFR, only a few loci associated with eGFR decline over time have been identified. METHODS We performed a meta-analysis of genome-wide association studies of eGFR decline among 116,870 participants with CKD-defined by two outpatient eGFR measurements of <60 ml/min per 1.73 m 2 , obtained 90-365 days apart-from the Million Veteran Program and Vanderbilt University Medical Center's DNA biobank. The primary outcome was the annualized relative slope in outpatient eGFR. Analyses were stratified by ethnicity and diabetes status and meta-analyzed thereafter. RESULTS In cross-ancestry meta-analysis, the strongest association was rs77924615, near UMOD / PDILT ; each copy of the G allele was associated with a 0.30%/yr faster eGFR decline ( P = 4.9×10 -27 ). We also observed an association within BICC1 (rs11592748), where every additional minor allele was associated with a 0.13%/yr slower eGFR decline ( P = 5.6×10 -9 ). Among participants without diabetes, the strongest association was the UMOD/PDILT variant rs36060036, associated with a 0.27%/yr faster eGFR decline per copy of the C allele ( P = 1.9×10 -17 ). Among Black participants, a significantly faster eGFR decline was associated with variant rs16996674 near APOL1 (R 2 =0.29 with the G1 high-risk genotype); among Black participants with diabetes, lead variant rs11624911 near HEATR4 also was associated with a significantly faster eGFR decline. We also nominally replicated loci with known associations with eGFR decline, near PRKAG2, FGF5, and C15ORF54. CONCLUSIONS Three loci were significantly associated with longitudinal eGFR change at genome-wide significance. These findings help characterize molecular mechanisms of eGFR decline and may contribute to the development of new therapeutic approaches for progressive CKD.
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Affiliation(s)
- Cassianne Robinson-Cohen
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jefferson L Triozzi
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bryce Rowan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jing He
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hua C Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neil S Zheng
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Otis D Wilson
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System, Clinical Sciences Research and Development, Nashville, Tennessee
| | - Jacklyn N Hellwege
- VA Tennessee Valley Healthcare System, Clinical Sciences Research and Development, Nashville, Tennessee
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Philip S Tsao
- Department of Medicine, Division of Cardiovascular Medicine, VA Palo Alto Health Care System, Palo Alto, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - J Michael Gaziano
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital and Harvard School of Medicine, Boston, Massachusetts
| | - Alexander Bick
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael E Matheny
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatrics Research Education and Clinical Care Service, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Cecilia P Chung
- VA Tennessee Valley Healthcare System, Clinical Sciences Research and Development, Nashville, Tennessee
- Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Loren Lipworth
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ran Tao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adriana M Hung
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System, Clinical Sciences Research and Development, Nashville, Tennessee
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2
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Kiernan E, Surapaneni A, Zhou L, Schlosser P, Walker KA, Rhee EP, Ballantyne CM, Deo R, Dubin RF, Ganz P, Coresh J, Grams ME. Alterations in the Circulating Proteome Associated with Albuminuria. J Am Soc Nephrol 2023; 34:1078-1089. [PMID: 36890639 PMCID: PMC10278823 DOI: 10.1681/asn.0000000000000108] [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: 09/08/2022] [Accepted: 02/05/2023] [Indexed: 03/10/2023] Open
Abstract
SIGNIFICANCE STATEMENT We describe circulating proteins associated with albuminuria in a population of African American Study of Kidney Disease and Hypertension with CKD (AASK) using the largest proteomic platform to date: nearly 7000 circulating proteins, representing approximately 2000 new targets. Findings were replicated in a subset of a general population cohort with kidney disease (ARIC) and a population with CKD Chronic Renal Insufficiency Cohort (CRIC). In cross-sectional analysis, 104 proteins were significantly associated with albuminuria in the Black group, of which 67 of 77 available proteins were replicated in ARIC and 68 of 71 available proteins in CRIC. LMAN2, TNFSFR1B, and members of the ephrin superfamily had the strongest associations. Pathway analysis also demonstrated enrichment of ephrin family proteins. BACKGROUND Proteomic techniques have facilitated understanding of pathways that mediate decline in GFR. Albuminuria is a key component of CKD diagnosis, staging, and prognosis but has been less studied than GFR. We sought to investigate circulating proteins associated with higher albuminuria. METHODS We evaluated the cross-sectional associations of the blood proteome with albuminuria and longitudinally with doubling of albuminuria in the African American Study of Kidney Disease and Hypertension (AASK; 38% female; mean GFR 46; median urine protein-to-creatinine ratio 81 mg/g; n =703) and replicated in two external cohorts: a subset of the Atherosclerosis Risk in Communities (ARIC) study with CKD and the Chronic Renal Insufficiency Cohort (CRIC). RESULTS In cross-sectional analysis, 104 proteins were significantly associated with albuminuria in AASK, of which 67 of 77 available proteins were replicated in ARIC and 68 of 71 available proteins in CRIC. Proteins with the strongest associations included LMAN2, TNFSFR1B, and members of the ephrin superfamily. Pathway analysis also demonstrated enrichment of ephrin family proteins. Five proteins were significantly associated with worsening albuminuria in AASK, including LMAN2 and EFNA4, which were replicated in ARIC and CRIC. CONCLUSIONS Among individuals with CKD, large-scale proteomic analysis identified known and novel proteins associated with albuminuria and suggested a role for ephrin signaling in albuminuria progression.
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Affiliation(s)
- Elizabeth Kiernan
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aditya Surapaneni
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
- Division of Precision Medicine, New York University Grossman School of Medicine, New York, New York
| | - Linda Zhou
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Pascal Schlosser
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Keenan A. Walker
- Laboratory of Behavioral Neuroscience, Intramural Research Program, National Institute on Aging, Baltimore, Maryland
| | - Eugene P. Rhee
- Nephrology Division and Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Rajat Deo
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ruth F. Dubin
- Division of Nephrology, University of Texas—Southwestern, Dallas, Texas
| | - Peter Ganz
- Division of Cardiology, Zuckerberg San Francisco General Hospital and Department of Medicine, University of California San Francisco, San Francisco, California
| | - Josef Coresh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
- Division of Precision Medicine, New York University Grossman School of Medicine, New York, New York
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3
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Missikpode C, Ricardo AC, Brown J, Durazo-Arvizi RA, Fischer MJ, Hernandez R, Porter AC, Cook JA, Anderson A, Dolata J, Feldman HI, Horwitz E, Lora C, Wright Nunes J, Rao PS, Lash JP. Association between Depressive Symptom Trajectory and Chronic Kidney Disease Progression: Findings from the Chronic Renal Insufficiency Cohort Study. Kidney360 2023; 4:606-614. [PMID: 36814088 PMCID: PMC10278792 DOI: 10.34067/kid.0000000000000087] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 01/26/2023] [Indexed: 05/27/2023]
Abstract
Key Points Depressive symptoms are largely stable over time among individuals with mild-to-moderate CKD Low educational attainment, cigarette smoking, and poor quality of life are associated with persistent depressive symptoms Persistent depressive symptoms are associated with nonlinear and rapid decline in kidney function Background Although depression is highly prevalent among individuals with CKD, little is known about the course of depressive symptoms over time. We characterized trajectories of depressive symptoms and CKD progression and evaluated the association between depressive symptoms trajectory and CKD progression. Methods Two thousand three hundred sixty-one individuals with mild-to-moderate CKD enrolled in the Chronic Renal Insufficiency Cohort Study were analyzed. The Beck Depression Inventory (BDI) was used to assess depressive symptoms at baseline and biennially. Higher BDI scores indicate worse depressive symptoms. eGFR was calculated using the 2021 CKD-EPI equation. Group-based trajectory models were used to determine trajectories of BDI score and eGFR change over time. Multinomial logistic regression was used to examine factors associated with BDI trajectories and to evaluate the association of BDI trajectories with eGFR change. Results Over 8 years of follow-up, three patterns of depressive symptoms were identified: persistently low BDI score (57.7%), persistently moderate BDI score (33.1%), and persistently high BDI score (9.2%). Three eGFR trajectory groups were identified: nonlinear, rapid eGFR decline (21.5%); linear, expected eGFR decline (54.8%); and stable eGFR (23.7%). Predictors of persistently moderate and high BDI trajectories included low educational attainment, smoking, and poor quality of life. Compared with those with a persistently low BDI score, the odds for nonlinear, rapid eGFR decline were higher for those with persistently moderate BDI scores (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.04 to 2.03) and persistently high BDI scores (OR, 1.90; 95% CI, 1.02 to 3.56). No association between moderate BDI score and linear, expected eGFR decline was observed. Conclusions Depressive symptoms remained largely stable among individuals with mild-to-moderate CKD, and persistently moderate and high BDI scores were associated with nonlinear, rapid eGFR decline. Future work is needed to better understand the interplay between depression and CKD progression.
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Affiliation(s)
- Celestin Missikpode
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Julia Brown
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | | | - Michael J. Fischer
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- Medical Service, Jesse Brown VA Medical Center, Chicago, Illinois
| | - Rosalba Hernandez
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Anna C. Porter
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Judith A. Cook
- Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois
| | - Amanda Anderson
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Jacquie Dolata
- Division of Nephrology and Hypertension, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Harold I. Feldman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward Horwitz
- Division of Nephrology and Hypertension, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Claudia Lora
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | | | | | - James P Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
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Gluck CA, Forrest CB, Davies AG, Maltenfort M, Mcdonald JR, Mitsnefes M, Dharnidharka VR, Dixon BP, Flynn JT, Somers MJ, Smoyer WE, Neu A, Hovinga CA, Skversky AL, Eissing T, Kaiser A, Breitenstein S, Furth SL, Denburg MR. Evaluating Kidney Function Decline in Children with Chronic Kidney Disease Using a Multi-Institutional Electronic Health Record Database. Clin J Am Soc Nephrol 2023; 18:173-182. [PMID: 36754006 PMCID: PMC10103199 DOI: 10.2215/cjn.0000000000000051] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 12/03/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND The objectives of this study were to use electronic health record data from a US national multicenter pediatric network to identify a large cohort of children with CKD, evaluate CKD progression, and examine clinical risk factors for kidney function decline. METHODS This retrospective cohort study identified children seen between January 1, 2009, to February 28, 2022. Data were from six pediatric health systems in PEDSnet. We identified children aged 18 months to 18 years who met criteria for CKD: two eGFR values <90 and ≥15 ml/min per 1.73 m2 separated by ≥90 days without an intervening value ≥90. CKD progression was defined as a composite outcome: eGFR <15 ml/min per 1.73 m2, ≥50% eGFR decline, long-term dialysis, or kidney transplant. Subcohorts were defined based on CKD etiology: glomerular, nonglomerular, or malignancy. We assessed the association of hypertension (≥2 visits with hypertension diagnosis code) and proteinuria (≥1 urinalysis with ≥1+ protein) within 2 years of cohort entrance on the composite outcome. RESULTS Among 7,148,875 children, we identified 11,240 (15.7 per 10,000) with CKD (median age 11 years, 50% female). The median follow-up was 5.1 (interquartile range 2.8-8.3) years, the median initial eGFR was 75.3 (interquartile range 61-83) ml/min per 1.73 m2, 37% had proteinuria, and 35% had hypertension. The following were associated with CKD progression: lower eGFR category (adjusted hazard ratio [aHR] 1.44 [95% confidence interval (95% CI), 1.23 to 1.69], aHR 2.38 [95% CI, 2.02 to 2.79], aHR 5.75 [95% CI, 5.05 to 6.55] for eGFR 45-59 ml/min per 1.73 m2, 30-44 ml/min per 1.73 m2, 15-29 ml/min per 1.73 m2 at cohort entrance, respectively, when compared with eGFR 60-89 ml/min per 1.73 m2), glomerular disease (aHR 2.01 [95% CI, 1.78 to 2.28]), malignancy (aHR 1.79 [95% CI, 1.52 to 2.11]), proteinuria (aHR 2.23 [95% CI, 1.89 to 2.62]), hypertension (aHR 1.49 [95% CI, 1.22 to 1.82]), proteinuria and hypertension together (aHR 3.98 [95% CI, 3.40 to 4.68]), count of complex chronic comorbidities (aHR 1.07 [95% CI, 1.05 to 1.10] per additional comorbid body system), male sex (aHR 1.16 [95% CI, 1.05 to 1.28]), and younger age at cohort entrance (aHR 0.95 [95% CI, 0.94 to 0.96] per year older). CONCLUSIONS In large-scale real-world data for children with CKD, disease etiology, albuminuria, hypertension, age, male sex, lower eGFR, and greater medical complexity at start of follow-up were associated with more rapid decline in kidney function.
