Dipstick proteinuria as a predictor of all-cause and cardiovascular disease mortality in Bangladesh: A prospective cohort study

Persistent proteinuria is associated with the occurrence of cardiovascular disease: a nationwide population-based cohort study

Proteinuria is an important risk factor for cardiovascular disease (CVD) and acts as a surrogate marker of renal damage. This study aimed to determine the association between changes in proteinuria and the occurrence of CVD. In our study, 1,708,712 participants who consecutively underwent national health examinations from 2003-2004 (first period) to 2005-2006 (second period) were included. They were classified into four groups based on the presence of proteinuria at the two consecutive health examinations: (1) normal (0 → 0), (2) proteinuria-improved (participants who had improved proteinuria (+ 1 → 0, + 2 → ≤ +1 [0 or + 1], ≥ +3 → ≤ +2 [0, + 1 or + 2]), (3) proteinuria-progressed (0 → ≥ +1, + 1 → ≥ +2, + 2 → ≥ +3), and (4) proteinuria-persistent (+ 1 → +1, + 2 → +2, ≥ +3 → ≥ +3). We used a multivariate Cox proportional hazards model to assess the occurrence of CVD according to changes of presence and severity of proteinuria. During a median of 14.2 years of follow-up, 143,041 participants (event rate, 8.37%) with composite CVD were observed. Compared with the normal group, the risk of incident risk of CVD was increased according to the severity of proteinuria in each of the persistent, progressed, and improved groups (p for trend < 0.001). In a pairwise comparison, the risk of composite CVD in the improved (hazard ratio [HR]: 1.32, 95% confidence interval [CI]: 1.27-1.37), progressed (HR: 1.49, 95% CI: 1.44-1.54), and persistent groups (HR: 1.78, 95% CI: 1.64-1.94) were higher than that of the normal group. Furthermore, the improved group had a relatively lower risk of composite CVD compared to the persistent group (HR: 0.75, 95% CI: 0.69-0.83, p < 0.001). The incidence risk of composite CVD was associated with changes of presence and severity of proteinuria. Persistent proteinuria may be associated with increased risk of CVD, even compared with improved or progressed proteinuria status.

Changes in proteinuria and the associated risks of ischemic heart disease, acute myocardial infarction, and angina pectoris in Korean population

OBJECTIVES

Proteinuria is widely used to predict cardiovascular risk. However, there is insufficient evidence to predict how changes in proteinuria may affect the incidence of cardiovascular disease.

METHODS

The study included 265,236 Korean adults who underwent health checkups in 2003-2004 and 2007-2008. They were categorized into 4 groups based on changes in proteinuria (negative: negative → negative; resolved: proteinuria ≥1+ → negative; incident: negative → proteinuria ≥1+; persistent: proteinuria ≥1+ → proteinuria ≥1+). We conducted 6 years of follow-up to identify the risks of developing ischemic heart disease (IHD), acute myocardial infarction (AMI), and angina pectoris according to changes in proteinuria. A multivariate Cox proportional-hazards model was used to calculate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for incident IHD, AMI, and angina pectoris.

RESULTS

The IHD risk (expressed as HR [95% CI]) was the highest for persistent proteinuria, followed in descending order by incident and resolved proteinuria, compared with negative proteinuria (negative: reference, resolved: 1.211 [95% CI, 1.104 to 1.329], incident: 1.288 [95% CI, 1.184 to 1.400], and persistent: 1.578 [95% CI, 1.324 to 1.881]). The same pattern was associated with AMI (negative: reference, resolved: 1.401 [95% CI, 1.048 to 1.872], incident: 1.606 [95% CI, 1.268 to 2.035], and persistent: 2.069 [95% CI, 1.281 to 3.342]) and angina pectoris (negative: reference, resolved: 1.184 [95% CI, 1.065 to 1.316], incident: 1.275 [95% CI, 1.160 to 1.401], and persistent: 1.554 [95% CI, 1.272 to 1.899]).

CONCLUSIONS

Experiencing proteinuria increased the risks of IHD, AMI, and angina pectoris even after proteinuria resolved.

