Association between carotid artery intima-media thickness and cardiovascular risk factors in CKD

Correlation of renal function indicators and vascular damage in T2DM patients with normal renal function

Background

This study aimed to assess the correlation between renal function-related indices and vascular damages among patients with type 2 diabetes mellitus (T2DM) and normal renal function.

Methods

We screened a cohort of eligible patients with T2DM, ultimately including 826 individuals. Utilizing multifactorial logistic regression, we conducted an in-depth analysis to explore the potential associations between renal function-related indices-specifically BUN, Cr, ALB, ACR, and eGFR-and the incidence of diabetic vascular damage. Additionally, to comprehensively understand the relationships, we employed Spearman correlation analysis to assess the connections between these indicators and the occurrence of vascular damage.

Results

In this cross-sectional study of 532 patients with carotid atherosclerosis (CA), the prevalence of CA was positively correlated with Cr (53.1%, 72.3%, 68.0%, P<0.05) and negatively correlated with eGFR (71.6%, 68.5%, 53.1%, P<0.05). the higher the Cr, the higher the predominance ratio of CA (T1: reference; T2:OR. 2.166,95%CI:1.454,3.225; T3:OR:1.677, 95%CI:1.075, 2.616; P<0.05), along with an eGFR of 66.9% and 52.0% in terms of sensitivity and specificity, with a 95% CI of 0.562-0.644.

Conclusion

Within our experimental sample, a noteworthy observation emerged: Creatinine (Cr) exhibited a positive correlation with the prevalence of individuals affected by carotid atherosclerosis (CA), underscoring a potential connection between Cr levels and CA incidence. Conversely, the estimated Glomerular Filtration Rate (eGFR) demonstrated a negative correlation with the occurrence of CA, implying that lower eGFR values might be associated with an increased likelihood of CA development.

Risks of Carotid Artery Stenosis and Atherosclerotic Cardiovascular Disease in Patients with Calcium Kidney Stone: Assessment of Systemic Inflammatory Biomarkers

(1) Background: To assess the clinical significance of preoperative inflammatory biomarkers combined with atherosclerotic cardiovascular disease (ASCVD) risk score to evaluate carotid artery stenosis in patients with calcium kidney stones; (2) Methods: We conducted a prospective observational case-control study, enrolling 74 patients with calcium kidney stones and 66 age- and sex-matched healthy controls. We calculated the inflammatory biomarkers including the neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), and systemic inflammation response index (SIRI). An ultrasound of the carotid arteries was performed on all participants to identify the severity of the stenosis; (3) Results: All inflammatory biomarkers and the severity of carotid artery stenosis were higher in the calcium kidney stone group than in controls. After stratification of ASCVD, inflammatory biomarkers and carotid artery stenosis severity were still significantly higher in the calcium kidney stone group. Multivariate analyses showed that calcium kidney stones significantly increased the risk of ASCVD and carotid artery stenosis. In multivariate linear logistic regression analyses, calcium kidney stone and ASCVD score had a significant association with carotid artery occlusion, but SIRI did not; (4) Conclusions: Calcium kidney stone is associated with higher levels of inflammatory biomarkers and carotid artery stenosis. Calcium kidney stone is associated with higher levels of inflammatory biomarkers and carotid artery stenosis.

Nontraditional risk factors in chronic kidney disease: correlation between creatinine clearance, Framingham risk score, endothelial dysfunction, and inflammation

Background

Chronic kidney disease became a public health problem increasing healthcare burden. Our aim was to detect the relationship between cardiovascular risk, endothelial dysfunction, inflammation, and kidney function in chronic kidney disease patients and to detect the nontraditional factors affecting the decline in kidney functions.

Methods

A cross-sectional study including 30 male and female patients with chronic kidney disease stages 3–5. Creatinine clearance and Framingham risk score points were calculated. Carotid intimal medial thickness was measured as well as absolute flow mediated dilatation in brachial artery. Highly sensitive C-reactive protein, parathyroid hormone, kidney function tests, and lipid profile were measured.

Results

Framingham risk score points and carotid intimal medial thickness increased significantly with decreasing creatinine clearance (p 0.0025, 0.0285) respectively. A significant correlation was found between highly sensitive C-reactive protein and Framingham risk score points but not with carotid intimal medial thickness (p 0.0043, 0.2229) respectively. An inverse correlation was found between creatinine clearance and highly sensitive C-reactive protein (p 0.0174). Absolute flow mediated dilatation in brachial artery decreases with increasing Framingham risk score points and decreasing creatinine clearance (p 0.0044, 0.0269) respectively.

Conclusion

There is correlation between chronic kidney disease and impaired vascular function, subclinical atherosclerosis, and heightened inflammatory response. Chronic kidney disease patients are at increased risk of cardiovascular events with higher [10-]year cardiovascular risk.

Chronic kidney disease, atherosclerotic plaque characteristics on carotid magnetic resonance imaging, and cardiovascular outcomes

Background

It is unclear whether faster progression of atherosclerosis explains the higher risk of cardiovascular events in CKD. The objectives of this study were to 1. Characterize the associations of CKD with presence and morphology of atherosclerotic plaques on carotid magnetic resonance imaging (MRI) and 2. Examine the associations of baseline CKD and carotid atherosclerotic plaques with subsequent cardiovascular events.

Methods

In a subgroup (N = 465) of Systolic Blood Pressure Intervention Trial.

(SPRINT) participants, we measured carotid plaque presence and morphology at baseline and after 30-months with MRI. We examined the associations of CKD (baseline eGFR < 60 ml/min/1.73m²) with progression of carotid plaques and the SPRINT cardiovascular endpoint.

Results

One hundred and ninety six (42%) participants had CKD. Baseline eGFR in the non-CKD and CKD subgroups were 77 ± 14 and 49 ± 8 ml/min/1.73 m², respectively. Lipid rich necrotic-core plaque was present in 137 (29.5%) participants. In 323 participants with both baseline and follow-up MRI measurements of maximum wall thickness, CKD was not associated with progression of maximum wall thickness (OR 0.62, 95% CI 0.36 to 1.07, p = 0.082). In 96 participants with necrotic core plaque at baseline and with a valid follow-up MRI, CKD was associated with lower odds of progression of necrotic core plaque (OR 0.41, 95% CI 0.17 to 0.95, p = 0.039). There were 28 cardiovascular events over 1764 person-years of follow-up. In separate Cox models, necrotic core plaque (HR 2.59, 95% CI 1.15 to 5.85) but not plaque defined by maximum wall thickness or presence of a plaque component (HR 1.79, 95% CI 0.73 to 4.43) was associated with cardiovascular events. Independent of necrotic core plaque, CKD (HR 3.35, 95% CI 1.40 to 7.99) was associated with cardiovascular events.

Conclusions

Presence of necrotic core in carotid plaque rather than the presence of plaque per se was associated with increased risk of cardiovascular events. We did not find CKD to be associated with faster progression of necrotic core plaques, although both were independently associated with cardiovascular events. Thus, CKD may contribute to cardiovascular disease principally via mechanisms other than atherosclerosis such as arterial media calcification or stiffening.

Trial Registration

NCT01475747, registered on November 21, 2011.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02260-x.

Carotid intima-media thickness is an independent predictor of all-cause mortality and cardiovascular morbidity in patients with diabetes mellitus type 2 and chronic kidney disease

BACKGROUND

Intima-Media-Thickness of the carotid artery wall (cIMT) is a strong predictor of cardiovascular (CV) disease. The aim of this study was to investigate the significance of cIMT as an independent prognostic factor for CV morbidity and mortality in patients with chronic kidney disease (CKD) and diabetes mellitus type 2 (DM2).

METHODS

The study included 142 diabetic patients in different stages of CKD. Patients were categorized into two groups according to low (≤0.86 mm) or high cIMT (>0.86 mm), respectively. CV events and death from all causes were registered during a seven-year follow-up.

RESULTS

Mean age, BMI and duration of diabetes were 68 years (range: 45-90), >30 kg/m² and 15 years (range: 5-40), respectively. Patients with increased cIMT were older, suffered from a lower estimated glomerular filtration rate (eGFR), peripheral atherosclerosis and plaque presence in either carotid artery. Increased BMI (beta= -0.29, p = .01), lower eGFR (beta = 0.353, p = .003) and male gender (beta= -0.339, p = .005) were found to predict increased cIMT. Predictors of all-cause mortality in Cox proportional hazard models were low eGFR and high cIMT with HR = 0.96 (CI = 0.94-0.98), p < .001 and HR = 2.9 (CI = 1.03-7.99), p = .04, respectively. The risk of future CV event was determined by albuminuria and cIMT with HR = 1 (CI = 1.0-1.0), p < .001 and HR = 2.04 (CI = 1.1-3.78), p = .02, respectively. Patients with high cIMT presented significantly higher all-cause mortality and a new CV event (p = .005/p = .018, respectively).

