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Katsiki N, Filippatos T, Vlachopoulos C, Panagiotakos D, Milionis H, Tselepis A, Garoufi A, Rallidis L, Richter D, Nomikos T, Kolovou G, Kypreos K, Chrysohoou C, Tziomalos K, Skoumas I, Koutagiar I, Attilakos A, Papagianni M, Boutari C, Kotsis V, Pitsavos C, Elisaf M, Tsioufis K, Liberopoulos E. Executive summary of the Hellenic Atherosclerosis Society guidelines for the diagnosis and treatment of dyslipidemias - 2023. ATHEROSCLEROSIS PLUS 2024; 55:74-92. [PMID: 38425675 PMCID: PMC10901915 DOI: 10.1016/j.athplu.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/20/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains the main cause of death worldwide, and thus its prevention, early diagnosis and treatment is of paramount importance. Dyslipidemia represents a major ASCVD risk factor that should be adequately managed at different clinical settings. 2023 guidelines of the Hellenic Atherosclerosis Society focus on the assessment of ASCVD risk, laboratory evaluation of dyslipidemias, new and emerging lipid-lowering drugs, as well as diagnosis and treatment of lipid disorders in women, the elderly and in patients with familial hypercholesterolemia, acute coronary syndromes, heart failure, stroke, chronic kidney disease, diabetes, autoimmune diseases, and non-alcoholic fatty liver disease. Statin intolerance is also discussed.
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Affiliation(s)
- N Katsiki
- Department of Nutritional Sciences and Dietetics, International Hellenic University, Thessaloniki, Greece
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Td Filippatos
- Department of Internal Medicine, School of Medicine, University of Crete, Crete, Greece
| | - C Vlachopoulos
- Cardiology Department, First Cardiology Clinic, Athens Medical School, Hippokration Hospital, Athens, Greece
| | - D Panagiotakos
- Department of Nutrition and Dietetics, School of Health Sciences & Education, Harokopio University, Athens, Greece
| | - H Milionis
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - A Tselepis
- Atherothrombosis Research Centre, University of Ioannina, Ioannina, Greece
| | - A Garoufi
- 2nd Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - L Rallidis
- 2nd Department of Cardiology, Medical School, National and Kapodistrian University of Athens, University General Hospital ATTIKON, Athens, Greece
| | - D Richter
- Head of Cardiac Department, Euroclinic Hospital, Athens, Greece
| | - T Nomikos
- Department of Nutrition and Dietetics, School of Health Sciences & Education, Harokopio University, Athens, Greece
| | - G Kolovou
- Metropolitan Hospital, Cardiometabolic Center, Lipoprotein Apheresis and Lipid Disorders Clinic, Athens, Greece
| | - K Kypreos
- School of Medicine, European University Cyprus, Nicosia, Cyprus
- University of Patras, School of Health Science, Department of Medicine, Pharmacology Laboratory, Patras, 26500, Greece
| | - C Chrysohoou
- 1st Cardiology Clinic National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - K Tziomalos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - I Skoumas
- 1st Department of Cardiology, National & Kapodistrian University of Athens, Athens, Greece
| | - I Koutagiar
- 1st Cardiology Department, Hygeia Hospital, Athens, Greece
| | - A Attilakos
- 3rd Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece
| | - M Papagianni
- Third Department of Pediatrics, Aristotle University of Thessaloniki, School of Medicine, “Hippokrateion" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - C Boutari
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - V Kotsis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University Thessaloniki, Greece
| | - C Pitsavos
- First Cardiology Clinic, School of Medicine, University of Athens, Greece
| | - M Elisaf
- Department of Internal Medicine, Faculty of Medicine, University Hospital of Ioannina, 45110, Ioannina, Greece
| | - K Tsioufis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Hippocration Hospital, Greece
| | - E Liberopoulos
- 1st Department of Propedeutic Medicine, School of Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
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Farrell DR, Vassalotti JA. Screening, identifying, and treating chronic kidney disease: why, who, when, how, and what? BMC Nephrol 2024; 25:34. [PMID: 38273240 PMCID: PMC10809507 DOI: 10.1186/s12882-024-03466-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/15/2024] [Indexed: 01/27/2024] Open
Abstract
1 in 7 American adults have chronic kidney disease (CKD); a disease that increases risk for CKD progression, cardiovascular events, and mortality. Currently, the US Preventative Services Task Force does not have a screening recommendation, though evidence suggests that screening can prevent progression and is cost-effective. Populations at risk for CKD, such as those with hypertension, diabetes, and age greater than 50 years should be targeted for screening. CKD is diagnosed and risk stratified with estimated glomerular filtration rate utilizing serum creatinine and measuring urine albumin-to-creatinine ratio. Once identified, CKD is staged according to C-G-A classification, and managed with lifestyle modification, interdisciplinary care and the recently expanding repertoire of pharmacotherapy which includes angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers, sodium-glucose-cotransporter-2 inhibitors, and mineralocorticorticoid receptor antagonists. In this paper, we present the why, who, when, how, and what of CKD screening.
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Affiliation(s)
- Douglas R Farrell
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, 10029, New York, NY, USA.
| | - Joseph A Vassalotti
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, 10029, New York, NY, USA
- National Kidney Foundation, Inc, New York, NY, USA
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Kim JA, Kim SE, El Hachem K, Virk HUH, Alam M, Virani SS, Sharma S, House A, Krittanawong C. Medical Management of Coronary Artery Disease in Patients with Chronic Kidney Disease. Am J Med 2023; 136:1147-1159. [PMID: 37380060 DOI: 10.1016/j.amjmed.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023]
Abstract
Chronic kidney disease patients are at increased risk of cardiovascular disease, which is the leading cause of mortality among this population. In addition, chronic kidney disease is a major risk factor for the development of coronary artery disease and is widely regarded as a coronary artery disease risk equivalent. Medical therapy is the cornerstone of coronary artery disease management in the general population. However, there are few trials to guide medical therapy of coronary artery disease in chronic kidney disease, with most data extrapolated from clinical trials of mainly non-chronic kidney disease patients, which were not adequately powered to evaluate this subgroup. There is some evidence to suggest that the efficacy of certain therapies such as aspirin and statins is attenuated with declining estimated glomerular filtration rate, with questionable benefit among end-stage renal disease (ESRD) patients. Furthermore, chronic kidney disease and ESRD patients are at higher risk of potential side effects with therapy, which may limit their use. In this review, we summarize the available evidence supporting the safety and efficacy of medical therapy of coronary artery disease in chronic kidney disease and ESRD patients. We also discuss the data on new emerging therapies, including PCSK9i, SGLT2i, GLP1 receptor agonists, and nonsteroidal mineralocorticoid receptor antagonists, which show promise at reducing risk of cardiovascular events in the chronic kidney disease population and may offer additional treatment options. Overall, dedicated studies directly evaluating chronic kidney disease patients, particularly those with advanced chronic kidney disease and ESRD, are greatly needed to establish the optimal medical therapy for coronary artery disease and improve outcomes in this vulnerable population.
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Affiliation(s)
- Jitae A Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Seulgi E Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Ohio
| | - Mahboob Alam
- Texas Heart Institute and Baylor College of Medicine, Houston
| | - Salim S Virani
- Section of Cardiology, Baylor College of Medicine, Houston, Texas; Office of the Vice Provost (Research), The Aga Khan University, Karachi, Pakistan
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
| | - Andrew House
- Division of Nephrology, Department of Medicine, Western University and London Health Sciences Centre, Ont, Canada
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Ndumele CE, Neeland IJ, Tuttle KR, Chow SL, Mathew RO, Khan SS, Coresh J, Baker-Smith CM, Carnethon MR, Després JP, Ho JE, Joseph JJ, Kernan WN, Khera A, Kosiborod MN, Lekavich CL, Lewis EF, Lo KB, Ozkan B, Palaniappan LP, Patel SS, Pencina MJ, Powell-Wiley TM, Sperling LS, Virani SS, Wright JT, Rajgopal Singh R, Elkind MSV, Rangaswami J. A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association. Circulation 2023; 148:1636-1664. [PMID: 37807920 DOI: 10.1161/cir.0000000000001186] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
A growing appreciation of the pathophysiological interrelatedness of metabolic risk factors such as obesity and diabetes, chronic kidney disease, and cardiovascular disease has led to the conceptualization of cardiovascular-kidney-metabolic syndrome. The confluence of metabolic risk factors and chronic kidney disease within cardiovascular-kidney-metabolic syndrome is strongly linked to risk for adverse cardiovascular and kidney outcomes. In addition, there are unique management considerations for individuals with established cardiovascular disease and coexisting metabolic risk factors, chronic kidney disease, or both. An extensive body of literature supports our scientific understanding of, and approach to, prevention and management for individuals with cardiovascular-kidney-metabolic syndrome. However, there are critical gaps in knowledge related to cardiovascular-kidney-metabolic syndrome in terms of mechanisms of disease development, heterogeneity within clinical phenotypes, interplay between social determinants of health and biological risk factors, and accurate assessments of disease incidence in the context of competing risks. There are also key limitations in the data supporting the clinical care for cardiovascular-kidney-metabolic syndrome, particularly in terms of early-life prevention, screening for risk factors, interdisciplinary care models, optimal strategies for supporting lifestyle modification and weight loss, targeting of emerging cardioprotective and kidney-protective therapies, management of patients with both cardiovascular disease and chronic kidney disease, and the impact of systematically assessing and addressing social determinants of health. This scientific statement uses a crosswalk of major guidelines, in addition to a review of the scientific literature, to summarize the evidence and fundamental gaps related to the science, screening, prevention, and management of cardiovascular-kidney-metabolic syndrome.
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Ndumele CE, Rangaswami J, Chow SL, Neeland IJ, Tuttle KR, Khan SS, Coresh J, Mathew RO, Baker-Smith CM, Carnethon MR, Despres JP, Ho JE, Joseph JJ, Kernan WN, Khera A, Kosiborod MN, Lekavich CL, Lewis EF, Lo KB, Ozkan B, Palaniappan LP, Patel SS, Pencina MJ, Powell-Wiley TM, Sperling LS, Virani SS, Wright JT, Rajgopal Singh R, Elkind MSV. Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association. Circulation 2023; 148:1606-1635. [PMID: 37807924 DOI: 10.1161/cir.0000000000001184] [Citation(s) in RCA: 78] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Cardiovascular-kidney-metabolic health reflects the interplay among metabolic risk factors, chronic kidney disease, and the cardiovascular system and has profound impacts on morbidity and mortality. There are multisystem consequences of poor cardiovascular-kidney-metabolic health, with the most significant clinical impact being the high associated incidence of cardiovascular disease events and cardiovascular mortality. There is a high prevalence of poor cardiovascular-kidney-metabolic health in the population, with a disproportionate burden seen among those with adverse social determinants of health. However, there is also a growing number of therapeutic options that favorably affect metabolic risk factors, kidney function, or both that also have cardioprotective effects. To improve cardiovascular-kidney-metabolic health and related outcomes in the population, there is a critical need for (1) more clarity on the definition of cardiovascular-kidney-metabolic syndrome; (2) an approach to cardiovascular-kidney-metabolic staging that promotes prevention across the life course; (3) prediction algorithms that include the exposures and outcomes most relevant to cardiovascular-kidney-metabolic health; and (4) strategies for the prevention and management of cardiovascular disease in relation to cardiovascular-kidney-metabolic health that reflect harmonization across major subspecialty guidelines and emerging scientific evidence. It is also critical to incorporate considerations of social determinants of health into care models for cardiovascular-kidney-metabolic syndrome and to reduce care fragmentation by facilitating approaches for patient-centered interdisciplinary care. This presidential advisory provides guidance on the definition, staging, prediction paradigms, and holistic approaches to care for patients with cardiovascular-kidney-metabolic syndrome and details a multicomponent vision for effectively and equitably enhancing cardiovascular-kidney-metabolic health in the population.
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Ramesh PL, Khandelwal P, Lakshmy R, Sinha A, Bagga A, Hari P. Short-term safety and efficacy of escalating doses of atorvastatin for dyslipidemia in children with predialysis chronic kidney disease stage 2-5. Pediatr Nephrol 2023; 38:2763-2770. [PMID: 36780007 DOI: 10.1007/s00467-023-05887-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 12/08/2022] [Accepted: 12/30/2022] [Indexed: 02/14/2023]
Abstract
BACKGROUND Dyslipidemia is a potentially modifiable risk factor in patients with chronic kidney disease (CKD). Information on the safety and efficacy of statins in pediatric CKD is limited. METHODS Patients with CKD stage 2-5 and aged 5-18 years with low-density lipoprotein cholesterol (LDL-C) > 130 mg/dL and/or non-high-density lipoprotein cholesterol (non-HDL-C) > 145 mg/dL were enrolled from September 2019 to February 2021. All patients were administered atorvastatin 10 mg/day, which was escalated to 20 mg/day if LDL-C remained > 100 mg/dL and/or non-HDL-C > 120 mg/dL at 12 weeks. Proportion of patients achieving target lipid levels (LDL-C ≤ 100 mg/dL and non-HDL-C ≤ 120 mg/dL) and adverse events were assessed at 24 weeks. RESULTS Of 31 patients enrolled, target lipid levels were achieved in 45.2% (95% CI 27.8-63.7%) at 24 weeks; 22 patients required dose escalation to 20 mg at 12 weeks. There was no difference in median lipid level reduction with 10 (n = 9) versus 20 mg/day (n = 22, P = 0.3). Higher baseline LDL-C (OR 1.06, 95% CI 1.00-1.11) and older age (OR 36.5, 95% CI 2.57-519.14) were independent predictors of failure to achieve target lipid levels with 10 mg/day atorvastatin. None had persistent rise in AST/ALT > 3 times upper normal limit (UNL) or CPK > 10 times UNL. No differences were noted in adverse events due to atorvastatin 10 or 20 mg/day. CONCLUSION Atorvastatin (10-20 mg/day) administered for 24 weeks was safe and effectively reduced LDL-C and non-HDL-C in children with CKD stages 2-5. Patients with higher baseline LDL-C required higher doses to achieve the target. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Punitha Lakxmi Ramesh
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - R Lakshmy
- Department of Cardiac Biochemistry, All India Institute of Medical Sciences, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
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7
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Bae SR, Bicki A, Coufal S, Jin E, Ku E. Cardiovascular disease risk factors and lifestyle modification strategies after pediatric kidney transplantation: what are we dealing with, and what can we target? Pediatr Nephrol 2023; 38:663-671. [PMID: 35552523 PMCID: PMC10799690 DOI: 10.1007/s00467-022-05589-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 01/19/2023]
Abstract
Kidney transplantation in pediatric patients can lead to partial improvement of some of the cardiometabolic parameters that increase the risk for cardiovascular disease (CVD) in patients with chronic kidney disease. However, even after restoration of kidney function, transplant recipients remain at risk for CVD due to the continual presence of traditional and non-traditional risk factors, including the side effects of immunosuppression and chronic inflammation. This educational review describes the prevalence of CVD risk factors in pediatric kidney transplant recipients and presents available evidence for therapeutic lifestyle changes and other non-pharmacologic strategies that can be used to improve traditional and modifiable CVD risk factors. Although trial-grade evidence for interventions that improve CVD in pediatric kidney transplant recipients is limited, potential strategies include lowering dietary sodium and saturated fat intake and increasing physical activity levels. Intensive follow-up may help patients achieve guideline-recommended goals for reducing their overall CVD risk.
