Cardiovascular Disease in Chronic Kidney Disease: Pathophysiological Insights and Therapeutic Options

HDL Functions-Current Status and Future Perspectives

Cardiovascular disease (CVD) is the leading cause of death in Western countries. A low HDL-C is associated with the development of CVD. However, recent epidemiology studies have shown U-shaped curves between HDL-C and CVD mortality, with paradoxically increased CVD mortality in patients with extremely high HDL-C levels. Furthermore, HDL-C raising therapy using nicotinic acids or CETP inhibitors mostly failed to reduce CVD events. Based on this background, HDL functions rather than HDL-C could be a novel biomarker; research on the clinical utility of HDL functionality is ongoing. In this review, we summarize the current status of HDL functions and their future perspectives from the findings of basic research and clinical trials.

A Meta-Analysis and Cohort Study of Histopathologic and Clinical Outcomes in ANCA-Negative versus -Positive Vasculitis

BACKGROUND

ANCA-negative pauci-immune glomerulonephritis (PIGN) represents a rare and often under-studied subgroup of the vasculitides. This study aims to investigate differences in the clinical phenotype, renal histological features, and clinical outcomes of patients with PIGN, with and without serum ANCA positivity.

METHODS

A cohort of biopsy-proven PIGN with and without detectable circulating ANCA was constructed from a single center between 2006 and 2016. Primary outcomes compared clinical presentation and histopathological features according to ANCA status, with multivariate Cox regression to compare mortality and ESKD. A systematic review and meta-analysis of the published literature was undertaken.

RESULTS

In our cohort of 146 patients, 22% (n=32) had ANCA-negative disease, with a comparatively younger mean age at diagnosis; 51.4 versus 65.6 years (P<0.001). In total, 14 studies, inclusive of our cohort, were eligible for meta-analysis, totaling 301 patients who were ANCA negative. Those with ANCA-negative disease tended to have fewer extrarenal symptoms and a higher frequency of renal-limited disease, but both failed to reach statistical significance (P=0.92 and P=0.07). The risk of ESKD was significantly higher in seronegative disease (RR, 2.28; 95% confidence interval, 1.42 to 3.65; P<0.001), reflecting our experience, with a fivefold increased risk of ESKD in ANCA-negative disease (P<0.001). No significant difference in the chronicity of histopathological findings was seen and the meta-analysis showed no difference in morality (RR, 1.22; 95% confidence interval, 0.63 to 2.38; P=0.55).

CONCLUSION

Our findings demonstrate that ANCA-negative PIGN presents in younger patients, with fewer extrarenal manifestations and higher ESKD risk, despite a lack of difference in histopathology. This study provides the impetus for further research into the pathogenesis, treatment response, and duration of immunotherapy in ANCA-negative disease. We suggest that the absence of positive ANCA serology should not discourage treatment and for clinical trials to include patients who are ANCA negative.

Clonal hematopoiesis, somatic mosaicism, and age-associated disease

Somatic mosaicism, the occurrence of multiple genetically distinct cell clones within the same tissue, is an evitable consequence of human aging. The hematopoietic system is no exception to this, where studies have revealed the presence of expanded blood cell clones carrying mutations in preleukemic driver genes and/or genetic alterations in chromosomes. This phenomenon is referred to as clonal hematopoiesis and is remarkably prevalent in elderly individuals. While clonal hematopoiesis represents an early step toward a hematological malignancy, most individuals will never develop blood cancer. Somewhat unexpectedly, epidemiological studies have found that clonal hematopoiesis is associated with an increase in the risk of all-cause mortality and age-related disease, particularly in the cardiovascular system. Studies using murine models of clonal hematopoiesis have begun to shed light on this relationship, suggesting that driver mutations in mature blood cells can causally contribute to aging and disease by augmenting inflammatory processes. Here we provide an up-to-date review of clonal hematopoiesis within the context of somatic mosaicism and aging and describe recent epidemiological studies that have reported associations with age-related disease. We will also discuss the experimental studies that have provided important mechanistic insight into how driver mutations promote age-related disease and how this knowledge could be leveraged to treat individuals with clonal hematopoiesis.

Changes in the size and electrophoretic mobility of HDL subpopulation particles in chronic kidney disease

BACKGROUND

High-density lipoprotein (HDL) is a heterogeneous group of particles with anti-atherogenic properties whose metabolism is alterated in chronic kidney disease (CKD). The aim of this study was to evaluate the particle size and mobility of HDL subpopulations in non-dialysis CKD patients.

METHODS

The study involved 42 non-dialysis CKD patients (stages 3a-4) and 18 control subjects. HDL was separated by non-denaturing two-dimensional polyacrylamide gradient gel electrophoresis (2D-PAGGE) and eight HDL subpopulations; preβ1, preβ2a-c, and α1-4 were distinguished. The size and electrophoretic mobility of HDL subpopulation particles were compared between the groups, and a regression analysis was conducted.

RESULTS

In CKD patients, the mean sizes of α-HDL and preβ2-HDL particles were significantly lower compared to the control group (8.42 ± 0.32 nm vs. 8.64 ± 0.26 nm, p = 0.014; 11.45 ± 0.51 vs. 12.34 ± 0.78 nm, p = 0.003, respectively). The electrophoretic mobility of preβ2-HDL relative to α-HDL was significantly higher in CKD patients compared to the control group (Rf 0.65 ± 0.06 vs. 0.53 ± 0.10, p = 0.002). The size and mobility of HDL subpopulations correlated with eGFR values (p < 0.01). These relationships remained statistically significant after adjusting for age, gender, statin treatment, apolipoprotein AI, total cholesterol, and triglyceride levels.

DISCUSSION

CKD affects the size and mobility of HDL particles, which can be related to HDL dysfunction. The magnitude of HDL size and mobility changes depended on CKD stage and differed for individual HDL subpopulations, which indicates that some stages of HDL metabolism may be more affected by the presence of chronic kidney disease.

Comorbidity and nutritional status in adult with advanced chronic kidney disease influence the decision-making choice of renal replacement therapy modality: A retrospective 5-year study

Background

Nutritional and inflammation status are significant predictors of morbidity and mortality risk in advanced chronic kidney disease (ACKD). To date, there are a limited number of clinical studies on the influence of nutritional status in ACKD stages 4-5 on the choice of renal replacement therapy (RRT) modality.

Aim

This study aimed to examine relationships between comorbidity and nutritional and inflammatory status and the decision-making on the choice of RRT modalities in adults with ACKD.

Methods

A retrospective cross-sectional study was conducted on 211 patients with ACKD with stages 4-5 from 2016 to 2021. Comorbidity was assessed using the Charlson comorbidity index (CCI) according to severity (CCI: ≤ 3 and >3 points). Clinical and nutritional assessment was carried out by prognosis nutritional index (PNI), laboratory parameters [serum s-albumin, s-prealbumin, and C-reactive protein (s-CRP)], and anthropometric measurements. The initial decision-making of the different RRT modalities [(in-center, home-based hemodialysis (HD), and peritoneal dialysis (PD)] as well as the informed therapeutic options (conservative treatment of CKD or pre-dialysis living donor transplantation) were recorded. The sample was classified according to gender, time on follow-up in the ACKD unit (≤ 6 and >6 months), and the initial decision-making of RRT (in-center and home-RRT). Univariate and multivariate regression analyses were carried out for evaluating the independent predictors of home-based RRT.

Results

Of the 211 patients with ACKD, 47.4% (n = 100) were in stage 5 CKD, mainly elderly men (65.4%). DM was the main etiology of CKD (22.7%) together with hypertension (96.6%) as a CV risk factor. Higher CCI scores were significantly found in men, and severe comorbidity with a CCI score > 3 points was 99.1%. The mean time of follow-up time in the ACKD unit was 9.6 ± 12.8 months. A significantly higher CCI was found in those patients with a follow-up time > 6 months, as well as higher mean values of eGFR, s-albumin, s-prealbumin, s-transferrin, and hemoglobin, and lower s-CRP than those with a follow-up <6 months (all, at least p < 0.05). The mean PNI score was 38.9 ± 5.5 points, and a PNI score ≤ 39 points was found in 36.5%. S-albumin level > 3.8 g/dl was found in 71.1% (n = 150), and values of s-CRP ≤ 1 mg/dl were 82.9% (n = 175). PEW prevalence was 15.2%. The initial choice of RRT modality was higher in in-center HD (n = 119 patients; 56.4%) than in home-based RRT (n = 81; 40.5%). Patients who chose home-based RRT had significantly lower CCI scores and higher mean values of s-albumin, s-prealbumin, s-transferrin, hemoglobin, and eGFR and lower s-CRP than those who chose in-center RRT (p < 0.001). Logistic regression demonstrated that s-albumin (OR: 0.147) and a follow-up time in the ACKD unit >6 months (OR: 0.440) were significantly associated with the likelihood of decision-making to choose a home-based RRT modality (all, at least p < 0.05).

Conclusion

Regular monitoring and follow-up of sociodemographic factors, comorbidity, and nutritional and inflammatory status in a multidisciplinary ACKD unit significantly influenced decision-making on the choice of RRT modality and outcome in patients with non-dialysis ACKD.

Still finding ways to augment the existing management of acute and chronic kidney diseases with targeted gene and cell therapies: Opportunities and hurdles

The rising global incidence of acute and chronic kidney diseases has increased the demand for renal replacement therapy. This issue, compounded with the limited availability of viable kidneys for transplantation, has propelled the search for alternative strategies to address the growing health and economic burdens associated with these conditions. In the search for such alternatives, significant efforts have been devised to augment the current and primarily supportive management of renal injury with novel regenerative strategies. For example, gene- and cell-based approaches that utilize recombinant peptides/proteins, gene, cell, organoid, and RNAi technologies have shown promising outcomes primarily in experimental models. Supporting research has also been conducted to improve our understanding of the critical aspects that facilitate the development of efficient gene- and cell-based techniques that the complex structure of the kidney has traditionally limited. This manuscript is intended to communicate efforts that have driven the development of such therapies by identifying the vectors and delivery routes needed to drive exogenous transgene incorporation that may support the treatment of acute and chronic kidney diseases.

