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Chagnac A, Friedman AN. Measuring Albuminuria in Individuals With Obesity: Pitfalls of the Urinary Albumin-Creatinine Ratio. Kidney Med 2024; 6:100804. [PMID: 38576526 PMCID: PMC10993191 DOI: 10.1016/j.xkme.2024.100804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
An increased urinary albumin excretion rate is an important early risk factor for chronic kidney disease and other major outcomes and is usually measured using the urinary albumin-creatinine ratio (ACR). Obesity is highly prevalent in the general and chronic kidney disease populations and is an independent risk factor for moderately increased albuminuria (henceforth, moderate albuminuria). In this review, we describe how the ACR was developed and used to define moderate albuminuria. We then investigate how biases related to urinary creatinine excretion are introduced into the ACR measurement and how the use of the 30-mg/g threshold decreases the performance of the test in populations with higher muscle mass, with a primary focus on why and how this occurs in the obese population. The discussion then raises several strategies that can be used to mitigate such bias. This review provides a comprehensive overview of the medical literature on the uses and limitations of ACR in individuals with obesity and critically assesses related issues. It also raises into question the widely accepted 30-mg/g threshold as universally adequate for the diagnosis of moderate albuminuria. The implications of our review are relevant for clinicians, epidemiologists, and clinical trialists.
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Affiliation(s)
- Avry Chagnac
- Maccabi Healthcare Services, Ramat Hasharon Medical Center, Israel
| | - Allon N. Friedman
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN
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2
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Chien MJ, Li SJ, Wong SC, Chiang CH, Lin YY, Mersmann HJ, Chen CY. Determination of mitochondrial functions and damage in kidney in female LeeSung minipigs with a high-fat diet-induced obesity. Arch Physiol Biochem 2023; 129:1289-1297. [PMID: 34338085 DOI: 10.1080/13813455.2021.1949022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
The purpose of this study was to investigate the nexus between mitochondrial function and kidney injury by using a dietary-induced obese minipig model. Female Lee-Sung minipigs feeding a high-fat diet (HFD) for 6 months exhibited obesity, hyperglycaemia and dyslipidemia. HFD elevated the levels of plasma biomarkers related to renal injury, including symmetric dimethylarginine, creatinine and urea nitrogen. An extensive structural change in tubules and glomeruli was observed in HFD-fed pigs. A great amount of triacylglycerol was accumulated in HFD kidney compared to control kidney, whereas a reduction of ATP level and antioxidant capacity were exhibited in HFD kidney. Moreover, HFD altered the expressions of mitochondrial-related protein in renal cortex. To conclude, long-term HFD feeding to Lee-Sung minipigs induced obesity and kidney injury accompanied by abnormal mitochondrial functions in the renal cortex, suggesting an interrelationship with renal disease progression.
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Affiliation(s)
- Miao-Ju Chien
- Department of Animal Science and Technology, National Taiwan University, Taipei, Taiwan
| | - Sin-Jin Li
- Department of Animal Science and Technology, National Taiwan University, Taipei, Taiwan
| | - Shiu-Chung Wong
- National Taiwan University Veterinary Hospital, National Taiwan University, Taipei, Taiwan
| | - Chun-Hsien Chiang
- Department of Animal Science and Technology, National Taiwan University, Taipei, Taiwan
| | - Yuan-Yu Lin
- Department of Animal Science and Technology, National Taiwan University, Taipei, Taiwan
| | - Harry J Mersmann
- Department of Animal Science and Technology, National Taiwan University, Taipei, Taiwan
| | - Ching-Yi Chen
- Department of Animal Science and Technology, National Taiwan University, Taipei, Taiwan
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3
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Bracchi I, Guimarães J, Rodrigues C, Azevedo R, Coelho CM, Pinheiro C, Morais J, Barreiros-Mota I, Fernandes VC, Delerue-Matos C, Pinto E, Moreira-Rosário A, de Azevedo LFR, Dias CC, Lima J, Sapinho I, Ramalho C, Calhau C, Leite JC, Almeida A, Pestana D, Keating E. Essential Trace Elements Status in Portuguese Pregnant Women and Their Association with Maternal and Neonatal Outcomes: A Prospective Study from the IoMum Cohort. BIOLOGY 2023; 12:1351. [PMID: 37887061 PMCID: PMC10604833 DOI: 10.3390/biology12101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/16/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023]
Abstract
Cobalt (Co), copper (Cu), manganese (Mn), molybdenum (Mo), and zinc (Zn) are essential trace elements (ETEs) and important cofactors for intermediary metabolism or redox balance. These ETEs are crucial during pregnancy, their role on specific pregnancy outcomes is largely unknown. This prospective study (#NCT04010708) aimed to assess urinary levels of these ETEs in pregnancy and to evaluate their association with pregnancy outcomes. First trimester pregnant women of Porto and Lisbon provided a random spot urine sample, and sociodemographic and lifestyle data. Clinical data were obtained from clinical records. Urinary ETEs were quantified by inductively coupled plasma mass spectrometry (ICP-MS). A total of 635 mother:child pairs were included. Having urinary Zn levels above the 50th percentile (P50) was an independent risk factor for pre-eclampsia (PE) (aOR [95% CI]: 5.350 [1.044-27.423], p = 0.044). Urinary Zn levels above the P50 decreased the risk of small for gestational age (SGA) birth head circumference (aOR [95% CI]: 0.315 [0.113-0.883], p = 0.028), but it increased the risk SGA length (aOR [95% CI]: 2.531 [1.057-6.062], p = 0.037). This study may provide valuable information for public health policies related to prenatal nutrition, while informing future efforts to de-fine urinary reference intervals for ETEs in pregnant women.