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Affiliation(s)
- Caroline A. Gluck
- Division of Pediatric Nephrology, Nemours Children's Health, Wilmington, Delaware
| | - Christopher B. Forrest
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amy Goodwin Davies
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mitchell Maltenfort
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jill R. Mcdonald
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mark Mitsnefes
- Division of Pediatric Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Vikas R. Dharnidharka
- Division of Pediatric Nephrology, Hypertension, Pheresis, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, Missouri
| | - Bradley P. Dixon
- Division of Pediatric Nephrology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joseph T. Flynn
- Division of Pediatric Nephrology, Seattle Children's Hospital, Seattle, Washington
| | - Michael J. Somers
- Division of Pediatric Nephrology, Boston Children's, Boston, Massachusetts
| | - William E. Smoyer
- Division of Pediatric Nephrology, Nationwide Children's Hospital, Columbus, Ohio
| | - Alicia Neu
- Division of Pediatric Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Collin A. Hovinga
- Clinical and Scientific Development, Institute for Advanced Clinical Trials for Children, Rockville, Maryland
| | - Amy L. Skversky
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Thomas Eissing
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Andreas Kaiser
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Stefanie Breitenstein
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Susan L. Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle R. Denburg
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Khine A, Lin E. A Blueprint for Assessing Affordability of SGLT2 Inhibitors in the United States: The Cost-Effectiveness of Dapagliflozin in Three European Countries. Clin J Am Soc Nephrol 2022; 17:1707-1709. [PMID: 36323445 PMCID: PMC9718012 DOI: 10.2215/cjn.09900822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Annika Khine
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California
| | - Eugene Lin
- Department of Medicine, Division of Nephrology, Keck School of Medicine of the University of Southern California, Los Angeles, California
- The Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California
- Department of Health Policy & Management, Sol Price School of Public Policy, University of Southern California, Los Angeles, California
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Denburg MR, Xu Y, Abraham AG, Coresh J, Chen J, Grams ME, Feldman HI, Kimmel PL, Rebholz CM, Rhee EP, Vasan RS, Warady BA, Furth SL. Metabolite Biomarkers of CKD Progression in Children. Clin J Am Soc Nephrol 2021; 16:1178-1189. [PMID: 34362785 PMCID: PMC8455058 DOI: 10.2215/cjn.00220121] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/17/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Metabolomics facilitates the discovery of biomarkers and potential therapeutic targets for CKD progression. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We evaluated an untargeted metabolomics quantification of stored plasma samples from 645 Chronic Kidney Disease in Children (CKiD) participants. Metabolites were standardized and logarithmically transformed. Cox proportional hazards regression examined the association between 825 nondrug metabolites and progression to the composite outcome of KRT or 50% reduction of eGFR, adjusting for age, sex, race, body mass index, hypertension, glomerular versus nonglomerular diagnosis, proteinuria, and baseline eGFR. Stratified analyses were performed within subgroups of glomerular/nonglomerular diagnosis and baseline eGFR. RESULTS Baseline characteristics were 391 (61%) male; median age 12 years; median eGFR 54 ml/min per 1.73 m2; 448 (69%) nonglomerular diagnosis. Over a median follow-up of 4.8 years, 209 (32%) participants developed the composite outcome. Unique association signals were identified in subgroups of baseline eGFR. Among participants with baseline eGFR ≥60 ml/min per 1.73 m2, two-fold higher levels of seven metabolites were significantly associated with higher hazards of KRT/halving of eGFR events: three involved in purine and pyrimidine metabolism (N6-carbamoylthreonyladenosine, hazard ratio, 16; 95% confidence interval, 4 to 60; 5,6-dihydrouridine, hazard ratio, 17; 95% confidence interval, 5 to 55; pseudouridine, hazard ratio, 39; 95% confidence interval, 8 to 200); two amino acids, C-glycosyltryptophan, hazard ratio, 24; 95% confidence interval 6 to 95 and lanthionine, hazard ratio, 3; 95% confidence interval, 2 to 5; the tricarboxylic acid cycle intermediate 2-methylcitrate/homocitrate, hazard ratio, 4; 95% confidence interval, 2 to 7; and gulonate, hazard ratio, 10; 95% confidence interval, 3 to 29. Among those with baseline eGFR <60 ml/min per 1.73 m2, a higher level of tetrahydrocortisol sulfate was associated with lower risk of progression (hazard ratio, 0.8; 95% confidence interval, 0.7 to 0.9). CONCLUSIONS Untargeted plasma metabolomic profiling facilitated discovery of novel metabolite associations with CKD progression in children that were independent of established clinical predictors and highlight the role of select biologic pathways.
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Affiliation(s)
- Michelle R. Denburg
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yunwen Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alison G. Abraham
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jingsha Chen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Harold I. Feldman
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul L. Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Casey M. Rebholz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eugene P. Rhee
- Department of Medicine, Massachusetts General Hospital, Department of Medicine, Harvard University, Boston, Massachusetts
| | - Ramachandran S. Vasan
- Department of Medicine, Boston University School of Medicine, Boston University School of Public Health, and Boston University Center for Computing and Data Science, Boston, Massachusetts
| | - Bradley A. Warady
- Children’s Mercy Kansas City, Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Susan L. Furth
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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7
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Abstract
Acid-related injury from chronic metabolic acidosis is recognized through growing evidence of its deleterious effects, including kidney and other organ injury. Progressive acid accumulation precedes the signature manifestation of chronic metabolic acidosis, decreased plasma bicarbonate concentration. Acid accumulation that is not enough to manifest as metabolic acidosis, known as eubicarbonatemic acidosis, also appears to cause kidney injury, with exacerbated progression of CKD. Chronic engagement of mechanisms to mitigate the acid challenge from Western-type diets also appears to cause kidney injury. Rather than considering chronic metabolic acidosis as the only acid-related condition requiring intervention to reduce kidney injury, this review supports consideration of acid-related injury as a continuum. This "acid stress" continuum has chronic metabolic acidosis at its most extreme end, and high-acid-producing diets at its less extreme, yet detrimental, end.
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Affiliation(s)
- Donald E. Wesson
- Department of Internal Medicine, Texas A&M Health Science Center College of Medicine, Dallas, Texas
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Silver SA, Adhikari NK, Bell CM, Chan CT, Harel Z, Kitchlu A, Meraz-Muñoz A, Norman PA, Perez A, Zahirieh A, Wald R. Nephrologist Follow-Up versus Usual Care after an Acute Kidney Injury Hospitalization (FUSION): A Randomized Controlled Trial. Clin J Am Soc Nephrol 2021; 16:1005-1014. [PMID: 34021031 PMCID: PMC8425610 DOI: 10.2215/cjn.17331120] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [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: 11/05/2020] [Accepted: 04/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Survivors of AKI are at higher risk of CKD and death, but few patients see a nephrologist after hospital discharge. Our objectives during this 2-year vanguard phase trial were to determine the feasibility of randomizing survivors of AKI to early follow-up with a nephrologist or usual care, and to collect data on care processes and outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a randomized controlled trial in patients hospitalized with Kidney Disease Improving Global Outcomes (KDIGO) stage 2-3 AKI at four hospitals in Toronto, Canada. We randomized patients to early nephrologist follow-up (standardized basket of care that emphasized BP control, cardiovascular risk reduction, and medication safety) or usual care from July 2015 to June 2017. Feasibility outcomes included the proportion of eligible patients enrolled, seen by a nephrologist, and followed to 1 year. The primary clinical outcome was a major adverse kidney event at 1 year, defined as death, maintenance dialysis, or incident/progressive CKD. RESULTS We screened 3687 participants from July 2015 to June 2017, of whom 269 were eligible. We randomized 71 (26%) patients (34 to nephrology follow-up and 37 to usual care). The primary reason stated for declining enrollment included hospitalization-related fatigue (n=65), reluctance to add more doctors to the health care team (n=59), and long travel times (n=40). Nephrologist visits occurred in 24 of 34 (71%) intervention participants, compared with three of 37 (8%) participants randomized to usual care. The primary clinical outcome occurred in 15 of 34 (44%) patients in the nephrologist follow-up arm, and 16 of 37 (43%) patients in the usual care arm (relative risk, 1.02; 95% confidence interval, 0.60 to 1.73). CONCLUSIONS Major adverse kidney events are common in AKI survivors, but we found the in-person model of follow-up posed a variety of barriers that was not acceptable to many patients. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Nephrologist Follow-up versus Usual Care after an Acute Kidney Injury Hospitalization (FUSION), NCT02483039 CJASN 16: 1005-1014, 2021. doi: https://doi.org/10.2215/CJN.17331120.
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Affiliation(s)
- Samuel A. Silver
- Division of Nephrology, Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
| | - Neill K. Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada,,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Chaim M. Bell
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada,,Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher T. Chan
- Division of Nephrology, University Health Network–Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ziv Harel
- Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, University Health Network–Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alejandro Meraz-Muñoz
- Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Patrick A. Norman
- Kingston General Health Research Institute, Kingston, Ontario, Canada,,Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Adic Perez
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Zahirieh
- Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Ron Wald
- Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
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9
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Ramspek CL, Evans M, Wanner C, Drechsler C, Chesnaye NC, Szymczak M, Krajewska M, Torino C, Porto G, Hayward S, Caskey F, Dekker FW, Jager KJ, van Diepen M. Kidney Failure Prediction Models: A Comprehensive External Validation Study in Patients with Advanced CKD. J Am Soc Nephrol 2021; 32:1174-1186. [PMID: 33685974 PMCID: PMC8259669 DOI: 10.1681/asn.2020071077] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [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: 07/26/2020] [Accepted: 12/26/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Various prediction models have been developed to predict the risk of kidney failure in patients with CKD. However, guideline-recommended models have yet to be compared head to head, their validation in patients with advanced CKD is lacking, and most do not account for competing risks. METHODS To externally validate 11 existing models of kidney failure, taking the competing risk of death into account, we included patients with advanced CKD from two large cohorts: the European Quality Study (EQUAL), an ongoing European prospective, multicenter cohort study of older patients with advanced CKD, and the Swedish Renal Registry (SRR), an ongoing registry of nephrology-referred patients with CKD in Sweden. The outcome of the models was kidney failure (defined as RRT-treated ESKD). We assessed model performance with discrimination and calibration. RESULTS The study included 1580 patients from EQUAL and 13,489 patients from SRR. The average c statistic over the 11 validated models was 0.74 in EQUAL and 0.80 in SRR, compared with 0.89 in previous validations. Most models with longer prediction horizons overestimated the risk of kidney failure considerably. The 5-year Kidney Failure Risk Equation (KFRE) overpredicted risk by 10%-18%. The four- and eight-variable 2-year KFRE and the 4-year Grams model showed excellent calibration and good discrimination in both cohorts. CONCLUSIONS Some existing models can accurately predict kidney failure in patients with advanced CKD. KFRE performed well for a shorter time frame (2 years), despite not accounting for competing events. Models predicting over a longer time frame (5 years) overestimated risk because of the competing risk of death. The Grams model, which accounts for the latter, is suitable for longer-term predictions (4 years).
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Affiliation(s)
- Chava L. Ramspek
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marie Evans
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Wurzburg, Wurzburg, Germany
| | - Christiane Drechsler
- Division of Nephrology, Department of Internal Medicine 1, University Hospital Wurzburg, Wurzburg, Germany
| | - Nicholas C. Chesnaye
- Department of Medical Informatics, European Renal Association–European Dialysis and Transplant Association Registry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health Institute, Amsterdam, The Netherlands
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Claudia Torino
- Department of Clinical Epidemiology of Renal Diseases and Hypertension, Consiglio Nazionale della Ricerche - Istituto di fisiologia clinica, Reggio Calabria, Italy
| | - Gaetana Porto
- Department of Clinical Epidemiology of Renal Diseases and Hypertension, Consiglio Nazionale della Ricerche - Istituto di fisiologia clinica, Reggio Calabria, Italy
| | - Samantha Hayward
- Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom,United Kingdom Renal Registry, Bristol, United Kingdom
| | - Fergus Caskey
- Departmen of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Friedo W. Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kitty J. Jager
- Department of Medical Informatics, European Renal Association–European Dialysis and Transplant Association Registry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Public Health Institute, Amsterdam, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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10
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Hannan M, Ansari S, Meza N, Anderson AH, Srivastava A, Waikar S, Charleston J, Weir MR, Taliercio J, Horwitz E, Saunders MR, Wolfrum K, Feldman HI, Lash JP, Ricardo AC. Risk Factors for CKD Progression: Overview of Findings from the CRIC Study. Clin J Am Soc Nephrol 2021; 16:648-659. [PMID: 33177074 PMCID: PMC8092061 DOI: 10.2215/cjn.07830520] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [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] [Indexed: 12/12/2022]
Abstract
The Chronic Renal Insufficiency Cohort (CRIC) Study is an ongoing, multicenter, longitudinal study of nearly 5500 adults with CKD in the United States. Over the past 10 years, the CRIC Study has made significant contributions to the understanding of factors associated with CKD progression. This review summarizes findings from longitudinal studies evaluating risk factors associated with CKD progression in the CRIC Study, grouped into the following six thematic categories: (1) sociodemographic and economic (sex, race/ethnicity, and nephrology care); (2) behavioral (healthy lifestyle, diet, and sleep); (3) genetic (apoL1, genome-wide association study, and renin-angiotensin-aldosterone system pathway genes); (4) cardiovascular (atrial fibrillation, hypertension, and vascular stiffness); (5) metabolic (fibroblast growth factor 23 and urinary oxalate); and (6) novel factors (AKI and biomarkers of kidney injury). Additionally, we highlight areas where future research is needed, and opportunities for interdisciplinary collaboration.