Health-related patterns and chronic kidney disease in the Brazilian population: National Health Survey, 2019

Objective

The aim of this study was to identify patterns related to health and their association with chronic kidney disease (CKD) in the Brazilian population.

Methods

We used data from the National Health Survey (PNS), 2019. Participants were interviewed and answered questions related to socioeconomic and demographic information (gender, age, education, race/color), health conditions (presence of hypertension, diabetes mellitus, hyperlipidemia, cardiovascular disease, overweight and CKD) and lifestyle (smoking, alcohol consumption, physical activity and food consumption). To identify patterns, we used exploratory factor analysis. We performed logistic regression models to describe the association of CKD with each pattern in crude models and adjusted for gender, age group, education level and race/color.

Results

A total of 90,846 individuals were evaluated. The prevalence of CKD was 1.49% (95% CI: 1.3-1.6). Three health-related patterns - metabolic factors, behavioral risk factors and behavioral protective factors - were identified by factor analysis. Metabolic factors were determined by the presence of hypertension, diabetes mellitus, hyperlipidemia and cardiovascular diseases. Behavioral risk factors were determined by smoking, alcohol consumption, regular consumption of soft drinks, sweets and artificial juices, and high salt consumption. The protective behavioral factors were established by the practice of physical activity and regular consumption of vegetables and fruits. Participants of the highest tertile for metabolic factors were more likely to have CKD in the adjusted model (OR = 3.61, 95% CI: 2.69-4.85), when compared to those of the lower tertile.

Conclusion

The pattern referring to metabolic factors was associated with a higher chance of presenting CKD.

The Growing Challenge of Chronic Kidney Disease: An Overview of Current Knowledge

Chronic kidney disease (CKD) is becoming one of the world's most prevalent noncommunicable chronic diseases. The World Health Organization projects CKD to become the 5th most common chronic disease in 2040. Causes of CKD are multifactorial and diverse, but early-stage symptoms are often few and silent. Progression rates are highly variable, but patients encounter both an increased risk for end-stage kidney disease (ESKD) as well as increased cardiovascular risk. End-stage kidney disease incidence is generally low, but every single case carries a significant burden of illness and healthcare costs, making prevention by early intervention both desirable and worthwhile. This review focuses on the prevalence, diagnosis, and causes of CKD. In addition, we discuss the developments in the general treatment of CKD, with particular attention to what can be initiated in general practice. With the addition of recent landmark findings and the expansion of the indication for using sodium-glucose cotransporter 2 inhibitors, there are now new effective treatments to add to standard therapy. This will also be relevant for primary care physicians as many patients with CKD have their family physician as their primary health care professional handling kidney function preservation. In the future, more precise and less invasive diagnostic methods may not only improve the determination of the underlying cause of CKD but may also carry information regarding which treatment to use (i.e. personalized medicine). This could lead to a reduced number of preventive treatments per individual, while at the same time improving the prognosis. This review summarizes ongoing efforts in this area.

Early metabolomic, lipid and lipoprotein changes in response to medical and surgical therapeutic approaches to obesity

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1RA) and bariatric surgery have proven to be effective treatments for obesity and cardiometabolic conditions. We aimed to explore the early metabolomic changes in response to GLP-1RA (liraglutide) therapy vs. placebo and in comparison to bariatric surgery.

METHODS

Three clinical studies were conducted: a bariatric surgery cohort study of participants with morbid obesity who underwent either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) studied over four and twelve weeks, and two randomized placebo-controlled, crossover double blind studies of liraglutide vs. placebo administration in participants with type 2 diabetes (T2D) and participants with obesity studied for three and five weeks, respectively. Nuclear magnetic resonance spectroscopy-derived metabolomic data were assessed in all eligible participants who completed all the scheduled in-clinic visits. The primary outcome of the study was to explore the changes of the metabolome among participants with obesity with and without T2D receiving the GLP-1RA liraglutide vs. placebo and participants with obesity undergoing bariatric surgery during the three to five-week study period. In addition, we assessed the bariatric surgery effects longitudinally over the twelve weeks of the study and the differences between the bariatric surgery subgroups on the metabolome. The trials are registered with ClinicalTrials.gov, numbers NCT03851874, NCT01562678 and NCT02944500.

RESULTS

Bariatric surgery had a more pronounced effect on weight and body mass index reduction (-14.19 ± 5.27 kg and - 5.19 ± 5.27, respectively, p < 0.001 for both) and resulted in more pronounced metabolomic and lipidomic changes compared to liraglutide therapy at four weeks postoperatively. Significant changes were observed in lipoprotein parameters, inflammatory markers, ketone bodies, citrate, and branched-chain amino acids after the first three to five weeks of intervention. After adjusting for the amount of weight loss, a significant difference among the study groups remained only for acetoacetate, β-hydroxybutyrate, and citrate (p < 0.05 after FDR correction). Glucose levels were significantly reduced in all intervention groups but mainly in the T2D group receiving GLP-1RA treatment. After adjusting for weight loss, only glucose levels remained significant (p = 0.001 after FDR correction), mainly due to the glucose change in the T2D group receiving GLP-1RA. Similar results with those observed at four weeks were observed in the surgical group when delta changes at twelve weeks were assessed. Comparing the two types of bariatric surgery, an intervention effect was more pronounced in the RYGB subgroup regarding total triglycerides, triglyceride-rich lipoprotein size, and trimethylamine-N-oxide (p for intervention: 0.031, 0.028, 0.036, respectively). However, after applying FDR correction, these changes deemed to be only suggestive; only time effects remained significant with no significant changes persisting in relation to the types of bariatric surgery.

CONCLUSIONS

The results of this study suggest that the early metabolomic, lipid and lipoprotein changes observed between liraglutide treatment and bariatric surgery are similar and result largely from the changes in patients' body weight. Specific changes observed in the short-term post-surgical period between bariatric vs. nonsurgical treated participants, i.e., acetoacetate, β-hydroxybutyrate, and citrate changes, may reflect changes in patient diets and calorie intake indicating potential calorie and diet-driven metabolomics/lipidomic effects in the short-term postoperatively. Significant differences observed between SG and RYGB need to be confirmed and extended by future studies.

Geriatric nutritional risk index predicts all-cause mortality in the oldest-old patients with acute coronary syndrome: A 10-year cohort study

Background and objective

Nutritional status assessment in acute coronary syndrome (ACS) patients has been neglected for a long time. The geriatric nutritional risk index (GNRI) is a sensitive indicator for assessing the nutritional status of the elderly. This study aims to explore the association between GNRI and all-cause mortality in the oldest-old patients with ACS.

Methods

The patients who met the inclusion criteria were consecutively enrolled from January 2006 to December 2012. Clinical data were collected on admission, and all subjects were followed after being discharged. The nutritional status was evaluated using GNRI. The relationship between GNRI and all-cause mortality was assessed by using different analyses.

Results

A total of 662 patients with a mean age of 81.87 ± 2.14 years old were included in our study, and followed (median: 63 months, IQR 51-71). Patients whose GNRI ≤ 98 were reported as at risk of malnutrition (31.11%, n = 206). In multivariable analysis, we found that for each SD increase in GNRI, the risk of all-cause mortality lowered by 23%, and the HR for GNRI ≤ 98 was 1.39 (95% CI 1.04-1.86). After stratifying patients into three groups by tertiles of GNRI, we found that the HRs for tertile 2 and tertile 3 were 1.49 (95% CI 1.02-2.19) and 1.74 (95% CI 1.22-2.50), respectively. The trend test revealed a dose-response relationship between GNRI and all-cause mortality in the oldest-old with ACS. Lastly, in subgroup analyses, we found a reliable association between GNRI and all-cause mortality.

Conclusion

Malnutrition is common in the oldest-old patients with ACS, and GNRI could predict their long-term all-cause mortality in a dose-dependent manner. GNRI may be a prospective index for risk-stratification and secondary-prevention in the oldest-old patients with ACS.

Development of a health economic model to evaluate the cost-effectiveness of roxadustat in treating anemia associated with non-dialysis-dependent chronic kidney disease

BACKGROUND

Treatment for anemia of chronic kidney disease (CKD) largely consists of erythropoiesis-stimulating agents (ESAs) with iron supplementation. Although ESAs are well-established and efficacious, their use has been associated with considerable economic and humanistic burdens. Roxadustat, an oral medication, is a hypoxia-inducible factor prolyl hydroxylase inhibitor that targets multiple causes of CKD and has a similar efficacy and safety profile to ESAs. The cost-effectiveness of this treatment, however, has yet to be investigated.

OBJECTIVE

The study objective was to develop a health economic model to evaluate the cost-effectiveness of roxadustat compared with ESAs for treating anemia of non-dialysis-dependent (NDD) CKD.

METHODS

A cohort-based model was developed for a hypothetical cohort of 1,000 patients with anemia of NDD CKD, incorporating eight health states, representing the hemoglobin level of each patient. The model was informed by individual patient-level data from the roxadustat global phase 3 clinical trial program. Total and incremental costs as well as quality-adjusted life-years (QALYs) associated with roxadustat versus ESAs were estimated from the perspective of the UK National Health Service. Sensitivity analyses were performed to assess the robustness of the model. Analyses exploring alternative scenarios were also conducted.

RESULTS

On a per-person basis, over 1,000 simulations, roxadustat was found to be on average less costly (-£32) and more effective (+0.01 QALYs) than ESAs, with a dominant incremental cost-effectiveness ratio. The probability of cost-effectiveness at a £20,000 per QALY willingness-to-pay threshold from the UK perspective was 67%.

CONCLUSION

The model developed may be a useful instrument that, alongside expert clinical opinion, can inform clinical and policy decision-making regarding treatment of anemia of NDD CKD. The model highlights the cost-effectiveness of roxadustat, as well as its potential to have a meaningful impact in reducing the burden of anemia of NDD CKD.

