The relationships of proteinuria, serum creatinine, glomerular filtration rate with cardiovascular disease mortality in Japanese general population

Molecular mechanisms underlying cisplatin-induced nephrotoxicity and the potential ameliorative effects of essential oils: A comprehensive review

Since the Middle Ages, essential oils (EO) have been widely used for bactericidal, virucidal, fungicidal, insecticidal, medicinal and cosmetic applications, nowadays in pharmaceutical, agricultural and food industries. Recently, EO have emerged as promising adjuvant therapies to mitigate the toxicities induced by anti - cancerous drugs; among them cisplatin induced renal damage amelioration remain remarkable. Cisplatin (cis-diaminedichloroplatinum II, CDDP) is renowned as one of the most effective anti-neoplastic agents, widely used as a broad-spectrum anti-tumor agent for various solid tumors. However, its clinical use is hampered by several side effects, notably nephrotoxicity and acute kidney injury, which arise from the accumulation of CDDP in the proximal tubular epithelial cells (PTECs). To better understand and analyze the molecular mechanisms of CDDP-induced renal damage, it is crucial to investigate potential interventions to protect against cisplatin-mediated nephrotoxicity. These EO have shown the ability to counteract oxidative stress, reduce inflammation, prevent apoptosis, and exert estrogenic effects, all contributing to renal protection. In this review, we have made an effort to summarize the molecular mechanisms and exploring new interventions by which we can pave the way for safer and more effective cancer management in the future.

Impact of medical checkup parameters on major adverse cardiovascular events in the general Japanese population

Medical checkups play a role in the identification of individuals at increased cardiovascular risk. However, the impact of each medical examination parameter on the incidence of major adverse cardiovascular events (MACE) has not been intensively studied. Here we assessed the predictors of MACE among parameters examined during medical checkups in the general Japanese population. A total of 13,522 individuals (mean age, 52.8 ± 12.3 years) who participated in our medical checkup program from 2008 to 2015 were followed up for a median of 1,827 days with the endpoint of MACE. MACE included cardiovascular death, non-fatal myocardial infarction, angina, decompensated heart failure, stroke, and other cardiovascular events requiring hospitalization. Possible associations between MACE and baseline clinical test parameters were investigated. During follow-up, MACE occurred in 196 participants. Participants with hypertension, diabetes mellitus, dyslipidemia, or metabolic syndrome were at increased risk of MACE on the univariate analysis. Multivariate Cox hazard analysis demonstrated that male sex, age, systolic blood pressure, and baseline B-type natriuretic peptide level were independently correlated with future MACE after the adjustment for confounders; the impact of B-type natriuretic peptide was most prominent among the investigated variables. These results suggest that B-type natriuretic peptide level obtained during a medical checkup examination is an independent and strong predictor of MACE. The inclusion of BNP as part of medical checkup parameters may improve the ability to identify individuals at increased cardiovascular risk and prevent cardiovascular disease among them.

Impact of proteinuria on long-term prognosis in patients with coronary artery disease

BACKGROUND

This study aimed to investigate the association between proteinuria and long-term prognosis in patients with coronary artery disease.

METHODS

This was a single-center observational study. A total of 1351 patients were identified who underwent percutaneous coronary intervention, and whose urine data were available. Patients were divided into two groups according to the presence (n = 245) or absence (n = 1106) of proteinuria. All-cause and cardiovascular deaths were primarily evaluated.

RESULTS

The prevalence rates of hypertension and diabetes were significantly higher, and the baseline estimated glomerular filtration rate (eGFR) was lower in patients with proteinuria than in those without proteinuria. During the median follow-up of 4.1 years (interquartile range, 1.7-6.8 years), the occurrences of all-cause and cardiovascular deaths were significantly higher in patients with proteinuria. Multivariable Cox regression analysis indicated that the presence of proteinuria was a significant predictor of cardiovascular death as well as age, BMI, reduced eGFR, and left ventricular ejection fraction. When stratified into four groups based on eGFR category (eGFR <60 or ≥60 ml/min/1.73 m2) and absence or presence of proteinuria, the incidence rates of all-cause and cardiovascular deaths were highest in patients with proteinuria and eGFR less than 60 ml/min/1.73 m2. Furthermore, the incidence rates of all-cause and cardiovascular deaths were significantly higher in patients with proteinuria among both diabetic and nondiabetic patients.

CONCLUSION

Proteinuria is associated with the long-term prognosis, and all-cause and cardiovascular deaths in patients with coronary artery disease, regardless of eGFR and the presence or absence of diabetes mellitus.

Impact of C-Reactive Protein on Long-Term Cardiac Events in Stable Coronary Artery Disease Patients with Chronic Kidney Disease

AIM

Chronic inflammation is associated with atherosclerosis development. Chronic kidney disease (CKD) is an independent risk factor for cardiovascular events and is associated with chronic inflammation. We aimed to investigate the influence of C-reactive protein (CRP), an important marker of inflammation, on the clinical outcomes of patients with CKD and stable coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI).

METHODS

Among patients with stable CAD and CKD who underwent PCI, 516 patients whose CRP levels were available before the PCI procedure were identified. The patients were divided into two groups according to the CRP levels: those with CRP ≥ 2.0 mg/L (high-CRP group) and those with CRP ＜2.0 mg/L (low-CRP group). The primary endpoint of this study was the occurrence of major adverse cardiac events (MACE), defined as a composite of cardiac death, myocardial infarction, and unplanned revascularization.

RESULTS

Overall, the mean age of the patients was 72.5±9.7 years, and 20.7% were female. The median CRP level was 1.43 mg/L (0.6-4.9 mg/L). The median follow-up period was 3.6 years. The occurrence of MACE was significantly higher in the high-CRP group than in the low-CRP group (log-rank p＜0.001). Notably, the incidence rate of cardiac death was significantly higher in the high-CRP group (log-rank p＜0.001). According to the multivariable analysis, CRP level ≥ 2.0 mg/L was found to be a significant predictor of MACE (hazard ratio [HR]: 1.54, 95% confidence interval [CI]: 1.04-2.28, p=0.003), as well as estimated glomerular filtration rate (HR: 0.98, 95% CI: 0.97-0.99, p＜0.01).

CONCLUSION

High-CRP levels adversely affect long-term cardiac events in patients with stable CAD and CKD.

Serum uric acid to creatinine ratio as a risk factor for mortality among patients on continuous ambulatory peritoneal dialysis: a multi-center retrospective study

BACKGROUND

Serum uric acid to serum creatinine ratio (SUA/Scr) has emerged as a new biomarker, which is significantly associated with several metabolic diseases. However, no study has investigated the association between SUA/Scr and mortality among patients on continuous ambulatory peritoneal dialysis (CAPD).

METHODS

In this multicenter retrospective cohort study, we enrolled CAPD patients in eight tertiary hospitals in China from 1 January 2005 to 31 May 2021. Cox proportional hazard models were used to determine the relationship between SUA/Scr and mortality.

RESULTS

A total of 2480 patients were included; the mean age was 48.9 ± 13.9 years and 56.2% were males. During 12648.0 person-years of follow-up, 527 (21.3%) patients died, of which 267 (50.7%) deaths were caused by cardiovascular disease. After multivariable adjustment for covariates, per unit increase in SUA/Scr was associated with a 62.9% (HR, 1.629 (95% confidence interval (CI) 1.420-1.867)) and 73.0% (HR, 1.730 (95% CI 1.467-2.041)) higher risk of all-cause and cardiovascular mortality. Results were similar when categorized individuals by SUA/Scr quartiles. Compared with the lowest quartile of SUA/Scr, the highest and the second highest quartile of SUA/Scr had a 2.361-fold (95% CI 1.810-3.080) and 1.325-fold (95% CI 1.003-1.749) higher risk of all-cause mortality, as well as a 3.701-fold (95% CI 2.496-5.489) and 2.074-fold (95% CI 1.387-3.100) higher risk of cardiovascular mortality. Multivariable-adjusted spline regression models showed nonlinear association of SUA/Scr with mortality in CAPD patients.

CONCLUSIONS

Higher levels of SUA/Scr were associated with higher risk of all-cause and cardiovascular mortality in CAPD patients.