CONCLUSIONS

cIMT is a strong and independent predictor of CV morbidity and mortality, and should be considered a valuable tool for the stratification of CV risk in patients with CKD and DM2.

Assessment of subclinical atherosclerosis and endothelial dysfunction in chronic kidney disease by measurement of carotid intima media thickness and flow-mediated vasodilatation in North Indian population

Background:

Chronic kidney disease (CKD) predisposes to accelerated atherosclerosis that is measured by carotid artery intima media thickness (CIMT) and brachial artery flow-mediated dilation (FMD). The aim of this study was to assess the noninvasive risk markers of subclinical atherosclerosis and endothelial dysfunction and their correlation with disease severity.

Methods and Results:

This was a cross-sectional study conducted in 62 patients with CKD: 38 predialysis and 24 on hemodialysis and 50 age- and gender-matched controls. In both the patients and controls, high-sensitivity C-reactive protein (CRP) levels, %FMD, and CIMT were measured. Patients with CKD had increased CRP levels {[5.8 (1.0–6.0)] mg/L vs [1.0 (0.5–2.20)] mg/L; P < 0.001}; %FMD was significantly lower in patients on hemodialysis (5.51%) compared with stage IV (7.62%) and stage III (15.02%) and 17.95% in control subjects (P < 0.001); and CIMT values in hemodialysis patients (0.88 ± 0.06 mm) were significantly higher compared with stage IV (0.67 ± 0.10) and stage III (0.61 ± 0.12) (P < 0.001). Increased CIMT values were seen in patients with CKD (0.82 ± 0.21 mm) than in the healthy controls (0.55 ± 0.16 mm). In patients with CKD, a significant negative correlation was found between CRP levels and FMD responses (r = −0.315; P < 0.001), while a significant positive correlation was found between CRP and CIMT values (r = 0.327; P < 0.001). Compared with predialysis, hemodialysis subjects had significantly lower FMD and higher CRP and IMT values.

Conclusion:

CKD confers a higher inflammatory status when compared with apparently healthy general population. Abnormal FMD responses and CIMT values are more commonly found in dialysis patients. Our findings suggest that CIMT and FMD can be used as noninvasive markers for early risk assessment and stratification in various stages of CKD.

Factors associated with carotid intima-media thickness in patients on maintenance hemodialysis

PURPOSE

The aim of this study was to analyze the association of the carotid intima-media thickness (CIMT) with various parameters in patients on maintenance hemodialysis (mHD).

METHODS

A cross-sectional study was conducted, enrolling 68 subjects (41 men, 27 women) on mHD in the Hemodialysis Unit, Sanglah Hospital, Denpasar, Indonesia. CIMT was measured with B-mode ultrasonography using a USG Sonoace 8000 and a 7.5 MHz linear transducer.

RESULTS

CIMT was higher in subjects with cardiovascular disease (CVD) compared with those without CVD (0.6494 vs 0.7288 mm; P=0.026), and in men compared with women (0.7056 vs 0.6141 mm; P=0.003). CIMT was correlated with age (R=0.607; P<0.001), plasma albumin (R=-0.291, P=0.016), serum phosphate (R=-0.294, P=0.015), calcium-phosphate product (R=-0.284, P=0.011), and plasma high-sensitivity C-reactive protein (R=0.279, P=0.030). However, after multiple linear regression testing, only age consistently had a role in determining the CIMT value (β=0.452, P<0.001).

CONCLUSION

Subjects with CVD have higher CIMT than those without CVD and men had higher CIMT than women. In addition, older age, higher high-sensitivity C-reactive protein, and lower albumin, phosphate, and calcium-phosphate product levels were correlated with higher CIMT. Age was the most important marker for CIMT in subjects on mHD.

The Relationship between Carotid and Femoral Artery Intima-Media Thickness and Histopathologic Grade of Atherosclerosis in Patients with Chronic Kidney Disease

BACKGROUND/AIMS

Variability in the grade of atherosclerosis among patients with chronic kidney disease (CKD) could affect the ultrasound measurements of intima media thickness (IMT). We sought to investigate IMTs of carotid (cIMT) and femoral (fIMT) arteries in CKD patients and assess the degree of their correlation with histopathological atherosclerosis.

METHODS

Eighty-nine out of 99 enrolled subjects completed this study. The subjects were divided into 3 groups: 34 patients with CKD (Case group), 31 with coronary artery disease undergoing coronary artery bypass graft (CABG, positive control group), and 24 healthy kidney donors (negative control group). For histopathological assessment of atherosclerosis, arterial tissue samples were obtained from the patients in each study group. The cIMT and fIMTs were measured by ultrasonography.

RESULTS

Histopathological atherosclerosis was present in 82.3, 100, and 20.8% of CKD, CABG, and donor groups respectively (p < 0.001). CKD patients had higher values of cIMT and fIMT than the donor group (p = 0.01 and 0.004, respectively). cIMT was positively correlated with the grade of atherosclerosis in the CKD group only (p < 0.001), while fIMT was correlated with the grade of atherosclerosis in both CKD and donor groups (p < 0.001 and p = 0.009 respectively). In CKD patients, cIMT >0.65 mm and femoral values >0.57 mm predicted the presence of histopathological atherosclerosis with sensitivities of 96 and 92% respectively.

CONCLUSION

Higher values of cIMT and fIMT in CKD patients are associated with higher rates and degrees of histopathological atherosclerosis. Additionally, when compared to fIMT, cIMT has a higher sensitivity for detecting atherosclerosis in CKD patients.

Osteopontin, Cardiovascular Risk Factors and Carotid Intima-Media Thickness in Chronic Kidney Disease

The pleiotropic cytokine osteopontin (OPN) is found to be involved in the pathogenesis of both kidney and cardiovascular disease (CVD). We evaluated the relationship between OPN, other cardiovascular risk factors and carotid intima-media thickness (CIMT) in chronic kidney disease (CKD) (predialysis) patients. This is a 2-year cross-sectional prospective study involving 75 patients with CKD from stage 1 to stage 5 attending the nephrology outpatient department and 25 healthy controls. Routine biochemical parameters were analyzed on clinical chemistry Autoanalyzer Beckman Coulter DXC 600 Synchron, USA. OPN was estimated by ELISA method. Carotid intima-media wall thickness was estimated by Doppler of carotid vessels. Serum OPN and other nontraditional cardiovascular risk factors such as CIMT, lipoprotein (a) Lp(a), fibrinogen, and homocysteine were significantly increased in patients of CKD compared to controls. OPN, Lp(a), fibrinogen, CIMT, parathyroid hormone, and homocysteine progressively increased from early stages of CKD and increased further with progression of the disease, but nitric oxide (NO) level progressively decreased with progression of CKD. OPN showed a positive correlation with CIMT, Lp(a), fibrinogen, and homocysteine and negative correlation with estimated glomerular filtration rate and NO. There was a close direct association between circulating levels of OPN and the presence of atherosclerotic plaques in carotid arteries of patients with CKD. Osteopontin and nontraditional CVD risk factors are altered in early stages of CKD and might predict adverse outcomes in these patients.

Mineral metabolism factors predict accelerated progression of common carotid intima-media thickness in chronic kidney disease: the NEFRONA study

Background

The leading cause of premature death in chronic kidney disease (CKD) is cardiovascular disease (CVD), but risk assessment in renal patients is challenging. The aim of the study was to analyse the factors that predict accelerated progression of common carotid intima-media thickness (CCIMT) in a CKD cohort after 2 years of follow-up (2010-12).

Methods

The study included 1152 patients from the NEFRONA cohort with CKD stages 3-5D and without a clinical history of CVD. CCIMT was measured at the far wall on both common carotids. CCIMT progression was defined as the change between CCIMT at baseline and at 24 months for each side, averaged and normalized as change per year. Accelerated progressors were defined as those with a CCIMT change ≥75th percentile.

Results

The median CCIMT progression rate was 0.0125 mm/year, without significant differences between CKD stages. The cut-off value for defining accelerated progression was 0.0425 mm/year. After adjustment, age was a common factor among all CKD stages. Traditional cardiovascular risk factors, such as diabetes and systolic blood pressure, were predictors of progression in CKD stages 4-5, whereas high-density lipoprotein and low-density lipoprotein cholesterol predicted progression in women in stage 3. Mineral metabolism factors predicting accelerated progression were serum phosphorus in stages 3 and 5D; low 25-hydroxyvitamin D and parathyroid hormone levels >110 pg/mL in stages 4-5 and intact parathyroid hormone levels out of the recommended range in stage 5D.