Altered serum metabolome associated with vascular calcification developed from CKD and the critical pathways

Introduction

Vascular calcification (VC) is more likely to be detected in the chronic kidney disease (CKD) population. The mechanism of VC development from CKD is different from that for simple VC and has always been a major research area. The aim of this study was to detect alterations in the metabolome during development of VC in CKD and to identify the critical metabolic pathways and metabolites involved in its pathogenesis.

Methods

Rats in the model group were given an adenine gavage combined with a high-phosphorus diet to imitate VC in CKD. The aorta calcium content was measured and used to divide the model group into a VC group and non-vascular calcification group (non-VC group). The control group was fed a normal rat diet and given a saline gavage. Ultra-high-performance liquid chromatography-mass spectrometry (UHPLC-MS) was used to determine the altered serum metabolome in the control, VC, and non-VC groups. The identified metabolites were mapped into the Kyoto Encyclopedia of Genes and Genomes (KEGG) database (https://www.genome.jp/kegg/) for pathway and network analyses.

Result

There were 14 metabolites that changed significantly in the VC group, with three metabolic pathways playing critical roles in the pathogenesis of VC in CKD: steroid hormone biosynthesis; valine, leucine and isoleucine biosynthesis; and pantothenate and CoA biosynthesis.

Conclusion

Our results indicated changes in the expression of steroid sulfatase and estrogen sulfotransferase, and down-regulation of the in situ synthesis of estrogens in the VC group. In conclusion, the serum metabolome alters significantly during the pathogenesis of VC in CKD. The key pathways, metabolites, and enzymes we identified are worth further study and may become a promising therapeutic target for the treatment of VC in CKD.

Human Cytomegalovirus Infection and Cardiovascular Disease: Current Perspectives

Infections with human cytomegalovirus (HCMV) are often asymptomatic in healthy adults but can be severe in people with a compromised immune system. While several studies have demonstrated associations between cardiovascular disease in older adults and HCMV seropositivity, the underlying mechanisms are unclear. We review evidence published within the last 5 years establishing how HCMV can contribute directly and indirectly to the development and progression of atherosclerotic plaques. We also discuss associations between HCMV infection and cardiovascular outcomes in populations with a high or very high burden of HCMV, including patients with renal or autoimmune disease, transplant recipients, and people living with HIV.

Cardiac epigenetic changes in VEGF signaling genes associate with myocardial microvascular rarefaction in experimental chronic kidney disease

Chronic kidney disease (CKD) is common in patients with heart failure and often results in left ventricular diastolic dysfunction (LVDD). However, the mechanisms responsible for cardiac damage in CKD-LVDD remain to be elucidated. Epigenetic alterations may impose long-lasting effects on cellular transcription and function, but their exact role in CKD-LVDD is unknown. We investigate whether changes in cardiac site-specific DNA methylation profiles might be implicated in cardiac abnormalities in CKD-LVDD. CKD-LVDD and normal control pigs (n = 6 each) were studied for 14 wk. Renal and cardiac hemodynamics were quantified by multidetector CT and echocardiography. In randomly selected pigs (n = 3/group), cardiac site-specific 5-methylcytosine (5mC) immunoprecipitation (MeDIP)- and mRNA-sequencing (seq) were performed, followed by integrated (MeDiP-seq/mRNA-seq analysis), and confirmatory ex vivo studies. MeDIP-seq analysis revealed 261 genes with higher (fold change > 1.4; P < 0.05) and 162 genes with lower (fold change < 0.7; P < 0.05) 5mC levels in CKD-LVDD versus normal pigs, which were primarily implicated in vascular endothelial growth factor (VEGF)-related signaling and angiogenesis. Integrated MeDiP-seq/mRNA-seq analysis identified a select group of VEGF-related genes in which 5mC levels were higher, but mRNA expression was lower in CKD-LVDD versus normal pigs. Cardiac VEGF signaling gene and VEGF protein expression were blunted in CKD-LVDD compared with controls and were associated with decreased subendocardial microvascular density. Cardiac epigenetic changes in VEGF-related genes are associated with impaired angiogenesis and cardiac microvascular rarefaction in swine CKD-LVDD. These observations may assist in developing novel therapies to ameliorate cardiac damage in CKD-LVDD.NEW & NOTEWORTHY Chronic kidney disease (CKD) often leads to left ventricular diastolic dysfunction (LVDD) and heart failure. Using a novel translational swine model of CKD-LVDD, we characterize the cardiac epigenetic landscape, identifying site-specific 5-methylcytosine changes in vascular endothelial growth factor (VEGF)-related genes associated with impaired angiogenesis and cardiac microvascular rarefaction. These observations shed light on the mechanisms of cardiac microvascular damage in CKD-LVDD and may assist in developing novel therapies for these patients.

Polypharmacy, chronic kidney disease, and mortality among older adults: A prospective study of National Health and nutrition examination survey, 1999-2018

Introduction

Polypharmacy might contribute to a range of adverse outcomes, which could get worse in the elderly with chronic kidney disease (CKD). Evidence on polypharmacy, CKD, and mortality is scarce. We aimed to investigate the prospective association between polypharmacy, CKD and all-cause and cause-specific mortality in adults aged ≥65 years.

Methods

A total of 13,513 adults from the National Health and Nutrition Examination Surveys were included, following up from 1999 to 2018 until December 31, 2019. The simultaneous use of ≥5 medications by one individual was defined as polypharmacy. Survey-weighted Cox proportional hazard models were used to estimate the hazard ratio (HRs) for mortality from all-cause, cardiovascular diseases (CVD), and cancer after adjusting for potential confounding factors.

Results

Among the elderly with CKD, we identified 3,825 total deaths (1,325 CVD and 714 cancer) during a median follow-up of 7.7 years. Participants with polypharmacy had a 27% (HR = 1.27 [1.15, 1.39]) and 39% (HR = 1.39 [1.19, 1.62]) higher risk of all-cause and CVD mortality, respectively, but not for cancer mortality. Compared with the elderly with no polypharmacy and no CKD, the corresponding HRs (95%CIs) for all-cause mortality were 1.04 (0.96, 1.14) for those with no polypharmacy but CKD, 1.24 (1.11, 1.39) for with polypharmacy but no CKD, and 1.34 (1.21, 1.49) for those with both polypharmacy and CKD. A similar pattern was detected for CVD mortality.

Discussion

Polypharmacy was associated with elevated risks of all-cause and CVD mortality among the elderly CKD patients. More evidence-based approaches should be promoted for the appropriate deprescribing in the older adults with CKD.

Chronic Kidney Disease Induces Proarrhythmic Remodeling

BACKGROUND

Patients with chronic kidney disease (CKD) are at increased risk of developing cardiac arrhythmogenesis and sudden cardiac death; however, the basis for this association is incompletely known.

METHODS

Here, using murine models of CKD, we examined interactions between kidney disease progression and structural, electrophysiological, and molecular cardiac remodeling.

RESULTS

C57BL/6 mice with adenine supplemented in their diet developed progressive CKD. Electrocardiographically, CKD mice developed significant QT prolongation and episodes of bradycardia. Optical mapping of isolated-perfused hearts using voltage-sensitive dyes revealed significant prolongation of action potential duration with no change in epicardial conduction velocity. Patch-clamp studies of isolated ventricular cardiomyocytes revealed changes in sodium and potassium currents consistent with action potential duration prolongation. Global transcriptional profiling identified dysregulated expression of cellular stress response proteins RBM3 (RNA-binding motif protein 3) and CIRP (cold-inducible RNA-binding protein) that may underlay the ion channel remodeling. Unexpectedly, we found that female sex is a protective factor in the progression of CKD and its cardiac sequelae.

CONCLUSIONS

Our data provide novel insights into the association between CKD and pathologic proarrhythmic cardiac remodeling. Cardiac cellular stress response pathways represent potential targets for pharmacologic intervention for CKD-induced heart rhythm disorders.

Deletion of the P2Y2 receptor aggravates internal elastic lamina calcification in chronic kidney disease mice through upregulation of alkaline phosphatase and lipocalin-2

Calcification of the medial layer, inducing arterial stiffness, contributes significantly to cardiovascular mortality in patients with chronic kidney disease (CKD). Extracellular nucleotides block the mineralization of arteries by binding to purinergic receptors including the P2Y₂ receptor. This study investigates whether deletion of the P2Y₂ receptor influences the development of arterial media calcification in CKD mice. Animals were divided into: (i) wild type mice with normal renal function (control diet) (n = 8), (ii) P2Y₂ R^-/- mice with normal renal function (n = 8), (iii) wild type mice with CKD (n = 27), and (iv) P2Y₂ R^-/- mice with CKD (n = 22). To induce CKD, animals received an alternating (0.2-0.3%) adenine diet for 7 weeks. All CKD groups developed a similar degree of chronic renal failure as reflected by high serum creatinine and phosphorus levels. Also, the presence of CKD induced calcification in the heart and medial layer of the aortic wall. However, deletion of the P2Y₂ receptor makes CKD mice more susceptible to the development of calcification in the heart and aorta (aortic calcium scores (median ± IQR), CKD-wild type: 0.34 ± 4.3 mg calcium/g wet tissue and CKD-P2Y₂ R^-/- : 4.0 ± 13.2 mg calcium/g wet tissue). As indicated by serum and aortic mRNA markers, this P2Y₂ R^-/- mediated increase in CKD-related arterial media calcification was associated with an elevation of calcification stimulators, including alkaline phosphatase and inflammatory molecules interleukin-6 and lipocalin 2. The P2Y₂ receptor should be considered as an interesting therapeutic target for tackling CKD-related arterial media calcification.

The effect of pharmacist-led interventions on the management and outcomes in chronic kidney disease (CKD): A systematic review and meta-analysis protocol

Background and Aims

Chronic kidney disease (CKD) is a progressive condition that results in a decline in kidney function over time. There are several conditions that increase the likelihood of developing CKD, particularly diabetes and hypertension. CKD increases the risk of mortality and has a detrimental impact on quality of life (QoL). Strategies for managing CKD include controlling cardiovascular risk factors and treating complications of CKD. There is an ever-increasing role of pharmacists in managing CKD, from the optimization of risk factors to patient education. However, currently, there is a lack of data on the effect pharmacist-led interventions have on the clinical, economic, and humanistic outcomes.