Exposure to Cadmium, Lead, Mercury, and Arsenic and Uric Acid Levels: Results from NHANES 2007-2016

Mechanisms underlying abnormal uric acid (UA) levels from exposure to toxic metals/metalloids have not been not fully elucidated, especially in the context of mixtures. The aim was to identify major toxic metals/metalloids that affected UA levels with a mixture exposure concept in the association model. From 2007-2016 National Health and Nutrition Examination Survey (NHANES), 4794 adults were involved. Serum UA (SUA) and SUA to serum creatinine ratio (SUA/SCr) were used to estimate the UA levels, and cadmium (Cd), lead (Pb), mercury (Hg), and arsenic (As) in the blood and/or urine were evaluated in the study. We assessed the associations between toxic metals and UA levels using linear regression and Bayesian kernel machine regression (BKMR). The median [P₂₅, P₇₅] SUA/SCr and SUA level were 6.22 [5.27, 7.32] and 0.83 [0.72, 0.98], respectively. There was no difference for SUA/SCr by gender (men, 6.25 [5.39, 7.29]; women, 6.17 [5.17, 7.36], P = 0.162), but men had higher SUA than women (men, 0.95 [0.85, 1.05]; women, 0.72 [0.64, 0.82], P < 0.001). Blood Pb (β_men = 0.651 and β_women = 1.014) and urinary Cd (β_men = 0.252 and β_women = 0.613) were positively associated with SUA/SCr, and urinary Pb (β_men =  - 0.462 and β_women =  - 0.838) was inversely associated with SUA/SCr in multivariate linear regression analysis. However, urinary As (β_men = 0.351) was positively associated with SUA/SCr only in men. BKMR showed that higher concentrations of exposure to a mixture of toxic metals were positively associated with higher UA levels, where Cd, Pb, and urinary As contributed most to the overall mixture effect in men, while Pb and urinary Cd in women. Our study provided the first evidence that mixtures of metals are associated with the UA levels. Increased concentrations of metals, mainly blood Pb, urinary Cd, and As (only in men) may increase the level of UA.

CHA2DS2VASc score predicts risk of end stage renal disease in patients with atrial fibrillation: Long-term follow-up study

Background

End stage renal disease (ESRD) is an increasing worldwide epidemic disease. CHA2DS2-VASc score is a well-established predictor of cardiovascular outcome among atrial fibrillation (AF) patients.

Objective

The aim of this study was to test whether CHA2DS2-VASc score is a good predictor for incident ESRD events.

Methods

This is a retrospective cohort study (from January 2010 to December 2020) with median follow-up of 61.7 months. Clinical parameters and baseline characteristics were recorded. The endpoint was defined as ESRD with dialysis dependent.

Results

The study cohort comprised 29,341 participants. Their median age was 71.0 years, 43.2% were male, 21.5% had diabetes mellitus, 46.1% had hypertension, and mean CHA2DS2-VASc score was 2.89. CHA2DS2-VASc score was incrementally associated with the risk of ESRD status during follow-up. Using the univariate Cox model, we found a 26% increase in ESRD risk with an increase of one point in the CHA2DS2-VASc score (HR 1.26 [1.23-1.29], P < 0.001). And using the multi-variate Cox model adjusted by initial CKD stage, we still observed a 5.9% increase in risk of ESRD with a one-point increase in the CHA2DS2-VASc score (HR 1.059 [1.037-1.082], P < 0.001). The CHA2DS2-VASC score and the initial stage of CKD were associated with the risk of ESRD development in patients with AF.

Conclusions

Our results first confirmed the utility of CHA2DS2-VASC score in predicting progression to ESRD in AF patients. The efficiency is best in CKD stage 1.

Left ventricular myocardial mass index associated with cardiovascular and renal prognosis in IgA nephropathy

Introduction

In chronic kidney disease (CKD), like in IgA nephropathy (IgAN), cardiovascular (CV) mortality and morbidity are many times higher than in the general population, and left ventricular hypertrophy (LVH) is an independent risk factor for CV disease. This follow-up study investigated the association between left ventricular mass index (LVMI) and renal or cardiovascular outcomes.

Methods

We examined 118 IgAN patients prospectively. LVMI and LV geometry was investigated using echocardiography. The primary combined endpoints were total mortality, major CV events, and end-stage renal disease. Secondary endpoints, i.e.—cardiovascular or renal endpoints,—were also examined separately.

Results

Sixty seven percent were males, mean age 53.5 ± 13.5. Mean follow-up time: 184 months. LVMI inversely correlated with eGFR (corr. coefficient: -0.365; p < 0.01). We divided the patients into two groups based on the LVMI cut-off suggested by the literature. The presence of LVH caused a worse prognosis in primary (p < 0.001), renal endpoints (p = 0.01), and also in CV endpoints (p = 0.001). The higher LVMI in men significantly worsened the prognosis in all endpoints. Concentric hypertrophy meant a worse prognosis. Independent predictors of LVMI were gender and eGFR in uni- and multivariate regression and hemoglobin levels only in logistic regression. Independent predictors of the primary endpoint were LVMI, eGFR, gender, obesity, HT, DM, and metabolic syndrome in Cox regression analysis.

Conclusion

Increased LVMI may predict the progression to end-stage renal disease and CV events in IgAN. Determining LVMI may be a useful parameter not only in CV risk but also in the stratification of renal risk in CKD.

Pulse Wave Velocity, Central Haemodynamic Parameters, and Markers of Kidney Function in Children

OBJECTIVES

Chronic kidney disease (CKD) is a well-established risk factor for cardiovascular diseases. Studies in adults have demonstrated the association between mildly decreased kidney function or even normal values of markers of kidney function to pulse wave velocity (PWV), a measure of arterial stiffness and a predictor of cardiovascular events. Our study aimed to evaluate associations between markers of CKD, PWV, and central haemodynamic parameters in children and adolescents at risk of subclinical kidney damage.

METHODS

182 children and adolescents with hypertension, obesity, or hypercholesterolaemia (risk factors for subclinical kidney damage) were included in the study. The subjects were subdivided into 4 groups comprising children and adolescents with hypertension (group 1), obesity (group 2), hypercholesterolaemia (group 3), and a group with a combination of risk factors, such as obesity-related hypertension and metabolic syndrome (group 4). The study groups were compared to a group of healthy controls (group 5). PWV was measured by applanation tonometry (SphygmoCor, SCOR-Vx, Sydney, NSW, Australia) and laboratory parameters (serum creatinine, serum cystatin C, and microalbuminuria) were collected.

RESULTS

Pearson's correlation coefficient demonstrated a statistically significant correlation between PWV and serum creatinine in group of all subjects (r = 0.220, p = 0.002). Further subdivision showed the correlation was significant in group 4 (r = 0.370, p = 0.002). In group 2 a correlation between PWV and cystatin C was found (r = -0.535, p = 0.009). In multiple regression analysis of all subjects with PWV as the dependent variable, age and diastolic blood pressure were statistically significant. Correlations between markers of kidney function and central haemodynamic parameters also showed significant correlations between serum creatinine and heart rate (HR) (r = -0.476, p < 0.001) as well as associated parameters (augmentation index, standardized at HR 75/min, ejection duration, and subendocardial viability ratio).

CONCLUSIONS

Our study demonstrated a correlation between serum creatinine and PWV in children with combined risk factors for atherosclerosis and probable subclinical kidney damage. Further prospective research is needed to confirm the findings, and thus the preventive role of PWV determination in paediatric nephrology.

Effect of body mass index on the association between alcohol consumption and the development of chronic kidney disease

The influence of body mass or metabolic capacity on the association between alcohol consumption and lower risks of developing chronic kidney disease (CKD) is not fully elucidated. We examined whether the body mass index (BMI) affects the association between drinking alcohol and CKD. We defined CKD as an estimated glomerular filtration rate decline < 60 mL/min/1.73 m² and/or positive proteinuria (≥ 1+). Participants were 11,175 Japanese individuals aged 40–74 years without baseline CKD who underwent annual health checkups. Daily alcohol consumption at baseline was estimated using a questionnaire, and the participants were categorized as “infrequent (occasionally, rarely or never),” “light (< 20 g/day),” “moderate (20–39 g/day),” and “heavy (≥ 40 g/day).” Over a median 5-year observation period, 936 participants developed CKD. Compared with infrequent drinkers, light drinkers were associated with low CKD risks; adjusted hazard ratios (95% confidence intervals) were 0.81 (0.69–0.95). Stratified by BMI (kg/m²), moderate drinkers in the low (< 18.5), normal (18.5–24.9), and high (≥ 25.0) BMI groups had adjusted hazard ratios (95% confidence intervals) of 3.44 (1.60–7.42), 0.75 (0.58–0.98), and 0.63 (0.39–1.04), respectively. Taken together, the association between alcohol consumption and CKD incidence was not the same in all the individuals, and individual tolerance must be considered.

Association between renal function and cardiovascular mortality: a retrospective cohort study of elderly from health check-up

OBJECTIVES

This study aimed to investigate the relationship between cardiovascular mortality in elderly Asians and decline in renal function.

DESIGN

A retrospective cohort study.

SETTING

Community-based health examination database from Taipei city.

PARTICIPANTS

At the beginning, the database included 315 045 health check-up visits of 97 803 elderly persons aged ≥65 years old from 2005 to 2012. After excluding missing values and outliers, there were 64 732 elderly persons with at least two visits retained for further analyses.

