Trends in the prevalence of chronic kidney disease and its risk factors in a general Japanese population: the Hisayama Study

Association between Vascular Calcification and Intraplaque Hemorrhage in Coronary Atherosclerosis from Autopsy: The Hisayama Study

AIMS

Vascular calcification is observed in advanced atherosclerotic lesions. Vascular calcification is considered to increase the risk of intraplaque hemorrhage and subsequent plaque destabilization; however, there is limited pathohistoological evidence of the association between vascular calcification and intraplaque hemorrhage. The aim of this study was to investigate the association between vascular calcification and intraplaque hemorrhage in the coronary arteries.

METHODS

We examined 374 coronary arteries obtained from the autopsy samples of 126 deceased individuals. The vascular calcification levels of each artery were categorized into no calcification and quintiles of calcification area size among the arteries with calcification. Macrophage infiltration and neovascularization were also evaluated. The association of the calcification area, macrophage area, or number of vessels with the presence of intraplaque hemorrhage in the coronary arteries was estimated using a logistic regression analysis.

RESULTS

Calcification lesions were observed in 149 coronary arteries. Arteries in the fourth quintile of calcification area size had a significantly greater likelihood of intraplaque hemorrhage than the arteries without calcification, after adjusting for confounders: odds ratio 13.13 (95% confidence interval: 2.97-58.16). After evaluating the influence of macrophage infiltration, the highest odds ratio of intraplaque hemorrhage was associated with the combination of large macrophage area and moderately sized calicification areas. The odds ratio of intraplaque hemorrhage additively increased with the combination of calcification and the number of vessels.

CONCLUSIONS

The present findings suggest that vascular calcification is significantly associated with intraplaque hemorrhage. The association between vascular calcification and intraplaque hemorrhage may decrease above a certain size of the calcification area.

Cognitive Impairment and Brain Atrophy in Patients with Chronic Kidney Disease

In Japan, the aging of the population is rapidly accelerating, with an increase in patients with chronic kidney disease (CKD) and those undergoing dialysis. As a result, the number of individuals with cognitive impairment (CI) is rising, and addressing this issue has become an urgent problem. A notable feature of dementia in CKD patients is the high frequency of vascular dementia, making its prevention through the management of classical risk factors such as hypertension, diabetes mellitus, dyslipidemia, smoking, etc., associated with atherosclerosis and arteriosclerosis. Other effective measures, including the use of renin-angiotensin system inhibitors, addressing anemia, exercise therapy, and lifestyle improvements, have been reported. The incidence and progression of CI may also be influenced by the type of kidney replacement therapy, with reports suggesting that long-duration dialysis, low-temperature hemodialysis, peritoneal dialysis, and kidney transplantation can have a preferable effect on the preservation of cognitive function. In conclusion, patients with CKD are at a higher risk of developing CI, with brain atrophy being a contributing factor. Despite the identification of various preventive measures, the evidence substantiating their efficacy remains limited across all studies. Future expectations lie in large-scale randomized controlled trials.

Prevalence of chronic kidney disease and metabolic related indicators in Mianzhu, Sichuan, China

Background

Chronic kidney disease (CKD) is a major public health problem worldwide. Periodic surveys are essential for monitoring the prevalence of CKD and its risk factors. We assessed the prevalence of CKD and its risk factors in Mianzhu City in 2020.

Method

The Natural Population Cohort Study surveyed 7,770 individuals aged>20 years in Mianzhu City of Sichuan province in 2020. Our investigation encompassed the measurement of CKD prevalence, the evaluation of various renal function indicators, and comparisons based on age, gender, and hukou status. Additionally, some metabolic indices were also measured to identify the underlying causes of CKD.

Results

(1) Overall, the prevalence of reduced renal function (eGFR<60 mL/min/1.73m2), albuminuria, and CKD were 1.3, 10.0, and 10.4%, respectively, (2) the overall prevalence of CKD was higher among men than among women (14.5% vs. 8.6%). Similarly, the prevalence of CKD was higher among men than women in most age groups, (3) among urban residents, the prevalence of CKD was higher among middle-aged individuals and lower among young individuals and older adults, and (4) considering eGFR, the albuminuria and CKD for group definition, Blood pressure, triglyceride, high-density lipoprotein, blood sugar, and BMI were all statistically different among between normal groups and abnormal groups s in the albuminuria and CKD.

Conclusion

The incidence of CKD greatly varied between Mianzhu City and other regions in China and other countries. The differences in risk factors of CKD should be explored in the future. The gender difference in the prevalence of CKD in this study was markedly different from that in previous studies. More high-quality studies are needed to further explore this controversy. Based on the different prevalence of CKD and metabolism-related indices in rural and urban areas in this study, we speculated that the high incidence of CKD in Mianzhu City might be related to diet, lifestyle, and availability of healthcare services.

Prevalence of and risk factors for chronic kidney disease in ten metropolitan areas of China: a cross-sectional study using three kidney damage markers

INTRODUCTION

To estimate the up-to-date prevalence of chronic kidney disease among the health check-up population in economically developed areas of China using estimated glomerular filtration rate, urinary albumin creatinine ratio, and kidney ultrasound.

METHODS

Healthcare data from 38,093 subjects in 10 megalopolises of China who had an annual health check-up in 2021 were used. The overall and stratified prevalence of chronic kidney disease by sex, age, region and comorbidity group was reported. The association between chronic kidney disease and covariates of demographics, and comorbidities were analyzed in the multivariable-adjusted logistic regression model.

RESULTS

A total of 3837 CKD cases were detected meeting any of the three CKD diagnostic criteria, with a crude prevalence of 10.1% in the study population. Using one criterion of decreased glomerular filtration rate, albuminuria and kidney structural abnormalities alone detected 204 (5.3%), 3289 (85.7%) and 563 (14.7%) cases, respectively. The addition of kidney ultrasound detected 427 (11.1%) structural abnormality cases without decreased GFR and albuminuria. The most common abnormalities were renal masses, hydronephrosis due to obstruction and congenital anomalies of kidney and urinary tract. Female, older age, low city-tier, hypertension, diabetes, obesity, hypertriglyceridemia as well as early disease stages such as pre-hypertension, impaired fasting glucose and overweight were significantly associated with chronic kidney disease.

CONCLUSION

Kidney ultrasound helps to amplify the detection of CKD patients, which is a supplement to kidney function and urine protein.

Combination of Risks of BMI and Health-Related Lifestyles on Kidney Function in the Prediabetic Japanese Population: A Prospective Cohort Study

Diabetic overweight patients are more likely to show the progression of kidney damage than the general population. The majority of people in the early stages of kidney damage do not recognize the importance of risk modification, mainly due to the asymptomatic nature of the disease. This study aimed to examine specific risk combinations of lifestyle and BMI regarding the deterioration of kidney function and to explore whether there are gender-based differences among the prediabetic population. Prediabetic participants with normal kidney function were identified via annual health examination from April 2016 to March 2019. The information on health status and lifestyle was collected at enrollment. The study subjects were followed until March 2021 to observe the progression of kidney damage. There were 2241 participants enrolled in this study. Smoking (HR = 3.5, p < 0.001), eating snacks (HR = 3.2, p < 0.001), not engaging in regular exercise (HR = 2.9, p < 0.001), and not having adequate sleep (HR = 3.0, p < 0.001) showed accelerated risks for kidney damage progression among the prediabetic population in males. These lifestyle effects were not observed in females. In conclusion, risk-based modification of lifestyle behavior is important to prevent kidney function damage among the overweight prediabetic population in males.

Association between physical activity and mortality in the Japanese general population with mild to moderate impaired renal function: the Jichi Medical School (JMS) cohort study

BACKGROUND

The association between physical activity volume or intensity and mortality in general population with impaired renal function is unclear. We assessed these relationships among Japanese residents with impaired renal function.

METHODS

We analyzed 638 individuals with estimated creatinine clearance below 60 ml/min in the Jichi Medical School cohort study. Exposures included the daily amount of physical activity converted to the physical activity index (PAI) used in the Framingham study and the activity time for each intensity. Physical activity intensity was classified into sedentary and nonsedentary. Nonsedentary activity was further divided into light-intensity and moderate-to-vigorous physical activity (MVPA). The outcome was all-cause mortality. Quartiles of the exposures were created, and hazard ratios (HRs) were calculated using the Cox proportional hazards model.

RESULTS

The mean age of the subjects was 63.3 years, and 72.4% were female. In total, 172 deaths were registered during 11,567 person-years. No significant association was found between PAI and mortality. A significant association was found between long sedentary time and increased mortality (p = 0.042). Regarding nonsedentary activity, the HRs [95% confidence intervals (CIs)] for Q2, Q3, and Q4 versus Q1 were 0.85 (0.55-1.31), 0.67 (0.41-1.08), and 0.90 (0.54-1.45), respectively. In the subdivided analysis for light-intensity activity, the HRs (95% CIs) of Q2, Q3, and Q4 versus Q1 were 0.53 (0.33-0.84), 0.51 (0.34-0.82), and 0.57 (0.34-0.96), respectively. No significant association was found between MVPA and mortality.

CONCLUSIONS

Nonsedentary activity, especially light-intensity activity, significantly reduced mortality among residents with impaired renal function.