Methods

This protocol, in adherence to PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) standards, describes a prospective systematic review and meta-analysis of randomized controlled trials, where any intervention led by a pharmacist in CKD is used. Comparison groups will consist of usual care or non-pharmacist-led interventions. Literature searches will be conducted in the following databases: MEDLINE, Scopus, and Web of Science. Data pertaining to clinical (e.g., mortality), economic (e.g., healthcare-associated costs), and humanistic (e.g., QoL) outcomes will be extracted. Risk of bias will be assessed using the United States National Heart Lung and Blood Institute quality assessment tool for controlled intervention studies. A meta-analysis will be conducted to synthesize appropriate comparable outcomes.

Results

The findings of this review will be published in a peer-reviewed journal, where the results will be presented in lay language with appropriate infographics online and via social media.

Conclusion

The findings of this review can identify gaps in the literature concerning optimizing pharmacist-led interventions in improving outcomes. In addition, this review will establish the importance of pharmacists in managing CKD patients, and whether this may result in their increased incorporation in multidisciplinary teams.

Recognizing risk factors associated with poor outcomes among patients with COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has affected >610 million people globally, exerting major social, economic, and health impacts. Despite the large number of global casualities and severe symptomatology associated with COVID-19, a large number of individuals remain at elevated risk of infection and severe outcomes related to poor lifestyle behaviors and/or associated comorbidities. Beyond the well-known social distance and masking policies, maintaining an active lifestyle, minimizing the consumption of tobacco products, and maintaining an adequate nutrition status are some of the key factors that, in an affordable and accessible way, have the potential to improve health and minimize COVID-19 impact. In addition, bringing awareness of the higher risks and poor prognosis of COVID-19 when other conditions are present seems to be essential to protect those individuals with the highest risks.

Renal function during hospitalization and outcome in Chinese patients with acute decompensated heart failure: A retrospective study and literature review

BACKGROUND

The heart and kidneys had demonstrated a bidirectional interaction that dysfunction of the heart or kidneys can induce dysfunction in the other organ.

HYPOTHESIS

Renal function and its decline during hospitalization may have impact on cardiovascular outcomes in patients with acute decompensated heart failure (ADHF).

METHODS

A total of 119 consecutive Chinese patients admitted for ADHF were prospectively enrolled. The course of renal function was presented with estimated glomerular filtration rate (eGFR), calculated by the four-variable equation proposed by the Modification of Diet in Renal Disease (MDRD) Study. Worsening renal function (WRF) was defined as eGFR decline between admission (eGFR_admission ) and predischarge (eGFR_predischarge ). Clinical outcomes were defined as 4P-major adverse cardiovascular events (4P-MACE), including the composition of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and nonfatal HF hospitalization.

RESULTS

During an average 2.6 ± 3.2 years follow-up, 66 patients (55%) experienced 4P-MACE. Patients with impaired eGFR_predischarge (<60 ml/min/1.73 m² ) had more 4P-MACE than those with preserved eGFR_predischarge (64.7% vs. 43.1%, p = .019). The Kaplan-Meier survival curves showed significantly higher incidence of 4P-MACE in patients with impaired eGFR_predischarge than those with preserved eGFR_predischarge (p = .002). Cox regression analysis revealed that impaired eGFR_predischarge was significantly correlated with the development of 4P-MACE (hazard ratio, 2.003; 95% confidence interval, 1.072-3.744; p = .029). In contrast, outcomes would be similar with regard to eGFR on admission and eGFR decline during hospitalization.

CONCLUSIONS

Impaired renal function before discharge, but not impaired renal function on admission or WRF, is a significant risk factor for poor outcomes in patients with ADHF.

Translating the efficacy of dapagliflozin in chronic kidney disease to lower healthcare resource utilization and costs: a medical care cost offset analysis

AIMS

Dapagliflozin was approved for use in patients with chronic kidney disease (CKD) based on results of the DAPA-CKD trial, demonstrating attenuation of CKD progression and reduced risk of cardio-renal outcomes and all-cause mortality (ACM) versus placebo, in addition to standard therapy. The study objective was to assess the potential medical care cost offsets associated with reduced rates of cardio-renal outcomes across 31 countries and regions.

MATERIALS AND METHODS

A comparative cost-determination framework estimated outcome-related costs of dapagliflozin plus standard therapy versus standard therapy alone over a 3-year horizon based on the DAPA-CKD trial. Incidence rates of end-stage kidney disease (ESKD), hospitalizations for heart failure (HHF), acute kidney injury (AKI), and ACM were estimated for a treated population of 100,000 patients. Associated medical care costs for non-fatal events were calculated using sources from a review of publicly available data specific to each considered setting.

RESULTS

Patients treated with dapagliflozin plus standard therapy experienced fewer incidents of ESKD (7,221 vs 10,767; number needed to treat, NNT: 28), HHF (2,370 vs 4,684; NNT: 43), AKI (4,110 vs. 5,819; NNT: 58), and ACM (6,383 vs 8,874; NNT: 40) per 100,000 treated patients versus those treated with standard therapy alone. Across 31 countries/regions, reductions in clinical events were associated with a 33% reduction in total costs, or a cumulative mean medical care cost offset of $264 million per 100,000 patients over 3 years.

LIMITATIONS AND CONCLUSIONS

This analysis is limited by the quality of country/region-specific data available for medical care event costs. Based on the DAPA-CKD trial, we show that treatment with dapagliflozin may prevent cardio-renal event incidence at the population level, which could have positive effects upon healthcare service delivery worldwide. The analysis was restricted to outcome-associated costs and did not consider the cost of drug treatments and disease management.

A comparative analysis of conventional and speckle-tracking strain echocardiographic findings in diabetic and non-diabetic kidney disease patients with normal ejection fraction

This study aimed to compare the differences in echocardiographic and strain parameters in patients with diabetic kidney disease (DKD) and non-diabetic kidney disease (NDKD) in a cohort with pre-dialysis chronic kidney disease (CKD) and normal ejection fraction (EF). In this single-center prospective study, patients with CKD stages 3-5 and EF > 55% were included. We compared cardiac structure and function using conventional and speckle-tracking strain echocardiography among DKD and NDKD groups. Cardiovascular outcomes were assessed at the end of the study. Of the included 117 patients, 56 (47.9%) had DKD, and 61 (52.1%) had NDKD. Patients with DKD had higher ratios of early mitral inflow velocity and mitral annular early diastolic velocity (E/e') (11.9 ± 4.4 vs. 9.8 ± 3.5; p = 0.004), lower septal e' velocity (7.1 ± 2.5 vs. 8.2 ± 2.8; p = 0.031), lower lateral e' velocity (9.2 ± 2.9 vs. 10.4 ± 3.8; p = 0.045) and longer deceleration times (209.2 ± 41.5 vs. 189.1 ± 48.0; p = 0.017), compared to those with NDKD. Left ventricular mass index (LVMI), global longitudinal strain (GLS), early diastolic strain rate (SR_E), and E/SR_E were similar. At a median follow-up of 239 days, 3-P MACE (11.5% vs. 4.9%; p = 0.047) and 4-P MACE (28.6% vs. 11.5%; p = 0.020) were observed to be higher in the DKD group. Diastolic dysfunction was more common in patients with DKD, compared to those with NDKD, although both groups had similar LVMI and GLS. Those with DKD also had poorer cardiovascular outcomes. This highlights the importance of the assessment of diastolic function in CKD, particularly in those with diabetic CKD.

Emerging vascular cell-specific roles for mineralocorticoid receptor: implications for understanding sex differences in cardiovascular disease

As growing evidence implicates extrarenal mineralocorticoid receptor (MR) in cardiovascular disease (CVD), recent studies have defined both cell- and sex-specific roles. MR is expressed in vascular smooth muscle (SMC) and endothelial cells (ECs). This review integrates published data from the past 5 years to identify novel roles for vascular MR in CVD, with a focus on understanding sex differences. Four areas are reviewed in which there is recently expanded understanding of the cell type- or sex-specific role of MR in 1) obesity-induced microvascular endothelial dysfunction, 2) vascular inflammation in atherosclerosis, 3) pulmonary hypertension, and 4) chronic kidney disease (CKD)-related CVD. The review focuses on preclinical data on each topic describing new mechanistic paradigms, cell type-specific mechanisms, sexual dimorphism if addressed, and clinical implications are then considered. New data support that MR drives vascular dysfunction induced by cardiovascular risk factors via sexually dimorphic mechanisms. In females, EC-MR contributes to obesity-induced endothelial dysfunction by regulating epithelial sodium channel expression and by inhibiting estrogen-induced nitric oxide production. In males with hyperlipidemia, EC-MR promotes large vessel inflammation by genomic regulation of leukocyte adhesion molecules, which is inhibited by the estrogen receptor. In pulmonary hypertension models, MRs in EC and SMC contribute to distinct components of disease pathologies including pulmonary vessel remodeling and RV dysfunction. Despite a female predominance in pulmonary hypertension, sex-specific roles for MR have not been explored. Vascular MR has also been directly implicated in CKD-related vascular dysfunction, independent of blood pressure. Despite these advances, sex differences in MR function remain understudied.

SGLT2 inhibitors reduce adverse kidney and cardiovascular events in patients with advanced diabetic kidney disease: A population-based propensity score-matched cohort study

BACKGROUND

There were limited data on the efficacy and safety profile on use of sodium-glucose co-transporter 2 receptor (SGLT2) inhibitors in diabetic patients with advanced chronic kidney disease (CKD). We aimed to evaluate the efficacy, in terms of improvement in glycemic profile, kidney function, prevention of adverse kidney and cardiovascular events, and the safety profile of SGLT2 inhibitors in a group of diabetic patients at CKD stage 3B-5 from a real-world population-based cohort.

METHODS

We performed a retrospective observational cohort study of type 2 diabetic patients at CKD stage 3B-5 who received SGLT2 inhibitors as compared to control from 1 January 2015 through 31 December 2021. Propensity score assignment by logistic regression and matching with control by the nearest score at 1:3 ratio was done. All patients were followed for 1 year. Outcomes were kidney-related adverse events and major adverse cardiovascular events (MACE), change in estimated glomerular filtration rate (eGFR), glycemic control, and side effects profiling.

