1
|
Tunnicliffe DJ, Reid S, Craig JC, Samuels JA, Molony DA, Strippoli GF. Non-immunosuppressive treatment for IgA nephropathy. Cochrane Database Syst Rev 2024; 2:CD003962. [PMID: 38299639 PMCID: PMC10832348 DOI: 10.1002/14651858.cd003962.pub3] [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] [Indexed: 02/02/2024]
Abstract
BACKGROUND IgA nephropathy (IgAN) is the most common primary glomerular disease, with approximately 20% to 40% of patients progressing to kidney failure within 25 years. Non-immunosuppressive treatment has become a mainstay in the management of IgAN by improving blood pressure (BP) management, decreasing proteinuria, and avoiding the risks of long-term immunosuppressive management. Due to the slowly progressive nature of the disease, clinical trials are often underpowered, and conflicting information about management with non-immunosuppressive treatment is common. This is an update of a Cochrane review, first published in 2011. OBJECTIVES To assess the benefits and harms of non-immunosuppressive treatment for treating IgAN in adults and children. We aimed to examine all non-immunosuppressive therapies (e.g. anticoagulants, antihypertensives, dietary restriction and supplementation, tonsillectomy, and herbal medicines) in the management of IgAN. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to December 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs of non-immunosuppressive agents in adults and children with biopsy-proven IgAN were included. DATA COLLECTION AND ANALYSIS Two authors independently reviewed search results, extracted data and assessed study quality. Results were expressed as mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI) using random-effects meta-analysis. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS This review includes 80 studies (4856 participants), of which 24 new studies (2018 participants) were included in this review update. The risk of bias within the included studies was mostly high or unclear for many of the assessed methodological domains, with poor reporting of important key clinical trial methods in most studies. Antihypertensive therapies were the most examined non-immunosuppressive therapy (37 studies, 1799 participants). Compared to placebo or no treatment, renin-angiotensin system (RAS) inhibition probably decreases proteinuria (3 studies, 199 participants: MD - 0.71 g/24 h, 95% CI -1.04 to -0.39; moderate certainty evidence) but may result in little or no difference to kidney failure or doubling of serum creatinine (SCr), or complete remission of proteinuria (low certainty evidence). Death, remission of haematuria, relapse of proteinuria or > 50% increase in SCr were not reported. Compared to symptomatic treatment, RAS inhibition (3 studies, 168 participants) probably decreases proteinuria (MD -1.16 g/24 h, 95% CI -1.52 to -0.81) and SCr (MD -9.37 µmol/L, 95% CI -71.95 to -6.80) and probably increases creatinine clearance (2 studies, 127 participants: MD 23.26 mL/min, 95% CI 10.40 to 36.12) (all moderate certainty evidence); however, the risk of kidney failure is uncertain (1 study, 34 participants: RR 0.20, 95% CI 0.01 to 3.88; very low certainty evidence). Death, remission of proteinuria or haematuria, or relapse of proteinuria were not reported. The risk of adverse events may be no different with RAS inhibition compared to either placebo or symptomatic treatment (low certainty evidence). In low certainty evidence, tonsillectomy in people with IgAN in addition to standard care may increase remission of proteinuria compared to standard care alone (2 studies, 143 participants: RR 1.90, 95% CI 1.45 to 2.47) and remission of microscopic haematuria (2 studies, 143 participants: RR 1.93, 95% CI 1.47 to 2.53) and may decrease relapse of proteinuria (1 study, 73 participants: RR 0.70, 95% CI 0.57 to 0.85) and relapse of haematuria (1 study, 72 participants: RR 0.70, 95% CI 0.51 to 0.98). Death, kidney failure and a > 50% increase in SCr were not reported. These trials have only been conducted in Japanese people with IgAN, and the findings' generalisability is unclear. Anticoagulant therapy, fish oil, and traditional Chinese medicines exhibited small benefits to kidney function in patients with IgAN when compared to placebo or no treatment. However, compared to standard care, the kidney function benefits are no longer evident. Antimalarial therapy compared to placebo in one study reported an increase in a > 50% reduction of proteinuria (53 participants: RR 3.13 g/24 h, 95% CI 1.17 to 8.36; low certainty evidence). Although, there was uncertainty regarding adverse events from this study due to very few events. AUTHORS' CONCLUSIONS Available RCTs focused on a diverse range of interventions. They were few, small, and of insufficient duration to determine potential long-term benefits on important kidney and cardiovascular outcomes and harms of treatment. Antihypertensive agents appear to be the most beneficial non-immunosuppressive intervention for IgAN. The antihypertensives examined were predominantly angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. The benefits of RAS inhibition appear to outweigh the harms in patients with IgAN. The certainty of the evidence of RCTs demonstrating a benefit of tonsillectomy to patients with Japanese patients with IgAN was low. In addition, these findings are inconsistent across observational studies in people with IgAN of other ethnicities; hence, tonsillectomy is not widely recommended, given the potential harm of therapy. The RCT evidence is insufficiently robust to demonstrate efficacy for the other non-immunosuppressive treatments evaluated here.
Collapse
Affiliation(s)
| | - Sharon Reid
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Joshua A Samuels
- Division of Pediatric Nephrology and Hypertension, UT-Houston Health Science Center, Houston, TX, USA
| | - Donald A Molony
- Internal Medicine, UT-Houston Health Science Center, Houston, TX, USA
| | - Giovanni Fm Strippoli
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| |
Collapse
|
2
|
Li WL, Zhang NH, Ge SW, Xu G. Dietary Omega-3 Fatty Acid Intake and Mortality in CKD Population: A 1999-2014 NHANES Analysis. Am J Nephrol 2021; 52:909-918. [PMID: 34839290 DOI: 10.1159/000520027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/21/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION High risk of early death, especially contributed to cardiovascular disease, exists in patients who have chronic kidney disease (CKD). And the burden of cardiovascular disease is able to be lightened by an increase in omega-3 polyunsaturated fatty acid (omega-3 PUFA). A diet high in omega-3 PUFA in the general population is protective, although it is inconclusive about its beneficial role in the CKD population. METHODS From the 1999 to 2014 National Health and Nutrition Examination Surveys (NHANES), we can collect 2,990 participants who suffered from CKD, who were classified into 4 groups: <0.86, 0.87-1.30, 1.31-1.92, and 1.93-9.65 g/day based on NHANES 24-h dietary recall questionnaire dietary omega-3 PUFA. Moreover, their mortality details were available to be obtained by linking NHANES to the National Death Index. The associations between dietary omega-3 PUFA and mortality were evaluated by constructing multivariable Cox proportional hazards models. RESULTS Over 8 years of a median follow-up, 864 deaths were recorded. The adjusted hazard ratios (95% confidence interval) for all-cause mortality of the diseased people with CKD in the 2nd (0.87-1.30 g/day), 3rd (0.87-1.30 g/day), and 4th (1.93-9.65 g/day) quartiles of dietary omega-3 PUFA were 0.94 (0.72, 1.23), 0.74 (0.54, 1.02), and 0.67 (0.48, 0.93), respectively, versus those with the lowest quartile of dietary omega-3 PUFA intake (<0.86 g/day) (p for trend = 0.011). CONCLUSION There may be a inverse relation of dietary omega-3 PUFA intake and all-cause mortality in patients with CKD. Therefore, an increase of dietary omega-3 PUFA may be encouraged to be used clinically in patients with CKD.