PRIMARY OUTCOME MEASURES

Kidney function indicators include estimated glomerular filtration rate (eGFR) and urine protein, and rapid decline in eGFR was defined as slope ≤ -5 mL/min/1.73 m² per year. The endpoint outcome was defined as the cardiovascular deaths registered in the death registry encoded by the International Classification of Diseases. We applied a Cox proportional hazards model to analyse the association between renal function and cardiovascular mortality.

RESULTS

In this study, we found 1264 elderly persons died from cardiovascular diseases, for whom the data included 4055 previous health check-up visits. We observed significant and independent associations of eGFR <60 mL/min/1.73 m² (HR (95% CI) of 60>eGFR≥45 and eGFR<45 in males: 2.85 (1.33 to 6.09) and 3.98 (1.84 to 8.61); in females: 3.66 (1.32 to 10.15) and 6.77 (2.41 to 18.99)), positive proteinuria (HR (95% CI) of +/-, +,++ and +++, ++++ in males: 1.51 (1.29 to 1.78) and 2.31 (1.51 to 3.53); in females: 1.93 (1.54 to 2.42) and 4.23 (2.34 to 7.65)) and rapid decline in eGFR (HR (95% CI) in males: 3.24 (2.73 to 3.85); in females: 2.83 (2.20 to 3.64) with higher risk of cardiovascular mortality. The joint effect of increased concentration of urine protein and reduced eGFR was associated with a higher risk of cardiovascular mortality.

CONCLUSIONS

Renal function and rapid decline in renal function are independent risk factors for cardiovascular mortality in the elderly.

Association of achieved blood pressure after treatment for primary aldosteronism with long-term kidney function

Little is known regarding the association of blood pressure (BP) after treatment for primary aldosteronism (PA) (i.e., adrenalectomy and mineralocorticoid receptor antagonists) with long-term renal outcomes, and whether the association is independent of BP before treatment. Using a dataset from a nationwide registry of PA in Japan, we assessed whether achieved BP levels 6 months after treatment for PA are associated with annual changes in estimated glomerular filtration rate (eGFR), rapid eGFR decline, and incident chronic kidney disease (CKD) during the 5-year follow-up period. The cohort included 1266 PA patients. In multivariable linear regression including systolic BP (SBP) levels before treatment for PA, estimates (95% confidence interval [CI]) for annual changes in eGFR after month 6 associated with one-standard deviation (1-SD) higher SBP at month 6 were -0.08 (-0.15, -0.02) mL/min/1.73 m²/year. After multivariable adjustment, the estimate (95% CI) for annual changes in eGFR after month 6 was -0.12 (-0.21, -0.02) for SBP ≥ 130 mmHg vs. SBP < 130 mmHg at month 6. Among 537 participants without CKD at baseline, a 1-SD higher SBP was associated with a higher risk for incident CKD events (hazard ratio [95% CI]: 1.40 [1.00, 1.94]). Higher SBP after treatment for PA was associated with a higher risk for kidney dysfunction over time, independently of BP levels before treatment. Achieving SBP lower than 130 mmHg after treatment for PA may be linked to better kidney outcomes.

Impact of Major Cardiovascular Risk Factors on the Incidence of Cardiovascular Disease among Overweight and Non-Overweight Individuals: The Circulatory Risk in Communities Study (CIRCS)

Aim: We aimed to examine the impact of high-risk levels of cardiovascular risk factors on the incidence of cardiovascular disease (CVD) in overweight and non-overweight individuals without treatment for the risk factors.

Methods: A total of 8,051 individuals aged 40–74 years without a history of CVD and/or without treatment for hypertension, diabetes, hyperlipidemia, and kidney disease at baseline in 1995–2000 were followed up for a median of 14.1 years. We classified the participants into three risk categories (low-, intermediate-, and high-risk groups) on the basis of individual risk factors (blood pressure, serum glucose, low-density lipoprotein cholesterol [LDL-C], and urinary protein) according to the guidelines of Japanese clinical societies. The high-risk group (systolic blood pressure ≥ 160 mmHg or diastolic blood pressure ≥ 100 mmHg, fasting serum glucose ≥ 130 mg/dL or non-fasting serum glucose ≥ 180 mg/dL, LDL-C ≥ 180 mg/dL, proteinuria ≥ 2+) needed to refer to physicians or start treatment immediately. Overweight was defined as a body mass index of ≥ 25 kg/m ² .

Results: Compared with those in the non-overweight low-risk group, the hazard ratios (HRs) (95% confidence intervals, population-attributable fractions [PAFs]) of CVD in the high-risk categories of blood pressure were 2.0 (1.4–2.9, 7.0%) in the non-overweight high-risk group and 2.9 (1.9–4.3, 6.8%) in the overweight high-risk group. The corresponding HRs (95% confidence intervals, PAFs) of serum glucose were 2.0 (1.2–3.4, 2.5%) and 2.2 (1.1–4.3, 1.5%) in the non-overweight and overweight high-risk groups, respectively. Such associations were not observed for the high-risk group of LDL-C and proteinuria.

Conclusions: The present long-term observational study implies that targeting persons with non-treated severe hypertension and diabetes is prioritized to prevent CVD regardless of overweight status.

Circulating Renalase as Predictor of Renal and Cardiovascular Outcomes in Pre-Dialysis CKD Patients: A 5-Year Prospective Cohort Study

Chronic kidney disease (CKD) is an independent risk factor for adverse cardiovascular and cerebrovascular events (MACCEs), and mortality since the earlier stages. Therefore, it is critical to identify the link between CKD and cardiovascular risk (CVR) through early and reliable biomarkers. Acknowledging that CKD and CKD progression are associated with increased sympathetic tone, which is implicated in CVR, and that renalase metabolizes catecholamines, we aimed to evaluate the relationship between renalase serum levels (RNLS) and cardiovascular and renal outcomes. The study included 40 pre-dialysis CKD patients (19F:21M) with median age of 61 (IQ 45–66) years. At baseline, we measured RNLS as well as routine biomarkers of renal and cardiovascular risk. A prospective analysis was performed to determine whether RNLS are associated with CKD progression, MACCEs, hospitalizations and all-cause mortality. At baseline, the median level of RNLS and median estimated glomerular filtration rate (eGFR) were 63.5 (IQ 48.4–82.7) µg/mL and 47 (IQ 13–119) mL/min/1.73 m², respectively. In univariate analysis, RNLS were strongly associated with eGFR, age and Charlson Index. Over the course of a mean follow-up of 65 (47 to 70) months, 3 (7.5%) deaths, 2 (5%) fatal MACCEs, 17 (42.5%) hospital admissions occurred, and 16 (40%) patients experienced CKD progression. In univariate analysis, RNLS were associated with CKD progression (p = 0.001), hospitalizations (p = 0.001) and all-cause mortality (p = 0.022) but not with MACCEs (p = 0.094). In adjusted analysis, RNLS predicted CKD progression and hospitalizations regardless of age, Charlson comorbidity index, cardiovascular disease, hypertension, diabetes and dyslipidemia. Our results suggest that RNLS, closely related with renal function, might have a potential role as predictor of renal outcomes, hospitalizations, and mortality in pre-dialysis CKD patients.

Ultra-processed food consumption is associated with increased risk of all-cause and cardiovascular mortality in the Moli-sani Study

BACKGROUND

Consumption of ultra-processed food (UPF) is gaining growing attention in relation to disease/mortality risk, but less is known on the main nutritional factors or biological mechanisms potentially underlying such associations.

OBJECTIVES

We aimed to assess the association between UPF and mortality risk in a large sample of the Italian adult population and test which nutritional factors were on the pathway of this relation. Established risk factors for cardiovascular disease (CVD) were analyzed as potential biological mechanisms linking UPF to mortality.

METHODS

Longitudinal analysis was conducted on 22,475 men and women (mean ± SD age: 55 ± 12 y) recruited in the Moli-sani Study (2005-2010, Italy) and followed for 8.2 y. Food intake was assessed using a semiquantitative FFQ. UPF was defined using the NOVA classification according to degree of processing, and UPF intakes were categorized as quartiles of the ratio (%) of UPF (g/d) to total food consumed (g/d).

RESULTS

Individuals reporting the highest intake of UPF (Q4, >14.6% of total food), as opposed to the lowest (Q1, UPF < 6.6%), experienced increased risks of CVD mortality (HR: 1.58; 95% CI: 1.23, 2.03), death from ischemic heart disease (IHD)/cerebrovascular disease (HR: 1.52; 95% CI: 1.10, 2.09), and all-cause mortality (HR: 1.26; 95% CI: 1.09, 1.46). High sugar content explained 36.3% of the relation of UPF with IHD/cerebrovascular mortality, whereas other nutritional factors (e.g., saturated fats) were unlikely to be on the pathway. Biomarkers of renal function accounted for 20.1% of the association of UPF with all-cause mortality, and 12.0% for that of UPF with CVD mortality.

