Strategies to Treat Obesity in Patients With CKD

The association between nutritional-inflammatory status and chronic kidney disease prognosis: a population-based study

BACKGROUND

Chronic kidney disease (CKD) prognosis is closely tied to the interplay between nutrition and inflammation. However, comprehensive nutritional-inflammatory indices for prognostic evaluation are rare in CKD. This study explored the association of the advanced lung cancer inflammation index (ALI) with estimated glomerular filtration rate (eGFR) and all-cause mortality in CKD patients.

METHODS

A total of 1,982 CKD patients from the National Health and Nutrition Examination Survey (NHANES) database (2011-2018) were included in the analysis. Analytical methods included linear regression, cox regression, and restricted cubic spline (RCS) analysis. Subgroup and sensitivity analyses were performed, and further evaluation was conducted using the receiver operating characteristic (ROC) curve and C-index for all-cause mortality across different CKD stages.

RESULTS

Among CKD patients, 1,103 patients (55.7%) were classified as stage I-II, and 879 patients (44.3%) as stage III-V. After adjusting covariates, ALI was found to be positively correlated with eGFR (Beta = 0.11; 95% CI: 0.07-0.15), and negatively related with all-cause mortality (HR = 0.72; 95% CI: 0.63-0.83). Subgroup analysis showed that the positive correlation between ALI and eGFR was stronger in CKD stage III-V compared to stage I-II. However, ALI's protective effect on mortality was weaker in stage III-V. The C-index for ALI was 0.648 in stage I-II and 0.660 in stage III-V.

CONCLUSION

ALI was significantly associated with eGFR and all-cause mortality in CKD patients. Nutritional and anti-inflammatory interventions in early-stage CKD may improve prognosis, and ALI may have great potential as a multifaceted biomarker to influence the prognosis of CKD, particularly in stages III-V.

Efficacy of Oral Medication in Weight Loss Management: A Systematic Review and Network Meta-Analysis

PURPOSE

This systematic review was conducted to determine which type of oral medication for obesity provides the best weight loss effect.

METHODS

This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guideline. For this systematic review, we used 3 databases for journal searches: PubMed, ScienceDirect, and Scopus. This study only included randomized controlled trials or open-label clinical trials. There was no year limit used in the journal search for this systematic review.

FINDINGS

Eighteen randomized controlled trials, with a total population of 12,259 patients, were included. Of 18 studies, 15 were used for network meta-analysis. Based on the results of the network meta-analysis, weight loss was found in phentermine/topiramate (mean difference [MD], -3.28; 95% CI, -4.47 to -2.09), semaglutide (MD, -2.92; 95% CI, -4.38 to -1.46), phentermine (MD, -2.31; 95% CI, -3.82 to -0.81), naltrexone/bupropion (MD, -1.68; 95% CI, -2.87 to -0.49), topiramate (MD, -1.67; 95% CI, -2.86 to -0.48), and orlistat (MD, -1.44; 95% CI, -2.32 to -0.55). There were no significant differences among the groups. However, compared with placebo, all oral obesity therapies provide better benefits in weight loss (MD, -2.12; 95% CI, -2.64 to -1.59; P ≤ 0.00001).

IMPLICATIONS

Oral antiobesity drugs provide better weight loss than placebo. However, some side effects can be incurred by utilizing the drug for weight loss, especially related to the gastrointestinal system. Nonetheless, in clinical settings, consideration should be given to particular patients to reduce risk of side effects.

Preschool age-specific obesity and later-life kidney health: a Mendelian randomization and colocalization study

OBJECTIVES

While the association between obesity and kidney diseases has been found in previous studies, the relationship between preschool-age obesity and later-life kidney health remains unclear, posing challenges for effective interventions in this critical life period.

METHODS

Utilizing the hitherto largest genome-wide association studies, we conducted two-sample mendelian randomization (MR) to estimate the association of preschool age-specific obesity on kidney health and diseases, including blood urea nitrogen (BUN), eGFRcrea, eGFRcys, chronic kidney disease (CKD), IgA nephropathy, and diabetic nephropathy. Then, we applied multivariable Mendelian randomization (MVMR) and stepwise MR to elucidate the role of adult obesity and 12 other potential factors in the pathway between preschool age-specific obesity and kidney health. Finally, we employed colocalization analysis to understand the mechanism of preschool age-specific obesity and kidney damage further by detecting shared causal variants.

RESULTS

Our two-sample MR results indicated that preschool obesity could be associated with kidney health and disease. In addition, we observed a switch in the direction of associations between age-specific body mass index (BMI) and CKD, manifesting as negative associations before 3 years old and positive associations after 3 years old. Furthermore, MVMR and stepwise MR results suggested potential pathways linking preschool obesity to kidney health, involving factors such as adult BMI, circulating high-density lipoprotein cholesterol levels, and circulating C-reactive protein levels. Finally, we detected that preschool-age BMI and kidney function could share causal variants such as rs76111507, rs62107261, rs77165542 in the region of chromosome 2, and rs571312 in the region of chromosome 18.

CONCLUSION

Our study supports the association between preschool obesity and kidney health, emphasizing the role of adult BMI in this relationship. These findings underscore the importance of interventions starting in early childhood and continuing through adulthood to reduce the long-term risk of obesity-related kidney damage.

Association between anthropometric indices and chronic kidney disease: Insights from NHANES 2009-2018

INTRODUCTION

The strong association between obesity and chronic kidney disease (CKD) has been empirically validated, yet traditional measures like the Body Mass Index (BMI) fail to accurately assess the extent of obesity due to CKD's characteristics, such as reduced muscle mass and increased visceral fat. This study investigates the association between CKD and several anthropometric indices, including A Body Shape Index (ABSI), Body Roundness Index (BRI), Waist-to-Height Ratio (WHtR), and the Conicity Index (C-index), to determine their predictive capabilities.

METHODS

Based on the datasets from the National Health and Nutrition Examination Survey (NHANES) 2009-2018, weighted multivariable regression analyses were carried out to examine the independent relationship between two anthropometric indices and CKD. Also, subgroup analyses, restricted cubic spline regression (RCS), and receiver operating characteristic curve analysis were conducted for further data analyses.

RESULTS

A total of 24,162 participants were enrolled in this study. After adjusting for confounding factors, ABSI, BRI, WHtR, and the C-index were significantly associated with an increased risk of CKD, while BMI was not. Height showed a protective effect against CKD. ABSI and the C-index demonstrated the highest areas under the curve (AUCs), indicating superior predictive capabilities compared to traditional measures like BMI and waist circumference (WC). Subgroup analyses revealed significant interactions between the anthropometric indices and factors such as age, disease status, dietary intake, and physical activity levels.

CONCLUSIONS

This study highlights the significant associations between various anthropometric indices (including ABSI, BRI, WHtR, and C-index) and the risk of CKD. ABSI and the C-index demonstrated the strongest predictive capabilities for CKD, with the highest AUC values.

Investigating the role of the metabolic score for visceral Fat in assessing the prevalence of chronic kidney disease from the NHANES 1999-2018

This study investigates the association between the Metabolic Score for Visceral Fat (METS-VF) and chronic kidney disease (CKD), assessing METS-VF as a potential predictor of CKD risk. Utilizing data from the 1999-2018 National Health and Nutrition Examination Survey (NHANES), this cross-sectional study included 24,387 adult participants. Multivariable logistic regression, restricted cubic spline models, and threshold effect analyses were employed to explore the relationship. The results revealed a significant positive association, with multivariable logistic regression showing that each unit increase in METS-VF was associated with an 86% higher risk of CKD (OR: 1.86, 95% CI: 1.48-2.34). Critical METS-VF thresholds (6.10 and 7.55) were identified, at which CKD risk increased substantially. Subgroup analyses indicated that the association was particularly pronounced among older adults and males. These findings suggest that METS-VF is a reliable predictor for assessing CKD risk and that lifestyle interventions, including dietary modifications and exercise programs, may mitigate this risk.

