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Shubham S, Kumar M, Sarma DK, Kumawat M, Verma V, Samartha RM, Tiwari RR. Role of air pollution in chronic kidney disease: an update on evidence, mechanisms and mitigation strategies. Int Arch Occup Environ Health 2021; 95:897-908. [PMID: 34716808 DOI: 10.1007/s00420-021-01808-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/05/2021] [Indexed: 01/19/2023]
Abstract
Air pollution results from a variable and complex mixture of harmful gases and suspended particles and is the most worrisome of all environmental hazards. It is implicated in several non -communicable diseases and is recognized to be a public health problem. Though the initial exposure to air pollution is through the respiratory system, kidneys are thought to be exposed to higher concentrations owing to their filtration function. Chronic kidney disease is the insidious end result of several disease processes which cumulatively form a large healthcare burden, particularly in low- and middle-income countries. There is a growing body of evidence that air pollution may be a contributing factor that leads to CKD by not only its direct effects, but can also compound the effect of other factors/diseases causing kidney injury. PM2.5 exposure particularly has been implicated, although there is some evidence regarding other air pollutants as well. These pollutants are thought to act on kidneys through several interlinked systemic pathways and mechanisms which individually and collectively damage the nephrons. Long-term exposures seem to gradually diminish renal function and lead to end-stage renal disease. A thorough understanding of the mechanism of kidney injury is the key for formulating and implementing effective strategies for reducing this burden. Maintaining the air quality, promoting education, improving health quality and promotion of targeted nephroprotective measures through effective policy and research support are required in addressing this global public health problem.
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Affiliation(s)
- Swasti Shubham
- Indian Council of Medical Research-National Institute for Research in Environmental Health, Bhopal, India.
| | - Manoj Kumar
- Indian Council of Medical Research-National Institute for Research in Environmental Health, Bhopal, India
| | - Devojit Kumar Sarma
- Indian Council of Medical Research-National Institute for Research in Environmental Health, Bhopal, India
| | - Manoj Kumawat
- Indian Council of Medical Research-National Institute for Research in Environmental Health, Bhopal, India
| | - Vinod Verma
- Sanjay Gandhi Post Graduate Institute, Lucknow, India
| | - R M Samartha
- Bhopal Memorial Hospital & Research Centre, Bhopal, India
| | - R R Tiwari
- Indian Council of Medical Research-National Institute for Research in Environmental Health, Bhopal, India
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Feng Y, Jones MR, Ahn JB, Garonzik-Wang JM, Segev DL, McAdams-DeMarco M. Ambient air pollution and posttransplant outcomes among kidney transplant recipients. Am J Transplant 2021; 21:3333-3345. [PMID: 33870639 PMCID: PMC8500923 DOI: 10.1111/ajt.16605] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/16/2021] [Accepted: 04/03/2021] [Indexed: 01/25/2023]
Abstract
Fine particulate matter (PM2.5 ), a common form of air pollution which can induce systemic inflammatory response, is a risk factor for adverse health outcomes. Kidney transplant (KT) recipients are likely vulnerable to PM2.5 due to comorbidity and chronic immunosuppression. We sought to quantify the association between PM2.5 and post-KT outcomes. For adult KT recipients (1/1/2010-12/31/2016) in the Scientific Registry of Transplant Recipients, we estimated annual zip-code level PM2.5 concentrations at the time of KT using NASA's SEDAC Global PM2.5 Grids. We determined the associations between PM2.5 and delayed graft function (DGF) and 1-year acute rejection using logistic regression and death-censored graft failure (DCGF) and mortality using Cox proportional hazard models. All models were adjusted for sociodemographics, recipient, transplant, and ZIP code level confounders. Among 87 233 KT recipients, PM2.5 was associated with increased odds of DGF (OR = 1.59; 95% CI: 1.48-1.71) and 1-year acute rejection (OR = 1.31; 95% CI: 1.17-1.46) and increased risk of all-cause mortality (HR = 1.15; 95% CI: 1.07-1.23) but not DCGF (HR = 1.05; 95% CI: 0.97-1.51). In conclusion, PM2.5 was associated with higher odds of DGF and 1-year acute rejection and elevated risk of mortality among KT recipients. Our study highlights the importance of considering environmental exposure as risk factors for post-KT outcomes.