CONCLUSIONS

A high proportion of UPF in the diet was associated with increased risk of CVD and all-cause mortality, partly through its high dietary content of sugar. Some established biomarkers of CVD risk were likely to be on the pathway of such associations. These findings should serve as an incentive for limiting consumption of UPF, and encouraging natural or minimally processed foods, as several national nutritional policies recommend.

Incidence of cardiovascular events and mortality in Korean patients with chronic kidney disease

Few studies have investigated the incidence of cardiovascular disease (CVD) in the Asian chronic kidney disease (CKD) population. This study assessed the incidence of CVD, death, and a composite outcome of CVD and death in a prospective Korean predialysis CKD cohort. From a total of 2179 patients, incidence rates were analyzed, and competing risk analyses were conducted according to CKD stage. Additionally, incidence was compared to the general population. During a median 4.1 years of follow-up, the incidence of CVD, all-cause death, and the composite outcome was 17.2, 9.6, and 24.5 per 1000 person-years, respectively. These values were higher in diabetic vs. non-diabetic subjects (P < 0.001). For all outcomes, incidence rates increased with increasing CKD stage (CVD, P = 0.001; death, P < 0.001; and composite, P < 0.001). Additionally, CKD stage G4 [hazard ratio (HR) 2.8, P = 0.008] and G5 (HR 5.0, P < 0.001) were significant risk factors for the composite outcome compared to stage G1 after adjustment. Compared to the general population, the total cohort population (stages G1-G5) showed significantly higher risk of CVD (HR 2.4, P < 0.001) and the composite outcome (HR 1.7, P < 0.001). The results clearly demonstrate that CKD is a risk factor for CVD in an Asian population.

Plasminogenuria is associated with podocyte injury, edema, and kidney dysfunction in incident glomerular disease

Urinary plasminogen/plasmin, or plasmin (ogen) uria, has been demonstrated in proteinuric patients and exposure of cultured podocytes to plasminogen results in injury via oxidative stress pathways. A causative role for plasmin (ogen) as a "second hit" in kidney disease progression has yet to have been demonstrated in vivo. Additionally, association between plasmin (ogen) uria and kidney function in glomerular diseases remains unclear. We performed comparative studies in a puromycin aminonucleoside (PAN) nephropathy rat model treated with amiloride, an inhibitor of plasminogen activation, and measured changes in plasmin (ogen) uria. In a glomerular disease biorepository cohort (n = 128), we measured time-of-biopsy albuminuria, proteinuria, and plasmin (ogen) uria for correlations with kidney outcomes. In cultured human podocytes, plasminogen treatment was associated with decreased focal adhesion marker expression with rescue by amiloride. Increased glomerular plasmin (ogen) was found in PAN rats and focal segmental glomerulosclerosis (FSGS) patients. PAN nephropathy was associated with increases in plasmin (ogen) uria and proteinuria. Amiloride was protective against PAN-induced glomerular injury, reducing CD36 scavenger receptor expression and oxidative stress. In patients, we found associations between plasmin (ogen) uria and edema status as well as eGFR. Our study demonstrates a role for plasmin (ogen)-induced podocyte injury in the PAN nephropathy model, with amiloride having podocyte-protective properties. In one of the largest glomerular disease cohorts to study plasminogen, we validated previous findings while suggesting a potentially novel relationship between plasmin (ogen) uria and estimated glomerular filtration rate (eGFR). Together, these findings suggest a role for plasmin (ogen) in mediating glomerular injury and as a viable targetable biomarker for podocyte-sparing treatments.

Estimation of 10-Year Risk of Death from Coronary Heart Disease, Stroke, and Cardiovascular Disease in a Pooled Analysis of Japanese Cohorts: EPOCH-JAPAN

AIMS

We aimed to develop and validate risk prediction models to estimate the absolute 10-year risk of death from coronary heart disease (CHD), stroke, and cardiovascular disease (CVD).

METHODS

We evaluated a total of 44,869 individuals aged 40-79 years from eight Japanese prospective cohorts to derive coefficients of risk equations using cohort-stratified Cox proportional hazard regression models. Discrimination (C-index) of the equation was examined in each cohort and summarised using random-effect meta-analyses. Calibration of the equation was assessed using Hosmer-Lemeshow chi-squared statistic.

RESULTS

Within a median follow-up of 12.7 years, we observed 765 deaths due to CVD (276 CHDs and 489 strokes). After backward selection, age, sex, current smoking, systolic blood pressure (SBP), proteinuria, prevalent diabetes mellitus, the ratio of total cholesterol to high-density lipoprotein cholesterol (TC/HDLC), interaction terms of age by SBP, and age by current smoking were retained as predictors for CHD. Sex was excluded in the stroke equation. We did not consider TC/HDLC as a risk factor for the stroke and CVD equations. The pooled C-indices for CHD, stroke, and CVD were 0.83, 0.80, and 0.81, respectively, and the corresponding p-values of the Hosmer-Lemeshow tests were 0.18, 0.003, and 0.25, respectively.

CONCLUSIONS

Risk equations in the present study can adequately estimate the absolute 10-year risk of death from CHD, stroke, and CVD. Future work will evaluate the system as an education and risk communication tool for primary prevention of CHD and stroke.

Amlodipine Compared with Benidipine in the Management of Hypertension: A Systematic Review and Meta-Analysis

INTRODUCTION

Benidipine and amlodipine are two well-known drugs used in hypertensive patients with chronic kidney disease (CKD).

AIM

In this systematic review we aimed to compare benidipine and amlodipine in terms of efficacy in the management of hypertensive patients.

METHODS

We searched PubMed, Cochrane CENTRAL, SCOPUS and Web of Science for relevant clinical trials and excluded observational studies. Quality appraisal was evaluated according to GRADE and we assessed the risk of bias using the Cochrane's risk of bias tool. We included the following outcomes: Systolic blood pressure, diastolic blood pressure, heart rate, estimated glomerular filtration rate (eGFR), and urinary albumin/creatinine ratio. Data were pooled as mean differences (MD) with relative 95% confidence intervals (CI).

RESULTS

Eight studies were eligible for our meta-analysis. We found no significant difference between both drugs regarding systolic (MD = - 0.21 [- 1.48, 1.89], (P = 0.81) and diastolic (MD = 0.01[- 0.51, 0.53], (P = 0.97)) blood pressure measurements. The overall heart rate did not differ as well (MD = - 0.03 [- 1.63, 1.57], (P = 0.97)). We found that benidipine was statistically better than amlodipine in terms of eGFR (MD = 1.07 [0.43, 1.71], (P = 0.001)), and urinary albumin/creatinine ratio (MD = - 43.41 [- 53.53, - 33.29], (P < 0.00001)).

CONCLUSIONS

Finally we conclude that benidipine seems to show more positive and promising results in the management of hypertensive patients with chronic kidney disease.

Increased Urinary Liver-Type Fatty Acid-Binding Protein Level Predicts Major Adverse Cardiovascular Events in Patients With Hypertension

BACKGROUND

Urinary liver-type fatty acid-binding protein (L-FABP) has been known as a potential biomarker for acute kidney injury. It has also been suggested to have an effective predictive value for cardiovascular mortality in patients with diabetes or critically ill condition. Therefore, this study aimed to examine the ability of urinary L-FABP in predicting mid-term cardiovascular morbidity and mortality in patients with hypertension.

METHODS

Urinary L-FABP levels in stable outpatients without diabetes who were treated with antihypertensive drugs were measured, and a 5-year follow-up was planned. The primary end-point was a combination of acute heart failure requiring hospitalization, myocardial infarction, stroke, and cardiovascular death. The secondary end-point was kidney disease progression defined as a relative decline in the estimated glomerular filtration rate of ≥30% from the baseline.

RESULTS

A total of 197 patients were recruited. Primary and secondary end-points occurred in 24 (12.2%) and 42 (21.3%) patients, respectively, during a median follow-up of 5.7 years. Patients with urinary L-FABP levels higher than the upper limit (8.4 µg/g creatinine) were more likely to reach the primary (30.43% vs. 9.77%; P = 0.003) and secondary end-points (56.52% vs. 16.67%; P < 0.001) than those with urinary L-FABP levels within the normal limits. Urinary L-FABP level was independently associated with both primary (hazard ratio (HR) 1.21; P = 0.03) and secondary end-points (HR 1.19; P = 0.02).

CONCLUSIONS

This study demonstrated that increased urinary L-FABP levels may predict adverse cardiovascular events and renal dysfunction progression even among stable nondiabetic patients with hypertension.

Long-Term Exposure to Particulate Matter and Mortality from Cardiovascular Diseases in Japan: The Ibaraki Prefectural Health Study (IPHS)

Aim: To examine the association between long-term exposure to suspended particulate matter (SPM) and cardiovascular mortality in Japan after controlling for known major confounding factors among a large middle and elderly cohort study in Ibaraki Prefecture, Japan.

