Dyslipidemia, malnutrition, inflammation, cardiovascular disease and mortality in chronic kidney disease

Association Between Peritoneal Glucose Absorption, Lipid Metabolism, and Cardiovascular Disease Risk in Nondiabetic Patients on Peritoneal Dialysis

BACKGROUND

Excessive sugar intake increases the energy metabolic burden and the risk of cardiovascular disease (CVD). Patients on peritoneal dialysis absorb much more glucose than the World Health Organization recommends, but the link to CVD is unclear.

OBJECTIVE

To identify the association between peritoneal glucose absorption, lipid metabolism, and CVD.

METHODS

We applied generalized additive mixed effects and mixed effects Cox proportional hazard models to evaluate the impact of peritoneal glucose absorption on lipid profiles and CVD risk. We performed subgroup analyses by using protein intake (normalized protein nitrogen appearance [nPNA] and normalized protein catabolic rate [nPCR] were used to assess protein intake) and high-sensitivity C-reactive protein (hs-CRP).

RESULTS

After multivariable adjustment, peritoneal glucose absorption per 10 g/d increase was associated with an increase in cholesterol of 0.145 (95% confidence interval [CI]: 0.086-0.204) mmol/L. No link with the total risk of CVD was observed; however, protein intake and hs-CRP levels affected the relationship between glucose absorption and CVD risk. Patients with values for nPNA and nPCR <1.0 g/(kg·d) were associated with a lower risk of CVD (hazard ratio [HR] 95% CI: 0.68 (0.46-0.98)) with glucose absorption per 10 g/d increase. While patients with hs-CRP levels ≥3 mg/d or values for nPNA or nPCR ≥1.0 g/(kg·d) were associated with a higher risk of CVD (HR 95% CI: 1.32 (1.07-1.63); 1.31 (1.02-1.68)) for glucose absorption per 10 g/d increase.

CONCLUSIONS

Our study found a positive correlation between peritoneal glucose absorption and lipid profiles. Increased glucose absorption was associated with a lower risk of CVD in lower protein intake patients and a higher risk of CVD in higher hs-CRP or protein intake levels in patients on peritoneal dialysis.

Incidence of major cardiovascular events at 1, 2, and 5 years and mortality in incident patients on peritoneal dialysis regarding their nutritional status by bioimpedanciometry: A multicenter study in Colombia

BACKGROUND

The nutritional status of incident patients on peritoneal dialysis (PD) has been associated with survival outcomes. Bioimpedanciometry (BCM) enables to establish a nutritional diagnosis, the volume status, and correlates these findings with survival.

METHODS

This study used a retrospective multicenter historical cohort.

RESULTS

In this study, which included 420 incident patients on peritoneal dialysis with a 5-year follow-up, a cumulative incidence of major adverse cardiovascular events (MACE) of 28.8% was found, being higher in the diabetic population at 36.8%. In regard to the nutritional status in this population, it was found that approximately 44% had altered nutritional status; 34% were found to be in sarcopenia; 6.7% sarcopenic obesity; and 2.8% in obesity (p < 0.001). In the survival analysis, a lower probability of survival was found in patients with overhydration (OH) greater than 3 L (p < 0.001) and in patients with altered nutritional status due to sarcopenia, sarcopenic obesity, and obesity (p 0.016). According to survival in the subgroup of the diabetic population, a lower probability of survival was found in this group of patients (p: 0.011). The overall mortality of the study population was 18%, being higher in the first 2 years, with the most important causes of mortality being cardiovascular. Of the deceased population, 51% were diabetic patients (p: 0.012).

CONCLUSION

In incident patients on peritoneal dialysis, sarcopenic obesity, sarcopenia, overhydration status determined by BCM, and having a diagnosis of diabetes are related to a lower probability of survival; MACE outcomes are more frequent in the diabetic population.

Association of Neutrophil and Albumin With Mortality Risk in Patients Receiving Peritoneal Dialysis

OBJECTIVE

Inflammation and nutrition have been recognized as predicting mortality in patients receiving peritoneal dialysis (PD). Serum neutrophil and albumin are crucial factors in inflammation and nutrition status. Up until now, the synergistic effect of neutrophil and albumin on mortality prediction in PD patients is still being determined. Our study sought to assess the effect of the interaction between neutrophils and albumin on the risk of all-cause mortality and cardiovascular disease (CVD) mortality patients receiving PD.

METHODS

A total of 1229 PD patients were recruited and divided into three categories in this cohort study. Their relationships with all-cause mortality and CVD mortality were analyzed in multivariable COX regression models adjusted for confounding factors.

RESULTS

During the median follow-up of 34.2 months, 222 (18.1%) patients died, and 115 (51.8%) suffered from cardiovascular events. Patients with high neutrophil percentage-to-albumin ratio (NPAR) showed increased all-cause mortality and CVD mortality, with adjusted hazard ratios of 1.490 (95% confidence interval, 1.070-2.074, P = .018) and 1.633 (95% confidence interval, 1.041-2.561, P = .033), respectively, compared with those with low NPAR. Competitive risk models and sensitivity analyses further confirmed this association. In the receiver operating characteristic curve analysis, however, there was little evidence that NPAR is a better indicator than albumin and neutrophil count.

CONCLUSIONS

Having a high NPAR is linked to a higher risk of mortality, especially when both high neutrophil and low albumin are present.

Comparative analysis of four nutritional scores in predicting adverse outcomes in biopsy-confirmed diabetic kidney Disease

Malnutrition is associated with adverse outcomes in patients with diabetic kidney disease (DKD). However, it is uncertain which nutritional assessment tools are most effective in predicting the adverse outcomes of DKD. This retrospective study was conducted at a single center and included 367 patients diagnosed with DKD based on biopsy results between August 2009 and December 2018. Four nutritional assessment indices, namely the Prognostic Nutritional Index (PNI), Geriatric Nutritional Risk Index (GNRI), Triglycerides (TG) × Total Cholesterol (TC) × Body Weight (BW) Index (TCBI), and Controlling Nutritional Status (CONUT) score, were selected and calculated. We aimed to assess the association between these nutritional scores and adverse outcomes, including progression to end-stage kidney disease (ESKD), cardiovascular diseases events (CVD), and all-cause mortality. Univariate and multivariate Cox regression analyses, Kaplan-Meier analysis, along with Restricted cubic spline analysis were used to examine the relationship between nutritional scores and adverse outcomes. Furthermore, the area under the curve (AUC) was calculated using time-dependent receiver operating characteristics to determine the predictive value of the four nutritional scores alone and some combinations. Lastly, ordered logistic regression analysis was conducted to explore the correlation between the four nutritional scores and different renal histologic changes. The incidence of ESKD, CVD, and all-cause mortality was significantly higher in patients with DKD who had a lower PNI, lower GNRI, and higher CONUT score. Additionally, The TCBI performed the worst in terms of grading and risk assessment. The PNI offer the highest predictive value for adverse outcomes and a stronger correlation with renal histologic changes compared to other nutritional scores. Patients diagnosed with DKD who have a worse nutritional status are more likely to experience higher rates of adverse outcomes. The PNI might offer more valuable predictive values and a stronger correlation with different renal histologic changes compared to other nutritional scores.

Mapping the global research landscape on malnutrition for patients with chronic kidney disease: a visualization analysis

BACKGROUND

Chronic kidney disease (CKD) is seen as a diverse disease and a primary contributor to global mortality. Malnutrition arises within chronic illness, which involves protein energy depletion and inadequate levels of essential nutrients. These factors increase the likelihood of death and the overall impact of the disease on affected individuals. Consequently, this study aims to utilize bibliometric and visual analysis to assess the current state of research, the latest advances and emerging patterns in the fields of CKD and malnutrition.

METHODS

Extensive research was conducted using the Scopus database, which is the most authoritative database of research publications and citations, to focus on CKD research between 2003 and 2022, as indicated by title and author keywords. Then, within this vast collection of academic publications, a notable subset of articles was exclusively dedicated to investigating the relationship between CKD and malnutrition. Finally, we performed bibliometric analysis and visualization using VOSviewer 1.6.19 and Microsoft Excel 2013.