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Affiliation(s)
- Yijing Feng
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miranda R. Jones
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - JiYoon B. Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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53
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Chen Y, Cao F, Xiao JP, Fang XY, Wang XR, Ding LH, Wang DG, Pan HF. Emerging role of air pollution in chronic kidney disease. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2021; 28:52610-52624. [PMID: 34448134 DOI: 10.1007/s11356-021-16031-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/14/2021] [Indexed: 06/13/2023]
Abstract
Chronic kidney disease (CKD), a global disease burden related to high rates of incidence and mortality, manifests as progressive and irretrievable nephron loss and decreased kidney regeneration capacity. Emerging studies have suggested that exposure to air pollution is closely relevant to increased risk of CKD, CKD progression and end-stage kidney disease (ESKD). Inhaled airborne particles may cause vascular injury, intraglomerular hypertension, or glomerulosclerosis through non-hemodynamic and hemodynamic factors with multiple complex interactions. The mechanisms linking air pollutants exposure to CKD include elevated blood pressure, worsening oxidative stress and inflammatory response, DNA damage and abnormal metabolic changes to aggravate kidney damage. In the present review, we will discuss the epidemiologic observations linking air pollutants exposure to the incidence and progression of CKD. Then, we elaborate the potential roles of several air pollutants including particulate matter and gaseous co-pollutants, environmental tobacco smoke, and gaseous heavy metals in its pathogenesis. Finally, this review outlines the latent effect of air pollution in ESKD patients undergoing dialysis or renal transplant, kidney cancer and other kidney diseases. The information obtained may be beneficial for further elucidating the pathogenesis of CKD and making proper preventive strategies for this disease.
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Affiliation(s)
- Yue Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, 81 Meishan Road, Hefei, Anhui, China
| | - Fan Cao
- Department of Ophthalmology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, Anhui, China
| | - Jian-Ping Xiao
- Department of Nephrology, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xin-Yu Fang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, 81 Meishan Road, Hefei, Anhui, China
| | - Xue-Rong Wang
- Department of Nephrology, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Li-Hong Ding
- Department of Nephrology, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - De-Guang Wang
- Department of Nephrology, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China.
| | - Hai-Feng Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China.
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, 81 Meishan Road, Hefei, Anhui, China.
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Jung J, Park JY, Kim YC, Lee H, Kim E, Kim YS, Lee JP, Kim H. Effects of air pollution on mortality of patients with chronic kidney disease: A large observational cohort study. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 786:147471. [PMID: 33971609 DOI: 10.1016/j.scitotenv.2021.147471] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/08/2021] [Accepted: 04/28/2021] [Indexed: 05/24/2023]
Abstract
Due to industrialization, the burden of diseases associated with air pollution is increasing. Although the risk associated with air pollution in the general population has been actively investigated, few studies have been conducted on the effects of exposure to air pollution in patients with chronic kidney disease (CKD) in East Asia. A total of 29,602 patients with CKD in Seoul participated in a retrospective cohort at three medical centers. We assessed the association of individualized exposure to five types of air pollutants (PM2.5, PM10, NO2, SO2, and CO) using inverse distance weighting (IDW) on mortality in CKD patients in the Cox proportional hazard model that was adjusted for sex, age, eGFR, hemoglobin, hypertension, diabetes, and area-level characteristics. During the 6.14 ± 3.96 years, 3863 deaths (13%) were observed. We confirmed the significant effects of PM2.5 (hazard ratio [HR] 1.17, 95% confidence interval [CI] 1.07-0.29) and CO (HR 1.17, 95% CI 1.00-1.38) on mortality in CKD patients. Different associations were found when stratified by age, body mass index, smoking, and drinking status. Long-term exposure to air pollutants had negative effects on mortality in patients with CKD. These effects were prominent in patients aged over 65 years, patients with a lean body, and those who did not drink alcohol.
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Affiliation(s)
- Jiyun Jung
- Data Management and Statistics Institute, Dongguk University Ilsan Hospital, South Korea
| | - Jae Yoon Park
- Department of Internal Medicine, Dongguk University Ilsan Hospital, South Korea; Department of Internal Medicine, Dongguk University College of Medicine, South Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University College of Medicine, South Korea
| | - Hyewon Lee
- Department of Health Administration and Management, College of Medical Sciences, Soonchunhyang University, South Korea; Department of Software Convergence, Soonchunhyang University Graduate School, Asan, South Korea
| | - Ejin Kim
- Institute of Health and Environment, Seoul National University, South Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, South Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, South Korea; Department of Internal Medicine, Seoul National University Boramae Medical Center, South Korea.
| | - Ho Kim
- Institute of Health and Environment, Seoul National University, South Korea; Department of Public Health Science, School of Public Health, Seoul National University, South Korea.
