Menopausal symptoms in women with chronic kidney disease

Osteoporosis management in patients with chronic kidney disease (ERCOS Study): A challenge in nephrological care

Fracture risk assessment in patients with chronic kidney disease (CKD) has been included in the CKD-MBD ("Chronic Kidney Disease-Mineral and Bone Disorders") complex in international and national nephrology guidelines, suggesting for the first time the assessment of bone mineral density (BMD) if the results can influence therapeutic decision-making. However, there is very little information on actual clinical practice in this population. The main objective of the ERCOS (ERC-Osteoporosis) study is to describe the profile of patients with CKD G3-5D with osteoporosis (OP) and/or fragility fractures treated in specialized nephrology, rheumatology and internal medicine clinics in Spain. Fifteen centers participated and 162 patients (mostly women [71.2%] postmenopausal [98.3%]) with a median age of 77 years were included. Mean estimated glomerular filtration rate (eGFR) was 36 mL/min/1.73 m2 and 38% of the included patients were on dialysis. We highlight the high frequency of prevalent fragility fractures [37.7%), mainly vertebral (52.5%) and hip (24.6%)], the disproportionate history of patients with glomerular disease compared to purely nephrological series (corticosteroids) and undertreatment for fracture prevention, especially in nephrology consultations. This study is an immediate call to action with the dissemination of the new, more proactive, clinical guidelines, and underlines the need to standardize a coordinated and multidisciplinary care/therapeutic approach to these patients in an efficient way to avoid current discrepancies and therapeutic nihilism.

Evaluating Osteoporosis in Chronic Kidney Disease: Both Bone Quantity and Quality Matter

Bone strength is determined not only by bone quantity [bone mineral density (BMD)] but also by bone quality, including matrix composition, collagen fiber arrangement, microarchitecture, geometry, mineralization, and bone turnover, among others. These aspects influence elasticity, the load-bearing and repair capacity of bone, and microcrack propagation and are thus key to fractures and their avoidance. In chronic kidney disease (CKD)-associated osteoporosis, factors traditionally associated with a lower bone mass (advanced age or hypogonadism) often coexist with non-traditional factors specific to CKD (uremic toxins or renal osteodystrophy, among others), which will have an impact on bone quality. The gold standard for measuring BMD is dual-energy X-ray absorptiometry, which is widely accepted in the general population and is also capable of predicting fracture risk in CKD. Nevertheless, a significant number of fractures occur in the absence of densitometric World Health Organization (WHO) criteria for osteoporosis, suggesting that methods that also evaluate bone quality need to be considered in order to achieve a comprehensive assessment of fracture risk. The techniques for measuring bone quality are limited by their high cost or invasive nature, which has prevented their implementation in clinical practice. A bone biopsy, high-resolution peripheral quantitative computed tomography, and impact microindentation are some of the methods established to assess bone quality. Herein, we review the current evidence in the literature with the aim of exploring the factors that affect both bone quality and bone quantity in CKD and describing available techniques to assess them.

Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Hispanic/Latino individuals are less likely to receive optimal treatment for chronic kidney disease than non-Hispanic whites. This may be particularly detrimental for women of reproductive age as chronic kidney disease increases risk for infertility, menstrual irregularities, and pregnancy loss. While these maternal outcomes have been associated with advanced chronic kidney disease, their occurrence in early chronic kidney disease is unclear.

OBJECTIVES/DESIGN

Using baseline (2008-2011) and second study visit (2014-2017) data from the Hispanic Community Health Study/Study of Latinos, we retrospectively assessed the prevalence of chronic kidney disease as well as the association between chronic kidney disease and self-reported infertility, cessation of menses, hysterectomy, and nonviable pregnancy loss (experienced at less than 24 weeks gestation) in women of reproductive age (18-45 years).

METHODS

Multivariable survey logistic regression analyses determined the unadjusted and multivariable-adjusted prevalence odds ratios with 95% confidence intervals between chronic kidney disease and the separate outcomes.