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Affiliation(s)
- Isabella Bracchi
- Unit of Biochemistry, Department Biomedicine, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- CINTESIS, Center for Health Technology and Services Research, 4200-319 Porto, Portugal
| | - Juliana Guimarães
- Unit of Biochemistry, Department Biomedicine, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- CINTESIS, Center for Health Technology and Services Research, 4200-319 Porto, Portugal
| | - Catarina Rodrigues
- CHRC, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, 1150-082 Lisbon, Portugal
| | - Rui Azevedo
- LAQV/REQUIMTE, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
| | - Cláudia Matta Coelho
- Unit of Biochemistry, Department Biomedicine, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- CINTESIS, Center for Health Technology and Services Research, 4200-319 Porto, Portugal
| | - Cátia Pinheiro
- Unit of Biochemistry, Department Biomedicine, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- CINTESIS, Center for Health Technology and Services Research, 4200-319 Porto, Portugal
| | - Juliana Morais
- CINTESIS@RISE, Nutrition & Metabolism, NOVA Medical School|FCM, NOVA University Lisbon, 1169-056 Lisbon, Portugal
- UniC@RISE, Unidade de Investigação e Desenvolvimento Cardiovascular, Faculdade de Medicina, Universidade do Porto, 4200-319 Porto, Portugal
| | - Inês Barreiros-Mota
- CINTESIS@RISE, Nutrition & Metabolism, NOVA Medical School|FCM, NOVA University Lisbon, 1169-056 Lisbon, Portugal
| | - Virgínia Cruz Fernandes
- REQUIMTE/LAQV, ISEP, Polytechnic of Porto, rua Dr. António Bernardino de Almeida, 4249-015 Porto, Portugal
| | - Cristina Delerue-Matos
- REQUIMTE/LAQV, ISEP, Polytechnic of Porto, rua Dr. António Bernardino de Almeida, 4249-015 Porto, Portugal
| | - Edgar Pinto
- LAQV/REQUIMTE, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Departamento de Saúde Ambiental, Escola Superior de Saúde, Instituto Politécnico do Porto, Rua Dr. António Bernardino de Almeida 400, 4200-072 Porto, Portugal
| | - André Moreira-Rosário
- CINTESIS@RISE, Nutrition & Metabolism, NOVA Medical School|FCM, NOVA University Lisbon, 1169-056 Lisbon, Portugal
| | - Luís Filipe Ribeiro de Azevedo
- CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | - Cláudia Camila Dias
- CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | - Jorge Lima
- CHRC, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, 1150-082 Lisbon, Portugal
- Immunology, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal
- Department of Obstetrics and Gynecology, Hospital da Luz Lisboa, 1500-650 Lisboa, Portugal
| | - Inês Sapinho
- Endocrinology Service, CUF Descobertas Hospital, 1998-018 Lisbon, Portugal
| | - Carla Ramalho
- Department of Obstetrics, São João Hospital Center, 4200-319 Porto, Portugal
- Department of Ginecology-Obstetrics and Pediatrics, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- Institute for Research and Innovation in Health, i3S, University of Porto, 4200-135 Porto, Portugal
| | - Conceição Calhau
- CINTESIS@RISE, Nutrition & Metabolism, NOVA Medical School|FCM, NOVA University Lisbon, 1169-056 Lisbon, Portugal
| | - João Costa Leite
- CINTESIS@RISE, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | - Agostinho Almeida
- LAQV/REQUIMTE, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
| | - Diogo Pestana
- CINTESIS@RISE, Nutrition & Metabolism, NOVA Medical School|FCM, NOVA University Lisbon, 1169-056 Lisbon, Portugal
| | - Elisa Keating
- Unit of Biochemistry, Department Biomedicine, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
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Gouju J, Legeay S. Pharmacokinetics of obese adults: Not only an increase in weight. Biomed Pharmacother 2023; 166:115281. [PMID: 37573660 DOI: 10.1016/j.biopha.2023.115281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/04/2023] [Indexed: 08/15/2023] Open
Abstract
Obesity is a pathophysiological state defined by a body mass index > 30 kg/m2 and characterized by an adipose tissue accumulation leading to an important weight increased. Several pathologies named comorbidities such as cardiovascular disease, type 2 diabetes and cancer make obesity the fifth cause of death in the world. Physiological changes impact the four main phases of pharmacokinetics of some drugs and leads to an inappropriate drug-dose. For absorption, the gastrointestinal transit is accelerated, and the gastric empty time is shortened, that can reduce the solubilization and absorption of some oral drugs. The drug distribution is probably the most impacted by the obesity-related changes because the fat mass (FM) increases at the expense of the lean body weight (LBW), leading to an important increase of the volume of distribution for lipophilic drugs and a low or moderately increase of this parameter for hydrophilic drugs. This modification of the distribution may require drug-dose adjustments. By various mechanisms, the metabolism and elimination of drugs are impacted by obesity and should be considered as similar or lower than that non-obese patients. To better understand the necessary drug-dose adjustments in obese patients, a narrative review of the literature was conducted to highlight the main elements to consider in the therapeutic management of adult obese patients.
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Affiliation(s)
- Julien Gouju
- MINT, INSERM U1066, CNRS 6021, UNIV Angers, SFR-ICAT 4208, IBS-CHU Angers, 4 rue Larrey, Angers 49933 Cedex 9, France; CHU Angers, 4 rue Larrey, Angers 49933 Cedex 9, France.
| | - Samuel Legeay
- MINT, INSERM U1066, CNRS 6021, UNIV Angers, SFR-ICAT 4208, IBS-CHU Angers, 4 rue Larrey, Angers 49933 Cedex 9, France
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Seo DH, Suh YJ, Cho Y, Ahn SH, Seo S, Hong S, Lee YH, Choi YJ, Lee E, Kim SH. Effect of low skeletal muscle mass and sarcopenic obesity on chronic kidney disease in patients with type 2 diabetes. Obesity (Silver Spring) 2022; 30:2034-2043. [PMID: 36062861 DOI: 10.1002/oby.23512] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/09/2022] [Accepted: 05/18/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This study aimed to investigate the association between low muscle mass or sarcopenic obesity and the risk of incident chronic kidney disease (CKD) in patients with type 2 diabetes mellitus (T2DM). METHODS A total of 3123 patients with T2DM with preserved renal function were followed up for incident CKD. Skeletal muscle mass was estimated from bioelectrical impedance analysis. CKD was defined as estimated glomerular filtration rate < 60 mL/min/1.73 m2 . Sarcopenic obesity was defined as the coexistence of sarcopenia and abdominal obesity. RESULTS During 8.9 years of follow-up, 530 (17.0%) patients developed incident CKD. When patients were divided into three groups based on sex-specific tertiles, lower muscle mass was not associated with an increased risk of incident CKD after adjustment for risk factors. However, when patients were divided into four groups according to the presence of sarcopenia and obesity, sarcopenic obesity was associated with an increased risk of incident CKD (adjusted hazard ratio 1.77; 95% CI: 1.24-2.51; p = 0.001) compared with the other groups. CONCLUSIONS Sarcopenic obesity, but not low muscle mass alone, may increase the risk of CKD in patients with T2DM.
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Affiliation(s)
- Da Hea Seo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Young Ju Suh
- Department of Biomedical Sciences, Inha University College of Medicine, Incheon, Republic of Korea
| | - Yongin Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Seong Hee Ahn
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Seongha Seo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Seongbin Hong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Yong-Ho Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | - Eunjig Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - So Hun Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inha University College of Medicine, Incheon, Republic of Korea
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Laucyte-Cibulskiene A, Nilsson PM, Engström G, Christensson A. Increased fat mass index is associated with decreased glomerular filtration rate estimated from cystatin C. Data from Malmö Diet and Cancer cohort. PLoS One 2022; 17:e0271638. [PMID: 35862349 PMCID: PMC9302820 DOI: 10.1371/journal.pone.0271638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/05/2022] [Indexed: 11/29/2022] Open
Abstract
Background This study aims to describe associations of obesity and CKD in a Swedish urban population. The impact of fat mass, from bioimpedance analysis, on eGFR based on cystatin C and/or creatinine is studied. Methods 5049 participants from Malmö Diet and Cancer Study the cardiovascular arm (MDCS‐CV) with available body mass composition (single frequency bioimpedance analysis) and cystatin C measured at baseline were selected. Body mass index (kg/m2) was used to define overweight/obesity. eGFR was calculated using cystatin C (eGFRCYS) and creatinine (eGFRCR) equations: Chronic Kidney Disease Epidemiology Collaboration 2012 (CKD-EPICR, CKD-EPICYS, CKD-EPICR-CYS), eGFRCYS based on Caucasian, Asian, pediatric, and adult cohorts (CAPA), the Lund-Malmö revised equation (LMrev), and Modified Full Age Spectrum creatinine-based equation (EKFCCR). Two different fat mass index (FMI) z-scores were calculated: FMI z-scoreLarsson and FMI z-scoreLee. Results Lower eGFRCYS and eGFRCR-CYS following multiple adjustments were prevalent in overweight/obese subjects. Increase in FMI z-scoreLarsson or FMI z-scoreLee was related to decrease in predicted CAPA, CKD-EPICYS, CKD-EPICR-CYS and CAPA-LMrev equation. Conclusion eGFRCYS, in contrast to combined eGFRCR-CYS and eGFRCR, demonstrate the strongest association between FMI and kidney function.