Collapse
Affiliation(s)
- Wei-Lan Li
- Division of Internal Medicine, Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,
| | - Nan-Hui Zhang
- Department of Nephrology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Shu-Wang Ge
- Division of Internal Medicine, Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gang Xu
- Division of Internal Medicine, Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
3
|
IgA Vasculitis: Etiology, Treatment, Biomarkers and Epigenetic Changes. Int J Mol Sci 2021; 22:ijms22147538. [PMID: 34299162 PMCID: PMC8307949 DOI: 10.3390/ijms22147538] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 07/12/2021] [Indexed: 02/06/2023] Open
Abstract
IgA, previously called Henoch-Schönlein vasculitis, is an essential immune component that drives the host immune response to the external environment. As IgA has the unique characteristic of a flexible response to broad types of microorganisms, it sometimes causes an autoreactive response in the host human body. IgA vasculitis and related organ dysfunction are representative IgA-mediated autoimmune diseases; bacterial and viral infections often trigger IgA vasculitis. Recent drug developments and the presence of COVID-19 have revealed that these agents can also trigger IgA vasculitis. These findings provide a novel understanding of the pathogenesis of IgA vasculitis. In this review, we focus on the characteristics of IgA and symptoms of IgA vasculitis and other organ dysfunction. We also mention the therapeutic approach, biomarkers, novel triggers for IgA vasculitis, and epigenetic modifications in patients with IgA vasculitis.
Collapse
|
4
|
Fazelian S, Moradi F, Agah S, Hoseini A, Heydari H, Morvaridzadeh M, Omidi A, Pizarro AB, Ghafouri A, Heshmati J. Effect of omega-3 fatty acids supplementation on cardio-metabolic and oxidative stress parameters in patients with chronic kidney disease: a systematic review and meta-analysis. BMC Nephrol 2021; 22:160. [PMID: 33933009 PMCID: PMC8088683 DOI: 10.1186/s12882-021-02351-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background Omega-3 fatty acids (FAs) have been suggested as a beneficial supplement in chronic kidney disease (CKD) patients, but the results of randomized clinical trials (RCTs) are controversial. We conducted a systematic review and meta-analysis to evaluate all the RCTs about the impact of omega-3 FAs supplementation on cardiometabolic outcomes and oxidative stress parameters in patients with CKD. Methods We performed a systematic database search in PubMed/MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Central, up to May 2020. We included all placebo-controlled randomized trials that assessed the effect of omega-3 FAs supplementation on any cardiometabolic outcomes: blood pressure, total cholesterol (TC), low-density lipoprotein (LDL) and high-density lipoprotein (HDL) or triglycerides (TG) and oxidative stress parameters. Data were pooled using DerSimonian–Laird’s random-effects model. Results Finally, thirteen articles met the inclusion criteria for this review omega-3 FAs supplementation significantly decrease TC (SMD: -0.26; 95% CI: − 0.51, − 0.02; I2 = 52.7%), TG (SMD: -0.22; 95% CI: − 0.43, − 0.02; I2 = 36.0%) and Malondialdehyde (MDA) levels (SMD: -0.91; 95% CI: − 1.29, − 0.54; I2 = 00.0%) and also significantly increase superoxide dismutase (SOD) (SMD: 0.58; 95% CI: 0.27, 0.90; I2 = 00.0%) and Glutathione peroxidase (GPx) (SMD: 0.50; 95% CI: 0.14, 0.86; I2 = 00.0%) activities. However our results show that omega-3 FAs supplementation have no significant effects on HDL, LDL and blood pressure. Conclusion This systematic review and meta-analysis supports current evidence for the clinical benefit of omega-3 FAs intake to improve cardiometabolic parameters in CKD patients. However, well-designed RCTs still needed to provide a conclusive picture in this field. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02351-9.
Collapse
Affiliation(s)
- Siavash Fazelian
- Clinical Research Development Unit, Ayatollah Kashani Hospital, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Fatemeh Moradi
- Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shahram Agah
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Akramsadat Hoseini
- Department of Education and Health Promotion,School of Health, Iran University of Medical Sciences, Tehran, Iran
| | - Hafez Heydari
- Cellular and Molecular Research Center, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Mojgan Morvaridzadeh
- Department of Nutritional Science, School of Nutritional Science and Food Technology, Kermanshah University of Medical Sciences, Farabi Hospital, Faculty of Nutrition Sciences and Food Technology, Postal Code: 6715847141, Isar Square, Kermanshah, Iran
| | - Amirhosein Omidi
- Department of Nutritional Science, School of Nutritional Science and Food Technology, Kermanshah University of Medical Sciences, Farabi Hospital, Faculty of Nutrition Sciences and Food Technology, Postal Code: 6715847141, Isar Square, Kermanshah, Iran
| | | | - Atie Ghafouri
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran.
| | - Javad Heshmati
- Department of Nutritional Science, School of Nutritional Science and Food Technology, Kermanshah University of Medical Sciences, Farabi Hospital, Faculty of Nutrition Sciences and Food Technology, Postal Code: 6715847141, Isar Square, Kermanshah, Iran.
| |
Collapse
|
5
|
Zhang C, Ge C, Wang J, Sun D. Effects of fish oil during hemodialysis on nutritional status and quality of life: a randomized double-blinded trial. Food Nutr Res 2020; 64:4450. [PMID: 32821255 PMCID: PMC7413645 DOI: 10.29219/fnr.v64.4450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/20/2020] [Accepted: 05/19/2020] [Indexed: 11/20/2022] Open
Abstract
Background Supplementation of fish oil has been shown to exert beneficial effects in patients undergoing hemodialysis. The aim of this study was to investigate the efficacy of fish oil in improving the quality of life of these patients through a randomized, double-blinded clinical trial. Methods Among the 103 patients enrolled in the study, a total of 74 patients were randomized to receive fish oil (intervention group) or placebo (n=37 per group). Patients received identical soft-gel capsules, with each capsule containing either 1000 mg fish oil or placebo for 4 months. Personnel responsible for data collection and analyses were blinded to the grouping. Results The reduction of protein-energy wasting (PEW) in the intervention group was significantly more prominent compared to the placebo group (P=0.023). The intervention group demonstrated significant increase in midarm circumference, arm muscle circumference, and triceps skinfold thickness after fish oil intake. The intervention group also exhibited significant differences from the placebo group in creatinine, uric acid, and serum calcium levels. Significant improvement was seen regarding the physical role and energy/figure in the intervention group. Conclusions Our study demonstrated that fish oil intake in patient undergoing hemodialysis can significantly reduce PEW, and improve physical and biochemical parameters and quality of life, which could provide guidance to clinical management of these patients.