RESULTS

We analyzed 1,450 SGLT2 inhibitor users. They had significantly lower rates of kidney-related adverse events (7.7 % versus 24.1 %, p < 0.001) and MACE (9.6 % versus 15.1 %, p < 0.001) as compared to control group. Their eGFR also significantly improved (0.4 ± 9.3 versus -5.5 ± 10.6 ml/min/1.73 m², p < 0.001). These patients also had a greater reduction in HbA1c (-0.40 ± 1.13 versus -0.04 ± 1.47 %, p < 0.001), and insulin requirement (-8.8 ± 35.2 versus 4.1 ± 19.4 units/day, p < 0.001). After adjusting for confounders, SGLT2 inhibitors protected against kidney-related adverse events (odds ratio [OR] 0.48, 95 % confidence interval [CI] 0.33 - 0.71, p < 0.001) and MACE (OR 0.47, 95 % CI 0.37 - 0.60, p < 0.001). Apart from a marginally higher rate of fungal urinary tract infection (0.08 ± 0.66 versus 0.03 ± 0.23 episodes per year, p < 0.001), SGLT2 inhibitor use was not associated with other side effects.

CONCLUSIONS

SGLT2 inhibitor improved kidney function, glycemic profile, and reduced adverse kidney-related and cardiovascular events in diabetic patients with advanced CKD.

Cardiovascular disease and kidney transplantation

Compared to general population, patients with chronic kidney disease (CKD) exhibit high prevalence of cardiovascular disease (CVD) that increases with a stage of CKD. Traditional and non-traditional risk factors associated with CKD contribute to accelerated atherosclerosis leading to CVD. CVD represents the main cause of morbidity and mortality in CKD population. Pretransplant examination is essential to evaluate and optimize the state of cardiovascular system prior transplantation, thus   to minimize risks that could have a negative impact on transplant outcome.

The effects of mineralocorticoid receptor antagonists on cardiovascular outcomes in patients with end-stage renal disease and heart failure

AIMS

Mineralocorticoid receptor antagonists (MRAs) have been shown to provide survival benefits in patients with heart failure; however, MRA use in patients with chronic kidney disease has been limited by safety concerns. The effects of MRAs on outcomes in patients with end-stage renal disease (ESRD) and heart failure remain unknown. The aim of this study was to evaluate the effects of MRAs on cardiovascular outcomes in patients with heart failure under maintenance dialysis in a real-world setting.

METHODS AND RESULTS

A retrospective cohort study was conducted by collecting data from the Taiwan National Health Insurance Research Database (NHIRD). Patients diagnosed with heart failure and ESRD and who started maintenance dialysis between 1 January 2001 and 31 December 2013 were identified. Patients were grouped according to MRA prescription. The outcomes of interest included cardiovascular (CV) death, hospitalization for heart failure (HHF), all-cause mortality, acute myocardial infarction (AMI), ischaemic stroke, any coronary revascularization procedures, and new-onset hyperkalaemia. Propensity score matching was performed at a 1:3 ratio between MRA users and non-users to minimize selection bias. A total of 50 872 patients who satisfied our inclusion and exclusion criteria were identified. After 1:3 matching, 2176 patients were included in the MRA group, and 6528 patients were included in the non-MRA group. The risk of CV death was significantly lower among patients who received MRAs than those who did not (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.80-0.95), as was the risk of all-cause mortality (HR 0.88, 95% CI 0.83-0.94). Reductions in the risks of CV death and all-cause mortality were more prominent among patients undergoing haemodialysis and those with coronary artery disease.

CONCLUSIONS

In patients undergoing regular dialysis who are diagnosed with heart failure, the use of MRAs is associated with lower risks of all-cause mortality and CV death. The benefits of MRA treatment in heart failure may persist in patients with ESRD. Further investigations through randomized controlled trials are needed to assess the efficacy and safety of MRAs in this high-risk population.

Identifying effective diagnostic biomarkers and immune infiltration features in chronic kidney disease by bioinformatics and validation

Background: Chronic kidney disease (CKD), characterized by sustained inflammation and immune dysfunction, is highly prevalent and can eventually progress to end-stage kidney disease. However, there is still a lack of effective and reliable diagnostic markers and therapeutic targets for CKD. Methods: First, we merged data from GEO microarrays (GSE104948 and GSE116626) to identify differentially expressed genes (DEGs) in CKD and healthy patient samples. Then, we conducted GO, KEGG, HPO, and WGCNA analyses to explore potential functions of DEGs and select clinically significant modules. Moreover, STRING was used to analyse protein-protein interactions. CytoHubba and MCODE algorithms in the cytoscape plug-in were performed to screen hub genes in the network. We then determined the diagnostic significance of the obtained hub genes by ROC and two validation datasets. Meanwhile, the expression level of the biomarkers was verified by IHC. Furthermore, we examined immunological cells' relationships with hub genes. Finally, GSEA was conducted to determine the biological functions that biomarkers are significantly enriched. STITCH and AutoDock Vina were used to predict and validate drug-gene interactions. Results: A total of 657 DEGs were screened and functional analysis emphasizes their important role in inflammatory responses and immunomodulation in CKD. Through WGCNA, the interaction network, ROC curves, and validation set, four hub genes (IL10RA, CD45, CTSS, and C1QA) were identified. Furthermore, IHC of CKD patients confirmed the results above. Immune infiltration analysis indicated that CKD had a significant increase in monocytes, M0 macrophages, and M1 macrophages but a decrease in regulatory T cells, activated dendritic cells, and so on. Moreover, four hub genes were statistically correlated with them. Further analysis exhibited that IL10RA, which obtained the highest expression level in hub genes, was involved in abnormalities in various immune cells and regulated a large number of immune system responses and inflammation-related pathways. In addition, the drug-gene interaction network contained four potential therapeutic drugs targeting IL10RA, and molecular docking might make this relationship viable. Conclusion: IL10RA and its related hub molecules might play a key role in the development of CKD and could be potential biomarkers in CKD.

Assessment of the Influence of Asymmetric Triacetate Cellulose Membrane on the Rate of Removal of Middle Molecular Weight Uremic Toxins in Patients Treated with Postdilution Online Hemodiafiltration

BACKGROUND: Postdilution online hemodiafiltration (OL-HDF) effectively removes uremic toxins of middle molecular weight from the blood of patients with end-stage chronic kidney disease. The rate of removal of uremic toxins depends on the type of dialysis membrane, blood flow rate (Qb), net ultrafiltration flow rate (Qnuf), and total convective volume (Vconv). AIM: The aim of this study was to examine the efficacy of asymmetric triacetate cellulose dialysis membrane in patients on post-dilution OL-HDF. METHODS: Thirty-five patients treated with post-dilution OL-HDF hemodiafiltration for at least 3 months were examined. The main parameters for assessing the efficiency of removal of uremic toxins of middle molecular weight are the concentration of β2-microglobulin (β2-M) and interleukin-6 (IL-6) in serum before and after a single session of post-dilution OL-HDF. The followings were used for statistical analysis: Kolmogorov–Smirnov test, Student’s T test for bound samples and Wilcoxon test. RESULTS: The average Vconv was 20.90 ± 3.30 liters/session. The β2-M reduction index during a single session of postdilution OL-HDF was 71.10 ± 6.39%, the IL-6 reduction index was 43.75 ± 15.60%, and the albumin reduction index was 4.55 ± 2.31%. CONCLUSION: The asymmetric triacetate cellulose dialysis membrane effectively removes β2-M and IL-6 during a single session of postdilution OL-HDF. The β2-M reduction index is ∼70%, the IL-6 reduction index is ∼40%, and albumin loss is <4.0 g/4 h. The examined dialysis membrane and dialysis modality prevent the development of amyloidosis associated with dialysis, microinflammation and reduce the risk of developing atherosclerotic cardiovascular diseases in the population of patients treated with regular hemodiafiltration.

Effects of Mediterranean Diet, DASH Diet, and Plant-Based Diet on Outcomes among End Stage Kidney Disease Patients: A Systematic Review and Meta-Analysis

BACKGROUND

The Mediterranean, Dietary Approach to Stop Hypertension (DASH), and plant-based diets may provide cardiovascular benefit to the general population. However, data on their effect on end stage kidney disease (ESKD) patients are limited. This systematic review aims to assess the impact of Mediterranean, DASH, and plant-based diets on outcomes among ESKD patients.

METHODS

A literature review was conducted in EMBASE, MEDLINE, and Cochrane databases from inception through September 2022 to identify studies that assess the clinical outcomes of Mediterranean, DASH, or plant-based diets on ESKD patients on hemodialysis (HD) or peritoneal dialysis (PD). Effect estimates from the individual studies were derived utilizing the random-effect, generic inverse variance approach of DerSimonian and Laird.

RESULTS

Seven studies with 9400 ESKD patients (8395 HD and 1005 PD) met the eligibility criteria and were included in the data analysis. Pooled odds ratios (ORs) of mortality for ESKD patients who adhered to the Mediterranean versus plant-based diet were 0.49 (95% CI: 0.07-3.54; two studies, I² = 67%) and 0.87 (95% CI: 0.75-1.01; two studies, I² = 0%), respectively. Data on mortality for ESKD patients on a DASH diet were limited to one study with an OR of 1.00 (95% CI: 0.89-1.12). The pooled OR of cardiovascular mortality among ESKD patients who adhered to a plant-based diet was 0.86 (95% CI: 0.68-1.08; two studies, I² = 0%), compared to those who did not. Data on cardiovascular mortality among those with Mediterranean and DASH diet were limited to one study with ORs of 1.14 (95% CI: 0.90-1.43) and 1.19 (95% CI: 0.99-1.43), respectively. Mediterranean diet adherence was found to be associated with reduced risk of left ventricular hypertrophy (LVH) with an OR of 0.82 (95% CI: 0.68-0.99) in a study including 127 ESKD patients. The risk of hyperkalemia was not significant among those with a plant-based diet with an OR of 1.00 (95% CI: 0.94-1.07) in a study including 150 ESKD patients.