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Affiliation(s)
- Se Ri Bae
- University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Alexandra Bicki
- Division of Pediatric Nephrology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.
| | - Sarah Coufal
- Division of Nephrology, Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Ethan Jin
- College of Osteopathic Medicine, Touro University, Vallejo, CA, USA
| | - Elaine Ku
- Division of Pediatric Nephrology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
- Division of Nephrology, Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
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Lee DY, Huang CJ, Yeh WY, Sung SH, Chen CH, Cheng HM. Improvement of clinical outcomes in patients undergoing peritoneal dialysis using hydroxymethylglutaryl-CoA reductase inhibitors: A systematic review and meta-analysis. J Chin Med Assoc 2023; 86:155-165. [PMID: 36652565 DOI: 10.1097/jcma.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND It is unclear whether hydroxymethylglutaryl-CoA reductase inhibitor (statin) therapy decreases the risk of mortality and cardiovascular disease (CVD) in patients undergoing peritoneal dialysis (PD). METHODS We performed a literature search of PubMed, Cochrane Library, Embase, and other databases for research publications up to June 2022. The outcomes of interest were fatal and nonfatal CVDs, all-cause mortality, and changes in the biochemical profiles. Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled and synthesized using a random-effects model. The certainty of the evidence was determined using Grading of Recommendations, Assessment, Development, and Evaluation. RESULTS Nine studies, including 2,933 patients undergoing PD, were included. Among them, three studies, including 2,099 patients, reported all-cause mortality, and three, including 1,571 patients, reported CVDs. In these patients, pooling results of two observational studies (very low-certainty evidence) showed that statin therapy significantly reduced CVDs (HR = 0.67; 95% CI = 0.54-0.84; p = 0.0004). Moreover, statin therapy was associated with significantly reduced low-density lipoprotein cholesterol, total cholesterol, and C-reactive protein levels (very low certainty of evidence). However, the effects of statin therapy on triglyceride, high-density lipoprotein, and albumin levels were not statistically significant. CONCLUSION Although statin therapy was associated with significantly reduced low-density lipoprotein cholesterol, total cholesterol, and C-reactive protein levels, the probable beneficial effect of statins on CVD risk in patients undergoing PD could not be concluded firmly. Additional high-quality studies are required to assess the potential beneficial effects of statin therapy in PD patients.
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Affiliation(s)
- Dan-Ying Lee
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chi-Jung Huang
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wan-Yu Yeh
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shih-Hsien Sung
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chen-Huan Chen
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hao-Min Cheng
- Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- PhD Program of Interdisciplinary Medicine (PIM), National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
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Lu L, Xu L, He Y, Shen J, Xin J, Zhou J, Wang C, Wang Y, Pan X, Gao J. Evaluation the effectiveness of the Jiangniaosuan formulation in the treatment of hyperuricemic nephropathy in patients with chronic kidney disease stages 3-4: Study protocol of a randomized controlled trial. Contemp Clin Trials Commun 2023; 32:101065. [PMID: 36793790 PMCID: PMC9922735 DOI: 10.1016/j.conctc.2023.101065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/04/2022] [Accepted: 01/14/2023] [Indexed: 01/18/2023] Open
Abstract
Background Hyperuricemic nephropathy is a highly prevalent kidney disease induced by excessive accumulation and deposition of monosodium urate in kidney, which contributes to the loss of kidney function. The Jiangniaosuan formulation (JNSF) is a Chinese herbal medicine treatment. The aim of this study is to evaluate its efficacy and safety among patients with hyperuricemic nephropathy at chronic kidney disease (CKD) stages 3-4 and with obstruction of phlegm turbidity and blood stasis syndrome. Methods Our research is designed as a single-centre, double-blinded, randomized, placebo-controlled trial for 118 patients diagnosed with hyperuricemic nephropathy at CKD stages 3-4 and with obstruction of phlegm turbidity and blood stasis syndrome in mainland China. Patients are to be randomized into two groups: either the intervention group which receives JNSF 20.4 g/day combined with febuxostat 20-40 mg/day, or the control group which receives JNSF placebo 20.4 g/day combined with febuxostat 20-40 mg/day. The intervention will be carried on for 24 weeks. The change in estimated glomerular filtration rate (eGFR) is set as the primary outcome. Secondary outcomes include changes in serum uric acid, serum nitric oxide, urinary albumin/creatinine ratio, urinary N-acetyl-β-D glucosaminidase, urinary β2 microglobulin, urinary retinol binding protein and TCM syndromes in 24 weeks. Statistical analysis will be formulated by SPSS 24.0. Discussion The trial will conduce to the comprehensive assessment in the efficacy and safety of JNSF among patients diagnosed with hyperuricemic nephropathy at CKD stages 3-4, and provide a clinical method available on systems of the combination of modern medicine and TCM.
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Affiliation(s)
- Lili Lu
- Department of Nephrology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, TCM Institute of Kidney Disease, Shanghai University of Traditional Chinese Medicine, Key Laboratory of Liver and Kidney Diseases(Shanghai University of Traditional Chinese Medicine), Ministry of Education, Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, China
| | - Li Xu
- Department of Nephrology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, TCM Institute of Kidney Disease, Shanghai University of Traditional Chinese Medicine, Key Laboratory of Liver and Kidney Diseases(Shanghai University of Traditional Chinese Medicine), Ministry of Education, Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, China
| | - Yikun He
- Department of Rheumatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiaying Shen
- Department of Rheumatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiadong Xin
- Department of Nephrology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, TCM Institute of Kidney Disease, Shanghai University of Traditional Chinese Medicine, Key Laboratory of Liver and Kidney Diseases(Shanghai University of Traditional Chinese Medicine), Ministry of Education, Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, China
| | - Jiabao Zhou
- Department of Nephrology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, TCM Institute of Kidney Disease, Shanghai University of Traditional Chinese Medicine, Key Laboratory of Liver and Kidney Diseases(Shanghai University of Traditional Chinese Medicine), Ministry of Education, Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, China
| | - Chuanxu Wang
- Department of Nephrology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, TCM Institute of Kidney Disease, Shanghai University of Traditional Chinese Medicine, Key Laboratory of Liver and Kidney Diseases(Shanghai University of Traditional Chinese Medicine), Ministry of Education, Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, China
| | - Yating Wang
- Department of Nephrology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, TCM Institute of Kidney Disease, Shanghai University of Traditional Chinese Medicine, Key Laboratory of Liver and Kidney Diseases(Shanghai University of Traditional Chinese Medicine), Ministry of Education, Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, China
| | - Xin Pan
- Department of Rheumatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiandong Gao
- Department of Nephrology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, TCM Institute of Kidney Disease, Shanghai University of Traditional Chinese Medicine, Key Laboratory of Liver and Kidney Diseases(Shanghai University of Traditional Chinese Medicine), Ministry of Education, Shanghai Key Laboratory of Traditional Chinese Clinical Medicine, Shanghai, China,Corresponding author. No. 528 Road ZhangHeng, Shanghai, 201203, China.
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10
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Shen Y, Chen Y, Huang S, Yao X, Kanwar YS, Zhan M. The Association between Symptoms of Depression and Anxiety, Quality of Life, and Diabetic Kidney Disease among Chinese Adults: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:475. [PMID: 36612797 PMCID: PMC9819882 DOI: 10.3390/ijerph20010475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/23/2022] [Accepted: 12/25/2022] [Indexed: 06/17/2023]
Abstract
Depression and anxiety are common comorbid symptoms among patients with diabetic kidney disease (DKD). Little is known about the influence of poor psychological conditions on the disease progression and quality of life (QOL) in DKD patients. This study aimed to investigate the prevalence of, and risk factors for, depression and anxiety in Chinese DKD patients, and to analyze their impact on the renal function, proteinuria, and QOL. A total of 620 adult patients with Type 2 diabetes and DKD being treated at a tertiary hospital in East China were recruited. Depression and anxiety symptoms were assessed by the Zung Self-Rating Depression Scale and Anxiety Scale. Among the DKD participants, 41.3% had symptoms of depression and 45.0% had anxiety symptoms. A poor education, physical inactivity, stroke, low serum albumin, CKD stage 3-4, macroalbuminuria, and a poor QOL were independent risk factors for depression in the DKD patients. Whereas a higher education, physical inactivity, diabetic retinopathy and neuropathy, low hemoglobin, CKD stage 3-4, and a poor QOL were risk factors for anxiety. Depression and anxiety scores among the DKD patients were negatively correlated with the eGFR and QOL scores. Moreover, depression and anxiety symptoms were independent risk factors for DKD patients with CKD stage 3-4 and a poor QOL. Our findings suggest a high prevalence of depression and anxiety among Chinese DKD patients, and the severity of psychological symptoms is closely linked to the deterioration of renal function and the QOL. The early screening and intervention of psychopathological disorders is thus strongly recommended for improving the QOL and clinical outcomes among DKD patients.
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Affiliation(s)
- Yan Shen
- School of Medicine, Ningbo University, Ningbo 315000, China
| | - Yi Chen
- School of Medicine, Ningbo University, Ningbo 315000, China
| | - Shichun Huang
- School of Medicine, Ningbo University, Ningbo 315000, China
| | - Xuejie Yao
- Department of Medicine, Ningbo First Hospital, Zhejiang University, Ningbo 315000, China
| | - Yashpal S. Kanwar
- Department of Pathology, Northwestern University, Chicago, IL 60611, USA
- Department of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Ming Zhan
- Department of Medicine, Ningbo First Hospital, Zhejiang University, Ningbo 315000, China
- China Health Institute, University of Nottingham Ningbo China, Ningbo 315100, China
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Dyslipidemia may be a risk factor for progression in children with IgA nephropathy. Pediatr Nephrol 2022; 37:3147-3156. [PMID: 35347403 DOI: 10.1007/s00467-022-05480-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND IgA nephropathy (IgAN) is often chronically progressive and commonly accompanied by dyslipidemia. However, the intrinsic relationship between dyslipidemia and IgAN remains to be elucidated. This study aimed to investigate the impact of different types of dyslipidemia on clinical and pathological characteristics in children with IgAN. METHODS In our retrospective cohort study from January 2006 to January 2021, 276 children with IgAN were ultimately included in the baseline analysis, and 169 were included in the follow-up analysis. The clinical and pathological features of different types of dyslipidemia and their effect on kidney prognosis were analyzed. RESULTS Children in the dyslipidemia group had more severe clinical characteristics (higher blood urea nitrogen, serum uric acid, and 24-h proteinuria; higher proportion of hypertension; and lower serum albumin and estimated glomerular filtration rate) and pathological changes (higher proportion of Lee grades IV-V and E1, S1, and C2 in MEST-C). Furthermore, the clinical and pathological characteristics were worse in the mixed hyperlipidemia group. Multivariate logistic analysis showed that hypertension, steroid treatment, lower serum albumin, severe proteinuria, and segmental glomerulosclerosis were independent risk factors for dyslipidemia in children with IgAN. The Kaplan-Meier analysis revealed that the probability of kidney survival in children with dyslipidemia was lower than that in those without dyslipidemia, with a median follow-up of 5.9 years. CONCLUSIONS Children with IgAN and dyslipidemia, especially mixed hyperlipidemia, are prone to more severe clinical and pathological changes. Our study provides further insight into dyslipidemia as a potential risk factor in children with IgAN. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Feng X, Zhan X, Wen Y, Peng F, Wang X, Wang N, Wu X, Wu J. Hyperlipidemia and mortality in patients on peritoneal dialysis. BMC Nephrol 2022; 23:342. [PMID: 36280801 PMCID: PMC9590170 DOI: 10.1186/s12882-022-02970-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 09/26/2022] [Accepted: 10/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND New lipid-lowering therapy at the start of dialysis and measurement of lipid parameters over the follow-up period is not recommended in dialysis patients, which seems unappropriated in clinical practice. We aimed to examine the effect of hyperlipidemia on mortality in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). METHODS A retrospective cohort study was performed, including 2939 incident CAPD patients from five dialysis facilities between January 1, 2005, and December 31, 2018. The primary outcome was all-cause mortality. The association between hyperlipidemia at the start of CAPD and all-cause mortality was evaluated using Cox proportional hazards regression. RESULTS Of 2939 with a median age of 50.0 (interquartile range, 39.0-61.0), 1697 (57.7%) were men, 533 (18.1%) had hyperlipidemia, 549 (18.7%) had diabetes mellitus, 1915 (65.2%) had hypertension, and 410 (14.0%) had a history of CVD. During the median follow-up period of 35.1 months, 519 (17.7%) died, including 402 (16.7%, 47.4/1000 patient-years) in the non-hyperlipidemia group and 117 (22.0%, 71.1/1000 patient-years) in the hyperlipidemia group. Over the overall follow-up period, patients with hyperlipidemia had an equally high risk of all-cause mortality throughout follow-up as those without hyperlipidemia ([HR] 1.04, 95% confidence interval [CI] 0.83 to 1.31). However, from the 48-month follow-up onwards, hyperlipidemia was associated with a 2.26 (95% CI 1.49 to 3.43)-time higher risk of all-cause mortality than non-hyperlipidemia. Hypertension modified the association between hyperlipidemia and all-cause mortality (P for interaction < 0.001). A significantly increased risk of all-cause mortality was observed among patients with hypertension (HR 2.27, 95%CI 1.44-3.58). CONCLUSION Among CAPD patients, hyperlipidemia at the beginning of CAPD was associated with a high risk of long-term mortality. Hypertension may mediate the association. Our findings suggested that long-term lipid-lowering treatment should be used in those patients with hyperlipidemia.