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Affiliation(s)
- Agne Laucyte-Cibulskiene
- Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
- Department of Nephrology, Lund University, Skane University Hospital, Malmö, Sweden
- * E-mail:
| | - Peter M. Nilsson
- Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Gunnar Engström
- Cardiovascular Epidemiology, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Anders Christensson
- Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
- Department of Nephrology, Lund University, Skane University Hospital, Malmö, Sweden
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Alagh AR, Shukla S, Acharya S, Vagha S, Dhingra L. Evaluation of microalbuminuria in obesity phenotypes. J Family Community Med 2022; 29:162-167. [PMID: 35754751 PMCID: PMC9221229 DOI: 10.4103/jfcm.jfcm_57_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/13/2022] [Accepted: 04/25/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND: Obesity is a universal health issue of the present time. Nearly 2 billion people were estimated to be either overweight or obese in 2020, with nearly 3.4 million deaths worldwide. Proteinuria is now widely known to be a significant predictor of renal pathologies including end-stage renal disease. This study aimed to assess the relationship between the presence of microalbuminuria (MA) in obese individuals. MATERIALS AND METHODS: This cross-sectional study was conducted among patients attending the outpatient department of Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha. From the subjects meeting the study criteria, selected 150 individuals with BMI ≥ 25 that formed the obese group. Obese individuals were further subdivided as metabolic healthy obese (MHO) and metabolic abnormal obese (MAO) based on metablic syndrome criteria. From the non-obese patients (BMI≤25), one age and gender matched control was selected for each obese subject. All subjects were tested for MA by dipstick method. Data was analyzed using SPSS and Chi-square test was performed to test for statistical significance. RESULTS: The study reflected the association of MA in the groups studied. The metabolic abnormal obese group was noted as having the highest percentage of positive cases (53.7%) of MA, followed by the MHO group (31.3%). A significant association of prevalence of MA was seen in MHO and MAO obese individuals (P < 0.001). MA was present in the urine samples of 26 (31.3%) obese subjects in the MHO group, 36 (53.7%) in the MAO group, and 8 (5.3%) in the control population. CONCLUSION: Both MHO and MAO subgroups of obese individuals showed higher proportion of MA indicating adverse renal function. Therefore, primary prophylactic measures such as health education and lifestyle modification should be promoted for the obese to reduce their body weight and thereby possibly reduce the risk of future obesity-related renal complications.
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Affiliation(s)
- Arzoo R Alagh
- Department of Pathology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
| | - Samarth Shukla
- Department of Pathology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
| | - Sunita Vagha
- Department of Pathology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
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Bures C, Uluk Y, Besmens M, Akca A, Dobrindt EM, Pratschke J, Goretzki P, Mogl M, Uluk D. Hyperkalemia Following Parathyroidectomy in Patients with Renal Hyperparathyroidism-New Thresholds for Urgent Perioperative Dialysis. J Clin Med 2022; 11:jcm11020409. [PMID: 35054103 PMCID: PMC8777922 DOI: 10.3390/jcm11020409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/01/2022] [Accepted: 01/12/2022] [Indexed: 02/04/2023] Open
Abstract
Parathyroidectomy (PTX) is a mainstay of treating secondary hyperparathyroidism (SHPT) in patients with kidney failure in order to reduce the incidence of cardiovascular events (CVE), increase overall survival and improve quality of life. Perioperative hyperkalemia may lead to devastating cardiac complications. Distinct preoperative thresholds for serum potassium levels (SPL) were defined, but neither their usefulness nor consecutive risks are understood. This study compared the results and efficacy of different clinical procedures in preventing or treating perioperative hyperkalemia, including postoperative urgent hemodialysis (UHD). Methods: Patients from Charité-Universitätsmedizin Berlin and Rheinland Klinikum Lukaskrankenhaus, Neuss, undergoing PTX due to SHPT between 2008 and 2018 were analyzed retrospectively with regard to demographic parameters, surgery specific conditions and perioperative laboratory results. Comparisons of patient values from both centers with focus on perioperative hyperkalemia and the need for UHD were performed. Results: A total of 251 patients undergoing PTX for SHPT were included (Neuss: n = 121 (48%); Berlin: n = 130 (52%)). Perioperative hyperkalemia (SPL ≥ 5.5 mmol/L) was noted in 134 patients (53%). UHD on the day of surgery was performed especially in patients with intraoperative hyperkalemia, in females (n = 40 (16%) vs. n = 27 (11%); p = 0.023), in obese patients (n = 27 (40%) vs. n = 50 (28%), p = 0.040) and more often in patients treated in Neuss (n = 42 (35%) vs. 25 (19%); p = 0.006). For patients treated in Neuss, the intraoperative hyperkalemia cut-off level above 5.75 mmol/L was the most predictive factor for UHD (n = 30 (71%) vs. n = 8 (10%); p < 0.001). Concerning secondary effects of hyperkalemia or UHD, no patient died within the postoperative period, and only three patients suffered from acute CVE, with SPL > 5.5 mmol/L measured in only one patient. Conclusion: Perioperative values could not predict postoperative hyperkalemia with the need for UHD. Previously defined cut-off levels for SPL should be reconsidered, especially for patients undergoing PTX. Early postoperative dialysis in patients with postoperative hyperkalemia can be performed with a low risk for complications and may be indicated for all patients with increased perioperative SPL.
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Affiliation(s)
- Claudia Bures
- Department of Surgery, Campus Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (C.B.); (Y.U.); (E.-M.D.); (J.P.); (P.G.); (M.M.)
| | - Yasmin Uluk
- Department of Surgery, Campus Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (C.B.); (Y.U.); (E.-M.D.); (J.P.); (P.G.); (M.M.)
| | - Mona Besmens
- Department of Surgery, Rheinland Klinikum Lukaskrankenhaus Neuss, 41464 Neuss, Germany; (M.B.); (A.A.)
| | - Aycan Akca
- Department of Surgery, Rheinland Klinikum Lukaskrankenhaus Neuss, 41464 Neuss, Germany; (M.B.); (A.A.)
| | - Eva-Maria Dobrindt
- Department of Surgery, Campus Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (C.B.); (Y.U.); (E.-M.D.); (J.P.); (P.G.); (M.M.)
| | - Johann Pratschke
- Department of Surgery, Campus Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (C.B.); (Y.U.); (E.-M.D.); (J.P.); (P.G.); (M.M.)
| | - Peter Goretzki
- Department of Surgery, Campus Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (C.B.); (Y.U.); (E.-M.D.); (J.P.); (P.G.); (M.M.)
| | - Martina Mogl
- Department of Surgery, Campus Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (C.B.); (Y.U.); (E.-M.D.); (J.P.); (P.G.); (M.M.)
| | - Deniz Uluk
- Department of Surgery, Campus Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; (C.B.); (Y.U.); (E.-M.D.); (J.P.); (P.G.); (M.M.)
- Correspondence: ; Tel.: +49-(30)-450622187
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9
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Dong Y, Silver SM, Sterns RH. Estimating urine volume from the urine creatinine concentration. Nephrol Dial Transplant 2021; 38:811-818. [PMID: 34850163 DOI: 10.1093/ndt/gfab337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Indexed: 11/12/2022] Open
Abstract
Spot determinations of the urine creatinine concentration are widely used as a substitute for 24-hour urine collections. Expressed as the amount excreted per gram of creatinine, urine concentrations in a single-voided sample are often used to estimate 24-hour excretion rates of protein, sodium, potassium, calcium, magnesium, urea, and uric acid. These estimates are predicated on the assumption that daily creatinine excretion equals 1 gm (and that a urine creatinine concentration of 100 mg/dl reflects a 1 Liter 24-hour urine volume). Such estimates are invalid if the serum creatinine concentration is rising or falling. In addition, because creatinine excretion is determined by muscle mass, the assumption that 24-hour urine creatinine excretion equals 1 gm yields a misleading estimate at the extremes of age and body size. In this review we evaluate seven equations for the accuracy of their estimates of urine volume based on urine creatinine concentrations in actual and idealized patients. None of the equations work well in patients who are morbidly obese or in patients with markedly decreased muscle mass. In other patients, estimates based on a reformulation of the Cockroft-Gault equation are reasonably accurate. A recent study based on this relationship found a high strength of correlation between estimated and measured urine output with chronic kidney disease (CKD) studied in the African American Study of Kidney Disease (AASK) trial and for the patients studied in the CKD Optimal Management with Binders and NictomidE (COMBINE) trial. However, the equation systematically underestimated urine output in the AASK trial. Hence, an intercept was added to account for the bias in estimated output. A more rigorous equation, derived from an ambulatory Swiss population, that includes body mass index and models the non-linear accelerated decline in creatinine excretion with age, could potentially be more accurate in overweight and elderly patients. In addition to extremes of body weight and muscle mass, decreased dietary intake or reduced hepatic synthesis of creatine, a precursor of creatinine, or ingestion of creatine supplements will also result in inaccurate estimates. These limitations must be appreciated to rationally use predictive equations to estimate urine volume. If the baseline urine creatinine concentration is determined in a sample of known volume, subsequent urine creatinine concentrations will reveal actual urine output as well as the change in urine output. Given the constraints of the various estimating equations, a single baseline timed collection may be more useful strategy for monitoring urine volume than entering anthropomorphic data into a calculator.