RESULTS

Among 2589 Hispanic/Latino women included (mean age = 31.4 years), 4.6% were considered to have chronic kidney disease. In adjusted analyses, women with chronic kidney disease did not have a significantly increased odds of infertility (odds ratio = 1.02, 95% confidence interval = 0.42-2.49), cessation of menses (odds ratio = 1.25, 95% confidence interval = 0.52-3.04), or hysterectomy (odds ratio = 1.17, 95% confidence interval = 0.61-2.25) compared to those without chronic kidney disease. In those with chronic kidney disease, the adjusted odds of a nonviable pregnancy loss occurring after baseline visit were increased (odds ratio = 2.11, 95% confidence interval = 0.63-7.02) but not statistically significance.

CONCLUSION

The presence of early stage chronic kidney disease did not confer a significant risk of infertility, cessation of menses, or nonviable pregnancy loss.

The Association of Kidney Function and Inflammatory Biomarkers with Epithelial Ovarian Cancer Risk

BACKGROUND

One of the mechanisms of ovarian tumorigenesis is through inflammation. Kidney dysfunction is associated with increased inflammation; thus, we assessed its relationship with ovarian cancer risk.

METHODS

In prospectively collected samples, we evaluated the association of kidney function markers and C-reactive protein (CRP) with ovarian cancer risk in the UK Biobank. We used multivariable-adjusted Cox proportional hazards models to evaluate quartiles of serum and urine markers with ovarian cancer risk overall and by histology. We assessed effect modification by CRP (≤3.0, >3.0 mg/L).

RESULTS

Among 232,908 women (1,110 ovarian cancer cases diagnosed from 2006-2020), we observed no association between estimated glomerular filtration rate and ovarian cancer risk (Q4 vs. Q1: HR, 1.00; 95% confidence intervals, 0.83-1.22). Potassium was associated with endometrioid (Q4 vs. Q1: 0.33, 0.11-0.98) and clear cell (4.74, 1.39-16.16) tumors. Poor kidney function was associated with a nonsignificant increase in ovarian cancer risk among women with CRP>3.0 mg/L (e.g., uric acid Q4 vs. Q1; 1.23, 0.81-1.86), but not CRP≤3.0 mg/L (0.83, 0.66-1.05). Other associations did not vary across CRP categories.

CONCLUSIONS

Kidney function was not clearly associated with ovarian cancer risk. Larger studies are needed to evaluate possible histology specific associations. Given the suggestive trend for increased ovarian cancer risk in women with poor kidney function and high CRP, future work is needed, particularly in populations with a high prevalence of inflammatory conditions.

IMPACT

This study provided the first evaluation of markers of kidney function in relation to ovarian cancer risk.

Menstrual Abnormalities and Reproductive Lifespan in Females with CKD: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Menstrual abnormalities and shortened reproductive lifespan are associated with shorter life expectancy and higher cardiovascular and osteoporosis risk in the general population, although the magnitude of these reproductive factor irregularities in females with CKD is unclear. This systematic review and meta-analysis aimed to summarize the current knowledge regarding menstrual abnormalities and reproductive lifespan among females with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A comprehensive bibliographic search (MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) was completed from database inception to February 2022 to identify all original articles reporting on females of reproductive age with nondialysis-dependent/nonkidney transplant CKD, dialysis-dependent CKD, or kidney transplantation and menstruation patterns, age of menarche, and/or menopause. Data extraction and study quality assessment were completed in duplicate. Random effects meta-analyses were used to derive pooled proportions estimates.

RESULTS

Forty-six studies were identified, and 35 were meta-analyzed, stratified by KRT modality and reported outcome. Menstrual abnormalities were present in 19%-47% of patients on hemodialysis and 75% of patients on peritoneal dialysis. Kidney transplantation was associated with a 7%-30% decrease in menstrual abnormalities. Reproductive lifespan was 32 years (95% confidence interval, 30 to 34 years). Although significant heterogeneity was present, study quality ranged from fair to good, and no evidence of publication bias was noted.

CONCLUSIONS

Menstrual abnormalities and shorter reproductive lifespan are common in females with CKD, although kidney transplantation may improve menstrual health.

Cancer Mortality in People Receiving Dialysis for Kidney Failure: An Australian and New Zealand Cohort Study, 1980-2013

RATIONALE & OBJECTIVE

Cancer is a significant cause of morbidity in the population with kidney failure; however, cancer mortality in people undergoing dialysis has not been well described. We sought to compare cancer mortality in people on dialysis for kidney failure with cancer mortality in the general population.