Conclusions

Mineral metabolism parameters might predict accelerated CCIMT progression from early CKD stages.

FGF23 Level and Intima-Media Thickness Are Elevated From Early Stages of Chronic Kidney Disease

Considering high cardiovascular (CV) risk in chronic kidney disease (CKD), the aim of this cross-sectional study was to assess the association between carotid intima-media thickness (IMT) and fibroblast growth factor (FGF) 23 as important players in CV pathophysiology. Eighty-seven patients with mean estimated glomerular filtration rate 40.1 mL/min per 1.73 m² were involved. FGF23 and IMT were elevated from early stages of CKD. Mean IMT value was 1.10 ± 0.20 mm, being significantly elevated starting from early CKD, showing no correlation with FGF23 (r = -0.01, P = -0.91). Unlike the FGF23 level that followed worsening of kidney function, IMT was increasing only in the initial CKD stages, with no further increase from CKD stage 3 on. Although we found no direct association between current use of vitamin D and statin therapy, this may be associated with the sustained reference values of lipid and vitamin D status under treatment that further preclude worsening of IMT in patients with advanced CKD.

Renal function and carotid atherosclerosis in adults with no known kidney disease

BACKGROUND AND AIMS

A high prevalence of atherosclerotic lesions characterizes patients with chronic kidney disease, though there is little data on the relationship between kidney function and atherosclerotic changes in the healthy population or in people with no known renal impairment. The aim of our study was to analyze, in a comprehensive general population with no known kidney disease, the relationship between renal function and subclinical carotid atherosclerotic damage.

METHODS AND RESULTS

A general real-life population of 611 participants (233 males and 378 females; age ≥18 years) with no known kidney failure was selected for the study. The glomerular filtration rate (GFR) was estimated according to the CKD-EPI equation. Carotid intima-media thickness (c-IMT) and plaques were assessed by duplex Doppler ultrasonography of the carotid vessels. The main laboratory and metabolic parameters were evaluated in all participants. When we divided the overall study population into tertiles according to GFR values (I tertile <85; II tertile: 85-99; III tertile >99 ml/min/1.73 m²), the c-IMT mean values and the prevalence of carotid plaques decreased with the increasing tertile of GFR. On univariate analysis, c-IMT was significantly correlated with eGFR (r = -0.33; p < 0.001), serum creatinine (r = 0.17; p < 0.001), and other variables such as age, systolic blood pressure, waist circumference, fasting or random glycemia, and glycated hemoglobin (HbA₁c). On multiple regression analysis, serum creatinine was associated with c-IMT (β = 0.069; p = 0.017), independent of other covariates.

CONCLUSION

Our study seems to suggest the importance of early identification of people with near normal or mildly decreased renal function due to its association with carotid atherosclerosis.

Subclinical cardiovascular disease markers and vitamin D deficiency in non-dialysis chronic kidney disease patients

INTRODUCTION

Since 25-hydroxyvitamin D (25(OH)D) deficiency has been linked to an increased risk for cardiovascular disease (CVD) in the hemodialysis population, we aimed to determine the relationship between serum 25(OH)D level and markers of subclinical CVD in non-dialysis chronic kidney disease (CKD) patients.

MATERIAL AND METHODS

This cross-sectional, single-center study prospectively enrolled 87 clinically stable CKD patients (median age: 61 (57-66) years, 51% male, median estimated glomerular filtration rate (eGFR): 32 (27-37) ml/min). Five markers of subclinical CVD were assessed: intima-media thickness, abdominal aortic calcifications (AAC) using the Kauppila score, cardio-ankle vascular index, ankle-brachial index (ABI) and interventricular septum thickness.

RESULTS

Vascular (37%), glomerular (23%) and interstitial (18%) nephropathies were the main causes of CKD. 25(OH)D had a median value of 14 (12.5-17.1) ng/ml, and its levels decreased with eGFR (rs = 0.19; p = 0.04). Patients with 25(OH)D deficiency (54%) were older, had a higher serum alkaline phosphatase level, lower ABI and higher AAC score. There were no differences between the two groups regarding other traditional or non-traditional risk factors for atherosclerosis. The association between subclinical CVD markers and 25(OH)D was further evaluated in multivariable binomial logistic regression models adjusted for CV risk factors. Lower 25(OH)D level was retained as an independent predictor only for pathological ABI.

CONCLUSIONS

This is the first study to evaluate the relationship between a large set of subclinical CVD markers and 25(OH)D deficiency in non-dialysis CKD patients. We found that hypovitaminosis D is associated with subclinical peripheral arterial disease, independently of other cardiovascular risk factors.

Risk of Retinal Artery Occlusion in Patients With End-Stage Renal Disease: A Retrospective Large-Scale Cohort Study

There is globally increasing prevalence and incidence in end-stage renal disease (ESRD). These patients are frequently reported to have retinal abnormalities and both diseases share some systemic risk factors. Hence, it is clinically relevant to determine whether ESRD is a predictor of retinal artery occlusion (RAO).To investigate the risk of RAO in ESRD patients.A retrospective, nationwide, matched cohort study. The study included 93,766 ESRD patients recruited between 2000 and 2009 from the Taiwan National Health Insurance Research Database. The same number control group included age- and sex-matched patients without ESRD selected from the Taiwan Longitudinal Health Insurance Database, 2000. Data for each patient were collected from the index date until December 2011.The incidence and risk of RAO were compared between the 2 groups. The hazard ratio (HR) for RAO after adjustment for potential confounders was calculated using Cox proportional hazards regression. Kaplan-Meier analysis was used to calculate the cumulative RAO incidence rate.In total, 237 ESRD patients and 73 controls exhibited RAO during follow-up; thus, the RAO incidence rate in ESRD patients was 4.49 times (95% confidence interval (CI), 3.45-5.83) that in the control patients. After adjustment for potential confounders, including diabetes mellitus, hypertension, hyperlipidemia, congestive heart failure, and coronary artery disease, ESRD patients were 2.78 times (95% CI, 2.02-3.84) more likely to develop RAO in cohort for the total sample. Among patients with hypertension, the RAO incidence rate was significantly higher in the ESRD group, and hypertension significantly increased RAO risk even after adjustment for other confounders in the cohort.ESRD increases the risk of RAO, particularly in ESRD patients with hypertension. Therefore, clinicians should educate ESRD patients about RAO and ensure appropriate blood pressure control.

Carotid Intima-Media Thickness and Visit-to-Visit HbA1c Variability Predict Progression of Chronic Kidney Disease in Type 2 Diabetic Patients with Preserved Kidney Function

Background/Aims. Subclinical atherosclerosis and long-term glycemic variability have been reported to predict incident chronic kidney disease (CKD) in the general population. However, these associations have not been investigated in patients with type 2 diabetes with preserved kidney function. Methods. We prospectively followed up 162 patients with type 2 diabetes (mean age, 62.3 years; 53.6% men) and assessed whether carotid intima-media thickness (IMT) measured by B-mode ultrasound and visit-to-visit HbA1c variability are associated with deterioration of CKD (incident CKD defined as estimated GFR [eGFR] < 60 mL/min/1.73 m² and progression of CKD stages) over a median follow-up of 6.0 years. At baseline, 25 patients (15.4%) had CKD. Cox proportional hazards regression models were used for identifying associated factors of CKD deterioration. Results. Estimated GFR decreased from 75.8 ± 16.3 to 67.4 ± 18.2 mL/min/1.73 m² (p < 0.01). Of 162 patients, 32 developed CKD and 8 made a progression of CKD stages. Multivariate Cox regression analysis revealed that carotid IMT (HR: 4.0, 95% CI: 1.1-14.226.7, and p = 0.03) and coefficient of variation of HbA1c (HR: 1.12, 95%: 1.04-1.21, and p = 0.003) were predictors of deterioration of CKD independently of age, mean HbA1c, urinary albumin/creatinine ratio, baseline eGFR, uric acid, and leucocyte count. Conclusions. Subclinical atherosclerosis and long-term glycemic variability predict deterioration of chronic kidney disease (as defined by incident or worsening CKD) in type 2 diabetic patients with preserved kidney function.

Does a Reduction in the Glomerular Filtration Rate Increase the Overall Severity of Coronary Artery Stenosis?

OBJECTIVE

Chronic kidney disease is a risk factor of coronary events, however, its impact on coronary artery stenosis has not yet been clarified with the use of a large database. We examined the association between a reduced glomerular filtration rate (GFR) and the overall severity of coronary stenosis.

METHODS

We enrolled 1,150 patients [mean age, 68±12 (SD) years; 66.6% men] who consecutively underwent coronary angiography for suspected stable angina pectoris. The overall severity of stenosis in the coronary arteries was assessed by the Gensini score (GS), and its logarithmic values (log-GS) were used for statistical analyses since the GS does not follow a normal distribution.