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Szyszkowicz M, Schoen S, de Angelis N. Air Pollution and Emergency Department Visits for Disease of the Genitourinary System. ENVIRONMENTAL HEALTH INSIGHTS 2021; 15:11786302211025360. [PMID: 34188483 PMCID: PMC8212373 DOI: 10.1177/11786302211025360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/27/2021] [Indexed: 05/24/2023]
Abstract
The aim of this study is to determine associations between ambient air pollution and the number of emergency department (ED) visits for diseases of the genitourinary tract in Toronto, Canada. We used the National Ambulatory Care Reporting System (NACRS) database to obtain the related ED visits and developed statistical models using daily data on ED visits, temperature, relative humidity, and outdoor air pollution concentration levels. The NACRS database contains data on hospital-based and community-based ambulatory care. The environmental data were retrieved from the National Air Pollution Surveillance (NAPS) program. The NAPS is the main source of ambient air quality data in Canada. We considered 2 air quality health indexes and 6 air pollutants: daily means of fine particulate matter PM2.5, O3, CO, NO2, SO2, and also maximum 8-hour average ozone. For every air pollutant, we fit 270 models (15 lags × 18 strata). We found that same-day air pollution concentrations have the highest number of statistically significantly positive associations with ED visits for genitourinary health outcomes. A total of 133 positive associations were identified over the 14 days lag. In subgroup (strata) analysis, females older than 60 years of age were found to have the most positive associations. In particular, nitrogen dioxide was found to be highly associated with ED visits for females over 60; an increase in NO2 was associated with an increased relative risk (RR) of ED visits when lagged over 0, 1, and 2 days (RR = 1.040 [95% confidence interval: 1.028, 1.052], 1.020 [1.009, 1.032], and 1.025 [1.013, 1.036], respectively). The values of risks are reported for a 1 interquartile range increase in concentration (8.8 ppb). Our results suggest that urban ambient air pollution affect the number of ED visits due to genitourinary system conditions.
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Affiliation(s)
| | - Stephanie Schoen
- Environmental Health Science and
Research Bureau, Health Canada, Ottawa, ON, Canada
| | - Nicholas de Angelis
- Biomedical Program, Department of
Mechanical and Aerospace Engineering, Carleton University, Ottawa, ON, Canada
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Bo Y, Brook JR, Lin C, Chang LY, Guo C, Zeng Y, Yu Z, Tam T, Lau AKH, Lao XQ. Reduced Ambient PM 2.5 Was Associated with a Decreased Risk of Chronic Kidney Disease: A Longitudinal Cohort Study. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:6876-6883. [PMID: 33904723 DOI: 10.1021/acs.est.1c00552] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Many countries have dedicated to the mitigation of air pollution in the past several decades. However, evidence of beneficial effects of air quality improvement on chronic kidney disease (CKD) remains limited. We thus investigated the effects of dynamic changes (including deterioration and improvement) in air quality on the incidence of CKD in a longitudinal study in Taiwan. During 2001-2016, this study recruited a total of 163,197 Taiwanese residents who received at least two standard physical examinations. The level of fine particle matter (PM2.5) was estimated using a high-resolution (1 km2) satellite-based spatio-temporal model. We defined changes of PM2.5 concentrations (ΔPM2.5) as the difference between the two-year average measurements during follow-up and during the immediately preceding visit. The time-dependent Cox regression model was adopted to evaluate the relationships between ΔPM2.5 and the incidence of CKD after adjusting for a series of covariates. The concentrations of PM2.5 in Taiwan peaked around 2004 and began to decrease since 2005. We observed an approximate linear concentration-response relationship of ΔPM2.5 with CKD incidence. Every 5 μg/m3 decrease in the ambient concentration of PM2.5 was associated with a 25% reduced risk of CKD development [hazard ratio (HR): 0.75; 95% CI: 0.73, 0.78]. In conclusion, this study demonstrated that the improvement of PM2.5 air quality might be associated with a lower risk of CKD development. Our findings indicate that reducing air pollution may effectively prevent the development of CKD.