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Affiliation(s)
- Mary Hannan
- Department of Medicine, University of Illinois, Chicago, Illinois
| | - Sajid Ansari
- Department of Medicine, University of Illinois, Chicago, Illinois
| | - Natalie Meza
- Department of Medicine, University of Illinois, Chicago, Illinois
| | - Amanda H. Anderson
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sushrut Waikar
- Nephrology Section, Boston University Medical Center, Boston, Massachusetts
| | - Jeanne Charleston
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Matthew R. Weir
- Division of Nephrology, Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Jonathan Taliercio
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | | | - Milda R. Saunders
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Katherine Wolfrum
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harold I. Feldman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James P. Lash
- Department of Medicine, University of Illinois, Chicago, Illinois
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois, Chicago, Illinois
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11
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Ku E, McCulloch CE, Adey DB, Li L, Johansen KL. Racial Disparities in Eligibility for Preemptive Waitlisting for Kidney Transplantation and Modification of eGFR Thresholds to Equalize Waitlist Time. J Am Soc Nephrol 2021; 32:677-685. [PMID: 33622978 PMCID: PMC7920175 DOI: 10.1681/asn.2020081144] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [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: 08/07/2020] [Accepted: 12/07/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients may accrue wait time for kidney transplantation when their eGFR is ≤20 ml/min. However, Black patients have faster progression of their kidney disease compared with White patients, which may lead to disparities in accruable time on the kidney transplant waitlist before dialysis initiation. METHODS We compared differences in accruable wait time and transplant preparation by CKD-EPI estimating equations in Chronic Renal Insufficiency Cohort participants, on the basis of estimates of kidney function by creatinine (eGFRcr), cystatin C (eGFRcys), or both (eGFRcr-cys). We used Weibull accelerated failure time models to determine the association between race (non-Hispanic Black or non-Hispanic White) and time to ESKD from an eGFR of ≤20 ml/min per 1.73 m2. We then estimated how much higher the eGFR threshold for waitlisting would be required to achieve equity in accruable preemptive wait time for the two groups. RESULTS By eGFRcr, 444 CRIC participants were eligible for waitlist registration, but the potential time between eGFR ≤20 ml/min per 1.73 m2 and ESKD was 32% shorter for Blacks versus Whites. By eGFRcys, 435 participants were eligible, and Blacks had 35% shorter potential wait time compared with Whites. By the eGFRcr-cys equation, 461 participants were eligible, and Blacks had a 31% shorter potential wait time than Whites. We estimated that registering Blacks on the waitlist as early as an eGFR of 24-25 ml/min per 1.73 m2 might improve racial equity in accruable wait time before ESKD onset. CONCLUSIONS Policies allowing for waitlist registration at higher GFR levels for Black patients compared with White patients could theoretically attenuate disparities in accruable wait time and improve racial equity in transplant access.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Deborah B. Adey
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Libo Li
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Kirsten L. Johansen
- Division of Nephrology, Department of Medicine and University of Minnesota, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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12
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Denic A, Elsherbiny H, Mullan AF, Leibovich BC, Thompson RH, Ricaurte Archila L, Narasimhan R, Kremers WK, Alexander MP, Lieske JC, Lerman LO, Rule AD. Larger Nephron Size and Nephrosclerosis Predict Progressive CKD and Mortality after Radical Nephrectomy for Tumor and Independent of Kidney Function. J Am Soc Nephrol 2020; 31:2642-2652. [PMID: 32938650 PMCID: PMC7608955 DOI: 10.1681/asn.2020040449] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 04/15/2020] [Accepted: 08/17/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Nephron hypertrophy and nephrosclerosis may be important determinants of CKD and mortality. However, studies of outcomes associated with these microstructural features have been limited to small tissue specimens from patients selected for either good kidney health or known kidney disease. METHODS To determine whether microstructural features are predictive of progressive CKD and mortality outcomes, we studied patients who underwent a radical nephrectomy for a tumor. Large wedge sections of renal parenchyma distal to the tumor were stained and scanned into high-resolution images; we annotated the cortex and all glomeruli to calculate glomerular volume, cortex volume per glomerulus, and percentage of globally sclerotic glomeruli. Morphometric measurements also included percentages of artery luminal stenosis and interstitial fibrosis/tubular atrophy (IF/TA) of the cortex. At follow-up visits every 6-12 months, we determined which patients experienced progressive CKD (defined as dialysis, kidney transplantation, or a 40% decline from postnephrectomy eGFR). Cox models for these outcomes were adjusted for age, sex, body mass index, hypertension, diabetes, smoking, eGFR, and proteinuria. RESULTS Among 936 patients (mean age, 64 years; postnephrectomy baseline eGFR, 48 ml/min per 1.73 m2), 117 progressive CKD events, 183 noncancer deaths, and 116 cancer deaths occurred during a median follow-up of 6.4 years. Larger glomerular volume, larger cortex per glomerulus, and higher percentage of globally sclerotic glomeruli or IF/TA predicted progressive CKD. Higher percentage IF/TA also predicted noncancer mortality. Microstructural features did not predict cancer mortality or recurrence. CONCLUSIONS After a radical nephrectomy, larger nephrons and nephrosclerosis predicted progressive CKD, and IF/TA predicted noncancer mortality. Morphometric analysis of renal parenchyma can predict noncancer clinical events in patients long after their radical nephrectomy.
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Affiliation(s)
- Aleksandar Denic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Hisham Elsherbiny
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Aidan F. Mullan
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Ramya Narasimhan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Walter K. Kremers
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Mariam P. Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - John C. Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Lilach O. Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota,Division of Epidemiology, Mayo Clinic, Rochester, Minnesota
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13
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Hundemer GL, Tangri N, Sood MM, Ramsay T, Bugeja A, Brown PA, Clark EG, Biyani M, White CA, Akbari A. Performance of the Kidney Failure Risk Equation by Disease Etiology in Advanced CKD. Clin J Am Soc Nephrol 2020; 15:1424-1432. [PMID: 32928746 PMCID: PMC7536763 DOI: 10.2215/cjn.03940320] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 03/26/2020] [Accepted: 08/03/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES The kidney failure risk equation is a clinical tool commonly used for prediction of progression from CKD to kidney failure. The kidney failure risk equation's accuracy in advanced CKD and whether this varies by CKD etiology remains unknown. This study examined the kidney failure risk equation's discrimination and calibration at 2 and 5 years among a large tertiary care population with advanced CKD from heterogeneous etiologies. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective cohort study included 1293 patients with advanced CKD (median eGFR 15 ml/min per 1.73 m2) referred to the Ottawa Hospital Multi-Care Kidney Clinic between 2010 and 2016, with follow-up clinical data available through 2018. Four-variable kidney failure risk equation scores for 2- and 5-year risks of progression to kidney failure (defined as dialysis or kidney transplantation) were calculated upon initial referral and correlated with the subsequent observed kidney failure incidence within these time frames. Receiver operating characteristic curves and calibration plots were used to measure the discrimination and calibration of the kidney failure risk equation both in the overall advanced CKD population and by CKD etiology: diabetic kidney disease, hypertensive nephrosclerosis, GN, polycystic kidney disease, and other. Pairwise comparisons of the receiver operating characteristic curves by CKD etiology were performed to compare kidney failure risk equation discrimination. RESULTS The kidney failure risk equation provided adequate to excellent discrimination in identifying patients with CKD likely to progress to kidney failure at the 2- and 5-year time points both overall (2-year area under the curve, 0.83; 95% confidence interval, 0.81 to 0.85; 5-year area under the curve, 0.81; 95% confidence interval, 0.77 to 0.84) and across CKD etiologies. The kidney failure risk equation displayed adequate calibration at the 2- and 5-year time points both overall and across CKD etiologies (Hosmer-Lemeshow P≥0.05); however, the predicted risks of kidney failure were higher than the observed risks across CKD etiologies with the exception of polycystic kidney disease. CONCLUSIONS The kidney failure risk equation provides adequate discrimination and calibration in advanced CKD and across CKD etiologies.
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Affiliation(s)
- Gregory L Hundemer
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Navdeep Tangri
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ann Bugeja
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Pierre A Brown
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mohan Biyani
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Christine A White
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ayub Akbari
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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14
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Affiliation(s)
- Marie-Michèle Gaudreault-Tremblay
- Division of Nephrology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Bethany J Foster
- Division of Nephrology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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15
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Bonnéric S, Karadkhele G, Couchoud C, Patzer RE, Greenbaum LA, Hogan J. Sex and Glomerular Filtration Rate Trajectories in Children. Clin J Am Soc Nephrol 2020; 15:320-329. [PMID: 32111703 PMCID: PMC7057295 DOI: 10.2215/cjn.08420719] [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: 07/19/2019] [Accepted: 01/21/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Differences in CKD progression by sex have been hypothesized to explain disparities in access to kidney transplantation in children. This study aims to identify distinct trajectories of eGFR decline and to investigate the association of sex with eGFR decline. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used data from the CKD in Children study. Latent class mixed models were used to identify eGFR trajectories and patient characteristics were compared between trajectories. Progression was studied to two outcomes: ESKD (dialysis or transplantation) and a combined outcome of ESKD or 50% eGFR decline from baseline, using multivariable parametric failure time models. RESULTS Among 888 patients, 613 with nonglomerular and 275 with glomerular diseases, we observed four and two distinct GFR trajectories, respectively. Among patients with nonglomerular diseases, there was a higher proportion of males in the group with a low baseline GFR. This group had an increased risk of ESKD or 50% GFR decline, despite a similar absolute decline in GFR. Eight patients with nonglomerular diseases, mostly males with obstructive uropathies, had a more rapid absolute GFR decline. However, the association between male sex and rapid absolute GFR decline was NS after adjustment for age, baseline GFR, and proteinuria. Among patients with glomerular diseases, a subgroup including mostly females with systemic immunologic diseases or crescentic GN had a rapid absolute GFR decline. CONCLUSIONS This study identifies different trajectories of CKD progression in children and found a faster progression of CKD in females in patients with glomerular diseases, but no significant sex difference in patients with nonglomerular diseases. The differences in progression seem likely explained by sex differences in the underlying primary kidney disease and in baseline GFR rather than by a direct effect of sex on progression.
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Affiliation(s)
- Stéphanie Bonnéric
- Department of Pediatric Nephrology, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Geeta Karadkhele
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia
| | - Cécile Couchoud
- Renal Epidemiology and Information Network (REIN) Registry, French Biomedicine Agency, La Plaine-Saint Denis, France
| | - Rachel E Patzer
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; and
| | - Larry A Greenbaum
- Department of Pediatric Nephrology, Children's Healthcare of Atlanta, Emory School of Medicine, Atlanta, Georgia
| | - Julien Hogan
- Department of Pediatric Nephrology, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; .,Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia
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16
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Abstract
Retrospective analyses and single-center prospective studies identify chronic metabolic acidosis as an independent and modifiable risk factor for progression of CKD. In patients with CKD, untreated chronic metabolic acidosis often leads to an accelerated reduction in GFR. Mechanisms responsible for this reduction include adaptive responses that increase acid excretion but lead to a decline in kidney function. Metabolic acidosis in CKD stimulates production of intrakidney paracrine hormones including angiotensin II, aldosterone, and endothelin-1 (ET-1) that mediate the immediate benefit of increased kidney acid excretion, but their chronic upregulation promotes inflammation and fibrosis. Chronic metabolic acidosis also stimulates ammoniagenesis that increases acid excretion but also leads to ammonia-induced complement activation and deposition of C3 and C5b-9 that can cause tubule-interstitial damage, further worsening disease progression. These effects, along with acid accumulation in kidney tissue, combine to accelerate progression of kidney disease. Treatment of chronic metabolic acidosis attenuates these adaptive responses; reduces levels of angiotensin II, aldosterone, and ET-1; reduces ammoniagenesis; and diminishes inflammation and fibrosis that may lead to slowing of CKD progression.
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Affiliation(s)
- Donald E Wesson
- Baylor Scott & White Health and Wellness Center, Dallas, Texas; .,Department of Internal Medicine, Texas A&M College of Medicine, Bryan, Texas
| | | | - David A Bushinsky
- Division of Nephrology, University of Rochester School of Medicine, Rochester, New York
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17
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Grams ME, Sang Y, Ballew SH, Matsushita K, Astor BC, Carrero JJ, Chang AR, Inker LA, Kenealy T, Kovesdy CP, Lee BJ, Levin A, Naimark D, Pena MJ, Schold JD, Shalev V, Wetzels JFM, Woodward M, Gansevoort RT, Levey AS, Coresh J. Evaluating Glomerular Filtration Rate Slope as a Surrogate End Point for ESKD in Clinical Trials: An Individual Participant Meta-Analysis of Observational Data. J Am Soc Nephrol 2019; 30:1746-1755. [PMID: 31292199 DOI: 10.1681/asn.2019010008] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [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: 01/04/2019] [Accepted: 04/17/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Decline in eGFR is a biologically plausible surrogate end point for the progression of CKD in clinical trials. However, it must first be tested to ensure strong associations with clinical outcomes in diverse populations, including patients with higher eGFR. METHODS To investigate the association between 1-, 2-, and 3-year changes in eGFR (slope) with clinical outcomes over the long term, we conducted a random effects meta-analysis of 3,758,551 participants with baseline eGFR≥60 ml/min per 1.73 m2 and 122,664 participants with eGFR<60 ml/min per 1.73 m2 from 14 cohorts followed for an average of 4.2 years. RESULTS Slower eGFR decline by 0.75 ml/min per 1.73 m2 per year over 2 years was associated with lower risk of ESKD in participants with baseline eGFR≥60 ml/min per 1.73 m2 (adjusted hazard ratio, 0.70; 95% CI, 0.68 to 0.72) and eGFR<60 ml/min per 1.73 m2 (0.71; 95% CI, 0.68 to 0.74). The relationship was stronger with 3-year slope. For a rapidly progressing population with predicted 5-year risk of ESKD of 8.3%, an intervention that reduced eGFR decline by 0.75 ml/min per 1.73 m2 per year over 2 years would reduce the ESKD risk by 1.6%. For a hypothetical low-risk population with a predicted 5-year ESKD risk of 0.58%, the same intervention would reduce the risk by only 0.13%. CONCLUSIONS Slower decline in eGFR was associated with lower risk of subsequent ESKD, even in participants with eGFR≥60 ml/min per 1.73 m2, but those with the highest risk would be expected to benefit the most.