RESULTS

Large global research between 2003 and 2022 resulted in 50,588 documents focused on CKD, as indicated by title and author keywords. In this extensive collection of scientific publications, a staggering portion of 823 articles is devoted exclusively to investigating the link between CKD and malnutrition. Further analysis reveals that this body of work consists of 565 articles (68.65%), 221 reviews (26.85%), and 37 miscellaneous entries (4.50%), which encompass letters and editorials. The USA was found to be the most productive country (n = 173; 21.02%), followed by Italy (n = 83; 10.09%), Sweden (n = 56; 6.80%), Brazil (n = 54; 6.56%) and China (n = 51; 6.20%). The most common terms on the map include those related to the topic of (a) malnutrition in hemodialysis patients and predicting factors; terms associated with the (b) impact of malnutrition on cardiovascular risk and complications in CKD patients; and terms related to the (c) dietary protein intake and malnutrition in CKD.

CONCLUSIONS

This study is the first of its kind to analyze CKD and malnutrition research using data from Scopus for visualization and network mapping. Recent trends indicate an increasing focus on protein-energy wasting/malnutrition in hemodialysis patients and predicting factors, dietary protein intake, and malnutrition in CKD. These topics have gained significant attention and reflect the latest scientific advances. Intervention studies are crucial to examining diet therapy's impact on patients with stages 1 to 5 CKD. We hope this study will offer researchers, dietitians and nephrologists valuable information.

Prevalence and prognostic value of malnutrition in patients with acute coronary syndrome and chronic kidney disease

Background

Malnutrition is a rising global health issue associated with unfavorable outcomes of a variety of disorders. Currently, the prevalence and prognostic significance of malnutrition to patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) remained largely unclear.

Methods

A total of 705 patients diagnosed with ACS and CKD in the First Affiliated Hospital of Wenzhou Medical University between 2013 and 2021 were included in this retrospective cohort study. Malnutrition was assessed by the Controlling Nutritional Status (CONUT), the Geriatric Nutritional Risk Index (GNRI), and the Prognostic Nutritional Index (PNI), respectively. The relationships between malnutrition and all-cause mortality and major cardiovascular events (MACEs) were analyzed.

Results

During a median follow-up of 31 months, 153 (21.7%) patients died, and 165 (23.4%) had MACEs. The prevalence of malnutrition was 29.8, 80.6, and 89.8% for the PNI, CONUT, and GNRI, respectively. All the malnutrition indexes were correlated with each other (r = 0.77 between GNRI and PNI, r = -0.72 between GNRI and CONUT, and r = -0.88 between PNI and CONUT, all p < 0.001). Compared with normal nutrition, malnutrition was independently associated with an increased risk for all-cause mortality (adjusted hazard ratio for moderate and severe degrees of malnutrition, respectively: 7.23 [95% confidence interval (CI): 2.69 to 19.49] and 17.56 [95% CI: 5.61 to 55.09] for the CONUT score, 2.18 [95% CI: 0.93 to 5.13] and 3.16 [95% CI: 1.28 to 7.79] for the GNRI, and 2.52 [95% CI: 1.62 to 3.94] and 3.46 [95% CI: 2.28 to 5.25] for the PNI score. p values were lower than 0.05 for all nutritional indexes, except for moderate GNRI p value = 0.075). As for MACEs, similar results were observed in the CONUT and PNI. All the risk scores could improve the predictive ability of the Global Registry of Acute Coronary Events (GRACE) risk score for both all-cause mortality and MACEs.

Conclusion

Malnutrition was common in patients with ACS and CKD regardless of the screening tools used, and was independently associated with all-cause mortality and MACEs. Malnutrition scores could facilitate risk stratification and prognosis assessment.

An Exploratory Study on a New Method for Nutritional Status Assessment in Patients with Chronic Kidney Disease

Malnutrition is a risk factor for disease progression and poor prognosis in chronic kidney disease (CKD). However, the complexity of nutritional status assessment limits its clinical application. This study explored a new method of nutritional assessment in CKD (stage 1-5) patients using the Subjective Global Assessment (SGA) as the gold standard and evaluated its applicability. The kappa test was used to analyze the consistency of the Renal Inpatient Nutrition Screening Tool (Renal iNUT) with SGA and protein-energy wasting. Logistic regression analysis was used to analyze the risk factors of CKD malnutrition and calculate the prediction probability of multiple indicators combined for the diagnosis of CKD malnutrition. The receiver operating characteristic curve of the prediction probability was drawn to evaluate its diagnostic efficiency. A total of 161 CKD patients were included in this study. The prevalence of malnutrition according to SGA was 19.9%. The results showed that Renal iNUT had a moderate consistency with SGA and a general consistency with protein-energy wasting. Age > 60 years (odds ratio, OR = 6.78), neutrophil-lymphocyte ratio > 2.62 (OR = 3.862), transferrin < 200 mg/dL (OR = 4.222), phase angle < 4.5° (OR = 7.478), and body fat percentage < 10% (OR = 19.119) were risk factors for malnutrition in patients with CKD. The area under the receiver operating characteristic curve of multiple indicators for the diagnosis of CKD malnutrition was 0.89 (95% confidence interval: 0.834-0.946, p < 0.001). This study demonstrated that Renal iNUT has good specificity as a new tool for the nutrition screening of CKD patients, but its sensitivity needs to be optimized. Advanced age, high neutrophil-lymphocyte ratio, low transferrin level, low phase angle, and low body fat percentage are risk factors for malnutrition in patients with CKD. The combination of the above indicators has high diagnostic efficiency in the diagnosis of CKD malnutrition, which may be an objective, simple, and reliable method to evaluate the nutritional status of patients with CKD.

Undernutrition during development modulates endoplasmic reticulum stress genes in the hippocampus of juvenile rats: Involvement of oxidative stress

To evaluate whether exercise training mitigates the deleterious effects of undernutrition during the developmental period in juvenile Wistar rats. Pregnant Wistar rats were fed with a diet containing 17 % or 8 % casein during pregnancy and lactation. At 30 days of life, male offspring were divided into 4 groups: Low-Protein non-trained (LS), Low-Protein Trained (LT), Normoprotein non-trained (NS), and Normoprotein Trained (NT). Trained rats performed aerobic exercise training (AET) for 4 weeks, 5 days a week, 1 h a day. 24 h from the last day of training, the animals were sacrificed. The tissues were removed to analyze indicators of mitochondrial metabolism, oxidative stress, and gene expression of GRP78, PERK, ATF6 ER stress markers, and BDNF. The results showed that undernutrition during development promotes deleterious effects on mitochondrial oxidative metabolism and induces reticulum stress in the hippocampus of juvenile rats. On the other hand, AET improves mitochondrial function and increases enzymatic and non-enzymatic antioxidant capacity, as well as declines ER stress. AET at moderate intensity for 4 weeks in male juvenile Wistar rats acts as a lifestyle intervention opposing the negative effects induced by a protein-restricted maternal diet.

Hyperlipidemia and mortality in patients on peritoneal dialysis

BACKGROUND

New lipid-lowering therapy at the start of dialysis and measurement of lipid parameters over the follow-up period is not recommended in dialysis patients, which seems unappropriated in clinical practice. We aimed to examine the effect of hyperlipidemia on mortality in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

METHODS

A retrospective cohort study was performed, including 2939 incident CAPD patients from five dialysis facilities between January 1, 2005, and December 31, 2018. The primary outcome was all-cause mortality. The association between hyperlipidemia at the start of CAPD and all-cause mortality was evaluated using Cox proportional hazards regression.