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Affiliation(s)
- Yacong Bo
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Kowloon 999077, Hong Kong, China
| | | | - Changqing Lin
- Division of Environment and Sustainability, The Hong Kong University of Science and Technology, Kowloon 999077, Hong Kong, China
- Department of Civil and Environmental Engineering, The Hong Kong University of Science and Technology, Kowloon 999077, Hong Kong, China
| | - Ly-Yun Chang
- Gratia Christian College, Kowloon 999077, Hong Kong, China
- Institute of Sociology, Academia Sinica, Taipei 11529, Taiwan
| | - Cui Guo
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Kowloon 999077, Hong Kong, China
| | - Yiqian Zeng
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Kowloon 999077, Hong Kong, China
| | - Zengli Yu
- Department of Nutrition and Food Hygiene, School of Public Health, Zhengzhou University, Zhengzhou 450000, China
| | - Tony Tam
- Department of Sociology, The Chinese University of Hong Kong, Kowloon 999077, Hong Kong, China
| | - Alexis K H Lau
- Division of Environment and Sustainability, The Hong Kong University of Science and Technology, Kowloon 999077, Hong Kong, China
- Department of Civil and Environmental Engineering, The Hong Kong University of Science and Technology, Kowloon 999077, Hong Kong, China
| | - Xiang Qian Lao
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Kowloon 999077, Hong Kong, China
- Shenzhen Research Institute of The Chinese University of Hong Kong, Shenzhen 518000, China
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Kim YC, Kim E, Jung J, Park JY, Lee H, Kim DK, Kim YS, Lim CS, Lee JP, Kim H. Clinical outcomes associated with long-term exposure to airborne particulate pollution in kidney transplant recipients. Environ Health 2021; 20:61. [PMID: 33992106 PMCID: PMC8126074 DOI: 10.1186/s12940-021-00741-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/30/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Researchers have yet to investigate the specific association between 10-μm particulate matter (PM10) levels and the risk of graft failure, kidney disease, or the functional decline of transplanted kidneys, in kidney transplant recipients (KTRs). Furthermore, we know very little about the association between PM10 levels and the development of allograft rejection in transplanted kidneys. Identification of air pollution as a potential contributor to kidney disease could help reduce future disease burden, stimulate policy discussions on the importance of reducing air pollution with respect to health and disease, and increase public awareness of the hazards of air pollution. We aimed to evaluate the relationship of PM10 with the risk of graft failure, mortality, and decline of graft function in KTRs. METHODS Air pollutant data were obtained from the Korean National Institute of Environmental Research. We then investigated potential associations between these data and the clinical outcomes of 1532 KTRs who underwent kidney transplantation in a tertiary hospital between 2001 and 2015. Survival models were used to evaluate the association between PM10 concentrations and the risk of death-censored graft failure (DCGF), all-cause mortality, and biopsy-proven rejection (BPR), over a median follow-up period of 6.31 years. RESULTS The annual mean PM10 exposure after kidney transplantation was 27.1 ± 8.0 μg/m3. Based on 1-year baseline exposure, 1 μg/m3 increase in PM10 concentration was associated with an increased risk of DCGF (hazard ratio (HR): 1.049; 95% confidence interval (CI): 1.014-1.084) and BPR (HR: 1.053; 95% CI: 1.042-1.063). Fully adjusted models showed that all-cause mortality was significantly associated with 1-year average PM10 concentrations (HR, 1.09; 95% CI, 1.043 to 1.140). CONCLUSIONS Long-term PM10 exposure is significantly associated with BPR, DCGF, and all-cause mortality in KTRs.
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Affiliation(s)
- Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ejin Kim
- Institute of Health and Environment, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Jiyun Jung
- Department of Public Health Science, Institute of Sustainable Development, Institute of Health and Environment, Graduate School of Public Health, Seoul National University, Room 708, Building 220, Gwanak-Ro Gwanak-Gu, Seoul, 08826, Republic of Korea
| | - Jae Yoon Park
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Yon Su Kim
- Kidney Research Institute, Seoul National University Hospital, Seoul, Korea
- Department of Medical Science, Seoul National University College of Medicine, Seoul, Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
- Department of Internal Medicine, Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Seoul, Republic of Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea.
- Department of Internal Medicine, Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Seoul, Republic of Korea.
| | - Ho Kim
- Department of Public Health Science, Institute of Sustainable Development, Institute of Health and Environment, Graduate School of Public Health, Seoul National University, Room 708, Building 220, Gwanak-Ro Gwanak-Gu, Seoul, 08826, Republic of Korea.
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Hwang SY, Jeong S, Choi S, Kim DH, Kim SR, Lee G, Son JS, Park SM. Association of Air Pollutants with Incident Chronic Kidney Disease in a Nationally Representative Cohort of Korean Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073775. [PMID: 33916625 PMCID: PMC8038583 DOI: 10.3390/ijerph18073775] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/16/2022]
Abstract
(1) Background: There is limited information regarding association between long-term exposure to air pollutants and risk of chronic kidney disease (CKD) (2). Methods: This study acquired data of 164,093 adults aged at least 40 years who were residing in 7 metropolitan cities between 2002 and 2005 from the Korean National Health Insurance Service National Sample Cohort database. CKD risk was evaluated using the multivariate Cox hazards proportional regression. All participants were followed up with until CKD, death, or 31 December 2013, whichever occurred earliest. (3) Results: Among 1,259,461 person-years of follow-up investigation, CKD cases occurred in 1494 participants. Air pollutant exposures including PM10, SO2, NO2, CO, and O3 showed no significant association with incident CKD after adjustments for age, sex, household income, area of residence, and the Charlson comorbidity index. The results were consistent in the sensitivity analyses including first and last year annual exposure analyses as well as latent periods-washed-out analyses. (4) Conclusions: Long-term exposure to air pollution is not likely to increase the risk of CKD.