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Affiliation(s)
- Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Brad C Astor
- Departments of Medicine and.,Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Alex R Chang
- Geisinger Health System and Department of Epidemiology and Health Services Research, Geisinger Health System, Kidney Health Research Institute, Danville, Pennsylvania
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Timothy Kenealy
- Departments of Medicine and.,General Practice & Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Brian J Lee
- Nephrology Division, Kaiser Permanente, Hawaii Region, Moanalua Medical Center, Honolulu, Hawaii
| | - Adeera Levin
- British Columbia Provincial Renal Agency and University of British Columbia, Vancouver, British Columbia, Canada
| | - David Naimark
- Department of Medicine and Institute of Health Policy, Management and Evaluation, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Jesse D Schold
- Department of Quantitative Health Sciences and.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Varda Shalev
- Medical Division, Maccabi Healthcare Services, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, The Netherlands
| | - Mark Woodward
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,The George Institute for Global Health, University of Oxford, Oxford, United Kingdom; and.,The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ron T Gansevoort
- Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
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18
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Zewinger S, Rauen T, Rudnicki M, Federico G, Wagner M, Triem S, Schunk SJ, Petrakis I, Schmit D, Wagenpfeil S, Heine GH, Mayer G, Floege J, Fliser D, Gröne HJ, Speer T. Dickkopf-3 (DKK3) in Urine Identifies Patients with Short-Term Risk of eGFR Loss. J Am Soc Nephrol 2018; 29:2722-2733. [PMID: 30279273 DOI: 10.1681/asn.2018040405] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/21/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The individual course of CKD may vary, and improved methods for identifying which patients will experience short-term eGFR loss are needed. Assessing urinary Dickkopf-3 (DKK3), a stress-induced tubular epithelia-derived profibrotic glycoprotein, may provide information about ongoing tubulointerstitial fibrosis and short-term eGFR loss. METHODS To investigate urinary DKK3's potential as a biomarker of short-term eGFR loss (over 12 months), we prospectively assessed eGFR and urinary DKK3 levels in patients with CKD of various etiologies at baseline and annual follow-ups. We also measured urinary DKK3 in a general population sample and patients with diagnostic kidney biopsies or IgA nephropathy under treatment. RESULTS Median urinary DKK3-to-creatinine concentration at baseline was significantly higher in patients with CKD than the general population sample (431 versus 33 pg/mg). In the CKD cohort, having a urinary DKK3-to-creatinine level >4000 pg/mg was independently and significantly associated after multiple adjustments with mean annual decline in eGFR of 7.6% over 12 months. Urinary DKK3 significantly improved prediction of kidney function decline compared with eGFR or albuminuria alone. Urinary DKK3-to-creatinine levels were related to the extent of tubulointerstitial fibrosis in kidney biopsies. In patients with IgA nephropathy, a rise in urinary DKK3 was associated with significant eGFR decline within 6 months, whereas stable or decreasing urinary DKK3 indicated a more favorable course. CONCLUSIONS Urinary DKK3 levels identify patients at high risk for eGFR decline over the next 12 months regardless of the cause of kidney injury and beyond established biomarkers, potentially providing a tool to monitor CKD progression and assess effects of interventions.
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Affiliation(s)
- Stephen Zewinger
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany;
| | - Thomas Rauen
- Department of Internal Medicine II, Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Michael Rudnicki
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Giuseppina Federico
- Department of Cellular and Molecular Pathology, German Cancer Research Center, Heidelberg, Germany; and
| | - Martina Wagner
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
| | - Sarah Triem
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
| | - Stefan J Schunk
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
| | - Ioannis Petrakis
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
| | - David Schmit
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg, Germany
| | - Gunnar H Heine
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
| | - Gert Mayer
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Jürgen Floege
- Department of Internal Medicine II, Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Danilo Fliser
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hermann-Josef Gröne
- Department of Cellular and Molecular Pathology, German Cancer Research Center, Heidelberg, Germany; and
| | - Thimoteus Speer
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany
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19
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Bundy JD, Bazzano LA, Xie D, Cohan J, Dolata J, Fink JC, Hsu CY, Jamerson K, Lash J, Makos G, Steigerwalt S, Wang X, Mills KT, Chen J, He J. Self-Reported Tobacco, Alcohol, and Illicit Drug Use and Progression of Chronic Kidney Disease. Clin J Am Soc Nephrol 2018; 13:993-1001. [PMID: 29880471 PMCID: PMC6032576 DOI: 10.2215/cjn.11121017] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [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: 10/04/2017] [Accepted: 04/05/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND OBJECTIVES Previous studies suggest that tobacco, alcohol, and illicit drug use is associated with CKD. We examined the associations of substance use with CKD progression and all-cause mortality among patients with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Chronic Renal Insufficiency Cohort Study is a prospective, longitudinal cohort study among 3939 participants with CKD in the United States. Self-reported tobacco smoking, alcohol drinking, marijuana use, and hard illicit drug (cocaine, heroin, or methamphetamine) use were obtained at baseline and annual follow-up visits. CKD progression was defined as incident ESKD or halving of eGFR. Substance use was modeled as the cumulative average exposure to capture both recent and long-term use in multivariable time-dependent Cox regression. RESULTS Over a median 5.5-year follow-up, 1287 participants developed CKD progression, and 1001 died. Baseline proportions of tobacco smoking, alcohol drinking, marijuana use, and hard illicit drug use were 13%, 20%, 33%, and 12%, respectively. Compared with nonsmoking throughout follow-up, multivariable-adjusted hazard ratios for persistent tobacco smoking were 1.02 (95% confidence interval, 0.86 to 1.21) for CKD progression and 1.86 (95% confidence interval, 1.54 to 2.24) for all-cause mortality. Compared with nondrinking throughout follow-up, multivariable-adjusted hazard ratios for persistent alcohol drinking were 1.06 (95% confidence interval, 0.88 to 1.29) for CKD progression and 0.73 (95% confidence interval, 0.58 to 0.91) for all-cause mortality. Compared with nonuse throughout follow-up, multivariable-adjusted hazard ratios for persistent marijuana use were 0.94 (95% confidence interval, 0.82 to 1.07) for CKD progression and 1.11 (95% confidence interval, 0.96 to 1.30) for all-cause mortality. Compared with nonuse throughout follow-up, multivariable-adjusted hazard ratios for persistent hard illicit drug use were 1.25 (95% confidence interval, 1.00 to 1.55) for CKD progression and 1.41 (95% confidence interval, 1.10 to 1.81) for all-cause mortality. CONCLUSIONS Hard illicit drug use is associated with higher risk of CKD progression and all-cause mortality, tobacco smoking is associated with higher risk of all-cause mortality, and alcohol drinking is associated with lower risk of all-cause mortality among patients with CKD.
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Affiliation(s)
- Joshua D. Bundy
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Lydia A. Bazzano
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Dawei Xie
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Janet Cohan
- Department of Medicine, University of Illinois, Chicago, Illinois
| | - Jacqueline Dolata
- Division of Nephrology, Case Western Reserve University, Cleveland, Ohio
| | - Jeffrey C. Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Chi-yuan Hsu
- Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Kenneth Jamerson
- Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - James Lash
- Department of Medicine, University of Illinois, Chicago, Illinois
| | - Gail Makos
- Division of Nephrology, St. John Hospital and Medical Center, Detroit, Michigan; and
| | - Susan Steigerwalt
- Division of Nephrology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Xue Wang
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Katherine T. Mills
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Jing Chen
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - the CRIC Study Investigators
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Department of Medicine, University of Illinois, Chicago, Illinois
- Division of Nephrology, Case Western Reserve University, Cleveland, Ohio
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Division of Nephrology, University of California San Francisco, San Francisco, California
- Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, Michigan
- Division of Nephrology, St. John Hospital and Medical Center, Detroit, Michigan; and
- Division of Nephrology, University of Michigan School of Medicine, Ann Arbor, Michigan
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20
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Garlo KG, White WB, Bakris GL, Zannad F, Wilson CA, Kupfer S, Vaduganathan M, Morrow DA, Cannon CP, Charytan DM. Kidney Biomarkers and Decline in eGFR in Patients with Type 2 Diabetes. Clin J Am Soc Nephrol 2018; 13:398-405. [PMID: 29339356 PMCID: PMC5967667 DOI: 10.2215/cjn.05280517] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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: 05/17/2017] [Accepted: 12/04/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Biomarkers may improve identification of individuals at risk of eGFR decline who may benefit from intervention or dialysis planning. However, available biomarkers remain incompletely validated for risk stratification and prediction modeling. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined serum cystatin C, urinary kidney injury molecule-1 (uKIM-1), and urinary neutrophil gelatinase-associated lipocalin (UNGAL) in 5367 individuals with type 2 diabetes mellitus and recent acute coronary syndromes enrolled in the Examination of Cardiovascular Outcomes with Alogliptin versus Standard of Care (EXAMINE) trial. Baseline concentrations and 6-month changes in biomarkers were also evaluated. Cox proportional regression was used to assess associations with a 50% decrease in eGFR, stage 5 CKD (eGFR<15 ml/min per 1.73 m2), or dialysis. RESULTS eGFR decline occurred in 98 patients (1.8%) over a median of 1.5 years. All biomarkers individually were associated with higher risk of eGFR decline (P<0.001). However, when adjusting for baseline eGFR, proteinuria, and clinical factors, only baseline cystatin C (adjusted hazard ratio per 1 SD change, 1.66; 95% confidence interval, 1.41 to 1.96; P<0.001) and 6-month change in urinary neutrophil gelatinase-associated lipocalin (adjusted hazard ratio per 1 SD change, 1.07; 95% confidence interval, 1.02 to 1.12; P=0.004) independently associated with CKD progression. A base model for predicting kidney function decline with nine standard risk factors had strong discriminative ability (C-statistic 0.93). The addition of baseline cystatin C improved discrimination (C-statistic 0.94), but it failed to reclassify risk categories of individuals with and without eGFR decline. CONCLUSIONS The addition of cystatin C or biomarkers of tubular injury did not meaningfully improve the prediction of eGFR decline beyond common clinical factors and routine laboratory data in a large cohort of patients with type 2 diabetes and recent acute coronary syndrome. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_01_16_CJASNPodcast_18_3_G.mp3.
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Affiliation(s)
- Katherine G. Garlo
- Division of Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts
- Department of Medicine, Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - William B. White
- Division of Hypertension and Clinical Pharmacology, Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut
| | - George L. Bakris
- Department of Medicine and American Society of Hypertension Comprehensive Hypertension Center University of Chicago, University of Chicago School of Medicine, Chicago, Illinois
| | - Faiez Zannad
- Department of Medicine, Universite de Lorraine and Centre Hospitalier Universitaire, Nancy, France
| | - Craig A. Wilson
- Division of Cardiovascular and Metabolic Diseases, Takeda Development Center Americas, Inc., Deerfield, Illinois; and
| | - Stuart Kupfer
- Division of Cardiovascular and Metabolic Diseases, Takeda Development Center Americas, Inc., Deerfield, Illinois; and
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - David A. Morrow
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher P. Cannon
- Division of Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - David M. Charytan
- Division of Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts
- Department of Medicine, Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
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21
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Abstract
The picture of HDL cholesterol (HDL-C) as the "good" cholesterol has eroded. This is even more surprising because there exists strong evidence that HDL-C is associated with cardiovascular disease (CVD) in the general population as well as in patients with impairment of kidney function and/or progression of CKD. However, drugs that dramatically increase HDL-C have mostly failed to decrease CVD events. Furthermore, genetic studies took the same line, as genetic variants that have a pronounced influence on HDL-C concentrations did not show an association with cardiovascular risk. For many, this was not surprising, given that an HDL particle is highly complex and carries >80 proteins and several hundred lipid species. Simply measuring cholesterol might not reflect the variety of biologic effects of heterogeneous HDL particles. Therefore, functional studies and the involvement of HDL components in the reverse cholesterol transport, including the cholesterol efflux capacity, have become a further focus of study during recent years. As also observed for other aspects, CKD populations behave differently compared with non-CKD populations. Although clear disturbances have been observed for the "functionality" of HDL particles in patients with CKD, this did not necessarily translate into clear-cut associations with outcomes.