STUDY DESIGN

A retrospective cohort study using linked health-administrative and dialysis registry data.

SETTING & PARTICIPANTS

All people receiving dialysis represented in the Australian and New Zealand Dialysis and Transplantation Registry, 1980-2013.

EXPOSURE

Dialysis; hemodialysis (HD) and peritoneal dialysis (PD).

OUTCOME

Death and underlying cause of death ascertained using health administrative data and classified using International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) codes.

ANALYTICAL APPROACH

Indirect standardization on age at death, sex, year, and country to estimate standardized mortality ratios (SMR).

RESULTS

Over 269,598 person years of observation, 34,100 deaths occurred among 59,648 people on dialysis, including 3,677 cancer deaths. The relative risk of all-site cancer death in dialysis was twice (SMR, 2.4 [95% CI, 2.33-2.49]) that of the general population and highest for oral and pharynx cancers (SMR, 24.3 [95% CI, 18.0-31.5]) and multiple myeloma (SMR, 22.5 [95% CI, 20.3-23.9]). Women on dialysis had a significantly higher risk of all-site cancer mortality (SMR, 2.7 [95% CI, 2.59-2.89]) compared with men (SMR, 2.3 [95% CI, 2.17-2.36]) (P < 0.001). People on HD (SMR, 2.2 [95% CI, 2.11-2.30]) experienced greater excess deaths from all-site cancer compared with people on PD (SMR, 1.3 [95% CI, 1.23-1.44]). Excess deaths have gradually decreased over time for all-site, multiple myeloma, and kidney cancers (P < 0.001) but have not kept up with improvements in the general population. By contrast, among people receiving dialysis, excess deaths increased for colorectal and lung cancers (P < 0.001).

LIMITATIONS

Confirmation of cancer diagnoses and population incidence data were not available; inability to exclude pre-existing cancers.

CONCLUSIONS

People on dialysis experience excess all-site and site-specific cancer mortality compared with the general population. Mortality differs by modality type, age, and sex. Understanding the role of kidney failure and other morbidities in the treatment of cancer is important for shared decision-making regarding cancer treatments and identifying potential approaches to improve outcomes.

Early Menopause May Associate With a Higher Risk of CKD and All-Cause Mortality in Postmenopausal Women: An Analysis of NHANES, 1999–2014

Background

Chronic kidney disease (CKD) in women is often accompanied by hormone disorders such as sex hormones, and most women with CKD are in the post-menopausal age group. Due to the close relationship between menopause and sex hormones, we aimed to explore the association between early menopause and CKD in post-menopausal women, and the influence of early menopause on longevity in the CKD population.

Methods

Information regarding 4,945 post-menopausal women was extracted from the database of the National Health and Nutrition Examination Survey (NHANES) 1999–2014, and then divided into 4 groups according to the type of menopause (natural or surgical) and early menopause (menopause at age <45) or not. The association between early menopause and CKD prevalence was examined using multivariable logistic regression, while we used multivariable Cox proportional hazards models to investigate the possible relationship between early menopause and all-cause mortality in CKD and non-CKD populations. The differences in the levels of sex hormones between women with and without CKD were also explored.

Results

Compared with women with natural menopause at age ≥45, women experiencing early natural menopause had a higher risk of CKD [OR = 1.26 (1.01–1.56)]. Similarly, as compared to women with surgical menopause at age ≥ 45, women in the early surgical menopause group were more likely to have CKD [OR = 1.38 (1.05–1.81)]. In addition, early surgical menopause was associated with higher mortality in the non-CKD group [HR = 1.62 (1.06–2.49)], but not in the CKD group. Women with CKD had a higher level of luteinizing hormone and follicle-stimulating hormone, combined with a lower level of testosterone and estradiol than the non-CKD women.

Conclusion

Both early natural and surgical menopause were associated with a higher risk of CKD. Early surgical menopause was a hazard factor for survival in the non-CKD group, but not in the CKD group. Further research is required to understand the mechanisms.

Sex differences in mortality among binational cohort of people with chronic kidney disease: population based data linkage study

OBJECTIVE

To evaluate sex differences in mortality among people with kidney failure compared with the general population.

DESIGN

Population based cohort study using data linkage.

SETTING

The Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), which includes all patients receiving kidney replacement therapy in Australia (1980-2019) and New Zealand (1988-2019). Data were linked to national death registers to determine deaths and their causes, with additional details obtained from ANZDATA.