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Affiliation(s)
- Xiaoran Feng
- Department of Nephrology, Jiujiang No. 1 People’s Hospital, Jiujiang, China
| | - Xiaojiang Zhan
- grid.412604.50000 0004 1758 4073Department of Nephrology, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yueqiang Wen
- grid.412534.5Department of Nephrology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - FenFen Peng
- grid.417404.20000 0004 1771 3058Department of Nephrology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Xiaoyang Wang
- grid.412633.10000 0004 1799 0733Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Niansong Wang
- grid.16821.3c0000 0004 0368 8293Department of Nephrology, Affiliated Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China ,grid.412528.80000 0004 1798 5117Clinical Research Center for Chronic Kidney Disease, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Xianfeng Wu
- grid.16821.3c0000 0004 0368 8293Department of Nephrology, Affiliated Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China ,grid.412528.80000 0004 1798 5117Clinical Research Center for Chronic Kidney Disease, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Junnan Wu
- grid.415999.90000 0004 1798 9361Department of Nephrology, Zhejiang University Medical College Affiliated Sir Run Run Shaw Hospital, Qingchun Road 3rd, 310016 Hangzhou, Zhejiang Province China
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Alicic R, Nicholas SB. Diabetic Kidney Disease Back in Focus: Management Field Guide for Health Care Professionals in the 21st Century. Mayo Clin Proc 2022; 97:1904-1919. [PMID: 36202498 DOI: 10.1016/j.mayocp.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 03/28/2022] [Accepted: 05/03/2022] [Indexed: 12/02/2022]
Abstract
Chronic kidney disease due to diabetes, or diabetic kidney disease (DKD), is a worldwide leading cause of chronic kidney disease and kidney failure and an increasingly important global public health issue. It is associated with poor quality of life, high burden of chronic diseases, and increased risk of premature death. Until recently, people with DKD had limited therapeutic options. Treatments have focused largely on glycemic and blood pressure control and renin-angiotensin system blockade, leaving patients with significant residual risk for progression of DKD. The availability of newer classes of glucose-lowering agents, namely, sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, has changed the therapeutic landscape for these patients. These therapies have offered unprecedented opportunities to reduce the risk for progression of kidney disease and the risk of death that have led to recent updates to clinical guidelines. As such, the American Diabetes Association, the Kidney Disease: Improving Global Outcomes, and the European Association for the Study of Diabetes now recommend the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists for patients with DKD to provide both kidney and cardiovascular protective benefits. This review highlights the importance of early detection of DKD and summarizes the latest recommendations in the clinical guidelines on management of patients with DKD with hope of facilitating their uptake into everyday clinical practice. An integrated approach to patient care with a multidisciplinary focus can help achieve the necessary shift in clinical care of patients with DKD.
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Affiliation(s)
- Radica Alicic
- Providence Medical Research Center, Providence Health Care, University of Washington, Spokane and Seattle
| | - Susanne B Nicholas
- David Geffen School of Medicine at University of California, Los Angeles.
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Wu X, Zhou L, Zhan X, Wen Y, Wang X, Feng X, Wang N, Peng F, Wu J. Low-Density Lipoprotein Cholesterol and Mortality in Peritoneal Dialysis. Front Nutr 2022; 9:910348. [PMID: 35938138 PMCID: PMC9351358 DOI: 10.3389/fnut.2022.910348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIn dialysis patients, lowering low-density lipoprotein cholesterol (LDL-C) did not provide benefits, which seemed implausible in clinical practice. We hypothesized a U-shaped association between LDL-C and mortality in dialysis patients.MethodsIn this multi-center retrospective real-world cohort study, 3,565 incident Chinese peritoneal dialysis (PD) patients between January 1, 2005, and May 31, 2020, were included. The associations between baseline LDL-C and mortality were examined using cause-specific hazard models.ResultsOf 3,565 patients, 820 died, including 415 cardiovascular deaths. As compared with the reference range (2.26-2.60 mmol/L), both higher levels of LDL-C (> 2.60 mmol/L) and lower levels of LDL-C (< 2.26 mmol/L) were associated with increased risks of all-cause mortality (hazard ratio [HR],1.35, 95% confidence index [CI], 1.09-1.66; HR 1.36, 95%CI, 1.13-1.64) and cardiovascular mortality (HR, 1.31, 95% CI, 1.10-1.72; HR, 1.64; 95% CI, 1.22-2.19). Malnutrition (albumin < 36.0 g/L) modified the association between LDL-C and cardiovascular mortality (P for interaction = 0.01). A significantly increased risk of cardiovascular mortality was observed among patients with malnutrition and lower levels of LDL-C (HR 2.96, 95%CI 1.43-6.12) or higher levels of LDL-C (HR 2.81, 95%CI 1.38-5.72).ConclusionLow and high levels of LDL-C at the start of PD procedure were associated with increased all-cause and cardiovascular mortality risks. Malnutrition may modify the association of LDL-C with cardiovascular mortality.
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Affiliation(s)
- Xianfeng Wu
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Clinical Research Center for Chronic Kidney Disease, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- *Correspondence: Xianfeng Wu,
| | - Lei Zhou
- Evergreen Tree Nephrology Association, Guangzhou, China
| | - Xiaojiang Zhan
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yueqiang Wen
- Department of Nephrology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoyang Wang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoran Feng
- Department of Nephrology, Jiujiang No. 1 People’s Hospital, Jiujiang, China
| | - Niansong Wang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Clinical Research Center for Chronic Kidney Disease, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Fenfen Peng
- Department of Nephrology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Junnan Wu
- Department of Nephrology, Zhejiang University Medical College Affiliated Sir Run Run Shaw Hospital, Hangzhou, China
- Junnan Wu,
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Kang MH, Kim W, Kim JS, Jeong KH, Jeong MH, Hwang J, Hur SH, Hwang HS. Hydrophilic Versus Lipophilic Statin Treatments in Patients With Renal Impairment After Acute Myocardial Infarction. J Am Heart Assoc 2022; 11:e024649. [PMID: 35656978 PMCID: PMC9238700 DOI: 10.1161/jaha.121.024649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Hydrophilic and lipophilic statins have similar efficacies in treating coronary artery disease. However, specific factors relevant to renal impairment and different arterial pathogeneses could modify the clinical effects of statin lipophilicity, and create differences in protective effects between statin types in patients with renal impairment. Methods and Results A total of 2062 patients with acute myocardial infarction with an estimated glomerular filtration rate <60 mL/min per 1.73 m2 were enrolled from the Korea Acute Myocardial Infarction Registry between November 2011 and December 2015. The primary end point was a composite of 2-year major adverse cardiac and cerebrovascular events (MACEs) after acute myocardial infarction occurrence. MACEs were defined as all-cause death, recurrent myocardial infarction, revascularization, and stroke. Propensity-score matching and Cox proportional hazards regression were performed. A total of 529 patients treated with hydrophilic statins were matched to 529 patients treated with lipophilic statins. There was no difference in the statin equivalent dose between the 2 statin groups. The cumulative event rate of MACEs, all-cause mortality, and recurrent myocardial infarction were significantly lower in patients treated with hydrophilic statins in the propensity-score matched population (all P<0.05). In the multivariable Cox regression analysis, patients treated with hydrophilic statins had a lower risk for composite MACEs (hazard ratio [HR], 0.70 [95% CI, 0.55-0.90]), all-cause mortality (HR, 0.67 [95% CI, 0.49-0.93]), and recurrent myocardial infarction (HR, 0.40 [95% CI, 0.21-0.73]), but not for revascularization and ischemic stroke. Conclusions Hydrophilic statin treatment was associated with lower risk of MACEs and all-cause mortality than lipophilic statin in a propensity-score matched observational cohort of patients with renal impairment following acute myocardial infarction.
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Affiliation(s)
- Min Hye Kang
- Division of NephrologyDepartment of Internal MedicineKyung Hee UniversitySeoulRepublic of Korea
| | - Weon Kim
- Division of CardiologyDepartment of Internal MedicineKyung Hee UniversitySeoulRepublic of Korea
| | - Jin Sug Kim
- Division of NephrologyDepartment of Internal MedicineKyung Hee UniversitySeoulRepublic of Korea
| | - Kyung Hwan Jeong
- Division of NephrologyDepartment of Internal MedicineKyung Hee UniversitySeoulRepublic of Korea
| | - Myung Ho Jeong
- Department of Internal Medicine and Heart CenterChonnam National University HospitalGwangjuRepublic of Korea
| | - Jin‐Yong Hwang
- Department of Internal MedicineGyeongsang National University HospitalJinjuRepublic of Korea
| | - Seung Ho Hur
- Division of CardiologyKeimyung University Medical CenterTaeguRepublic of Korea
| | - Hyeon Seok Hwang
- Division of NephrologyDepartment of Internal MedicineKyung Hee UniversitySeoulRepublic of Korea
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Lidgard B, Zelnick LR, Go A, O'Brien KD, Bansal N. Framingham and American College of Cardiology/American Heart Association Pooled Cohort Equations, High-Sensitivity Troponin T, and N-Terminal Pro-Brain-Type Natriuretic Peptide for Predicting Atherosclerotic Cardiovascular Events Across the Spectrum of Kidney Dysfunction. J Am Heart Assoc 2022; 11:e024913. [PMID: 35621223 PMCID: PMC9238746 DOI: 10.1161/jaha.121.024913] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Contemporary guidelines recommend using atherosclerotic cardiovascular disease screening tools to guide primary prevention. The performance of these scores is not well known in patients with moderate to advanced chronic kidney disease, particularly in combination with clinically available cardiac biomarkers including N‐terminal pro–brain‐type natriuretic peptide and high‐sensitivity troponin T (hsTnT). Methods and Results We studied 1027 participants from the Chronic Renal Insufficiency Cohort without self‐reported atherosclerotic cardiovascular disease who were not taking aspirin or statins at enrollment. Framingham Risk Score, Pooled Cohort Equation, N‐terminal pro–brain‐type natriuretic peptide, and hsTnT were measured at baseline. Outcomes included fatal and nonfatal myocardial infarction, stroke, and cardiac death. We calculated 10‐fold cross‐validated Harrell’s C‐indices for each risk score and cardiac biomarker alone and in combination. The C‐index (95% CI) for discrimination of atherosclerotic cardiovascular disease was 0.72 (0.67, 0.77) for the Framingham Risk Score, and 0.72 (0.67, 0.76) for the Pooled Cohort Equation. HsTnT had comparable discrimination to each risk score, and improved the discrimination of each (change in Framingham 0.029, 95% CI 0.003, 0.055; change in Pooled Cohort Equation 0.027, 95% CI 0.002, 0.052). N‐terminal pro–brain‐type natriuretic peptide had poorer discrimination than the risk scores and did not significantly improve their discrimination (change in Framingham 0.009, 95% CI −0.001, 0.018; change in Pooled Cohort Equation 0.011, 95% CI −0.001, 0.024). Conclusions The Framingham Risk Score and Pooled Cohort Equation demonstrated moderate discrimination for atherosclerotic cardiovascular disease in patients with chronic kidney disease. HsTnT, but not N‐terminal pro–brain‐type natriuretic peptide, improved their discrimination overall. Until chronic kidney disease–specific atherosclerotic cardiovascular disease risk scores can be developed, it may be worth considering how to incorporate hsTnT into existing clinical risk scores.
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Affiliation(s)
| | | | - Alan Go
- Kaiser Permanente Division of ResearchNorthern California Oakland CA
| | | | - Nisha Bansal
- Department of Medicine University of Washington Seattle WA
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Association of Dietary Fish and n-3 Unsaturated Fatty Acid Consumption with Diabetic Nephropathy from a District Hospital in Northern Taiwan. Nutrients 2022; 14:nu14102148. [PMID: 35631289 PMCID: PMC9145694 DOI: 10.3390/nu14102148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 12/10/2022] Open
Abstract
Nephropathy caused by diabetes mellitus (DM) is the main cause of end-stage renal disease (ESRD). To understand the association of dietary intake with renal function indicators among patients with diabetic nephropathy (DN), this cross-sectional study was conducted at the dietetic consultation clinic of the Taoyuan Armed Forces General Hospital in Taiwan. In total, 317 participants were recruited for this study. Patients with diabetes who had a urinary albumin–creatinine ratio (UACR) of ≥30 mg/g were defined as having DN. The anthropometric characteristics, blood biochemistry, and renal function of the participants were assessed. Furthermore, a semiquantitative food frequency questionnaire (SQFFQ) was administered to investigate the dietary intake of the participants in the DM and DN groups. The result showed that participants in the DN group were older, had longer diabetes duration and poorer glycemic control and renal function than those in the DM group. Logistic regression models revealed that intake of high-fat marine fishes had the lowest odds ratio (OR) for DN risk compared with other fishes (OR: 0.868; 95% CI: 0.781–0.965, p = 0.009). Shellfish, soybean products, and skim milk also provided better protective effects to decrease the risk of DN. A further analysis of polyunsaturated fatty acids revealed that Σn-3 PUFAs significantly reduced DN risk, while Σn-6 PUFAs did not, especially EPA (OR: 0.821; 95% CI: 0.688–0.979, p = 0.029) and DHA (OR: 0.903; 95% CI: 0.823–0.992, p = 0.033) regardless of whether the variables were adjusted, including diabetes duration, age, and HbA1c. Our findings suggest that a diet that incorporates high-fat fish, shellfish, soybean products, and a lower Σn-6/Σn-3 ratio can mitigate DN risk.