Chronic kidney disease is more prevalent among women but more men than women are under nephrological care : Analysis from six outpatient clinics in Austria 2019

BACKGROUND

A discrepancy between sex-specific treatment of kidney failure by dialysis (higher in men) and the prevalence of chronic kidney disease in the general population (higher in women) has been reported internationally, but the prevalence by sex has not been described for Austria. Sex disparity among nephrology outpatients has not been studied.

METHODS

We employed two formulae (2009 CKD-EPI suppressing the race factor, and race-free 2021 CKD-EPI) to estimate the sex distribution of CKD in Austrian primary care, based on creatinine measurements recorded in a medical sample of 39,800 patients from general practitioners' offices (1989-2008). Further, we collected information from all clinic appointments scheduled at nephrology departments of 6 Austrian hospitals (Wien, Linz, Wels, St. Pölten, Villach, Innsbruck) during 2019 and calculated visit frequencies by sex.

RESULTS

Using the 2009 CKD-EPI formula, the prevalence of CKD in stages G3-G5 (estimated glomerular filtration rate < 60 mL/min/1.73 m²) was 16.4% among women and 8.5% among men aged > 18 years who had attended general practitioners' offices in Austria between 1989 and 2008 and had at least one creatinine measurement performed. Using the 2021 CKD-EPI formula, the respective CKD prevalence was 12.3% among women and 6.1% among men. In 2019, 45% of all outpatients at 6 participating nephrology departments were women. The median of nephrology clinic visits in 2019 was two (per year) for both sexes.

CONCLUSION

CKD is more prevalent among Austrian women than men. Men are more prevalent in nephrology outpatient services. Research into causes of this sex disparity is urgently needed.

The Beneficial Effect of Personalized Lifestyle Intervention in Chronic Kidney Disease Follow-Up Project for National Health Insurance Specific Health Checkup: A Five-Year Community-Based Cohort Study

Background and Objectives: Mimasaka city is a relatively small city with a population of 28,381, and an aging rate (≥65 years old) of 38.9%, where only one nephrology clinic is available. Since 2013, the city has conducted its own unique lifestyle intervention for the participants of the National Health Insurance specific medical health checkup, aiming to prevent the progression of chronic kidney disease (CKD) severity. Materials and Methods: The persons in National Health Insurance specific medical health checkup (40−74 years old) conducted in Mimasaka city in 2013, with eGFR less than 50 mL/min/1.73 m² or 50−90 mL/min/1.73 m² with urine dipstick protein 1+ or more, were registered for the CKD follow-up project, as high-risk subjects for advanced renal dysfunction. Municipal workers directly visited the subjects’ homes to provide individual health guidance and encourage medical consultation. We aimed to examine the effect of home-visit intervention on the changes of renal function and related factors until 2017. Results: The number of the high-risk subjects who continuously received the health checkup until 2017 was 63, and only 23 (36.5%) visited a medical institution in the first year. The eGFR decreased by only 0.4 mL/min/1.73 m²/year, and the subjects with urinary protein 1+ or higher decreased significantly from 20 (31.7%) to 9 (14.3%) (p = 0.034) in the high-risk subjects. The changes in eGFR and urinary protein was almost in the same fashion regardless of their medical institution visits. Next, we examined the effects of various factors on ΔeGFR, the changes of eGFR from 2013 to 2017, by multivariate linear regression analysis. The effects of medical institution visit were not significant, and the degree of urinary protein (coefficient B: 4.503, β: 0.705, p < 0.001), age (coefficient B: 4.753, β: 0.341, p = 0.004), and smoking (coefficient B: 5.878, β: 0.295, p = 0.031) had independent significant effects, indicating that they were the factors exacerbating the decrease in eGFR from the baseline. Conclusions: The personalized lifestyle intervention by home-visit in CKD follow-up project showed the possibility of beneficial effects on the deterioration of renal function. This may be an efficient method to change behavior in a small community with limited medical resources.

Chronic kidney disease among greenhouse workers and field workers in China

BACKGROUND

Agricultural workers are at increased risk of developing chronic kidney disease of non-traditional etiology (CKDnt). The environment in solar greenhouse has high-intensity agricultural hazard factors. However, the association between solar greenhouse work and CKDnt remains unknown.

OBJECTIVES

We aimed to evaluate the relationship among solar greenhouse work, field work, and CKDnt risk, and to explore gender differences in CKDnt risk among solar greenhouse workers.

METHODS

Solar greenhouse workers and field workers were selected as the greenhouse worker and field worker groups in a cross-sectional study. Individuals with an estimated glomerular filtration rate (eGFR) of <60 ml/min per 1.73 m² were defined as CKDnt patients. Binary logistic regression and generalized linear regression models were used to estimate the association among solar greenhouse workers, field workers and CKDnt. Furthermore, gender differences in CKDnt were also analyzed.

RESULTS

A total of 638 solar greenhouse workers and 231 field workers were included. The prevalence of CKDnt was 2.8% in the solar greenhouse workers and 0.4% in the field workers, and the prevalence of CKDnt was higher in female solar greenhouse workers than in males. The eGFR reduced by 20.0% (19.74 ml/min per 1.73 m²) in the greenhouse worker group compared with that in the field worker group (p < 0.05). Generalized linear analysis showed that the level of eGFR was lower in women than that in men after adjusting for parameters (β = -10.99 [-12.79, -9.10]).

CONCLUSION

Solar greenhouse workers may be at an increased risk of CKDnt, and women are more vulnerable.

The Relationship Between Edema and Body Functions in Patients With Chronic Kidney Disease: A Preliminary Study

Introduction: Chronic kidney disease (CKD) is known to be a risk factor for falls. In addition, numerous factors such as impaired body balance and loss of muscle mass were reported as risk factors for falls. Patients with CKD often have edema in their lower extremes. In Japan, edema, as well as physical factors, are listed as fall assessment items. Little is known about the relation between body functions and edema in patients with CKD. Thus, we conducted a multivariate regression analysis to investigate the factors related to knee extension muscle strength and dynamic balance in motion (TUG).

Materials and methods: Thirty patients with CKD participated in this study. The basic characteristics were sex, age, blood pressure, body mass index (BMI), and medications. The laboratory data were estimated glomerular filtration rate (eGFR), hemoglobin (Hb), and C-reactive protein (CRP). Edema and muscle mass was measured by using InBody S10 (Inbody Japan Inc., Tokyo, Japan). The balance function while standing at rest and motion was measured as the total trajectory length of the center of gravity and the index of postural stability (IPS) using a kinetogravicorder 7100 (Anima Inc., Tokyo, Japan). Dynamic balance was assessed by the timed up & go (TUG) test. Knee extension muscle strength was measured by the Micro Total Analysis System (μ-Tas) F-1 (Anima Inc., Tokyo, Japan) test. Nutritional assessment was measured by the geriatric nutritional risk index (GNRI). Activities of daily living were measured using the functional independence measure (FIM). We conducted a multivariate regression analysis to investigate the factors related to knee extension muscle strength and dynamic balance in motion.

Results: Extracellular water/total body water (ECW/TBW) was not significantly correlated with balance at rest and IPS. The ECW/TBW was associated with knee extension muscle strength, TUG, albumin (Alb), Hb, and GNRI with statistical significance. After adjusting for sex and age, knee extension muscle strength was associated with ECW/TBW and TUG (p=0.044). The TUG was also associated with ECW/TBW after being adjusted for age and sex (p=0.046). 

Conclusion: Patients with CKD who have edema may have decreased knee extensor strength and body balance function. Investigation of knee extension muscle strength and the body balance test in addition to the presence of leg edema at the time of physical examination may help predict a functional decline in CKD patients.

Late Presentation for Kidney Biopsy: Clinical Presentations and Laboratory Findings

Although the number of patients reaching end-stage kidney disease without a biopsy- proven diagnosis is increasing, kidney biopsies play a key role in diagnosing kidney disease. We analyzed prospective data from patients with kidney disease who underwent percutaneous native kidney biopsies from January 2006 to December 2017. Demographic data, clinical presentations, and the laboratory and radiological findings at the time of biopsy were analyzed. Of 530 patients, 42.8% were male. The mean age was 33.9 (32.8-34.9.2) years; 66.3% were aged 25-64 years. Edema was the main clinical presentation (61.9%), with clinical urine changes seen in 66.7%. Most (89.6%) were nondiabetic; 46.8% had high blood pressure or were on antihypertensive therapy. Most patients (77.5%) were in Stages I, II, and III, and 12.3% underwent hemodialysis at the time of admission. Most (54.4%) were obese. Low hemoglobin (31.8%), high triglycerides (30%), high total cholesterol (58.2%), low serum albumin (73.9%), nephrotic proteinuria (61.8.6%), and microscopic hematuria (79.8%) were the main laboratory findings. The immunological investigations showed that antinuclear antibodies, positive anti-double-stranded DNA (anti-dsDNA), and extractable nuclear antigens were positive in 29.6%, 20.7%, and 19.7%, respectively. Perinuclear antineutrophil cytoplasmic antibodies (ANCA) were positive in 9.6% and cytoplasmic ANCA were positive in 5.4%, whereas immunoglobulin A was detected in 4.6%. More than one- third of the patients had reached advanced chronic kidney disease (CKD) Stages IIIB, IV, and V. This indicates the need to increase awareness about CKD, greater utilization of kidney biopsies, and earlier investigations to enable accurate diagnoses, and proper and timely management.