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Affiliation(s)
- Florian Kronenberg
- Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
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22
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Affiliation(s)
- Colin Baigent
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England;
| | - Rachel Lennon
- Wellcome Trust Centre for Cell-Matrix Research, Department of Paediatric Nephrology, School of Biological Sciences, University of Manchester, Manchester, England; and.,Royal Manchester Children's Hospital, Manchester, England
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23
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Fuhrman DY, Schneider MF, Dell KM, Blydt-Hansen TD, Mak R, Saland JM, Furth SL, Warady BA, Moxey-Mims MM, Schwartz GJ. Albuminuria, Proteinuria, and Renal Disease Progression in Children with CKD. Clin J Am Soc Nephrol 2017; 12:912-920. [PMID: 28546440 PMCID: PMC5460717 DOI: 10.2215/cjn.11971116] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [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: 11/22/2016] [Accepted: 02/21/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES The role of albuminuria as an indicator of progression has not been investigated in children with CKD in the absence of diabetes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Children were enrolled from 49 centers of the CKD in Children study between January of 2005 and March of 2014. Cross-sectional multivariable linear regression (n=647) was used to examine the relationship between urine protein-to-creatinine (UP/C [milligrams per milligram]) and albumin-to-creatinine (ACR [milligrams per gram]) with eGFR (milliliters per minute per 1.73 m2). Parametric time-to-event analysis (n=751) was used to assess the association of UP/C, ACR, and urine nonalbumin-to-creatinine (Unon-alb/cr [milligrams per gram]) on the time to the composite endpoint of initiation of RRT or 50% decline in eGFR. RESULTS The median follow-up time was 3.4 years and 202 individuals experienced the event. Participants with a UP/C≥0.2 mg/mg and ACR≥30 mg/g had a mean eGFR that was 16 ml/min per 1.73 m2 lower than those with a UP/C<0.2 mg/mg and ACR<30 mg/g. Individuals with ACR<30 mg/g, but a UP/C≥0.2 mg/mg, had a mean eGFR that was 9.3 ml/min per 1.73 m2 lower than those with a UP/C<0.2 mg/mg and ACR<30 mg/g. When categories of ACR and Unon-alb/cr were created on the basis of clinically meaningful cutoff values of UP/C with the same sample sizes for comparison, the relative times (RTs) to the composite end-point were almost identical when comparing the middle (RT=0.31 for UP/C [0.2-2.0 mg/mg], RT=0.38 for ACR [56-1333 mg/g], RT=0.31 for Unon-alb/cr [118-715 mg/g]) and the highest (RT=0.08 for UP/C [>2.0 mg/mg], RT=0.09 for ACR [>1333 mg/g], RT=0.07 for Unon-alb/cr [>715 mg/g]) levels to the lowest levels. A similar trend was seen when categories were created on the basis of clinically meaningful cutoff values of ACR (<30, 30-300, >300 mg/g). CONCLUSIONS In children with CKD without diabetes, the utility of an initial UP/C, ACR, and Unon-alb/cr for characterizing progression is similar.
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Affiliation(s)
- Dana Y Fuhrman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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24
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de Boer IH, Gao X, Cleary PA, Bebu I, Lachin JM, Molitch ME, Orchard T, Paterson AD, Perkins BA, Steffes MW, Zinman B. Albuminuria Changes and Cardiovascular and Renal Outcomes in Type 1 Diabetes: The DCCT/EDIC Study. Clin J Am Soc Nephrol 2016; 11:1969-1977. [PMID: 27797889 PMCID: PMC5108190 DOI: 10.2215/cjn.02870316] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [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: 03/14/2016] [Accepted: 07/14/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND OBJECTIVES In trials of people with type 2 diabetes, albuminuria reduction with renin-angiotensin system inhibitors is associated with lower risks of cardiovascular events and CKD progression. We tested whether progression or remission of microalbuminuria is associated with cardiovascular and renal risk in a well characterized cohort of type 1 diabetes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied 1441 participants in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications study. Albumin excretion rate (AER) was quantified annually or biennially for up to 30 years. For each participant, albuminuria status was defined over time as normoalbuminuria (AER continuously <30 mg/d), sustained microalbuminuria (AER, 30-299 mg/d on two consecutive visits), macroalbuminuria (AER≥300 mg/d), or remitted microalbuminuria (transition from sustained microalbuminuria to AER<30 mg/d on two consecutive visits). We tested associations of time-updated albuminuria status with adjudicated clinical cardiovascular events, the development of reduced GFR (<60 ml/min per 1.73 m2 on two consecutive visits), and subclinical cardiovascular disease. RESULTS At least one cardiovascular event occurred in 184 participants, and 98 participants developed reduced eGFR. Compared with normoalbuminuria, sustained microalbuminuria, remitted microalbuminuria, and macroalbuminuria were each associated with higher risk of cardiovascular events (adjusted hazard ratios [HRs] and 95% confidence intervals [95% CIs]: 1.79 [1.13 to 2.85], 2.62 [1.68 to 4.07], and 2.65 [1.68 to 4.19], respectively) and reduced eGFR (adjusted HRs [95% CIs], 5.26 [2.43 to 11.41], 4.36 [1.80 to 10.57], and 54.35 [30.79 to 95.94], respectively). Compared with sustained microalbuminuria, remission to normoalbuminuria was not associated with reduced risk of cardiovascular events (adjusted HR, 1.33; 95% CI, 0.68 to 2.59) or reduced eGFR (adjusted HR, 1.75; 95% CI, 0.56 to 5.49). Compared with normoalbuminuria, sustained microalbuminuria, remitted microalbuminuria, and macroalbuminuria were associated with greater carotid intima-media thickness, and macroalbuminuria was associated with a greater degree of coronary artery calcification. CONCLUSIONS In type 1 diabetes, microalbuminuria and macroalbuminuria are associated with higher risks of cardiovascular disease and reduced eGFR, but achieving a remission of established microalbuminuria to normoalbuminuria does not appear to improve outcomes.
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Affiliation(s)
- Ian H de Boer
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington
| | - Xiaoyu Gao
- Biostatistics Center, The George Washington University, Rockville, Maryland
| | - Patricia A Cleary
- Biostatistics Center, The George Washington University, Rockville, Maryland
| | - Ionut Bebu
- Biostatistics Center, The George Washington University, Rockville, Maryland
| | - John M Lachin
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington
- Biostatistics Center, The George Washington University, Rockville, Maryland
- Division of Endocrinology, Metabolism & Molecular Medicine, Northwestern University, Chicago, Illinois
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
- Dalla Lana School of Public Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, University of Toronto and University Health Network, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota; and
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark E Molitch
- Division of Endocrinology, Metabolism & Molecular Medicine, Northwestern University, Chicago, Illinois
| | - Trevor Orchard
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew D Paterson
- Dalla Lana School of Public Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Division of Endocrinology and Metabolism, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Michael W Steffes
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota; and
| | - Bernard Zinman
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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25
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Portale AA, Wolf MS, Messinger S, Perwad F, Jüppner H, Warady BA, Furth SL, Salusky IB. Fibroblast Growth Factor 23 and Risk of CKD Progression in Children. Clin J Am Soc Nephrol 2016; 11:1989-1998. [PMID: 27561289 PMCID: PMC5108188 DOI: 10.2215/cjn.02110216] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [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: 02/26/2016] [Accepted: 07/25/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Plasma fibroblast growth factor 23 (FGF23) concentrations increase early in the course of CKD in children. High FGF23 levels associate with progression of CKD in adults. Whether FGF23 predicts CKD progression in children is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We tested the hypothesis that high plasma FGF23 is an independent risk factor for CKD progression in 419 children, aged 1-16 years, enrolled in the Chronic Kidney Disease in Children (CKiD) cohort study. We measured plasma FGF23 concentrations at baseline and determined GFR annually using plasma disappearance of iohexol or the CKiD study estimating equation. We analyzed the association of baseline FGF23 with risk of progression to the composite end point, defined as start of dialysis or kidney transplantation or 50% decline from baseline GFR, adjusted for demographics, baseline GFR, proteinuria, other CKD-specific factors, and other mineral metabolites. RESULTS At enrollment, median age was 11 years [interquartile range (IQR), 8-15], GFR was 44 ml/min per 1.73 m2 (IQR, 33-57), and FGF23 was 132 RU/ml (IQR, 88-200). During a median follow-up of 5.5 years (IQR, 3.5-6.6), 32.5% of children reached the progression end point. Higher FGF23 concentrations were independently associated with higher risk of the composite outcome (fully adjusted hazard ratio, 2.52 in the highest versus lowest FGF23 tertile; 95% confidence interval, 1.44 to 4.39, P=0.002; fully adjusted hazard ratio, 1.33 per doubling of FGF23; 95% confidence interval, 1.13 to 1.56, P=0.001). The time to progression was 40% shorter for participants in the highest compared with the lowest FGF23 tertile. In contrast, serum phosphorus, vitamin D metabolites, and parathyroid hormone did not consistently associate with progression in adjusted analyses. CONCLUSIONS High plasma FGF23 is an independent risk factor for CKD progression in children.
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Affiliation(s)
- Anthony A. Portale
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Myles S. Wolf
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Shari Messinger
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Farzana Perwad
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Harald Jüppner
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bradley A. Warady
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Susan L. Furth
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Isidro B. Salusky
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California
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26
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Parsa A, Kanetsky PA, Xiao R, Gupta J, Mitra N, Limou S, Xie D, Xu H, Anderson AH, Ojo A, Kusek JW, Lora CM, Hamm LL, He J, Sandholm N, Jeff J, Raj DE, Böger CA, Bottinger E, Salimi S, Parekh RS, Adler SG, Langefeld CD, Bowden DW, Groop PH, Forsblom C, Freedman BI, Lipkowitz M, Fox CS, Winkler CA, Feldman HI. Genome-Wide Association of CKD Progression: The Chronic Renal Insufficiency Cohort Study. J Am Soc Nephrol 2016; 28:923-934. [PMID: 27729571 DOI: 10.1681/asn.2015101152] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [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: 10/20/2015] [Accepted: 08/25/2016] [Indexed: 11/03/2022] Open
Abstract
The rate of decline of renal function varies significantly among individuals with CKD. To understand better the contribution of genetics to CKD progression, we performed a genome-wide association study among participants in the Chronic Renal Insufficiency Cohort Study. Our outcome of interest was CKD progression measured as change in eGFR over time among 1331 blacks and 1476 whites with CKD. We stratified all analyses by race and subsequently, diabetes status. Single-nucleotide polymorphisms (SNPs) that surpassed a significance threshold of P<1×10-6 for association with eGFR slope were selected as candidates for follow-up and secondarily tested for association with proteinuria and time to ESRD. We identified 12 such SNPs among black patients and six such SNPs among white patients. We were able to conduct follow-up analyses of three candidate SNPs in similar (replication) cohorts and eight candidate SNPs in phenotype-related (validation) cohorts. Among blacks without diabetes, rs653747 in LINC00923 replicated in the African American Study of Kidney Disease and Hypertension cohort (discovery P=5.42×10-7; replication P=0.039; combined P=7.42×10-9). This SNP also associated with ESRD (hazard ratio, 2.0 (95% confidence interval, 1.5 to 2.7); P=4.90×10-6). Similarly, rs931891 in LINC00923 associated with eGFR decline (P=1.44×10-4) in white patients without diabetes. In summary, SNPs in LINC00923, an RNA gene expressed in the kidney, significantly associated with CKD progression in individuals with nondiabetic CKD. However, the lack of equivalent cohorts hampered replication for most discovery loci. Further replication of our findings in comparable study populations is warranted.
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Affiliation(s)
- Afshin Parsa
- Division of Nephrology and .,Department of Medicine, Baltimore Veterans Affairs Medical Center, Baltimore, Maryland
| | - Peter A Kanetsky
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rui Xiao
- Department of Biostatistics and Epidemiology and
| | - Jayanta Gupta
- Department of Health Sciences, College of Health Professions and Social Work, Florida Gulf Coast University, Fort Myers, FL
| | | | - Sophie Limou
- Molecular Genetic Epidemiology Section, Basic Research Laboratory, Center for Cancer Research, National Cancer Institute and Basic Science Program, Leidos Biomedical Research, Inc., Frederick National Laboratory, Frederick, Maryland
| | - Dawei Xie
- Department of Biostatistics and Epidemiology and
| | | | - Amanda Hyre Anderson
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Akinlolu Ojo
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - John W Kusek
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Claudia M Lora
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, Illinois
| | - L Lee Hamm
- Department of Medicine, Section of Nephrology, Tulane University, New Orleans, Louisiana
| | - Jiang He
- Department of Medicine, Section of Nephrology, Tulane University, New Orleans, Louisiana
| | - Niina Sandholm
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Janina Jeff
- Department of Medicine, The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine Mount Sinai, New York, New York
| | - Dominic E Raj
- Department of Medicine, The George Washington University School of Medicine, Washington, DC
| | - Carsten A Böger
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Erwin Bottinger
- Department of Medicine, The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine Mount Sinai, New York, New York
| | - Shabnam Salimi
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rulan S Parekh
- Division of Nephrology, Department of Pediatrics and Medicine, Hospital for Sick Children, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Sharon G Adler
- Department of Medicine, Division of Nephrology and Hypertension, Harbor-University of California, Los Angeles Medical Center, Los Angeles, California
| | | | | | | | - Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Carol Forsblom
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael Lipkowitz
- Department of Medicine, Georgetown University Medical Center, Washington, DC; and
| | - Caroline S Fox
- Division of Intramural Research, National Heart, Lung and Blood Institute's Framingham Heart Study, National Heart, Lung and Blood Institute, Framingham, Massachusetts
| | | | - Harold I Feldman
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
IgA nephropathy (IgAN) is a common chronic glomerular disease that, in most patients, slowly progresses to ESRD. The immune and autoimmune responses that characterize IgAN indicate a potential benefit for corticosteroids. The 2012 Kidney Disease Improving Global Outcome (KDIGO) guidelines suggest giving corticosteroids to patients with rather preserved renal function (GFR>50 ml/min per 1.73 m2) and persistent proteinuria >1 g/d, despite 3-6 months of optimized supportive care with renin-angiotensin system blockers. However, the evidence supporting this guideline was considered of low quality. More recent results from large cohort studies and randomized, controlled trials have provided conflicting messages about the benefits of corticosteroid treatment over supportive care alone, mostly involving optimized renin-angiotensin system blockade, which might generate further uncertainty in the therapeutic choice. Overall, these results indicate that corticosteroids are a powerful tool for treating patients with IgAN; however, treatment success is not universal and mostly occurs in patients who are highly proteinuric with early CKD. In patients with advanced CKD, the side effects of corticosteroids increase, and the renal protection decreases. This brief review aimed at integrating the findings of these recently published reports to provide balanced advice for clinicians as well as suggestions for future trials.