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Affiliation(s)
- Seo Yun Hwang
- School of Health and Environmental Science, Korea University, Seoul 02841, Korea;
| | - Seogsong Jeong
- Department of Biomedical Sciences, Seoul National University Graduate School, Seoul 03080, Korea; (S.J.); (S.C.)
| | - Seulggie Choi
- Department of Biomedical Sciences, Seoul National University Graduate School, Seoul 03080, Korea; (S.J.); (S.C.)
| | - Dong Hyun Kim
- Department of Medicine, Seoul National University College of Medicine, Seoul 03080, Korea; (D.H.K.); (S.R.K.)
| | - Seong Rae Kim
- Department of Medicine, Seoul National University College of Medicine, Seoul 03080, Korea; (D.H.K.); (S.R.K.)
| | - Gyeongsil Lee
- Department of Family Medicine, Seoul National University Hospital, Seoul 03080, Korea;
| | - Joung Sik Son
- Department of Family Medicine, Korea University Guro Hospital, Seoul 08308, Korea;
| | - Sang Min Park
- Department of Biomedical Sciences, Seoul National University Graduate School, Seoul 03080, Korea; (S.J.); (S.C.)
- Department of Family Medicine, Seoul National University Hospital, Seoul 03080, Korea;
- Correspondence:
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59
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Ye JJ, Wang SS, Fang Y, Zhang XJ, Hu CY. Ambient air pollution exposure and risk of chronic kidney disease: A systematic review of the literature and meta-analysis. ENVIRONMENTAL RESEARCH 2021; 195:110867. [PMID: 33582130 DOI: 10.1016/j.envres.2021.110867] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 01/07/2021] [Accepted: 02/06/2021] [Indexed: 06/12/2023]
Abstract
Ambient air pollution has been identified as one of the leading causes of global burden of disease. The relationship between ambient air pollution exposure and risk of chronic kidney disease (CKD) has stimulated increasing scientific interest in the past few years. However, evidence from human epidemiological studies is still limited and inconsistent. We performed an updated systematic review and meta-analysis to clarify the potential association comprehensively. Selected electronic databases were searched for related English language studies until March 1, 2020 with a final follow-up in December 31, 2020. Risk of bias assessment for individual studies were assessed using the OHAT (Office of Health Assessment and Translation) risk-of-bias rating tool. Confidence rating and level-of-evidence conclusions were developed for bodies of evidence for a given ambient air pollutant. Summary effect estimates were calculated using random-effects meta-analyses when three or more studies are identified for the same air pollutant-CKD combination. A total of 13 studies were finally identified in our study. The meta-analytic estimates (ORs) for risk of CKD were 1.15 (95% CI: 1.07, 1.24) for each 10 μg/m3 increase in PM2.5, 1.25 (95% CI: 1.11, 1.40) for each 10 μg/m3 increase in PM10, 1.10 (95% CI: 1.03, 1.17) for each 10 ppb increase in NO2, 1.06 (95% CI: 0.98, 1.15) for each 1 ppb increase in SO2 and 1.04 (95% CI: 1.00, 1.08) for each 0.1 ppm increase in CO, respectively. The level of evidence was appraised as moderate for four of the five tested air pollutant-CKD combinations using an adaptation of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool. In conclusion, this study suggests that certain ambient air pollutant exposure was significantly associated with an increased risk of CKD. Given the limitations, the results of this study should be interpreted with caution, and further well-designed epidemiological studies are needed to draw a definite evidence of a causal relationship.
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Affiliation(s)
- Jia-Jia Ye
- Department of Clinical Medicine, The First School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Shu-Si Wang
- Department of Healthcare-associated Infection Management, Hefei Stomatological Hospital, Anhui Medical University Hefei Oral Clinic College, 265 Changjiang Middle Road, Hefei, 230001, China
| | - Yuan Fang
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000, CA Rotterdam, the Netherlands
| | - Xiu-Jun Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China.
| | - Cheng-Yang Hu
- Department of Humanistic Medicine, School of Humanistic Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China; Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China.