CONCLUSIONS

While our systematic review demonstrated no significant associations of Mediterranean, DASH, and plant-based diets with reduced all-cause mortality or cardiovascular mortality, there was also no evidence that suggested harmful effects of these diets to ESKD patients.

Imbalance in Bone Morphogenic Proteins 2 and 7 Is Associated with Renal and Cardiovascular Damage in Chronic Kidney Disease

Arterial stiffness is a major vascular complication of chronic kidney disease (CKD). The development of renal damage, hypertension, and increased pulse wave velocity (PWV) in CKD might be associated with an imbalance in bone morphogenetic proteins (BMP)-2 and BMP-7. Plasma BMP-2 and BMP-7 were determined by ELISA in CKD patients (stages I-III; n = 95) and Munich Wistar Frömter (MWF) rats. Age-matched Wistar rats were used as a control. The expression of BMP-2, BMP-7, and profibrotic and calcification factors was determined in kidney and perivascular adipose tissues (PVAT). BMP-2 was higher in stage III CKD patients compared to control subjects. BMP-7 was lower at any CKD stage compared to controls, with a significant further reduction in stage III patients. A similar imbalance was observed in MWF rats together with the increase in systolic (SBP) and diastolic blood pressure (DBP), or pulse wave velocity (PWV). MWF exhibited elevated urinary albumin excretion (UAE) and renal expression of BMP-2 or kidney damage markers, Kim-1 and Ngal, whereas renal BMP-7 was significantly lower than in Wistar rats. SBP, DBP, PWV, UAE, and plasma creatinine positively correlated with the plasma BMP-2/BMP-7 ratio. Periaortic and mesenteric PVAT from MWF rats showed an increased expression of BMP-2 and profibrotic and calcification markers compared to Wistar rats, together with a reduced BMP-7 expression. BMP-2 and BMP-7 imbalance in plasma, kidney, and PVATs is associated with vascular damage, suggesting a profibrotic/pro-calcifying propensity associated with progressive CKD. Thus, their combined analysis stratified by CKD stages might be of clinical interest to provide information about the degree of renal and vascular damage in CKD.

Antidyslipidemia Pharmacotherapy in Chronic Kidney Disease: A Systematic Review and Bayesian Network Meta-Analysis

BACKGROUND AND AIMS

The benefits and safety of antidyslipidemia pharmacotherapy in patients with chronic kidney disease were not well defined so the latest evidence was summarized by this work.

METHODS

This systematic review and Bayesian network meta-analysis (NMA) included searches of PubMed, Embase, and Cochrane Library from inception to 28 February 2022, for randomized controlled trials of any antilipidaemic medications administered to adults with chronic kidney disease [CKD: defined as estimated glomerular filtration rate (eGFR) ≤ 60 mL/min/1.73 m² not undergoing transplantation], using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool to assess the certainty of the evidence.

RESULTS

55 trials and 30 works of them were included in our systematic review and NMA, respectively. In comparisons with no antidyslipidemia therapy or placebo, proprotein convertase subtilisin/Kexin type 9 inhibitors plus statin (PS) was the most effective drug regimen for reducing all-cause mortality (OR 0.62, 95% CI [0.40, 0.93]; GRADE: moderate), followed by moderate-high intensity statin (HS, OR 0.76, 95% CI [0.60, 0.93]; I² = 66.9%; GRADE: moderate). PS, HS, low-moderate statin (LS), ezetimibe plus statin (ES), and fibrates (F) significantly decreased the composite cardiovascular events. The subgroup analysis revealed the null effect of statins on death (OR 0.92, 95% CI [0.81, 1.04]) and composite cardiovascular events (OR 0.94, 95% CI [0.82, 1.07]) in dialysis patients.

CONCLUSION

In nondialysis CKD patients, statin-based therapies could significantly and safely reduce all-cause death and major composite cardiovascular events despite the presence of arteriosclerotic cardiovascular disease and LDL-c levels. Aggressive medication regimens, PS and HS, appeared to be more effective, especially in patients with established CAD.

Heart failure with reduced ejection fraction and the intersection of cardio-renal-metabolic medicine #CaReMe

Diabetes and chronic kidney disease (CKD) are important comorbidities in patients with heart failure (HF) that can complicate the clinical management and have major implications for morbidity and mortality. In addition, the presence of these comorbidities, particularly advanced CKD, is a limitation for the implementation of guideline-directed therapies in patients with HF with reduced ejection fraction (HFrEF). Though clinical trials in patients with HFrEF trials included varying percentages of patients with diabetes and/or CKD, patients with advanced CKD have been excluded in most HF studies. Thus, management recommendations for these patients often have to be extrapolated from subgroup analyses. This article summarizes pathophysiological aspects of the interaction of HFrEF, CKD, and diabetes and addresses clinical aspects for the screening of these comorbidities. Moreover, current treatment options for patients with HFrEF and CKD and/or diabetes are discussed and novel strategies such as the use of the selective mineralocorticoid receptor antagonist Finerenone are addressed.

Impacting Management of Chronic Kidney Disease Through Primary Care Practice Audits: A Quality Improvement Study

Background

Risk prediction tools are important in chronic disease management, but their implementation into clinical workflow is often limited by lack of electronic health record (EHR)-linked solutions.

Objective

To implement the Khure Health (KH) clinical decision support platform with an artificial intelligence (AI)-enabled algorithm for chronic kidney disease (CKD) risk detection in 201 primary care provider practices across Ontario.

Design

Multi-practice quality improvement study.

Setting

The study was conducted in Ontario, Canada.

Participants

201 primary care practices.

Measurements

Per-practice CKD risk stratification and clinician action.

Methods

Data for estimated glomerular filtration rate (eGFR), albuminuria, demographics, and comorbid conditions were extracted from the EHR using KH's natural language processing (NLP) algorithms. Patients already on dialysis, visiting a nephrologist, older than 85, or already on a sodium-glucose cotransporter 2 inhibitor (SGLT2i) were excluded. The remaining individuals were risk stratified using the kidney failure risk equation, presence or absence of cardiovascular disease (CVD), or other comorbid conditions. A dashboard with disease-specific educational information and links to the EHRs of the identified patients was created.

Results

We screened 361 299 individuals and identified 8194 patients with CKD Stage 3 at risk for progression or cardiovascular events. A total of 620 individuals were at high risk for CKD progression or CVD, and 2592 were at intermediate risk. A total of 2010 individuals (10 patients per practice) at high or moderate risk were selected for a chart audit, and appropriate additional testing (repeat eGFR or albuminuria) or prescription of disease-modifying therapy occurred in 24.32% of these patients.

Limitations

Data on comorbidities, medications, or demographic variables are not available for presentation or statistical analysis due to privacy legislation and primary care provider (PCP) custodianship over EHR data.

Conclusion

An AI-enabled EHR clinical decision support application that can detect and risk stratify patients with CKD can enable improved laboratory testing and management. Larger trials of clinical decision support and practice audit applications will be needed to impact CKD management nationally.

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

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

Smoking and combined oral contraceptives should be considered as an independent variable in sex and gender-oriented studies

The influence of sex combined with smoking and combined oral contraceptives (COC) use on atherogenic indexes is scarcely studied. Thus, traditional lipid parameters were measured, and non-traditional atherogenic indexes were calculated in a young and healthy population of men, COC-free women, and COC users. Total cholesterol (TChol), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and HDL/LDL ratio were lower in men, while triglycerides (TG)/HDL ratio, atherogenic index of plasma (AIP), Castelli's Risk Index I (CRII) and CRI-II, atherogenic coefficient (AC), creatinine, creatinine clearance, and estimated glomerular filtration rate (eGFR) were higher in men. The use of COC modified TChol, HDL, TG, TG/HDL, and AIP which had significantly higher values in COC users. In addition, TG were also increased in COC users in comparison with men. Smoking reduced sexually divergent parameters: BMI, TG, HDL/LDL, TG/HDL, AIP, CRII, CRI-II, and AC became similar among the three cohorts, losing the reported sex differences. Smoking also reduced differences in TChol, HDL, TG, and AIP between COC-free women and COC users, but it does not affect CRII, CRI-II, creatinine, creatinine clearance, and eGFR, underlining that COC users and COC-free women have to be considered two different populations. Our results represent a complex landscape suggesting that for both sexes smoking should be an independent variable in medical studies. Moreover, in women, the use of COC evidenced two different cohorts. Thus, more variables should be considered during a single study indicating that sex, smoking, and COC should be studied together to get a picture of the real-life context.

Catheter-based renal denervation in Chinese patients with chronic kidney disease and uncontrolled hypertension

Sympathetic activation contributes to the progression of hypertension and chronic kidney disease (CKD). Ablation of renal sympathetic nerves lowers blood pressure (BP) and preserves renal function in patients with CKD and uncontrolled hypertension by reducing sympathetic nerve activity. But whether this approach is safe and effective in Chinese patients with CKD is unknown. We performed an observational study of eight patients with CKD stages from 1 to 5, office BP ≥150/90 mmHg, while on at least three antihypertensive drug classes including a diuretic, and diagnosis confirmed by 24 h ambulatory systolic BP measurement ≥135 mmHg. All patients underwent catheter-based renal denervation (RDN) using a newly designed RDN System (Golden Leaf Medtech, Shanghai, China). For up to 6 months after RDN, BP was monitored and renal function was assessed. Mean baseline office BP was 165.0 ± 13.9/97.8 ± 5.5 mmHg, despite treatment with three antihypertensive drugs. Six months after RDN, office BP was reduced by 22.1 ± 12.0 (P = .002)/11.0 ± 8.8 mmHg (P = .012) and average 24 h ambulatory BP by 18 ± 13.7 (P = .01)/9.3 ± 7.7 mmHg (P = .016). After RDN, heart rate and estimated glomerular filtration rate (GFR) had no significant change compared with before RDN. In Chinese patients with CKD, our observational pilot study found that treating hypertension with RDN lowers BP while not affecting renal function. Brief Abstract: We performed RDN in eight Chinese patients with hypertension and CKD. The results showed that RDN lowered blood pressure of these patients significantly and eGFR was stable. No obvious adverse event was observed.