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Affiliation(s)
- Rosanna Coppo
- Fondazione Ricerca Molinette, Nephrology, Dialysis and Transplantation, Regina Margherita Hospital, Turin, Italy
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28
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Gotot J, Piotrowski E, Otte MS, Tittel AP, Linlin G, Yao C, Ziegelbauer K, Panzer U, Garbi N, Kurts C, Thaiss F. Inhibitor of NFκB Kinase Subunit 2 Blockade Hinders the Initiation but Aggravates the Progression of Crescentic GN. J Am Soc Nephrol 2016; 27:1917-24. [PMID: 26574045 PMCID: PMC4926984 DOI: 10.1681/asn.2015060699] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 10/08/2015] [Indexed: 12/16/2022] Open
Abstract
The NFκB transcription factor family facilitates the activation of dendritic cells (DCs) and CD4(+) T helper (Th) cells, which are important for protective adaptive immunity. Inappropriate activation of these immune cells may cause inflammatory disease, and NFκB inhibitors are promising anti-inflammatory drug candidates. Here, we investigated whether inhibiting the NFκB-inducing kinase IKK2 can attenuate crescentic GN, a severe DC- and Th cell-dependent kidney inflammatory disease. Prophylactic pharmacologic IKK2 inhibition reduced DC and Th cell activation and ameliorated nephrotoxic serum-induced GN in mice. However, therapeutic IKK2 inhibition during ongoing disease aggravated the nephritogenic immune response and disease symptoms. This effect resulted from the renal loss of regulatory T cells, which have been shown to protect against crescentic GN and which require IKK2. In conclusion, although IKK2 inhibition can suppress the induction of nephritogenic immune responses in vivo, it may aggravate such responses in clinically relevant situations, because it also impairs regulatory T cells and thereby, unleashes preexisting nephritogenic responses. Our findings argue against using IKK2 inhibitors in chronic GN and perhaps, other immune-mediated diseases.
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Affiliation(s)
- Janine Gotot
- Institute of Experimental Immunology, Rheinische Friedrich Wilhelms University, Bonn, Germany
| | - Eveline Piotrowski
- Third Medical Department of Clinical Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Martin S Otte
- Institute of Experimental Immunology, Rheinische Friedrich Wilhelms University, Bonn, Germany; Department of Otorhinolaryngology, Head and Neck Surgery, University of Cologne Germany; and
| | - André P Tittel
- Institute of Experimental Immunology, Rheinische Friedrich Wilhelms University, Bonn, Germany
| | - Guo Linlin
- Third Medical Department of Clinical Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Chen Yao
- Third Medical Department of Clinical Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Karl Ziegelbauer
- Global Drug Discovery, TRG Oncology/GT, Bayer Pharma AG, Berlin, Germany
| | - Ulf Panzer
- Third Medical Department of Clinical Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Natalio Garbi
- Institute of Experimental Immunology, Rheinische Friedrich Wilhelms University, Bonn, Germany
| | - Christian Kurts
- Institute of Experimental Immunology, Rheinische Friedrich Wilhelms University, Bonn, Germany;
| | - Friedrich Thaiss
- Third Medical Department of Clinical Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany;
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29
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Garneata L, Stancu A, Dragomir D, Stefan G, Mircescu G. Ketoanalogue-Supplemented Vegetarian Very Low-Protein Diet and CKD Progression. J Am Soc Nephrol 2016; 27:2164-76. [PMID: 26823552 PMCID: PMC4926970 DOI: 10.1681/asn.2015040369] [Citation(s) in RCA: 195] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/24/2015] [Indexed: 01/23/2023] Open
Abstract
Dietary protein restriction may improve determinants of CKD progression. However, the extent of improvement and effect of ketoanalogue supplementation are unclear. We conducted a prospective, randomized, controlled trial of safety and efficacy of ketoanalogue-supplemented vegetarian very low-protein diet (KD) compared with conventional low-protein diet (LPD). Primary end point was RRT initiation or >50% reduction in initial eGFR. Nondiabetic adults with stable eGFR<30 ml/min per 1.73 m(2), proteinuria <1 g/g urinary creatinine, good nutritional status, and good diet compliance entered a run-in phase on LPD. After 3 months, compliant patients were randomized to KD (0.3 g/kg vegetable proteins and 1 cps/5 kg ketoanalogues per day) or continue LPD (0.6 g/kg per day) for 15 months. Only 14% of screened patients patients were randomized, with no differences between groups. Adjusted numbers needed to treat (NNTs; 95% confidence interval) to avoid composite primary end point in intention to treat and per-protocol analyses in one patient were 4.4 (4.2 to 5.1) and 4.0 (3.9 to 4.4), respectively, for patients with eGFR<30 ml/min per 1.73 m(2) Adjusted NNT (95% confidence interval) to avoid dialysis was 22.4 (21.5 to 25.1) for patients with eGFR<30 ml/min per 1.73 m(2) but decreased to 2.7 (2.6 to 3.1) for patients with eGFR<20 ml/min per 1.73 m(2) in intention to treat analysis. Correction of metabolic abnormalities occurred only with KD. Compliance to diet was good, with no changes in nutritional parameters and no adverse reactions. Thus, this KD seems nutritionally safe and could defer dialysis initiation in some patients with CKD.
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Affiliation(s)
- Liliana Garneata
- Department of Nephrology and Internal Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; and Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Alexandra Stancu
- Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Diana Dragomir
- Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gabriel Stefan
- Department of Nephrology and Internal Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; and Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gabriel Mircescu
- Department of Nephrology and Internal Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania; and Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
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30
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Xie Y, Bowe B, Li T, Xian H, Balasubramanian S, Al-Aly Z. Proton Pump Inhibitors and Risk of Incident CKD and Progression to ESRD. J Am Soc Nephrol 2016; 27:3153-3163. [PMID: 27080976 DOI: 10.1681/asn.2015121377] [Citation(s) in RCA: 213] [Impact Index Per Article: 26.6] [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: 12/29/2015] [Accepted: 02/23/2016] [Indexed: 12/13/2022] Open
Abstract
The association between proton pump inhibitors (PPI) use and risk of acute interstitial nephritis has been described. However, whether exposure to PPI associates with incident CKD, CKD progression, or ESRD is not known. We used Department of Veterans Affairs national databases to build a primary cohort of new users of PPI (n=173,321) and new users of histamine H2-receptor antagonists (H2 blockers; n=20,270) and followed these patients over 5 years to ascertain renal outcomes. In adjusted Cox survival models, the PPI group, compared with the H2 blockers group, had an increased risk of incident eGFR<60 ml/min per 1.73 m2 and of incident CKD (hazard ratio [HR], 1.22; 95% confidence interval [95% CI], 1.18 to 1.26; and HR, 1.28; 95% CI, 1.23 to 1.34, respectively). Patients treated with PPI also had a significantly elevated risk of doubling of serum creatinine level (HR, 1.53; 95% CI, 1.42 to 1.65), of eGFR decline >30% (HR, 1.32; 95% CI, 1.28 to 1.37), and of ESRD (HR, 1.96; 95% CI, 1.21 to 3.18). Furthermore, we detected a graded association between duration of PPI exposure and risk of renal outcomes among those exposed to PPI for 31-90, 91-180, 181-360, and 361-720 days compared with those exposed for ≤30 days. Examination of risk of renal outcomes in 1:1 propensity score-matched cohorts of patients taking H2 blockers versus patients taking PPI and patients taking PPI versus controls yielded consistent results. Our results suggest that PPI exposure associates with increased risk of incident CKD, CKD progression, and ESRD.
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Affiliation(s)
- Yan Xie
- Clinical Epidemiology Center, Veterans Affairs Saint Louis Health Care System
| | - Benjamin Bowe
- Clinical Epidemiology Center, Veterans Affairs Saint Louis Health Care System
| | - Tingting Li
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Hong Xian
- Clinical Epidemiology Center, Veterans Affairs Saint Louis Health Care System, Department of Biostatistics, College for Public Health and Social Justice, Saint Louis University
| | | | - Ziyad Al-Aly
- Clinical Epidemiology Center, Veterans Affairs Saint Louis Health Care System, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri; Division of Nephrology, Department of Medicine, Veterans Affairs Saint Louis Health Care System, Saint Louis, Missouri
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31
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Kovesdy CP, Coresh J, Ballew SH, Woodward M, Levin A, Naimark DMJ, Nally J, Rothenbacher D, Stengel B, Iseki K, Matsushita K, Levey AS. Past Decline Versus Current eGFR and Subsequent ESRD Risk. J Am Soc Nephrol 2015; 27:2447-55. [PMID: 26657867 DOI: 10.1681/asn.2015060687] [Citation(s) in RCA: 66] [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: 06/23/2015] [Accepted: 10/27/2015] [Indexed: 12/17/2022] Open
Abstract
eGFR is a robust predictor of ESRD risk. However, the prognostic information gained from the past trajectory (slope) beyond that of the current eGFR is unclear. We examined 22 cohorts to determine the association of past slopes and current eGFR level with subsequent ESRD. We modeled hazard ratios as a spline function of slopes, adjusting for demographic variables, eGFR, and comorbidities. We used random effects meta-analyses to combine results across studies stratified by cohort type. We calculated the absolute risk of ESRD at 5 years after the last eGFR using the weighted average baseline risk. Overall, 1,080,223 participants experienced 5163 ESRD events during a mean follow-up of 2.0 years. In CKD cohorts, a slope of -6 versus 0 ml/min per 1.73 m(2) per year over the previous 3 years (a decline of 18 ml/min per 1.73 m(2) versus no decline) associated with an adjusted hazard ratio of ESRD of 2.28 (95% confidence interval, 1.88 to 2.76). In contrast, a current eGFR of 30 versus 50 ml/min per 1.73 m(2) (a difference of 20 ml/min per 1.73 m(2)) associated with an adjusted hazard ratio of 19.9 (95% confidence interval, 13.6 to 29.1). Past decline contributed more to the absolute risk of ESRD at lower than higher levels of current eGFR. In conclusion, during a follow-up of 2 years, current eGFR associates more strongly with future ESRD risk than the magnitude of past eGFR decline, but both contribute substantially to the risk of ESRD, especially at eGFR<30 ml/min per 1.73 m(2).
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Affiliation(s)
- Csaba P Kovesdy
- Department of Medicine, Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee; Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mark Woodward
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; The George Institute for Global Health, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - David M J Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Nally
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dietrich Rothenbacher
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany; Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Benedicte Stengel
- Institut National de la Santé et de la Recherche Médicale (Inserm) Unité mixte de recherche 1018 - UMR1018) Center for Research in Epidemiology and Population Health, Villejuif, France; UMRS 1018, Paris-Sud University and Versailles Saint Quentin University, Villejuif, France
| | - Kunitoshi Iseki
- Dialysis Unit, University Hospital of The Ryukyus, Nishihara, Okinawa, Japan; and
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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32
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Hall YN, Himmelfarb J. Border Health: State-Level Variation in Predialysis Nephrology Care. Clin J Am Soc Nephrol 2015; 10:1892-4. [PMID: 26450934 DOI: 10.2215/cjn.09440915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Yoshio N Hall
- Kidney Research Institute, University of Washington, Seattle, Washington
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33
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Ix JH, Biggs ML, Mukamal K, Djousse L, Siscovick D, Tracy R, Katz R, Delaney JA, Chaves P, Rifkin DE, Hughes-Austin JM, Garimella PS, Sarnak MJ, Shlipak MG, Kizer JR. Urine Collagen Fragments and CKD Progression-The Cardiovascular Health Study. J Am Soc Nephrol 2015; 26:2494-503. [PMID: 25655067 PMCID: PMC4587692 DOI: 10.1681/asn.2014070696] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [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: 07/21/2014] [Accepted: 12/22/2014] [Indexed: 11/03/2022] Open
Abstract
Tubulointerstitial fibrosis is common with ageing and strongly prognostic for ESRD but is poorly captured by eGFR or urine albumin to creatinine ratio (ACR). Higher urine levels of procollagen type III N-terminal propeptide (PIIINP) mark the severity of tubulointerstitial fibrosis in biopsy studies, but the association of urine PIIINP with CKD progression is unknown. Among community-living persons aged ≥65 years, we measured PIIINP in spot urine specimens from the 1996 to 1997 Cardiovascular Health Study visit among individuals with CKD progression (30% decline in eGFR over 9 years, n=192) or incident ESRD (n=54) during follow-up, and in 958 randomly selected participants. We evaluated associations of urine PIIINP with CKD progression and incident ESRD. Associations of urine PIIINP with cardiovascular disease, heart failure, and death were evaluated as secondary end points. At baseline, mean age (±SD) was 78±5 years, mean eGFR was 63±18 ml/min per 1.73 m(2), and median urine PIIINP was 2.6 (interquartile range, 1.4-4.2) μg/L. In a case-control study (192 participants, 231 controls), each doubling of urine PIIINP associated with 22% higher odds of CKD progression (adjusted odds ratio, 1.22; 95% confidence interval, 1.00 to 1.49). Higher urine PIIINP level was also associated with incident ESRD, but results were not significant in fully adjusted models. In a prospective study among the 958 randomly selected participants, higher urine PIIINP was significantly associated with death, but not with incident cardiovascular disease or heart failure. These data suggest higher urine PIIINP levels associate with CKD progression independently of eGFR and ACR in older individuals.