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Nguyen Huu D, Dao Bui Quy Q, Nguyen Minh T, Nguyen Duc L, Truong Dinh C, Trung KN, Do Q, Tran Viet T, Le Viet T. Low serum prealbumin concentration predicts long-term mortality in maintenance hemodialysis patients with hepatitis B and/or C virus infections. JGH Open 2021; 5:1344-1350. [PMID: 34950777 PMCID: PMC8674549 DOI: 10.1002/jgh3.12677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 10/13/2021] [Accepted: 11/04/2021] [Indexed: 11/08/2022]
Abstract
Background and Aim A low serum prealbumin concentration is common in maintenance hemodialysis patients with hepatitis B and C and may be associated with mortality. In this study, we assessed Department of Nephrology and Hemodialysis predictive value of a low serum prealbumin concentration on mortality in HD patients using reused low-flux dialyzers who were infected with hepatitis B and/or C virus. Methods We used serum prealbumin levels to predict the long-term mortality of 326 hemodialysis patients. The patients were divided into two groups: group 1 (n = 140, with hepatitis B and/or C virus infections), and group 2 (n = 186, without hepatitis virus infections). Results During a 5-year follow-up, there were 75 deaths due to all-cause mortality (23.0%). Mortality was significantly higher (P < 0.001) in patients with hepatitis B and/or C infection (44%) than in those without hepatitis infection (8%). Serum prealbumin was lower in the hepatitis infected group and mortality group than in non-infected group and survival group. Multivariate Cox regression analysis showed that long duration of HD and lower serum prealbumin and albumin were related to mortality in patients undergoing maintenance HD. Receiver operating characteristic curves showed that serum prealbumin had a good prognostic value in predicting mortality in both groups with hepatitis B and/or C virus infection and without hepatitis infection (AUC = 0.792 [95% confidence interval: 0.714-0.87], P < 0.001; cut-off value = 24.5 mg/dl, sensitivity = 62.3%, and specificity = 88.6%). Conclusion In HD patients, serum prealbumin was a good prognostic biomarker of mortality in both groups of patients with hepatitis B and/or C virus infections and without hepatitis infections.
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Affiliation(s)
- Dung Nguyen Huu
- Center of Uro-Nephrology-Hemodialysis Bach Mai Hospital Ha Noi Viet Nam
| | | | - Tuan Nguyen Minh
- Department of Hemodialysis Cho Ray Hospital Ho Chi Minh Viet Nam
| | - Loc Nguyen Duc
- Department of Hemodialysis An Sinh Hospital Ho Chi Minh Viet Nam
| | | | - Kien Nguyen Trung
- Center of Hematology and Blood Transfusion Military Hospital 103 Ha Noi Viet Nam
| | - Quyet Do
- Director, Viet Nam Military Medical University Ha Noi Viet Nam
| | | | - Thang Le Viet
- Department of Nephrology - Hemodialysis Military Hospital 103 Ha Noi Viet Nam
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Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Dao Bui Quy Q, Pham Ngoc Huy T, Nguyen Minh T, Nguyen Duc L, Nguyen Minh T, Nguyen Trung K, Tran Viet T, Do Q, Le Viet T. High Serum Uric Acid and High-Sensitivity C Reactive Protein Concentrations Predict Three-Year Cardiovascular Mortality in Patients Treated With Continuous Ambulatory Peritoneal Dialysis. Cureus 2021; 13:e17900. [PMID: 34532198 PMCID: PMC8435087 DOI: 10.7759/cureus.17900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2021] [Indexed: 12/03/2022] Open
Abstract
AIMS This study aims to access the predicting value of serum uric acid (UA) and high-sensitivity C reactive protein (hs-CRP) concentration on three-year cardiovascular-related mortality in patients performing continuous ambulatory peritoneal dialysis (CAPD). METHODS A total of267 CAPD patients [150 male (56.2%); mean age 48.93 ± 13.58 years] were included in our study. All patients had measured serum UA and hs-CRP concentration. A high-sensitivity particle-enhanced immunoturbidimetric assay determined serum hs-CRP; serum UA levels were determined using an enzymatic colorimetric assay. All patients were followed for three years to detect cardiovascular-related mortality by cardiologists and stroke specialists. RESULTS Mean serum UA level was 415.16 ± 84.28 µmol/L, 58.4% of patients had increased serum UA level. Median serum hs-CRP level was 2 (1-4) mg/L, 12.4% of patients had increased serum hs-CRP level. During 36 months of follow-up, 41 patients (15.4%) had cardiovascular-related mortality. The results of Cox proportional hazards regression showed that hypertension, diabetes, high serum UA and hs-CRP were risk factors that related to cardiovascular-related mortality (p<0.05). The receiver operating characteristic (ROC) curve and Kaplan-Meier analysis results showed that UA and hs-CRP level had predictive value for three-year cardiovascular-related mortality in CAPD patients [uric acid: area under the curve (AUC)=0.822; hs-CRP: AUC=0.834, p < 0.001]. CONCLUSION High serum UA and hs-CRP levels were predictive factors of cardiovascular-related mortality in CAPD patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Quyet Do
- Director, Vietnam Military Medical University, Hanoi, VNM
| | - Thang Le Viet
- Nephrology and Hemodialysis, Military Hospital 103, Hanoi, VNM
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Deng Y, Wang C, Shen Y, Shen B, Ding F, Tang G, Liu W. Prevalence and risk of chronic kidney disease in oral lichen planus: a large cross-sectional study from eastern China. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1078. [PMID: 34422990 PMCID: PMC8339811 DOI: 10.21037/atm-21-699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/16/2021] [Indexed: 12/15/2022]
Abstract
Background Oral lichen planus (OLP) is a chronic inflammatory mucocutaneous disease which is frequently associated with comorbidities such as diabetes and cardiovascular diseases. However, little is known about the association of OLP with impaired kidney function. To elucidate the possible association of chronic kidney disease (CKD) with OLP and its severity, this study investigated the prevalence of CKD as well as its risk factors in patients with OLP. Methods A large prospective cross-sectional study of 1,021 patients with OLP was carried out using questionnaires and laboratory tests available from an oral medicine clinic at a university in eastern China. According to the Kidney Disease: Improving Global Outcomes (KDIGO) diagnostic guideline, CKD was classified based on the estimated glomerular filtration rate (eGFR, <60 mL/min/1.73 m2) or urinary albumin to creatinine ratio (UACR, >30 mg/g). Results The prevalence of CKD in the patients with OLP in this study was 14.3% (95% CI, 12.3–16.6%), which was higher than that in the general Chinese population (10.8%; 95% CI, 10.2–11.3%). The mean values of serum creatinine, eGFR, UACR, and urine N-acetyl-β-D-glucosidase in patients with CKD were significantly higher than those in patients without CKD (all P<0.01). Pearson’s correlation analysis revealed that CKD stage and UACR were positively correlated with the severity of OLP (both P<0.001). Importantly, multivariate regression analysis revealed that age ≥58 years old, female sex, and hypertension were independent risk factors for incident CKD and abnormal UACR (>30 mg/g) in patients with OLP (all P<0.01). Conclusions This study has reported for the first time that CKD is a comorbidity in patients with OLP. The occurrence and staging of incident CKD are associated with OLP and its severity.
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Affiliation(s)
- Yiwen Deng
- Department of Oral Mucosal Diseases, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Chengyi Wang
- Department of Oral Mucosal Diseases, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Yeqing Shen
- Department of Oral Mucosal Diseases, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Bo Shen
- Department of Nephrology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Ding
- Department of Nephrology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guoyao Tang
- Department of Oral Mucosal Diseases, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Wei Liu
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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22
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Kim JE, Park S, Kim MS, Kang SJ, Lee JW, Kim KS, Kim YC, Kim DK, Joo KW, Kim YS, Park M, Lee H. Statin initiation and all-cause mortality in incident statin-naïve dialysis patients. Atherosclerosis 2021; 337:59-65. [PMID: 34429195 DOI: 10.1016/j.atherosclerosis.2021.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 07/21/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS Cardiovascular disease is the main cause of death in end-stage kidney disease (ESKD) patients. We aimed to explore the association between statin initiation after starting dialysis and all-cause mortality in statin-naïve ESKD patients. METHODS We analyzed nationwide claims data of incident dialysis patients from 2010 to 2017 in South Korea. Patients who had previous cardiovascular events or were administered statins before dialysis were excluded. The study group included dialysis patients receiving statins within 1 year after dialysis initiation. The control group was organized after propensity-score matching with age, sex, time of dialysis initiation, and underlying diabetes mellitus and hypertension. The main outcomes were all-cause mortality and major cardiovascular events. RESULTS We included 1596 patients who started statin treatment and 1:1 matched statin-nonusers. During the 9438 person-year follow-up, 468 deaths and 264 major adverse cardiovascular events (MACEs) occurred. Statin initiation was associated with a reduced risk of all-cause mortality (adjusted hazard ratio (aHR) 0.72, 95% confidence interval (CI) 0.60-0.87, p = 0.001), but not with MACE incidence (aHR 1.06, 95% CI 0.83-1.36, p = 0.62). In particular, patients prescribed the recommended dosage of statins according to the Kidney Disease Improving Global Outcomes guidelines showed the lowest mortality risk (aHR 0.55, 95% CI 0.40-0.75, p < 0.001). CONCLUSIONS Statin initiation was associated with lower risk of all-cause mortality in statin-naïve ESKD patients. As indication bias may be present in observational study setting, further prospective studies are warranted to validate the association of statin initiation with mortality in incident dialysis cases.
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Affiliation(s)
- Ji Eun Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Sehoon Park
- Department of Internal Medicine, Armed Forces Capital Hospital, Gyeonggi-do, South Korea
| | - Myeong-Seok Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sung Jin Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jang Wook Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kwang Soo Kim
- Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, South Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea; Kidney Research Institute, Seoul National University, Seoul, South Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea; Kidney Research Institute, Seoul National University, Seoul, South Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea; Kidney Research Institute, Seoul National University, Seoul, South Korea
| | - Minsu Park
- Department of Informations and Statistics, Chungnam National University, Daejeon, South Korea.
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea; Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
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Abstract
Cardiovascular (CV) disease (CVD) is the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD) and with end-stage renal disease. CKD has a strong association with dyslipidemia. Dyslipidemias can affect kidney function and increase the risk for CVD development, so it is an important risk factor. Statin therapy can decrease CV events in patients with pre-end-stage CKD and in renal transplant patients, but not in those already on dialysis. This article focuses on epidemiology of CKD, how dyslipidemias confer a higher risk for CVD, the approach to management and treatment of dyslipidemias, and recent guidelines.
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Affiliation(s)
- Aneesha Thobani
- Department of Cardiovascular Disease, Emory University School of Medicine, Cardiovascular Disease Fellowship Training Program, 101 Woodruff Circle, WMB 2125, Atlanta, GA 30322, USA
| | - Terry A Jacobson
- Department of Medicine, Lipid Clinic and Cardiovascular Disease Prevention Program, Emory University School of Medicine, Faculty Office Building, 49 Jesse Hill Jr Dr SE, Atlanta, GA 30303, USA.
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24
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Dung NH, Loc ND, Quyen DBQ, Tuan NM, Tuan PNH, Quyet D, Thang LV. Association between low serum prealbumin levels and carpal tunnel syndrome in maintenance hemodialysis patients. Ren Fail 2021; 42:944-949. [PMID: 32912012 PMCID: PMC7946053 DOI: 10.1080/0886022x.2020.1811118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Aims Carpal tunnel syndrome (CTS) and low serum prealbumin concentration are common in maintenance hemodialysis patients. In this study, we focused on the association between low serum prealbumin levels and carpal tunnel syndrome in maintenance hemodialysis (MHD) patients using low-flux dialysis reuse. Materials and methods Serum prealbumin levels were assessed to determine the association between low serum prealbumin levels and CTS in 373 prevalent MHD patients (the mean age was 45 years old, hemodialysis duration was 46 months). The patients were divided into 2 groups: the CTS group with 44 patients and the non-CTS group with 329 patients. Results The prevalence of CTS was 11.8%. Serum prealbumin showed a good prognostic value to predict CTS in MHD patients using low-flux dialysis reuse (the Area Under the Curve = 0.841, p < .001; cutoff value: 26.5 mg/dL with sensitivity = 72.7% and specificity = 79.9%). Conclusions Serum prealbumin was a good prognostic biomarker of CTS in MHD patients using low-flux dialysis reuse.
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Affiliation(s)
| | | | | | | | | | - Do Quyet
- Viet Nam Military Medical University, Hanoi, Vietnam
| | - Le Viet Thang
- Viet Nam Military Medical University, Hanoi, Vietnam.,Military Hospital 103, Hanoi, Vietnam
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25
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Barbagallo CM, Cefalù AB, Giammanco A, Noto D, Caldarella R, Ciaccio M, Averna MR, Nardi E. Lipoprotein Abnormalities in Chronic Kidney Disease and Renal Transplantation. Life (Basel) 2021; 11:life11040315. [PMID: 33916487 PMCID: PMC8067409 DOI: 10.3390/life11040315] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 12/15/2022] Open
Abstract
Chronic kidney disease (CKD) is one of the most important risk factors for cardiovascular disease (CVD). Despite the kidney having no direct implications for lipoproteins metabolism, advanced CKD dyslipidemia is usually present in patients with CKD, and the frequent lipid and lipoprotein alterations occurring in these patients play a role of primary importance in the development of CVD. Although hypertriglyceridemia is the main disorder, a number of lipoprotein abnormalities occur in these patients. Different enzymes pathways and proteins involved in lipoprotein metabolism are impaired in CKD. In addition, treatment of uremia may modify the expression of lipoprotein pattern as well as determine acute changes. In renal transplantation recipients, the main lipid alteration is hypercholesterolemia, while hypertriglyceridemia is less pronounced. In this review we have analyzed lipid and lipoprotein disturbances in CKD and also their relationship with progression of renal disease. Hypolipidemic treatments may also change the natural history of CVD in CKD patients and may represent important strategies in the management of CKD patients.