PARTICIPANTS

Of 82 844 people with kidney failure, 33 329 were female (40%) and 49 555 were male (60%); 49 376 deaths (20 099 in female patients; 29 277 in male patients) were recorded over a total of 536 602 person years of follow-up.

MAIN OUTCOME MEASURES

Relative measures of survival, including standardised mortality ratios, relative survival, and years of life lost, using general population data to account for background mortality (adjusting for country, age, sex, and year). Estimates were stratified by dialysis modality (haemodialysis or peritoneal dialysis) and for the subpopulation of kidney transplant recipients.

RESULTS

Few differences in outcomes were found between male and female patients with kidney failure. However, compared with the general population, female patients with kidney failure had greater excess all cause deaths than male patients (female patients: standardised mortality ratio 11.3, 95% confidence interval 11.2 to 11.5, expected deaths 1781, observed deaths 20 099; male patients: 6.9, 6.8 to 6.9, expected deaths 4272, observed deaths 29 277). The greatest difference was observed among younger patients and those who died from cardiovascular disease. Relative survival was also consistently lower in female patients, with adjusted excess mortality 11% higher (95% confidence interval 8% to 13%). Average years of life lost was 3.6 years (95% confidence interval 3.6 to 3.7) greater in female patients with kidney failure compared with male patients across all ages. No major differences were found in mortality by sex for haemodialysis or peritoneal dialysis. Kidney transplantation reduced but did not entirely remove the sex difference in excess mortality, with similar relative survival (P=0.83) and years of life lost difference reduced to 2.3 years (95% confidence interval 2.2 to 2.3) between female and male patients.

CONCLUSIONS

Compared with the general population, female patients had greater excess deaths, worse relative survival, and more years of life lost than male patients, however kidney transplantation reduced these differences. Future research should investigate whether systematic differences exist in access to care and possible strategies to mitigate excess mortality among female patients.

Endogenous estrogen exposure and chronic kidney disease; a 15-year prospective cohort study

BACKGROUND

Despite strong evidence demonstrating the role of estrogen as a protective factor for kidney function in women, limited data are available regarding the influence of endogenous estrogen exposure (EEE) on chronic kidney disease (CKD). The present study aimed to assess the incidence of CKD in women with various levels of EEE.

METHODS

In a prospective population-based study over a 15-year follow-up, a total of 3043 eligible women aged 30-70 years, participating in Tehran-Lipid and Glucose-Study were recruited and divided into two groups (EEE < 11 and EEE ≥ 11 years). EEE calculated based on age at menarche, age at menopause, number and duration of pregnancies, lactation, and duration of oral contraceptive use after excluding the progesterone dominant phase of the menstrual cycle. Cox's proportional hazards model was applied to estimate the hazard ratio of CKD between the study groups, after adjusting for confounders.

RESULTS

The total cumulative incidence rate of CKD was 50.1 per 1000 person years; 95% CI: 47.7-52.6); this was 53.9 (95%CI, 50.2-57.8) and 47.1 (95%CI, 44.0-50.4) per 1000 person years in women with EEE < 11 and EEE ≥ 11 years, respectively. The model adjusted for age, BMI, smoking, hypertension, and diabetes showed that the hazard ratio (HR) of incidence CKD in women with EEE < 11 compare to those with EEE ≥ 11 years in the subgroup of women aged< 45 years was 2.66(95% CI, 2.2, 3.2), whereas, in the subgroup aged ≥45 years, it was 1.22 (95% CI, 1.04, 1.4).

CONCLUSION

This study shows a higher HR of CKD incidence in women with low EEE levels in their later life. Screening of these women for CKD may be recommended.

Predictors of the age at which natural menopause occurs in women with type 1 diabetes: the Pittsburgh Epidemiology of Diabetes Complications (EDC) study

OBJECTIVE

Women with type 1 diabetes (T1D) are thought to experience menopause earlier than women without diabetes, although not all studies agree. We assessed metabolic predictors of the age at which natural menopause occurs among women with T1D participating in the Epidemiology of Diabetes Complications study.