Collapse
Affiliation(s)
- Chi Zhang
- Department of Nephrology, Xuzhou Medical University, Jiangsu, China.,Department of Nephrology, The Affiliated Suqian Hospital of Xuzhou Medical University, Jiangsu, China
| | - Chang Ge
- Department of Otorhinolaryngology-Head and Neck Surgery, The Affiliated Suqian Hospital of Xuzhou Medical University, Jiangsu, China
| | - Junsheng Wang
- Department of Nephrology, The Affiliated Suqian Hospital of Xuzhou Medical University, Jiangsu, China
| | - Dong Sun
- Department of Nephrology, Xuzhou Medical University, Jiangsu, China.,Department of Internal Medicine and Diagnostics, Xuzhou Medical University, Jiangsu, China
| |
Collapse
|
6
|
Uwaezuoke SN, Muoneke UV, Mbanefo NR. The Supportive Treatment of IgA Nephropathy and Idiopathic Nephrotic Syndrome: How Useful are Omega-3 Polyunsaturated Fatty Acids? Int J Nephrol Renovasc Dis 2020; 13:27-35. [PMID: 32161487 PMCID: PMC7049740 DOI: 10.2147/ijnrd.s237527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/12/2020] [Indexed: 01/02/2023] Open
Abstract
IgA nephropathy (IgAN) is the most prevalent glomerular disease in young adults worldwide, while idiopathic nephrotic syndrome (INS) represents the most frequent manifestation of glomerular disease in childhood. Over the years, studies have speculated about the potential benefits of omega-3 polyunsaturated fatty acids (PUFAs) in improving morbidity in both forms of chronic kidney disease (CKD). The proposed mechanisms of action include reduction of proteinuria and modulation of dyslipidemia. Although in vitro and in vivo experimental studies report the suppressive effect of omega-3 PUFAs on inflammatory pathways linked with the progression of nephropathy, the evidence supporting their beneficial effect in IgAN and INS is still weak. Also, their ability to regulate levels of total cholesterol, low-density lipoprotein-cholesterol (LDL-C), and triglycerides (TG) suggests that they could delay both dyslipidemia-associated nephrotoxicity and atherosclerosis. Most of the clinical trials that were conducted on their therapeutic benefits in IgAN patients reported positive outcomes with low and high doses of omega-3 PUFAs. However, few of the trials noted inconclusive findings, with low-quality evidence suggesting potential improvements in surrogate renal function outcomes. If the beneficial effect of omega-3 PUFAs is predicated on their hypolipidemic action, much higher doses could be used in well-designed randomized-controlled trials (RCTs) to determine if they could produce better renal function outcomes and provide much stronger evidence of their therapeutic benefits in IgAN and INS. However, the current hypothetical mechanisms of action in these forms of CKD also include the effect of omega-3 PUFAs on renal inflammatory pathways and glomerular proteinuria. Perhaps, the unresolved therapeutic efficacy of these fatty acids in IgAN and INS suggests that their exact mechanisms of action are yet to be fully established. In this narrative review, we aim to appraise the current evidence of their potential therapeutic benefits in these diseases.
Collapse
Affiliation(s)
- Samuel N Uwaezuoke
- Pediatric Nephrology Firm, Department of Pediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Uzoamaka V Muoneke
- Pediatric Nephrology Firm, Department of Pediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Ngozi R Mbanefo
- Pediatric Nephrology Firm, Department of Pediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| |
Collapse
|
7
|
Saglimbene VM, Wong G, van Zwieten A, Palmer SC, Ruospo M, Natale P, Campbell K, Teixeira-Pinto A, Craig JC, Strippoli GF. Effects of omega-3 polyunsaturated fatty acid intake in patients with chronic kidney disease: Systematic review and meta-analysis of randomized controlled trials. Clin Nutr 2020; 39:358-368. [DOI: 10.1016/j.clnu.2019.02.041] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/27/2019] [Accepted: 02/28/2019] [Indexed: 12/29/2022]
|
8
|
Foroughinia F, Mirjalili M, Mirzaei E, Oboodi A. Omega-3 Supplementation in the Prevention of Contrast Induced Nephropathy in Patients Undergoing Elective Percutaneous Coronary Intervention: A Randomized Placebo-Controlled Trial. Adv Pharm Bull 2019; 9:307-313. [PMID: 31380258 PMCID: PMC6664110 DOI: 10.15171/apb.2019.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 03/02/2019] [Accepted: 04/14/2019] [Indexed: 12/15/2022] Open
Abstract
Purpose: Contrast-induced nephropathy (CIN) is the third cause of hospital-acquired renal failure and is associated with significant morbidity and mortality. Several studies have revealed the protective role of omega-3 in prevention and treatment of some kidney injuries. This study was conducted to examine the effect of omega-3 supplementation on the markers of renal function and to evaluate its potential in the prevention of CIN in patients undergoing elective percutaneous coronary intervention (PCI). Methods: In this double-blind, randomized clinical trial, 85 eligible patients scheduled for PCI was randomly divided into omega-3 (a single 3750 mg dose of omega-3 as well as routine hydration therapy within 12 hours before PCI) or control (placebo plus routine hydration therapy) groups. Serum creatinine (SCr) and cystatin C levels were measured at baseline and 24 hours after PCI. Results: Our results indicated that post- PCI cystatin C levels were significantly decreased in the omega-3 group compared to the control group (P < 0.001). Although less upward manner was seen in the level of 24-hour creatinine in the omega-3 group, it did not reach the significance level (P = 0.008). Conclusion: The positive effect of omega-3 on cystatin C levels showed that it may have a protective role in the prevention of CIN in post-PCI patients with normal kidney function. However, to better assess this effect, it is highly recommended to design future studies with higher doses and longer duration of therapy with omega-3 plus long-term follow up.
Collapse
Affiliation(s)
- Farzaneh Foroughinia
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Clinical Pharmacy Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Ehsan Mirzaei
- Clinical Pharmacy Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Oboodi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
9
|
New strategies and perspectives on managing IgA nephropathy. Clin Exp Nephrol 2019; 23:577-588. [PMID: 30756248 PMCID: PMC6469670 DOI: 10.1007/s10157-019-01700-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/17/2019] [Indexed: 12/23/2022]
Abstract
IgA nephropathy is an inflammatory renal disease characterised by the deposition of IgA in the glomerular mesangium and is the most commonly reported primary glomerulonephritis worldwide. Thirty to forty percent of patients with the disease develop progressive renal function decline, requiring renal replacement therapy within two decades of diagnosis. Despite this, accurate individual risk stratification at diagnosis and predicting treatment response remains a challenge. Furthermore, there are currently no disease specific treatments currently licensed to treat the condition due to long standing challenges in the nature and prevalence of the disease. Despite this, there have been exciting recent advances in the field that may represent paradigm shifts in the way IgA nephropathy is managed in the near future. In this review, we explore the evidence base informing current approaches to management and explore new strategies and future directions in the diagnosis and management of IgA nephropathy.