RESULTS

Of 2939 with a median age of 50.0 (interquartile range, 39.0-61.0), 1697 (57.7%) were men, 533 (18.1%) had hyperlipidemia, 549 (18.7%) had diabetes mellitus, 1915 (65.2%) had hypertension, and 410 (14.0%) had a history of CVD. During the median follow-up period of 35.1 months, 519 (17.7%) died, including 402 (16.7%, 47.4/1000 patient-years) in the non-hyperlipidemia group and 117 (22.0%, 71.1/1000 patient-years) in the hyperlipidemia group. Over the overall follow-up period, patients with hyperlipidemia had an equally high risk of all-cause mortality throughout follow-up as those without hyperlipidemia ([HR] 1.04, 95% confidence interval [CI] 0.83 to 1.31). However, from the 48-month follow-up onwards, hyperlipidemia was associated with a 2.26 (95% CI 1.49 to 3.43)-time higher risk of all-cause mortality than non-hyperlipidemia. Hypertension modified the association between hyperlipidemia and all-cause mortality (P for interaction < 0.001). A significantly increased risk of all-cause mortality was observed among patients with hypertension (HR 2.27, 95%CI 1.44-3.58).

CONCLUSION

Among CAPD patients, hyperlipidemia at the beginning of CAPD was associated with a high risk of long-term mortality. Hypertension may mediate the association. Our findings suggested that long-term lipid-lowering treatment should be used in those patients with hyperlipidemia.

Decreased low‑density lipoprotein and the presence of pulmonary arterial hypertension among newly diagnosed drug‑naïve patients with systemic lupus erythematosus: D‑dimer as a mediator

Pulmonary arterial hypertension (PAH) is commonly associated with systemic lupus erythematosus (SLE). The present study investigated the relationship between coagulation and changes in lipid parameters in newly-diagnosed patients with SLE in the presence of PAH and whether the coagulation parameters were mediators between lipids and PAH presence. A total of 301 subjects scheduled for new-onset drug-naïve SLE were consecutively enrolled. Baseline data for patients without PAH and with PAH were gathered and compared. Coagulation and lipid parameters were compared across patients without lipid regulating and anticoagulation medications. Multivariable logistic regression model was applied to examine potential predictors of PAH in SLE. The relationships between them were examined using Spearman's correlation analysis. The relationship between coagulation index and lipids with SLE-PAH was evaluated using mediation analysis. Female patients accounted for 88.0% of the 301 subjects, and the average age was 32 years (range, 25-45 years). A total of 40 patients (13.3%) had PAH, and the average pulmonary artery systolic pressure (sPAP) was 55.825±26.67 mmHg. Patients with PAH were older and had higher levels of fibrin/fibrinogen degradation products (FDP), D-dimer, C-reactive protein, lower levels of complement 3, complement 4 and 25-hydroxy vitamin D3 compared with the non-PAH group. Multivariable logistic regression analysis showed that age and D-dimer were independent predictor factors for PAH. Among patients without lipid regulating and anticoagulation medications, patients in the PAH group had higher levels of D-dimer and FDP, and lower low-density lipoprotein (LDL) levels compared with patients without PAH. There was also a positive relationship between sPAP and D-dimer and FDP, and a negative relationship between sPAP and total cholesterol and LDL. Mediation analysis indicated that 25.61% of the effect of low LDL on PAH presence in systemic lupus erythematosus was mediated by D-dimer. Overall, the effect of low LDL on SLE-PAH appeared to be mediated by D-dimer, which mediated 25.61% of this effect.

Systematic review and meta-analyses of vitamin E (alpha-tocopherol) supplementation and blood lipid parameters in patients with diabetes mellitus

BACKGROUND AND AIMS

The studies have shown that α-tocopherol supplementation could improve lipid profile in diabetes mellitus (DM) patients. Nonetheless, the result remains inconsistent. Therefore, this meta-analysis was performed to evaluate the efficacy of α-tocopherol supplement on lipid parameters in DM patients.

METHODS

We conducted an extensive search via Cochrane Library, PubMed, Scopus, and Web of Science databases to acquire the reported RCTs up to October 2020.

RESULTS

The results showed no effects of α-tocopherol supplementation on lipid profile in DM patients except when used ≥12 weeks.

CONCLUSIONS

α-tocopherol supplementation in DM patients had no significant effect on lipid profiles.

Management of Cardiovascular Disease in Kidney Disease Study: Rationale and Design

INTRODUCTION

Atherosclerosis, inflammation, and vascular stiffness are prominent interrelated risk factors contributing to the high incidence of cardiovascular disease (CVD) in patients with CKD. Conventional CVD management strategies in CKD largely target atherosclerotic CVD and have had a limited impact on the cardiovascular mortality in this population. Multiple in vivo and in vitro studies and epidemiological evidence from the rheumatologic cohorts have shown that low-dose hydroxychloroquine has beneficial effects on inflammation, endothelial function, insulin sensitivity, and metabolic syndrome. Our recent proof-of-concept animal study showed that hydroxychloroquine has marked protection against atherosclerosis and vascular stiffness. We hypothesize that hydroxychloroquine has the potential to provide significant cardiovascular benefits in patients with CKD.

METHODS

The Management of Cardiovascular disease in Kidney disease study (NCT03636152) is a phase 2B, randomized, double-blind, placebo-controlled trial evaluating the effects of low-dose hydroxychloroquine therapy on the parameters of atherosclerosis, inflammation, and vascular stiffness in patients with CKD. The study plans to enroll 100 CKD patients estimated to be at high cardiovascular risk by a combination of low estimated glomerular filtration rate and albuminuria and treat them for 18 months with hydroxychloroquine or placebo in 1:1 allocation.

RESULTS

The study will assess the change in the total carotid plaque volume as measured by serial noncontrast carotid MRI as the primary outcome and the serial changes in plasma inflammation markers, vascular stiffness, renal function, and the composition characteristics of the carotid plaque as secondary outcome measures.

DISCUSSION/CONCLUSION

The results of this trial will provide the proof-of-applicability for hydroxychloroquine in the CVD in CKD. If positive, this trial should lead to phase-3 trials with clinical end points for this potentially transformative, novel, and inexpensive therapy for CVD in CKD.

Exercise reduces hyperlipidemia-induced kidney damage in apolipoprotein E-deficient mice

Hyperlipidemia is a risk factor of kidney damage that can lead to chronic kidney disease. Studies have shown that exercise reduces kidney damage; however, the specific mechanisms underlying the protective effects of exercise remain unclear. For 12 weeks, 8-week-old male apolipoprotein E-deficient (ApoE^-/-) mice were randomly divided into four treatment groups (n=7/group) as follows: Mice fed a normal diet (ND group); mice fed a ND and exercised (ND + E group); mice fed a high-fat diet (HD group); and mice fed a HD and exercised (HD + E group). Exercise training consisted of swimming for 40 min, 5 days/week. Metabolic parameters, such as low-density lipoprotein-cholesterol, total cholesterol and creatinine levels were higher in the ApoE^-/- HD mice compared with those in the ApoE^-/- HD + E mice. Serum levels of glutathione peroxidase and superoxide dismutase were significantly decreased in the HD group compared with those in the HD + E group. Significant pathological changes were observed in the HD + E group compared with in the HD group. Immunohistochemistry and immunoblotting revealed increased levels of oxidative stress (nuclear factor erythroid-2-related factor 2) and fibrosis (Smad3 and TGF-β) markers in the ApoE^-/- HD group; however, the expression levels of these markers were significantly decreased in the ApoE^-/- HD + E group. Furthermore, NF-κB expression in the HD + E group was significantly lower compared with that in the HD group. These results suggested that exercise may exert protective effects against kidney damage caused by hyperlipidemia.

Hyperlipidemia and mortality associated with diabetes mellitus co-existence in Chinese peritoneal dialysis patients

Background

To evaluate associations between diabetes mellitus (DM) coexisting with hyperlipidemia and mortality in peritoneal dialysis (PD) patients.

Methods

This was a retrospective cohort study with 2939 incident PD patients in China from January 2005 to December 2018. Associations between the DM coexisting with hyperlipidemia and mortality were evaluated using the Cox regression.