Risk Factors for Progression of CKD with and without Diabetes

OBJECTIVE

We aim to identify independent risk factors to predict CKD progression to end stage renal disease (ESRD) in patients with or without diabetes.

METHODS

In this retrospective study, we enrolled CKD stage 3-4 patients between January 2013 and December 2018 and followed them until December 2020 or the initiation of dialysis. We used Kaplan-Meier to plot the survival curve. Univariate and multivariable Cox proportional hazards model was used to explore risk factors affecting the progression of CKD. The final model was used to construct nomogram for predicting CKD progression. Calibration plots and concordance index (C-index) were used to evaluate the accuracy and discrimination of the risk model.

RESULTS

We enrolled 309 CKD patients, including 80 cases in G3a, 98 cases in G3b, and 131 cases in G4. Among them, 141 patients had diabetes and 168 did not. The mean age of patients at enrolled was 57.86 ± 15.10 years, and 67% were male. The median follow-up time was 25.6 months. There were 81 patients (26.2%) that started dialysis in the total CKD cohort, 52 cases (36.9%) in the CKD with diabetes group, and 29 cases (17.3%) in the CKD without diabetes group. Hypoalbuminemia (HR =2.655, P < 0.001), proteinuria (HR =2.592, P = 0.042), increased LDL (HR =2.494, P < 0.001), diabetes (HR =2.759, P < 0.001), hypertension (HR =3.471, P = 0.037), and CKD stage (HR =2.001, P = 0.046) were risk factors for CKD progression to ESRD in the overall population. For those without diabetes, only hypoalbuminemia (HR =2.938, P = 0.030) was a risk factor for CKD progression to ESRD. For those with diabetes, both hypoalbuminemia (HR =2.758, P = 0.002), the increased level of LDL (HR =3.982, P < 0.001), and CKD stage (HR =3.781, P = 0.001) were risk factors for CKD progression to ESRD. The C-index of the final nomograms was 0.760 (P < 0.001).

CONCLUSIONS

The results from our risk factor model suggest that CKD disease progression can be predicted and early strategic intervention is necessary for CKD patients to avoid renal function deterioration.

Nephrologists’ Perspectives on Gender Disparities in CKD and Dialysis

Introduction

Globally, there are more women with chronic kidney disease (CKD), yet they comprise only 40% of patients receiving kidney replacement therapy by dialysis. We aimed to describe the perspectives of nephrologists on gender disparities in access to care and outcomes in CKD and dialysis.

Methods

We conducted semistructured interviews with 51 nephrologists (28, 55% women) from 22 countries from October 2019 to April 2020. Transcripts were analyzed thematically.

Results

We identified 6 themes. Related to women were primary commitment to caregiving (with subthemes of coordinating care, taking charge of health management, deprioritizing own health, centrality of family in decision-making); vigilance and self-reliance (diligence and conscientiousness, stoicism and tolerating symptoms, avoiding burden on family, isolation and coping alone); and stereotyping, stigma, and judgment (body image, dismissed as anxiety, shame and embarrassment, weakness and frailty). Related to men was protecting masculinity (safeguarding the provider role, clinging to control, self-regard, and entitled). Decisional power and ownership included men’s dominance in decision-making and women’s analytical approach in treatment decisions. Inequities compounded by social disadvantage (financial and transport barriers, without social security, limited literacy, entrenched discrimination, vulnerability) were barriers to care for women, particularly in socioeconomically disadvantaged communities.

Conclusion

Nephrologists perceived that women with CKD faced many challenges in accessing care related to social norms and roles of caregiving responsibilities, disempowerment, lack of support, stereotyping by clinicians, and entrenched social and economic disadvantage. Addressing power differences, challenging systemic patriarchy, and managing unconscious bias may help to improve equitable care and outcomes for all people with CKD.

Changes in Prevalence and Health Checkup Coverage Rate of Chronic Kidney Disease (CKD) after Introduction of Prefecture-Wide CKD Initiative: Results of the Kagawa Association of CKD Initiatives

The National Health Insurance (NHI) special health checkup system in Japan targets the NHI population aged 40–74 years. Since 2015, the Kagawa NHI special health checkup was initiated in a prefecture-wide chronic kidney disease (CKD) initiative, including renal examination as an essential item in NHI health checkups. Here, we aimed to investigate the effects of the prefecture-wide CKD initiative. We conducted a retrospective cohort survey using the Kagawa National Health Insurance database created by the Kagawa National Health Insurance Organization. Results of the NHI health checkup (2015–2019) and prefecture-wide outcomes (2013–2019) were analyzed. The prevalence of CKD among examinees who underwent the NHI health checkup increased from 17.7% in 2015 to 23.2% in 2019. The percentage of examinees who completed a medical visit was 29.4% in 2015. After initiation of the initiative, the NHI health checkup coverage rate increased significantly, from a mean (standard deviation) of 40.8% (0.4%) to 43.2% (1.1%) (p = 0.04). After the start of the CKD initiative, we found an increase in the prevalence of CKD and the NHI health checkup coverage rate.

Prognostic impact of malnutrition on cardiovascular events in coronary artery disease patients with myocardial damage

BACKGROUND

Stable coronary artery disease (CAD) patients with myocardial damage have a poor prognosis compared to those without myocardial damage. Recently, malnutrition has been reported to affect the prognosis of cardiovascular diseases. However, the effects of malnutrition on prognosis of CAD patients with myocardial damage remains uncertain. We investigated the effects of malnutrition on prognosis of CAD patients with myocardial damage who received percutaneous coronary intervention (PCI).

METHODS

Subjects comprised 241 stable CAD patients with myocardial damage due to myocardial ischemia or infraction. Patients underwent successful revascularization for the culprit lesion by PCI using second-generation drug-eluting stents and intravascular ultrasound. The geriatric nutritional risk index (GNRI), which is widely used as a simple method for screening nutritional status using body mass index and serum albumin, was used to assess nutritional status. Associations between major cardiovascular and cerebrovascular events (MACCE) and patient characteristics were assessed.

RESULTS

Mean GNRI was 100 ± 13, and there were 55 malnourished patients (23%; GNRI < 92) and 186 non-malnourished patients (77%). MACCE occurred within 3 years after PCI in 42 cases (17%), including 34 deaths (14%), and the malnourished group showed a higher rate of MACCE (38%) compared with the non-malnourished group (11%, p < 0.001). Univariate Cox proportional hazards analyses showed that MACCE was associated with age [hazard ratio (HR), 1.04; 95% confidence interval (CI), 1.04-1.07; p = 0.004], prior heart failure (HR 2.35; 95% CI 1.10-5.01; p = 0.027), high-sensitivity C-reactive protein (HR 1.08; 95% CI 1.03-1.11; p < 0.001), hemodialysis (HR 2.63; 95% CI 1.51-4.58; p < 0.001) and malnutrition (HR 3.69; 95% CI 2.11-6.42; p < 0.001). Multivariate Cox proportional hazards analysis revealed hemodialysis (HR 2.17; 95% CI 1.19-3.93; p = 0.011) and malnutrition (HR 2.30; 95% CI 1.13-4.67; p = 0.020) as significantly associated with MACCE. Furthermore, Cox proportional hazards models using malnutrition and hemodialysis revealed that patients with malnutrition and hemodialysis were at greater risk of MACCE after PCI than patients with neither malnutrition nor hemodialysis (HR 6.91; 95% CI 3.29-14.54; p < 0.001).

CONCLUSIONS

In CAD patients with myocardial damage, malnutrition (GNRI < 92) represents an independent risk factor for MACCE. Assessment of nutritional status may help stratify the risk of cardiovascular events and encourage improvements in nutritional status.

T-Lymphocyte Subsets Alteration, Infection and Renal Outcome in Advanced Chronic Kidney Disease

Background: T-lymphocyte subsets reflect patients' immune status and are associated with adverse outcomes in various diseases. However, the association between T-lymphocyte subsets and major infection and renal outcome in chronic kidney disease (CKD) patients has not been well-addressed.

Methods: Patients diagnosed with stage 3–5 of non-dialysis CKD were recruited, and healthy subjects were selected as the controls. T-lymphocyte subsets (CD3⁺, CD4⁺, CD8⁺) were detected by flow cytometry, and the CD4⁺/CD8⁺ T cell ratio was then calculated. Patients were divided into the normal-level group and the low-level group according to the clinical reference value. The primary outcomes were the major infection and renal outcome.

Results: A total of 410 CKD patients were enrolled; the average age was 47.25 years. Compared to the healthy controls, the level of CD3⁺, CD4⁺, CD8⁺ T cells, and the CD4⁺/CD8⁺ T cell ratio were significantly decreased in CKD patients (p < 0.05). During the median follow-up of 2.56 (quartile interval 1.24–3.46) years, major infections occurred in 15.10% of the CKD patients. The incidence of infection was significantly higher in the low-level group of CD3⁺, CD4⁺ T cells, and CD4⁺/CD8⁺ T cell ratio compared with the normal level groups. Kaplan-Meier analysis showed that the lower level of CD3⁺, CD4⁺ T cells, and CD4⁺/CD8⁺T cell ratio is associated with a greater risk of infection. Cox regression analysis further confirmed that low CD3⁺, CD4⁺ T cells, and CD4⁺/CD8⁺ T cell ratio were independent risk factors of infection in CKD patients. Moreover, during the follow-up, renal events occurred in 37.50% of patients. Kaplan-Meier analysis indicated that low levels of CD3⁺, CD4⁺, and CD8⁺ T cells are significantly associated with renal outcome in CKD patients. Cox regression analysis showed that low level of CD3⁺ T cells (HR = 2.407, 95% CI: 1.664–3.482, p < 0.001), CD4⁺ T cells (HR = 2.397, 95% CI: 1.633–3.518, p < 0.001) and CD8⁺ T cells (HR = 2.416, 95% CI: 1.476–3.955, p < 0.001) were independent risk factors for renal outcome after multivariable-adjusted.