Methods: We followed 91,808 residents (men 34%) who undertook a national health check-up at age 40–79 years for 17 years (1993–2010). Two different exposure indices were adopted: baseline SPM concentration (in the year 1990) and average SPM concentration for the first (average of 1990 and 1995) and the second half (average of 2005 to 2009) of the study period. Sex-specific adjusted risk ratios (RRs) for cardiovascular mortality were calculated using general mixed Poisson regression models after adjusting the age, BMI, history of diabetes mellitus and hypertension, creatinine, glutamic pyruvic transaminase, total cholesterol, high-density lipoprotein cholesterol, smoking, alcohol, and temperature. The variation between seven medical administration areas was also taken into account as a random effect.

Results: Baseline SPM concentration was associated with an increased risk of mortality from all cardiovascular diseases, coronary artery disease, and stroke. The adjusted RRs (95% confidence interval [CI]) per 10 µg/m³ increase in SPM concentration for all cardiovascular mortality were 1.147 (1.014–1.300) for men and 1.097 (0.985–1.222) for women. The point estimate of RR was highest for non-hemorrhagic stroke in men (1.248 [0.991–1.571]), although CI overlapped the unity. The RRs seemed slightly lower in the second half than in the first half, though the CIs widened in the second half.

Conclusion: Our results suggest that long-term exposure to SPM is associated with an increased risk of all cardiovascular mortality for men in Ibaraki, Japan.

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.

Cause-specific mortality in the general population with transient dipstick-proteinuria

Recently, changes in urinary albumin and in GFR have been recognized as risk factors for the development of end-stage kidney disease and mortality. Though most clinical epidemiology studies of chronic kidney disease (CKD) used renal function and proteinuria at baseline alone, definitive diagnosis of CKD with multiple measurements intensifies the differences in the risk for mortality between the CKD and non-CKD populations. We hypothesized that a transient diagnosis of proteinuria and reduced renal function each indicate a significantly higher mortality compared to definitive non-CKD as the negative control and lower mortality compared with definitive CKD as the positive control. The present longitudinal study evaluated a general-population cohort of 338,094 persons who received annual health checkups, with a median 4.3-year study period. There were 2,481 deaths, including 510 CVD deaths (20.6%) and 1,328 cancer deaths (53.5%), and mortality risk was evaluated for transient proteinuria and for transiently reduced renal function. The hazard ratios (HRs) for all-cause mortality and cancer mortality were not significant, but that for cardiovascular mortality was significantly higher for transient proteinuria (HR, 1.94 [95% confidence interval, 1.27–2.96] in men and 2.78 [1.50–5.16] in women). On the other hand, transiently reduced renal function was not significant for either cardiovascular mortality risk or cancer mortality risk. We surmise that this is the first study of the mortality risk of transient dipstick proteinuria in a large general-population cohort with cause-specific death registration. Transiently positive proteinuria appears to be a significant risk specifically for cardiovascular mortality compared with definitely negative for proteinuria.

Spot urine protein/creatinine ratio as a reliable estimate of 24-hour proteinuria in patients with immunoglobulin A nephropathy, but not membranous nephropathy

BACKGROUND

Proteinuria is known to be associated with both kidney function deterioration and cardiovascular diseases. While proteinuria estimation from 24-h urine samples has traditionally been considered as the standard method for assessment of the degree of urinary protein excretion, sample collection is associated with several technical problems such as inaccurate collection and the potential spread of drug-resistant pathogens. Therefore, the spot urine protein/creatinine ratio (PCR) assessment is currently recommended as an alternative. While the utility of PCR has been validated, studies on the association between spot urine PCR and 24-h proteinuria (24HP) in patients with chronic glomerular nephritis (CGN) and nephrotic syndrome (NS) are limited. This study aimed to evaluate whether an estimated result from a spot urine PCR could sufficiently approximate the daily urine protein excretion amount from a 24-h urine sample in patients with immunoglobulin A nephropathy (IgAN), minimal change disease (MCD), and membranous nephropathy- nephrotic syndrome (MN-NS).

METHODS

The study participants included 161 patients with IgAN, MCD, or MGN-NS at the Jikei University Kashiwa Hospital and Kanagawa Prefecture Shiomidai Hospital. The correlation between spot urine PCR and a 24-h urine protein was investigated using linear regression analysis with Spearman's correlation (r) coefficient and intraclass correlation coefficient (ICC).

RESULTS

While high correlation coefficients (r = 0.86, P < 0.001) and substantial agreement (ICC: 0.806, P < 0.001) were observed in patients with IgAN, similar correlations were not observed in patients with MCD or MN-NS. In the patients with MCD, r was 0.53 (P < 0.001), which signified a slight correlation, and in the patients with MN-NS, r was 0.289 (P = 0.17), which was not statistically significant.

CONCLUSIONS

This study revealed that spot urine PCR is a reliable estimate of 24HP value in patients with IgAN. In contrast, there is a considerable difference between the daily urine protein excretion amount based on a 24-h urine sample and that which is calculated from spot urine PCR in patients with NS.

Higher medical costs for CKD patients with a rapid decline in eGFR: A cohort study from the Japanese general population

To investigate how changes in eGFR can affect medical costs, a regional cohort of national health insurance beneficiaries in Japan was developed from a nationwide database system (Kokuho database, KDB), and non-individualized data were obtained. From 105,661 people, subjects on chronic dialysis and subjects without consecutive medical checkups were excluded. Finally, medical costs in the follow-up year categorized by annual changes in eGFR between baseline and the next year were longitudinally examined in 70,627 people ranging in age from 40 to 74 years. Global mean costs for subjects with a rapid decrease in eGFR (≤-30%/year) were the highest among all ΔeGFR categories. In men, the cost was 1.42 times that for a stable eGFR. A total of 6,268 (19.4%) men and 5,381 (14.0%) women with eGFR <60 ml/min/1.73 m² were identified in the baseline year. The mean cost was higher with a low eGFR than without a low eGFR, and there were also higher proportions newly initiating dialysis in 2014 (low eGFR with rapid decrease in eGFR vs. with stable eGFR: 9.61% vs. 0.02% in women, P<0.001). Moreover, the costs for low eGFR subjects with a rapid decrease in eGFR were more than twice those of non-low eGFR subjects with a rapid decrease in eGFR and also compared to low eGFR subjects with a stable eGFR. Moreover, initiating chronic dialysis was considered one of the major causes of high medical costs in women with rapid eGFR decline. To the best of our knowledge, this is the first study of renal disease using a cohort developed from the KDB system recently established in Japan.

Identification of potential plasma biomarkers and metabolic dysfunction for unstable angina pectoris and its complication based on global metabolomics

Unstable angina pectoris (UA) is one of the most dangerous clinical symptoms of acute coronary syndrome due to the risk of myocardial ischemia, which can lead to high morbidity and mortality worldwide. Though there are many advantages in understanding the pathophysiology of UA, the identification of biomarkers for the diagnosis, prognosis, and treatment of UA remains a challenge in the clinic. A global metabolomics research based on ultra-performance liquid chromatography (UPLC) combined with Q-TOF/MS was performed to discover the metabolic profile of health controls, UA patients, and UA patients with diabetes mellitus (DM), and screen for potential biomarkers. Twenty-seven potential biomarkers were determined using pattern recognition. These biomarkers, which include free fatty acids, amino acids, lysoPE and lysoPC species, and organic acids, can benefit the clinical diagnosis of UA. Pathway analysis indicated that arginine and proline metabolism, glycerophospholipid metabolism, and purine metabolism were affected in the UA patients, uniquely. Additionally, alterations in the metabolic signatures between UA and UA-complicated DM were also explored. As a result, six differential metabolites with an area under the curve (AUC) of more than 0.85 were identified as biomarkers for the diagnosis of UA and UA complicated with DM. Pathway analysis implied tryptophan metabolism was a key metabolic pathway in UA patients with DM, which provides new insights into the pathological study and drug discovery of UA.

New risk prediction model of coronary heart disease in participants with and without diabetes: Assessments of the Framingham risk and Suita scores in 3-year longitudinal database in a Japanese population

The Framingham Risk Score (FRS) has been reported to predict coronary heart disease (CHD), but its assessment has been unsuccessful in Asian population. We aimed to assess FRS and Suita score (a Japanese CHD prediction model) in a Japanese nation-wide annual health check program, participants aged 40-79 years were followed up longitudinally from 2008 to 2011. Of 35,379 participants analyzed, 1,234 had new-onset CHD. New-onset CHD was observed in diabetic men [6.00%], non-diabetic men [3.96%], diabetic women [5.51%], and non-diabetic women [2.86%], respectively. Area under the curve (AUC) of receiver operating characteristic (ROC) curve for CHD prediction were consistently low in Suita score (TC), FRS (TC) and NCEP-ATPIII FRS (TC), suggesting that these scores have only a limited power. ROC, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA) and Hosmer-Lemeshow goodness-of-fit test did not show clear differences between Suita score (TC) and FRS (TC). New models combining waist circumference ≥85 cm in men or proteinuria ≥1+ in women to Suita score (TC) was superior in diabetic men and women. New models could be useful to predict 3-year risk of CHD at least in Japanese population especially in diabetic population.