METHODS

Women with childhood-onset (<17 y) of T1D who underwent natural menopause without use of hormone therapy during their menopausal transition were included in the analysis (n = 105; mean baseline age, 29.5 and diabetes duration, 20.2 y). Self-reported reproductive history and the Women's Ischemia Syndrome Evaluation hormonal algorithms were used to determine menopause status. Linear regression was used to ascertain whether time-weighted metabolic factors (eg, BMI, lipids, HbA1c, insulin dose, albumin excretion rate [AER]) were associated with age at natural menopause.

RESULTS

Univariately, only insulin dose (β = -4.87, P = 0.04) and log (AER) (β = -0.62, P = 0.02) were associated (negatively) with age at natural menopause. Adjusting for BMI, smoking status, lipids, HbA1c, number of pregnancies, and oral contraceptive use, each 0.1 unit increase in the daily dose of insulin per kilogram body weight was associated with 0.64 years younger age at natural menopause (P = 0.01), while for every 30% increase in AER, age at natural menopause decreased by 0.18 years (P = 0.03).

CONCLUSION

Higher average levels of insulin dose and AER over time were significantly associated with a younger age at which natural menopause occurred among women with T1D. The biologic mechanisms underlying the observed associations between exogenous insulin dose and AER on reproductive health should be investigated among women with T1D.

Association of Reproductive Lifespan Duration and Chronic Kidney Disease in Postmenopausal Women

OBJECTIVE

To investigate the relationship between endogenous estrogen exposure and renal function, the association of female reproductive life span duration (RLD) and chronic kidney disease (CKD) was analyzed in postmenopausal women.

PATIENTS AND METHODS

Data were retrieved from the Korean Genome and Epidemiology Study, which was constructed from May 1, 2001, through December 25, 2017. A total of 50,338 and 3155 postmenopausal women were each included in the cross-sectional and longitudinal analyses. The RLD was determined by subtracting the age at menarche from the age at menopause. Participants were grouped into RLD quartiles. Participants with estimated glomerular filtration rates less than 60 mL/min/1.73 m² were regarded to have CKD.

RESULTS

In the cross-sectional analysis, mean ± SD age and estimated glomerular filtration rate were 56.3±4.9 years and 93.1±13.6 mL/min/1.73 m², respectively. Mean ± SD RLD was 34.2±4.0 years. A total of 765 of 50,338 (1.52%) women were found to have CKD. Logistic regression analysis revealed that the odds ratio for CKD was lower in groups with longer RLDs as compared with the shortest RLD group. In longitudinal analysis, postmenopausal women with normal kidney function were followed up for 9.7 years and incident CKD occurred in 221 of 3155 (7.00%) participants. Cox analysis revealed that the risk for CKD development was significantly lower in longer RLD groups. This finding was significant even after adjustments for confounding factors.

CONCLUSION

The risk for CKD was lower in women with longer RLDs. The amount of endogenous estrogen exposure could be a determining factor for renal function in postmenopausal women.

Relationship Between Metabolic Syndrome and Beta-Cell Function in Nondiabetic Korean Premenopausal and Postmenopausal Women: 2015 Korean National Health and Nutrition Examination Survey

Background: This study was conducted to assess the relationship between metabolic syndrome (MetS) and beta-cell function in nondiabetic Korean women. Methods: This study included 2,507 women (premenopausal women, 1,359; postmenopausal women, 1,148) who were aged ≥20 and used 2015 Korean National Health and Nutrition Examination Survey (KNHANES) data. Results: Key study results were as follows: first, in both premenopausal and postmenopausal women, after adjusting for related variables [except body mass index (BMI)], MetS (P < 0.001) and metabolic syndrome score (MSS; P < 0.001) were positively associated with the homeostasis model assessment of beta-cell function (HOMA-B) levels. Second, in premenopausal women, when further adjusted for BMI, MetS (P = 0.002) and MSS (P < 0.001) were also positively associated with HOMA-B levels. However, in postmenopausal women, when further adjusting for BMI, the associations of MetS (P = 0.322) or MSS (P = 0.855) and HOMA-B levels were no longer significant. Conclusions: Metabolic syndrome was positively associated with beta-cell function in nondiabetic Korean premenopausal women, but not in Korean postmenopausal women.