Conclusion: CKD patients had a defect in T-lymphocyte subpopulation. T-lymphocyte subsets were closely associated with infection and renal outcome in CKD patients. Suggesting T-lymphocyte subsets are independent predictors of infection and renal outcome in CKD patients.

Young age at diabetes diagnosis amplifies the effect of diabetes duration on risk of chronic kidney disease: a prospective cohort study

AIMS/HYPOTHESIS

We postulated that the increased lifetime risk of chronic kidney disease (CKD) in young-onset diabetes is attributable to both long disease duration and more aggressive disease. We examined whether age at diabetes diagnosis modifies the effect of diabetes duration on risk of CKD.

METHODS

We included 436,744 people with incident type 2 diabetes in the Hong Kong Diabetes Surveillance Database (HKDSD) and 16,979 people with prevalent type 2 diabetes in the Hong Kong Diabetes Register (HKDR). We used Poisson models to describe joint effects of age at diabetes diagnosis, diabetes duration and attained age on incidence of CKD in HKDSD. We used Cox proportional hazards models to examine interaction effect of age at diabetes diagnosis and diabetes duration on risk of CKD with adjustment for confounders in HKDR.

RESULTS

During a median follow-up of 5.3 years, 134,043 cases of CKD were recorded in the HKDSD. The incidence rate ratio for CKD comparing people of the same attained age but diagnosed with diabetes at ages 5 years apart was higher for people with a younger age at diabetes diagnosis, but decreased with increasing age at diabetes diagnosis. During a median follow-up of 6.3 years, 6500 people developed CKD in the HKDR. The increased risk of CKD with longer diabetes duration decreased with older age at diabetes diagnosis. The adjusted HR for CKD associated with 5 year increase in diabetes duration was 1.37 (95% CI 1.13, 1.65) in people with diabetes diagnosed at 20-29 years and 1.01 (95% CI 0.87, 1.18) in those diagnosed at ≥70 years.

CONCLUSIONS/INTERPRETATION

Young age at diabetes diagnosis amplified the effect of increasing diabetes duration on increased risk of CKD.

Tailored synbiotic powder (functional food) to prevent hyperphosphataemia (kidney disorder)

Hyperphosphataemia is treated with phosphate binders, which can cause adverse effects. Spray-dried synbiotic powder (SP) composed of Lactobacillus casei JCM1134 (a phosphate-accumulating organism; PAO) and Aloe vera is potentially a safer alternative for efficient phosphate removal. In this study, a novel strategy was developed; lysine-derivatized deacetylated A. vera (DAVK) was synthesised and fabricated on phosphate-deficient PAO (PDP) for efficient phosphate transfer and then spray-dried with the supernatant of DAV centrifugation to form a sacrificial layer on PDP for SP integrity during gastric passage. In vitro experiments revealed that PAO removed only 1.6% of the phosphate from synthetic media, whereas SP removed 89%, 87%, and 67% (w/v) of the phosphate from milk, soft drink, and synthetic media, respectively, confirming the protective role of A. vera and efficient phosphate transport. Compared with commercial binders, SP effectively removed phosphate from synthetic media, whereas SP and CaCO3 exhibited comparative results for milk and soft drink. Importantly, CaCO3 caused hypercalcaemia. Thus, the described SP presents a promising tool to prevent hyperphosphataemia. This study also revealed a novel factor: diets of patients with chronic kidney disease should be monitored to determine the optimal phosphate binders, as phosphate removal performance depends on the accessible phosphate forms.

Risk Prediction Model for Incident Atrial Fibrillation in a General Japanese Population - The Hisayama Study

BACKGROUND

The risk prediction of incident atrial fibrillation (AF) is useful to prevent AF and its complications. The aim of this study is to develop a new risk prediction model for incident AF using the prospective longitudinal data from a general Japanese population.Methods and Results:A total of 2,442 community-dwelling AF-free residents aged ≥40 years were followed up from 1988 to 2012 (46,422 person-years). The development of AF was confirmed by a standard 12-lead electrocardiogram at repeated health examinations and by medical records at clinics or hospitals. The risk prediction model for incident AF was developed using a Cox proportional hazards model. During the follow up, 230 AF events were confirmed. Age, sex, systolic blood pressure, waist circumference, estimated glomerular filtration rate, abnormal cardiac murmur, high R-wave amplitude, and arrhythmia other than AF were selected for inclusion in the model. This model showed good discrimination (Harrell's c statistics: 0.785) and calibration (Greenwood-Nam-D'Agostino test: P=0.87) for AF risk at 10 years.

CONCLUSIONS

The new risk prediction model showed good performance on the individual risk assessment of the future onset of AF in a general Japanese population. As this model included commonly used clinical parameters, it may be useful for determining the requirements for the careful evaluation of AF, such as frequent electrocardiogram examinations in clinical settings, and subsequent reductions in the risk of AF-related complications.

Acetic acid treatment causes renal inflammation and chronic kidney disease in mice

We established a novel mouse model of chronic kidney disease (CKD) using acetic acid and compared it with the 5/6-nephrectomized mouse model. In our novel model, significant increases were observed in blood biochemical values and urinary parameters. Moreover, a decrease in creatinine clearance (Ccr) was observed. This model also demonstrated a higher survival rate than the 5/6-nephrectomized model. Observed histological changes in our model included cell infiltration in the renal interstitium, tubular dilation, regenerated tubules, and glomerulosclerosis. Inflammation of the renal interstitium was particularly remarkable. TNF-α, IL-1β, and ICAM-1 mRNA expression were up-regulated prior to elevation of mean blood pressure and prior to changes in blood biochemical values and urinary parameters. Up-regulation of TGF-β mRNA and down-regulation of nephrin mRNA were also observed at 12 weeks after acetic acid treatment. However, no correlation between the progression of CKD and the decrease in renal blood flow was observed. Finally, repeated losartan administration attenuated the effects of acetic acid-induced renal injury. Our findings suggest that chronic kidney conditions associated with this model may be triggered by interstitial inflammation. Moreover, we suggest that this model is useful for understanding the pathophysiological mechanisms of CKD, and for evaluating the effects of therapeutic agents.

High urinary glucose is associated with improved renal prognosis in patients with diabetes mellitus

AIMS/INTRODUCTION

The relationship between renal function and urinary glucose is poorly understood in diabetes patients who are not using sodium-glucose cotransporter 2 inhibitors. This study aimed to investigate the association of urinary glucose excretion with renal function prognosis in such patients.

MATERIALS AND METHODS

This retrospective cohort study included 1,172 patients with type 1 or 2 diabetes mellitus. Patients were recruited and data were collected between 1 January 2007 and 31 December 2011; follow-up data were collected until 30 June 2015. The primary outcome was set as a 30% decline in estimated glomerular filtration rate relative to baseline. The relationship between this outcome and urinary glucose was investigated using Cox proportional hazards model. For analysis, patients were categorized into two groups: urinary glucose <5 g/day or ≥5 g/day. Interaction terms were analyzed.

RESULTS

Multivariate analysis showed that the prognosis of renal function was significantly better in patients with high urinary glucose (≥5 g/day; adjusted hazard ratio 0.58, 95% confidence interval 0.35-0.96; P = 0.034). Significant interactions were observed between high urinary glucose and male sex (hazard ratio 0.33, 95% confidence interval 0.14-0.74; P = 0.007), and between high urinary glucose and longer duration of diabetes (≥10 years; hazard ratio 0.25, 95% confidence interval 0.11-0.58; P = 0.001).

CONCLUSIONS

The present study suggests that high urinary glucose is associated with prognosis in diabetes patients not taking sodium-glucose cotransporter 2 inhibitors. Measurement of 24-h urinary glucose excretion might have clinical utility for predicting renal prognosis.

Thickness, vessel density of retina and choroid on OCTA in young adults (18-24 years old)

PURPOSE

The purpose of this study was to quantify thickness, vessel density (VD) of retina and choroid in young adults (18-24 years old) using OCTA.

METHODS

This observational, cross-sectional study included 154 eyes from 77 young myopic adults. En-face angiogram OCTA was performed on a 3.00 × 3.00 mm region centered on the macula. Automated thickness calculations and macular maps were measured. Spherical equivalent refraction (SER) and AL were examined to determine associations with thickness, vessel density (VD) of retina and choroid.