Chronic kidney disease prevention campaign: relationship between proteinuria and elderly people

OBJECTIVE

To verify the relationship between the presence of proteinuria as a renal injury marker in elderly without history of systemic arterial hypertension and cardiovascular diseases. A cross-sectional study was developed from January 2014 to December 2019, through kidney disease prevention campaigns promoted by the Federal University of Ceará in the city of Fortaleza.

METHODS

The sample consisted of 417 elderlies. A questionnaire was used to characterize individuals and assess previous diseases, and urinalysis reagent strips were used to assess proteinuria.

RESULTS

Statistically significant differences (p < 0.05) and moderate effect sizes were found for blood pressure levels (CI 0.53-0.93), systolic blood pressure, and diastolic blood pressure (CI 0.21-0.61). Significant differences in capillary glycemia were also found between groups (p = 0.033), but with a low effect size (0.02-0.42). The group with comorbidities was 2.94 times more likely to have proteinuria than those without comorbidities (OR 2.94, CI 1.55-4.01; p < 0.05). In the group without cardiovascular disease/high blood pressure, a statistically significant association was found for previous diabetes and proteinuria (p = 0.037), presenting 2.68 times higher risk of proteinuria in those with diabetes mellitus (OR 2.68, CI 1.05-6.85). Significant association was also found between age groups, with the older group having 2.69 times higher risk of developing proteinuria (75 to 90 compared to 60 to 74 years) (CI 1.01-7.16; p = 0.045).

CONCLUSION

Even without systemic arterial hypertension or cardiovascular disease, diabetes and older age can be considered high risk factors for proteinuria.

Mechanistic insight into the protective effects of fisetin against arsenic-induced reproductive toxicity in male rats

Arsenic is one of the most hazardous environmental contaminants, which adversely affects the dynamics of male reproductive system. Fisetin (FIS) is a bioactive flavonoid, which is known to exert strong antioxidative effects. Therefore, the current research was planned to evaluate the alleviative efficacy of FIS against arsenic-induced reproductive damages. Forty-eight male albino rats were divided into 4 groups (n = 12), which were treated as follows: (1) Control, (2) Arsenic-intoxicated group (8 mg kg-1), (3) Arsenic + FIS-treated group (8 mg kg-1 + 10 mg kg-1), and (4) FIS-treated group (10 mgkg-1). After 56 days of treatment, the biochemical, lipidemic, steroidogenic, hormonal, spermatological, apoptotic and histoarchitectural profiles of rats were analyzed. Arsenic intoxication reduced the enzymatic activities of catalase (CAT), superoxide dismutase (SOD), glutathione peroxidase (GPx) and glutathione reductase (GSR), in addition to glutathione (GSH) level. Conversely, the levels of thiobarbituric acid reactive substance (TBARS) and reactive oxygen species (ROS) were increased. Moreover, it escalated the level of low-density lipoprotein (LDL), triglycerides and total cholesterol, while declining the level of high-density lipoprotein (HDL). Furthermore, steroidogenic enzymes expressions, 3β-hydroxysteroid dehydrogenase (HSD), 17β-HSD, steroidogenic acute regulatory protein (StAR), cholesterol side-chain cleavage enzyme (CYP11A1) and 17α-hydroxylase/17, 20-lyase (CYP17A1), were found to be reduced, which brought down the level of testosterone. Besides, the levels of gonadotropins (LH and FSH) were decreased. Additionally, a decline in sperm mitochondrial membrane potential (MMP), motility, epididymal sperm count and hypo-osmotic swelling (HOS) coil-tailed sperms was observed, whereas the dead sperms and structural damages (head, midpiece and tail) of sperms were escalated. Moreover, arsenic exposure up-regulated the mRNA expressions of apoptotic markers, namely Bax and caspase-3, whereas lowered the expression of anti-apoptotic marker, Bcl-2. In addition, it induced histoarchitectural changes in testes of rats. However, FIS treatment resulted in remarkable improvements in testicular and sperm parameters. Therefore, it was inferred that FIS could serve as a therapeutic candidate against arsenic-generated male reproductive toxicity attributing to its anti-oxidant, anti-lipoperoxidative, anti-apoptotic, and androgenic efficacy.