Collapse
|
10
|
Itsiopoulos C, Marx W, Mayr H, Tatucu-Babet O, Dash S, George E, Trakman G, Kelly J, Thomas C, Brazionis L. The role of omega-3 polyunsaturated fatty acid supplementation in the management of type 2 diabetes mellitus: A narrative review. JOURNAL OF NUTRITION & INTERMEDIARY METABOLISM 2018. [DOI: 10.1016/j.jnim.2018.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
|
11
|
Cosola C, Sabatino A, di Bari I, Fiaccadori E, Gesualdo L. Nutrients, Nutraceuticals, and Xenobiotics Affecting Renal Health. Nutrients 2018; 10:nu10070808. [PMID: 29937486 PMCID: PMC6073437 DOI: 10.3390/nu10070808] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 06/18/2018] [Accepted: 06/20/2018] [Indexed: 02/07/2023] Open
Abstract
Chronic kidney disease (CKD) affects 8–16% of the population worldwide. In developed countries, the most important risk factors for CKD are diabetes, hypertension, and obesity, calling into question the importance of educating and acting on lifestyles and nutrition. A balanced diet and supplementation can indeed support the maintenance of a general health status, including preservation of renal function, and can help to manage and curb the main risk factors for renal damage. While the concept of protein and salt restriction in nephrology is historically acknowledged, the role of some nutrients in renal health and the importance of nutrition as a preventative measure for renal care are less known. In this narrative review, we provide an overview of the demonstrated and potential actions of some selected nutrients, nutraceuticals, and xenobiotics on renal health and function. The direct and indirect effects of fiber, protein, fatty acids, curcumin, steviol glycosides, green tea, coffee, nitrates, nitrites, and alcohol on kidney health are reviewed here. In view of functional and personalized nutrition, understanding the renal and systemic effects of dietary components is essential since many chronic conditions, including CKD, are related to systemic dysfunctions such as chronic low-grade inflammation.
Collapse
Affiliation(s)
- Carmela Cosola
- Department of Emergency and Organ Transplantation-Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, 70124 Bari, Italy.
| | - Alice Sabatino
- Department of Medicine and Surgery, Parma University Medical School, 43126 Parma, Italy.
| | - Ighli di Bari
- Department of Emergency and Organ Transplantation-Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, 70124 Bari, Italy.
| | - Enrico Fiaccadori
- Department of Medicine and Surgery, Parma University Medical School, 43126 Parma, Italy.
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation-Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, 70124 Bari, Italy.
| |
Collapse
|
12
|
Zhang YM, Zhang XH, Zhu P, Tan RH, Zhao JS, Wang F, Zhang JJ, Yan W, Xi Y, Wan JB, Kang JX, Zou ZQ, Bu SZ. Endogenous synthesis of n-3 polyunsaturated fatty acids in fat-1 transgenic mice ameliorates streptozocin-induced diabetic nephropathy. J Funct Foods 2018. [DOI: 10.1016/j.jff.2018.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
|
13
|
Sabatino A, Regolisti G, Gandolfini I, Delsante M, Fani F, Gregorini MC, Fiaccadori E. Diet and enteral nutrition in patients with chronic kidney disease not on dialysis: a review focusing on fat, fiber and protein intake. J Nephrol 2017; 30:743-754. [PMID: 28884267 DOI: 10.1007/s40620-017-0435-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/24/2017] [Indexed: 02/07/2023]
Abstract
The clinical data available on dietary requirements of patients with chronic kidney disease (CKD) not on dialysis are limited and largely inconclusive in terms of the renal, cardiovascular and nutritional outcomes achievable through dietary modifications. Restriction of protein intake during the early stages of CKD may in fact slow its progression, but at the same time this approach may also lead to protein-energy wasting, if energy intake is not adequate and properly monitored. Unfortunately, compliance to dietary recommendations is traditionally low in this patient population. A switch from saturated to mono- and polyunsaturated fats is generally recognized as advantageous for cardiac health; however, the benefits in term of renal function are largely unknown. Similarly, the association between dietary fiber intake and kidney disease is largely unknown. In fact, while there is evidence on the positive health effects of dietary fibers in the general population, nutritional guidelines for CKD lack formal recommendations concerning fiber intake. This paper reviews data and evidence from clinical trials and meta-analyses on renal and cardiovascular outcomes related to modifications in protein, fat and fiber intake. Suggestions for maintaining nutritional status through patient-oriented dietary patterns and enteral supplementation in CKD patients on conservative therapy are also presented.
Collapse
Affiliation(s)
- Alice Sabatino
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Giuseppe Regolisti
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Ilaria Gandolfini
- Postgraduate School of Nephrology, University of Parma, Parma, Italy
| | - Marco Delsante
- Postgraduate School of Nephrology, University of Parma, Parma, Italy
| | - Filippo Fani
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy
| | | | - Enrico Fiaccadori
- Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43100, Parma, Italy. .,Postgraduate School of Nephrology, University of Parma, Parma, Italy.
| |
Collapse
|
14
|
Hirahashi J. Omega-3 Polyunsaturated Fatty Acids for the Treatment of IgA Nephropathy. J Clin Med 2017; 6:jcm6070070. [PMID: 28753924 PMCID: PMC5532578 DOI: 10.3390/jcm6070070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/07/2017] [Accepted: 07/12/2017] [Indexed: 12/16/2022] Open
Abstract
IgA nephropathy is a common disease that causes end-stage renal failure and requires renal replacement therapy. The main purpose of therapeutic intervention in this disease is not limited to improvement of prognosis and prevention of transition to end-stage renal failure, but also prevention of the occurrence of cardiovascular lesions, which increases risk in patients with chronic kidney disease. Steroids and immunosuppressants have been widely used as remission induction therapies; however, the balance between their therapeutic benefits and detrimental side-effects are controversial. In this regard, it is critical to identify alternative therapies which would provide holistic life-long benefits. Currently, the potential of ω-3 fatty acids as anti-inflammatory and inflammation-convergent drugs—especially the remarkable progress of the multifunctional ω-3 polyunsaturated fatty acids (PUFAs)—has garnered attention. In this section, we outline the background and current status of ω-3 PUFA-based treatment in IgA nephropathy.