Results

Of 2939 patients, with a median age of 50.0 years, 519 (17.7%) died during the median of 35.1 months. DM coexisting with hyperlipidemia, DM, and hyperlipidemia were associated with 1.93 (95% CI 1.45 to 2.56), 1.86 (95% CI 1.49 to 2.32), and 0.90 (95% CI 0.66 to 1.24)-time higher risk of all-cause mortality, compared with without DM and hyperlipidemia, respectively (P for trend < 0.001). Subgroup analyses showed a similar pattern. Among DM patients, hyperlipidemia was as a high risk of mortality as non-hyperlipidemia (hazard ratio 1.02, 95%CI 0.73 to 1.43) during the overall follow-up period, but from 48-month follow-up onwards, hyperlipidemia patients had 3.60 (95%CI 1.62 to 8.01)-fold higher risk of all-cause mortality than those non-hyperlipidemia (P interaction = 1.000).

Conclusions

PD patients with DM coexisting with hyperlipidemia were at the highest risk of all-cause mortality, followed by DM patients and hyperlipidemia patients, and hyperlipidemia may have an adverse effect on long-term survival in DM patients.

The Healthy, Aging, and Diseased Kidney: Relationship with Cardiovascular Disease

The cardiovascular and renal systems share an intimate physiological relationship, wherein a perturbance in one system may have an adverse effect on the other. Since the burden of renal disease increases with age, there is a considerable interest in the pathophysiology of kidney disease in the geriatric patient population. This review will explore the physiological dynamics behind the increased susceptibility to kidney disease in this population. A better understanding of these pathophysiological changes may lead to improved prevention and management strategies.

J-shaped association of platelet-to-lymphocyte ratio with 5-year mortality among patients with chronic kidney disease in a prospective cohort study

PURPOSE

To examine whether platelet-to-lymphocyte ratio (PLR) is associated with 5-year mortality in patients with chronic kidney disease (CKD), we performed this study using data from the National Health and Nutrition Examination Survey (NHANES) through 1999 to 2006.

METHODS

3285 patients with CKD stage 1-5 were included. Patients' baseline characteristics were collected. Cox proportional hazards models were used to investigate the association of PLR with 5-year mortality including all-cause and cardiovascular mortality. Subgroup analysis was performed.

RESULTS

Within 5 years following the date of the NHANES 1999 to 2006 survey participation, 655 (19.94%) deaths were recorded and 207 patients died from cardiovascular disease. A J-shaped association between PLR and 5-year mortality was observed. In adjusted model 2, the elevated PLR Z-score was not significantly associated with a decreased 5-year all-cause mortality risk (HR: 0.44, 95% CI: 0.16-1.22) when PLR Z-score < - 0.91 whereas the elevated PLR Z-score was significantly associated with an increased 5-year all-cause mortality risk (HR: 1.09, 95% CI: 1.01-1.17) when PLR Z-score ≥ - 0.91. In adjusted model 2, neither the elevated PLR Z-score was significantly associated with a decreased 5-year cardiovascular mortality risk (HR: 0.85, 95% CI: 0.36-2.04) when PLR Z-score < - 0.47 nor the elevated PLR Z-score was significantly associated with an increased 5-year cardiovascular mortality risk (HR: 1.12, 95% CI: 0.93-1.34) when PLR Z-score ≥ - 0.47.

CONCLUSION

The elevated PLR is independently associated with an increased 5-year all-cause mortality risk among patients with CKD stage 1-5 when PLR ≥ 83.18, indicating that PLR might be a potential biomarker to predict 5-year all-cause mortality in CKD patients.

Dietary Assessment of Korean Non-dialysis Chronic Kidney Disease Patients with or without Diabetes

BACKGROUND

Dietary intervention at the early stage of chronic kidney disease (CKD) is important for preventing progression to the end-stage renal disease (ESRD). However, few studies have investigated dietary intake of CKD patients in non-dialysis stage. Therefore, we investigated the dietary intake of Korean non-dialysis CKD patients and aimed to establish baseline data for the development of dietary education and intervention strategies for CKD patients.

METHODS

Three hundred fifty CKD patients who visited Seoul National University Hospital outpatient clinic from February 2016 to January 2017 were recruited for this cross-sectional study. Subjects on dialysis and those who had undergone kidney transplantation were excluded. Dietary intake, demographic information, and biochemical characteristics of 256 subjects who completed three-day dietary records were analyzed. Subjects were divided into four groups based on diabetes mellitus (DM) (DM-CKD and Non-DM-CKD groups) and kidney function (Early-CKD and Late-CKD groups).

RESULTS

Total energy intake was lower in the Late-CKD group compared with the Early-CKD group. In men, carbohydrate intake was higher and protein and fat intakes tended to be lower in the Late-CKD group compared with the Early-CKD group. In women, carbohydrate intake tended to be lower in the DM-CKD group than the Non-DM-CKD group. Protein intake tended to be higher in the DM-CKD groups. Phosphorus and sodium intakes were higher in the DM-CKD groups compared with the Non-DM-CKD groups in women, and tended to be higher in the DM-CKD groups in men.

CONCLUSION

DM and kidney function affected energy and nutrient intakes. Subjects in the Late-CKD group consumed less energy than those in the Early-CKD group. Non-DM subjects seemed to restrict protein intake starting from the Early-CKD stage than subjects with DM. Subjects in this study had low energy and high sodium intakes compared with recommended levels. Protein intake was lower in advanced CKD patients, but their intake level was still higher than the recommendation. Dietary intervention strategies for non-dialysis CKD patients need to be customized depending on the presence of DM and kidney function.

Association between albumin-to-globulin ratio and long-term mortality in patients with chronic kidney disease: a cohort study

PURPOSE

To examine whether albumin-to-globulin ratio (AGR) is correlated with long-term mortality in patients with chronic kidney disease (CKD), we performed this study using data from the National Health and Nutrition Examination Survey through 1999-2006.

METHODS

3302 CKD patients were included. Patients' baseline characteristics were collected. Multivariate Cox proportional hazards models were used to investigate the association between AGR and the study outcomes, including long-term all-cause and cardiovascular mortality. Subgroup analysis using the Cox proportional hazards model was performed as a sensitivity test.

RESULTS

During a median follow-up duration of 122.00 months, 1627 (49.27%) deaths were recorded and 440 patients died from cardiovascular disease. In adjusted model 1, AGR ≥ 1.26 group was associated with a lower risk of long-term all-cause mortality HR 0.72, 95% CI 0.65-0.81) compared with AGR < 1.26 group. A similar result was obtained in adjusted model 2. In adjusted model 1, AGR ≥ 1.08 group was associated with a lower risk of long-term cardiovascular mortality (HR 0.59, 95% CI 0.45-0.78) compared with AGR < 1.08 group. In adjusted model 2, there was no significant association between AGR ≥ 1.08 group and a decreased risk of long-term cardiovascular mortality (HR 0.82, 95% CI 0.95-1.12) compared with AGR < 1.08 group. The association of AGR with long-term all-cause mortality differed by gender and age while the association of AGR with long-term cardiovascular mortality differed by age after multivariate adjustment.

CONCLUSION

AGR is a potential biomarker in risk predictions for long-term mortality in CKD patients, especially in males under age 65.

Serum lipoprotein(a) and risk of mortality in patients on peritoneal dialysis

BACKGROUND

Elevated serum lipoprotein(a) [Lp(a)] level is an independent risk factor for atherosclerotic diseases in the general population and hemodialysis patients. However, the association between Lp(a) levels and mortality has received little attention in peritoneal dialysis (PD) patients.

OBJECTIVE

The objective of the study was to evaluate the association of Lp(a) levels with all-cause and cardiovascular (CV) mortality in PD patients.

METHODS

This retrospective cohort study was conducted in PD patients enrolled from January 1, 2006 to December 31, 2015, and followed until December 31, 2018. Cox regression models were performed to assess the association of serum Lp(a) levels with all-cause and CV mortality in PD patients.