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Affiliation(s)
- Carlo Maria Barbagallo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties—University of Palermo, Via del Vespro, 127, 90127 Palermo, Italy; (C.M.B.); (A.B.C.); (A.G.); (D.N.); (R.C.); (M.R.A.)
| | - Angelo Baldassare Cefalù
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties—University of Palermo, Via del Vespro, 127, 90127 Palermo, Italy; (C.M.B.); (A.B.C.); (A.G.); (D.N.); (R.C.); (M.R.A.)
| | - Antonina Giammanco
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties—University of Palermo, Via del Vespro, 127, 90127 Palermo, Italy; (C.M.B.); (A.B.C.); (A.G.); (D.N.); (R.C.); (M.R.A.)
| | - Davide Noto
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties—University of Palermo, Via del Vespro, 127, 90127 Palermo, Italy; (C.M.B.); (A.B.C.); (A.G.); (D.N.); (R.C.); (M.R.A.)
| | - Rosalia Caldarella
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties—University of Palermo, Via del Vespro, 127, 90127 Palermo, Italy; (C.M.B.); (A.B.C.); (A.G.); (D.N.); (R.C.); (M.R.A.)
| | - Marcello Ciaccio
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), Section of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, University of Palermo, 90127 Palermo, Italy;
| | - Maurizio Rocco Averna
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties—University of Palermo, Via del Vespro, 127, 90127 Palermo, Italy; (C.M.B.); (A.B.C.); (A.G.); (D.N.); (R.C.); (M.R.A.)
| | - Emilio Nardi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties—University of Palermo, Via del Vespro, 127, 90127 Palermo, Italy; (C.M.B.); (A.B.C.); (A.G.); (D.N.); (R.C.); (M.R.A.)
- Correspondence: ; Tel.: +39-916-554-316
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Charnaya O, Seifert M. Promoting cardiovascular health post-transplant through early diagnosis and adequate management of hypertension and dyslipidemia. Pediatr Transplant 2021; 25:e13811. [PMID: 32871051 DOI: 10.1111/petr.13811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/18/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
Abstract
Despite correction of underlying solid organ failure by transplantation, pediatric transplant recipients still have increased mortality rates compared to the general pediatric population, in part due to increased cardiovascular risk. In particular, pediatric kidney and non-kidney transplant recipients with chronic kidney disease have significant cardiovascular risk that worsens with declining kidney function. Biomarkers associated with future cardiovascular risk such as casual and ambulatory hypertension, dyslipidemia, vascular stiffness and calcification, and left ventricular hypertrophy can be detected throughout the post-transplant period and in patients with stable kidney function. Among these, hypertension and dyslipidemia are two potentially modifiable cardiovascular risk factors that are highly prevalent in kidney and non-kidney pediatric transplant recipients. Standardized approaches to appropriate BP measurement and lipid monitoring are needed to detect and address these risk factors in a timely fashion. To achieve sustained improvement in cardiovascular health, clinicians should partner with patients and their caregivers to address these and other risk factors with a combined approach that integrates pharmacologic with non-pharmacologic approaches. This review outlines the scope and impact of hypertension and dyslipidemia in pediatric transplant recipients, with a particular focus on pediatric kidney transplantation given the high burden of chronic kidney disease-associated cardiovascular risk. We also review the current published guidelines for monitoring and managing abnormalities in blood pressure and lipids, highlighting the important role of therapeutic lifestyle changes in concert with antihypertensive and lipid-lowering medications.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Seifert
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL, USA
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27
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Bacharaki D, Diamandopoulos A. Emperor's syndrome in the COVID-19 era: Time for patient-centered nephrology? World J Nephrol 2021; 10:1-7. [PMID: 33552939 PMCID: PMC7829681 DOI: 10.5527/wjn.v10.i1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/04/2020] [Accepted: 11/11/2020] [Indexed: 02/06/2023] Open
Abstract
The coronavirus disease-19 (COVID-19) pandemic has been a wake-up call in which has forced us to react worldwide. Health policies and practices have attracted particular attention in terms of human and financial cost. Before COVID-19, chronic kidney disease was already considered a risk multiplier in patients with diabetes and hypertension, the two now being the major risk factors for COVID-19 infection and adverse outcome. In contrast to the urgent need for action, the nephrology field is considered to be in a state of stagnation regarding the management of chronic kidney disease patients who still experience unacceptably high morbidity and mortality. Ironically and paradoxically in a field lacking robust clinical trials, clinical practice is driven by guidelines-based medicine on weak evidence. The Emperor's syndrome, referring to Hans Christian Andersen's fairy tale, has been described in medicine as voluntary blindness to an obvious truth, being a weak evidence-based therapeutic intervention or weak health care. A promising positive example of improving heart and kidney outcomes is the emerging treatment with sodium-glucose cotransporter 2 inhibitors. COVID-19 could boost actions for patient-centered care as a positive shift in nephrology care.
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Affiliation(s)
- Dimitra Bacharaki
- Department of Nephrology, Attikon University Hospital, Chaidari 12462, Greece
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28
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Bock ME, Wall L, Dobrec C, Chandran M, Goebel J. Management of dyslipidemia in pediatric renal transplant recipients. Pediatr Nephrol 2021; 36:51-63. [PMID: 31897714 DOI: 10.1007/s00467-019-04428-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/11/2019] [Accepted: 11/19/2019] [Indexed: 01/07/2023]
Abstract
Dyslipidemia after kidney transplantation is a common complication that has historically been underappreciated, especially in pediatric recipients. It is also a major modifiable risk factor for cardiovascular disease, a top cause of morbidity and mortality of transplant patients. While most knowledge about post-transplant dyslipidemia has been generated in adults, recommendations and treatment strategies also exist for children and are presented in this review. Awareness of these applicable guidelines and approaches is required, but not sufficient, for the reliable management of dyslipidemia in our patients, and additional needs and opportunities for comprehensive care in this area (e.g., quality improvement) are outlined.
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Affiliation(s)
- Margret E Bock
- Section of Pediatric Nephrology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Leslie Wall
- Clinical Nutrition Department, Children's Hospital Colorado, Aurora, CO, USA
| | - Carly Dobrec
- Clinical Nutrition Department, Children's Hospital Colorado, Aurora, CO, USA
| | - Mary Chandran
- Pharmacy Department, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Jens Goebel
- Section of Pediatric Nephrology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA.
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29
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Wang S, Wang F, Wang X, Zhang Y, Song L. Elevated Creatinine Clearance in Lupus Nephritis patients with Normal Creatinine. Int J Med Sci 2021; 18:1449-1455. [PMID: 33628102 PMCID: PMC7893553 DOI: 10.7150/ijms.51117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 01/07/2021] [Indexed: 11/05/2022] Open
Abstract
Objectives: The present study aimed to observe the differences in creatinine clearance (Ccr) in systemic lupus erythematosus (SLE) patients with normal serum creatinine at different levels of urinary protein. Method: The present cross-sectional study included 177 SLE patients with normal serum creatinine from Qilu Hospital of Shandong University between January 2010 and April 2020. The following data were collected: blood urea nitrogen (BUN), serum creatinine (Cr), serum total protein, serum albumin, immunoglobulin (Ig) G, IgA, IgM, complement 3, complement 4, anti-ds-DNA antibody, routine urine test, urine protein/creatinine ratio (UPCR) (g/g), and the SLE disease activity index. The estimated Ccr was calculated according to the Cockcroft formula. Results: 123 patients were with positive urinary protein (Lupus Nephritis, LN group) and 54 patients were with negative urinary protein (Non-LN group). Compared with the Non-LN group, the LN group had higher BUN (5.76±3.22 vs. 4.78±1.58, P=0.007) and Cr (62.36±19.53 vs. 54.83±11.09, P=0.001). There was a strong correlation between the UPCR and the semi-quantitative determination of urine protein in LN patients (r=0.9583, P=0.0417). The serum creatinine levels were significantly higher in patients with urine protein 3+ (72.97±25.16) or massive proteinuria (62.32±19.66) than the other groups. Patients with urinary protein ± exhibited a significantly elevated Ccr when compared to patients with urinary protein 3+ (130.6±44.15 vs. 110.5±33.50, P=0.02), and patients with UPCR<0.15 g/g had higher Ccr than other groups and showed significantly increased Ccr compared with patients with UPCR≥0.15 g/g (132.44±21.02 vs. 115.14±35.89, P=0.007). Conclusions: Early renal function impairment may be present in LN patients. The kidneys of LN patients with urinary protein ± or UPCR<0.15 g/g are in a state of hyperfunction.
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Affiliation(s)
- Sheng Wang
- Department of Rheumatology, Qilu Hospital of Shandong University, Ji'nan 250012, Shandong, China
| | - Fang Wang
- Department of Rheumatology, Qilu Hospital of Shandong University, Ji'nan 250012, Shandong, China
| | - Xiao Wang
- Department of Rheumatology, Qilu Hospital of Shandong University, Ji'nan 250012, Shandong, China
| | - Yuxian Zhang
- Department of Rheumatology, Qilu Hospital of Shandong University, Ji'nan 250012, Shandong, China
| | - Lijun Song
- Department of Rheumatology, Qilu Hospital of Shandong University, Ji'nan 250012, Shandong, China
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30
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Morcos R, Lazar I, Kucharik M, Lavin A, Fahmy A, Chandrasekhar S, Ibrahim A, Neupane A, Khalili H, Maini B, Ouslander JG. The Healthy, Aging, and Diseased Kidney: Relationship with Cardiovascular Disease. J Am Geriatr Soc 2020; 69:539-546. [PMID: 33104236 DOI: 10.1111/jgs.16866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 12/01/2022]
Abstract
The cardiovascular and renal systems share an intimate physiological relationship, wherein a perturbance in one system may have an adverse effect on the other. Since the burden of renal disease increases with age, there is a considerable interest in the pathophysiology of kidney disease in the geriatric patient population. This review will explore the physiological dynamics behind the increased susceptibility to kidney disease in this population. A better understanding of these pathophysiological changes may lead to improved prevention and management strategies.
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Affiliation(s)
- Ramez Morcos
- Department of Cardiovascular Diseases, Florida Atlantic University, Boca Raton, Florida, USA
| | - Ira Lazar
- Department of Internal Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Michael Kucharik
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Arye Lavin
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Andrew Fahmy
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Sanjay Chandrasekhar
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Amira Ibrahim
- Department of Internal Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Aashish Neupane
- Department of Internal Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Houman Khalili
- Department of Cardiovascular Diseases, Florida Atlantic University, Boca Raton, Florida, USA.,Tenet Healthcare Corporation, Boca Raton, Florida, USA
| | - Brijeshwar Maini
- Department of Cardiovascular Diseases, Florida Atlantic University, Boca Raton, Florida, USA.,Tenet Healthcare Corporation, Boca Raton, Florida, USA
| | - Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
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31
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Thang LV, Loc ND, Kien NT, Dung NH, Quyen DBQ, Tuan NM, Ha DM, Kien TQ, Dung NTT, Van DT, Van Duc N, Ha NTT, Toan PQ, Nghia VX. Interleukin 6 is a better predictor of 5-year cardiovascular mortality than high-sensitivity C-reactive protein in hemodialysis patients using reused low-flux dialyzers. Int Urol Nephrol 2020; 52:1135-1142. [PMID: 32306196 DOI: 10.1007/s11255-020-02461-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE In this study, we focused on the role of elevated serum interleukin 6 (IL-6) concentration in predicting 5-year cardiovascular mortality in hemodialysis patients using low-flux dialyzer reuse. MATERIALS AND METHODS We measured serum IL-6 concentrations in 236 hemodialysis patients (138 males and 98 females) to predict 5-year cardiovascular mortality. We assessed the baseline demographics of all patients who had a mean age of 44 years and a median hemodialysis duration of 38.5 months. We divided all patients into two equal groups based on the serum IL-6 concentration: G1 (n = 118) with serum IL-6 concentration < 6.78 pg/L and G2 (n = 118) with serum IL-6 concentration ≥ 6.78 pg/L. RESULTS After the 5-year follow-up, 45 patients died due to cardiovascular causes (19.1%). Lipid disorder, hemoglobin, serum albumin, β2-M, and IL-6 concentration were independent risk factors for predicting cardiovascular mortality during the 60-month follow-up in hemodialysis patients. Based on the Kaplan-Meier analysis, we realized that patients with a higher interleukin 6 concentration (G2) had a significantly higher cardiovascular mortality rate than patients in G1 (log-rank test p < 0.001). Serum IL-6 concentration was a better predictor of 5-year cardiovascular mortality than high-sensitivity C-reactive protein in hemodialysis patients using low-flux dialyzer reuse (AUC = 0.818; p < 0.001; cut-off value: 8.055 pg/mL, Se = 77.8%, Sp = 78.5%). CONCLUSION Serum IL-6 concentration was a better predictor of 5-year cardiovascular mortality than high-sensitivity C-reactive protein in maintenance hemodialysis patients using low-flux dialysis reuse.
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Lin MH, Chiu SY, Chang PH, Lai YL, Chen PC, Ho WC. Hyperlipidemia and Statins Use for the Risk of New Diagnosed Sarcopenia in Patients with Chronic Kidney: A Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1494. [PMID: 32110901 PMCID: PMC7084510 DOI: 10.3390/ijerph17051494] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/16/2020] [Accepted: 02/19/2020] [Indexed: 11/17/2022]
Abstract
Background: Previous research found that statins, in addition to its efficiency in treating hyperlipidemia, may also incur adverse drug reactions, which mainly include myopathies and abnormalities in liver function. Aim: This study aims to assess the risk for newly onset sarcopenia among patients with chronic kidney disease using statins. Material and Method: In a nationwide retrospective population-based cohort study, 75,637 clinically confirmed cases of chronic kidney disease between 1997 and 2011were selected from the National Health Insurance Research Database of Taiwan. The selection of the chronic kidney disease cohort included a discharge diagnosis with chronic kidney disease or more than 3 outpatient visits with the diagnosis of chronic kidney disease found within 1 year. After consideration of patient exclusions, we finally got a total number of 67,001 cases of chronic kidney disease in the study. The Cox proportional hazards model was used to perform preliminary analysis on the effect of statins usage on the occurrence of newly diagnosed sarcopenia; the Cox proportional hazards model with time-dependent covariates was conducted to take into consideration the individual temporal differences in medication usage, and calculated the hazard ratio (HR) and 95% confidence interval after controlling for gender, age, income, and urbanization. Results: Our main findings indicated that patients with chronic kidney disease who use statins seem to effectively prevent patients from occurrences of sarcopenia, high dosage of statins seem to show more significant protective effects, and the results are similar over long-term follow-up. In addition, the risk for newly diagnosed sarcopenia among patients with lipophilic statins treatment was lower than that among patients with hydrophilic statins treatment. Conclusion: It seems that patients with chronic kidney disease could receive statin treatment to reduce the occurrence of newly diagnosed sarcopenia. Additionally, a higher dosage of statins could reduce the incidence of newly diagnosed sarcopenia in patients with chronic kidney disease.