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60
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Feng Y, Jones MR, Chu NM, Segev DL, McAdams-DeMarco M. Ambient Air Pollution and Mortality among Older Patients Initiating Maintenance Dialysis. Am J Nephrol 2021; 52:217-227. [PMID: 33789279 DOI: 10.1159/000514233] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Fine particulate matter (particulate matter with diameter <2.5 µm [PM2.5]) is associated with CKD progression and may impact the health of patients living with kidney failure. While older (aged ≥65 years) adults are most vulnerable to the impact of PM2.5, it is unclear whether older patients on dialysis are at elevated risk of mortality when exposed to fine particulate matter. METHODS Older adults initiating dialysis (2010-2016) were identified from US Renal Data System (USRDS). PM2.5 concentrations were obtained from NASA's Socioeconomic Data and Application Center (SEDAC) Global Annual PM2.5 Grids. We investigated the association between PM2.5 and all-cause mortality using Cox proportional hazard models with linear splines [knot at the current Environmental Protection Agency (EPA) National Ambient Air Quality Standard for PM2.5 of 12 μg/m3] and robust variance. RESULTS For older dialysis patients who resided in areas with high PM2.5, a 10 μg/m3 increase in PM2.5 was associated with 1.16-fold (95% CI: 1.08-1.25) increased risk of mortality; furthermore, those who were female (aHR = 1.26, 95% CI: 1.13-1.42), Black (aHR = 1.31, 95% CI: 1.09-1.59), or had diabetes as a primary cause of kidney failure (aHR = 1.25, 95% CI: 1.13-1.38) were most vulnerable to high PM2.5. While the mortality risk associated with PM2.5 was stronger at higher levels (aHR = 1.19, 95% CI: 1.08-1.32), at lower levels (≤12 μg/m3), PM2.5 was significantly associated with mortality risk (aHR = 1.04, 95% CI: 1.00-1.07) among patients aged ≥75 years (Pslope difference = 0.006). CONCLUSIONS Older adults initiating dialysis who resided in ZIP codes with PM2.5 levels >12 μg/m3 are at increased risk of mortality. Those aged >75 were at elevated risk even at levels below the EPA Standard for PM2.5.
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Affiliation(s)
- Yijing Feng
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Miranda R Jones
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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61
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Liu M, Guo W, Yang H, Zhao L, Fang Q, Li M, Shu J, Jiang Y, Lai X, Yang L, Zhang X. Short-term effects of size-fractionated particulate matters and their constituents on renal function in children: A panel study. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2021; 209:111809. [PMID: 33373927 DOI: 10.1016/j.ecoenv.2020.111809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 06/12/2023]
Abstract
Evidence available on the effects of size-fractionated particulate matters and their constituents on children's renal function is lack. We conducted a longitudinal panel study among 144 children aged 4-12 years with up to 3 repeated visits from 2018 to 2019. We estimated the effects of size-fractionated particle number counts (PNCs) and their 13 constituents on estimated glomerular filtration rate (eGFR) over different lag times with linear mixed-effects models and Bayesian kernel machine regression. We found the inverse dose-responsive associations of 3 sizes PNCs with eGFR were the strongest at lag 2 day. Compared to PNC0.5, PNC1 and PNC2.5 showed stronger and similar effects on eGFR reduction. On average, an interquartile range increase in PNC0.5, PNC1 and PNC2.5 were significantly associated with 1.70%, 2.82% and 2.76% decrease in eGFR, respectively. Girls were more susceptible to the toxicity of PNC1 and PNC2.5 exposure on eGFR. Several constituents including organic carbon (OC), Mg+, PO3- and HC2O4- in 3 sizes PNCs were robustly and consistently linked to eGFR reduction at lag 2 day. Moreover, the cumulative effects of different constituents on lower eGFR were significant, when they were all at or above a size-independent threshold (the 60th, 65th, and 70th percentiles in PNC0.5, PNC1 and PNC2.5 constituents, respectively), compared to their median value. And only OC displayed a significantly detrimental effect on eGFR when all the other constituents were fixed at 25th, 50th, and 75th percentiles. In summary, short-term exposure to PNCs were size-dependent related to reduced eGFR in dose-responsive manner among healthy children, and OC might play a more important role in PNC-induced nephrotoxicity than others.