RESULTS

In total, 1492 incident PD patients were eligible for the study. During a median follow-up period of 45.1 months, 402 all-cause and 210 CV deaths occurred. Multivariate Cox regression analysis revealed that the first and third tertiles of Lp(a) levels were significantly associated with increased risk for all-cause mortality [hazard ratio (HR) = 1.33, 95% confidence interval (95% CI) = 1.01-1.75, P = .041; HR = 1.53, 95% CI = 1.18-1.98, P = .001, respectively] when compared with the second tertile, and the third tertile of Lp(a) level was independently associated with an 80% increased risk of CV mortality (HR = 1.80, 95% CI = 1.26-2.56, P = .001). Moreover, our results showed that the HRs per log unit higher Lp(a) level for all-cause and CV mortality were 1.53 (95% CI = 1.05-2.22, P = .027) and 2.41 (95% CI = 1.44-4.03, P < .001), respectively.

CONCLUSIONS

Our results suggest that both low and high serum Lp(a) levels are risk markers for all-cause death, but only a higher baseline serum Lp(a) level is an independent risk factor for CV mortality in PD patients.

Geriatric nutrition risk index is associated with renal progression, cardiovascular events and all-cause mortality in chronic kidney disease

BACKGROUND

Malnutrition is common and associated with poor outcomes in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Recently, the geriatric nutritional risk index (GNRI) was reported as a novel tool for evaluating nutritional status. However, the association between GNRI and renal outcome, cardiovascular (CVD) events, and mortality in patients with CKD remains unclear.

METHODS

A prospective cohort study with adult patients with CKD stages 1-4 was conducted at 39 centers around China starting in 2011. Patients were divided into quartiles (Q1, Q2, Q3, and Q4) according to their GNRI category.

RESULTS

A total of 2791 CKD patients within a median follow-up of 4.38 years were included. A low GNRI quartile was independently associated with progression to ESRD, CVD events, and overall mortality. Compared to that in the Q1 group (the reference group), belonging to a higher GNRI quartile significantly reduced the risk of progression to ESRD in the crude and multivariate-adjusted models. Moreover, a significant inverse association was found between those in the high GNRI quartiles and overall mortality among patients with CKD (HR 0.25; 95% CI 0.15-0.43; p = 0.0007, Q4 vs. Q1) after multivariate adjustment. In addition, there was also a significant association between GNRI and CVD events (HR 0.57; 95% CI 0.39-0.84; p = 0.005, Q4 vs. Q1). Moreover, after adjusting for other confounders, only the Q3 group remained significantly fewer CVD events (HR 0.44; 95% CI 0.19-0.98; p = 0.04).

CONCLUSIONS

These findings suggest that GNRI might be a useful prognostic tool for patients with CKD.

Blood pressure modifies outcomes in patients with stage 3 to 5 chronic kidney disease

Observational studies have demonstrated that low blood pressure is related to poor clinical outcomes in patients with chronic kidney disease (CKD). Subgroup analyses from the SPRINT trial showed that targeting systolic blood pressure under 120 mmHg is less beneficial for patients with CKD. Although malnutrition and inflammation are common in patients with advanced CKD, such patients are usually excluded from clinical trials. Therefore, we hypothesized that malnutrition-inflammation-cachexia syndrome could explain this J-shaped relationship. To test this, we studied 2441 patients with CKD stages 3-5 who received anti-hypertensive treatment for at least one year. Averaged blood pressures of the first year were used in the analyses. Fine-Gray competing risks regression showed a J-shaped relationship between continuous systolic blood pressure and end-stage kidney disease (ESKD) with a nadir risk at a systolic blood pressure of 120 mmHg. Adjusted sub-distribution hazard ratios of categorical systolic blood pressure 100-109 and 110-119 mmHg were 2.17 (95% confidence interval: 1.21-3.89) and 1.37 (0.94-1.99) for ESKD, respectively, compared with systolic blood pressures of 120-129 mmHg. Cox regression also showed J-shaped relationships between continuous systolic or diastolic blood pressures, and the composite outcomes of cardiovascular events and all-cause mortality. Logistic regression demonstrated the odds ratios of blood pressure components for Malnutrition-Inflammation Scores over 4 were J-shaped. Sub-distribution hazard ratios of systolic blood pressure 100-119 mmHg for ESKD was higher in those with a Malnutrition-Inflammation Score over 4, compared to 0.93 (0.53-1.63) in those with a score of 4 or under with significant interaction. Thus, malnutrition-inflammation-cachexia syndrome is associated with low blood pressure and modifies the J-shaped relationship in patients with advanced CKD.

[Nutrition in chronic kidney disease]

INTRODUCTION

Chronic kidney disease patients often also present protein-calorie malnutrition, and it is a powerful predictor of morbidity and mortality. In this article, causes and management are shown, highlighting oral and parenteral nutritional supplementation, especially during dialysis process.

Effect of omega-3 fatty acid plus vitamin E Co-Supplementation on lipid profile: A systematic review and meta-analysis

BACKGROUND

Dyslipidemia is linked to chronic inflammation, which in return leads to a set of chronic disorders. Omega-3 fatty acids have been reported to reduce inflammation. Furthermore, Vitamin E is a fat-soluble vitamin which has antioxidant and anti-inflammatory effects. Vitamin E and omega-3 fatty acids co-supplementations may be more effective than the single supplementation in control dyslipidemia. Therefore, we designed and conducted the current systematic review and meta-analysis to investigate the effect of co-supplementation of vitamin E and omega-3 fatty acids on the lipid profile.

METHODS

A comprehensive search for studies published between January 1990 and July 2018 was performed. The initial search extracted 3015 potentially relevant articles. After studying these publications, 9 RCTs were potentially eligible and retrieved in full text.

RESULTS

The meta-analysis indicate that on total cholesterol, HDL, LDL and triglyceride individually did not show any significant difference between intervention and control groups, but vitamin E an omega-3 fatty acids co-supplementations significantly reduce VLDL levels.

CONCLUSIONS

Based on the available evidence, omega-3 fatty acid and vitamin E co-supplementation can reduce VLDL, although its effect on other lipid profile parameters requires more well-designed studies.

Chrysin attenuates inflammatory and metabolic disorder indices in aged male rat

Advanced age is a major risk factor for metabolic disorders. Accelerated inflammatory processes with increased age can contribute to the pathogenesis of metabolic disturbances. Chrysin is a natural flavonoid ingredient of honey and propolis. Chrysin has been effective in decreasing cholesterol and glucose levels preventing metabolic disturbances. The aim of this study was to evaluate the effects of chrysin against age-associated inflammation, hyperglycemia, and hypercholesterolemia. Male Wistar rats (2, 10, and 20 month-old) were intraperitoneally (i.p.) injected with chrysin (20 mg/kg) for 30 days. The findings showed elevated inflammatory cytokines, glucose, and lipid parameters in the sera of aged rats when compared with young ones. However, chrysin treatment ameliorated these alterations. Furthermore, chrysin reduced the levels of adiponectin, HDL-C, and insulin in 20 month-old rats. The current study showed that chrysin was effective in attenuating age-related lipid abnormalities, glucose elevation, and inflammation.

Jian-Pi-Yi-Shen Formula Regulates Inflammatory Cytokines Production in 5/6 Nephrectomized Rats via Suppression of NF-κB Activation

Jian-Pi-Yi-Shen formula (JPYSF) is a Chinese herbal decoction used for treating chronic kidney disease (CKD) for over 20 years with good efficiency. However, the mechanism lacks solid evidence. In the present study, we tested the hypothesis that JPYSF may retard CKD progression via inhibition of inflammation in 5/6 nephrectomy (5/6 Nx) rat model. The 5/6 Nx rats were randomly divided into 2 groups: 5/6 Nx group and JPYSF group. Sham-operated rats served as control. JPYSF (2.06 g/kg/d) were administrated by gavage to 5/6 Nx rats daily for 6 weeks. Results showed that JPYSF treatment significantly improved kidney function and pathological injury in 5/6 Nx rats. Multiplex analysis of cytokines revealed that JPYSF reduced proinflammatory cytokines and increased anti-inflammatory cytokine production. Furthermore, JPYSF inhibited the activation of nuclear factor-kappa B (NF-κB) signaling pathway. In conclusion, our data demonstrated that JPYSF remarkably retards development and progression of CKD in a 5/6 Nx rat model, which may be associated with inhibition of inflammation via NF-κB signaling pathway.