Effects of lipoic acid and ω-3 long-chain polyunsaturated fatty acids on the kidney in the ovariectomized rat model of menopause

OBJECTIVES

The loss of antioxidant protection from estrogen during menopause may lead to oxidative stress in the kidneys. Thus, antioxidant supplementation may potentially decrease the menopause-derived oxidative stress. The aim of this study was to evaluate the effect of α-lipoic acid (LA) and ω-3 long-chain polyunsaturated fatty acids on the redox profile of the kidneys in the ovariectomized rat model of menopause.

METHODS

We assessed oxidative damage markers and antioxidant defenses in the kidneys of ovariectomized rats supplemented with LA, docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA). Animals received 3 mo of dietary supplementation.

RESULTS

Ovariectomy did not increase the levels of the damage markers carbonyl and malondialdehyde. EPA supplementation increased carbonyl and malondialdehyde levels. Ovariectomy increased fumarase activity but did not affect the levels of vitamin C, glutathione, and glutathione S-transferase activity. LA, DHA, and EPA supplementation decreased fumarase activity, but increased the levels of vitamin C, glutathione, and glutathione S-transferase activity. Vitamin E, superoxide dismutase, glutathione peroxidase, and peroxide consumption were not affected by ovariectomy or supplementation.

CONCLUSIONS

The results suggest that ovariectomy did not affect the redox profile in the kidneys. LA, DHA, and EPA supplementation increased certain endogenous antioxidants; however, EPA may have a prooxidant effect on the kidneys.

Menopausal symptoms and associated factors in women living with HIV in Cambodia

This study investigated the prevalence and severity of menopausal symptoms and associated factors among women living with HIV in Cambodia. Menopause Rating Scale (MRS) assessed the menopausal symptoms, and SPSS Version 20.0 analyzed the data. The three most dominant symptoms, which were also rated the top three "severe" symptoms, were psychological: physical and mental exhaustion (91.5%), irritability (84.1%), and depressive mood (83.6%). The highest incidence was among the perimenopausal women. Severity of symptoms was associated with personal income, abortion, and intake of calcium supplements. Health-care professionals need to provide appropriate individualized interventions to maintain the social, emotional, and overall well-being of menopausal women living with HIV.

Associations of urinary polycyclic aromatic hydrocarbons with age at natural menopause in U.S. women aged 35-65, NHANES 2003-2012

Polycyclic aromatic hydrocarbons (PAHs) mediated ovarian toxicity has been demonstrated in animal experiments. However, this issue has not been assessed in humans. Based on the National Health and Nutrition Examination Survey (NHANES) 2003-2012, data analysis was restricted to 1221 general U.S. women aged 35-65 years with complete data of interest. Levels of nine PAH metabolites in spot urine specimens were measured by isotope dilution gas chromatography/tandem mass spectrometry (GC-MS/MS). Self-reported information on the menopause status and age at menopause were obtained during interview. Cox proportional hazards regression was employed to assess the associations between PAH levels and natural menopause. Compared with women in the first quartile, subjects in the highest quartile of 1-Hydroxynapthalene [hazard ratio (HR) = 1.46, 95% confidence interval (CI) = 1.06 to 2.01], 2-Hydroxynapthalene (HR = 1.51, 95% CI = 1.12 to 2.05) and 3-Hydroxyfluorene (HR = 1.51, 95% CI = 1.06 to 2.16), or in the second quartile of 9-Hydroxyfluorene (HR = 1.53, 95% CI = 1.05 to 2.22), had elevated risks of earlier onset of natural menopause. Our findings suggested positive associations between urinary PAH levels and earlier age at natural menopause in the general U.S. women. Prospective studies are warranted to confirm the causality in the future.

Sex and gender differences in chronic kidney disease: progression to end-stage renal disease and haemodialysis

Sex and gender differences are of fundamental importance in most diseases, including chronic kidney disease (CKD). Men and women with CKD differ with regard to the underlying pathophysiology of the disease and its complications, present different symptoms and signs, respond differently to therapy and tolerate/cope with the disease differently. Yet an approach using gender in the prevention and treatment of CKD, implementation of clinical practice guidelines and in research has been largely neglected. The present review highlights some sex- and gender-specific evidence in the field of CKD, starting with a critical appraisal of the lack of inclusion of women in randomized clinical trials in nephrology, and thereafter revisits sex/gender differences in kidney pathophysiology, kidney disease progression, outcomes and management of haemodialysis care. In each case we critically consider whether apparent discrepancies are likely to be explained by biological or psycho-socioeconomic factors. In some cases (a few), these findings have resulted in the discovery of disease pathways and/or therapeutic opportunities for improvement. In most cases, they have been reported as merely anecdotal findings. The aim of the present review is to expose some of the stimulating hypotheses arising from these observations as a preamble for stricter approaches using gender for the prevention and treatment of CKD and its complications.