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Affiliation(s)
- Yishan Dong
- Rochester General Hospital, Rochester, New York, USA
| | | | - Richard H Sterns
- Rochester General Hospital, Rochester, New York, USA.,University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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10
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Bielopolski D, Singh N, Bentur OS, Renert-Yuval Y, MacArthur R, Vasquez KS, Moftah DS, Vaughan RD, Charytan DM, Kost RG, Tobin JN. Obesity Related Glomerulopathy in Adolescent Women: The Effect of Body Surface Area. KIDNEY360 2021; 3:113-121. [PMID: 35368563 PMCID: PMC8967610 DOI: 10.34067/kid.0005312021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/08/2021] [Indexed: 01/10/2023]
Abstract
Background Adolescent obesity, a risk factor for cardiorenal morbidity in adulthood, has reached epidemic proportions. Obesity-related glomerulopathy (ORG) has an early reversible stage of hyperfiltration. Age-appropriate formulae for eGFR, which are standardized to ideal body surface area (BSA) and provide assessment of kidney function in ml/min/1.73 m2, may underestimate prevalence of early ORG. We investigated whether adjusting eGFR to actual BSA more readily identifies early ORG. Methods We studied a cohort of 22,417 young individuals, aged 12-21 years, from a New York metropolitan multi-institutional electronic health records clinical database. eGFR was calculated in two ways: BSA-standardized eGFR, and absolute eGFR. Hyperfiltration was defined above a threshold of 135 ml/min per 1.73 m2 or 135 ml/min, respectively. The prevalence of hyperfiltration according to each formula was assessed in parallel to creatinine clearance. Results Serum creatinine values and hyperfiltration prevalence according to BSA-standardized eGFR were similar, 13%-15%, across body mass index (BMI) groups. The prevalence of hyperfiltration determined by absolute eGFR differed across BMI groups: underweight, 2%; normal weight, 6%; overweight, 17%; and obese, 31%. This trend paralleled the rise in creatinine clearance across BMI groups. Conclusions Absolute eGFR more readily identifies early ORG than the currently used formulae, which are adjusted to a standardized BSA and are not representative of current population BMI measures. Using absolute eGFR in clinical practice and research may improve the ability to identify, intervene, and reverse early ORG, which has great importance with increasing obesity rates.
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Affiliation(s)
- Dana Bielopolski
- The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | - Neha Singh
- The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | - Ohad S. Bentur
- The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | - Yael Renert-Yuval
- The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | - Robert MacArthur
- The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | - Kimberly S. Vasquez
- The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | | | - Roger D. Vaughan
- The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | - David M. Charytan
- Nephrology Division, New York University Langone Medical Center and New York University Grossman School of Medicine, New York, New York
| | - Rhonda G. Kost
- The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | - Jonathan N. Tobin
- The Rockefeller University Center for Clinical and Translational Science, New York, New York,Clinical Directors Network, New York, New York
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11
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Abstract
Obesity-related glomerulopathy (ORG) and other obesity-associated kidney diseases pose a major challenge to the treating nephrologist. We review the benefits of weight loss and optimal management of ORG and kidney disease in the setting of obesity. Therapeutic strategies in ORG were limited mainly in the past to weight loss through lifestyle interventions and bariatric surgery, antihypertensive treatment, and renin-angiotensin-aldosterone system blockade. Current approaches to obtain the desired weight loss include novel pharmacologic therapies that have been approved for the treatment of diabetes while offering kidney protection, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1-receptor agonists. This review focuses on the nephroprotective role of the renin-angiotensin-aldosterone system blockade and of these new pharmacologic agents, and on the renal effects of bariatric surgery in chronic kidney disease.
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Affiliation(s)
- Michal Herman-Edelstein
- Nephrology Department, Rabin Medical Center, Petach Tikva, Israel; Nephrology Research Laboratory, Felsenstein Medical Research Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Talia Weinstein
- Department of Nephrology and Hypertension, Tel Aviv Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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12
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Paterson EN, Maxwell AP, Kee F, Cruise S, Young IS, McGuinness B, McKay GJ. Association of renal impairment with cognitive dysfunction in the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA). Nephrol Dial Transplant 2021; 36:1492-1499. [PMID: 34038557 PMCID: PMC8311575 DOI: 10.1093/ndt/gfab182] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/17/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction Chronic kidney disease (CKD) is a recognized risk factor for cognitive impairment. Identification of those at greatest risk of cognitive impairment may facilitate earlier therapeutic intervention. This study evaluated associations between estimated glomerular filtration rate (eGFR) and cognitive function in the Northern Ireland Cohort for the Longitudinal Study of Ageing. Methods Data were available for 3412 participants ≥50 years of age living in non-institutionalized settings who attended a health assessment between February 2014 and March 2016. Measures of serum creatinine (SCr) and cystatin C (cys-C) were used for eGFR. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE). Results Following adjustment for potential confounders, a single unit decrease in eGFR was significantly associated with reduced cognitive function defined by an MMSE ≤24/30 {eGFR calculated using serum cys-C [eGFRcys]: β = −0.01 [95% confidence interval (CI) −0.001 to −0.01], P = 0.01} and MoCA <26/30 [β = −0.01 (95% CI −0.002 to −0.02), P = 0.02]. Similarly, CKD Stages 3–5 were also associated with a moderate increase in the odds of cognitive impairment (MMSE ≤24) following adjustment for confounders [eGFRcys: odds ratio 2.73 (95% CI 1.38–5.42), P = 0.004]. Conclusions Decreased eGFRcys was associated with a significantly increased risk of cognitive impairment in a population-based cohort of older adults. However, there was no evidence of an association between cognitive impairment and the more commonly used eGFR calculated using SCr. eGFRcys may offer improved sensitivity over eGFRcr in the determination of renal function and associated risk of cognitive impairment.
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Affiliation(s)
- Euan N Paterson
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Alexander P Maxwell
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Frank Kee
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Sharon Cruise
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Ian S Young
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | | | - Gareth J McKay
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
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13
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Zheng Z, Waikar SS, Schmidt IM, Landis JR, Hsu CY, Shafi T, Feldman HI, Anderson AH, Wilson FP, Chen J, Rincon-Choles H, Ricardo AC, Saab G, Isakova T, Kallem R, Fink JC, Rao PS, Xie D, Yang W. Subtyping CKD Patients by Consensus Clustering: The Chronic Renal Insufficiency Cohort (CRIC) Study. J Am Soc Nephrol 2021; 32:639-653. [PMID: 33462081 PMCID: PMC7920178 DOI: 10.1681/asn.2020030239] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 10/31/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND CKD is a heterogeneous condition with multiple underlying causes, risk factors, and outcomes. Subtyping CKD with multidimensional patient data holds the key to precision medicine. Consensus clustering may reveal CKD subgroups with different risk profiles of adverse outcomes. METHODS We used unsupervised consensus clustering on 72 baseline characteristics among 2696 participants in the prospective Chronic Renal Insufficiency Cohort (CRIC) study to identify novel CKD subgroups that best represent the data pattern. Calculation of the standardized difference of each parameter used the cutoff of ±0.3 to show subgroup features. CKD subgroup associations were examined with the clinical end points of kidney failure, the composite outcome of cardiovascular diseases, and death. RESULTS The algorithm revealed three unique CKD subgroups that best represented patients' baseline characteristics. Patients with relatively favorable levels of bone density and cardiac and kidney function markers, with lower prevalence of diabetes and obesity, and who used fewer medications formed cluster 1 (n=1203). Patients with higher prevalence of diabetes and obesity and who used more medications formed cluster 2 (n=1098). Patients with less favorable levels of bone mineral density, poor cardiac and kidney function markers, and inflammation delineated cluster 3 (n=395). These three subgroups, when linked with future clinical end points, were associated with different risks of CKD progression, cardiovascular disease, and death. Furthermore, patient heterogeneity among predefined subgroups with similar baseline kidney function emerged. CONCLUSIONS Consensus clustering synthesized the patterns of baseline clinical and laboratory measures and revealed distinct CKD subgroups, which were associated with markedly different risks of important clinical outcomes. Further examination of patient subgroups and associated biomarkers may provide next steps toward precision medicine.