Recent Advances in Biosensor Technologies for Point-of-Care Urinalysis

Human urine samples are non-invasive, readily available, and contain several components that can provide useful indicators of the health status of patients. Hence, urine is a desirable and important template to aid in the diagnosis of common clinical conditions. Conventional methods such as dipstick tests, urine culture, and urine microscopy are commonly used for urinalysis. Among them, the dipstick test is undoubtedly the most popular owing to its ease of use, low cost, and quick response. Despite these advantages, the dipstick test has limitations in terms of sensitivity, selectivity, reusability, and quantitative evaluation of diseases. Various biosensor technologies give it the potential for being developed into point-of-care (POC) applications by overcoming these limitations of the dipstick test. Here, we present a review of the biosensor technologies available to identify urine-based biomarkers that are typically detected by the dipstick test and discuss the present limitations and challenges that future development for their translation into POC applications for urinalysis.

Campanha de prevenção de doença renal crônica: relação entre proteinúria e idosos

Resumo Objetivo: Verificar a relação entre a presença de proteinúria como marcador de lesão renal em idosos sem histórico de hipertensão arterial sistêmica e doenças cardiovasculares. Um estudo transversal foi desenvolvido de Janeiro de 2014 a Dezembro de 2019, por meio de campanhas de prevenção a doenças renais promovidas pela Universidade Federal do Ceará, na cidade de Fortaleza. Métodos: A amostra foi composta por 417 idosos. Um questionário foi usado para caracterizar indivíduos e avaliar doenças prévias, e foram utilizadas tiras reagentes de urinálise para avaliar proteinúria. Resultados: Diferenças estatisticamente significativas (p < 0,05) e tamanhos de efeito moderados foram encontrados para níveis de pressão arterial (IC 0,53-0,93), pressão arterial sistólica e pressão arterial diastólica (IC 0,21-0,61). Também foram encontradas diferenças significativas na glicemia capilar entre grupos (p = 0,033), mas com um tamanho de efeito baixo (0,02–0,42). O grupo com comorbidades apresentou 2,94 vezes mais probabilidade de ter proteinúria do que aqueles sem comorbidades (OR 2,94; IC 1,55-4,01; p < 0,05). No grupo sem doença cardiovascular/hipertensão, foi encontrada uma associação estatisticamente significativa para diabetes anterior e proteinúria (p = 0,037), apresentando risco 2,68 vezes maior de proteinúria naqueles com diabetes mellitus (OR 2,68; IC 1,05-6,85). Também foi encontrada uma associação significativa entre faixas etárias, com o grupo mais velho apresentando risco 2,69 vezes maior de desenvolver proteinúria (75 a 90 em comparação com 60 a 74 anos) (IC 1,01-7,16; p = 0,045). Conclusão: Mesmo sem hipertensão arterial sistêmica ou doença cardiovascular, o diabetes e a idade avançada podem ser considerados fatores de alto risco para proteinúria.

The association between changes in proteinuria and the risk of cerebral infarction in the Korean population

BACKGROUND

Proteinuria is a risk factor for cerebral infarction. It is known that proteinuria can change over time. However, published data is scarce for the association between changes in proteinuria and the risk of cerebral infarction.

METHOD

Study participants were 276,861 Koreans who were assessed for urine dipstick proteinuria both in 2003-2004 and 2007-2008. They were categorized into four groups by changes in proteinuria over 4 years (negative: negative → negative, resolved: proteinuria ≥ 1+ → negative, incident: negative → proteinuria ≥ 1+, persistent: proteinuria ≥ 1+ → proteinuria ≥ 1 + ). We used multivariate adjusted Cox-proportional hazard model in calculating the adjusted hazard ratios (HR) and 95% confidence interval (CI) for cerebral infarction until 2013 according to changes in proteinuria.

RESULT

Adjusted HR and 95% CI for cerebral infarction significantly increased in order of persistent, incident, and resolved proteinuria, compared with negative proteinuria (negative: reference, resolved: 1.166 [1.009-1.347], incident: 1.345 [1.188-1.522], and persistent: 1.443 [1.089-1.912]). In gender subgroup analysis, men showed the more clear association between changes in proteinuria and the risk of cerebral infarction (negative: reference, resolved: 1.284 [1.057-1.560], incident: 1.351 [1.149-1.589], and persistent: 1.428 [1.014-2.012]).