RESULTS

The log-GS was significantly larger in men than in women (2.5±1.5 vs. 1.9±1.7), while the estimated GFR (eGFR) and comorbidities were comparable between both sexes. A multivariate regression analysis indicated that age, smoking, eGFR, HDL-cholesterol and HbA1c were independent explanatory variables of the log-GS in men, although the eGFR explained only 1.2% of the log-GS variation. In women, the eGFR was not included in the significant explanatory variables shown by the multivariate analysis. However, the sex difference in the regression for the eGFR-log-GS relationship was not statistically significant.

CONCLUSION

A reduced eGFR is a significant, but minor, determinant of the overall severity of coronary artery stenosis in men and potentially women.

Nocturnal Hypertension Correlates Better With Target Organ Damage in Patients With Chronic Kidney Disease than a Nondipping Pattern

Both nocturnal hypertension and nondipping pattern are associated with target organ damages (TODs); however, no data exist with respect to Chinese patients with chronic kidney disease (CKD). The authors recruited 1322 patients with CKD admitted to our hospital division and referred with data in this cross-sectional study. Patients with nocturnal systolic hypertension had a lower estimated glomerular filtration rate (eGFR) and higher left ventricular mass index (LVMI) and carotid intima-media thickness (cIMT) compared with patients with normal nocturnal systolic blood pressure (SPB; all, P<.001), while patients in the dipper and nondipper groups had similar levels of eGFR, LVMI, and cIMT when the patients had a similar nocturnal SBP. Factorial-designed analysis of variance indicated that the main effect of nocturnal SBP was significant for all TOD differences (all, P<.001), but no significance existed with respect to the main effect of the dipper pattern and an interaction between the two factors (all, P>.05). Nocturnal systolic hypertension, rather than nondipping pattern, was an independent risk factor for TOD in CKD patients. Nocturnal hypertension, rather than a nondipping pattern, was better associated with TOD in CKD patients.

Changes over the last decade in carotid atherosclerosis in patients with end-stage kidney disease

OBJECTIVE

Therapies for chronic kidney disease have changed greatly over the last decade. The aim of this study was to examine the changes in the clinical characteristics and carotid atherosclerosis of patients with end-stage kidney disease (ESKD) over the last 9 years.

METHODS

A cross-sectional study of 150 consecutive patients with ESKD who had initiated maintenance dialysis between January 2005 and December 2013 was conducted. The patients' mean age was 68 ± 13 years. The group comprised 73% men, and 63% of the patients had diabetic nephropathy. The carotid artery-intima media thicknesses and the plaque scores (PS) were measured using carotid artery ultrasonography within 3 months of dialysis initiation. Changes in the patients' carotid atherosclerosis and clinical characteristics over the years were examined by categorizing the patients into 3 groups representing 3-year intervals based on when dialysis was initiated.

RESULTS

The PS declined from 12.8 to 5.4 (P = 0.001). Low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol levels declined over the 9-year period (P = 0.005 and P = 0.006, respectively), and the ratio of statin users increased markedly from 24% to 54% (P = 0.001). Univariate regression analysis identified a positive correlation between the PS and LDL-C (r = 0.281; P = 0.01), and a strong positive correlation was found between the PS and LDL-C after adjusting for various risk factors for atherosclerosis.

CONCLUSION

Carotid atherosclerosis in patients with ESKD has decreased over the past 9 years, which may be a consequence of improvements in dyslipidemia management.

Evaluation of influence of chronic kidney disease and sodium disturbances on clinical course of acute and sub-acute stage first-ever ischemic stroke

BACKGROUND

Chronic kidney disease (CKD) is an independent risk factor for cardiovascular morbidity and mortality. Hyponatremia is the most common electrolyte disturbance encountered in the neurological and neurosurgical intensive care units, and can exacerbate existing neurological deficits. The objective of this study was to observe the influences of chronic kidney disease and sodium disturbances on the clinical course of acute and sub-acute stages of first-ever ischemic stroke.

MATERIAL AND METHODS

464 patients with previously diagnosed chronic kidney disease (aged 70.42±11.49 years; 250 women) who had experienced their first-ever ischemic stroke were qualified. The following examinations were performed: serum levels of sodium, creatinine, lipids, estimated glomerular filtration rate (eGFR), neurological state on 1st day of stroke (according to National Institutes of Health Stroke Scale), functional state measured with the Rankin scale, (RS) and mortality rate at 1 month after stroke.

RESULTS

The neurological state on 1st day of stroke was worse and the median RS (30 days after stroke) was higher in patients with eGFR ≤60 ml/ (min×1.73). Men with eGFR ≤60 ml had greater neurological deficits and increased mortality within 1 month. In patients with eGFR >60 ml/, male sex was more often associated with worse outcomes at 1 month after ischemic stroke. Hyponatremia was associated with a more severe state in both the acute and sub-acute stages of stroke, with higher incidence of death within 1 month after stroke. Men with hyponatremia had greater neurological deficits on the 1st day and increased mortality within 1 month.

CONCLUSIONS

Renal impairment and hyponatremia are associated with worse neurological outcomes in patients in the acute stage of their first-ever stroke and within 1 month after the event. Males with impaired kidney function and hyponatremia have a more severe course in their first-ever ischemic stroke, as well as having increased mortality.

Stroke and renal dysfunction

Stroke is the most frequent neurological disease and represents a continuously evolving medical and social problem. Chronic kidney disease (CKD) is also an important worldwide public health problem. Renal dysfunction carries a substantial risk of cardiovascular morbidity and mortality and an independent, graded association between renal function and cardiovascular events was found. In the last 15years the link between CKD and cerebrovascular disease has become more apparent. Patients with end stage renal disease treated with maintenance hemodialysis have a much higher incidence of stroke than the general population and stroke is one of the major causes of death in these patients. Nowadays ischemic subtype of stroke is present in approximately 70% of dialysis patients. In population based studies conflicting results have been reported about the association between stroke and CKD before replacement therapy. However, in high risk patients, defined by the presence of either cardiovascular disease or cardiovascular risk factors, different stages of CKD are clearly associated with subsequent stroke. In patients with stroke the exact prevalence of renal dysfunction is not known. Reported prevalence from a few published studies is up to 38% and it is higher than that in age-matched control groups. Furthermore, in patients suffering from stroke renal dysfunction is associated with short and long term mortality. The most effective treatment of stroke in patients with CKD is not known and further studies are needed.

The ambulatory arterial stiffness index and target-organ damage in Chinese patients with chronic kidney disease

Background

The ambulatory arterial stiffness index (AASI) can be used to predict cardiovascular morbidity and mortality in hypertensive patients. However, data on AASI in Chinese patients with chronic kidney disease (CKD) is not available.

Methods

This cross-sectional study enrolled 583 CKD patients. Univariate and multivariate analyses were used to evaluate the relationship between AASI and renal function and parameters of cardiovascular injury.

Results

Patients with a higher AASI had a higher systolic blood pressure, a lower estimated glomerular filtration rate (eGFR), a higher serum cystatin C, a higher left ventricular mass index (LVMI) and carotid intima-media thickness (cIMT). Univariate analyses showed that AASI was positively correlated with serum cystatin C (r=0.296, P < 0.001), serum creatinine (r=0.182, P < 0.001), and LVMI (r = 0.205, P < 0.001) and negatively correlated with the eGFR (r = –0.200, P < 0.001). Multivariate analyses revealed that serum cystatin C, eGFR, serum creatinine and LVMI were independently correlated with AASI.

Conclusions

These data suggest that AASI was closely correlated with renal function and parameters of cardiovascular injury in Chinese CKD patients. Good quality, long-term, large longitudinal trials to validate the role of AASI in clinical practice for Chinese CKD patients.

Increased Th17 cell frequency concomitant with decreased Foxp3+ Treg cell frequency in the peripheral circulation of patients with carotid artery plaques

OBJECTIVE AND DESIGN

We investigated a possible imbalance between T helper (Th)17 and CD4+ CD25+ forkhead/winged helix transcription factor (Foxp3) T regulatory (Treg) cells in patients with carotid artery plaques.

MATERIAL OR SUBJECTS

From November 2009 to September 2010, we enrolled 126 males and 104 females with mean age 68.24 ± 6.71 years.

TREATMENT

Based on carotid artery sonography, the 230 subjects were categorized into three groups: plaque negative; stable plaques; and unstable plaques.

METHODS

Th17 and Treg cell frequencies, relevant plasma cytokines (IL-17, IL-6, IL-23, and TNF-α), and RORγt mRNA levels were determined.

