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Nash PS, Fandler-Höfler S, Ambler G, Zhang W, Ozkan H, Locatelli M, Du Y, Obergottsberger L, Wünsch G, Jäger HR, Enzinger C, Wheeler DC, Simister RJ, Gattringer T, Werring DJ. Associations of Cerebral Small Vessel Disease and Chronic Kidney Disease in Patients With Acute Intracerebral Hemorrhage: A Cross-Sectional Study. Neurology 2024; 103:e209540. [PMID: 38889380 PMCID: PMC11254447 DOI: 10.1212/wnl.0000000000209540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/15/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Chronic kidney disease (CKD) may be associated with the pathogenesis and phenotype of cerebral small vessel disease (SVD), which is the commonest cause of intracerebral hemorrhage (ICH). The purpose of this study was to investigate the associations of CKD with ICH neuroimaging phenotype, volume, and location, total burden of small vessel disease, and its individual components. METHODS In 2 cohorts of consecutive patients with ICH evaluated with MRI, we investigated the frequency and severity of CKD based on established Kidney Disease Improving Global Outcomes criteria, requiring estimated glomerular filtration rate (eGFR) measurements <60 mL/min/1.732 ≥ 3 months apart to define CKD. MRI scans were rated for ICH neuroimaging phenotype (arteriolosclerosis, cerebral amyloid angiopathy, mixed location SVD, or cryptogenic ICH) and the presence of markers of SVD (white matter hyperintensities [WMHs], cerebral microbleeds [CMBs], lacunes, and enlarged perivascular spaces, defined according to the STandards for ReportIng Vascular changes on nEuroimaging criteria). We used multinomial, binomial logistic, and ordinal logistic regression models adjusted for age, sex, hypertension, and diabetes to account for possible confounding caused by shared risk factors of CKD and SVD. RESULTS Of 875 patients (mean age 66 years, 42% female), 146 (16.7%) had CKD. After adjusting for age, sex, and comorbidities, patients with CKD had higher rates of mixed SVD than those with eGFR >60 (relative risk ratio 2.39, 95% CI 1.16-4.94, p = 0.019). Severe WMHs, deep microbleeds, and lacunes were more frequent in patients with CKD, as was a higher overall SVD burden score (odds ratio 1.83 for each point on the ordinal scale, 95% CI 1.31-2.56, p < 0.001). Patients with eGFR ≤30 had more CMBs (median 7 [interquartile range 1-23] vs 2 [0-8] for those with eGFR >30, p = 0.007). DISCUSSION In patients with ICH, CKD was associated with SVD burden, a mixed SVD phenotype, and markers of arteriolosclerosis. Our findings indicate that CKD might independently contribute to the pathogenesis of arteriolosclerosis and mixed SVD, although we could not definitively account for the severity of shared risk factors. Longitudinal and experimental studies are, therefore, needed to investigate causal associations. Nevertheless, stroke clinicians should be aware of CKD as a potentially independent and modifiable risk factor of SVD.
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Affiliation(s)
- Philip S Nash
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Simon Fandler-Höfler
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Gareth Ambler
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Wenpeng Zhang
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Hatice Ozkan
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Martina Locatelli
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Yang Du
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Lena Obergottsberger
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Gerit Wünsch
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Hans Rolf Jäger
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Christian Enzinger
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - David C Wheeler
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Robert J Simister
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Thomas Gattringer
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
| | - David J Werring
- From the UCL Stroke Research Centre (P.S.N., S.F.-H., W.Z., H.O., M.L., Y.D., R.J.S., D.J.W.), Department of Brain Repair and Rehabilitation, and Comprehensive Stroke Service (P.S.N., H.O., R.J.S., D.J.W.), National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, UCL Queen Square Institute of Neurology, London, United Kingdom; Department of Neurology (S.F.-H., L.O., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Institute for Medical Informatics (G.W.), Statistics and Documentation, Medical University of Graz, Austria; Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, UCL Institute of Neurology; Department of Renal Medicine (D.C.W.), University College London, United Kingdom; and Division of Neuroradiology (T.G.), Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Austria
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Wang M, Tang WW, Li XS, de Oliveira Otto MC, Lee Y, Lemaitre RN, Fretts A, Nemet I, Sotoodehnia N, Sitlani CM, Budoff M, DiDonato JA, Wang Z, Bansal N, Shlipak MG, Psaty BM, Siscovick DS, Sarnak MJ, Mozaffarian D, Hazen SL. The Gut Microbial Metabolite Trimethylamine N -oxide, Incident CKD, and Kidney Function Decline. J Am Soc Nephrol 2024; 35:749-760. [PMID: 38593157 PMCID: PMC11164118 DOI: 10.1681/asn.0000000000000344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 04/01/2024] [Indexed: 04/11/2024] Open