Dim blue light at night worsens high-fat diet-induced kidney damage via increasing corticosterone levels and modulating the expression of circadian clock genes

Obesity is a contributing factor that increases the likelihood of developing chronic kidney disease. In recent years, studies have found that light pollution worldwide promoted obesity, which was known to be a consequence of circadian rhythm disruption. Nevertheless, the impact of light pollution on kidney disease associated with obesity remains mostly unknown, and potential processes have been minimally investigated. Herein, we fed mice a high-fat diet and gave them dim white (dWL), blue (dBL), green (dGL), and red (dRL) light for 12 weeks. Our results showed that both dWL and dBL tended to be more susceptible to damage to kidney dysfunction caused by a high-fat diet compared to LD, with more pronounced changes in dBL. The analysis of kidney found that dBL activated the TGF-β1/Smad signaling pathway to promote epithelial-mesenchymal transition (EMT) in the kidney. Additionally, dBL activated the NF-κB signaling pathway and resulted in elevated protein levels of TLR4, p-IκB, p-P65, and TNF-α. Furthermore, dBL increased BAX protein levels and decreased BCL2 protein levels. At the same time, dBL affected the Keap1/Nrf2/HO-1 signaling pathway, elevating KEAP1 and decreasing NRF2 and HO-1 protein levels. We were surprised to find that dBL altered the expression of the circadian clock genes, resulting in a decrease in the positively regulated genes Bmal1, Clock, and an increase in the negatively regulated genes Per1, Per2, Per3. Mechanistically, dBL increased plasma CORT levels as well as decreased renal GR α expression, and in vitro experiments showed that the circadian clock genes were altered by the addition of CORT and returned to normal levels after the addition of the GR inhibitor RU486. Consequently, dBL can exacerbate renal injury by elevating plasma CORT levels and altering rhythmic changes by acting on the biological clock via GR.

Deep phenotyping obesity using EHR data: Promise, Challenges, and Future Directions

Obesity affects approximately 34% of adults and 15-20% of children and adolescents in the U.S, and poses significant economic and psychosocial burdens. Due to the multifaceted nature of obesity, currently patient responses to any single anti-obesity medication (AOM) vary significantly, highlighting the need for developing approaches to obesity deep phenotyping and associated precision medicine. While recent advancement in classical phenotyping-guided pharmacotherapies have shown clinical value, they are less embraced by healthcare providers within the precision medicine framework, primarily due to their operational complexity and lack of granularity. From this perspective, several recent review articles highlighted the importance of obesity deep phenotyping for personalized precision medicine. In view of the established role of electronic health record (EHR) as an important data source for clinical phenotypings, we offer an in-depth analysis of the commonly available data elements from obesity patients prior to pharmacotherapy. We also experimented with a multi-modal longitudinal deep autoencoder to explore the feasibility, data requirements, clustering patterns, and challenges associated with EHR-based obesity deep phenotyping. Our analysis indicates at least nine clusters, among which five have distinct explainable clinical relevance. Further research within larger independent cohorts to validate the reproducibility, uncover more detailed substructures and corresponding treatment response is warranted.

Background

Obesity affects approximately 40% of adults and 15-20% of children and adolescents in the U.S, and poses significant economic and psychosocial burdens. Currently, patient responses to any single anti-obesity medication (AOM) vary significantly, making obesity deep phenotyping and associated precision medicine important targets of investigation.

Objective

To evaluate the potential of EHR as a primary data source for obesity deep phenotyping, we conduct an in-depth analysis of the data elements and quality available from obesity patients prior to pharmacotherapy, and apply a multi-modal longitudinal deep autoencoder to investigate the feasibility, data requirements, clustering patterns, and challenges associated with EHR-based obesity deep phenotyping.

Methods

We analyzed 53,688 pre-AOM periods from 32,969 patients with obesity or overweight who underwent medium- to long-term AOM treatment. A total of 92 lab and vital measurements, along with 79 ICD-derived clinical classifications software (CCS) codes recorded within one year prior to AOM treatment, were used to train a gated recurrent unit with decay based longitudinal autoencoder (GRU-D-AE) to generate dense embeddings for each pre-AOM record. principal component analysis (PCA) and gaussian mixture modeling (GMM) were applied to identify clusters.

Results

Our analysis identified at least nine clusters, with five exhibiting distinct and explainable clinical relevance. Certain clusters show characteristics overlapping with phenotypes from traditional phenotyping strategy. Results from multiple training folds demonstrated stable clustering patterns in two-dimensional space and reproducible clinical significance. However, challenges persist regarding the stability of missing data imputation across folds, maintaining consistency in input features, and effectively visualizing complex diseases in low-dimensional spaces.

Conclusion

In this proof-of-concept study, we demonstrated longitudinal EHR as a valuable resource for deep phenotyping the pre-AOM period at per patient visit level. Our analysis revealed the presence of clusters with distinct clinical significance, which could have implications in AOM treatment options. Further research using larger, independent cohorts is necessary to validate the reproducibility and clinical relevance of these clusters, uncover more detailed substructures and corresponding AOM treatment responses.

Approaches to patients with obesity and CKD: focus on nutrition and surgery

Obesity is recognized as a public health challenge. During the last three decades, the global age-standardized prevalence increased from 8.8% to 18.5% in women and from 4.8% to 14.0% in men, with an absolute current number of 878 million obese subjects. Obesity significantly increases per se the risk of developing disability and chronic diseases, including chronic kidney disease (CKD). Specifically, obesity acts as a major, modifiable cause of CKD onset and progression toward kidney failure; as such, it is considered by the International Society of Nephrology a major health priority. This review analyses the effectiveness, safety and practicability of non-pharmacological anti-obesity interventions in CKD as the different patient phenotypes that may take advantage of personalized approaches.

Case Study: The Weighty Issue of Treatment Options for Obese Dialysis Patients

Obesity is a complex chronic disease and common comorbidity in kidney failure and is the leading causes of death and disability in this population. Guidelines do not specifically address the preferred weight management option(s) for obesity while on dialysis. Large body size is a limiting factor for consideration of a kidney transplantation. We report on a successful bariatric surgery with a young adult after 5.5 years on dialysis with hope for a future transplant. Success was demonstrated with progressive weight loss without adverse changes in renal clinical markers accompanied by improvements in exercise tolerance and health status thereby improving her suitability for a kidney transplant. Further studies and guidelines are needed to address weight loss options for those with obesity on dialysis and want to lose weight.

Exploring Adiposity and Chronic Kidney Disease: Clinical Implications, Management Strategies, Prognostic Considerations

Obesity poses a significant and growing risk factor for chronic kidney disease (CKD), requiring comprehensive evaluation and management strategies. This review explores the intricate relationship between obesity and CKD, emphasizing the diverse phenotypes of obesity, including sarcopenic obesity and metabolically healthy versus unhealthy obesity, and their differential impact on kidney function. We discuss the epidemiological evidence linking elevated body mass index (BMI) with CKD risk while also addressing the paradoxical survival benefits observed in obese CKD patients. Various measures of obesity, such as BMI, waist circumference, and visceral fat assessment, are evaluated in the context of CKD progression and outcomes. Mechanistic insights into how obesity promotes renal dysfunction through lipid metabolism, inflammation, and altered renal hemodynamics are elucidated, underscoring the role of adipokines and the renin-angiotensin-aldosterone system. Furthermore, the review examines current strategies for assessing kidney function in obese individuals, including the strengths and limitations of filtration markers and predictive equations. The management of obesity and associated comorbidities like arterial hypertension, type 2 diabetes mellitus, and non-alcoholic fatty liver disease in CKD patients is discussed. Finally, gaps in the current literature and future research directions aimed at optimizing the management of obesity-related CKD are highlighted, emphasizing the need for personalized therapeutic approaches to mitigate the growing burden of this intertwined epidemic.

Abdominal obesity and CKD: A potential mediating role of serum metabolites in the UK Biobank population

BACKGROUND

It is generally known that although a connection between abdominal obesity and chronic kidney disease (CKD) is well-established, there is a lack of systematic research investigating the specific roles of serum metabolites, including lipid metabolites, amino acid metabolites, carbohydrate metabolites and inflammatory substances in explaining this associations.

METHODS

We included 118,020 general patients with data of serum metabolites from UK Biobank. We defined abdominal obesity and CKD based on waist circumference and ICD-10 criteria. The serum metabolites were assessed by a high-throughput nuclear magnetic resonance (NMR) based metabolic biomarker profiling platform. We conducted mediation analysis by R software and used the proportion of mediation to quantify the mediation effect.

RESULTS

This study demonstrated that lipid metabolites played a more important role in mediating the relationship between abdominal obesity and CKD than amino acid metabolites and carbohydrate metabolites. And Glycoprotein Acetyls (GlycA) was the strongest mediator for the correlation between abdominal obesity and CKD, accounting for 26.4 %. And In the mediation analysis stratified by sex, we found that the mediating effects of lipid metabolites were mostly higher in men than in women, while GlycA accounted for the largest proportion of the mediation association in both two groups (31.0 % for women and 19.8 % for men).

CONCLUSION

Among lipid metabolites, amino acid metabolites, carbohydrate metabolites and inflammatory substances, our study showed that infammation marker GlycA was the novel and key mediator for the correlation between abdominal obesity and CKD.