Relations of established aging biomarkers (IL-6, D-dimer, s-VCAM) to glomerular filtration rate and mortality in community-dwelling elderly adults

Background

Biomarkers improving risk prediction for elderly populations with chronic kidney disease (CKD), an independent predictor of mortality, could be particularly useful. We previously observed that interleukin-6 (IL-6), D-dimer and soluble vascular adhesion molecule (s-VCAM) were independent biomarkers of mortality in elderly individuals. Therefore, we investigated whether these established biomarkers were independently associated with both estimated glomerular filtration rate (eGFR) and mortality.

Methods

The Established Populations for Epidemiologic Studies of the Elderly (EPESE) is a longitudinal cohort of community-dwelling elderly individuals. We investigated the association among eGFR, the biomarkers (IL-6, D-dimer and s-VCAM) and 4-year all-cause mortality using restricted cubic splines within Cox proportional hazards models.

Results

Among 1907 participants in EPESE, 1342 had available creatinine and biomarker measures. Incidence of all-cause mortality was 21.6%. eGFR was associated with all-cause mortality (P < 0.01); individuals at the lowest (<30 mL/min/1.73 m²) levels had the highest mortality rates. D-dimer and s-VCAM were associated (P < 0.01) with mortality, and after adjustment for IL-6, D-dimer and s-VCAM, the mortality risk varied by eGFR level.

Conclusions

In community-dwelling elderly individuals, we observed an association among eGFR, 4-year mortality and IL-6, D-dimer and s-VCAM. eGFR was independently associated with mortality, and the relation between eGFR and mortality was modified by IL-6, D-dimer and s-VCAM, which was most notable in individuals with severely reduced eGFR. These findings suggest that IL-6, D-dimer and s-VCAM may be useful biomarkers for improving risk prediction, but further studies are needed examining the role of these biomarkers in elderly individuals with CKD.

Red Blood Cell Distribution Width is an Independent Predictor of AKI and Mortality in Patients in the Coronary Care Unit

BACKGROUND/AIMS

We investigated the hypothesis that RDW is an independent predictor of acute kidney injury (AKI) and mortality in patients in the coronary care unit (CCU).

METHODS

In this prospective, observational study, we screened 412 adults admitted to the CCU at Zhongnan Hospital of Wuhan University from January 1, 2014 to June 1, 2015. AKI was defined based on the KDIGO-AKI criteria. The survivors were followed up for up to 2 years after hospital discharge. The primary endpoint of the study was the incidence of AKI, while the secondary endpoints of the study were in-hospital mortality and 2-year mortality.

RESULTS

RDW was significantly correlated with the acute physiology and chronic health evaluation II (APACHEII) score, hemoglobin, mean corpuscular volume, inflammatory marker levels, nutrition and renal function at the time of CCU admission. The incidence of AKI was much higher in the high RDW group (RDW ≥14.0%) than in the low RDW group, a finding that was confirmed by multivariable logistic regression, which showed that RDW was independently associated with the incidence of AKI (odds ratio (OR), 1.059, 95% coincidence interval (95% CI), 1.024-1.095, P=0.001). A total of 61 patients died during their hospital stay, and baseline RDW was also an independent predictor of in-hospital mortality (hazard ratio (HR), 1.129, 95% CI 1.005-1.268, P=0.041). Patients with a high RDW exhibited significantly higher 2-year mortality than patients with a low RDW during a median follow-up period of 19.8 months (P<0.001), and RDW independently predicted the risk of 2-year mortality (HR, 1.189, 95% CI 1.045 to 1.354, P=0.009) in the multivariate Cox proportional hazard analysis after adjustments for other clinical and laboratory variables.

CONCLUSION

RDW is an independent predictor of AKI and mortality in patients in the CCU.

Benefit of Ezetimibe Added to Simvastatin in Reduced Kidney Function

Efficacy of statin-based therapies in reducing cardiovascular mortality in individuals with CKD seems to diminish as eGFR declines. The strongest evidence supporting the cardiovascular benefit of statins in individuals with CKD was shown with ezetimibe plus simvastatin versus placebo. However, whether combination therapy or statin alone resulted in cardiovascular benefit is uncertain. Therefore, we estimated GFR in 18,015 individuals from the IMPROVE-IT (ezetimibe plus simvastatin versus simvastatin alone in individuals with cardiovascular disease and creatinine clearance >30 ml/min) and examined post hoc the relationship of eGFR with end points across treatment arms. For the primary end point of cardiovascular death, major coronary event, or nonfatal stroke, the relative risk reduction of combination therapy compared with monotherapy differed by eGFR (P=0.04). The difference in treatment effect was observed at eGFR≤75 ml/min per 1.73 m2 and most apparent at levels ≤60 ml/min per 1.73 m2 Compared with individuals receiving monotherapy, individuals receiving combination therapy with a baseline eGFR of 60 ml/min per 1.73 m2 experienced a 12% risk reduction (hazard ratio [HR], 0.88; 95% confidence interval [95% CI], 0.82 to 0.95); those with a baseline eGFR of 45 ml/min per 1.73 m2 had a 13% risk reduction (HR, 0.87; 95% CI, 0.78 to 0.98). In stabilized individuals within 10 days of acute coronary syndrome, combination therapy seemed to be more effective than monotherapy in individuals with moderately reduced eGFR (30-60 ml/min per 1.73 m2). Further studies examining potential benefits of combination lipid-lowering therapy in individuals with CKD are needed.

Use of Proteomics To Investigate Kidney Function Decline over 5 Years

BACKGROUND AND OBJECTIVES

Using a discovery/replication approach, we investigated associations between a multiplex panel of 80 circulating proteins associated with cardiovascular pathology or inflammation, and eGFR decline per year and CKD incidence.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used two cohorts, the Prospective Investigation of the Vasculature in Uppsala Seniors Study (PIVUS; n=687, mean age of 70 years, 51% women) and the Uppsala Longitudinal Study of Adult Men (ULSAM; n=360 men, mean age of 78 years), with 5-year follow-up data on eGFR. There were 231 and 206 incident cases of CKD during follow-up in the PIVUS and ULSAM studies, respectively. Proteomic profiling of 80 proteins was assessed by a multiplex assay (proximity extension assay). The assay uses two antibodies for each protein and a PCR step to achieve a high-specific binding and the possibility to measure multiple proteins in parallel, but gives no absolute concentrations.

RESULTS

In the discovery cohort from the PIVUS Study, 28 plasma proteins were significantly associated with eGFR decline per year, taking into account the multiple testing. Twenty of these proteins were significantly associated with eGFR decline per year in the replication cohort from the ULSAM Study after adjustment for age, sex, cardiovascular risk factors, medications, and urinary albumin-to-creatinine ratio (in order of significance: TNF-related apoptosis-inducing ligand receptor 2*, CD40L receptor, TNF receptor 1*, placenta growth factor*, thrombomodulin*, urokinase plasminogen activator surface receptor*, growth/differentiation factor 15*, macrophage colony-stimulating factor 1, fatty acid-binding protein*, cathepsin D, resistin, kallikrein 11*, C-C motif chemokine 3, proteinase-activated receptor 1*, cathepsin L, chitinase 3-like protein 1, TNF receptor 2*, fibroblast growth factor 23*, monocyte chemotactic protein 1, and kallikrein 6). Moreover, 11 of the proteins predicted CKD incidence (marked with * above). No protein consistently predicted eGFR decline per year independently of baseline eGFR in both cohorts.