RESULTS

A total of 148 healthy eyes from 77 young myopic adults (29 males and 48 females) with a mean age of 21.80 ± 1.32 years (range: 18-24 years) were included. The mean SER and AL were - 4.06 ± 2.26D and 25.25 ± 1.28 mm, respectively. The mean retinal thickness (RT, ILM-RPE layer) was 240.91 ± 13.36 μm, the retinal superficial (SVD) and deep vessel density (DVD) in fovea region were 18.35 ± 4.77% and 32.99 ± 6.01%, respectively. The foveal avascular zone (FAZ) area was 0.31 ± 0.10 mm². The mean subfoveal choroidal thickness (SFCT) and choriocapillaris (CC) perfusion area were 232.16 ± 56.65 μm and 2.17 ± 0.10 mm², respectively. By Pearson's correlation analysis, SER was revealed to be negatively correlated with RT (r = -0.180, p = 0.028) and DVD (r = -0.185, p = 0.025) in fovea region. SER was revealed to be positively correlated with RT in nasal (r = 0.224, p = 0.006) and inferior (r = 0.217, p = 0.008) regions. AL was revealed to be positively correlated with RT (r = 0.250, p = 0.002) and DVD (r = 0.284, p < 0.001) in fovea region. SER was revealed to be positively correlated with SFCT (r = 0.486, p < 0.001). AL was revealed to be negatively correlated with FAZ area (r = -0.232, p = 0.005) and SFCT (r = -0.407). RT was revealed to be negatively correlated with FAZ area (r = -0.645, p < 0.001). SER (r = -0.079), AL (r = 0.071) and SFCT (r = 0.089) did not correlate significantly with the CC perfusion area (all p > 0.05).

CONCLUSION

Myopic eyes present increased RT, DVD and thinned SFCT in fovea, while no significant correlation could be found between SER, AL, SFCT and CC perfusion area. It may indicate that the SFCT thinning may be secondary to ocular elongation, while the CC perfusion area may be a factor independent of AL growth.

Independent and interactive effects of kidney stone formation and conventional risk factors for chronic kidney disease: a follow-up study of Japanese men

PURPOSE

To assess the impact of interactions between kidney stone formation and conventional risk factors on incident chronic kidney disease (CKD).

METHODS

A total of 11,402 subjects (men 30-69 years of age, Japanese) without CKD at baseline were observed over an average period of 4 years. Cox proportional hazards regression models were used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) to determine the association between incident CKD, kidney stone formation, and conventional risk factors (diabetes mellitus, hypertension, overweight/obesity, dyslipidemia, and hyperuricemia/gout). We also examined the interactions of renal stones and the conventional risk factors for CKD.

RESULTS

In total, 2301 men (20.2%) developed incident CKD during the follow-up period. After multivariable adjustment, kidney stones were found to increase the risk of incident CKD (HR 1.16; 95% CI 1.03-1.32). Kidney stone formers with hypertension, dyslipidemia, or hyperuricemia/gout presented a greater risk for incident CKD than those who had either kidney stones or other risk factors. However, no significant interactions between kidney stones and other risk factors were found to increase CKD risk. On the other hand, a negative interactive effect between kidney stones and overweight/obesity was observed, leading to reversed risk of incident CKD in coexistence of both factors.

CONCLUSION

Kidney stones were linked to a higher risk for the development of CKD. However, no positive interactive effects were identified between renal stones and conventional risk factors on the risk of incident CKD.

Serum High-Sensitivity C-Reactive Protein Levels and the Development of Atrial Fibrillation in a General Japanese Population - The Hisayama Study

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia in the elderly, and causes complications such as cardioembolic stroke. Serum high-sensitivity C-reactive protein (hs-CRP), a marker of systemic inflammation, has been reported to be a risk factor for developing AF in Western countries. However, few community-based studies have examined this issue in general Asian populations.Methods and Results:A total of 2,510 community-dwelling Japanese participants aged ≥40 years without a history of AF were divided into 4 groups according to the sex-specific quartiles of serum hs-CRP concentrations (Q1, lowest and Q4, highest) and followed up for 24 years. The hazard ratios and their 95% confidence intervals for the development of AF were estimated using a Cox proportional hazards model. During the follow up, 234 subjects developed AF. The risk of AF increased significantly with elevating serum hs-CRP levels after adjustment for potential confounding factors (hazard ratio [95% confidence interval], Q1, 1.00 [reference]; Q2, 1.26 [0.83-1.92]; Q3, 1.77 [1.18-2.66]; and Q4, 1.89 [1.24-2.86]; P for trend <0.001).

CONCLUSIONS

The study findings suggest that elevated serum hs-CRP levels are an independent risk factor for the development of AF in a general Japanese population.

Prediction of Mortality Incidence in Patients with Chronic Kidney Disease Based on Influential Prognostic Factors with Competing Risks Approach

BACKGROUND

Chronic Kidney Disease (CKD) is a disease in which the kidney's functionality declines gradually. The aim of this study was to identify significant laboratory prognostic factors on death due to CKD in a clinical complex.

MATERIALS AND METHODS

A retrospective study including 109 patients with the end-stage renal disease treated at Iran Helal pharmaceutical and the clinical complex was conducted between 2014-2018. The survival time was set as the time interval between starting dialysis until death due to CKD. Also, the transplantation was considered as competing risk, which was occurred for a few patients. A three-parameter Gompertz model was used that considers both the event of interest and the competing event simultaneously.

RESULTS

Death due to CKD occurred in 29 (26.6%) of the patients and 19(17.4%) with transplantation. Serum uric acid was a significant prognostic factor that decreased the hazard of mortality by 21%. Serum phosphorus and age by increasing the risk of death, were poor prognoses for the event of interest. Serum uric acid and phosphorus 6.9-9.9 (mg/dl) were associated with 72% and 4.05- fold increased hazard of transplant, respectively. The 4-year cumulative incidence of death and transplant was 48.4% and 29.2%, respectively.

CONCLUSION

We have deduced that high serum phosphorus levels and increased levels of age were associated with worse outcomes. High serum uric acid level was related to better survival, which could be explained by having a better protein-rich diet alongside the high albumin level.

Vasculature-Associated Lymphoid Tissue: A Unique Tertiary Lymphoid Tissue Correlates With Renal Lesions in Lupus Nephritis Mouse Model

Lupus nephritis (LN) is a common complication in young patients and the most predominant cause of glomerulonephritis. Infiltrating immune cells and presence of immunocomplexes in the kidney are hallmarks of LN, which is closely associated with renal lesions (RLs). However, their regulatory mechanism in the kidney remains unclear, which is valuable for prevention of RL development. Here, we show the development of vasculature-associated lymphoid tissue (VALT) in LN, which is related to renal inflammatory cytokines, indicating that VALT is a unique tertiary lymphoid tissue. Transcriptomic analysis revealed different chemokines and costimulatory molecules for VALT induction and organization. Vascular and perivascular structures showed lymphoid tissue organization through lymphorganogenic chemokine production. Transcriptional profile and intracellular interaction also demonstrated antigen presentation, lymphocyte activity, clonal expansion, follicular, and germinal center activity in VALT. Importantly, VALT size was correlated with infiltrating immune cells in kidney and RLs, indicating its direct correlation with the development of RLs. In addition, dexamethasone administration reduced VALT size. Therefore, inhibition of VALT formation would be a novel therapeutic strategy against LN.

Association of the ward pharmacy service with active implementation of therapeutic drug monitoring for vancomycin and teicoplanin-an epidemiological surveillance study using Japanese large health insurance claims database

Background

Ward pharmacists are required for the active implementation of therapeutic drug monitoring (TDM). This epidemiological study verified whether Japanese ward pharmacists contribute to improving the TDM implementation proportions of anti-methicillin-resistant Staphylococcus aureus (MRSA) agents using the large health insurance claims database.

Methods

The patients who received intravenous anti-MRSA agents from April 2012 to March 2017 were enrolled. We defined ward pharmacy service as the “drug management and guidance fee” and/or “inpatient pharmaceutical services premium”. In addition, implementation of TDM was identified by “the specific drug treatment management fee”. We compared the proportions of TDM implementation for vancomycin (VCM), teicoplanin (TEIC), and arbekacin (ABK) in the ward and non-ward pharmacy service groups. To avoid confounding, the propensity score method was employed. Moreover, the clinical variables affecting TDM implementation in each anti-MRSA agent were analyzed by using a multiple logistic regression model.

Results

The following number of patients were included in the study: VCM (n = 2138), TEIC (n = 596), and ABK (n = 142). After propensity score matching, the proportions of TDM implementation for VCM and TEIC were higher in the ward pharmacy service group than in the non-ward pharmacy service group (VCM: 69.2% vs 60.3%, TEIC: 51.4% vs 34.7%), while no significant difference was observed for ABK (21.2% vs 23.1%). As independent clinical variables affecting TDM implementation for VCM and TEIC, several clinical variables, including ward pharmacy services, were extracted. In contrast, no clinical variables were extracted for ABK.

Conclusions

We found that the ward pharmacy service is associated with the active implementation of TDM for anti-MRSA agents, such as VCM and TEIC.

Prevalence of chronic kidney disease in adults in England: comparison of nationally representative cross-sectional surveys from 2003 to 2016

OBJECTIVES

To identify recent trends in chronic kidney disease (CKD) prevalence in England and explore their association with changes in sociodemographic, behavioural and clinical factors.

DESIGN

Pooled cross-sectional analysis.

SETTING

Health Survey for England 2003, 2009/2010 combined and 2016.

PARTICIPANTS

17 663 individuals (aged 16+) living in private households.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 and albuminuria (measured by albumin-creatinine ratio) during 2009/2010 and 2016 and trends in eGFR between 2003 and 2016. eGFR was estimated using serum creatinine Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease equations.