Pharmacotherapy as an Augmentation to Bariatric Surgery for Obesity

A global obesity pandemic is one of the most significant health threats worldwide owing to its close association with numerous comorbidities such as type 2 diabetes mellitus, arterial hypertension, dyslipidemia, heart failure, cancer and many others. Obesity and its comorbidities lead to a higher rate of cardiovascular complications, heart failure and increased cardiovascular and overall mortality. Bariatric surgery is at present the most potent therapy for obesity, inducing a significant weight loss in the majority of patients. In the long-term, a substantial proportion of patients after bariatric surgery experience a gradual weight regain that may, in some, reach up to a presurgical body weight. As a result, anti-obesity pharmacotherapy may be needed in some patients after bariatric surgery to prevent the weight regain or to further potentiate weight loss. This article provides an overview of the use of anti-obesity medications as an augmentation to bariatric surgery for obesity. Despite relatively limited published data, it can be concluded that anti-obesity medication can serve as an effective adjunct therapy to bariatric surgery to help boost post-bariatric weight loss or prevent weight regain.

Body mass index modifies the effect of urinary protein-to-creatinine ratio on chronic kidney disease progression

BACKGROUND

This study aimed to determine the association between the urinary protein-to-creatinine ratio (UPCR) and chronic kidney disease (CKD) progression in a cohort study, and to determine whether body mass index (BMI) modifies this association.

METHODS

The study population consisted of 856 hypertensive patients with CKD stages 2-5, enrolled between 2010 and 2011 in Japan. Generalized linear models with a logit link were used to evaluate the independent and combined effects of the UPCR and BMI on CKD progression RESULTS: During a median follow-up of 25 months, 242 patients developed CKD progression during follow-up. A notably higher risk of CKD progression was found in participants in tertiles 2 [odds ratio (OR): 5.46, 95% confidence interval (95% CI): 2.49-11.99] and 3 (OR 27.74, 95% CI 12.34-62.38) comparing with tertiles 1 for UPCR levels. Moreover, an interaction was found between UPCR and BMI on CKD progression (P for interaction = 0.006). Participants in both the highest tertile of UPCR and overweight (UPCR ≥ 248.9 mg/mmol and BMI ≥ 25 kg/m2) had a 45.59-times higher risk of CKD progression compared with those in the lowest tertile of UPCR and nonoverweight (UPCR < 36.2 mg/mmol and BMI < 25 kg/m2) CONCLUSIONS: The present study demonstrates that the combination of elevated UPCR and BMI may contribute to an increased risk of CKD progression.

Cardiometabolic comorbidities and complications of obesity and chronic kidney disease (CKD)

Obesity and chronic kidney disease are two ongoing progressive clinical pandemics of major public health and clinical care significance. Because of their growing prevalence, chronic indolent course and consequent complications both these conditions place significant burden on the health care delivery system especially in developed countries like the United States. Beyond the chance coexistence of both of these conditions in the same patient based on high prevalence it is now apparent that obesity is associated with and likely has a direct causal role in the onset, progression and severity of chronic kidney disease. The causes and underlying pathophysiology of this are myriad, complicated and multi-faceted. In this review, continuing the theme of this special edition of the journal on " The Cross roads between Endocrinology and Nephrology" we review the epidemiology of obesity related chronic kidney disease (ORCKD), and its various underlying causes and pathophysiology. In addition, we delve into the consequent comorbidities and complications associated with ORCKD with particular emphasis on the cardio metabolic consequences and then review the current body of evidence for available strategies for chronic kidney disease modulation in ORCKD as well as the potential unique role of weight reduction and management strategies in its improvement and risk reduction.

Independent and joint associations of monocyte to high-density lipoprotein-cholesterol ratio and body mass index with cardiorenal syndrome: insights from NHANES 2003-2020

BACKGROUND

With the development of pathophysiology, cardiorenal syndrome (CRS), a complex and severe disease, has received increasing attention. Monocyte to high-density lipoprotein-cholesterol ratio (MHR) and body mass index (BMI) are independent risk factors for cardiovascular diseases, but their association with CRS remains unexplored. This study aims to explore the independent and joint effects of MHR and BMI on CRS.

METHODS

We included 42,178 NHANES participants. The determination of CRS referred to the simultaneous presence of cardiovascular disease (identified through self-report) and chronic kidney disease (eGFR < 60 mL/min per 1.73 m²). We employed multivariate weighted logistic regression to evaluate the odds ratio (OR) and 95% confidence interval (CI) for the independent and joint associations of MHR and BMI with CRS. We also conducted restricted cubic spines to explore nonlinear associations.

RESULTS

The prevalence of CRS was 3.45% among all participants. An increase in both MHR and BMI is associated with a higher risk of CRS (MHR: OR = 1.799, 95% CI = 1.520-2.129, P < 0.001, P-trend < 0.001; BMI: OR = 1.037, 95% CI = 1.023-1.051, P < 0.001). Individuals who simultaneously fall into the highest quartile of MHR and have a BMI of 30 or more face the highest risk of CRS compared to those in the lowest MHR quartile with a BMI of less than 25 (OR = 3.45, 95% CI = 2.40-4.98, P < 0.001). However, there is no interactive association between MHR and BMI with CRS.

CONCLUSIONS

Higher MHR and BMI are associated with higher odds of CRS. MHR and BMI can serve as tools for early prevention and intervention of CRS, respectively.

Relationship between parity and the prevalence of chronic kidney disease in Japan considering hypertensive disorders of pregnancy and body mass index

BACKGROUND

Global studies exploring the relationship between parity and chronic kidney disease (CKD) are scarce. Furthermore, no study has examined the relationship between parity and CKD in Japan. Therefore, this study aimed to examine the relationship between parity and the prevalence of CKD in a Japanese population, considering the clinical history of hypertensive disorders of pregnancy (HDP) and current body mass index (BMI) based on menopausal status.

METHODS

This cross-sectional study included 26,945 Japanese multiparous women (5,006 premenopausal and 21,939 postmenopausal women) and 3,247 nulliparous women (1,599 premenopausal and 1,648 postmenopausal women). Participants were divided into two groups based on their menopausal status (premenopausal and postmenopausal women). The relationship between parity and the prevalence of CKD was evaluated using a multiple logistic regression model adjusted for several covariates, including a clinical history of HDP and current BMI.

RESULTS

The relationship between parity and the prevalence of CKD was not statistically significant in either premenopausal or postmenopausal multiparous women. A clinical history of HDP was significantly associated with an increased risk of CKD in premenopausal and postmenopausal multiparous women. However, the relationship between a clinical history of HDP and CKD in premenopausal women was weakened after adjusting for current BMI. Furthermore, the current BMI was significantly associated with an increased risk of CKD in both premenopausal and postmenopausal women.

CONCLUSIONS

Parity is not significantly associated with the prevalence of CKD in premenopausal and postmenopausal multiparous women. A clinical history of HDP is a risk factor for CKD in both premenopausal and postmenopausal women. Current BMI is also associated with an increased risk of CKD in premenopausal and postmenopausal women. Therefore, continuous surveillance and preventive measures against CKD should be provided to women with a clinical history of HDP. In addition, maintaining an appropriate body weight is beneficial in reducing the risk of CKD.

Are we ready for an adipocentric approach in people living with type 2 diabetes and chronic kidney disease?

We are entering a new era in the management of adiposity-based chronic disease (ABCD) with type 2 diabetes (T2D) and related chronic kidney disease (CKD). ABCD, T2D and CKD can affect almost every major organ system and have a particularly strong impact on the incidence of cardiovascular disease (CVD) and heart failure. ABCD and the associated insulin resistance are at the root of many cardiovascular, renal and metabolic (CKM) disorders, thus an integrated therapeutic framework using weight loss (WL) as a disease-modifying intervention could simplify the therapeutic approach at different stages across the lifespan. The breakthrough of highly effective WL drugs makes achieving a WL of >10% possible, which is required for a potential T2D disease remission as well as for prevention of microvascular disease, CKD, CVD events and overall mortality. The aim of this review is to discuss the link between adiposity and CKM conditions as well as placing weight management at the centre of the holistic CKM syndrome approach with a focus on CKD. We propose the clinical translation of the available evidence into a transformative Dysfunctional Adipose Tissue Approach (DATA) for people living with ABCD, T2D and CKD. This model is based on the interplay of four essential elements (i.e. adipocentric approach and target organ protection, dysfunctional adiposity, glucose homeostasis, and lifestyle intervention and de-prescription) together with a multidisciplinary person-centred care. DATA could facilitate decision-making for all clinicians involved in the management of these individuals, and if we do this in a multidisciplinary way, we are prepared to meet the adipocentric challenge.