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Affiliation(s)
- Zihe Zheng
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sushrut S. Waikar
- Section of Nephrology, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Insa M. Schmidt
- Section of Nephrology, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - J. Richard Landis
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chi-yuan Hsu
- Division of Nephrology, University of California, San Francisco, California
| | - Tariq Shafi
- Nephrology Division, The University of Mississippi Medical Center, Jackson, Mississippi
| | - Harold I. Feldman
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda H. Anderson
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Francis P. Wilson
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Jing Chen
- Section of Nephrology & Hypertension, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Ana C. Ricardo
- Division of Nephrology, University of Illinois Chicago College of Medicine, Chicago, Illinois
| | - Georges Saab
- Nephrology Division, MetroHealth, Cleveland, Ohio
| | - Tamara Isakova
- Nephrology and Hypertension Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Radhakrishna Kallem
- Renal Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey C. Fink
- Division of General Internal Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Panduranga S. Rao
- Nephrology Division, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Dawei Xie
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Millward DJ. Interactions between Growth of Muscle and Stature: Mechanisms Involved and Their Nutritional Sensitivity to Dietary Protein: The Protein-Stat Revisited. Nutrients 2021; 13:729. [PMID: 33668846 PMCID: PMC7996181 DOI: 10.3390/nu13030729] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/15/2021] [Accepted: 02/22/2021] [Indexed: 02/07/2023] Open
Abstract
Childhood growth and its sensitivity to dietary protein is reviewed within a Protein-Stat model of growth regulation. The coordination of growth of muscle and stature is a combination of genetic programming, and of two-way mechanical interactions involving the mechanotransduction of muscle growth through stretching by bone length growth, the core Protein-Stat feature, and the strengthening of bone through muscle contraction via the mechanostat. Thus, growth in bone length is the initiating event and this is always observed. Endocrine and cellular mechanisms of growth in stature are reviewed in terms of the growth hormone-insulin like growth factor-1 (GH-IGF-1) and thyroid axes and the sex hormones, which together mediate endochondral ossification in the growth plate and bone lengthening. Cellular mechanisms of muscle growth during development are then reviewed identifying (a) the difficulties posed by the need to maintain its ultrastructure during myofibre hypertrophy within the extracellular matrix and the concept of muscle as concentric "bags" allowing growth to be conceived as bag enlargement and filling, (b) the cellular and molecular mechanisms involved in the mechanotransduction of satellite and mesenchymal stromal cells, to enable both connective tissue remodelling and provision of new myonuclei to aid myofibre hypertrophy and (c) the implications of myofibre hypertrophy for protein turnover within the myonuclear domain. Experimental data from rodent and avian animal models illustrate likely changes in DNA domain size and protein turnover during developmental and stretch-induced muscle growth and between different muscle fibre types. Growth of muscle in male rats during adulthood suggests that "bag enlargement" is achieved mainly through the action of mesenchymal stromal cells. Current understanding of the nutritional regulation of protein deposition in muscle, deriving from experimental studies in animals and human adults, is reviewed, identifying regulation by amino acids, insulin and myofibre volume changes acting to increase both ribosomal capacity and efficiency of muscle protein synthesis via the mechanistic target of rapamycin complex 1 (mTORC1) and the phenomenon of a "bag-full" inhibitory signal has been identified in human skeletal muscle. The final section deals with the nutritional sensitivity of growth of muscle and stature to dietary protein in children. Growth in length/height as a function of dietary protein intake is described in the context of the breastfed child as the normative growth model, and the "Early Protein Hypothesis" linking high protein intakes in infancy to later adiposity. The extensive paediatric studies on serum IGF-1 and child growth are reviewed but their clinical relevance is of limited value for understanding growth regulation; a role in energy metabolism and homeostasis, acting with insulin to mediate adiposity, is probably more important. Information on the influence of dietary protein on muscle mass per se as opposed to lean body mass is limited but suggests that increased protein intake in children is unable to promote muscle growth in excess of that linked to genotypic growth in length/height. One possible exception is milk protein intake, which cohort and cross-cultural studies suggest can increase height and associated muscle growth, although such effects have yet to be demonstrated by randomised controlled trials.
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Affiliation(s)
- D Joe Millward
- Department of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
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15
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The failure of glomerular filtration rate estimating equations among obese population. PLoS One 2020; 15:e0242447. [PMID: 33206712 PMCID: PMC7673537 DOI: 10.1371/journal.pone.0242447] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 11/03/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Obesity is a major public health with increasing numbers of obese individuals are at risk for kidney disease. However, the validity of serum creatinine-based glomerular filtration rate (GFR) estimating equations in obese population is yet to be determined. METHODS We evaluated the performance of the reexpressed Modification of Diet in Renal Disease (MDRD), reexpressed MDRD with Thai racial factor, Thai estimated GFR (eGFR) as well as Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations among obese patients, defined as body mass index (BMI) ≥25 kg/m2 with the reference measured GFR (mGFR) determined by 99mTc-diethylene triamine penta-acetic acid (99mTc-DTPA) plasma clearance method. Serum creatinine levels were measured using standardized enzymatic method simultaneously with GFR measurement. The statistical methods in assessing agreement for continuous data including total deviation index (TDI), concordance correlation coefficient (CCC), and coverage probability (CP) for each estimating equation were compared with the reference mGFR. Accuracy within 10% representing the percentage of estimations falling within the range of ±10% of mGFR values for all equations were also tested. RESULTS A total of 240 Thai obese patients were finally recruited with mean BMI of 31.5 ± 5.8 kg/m2. In the total population, all eGFR equations underestimated the reference mGFR. The average TDI values were 55% indicating that 90% of the estimates falling within the range of -55 to +55% of the reference mGFR. The CP values averaged 0.23 and CCC scores ranged from 0.75 to 0.81, reflecting the low to moderate levels of agreement between each eGFR equation and the reference mGFR. The proportions of patients achieving accuracy 10% ranged from 23% for the reexpressed MDRD equation to 33% for the Thai eGFR formula. Among participants with BMI more than 35 kg/m2 (n = 48), the mean error of all equations was extremely wide and significantly higher for all equations compared with the lower BMI category. Also, the strength of agreement evaluated by TDI, CCC, and CP were low in the subset of patients with BMI ≥35 kg/m2. CONCLUSION Estimating equations generally underestimated the reference mGFR in subjects with obesity. The overall performance of GFR estimating equations demonstrated poor concordance with the reference mGFR among individuals with high BMI levels. In certain clinical settings such as decision for dialysis initiation, the direct measurements of GFR are required to establish real renal function among obese population.