Collapse
Affiliation(s)
- Junichi Hirahashi
- Apheresis and Dialysis Center, Keio Univerisity School of Medicine, Tokyo 1608582, Japan.
| |
Collapse
|
15
|
Hu J, Liu Z, Zhang H. Omega-3 fatty acid supplementation as an adjunctive therapy in the treatment of chronic kidney disease: a meta-analysis. Clinics (Sao Paulo) 2017; 72:58-64. [PMID: 28226034 PMCID: PMC5251198 DOI: 10.6061/clinics/2017(01)10] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 10/20/2016] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to evaluate the benefits and risks of omega-3 fatty acid supplementation in patients with chronic kidney disease. A systematic search of articles in PubMed, Embase, the Cochrane Library, and reference lists was performed to find relevant literature. All eligible studies assessed proteinuria, the serum creatinine clearance rate, the estimated glomerular filtration rate, or the occurrence of end-stage renal disease. Standard mean differences with 95% confidence intervals for continuous data were used to estimate the effects of omega-3 fatty acid supplementation on renal function, as reflected by the serum creatinine clearance rate, proteinuria, the estimated glomerular filtration rate, and relative risk. Additionally, a random-effects model was used to estimate the effect of omega-3 fatty acid supplementation on the risk of end-stage renal disease. Nine randomized controlled trials evaluating 444 patients with chronic kidney disease were included in the study. The follow-up duration ranged from 2 to 76.8 months. Compared with no or low-dose omega-3 fatty acid supplementation, any or high-dose omega-3 fatty acid supplementation, respectively, was associated with a lower risk of proteinuria (SMD: -0.31; 95% CI: -0.53 to -0.10; p=0.004) but had little or no effect on the serum creatinine clearance rate (SMD: 0.22; 95% CI: -0.40 to 0.84; p=0.482) or the estimated glomerular filtration rate (SMD: 0.14; 95% CI: -0.13 to 0.42; p=0.296). However, this supplementation was associated with a reduced risk of end-stage renal disease (RR: 0.49; 95% CI: 0.24 to 0.99; p=0.047). In sum, omega-3 fatty acid supplementation is associated with a significantly reduced risk of end-stage renal disease and delays the progression of this disease.
Collapse
Affiliation(s)
- Jing Hu
- The Third Xiangya Hospital of Central South University, Department of Nephrology, Changsha 410013, China
| | - Zuoliang Liu
- The Third Xiangya Hospital of Central South University, Medical Intensive Care Unit, Changsha 410013, China
| | - Hao Zhang
- The Third Xiangya Hospital of Central South University, Department of Nephrology, Changsha 410013, China
- *Corresponding author. E-mail:
| |
Collapse
|
16
|
Xu H, Ärnlöv J, Sandhagen B, Risérus U, Lindholm B, Lind L, Carrero JJ. Lipophilic index, kidney function, and kidney function decline. Nutr Metab Cardiovasc Dis 2016; 26:1096-1103. [PMID: 27773469 DOI: 10.1016/j.numecd.2016.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/17/2016] [Accepted: 09/04/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIMS Unhealthy dietary fats are associated with faster kidney function decline. The cell membrane composition of phospholipid fatty acids (FAs) is a determinant of membrane fluidity and rheological properties. These properties, which have been linked to kidney damage, are thought to be reflected by the lipophilic index (LI). We prospectively investigated the associations of LI with kidney function and its decline. METHODS AND RESULTS Observational study from the Prospective Investigation of Vasculature in Uppsala Seniors including 975 men and women with plasma phospholipid FAs composition and cystatin-C estimate glomerular filtration rate (eGFR). Of these, 780 attended re-examination after 5 years, and eGFR changes were assessed. Participants with a 5-year eGFR reduction ≥30% were considered chronic kidney disease (CKD) progressors (n = 198). LI was calculated as the sum of the products of the FA proportions with the respective FAs melting points. Blood rheology/viscosity measurements were performed in a random subsample of 559 subjects at baseline. Increased LI showed a statistically significant but overall weak association with blood, plasma viscosity (both Spearman rho = 0.16, p < 0.01), and erythrocyte deformability (rho = -0.09, p < 0.05). In cross-sectional analyses, LI associated with lower eGFR (regression coefficient 3.00 ml/min/1.73 m2 1-standard deviation (SD) increment in LI, 95% CI: -4.31, -1.69, p < 0.001). In longitudinal analyses, LI associated with a faster eGFR decline (-2.13 [95% CI -3.58, -0.69] ml/min/1.73 m2, p < 0.01) and with 32% increased odds of CKD progression (adjusted OR 1.32 [95%, CI 1.05-1.65]). CONCLUSIONS A high LI was associated with lower kidney function, kidney function decline, and CKD progression.
Collapse
Affiliation(s)
- H Xu
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - J Ärnlöv
- Department of Medical Sciences, Cardiovascular Epidemiology, Uppsala University, Uppsala, Sweden; School of Health and Social Studies, Dalarna University, Falun, Sweden
| | - B Sandhagen
- Department of Medical Sciences, Cardiovascular Epidemiology, Uppsala University, Uppsala, Sweden
| | - U Risérus
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden
| | - B Lindholm
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - L Lind
- Department of Medical Sciences, Cardiovascular Epidemiology, Uppsala University, Uppsala, Sweden
| | - J J Carrero
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden; Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.
| |
Collapse
|
17
|
Zivkovic AM, Yang J, Georgi K, Hegedus C, Nording ML, O’Sullivan A, German JB, Hogg RJ, Weiss RH, Bay C, Hammock BD. Serum oxylipin profiles in IgA nephropathy patients reflect kidney functional alterations. Metabolomics 2012; 8:1102-1113. [PMID: 23833568 PMCID: PMC3700377 DOI: 10.1007/s11306-012-0417-5] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Immunoglobulin A nephropathy (IgAN) is a leading cause of chronic kidney disease, frequently associated with hypertension and renal inflammation. ω-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in fish oil (FO) improve kidney function in animal models, but have inconsistent metabolic effects in humans. Oxylipin profiles in serum from IgAN patients supplemented with either FO or corn oil (CO) placebo were analyzed by liquid chromatography coupled to tandem mass spectrometry. EPA cyclooxygenase and lipoxygenase metabolites, and EPA and DHA epoxides and diols were increased in response to FO supplementation, as were total epoxides and epoxide/diol ratios. Several of these metabolites were drivers of separation as assessed by multivariate analysis of FO patients pre- vs. post-supplementation, including 17,18-dihydroxyeicosatrienoic acid, prostaglandin D3, prostagalandin E3, Resolvin E1, 12-hydroxyeicosapentaenoic acid, and 10(11)-epoxydocosapentaenoic acid. In patients whose proteinuria improved, plasma total oxylipins as well as several hydroxyoctadecadienoic acids, hydroxyeicosatetraenoic acids, and leukotriene B4 metabolites were among the metabolites that were significantly lower than in patients whose proteinuria either did not improve or worsened. These data support the involvement of oxylipins in the inflammatory component of IgAN as well as the potential use of oxylipin profiles as biomarkers and for assessing responsiveness to ω-3 fatty acid supplementation in IgAN patients.