Relevance of obesity-related organ damage and metabolic syndrome classification in cardiovascular and renal risk stratification in patients with essential hypertension

Introduction

Hypertension is a relevant cardiovascular comorbidity. Adipose tissue represents a metabolically active tissue involved in the regulation of blood pressure and metabolic alterations. In recent decades, several classifications for the metabolic syndrome (MS) have been proposed. Recently, a new syndrome called the "Cardiovascular-kidney-metabolic" (CKM) syndrome was identified, to determine patients at high cardiovascular and metabolic risk. The aim of the study was to compare different classifications in a large population of hypertensive patients.

Materials and methods

Between September 2022 and August 2023, we consecutively enrolled 772 hypertensive patients (407 men; 365 women; mean age 52.2 ± 15.1 years), evaluating anthropometric, biochemical, and instrumental parameters (transthoracic echocardiogram, carotid echo-Doppler, 24-h ambulatory blood pressure monitoring, fundus oculi).

Results

Using different classifications we found MS prevalence: Adult Treatment Panel III (ATP-III) 28.8%, International Diabetes Federation (IDF) 31.5%, CKM 40.7%. CKM Classes 3 and 4 showed higher body mass index and waist circumference compared with other groups. Compared with ATP-III and IDF, CKM Class 4 showed higher 24-h systolic blood pressure, lower percentage of controlled hypertension, increased interventricular septum and posterior wall, reduced ejection fraction, and greater prevalence of hypertensive arterial retinal damage.

Discussion

Visceral obesity and MS are frequent conditions with healthy impact, becoming an important trigger for the development of cardiovascular and metabolic complications. The different MS classifications allow the early identification of patients at high risk of cardiometabolic complications. The new CKM syndrome proves useful to identify individuals at high risk for CKM morbidity and mortality.

Trend analysis and prediction of the incidence and mortality of CKD in China and the US

BACKGROUND

Currently, limited research is available on the comparative analysis of chronic kidney disease (CKD) incidence and mortality rates between China and the United States. This study aimed to explore the trends in CKD incidence and mortality rates in both countries, as well as make some future predictions.

METHODS

The data on CKD incidence and mortality in China and the US from 1990 to 2019 were derived from the 2019 Global Burden of Disease database. A Joinpoint regression model was used to analyze temporal trends in CKD incidence and mortality. An age-period-cohort model was used to assess the effects of age, period, and birth cohort on CKD risk and forecast the age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) of CKD in China and the US over the next 15 years.

RESULTS

CKD incidence in China and the US showed an upward trend. Its mortality rate showed a downward trend in China but an upward one in the US. The relative risk (RR) of CKD incidence and mortality increases with age. The RR of CKD incidence in the 0-5 age group exceeds that in the 5-55 age group, and the RR for mortality surpasses that in the 5-35 age group. Over time, the RR of CKD incidence has gradually increased in China and the US. Individuals born in later birth cohorts had a lower RR of CKD incidence and mortality. The ASIR of CKD may increase in both China and the US, whereas its ASMR may decline over the next 15 years.

CONCLUSION

Screening measures should be strengthened among populations at high risk of CKD; prenatal examinations of pregnant women should be emphasized to reduce CKD incidence in newborns. It is imperative to increase health education and encourage individuals to adopt healthy lifestyles.

Potentially modifiable factors associated with health-related quality of life among people with chronic kidney disease: baseline findings from the National Unified Renal Translational Research Enterprise CKD (NURTuRE-CKD) cohort

Background

Many non-modifiable factors are associated with poorer health-related quality of life (HRQoL) experienced by people with chronic kidney disease (CKD). We hypothesize that potentially modifiable factors for poor HRQoL can be identified among CKD patients, providing potential targets for intervention.

Method

The National Unified Renal Translational Research Enterprise Chronic Kidney Disease (NURTuRE-CKD) cohort study recruited 2996 participants from nephrology centres with all stages of non-dialysis-dependent CKD. Baseline data collection for sociodemographic, anthropometric, biochemical and clinical information, including Integrated Palliative care Outcome Scale renal, Hospital Anxiety and Depression score (HADS) and the 5-level EuroQol-5D (EQ-5D-5L) as HRQoL measure, took place between 2017 and 2019. EQ-5D-5L dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) were mapped to an EQ-5D-3L value set to derive index value. Multivariable mixed effects regression models, adjusted for known factors affecting HRQoL with recruitment region as a random effect, were fit to assess potentially modifiable factors associated with index value (linear) and within each dimension (logistic).

Results

Among the 2958/2996 (98.7%) participants with complete EQ-5D data, 2201 (74.4%) reported problems in at least one EQ-5D-5L dimension. Multivariable linear regression identified independent associations between poorer HRQoL (EQ-5D-3L index value) and obesity (body mass index ≥30.0 kg/m2, β -0.037, 95% CI -0.058 to -0.016, P = .001), HADS depression score ≥8 (β -0.159, -0.182 to -0.137, P < .001), anxiety score ≥8 (β -0.090, -0.110 to -0.069, P < .001), taking ≥10 medications (β -0.065, -0.085 to -0.046, P < .001), sarcopenia (β -0.062, -0.080 to -0.043, P < .001) haemoglobin <100 g/L (β -0.047, -0.085 to -0.010, P = .012) and pain (β -0.134, -0.152 to -0.117, P < .001). Smoking and prescription of prednisolone independently associated with problems in self-care and usual activities respectively. Renin-angiotensin system inhibitor (RASi) prescription associated with fewer problems with mobility and usual activities.

Conclusion

Potentially modifiable factors including obesity, pain, depression, anxiety, anaemia, polypharmacy, smoking, steroid use and sarcopenia associated with poorer HRQoL in this cohort, whilst RASi use was associated with better HRQoL in two dimensions.

Angiotensin II type 1 receptor-associated protein in immune cells: a possible key factor in the pathogenesis of visceral obesity

BACKGROUND AND AIM

Dysregulation of angiotensin II type 1 receptor-associated protein (ATRAP) expression in cardiovascular, kidney, and adipose tissues is involved in the pathology of hypertension, cardiac hypertrophy, atherosclerosis, kidney injury, and metabolic disorders. Furthermore, ATRAP is highly expressed in bone marrow-derived immune cells; however, the functional role of immune cell ATRAP in obesity-related pathology remains unclear. Thus, we sought to identify the pathophysiological significance of immune cell ATRAP in the development of visceral obesity and obesity-related metabolic disorders using a mouse model of diet-induced obesity.

METHODS

Initially, we examined the effect of high-fat diet (HFD)-induced obesity on the expression of immune cell ATRAP in wild-type mice. Subsequently, we conducted bone marrow transplantation to generate two types of chimeric mice: bone marrow wild-type chimeric (BM-WT) and bone marrow ATRAP knockout chimeric (BM-KO) mice. These chimeric mice were provided an HFD to induce visceral obesity, and then the effects of immune cell ATRAP deficiency on physiological parameters and adipose tissue in the chimeric mice were investigated.

RESULTS

In wild-type mice, body weight increase by HFD was associated with increased expression of immune cell ATRAP. In the bone marrow transplantation experiments, BM-KO mice exhibited amelioration of HFD-induced weight gain and visceral fat expansion with small adipocytes compared BM-WT mice. In addition, BM-KO mice on the HFD showed significant improvements in white adipose tissue metabolism, inflammation, glucose tolerance, and insulin resistance, compared with BM-WT mice on the HFD. Detailed analysis of white adipose tissue revealed significant suppression of HFD-induced activation of transforming growth factor-beta signaling, a key contributor to visceral obesity, via amelioration of CD206+ macrophage accumulation in the adipose tissue of BM-KO mice. This finding suggests a relevant mechanism for the anti-obesity phenotype in BM-KO mice on the HFD. Finally, transcriptome analysis of monocytes indicated the possibility of genetic changes, such as the enhancement of interferon-γ response at the monocyte level, affecting macrophage differentiation in BM-KO mice.

CONCLUSION

Collectively, our results indicate that ATRAP in bone marrow-derived immune cells plays a role in the pathogenesis of visceral obesity. The regulation of ATRAP expression in immune cells may be a key factor against visceral adipose obesity with metabolic disorders.

Blockbuster Medications for Obesity: A Primer for Nephrologists

The prevalence of obesity in the United States and across the world continues to climb, imparting increased risk of chronic disease. This impact is doubly felt in nephrology because obesity not only increases the risk of chronic kidney disease (CKD) but also exacerbates existing cardiovascular morbidity and mortality. The role of medical weight loss therapy in CKD has been debated, but increasing evidence suggests that intentional weight loss is protective against adverse kidney and cardiovascular outcomes. This may be particularly true with the advent of novel pharmacotherapies taking advantage of the incretin system, resulting in weight loss approaching that seen with surgical interventions. Moreover, these novel therapies have repeatedly demonstrated protective effects on the cardiovascular system. Here, we review the impact of obesity and weight loss on CKD, and the biological basis and clinical evidence for incretin therapy. This perspective provides recommended prescribing practices as a practical tool to engage nephrologists and patients with CKD in the treatment of obesity-related morbidity.