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16
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Chang AR, George J, Levey AS, Coresh J, Grams ME, Inker LA. Performance of Glomerular Filtration Rate Estimating Equations Before and After Bariatric Surgery. Kidney Med 2020; 2:699-706.e1. [PMID: 33319195 PMCID: PMC7729215 DOI: 10.1016/j.xkme.2020.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Rationale & Objective Evaluation of glomerular filtration rate (GFR) is challenging in adults undergoing bariatric surgery because creatinine and cystatin C levels are influenced by changes in muscle and fat mass. Additionally, indexing of GFR by body surface area (BSA) may by affected by decreases in BSA. Study Design Prospective observational study. Setting & Participants 27 adults with body mass index (BMI) ≥ 35 kg/m2 who underwent measurement of GFR before and after bariatric surgery. Outcomes Indexed and nonindexed GFRs measured (mGFRs) using plasma iohexol clearance, indexed and nonindexed estimated GFR (eGFR) based on levels of creatinine, cystatin C, or both from Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. Analytic Approach Bias and percent of estimates within 20% and 30% of mGFR (P20 and P30) for estimating equations were examined. Results Mean presurgery BMI was 49.5 (SD, 9.4) kg/m2, BSA was 2.42 (SD, 0.27) m2, nonindexed mGFR was 117.3 (SD, 34.1) mL/min, and indexed mGFR was 84.1 (SD, 22.0) mL/min/1.73 m2. After 6 months, mean BMI changed by –13.8 (95% CI, −15.9 to −11.8) kg/m2, BSA by −0.30 (95% CI, −0.33 to −0.27) m2, and nonindexed mGFR by −9.2 (95% CI, −17.2 to −1.1) mL/min, while indexed mGFR was unchanged at 5.1 (95% CI, −0.1 to 10.4) mL/min/1.73 m2. Nonindexed eGFRcr was unbiased (median bias, 5.0 [95% CI, −4.3 to 11.6] mL/min) before surgery, but overestimated mGFR (8.8 [95% CI, 1.8 to 16.9] mL/min) after surgery. Nonindexed eGFRcys underestimated mGFR before (median bias, −12.1 [95% CI, −21.4 to −1.2] mL/min) and after surgery (−11.2 [95% CI, −21.8 to −7.3] mL/min). Nonindexed eGFRcr-cys was unbiased before (median bias, −6.0 [95% CI, −11.0 to 1.0] mL/min) and after surgery (−2.0 [95% CI, −8.8 to 4.9] mL/min). Findings were similar for indexed eGFR compared with indexed mGFR. Limitations Small, mostly white sample. Conclusions Changes in indexed and nonindexed GFRs may be discordant after bariatric surgery in adults because of decreases in BSA. Indexed and nonindexed eGFRcr-cys may be less biased than indexed or nonindexed eGFRcr or eGFRcys because of opposite biases in estimating mGFR.
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Affiliation(s)
- Alex R. Chang
- Kidney Health Research Institute, Geisinger, Danville, PA
- Department of Population Health Sciences, Geisinger, Danville, PA
- Address for Correspondence: Alex R. Chang, MD, MS, 100 N Academy Ave, Danville, PA 17822.
| | - Jason George
- Department of Population Health Sciences, Geisinger, Danville, PA
| | | | - Josef Coresh
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD
- Divison of Nephrology, Johns Hopkins University, Baltimore, MD
| | - Morgan E. Grams
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD
- Divison of Nephrology, Johns Hopkins University, Baltimore, MD
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17
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Guebre-Egziabher F, Brunelle C, Thomas J, Pelletier CC, Normand G, Juillard L, Dubourg L, Lemoine S. Estimated Glomerular Filtration Rate Bias in Participants with Severe Obesity Regardless of Deindexation. Obesity (Silver Spring) 2019; 27:2011-2017. [PMID: 31579999 DOI: 10.1002/oby.22574] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 05/23/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Morbid obesity is associated with a higher independent risk of chronic kidney disease (CKD). Estimated glomerular filtration rate (eGFR) has been evaluated in a limited number of study participants with severe obesity. METHODS A total of 706 measured GFR (mGFR) results from 598 participants with obesity (BMI ≥ 35 kg/m2 ) were retrospectively collected. The performance of the Modification of Diet in Renal Disease (MDRD) equation, Chronic Kidney Disease-Epidemiology (CKD-EPI) equation, and deindexed eGFR were compared with mGFR from the gold standard technique (inuline or iohexol), adjusted (mGFRr) or nonadjusted (mGFR) to body surface area. Absolute bias, precision, and accuracy were calculated. RESULTS Mean mGFRr (58 ± 31 mL/min/1.73 m2 ) was significantly different from CKD-EPI and MDRD (P < 0.001). Mean mGFR (nonindexed) (70 ± 40 mL/min) was significantly higher than mGFRr (P < 0.001). eGFR showed important biases and low accuracies for CKD-EPI and MDRD (10.7 ± 10.7 and 12.2 ± 13.7 mL/min/1.73 m2 ; 78% vs. 75% respectively). Deindexation worsened bias and accuracy 30% (percentage of GFR estimates within 30% of mGFRr or mGFR) between eGFR and mGFR. CONCLUSIONS eGFR overestimates mGFR and is associated with important biases and inaccuracies in patients with severe obesity, and deindexing eGFR worsens the overestimation. These findings may have important implications in examining kidney function in patients with obesity.
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Affiliation(s)
- Fitsum Guebre-Egziabher
- Nephrology and Renal Function Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Faculté de Médecine Lyon Est, Université Lyon-1 Claude Bernard, Lyon, France
- INSERM U1060, CarMeN Laboratory, Lyon, France
- Federation Hospitalo-Universitaire FHU-DO-IT, Lyon, France
| | - Charlotte Brunelle
- Nephrology and Renal Function Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- INSERM U1060, CarMeN Laboratory, Lyon, France
| | - Jouve Thomas
- Nephrology Unit, Centre Hospitalo Universitaire Grenoble Alpes, La Tronche, France
| | - Caroline C Pelletier
- Nephrology and Renal Function Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- INSERM U1060, CarMeN Laboratory, Lyon, France
| | - Gabrielle Normand
- Nephrology and Renal Function Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Faculté de Médecine Lyon Est, Université Lyon-1 Claude Bernard, Lyon, France
- INSERM U1060, CarMeN Laboratory, Lyon, France
| | - Laurent Juillard
- Nephrology and Renal Function Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Faculté de Médecine Lyon Est, Université Lyon-1 Claude Bernard, Lyon, France
- INSERM U1060, CarMeN Laboratory, Lyon, France
- Federation Hospitalo-Universitaire FHU-DO-IT, Lyon, France
| | - Laurence Dubourg
- Nephrology and Renal Function Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Faculté de Médecine Lyon Est, Université Lyon-1 Claude Bernard, Lyon, France
- UMR 5305 CNRS, Université Lyon 1, Université de Lyon, Biologie tissulaire et ingénierie thérapeutique, Lyon, France
| | - Sandrine Lemoine
- Nephrology and Renal Function Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Faculté de Médecine Lyon Est, Université Lyon-1 Claude Bernard, Lyon, France
- INSERM U1060, CarMeN Laboratory, Lyon, France
- Federation Hospitalo-Universitaire FHU-DO-IT, Lyon, France
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18
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Chang AR, Zafar W, Grams ME. Kidney Function in Obesity-Challenges in Indexing and Estimation. Adv Chronic Kidney Dis 2018; 25:31-40. [PMID: 29499884 PMCID: PMC5836495 DOI: 10.1053/j.ackd.2017.10.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/16/2017] [Accepted: 10/16/2017] [Indexed: 01/08/2023]
Abstract
As the prevalence of obesity continues to increase worldwide, an increasing number of people are at risk for kidney disease. Thus, there is a critical need to understand how best to assess kidney function in this population, and several challenges exist. The convention of indexing glomerular filtration rate (GFR) to body surface area (BSA) attempts to normalize exposure to metabolic wastes across populations of differing body size. In obese individuals, this convention results in a significantly lower indexed GFR than unindexed GFR, which has practical implications for drug dosing. Recent data suggest that "unindexing" estimated GFR (multiplying by BSA/1.73 m2) for drug dosing may be acceptable, but pharmocokinetic data to support this practice are lacking. Beyond indexing, biomarkers commonly used for estimating GFR may induce bias. Creatinine is influenced by muscle mass, whereas cystatin C correlates with fat mass, both independent of kidney function. Further research is needed to evaluate the performance of estimating equations and other filtration markers in obesity, and determine whether unindexed GFR might better predict optimal drug dosing and clinical outcomes in patients whose BSA is very different than the conventional normalized value of 1.73 m2.