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Affiliation(s)
- Miao Liu
- Department of Occupational and Environmental Health, School of Public Health, School of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenting Guo
- Department of Occupational and Environmental Health, School of Public Health, School of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Huihua Yang
- Department of Occupational and Environmental Health, School of Public Health, School of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Lei Zhao
- Department of Occupational and Environmental Health, School of Public Health, School of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Qin Fang
- Department of Occupational and Environmental Health, School of Public Health, School of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China; Department of Medical Affairs, Zhuhai People's Hospital, (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, Guangdong, China
| | - Meng Li
- Department of Occupational and Environmental Health, School of Public Health, School of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jingyi Shu
- Department of Occupational and Environmental Health, School of Public Health, School of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yan Jiang
- Department of Occupational and Environmental Health, School of Public Health, School of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xuefeng Lai
- Department of Occupational and Environmental Health, School of Public Health, School of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liangle Yang
- Department of Occupational and Environmental Health, School of Public Health, School of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaomin Zhang
- Department of Occupational and Environmental Health, School of Public Health, School of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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Li G, Huang J, Wang J, Zhao M, Liu Y, Guo X, Wu S, Zhang L. Long-Term Exposure to Ambient PM 2.5 and Increased Risk of CKD Prevalence in China. J Am Soc Nephrol 2021; 32:448-458. [PMID: 33334736 PMCID: PMC8054885 DOI: 10.1681/asn.2020040517] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 10/19/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Fine particulate matter (PM2.5) is an important environmental risk factor for cardiopulmonary diseases. However, the association between PM2.5 and risk of CKD remains under-recognized, especially in regions with high levels of PM2.5, such as China. METHODS To explore the association between long-term exposure to ambient PM2.5 and CKD prevalence in China, we used data from the China National Survey of CKD, which included a representative sample of 47,204 adults. We estimated annual exposure to PM2.5 before the survey date at each participant's address, using a validated, satellite-based, spatiotemporal model with a 10 km×10 km resolution. Participants with eGFR <60 ml/min per 1.73 m2 or albuminuria were defined as having CKD. We used a logistic regression model to estimate the association and analyzed the influence of potential modifiers. RESULTS The 2-year mean PM2.5 concentration was 57.4 μg/m3, with a range from 31.3 to 87.5 μg/m3. An increase of 10 μg/m3 in PM2.5 was positively associated with CKD prevalence (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.22 to 1.35) and albuminuria (OR, 1.39; 95% CI, 1.32 to 1.47). Effect modification indicated these associations were significantly stronger in urban areas compared with rural areas, in males compared with females, in participants aged <65 years compared with participants aged ≥65 years, and in participants without comorbid diseases compared with those with comorbidities. CONCLUSIONS These findings regarding the relationship between long-term exposure to high ambient PM2.5 levels and CKD in the general Chinese population provide important evidence for policy makers and public health practices to reduce the CKD risk posed by this pollutant.
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Affiliation(s)
- Guoxing Li
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China,Department of Occupational and Environmental Health Sciences, Peking University School of Public Health, Beijing, China
| | - Jing Huang
- Department of Occupational and Environmental Health Sciences, Peking University School of Public Health, Beijing, China
| | - Jinwei Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China,Institute of Nephrology, Peking University, Beijing, China,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education of the People’s Republic of China, Beijing, China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China,Institute of Nephrology, Peking University, Beijing, China,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education of the People’s Republic of China, Beijing, China
| | - Yang Liu
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Xinbiao Guo
- Department of Occupational and Environmental Health Sciences, Peking University School of Public Health, Beijing, China
| | - Shaowei Wu
- Department of Occupational and Environmental Health Sciences, Peking University School of Public Health, Beijing, China,Key Laboratory of Molecular Cardiovascular Sciences, Peking University, Ministry of Education, Beijing, China
| | - Luxia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China,Institute of Nephrology, Peking University, Beijing, China,Key Laboratory of Renal Disease, Ministry of Health of the People’s Republic of China, Beijing, China,National Institutes of Health Data Science at Peking University, Beijing, China
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Kelly JT, Su G, Zhang L, Qin X, Marshall S, González-Ortiz A, Clase CM, Campbell KL, Xu H, Carrero JJ. Modifiable Lifestyle Factors for Primary Prevention of CKD: A Systematic Review and Meta-Analysis. J Am Soc Nephrol 2021; 32:239-253. [PMID: 32868398 PMCID: PMC7894668 DOI: 10.1681/asn.2020030384] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/20/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Despite increasing incidence of CKD, no evidence-based lifestyle recommendations for CKD primary prevention apparently exist. METHODS To evaluate the consistency of evidence associating modifiable lifestyle factors and CKD incidence, we searched MEDLINE, Embase, CINAHL, and references from eligible studies from database inception through June 2019. We included cohort studies of adults without CKD at baseline that reported lifestyle exposures (diet, physical activity, alcohol consumption, and tobacco smoking). The primary outcome was incident CKD (eGFR<60 ml/min per 1.73 m2). Secondary outcomes included other CKD surrogate measures (RRT, GFR decline, and albuminuria). RESULTS We identified 104 studies of 2,755,719 participants with generally a low risk of bias. Higher dietary potassium intake associated with significantly decreased odds of CKD (odds ratio [OR], 0.78; 95% confidence interval [95% CI], 0.65 to 0.94), as did higher vegetable intake (OR, 0.79; 95% CI, 0.70 to 0.90); higher salt intake associated with significantly increased odds of CKD (OR, 1.21; 95% CI, 1.06 to 1.38). Being physically active versus sedentary associated with lower odds of CKD (OR, 0.82; 95% CI, 0.69 to 0.98). Current and former smokers had significantly increased odds of CKD compared with never smokers (OR, 1.18; 95% CI, 1.10 to 1.27). Compared with no consumption, moderate consumption of alcohol associated with reduced risk of CKD (relative risk, 0.86; 95% CI, 0.79 to 0.93). These associations were consistent, but evidence was predominantly of low to very low certainty. Results for secondary outcomes were consistent with the primary finding. CONCLUSIONS These findings identify modifiable lifestyle factors that consistently predict the incidence of CKD in the community and may inform both public health recommendations and clinical practice.