Modifiable kidney disease risk factors among nondiabetic adults with obesity from the Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

It is unknown whether weight change or physical fitness is associated with chronic kidney disease (CKD) risk among nondiabetic adults with obesity.

METHODS

This was a prospective, longitudinal cohort study of adults with obesity without baseline CKD or diabetes enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA). Linear mixed-effects and multistate models were adjusted for demographics, time-varying covariates including blood pressure, and comorbidities these were used to examine associations of weight change and slow walking pace (<2 miles/h) with (i) rate of annual estimated glomerular filtration rate (eGFR) decline and (ii) incident CKD, defined as eGFRCr-Cys  < 60 mL/min/1.73 m2 , and tested for interaction by baseline hypertension status.

RESULTS

Among 1208 included MESA participants (median BMI 33.0 kg/m2 [interquartile range 31.2-35.9]), 15% developed CKD. Slow walking pace was associated with eGFR decline (-0.27 mL/min/1.73 m2 /year; 95% CI: -0.42 to -0.12) and CKD risk (adjusted hazard ratio 1.48; 95% CI: 1.08 to 2.01). Weight gain was associated with CKD risk (adjusted hazard ratio 1.34; 95% CI: 1.02 to 1.78 per 5 kg weight gain from baseline). There was no significant interaction by baseline hypertension status.

CONCLUSIONS

Slow walking pace and weight gain were associated with CKD risk among adults with obesity who did not have diabetes at baseline.

An Overview of Chronic Kidney Disease Pathophysiology: The Impact of Gut Dysbiosis and Oral Disease

Chronic kidney disease (CKD) is a severe condition and a significant public health issue worldwide, carrying the burden of an increased risk of cardiovascular events and mortality. The traditional factors that promote the onset and progression of CKD are cardiometabolic risk factors like hypertension and diabetes, but non-traditional contributors are escalating. Moreover, gut dysbiosis, inflammation, and an impaired immune response are emerging as crucial mechanisms in the disease pathology. The gut microbiome and kidney disease exert a reciprocal influence commonly referred to as "the gut-kidney axis" through the induction of metabolic, immunological, and endocrine alterations. Periodontal diseases are strictly involved in the gut-kidney axis for their impact on the gut microbiota composition and for the metabolic and immunological alterations occurring in and reciprocally affecting both conditions. This review aims to provide an overview of the dynamic biological interconnections between oral health status, gut, and renal pathophysiology, spotlighting the dynamic oral-gut-kidney axis and raising whether periodontal diseases and gut microbiota can be disease modifiers in CKD. By doing so, we try to offer new insights into therapeutic strategies that may enhance the clinical trajectory of CKD patients, ultimately advancing our quest for improved patient outcomes and well-being.

Patient and Health Care Professional Perspectives on Addressing Obesity in ESKD

RATIONALE & OBJECTIVE

Obesity is common among patients with end-stage kidney disease (ESKD) and is a pervasive barrier to kidney transplantation. Patient perspectives about barriers to weight loss and patient and health care professionals' viewpoints about optimal obesity management in ESKD are needed.

STUDY DESIGN

Qualitative study using a descriptive phenomenological approach to understand ESKD patients' lived experiences with obesity and weight loss and patients' and health professionals' perceptions about optimal obesity care for ESKD patients.

SETTING & PARTICIPANTS

Between October 2020 and December 2021, we conducted 90-minute semistructured interviews with 40 ESKD patients with obesity (body mass index [BMI] ≥30kg/m2) and 60-minute interviews with 20 ESKD health care professionals.

ANALYTICAL APPROACH

Deductive and inductive thematic analysis of interviews.

RESULTS

Among patients with ESKD, the median age was 55 (IQR, 46-63) years, median BMI was 39.5 (IQR, 35.3-41.6) kg/m2, and median dialysis vintage was 5 (IQR, 3-8) years; 58% were female, and 46% were non-Hispanic White. Among health care professionals, 50% were renal dietitians, 20% were nephrologists, and the remainder were transplant professionals (surgeons, nephrologists, and dietitians). ESKD patients described unique weight loss challenges, including (1) conflicting tenets of "kidney-friendly" versus popular diets, (2) fatigue due to dialysis that affects dietary choices, and (3) perceived pressure and unrealistic expectations from health professionals to lose weight for kidney transplantation. Professionals and patients described a lack of transparent and honest communication about obesity and unclear roles and responsibilities for obesity counseling.

LIMITATIONS

Lack of caregiver perspectives and potential lack of transferability to overall dialysis population given overrepresentation of patients with severe obesity and previous weight loss surgery.

CONCLUSIONS

Obesity interventions for ESKD patients should be tailored to meet the unique challenges reported by patients with ESKD. Clarifying ESKD health professionals' roles and responsibilities for obesity care would help to ensure that patients have consistent and effective support to manage obesity.

PLAIN-LANGUAGE SUMMARY

Adults with coexisting obesity and end-stage kidney disease (ESKD) are often required to lose weight for kidney transplantation. Yet there is little knowledge about barriers to healthy weight loss in this population. In this study, we conducted interviews with 40 ESKD patients with coexisting obesity and 20 ESKD health care professionals to learn about opportunities to improve obesity-related health care in ESKD. Patients reported that fatigue and dialysis affected dietary choices, and fluid and food restrictions hampered weight loss. Professionals described a lack of training, comfort, and time to address obesity. Patients and professionals reported a lack of open communication about obesity management. Improving obesity-related education and clinical communication should be prioritized to improve care for patients with ESKD and obesity.

Evaluation of the effects of ezetimibe on albuminuria and kidney fat in individuals with type 2 diabetes and chronic kidney disease

AIM

To investigate the effects of ezetimibe on the urine albumin creatinine ratio (UACR) and kidney parenchyma fat content (kidney-PF) in individuals with type 2 diabetes (T2D) and early chronic kidney disease.

MATERIALS AND METHODS

A randomized, double-blind, placebo-controlled study of ezetimibe 10 mg once daily for 16 weeks in individuals with T2D and a UACR of 30 mg/g or higher was conducted. Kidney-PF was assessed with magnetic resonance spectroscopy. Geometric mean changes from baseline were derived from linear regressions.

RESULTS

A total of 49 participants were randomized to ezetimibe (n = 25) or placebo (n = 24). Overall, mean ± standard deviation age was 67 ± 7 years, body mass index was 31 ± 4 kg/m2 and the proportion of men was 84%. The mean estimated glomerular filtration rate was 76 ± 22 mL/min/1.73m2 and median (first-third quartile) UACR was 95 (41-297) mg/g. Median kidney-PF was 1.0% (0.3%-2.1%). Compared with placebo, ezetimibe did not significantly reduce UACR (mean [95% confidence interval] change: -3% [-28%-31%]) or kidney-PF (mean change: -38% [-66%-14%]). In participants with baseline kidney-PF above the median, ezetimibe reduced kidney-PF significantly (mean change: -60% [-84%--3%]) compared with placebo, while the reduction in UACR was not significant (mean change: -28% [-54%-15%]).

CONCLUSIONS

Ezetimibe did not reduce the UACR or kidney-PF on top of modern T2D management. However, kidney-PF was reduced with ezetimibe in participants with high baseline kidney-PF.

Bariatric Surgery in Severely Obese Kidney Donors Before Kidney Transplantation: A Retrospective Study

BACKGROUND

Bariatric surgery (BS) is the optimal approach for sustained weight loss and may alter donation candidacy in potential donors with obesity. We evaluated the long-term effects of nephrectomy after BS on metabolic profile, including body mass index, serum lipids and diabetes, and kidney function of donors.

METHODS

This was a single-center retrospective study. Live kidney donors who underwent BS before nephrectomy were matched for age, gender, and body mass index with patients who underwent BS alone and with donors who underwent nephrectomy alone. Estimated glomerular filtration rate (eGFR) was calculated according to Chronic Kidney Disease Epidemiology Collaboration and adjusted to individual body surface area to create absolute eGFR.

RESULTS

Twenty-three patients who underwent BS before kidney donation were matched to 46 controls who underwent BS alone. At the last follow-up, the study group showed significantly worse lipid profile with low-density lipoprotein of 115 ± 25 mg/dL versus the control group with low-density lipoprotein of 99 ± 29 mg/dL ( P  = 0.036) and mean total cholesterol of 191 ± 32 versus 174 ± 33 mg/dL ( P  = 0.046). The second control group of matched nonobese kidney donors (n = 72) had similar serum creatinine, eGFR, and absolute eGFR as the study group before nephrectomy and 1 y after the procedure. At the end of follow-up, the study group had significantly higher absolute eGFR compared with the control group (86 ± 21 versus 76 ± 18 mL/min; P  = 0.02) and similar serum creatinine and eGFR.