Soluble klotho may be a marker of phosphate reabsorption

Background: Membrane-bound α-klotho functions as a co-receptor with fibroblast growth factor receptor at the renal tubule conferring specificity to fibroblast growth factor-23 (FGF-23), allowing it to inhibit tubular phosphate reabsorption at physiological concentrations. α-klotho also exists as a soluble protein. However, the complex interrelationships between soluble α-klotho (sKl), FGF-23 and phosphate reabsorption are poorly understood, with little known about the links between sKl, FGF-23 and phosphate reabsorption in chronic kidney disease (CKD). This study addresses this issue in a cohort of patients with and without CKD. Methods: We conducted a single-centre, cross-sectional study of contemporaneously obtained samples of blood and 24-h urine biochemistry along with sKl and intact FGF-23 (iFGF-23) from non-dialysis-dependent CKD patients and healthy volunteers. Pearson's correlation coefficients were used to determine correlations between natural log-transformed (Ln) sKl and iFGF-23 with other parameters of interest. Backward multivariate analysis was undertaken to evaluate the relationship between mineral parameters. Results: One hundred and sixteen participants (77 with CKD and 39 healthy volunteers) were studied, of which 74 (63.8%) were male. The median age was 61 (interquartile range 49-71) years. Those with CKD had lower sKl (408 versus 542 pg/mL), higher iFGF-23 (94 versus 41 pg/mL), higher fractional excretion of phosphate (25.05 versus 10.98%) and lower daily urinary phosphate excretion (UPE) (24.8 versus 32.3 mmol/L) compared with healthy volunteers (all P  ≤ 0.002). Age correlated inversely and estimated glomerular filtration rate (eGFR) correlated positively with phosphate reabsorption and Ln(sKl), while the opposite was seen with Ln(iFGF23). Upon multivariate analysis, eGFR, Ln(sKl) and parathyroid hormone were independently associated with phosphate reabsorption, whereas Ln(iFGF-23) was not, after adjustment for age. Conclusions: Abnormalities in phosphate regulatory pathways are disturbed early in CKD. While iFGF-23 is associated with phosphate excretion on univariate analyses, sKl demonstrates a significant association with phosphate reabsorption independent of iFGF-23, and this relationship deserves further exploration.

Prevalence and predictors of severe menopause symptoms among HIV-positive and -negative Nigerian women

We compared the prevalence of menopause symptoms between women living with HIV to their HIV-negative peers and determined predictors of severe menopause symptoms in Jos, Nigeria. This descriptive cross-sectional study included 714 women aged 40-80 years. We compared prevalence and severity of menopause symptoms using the menopause rating scale (MRS). Logistic regression analysis was used to determine the predictors of severe symptoms. Six-hundred and seven (85.0%) were HIV-positive, with a mean duration of infection of 5.6 ± 2.7 years. The mean age of the cohort was 46 ± 5 years. The most prevalent menopause symptoms were hot flushes (67.2%), joint and muscle discomfort (66.2%), physical/mental exhaustion (65.3%), heart discomfort (60.4%), and anxiety (56.4%). The median MRS score was higher for HIV-positive compared to HIV-negative women (p = 0.01). Factors associated with severe menopause symptoms included HIV-positive status (aOR: 3.01, 95% CI: 1.20-7.54) and history of cigarette smoking (aOR: 4.18, 95% CI: 1.31-13.26). Being married (aOR: 0.49, 95% CI: 0.32-0.77), premenopausal (aOR: 0.60, 95% CI: 0.39-0.94), and self-reporting good quality of life (aOR: 0.62. 95% CI: 0.39-0.98) were protective against severe menopause symptoms. We found HIV infection, cigarette smoking, quality of life, and stage of the menopause transition to be associated with severe menopause symptoms. As HIV-positive populations are aging, additional attention should be given to the reproductive health of these women.