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Affiliation(s)
- Joachim H Ix
- Division of Nephrology-Hypertension, University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California;
| | - Mary L Biggs
- Department of Biostatistics, School of Public Health and Community Medicine, University of Washington, Seattle, Washington
| | - Kenneth Mukamal
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Luc Djousse
- Division of Aging, Brigham and Women's Hospital and Boston Veterans Affairs Healthcare System, Boston, Massachusetts
| | | | - Russell Tracy
- Department of Pathology, University of Vermont, Burlington, Vermont
| | - Ronit Katz
- Division of Nephrology, University of Washington, Seattle, Washington
| | - Joseph A Delaney
- Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, Washington
| | - Paulo Chaves
- Department of Medicine, Florida International University, Miami, Florida
| | - Dena E Rifkin
- Division of Nephrology-Hypertension, University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Jan M Hughes-Austin
- Department of Family and Preventive Medicine, University of California San Diego, San Diego, California
| | | | - Mark J Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Michael G Shlipak
- Department of Medicine, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California; and
| | - Jorge R Kizer
- Departments of Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
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34
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Tesar V, Troyanov S, Bellur S, Verhave JC, Cook HT, Feehally J, Roberts ISD, Cattran D, Coppo R. Corticosteroids in IgA Nephropathy: A Retrospective Analysis from the VALIGA Study. J Am Soc Nephrol 2015; 26:2248-58. [PMID: 25677392 DOI: 10.1681/asn.2014070697] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [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: 07/22/2014] [Accepted: 11/17/2014] [Indexed: 11/03/2022] Open
Abstract
Current guidelines suggest treatment with corticosteroids (CS) in IgA nephropathy (IgAN) when proteinuria is persistently ≥1 g/d despite 3-6 months of supportive care and when eGFR is >50 ml/min per 1.73 m(2). Whether the benefits of this treatment extend to patients with an eGFR≤50 ml/min per 1.73 m(2), other levels of proteinuria, or different renal pathologic lesions remains unknown. We retrospectively studied 1147 patients with IgAN from the European Validation Study of the Oxford Classification of IgAN (VALIGA) cohort classified according to the Oxford-MEST classification and medication used, with details of duration but not dosing. Overall, 46% of patients received immunosuppression, of which 98% received CS. Treated individuals presented with greater clinical and pathologic risk factors of progression. They also received more antihypertensive medication, and a greater proportion received renin angiotensin system blockade (RASB) compared with individuals without immunosuppressive therapy. Immunosuppression was associated with a significant reduction in proteinuria, a slower rate of renal function decline, and greater renal survival. Using a propensity score, we matched 184 subjects who received CS and RASB to 184 patients with a similar risk profile of progression who received only RASB. Within this group, CS reduced proteinuria and the rate of renal function decline and increased renal survival. These benefits extended to those with an eGFR≤50 ml/min per 1.73 m(2), and the benefits increased proportionally with the level of proteinuria. Thus, CS reduced the risk of progression regardless of initial eGFR and in direct proportion to the extent of proteinuria in this cohort.
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Affiliation(s)
- Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | | | | | | | - H Terence Cook
- Imperial College, Hammersmith Hospital, London, United Kingdom
| | - John Feehally
- University Hospitals of Leicester, Leicester, United Kingdom
| | | | - Daniel Cattran
- University Health Network, Toronto General Hospital, Toronto, Canada; and
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Tesar V, Troyanov S, Bellur S, Verhave JC, Cook HT, Feehally J, Roberts ISD, Cattran D, Coppo R. Corticosteroids in IgA Nephropathy: A Retrospective Analysis from the VALIGA Study. J Am Soc Nephrol 2015. [PMID: 25677392 DOI: 10.1681/asn.201407069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Current guidelines suggest treatment with corticosteroids (CS) in IgA nephropathy (IgAN) when proteinuria is persistently ≥1 g/d despite 3-6 months of supportive care and when eGFR is >50 ml/min per 1.73 m(2). Whether the benefits of this treatment extend to patients with an eGFR≤50 ml/min per 1.73 m(2), other levels of proteinuria, or different renal pathologic lesions remains unknown. We retrospectively studied 1147 patients with IgAN from the European Validation Study of the Oxford Classification of IgAN (VALIGA) cohort classified according to the Oxford-MEST classification and medication used, with details of duration but not dosing. Overall, 46% of patients received immunosuppression, of which 98% received CS. Treated individuals presented with greater clinical and pathologic risk factors of progression. They also received more antihypertensive medication, and a greater proportion received renin angiotensin system blockade (RASB) compared with individuals without immunosuppressive therapy. Immunosuppression was associated with a significant reduction in proteinuria, a slower rate of renal function decline, and greater renal survival. Using a propensity score, we matched 184 subjects who received CS and RASB to 184 patients with a similar risk profile of progression who received only RASB. Within this group, CS reduced proteinuria and the rate of renal function decline and increased renal survival. These benefits extended to those with an eGFR≤50 ml/min per 1.73 m(2), and the benefits increased proportionally with the level of proteinuria. Thus, CS reduced the risk of progression regardless of initial eGFR and in direct proportion to the extent of proteinuria in this cohort.
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Affiliation(s)
- Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | | | | | | | - H Terence Cook
- Imperial College, Hammersmith Hospital, London, United Kingdom
| | - John Feehally
- University Hospitals of Leicester, Leicester, United Kingdom
| | | | - Daniel Cattran
- University Health Network, Toronto General Hospital, Toronto, Canada; and
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Maziarz M, Black RA, Fong CT, Himmelfarb J, Chertow GM, Hall YN. Evaluating risk of ESRD in the urban poor. J Am Soc Nephrol 2014; 26:1434-42. [PMID: 25475746 DOI: 10.1681/asn.2014060546] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [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: 06/05/2014] [Accepted: 08/22/2014] [Indexed: 01/13/2023] Open
Abstract
The capacity of risk prediction to guide management of CKD in underserved health settings is unknown. We conducted a retrospective cohort study of 28,779 adults with nondialysis-requiring CKD who received health care in two large safety net health systems during 1996-2009 and were followed for ESRD through September of 2011. We developed and evaluated the performance of ESRD risk prediction models using recently proposed criteria designed to inform population health approaches to disease management: proportion of cases followed and proportion that needs to be followed. Overall, 1730 persons progressed to ESRD during follow-up (median follow-up=6.6 years). ESRD risk for time frames up to 5 years was highly concentrated among relatively few individuals. A predictive model using five common variables (age, sex, race, eGFR, and dipstick proteinuria) performed similarly to more complex models incorporating extensive sociodemographic and clinical data. Using this model, 80% of individuals who eventually developed ESRD were among the 5% of cohort members at the highest estimated risk for ESRD at 1 year. Similarly, a program that followed 8% and 13% of individuals at the highest ESRD risk would have included 80% of those who eventually progressed to ESRD at 3 and 5 years, respectively. In this underserved health setting, a simple five-variable model accurately predicts most cases of ESRD that develop within 5 years. Applying risk prediction using a population health approach may improve CKD surveillance and management of vulnerable groups by directing resources to a small subpopulation at highest risk for progressing to ESRD.
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Affiliation(s)
- Marlena Maziarz
- Kidney Research Institute, Department of Medicine, Department of Biostatistics, and
| | - R Anthony Black
- Biomedical Informatics Consult Team, Institute of Translational Health Sciences, University of Washington, Seattle, Washington; and
| | - Christine T Fong
- Biomedical Informatics Consult Team, Institute of Translational Health Sciences, University of Washington, Seattle, Washington; and
| | | | - Glenn M Chertow
- School of Medicine, Stanford University, Palo Alto, California
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Khatri M, Moon YP, Scarmeas N, Gu Y, Gardener H, Cheung K, Wright CB, Sacco RL, Nickolas TL, Elkind MSV. The association between a Mediterranean-style diet and kidney function in the Northern Manhattan Study cohort. Clin J Am Soc Nephrol 2014; 9:1868-75. [PMID: 25359387 DOI: 10.2215/cjn.01080114] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [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: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Various dietary strategies have been investigated to slow kidney function decline. However, it is unknown whether a Mediterranean diet, which has been associated with improved cardiovascular risk, is associated with change in kidney function. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study used the Northern Manhattan Study, a prospective, multiethnic, observational cohort of participants who were stroke free at baseline. Data were collected between 1993 and 2008. Serum creatinine measurements were taken a mean 6.9 years apart. A baseline dietary questionnaire was extrapolated into a previously used 9-point scoring system (MeDi). The primary outcome was incident eGFR<60 ml/min per 1.73 m(2)using the Modification of Diet in Renal Disease formula. A secondary outcome was the upper quartile of annualized eGFR decline (≥ 2.5 ml/min per 1.73 m(2) per year). Conditional logistic regression models adjusted for demographics and baseline vascular risk factors. RESULTS Mean baseline age was 64 years, with 59% women and 65% Hispanics (N=900); mean baseline eGFR was 83.1 ml/min per 1.73 m(2). Incident eGFR<60 ml/min per 1.73 m(2) developed in 14% . In adjusted models, every 1-point increase in the MeDi score, indicating increasing adherence to a Mediterranean diet, was associated with decreased odds of incident eGFR<60 ml/min per 1.73 m(2) (odds ratio, 0.83; 95% confidence interval, 0.71 to 0.96) and decreased odds of being in the upper quartile of eGFR decline (odds ratio, 0.88; 95% confidence interval, 0.79 to 0.98). CONCLUSIONS A Mediterranean diet was associated with a reduced incidence of eGFR<60 ml/min per 1.73 m(2) and upper quartile of eGFR decline in a multiethnic cohort.
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Affiliation(s)
| | | | - Nikolaos Scarmeas
- Neurology, College of Physicians and Surgeons, Gertrude H. Sergievsky Center, Taub Institute for Research in Alzheimer's Disease and the Aging Brain, and Department of Social Medicine, Psychiatry, and Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece; and
| | - Yian Gu
- Taub Institute for Research in Alzheimer's Disease and the Aging Brain, and
| | - Hannah Gardener
- Evelyn F. McKnight Brain Institute, Department of Neurology, University of Miami, Miami, Florida
| | - Ken Cheung
- Neurology, College of Physicians and Surgeons, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Clinton B Wright
- Evelyn F. McKnight Brain Institute, Department of Neurology, University of Miami, Miami, Florida
| | - Ralph L Sacco
- Evelyn F. McKnight Brain Institute, Department of Neurology, University of Miami, Miami, Florida
| | | | - Mitchell S V Elkind
- Neurology, College of Physicians and Surgeons, Gertrude H. Sergievsky Center, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Robinson-Cohen C, Hall YN, Katz R, Rivara MB, de Boer IH, Kestenbaum BR, Himmelfarb J. Self-rated health and adverse events in CKD. Clin J Am Soc Nephrol 2014; 9:2044-51. [PMID: 25301857 DOI: 10.2215/cjn.03140314] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Little is known about the utility of self-rated general health assessments in persons with moderate-to-severe CKD. This study examined the ability of a single self-rated health measure to predict all-cause mortality and kidney disease progression in a cohort of 443 patients with stages 3-4 CKD, recruited between 2005 and 2011, and followed until the end of 2012. The performance of models incorporating self-rated health measures was compared with previously published predictive models and more complex models comprising a multibiomarker panel. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Participants were asked "In general, would you say your health is excellent, very good, good, fair, or poor?" Outcomes examined were time to all-cause mortality, kidney disease progression (initiation of RRT or 30% loss of eGFR), and a composite of these events. Model performances were compared using a nonparametric area under the curve (AUC) analysis. RESULTS Over a median follow-up of 3.3 years, 118 (27%) participants died and 138 (31%) had progression of kidney disease. Fair-to-poor self-rated health status was associated with significantly greater risks of mortality (fully adjusted hazard ratio [HR] for relative to good-to-excellent self-rated health, 2.76; 95% confidence interval [95% CI], 1.28 to 5.89), kidney disease progression (HR, 1.94; 95% CI, 1.49 to 2.56), and the combined end point (HR, 2.21; 95% CI, 1.66 to 2.96). For 3-year mortality prediction, the self-rated health model (AUC, 0.80; 95% CI, 0.76 to 0.85) had significantly higher AUCs than the base model (AUC, 0.71; 95% CI, 0.66 to 0.76) and the multibiomarker panel model (AUC, 0.74; 95% CI, 0.68 to 0.80) (P=0.03 and P=0.04, respectively). CONCLUSIONS A single, easily obtained measure of self-rated health helps identify patients with CKD at high risk of mortality and kidney disease progression. Routine evaluation of self-rated health may help target individuals who might benefit from more intensive monitoring strategies.
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Affiliation(s)
| | - Yoshio N Hall
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | | | - Matthew B Rivara
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Ian H de Boer
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Bryan R Kestenbaum
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
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Abstract
Loss of podocytes underlies progression of CKD. Detachment of podocytes from the glomerular basement membrane (GBM) rather than apoptosis or necrosis seems to be the major mechanism of podocyte loss. Such detachment of viable podocytes may be caused by increased mechanical distending and shear forces and/or impaired adhesion to the GBM. This review considers the mechanical challenges that may lead to podocyte loss by detachment from the GBM under physiologic and pathophysiologic conditions, including glomerular hypertension, hyperfiltration, hypertrophy, and outflow of filtrate from subpodocyte spaces. Furthermore, we detail the cellular mechanisms by which podocytes respond to these challenges, discuss the protective effects of angiotensin blockade, and note the questions that must be addressed to better understand the relationship between podocyte detachment and progression of CKD.