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Affiliation(s)
- Alex R Chang
- Kidney Health Research Institute, Geisinger Health System, Danville, PA; Department of Epidemiology and Health Services Research, Geisinger Health System, Danville, PA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD; and Divison of Nephrology, Johns Hopkins University, Baltimore, MA.
| | - Waleed Zafar
- Kidney Health Research Institute, Geisinger Health System, Danville, PA; Department of Epidemiology and Health Services Research, Geisinger Health System, Danville, PA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD; and Divison of Nephrology, Johns Hopkins University, Baltimore, MA
| | - Morgan E Grams
- Kidney Health Research Institute, Geisinger Health System, Danville, PA; Department of Epidemiology and Health Services Research, Geisinger Health System, Danville, PA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD; and Divison of Nephrology, Johns Hopkins University, Baltimore, MA
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19
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Delanaye P, Guerber F, Scheen A, Ellam T, Bouquegneau A, Guergour D, Mariat C, Pottel H. Discrepancies between the Cockcroft-Gault and Chronic Kidney Disease Epidemiology (CKD-EPI) Equations: Implications for Refining Drug Dosage Adjustment Strategies. Clin Pharmacokinet 2017; 56:193-205. [PMID: 27417226 DOI: 10.1007/s40262-016-0434-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The dosages of many medications require adjustment for renal function. There is debate regarding which equation, the Chronic Kidney Disease Epidemiology (CKD-EPI) equation vs. the Cockcroft-Gault (CG) equation, should be recommended to estimate glomerular filtration rate. METHODS We used a mathematical simulation to determine how patient characteristics influence discrepancies between equations and analyzed clinical data to demonstrate the frequency of such discrepancies in clinical practice. In the simulation, the modifiable variables were sex, age, serum creatinine, and weight. We considered estimated glomerular filtration rate results in mL/min, deindexed for body surface area, because absolute excretory function (rather than per 1.73 m2 body surface area) determines the rate of filtration of a drug at a given plasma concentration. An absolute and relative difference of maximum (±) 10 mL/min and 10 %, respectively, were considered concordant. Clinical data for patients aged over 60 years (n = 9091) were available from one hospital and 25 private laboratories. RESULTS In the simulation, differences between the two equations were found to be influenced by each variable but age and weight had the biggest effect. Clinical sample data demonstrated concordance between CKD-EPI and CG results in 4080 patients (45 %). The majority of discordant results reflected a CG result lower than the CKD-EPI equation. With aging, the CG result became progressively lower than the CKD-EPI result. When weight increased, the opposite occurred. DISCUSSION The choice of equation for excretory function adjustment of drug dosage will have different implications for patients of different ages and body habitus. CONCLUSIONS The optimum equation for drug dosage adjustment should be defined with consideration of individual patient characteristics.
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Affiliation(s)
- Pierre Delanaye
- Division of Nephrology, Dialysis and Transplantation, CHU Sart Tilman, University of Liège (ULg-CHU), 4000, Liège, Belgium.
| | | | - André Scheen
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines, University of Liège, Liège, Belgium
| | - Timothy Ellam
- Sheffield Kidney Institute, Northern General Hospital and Department of Infection, Immunity and Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Antoine Bouquegneau
- Division of Nephrology, Dialysis and Transplantation, CHU Sart Tilman, University of Liège (ULg-CHU), 4000, Liège, Belgium
| | - Dorra Guergour
- Biochemistry Laboratory, Grenoble University Hospital, Grenoble, France
| | - Christophe Mariat
- Division of Nephrology, Dialysis, Transplantation and Hypertension, CHU Hôpital Nord, University Jean Monnet, PRES Université de LYON, Saint-Etienne, France
| | - Hans Pottel
- Department of Public Health and Primary Care, KU, Leuven Kulak, Kortrijk, Belgium
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Bulka CM, Mabila SL, Lash JP, Turyk ME, Argos M. Arsenic and Obesity: A Comparison of Urine Dilution Adjustment Methods. ENVIRONMENTAL HEALTH PERSPECTIVES 2017; 125:087020. [PMID: 28858828 PMCID: PMC5783631 DOI: 10.1289/ehp1202] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 03/21/2017] [Accepted: 03/30/2017] [Indexed: 05/18/2023]
Abstract
INTRODUCTION A commonly used approach to adjust for urine dilution in analyses of biomarkers is to adjust for urinary creatinine. However, creatinine is a product of muscle mass and is therefore associated with body mass. In studies of urinary analytes and obesity or obesity-related outcomes, controlling for creatinine could induce collider stratification bias. We illustrate this phenomenon with an analysis of urinary arsenic. OBJECTIVE We aimed to evaluate various approaches of adjustment for urinary dilution on the associations between urinary arsenic concentration and measures of obesity. METHODS Using data from the National Health and Nutrition Examination Survey, we regressed body mass index (BMI) and waist-to-height ratios on urinary arsenic concentrations. We compared eight approaches to account for urine dilution, including standardization by urinary creatinine, osmolality, and flow rates, and inclusion of these metrics as independent covariates. We also used a recently proposed method known as covariate-adjusted standardization. RESULTS Inverse associations between urinary arsenic concentration with BMI and waist-to-height ratio were observed when either creatinine or osmolality were used to standardize or as covariates. Not adjusting for dilution, standardizing or adjusting for urinary flow rate, and using covariate-adjusted standardization resulted in null associations observed between arsenic concentration in relation to BMI and waist-to-height ratio. CONCLUSIONS Our findings suggest that arsenic exposure is not associated with obesity, and that urinary creatinine and osmolality may be colliders on the causal pathway from arsenic exposure to obesity, as common descendants of hydration and body composition. In studies of urinary biomarkers and obesity or obesity-related outcomes, alternative metrics such as urinary flow rate or analytic strategies such as covariate-adjusted standardization should be considered. https://doi.org/10.1289/EHP1202.
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Affiliation(s)
- Catherine M Bulka
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago , Chicago, Illinois, USA
- Institute for Minority Health Research, Section of General Internal Medicine, Department of Medicine, University of Illinois at Chicago , Chicago, Illinois, USA
| | - Sithembile L Mabila
- Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois at Chicago , Chicago, Illinois, USA
| | - James P Lash
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago , Chicago, Illinois, USA
| | - Mary E Turyk
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago , Chicago, Illinois, USA
| | - Maria Argos
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago , Chicago, Illinois, USA
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Delanaye P, Glassock RJ, De Broe ME. Epidemiology of chronic kidney disease: think (at least) twice! Clin Kidney J 2017; 10:370-374. [PMID: 28617483 PMCID: PMC5466090 DOI: 10.1093/ckj/sfw154] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/27/2016] [Indexed: 12/11/2022] Open
Abstract
The introduction of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines has substantially contributed to the early detection of different stages of chronic kidney disease (CKD). Several recent studies from different parts of the world mention a CKD prevalence of between 8 and 13%. There are several reasons the CKD prevalence found in a study of a particular population is clearly overestimated. The structure of the population pyramid (young or older age) of the study sample may result in high or low CKD prevalence. The absence of using an isotope dilution mass spectrometry creatinine assay can be the source of high bias in CKD prevalence. In addition, using an arbitrary single threshold of estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m2) for classifying CKD leads to a substantial 'overdiagnosis' (false positives) in the elderly (>65 years of age), particularly in those without albuminuria (or proteinuria), haematuria or hypertension. It also results in a significant 'underdiagnosis' (false negatives) in younger individuals with an eGFR >60 mL/min/1.73 m2 and below the third percentile for their age/gender category. The use of third percentile eGFR rates as a cut-off based on age/gender-specific reference values of eGFR allows the detection of these false positives and negatives. In the present article, we focus on an important and frequently omitted criterion in epidemiological studies: chronicity. Indeed, the two most important factors introducing a high number (up to 50%) of false positives are lack of confirming proteinuria and the absence of proof of chronicity of the eGFR found at first screening. There is an urgent need for quality studies of the prevalence of CKD using representative randomized samples of the population, applying the KDIGO guidelines correctly.