RESULTS

Compared to plaque negative, Th17 cells, Th17-related cytokines (IL-17, IL-6, IL-23, and TNF-α), and RORγt mRNA levels were higher with stable plaques, and highest with unstable plaques. The opposite trend was found for Treg cells, Treg-related cytokines (IL-10 and TGF-β1), and Foxp3 mRNA. Th17 cell frequencies were significantly negatively correlated with Treg cell frequencies.

CONCLUSIONS

Our investigation demonstrated that there is a Th17/Treg functional imbalance in patients with unstable carotid atherosclerotic plaques. Th17 cells may promote atherogenesis, while Treg cells may have a protective role against atherosclerosis plaques. An imbalance of Th17/Treg cells may offer a new direction for the treatment of atherosclerosis.

Association between microalbuminuria and subclinical atherosclerosis evaluated by carotid artery intima-media in elderly patients with normal renal function

Background

Moderate to severe renal insufficiency and albuminuria have been shown to be independent risk factors for atherosclerosis. However, little is known about the direct association between subclinical atherosclerosis evaluated by carotid artery intima-media thickness (IMT) and microalbuminuria in elderly patients with normal renal function.

Methods

Subjects were 272 elderly patients (age  ≥ 60 years) with normoalbuminuria (n = 238) and microalbuminuria (n = 34). Carotid IMT was measured by means of high-resolution B-mode ultrasonography. Estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m² was defined as normal renal function. Those who had macroalbuminuria and atherosclerotic vascular disease were not included.

Results

Compared to subjects with normoalbuminuria, subjects with microalbuminuria had higher mean carotid IMT (1.02 ± 0.38 vs. 0.85 ± 0.28 mm; P < 0.01) and maximal IMT (1.86 ± 0.86 vs. 1.60 ± 0.73 mm; P = 0.06). By a multiple linear regression, microalbuminuria positively correlated with mean carotid IMT after adjusting for traditional cardiovascular disease risk factors including age, sex, hypertension, diabetes, smoking, total cholesterol, pulse pressure, waist circumference, serum uric acid. As a categorical outcome, the prevalence of the highest mean cariotid IMT quartile (increased IMT ≥ 1.05 mm) was compared with the lower three quartiles. After adjusted for potential confounders, microalbuminuria was associated with increased carotid IMT, with an odds ratio of 2.95 [95 % confidence interval, 1.22 – 7.10]. eGFR was not significantly associated with mean carotid IMT in our analysis.

Conclusions

A slight elevation of albuminuria is a significant determinant of carotid IMT independent of traditional cardiovascular risk factors in our patients. Our study further confirms the importance of intensive examinations for the early detection of atherosclerosis when microalbuminuria is found in elderly patients, although with normal renal function.

Is adiponectin a marker of preclinical atherosclerosis in kidney transplantation?

The aim of this study was to analyze the relationship between pre-transplant adiponectin (pre-ADP), abnormalities in glucose homeostasis (AGH) at three months post-transplantation, and preclinical atherosclerosis in non-diabetic patients prior to kidney transplantation (KT).

METHODS

We carried out a multicenter study in 157 non-diabetic KT patients (66.5% men; age: 50±13 yr). Pre-ADP levels were analyzed using radioimmunoassay. Carotid ultrasound was performed to determine carotid intima-media thickness (c-IMT). Oral glucose tolerance test was carried out to classify patients according ADA criteria.

RESULTS

Of the patients, 52.8% had AGH. Median pre-ADP was 19.5 (14-27) μg/mL. An inverse correlation was found between ADP and HOMA index (r=-0.432; p<0.001). Median c-IMT was 0.6 (0.48-0.71) mm. Significant inverse correlation existed between ADP and c-IMT on both sides (p<0.05). Patients with c-IMT >0.6 mm had more AGH (p=0.012) and lower ADP levels (p=0.02). We performed a logistic regression analysis using preclinical atherosclerosis (c-IMT ≥0.6 mm) as dependent variable and sex, age, BMI, ADP, AGH, and HOMA index as independent variables of altered c-IMT. Age, pre-ADP, and AGH were independent risk factors for elevated c-IMT.

CONCLUSIONS

Patients with AGH have a greater presence of preclinical atherosclerosis. ADP has an inverse relationship with AGH and is an independent marker of preclinical atherosclerosis.

Cardiac and vascular structure and function parameters do not improve with alternate nightly home hemodialysis: an interventional cohort study

BACKGROUND

Nightly extended hours hemodialysis may improve left ventricular hypertrophy and function and endothelial function but presents problems of sustainability and increased cost. The effect of alternate nightly home hemodialysis (NHD) on cardiovascular structure and function is not known.

METHODS

Sixty-three patients on standard hemodialysis (SHD: 3.5-6 hours/session, 3-5 sessions weekly) converted to NHD (6-10 hours/session overnight for 3-5 sessions weekly). 2Dimensional transthoracic echocardiography and ultrasound measures of brachial artery reactivity (BAR), carotid intima-media thickness (CIMT), total arterial compliance (TAC) and augmentation index (AIX) were performed post dialysis at baseline and 18-24 months following conversion to NHD. In 37 patients, indices of oxidative stress: plasma malonyldialdehyde (MDA) and anti-oxidant enzymes: catalase (CAT), glutathione peroxidase (GPX) and superoxide dismutase (SOD) activity and total antioxidant status (TAS) were measured at baseline, 3 and 6 months.

RESULTS

Left ventricular mass index (LVMI) remained stable. Despite significant derangement at baseline, there were no changes in diastolic function measures, CIMT, BAR and TAC. AIX increased. Conversion to NHD improved bone mineral metabolism parameters and blood pressure control. Interdialytic weight gains increased. No definite improvements in measures of oxidative stress were demonstrated.

CONCLUSIONS

Despite improvement in uremic toxin levels and some cardiovascular risk factors, conversion to an alternate nightly NHD regimen did not improve cardiovascular structure and function. Continuing suboptimal control of uremic toxins and interdialytic weight gains may be a possible explanation. This study adds to the increasing uncertainty about the nature of improvement in cardiovascular parameters with conversion to intensive hemodialysis regimens. Future randomized controlled trials will be important to determine whether increases in dialysis session duration, frequency or both are most beneficial for improving cardiovascular disease whilst minimizing costs and the impact of dialysis on quality of life.

Carotid intima-media thickness in patients with end-stage renal disease

Accelerated atherosclerosis and cardiovascular disease are major causes of morbidity and mortality in patients of end-stage renal disease. Carotid intima media thickness is taken as a useful surrogate marker of atherosclerosis. Thirty end-stage renal disease (ESRD) patients were subjected to ultrasonography to study CIMT before the initiation of dialysis. CIMT was found to be higher in ESRD patients than in controls. Levels of a serum marker of oxidative stress were also found to be higher in patients than in the controls. CIMT is an easy, noninvasive, reproducible, and cost-effective investigation in patients with chronic renal failure.

Vascular health, systemic inflammation and progressive reduction in kidney function; clinical determinants and impact on cardiovascular outcomes

INTRODUCTION

Systemic inflammation, endothelial dysfunction and arterial thickening contribute to the elevated cardiovascular risk of dialysis patients. However, the course of these derangements and their relative contribution to the cardiovascular risk of nondialysed chronic kidney disease (CKD) are scarcely investigated.

METHODS

Flow-mediated dilatation (FMD) and intima-media thickness (IMT) were assessed in 304 nondialysed CKD patients Stages 1-5 (mean age 46 ± 12 years, 158 men), together with routine biochemical measurements, C-reactive protein (CRP) and insulin resistance. Patients were then followed for time-to-event analysis of cardiovascular outcomes (fatal and nonfatal).

RESULTS

CRP and IMT increased, while FMD decreased in parallel with estimated glomerular filtration rate (eGFR) decline (P < 0.001 for all). CRP and intact parathormone, as well as eGFR, appeared as strong determinants of FMD and IMT in multivariate analyses. After a median follow-up of 41 (range 6-46) months, 30 fatal and 59 nonfatal cardiovascular events occurred. In univariate analysis, FMD, IMT and CRP were significant predictors of outcome. In a multivariate Cox model excluding IMT, both FMD [hazard ratios 0.52 (95% confidence intervals 0.37-0.73) per %] and CRP [1.07 (1.03-1.11) per mg/L] predicted cardiovascular outcomes independently of confounders. In a model excluding FMD, only CRP (and not IMT) was a significant predictor.

CONCLUSIONS

Endothelial dysfunction, arterial thickening and inflammation occur in parallel with the decline in eGFR, contributing to the increased cardiovascular risk of nondialysed CKD. Our results support the use of FMD over IMT measurements to monitor nondialysed CKD patients at risk.

Surrogate markers of cardiovascular disease in CKD: what's under the hood?