Cardiovascular Alterations and Structural Changes in the Setting of Chronic Kidney Disease: a Review of Cardiorenal Syndrome Type 4

Cardiovascular and renal physiology are interrelated. More than a decade ago this was codified in guidelines defining the five subtypes of the cardiorenal syndrome. Morbidity and mortality for those with the cardiorenal syndrome is high compared to demographically matched individuals without cardiorenal disease, acute or chronic. The focus of this review will be the epidemiology, the impact of chronic kidney disease on cardiac structure and function, and associated clinical symptoms, outcomes, and potential treatments for patients with chronic reno-cardiac syndrome, or cardiorenal syndrome type 4. Cardiac structural changes can be profound and are described in detail both at a cellular and physiologic level. Integrating therapies for the treatment of causative or resulting comorbidities may ultimately slow progression of both cardiac and renal disease as well as minimize symptoms and death.

Signaling Pathways of Podocyte Injury in Diabetic Kidney Disease and the Effect of Sodium-Glucose Cotransporter 2 Inhibitors

Diabetic kidney disease (DKD) is one of the most important comorbidities for patients with diabetes, and its incidence has exceeded one tenth, with an increasing trend. Studies have shown that diabetes is associated with a decrease in the number of podocytes. Diabetes can induce apoptosis of podocytes through several apoptotic pathways or induce autophagy of podocytes through related pathways. At the same time, hyperglycemia can also directly lead to apoptosis of podocytes, and the related inflammatory reactions are all harmful to podocytes. Podocyte damage is often accompanied by the production of proteinuria and the progression of DKD. As a new therapeutic agent for diabetes, sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been demonstrated to be effective in the treatment of diabetes and the improvement of terminal outcomes in many rodent experiments and clinical studies. At the same time, SGLT2i can also play a protective role in diabetes-induced podocyte injury by improving the expression of nephrotic protein defects and inhibiting podocyte cytoskeletal remodeling. Some studies have also shown that SGLT2i can play a role in inhibiting the apoptosis and autophagy of cells. However, there is no relevant study that clearly indicates whether SGLT2i can also play a role in the above pathways in podocytes. This review mainly summarizes the damage to podocyte structure and function in DKD patients and related signaling pathways, as well as the possible protective mechanism of SGLT2i on podocyte function.

Design and Engineering of a Palm-Sized Optical Immunosensing Device for the Detection of a Kidney Dysfunction Biomarker

Creatinine is one of the most common and specific biomarkers for renal diseases, usually found in the serum and urine of humans. Its level is extremely important and critical to know, not only in the case of renal diseases, but also for various other pathological conditions. Hence, detecting creatinine in clinically relevant ranges in a simplistic and personalized manner is interesting and important. In this direction, an optical sensing device has been developed for the simple, point-of-care detection of creatinine. The developed biosensor was able to detect creatinine quantitatively based on optical signals measured through a change in color. The sensor has been integrated with a smartphone to develop a palm-sized device for creatinine analysis in personalized settings. The sensor has been developed following facile chemical modification steps to anchor the creatinine-selective antibody to generate a sensing probe. The fabricated sensor has been thoroughly characterized by FTIR, AFM, and controlled optical analyses. The quantitative analysis is mediated through the reaction between picric acid and creatinine which was detected by the antibody-functionalized sensor probe. The differences in color intensity and creatinine concentrations show an excellent dose-dependent correlation in two different dynamic ranges from 5 to 20 μM and 35 to 400 μM, with a detection limit of 15.37 (±0.79) nM. Several interfering molecules, such as albumin, glucose, ascorbic acid, citric acid, glycine, uric acid, Na⁺, K⁺, and Cl^-, were tested using the biosensor, in which no cross-reactivity was observed. The utility of the developed system to quantify creatinine in spiked serum samples was validated and the obtained percentage recoveries were found within the range of 89.71-97.30%. The fabricated biosensor was found to be highly reproducible and stable, and it retains its original signal for up to 28 days.

An analysis of the etiologies and economic indexes of inpatients with stage 5 chronic kidney disease in North China

Objective

The aim of this study was to analyze the epidemiological characteristics of the causes of chronic kidney disease (CKD) stage 5 patients in North China and to investigate the economic burden of those on hemodialysis (HD) or peritoneal dialysis (PD), as well as the associated influencing factors.

Methods

General clinical information, etiological categories, and hospitalization costs for HD or PD were collected from 1,515 patients hospitalized with stage 5 CKD at the Affiliated Hospital of Hebei University from 2016 to 2018. Logistic regression analysis was used to analyze the independent influencing factors affecting patients' financial burden.

Results

The highest rate of DN was found in patients aged 70 years or older (27.0%) and the highest incidence of primary glomerulopathy was found in patients aged <50 years (24.3%). Age, type of dialysis, and type of health insurance were independent influences on the total financial burden of patients, and the results of multifactorial logistic regression analysis showed that age [OR (95% CI): 1.009 (1.002, 1.020)] and type of dialysis [OR (95% CI): 1.746 (1.149, 2.659)] would increase the total financial burden. The type of health insurance would reduce the total financial burden [OR (95% CI): 0.222 (0.108, 0.418)].

Conclusion

Chronic kidney disease, with its complex etiology and the heavy financial burden required for treatment, remains a more serious public health problem globally, and it is therefore necessary to further improve medical coverage for dialysis patients, increase management efforts, broaden pro-poor policies and increase the accessibility of medical services in low- and middle-income areas.

Associations between plasma metal levels and mild renal impairment in the general population of Southern China

BACKGROUND

Metal exposure were assumed to be closely related with declined renal function, but the conclusions were controversial. We employed diverse statistical models and assessed the association between metal mixture exposure and mild renal impairment.

METHODS

A total of 13 plasma metals were measured in 896 general population from Southern China. Subjects with estimated glomerular filtration rate within 60-89 ml/min/1.73 m² and urinary albumin-creatinine ratio <30 mg/g creatinine were defined as mild renal impairment (MRI).

RESULTS

About 31.47 % participants showed MRI. In the multivariate logistic regression models, compared with the first quartile, high levels of arsenic and molybdenum (the fourth quartile) were both associated with MRI, and the ORs (95 % CI) were 1.68 (1.05, 2.68) and 2.21 (1.40, 3.48), respectively. Their predominant roles were identified by the weighted quantile regression (WQS). Besides, restricted cubic spline analysis verified the relationship between molybdenum level and increased MRI risk in a linear and dose-response manner.

CONCLUSION

High levels of arsenic and molybdenum might be independent risk factors of MRI, and they showed combined effect. Our findings might provide vigorous evidence in preventing mild decline in renal function.

Benefits and risks of essential trace elements in chronic kidney disease: a narrative review

Background and Objective

Chronic kidney disease (CKD) is an important public health concern. With the decline of renal function, CKD patients gradually progress to end-stage kidney disease and need to undergo dialysis or kidney transplantation to maintain life, bringing a heavy economic burden to the family and society. Therefore, it is necessary to effectively prevent and delay the progression of CKD. Essential trace elements play an indispensable role in CKD, and the objective of this study is to systematically review their benefits in the disease and summarize the risks of their excess.

Methods

The keywords "trace elements", "chronic kidney disease", "dialysis", "inflammation", and "fibrosis" and their combinations were used to search for relevant literature published in the PubMed database and Web of Science. We then summarized the role of trace element abnormalities in CKD patients in anemia, oxidative stress, inflammation, and chronic fibrosis, and the risk of their excess.

Key Content and Findings

Imbalance of essential trace elements is a common complication of CKD and a risk factor for CKD progression, cardiovascular events, and death. This article reviews the effects of essential trace elements (iron, zinc, selenium, copper, iodine, and manganese) on CKD. We analyze literature and discuss the advantages and disadvantages of various essential trace elements.

Conclusions

Research shows CKD patients have an imbalance of essential trace elements, and treatment based on these is an important direction for future exploration. A knowledge of the homeostasis of trace elements is important to improving the prognosis of CKD patients and delaying the progression of the disease.

Cost-Effectiveness of Dapagliflozin as a Treatment for Chronic Kidney Disease: A Health-Economic Analysis of DAPA-CKD

BACKGROUND AND OBJECTIVES

CKD imposes a significant burden on patients and health care providers, particularly upon reaching kidney failure when patients may require KRT. The Dapagliflozin and Prevention of Adverse Outcomes in CKD (DAPA-CKD) trial demonstrated that dapagliflozin, with standard therapy, reduced CKD progression and KRT requirement. The study objective was to estimate the cost-effectiveness of dapagliflozin for the treatment of CKD from payer perspectives in the United Kingdom, Germany, and Spain.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We constructed a lifetime Markov model to characterize outcomes in patients with CKD on the basis of the DAPA-CKD trial. Health states were defined by eGFR level and KRT type. Direct health care costs and utility values were sourced from published literature and the DAPA-CKD trial, respectively. Costs and benefits were discounted at 3.5% per annum in the United Kingdom and 3% in Germany and Spain.

RESULTS

In patients eligible for the DAPA-CKD trial, treatment with dapagliflozin was predicted to reduce rates of CKD progression, with patients predicted to spend 1.7 (95% credibility interval, 0.8 to 2.4) more years in the eGFR range 15-89 ml/min per 1.73 m2 versus standard therapy alone (12.1; 95% credibility interval, 8.9 to 14.1 versus 10.4; 95% credibility interval, 7.7 to 12.4 years). Life expectancy (undiscounted) was correspondingly predicted to increase by 1.7 (95% credibility interval, 0.7 to 2.5) years (15.5; 95% credibility interval, 11.1 to 18.2 versus 13.8; 95% credibility interval, 9.9 to 16.5 years). This in addition to reduced incidence of adverse clinical outcomes, including hospitalization for heart failure, resulted in modeled quality-adjusted life year (discounted) gains between 0.82 (95% credibility interval, 0.38 to 1.18) and 1.00 (95% credibility interval, 0.46 to 1.41). These gains translated to incremental cost-effectiveness ratios of $8280, $17,623, and $11,687 in the United Kingdom, Germany, and Spain, respectively, indicating cost-effectiveness at willingness-to-pay thresholds (United Kingdom: $27,510 per quality-adjusted life year; Germany and Spain: $35,503 per quality-adjusted life year).