CONCLUSION

All types of proteinuria changes were associated with the increased risk of cerebral infarction, even in participants with once manifested but vanishing proteinuria.

Proteinuria is independently associated with carotid atherosclerosis: a multicentric study

BACKGROUND AND AIMS

Atherosclerosis is a vital cause of cardiovascular diseases. The correlation between proteinuria and atherosclerosis, however, has not been confirmed. This study aimed to assess whether there is a relationship between proteinuria and atherosclerosis.

METHODS

From January 2016 to September 2020, 13,545 asymptomatic subjects from four centres in southern China underwent dipstick proteinuria testing and carotid atherosclerosis examination. Data on demography and past medical history were collected, and laboratory examinations were performed. The samples consisted of 7405 subjects (4875 males and 2530 females), excluding subjects failing to reach predefined standards and containing enough information. A multivariate logistic regression model was used to adjust the influence of traditional risk factors for atherosclerosis on the results.

RESULTS

Compared with proteinuria-negative subjects, proteinuria-positive subjects had a higher prevalence rate of carotid atherosclerosis. The differences were statistically significant (22.6% vs. 26.7%, χ² = 10.03, p = 0.002). After adjusting for common risk factors for atherosclerosis, age, sex, BMI, blood lipids, blood pressure, renal function, hypertensive disease, diabetes mellitus and hyperlipidaemia, proteinuria was an independent risk factor for atherosclerosis (OR = 1.191, 95% CI 1.015-1.398, p = 0.033). The Hosmer-Lemeshow test was used to test the risk prediction model of atherosclerosis, and the results showed that the model has high goodness of fit and strong independent variable prediction ability.

CONCLUSIONS

Proteinuria is independently related to carotid atherosclerosis. With the increase in proteinuria level, the risk of carotid atherosclerotic plaque increases. For patients with positive proteinuria, further examination of atherosclerosis should not be ignored.

Comparison of dipstick and quantitative tests for proteinuria and hematuria in middle-aged, male Japanese employees: A single-center study

BACKGROUND AND AIMS

The early and reliable detection of chronic kidney disease is important. In the present study, we aimed to compare the diagnostic results for proteinuria and hematuria between the dipstick test used in primary occupational health examinations and the quantitative tests used in more thorough examinations in clinics.

METHODS

We conducted a single-center observational study of male staff (N = 573) at Kagoshima University who underwent a health examination in 2017. Both dipsticks and biochemical methods were used to assess proteinuria and hematuria.

RESULTS

For the dipstick test, the sensitivity, specificity, and positive predictive value were 55.6%, 92.4% and 10.4% for proteinuria, and 64.3%, 98.3% and 66.7% for hematuria, respectively. Four participants for whom false-negative results were obtained using dipsticks for proteinuria, and two of these had 3+ urinary glucose.

CONCLUSION

Qualitative tests for proteinuria and hematuria had low sensitivities and positive predictive values. Therefore, for the early and reliable detection of chronic kidney disease, the use of quantitative urine tests should be considered during occupational health examinations.

Urine albumin dipstick independently predicts cardiovascular and renal outcomes among rural Thai population: a 14-year retrospective cohort study

Background

Albuminuria is an established risk marker for both cardiovascular and renal outcomes. In this study, we expected to use portable and inexpensive test strips to detect urine albumin level for risk stratification in cardiovascular and renal outcomes among rural Thai community.

Objective

To evaluate the relationship between urine albumin dipstick and cardiovascular and renal complications in rural Thai population.

Methods

We conducted a retrospective study in 635 rural Thai adults who tested urine albuminuria by using commercial urine albumin dipstick and the Micral-albumin test II strips at baseline. The subjects were divided into normoalbuminuria (albumin < 20 mg/L), microalbuminuria (albumin 20–200 mg/L), or macroalbuminuria (Urine dipstick at least 1+ or albumin > 200 mg/L). We collected data on the incidences of primary composite outcomes including cardiovascular or renal morbidity and mortality. Incident density and cox regression were analyzed to evaluate the association between albuminuria status and primary composite outcome.