RESULTS

GFR <60 mL/min/1.73 m2 prevalence was 7.7% (95% CI 7.1% to 8.4%), 7.0% (6.4% to 7.7%) and 7.3%(6.5% to 8.2%) in 2003, 2009/2010 and 2016, respectively. Albuminuria prevalence was 8.7% (8.1% to 9.5%) in 2009/2010 and 9.8% (8.7% to 10.9%) in 2016. Prevalence of CKD G1-5 (eGFR <60 mL/min/1.73 m2 or albuminuria) was 12.6% (11.8% to 13.4%) in 2009/2010 and 13.9% (12.8% to 15.2%) in 2016. Prevalence of diabetes and obesity increased during 2003-2016 while prevalence of hypertension and smoking fell. The age-adjusted and gender-adjusted OR of eGFR <60 mL/min/1.73 m2 for 2016 versus 2009/2010 was 0.99 (0.82 to 1.18) and fully adjusted OR was 1.13 (0.93 to 1.37). There was no significant period effect on the prevalence of albuminuria or CKD G1-5 from 2009/2010 to 2016 in age and gender or fully adjusted models.

CONCLUSION

The fall in eGFR <60 mL/min/1.73 m2 seen from 2003 to 2009/2010 did not continue to 2016. However, absolute CKD burden is likely to rise with population growth and ageing, particularly if diabetes prevalence continues to increase. This highlights the need for greater CKD prevention efforts and continued surveillance.

Evaluation of biochemical profile of Chronic Kidney Disease of uncertain etiology in Sri Lanka

Chronic Kidney Disease of uncertain etiology (CKDu) is an endemic, disease that mostly affects young agricultural workers in the rural dry zone of Sri Lanka. This study was designed to identify specific biochemical manifestations of CKDu cases. All (119) non-dialysis definite CKDu patients in Girandurukotte and Wilgamuwa were selected. Blood and urine samples were collected and measured biochemical parameters. All analyses were performed in IBM SPSS statistics version 23 (IBM Corp, USA). The median blood pressure was normal though nearly half of the patients (45.4%) who were in the advanced stages (Stage 3b, 4 and 5) of CKDu. Patients without a history of hypertension before the diagnosis of CKDu (100%) and minimal proteinuria (26%) are similar to the previous findings. Patients without a history of diabetes before the CKDu diagnosis had high percentages of diabetes (15.7%) and pre-diabetes (59.8%) and hence indicated the possibility of uremia induced impaired glucose intolerance in the rural areas of the country. There were 62.2% patients who had low vitamin D and only a minority had evidence of bone mineral diseases. Out of liver disease markers serum glutamic pyruvic transaminases (SGPT), serum glutamic oxaloacetic transaminases (SGOT), gamma-glutamyl transferase (GGT), and Lactic acid degydrogenase (LDH) had an inverse correlation with the advancement of the disease indicating subclinical liver disease. Osmolality in serum and urine showed a discrepancy despite > 50% of CKDu patients had increased their serum osmolality. The current study supports most of the previously described manifestations of CKDu. Moreover, some specific patterns have been identified which need to be validated in a larger group.

Diagnosis Patterns of CKD and Anemia in the Japanese Population

INTRODUCTION

Although early intervention for chronic kidney disease (CKD) and renal anemia are desirable, these conditions are often asymptomatic during their early stages and may be underdiagnosed.

METHODS

We retrospectively analyzed Japanese administrative claims data for general and hospital populations. The data period for the general and hospital data ranged from January 2011 to December 2016 and from April 2008 to July 2017, respectively. CKD stage was determined by estimated glomerular filtration rate (eGFR). Anemia was defined per Japanese guidelines using hemoglobin (Hb) values. The proportion of patients who had eGFR-defined stages G3-G5 CKD without a CKD diagnosis, and Hb-defined anemia without an anemia diagnosis or treatment records, was estimated.

RESULTS

Among 16,779 (general) and 68,161 (hospital) patients, a high proportion of G3 CKD patients did not have a CKD-related diagnosis (general: G3a, 95.0%; G3b, 68.4%; hospital: G3a, 89.2%; G3b, 67.9%); however, some patients were treated with antihypertensives. Among anemic patients, 75.7% (G3a) and 66.7% (G3b) of the general population, and 56.2% (G3a) and 47.5% (G3b) of the hospital population, did not have an anemia-related diagnosis or treatment. CKD and anemia were more likely to be diagnosed in patients with G4 and G5 CKD.

CONCLUSION

A high proportion of G3 CKD patients did not have a CKD-related diagnosis. Likewise, many anemic patients with G3 CKD did not have an anemia-related diagnosis. Despite the lack of a CKD-related diagnosis, some patients received appropriate treatment (e.g., antihypertensives). Further outreach to CKD and anemia patients at earlier stages may be warranted.

J-CKD-DB: a nationwide multicentre electronic health record-based chronic kidney disease database in Japan

The Japan Chronic Kidney Disease (CKD) Database (J-CKD-DB) is a large-scale, nation-wide registry based on electronic health record (EHR) data from participating university hospitals. Using a standardized exchangeable information storage, the J-CKD-DB succeeded to efficiently collect clinical data of CKD patients across hospitals despite their different EHR systems. CKD was defined as dipstick proteinuria ≥1+ and/or estimated glomerular filtration rate <60 mL/min/1.73 m² base on both out- and inpatient laboratory data. As an initial analysis, we analyzed 39,121 CKD outpatients (median age was 71 years, 54.7% were men, median eGFR was 51.3 mL/min/1.73 m²) and observed that the number of patients with a CKD stage G1, G2, G3a, G3b, G4 and G5 were 1,001 (2.6%), 2,612 (6.7%), 23,333 (59.6%), 8,357 (21.4%), 2,710 (6.9%) and 1,108 (2.8%), respectively. According to the KDIGO risk classification, there were 30.1% and 25.5% of male and female patients with CKD at very high-risk, respectively. As the information from every clinical encounter from those participating hospitals will be continuously updated with an anonymized patient ID, the J-CKD-DB will be a dynamic registry of Japanese CKD patients by expanding and linking with other existing databases and a platform for a number of cross-sectional and prospective analyses to answer important clinical questions in CKD care.

Association between Oral Health Status and Diabetic Nephropathy-Related Indices in Japanese Middle-Aged Men

Oral health status is known to be associated with lifestyle-related diseases such as diabetes and chronic kidney disease. In Japan, around 40% of hemodialysis cases are patients with diabetic nephropathy. The aim of this study was to clarify the association between oral health status and diabetic nephropathy-related indices in Japanese middle-aged men. Sixty-six men (age range: 55-64 years) with ≥20 remaining teeth and who received public medical checkups and oral examinations were enrolled. We examined correlations of age, body mass index, HbA1c, HDL-C, LDL-C, neutral fat, serum creatinine, and the estimated glomerular filtration rate (eGFR) with the number of remaining teeth or the community periodontal index (CPI) score (periodontal pocket < 4 mm: 0, 4-6 mm: 1, ≥6 mm: 2). A positive correlation between the CPI score and serum creatinine and a negative correlation between CPI score and eGFR (Spearman's rank correlation coefficient, r = 0.459, p < 0.01, and r = -0.460, p < 0.01, respectively) were observed. The mean eGFR in the CPI score 0 group was significantly higher than that in the CPI score 1/2 group (82.6 vs. 70.7, Student's t-test, p < 0.01). Logistic regression analysis using eGFR as a dependent variable and age, CPI score, body mass index, HbA1c, and neutral fat as independent variables suggested that low eGFR (<60) could be attributed to CPI score (OR = 3.169, 95% CI: 1.031-9.742, p = 0.044). These results suggest a possible association between periodontal status and renal function in Japanese middle-aged men. Periodontal condition is controlled by oral prophylaxis, and periodontal disease and chronic kidney disease have some common risk factors. Thus, periodontal management can contribute to the prevention of severe chronic kidney disease.

The effect of hemodialysis on ocular changes in patients with the end-stage renal disease

Background: Numerous metabolic parameters can be changed during hemodialysis in the end-stage renal disease (ESRD) caused by systemic diseases, such as diabetes mellitus, hypertension. Some ocular parameters also can be variable due to the changes after hemodialysis. This study evaluates the effects of ocular parameters, including best-corrected visual acuity (BCVA), intraocular pressure (IOP), central macular thickness (CMT), subfoveal choroidal thickness (SFCT), retinal arteriolar caliber (RAC), retinal venular calibre (RVC), in ESRD patients following hemodialysis. Materials and methods: Two-hundred and two ESRD patients were recruited resulting in 404 eyes evaluations. All patients underwent hemodialysis in the Dialysis Unit of the Second Hospital of Tianjin Medical University. BCVA, CMT, IOP, SFCT, RAC and RVC were evaluated before and after hemodialysis. Systemic parameters were collected such as age, body weight, systolic blood pressure (SBP), diastolic blood pressure (DBP), duration of hemodialysis, body weight changes, high density lipoprotein cholesterol (HDLC), low density lipoprotein cholesterol (LDLC), very low density lipoprotein cholesterol (VLDLC), glycosylated hemoglobin (HbA1c). Results: The causes of ESRD patients included chronic glomerulonephritis (n = 65), diabetes mellitus (n = 60), hypertensive nephrosclerosis (n = 37), and other causes (n = 40). In our study, BCVA (p = .817), CMT (p = .252) and IOP (p = .978) did not significantly change after hemodialysis. SFCT significantly decreased from 254.29 ± 69.36 μm to 235.54 ± 659.90 μm (p = .002) following hemodialysis. SFCT changes were significantly correlated with SBP (p = .042) and body weight changes (p = .044). The RAC and RVC were dilated significantly (p = .033, p = .007). RVC changes were correlated with baseline DBP (p = .003), HDLC (p = .009), LDLC (p = .004) and changes in DBP (p = .037) and body weight (p = .001). Conclusion: Hemodialysis can affect various ocular parameters including SFCT, RAC and RVC, which changed significantly following hemodialysis. Whereas BCVA, IOP and CMT did not change after hemodialysis in ESRD patients. The systemic compensatory mechanisms of the changes in SBP, DBP, body weight following hemodialysis need further study.