CONCLUSIONS

BS before live kidney donation is a safe procedure that could increase the donor pool and improve their health in the long run. Donors should be encouraged to maintain their weight and avoid adverse lipid profile and hyperfiltration.

The Impact and Effectiveness of Weight Loss on Kidney Transplant Outcomes: A Narrative Review

Obesity is a worldwide epidemic that leads to several non-communicable illnesses, including chronic kidney disease (CKD). Diet and lifestyle modifications have shown a limited impact in the treatment of obesity. Because the group of end-stage renal disease (ESRD) patients examined in this study had limited access to kidney transplantation (KT), patients with obesity were thought to be at an increased risk of intraoperative and postoperative KT complications. Although bariatric surgery (BS) is now recognized as the gold standard treatment for morbid obesity, its role in ESRD or kidney transplant patients remains unknown. It is critical to know the correlation between weight loss and complications before and after KT, the impact of the overall graft, and patients' survival. Hence, this narrative review aims to present updated reports addressing when to perform surgery (before or after a KT), which surgical procedure to perform, and again, if strategies to avoid weight regain must be specific for these patients. It also analyzes the metabolic alterations produced by BS and studies its cost-effectiveness pre- and post-transplantation. Due to the better outcomes found in KT recipients, the authors consider it more convenient to perform BS before KT. However, more multicenter trials are required to provide a solid foundation for these recommendations in ERSD patients with obesity.

The Effect of SGLT2 Inhibitors on the Development of Contrast-Induced Nephropathy in Diabetic Patients with Non-ST Segment Elevation Myocardial Infarction

Background and Objectives: Percutaneous procedures using contrast agents are modern diagnosis and treatment methods for cardiovascular diseases. Contrast use may cause nephropathy, especially in diabetic patients. SGLT2 inhibitors have strong cardioprotective and renal protective effects. In our study, we investigated the effectiveness of this drug group in preventing the development of Contrast-Induced Nephropathy (CIN). Materials and Methods: The results of 312 diabetic patients who underwent CAG were analyzed. The study group included 104 DM patients using SGLT2 and the control group did not use SGLT2. These groups were compared with each other in terms of clinical, demographic, and laboratory parameters. Results: The groups were similar characteristics. However, post-CAG creatinine values compared with before the procedure, the development of CIN was observed to be significantly less in the group using SGLT2 inhibitor (p = 0.03). When the results of the multivariate analysis were examined, it was seen that the use of SGLT2 inhibitors significantly reduced the risk of CIN (odds ratio (OR): 0.41, 95% confidence interval (CI): 0,142-0.966, p = 0.004). Conclusions: Our study showed that SGLT2 inhibitors may be protective against the development of CIN, especially in patients with comorbid conditions such as diabetes.

The postprandial actions of GLP-1 receptor agonists: The missing link for cardiovascular and kidney protection in type 2 diabetes

Recent clinical trials in people with type 2 diabetes have demonstrated beneficial actions on heart and kidney outcomes following treatment with GLP-1RAs. In part, these actions are consistent with improved glucose control and significant weight loss. But GLP-1RAs may also have additive benefits by improving postprandial dysmetabolism. In diabetes, dysregulated postprandial nutrient excursions trigger inflammation, oxidative stress, endothelial dysfunction, thrombogenicity, and endotoxemia; alter hormone levels; and modulate cardiac output and regional blood and lymphatic flow. In this perspective, we explore the actions of GLP-1RAs on the postprandial state and their potential role in end-organ benefits observed in recent trials.

Obesity and renal disease: Benefits of bariatric surgery

The prevalence of obesity, a preventable and reversible condition with a high impact on health, continues to rise, especially after the COVID-19 pandemic. Severe overweight is well recognized as a risk factor for diabetes and hypertension, among other conditions, that may increase cardiovascular risk. Obesity has grown simultaneously with a rise in the prevalence of chronic kidney disease, and a pathophysiological link has been established, which explains its role in generating the conditions to facilitate the emergence and maximize the impact of the risk factors of chronic kidney disease and its progression to more advanced stages. Knowing the mechanisms involved and having different tools to reverse the overweight and its consequences, bariatric surgery has arisen as a useful and efficient method, complementary or alternative to others, such as lifestyle changes and/or pharmacotherapy. In a detailed review, the mechanisms involved in the renal consequences of obesity, the impact on risk factors, and the potential benefit of bariatric surgery at different stages of the disease and its progression are exposed and analyzed. Although the observational evidence supports the value of bariatric surgery as a renoprotective measure in individuals with obesity, diabetic or not, randomized studies are expected to establish evidence-based recommendations that demonstrate its positive risk-benefit balance as a complementary or alternative therapeutic tool.

The Association of Sarcopenia and Central Obesity with Mortality Risk in Patients with Chronic Kidney Disease - a 2-Year Observational Study

Background

Patients with chronic kidney disease (CKD) face numerous challenges regarding their nutritional status, including undernutrition, wasting, overweight, and obesity. However, there is a gap in the knowledge on the importance of nutritional status on the survival of CKD in patients along the spectrum of progression of CKD.

Objectives

This study aimed to investigate the association of several nutritional measures with all-cause mortality. The hypothesis was that indicators of nutritional status exceeding BMI are associated with increased mortality risk.

Methods

One-hundred seventy adult patients with predialysis CKD (n = 82), receiving hemodialysis (n = 42) or kidney transplantation (n = 46) were recruited from 2014 to 2019. At baseline, nutritional status was assessed by anthropometry, body composition, and muscle function by handgrip strength. Patient survival was assessed after a 2-y follow-up by Cox regression models adjusted for age, sex, and renal function and generalized additive models.

Results

Thirty-one patients (18%) died during the 2-y follow-up. Sarcopenia (n = 30) was associated with an increased risk of death (HR: 2.92; 95% CI: 1.24, 6.89), whereas central obesity (n = 82) was not associated with mortality (1.05; 0.51, 2.15) in the Cox regression analyses. An association between BMI and mortality risk per unit increase (0.97; 0.90, 1.05) was not observed. Other markers of nutritional status were inversely associated with mortality risk, including handgrip strength (0.89; 0.83, 0.95), mid-upper arm circumference (0.86; 0.78, 0.95), and phase angle (per 0.1 degree increase 0.86; 0.81, 0.92). In the generalized additive models, U-shaped relationships were observed between mortality risk and waist circumference and mid-upper arm muscle circumference, while BMI < 22 kg/m2 was associated with increased mortality risk.

Conclusions

Sarcopenia, but not central obesity was associated with total mortality in patients with CKD. The inclusion of muscle strength and mass measures in clinical practice should be considered.

Association between probiotic, prebiotic, and yogurt consumption and chronic kidney disease: The NHANES 2010-2020

Background

Previous studies suggested that gut dysbacteriosis may promote the occurrence of chronic kidney disease (CKD), and probiotic, prebiotic, or yogurt supplements may alleviate CKD progression. This study aims to examine the association between probiotic, prebiotic, or yogurt supplements and the risk of CKD using the data from NHANES.

Methods

This study was designed to prospectively search data from the National Health and Nutrition Examination Survey (NHANES) (2011-2020). We examined dietary supplements and prescription medication labels to identify probiotic, or prebiotic product, and yogurt consumption during the dietary interview. The diagnosis of CKD was determined by the value of glomerular filtration rate (eGFR) and albumin creatinine ratio (ACR).

Results

The study enrolled a total of 6,522 individuals. The prevalence of CKD was lower in the probiotic, prebiotic, or yogurt consumption group [age-adjusted odds ratio (OR): 0.77, 95% CI: 0.62-0.95, P = 0.02; multivariable-adjusted OR: 0.86, 95% CI: 0.69-1.07, P = 0.05]. Furthermore, 32% reduced risk was observed in the older group aged 55 years or older, and 32% reduced risk was also observed in the female population. Probiotic, or prebiotic, or yogurt supplements was associated a 12% reduction in moderate risk of CKD and an 11% reduction in very high risk of CKD.

Conclusion

Our results suggest that probiotic, prebiotic, or yogurt supplements may contribute to the prevention of CKD and relieve its progression risk, especially in the female population and older population who were aged 55 years or older.

Cardiovascular Disease Risk Reduction and Body Mass Index

PURPOSE OF REVIEW

Anti-hypertensive and lipid lowering therapy addresses only half of the cardiovascular disease risk in patients with body mass index > 30 kg/m², i.e., obesity. We examine newer aspects of obesity pathobiology that underlie the partial effectiveness of anti-hypertensive lipid lowering therapy for the reduction of cardiovascular disease risk in obesity.