Results

During an average 14-year follow-up, 102 primary composite events occurred including 59 (13.1%), 32 (20.6%) and 11 (39.3%) among 452, 155, and 28 subjects with normoalbuminuria, microalbuminuria, and macroalbuminuria, respectively. Incident densities of primary composite outcome were elevated continually according to the degree of albuminuria (9.36, 17.11 and 38.12 per 1000 person-years). Compared with the subjects without albuminuria, subjects with microalbuminuria and macroalbuminuria at baseline had higher risk for primary composite outcome in univariate model. After multivariate analysis was performed, the effect of macroalbuminuria was only persisted with 3.13-fold risk (adjusted HR 3.13; 95% CI 1.40–6.96, P= 0.005).

Conclusion

Albuminuria from semi-quantitative methods is an important factor predicting cardiovascular and renal risk among subjects in Thai rural population. Our findings support to also incorporating urine albumin dipstick into assessments of cardiovascular risk in the general population.

Effect of Renin-Angiotensin System Blockade on Mortality in Korean Hypertensive Patients with Proteinuria

Background

Although renin-angiotensin system (RAS) blockade is recommended for hypertensive patients with proteinuria, the effect of RAS blockade on Korean hypertensive patients has not been investigated.

Methods

Among individuals who underwent a National Health Examination between 2002 and 2003 in Korea, hypertensive patients with proteinuria (defined as a dipstick test result ≥2+) were enrolled in this study. We investigated the outcomes of two groups stratified by RAS blockade prescription (with RAS blockade vs. without RAS blockade). Moreover, Cox proportional hazard regression and Kaplan-Meier analyses were performed to examine the effects of RAS blockade on mortality and end-stage renal disease (ESRD).

Results

A total of 8,460 patients were enrolled in this study, of whom 6,236 (73.7%) were prescribed with RAS blockade. The mean follow-up period was 129 months. A total of 1,003 (11.9%) patients died, of whom 273 (3.2%) died of cardiovascular (CV) events. The Kaplan-Meier curves for all-cause or CV mortality showed that the survival probability was significantly higher in the RAS blockade group than in the non-RAS blockade group. Multivariate Cox analysis also revealed RAS blockade significantly reduced the all-cause and CV mortality rates by 39.1% and 33.7%, respectively, compared with non-RAS blockade, even after adjusting for age, sex, and comorbid diseases; however, ESRD was not affected.

Conclusion

In this study, we found that RAS blockade was significantly associated with a reduction in mortality but not in the incidence of ESRD. However, 26.3% of the enrolled patients did not use RAS blockade. Physicians need to consider the usefulness of RAS blockade in hypertensive patients with proteinuria.

Identifying Synergistic Mechanisms of Multiple Ingredients in Shuangbai Tablets against Proteinuria by Virtual Screening and a Network Pharmacology Approach

Shuangbai Tablets (SBT), a traditional herbal mixture, has shown substantial clinical efficacy. However, a systematic mechanism of its active ingredients and pharmacological mechanisms of action against proteinuria continues being lacking. A network pharmacology approach was effectual in discovering the relationship of multiple ingredients and targets of the herbal mixture. This study aimed to identify key targets, major active ingredients, and pathways of SBT against proteinuria by network pharmacology approach combined with thin layer chromatography (TLC). Human phenotype (HP) disease analysis, gene ontology (GO) analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis, and molecular docking were used in this study. To this end, a total of 48 candidate targets of 118 active ingredients of SBT were identified. Network analysis showed PTGS2, ESR1, and NOS2 to be the three key targets, and beta-sitosterol, quercetin, and berberine were the three major active ingredients; among them one of the major active ingredients, quercetin, was discriminated by TLC. These results of the functional enrichment analysis indicated that the most relevant disease including these 48 candidate proteins is proteinuria, SBT treated proteinuria by sympathetically regulating multiple biological pathways, such as the HIF-1, RAS, AGE-RAGE, and VEGF signaling pathways. Additionally, molecular docking validation suggested that major active ingredients of SBT were capable of binding to HIF-1A and VEGFA of the main pathways. Consequently, key targets, major active ingredients, and pathways based on data analysis of SBT against proteinuria were systematically identified confirming its utility and providing a new drug against proteinuria.