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Affiliation(s)
- Min-Hua Lin
- Department of Nutrition, China Medical University, Taichung 40402, Taiwan; (M.-H.L.); (S.-Y.C.)
- Department of Dietetics, Yunlin Christian Hospital, Yunlin 64866, Taiwan
| | - She-Yu Chiu
- Department of Nutrition, China Medical University, Taichung 40402, Taiwan; (M.-H.L.); (S.-Y.C.)
| | - Pei-Hsuan Chang
- Department of Clinical Nutrition, China Medical University Hospital, Taichung 40402, Taiwan;
- Department of Public Health, China Medical University, Taichung 40402, Taiwan
| | - Yu-Liang Lai
- Department of Physical Therapy Medicine and rehabilitation, China Medical University, Hsinchu 302, Taiwan;
- Department of Physical Therapy and School of Medicine, China Medical University, Taichung 40402, Taiwan
| | - Pau-Chung Chen
- Department of Public Health, National Taiwan University, Taipei 10617, Taiwan;
| | - Wen-Chao Ho
- Department of Public Health, China Medical University, Taichung 40402, Taiwan
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Kim JY, Steingroever J, Lee KH, Oh J, Choi MJ, Lee J, Larkins NG, Schaefer F, Hong SH, Jeong GH, Shin JI, Kronbichler A. Clinical Interventions and All-Cause Mortality of Patients with Chronic Kidney Disease: An Umbrella Systematic Review of Meta-Analyses. J Clin Med 2020; 9:E394. [PMID: 32024136 PMCID: PMC7074128 DOI: 10.3390/jcm9020394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/12/2020] [Accepted: 01/27/2020] [Indexed: 02/07/2023] Open
Abstract
Patients with chronic kidney disease (CKD) have altered physiologic processes, which result in different treatment outcomes compared with the general population. We aimed to systematically evaluate the efficacy of clinical interventions in reducing mortality of patients with CKD. We searched PubMed, MEDLINE, Embase, and Cochrane Database of Systematic Reviews for meta-analyses of randomized controlled trials (RCT) or observational studies (OS) studying the effect of treatment on all-cause mortality of patients with CKD. The credibility assessment was based on the random-effects summary estimate, heterogeneity, 95% prediction intervals, small study effects, excess significance, and credibility ceilings. Ninety-two articles yielded 130 unique meta-analyses. Convincing evidence from OSs supported mortality reduction with three treatments: angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers for patients not undergoing dialysis, warfarin for patients with atrial fibrillation not undergoing dialysis, and (at short-term) percutaneous coronary intervention compared to coronary artery bypass grafting for dialysis patients. Two treatment comparisons were supported by highly credible evidence from RCTs in terms of all-cause mortality. These were high-flux hemodialysis (HD) versus low-flux HD as a maintenance HD method and statin versus less statin or placebo for patients not undergoing dialysis. Most significant associations identified in OSs failed to be replicated in RCTs. Associations of high credibility from RCTs were in line with current guidelines. Given the heterogeneity of CKD, it seems hard to assume mortality reductions based on findings from OSs.
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Affiliation(s)
- Jong Yeob Kim
- Yonsei University College of Medicine, Seoul 03722, Korea; (J.Y.K.); (M.J.C.)
| | - Johanna Steingroever
- Department of Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany; (J.S.); (J.O.)
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, C.P.O. Box 8044, Seoul 03722, Korea;
- Division of Pediatric Nephrology, Severance Children’s Hospital, Seoul 03722, Korea
| | - Jun Oh
- Department of Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany; (J.S.); (J.O.)
| | - Min Jae Choi
- Yonsei University College of Medicine, Seoul 03722, Korea; (J.Y.K.); (M.J.C.)
| | - Jiwon Lee
- Department of Pediatric Nephrology, Chungnam National University Hospital, Daejeon 35015, Korea;
| | - Nicholas G. Larkins
- Department of Nephrology, Perth Children’s Hospital, 15 Hospital Ave, Nedlands, WA 6909, Australia;
- Centre for Kidney Research, Kids Research Institute, Westmead, NSW 2031, Australia
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, 69120 Heidelberg, Germany;
| | - Sung Hwi Hong
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA;
| | - Gwang Hun Jeong
- College of Medicine, Gyeongsang National University, Jinju 52727, Korea;
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, C.P.O. Box 8044, Seoul 03722, Korea;
- Division of Pediatric Nephrology, Severance Children’s Hospital, Seoul 03722, Korea
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria;
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Hu YN, Luo CY, Tsai MT, Lin TW, Kan CD, Roan JN. Post-Coronary Artery Bypass Medications in Dialysis Patients: Do We Need to Change Strategies? Thorac Cardiovasc Surg 2020; 68:706-713. [PMID: 31891949 DOI: 10.1055/s-0039-3400471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is frequently performed in patients with end-stage renal disease (ESRD) together with severe coronary artery disease, after which, patients with ESRD have higher surgical risk and poorer long-term outcomes. We report our experience in patients with ESRD who survived in CABG and identify predictors of long-term outcomes. METHODS We retrospectively investigated 93 consecutive patients with ESRD who survived to discharge after isolated CABG between January 2005 and December 2016 at our institution. Long-term outcomes, including all-cause mortality after discharge, readmission due to major adverse cardiac events, and reintervention, were evaluated. Predictors affecting long-term outcomes were also analyzed. RESULTS The rates of freedom from all-cause mortality after discharge in 1, 3, 5, and 10 years were 92.1, 81.3, 71.9, and 34.9%, respectively. The rates of freedom from readmission due to major adverse cardiac events in 1, 3, 5, and 10 years were 90.7, 79.1, 69.9, and 55.6%, respectively. The rates of freedom from reintervention in 1, 3, 5, and 10 years were 95.3, 86.5, 79.0, and 66.6%, respectively. Postoperative β-blocker and statin use significantly improved overall long-term survival (β-blocker, p = 0.013; statin, p = 0.009). After case-control matching, patients who received statins showed better long-term survival than those without statins. The comparison of long-term survival between patients with and without β-blockers showed no significant difference after matching. CONCLUSIONS After CABG, dialysis patients who survived to discharge had acceptable long-term overall survival. Post-CABG statin use in dialysis patients is a predictor of better long-term survival.
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Affiliation(s)
- Yu-Ning Hu
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Chwan-Yau Luo
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Meng-Ta Tsai
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Ting-Wei Lin
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Chung-Dann Kan
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Jun-Neng Roan
- Department of Surgery, Division of Cardiovascular Surgery, National Cheng Kung University College of Medicine, Tainan, Taiwan.,Medical Device Innovation Center, National Cheng Kung University College of Medicine, Tainan, Taiwan.,Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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35
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Duong TV, Wu PY, Yang E, Lin YF, Chiou HY, Yang SH. Associations of Waist Circumference, Socioeconomic, Environmental, and Behavioral Factors with Chronic Kidney Disease in Normal Weight, Overweight, and Obese People. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16245093. [PMID: 31847161 PMCID: PMC6949979 DOI: 10.3390/ijerph16245093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/06/2019] [Accepted: 12/12/2019] [Indexed: 11/16/2022]
Abstract
Background: Chronic kidney disease (CKD) places a heavy burden on the healthcare system worldwide. The risk factors may vary by body adiposity. We aimed to investigate the associations of socioeconomic, environmental, and behavioral factors with CKD in different groups of body mass indexes (BMI). Methods: A case-control study was conducted in 3280 participants (1048 CKD and 2232 non-CKD) from seven hospitals and nearby communities from May 2012 to August 2015. Personal characteristics, anthropometrics, environmental exposures, and health-related behaviors were assessed using a structured questionnaire. The logistic regression models were utilized for analysis. Results: Older age (odd ratio, OR = 2.85; p < 0.001), being men (OR = 4.23; p < 0.001), smoking (OR = 3.36; p < 0.001), stable income (OR = 0.33; p < 0.001), higher education (OR = 0.37~0.38; p < 0.001), and daily adequate water intake (OR = 0.64; p = 0.010) were associated with CKD in normal weight people. Older age (OR = 2.49; p < 0.001), being men (OR = 3.36; p < 0.001), education (OR = 0.44, p = 0.004), hypertension (OR = 2.93; p<0.001), diabetes (OR = 1.83; p = 0.004), and using traditional Chinese medicine (OR = 2.03, p = 0.014) were associated with CKD in overweight people. Older age (OR = 2.71; p < 0.001), being men (OR = 2.69; p < 0.001), hypertension (OR = 2.93; p < 0.001), diabetes (OR = 1.94; p = 0.001) were associated with CKD in obese people. Conclusions: The associated factors of CKD varied by different groups of BMI. These findings may help to develop potential interventions to manage CKD.
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Affiliation(s)
- Tuyen Van Duong
- School of Nutrition and Health Sciences, Taipei Medical University, Taipei 11031, Taiwan; (T.V.D.); (P.-Y.W.)
| | - Pei-Yu Wu
- School of Nutrition and Health Sciences, Taipei Medical University, Taipei 11031, Taiwan; (T.V.D.); (P.-Y.W.)
| | - Evelyn Yang
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung City 40201, Taiwan;
| | - Yuh-Feng Lin
- International Master/Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan;
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University−Shuang Ho Hospital, New Taipei 23561, Taiwan
| | - Hung-Yi Chiou
- School of Public Health, College of Public Health, Taipei Medical University, Taipei 11031, Taiwan;
- Health and Clinical Research Data Center, Data Center, Taipei Medical University, Taipei 11031, Taiwan
- Master Program in Applied Molecular Epidemiology, Taipei Medical University, Taipei 11031, Taiwan
| | - Shwu-Huey Yang
- School of Nutrition and Health Sciences, Taipei Medical University, Taipei 11031, Taiwan; (T.V.D.); (P.-Y.W.)
- Research Center of Geriatric Nutrition, Taipei Medical University, Taipei 11031, Taiwan
- Nutrition Research Center, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Correspondence: ; Tel.: +886-2-2736-1661 (ext. 6568)
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36
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Saland JM, Kupferman JC, Pierce CB, Flynn JT, Mitsnefes MM, Warady BA, Furth SL. Change in Dyslipidemia with Declining Glomerular Filtration Rate and Increasing Proteinuria in Children with CKD. Clin J Am Soc Nephrol 2019; 14:1711-1718. [PMID: 31712386 PMCID: PMC6895497 DOI: 10.2215/cjn.03110319] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 10/09/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Dyslipidemia, a risk factor for cardiovascular disease, is common in CKD but its change over time and how that change is influenced by concurrent progression of CKD have not been previously described. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In the CKD in Children study we prospectively followed children with progressive CKD and utilized multivariable, linear mixed-effects models to quantify the longitudinal relationship between within-subject changes in lipid measures (HDL cholesterol, non-HDL cholesterol, triglycerides) and within-subject changes in GFR, proteinuria, and body mass index (BMI). RESULTS A total of 508 children (76% nonglomerular CKD, 24% glomerular CKD) had 2-6 lipid measurements each, with a median follow-up time of 4 (interquartile range [IQR], 2.1-6.0) years. Among children with nonglomerular CKD, dyslipidemia was common at baseline (35%) and increased significantly as children aged; 43% of children with glomerular CKD had dyslipidemia at baseline and demonstrated persistent levels as they aged. Longitudinal increases in proteinuria were independently associated with significant concomitant increases in non-HDL cholesterol (nonglomerular: 4.9 [IQR, 3.4-6.4] mg/dl; glomerular: 8.5 [IQR, 6.0-11.1] mg/dl) and triglycerides (nonglomerular: 3% [IQR, 0.8%-6%]; glomerular: 5% [IQR, 0.6%-9%]). Decreases in GFR over follow-up were significantly associated with concomitant decreases of HDL cholesterol in children with nonglomerular CKD (-1.2 mg/dl; IQR, -2.1 to -0.4 mg/dl) and increases of non-HDL cholesterol in children with glomerular CKD (3.9 mg/dl; IQR, 1.4-6.5 mg/dl). The effects of increased BMI also affected multiple lipid changes over time. Collectively, glomerular CKD displayed stronger, deleterious associations between within-subject change in non-HDL cholesterol (9 mg/dl versus 1.2 mg/dl; P<0.001) and triglycerides (14% versus 3%; P=0.004), and within-subject change in BMI; similar but quantitatively smaller differences between the two types of CKD were noted for associations of within-subject change in lipids to within-subject change in GFR and proteinuria. CONCLUSIONS Dyslipidemia is a common and persistent complication in children with CKD and it worsens in proportion to declining GFR, worsening proteinuria, and increasing BMI.
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Affiliation(s)
- Jeffrey M Saland
- Division of Pediatric Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York;
| | - Juan C Kupferman
- Division of Pediatric Nephrology, Maimonides Medical Center, Brooklyn, New York
| | - Christopher B Pierce
- Division of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington, Seattle, Washington.,Division of Nephrology, Seattle Children's Hospital, Seattle, Washington
| | - Mark M Mitsnefes
- Division of Pediatric Nephrology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Susan L Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and.,Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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37
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The association between dietary energy intake and the risk of mortality in maintenance haemodialysis patients: a multi-centre prospective cohort study. Br J Nutr 2019; 123:437-445. [DOI: 10.1017/s0007114519002861] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractMaintenance haemodialysis (MHD) is the use of a machine to filter wastes, salts and fluid from blood for at least 3 months to prolong the life of patients with advanced kidney failure. Although low dietary energy intake (DEI) has been observed in MHD patients, few studies have related DEI to the risk of mortality. To explore this relationship, a study included 1039 MHD patients from eight centres was conducted. DEI was assessed by three 24-h diet recalls and was normalised to ideal body weight (IBW). All-cause mortality and CVD mortality were the primary and secondary outcomes, respectively. During a median follow-up of 28 months, a U-shaped relationship was observed between DEI and all-cause or CVD mortality. The risk of all-cause mortality decreased significantly with the increase of DEI in participants with DEI <167·4 kJ/kg IBW per d (hazard ratio (HR) 0·98; 95 % CI 0·96, 1·00) and increased significantly with the increase of DEI in those with DEI ≥167·4 kJ/kg IBW per d (HR 1·12; 95 % CI 1·04, 1·20). Similarly, the risk of CVD mortality decreased with the increase of DEI in participants with DEI <152·7 kJ/kg IBW per d (HR 0·96; 95 % CI 0·93, 0·99) and increased with the increase of DEI in participants with DEI ≥152·7 kJ/kg IBW per d (HR 1·11; 95 % CI 1·04, 1·18). In summary, there was a U-shaped association between DEI and all-cause or CVD mortality, with a turning point at about 167·4 and 152·7 kJ/kg IBW per d, respectively, in MHD patients.