RECENT FINDINGS

Obesity-related insulin resistance, vascular endothelium dysfunction, increased sympathetic nervous system/renin-angiotensin-aldosterone system activity, and glomerulopathy lead to type 2 diabetes, coronary atherosclerosis, and chronic disease kidney disease that besides hypertension and dyslipidemia increase cardiovascular disease risk. Obesity increases cardiovascular disease risk through multiple pathways. Optimal reduction of cardiovascular disease risk in patients with obesity is likely to require therapy targeted at both obesity and obesity-associated conditions.

Successful therapeutic strategy for a patient with obese end-stage kidney disease by simultaneous laparoscopic sleeve gastrectomy and implantation of a buried peritoneal dialysis catheter: A case report

For morbidly obese patients with end-stage kidney disease (ESKD), there are often difficulties in accessing, implementing, and maintaining kidney replacement therapy (KRT). Although recent weight-loss surgery has the potential to solve these problems, its therapeutic strategy and appropriate perioperative management for morbidly obese patients with ESKD have not been established. Here, we describe the case history of a 47-year-old man diagnosed with ESKD due to obesity-related glomerulopathy with an uncorrected estimated glomerular filtration rate (eGFR) of 16.1 ml/min. He hoped for kidney transplantation but was not eligible due to his high body mass index (BMI) (36.9 kg/m²). Therefore, a combination strategy for both attaining weight loss and preparing for KRT was needed. We performed modified laparoscopic sleeve gastrectomy (LSG) combined with a buried catheter for peritoneal dialysis (PD), which resulted in reduction of multiple surgical invasions while simultaneously preparing for PD. After these operations, his body mass dropped to below 30.0 kg/m², making him a candidate for kidney transplantation, while maintaining PD. Finally, he was able to have kidney transplantation with success. Collectively, in this case, our novel therapeutic approach was able to avoid multiple surgeries, to assist catheter insertion by laparoscopy, and to provide optimal KRT for an obese patient with ESKD. Simultaneous LSG and implantation of a buried PD catheter may be a promising strategy for morbidly obese patients with ESKD.

Novel Insights in the Physiopathology and Management of Obesity-Related Kidney Disease

Obesity is recognized as an independent risk factor for the development of kidney disease, which has led to the designation of obesity-related glomerulopathy (ORG). Common renal features observed in this condition include glomerular hypertrophy, glomerulosclerosis, haemodynamic changes and glomerular filtration barrier defects. Additionally, and although less studied, obesity-related kidney disease also involves alterations in renal tubules, including tubule hypertrophy, lipid deposition and tubulointerstitial fibrosis. Although not completely understood, the harmful effects of obesity on the kidney may be mediated by different mechanisms, with alterations in adipose tissue probably playing an important role. An increase in visceral adipose tissue has classically been associated with the development of kidney damage, however, recent studies point to adipose tissue surrounding the kidney, and specifically to the fat within the renal sinus, as potentially involved in the development of ORG. In addition, new strategies for the treatment of patients with obesity-related kidney disease are focusing on the management of obesity. In this regard, some non-invasive options, such as glucagon-like peptide-1 (GLP-1) receptor agonists or sodium–glucose cotransporter-2 (SGLT2) inhibitors, are being considered for application in the clinic, not only for patients with diabetic kidney disease but as a novel pharmacological strategy for patients with ORG. In addition, bariatric surgery stands as one of the most effective options, not only for weight loss but also for the improvement of kidney outcomes in obese patients with chronic kidney disease.

Guiding Kidney Transplantation Candidates for Effective Weight Loss: A Clinical Cohort Study

BACKGROUND

Obesity is increasingly common in kidney transplant candidates and may limit access to transplantation. Obesity and diabetes are associated with a high risk for post-transplant complications. The best approach to weight loss to facilitate active transplant listing is unknown, but bariatric surgery is rarely considered due to patient- and physician-related apprehension, among other factors.

METHODS

We aimed to determine the magnitude of weight loss, listing, and transplant rates in 28 candidates with a mean BMI of 44.4±4.6 kg/m² and diabetes treated conservatively for 1 year post weight-loss consultations (group 1). Additionally, we evaluated 15 patients (group 2) who met the inclusion criteria but received bariatric intervention within the same time frame. All patients completed a multidisciplinary weight management consultation with at least 1 year of follow-up.

RESULTS

In the conservatively managed group (group 1), the mean weight at the time of initial consultation was 126.5±18.5 kg, and the mean BMI was 44.4±4.6 kg/m². At 1 year post weight-loss consultation, the mean weight decreased by 4.4±8.2 kg to 122.9±17 kg, and the mean BMI was 43±4.8 kg/m², with a total mean body weight decrease of 3% (P=0.01). Eighteen patients (64%) did not progress to become candidates for active listing/transplantation during the follow-up time of 4±2.9 years, with 15 (54%) subsequently developing renal failure/diabetes-related comorbidities prohibitive for transplantation. In contrast, mean total body weight decreased by 19% at 6 months post bariatric surgery, and the mean BMI was 34.2±4 and 32.5±3.7 kg/m² at 6 and 12 months, respectively. Bariatric surgery was strongly associated with subsequent kidney transplantation (HR=8.39 [95% CI 1.71 to 41.19]; P=0.009).

CONCLUSIONS

A conservative weight-loss approach involving multidisciplinary consultation was ineffective in most kidney transplant candidates with diabetes, suggesting that a more proactive approach is needed.

The Effect of TCM Syndrome Type and Western Medicine Detection on Patients with Hypertension and Diabetes Mellitus

Objective

To investigate the clinical changes of TCM syndrome type and microalbuminuria in patients with hypertension and diabetes mellitus.

Methods

A total of 442 patients with hypertension and diabetes who were admitted to our hospital from June 2016 to June 2021 were selected. All patients were divided into medication group and control group according to the random number method. Patients in the medication group were treated with conventional Western medicine-assisted traditional Chinese medicine, while patients in the control group were not treated with adjuvant medicine. The blood pressure and blood glucose of patients in the two groups were controlled within the normal range, and the clinical effects of the two groups were observed.

Results

The treatment of hypertension and diabetes in the two groups was diagnosed by the TCM syndrome type, and the cure rate was higher in the medication group. After 3 months, the glomerular filtration rate in the medication group increased steadily and the renal artery resistance index decreased, while the indexes in the control group had no significant change, with statistical significance (P < 0.05). After 6 months, the urinary albumin excretion rate and the ratio of urinary albumin to creatinine in the medication group were significantly decreased compared with those before medication, while there were no significant changes in the control group, with statistical significance (P < 0.05). The urine excretion rate of albumin in hypertensive patients with diabetes is higher, leading to the increased probability of microalbuminuria in patients, which is not only related to the course of hypertension and diabetes but also positively related to the course of hypertension and diabetes, smoking, drinking, and diet.

Conclusion

The combination of the TCM syndrome type and Western medicine detection method is more conducive to the two diagnosis and treatment methods that complement each other, improve each other, improve the effect of diagnosis and treatment, and are worthy of further research by researchers, so as to promote clinical application. Some other bad habits should also be corrected, such as smoking, drinking, and irregular diet, through adjusting the diet; control of high protein intake is also an important intervention measure for disease.

Ten things to know about ten cardiovascular disease risk factors - 2022

The American Society for Preventive Cardiology (ASPC) "Ten things to know about ten cardiovascular disease risk factors - 2022" is a summary document regarding cardiovascular disease (CVD) risk factors. This 2022 update provides summary tables of ten things to know about 10 CVD risk factors and builds upon the foundation of prior annual versions of "Ten things to know about ten cardiovascular disease risk factors" published since 2020. This 2022 version provides the perspective of ASPC members and includes updated sentinel references (i.e., applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful dietary intake, physical inactivity, dyslipidemia, pre-diabetes/diabetes, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis (with smoking as a potential contributor to thrombosis), kidney dysfunction and genetics/familial hypercholesterolemia. Other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the ASPC "Ten things to know about ten cardiovascular disease risk factors - 2022" to provide a tabular overview of things to know about ten of the most common CVD risk factors applicable to preventive cardiology and provide ready access to applicable guidelines and sentinel reviews.