Two-year changes in proteinuria and risk for myocardial infarction in patients with hypertension: a prospective cohort study

OBJECTIVE

To assess whether changes in proteinuria are associated with the incidence of myocardial infarction (MI) in patients with hypertension.

METHODS

The Kailuan study was a prospective longitudinal cohort study on cardiovascular risk factors and events. Hazard ratios with 95% confidence intervals (CIs) were calculated using Cox regression models.

RESULTS

A total of 24 926 hypertensive patients (mean age: 55.2 ± 10.9 years) without previous MI were included. After a mean follow-up of 6.8 years, 382 (1.5%) individuals developed MI. Participants with proteinuria at baseline had a 60% higher risk for developing MI as compared with participants without proteinuria at baseline (hazard ratio: 1.60, 95% CI: 1.12-2.29) after adjusting for dyslipidemia, diabetes mellitus and other cardiovascular risk factors. Compared with participants without proteinuria, individuals with incident proteinuria or persistent proteinuria during the follow-up had 54 and 141% higher risks for developing MI, respectively (hazard ratio: 1.54, 95% CI: 1.14-2.09 and hazard ratio: 2.41, 95% CI: 1.59-3.66; all P < 0.05).

CONCLUSION

Proteinuria is associated with an increased incidence of MI, but the association is likely to be underestimated if baseline measurements of proteinuria are used. Measures of changes in proteinuria, particular persistent proteinuria, are more likely to reflect the lifetime risk for MI.

Changes in proteinuria and the risk of myocardial infarction in people with diabetes or pre-diabetes: a prospective cohort study

Background

The relationship between changes in proteinuria and myocardial infarction (MI) remains unclear in people with diabetes or pre-diabetes. We aimed to evaluate the predictive value and independent role of changes in proteinuria over a 2-year period in the incidence of MI in people with diabetes or pre-diabetes.

Methods

Based on the baseline and 2-year dipstick screening results from the Kailuan prospective cohort study, participants were divided into four categories: no proteinuria, remittent proteinuria, incident proteinuria, and persistent proteinuria. Four multivariable Cox proportional hazard models were built to adjust for the effects of different confounding covariates.

Results

Among the 17,625 participants in this study, there were a total of 238 incidents of MI during a median follow-up of 6.69 years. After adjusting for demography factors and laboratory indices, the association between persistent proteinuria and MI incidence was maintained (hazard ratio [HR] 2.50, 95% confidence interval [CI] 1.48–4.22). Every decrease of proteinuria from 2006 to 2008 was observed to be responsible for a 21% decline of MI incidence (HR 0.79, 95% CI 0.68–0.90). The interaction between changes in proteinuria and diabetes was confirmed with no effect on MI (P = 0.3371).

Conclusions

Persistent proteinuria is an independent risk factor for MI incidence in the pre-diabetic and diabetic population. These findings may help clinicians to interpret proteinuria changes in the outpatient setting and provide possible preventive approaches for people with pre-diabetes or diabetes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-017-0586-7) contains supplementary material, which is available to authorized users.

A Review of Groundwater Arsenic Contamination in Bangladesh: The Millennium Development Goal Era and Beyond

Arsenic contamination in drinking water has a detrimental impact on human health which profoundly impairs the quality of life. Despite recognition of the adverse health implications of arsenic toxicity, there have been few studies to date to suggest measures that could be taken to overcome arsenic contamination. After the statement in 2000 WHO Bulletin that Bangladesh has been experiencing the largest mass poisoning of population in history, we researched existing literature to assess the magnitude of groundwater arsenic contamination in Bangladesh. The literature reviewed related research that had been initiated and/or completed since the implementation of the Millennium Development Goals (MDGs) under four domains: (1) extent of arsenic contamination; (2) health consequences; (3) mitigation and technologies and (4) future directions. To this means, a review matrix was established for analysis of previous literature based on these four core domains. Our findings revealed that several high-quality research articles were produced at the beginning of the MDG period, but efforts have dwindled in recent years. Furthermore, there were only a few studies conducted that focused on developing suitable solutions for managing arsenic contamination. Although the government of Bangladesh has made its population’s access to safe drinking water a priority agenda item, there are still pockets of the population that continue to suffer from arsenic toxicity due to contaminated water supplies.