CONCLUSIONS

Several circulating proteins involved in phosphate homeostasis, inflammation, apoptosis, extracellular matrix remodeling, angiogenesis, and endothelial dysfunction were associated with worsening kidney function. Multiplex proteomics appears to be a promising way of discovering novel aspects of kidney disease pathology.

Low-density lipoprotein cholesterol and survival in pulmonary arterial hypertension

Low-density lipoprotein cholesterol(LDL-C) is a well established metabolic marker of cardiovascular risk, however, its role in pulmonary arterial hypertension (PAH) has not been determined. Therefore we assessed whether LDL-C levels are altered in PAH patients, if they are associated with survival in this group and whether pulmonary hypertension (PH) reversal can influence LDL-C levels. Consecutive 46 PAH males and 94 females were age matched with a representative sample of 1168 males and 1245 females, respectively. Cox regression models were used to assess the association between LDL-C and mortality. The effect of PH reversal on LDL-C levels was assessed in 34 patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing invasive treatment. LDL-C was lower in both PAH (2.6 ± 0.8 mmol/l) and CTEPH (2.7 ± 0.7 mmol/l) patients when compared to controls (3.2 ± 1.1 mmol/l, p < 0.001). In PAH patients lower LDL-C significantly predicted death (HR:0.44/1 mmol/l, 95%CI:0.26-0.74, p = 0.002) after a median follow-up time of 33(21-36) months. In the CTEPH group, LDL-C increased (from 2.6[2.1-3.2] to 4.0[2.8-4.9]mmol/l, p = 0.01) in patients with PH reversal but remained unchanged in other patients (2.4[2.2-2.7] vs 2.3[2.1-2.5]mmol/l, p = 0.51). We concluded that LDL-C level is low in patients with PAH and is associated with an increased risk of death. Reversal of PH increases LDL-C levels.

Low prognostic nutritional index associated with cardiovascular disease mortality in incident peritoneal dialysis patients

PURPOSE

The prognostic nutritional index (PNI), a variable based on serum albumin concentration and total lymphocyte count in peripheral blood, is reported as a predictor of mortality in a variety of malignant tumor population. This study is aimed to evaluate whether PNI has prognostic value in patients on peritoneal dialysis (PD).

METHODS

This was a single-center, retrospective observational cohort study conducted in incident PD patients from January 1, 2006 to June 30, 2014, and followed until June 30, 2015. The associations of PNI levels with mortality were evaluated by Kaplan-Meier method and Cox proportional hazards models.

RESULTS

A total of 345 patients were included in this study. Median PNI level at baseline was 40.7 (range: 18.8-75.5) for all patients. During follow-up, 59 (17.1%) died during follow-up, among which 31 (52.5%) were due to cardiovascular diseases (CVD). In crude analysis, the patients with low PNI had a significant increase risk of CVD and all-cause mortality [hazard ratio (HR) 3.07, 95% confidence interval (CI) 1.51-6.25 and HR 2.18, 95% CI 1.28-3.72, respectively)]. After adjusting age, Davies comorbidity score, hemoglobin and leukocytes, the patients with low PNI still had a significant increased risk of CVD mortality (HR 2.37, 95% CI 1.10-5.12). However, there was no significant difference in risk of all-cause mortality (HR 1.72, 95% CI 0.97-3.06).

CONCLUSIONS

Low PNI at initiation of PD was independently associated with an increased CVD mortality.

Metabolic acidosis status and mortality in patients on the end stage of renal disease

BACKGROUND AND OBJECTIVES

Uncorrected metabolic acidosis leads to higher death risk in dialysis patients. We observed the relationship between metabolic acidosis status and mortality rate in patients on renal replacement therapy during a median follow up time of 60 months.

METHODS

We studied 76 patients on an on-line hemodiafiltration. The dialysis adequacy was defined by Kt/V for urea. The Framingham risk score (FRS) points were used to determine the 10-year risk for coronary heart disease. We examined the impact of high or low serum bicarbonate concentrations on mortality rate and on 10-year risk for coronary heart disease via the Kaplan-Meier method. Cox's model was used to evaluate a combination of prognostic variables, such as dialysis adequacy defined by Kt/V for urea, age and serum bicarbonate concentrations.

RESULTS

We divided the enrolled patients in three groups according to serum bicarbonate concentrations (< 20 mmol/L, 20-22 mmol/L and > 22 mmol/L). Kaplan-Meier survival curve for the impact of serum bicarbonate concentrations on overall mortality was found significant (log-rank = 7.8, P = 0.02). The prevalence of serum bicarbonate less or more than 20 mmol/L on high FRS (> 20%) by Kaplan-Meier curve was also found significant (log-rank = 4.9, P = 0.02). Cox's model revealed the significant predictive effect of serum bicarbonate on overall mortality (P = 0.006, OR = 1.5, 95% CI = 1.12-1.98) in combination to Kt/V for urea and age.

CONCLUSION

Uncorrected severe metabolic acidosis, defined by serum bicarbonate concentrations less than 20 mmol/L, is associated with a 10-year risk for coronary heart disease more than 20% and high overall mortality in patients on renal replacement therapy.

Noninvasive Cardiovascular Risk Assessment of the Asymptomatic Diabetic Patient: The Imaging Council of the American College of Cardiology

Increased cardiovascular morbidity and mortality in patients with type 2 diabetes is well established; diabetes is associated with at least a 2-fold increased risk of coronary heart disease. Approximately two-thirds of deaths among persons with diabetes are related to cardiovascular disease. Previously, diabetes was regarded as a "coronary risk equivalent," implying a high 10-year cardiovascular risk for every diabetes patient. Following the original study by Haffner et al., multiple studies from different cohorts provided varying conclusions on the validity of the concept of coronary risk equivalency in patients with diabetes. New guidelines have started to acknowledge the heterogeneity in risk and include different treatment recommendations for diabetic patients without other risk factors who are considered to be at lower risk. Furthermore, guidelines have suggested that further risk stratification in patients with diabetes is warranted before universal treatment. The Imaging Council of the American College of Cardiology systematically reviewed all modalities commonly used for risk stratification in persons with diabetes mellitus and summarized the data and recommendations. This document reviews the evidence regarding the use of noninvasive testing to stratify asymptomatic patients with diabetes with regard to coronary heart disease risk and develops an algorithm for screening based on available data.

Inflammation and nutrition in children with chronic kidney disease

Chronic inflammation and nutritional imbalance are important comorbid conditions that correlate with poor clinical outcomes in children with chronic kidney disease (CKD). Nutritional disorders such as cachexia/protein energy wasting, obesity and growth retardation negatively impact the quality of life and disease progression in children with CKD. Inadequate nutrition has been associated with growth disturbances in children with CKD. On the other hand, over-nutrition and obesity are associated with poor outcomes in children with CKD. The exact mechanisms leading to these unfavorable conditions are not fully elucidated and are most likely multifactorial. In this review, we focus on the pathophysiology of nutrition disorders and inflammation and their impact on clinical outcomes in children with CKD.

Examination of Potential Modifiers of the Association of APOL1 Alleles with CKD Progression

BACKGROUND AND OBJECTIVES

Common apolipoprotein L1 (APOL1) variants are associated with increased risk of progressive CKD; however, not all individuals with high-risk APOL1 variants experience CKD progression. Identification of factors contributing to heterogeneity has important scientific and clinical implications.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using multivariable Cox models, we analyzed data from 693 participants in the African American Study of Kidney Disease and Hypertension to identify factors that modify the association between APOL1 genotypes and CKD progression (doubling of serum creatinine or incident ESRD).

