Chronic kidney disease staging in nursing home and community older adults: does the choice of cockcroft-gault, modification of diet in renal disease study, or the chronic kidney disease epidemiology collaboration initiative equations matter?

Transforming growth factor beta (TGF-β) is activated by the CtBP2-p300-AP1 transcriptional complex in chronic renal failure

Chronic renal failure (CRF), also known as chronic kidney disease (CKD), is a common renal disorder characterized by gradual kidney dysfunction. Molecular dissection reveals that transforming growth factor beta (TGF-β) plays a central role in the pathogenesis of CRF. However, the mechanism underlying TGF-β upregulation has not been demonstrated. Here, we verified that the elevated level of TGF-β was associated with the severity of CRF stages and the activation of TGF-β-mediated signaling in 120 renal biopsies from CRF patients. By analyzing the promoter region of the TGFB1 gene, we identified one AP-1 (activator protein 1) and four NF-κB (nuclear factor kappa-light-chain-enhancer of activated B cells) binding sites. Knockdown of two AP-1 subunits (c-Jun and c-FOS) or blockage of AP-1 signaling with two inhibitors T-5224 and SR11302 could cause the downregulation of TGFB1, whereas knockdown of two NF-κB subunits (p65 and p50) or blockage of NF-κB signaling with two inhibitors TPCA1 and BOT-64 could not change the expression of TGFB1. Using mass spectrometry and coimmunoprecipitation analyses, we found that both c-Jun and c-FOS formed a complex with CtBP2 (C-terminal binding protein 2) and histone acetyltransferase p300. Our in vitro data demonstrated that induction of CtBP2 by recombinant IL-1β (interleukin-1 beta) led to the upregulation of TGFB1 and the activation of TGF-β downstream signaling, while knockdown of CtBP2 resulted in the reversed effects. Using chromatin immunoprecipitation assays, we revealed that the CtBP2-p300-AP1 complex specifically bound to the promoter of TGFB and that knockdown or blockage of CtBP2 significantly decreased the occupancies of the p300 and AP-1 subunits. Our results support a model in which the CtBP2-p300-AP1 transcriptional complex activates the expression of TGFB1, increasing its production and extracellular secretion. The secreted TGF-β binds to its receptors and initiates downstream signaling.

Competing Risks of Fracture and Death in Older Adults with Chronic Kidney Disease

OBJECTIVES

To examine whether chronic kidney disease (CKD) at any stage is associated with fracture risk after adjusting for competing mortality and to determine whether age or race modify the relationship between CKD and fracture risk.

DESIGN

Prospective cohort study.

SETTING

Department of Veterans Affairs (VA) national healthcare system.

PARTICIPANTS

Men receiving VA primary care aged 65 and older with no history of fracture or osteoporosis therapy (N = 712, 918).

MEASUREMENTS

We determined CKD stage from baseline estimated glomerular filtration rate (eGFR). Participants were followed for up to 10 years for occurrence of any fracture or death. We ascertained fractures and covariates from VA medical records and Medicare claims.

RESULTS

Of the 356,459 older veterans with CKD (defined as eGFR <60 mL/min per 1.73 m² ), 15.7% (n = 56,032) experienced a fracture, and 43.0% (n = 153,438) died over a median time at risk of 5.2 years. Veterans with CKD Stages 3 to 5 had a greater risk of death than those without CKD, which biased estimates from traditional survival models. Competing risk models showed that Stage 3 CKD was associated with greater hazard (adjusted subdistribution hazard ratio (sdHR) = 1.07, 95% confidence interval (CI) = 1.02-1.11) of fracture (than those without CKD) and a trend toward greater hazard for Stage 4 (sdHR = 1.07, 95% CI = 0.94-1.22) and Stage 5 (sdHR = 1.31, 95% CI = 0.97-1.77) CKD. Age, race, and bone mineral density did not modify the relationship between CKD and fracture risk.

CONCLUSIONS

In older male veterans, CKD, including Stage 3, is associated with a moderately greater fracture risk irrespective of age, race, or bone mineral density.

Clinical Update on Nursing Home Medicine: 2016

This is the tenth clinical update. It covers chronic kidney disease, dementia, hypotension, polypharmacy, rapid geriatric assessment, and transitional care.

Renal Insufficiency and Medication in Nursing Home Residents. A Cross-Sectional Study (IMREN)

BACKGROUND

Nursing home residents often suffer from a multiplicity of medical conditions and take many different drugs. Many drugs are eliminated via the kidneys and thus require dose adjustment in patients with renal insufficiency. This is the first study to address the prevalence of renal insufficiency among nursing home residents in Germany, and the extent to which such persons take drugs that are contraindicated or incorrectly dosed because of renal insufficiency.

METHODS

We carried out a cross-sectional study in nursing homes in the German regions of Bremen and Lower Saxony. Data were collected by nursing staff and given to us anonymously. Whenever the nursing home data did not include a current creatinine value, the patient's general practitioner was asked to supply this value. The estimated creatinine clearance (eCCr) was calculated with the Cockcroft-Gault formula.

RESULTS

852 residents of 21 nursing homes were included in the study; eCCr values were obtainable for 685 (80.4%) of them (average age, 83.3 years; 75.2% female). 48.2% of these patients (95% confidence interval [CI] 41.8-54.5) had moderate renal insufficiency (eCCr 59-30 mL/min), and 15.5% (95% CI 12.4-18.6) had severe renal insufficiency (eCCr <30 mL/min). 19.7% were regularly taking at least one medication that was contraindicated or incorrectly dosed in the light of renal insufficiency. Predictors for such inappropriate drug use were advanced age, female sex, arterial hypertension, and polypharmacy. The drugs that were most often inappropriately used were metformin, ramipril, and potassium chloride.

CONCLUSION

Nursing home residents often suffer from renal insufficiency and should therefore have their creatinine levels measured regularly. A knowledge of the creatinine level is a prerequisite for the proper adjustment of drug doses (if necessary). A practical and compact summary of dose-adjustment recommendations for patients with renal insufficiency would be desirable but is not yet available.

Chronic kidney disease and recurrent falls in nursing home residents: a retrospective cohort study

This study examined whether chronic kidney disease (CKD) is associated with recurrent falls in older adults in nursing homes (NHs). We used data abstracted over a six month period from 510 NH residents with a history of falls. Thirty-five percent of the NH residents had CKD. In adjusted analyses, the incidence of recurrent falls was similar in those with and without CKD [fall rate ratio (FRR) 1.00, 95% confidence interval (CI) 0.97-1.02]. Orthostatic hypotension (FRR 1.52, 95% CI 1.12-2.05), history of falls during the prior six month period (FRR 1.25, 95% CI 1.05-1.49), cane or walker use (FRR 1.64, 95% CI 1.16-2.33), and ambulatory dysfunction (FRR 1.47, 95% CI 1.23-1.75) were independently associated with increased fall rate. CKD was not an important predictor of falls in this cohort of nursing home residents with prior falls. Instead, traditional fall risk factors were much more strongly associated with recurrent falls.