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Treatment with Statins in Elderly Patients. MEDICINA-LITHUANIA 2019; 55:medicina55110721. [PMID: 31671689 PMCID: PMC6915405 DOI: 10.3390/medicina55110721] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 10/27/2019] [Accepted: 10/28/2019] [Indexed: 12/11/2022]
Abstract
Elderly patients are a special category of patients, due to the physiological changes induced by age, the great number of comorbidities and drug treatment and last, but not least, to the cognitive dysfunction frequently encountered in this population. Cardiovascular disease is the most important cause of morbidity and mortality in elderly individuals worldwide. The rate of cardiovascular events increases after 65 years in men and after 75 years in women. Myocardial infarction and stroke are the leading disorders caused by atherosclerosis, that lead to death or functional incapacity. Elderly people have a greater risk to develop atherosclerotic cardiovascular disease. The incidence and prevalence of atherosclerosis increase with age and the number of cardiovascular events is higher in elderly patients. The most efficient treatment against atherosclerosis is the treatment with statins, that has been shown to decrease the risk both of stroke and coronary artery disease in all age groups. The advantages of the treatment become evident after at least one year of treatment. Primary prevention is the most important way of preventing cardiovascular disease in elderly individuals, by promoting a healthy lifestyle and reducing the risk factors. Secondary prevention after a stroke or myocardial infarction includes mandatory a statin, to diminish the risk of a recurrent cardiovascular event. The possible side effects of statin therapy are diabetes mellitus, myopathy, and rhabdomyolysis, hepatotoxicity. The side effects of the treatment are more likely to occur in elderly patients, due to their multiple associated comorbidities and drugs that may interact with statins. In elderly people, the benefits and disadvantages of the treatment with statins should be put in balance, especially in those receiving high doses of statins.
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Abstract
An increased risk of cardiovascular disease, independent of conventional risk factors, is present even at minor levels of renal impairment and is highest in patients with end-stage renal disease (ESRD) requiring dialysis. Renal dysfunction changes the level, composition and quality of blood lipids in favour of a more atherogenic profile. Patients with advanced chronic kidney disease (CKD) or ESRD have a characteristic lipid pattern of hypertriglyceridaemia and low HDL cholesterol levels but normal LDL cholesterol levels. In the general population, a clear relationship exists between LDL cholesterol and major atherosclerotic events. However, in patients with ESRD, LDL cholesterol shows a negative association with these outcomes at below average LDL cholesterol levels and a flat or weakly positive association with mortality at higher LDL cholesterol levels. Overall, the available data suggest that lowering of LDL cholesterol is beneficial for prevention of major atherosclerotic events in patients with CKD and in kidney transplant recipients but is not beneficial in patients requiring dialysis. The 2013 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Lipid Management in CKD provides simple recommendations for the management of dyslipidaemia in patients with CKD and ESRD. However, emerging data and novel lipid-lowering therapies warrant some reappraisal of these recommendations.
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40
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Markossian TW, Kramer HJ, Burge NJ, Pacold IV, Leehey DJ, Huo Z, Schneider J, Ling B, Stroupe KT. Low statin use in nondialysis-dependent chronic kidney disease in the absence of clinical atherosclerotic cardiovascular disease or diabetes. Clin Kidney J 2019; 12:530-537. [PMID: 31384445 PMCID: PMC6671388 DOI: 10.1093/ckj/sfy131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Both reduced glomerular filtration rate and increased urine albumin excretion, markers of chronic kidney disease (CKD), are associated with increased risk of atherosclerotic cardiovascular disease (ASCVD). However, CKD is not recognized as an ASCVD risk equivalent by most lipid guidelines. Statin medications, especially when combined with ezetimibe, significantly reduce ASCVD risk in patients with nondialysis-dependent CKD. Unless physicians recognize the heightened ASCVD risk in this population, statins may not be prescribed in the absence of clinical cardiovascular disease or diabetes, a recognized ASCVD risk equivalent. We examined statin use in adults with nondialysis-dependent CKD and examined whether the use differed in the presence of clinical ASCVD and diabetes. METHODS This study ascertained statin use from pharmacy dispensing records during fiscal years 2012 and 2013 from the US Department of Veterans Affairs Healthcare System. The study included 581 344 veterans aged ≥50 years with nondialysis-dependent CKD Stages 3-5 with no history of kidney transplantation or dialysis. The 10-year predicted ASCVD risk was calculated with the pooled risk equation. RESULTS Of veterans with CKD, 62.1% used statins in 2012 and 55.4% used statins continuously over 2 years (2012-13). Statin use in 2012 was 76.2 and 75.5% among veterans with CKD and ASCVD or diabetes, respectively, but in the absence of ASCVD, diabetes or a diagnosis of hyperlipidemia, statin use was 21.8% (P < 0.001). The 10-year predicted ASCVD risk was ≥7.5% in 95.1% of veterans with CKD, regardless of diabetes status. CONCLUSIONS Statin use is low in veterans with nondialysis-dependent CKD in the absence of ASCVD or diabetes despite high-predicted ASCVD risk. Future studies should examine other populations.
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Affiliation(s)
- Talar W Markossian
- Center for Innovation in Complex Chronic Healthcare, Hines Veterans Administration Hospital, Hines, IL, USA
- Department of Public Health Sciences, Loyola University Chicago, Maywood, IL, USA
| | - Holly J Kramer
- Department of Public Health Sciences, Loyola University Chicago, Maywood, IL, USA
- Department of Medicine, Loyola University Chicago, Maywood, IL, USA
- Medicine Service Line, Hines Veterans Administration Hospital, Hines, IL, USA
| | - Nicholas J Burge
- Medicine Service Line, Hines Veterans Administration Hospital, Hines, IL, USA
| | - Ivan V Pacold
- Department of Medicine, Loyola University Chicago, Maywood, IL, USA
- Medicine Service Line, Hines Veterans Administration Hospital, Hines, IL, USA
| | - David J Leehey
- Department of Medicine, Loyola University Chicago, Maywood, IL, USA
- Medicine Service Line, Hines Veterans Administration Hospital, Hines, IL, USA
| | - Zhiping Huo
- Center for Innovation in Complex Chronic Healthcare, Hines Veterans Administration Hospital, Hines, IL, USA
| | - Julia Schneider
- Department of Medicine, Loyola University Chicago, Maywood, IL, USA
- Medicine Service Line, Hines Veterans Administration Hospital, Hines, IL, USA
| | - Benjamin Ling
- Department of Medicine, Loyola University Chicago, Maywood, IL, USA
- Medicine Service Line, Hines Veterans Administration Hospital, Hines, IL, USA
| | - Kevin T Stroupe
- Center for Innovation in Complex Chronic Healthcare, Hines Veterans Administration Hospital, Hines, IL, USA
- Department of Public Health Sciences, Loyola University Chicago, Maywood, IL, USA
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Parker K, Bull-Engelstad I, Benth JŠ, Aasebø W, von der Lippe N, Reier-Nilsen M, Os I, Stavem K. Effectiveness of using STOPP/START criteria to identify potentially inappropriate medication in people aged ≥ 65 years with chronic kidney disease: a randomized clinical trial. Eur J Clin Pharmacol 2019; 75:1503-1511. [PMID: 31359099 DOI: 10.1007/s00228-019-02727-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 07/17/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Polypharmacy and inappropriate prescribing are common in elderly with chronic kidney disease (CKD). This study identified potentially inappropriate prescriptions (PIPs) and potential prescribing omissions (PPOs) using the Screening Tool of Older Persons' Prescriptions (STOPP) and the Screening Tool to Alert doctors to the Right Treatment (START) criteria in elderly with advanced CKD and determined the effect of a medication review on medication adherence and health-related quality of life (HRQoL). METHODS The intervention consisted of a medication review using STOPP/START criteria with a recommendation to a nephrologist or similar review without a recommendation. End points were prevalence of PIP and PPO, medication adherence, and HRQoL. Group differences in outcomes were assessed using a generalized linear mixed model. The trial was registered under www.clinicaltrial.gov (ID: NCT02424786). RESULTS We randomized 180 patients with advanced CKD (mean age 77 years, 23% female). The prevalence of PIPs and PPOs in the intervention group was 54% and 50%, respectively. The odds of PPOs were lower in the intervention than the control group (OR 0.42, 95% CI 0.19-0.92, p = 0.032), while there was no intergroup difference in the number of PIPs (OR 0.57, CI 0.27-1.20, p = 0.14). There was no difference in changes in medication adherence or HRQoL from baseline to 6 months between the groups. CONCLUSIONS The intervention with the STOPP/START criteria identified a high prevalence of inappropriate medications in the elderly with advanced CKD and reduced the number of PPOs. However, there was no detectable impact of the intervention on medication adherence or HRQoL.
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Affiliation(s)
- Krystina Parker
- Department of Nephrology, Medical Division, Akershus University Hospital, Lørenskog, Norway. .,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Ingrid Bull-Engelstad
- Department of Nephrology, Medical Division, Vestre Viken HF, Drammen Hospital, Drammen, Norway
| | - Jūratė Šaltytė Benth
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Willy Aasebø
- Department of Nephrology, Medical Division, Akershus University Hospital, Lørenskog, Norway
| | - Nanna von der Lippe
- Department of Nephrology, Medical Division, Oslo University Hospital Ullevål, Oslo, Norway
| | - Morten Reier-Nilsen
- Department of Nephrology, Medical Division, Vestre Viken HF, Drammen Hospital, Drammen, Norway
| | - Ingrid Os
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Nephrology, Medical Division, Oslo University Hospital Ullevål, Oslo, Norway
| | - Knut Stavem
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Department of Pulmonary Medicine, Medical Division, Akershus University Hospital, Lørenskog, Norway
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Vijayaraghavan K, Szerlip HM, Ballantyne CM, Bays HE, Philip S, Doyle RT, Juliano RA, Granowitz C. Icosapent ethyl reduces atherogenic markers in high-risk statin-treated patients with stage 3 chronic kidney disease and high triglycerides. Postgrad Med 2019; 131:390-396. [PMID: 31306043 DOI: 10.1080/00325481.2019.1643633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective: Patients with chronic kidney disease (CKD) have increased cardiovascular disease (CVD) risk, likely driven by atherogenic and inflammatory markers beyond low-density lipoprotein cholesterol (LDL-C). The objective of this hypothesis-generating post hoc subgroup analysis was to explore the effects of icosapent ethyl at 2 or 4 g/day (prescription pure ethyl ester of the omega-3 fatty acid eicosapentaenoic acid [EPA]) on atherogenic lipid, apolipoprotein, inflammatory parameters (high-sensitivity C-reactive protein [hsCRP], lipoprotein-associated phospholipase A2 [Lp-PLA2]), and oxidative parameters (oxidized-LDL [ox-LDL]) in statin-treated patients from ANCHOR with stage 3 CKD.Methods: The 12-week ANCHOR study evaluated icosapent ethyl in 702 statin-treated patients at increased CVD risk with triglycerides (TG) 200-499 mg/dL despite controlled LDL-C (40-99 mg/dL). This post-hoc analysis included patients from ANCHOR with stage 3 CKD (estimated glomerular filtration rate [eGFR] ≤60 mL/min/1.73 m2 for ≥3 months) randomized to icosapent ethyl 4 g/day (n = 19), 2 g/day (n = 30), or placebo (n = 36).Results: At the prescription dose of 4 g/day, icosapent ethyl significantly reduced TG (-16.9%; P = 0.0074) and other potentially atherogenic lipids/lipoproteins, ox-LDL, hsCRP, and Lp-PLA2, and increased plasma and red blood cell EPA levels (+879% and +579%, respectively; both P < 0.0001) versus placebo. Icosapent ethyl did not significantly alter eGFR or serum creatinine. Safety and tolerability were similar to placebo.Conclusions: In patients with stage 3 CKD at high CVD risk with persistent high TG despite statins, icosapent ethyl 4 g/day reduced potentially atherogenic and other cardiovascular risk factors without raising LDL-C, with safety similar to placebo. These findings suggest prospective investigation may be warranted.
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Affiliation(s)
| | - Harold M Szerlip
- Nephrology Division and Nephrology Fellowship Program, Baylor University Medical Center, Dallas, TX, USA
| | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine and the Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA
| | - Harold E Bays
- Louisville Metabolic and Atherosclerosis Research Center, Louisville, KY, USA
| | - Sephy Philip
- Medical Affairs, Amarin Pharma Inc., Bedminster, NJ, USA
| | - Ralph T Doyle
- Clinical Development, Amarin Pharma Inc., Bedminster, NJ, USA
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43
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Lawal OM, Balogun MO, Akintomide AO, Ayoola OO, Mene-Afejuku TO, Ogunlade O, Okunola OO, Lawal AO, Akinsola A. Carotid Intima-Media Thickness: A Surrogate Marker for Cardiovascular Disease in Chronic Kidney Disease Patients. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2019; 13:1179546819852941. [PMID: 31258338 PMCID: PMC6589967 DOI: 10.1177/1179546819852941] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 05/03/2019] [Indexed: 12/18/2022]
Abstract
Background: Cardiovascular disease (CVD) is the leading cause of mortality in patients with chronic kidney disease (CKD). Carotid intima-media thickness (CIMT) is a measure of atherosclerotic vascular disease and considered a comprehensive picture of all alterations caused by multiple cardiovascular risk factors over time on the arterial walls. We therefore sought to determine the CIMT of the common carotid artery in patients with CKD and to evaluate the clinical pattern and prevalence of CVD in CKD patients. Methods: A case-control study involving 100 subjects made of 50 patients with CKD stages 2 to 4 and 50 age and sex matched apparently normal individuals. Carotid intima-media thickness of the common carotid artery was considered thickened if it measured greater than 0.8 mm. All subjects had laboratory investigations, 12-lead electrocardiogram, transthoracic echocardiography, and ankle-brachial index. Results: The mean CIMT was higher in CKD population compared with controls (P < .001). Eighty-four percent of the study population was found to have thickened CIMT compared with 18% of controls (P < .001). Patients with CKD had significantly higher blood pressure and heart rate than controls. Cardiovascular disease was also more prevalent among patients with CKD as compared with controls. Carotid intima-media thickness positively correlated with age, blood pressure, and random blood sugar. Conclusions: As CIMT was well correlated with many cardiovascular risk factors among CKD patients, it may serve as a surrogate marker for CVD and its early assessment may target patients who may need more aggressive therapy to retard the progression of kidney disease and improve outcome.