RESULTS

Participant mean age was 54 years old, median GFR was 49 ml/min per 1.73 m(2), and 23% had the APOL1 high-risk genotype (two copies of the high-risk allele). Over a mean follow-up of 7.8 years, 288 (42%) participants experienced CKD progression. As previously reported, the high-risk genotype was associated with higher risk of CKD progression compared with the low-risk genotype (hazard ratio [HR], 1.88; 95% confidence interval [95% CI], 1.46 to 2.41). Although we found some suggestion that obesity (HR, 1.48; 95% CI, 1.05 to 2.08 and HR, 2.44; 95% CI, 1.66 to 3.57 for body mass index ≥ 30 versus <30 kg/m(2); P interaction =0.04) and increased urinary excretion of urea nitrogen (HR, 1.43; 95% CI, 0.98 to 2.09 versus HR, 2.33; 95% CI, 1.65 to 3.30 for urine urea nitrogen ≥ 8 versus <8 g/d; P interaction =0.04) were associated with lower APOL1-associated risk for CKD progression, these findings were not robust in sensitivity analyses with alternative cut points. No other sociodemographic (e.g., education and income), clinical (e.g., systolic BP and smoking), or laboratory (e.g., net endogenous acid production, urinary sodium and potassium excretions, 25-hydroxy vitamin D, intact parathyroid hormone, or fibroblast growth factor 23) variables modified the association between APOL1 and CKD progression (P interaction >0.05 for each).

CONCLUSIONS

Sociodemographic factors and common risk factors for CKD progression do not seem to alter APOL1-related CKD progression. Additional investigation is needed to identify nontraditional factors that may affect the association between APOL1 and progressive CKD.

The first year on haemodialysis: a critical transition

The first year following the start of haemodialysis (HD) is associated with increased mortality, especially during the first 90–120 days after the start of dialysis. Whereas the start of dialysis has important effects on the internal environment of the patient, there are relatively few studies assessing changes in phenotype and underlying mechanisms during the transition period following pre-dialysis to dialysis care, although more insight into these parameters is of importance in unravelling the causes of this increased early mortality. In this review, changes in cardiovascular, nutritional and inflammatory parameters during the first year of HD, as well as changes in physical and functional performance are discussed. Treatment-related factors that might contribute to these changes include vascular access and pre-dialysis care, dialysate prescription and the insufficient correction of the internal environment by current dialysis techniques. Patient-related factors include the ongoing loss of residual renal function and the progression of comorbid disease. Identifying phenotypic changes and targeting risk patterns might improve outcome during the transition period. Given the scarcity of data on this subject, more research is needed.

High-density lipoprotein: structural and functional changes under uremic conditions and the therapeutic consequences

High-density lipoprotein (HDL) has attracted interest as a therapeutic target in cardiovascular diseases in recent years. Although many functional mechanisms of the vascular protective effects of HDL have been identified, increasing the HDL plasma level has not been successful in all patient cohorts with increased cardiovascular risk. The composition of the HDL particle is very complex and includes diverse lipids and proteins that can be modified in disease conditions. In patients with chronic kidney disease (CKD), the accumulation of uremic toxins, high oxidative stress, and chronic micro-inflammatory conditions contribute to changes in the HDL composition and may also account for protein/lipid modifications. These conditions are associated with a decreased protective function of HDL. Therefore, the HDL quantity and the functional quality of the particle must be considered. This review summarizes the current knowledge of dyslipidemia in CKD patients, the effects of lipid-modulating therapy, and the structural modifications of HDL that are associated with dysfunction.

Metformin enhances the anti-adipogenic effects of atorvastatin via modulation of STAT3 and TGF-β/Smad3 signaling

Adipocyte accumulation is associated with the development of obesity and obesity-related diseases. Interactions of master transcription factors and signaling cascades are required for adipogenesis. Regulation of excessive adipogenic processes may be an attractive therapeutic for treatment of obesity and obesity-related diseases. In this study, we found that atorvastatin exerts an anti-adipogenic activity in 3T3-L1 pre-adipocytes, and that this activity is elevated in combination with metformin. Expression of the adipogenic master regulators PPARγ and C/EBPα, and their target gene aP2, was suppressed by atorvastatin. Furthermore, atorvastatin treatment resulted in increased activation of the key master regulator of cellular energy homeostasis, AMPK. These biological activities of atorvastatin were elevated in combination with metformin. These anti-adipogenic activities were associated with regulation of the STAT3 and TGF-β signaling cascades, resulting in the regulation of the expression of STAT3 target genes, such as KLF5, p53, and cyclin D1, and TGF-β signaling inhibitory genes, such as SMAD7. Our results suggest that combination therapy with atorvastatin and metformin may have therapeutic potential for the treatment of obesity and obesity-related diseases caused by excessive adipogenesis.

Red yeast rice repairs kidney damage and reduces inflammatory transcription factors in rat models of hyperlipidemia

Xuezhikang (XZK), an extract of red yeast rice, has been widely used for the management of hyperlipidemia and coronary heart disease (CHD); however, the effects of XZK treatment on kidney injury have not yet been fully identified. The aim of the current study was to evaluate the effects of XZK on the kidneys and investigate the related mechanisms in a rat model of hyperlipidemia. Thus, the effect on inflammatory transcription factors and kidney damage was investigated with in vitro and in vivo experiments on hyperlipidemic rats following XZK treatment. The results revealed that the plasma levels of total cholesterol (TC), triglycerides (TG) and low-density lipoprotein-cholesterol (LDL-C) were significantly decreased, while the levels of high-density lipoprotein-cholesterol (HDL-C) were significantly upregulated in the XZK treatment group, as compared with those in the hyperlipidemia group (P<0.05). In addition, the results demonstrated that XZK was able to repair the kidney damage caused by hyperlipidemia. Furthermore, the expression levels of the inflammatory transcription factors, tumor necrosis factor-α and interleukin-6, were shown to be reduced in the XZK group when compared with the hyperlipidemia group. In summary, XZK reduces kidney injury, downregulates the levels of TG, TC and LDL-C, as well as the expression levels of inflammatory transcription factors, and upregulates HDL-C. These results further the understanding of the molecular pathogenic mechanisms underlying hyperlipidemia and aid the development of XZK as an effective therapeutic agent for hyperlipidemia.

Nutrition assessment and risk prediction in dialysis patients-a new integrative score

OBJECTIVE

We developed a quantitative nutritional score, based on biochemical measures, taken as part of monthly routine care. The score can be accomplished within a short time after routine laboratory results completion and identify a monthly change in nutritional status.

DESIGN

A longitudinal observational cohort study

SETTING

The Institute of Nephrology, Wolfson Medical Center, Holon, Israel.

SUBJECTS

A total of 179 hemodialysis patients were followed up for up to 2.5 years after study baseline.

INTERVENTION

The Integrative Clinical Nutrition Dialysis Score (ICNDS) is based on the biochemical measures of albumin, creatinine, urea, cholesterol, C-reactive protein, dialysis adequacy, and weight change. Each parameter is ranked between 1 and 5, with the higher rank derived from recommended National Kidney Foundation Kidney Disease/Dialysis Outcomes and Quality Initiative values and the lower rank indicating deviation from those values. The final ICNDS is the sum of ranks over 7 parameters.

MAIN OUTCOME MEASURE

The Pearson correlation coefficient was calculated for association between subjective global assessment and ICNDS in 63 randomly selected patients. In 179 dialysis patients, the baseline ICNDS, the slope of 3 subsequent monthly ICNDS values, were tested for their correlation with odds of all-cause mortality, hospitalization frequency, length of stay, after 31 months. Spline Cox regression was used to select the best cutoff point, associated with severe mortality risk.

RESULTS

Score results were significantly correlated with nutrition evaluation by subjective global assessment (r = 0.842, P < .01). For a unit increase in baseline score, death odds were significantly decreased (hazard ratio [HR] = 0.929, 95% confidence interval [CI] 0.88-0.974, P < .002). Each unit increase in slope significantly reduced mortality risk (HR = 0.485, 95% CI 0.278-0.847, P < .011). Hospitalization frequency was significantly increased across worsening baseline score (HR = 0.935, 95% CI 0.906-0.964, P < .0001). A 1-unit increase in slope significantly decreased hospitalization (HR = 0.799, 95% CI 0.726-0.881, P < .0001).

CONCLUSIONS

Results confirm that ICNDS is a useful prognostic tool that serves to detect nutrition deterioration at its very beginning.