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Affiliation(s)
- Jaimon T. Kelly
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Guobin Su
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China
| | - La Zhang
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China
| | - Xindong Qin
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China
| | - Skye Marshall
- Bond University Nutrition and Dietetics Research Group, Faculty of Health Science and Medicine, Bond University, Gold Coast, Queensland, Australia,Nutrition Research Australia, Sydney, New South Wales, Australia
| | - Ailema González-Ortiz
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Nephrology and Mineral Metabolism Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Catherine M. Clase
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Katrina L. Campbell
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Hong Xu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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64
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Zhang Y, Liu D, Liu Z. Fine Particulate Matter (PM 2.5) and Chronic Kidney Disease. REVIEWS OF ENVIRONMENTAL CONTAMINATION AND TOXICOLOGY 2021; 254:183-215. [PMID: 34529145 DOI: 10.1007/398_2020_62] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The impact of ambient particulate matter (PM) on public health has become a great global concern, which is especially prominent in developing countries. For health purposes, PM is typically defined by size, with the smaller particles having more health impacts. Particles with a diameter <2.5 μm are called PM2.5. Initial research studies have focused on the impact of PM2.5 on respiratory and cardiovascular diseases; nevertheless, an increasing number of data suggested that PM2.5 may affect every organ system in the human body, and the kidney is of no exception. The kidney is vulnerable to particulate matter because most environmental toxins are concentrated by the kidney during filtration. According to the high morbidity and mortality related to chronic kidney disease, it is necessary to determine the effect of PM2.5 on kidney disease and its mechanism that needs to be identified. To understand the current status of PM2.5 in the atmosphere and their potential harmful kidney effects in different regions of the world this review article was prepared based on peer-reviewed scientific papers, scientific reports, and database from government organizations published after the year 1998. In this review, we focus on the worldwide epidemiological evidence linking PM2.5 with chronic kidney disease and the effect of PM2.5 on the chronic kidney disease (CKD) progression. At the same time, we also discuss the possible mechanisms of PM2.5 exposure leading to kidney damage, in order to emphasize the contribution of PM2.5 to kidney damage. A global database on PM2.5 and kidney disease should be developed to provide new ideas for the prevention and treatment of kidney disease.
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Affiliation(s)
- Yilin Zhang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, P. R. China
- Research Center for Kidney Disease, Zhengzhou, Henan Province, P. R. China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, P. R. China
- Core Unit of National Clinical Medical Research Center of Kidney Disease, Zhengzhou, P. R. China
| | - Dongwei Liu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China.
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, P. R. China.
- Research Center for Kidney Disease, Zhengzhou, Henan Province, P. R. China.
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, P. R. China.
- Core Unit of National Clinical Medical Research Center of Kidney Disease, Zhengzhou, P. R. China.
| | - Zhangsuo Liu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China.
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, P. R. China.
- Research Center for Kidney Disease, Zhengzhou, Henan Province, P. R. China.
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, P. R. China.
- Core Unit of National Clinical Medical Research Center of Kidney Disease, Zhengzhou, P. R. China.
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Affiliation(s)
- Ziyad Al-Aly
- Clinical Epidemiology Center, Research and Development Service, Saint Louis, Missouri; .,Veterans Research & Education Foundation of St. Louis, Saint Louis, Missouri.,Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri.,Nephrology Section, Medicine Service, Veterans Affairs Saint Louis Health Care System, Saint Louis, Missouri.,Institute for Public Health, Washington University in Saint Louis, Saint Louis, Missouri; and
| | - Benjamin Bowe
- Clinical Epidemiology Center, Research and Development Service, Saint Louis, Missouri.,Veterans Research & Education Foundation of St. Louis, Saint Louis, Missouri.,Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri
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