Risk factors for increased left ventricular hypertrophy in patients with chronic kidney disease: findings from the CKD-JAC study

Background

Although left ventricular hypertrophy (LVH) has been established as a predictor of cardiovascular events in chronic kidney disease (CKD), the relationship between the prevalence of LVH and CKD stage during the pre-dialysis period has not been fully examined.

Methods

We measured left ventricular mass index (LVMI) in a cross-sectional cohort of participants in the Chronic Kidney Disease Japan Cohort (CKD-JAC) study to identify factors that are associated with increased LVMI in patients with stage 3–5 CKD.

Results

We analyzed the baseline characteristics in 1088 participants (male 63.8%, female 36.2%). Diabetes mellitus was the underlying disease in 41.7% of the patients, and mean age was 61.8 ± 11.1 years. LVH was detected in 23.4% of the patients at baseline. By multivariate logistic analysis, independent risk factors for LVH were past history of cardiovascular disease [odds ratio (OR) 2.364; 95% confidence interval ([CI) 1.463–3.822; P = 0.0004], body mass index (OR 1.108; 95% CI 1.046–1.173; P = 0.0005), systolic blood pressure (OR 1.173; 95% CI 1.005–1.369; P = 0.0433), urinary albumin (OR 1.425; 95% CI 1.028–1.974; P = 0.0333), and serum total cholesterol level (OR 0.994; 95% CI 0.989–0.999; P = 0.0174).

Conclusion

The cross-sectional baseline data from the CKD-JAC study shed light on the association between LVH and risk factors in patients with decreased renal function. Further longitudinal analyses of the CKD-JAC cohort are needed to evaluate the prognostic value of LVH in CKD patients.

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.

Effect of Angiotensin-Converting Enzyme Inhibitor/Calcium Antagonist Combination Therapy on Renal Function in Hypertensive Patients With Chronic Kidney Disease: Chikushi Anti-Hypertension Trial - Benidipine and Perindopril

Background

Appropriate blood pressure control suppresses progression of chronic kidney disease (CKD). If an angiotensin-converting enzyme (ACE) inhibitor is ineffective, adding a calcium antagonist is recommended. We compared the long-term effect of two ACE inhibitor/calcium antagonist combinations on renal function in hypertensive patients with CKD.

Methods

Patients who failed to achieve the target blood pressure (systolic/diastolic: < 130/80 mm Hg) with perindopril monotherapy were randomized to either combined therapy with perindopril and the L-type calcium antagonist amlodipine (group A) or perindopril and the T/L type calcium antagonist benidipine (group B). The primary endpoint was the change of the estimated glomerular filtration rate (eGFR) after 2 years. Eligible patients had a systolic pressure ≥ 130 mm Hg and/or diastolic pressure ≥ 80 mm Hg and CKD (urine protein (+) or higher, eGFR < 60 min/mL/1.73 m²).

Results

After excluding 38 patients achieving the target blood pressure with perindopril monotherapy, 121 patients were analyzed (62 in group A and 59 in group B). Blood pressure decreased significantly in both groups, but there was no significant change of the eGFR. However, among patients with diabetes, eGFR unchanged in group B (n = 37, 59.1 ± 15.1 vs. 61.2 ± 27.9, P = 0.273), whereas decreased significantly in group A (n = 31, 57.3 ± 16.0 vs. 53.7 ± 16.7, P = 0.005).

Conclusions

In hypertensive patients with diabetic nephropathy, combined therapy with an ACE inhibitor and T/L type calcium antagonist may prevent deterioration of renal function more effectively than an ACE inhibitor/L type calcium antagonist combination.

Estimated Glomerular Filtration Rate, Proteinuria, and Risk of Cardiovascular Diseases and All-cause Mortality in Diabetic Population: a Community-based Cohort Study

Data about associations between estimated glomerular filtration rate (eGFR) and proteinuria with cardiovascular diseases (CVDs) and all-cause mortality among diabetic population is less described. We aimed to describe these associations in Chinese diabetic population, and investigate the difference between sexes. The study was based on 8,301 diabetic participants in the Kailuan study, who was free of CVDs at baseline. We used Cox proportional hazard models to examine the associations of eGFR and proteinuria with CVDs and all-cause mortality. A stratified analysis by gender was performed. During a median follow-up of 8.05 years, 917 deaths and 813 incident CVDs occurred. Adjusted for all potential confounders, eGFR was associated with all-cause mortality, but not associated with incidence of CVDs. Compared to those with eGFR ≥ 90 ml/min/1.73 m², Participants with eGFR <45 ml/min/1.73 m² had 1.50 fold higher risk of all-cause mortality. Adjusted for all potential confounders, proteinuria was associated with risk of both CVDs and all-cause mortality. Additionally, the risk of all-cause mortality by proteinuria was greater in women than that in men. Both lower eGFR and proteinuria are independent risk factors for all-cause mortality in the Chinese diabetic population. Proteinuria conferred excessive risk for CVDs, and especially in women.

Assessment of novel cardiovascular biomarkers in women with a history of recurrent miscarriage

OBJECTIVES

A history of recurrent miscarriage is associated with future cardiovascular disease. The aim of this study was to determine novel cardiovascular biomarkers in women with a history of recurrent miscarriage as this might lead to a better understanding of the association.

STUDY DESIGN

Women who visited the recurrent miscarriage clinic at Leiden University Medical Centre (between 2000 and 2010), and had three consecutive miscarriages ≤30 years were invited to participate in this follow-up study (between 2012 and 2014). The reference group consisted of women with at least one uncomplicated pregnancy and a history of no miscarriage, matched on zip code, age, and date of pregnancy.

MAIN OUTCOME MEASURES

Cardiovascular biomarkers were determined, classified into; inflammation (HsCRP, lipoprotein-associated phospholipase A2), thrombosis (homocysteine, folate, anti-cardiolipin antibodies and anti-ß-2-glycoprotein antibodies), lipid metabolism (lipoprotein(a)), renal function (creatinine, microalbuminuria), myocardial damage (N-terminal pro-brain natriuretic peptide, high sensitive TroponineT) and multiple mechanisms (albumin, vitamin D).

RESULTS

In both groups, 36 women were included. Women with recurrent miscarriage had a significantly higher median HsCRP (1.49 mg/L) compared to women with no miscarriage (1.01 mg/L, p = 0.03) and a significantly lower mean albumin (46.0 vs 47.6g/L, p = 0.004) and vitamin D (55.6 vs 75.4nmol/L, p = 0.007), respectively. Differences remained after adjustments for classic cardiovascular risk factors (BMI, smoking, diabetes mellitus, and hypertension).

CONCLUSIONS

Our findings suggest a proinflammatory state in women with a history of recurrent miscarriage, which suggests a less optimal health, compared to women with no miscarriage. More research (observational and intervention) is warranted to investigate the association with vitamin D.

Chronic kidney disease, inflammation, and cardiovascular disease risk in rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA), a prototypic systemic autoimmune inflammatory condition, confers an increased risk of cardiovascular disease (CVD). Recently, chronic kidney disease (CKD) was suggested to increase the risk of CVD in RA patients, and inflammation was identified as a critical, nontraditional CKD-associated risk factor for CVD. This study aimed to examine the combined effects of CKD and CVD in RA patients.

METHODS

In this retrospective evaluation of 428 RA patients, the outcome of interest was the incidence of CVD. CKD was defined as an estimated glomerular filtration rate of <60mL/min/1.73m² and/or positive dipstick tests for proteinuria of ≥3 months duration. C-reactive protein (CRP) was used as an inflammation marker, and a high CRP level was defined as a mean CRP value of ≥0.57mg/dL during the first 6 months of follow-up. Patients were categorized as follows: non-CKD with low CRP, non-CKD with high CRP, CKD with low CRP, and CKD with high CRP.

RESULTS

During a median follow-up of 89 months, 67 patients (16%) had CKD, and 38 (9%) developed CVD. Using patients with non-CKD and low CRP as a reference group, the adjusted hazard ratios (HR, 95% confidence interval) for CVD were 1.88 (0.25-9.44) for patients with CKD/low CRP and 9.71 (3.27-31.97) for those with CKD/high CRP.

CONCLUSIONS

The coexistence of CKD and inflammation was associated with a higher risk of CVD than either condition alone in RA patients. Inflammation might increase the risk of CVD especially in patients with CKD.