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Affiliation(s)
- Pierre Delanaye
- Department of Nephrology Dialysis Transplantation, CHU Sart Tilman, University of Liège, Liège, Belgium
| | - Richard J. Glassock
- Department of Medicine, David Geffen School of Medicine at UCLA, Laguna Niguel, CA, USA
| | - Marc E. De Broe
- Laboratory of Pathophysiology, University of Antwerp, Antwerp, Belgium
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Fotheringham J, Kawar B, McKane W, Ellam T. Obesity modulates the association between systolic blood pressure and albuminuria. Nephrol Dial Transplant 2017; 33:607-613. [DOI: 10.1093/ndt/gfx081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/01/2017] [Indexed: 12/26/2022] Open
Affiliation(s)
| | | | | | - Timothy Ellam
- Sheffield Kidney Institute, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Royal Hallamshire Hospital, Sheffield, UK
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Clerte M, Wagner S, Carette C, Brodin-Sartorius A, Vilaine É, Alvarez JC, Abe E, Barsamian C, Czernichow S, Massy ZA. The measured glomerular filtration rate (mGFR) before and 6 months after bariatric surgery: A pilot study. Nephrol Ther 2017; 13:160-167. [DOI: 10.1016/j.nephro.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/30/2016] [Accepted: 10/01/2016] [Indexed: 01/06/2023]
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Jesudason D, Clifton P. Limitations of using the Chronic Kidney Disease-Epidemiology Collaboration equation for measuring renal function in obese populations. Kidney Int 2016; 89:1400-1. [PMID: 27181780 DOI: 10.1016/j.kint.2015.12.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 12/09/2015] [Indexed: 11/16/2022]
Affiliation(s)
- David Jesudason
- Department of Endocrinology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
| | - Peter Clifton
- University of South Australia, Adelaide, South Australia, Australia
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Bouquegneau A, Vidal-Petiot E, Moranne O, Mariat C, Boffa JJ, Vrtovsnik F, Scheen AJ, Krzesinski JM, Flamant M, Delanaye P. Creatinine-based equations for the adjustment of drug dosage in an obese population. Br J Clin Pharmacol 2016; 81:349-61. [PMID: 26531818 DOI: 10.1111/bcp.12817] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 10/21/2015] [Accepted: 10/24/2015] [Indexed: 12/30/2022] Open
Abstract
AIM For drug dosing adaptation, the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend using estimated glomerular filtration rate (eGFR) by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, after 'de-indexation' by body surface area (BSA). In pharmacology, the Cockcroft-Gault (CG) equation is still recommended to adapt drug dosage. In the context of obesity, adjusted ideal body weight (AIBW) is sometimes preferred to actual body weight (ABW) for the CG equation. The aim of the present study was to compare the performance of the different GFR-estimating equations, non-indexed or de-indexed by BSA for the purpose of drug-dosage adaptation in obese patients. METHODS We analysed data from patients with a body mass index (BMI) higher than 30 kg m(-2) who underwent a GFR measurement. eGFR was calculated using the CKD-EPI and Modification of Diet in Renal Disease (MDRD) equations, de-indexed by BSA, and the CG equation, using either ABW, AIBW or lean body weight (LBW) for the weight variable and compared with measured GFR, expressed in ml min(-1). RESULTS In our population of obese patients, use of the AIBW instead of the ABW in the CG equation, markedly improved the overall accuracy of this equation [57% for CGABW and 79% for CGAIBW (P < 0.05)]. For high BMI (over 40 kg m(-2)), the accuracy of the CG equations is no different when using LBW than when using AIBW. The MDRD and CKD-EPI equations de-indexed by the BSA also performed well, with an overall higher accuracy for the MDRD de-indexed equation [(80% and 76%, respectively (P < 0.05)]. CONCLUSIONS The de-indexed MDRD equation appeared to be the most suitable for estimating the non-indexed GFR for the purpose of drug dosage adaptation in obese patients.
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Affiliation(s)
- Antoine Bouquegneau
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Emmanuelle Vidal-Petiot
- Department of Renal Physiology, Hôpital Bichat, AP-HP and Paris Diderot University, Paris, France
| | - Olivier Moranne
- Department of Nephrology-Dialysis-Transplantation, CHU Nice, Nice, France
| | - Christophe Mariat
- Department of Nephrology, University Jean Monnet, Saint-Etienne, France
| | | | - François Vrtovsnik
- Department of Nephrology, Hôpital Bichat, AP-HP and Paris Diderot University, Paris, France
| | - André-Jean Scheen
- Department of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Jean-Marie Krzesinski
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Martin Flamant
- Department of Renal Physiology, Hôpital Bichat, AP-HP and Paris Diderot University, Paris, France
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
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Chang A, Greene TH, Wang X, Kendrick C, Kramer H, Wright J, Astor B, Shafi T, Toto R, Lewis J, Appel LJ, Grams M. The effects of weight change on glomerular filtration rate. Nephrol Dial Transplant 2015; 30:1870-7. [PMID: 26085555 DOI: 10.1093/ndt/gfv219] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 04/10/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Little is known about the effect of weight loss/gain on kidney function. Analyses are complicated by uncertainty about optimal body surface indexing strategies for measured glomerular filtration rate (mGFR). METHODS Using data from the African-American Study of Kidney Disease and Hypertension (AASK), we determined the association of change in weight with three different estimates of change in kidney function: (i) unindexed mGFR estimated by renal clearance of iodine-125-iothalamate, (ii) mGFR indexed to concurrently measured BSA and (iii) GFR estimated from serum creatinine (eGFR). All models were adjusted for baseline weight, time, randomization group and time-varying diuretic use. We also examined whether these relationships were consistent across a number of subgroups, including tertiles of baseline 24-h urine sodium excretion. RESULTS In 1094 participants followed over an average of 3.6 years, a 5-kg weight gain was associated with a 1.10 mL/min/1.73 m(2) (95% CI: 0.87 to 1.33; P < 0.001) increase in unindexed mGFR. There was no association between weight change and mGFR indexed for concurrent BSA (per 5 kg weight gain, 0.21; 95% CI: -0.02 to 0.44; P = 0.1) or between weight change and eGFR (-0.09; 95% CI: -0.32 to 0.14; P = 0.4). The effect of weight change on unindexed mGFR was less pronounced in individuals with higher baseline sodium excretion (P = 0.08 for interaction). CONCLUSION The association between weight change and kidney function varies depending on the method of assessment. Future clinical trials should examine the effect of intentional weight change on measured GFR or filtration markers robust to changes in muscle mass.
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Affiliation(s)
- Alex Chang
- Division of Nephrology, Geisinger Health System, Danville, PA, USA
| | - Tom H Greene
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Xuelei Wang
- Center for Clinical Investigation, Case Western Reserve University, Cleveland, OH, USA
| | - Cynthia Kendrick
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Holly Kramer
- Division of Nephrology, Loyola University Medical Center, Maywood, NJ, USA
| | - Jackson Wright
- Division of Nephrology and Hypertension, Case Western Reserve University, Cleveland, OH, USA
| | - Brad Astor
- Division of Nephrology, University of Wisconsin, Madison, WI, USA
| | - Tariq Shafi
- School of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | - Robert Toto
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Julia Lewis
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lawrence J Appel
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD, USA Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Morgan Grams
- School of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
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Berns JS. Clinical Decision Making in a Patient with Stage 5 CKD--Is eGFR Good Enough? Clin J Am Soc Nephrol 2015; 10:2065-72. [PMID: 25883071 DOI: 10.2215/cjn.00340115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The development and widespread use of serum creatinine concentration-based prediction equations to calculate eGFR have been major advances for detection of patients with CKD and the epidemiologic study of CKD and its outcomes. However, these equations as well as those that also incorporate serum cystatin C concentration provide GFR estimates that, although reasonably precise on average, can differ markedly and in clinically important ways from actual GFR. Thus, it is important that clinicians who use these equations for clinical decision-making be familiar with their strengths and weaknesses and have an appreciation of their potential for error. More precise knowledge of actual GFR is important in certain clinical circumstances, including, as presented in this Attending Rounds, patients with stage 5 CKD, in whom decisions regarding dialysis initiation are necessary. Nephrologists should have the ability to accurately determine GFR when needed if clinical circumstances suggest inaccuracy of the calculated eGFR reported by the clinical laboratory.
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Affiliation(s)
- Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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