Collapse
Affiliation(s)
- Angela M. Zivkovic
- Foods for Health Institute, Department of Entomology, Department of Food Science and Technology, University of California, Davis, CA, phone: 530-752-9211; Fax: 530-752-4759
| | - Jun Yang
- Department of Entomology, University of California, Davis, CA
| | - Katrin Georgi
- Department of Entomology, University of California, Davis, CA
| | | | | | | | - J. Bruce German
- Foods for Health Institute, Department of Food Science and Technology, University of California, Davis, CA
| | | | - Robert H. Weiss
- Nephrology Division, Department of Medicine, University of California at Davis, Davis, CA
| | - Curt Bay
- Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ
| | - Bruce D. Hammock
- Foods for Health Institute, Department of Entomology, University of California, Davis, CA
| |
Collapse
|
18
|
|
19
|
|
20
|
Chou HH, Chiou YY, Hung PH, Chiang PC, Wang ST. Omega3 Fatty Acids Ameliorate Proteinuria but Not Renal Function in IgA Nephropathy: A Meta-Analysis of Randomized Controlled Trials. ACTA ACUST UNITED AC 2012; 121:c30-5. [DOI: 10.1159/000341929] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 07/10/2012] [Indexed: 11/19/2022]
|
21
|
Rosselli JL, Thacker SM, Karpinski JP, Petkewicz KA. Treatment of IgA nephropathy: an update. Ann Pharmacother 2011; 45:1284-96. [PMID: 21954446 DOI: 10.1345/aph.1q122] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review current literature regarding treatment options for immunoglobulin A nephropathy (IgAN). DATA SOURCES A MEDLINE search was performed using the terms IgA nephropathy, Berger's disease, immunoglobulin A nephropathy, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, fish oil, omega-3 fatty acids, statins, hydroxymethylglutaryl-CoA reductase inhibitors, immunosuppressive therapy, corticosteroids, mycophenolate mofetil, cyclophosphamide, cyclosporine, azathioprine, leflunomide, antiplatelets, anticoagulants, vitamin E, infliximab, calcitriol, and intravenous immunoglobulins. A date limit was not set; however, focus was on publications from 1999 to June 2011 to review recent literature and therapeutic recommendations. STUDY SELECTION AND DATA EXTRACTION All articles in English, including studies conducted in humans, meta-analyses, review articles, guidelines, statements, and reference citations, were identified and evaluated. DATA SYNTHESIS IgAN is the most common primary glomerulonephritis worldwide, leading to end-stage renal disease in 20-30% of patients. Evidence guiding management of IgAN has been sparse and clinical trials have not conclusively demonstrated effective treatments, largely due to suboptimal methodologies. Treatment strategies have included management of blood pressure and lipids, improvement or stabilization of kidney function, and reduction of proteinuria. This review of IgAN provides an update regarding standard and nonconventional treatment options based on recently published literature. CONCLUSIONS Supportive therapies, including angiotensin blockade, should be considered as first-line therapy for patients with urine protein >0.5 g/day and/or blood pressure >140/90 mm Hg. Corticosteroids could be considered as add-on or monotherapy for patients with urine protein >1 g/day with preserved renal function. Conclusive data are lacking for general treatment recommendations for the use of other therapies for IgAN.
Collapse
Affiliation(s)
- Jennifer L Rosselli
- Pharmacy Practice, School of Pharmacy, Southern Illinois University Edwardsville, Edwardsville, IL, USA.
| | | | | | | |
Collapse
|
22
|
Reid S, Cawthon PM, Craig JC, Samuels JA, Molony DA, Strippoli GF. Non-immunosuppressive treatment for IgA nephropathy. Cochrane Database Syst Rev 2011:CD003962. [PMID: 21412884 DOI: 10.1002/14651858.cd003962.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND IgA nephropathy (IgAN) is the most common primary glomerular disease with approximately 30% to 40% of patients progressing to end-stage kidney disease (ESKD) within 20 years. The most common regimens include immunosuppressive agents, however the risks of long-term treatment often outweigh the potential benefits. Non-immunosuppressive options, including fish oils, anticoagulants, antihypertensive agents and tonsillectomy have also been examined but not reviewed systematically. OBJECTIVES To assess the benefits and harms of non-immunosuppressive treatments for treating IgAN in adults and children. SEARCH STRATEGY In July 2010 we searched the Cochrane Renal Group's specialised register, CENTRAL (in The Cochrane Library), MEDLINE (from 1966) and EMBASE (from 1980). We also searched reference lists of included studies, review articles and contacted local and international experts. SELECTION CRITERIA Randomised controlled trials (RCTs) of non-immunosuppressive agents in adults and children with biopsy-proven IgAN were included. DATA COLLECTION AND ANALYSIS Two authors independently reviewed search results, extracted data and assessed study quality. Results were expressed as mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI) using a random-effects model. MAIN RESULTS We included 56 studies (2838 participants). Antihypertensive agents were the most beneficial non-immunosuppressive intervention for IgAN. The antihypertensives examined were predominantly angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB) or combinations of both, versus other antihypertensives and other agents. The benefits of antihypertensive agents, particularly inhibitors of the renin angiotensin system, appear to potentially outweigh the harms in patients with IgAN. The benefits are largely manifest as a reduction in proteinuria, a surrogate outcome. There is no evidence that treatment with any of the antihypertensive agents evaluated affect major renal and/or cardiovascular endpoints or long-term mortality risk beyond the benefit that arises from controlling hypertension in patients with IgAN. The RCT evidence is insufficiently robust to demonstrate efficacy for any of the other non-immunosuppressive therapies evaluated here. AUTHORS' CONCLUSIONS IgAN remains a disease in search of adequately powered RCTs to reliably inform clinical practice. More and better evidence is needed to understand the magnitude of benefit and the possible risks of anti-hypertensive or more specifically of ACEi/ARB therapy alone or in combination and which specific types of patients with the IgAN might have the greatest potential for benefit. For other non-immunosuppressive therapies, where neither benefit nor significant harm has yet to be demonstrated, there remains some justification for further exploration of the potential benefits.
Collapse
Affiliation(s)
- Sharon Reid
- Sydney School of Public Health, University of Sydney, Edward Ford Building (A27), Room 301C, Sydney, NSW, Australia, 2006
| | | | | | | | | | | |
Collapse
|
23
|
Stangou M, Ekonomidou D, Giamalis P, Liakou H, Tsiantoulas A, Pantzaki A, Papagianni A, Efstratiadis G, Alexopoulos E, Memmos D. Steroids and azathioprine in the treatment of IgA nephropathy. Clin Exp Nephrol 2011; 15:373-380. [PMID: 21301920 DOI: 10.1007/s10157-011-0415-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Accepted: 01/17/2011] [Indexed: 11/26/2022]
Abstract
AIM IgA nephropathy (IgAN) is a very common glomerulonephritis among young adults, but the best therapeutic approach has not been fully elucidated. This study evaluated the effect of two different treatment regimes in IgAN, steroids alone or in combination with azathioprine. METHODS Among 122 patients with primary IgA nephropathy diagnosed in the 2000-2007 period, 22 fulfilled the inclusion criteria for the study: estimated glomerular filtration rate (eGRF) ≥30 ml/min/1.73 m(2), urine protein (Upr) ≥1 g/24 h, blood pressure (BP) <130/80 mmHg, and previous treatment with renin-angiotensin system inhibitors (RAASi) and polyunsaturated fatty acids (PFA) for at least 6 months. Patients were randomized to receive either methylprednisolone alone (MP group) or MP in combination with azathioprine (MP + Aza group) for 12 months, while treatment with RAASi + PFA continued unchanged in both groups. RESULTS At the completion of the trial, renal function in the MP group remained stable, eGFR from 52 ± 26.7 to 53.6 ± 27.3 ml/min/1.73 m(2), p = NS, and Upr decreased from 2.4 ± 0.9 to 0.8 ± 0.5 g/24 h, p < 0.001. In the MP + Aza group, eGFR slightly increased from 57.4 ± 28.7 to 66 ± 31 ml/min/1.73 m(2), p = NS, and Upr decreased from 2.4 ± 1 to 0.7 ± 0.7 g/24 h, p < 0.001. Four patients from the MP group with partial remission at the end of the trial had a complete response when converted to Aza. Eleven patients (5 from the MP and 6 from the MP + Aza group) relapsed after stopping treatment and were restarted on lower doses. CONCLUSIONS Both, steroid treatment alone and steroids in combination with azathioprine seem to be effective in reducing the severity of proteinuria and stabilizing renal function in IgAN. Patients who do not respond to steroids may have a better response with the combination of steroids and azathioprine.