Antialbuminuric effect of eplerenone in comparison to thiazide diuretics in patients with hypertension

This study investigated the effects and safety of eplerenone or thiazide diuretics in patients with hypertension and albuminuria (pretreatment urinary albumin/creatinine ratio ≥10 mg/gCr) treated with an angiotensin II receptor blocker. The primary end point was the mean percent change in the urinary albumin/creatinine ratio from baseline to 48 weeks. An efficacy analysis was performed in 195 patients (98 in the eplerenone group and 97 in the thiazide group). Systolic and diastolic blood pressures at 48 weeks were similar in the two groups. The mean percent change in the urinary albumin/creatinine ratio from baseline to 48 weeks was similar in the two groups (P=.804). In the safety analysis, the withdrawal rates for adverse events were similar in both groups. The antialbuminuric effects and safety of eplerenone therapy were similar to those of thiazide diuretics when combined with an angiotensin II receptor blocker in patients with hypertension and albuminuria.

Ankle-brachial Index for the Prognosis of Cardiovascular Disease in Patients with Mild Renal Insufficiency

Objective A low ankle-brachial index (ABI) is a known predictor for future cardiovascular events and mortality in patients with chronic kidney disease (CKD). While most prior studies have defined CKD as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, recent reports have suggested that the cardiovascular risk may be increased even in early stages of renal insufficiency. We hypothesized that a low ABI may predict future cardiovascular morbidity and mortality in patients with mild impairment of the renal function. Methods The IMPACT-ABI study was a retrospective, single-center, cohort study that enrolled and obtained ABI measurements for 3,131 patients hospitalized for cardiovascular disease between January 2005 and December 2012. From this cohort, we identified 1,500 patients with mild renal insufficiency (eGFR =60-89 mL/min/1.73 m2), and stratified them into 2 groups: ABI ≤0.9 (low ABI group; 9.2%) and ABI >0.9 (90.8%). The primary outcome measured was the cumulative incidence of major adverse cardiovascular events (MACE; cardiovascular death, myocardial infarction, and stroke). Results Over a mean follow-up of 5.0 years, 101 MACE occurred. The incidence of MACE was significantly higher in patients with low ABI than in those with ABI >0.9 (30.2% vs. 14.4%, log rank p<0.001). A low ABI was associated with MACE in a univariate Cox proportional hazard analysis. A low ABI remained an independent predictor of MACE in a multivariate analysis adjusted for cardiovascular risk factors (hazard ratio (HR): 2.27; 95% confidence interval (CI): 1.33-3.86; p=0.002). Conclusion Low ABI was an independent predictor for MACE in patients with mild renal insufficiency.

Blood pressure components and the risk for proteinuria in Japanese men: The Kansai Healthcare Study

Background

We examined prospectively which of the four blood pressure (BP) components (systolic BP [SBP], diastolic BP [DBP], pulse pressure [PP], and mean arterial pressure [MAP]) was best in predicting the risk of proteinuria.

Methods

This prospective study included 9341 non-diabetic Japanese middle-aged men who had no proteinuria and an estimated glomerular filtration rate ≥60 mL/min/1.73 m² and were not taking antihypertensive medications at entry. Persistent proteinuria was defined if proteinuria was detected two or more times consecutively and persistently at the annual examination until the end of follow-up. We calculated the difference in values of Akaike's information criterion (ΔAIC) in comparison of the BP components-added model to the model without them in a Cox proportional hazards model.

Results

During the 84,587 person-years follow-up period, we confirmed 151 cases of persistent proteinuria. In multiple-adjusted models that included a single BP component, the hazard ratios for persistent proteinuria for the highest quartile of SBP, PP, and MAP were 3.11 (95% confidence interval [CI], 1.79–5.39), 1.87 (95% CI, 1.18–2.94), and 2.21 (95% CI, 1.33–3.69) compared with the lowest quartile of SBP, PP, and MAP, respectively. The hazard ratio for the highest quartile of DBP was 2.69 (95% CI, 1.65–4.38) compared with the second quartile of DBP. Of all models that included a single BP component, those that included SBP alone or DBP alone had the highest values of ΔAIC (14.0 and 13.1, respectively) in predicting the risk of persistent proteinuria.

Conclusions

Of all BP components, SBP and DBP were best in predicting the risk of persistent proteinuria in middle-aged Japanese men.

•

We examined which blood pressure (BP) components increased risk of proteinuria.

•

We used systolic BP, diastolic BP, pulse pressure, and mean arterial pressure.

•

Systolic and diastolic BP were the best predictors of persistent proteinuria.

Blood Pressure Control During Chronic Kidney Disease Progression

BACKGROUND

Hypertension is a major cause of end-stage renal disease, and blood pressure (BP) control is crucial in patients with chronic kidney disease (CKD). However, it is generally inadequately controlled in CKD patients. We investigated the prevalence of CKD patients with inadequate BP control and its related factors, based on the CKD stage.

METHODS

We analyzed the health examination sample cohort database, which consisted of the randomly selected participants among all the citizens who received the health examination provided by National Health Insurance Service of Korea in 2012 and 2013.

RESULTS

There were 27,350 CKD patients (7.9%) out of a total of 345,044 participants. As CKD stage progressed, there were more patients with poorly controlled hypertension compared to those with well-controlled hypertension. In addition, systolic BP increased with CKD stage progression, while diastolic BP was not significantly different. Age, female, body mass index, increased pulse pressure, CKD stage, and levels of fasting glucose, total cholesterol, hemoglobin, and proteinuria were significant factors associated with poor control of BP in hypertensive CKD patients.

CONCLUSION

The proportion of CKD patients with poorly controlled hypertension significantly increased as CKD progressed, mainly associated with the increase in pulse pressure. However, future investigation for causal relationship between poorly controlled hypertension and its related factors is needed.

Impact of Polypharmacy on the Rehabilitation Outcome of Japanese Stroke Patients in the Convalescent Rehabilitation Ward

Background. A risk factor associated with stroke onset is chronic kidney disease (CKD). To prevent stroke reoccurrence, it is necessary to strictly manage blood pressure, lipids, and plasma glucose. Therefore, some cases are forced to polypharmacy, elderly patients in particular. Polypharmacy often leads to adverse drug reactions and has the potential to negatively affect the rehabilitation of stroke patients. The aim of the present study was to investigate the effects of polypharmacy using a functional independence measure (FIM). Methods. A total of 144 stroke patients with CKD were included in the present analysis. We divided stroke patients into those taking six or more drugs (polypharmacy group) and those taking less than six drugs (nonpolypharmacy group) upon admission. Patient background features, laboratory data, and FIM scores were compared. Results. FIM-Motor (FIM-M) efficiency, age, and diabetes mellitus were positively associated with polypharmacy. FIM-M efficiency in the polypharmacy group was significantly lower than in the nonpolypharmacy group. Conclusion. Polypharmacy interferes with the effect of rehabilitation in stroke patients with CKD. Pharmacists and doctors should make efforts to optimize medications to be able to respond to the outcome of each patient.

Cardiovascular events and death in Japanese patients with chronic kidney disease

The incidence of cardiovascular disease (CVD) is higher in patients with chronic kidney disease (CKD) than in the general population, and the risk of CVD increases with reductions in renal function. However, the incidence of CVD in Japanese patients with CKD has not been sufficiently investigated. To measure this we conducted the Chronic Kidney Disease Japan Cohort (CKD-JAC) Study over four years in 2,966 Japanese patients with CKD to examine the incidence of CVD and all-cause death. These patients had an estimated glomerular filtration rate (eGFR) of 10-59 ml/min/1.73 m², were under nephrologist care, and pooled from 17 medical institutions in Japan. At the median follow-up of 3.9 years, 69 patients had died, 217 had cardiovascular events, and 514 started maintenance dialysis therapy. The incidences of cardiovascular events were 11.9, 19.1, 25.0, and 39.4 per 1,000 person-years at eGFRs of 45-59, 30-44, 15-29, and under 15 ml/min/1.73 m², respectively. The adjusted Cox proportional hazards models showed that the risk of cardiovascular events increased as the eGFR decreased, with a significant difference only between CKD stage G5 (eGFR: under 15 ml/min/1.73 m²) and CKD stage G3a (eGFR: 45-59 ml/min/1.73 m²) (hazard ratio 3.16, 95% confidence interval 1.28 to 7.76). Thus, the risk of CVD and all-cause death was related to the decrease in eGFR, but not necessarily elevated in proportion to progression of the CKD stage in Japanese patients with predialysis CKD under a nephrologist's care.