The effects of a participatory structured group educational program on the development of CKD: a population-based study

BACKGROUND

The type of lifestyle guidance that is effective for preventing development of chronic kidney disease (CKD) is unknown. Here, we aim to investigate the effects of a participatory structured group education (SGE) program on the development of CKD in a population-based study.

METHODS

We retrospectively analyzed 1060 adult special health check-up examinees with CKD. Examinees with an estimated glomerular filtration rate (eGFR) from 50 to 60 mL/min/1.73 m² and/or proteinuria 1+ were encouraged to attend an SGE program. The SGE program included participatory small group discussions on the attendees' remaining risk factors. The primary outcome of this study was the change in eGFR per year.

RESULTS

The changes in eGFR in examinees who attended the SGE program (n = 209, + 2.9 mL/min/1.73 m² [95% confidence interval (CI) + 1.9 to  + 3.9]) significantly improved compared with control (n = 383, + 1.2 mL/min/1.73 m² [95% CI + 0.5 to + 1.9], p = 0.006). Attending an SGE program was independently and positively related to the changes in eGFR at 1 year after attendance, after adjusting for classical covariates (β = 1.55 [95% CI 0.37-2.73], p = 0.01). Attending an SGE program was effective for the examinees with a lower eGFR compared with those with only proteinuria.

CONCLUSIONS

Our SGE program showed the beneficial effects of preventing the development of CKD, independent of classical factors. The type of SGE program that is more effective for preventing development of CKD should be investigated in a long-term analysis.

Induced expression of Toll-like receptor 9 in peritubular capillary endothelium correlates with the progression of tubulointerstitial lesions in autoimmune disease-prone mice

BACKGROUND

Toll-like receptor (Tlr) 9 is capable of recognizing exogenous and/or endogenous nucleic acids and plays a crucial role in innate and adaptive immunity. Recently, we showed that Tlr9 is overexpressed in podocytes, a component of the blood-urine barrier (BUB), in glomeruli of autoimmune glomerulonephritis (AGN) model mice. This study investigated the activation of peritubular capillary (PTC) endothelial cells (ECs), a component of the BUB in the tubulointerstitium, through overexpressing Tlr9, and the subsequent development of tubulointerstitial lesions (TILs) in AGN model mice.

METHODS

Lupus-prone BXSB/MpJ-Yaa (Yaa) and BXSB/MpJ (BXSB) mice were used as an AGN model and control, respectively. In addition to histopathological and ultrastructural techniques, protein and mRNA levels were also evaluated. The relationship between Tlr9 and TIL indices was analyzed by statistical correlation analysis.

RESULTS

Yaa mice developed TILs and showed strong Tlr9 mRNA expression in PTC ECs at 24 weeks (wks) of age. However, BXSB mice showed no TIL but faint expression of Tlr9 mRNA at 8 and 24 wks of age. Tlr9 protein localization on PTC was almost absent in BXSB mice at both ages but intense expression was found in Yaa mice only at 24 wks of age. Relative mRNA expression of Tlr9 and its putative downstream cytokines, including interleukin 1 beta ( Il1b), Il6, interferon gamma ( Ifng), and tumor necrosis factor alpha ( Tnf) was markedly increased in isolated tubulointerstitium from Yaa mice at 24 wks of age. Furthermore, electron microscopy examination revealed PTC injury and TIL in Yaa mice at 24 wks. The expression level of Tlr9 in the tubulointerstitium was correlated with inflammatory cells in TILs, injured PTC, Ilb and Tnf expression, and damaged tubules ( P < 0.05 and 0.01).

CONCLUSION

Induced expression of Tlr9 in ECs correlates with PTC injury and the development of TILs in lupus-prone AGN model mice.

Overexpression of toll-like receptor 9 correlates with podocyte injury in a murine model of autoimmune membranoproliferative glomerulonephritis

Toll-like receptors (Tlrs) are sensors of danger signals which promote the activation of immune cells and intrinsic renal cells. Podocytes, the intrinsic cells of glomerulus, are continuously exposed to various plasma solutes and danger signals due to their unique location in the glomerulus. Herein, we show that Tlr9 is overexpressed in podocytes and the mechanisms which cause its injury and development of membranoproliferative glomerulonephritis (MPGN) in model BXSB/MpJ-Yaa (Yaa) mice. Yaa mice developed typical lesions of MPGN and showed strong expression of Tlr9 mRNA throughout the glomerulus particularly toward the periphery of the glomerulus. However, BXSB/MpJ (BXSB) mice showed no lesion for MPGN but a very weak expression of Tlr9 mRNA. Relative mRNA expression of Tlr9 and its downstream cytokines, including interleukin 1 beta (Il1b), Il6, interferon gamma (Ifng) and tumour necrosis factor alpha (Tnfa) was markedly increased in glomeruli isolated from Yaa mice. Tlr9 protein expression was almost absent in BXSB mice but intense expression was found in Yaa mice. Podocyte protein expression was normal in BXSB mice but decreased in Yaa mice and colocalized with Tlr9 protein. Furthermore, electron microscopy examination revealed podocyte injury and electron-dense materials in thickened glomerular basement membrane of Yaa mice. Glomerular Tlr9 mRNA expression was significantly correlated with anti-dsDNA antibody, proteinuria, renal function indices (sBUN and sCr), glomerular histopathology indices, downstream factors of Tlr family (Ilb and Tnfa), podocyte injury parameters (p < .05 and p < .01). In conclusion, overexpression of TLR9 correlates with podocyte injury and development of MPGN.

Urinary D-serine level as a predictive biomarker for deterioration of renal function in patients with atherosclerotic risk factors

BACKGROUND

D-serine, the enantiomer of L-serine, was identified in mammals 20 years ago. Although a close relationship between D-serine and renal dysfunction has been shown, the clinical implications of urinary D- and L-serine in humans are poorly understood. The aim of this study was to evaluate the relationship between urinary D- and L-serine with well-known renal biomarkers, and clarify the prognostic value of D- and L-serine for renal events.

METHODS

This cross-sectional, prospective study included 65 patients with atherosclerotic risk factors, who were followed up for a median of 16 months. The primary endpoint was a composite of end-stage renal disease and a decline in estimated glomerular filtration rate (eGFR) ≥ 25% from baseline.

RESULTS

Urinary D-serine concentrations showed a better correlation with eGFR than did urinary L-serine, whereas neither urinary D- nor L-serine correlated with tubular markers such as urinary liver-type fatty acid-binding protein and N-acetyl-beta-D-glucosaminidase. A Cox regression analysis revealed that low urinary D-serine levels were significantly associated with the primary endpoint after adjusting for confounding factors (hazard ratio 12.60; 95% confidence interval, 3.49-45.51).

CONCLUSIONS

Urinary D-serine is associated with glomerular filtration and can be a prognostic biomarker of renal dysfunction in patients with atherosclerotic risk factors.

A study on the information-motivation-behavioural skills model among Chinese adults with peritoneal dialysis

AIM AND OBJECTIVE

To examine whether the information-motivation-behavioural skills model could predict self-care behaviour among Chinese peritoneal dialysis patients.

BACKGROUND

Peritoneal dialysis is a treatment performed by patients or their caregivers in their own home. It is important to implement theory-based projects to increase the self-care of patients with peritoneal dialysis. The information-motivation-behavioural model has been verified in diverse populations as a comprehensive, effective model to guide the design, implementation and evaluation of self-care programmes.

DESIGN

A cross-sectional, observational study.

METHODS

A total of 201 adults with peritoneal dialysis were recruited at a 3A grade hospital in China. Participant data were collected on demographics, self-care information (knowledge), social support (social motivation), self-care attitude (personal motivation), self-efficacy (behaviour skills) and self-care behaviour. We also collected data on whether the recruited patients had peritoneal dialysis-associated peritonitis from electronic medical records. Measured variable path analysis was performed using mplus 7.4 to identify the information-motivation-behavioural model.

RESULTS

Self-efficacy, information and social motivation predict peritoneal dialysis self-care behaviour directly. Information and personal support affect self-care behaviour through self-efficacy, whereas peritoneal dialysis self-care behaviour has a direct effect on the prevention of peritoneal dialysis-associated peritonitis.

CONCLUSIONS

The information-motivation-behavioural model is an appropriate and applicable model to explain and predict the self-care behaviour of Chinese peritoneal dialysis patients. Poor self-care behaviour among peritoneal dialysis patients results in peritoneal dialysis-associated peritonitis.