Collapse
Affiliation(s)
- Maria Stangou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece.
| | - Domniki Ekonomidou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Panagiotis Giamalis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Helen Liakou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Apostolis Tsiantoulas
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Afroditi Pantzaki
- Department of Histopathology, Hippokration Hospital, Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - George Efstratiadis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Efstathios Alexopoulos
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Dimitrios Memmos
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| |
Collapse
|
24
|
Uchiyama-Tanaka Y, Mori Y. Effects of eicosapentaenoic acid supplementation on immunoglobulin A nephropathy. Ther Apher Dial 2010; 14:303-7. [PMID: 20609183 DOI: 10.1111/j.1744-9987.2009.00791.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Eicosapentaenoic acid (EPA), which is purified from fish oil, attenuates inflammatory responses by decreasing eicosanoid and cytokine production. EPA reportedly improves renal survival in patients with immunoglobulin (Ig)A nephropathy; however, this is unconfirmed. We studied the effects of EPA on IgA nephropathy patients. Eighteen biopsy-confirmed IgA nephropathy patients (aged 31 +/- 3 years) were enrolled. The prognoses based on glomerular findings were good (N = 5), relatively poor (N = 12), and poor (N = 1). EPA was administered at 1.8 g/day for 12 months. Five biopsy-confirmed IgA nephropathy patients were enrolled as control subjects. Administration of other drugs used to treat IgA nephropathy was not changed. The estimated creatinine clearance (eCCr), serum creatinine (Cr) concentration, urinary protein creatinine ratio (U/P), and other clinical parameters were checked. In the EPA group, the Cr went from 0.8 +/- 0.2 mg/dL to 0.7 +/- 0.2 mg/dL after 12 months of EPA treatment, and the U/P went from 550 +/- 580 mg/g Cr to 330 +/- 920 mg/g Cr. The values did not differ significantly; however, Cr and U/P tended to improve, with no adverse effects from the EPA. The eCCr improved significantly (99 +/- 7-110 +/- 8 mL/min, P = 0.001) in the EPA group, but not in the control group (126 +/- 12-120 +/- 13, P > 0.05). The effect of EPA in patients with IgA nephropathy is not pronounced, but these results suggest that EPA is a safe and worthwhile supplement to the drugs used to treat this disease.
Collapse
|
25
|
Stoycheff N, Pandya K, Okparavero A, Schiff A, Levey AS, Greene T, Stevens LA. Early change in proteinuria as a surrogate outcome in kidney disease progression: a systematic review of previous analyses and creation of a patient-level pooled dataset. Nephrol Dial Transplant 2010; 26:848-57. [PMID: 20817671 DOI: 10.1093/ndt/gfq525] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Proteinuria is a candidate surrogate end point for randomized controlled trials (RCTs) in chronic kidney disease (CKD). There is a reasonably sound biological basis for this hypothesis, but only preliminary empirical evidence currently exists. METHODS A systematic review and creation of a patient-level dataset of randomized controlled trials (RCTs) in CKD that reported changes in proteinuria and assessed progression of kidney disease as defined by dialysis, transplantation, death, or changes in GFR or creatinine were performed. RESULTS Systematic review. Seventy RCTs met the eligibility criteria; 17 eligible RCTs contained analyses of proteinuria as a predictor of outcomes; 15 RCTs concluded that greater proteinuria was associated with adverse outcomes. A majority were studies of diabetic or hypertensive kidney disease and tested renin-angiotensin system blockade. Definitions of predictor and outcome variables were too variable to conduct a meta-analysis of group data. Database creation. Over 4 years was required to create the patient-level dataset. The final dataset included 34 studies and > 9000 patients with a variety of CKD types and interventions. CONCLUSIONS There are a relatively small number of RCTs designed to rigorously test therapies for kidney disease progression. Current analyses of change in proteinuria as a predictor of CKD progression are heterogeneous and incomplete, indicating further evaluation in a pooled individual patient-level database is necessary to advance knowledge in this field.
Collapse
|
26
|
Fassett RG, Gobe GC, Peake JM, Coombes JS. Omega-3 polyunsaturated fatty acids in the treatment of kidney disease. Am J Kidney Dis 2010; 56:728-42. [PMID: 20493605 DOI: 10.1053/j.ajkd.2010.03.009] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Accepted: 03/01/2010] [Indexed: 01/25/2023]
Abstract
After more than 25 years of published investigation, including randomized controlled trials, the role of omega-3 polyunsaturated fatty acids in the treatment of kidney disease remains unclear. In vitro and in vivo experimental studies support the efficacy of omega-3 polyunsaturated fatty acids on inflammatory pathways involved with the progression of kidney disease. Clinical investigations have focused predominantly on immunoglobulin A (IgA) nephropathy. More recently, lupus nephritis, polycystic kidney disease, and other glomerular diseases have been investigated. Clinical trials have shown conflicting results for the efficacy of omega-3 polyunsaturated fatty acids in IgA nephropathy, which may relate to varying doses, proportions of eicosapentaenoic acid and docosahexaenoic acid, duration of therapy, and sample size of the study populations. Meta-analyses of clinical trials using omega-3 polyunsaturated fatty acids in IgA nephropathy have been limited by the quality of available studies. However, guidelines suggest that omega-3 polyunsaturated fatty acids should be considered in progressive IgA nephropathy. Omega-3 polyunsaturated fatty acids decrease blood pressure, a known accelerant of kidney disease progression. Well-designed, adequately powered, randomized, controlled clinical trials are required to further investigate the potential benefits of omega-3 polyunsaturated fatty acids on the progression of kidney disease and patient survival.