CONCLUSIONS

In patients meeting the eligibility requirements for the DAPA-CKD trial, dapagliflozin is likely to be a cost-effective treatment within the UK, German, and Spanish health care systems.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Dapagliflozin and Prevention of Adverse Outcomes in CKD (DAPA-CKD), NCT03036150.

A molecular phenotypic screen reveals that lobetyolin alleviates cardiac dysfunction in 5/6 nephrectomized mice by inhibiting osteopontin

BACKGROUND

Cardiovascular diseases are the major cause of mortality in patients with advanced chronic kidney diseases. The predominant abnormality observed among this population is cardiac dysfunction secondary to myocardial remodelings, such as hypertrophy and fibrosis, emphasizing the need to develop potent therapies that maintain cardiac function in patients with end-stage renal disease.

AIMS

To identify potential compounds and their targets as treatments for cardiorenal syndrome type 4 (CRS) using molecular phenotyping and in vivo/in vitro experiments.

METHODS

Gene expression was assessed using bioinformatics and verified in animal experiments using 5/6 nephrectomized mice (NPM). Based on this information, a molecular phenotyping strategy was pursued to screen potential compounds. Picrosirius red staining, wheat germ agglutinin staining, Echocardiography, immunofluorescence staining, and real-time quantitative PCR (qPCR) were utilized to evaluate the effects of compounds on CRS in vivo. Furthermore, qPCR, immunofluorescence staining and flow cytometry were applied to assess the effects of these compounds on macrophages/cardiac fibroblasts/cardiomyocytes. RNA-Seq analysis was performed to locate the targets of the selected compounds. Western blotting was performed to validate the targets and mechanisms. The reversibility of these effects was tested by overexpressing Osteopontin (OPN).

RESULTS

OPN expression increased more remarkably in individuals with uremia-induced cardiac dysfunction than in other cardiomyopathies. Lobetyolin (LBT) was identified in the compound screen, and it improved cardiac dysfunction and suppressed remodeling in NPM mice. Additionally, OPN modulated the effect of LBT on cardiac dysfunction in vivo and in vitro. Further experiments revealed that LBT suppressed OPN expression via the phosphorylation of c-Jun N-terminal protein kinase (JNK) signaling pathway.

CONCLUSIONS

LBT improved CRS by inhibiting OPN expression through the JNK pathway. This study is the first to describe a cardioprotective effect of LBT and provides new insights into CRS drug discovery.

Epidemiology, Pathophysiology, and Management of Coronary Artery Disease in the Elderly

Elderly patients over the age of ≥ 75 years are especially susceptible to coronary artery disease (CAD) as age is an important nonmodifiable risk factors for atherosclerosis and a predictor of poorer outcomes. In fact, CAD is a major cause of mortality and morbidity in this population. Due to concerns of functional frailty, comorbidities, and patient preference of conservative to no treatment have played a role in reducing the interest in pursuing prospective studies in this high-risk group. In this review, we provide an overview of the epidemiology, pathophysiology, and management of CAD in older adults.

Renal Klotho safeguards platelet lifespan in advanced chronic kidney disease through restraining Bcl-xL ubiquitination and degradation

BACKGROUND

Thrombosis and hemorrhage as two opposite pathologies are prevalent within the chronic kidney disease (CKD) population. Platelet homeostasis, which positions centrally in their pathogenesis, varies among the CKD population, while the underlying mechanism is poorly understood.

OBJECTIVE

To investigate the change character and mechanism of platelet homeostasis in CKD and its association with renal Klotho deficiency.

METHODS

The change character of platelet homeostasis and its association with renal Klotho deficiency were determined based on a cohort study as well as CKD mice and Klotho-deficient mice with CKD. The effects on thrombopoiesis and platelet lifespan were examined by flow cytometry and platelet transfer. The underlying mechanism was explored by proteomics, flow cytometry, western blot, and immunoprecipitation.

RESULTS

We show that platelet count declines both in patient and mouse models with advanced CKD (Adv-CKD) and is positively associated with circulating Klotho levels. Mechanistically, we identify that ubiquitin ligase UBE2O governs Bcl-xL ubiquitination and degradation in platelets, whereas Adv-CKD-induced oxidative stress in platelets stimulates p38MAPK to promote Bcl-xL phosphorylation, which facilitates UBE2O binding to Bcl-xL and subsequent Bcl-xL degradation. Consequently, platelet lifespan is shortened in Adv-CKD, culminating in platelet count decline. However, kidney-secreted soluble Klotho protein restricts oxidative stress in platelets, thereby preserving Bcl-xL expression and platelet lifespan.

CONCLUSIONS

Our findings uncover the mechanism of platelet count decline in Adv-CKD and identify renal Klotho as a long-range regulator of platelet lifespan, which not only provide a molecular mechanism underlying CKD-associated thrombocytopenia and hemorrhage but also offer a promising therapy choice.

Interconnection between cardiovascular, renal and metabolic disorders: A narrative review with a focus on Japan

Insights from epidemiological, clinical and basic research are illuminating the interplay between metabolic disorders, cardiovascular disease (CVD) and kidney dysfunction, termed cardio-renal-metabolic (CRM) disease. Broadly defined, CRM disease involves multidirectional interactions between metabolic diseases such as type 2 diabetes (T2D), various types of CVD and chronic kidney disease (CKD). T2D confers increased risk for heart failure, which-although well known-has only recently come into focus for treatment, and may differ by ethnicity, whereas atherosclerotic heart disease is a well-established complication of T2D. Many people with T2D also have CKD, with a higher risk in Asians than their Western counterparts. Furthermore, CVD increases the risk of CKD and vice versa, with heart failure, notably, present in approximately half of CKD patients. Molecular mechanisms involved in CRM disease include hyperglycaemia, insulin resistance, hyperactivity of the renin-angiotensin-aldosterone system, production of advanced glycation end-products, oxidative stress, lipotoxicity, endoplasmic reticulum stress, calcium-handling abnormalities, mitochondrial malfunction and deficient energy production, and chronic inflammation. Pathophysiological manifestations of these processes include diabetic cardiomyopathy, vascular endothelial dysfunction, cardiac and renal fibrosis, glomerular hyperfiltration, renal hypoperfusion and venous congestion, reduced exercise tolerance leading to metabolic dysfunction, and calcification of atherosclerotic plaque. Importantly, recognition of the interaction between CRM diseases would enable a more holistic approach to CRM care, rather than isolated treatment of individual conditions, which may improve patient outcomes. Finally, aspects of CRM diseases may differ between Western and East Asian countries such as Japan, a super-ageing country, with potential differences in epidemiology, complications and prognosis that represent an important avenue for future research.

Defining preventive cardiology: A clinical practice statement from the American Society for Preventive Cardiology

Remarkable transformations in science and healthcare have resulted in declines in mortality from cardiovascular disease over the past several decades, largely driven by progress in prevention and treatment of persons at risk. However, these trends are now beginning to stall, as our county faces increases in cardiovascular risk factors including overweight and obesity, type 2 diabetes mellitus, and metabolic syndrome. Furthermore, poor long-term adherence to a healthy lifestyle and lifesaving pharmacotherapy have exacerbated these trends, with recent data suggesting unprecedented increases in cardiovascular morbidity and mortality. A paradigm shift is needed to improve the cardiovascular health of our nation. Preventive cardiology, a growing subspecialty of cardiovascular medicine, is the practice of primordial, primary, and secondary prevention of all cardiovascular diseases. Preventive cardiologists and preventive cardiology specialists are well equipped with the knowledge and skill-set necessary to reduce deaths related to the growing burden of heart disease and its risk factors. Despite dedicated efforts, cardiovascular disease remains the leading killer of men and women in the United States. Although there is little debate regarding the importance of prevention, many healthcare professionals question the need for preventive cardiology as a distinct subspecialty. Additionally, the field's growth has been hampered by a lack of organization and standardization, and variability of training within programs across the country. The purpose of this document is to delineate the key attributes that define the field of preventive cardiology according to the American Society for Preventive Cardiology.

Effects of GLP-1 receptor agonists on cardiovascular outcomes in patients with type 2 diabetes and chronic kidney disease: A systematic review and meta-analysis

AIM

To evaluate the cardiovascular outcomes of glucagon-like peptide-1 receptor agonists (GLP1-RA) in patients with type 2 diabetes (T2DM) and chronic kidney disease (CKD).

MATERIALS AND METHODS

We searched PubMed, Ovid MEDLINE, CINAHL, and Web of Science databases for randomized controlled trials reporting event rates for a composite cardiovascular outcome of cardiovascular death, myocardial infarction, and stroke in patients with T2DM and CKD receiving GLP1-RA or placebo. Studies were restricted to those reporting specific event rates for patients with CKD separately from the overall population. We conducted a meta-analysis using a random-effects model. This meta-analysis was registered on PROSPERO (CRD42022320157).

RESULTS

A total of four studies comprising 7130 patients was included in our analysis. Four different GLP1-RA were assessed in a population with CKD defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² . Treatment with GLP1-RA was not associated with a significant reduction in the composite cardiovascular end point of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke (odds ratio (OR) 0.80; 95% confidence interval (CI), 0.59-1.07; p = 0.13) among patients with T2DM and CKD. Individual components of the composite cardiovascular end point were assessed in two trials and did not show evidence of an effect of GLP1-RA in reducing cardiovascular end points.

CONCLUSIONS

Pooled analysis of clinical trials reporting separate cardiovascular events rates in patients with T2DM and CKD did not find GLP1-RA to be associated with a reduction in composite cardiovascular event rates. Select GLP1-RA may offer cardiovascular event reduction in patients with T2DM and CKD, but this does not appear to be a class effect. Use of GLP1-RA with demonstrated cardiovascular benefits should be preferred in patients with CKD and T2DM to further reduce cardiovascular risk.