RELEVANCE TO CLINICAL PRACTICE

The findings suggest that self-care education programmes for peritoneal dialysis patients should include strategies based on the information-motivation-behavioural model to enhance knowledge, motivation and behaviour skills to change or maintain self-care behaviour.

Temporal trends in renal function and birthweight in Japanese adolescent males (1998-2015)

Background

Low birthweight (LBW) is a worldwide public health problem, demonstrating an increasing incidence in developed countries, including Japan. LBW is also a risk factor for later development of chronic kidney disease (CKD). To date, studies have not evaluated the population impacts of increasing LBW rates on renal function.

Methods

Estimated glomerular filtration rate (eGFR) was evaluated in 3737 Japanese adolescent males (15–16 years old) using annual cross-sectional data over an 18-year period (1998–2015).

Results

Between the initial (1998–2003) and final (2010–15) periods of the study, the mean birthweight decreased from 3213.4 ± 383.8 to 3116.2 ± 382.3 g and the LBW rate increased from 2.5 to 5.5% (both P ≤ 0.01). Additionally, the mean eGFR decreased from 105.1 ± 15.9 to 97.4 ± 13.8 mL/min/1.73 m² and the prevalence of mildly reduced renal function (eGFR ≤ 60– <90 mL/min/1.73 m²) increased from 16.4 to 30.0% (both P ≤ 0.01), most evident in the LBW group (from 10.3 to 41.7%, P ≤0.01). The prevalence of proteinuria also increased significantly. Mildly reduced renal function was significantly associated with LBW [odds ratio (LBW 3000–3999 g) 1.51; 95% confidence interval 1.00–2.55; P = 0.047].

Conclusions

In this population of Japanese adolescents, the frequency of mildly reduced renal function increased as the LBW frequency increased. Our findings may have implications for the broader Japanese population as well as for other populations in which the prevalence of LBW is increasing.

Sex and gender disparities in the epidemiology and outcomes of chronic kidney disease

Improved understanding of sex and gender-specific differences in the aetiology, mechanisms and epidemiology of chronic kidney disease (CKD) could help nephrologists better address the needs of their patients. Population-based studies indicate that CKD epidemiology differs by sex, affecting more women than men, especially with regard to stage G3 CKD. The effects of longer life expectancy on the natural decline of glomerular filtration rate (GFR) with age, as well as potential overdiagnosis of CKD through the inappropriate use of GFR equations, might be in part responsible for the greater prevalence of CKD in women. Somewhat paradoxically, there seems to be a preponderance of men among patients starting renal replacement therapy (RRT); the protective effects of oestrogens in women and/or the damaging effects of testosterone, together with unhealthier lifestyles, might cause kidney function to decline faster in men than in women. Additionally, elderly women seem to be more inclined to choose conservative care instead of RRT. Dissimilarities between the sexes are also apparent in the outcomes of CKD. In patients with predialysis CKD, mortality is higher in men than women; however, this difference disappears for patients on RRT. Although access to living donor kidneys among men and women seems equal, women have reduced access to deceased donor transplantation. Lastly, health-related quality of life while on RRT is poorer in women than men, and women report a higher burden of symptoms. These findings provide insights into differences in the underlying pathophysiology of disease as well as societal factors that can be addressed to reduce disparities in access to care and outcomes for patients with CKD.

Sex and gender disparities in the epidemiology and outcomes of chronic kidney disease

Improved understanding of sex and gender-specific differences in the aetiology, mechanisms and epidemiology of chronic kidney disease (CKD) could help nephrologists better address the needs of their patients. Population-based studies indicate that CKD epidemiology differs by sex, affecting more women than men, especially with regard to stage G3 CKD. The effects of longer life expectancy on the natural decline of glomerular filtration rate (GFR) with age, as well as potential overdiagnosis of CKD through the inappropriate use of GFR equations, might be in part responsible for the greater prevalence of CKD in women. Somewhat paradoxically, there seems to be a preponderance of men among patients starting renal replacement therapy (RRT); the protective effects of oestrogens in women and/or the damaging effects of testosterone, together with unhealthier lifestyles, might cause kidney function to decline faster in men than in women. Additionally, elderly women seem to be more inclined to choose conservative care instead of RRT. Dissimilarities between the sexes are also apparent in the outcomes of CKD. In patients with predialysis CKD, mortality is higher in men than women; however, this difference disappears for patients on RRT. Although access to living donor kidneys among men and women seems equal, women have reduced access to deceased donor transplantation. Lastly, health-related quality of life while on RRT is poorer in women than men, and women report a higher burden of symptoms. These findings provide insights into differences in the underlying pathophysiology of disease as well as societal factors that can be addressed to reduce disparities in access to care and outcomes for patients with CKD.

Acute kidney injury post-transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is a treatment option in high-risk patients with severe aortic stenosis who are not surgical candidates. In light of emerging evidence, it is being increasingly performed even in intermediate-risk patients in recent years. Patients who develop acute kidney injury (AKI) following TAVR are known to have worse outcomes. The objective of this concise review was to identify the prevalence and the impact of AKI following TAVR on patient outcomes by including the most recent literature in our search. After a thorough search on MEDLINE, Google Scholar, and PubMed, we included all literature relevant to AKI following TAVR. We found that AKI was caused by a variety of reasons, such as hemodynamic instability during rapid pacing, blood transfusion, periprocedural embolization, and use of contrast medium, to name a few. In patients who developed AKI following TAVR, 30-day and 1-year mortality were increased. Further, in these patients, length and cost of hospital stay were increased as well. Preventive measures such as optimal periprocedural hydration, careful contrast use, and techniques to prevent embolization during device implantation have been tried with limited success. Given that TAVR is expected to be increasingly performed, this review aimed to summarize the rapidly expanding currently available literature in an effort to reduce procedural complications and thereby improve patient outcomes.

White-coat and masked hypertension are associated with albuminuria in a general population: the Hisayama Study

Epidemiological and clinical studies have investigated the influence of hypertension on chronic kidney disease (CKD), but limited data are available for the associations of white-coat hypertension (WCHT), masked hypertension (MHT) and sustained hypertension (SHT) with kidney dysfunction in general populations. We examined the associations of these types of hypertension with CKD (albuminuria and reduction in estimated glomerular filtration rate (eGFR)) in a cross-sectional survey of 2974 community-dwelling Japanese aged ⩾40 years. The types of hypertension were defined based on combined measurements of clinic and home blood pressures. Albuminuria was determined as urinary albumin-creatinine ratio (UACR) levels ⩾30.0 mg g^-1. The eGFR was calculated using the Japanese equation. The age- and sex-adjusted geometric mean of the UACR values was significantly higher in the subjects with WCHT (20.2 mg g^-1), MHT (19.6 mg g^-1) and SHT (31.6 mg g^-1) than in those with normotension (NT) (12.5 mg g^-1) (all P<0.001). Compared with NT, all types of hypertension were significantly associated with an increased likelihood of albuminuria (the age- and sex-adjusted prevalence of albuminuria; NT 14.1%, WCHT 26.3%, MHT 26.4% and SHT 43.3%; all P<0.001). These associations remained significant even after adjustment for other risk factors. However, the age- and sex-adjusted mean of eGFR and the prevalence of low eGFR (<60 ml min^-1 per 1.73 m²) did not differ between NT and the three hypertension types. The associations of the types of hypertension with the likelihood of CKD were similar to those for albuminuria. Our findings suggest that WCHT, MHT and SHT are associated with albuminuria in the general Japanese population.

Serum Non-High-Density Lipoprotein Cholesterol and Risk of Cardiovascular Disease in Community Dwellers with Chronic Kidney Disease: the Hisayama Study

AIM

It is not clear whether elevated serum non-high-density lipoprotein cholesterol (non-HDL-C) levels are a risk factor for cardiovascular disease (CVD) in subjects with chronic kidney disease (CKD) in the general population.

METHODS

A total of 2,630 community-dwelling Japanese subjects (1,107 men and 1,523 women) without history of CVD and aged ≥40 years were prospectively followed up for an average of 19 years, and the association between serum non-HDL-C levels and the incidence of type-specific CVD was estimated using a Cox proportional hazards model. CKD was defined as estimated glomerular filtration rate ＜60 mL/min/1.73 m2 or proteinuria (≥1＋ on dipstick).

RESULTS

At baseline, 357 subjects had CKD. During the follow up, 186 coronary heart disease (CHD) and 277 stroke events occurred. The age- and sex-adjusted incidence of CHD was significantly higher in subjects with higher non-HDL-C levels, both in those with and without CKD. In the CKD group, the risk of CHD was significantly higher in those with non-HDL-C levels of 150- 189 mg/dL [adjusted hazard ratio (HR), 2.23; 95% confidence interval (CI), 1.04-4.77] and those with levels ≥190 mg/dL (adjusted HR, 3.20; 95% CI, 1.46-7.03) than in those with levels ＜150 mg/dL. In the non-CKD group, the risk of CHD was significantly higher only in those with nonHDL-C levels ≥190 mg/dL (adjusted HR, 2.12; 95% CI, 1.33-3.38). However, no such association was observed for the risk of stroke.

CONCLUSIONS

Our findings suggest that higher serum non-HDL-C levels are associated with greater risk of CHD in subjects with and without CKD and that this association is greater in subjects with CKD than in those without CKD.