Collapse
Affiliation(s)
- Robert G Fassett
- Renal Research, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
| | | | | | | |
Collapse
|
27
|
Abstract
Consumption of n-3 polyunsaturated fatty acids (PUFAs) found in fish oil suppresses inflammatory processes making these fatty acids attractive candidates for both the prevention and amelioration of several organ-specific and systemic autoimmune diseases. Both pre-clinical and clinical studies have been conducted to determine whether fish oils containing the n-3 PUFAs docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) can be used in the prevention and treatment of immunoglobulin A nephropathy (IgAN) and lupus nephritis. In a toxin-induced mouse model that mimics the early stages of IgAN, n-3 PUFA consumption suppresses aberrant interleukin (IL)-6-driven IgA production and mesangial IgA immune complex deposition by impairing phosphorylation of upstream kinases and activation of transcription factors essential for IL-6 gene transcription. n-3 PUFAs can also suppress production of anti-double-stranded DNA IgG antibodies and the resultant development of lupus nephritis in the NZBW F1 mouse and related models. These effects have been linked in part to impaired expression of proinflammatory cytokines and adhesion molecules as well as increases in antioxidant enzymes in kidney and immune organs. Several recent clinical trials have provided compelling evidence that n-3 PUFA supplementation could be useful in treatment of human IgAN and lupus nephritis, although some other studies suggest such supplementation might be without benefit. Future investigations employing genomics/proteomics and novel genetically altered mice should provide further insight into how n-3 PUFAs modulate these diseases as well help to identify clinically relevant biomarkers. The latter could be employed in future well-designed, long-term clinical studies that will resolve current controversies on n-3 PUFA efficacy in autoimmune-mediated glomerulonephritis.
Collapse
Affiliation(s)
- James J Pestka
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI 48824, USA.
| |
Collapse
|
28
|
STANGOU MARIA, ALEXOPOULOS EFSTATHIOS, PAPAGIANNI AIKATERINI, PANTZAKI AFRODITI, BANTIS CHRISTOS, DOVAS SPIROS, ECONOMIDOU DOMNIKI, LEONTSINI MARIA, MEMMOS DIMITRIOS. Urinary levels of epidermal growth factor, interleukin-6 and monocyte chemoattractant protein-1 may act as predictor markers of renal function outcome in immunoglobulin A nephropathy. Nephrology (Carlton) 2009; 14:613-20. [DOI: 10.1111/j.1440-1797.2008.01051.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
29
|
Miller ER, Juraschek SP, Appel LJ, Madala M, Anderson CAM, Bleys J, Guallar E. The effect of n-3 long-chain polyunsaturated fatty acid supplementation on urine protein excretion and kidney function: meta-analysis of clinical trials. Am J Clin Nutr 2009; 89:1937-45. [PMID: 19403630 PMCID: PMC3148029 DOI: 10.3945/ajcn.2008.26867] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Chronic kidney disease is a major worldwide problem. Although epidemiologic and experimental studies suggest that n-3 long-chain polyunsaturated fatty acid (n-3 LCPUFA) supplementation may prevent or slow the progression of kidney disease, evidence from clinical trials is inconsistent. OBJECTIVE The objective was to combine evidence from controlled clinical trials to assess the effect of n-3 LCPUFA supplementation on the change in urine protein excretion (UPE) and on glomerular filtration rate (GFR). DESIGN We performed a meta-analysis of clinical trials that tested the effect of n-3 LCPUFA supplementation on UPE, a marker of kidney damage, and on GFR, a marker of kidney function. A random-effects model was used to pool SD effect size (Cohen's d) across studies. RESULTS Seventeen trials with 626 participants were included in the meta-analysis. Most trials focused on patients with a single underlying diagnosis: IgA nephropathy (n = 5), diabetes (n = 7), or lupus nephritis (n = 1). The dose of n-3 LCPUFAs ranged from 0.7 to 5.1 g/d, and the median follow-up was 9 mo. In the pooled analysis, there was a greater reduction in UPE in the n-3 LCPUFA group than in the control group: Cohen's d for all trials was -0.19 (95% CI: -0.34, -0.04; P = 0.01). In a patient with 1 g UPE/d , this corresponds to a reduction of 190 mg/d. Effects on GFR were reported in 12 trials. The decline in GFR was slower in the n-3 LCPUFA group than in the control group, but this effect was not significant (0.11; 95% CI: -0.07, 0.29; P = 0.24). CONCLUSIONS In our meta-analysis, use of n-3 LCPUFA supplements reduced UPE but not the decline in GFR. However, small numbers of participants in trials, different methods of assessing proteinuria and GFR, and inconsistent data reporting limit the strength of these conclusions. Large, high-quality trials with clinical outcomes are warranted.
Collapse
Affiliation(s)
- Edgar R Miller
- Johns Hopkins School of Medicine, the Johns Hopkins Bloomberg School of Public Health, and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD 21205, USA.
| | | | | | | | | | | | | |
Collapse
|
30
|
Ferraro PM, Ferraccioli GF, Gambaro G, Fulignati P, Costanzi S. Combined treatment with renin-angiotensin system blockers and polyunsaturated fatty acids in proteinuric IgA nephropathy: a randomized controlled trial. Nephrol Dial Transplant 2008; 24:156-60. [DOI: 10.1093/ndt/gfn454] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
31
|
Donadio JV, Bergstralh EJ, Bibus DM, Grande JP. Is body size a biomarker for optimizing dosing of omega-3 polyunsaturated fatty acids in the treatment of patients with IgA nephropathy? Clin J Am Soc Nephrol 2006; 1:933-9. [PMID: 17699310 DOI: 10.2215/cjn.00260106] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Re-analysis of the North American IgA Nephropathy Study suggested that efficacy of omega-3 polyunsaturated fatty acids (omega-3 PUFA) was dosage-dependent on the basis of body size and plasma omega-3/omega-6 and eicosapentaenoic acid (EPA)/arachidonic acid (AA) ratios. The objective of this study was to confirm these assertions. Data from a previously reported randomized 2-yr clinical trial in which two dosages of an ethyl ester omega-3 PUFA (Omacor) were given to 73 high-risk patients with IgA nephropathy were reviewed. Omacor also was used in the North American IgA Nephropathy Study. Parameters included body weight; body mass index (BMI); plasma phospholipid AA, EPA, and docosahexanoic acid (DHA) levels and serum creatinine and 24-h urine protein (UP) levels during the 2-yr trial; and time to ESRD after 6.4 yr. Plasma phospholipid levels of EPA, DHA, and EPA/AA ratios were significantly inversely correlated with increasing body weight and BMI in the Omacor 4-g dosage group but not in the Omacor 8-g dosage group. Conversely, increasing levels of lipid parameters were observed with increasing dosages of Omacor (EPA+DHA) in grams per kilogram of body weight at 6 wk of treatment. None of the plasma omega-3 PUFA levels, EPA/AA ratios, or Omacor dosage per kilogram was significantly associated with reciprocal serum creatinine or UP slopes during the 2-yr trial or with ESRD. This post hoc analysis of body weight and BMI, plasma omega-3 PUFA status, and renal outcome did not find that treatment efficacy of omega-3 PUFA was dosage dependent on the basis of body size.
Collapse
|