Modifiable Lifestyle Behaviors and CKD Progression: A Narrative Review

Living a healthy lifestyle is one of the safest and most cost-effective ways to improve one's quality of life and prevent and/or manage chronic disease. As such, current CKD management guidelines recommend that patients adhere to a healthy diet, perform ≥150 minutes per week of physical activity, manage their body weight, abstain from tobacco use, and limit alcohol. However, there are limited studies that investigate the relationship between these lifestyle factors and the progression of CKD among people with established CKD. In this narrative review, we examine the reported frequencies of health lifestyle behavior engagement among individuals with non-dialysis-dependent CKD and the existing literature that examines the influences of diet, physical activity, weight management, alcohol consumption, and tobacco use on the progression of CKD, as measured by decline in GFR, incident ESKD, or elevated proteinuria or albuminuria in individuals with CKD. Many of the available studies are limited by length of follow-up and small sample sizes, and meta-analyses were limited because the studies were sparse and had heterogeneous classifications of behaviors and/or referent groups and of CKD progression. Further research should be done to determine optimal methods to assess behaviors to better understand the levels at which healthy lifestyle behaviors are needed to slow CKD progression, to investigate the effect of combining multiple lifestyle behaviors on important clinical outcomes in CKD, and to develop effective techniques for behavior change. Despite the lack of evidence of efficacy from large trials on the ability of lifestyle behaviors to slow CKD progression, maintaining a healthy lifestyle remains a cornerstone of CKD management given the undisputed benefits of healthy lifestyle behaviors on cardiovascular health, BP control, and survival.

Socioeconomic status and use of obesogenic and anti-obesity medications in the United States: A population-based study

Background

The Endocrine Society Clinical Practice Guidelines recommend the avoidance of medications that may cause weight gain (i.e., obesogenic medications) in individuals with overweight or obesity. Obesity disproportionately affects people with lower socioeconomic status (SES); however, it is unknown whether the use of obesogenic medications differs by SES.

Methods

We included adults with overweight or obesity and used prescription medications from 2009-2018 of the US National Health and Nutrition Examination Survey. We examined the associations between a composite measure of SES and use of obesogenic medications and anti-obesity medications. The composite SES included <high school education (1 point), household income below federal poverty level (1 point), no insurance (2 points), and public health insurance only (1 point). We defined 3 composite SES groups (0 [high], 1 [intermediate], and ≥2 points [low]).

Findings

Among 10,673 US adults with overweight or obesity, 20.0% had low SES. Use of obesogenic medications was common (37.7%). Low (vs. high) SES was associated with greater obesogenic medication use, independent of demographic characteristics, prescription medication burden, and comorbidities (OR 1.3 [1.2-1.5]). Among 12,133 eligible participants, utilization of anti-obesity medications was very low overall (0.5%) and within all SES groups (low 0.27%, intermediate 0.71, and high 0.65%).

Interpretation

Our findings highlight common and modifiable risk factors for obesity. Clinicians should screen patient medications for those that may cause weight gain and increase adoption of anti-obesity medications, especially among adults living in low SES.

Funding

The National Institute of Diabetes and Digestive and Kidney Disease (R01DK115534, K24HL155861, and K01DK121825).

Body Mass Index Thresholds and the Use of Bariatric Surgery in the Field of Kidney Transplantation in Germany

Background

Obesity in the recipient is linked to inferior transplant outcome. Consequently, access to kidney transplantation (KT) is often restricted by body mass index (BMI) thresholds. Bariatric surgery (BS) has been established as a superior treatment for obesity compared to conservative measures, but it is unclear whether it is beneficial for patients on the waiting list.

Methods

A national survey consisting of 16 questions was sent to all heads of German KT centers. Current situation of KT candidates with obesity and the status of BS were queried.

Results

Center response rate was 100%. Obesity in KT candidates was considered an important issue (96.1%; n = 49/51) and 68.6% (n = 35/51) of departments responded to use absolute BMI thresholds for KT waiting list access with ≥ 35 kg/m² (45.1%; n = 23/51) as the most common threshold. BS was considered an appropriate weight loss therapy (92.2%; n = 47/51), in particular before KT (88.2%; n = 45/51). Sleeve gastrectomy was the most favored procedure (77.1%; n = 37/51). Twenty-one (41.2%) departments responded to evaluate KT candidates with obesity by default but only 11 (21.6%) had experience with ≥ n = 5 transplants after BS. Concerns against BS were malabsorption of immunosuppressive therapy (39.2%; n = 20/51), perioperative morbidity (17.6%; n = 9/51), and malnutrition (13.7%; n = 7/51).

Conclusions

Obesity is potentially limiting access for KT. Despite commonly used BMI limits, only few German centers consider BS for obesity treatment in KT candidates by default. A national multicenter study is desired by nearly all heads of German transplant centers to prospectively assess the potentials, risks, and safety of BS in KT waitlisted patients.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-06000-4.

Kidney Damage Caused by Obesity and Its Feasible Treatment Drugs

The rapid growth of obesity worldwide has made it a major health problem, while the dramatic increase in the prevalence of obesity has had a significant impact on the magnitude of chronic kidney disease (CKD), especially in developing countries. A vast amount of researchers have reported a strong relationship between obesity and chronic kidney disease, and obesity can serve as an independent risk factor for kidney disease. The histological changes of kidneys in obesity-induced renal injury include glomerular or tubular hypertrophy, focal segmental glomerulosclerosis or bulbous sclerosis. Furthermore, inflammation, renal hemodynamic changes, insulin resistance and lipid metabolism disorders are all involved in the development and progression of obesity-induced nephropathy. However, there is no targeted treatment for obesity-related kidney disease. In this review, RAS inhibitors, SGLT2 inhibitors and melatonin would be presented to treat obesity-induced kidney injury. Furthermore, we concluded that melatonin can protect the kidney damage caused by obesity by inhibiting inflammation and oxidative stress, revealing its therapeutic potential.

Anything New in the Treatment of Obesity in Obese Patients with CKD?

Treatment for obesity in patients with CKD englobes a wide range of options, from lifestyle modification to bariatric surgery. Weight loss improves metabolic parameters and stimulates changes in renal function that lead to improvement of glomerular hyperfiltration. The most common clinical presentation is a slowly increasing non-nephrotic proteinuria that is followed by a progressive decline of kidney function. The use of multitarget therapies, with appropriate dietary education, emerging diets, the use of new RAAS blocking agents, the combination of iSGLT2 or GLP-1 agonists, as well as bariatric surgery, may play a key role in finally achieving the desired nephroprotection in this CKD population. New therapeutic agents and novel biomarkers, such as adipocyte cytokines, are needed to monitor and mitigate progression to end-stage renal disease. The emerging "lipidomics" and the role of nonalcoholic fatty liver are relevant research lines.

Impact of Obesity in Kidney Diseases

The clinical consequences of obesity on the kidneys, with or without metabolic abnormalities, involve both renal function and structures. The mechanisms linking obesity and renal damage are well understood, including several effector mechanisms with interconnected pathways. Higher prevalence of urinary albumin excretion, sub-nephrotic syndrome, nephrolithiasis, increased risk of developing CKD, and progression to ESKD have been identified as being associated with obesity and having a relevant clinical impact. Moreover, renal replacement therapy and kidney transplantation are also influenced by obesity. Losing weight is key in limiting the impact that obesity produces on the kidneys by reducing albuminuria/proteinuria, declining rate of eGFR deterioration, delaying the development of CKD and ESKD, and improving the outcome of a renal transplant. Weight reduction may also contribute to appropriate control of cardiometabolic risk factors such as hypertension, metabolic syndrome, diabetes, and dyslipidemia which may be protective not only in renal damage but also cardiovascular disease. Lifestyle changes, some drugs, and bariatric surgery have demonstrated the benefits.

Folic acid-induced animal model of kidney disease

The kidneys are a vital organ that is vulnerable to both acute kidney injury (AKI) and chronic kidney disease (CKD) which can be caused by numerous risk factors such as ischemia, sepsis, drug toxicity and drug overdose, exposure to heavy metals, and diabetes. In spite of the advances in our understanding of the pathogenesis of AKI and CKD as well AKI transition to CKD, there is still no available therapeutics that can be used to combat kidney disease effectively, highlighting an urgent need to further study the pathological mechanisms underlying AKI, CKD, and AKI progression to CKD. In this regard, animal models of kidney disease are indispensable. This article reviews a widely used animal model of kidney disease, which is induced by folic acid (FA). While a low dose of FA is nutritionally beneficial, a high dose of FA is very toxic to the kidneys. Following a brief description of the procedure for disease induction by FA, major mechanisms of FA-induced kidney injury are then reviewed, including oxidative stress, mitochondrial abnormalities such as impaired bioenergetics and mitophagy, ferroptosis, pyroptosis, and increased expression of fibroblast growth factor 23 (FGF23). Finally, application of this FA-induced kidney disease model as a platform for testing the efficacy of a variety of therapeutic approaches is also discussed. Given that this animal model is simple to create and is reproducible, it should remain useful for both studying the pathological mechanisms of kidney disease and identifying therapeutic targets to fight kidney disease.