Although clinical cardiovascular outcomes, such as heart attack, stroke, and sudden cardiac death, have a dramatic onset, they result from prolonged exposure to an ever-growing array of risk factors. Several noninvasive procedures are available to assess the cumulative effect of these exposures with the goal of more precisely estimating a person's cardiovascular risk. These include ankle-brachial index, which provides an estimation of obstruction in major-vessel lumen caliber; carotid ultrasound, which evaluates carotid intima-media thickness and plaque, visibly quantifying atherosclerotic burden; aortic pulse wave velocity, which provides a measure of large-artery stiffness; and echocardiography, which measures left ventricular mass, providing a measure of subclinical hypertensive heart disease. In this narrative review, we discuss the role of each of these measures, with a particular emphasis on patients with chronic kidney disease.

Renovascular protective effects of erythropoietin in patients with chronic kidney disease

BACKGROUND/AIMS

Erythropoietin (EPO) has been widely used for the treatment of anemia in chronic kidney disease (CKD). A growing body of evidence indicates that the therapeutic benefits of EPO could extend beyond the improvement of anemia. The aim of the present study was to determine whether EPO affects renovascular and oxidative stress biomarkers in pre-dialysis CKD patients with anemia.

METHODS

The study was a single-arm prospective study. Fifteen CKD patients (9 males and 6 females, mean age 63 years) with anemia (mean Hb: 8.1 g/dL) were treated with recombinant human EPO; 12,000 U administered subcutaneously once every 2 weeks. Various parameters were measured before and 6 months after treatment. These included serum hemoglobin (Hb), creatinine, estimated glomerular filtration rate (eGFR), proteinuria, urinary liver-type fatty acid binding protein (L-FABP--a biomarker of renal injury), urinary 8-hydroxydeoxyguanosine (8-OHdG--a marker of oxidative stress), serum asymmetrical dimethylarginine (ADMA), carotid artery intima-media thickness (IMT) and brachial-ankle pulse wave velocity (baPWV) as vascular markers and plasma brain natriuretic peptide (BNP) levels and left ventricular ejection fraction (LVEF) as cardiac function markers and cardio-thoracic ratio (CTR) and inferior vena cava dimension (IVCS) as extra fluid retention markers.

RESULTS

After 6 months, serum Hb was significantly increased (p<0.001) and urinary levels of protein, L-FABP and 8-OHdG, carotid IMT, baPWV, plasma BNP and serum ADMA levels were significantly decreased (p<0.001). Serum creatinine, eGFR, LVEF, CTR and IVCS showed little difference throughout the experimental period.

CONCLUSION

These data suggest that recombinant human EPO may ameliorate renal injury, oxidative stress and progression of atherosclerosis in addition to improving anemia in CKD patients.

Association of adiponectin with carotid arteriosclerosis in predialysis chronic kidney disease

BACKGROUND/AIMS

Adiponectin is an adipocyte-derived protein with antiatherogenic properties. Chronic kidney disease (CKD) is one of the risk factors for cardiovascular disease. We investigated the potential association between adiponectin and carotid arteriosclerosis in patients with predialysis CKD.

METHODS

We enrolled 95 CKD patients without dialysis and 81 non-CKD patients. Intima-media thickness (IMT) and plaque score (PS) in the common carotid artery were measured using an ultrasound system. Carotid arteriosclerosis was defined as IMT >1.2 mm and/or PS >5.0 mm.

RESULTS

The prevalence of CKD was independently associated with carotid arteriosclerosis after adjustment for other risk factors. Higher adiponectin levels were observed in CKD patients compared with non-CKD patients. Adiponectin levels were not independently correlated with the presence of carotid arteriosclerosis in all subjects. To evaluate the association between adiponectin and carotid arteriosclerosis among a CKD population, we divided the CKD patients into 2 groups according to a cutoff level of adiponectin determined by ROC analysis. The prevalence of carotid arteriosclerosis was significantly higher in the low-adiponectin group than in the high-adiponectin group among CKD patients. After adjusting for other risk factors, low levels of adiponectin were independently correlated with carotid arteriosclerosis in CKD patients.

CONCLUSION

Our data document that adiponectin is associated with increased risk of carotid atherosclerosis in a predialysis CKD population.

A randomized, double-blind, placebo-controlled trial of spironolactone on carotid intima-media thickness in nondiabetic hemodialysis patients

BACKGROUND AND OBJECTIVES

Hemodialysis patients (HD) display high rates of cardiac diseases and mortality. In chronic kidney disease, vascular injury leads to coronary artery disease, heart failure, and stroke. Carotid intima-media thickness (CIMT) measurements are currently widely used in randomized controlled trials (RCTs) to study the efficacy of interventions. An RCT was designed for the assessment of the safety and effectiveness of spironolactone to inhibit the progression of CIMT in HD patients as a primary outcome. Secondary outcomes included measurements of plasma potassium.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

HD patients were randomly assigned to receive 50 mg spironolactone or placebo thrice weekly after dialysis. In between dialysis sessions, plasma potassium concentrations were measured every month. Ultrasonographic measurements of CIMT were done at the beginning of the study and after 2 years.

RESULTS

Fifty-three age- and sex-adjusted patients (30 with drug and 23 with placebo) successfully completed the trial. There were no significant differences between the two groups in all profiles studied at baseline. Measurements of CIMT after 2 years showed a progression in the placebo group, whereas in the spironolactone group a significant decrease or even reversed CIMT was observed. Progression rates (mm/yr) were: common carotid, placebo: 0.06 +/- 0.07, spironolactone: 0.01 +/- 0.04; carotid bifurcation, placebo: 0.15 +/- 0.27, spironolactone: 0.0001 +/- 0.01; internal carotid, placebo: 0.10 +/- 0.12, spironolactone: -0.10 +/- 0.15. No episodes of hyperkalemia were observed, but a slight increase in plasma potassium was found in the spironolactone group.

CONCLUSIONS

Fifty milligrams of spironolactone thrice weekly significantly reduced the progression of CIMT in HD patients.

“Does chronic kidney disease define a particular risk pattern of cerebral vessels modifications in patients with symptomatic ischemic cerebrovascular disease?”

Cardiovascular complications, including stroke, may be attributed the highest rate of morbidity and mortality in patients with chronic kidney disease (CKD). The aim of our study was to evaluate the prevalence of CKD in patients with symptomatic ischaemic cerebrovascular disease and to establish of whether CKD may define a particular risk pattern of cerebral vessels modifications in this category of patients. The prevalence of CKD was evaluated in 590 consecutive patients with symptomatic ischaemic cerebrovascular disease admitted to a department of neurology. The types of stroke, the vascular territories, the vascular modifications and the haemodynamic changes (resistance index- RI) found by neurosonology (extracranial and transcranial Doppler ultrasound) were analysed in relation to classic and non-classic cerebrovascular risk factors, as well as to stages of CKD (defined by estimated glomerular filtration rate-eGFR-MDRD4 formula-K/DOQI 2002). The prevalence of CKD in the studied patients was 70.84%. Atherosclerosis in a diffuse pattern was detected in 79.7% of CKD patients, while carotid artery stenoses were found in 10% of cases, occlusions- 5.3%, stenoses + occlusions-1.2%, and multiple stenoses- 3.8% of cases. The RI evaluated in the internal carotid arteries correlated with fibrinogen(P<0.0001) and GFR(P<0.0001), while IR in the middle cerebral arteries correlated with fibrinogen(P<0.05), C-reactive protein(P<0.0001), and GFR(P<0.0001). There is a strong relation between symptomatic cerebrovascular disease and CKD, a fact demonstrated by the increased prevalence of CKD in these patients and by the severity of the cerebral vessels lesions.

The estimated GFR, but not the stage of diabetic nephropathy graded by the urinary albumin excretion, is associated with the carotid intima-media thickness in patients with type 2 diabetes mellitus: a cross-sectional study

Background

To study the relationship between the intima-media thickness (IMT) of the carotid artery and the stage of chronic kidney disease (CKD) based on the estimated glomerular filtration rate (eGFR) and diabetic nephropathy graded by the urinary albumin excretion (UAE) in the patients with type 2 diabetes mellitus.

Methods

A cross-sectional study was performed in 338 patients with type 2 diabetes mellitus. The carotid IMT was measured using an ultrasonographic examination.

Results

The mean carotid IMT was 1.06 ± 0.27 mm, and 42% of the subjects showed IMT thickening (≥ 1.1 mm). Cerebrovascular disease and coronary heart disease were frequent in the patients with IMT thickening. The carotid IMT elevated significantly with the stage progression of CKD (0.87 ± 0.19 mm in stage 1, 1.02 ± 0.26 mm in stage 2, 1.11 ± 0.26 mm in stage 3, and 1.11 ± 0.27 mm in stage 4+5). However, the IMT was not significantly different among the various stages of diabetic nephropathy. The IMT was significantly greater in the diabetic patients with hypertension compared to those without hypertension. The IMT positively correlated with the age, the duration of diabetes mellitus, and the brachial-ankle pulse wave velocities (baPWV), and negatively correlated with the eGFR. In a stepwise multivariate regression analysis, the eGFR and the baPWV were independently associated with the carotid IMT.