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Affiliation(s)
| | - Michael Olabode Balogun
- Cardiology Unit, Department of Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ife, Nigeria
| | - Anthony Olubunmi Akintomide
- Cardiology Unit, Department of Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ife, Nigeria
| | | | | | - Oluwadare Ogunlade
- Cardiology Unit, Department of Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ife, Nigeria
| | - Oluyomi Oluseun Okunola
- Nephrology Unit, Department of Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ife, Nigeria
| | | | - Adewale Akinsola
- Nephrology Unit, Department of Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ife, Nigeria
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44
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Zykov MV. [The problem of safety of lipid-lowering therapy]. ACTA ACUST UNITED AC 2019; 59:13-26. [PMID: 31221072 DOI: 10.18087/cardio.2505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Indexed: 11/18/2022]
Abstract
This study focused on analysis of current publications evaluating safety of lipid-lowering therapy. Search for literature was performed on websites of cardiological societies and online databases, including PubMed, EMBASE, and eLibrary by the following key words: statins, statin intolerance, lipid-lowering therapy, statin safety, and statin аdverse effects. The focus is on statins, in view of the fact that they are the most commonly prescribed, highly effective and safe drugs for primary and secondary cardiovascular prophylaxis. This review consistently summarized information about myopathies, hepatic and renal dysfunction, potentiation of DM, and other possible adverse effects of lipid-lowering therapy. The author concluded that despite the high safety of statins acknowledged by all international cardiological societies, practicing doctors still continue unreasonably cancel statins, exposing the patient under even greater danger. Information about the corresponding author.
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Affiliation(s)
- M V Zykov
- Research Institute for Complex Issues of Cardiovascular Diseases
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45
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Lipid-lowering agents for the treatment of hyperlipidemia in patients with chronic kidney disease and end-stage renal disease on dialysis: a review. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00646-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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46
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Kamilova UK, Rasulova ZD, Zakirova GA, Toshev BB. Features of cardiovascular remodeling, the level of neurohumoral factors depending on the degree of chronic heart failure and kidney dysfunction. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2019. [DOI: 10.15829/1728-8800-2019-3-35-40] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To study the relationship between the level of the N-terminal prohormone of brain natriuretic peptide (NTproBNP) and aldosterone in serum, cardiovascular remodeling parameters with the degree of chronic heart failure (CHF) and kidney dysfunction (KD).Material and methods. Fifty two patients with coronary artery disease with CHF of I (19 patients), II (21) and III (12) functional classes (FC) were examined. All patients underwent echocardiography with assessment of systolic function and structural-geometric parameters of the left ventricle (LV), blood flow study at the level of the common carotid artery (CCA) with the determination of the thickness of the intim-media complex, velocity parameters of blood flow, resistance (RI) and pulsation (PI) indexes, estimated glomerular filtration rate (eGFR) by CKD-ЕРI method, the level of NTproBNP and aldosterone in serum. The patients were divided depending on the eGFR elvel: 30< eGFR ≤60 ml/min/1,73 m2 — 14 patients, eGFR >60 ml/min/1,73 m2 — 38 patients.Results. Patients with II FC CHF had the medium-high NTproBNP and aldosterone values. Subjects with FC III CHF had high levels of NTproBNP and aldosterone. A correlation relationship was found between the NTproBNP, aldosterone and ejection fraction (EF) levels (r=-0,70 and r=-0,72, respectively), between the NTproBNP, aldosterone and enddiastolic LV velocity (r=0,78 and r=0,70, respectively). There was a significant thickening of the carotid intima-media complex and a decrease in the blood flow velocity and an increase in vascular resistance with increasing CHF. We also noted a significant difference in the maximum end-diastolic velocity in patients with eGFR ≤60 ml/min/1,73 m2 compared with this indicator in patients with eGFR >60 ml/min/1,73 m2.Conclusion. In patients with CHF, a significant increase in NTproBNP and aldosterone levels is associated with FC of CHF, LV systolic dysfunction and KD. The interrelation of cardiovascular remodeling indicators with the degree of CHF and KD was revealed.
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Affiliation(s)
- U. K. Kamilova
- Republican Specialized Scientific and Practical Medical Center for Therapy and Medical Rehabilitation
| | - Z. D. Rasulova
- Republican Specialized Scientific and Practical Medical Center for Therapy and Medical Rehabilitation
| | - G. A. Zakirova
- Republican Specialized Scientific and Practical Medical Center for Therapy and Medical Rehabilitation
| | - B. B. Toshev
- Republican Specialized Scientific and Practical Medical Center for Therapy and Medical Rehabilitation
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47
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Zhang X, Wang B, Yang J, Wang J, Yu Y, Jiang C, Xie L, Song Y, Zhong B, Li Y, Liang M, Wang G, Li J, Zhang Y, Huo Y, Xu X, Qin X. Serum Lipids and Risk of Rapid Renal Function Decline in Treated Hypertensive Adults With Normal Renal Function. Am J Hypertens 2019; 32:393-401. [PMID: 30615058 DOI: 10.1093/ajh/hpz001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/16/2018] [Accepted: 01/03/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We aim to evaluate the effect of different lipids parameters, including triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), the TG to HDL-C (TG:HDL-C) ratio, total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C), on the risk of rapid renal function decline and examine any possible effect modifiers in general hypertensive patients with normal renal function. METHODS A total of 12,549 hypertensive patients with estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m2 in the renal sub-study of the China Stroke Primary Prevention Trial were included in the analyses. The primary outcome was rapid renal function decline, defined as an average decline in eGFR ≥ 5 ml/min/1.73 m2 per year. RESULTS The median treatment duration was 4.4 years. After the full adjustment for TC, TG, HDL-C, and other major covariates, a significantly higher risk of rapid renal function decline was found in participants with higher TG [≥150 vs. <150 mg/dl, 7.7% vs. 5.5%; odds ratios (OR): 1.27; 95% confidence interval (CI): 1.06-1.51], higher TG:HDL-C ratio [≥2.7 (median) vs. <2.7, 7.7% vs. 5.0%; OR: 1.39; 95% CI: 1.14-1.71), lower TC (≥200 vs. <200 mg/dl, 6.0% vs. 7.0%; OR: 0.79; 95% CI: 0.67-0.93), or lower LDL-C levels (≥130 vs. <130 mg/dl, 6.1% vs. 7.0%; OR: 0.79; 95% CI: 0.67-0.94). Moreover, the increased risk of the primary outcome associated with elevated TG was particularly evident among individuals with lower total homocysteine levels [<12.4 (median) vs. ≥ 12.4 μmol/l, P interaction = 0.036]. CONCLUSIONS Higher TG and TG:HDL-C ratio were independent risk factors for rapid renal function decline in hypertensive adults with normal renal function.
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Affiliation(s)
- Xianglin Zhang
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Binyan Wang
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Institute for Biomedicine, Anhui Medical University, Hefei, China
| | - Juan Yang
- Department of Nephrology, Kidney and Urology Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Jiancheng Wang
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yaren Yu
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chongfei Jiang
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Liling Xie
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yun Song
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, Key Laboratory of Functional Dairy, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing, China
| | - Biyan Zhong
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Youbao Li
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Min Liang
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guobao Wang
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Xiping Xu
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, Key Laboratory of Functional Dairy, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing, China
| | - Xianhui Qin
- Division of Nephrology, State Key Laboratory of Organ Failure Research, National Clinical Research Center of Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Tsai CW, Huang HC, Chiang HY, Chung CW, Chang SN, Chu PL, Kuo CC. Longitudinal lipid trends and adverse outcomes in patients with CKD: a 13-year observational cohort study. J Lipid Res 2019; 60:648-660. [PMID: 30642880 PMCID: PMC6399497 DOI: 10.1194/jlr.p084590] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 01/01/2019] [Indexed: 02/06/2023] Open
Abstract
Studies on the effects of longitudinal lipid trajectories on end-stage renal disease (ESRD) development and deaths among patients with chronic kidney disease (CKD) are limited. We conducted a registry-based prospective study using data from a 13-year multidisciplinary pre-ESRD care program. The final study population comprised 4,647 patients with CKD. Using group-based trajectory modeling, we dichotomized longitudinal trajectories of total cholesterol (T-CHO), triglyceride (TG), LDL cholesterol (LDL-C), and HDL cholesterol (HDL-C). Time to ESRD or death was analyzed using multiple Cox regression. At baseline, higher levels of T-CHO and LDL-C were associated with rapid progression to ESRD, whereas only HDL-C was positively associated with all-cause mortality [adjusted hazard ratio (HR), 1.20; 95% CI, 1.06-1.36; P-value, 0.005]. Compared with those with a normal T-CHO trajectory, the fully adjusted HR of patients with a high T-CHO trajectory for ESRD risk was 1.21 (P-value, 0.019). Subgroup analysis showed that a high TG trajectory was associated with a 49% increase in mortality risk in CKD patients without diabetes (P-value for interaction, 0.012). In contrast to what was observed based on baseline HDL-C, patients with a trajectory of frequent hypo-HDL cholesterolemia had higher risk of all-cause mortality (adjusted HR, 1.53; P-value, 0.014). Thus, only T-CHO, both at baseline and over the longitudinal course, demonstrated a significant potential risk of incident ESRD. The inconsistency in the observed directions of association between baseline levels and longitudinal trajectories of HDL-C warrants further research to unveil specific pathogenic mechanisms underlying the HDL-C metabolism in patients with CKD.
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Affiliation(s)
- Ching-Wei Tsai
- Big Data Center, China Medical University, Taichung, Taiwan
- Division of Nephrology, Department of Internal Medicine China Medical University Hospital, China Medical University, Taichung, Taiwan
- College of Medicine China Medical University, Taichung, Taiwan
| | - Han-Chun Huang
- Big Data Center, China Medical University, Taichung, Taiwan
| | | | - Chih-Wei Chung
- Big Data Center, China Medical University, Taichung, Taiwan
| | - Shih-Ni Chang
- Big Data Center, China Medical University, Taichung, Taiwan
| | - Pei-Lun Chu
- Division of Nephrology, Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
- School of Medicine Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chin-Chi Kuo
- Big Data Center, China Medical University, Taichung, Taiwan
- Division of Nephrology, Department of Internal Medicine China Medical University Hospital, China Medical University, Taichung, Taiwan
- College of Medicine China Medical University, Taichung, Taiwan
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49
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Aziz F, Garg N, Parajuli S, Djamali A, Stein JH, Mandelbrot D. Lipid lowering in dialysis patients with cardiovascular disease who are awaiting kidney transplantation. Clin Transplant 2018; 33:e13452. [PMID: 30466167 DOI: 10.1111/ctr.13452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 11/11/2018] [Accepted: 11/16/2018] [Indexed: 11/27/2022]
Abstract
Dyslipidemias are highly prevalent in chronic kidney disease, end-stage renal disease, and kidney transplant patients. These dyslipidemias are associated with high cardiovascular risk and mortality. Many clinical trials have shown that statin therapy can significantly reduce adverse cardiovascular events in chronic kidney disease patients and kidney transplant recipients. However, three major trials did not show a benefit of statin therapy in end-stage renal disease patients on dialysis. Major guidelines either recommend against the use of statins in patients on dialysis or provide no recommendations about statin use for this complex patient population. As a result, we suspect many patients on dialysis are not on statins, even if they have known atherosclerotic cardiovascular disease. When these patients receive kidney transplants, the risk of adverse cardiovascular events increases in the peri-operative period. Although there are no randomized clinical trials looking at statin use in these patients, we suggest that statin use be considered in patients with a history of atherosclerotic cardiovascular disease, to potentially minimize peri-operative cardiovascular complications. We also recommend further research to determine whether statin therapy in dialysis patients awaiting kidney transplant is associated with better survival.
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Affiliation(s)
- Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - James H Stein
- Division of Cardiology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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50
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Gregg LP, Hedayati SS. Management of Traditional Cardiovascular Risk Factors in CKD: What Are the Data? Am J Kidney Dis 2018; 72:728-744. [PMID: 29478869 PMCID: PMC6107444 DOI: 10.1053/j.ajkd.2017.12.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/06/2017] [Indexed: 12/22/2022]
Abstract
Patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) are 10 times more likely to die of cardiovascular (CV) diseases than the general population, and dialysis-dependent patients are at even higher risk. Although traditional CV risk factors are highly prevalent in individuals with CKD, these patients were often excluded from studies targeting modification of these risks. Although treatment of hypertension is beneficial in CKD, the best target blood pressure has not been established. Trial data showed that renin-angiotensin-aldosterone blockade may prevent CV events in patients with CKD. The risks of aspirin may equal the benefits in NDD-CKD samples, and there are no trials testing aspirin in dialysis-dependent patients. Lipid-lowering therapy improves CV outcomes in NDD-CKD, but not in dialysis-dependent patients. Strict glycemic control prevents CV events in nonalbuminuric individuals, but showed no benefit in those with baseline albuminuria with albumin excretion > 300mg/g, and there are no data in dialysis-dependent patients. Data for lifestyle modifications, such as weight loss, physical activity, and smoking cessation, are mostly observational and extrapolated from non-CKD samples. This comprehensive review summarizes the best existing evidence and current clinical guidelines for modification of traditional risk factors for the prevention of CV events in patients with CKD and identifies knowledge gaps.
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Affiliation(s)
- L Parker Gregg
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX; Division of Nephrology, Medical Service, Veterans Affairs North Texas Health Care System, Dallas, TX.
| | - S Susan Hedayati
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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