Abstract
Key Points In community-based US adults, higher plasma trimethylamine N -oxide levels associated with higher risk of incident CKD and greater rate of kidney function decline. Findings from our study support future clinical trials to examine whether lowering plasma trimethylamine N -oxide levels may prevent CKD development and progression. Background Trimethylamine N -oxide (TMAO) is a gut microbiota–derived metabolite of dietary phosphatidylcholine and carnitine. Experimentally, TMAO causes kidney injury and tubulointerstitial fibrosis. Little is known about prospective associations between TMAO and kidney outcomes, especially incident CKD. We hypothesized that higher plasma TMAO levels would be associated with higher risk of incident CKD and greater rate of kidney function decline. Methods We included 10,564 participants from two community-based, prospective cohorts with eGFR ≥60 ml/min per 1.73 m2 to assess incident CKD. TMAO was measured using targeted mass spectrometry at baseline and one follow-up visit. Creatinine and cystatin C were measured up to four times during follow-up and used to compute eGFR. Incident CKD was defined as an eGFR decline ≥30% from baseline and a resulting eGFR <60 ml/min per 1.73 m2. Time-varying Cox models assessed the association of serial TMAO measures with incident CKD, adjusting for sociodemographic, lifestyle, diet, and cardiovascular disease risk factors. Linear mixed models assessed the association with annualized eGFR change in 10,009 participants with at least one follow-up eGFR measure without exclusions for baseline eGFR levels. Results During a median follow-up of 9.4 years (interquartile range, 9.1–11.6 years), 979 incident CKD events occurred. Higher TMAO levels were associated with higher risk of incident CKD (second to fifth versus first quintile hazard ratio [95% confidence interval]=1.65 [1.22 to 2.23], 1.68 [1.26 to 2.25], 2.28 [1.72 to 3.02], and 2.24 [1.68 to 2.98], respectively) and greater annualized eGFR decline (second to fifth versus first quintile annualized eGFR change=−0.21 [−0.32 to −0.09], −0.17 [−0.29 to −0.05], −0.35 [−0.47 to −0.22], and −0.43 [−0.56 to −0.30] ml/min per 1.73 m2, respectively) with monotonic dose–response relationships. These associations were consistent across different racial/ethnic groups examined. The association with eGFR decline was similar to or larger than that seen for established CKD risk factors, including diabetes, per 10 mm Hg of higher systolic BP, per 10 years of older age, and Black race. Conclusions In community-based US adults, higher serial measures of plasma TMAO were associated with higher risk of incident CKD and greater annualized kidney function decline.
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Affiliation(s)
- Meng Wang
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - W.H. Wilson Tang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland, Ohio
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Xinmin S. Li
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland, Ohio
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland, Ohio
| | - Marcia C. de Oliveira Otto
- Division of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, Texas
| | - Yujin Lee
- Department of Food and Nutrition, Myongji University, Yongin, South Korea
| | - Rozenn N. Lemaitre
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, Washington
| | - Amanda Fretts
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Ina Nemet
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland, Ohio
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland, Ohio
| | - Nona Sotoodehnia
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, Washington
| | - Colleen M. Sitlani
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, Washington
| | - Matthew Budoff
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Joseph A. DiDonato
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland, Ohio
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland, Ohio
| | - Zeneng Wang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland, Ohio
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland, Ohio
| | - Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Michael G. Shlipak
- Kidney Health Research Collaborative and Department of Medicine, San Francisco Veterans Administration Medical Center and University of California–San Francisco, San Francisco, California
| | - Bruce M. Psaty
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington
| | | | - Mark J. Sarnak
- Department of Medicine (Nephrology), Tufts University School of Medicine, Boston, Massachusetts
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Stanley L. Hazen
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland, Ohio
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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