Conclusions

Our study is the first report showing a relationship between the carotid IMT and the renal parameters including eGFR and the stages of diabetic nephropathy with a confirmed association between the IMT and diabetic macroangiopathy. Our study further confirms the importance of intensive examinations for the early detection of atherosclerosis and positive treatments for hypertension, dyslipidaemia, obesity, as well as hyperglycaemia are necessary when a reduced eGFR is found in diabetic patients.

Cardiovascular risk factors underestimate atherosclerotic burden in chronic kidney disease: usefulness of non-invasive tests in cardiovascular assessment

BACKGROUND

Cardiovascular risk scoring (Score) does not specifically address chronic kidney disease (CKD) patients. The aim of our study is to quantify atherosclerosis using carotid ultrasound and ankle-brachial index (ABI) and to assess its additional value in risk scoring.

METHODS

In this cross-sectional, observational study, patients were studied according to a standardized protocol including carotid ultrasound and ABI to determine the atherosclerosis score (AS), ranging from absence of to severe atherosclerosis (AS 0 to AS 3).

RESULTS

We included 409 CKD-affected patients (231 on dialysis, 99 in CKD Stages IV-V and 79 in CKD Stages I-III) and 851 subjects with normal renal function. The presence and severity of atherosclerosis was significantly higher in the CKD group than in the controls at every decade of age studied. Among the CKD-affected subjects, the prevalence of carotid plaques was significantly higher in the dialysis group (78.3%) than in the group in CKD Stages I-III (55.6%, P < 0.001). We identified 174 patients at low-intermediate risk. Among them, 110 (63.2%) presented either moderate (AS 2) or severe (AS 3) atherosclerosis. Variables significantly (P < 0.05) and positively related to atherosclerosis were being on dialysis [OR = 3.40, 95% CI (1.73, 6.78) vs CKD Stages I-III], age [OR = 1.08, 95% CI (1.06-1.11)] and C-reactive protein [OR = 1.04, 95% CI (1.01-1.08)]. Conversely, female sex was negatively related to atherosclerosis [OR = 0.40, 95% CI (0.23-0.71), P = 0.002].

CONCLUSION

The use of carotid ultrasound and ABI identifies atherosclerosis in a population of CKD patients in which risk scoring underestimates atherosclerosis burden.

Comparative effects of benidipine and amlodipine on proteinuria, urinary 8-OHdG, urinary L-FABP, and inflammatory and atherosclerosis markers in early-stage chronic kidney disease

INTRODUCTION

We examined the effects of 2 calcium channel blockers, benidipine (T-, L-, and N-type) and amlodipine (L- and N-type), on renal, inflammatory, oxidative, and atherosclerosis markers in hypertensive patients with mild chronic kidney disease (CKD).

METHODS

Forty hypertensive patients with CKD were assigned randomly to either of the 2 treatments: 8 mg benidipine once daily (n = 20, group A) or 5 mg amlodipine once daily (n = 20, group B). Treatment was continued for 12 months. Blood pressure, serum creatinine, estimated glomerular filtration rate, urinary protein excretion, urinary liver-type fatty acid-binding protein, interleukin-6, high mobility group box-1 protein, urinary 8-hydroxy-2'-deoxyguanosine, pulse wave velocity, intima-media thickness, and blood asymmetric dimethylarginine were monitored.

RESULTS

Blood pressure decreased equally in both groups (P < 0.001, at 6 and 12 months versus before treatment). Serum creatinine and estimated glomerular filtration rate changed little during the experimental period in each group. However, urinary protein excretion (P < 0.001), urinary liver-type fatty acid-binding protein (P < 0.001), urinary 8-hydroxy-2'-deoxyguanosine (P < 0.001), blood interleukin-6 (P < 0.001), blood high mobility group box-1 (P < 0.05), and pulse wave velocity (P < 0.01) decreased more in group A than in group B with 12 months of treatment. The percent reductions in intima-media thickness and blood asymmetric dimethylarginine were significantly greater in group A than in group B (P < 0.001).

CONCLUSIONS

Benidipine is more effective than amlodipine for protecting renal function and potentially for ameliorating atherosclerosis in hypertensive patients with mild CKD. T-type calcium channel blockers may be effective in patients with CKD.

Atheroma progression in chronic kidney disease

BACKGROUND AND OBJECTIVES

Cardiovascular events are 10 to 100 times more frequent in chronic kidney disease (CKD). We tested the hypothesis that the rate of atherosclerotic plaque growth is faster in severe versus moderate CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a prospective cohort study in 318 prevalent CKD patients with initial creatinine clearance (CCr) between 20 and 50 ml/min/1.73 m(2). Baseline clinical and laboratory data were obtained on all patients. Plaque area was determined every 6 mo using bilateral carotid ultrasonography. Plaque area distribution was normalized using a cube root transformation. Unadjusted and adjusted associations between CCr quintiles and rate of change in the transformed plaque area were assessed using multiple linear regression.

RESULTS

The rate of plaque progression appeared lower in patients with the lowest CCr. Median rate of plaque growth was 0.4 mm(2)/yr in the lowest quintile of CCr (< 23 ml/min/1.73 m(2)) versus 5.0 mm(2)/yr in the highest quintile (> 43 ml/min/1.73 m(2)). This association remained significant after adjustment for potential confounders. A secondary analysis using quintiles of Modification of Diet in Renal Disease (MDRD) GFR confirmed the absence of increased plaque growth at low GFR, although a reduced rate of growth in the lowest quintile of MDRD GFR was not observed.

CONCLUSION

We did not observe accelerated plaque growth at low levels of renal function. We suggest that mechanisms other than plaque growth are responsible for the observed excess of cardiovascular disease in CKD patients.

Comparison of renal and vascular protective effects between telmisartan and amlodipine in hypertensive patients with chronic kidney disease with mild renal insufficiency

The present study was conducted to compare the renal and vascular protective effects of telmisartan and amlodipine in untreated hypertensive chronic kidney disease (CKD) patients with moderate renal insufficiency. Thirty hypertensive CKD patients were randomly assigned to receive telmisartan 40 mg (n = 15) or amlodipine 5 mg (n = 15) once daily for 12 months. Changes in blood pressure, serum creatinine, 24-h creatinine clearance (Ccr), proteinuria, brachial-ankle pulse wave velocity (baPWV), intima-media thickness (IMT), plasma interleukin-6 (IL-6), plasma matrix metalloproteinase (MMP)-9 and lipid profiles were monitored in all patients. Before treatment, there were no significant differences in these parameters between the telmisartan and amlodipine groups. Over the 12 month observation period, blood pressure decreased equally in both groups. However, serum creatinine, proteinuria, baPWV, IMT, plasma levels of IL-6 and MMP-9 and total cholesterol decreased and 24-h Ccr increased more strikingly in the telmisartan group than the amlodipine group. These data suggest that telmisartan is more effective than amlodipine for protecting renovascular functions, and potentially for ameliorating atherosclerosis, in hypertensive CKD patients with moderate renal insufficiency.

Cystatin C and carotid intima-media thickness in asymptomatic adults: the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

Persons with early kidney disease have an increased risk of cardiovascular events and mortality, but the importance of accelerated atherosclerosis in promoting these outcomes is unclear. We therefore explored whether serum cystatin C level is associated with carotid intima-media thickness (IMT) in ambulatory adults without clinical heart disease.

STUDY DESIGN

Cross-sectional study.

SETTING & PARTICIPANTS

We evaluated 6,557 ethnically diverse persons free of clinical cardiovascular disease aged 45 to 84 years at the baseline visit of the Multi-Ethnic Study of Atherosclerosis.

PREDICTORS

Kidney function was estimated by using 2 methods: serum cystatin C level and estimated glomerular filtration rate, based on creatinine and cystatin C levels.

OUTCOMES & MEASUREMENTS

Study outcomes were internal and common carotid IMT, measured by using high-resolution B-mode ultrasound. Multivariate linear and logistic regressions were used to evaluate the independent association of kidney function with carotid IMT.

RESULTS

In unadjusted linear analysis, each SD (0.23 mg/L) greater cystatin C level was associated with 0.091-mm greater internal carotid IMT (P < 0.001), but this association was diminished by 70% after adjustment for age, sex, and race/ethnicity (0.027 mm; P < 0.001) and was no longer significant after adjustment for cardiovascular risk factors (0.005 mm; P = 0.5). Similarly, the strong unadjusted associations of cystatin C level with common carotid IMT disappeared after adjustment. Chronic kidney disease, defined by using either creatinine level or cystatin C-based estimated glomerular filtration rate less than 60 mL/min/1.73 m(2), had no independent association with internal and common carotid IMT.