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Affiliation(s)
- Wilhelm Kriz
- Institutes of Transfusion Medicine and Immunology and Neuroanatomy, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; and
| | - Kevin V Lemley
- Division of Nephrology, Children's Hospital Los Angeles, Los Angeles, California; and Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California
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Navarro-González JF, Mora-Fernández C, Muros de Fuentes M, Chahin J, Méndez ML, Gallego E, Macía M, del Castillo N, Rivero A, Getino MA, García P, Jarque A, García J. Effect of pentoxifylline on renal function and urinary albumin excretion in patients with diabetic kidney disease: the PREDIAN trial. J Am Soc Nephrol 2014; 26:220-9. [PMID: 24970885 DOI: 10.1681/asn.2014010012] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [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: 12/13/2022] Open
Abstract
Diabetic kidney disease (DKD) is the leading cause of ESRD. We conducted an open-label, prospective, randomized trial to determine whether pentoxifylline (PTF), which reduces albuminuria, in addition to renin-angiotensin system (RAS) blockade, can slow progression of renal disease in patients with type 2 diabetes and stages 3-4 CKD. Participants were assigned to receive PTF (1200 mg/d) (n=82) or to a control group (n=87) for 2 years. All patients received similar doses of RAS inhibitors. At study end, eGFR had decreased by a mean±SEM of 2.1±0.4 ml/min per 1.73 m(2) in the PTF group compared with 6.5±0.4 ml/min per 1.73 m(2) in the control group, with a between-group difference of 4.3 ml/min per 1.73 m(2) (95% confidence interval [95% CI], 3.1 to 5.5 ml/min per 1.73 m(2); P<0.001) in favor of PTF. The proportion of patients with a rate of eGFR decline greater than the median rate of decline (0.16 ml/min per 1.73 m(2) per month) was lower in the PTF group than in the control group (33.3% versus 68.2%; P<0.001). Percentage change in urinary albumin excretion was 5.7% (95% CI, -0.3% to 11.1%) in the control group and -14.9% (95% CI, -20.4% to -9.4%) in the PTF group (P=0.001). Urine TNF-α decreased from a median 16 ng/g (interquartile range, 11-20.1 ng/g) to 14.3 ng/g (interquartile range, 9.2-18.4 ng/g) in the PTF group (P<0.01), with no changes in the control group. In this population, addition of PTF to RAS inhibitors resulted in a smaller decrease in eGFR and a greater reduction of residual albuminuria.
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Affiliation(s)
- Juan F Navarro-González
- Nephrology Service, Research Unit, GEENDIAB (Spanish Group for the Study of Diabetic Nephropathy), University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Carmen Mora-Fernández
- Research Unit, GEENDIAB (Spanish Group for the Study of Diabetic Nephropathy), University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Mercedes Muros de Fuentes
- GEENDIAB (Spanish Group for the Study of Diabetic Nephropathy), University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain Clinical Analysis Service, and
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Irazabal MV, Rangel LJ, Bergstralh EJ, Osborn SL, Harmon AJ, Sundsbak JL, Bae KT, Chapman AB, Grantham JJ, Mrug M, Hogan MC, El-Zoghby ZM, Harris PC, Erickson BJ, King BF, Torres VE. Imaging classification of autosomal dominant polycystic kidney disease: a simple model for selecting patients for clinical trials. J Am Soc Nephrol 2014; 26:160-72. [PMID: 24904092 DOI: 10.1681/asn.2013101138] [Citation(s) in RCA: 378] [Impact Index Per Article: 37.8] [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: 01/11/2023] Open
Abstract
The rate of renal disease progression varies widely among patients with autosomal dominant polycystic kidney disease (ADPKD), necessitating optimal patient selection for enrollment into clinical trials. Patients from the Mayo Clinic Translational PKD Center with ADPKD (n=590) with computed tomography/magnetic resonance images and three or more eGFR measurements over ≥6 months were classified radiologically as typical (n=538) or atypical (n=52). Total kidney volume (TKV) was measured using stereology (TKVs) and ellipsoid equation (TKVe). Typical patients were randomly partitioned into development and internal validation sets and subclassified according to height-adjusted TKV (HtTKV) ranges for age (1A-1E, in increasing order). Consortium for Radiologic Imaging Study of PKD (CRISP) participants (n=173) were used for external validation. TKVe correlated strongly with TKVs, without systematic underestimation or overestimation. A longitudinal mixed regression model to predict eGFR decline showed that log2HtTKV and age significantly interacted with time in typical patients, but not in atypical patients. When 1A-1E classifications were used instead of log2HtTKV, eGFR slopes were significantly different among subclasses and, except for 1A, different from those in healthy kidney donors. The equation derived from the development set predicted eGFR in both validation sets. The frequency of ESRD at 10 years increased from subclass 1A (2.4%) to 1E (66.9%) in the Mayo cohort and from 1C (2.2%) to 1E (22.3%) in the younger CRISP cohort. Class and subclass designations were stable. An easily applied classification of ADPKD based on HtTKV and age should optimize patient selection for enrollment into clinical trials and for treatment when one becomes available.
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Affiliation(s)
| | | | | | | | | | | | - Kyongtae T Bae
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Arlene B Chapman
- Division of Nephrology, Emory University School of Medicine, Atlanta, Georgia
| | - Jared J Grantham
- The Kidney Institute, Department of Internal Medicine, Kansas University Medical Center, Kansas City, Kansas; and
| | - Michal Mrug
- Division of Nephrology, University of Alabama and Department of Veterans Affairs Medical Center, Birmingham, Alabama
| | | | | | | | - Bradley J Erickson
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Bernard F King
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota
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Rahman M, Yang W, Akkina S, Alper A, Anderson AH, Appel LJ, He J, Raj DS, Schelling J, Strauss L, Teal V, Rader DJ. Relation of serum lipids and lipoproteins with progression of CKD: The CRIC study. Clin J Am Soc Nephrol 2014; 9:1190-8. [PMID: 24832097 DOI: 10.2215/cjn.09320913] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [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: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Hyperlipidemia is common in patients with CKD. The objective of this study was to evaluate whether measures of plasma lipids and lipoproteins predict progression of kidney disease in patients with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Prospective cohort study in adults (n=3939) with CKD aged 21-74 years recruited between 2003 and 2008 and followed for a median of 4.1 years. At baseline, total cholesterol, triglycerides, very-low-density lipoprotein cholesterol (VLDL-C), LDL cholesterol (LDL-C), HDL cholesterol (HDL-C), apoA-I , apoB, and lipoprotein(a) [Lp(a)] were measured. The outcomes were composite end point of ESRD or 50% decline in eGFR from baseline (rate of change of GFR). RESULTS Mean age of the study population was 58.2 years, and the mean GFR was 44.9 ml/min per 1.73 m(2); 48% of patients had diabetes. None of the lipid or lipoprotein measures was independently associated with risk of the composite end point or rate of change in GFR. However, there were significant (P=0.01) interactions by level of proteinuria. In participants with proteinuria<0.2 g/d, 1-SD higher LDL-C was associated with a 26% lower risk of the renal end point (hazard ratio [HR], 0.74; 95% confidence interval [95% CI], 0.59 to 0.92; P=0.01), and 1-SD higher total cholesterol was associated with a 23% lower risk of the renal end point (HR, 0.77; 95% CI, 0.62 to 0.96; P=0.02). In participants with proteinuria>0.2 g/d, neither LDL-C (HR, 0.98; 95% CI, 0.98 to 1.05) nor total cholesterol levels were associated with renal outcomes. Treatment with statins was reported in 55% of patients and was differential across lipid categories. CONCLUSIONS In this large cohort of patients with CKD, total cholesterol, triglycerides, VLDL-C, LDL-C, HDL-C, apoA-I, apoB, and Lp(a) were not independently associated with progression of kidney disease. There was an inverse relationship between LDL-C and total cholesterol levels and kidney disease outcomes in patients with low levels of proteinuria.
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Affiliation(s)
- Mahboob Rahman
- Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio;
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics and
| | - Sanjeev Akkina
- Division of Nephrology, University of Illinois, Chicago, Illinois
| | - Arnold Alper
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | | | - Lawrence J Appel
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Jiang He
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | - Dominic S Raj
- Division of Nephrology, George Washington University, Washington, DC
| | - Jeffrey Schelling
- Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio; and
| | - Louise Strauss
- University Hospitals Case Medical Center, Cleveland, Ohio
| | - Valerie Teal
- Center for Clinical Epidemiology and Biostatistics and
| | - Daniel J Rader
- Division of Translational Medicine and Human Genetics, University of Pennsylvania, Philadelphia, Pennsylvania
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Affiliation(s)
- Robert L Chevalier
- Division of Pediatric Nephrology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
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Prowle JR, Kolic I, Purdell-Lewis J, Taylor R, Pearse RM, Kirwan CJ. Serum creatinine changes associated with critical illness and detection of persistent renal dysfunction after AKI. Clin J Am Soc Nephrol 2014; 9:1015-23. [PMID: 24742481 DOI: 10.2215/cjn.11141113] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [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: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES AKI is a risk factor for development or worsening of CKD. However, diagnosis of renal dysfunction by serum creatinine could be confounded by loss of muscle mass and creatinine generation after critical illness. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective, single center analysis of serum in patients surviving to hospital discharge with an intensive care unit admission of 5 or more days between 2009 and 2011 was performed. RESULTS In total, 700 cases were identified, with a 66% incidence of AKI. In 241 patients without AKI, creatinine was significantly lower (P<0.001) at hospital discharge than admission (median, 0.61 versus 0.88 mg/dl; median decrease, 33%). In 160 patients with known baseline, discharge creatinine was significantly lower than baseline in all patients except those patients with severe AKI (Kidney Disease Improving Global Outcomes category 3), who had no significant difference. In a multivariable regression model, median duration of hospitalization was associated with a predicted 30% decrease (95% confidence interval, 8% to 45%) in creatinine from baseline in the absence of AKI; after allowing for this effect, AKI was associated with a 29% (95% confidence interval, 10% to 51%) increase in predicted hospital discharge creatinine. Using a similar model to exclude the confounding effect of prolonged major illness on creatinine, 148 of 700 patients (95% confidence interval, 143 to 161) would have eGFR<60 ml/min per 1.73 m(2) at hospital discharge compared with only 63 of 700 patients using eGFR based on unadjusted hospital creatinine (a 135% increase in potential CKD diagnoses; P<0.001). CONCLUSION Critical illness is associated with significant falls in serum creatinine that persist to hospital discharge, potentially causing inaccurate assessment of renal function at discharge, particularly in survivors of AKI. Prospective measurements of GFR and creatinine generation are required to confirm the significance of these findings.
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Affiliation(s)
- John R Prowle
- Adult Critical Care Unit and Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; and William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | | | | | | | - Rupert M Pearse
- Adult Critical Care Unit and William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Christopher J Kirwan
- Adult Critical Care Unit and Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; and William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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45
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Affiliation(s)
- Robert L Chevalier
- Department of Pediatrics, the University of Virginia, Charlottesville, Virginia
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46
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Piccoli GB, Ferraresi M, Deagostini MC, Vigotti FN, Consiglio V, Scognamiglio S, Moro I, Clari R, Fassio F, Biolcati M, Porpiglia F. Vegetarian low-protein diets supplemented with keto analogues: a niche for the few or an option for many? Nephrol Dial Transplant 2013; 28:2295-305. [PMID: 23751187 DOI: 10.1093/ndt/gft092] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [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: 11/12/2022] Open
Abstract
BACKGROUND Low-protein diets are often mentioned but seldom used to slow chronic kidney disease (CKD) progression. The aim of the study was to investigate the potential for implementation of a simplified low-protein diet supplemented with alpha-keto analogues (LPD-KA) as part of the routine work-up in CKD patients. METHODS In an implementation study (December 2007-November 2011), all patients with CKD Stages IV-V not on dialysis, rapidly progressive Stage III and/or refractory proteinuria, were offered either a simplified LPD-KA, or commercially available low-protein food. LPD-KA consisted of proteins 0.6 g/kg/day, supplementation with Ketosteril 1 pill/10 Kg, 1-3 free-choice meals/week and a simplified schema based on 'allowed' and 'forbidden' foods. 'Success' was defined as at least 6 months on LPD-KA. Progression was defined as reduction in glomerular filtration rate (GFR)[(Chronic Kidney Disease Epidemiology Collaboration) formula CKD-EPI] in patients with at least 6 months of follow-up. RESULTS Of about 2500 patients referred (8% CKD Stages IV-V), 139 started LPD-KA; median age (70 years) and prevalence of comorbidity (79%) were in line with the dialysis population. Start of dialysis was the main reason for discontinuation (40 cases, unplanned in 7); clinical reasons were recorded in 7, personal preference in 14 and improvement and death in 8 each. The low gross mortality (4% per year) and the progression rate (from -8 to 0 mL/min/year at 6 months) are reassuring concerning safety. None of the baseline conditions, including age, educational level, comorbidity or kidney function, discriminated the patients who followed the diet for at least 6 months. CONCLUSIONS Our data suggest a wider offer of LPD-KA to patients with severe and progressive CKD. The promising results in terms of mortality and progression need confirmation with different study designs.
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Affiliation(s)
- Giorgina B Piccoli
- SS Nephrology, Department of Clinical and Biological Sciences, ASOU San Luigi, University of Turin, Orbassano, Turin, Italy
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