Cardiovascular disease in patients with chronic kidney disease: a neglected subgroup

The burden of non-communicable diseases has increased exponentially over the past decade and they account for majority of the health-related morbidity and mortality worldwide. In line with this, the prevalence of chronic kidney disease (CKD) has been increasing over the years. CKD progresses through stages and it is well known that patients are more likely to die than to progress to end-stage renal disease. The presence of multiple classical and novel risk factors predisposes this group of patients to premature cardiovascular mortality. Though being a common entity, prevention, diagnosis and treatment of cardiovascular diseases in CKD are mired with controversies. This is due to the fact that many of the well-established diagnostic modalities and treatment strategies have not been studied in detail in patients with CKD. Moreover, most of the studies have excluded patients with renal dysfunction though they are at a higher risk for adverse outcomes and require specific dose modifications. This has limited the evidence base for optimal decision making. In this review, we aim to cover the risk factors, diagnosis and effectiveness of interventional strategies in patients with CKD.

New Insight into Atherosclerosis in Hemodialysis Patients: Overexpression of Scavenger Receptor and Macrophage Colony-Stimulating Factor Genes

BACKGROUND

Scavenger receptors (SRs) play a pivotal role in atherogenesis. The mechanism of atherosclerosis, which is specific to hemodialysis (HD) patients, was studied on the basis of SR gene expressions.

METHODS

The gene expressions of SR type A (SR-A) and CD36 were studied in peripheral monocytes by real-time reverse transcription polymerase chain reaction. Data were compared between HD (n = 30) and age-matched control subjects (n = 10). Serum levels of macrophage colony-stimulating factor (M-CSF) were measured with enzyme-linked immunosorbent assay to test its role in SR expression. The statistical differences and associations between two continuous variables were assessed using the Mann-Whitney U test and Pearson's correlation coefficient, respectively.

RESULTS

The relative quantities of SR mRNAs were significantly greater in HD patients than in controls [median (interquartile range): SR-A, 1.67 (0.96-2.76) vs. 0.90 (0.60-1.04), p = 0.0060; CD36, 1.09 (0.88-1.74) vs. 0.74 (0.64-0.99), p = 0.0255]. The serum concentration of M-CSF was significantly higher in HD patients than in controls [1, 121 (999-1,342) vs. 176 (155-202) pg/ml, p < 0.0001]. In addition, the relative quantity of M-CSF mRNA was significantly greater in HD patients than in controls [0.79 (0.42-1.53) vs. 0.42 (0.28-0.66), p = 0.0392]. The serum M-CSF levels were positively correlated with both the relative quantity of SR-A mRNA (r² = 0.1681, p = 0.0086) and that of CD36 mRNA (r² = 0.1202, p = 0.0284) in all subjects (n = 40).

CONCLUSION

HD patients are predisposed to atherosclerosis as a consequence of their enhanced monocyte SR expressions. SRs and M-CSF are potential therapeutic targets for atherosclerosis in this high-risk population.

Influence of chronic kidney disease on hospitalization, chronic dialysis, and mortality in Japanese men: a longitudinal analysis

BACKGROUND

Little is known concerning the risk of hospitalization and the risk of death before receiving dialysis by the stage of chronic kidney disease (CKD) in Japan.

METHODS

The subjects comprised a total of 13,911 Japanese men (mean age 49.2 ± 9.9 years). Based on the results of a health checkup performed in 2006, they were divided into 5 groups according to their estimated glomerular filtration rate (GFR) levels and dialysis status: GFR ≥60, 45-59, 30-44, <30 mL/min/1.73 m², and undergoing dialysis. From 2006 through to 2013, we investigated their hospitalization, dialysis initiation, and cause-specific death. The adjusted hazard ratios (HRs) for each end point were calculated compared with the GFR ≥60 mL/min/1.73 m² group using a Cox proportional hazard model.

RESULTS

A lower GFR was independently associated with higher risks of overall hospitalization, dialysis initiation, and all-cause death. In particular, the HRs for long-term hospitalization (≥1 month a year), dialysis, and cardiovascular disease (CVD) death markedly increased along with a decreased GFR. The rate ratios of dialysis to all-cause death (calculated based on the incidences of dialysis and death per 1000 person-years) were 0.03 (0.11 vs. 3.19), 0.08 (0.29 vs. 3.62), 0.51 (12.5 vs. 24.7), and 4.50 (179.8 vs. 40.0) for GFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m², respectively.

CONCLUSION

In Japanese men, although the risk of CVD death before dialysis initiation can never be ignored, CKD patients aged <60 years with a GFR of <30 mL/min/1.73 m² are more likely to undergo dialysis prior to death.

Relationship between Estimated Glomerular Filtration Rate and Cardiovascular Mortality in a Japanese Cohort with Long-Term Follow-Up

BACKGROUND

Patients with renal impairment are at risk of not only end-stage kidney disease but also cardiovascular disease (CVD). The current definition of CKD stage G3a is eGFR 45-59 ml/min/1.73 m2 and of G3b is 30-44 ml/min/1.73 m2, and subjects in the CKD 3a category are considered to be at lower risk of mortality than are those in CKD 3b.

METHODS

We evaluated the outcome of 97,043 people (33,131 men and 63,912 women) living in Ibaraki Prefecture who underwent annual community-based health checkups beginning in 1993 at age 40-80 years and who were followed for a mean of 17.1 years.

RESULTS

The number of all-causes deaths was 20,534 (10,375 men and 10,159 women), of which 5,995 (2,695 men and 3,300 women) were deaths due to CVD. Multivariable-adjusted hazard ratio for CVD death in the eGFR 45-49 ml/min/1.73 m2 category was significantly increased (1.82; 95% confidential interval, 1.23-2.69) in non-elderly men, whereas all-cause mortality and CVD mortality in elderly men with eGFR 45-49 ml/min/1.73m2 were non significant. In contrast, both in non-elderly women and in elderly women with eGFR 45-49 ml/min/1.73 m2 showed small, but significant, increases in the risks of all-cause mortality and CVD.

CONCLUSIONS

We demonstrated proportionate increases in mortality with decreasing eGFR in a Japanese CKD population. Like patients in the CKD G3b subgroup, non-elderly men and women with an eGFR of 45-49 ml/min/1.73 m2 (i.e. a part of CKD G3a) are at considerable risk of CVD mortality. Age dependent and eGFR dependent finer risk recognition were required for CVD prevention in clinical practice with regard to CKD patients.

Stroke and Chronic Kidney Disease: Epidemiology, Pathogenesis, and Management Across Kidney Disease Stages

Cerebrovascular disease and stroke are very common at all stages of chronic kidney disease (CKD), likely representing both shared risk factors as well as synergy among risk factors. More subtle ischemic brain lesions may be particularly common in the CKD population, with subtle manifestations including cognitive impairment. For individuals with nondialysis CKD, the prevention, approach to, diagnosis, and management of stroke is similar to the general, non-CKD population. For individuals with end-stage renal disease, far less is known regarding strategies to prevent stroke. Stroke prophylaxis using warfarin in dialysis patients with atrial fibrillation in particular remains of uncertain benefit. End-stage renal disease patients can be managed aggressively in the setting of acute stroke. Outcomes after stroke at all stages of CKD are poor, and improving these outcomes should be the subject of future clinical trials.

Proteinuria and Reduced Estimated Glomerular Filtration Rate Independently Predict Risk for Acute Myocardial Infarction: Findings from a Population-Based Study in Keelung, Taiwan

BACKGROUND

The aim of this study was to evaluate the independent roles of proteinuria and reduced estimated glomerular filtration rate (GFR) in the development of acute myocardial infarction in a northern Taiwanese population.

METHODS

We conducted a community-based prospective cohort study in Keelung, the northernmost county of Taiwan. A total of 63,129 subjects (63% women) ≥ 20 years of age who had no history of coronary heart disease were recruited and followed-up. Univariate and multivariate proportional hazards regression analysis was performed to assess the association between proteinuria and estimated GFR and the risk of acute myocardial infarction.

RESULTS

There were 305 new cases of acute myocardial infarction (114 women and 191 men) documented during a four-year follow-up period. After adjustment of potential confounding covariates, heavier proteinuria (dipstick urinalysis reading 3+) and estimated GFR of less than 60 ml/min/1.73 m(2) independently predicted increased risk of developing acute myocardial infarction. The adjusted hazard ratio (aHR) of heavier proteinuria for occurrence of acute myocardial infarction was 1.85 [95% confidence intervals (CI), 1.17-2.91, p < 0.01] (vs. the reference group: negative dipstick proteinuria). The aHR of estimated GFR of 30-59 ml/min/1.73 m(2) for occurrence of acute myocardial infarction was 2.4 (95% CI, 1.31-4.38, p < 0.01) (vs. the reference group: estimated GFR ≥ 90 ml/ min/1.73 m(2)), and that of estimated GFR of 15-29 ml/min/1.73 m(2) was 5.26 (95% CI, 2.26-12.26, p < 0.01).

CONCLUSIONS

We demonstrated that both heavier proteinuria and lower estimated GFR are significant independent predictors of developing future acute myocardial infarction in a northern Taiwanese population.

KEY WORDS

Acute myocardial infarction; Estimated glomerular filtration rate; Proteinuria.