LIMITATIONS

There were few participants with severe kidney disease.

CONCLUSIONS

Cystatin C level had no independent association with carotid IMT in a population free of clinical heart disease. This observation suggests that accelerated atherosclerosis is unlikely to be the primary mechanism explaining the independent association of cystatin C level with cardiovascular risk.

Evolution of large-vessel arteriopathy in paediatric patients with chronic kidney disease

This observational study was designed to verify the hypothesis that the treatment modality significantly affects the evolution of CKD-associated arteriopathy.

PATIENTS

Paediatric patients (mean age 13.8 +/- 4.2 years) with chronic kidney disease (CKD) stages 3-5, including 24 patients with mean GFR 54 +/- 21 ml/min/1.73 m(2) (CKD group) and 32 patients in end-stage renal disease, of whom 19 received a renal allograft (D-Rtx) and 13 remained on dialysis (D-D).

METHODS

Sonography of the common carotid artery was performed at baseline and after 12 months. Intima-media thickness (IMT) and the cross-sectional areas of the vessel wall (WCSA) and lumen (LCSA) were measured and normalized to age (SDS).

RESULTS

At baseline IMT-SDS and WCSA-SDS were increased above normal, and were significantly higher in D than in CKD patients (P < 0.001). IMT-SDS increased over time in CKD and D-D patients (1.4 +/- 1.7 to 2.1 +/- 1.2, P = 0.05). In contrast, IMT-SDS (2.8 +/- 0.6 to 2.0 +/- 0.6, P < 0.005) decreased in those D-Rtx patients who had elevated values prior to transplantation. The total number of patients with elevated cIMT-SDS changed from 7 to 13 in the 24 CKD, from 8 to 11 in the 13 D-D and from 11 to 12 in the 19 D-Rtx patients. While IMT-SDS was independently correlated with blood pressure and serum phosphate in the CKD and D patients, only total dialysis vintage (r = 0.50; P < 0.05) and the IMT-SDS attained at the time of grafting (r = 0.46, P < 0.05) correlated with IMT-SDS 1 year post-Rtx.

CONCLUSION

While vascular lesions rapidly progress in CKD and D patients, abolition of the uraemic state by Rtx leads to stabilization or partial regression of CKD-associated arteriopathy. Cumulative dialysis duration and the degree of arterial damage prevalent at the time of grafting are the main determinants of persistent arteriopathy 1 year after Rtx.

Association between chronic kidney disease and carotid intima-media thickening in individuals with hypertension and impaired glucose metabolism

We investigated whether chronic kidney disease (CKD) was associated with carotid intima-media thickening in 1,351 male individuals undergoing general health screening. Glomerular filtration rate (GFR) was estimated by the Modification of Diet in Renal Disease equations using 0.881 as a coefficient for Japanese, and low estimated GFR (eGFR) was defined as an eGFR value of <60 mL/min/1.73 m(2). Albuminuria was defined as a urine albumin-to-urine creatinine ratio of >or=30 mg/g, and CKD was defined when low eGFR and/or albuminuria was present. After adjusting for age, CKD was associated with carotid intima-media thickening with an odds ratio of 1.47 (95% confidence interval [CI] 1.05-2.06, p=0.0024). After adjusting for age, fasting plasma glucose, and smoking status, both albuminuria and low eGFR were significantly associated with intima-media thickening in individuals with hypertension with an odds ratio of 1.85 (95% CI 1.13-3.03, p=0.015) and 1.79 (95% CI 1.09-2.94, p=0.022), respectively. On the other hand, neither of them was associated with carotid intima-media thickening in individuals without hypertension. Similarly, after adjusting for age, systolic blood pressure, and smoking status, both albuminuria and low eGFR were significantly associated with intima-media thickening in individuals with high fasting glucose (defined as fasting plasma glucose levels of >or=110 mg/dL or current use of anti-diabetic medication), but not in those without. Our data indicate that CKD or its components (low eGFR and albuminuria) may be associated with early carotid atherosclerosis in low-risk individuals, such as those undergoing general health screening, who have hypertension and/or impaired glucose metabolism.

Dyslipidaemia and cardiorenal disease: mechanisms, therapeutic opportunities and clinical trials

Dyslipidaemia is an important risk factor for the development of chronic kidney disease (CKD) and cardiovascular disease (CVD). CKD generates an atherogenic lipid profile, characterised by high triglycerides, low high-density lipoprotein (HDL) cholesterol and accumulation of small dense low-density lipoprotein (LDL) particles, comparable to that in the metabolic syndrome. These changes are due specifically to the effects of CKD on key enzymes, transfer proteins and receptors involved in lipid metabolism. Dyslipidaemia is further compounded by dialysis, immunosuppressive drugs, and concomitant diseases such as diabetes mellitus. Post hoc analyses from large intervention trials suggest the benefit of statins in patients with early CKD, but prospective clinical trials in haemodialysis (HD) and renal transplant recipients have not conclusively shown improvements in hard cardiovascular end-points. The lack of efficacy of statins in late-stage CKD could be a consequence of other disease processes, such as calcific arteriopathy and insulin resistance, which are not modified by lipid-lowering agents. Despite uncertainty and pending the results of ongoing statin trials such as Study of Heart and Renal Protection (SHARP) and AURORA (A study to evaluate the Use of Rosuvastatin in subjects On Regular haemodialysis: an Assessment of survival and cardiovascular events), major international guidelines continue to support statin therapy in CKD and renal transplant patients to reduce cardiovascular risk burden. Because of increased risk of toxicity, particularly myopathy, statins and other lipid-regulating agents should be used cautiously in CKD and renal transplant recipients.

Hypertensive renal vascular disease and cardiovascular endpoints

PURPOSE OF REVIEW

Hypertension involves the entire cardiovascular system, and hypertensive vascular disease may promote and exacerbate cardiac and renal dysfunction. We discuss the coexistence of cardiorenal disease as a manifestation of vascular involvement in hypertension, and the relationship of biomarkers of renal vascular involvement in hypertension with cardiovascular endpoints.

RECENT FINDINGS

Markers of renal dysfunction, especially microalbuminuria, have been considered recently as potent predictors of cardiovascular morbidity and mortality in all explored populations, including hypertensive individuals. Microalbuminuria, per se, is related to vascular injury and to the increased glomerular permeability of albumin as a direct manifestation of renal vascular involvement in hypertension, a systemic vascular disease. Left ventricular hypertrophy in hypertension develops even before proteinuria or impairment of renal function. Factors including anemia, inflammation and hyperuricemia are either induced or exacerbated by renal vascular disease, and each of these may exert additional influence in determining the increased incidence of cardiovascular events with progressive renal dysfunction.

SUMMARY

The development and progression of vascular disease is the primary determinant in the progressive cardiac and renal dysfunction observed in hypertension and, therefore, is the underlying mechanism of the overall clinical manifestations of cardiorenal disease. Commonly used biomarkers of renal and vascular function are important tools for determination of the progression and, hence, management of hypertensive disease and its complications.

An association between the estimated glomerular filtration rate and carotid atherosclerosis

OBJECTIVE

Chronic kidney disease (CKD) is a major public health problem. There is conflicting evidence concerning whether CKD is an independent risk factor for carotid intima-media thickness (IMT).

PATIENTS AND METHODS

The study subjects were 428 men aged 70+/-15 (mean+/-standard deviation) years and 582 women aged 75+/-12 years enrolled consecutively from patients in the Medical Department of Seiyo Municipal Nomura Hospital. Carotid IMT was derived via B-mode ultrasonography and CKD was evaluated by the estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease Study equation.

RESULTS

In men, age (p<0.001), systolic blood pressure (p<0.001), antihypertensive drug use (p<0.001), HDL-C (p=0.006), LDL-C (p=0.004), prevalence of diabetes (p=0.035) and eGFR (p<0.001) were significantly correlated with carotid IMT. In women, age (p<0.001), systolic blood pressure (p<0.001), antihypertensive drug use (p<0.001), HDL-C (p=0.035), LDL-C (p=0.017) and eGFR (p<0.001) were significantly correlated with carotid IMT. Stepwise multiple linear regression analysis using IMT as an objective variable, adjusted by various factors as explanatory variables, showed that eGFR was a significant independent contributing factor along with known risk factors in men (beta, -0.096; p=0.018) and women (beta, -0.080; p=0.035).

CONCLUSIONS

Our data suggested that eGFR was associated with an increased prevalence of carotid atherosclerosis independent of common cardiovascular risk factors in both men and women.