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Omosule CL, Blair CJ, Herries E, Zaydman MA, Farnsworth C, Ladenson J, Dietzen DJ, Gaut JP. Clinical Utility of LC-MS/MS for Blood Myo-Inositol in Patients with Acute Kidney Injury and Chronic Kidney Disease. Clin Chem 2024; 70:1172-1181. [PMID: 39092926 DOI: 10.1093/clinchem/hvae097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/12/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Diagnosing acute kidney injury (AKI) and chronic kidney disease (CKD) relies on creatinine, which lacks optimal diagnostic sensitivity. The kidney-specific proximal tubular enzyme myo-inositol oxygenase (MIOX) catalyzes the conversion of myo-inositol (MI) to D-glucuronic acid. We hypothesized that proximal tubular damage, which occurs in AKI and CKD, will decrease MIOX activity, causing MI accumulation. To explore this, we developed an LC-MS/MS assay to quantify plasma MI and assessed its potential in identifying AKI and CKD patients. METHODS MI was quantified in plasma from 3 patient cohorts [normal kidney function (n = 105), CKD (n = 94), and AKI (n = 54)]. The correlations between MI and creatinine were determined using Deming regression and Pearson correlation and the impact of age, sex, and ethnicity on MI concentrations was assessed. Receiver operating characteristic curve analysis was employed to evaluate MI diagnostic performance. RESULTS In volunteers with normal kidney function, the central 95th percentile range of plasma MI concentrations was 16.6 to 44.2 µM. Age, ethnicity, and sex showed minimal influence on MI. Patients with AKI and CKD exhibited higher median MI concentrations [71.1 (25th percentile: 38.2, 75th percentile: 115.4) and 102.4 (77, 139.5) µM], respectively. MI exhibited excellent sensitivity (98.9%) and specificity (100%) for diagnosing CKD. In patients with AKI, MI increased 32.9 (SD 16.8) h before creatinine. CONCLUSIONS This study unveils MI as a potential renal biomarker, notably elevated in plasma during AKI and CKD. Plasma MI rises 33 h prior to serum creatinine, enabling early AKI detection. Further validation and exploration of MI quantitation in kidney disease diagnosis is warranted.
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Affiliation(s)
- Catherine L Omosule
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, United States
| | - Connor J Blair
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, United States
| | - Elizabeth Herries
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, United States
| | - Mark A Zaydman
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, United States
| | - Christopher Farnsworth
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, United States
| | - Jack Ladenson
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, United States
| | - Dennis J Dietzen
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, United States
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Joseph P Gaut
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, United States
- Department of Medicine (Nephrology), Washington University School of Medicine, St. Louis, MO, United States
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Zarbock A, Forni LG, Ostermann M, Ronco C, Bagshaw SM, Mehta RL, Bellomo R, Kellum JA. Designing acute kidney injury clinical trials. Nat Rev Nephrol 2024; 20:137-146. [PMID: 37653237 DOI: 10.1038/s41581-023-00758-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/02/2023]
Abstract
Acute kidney injury (AKI) is a common clinical condition with various causes and is associated with increased mortality. Despite advances in supportive care, AKI increases not only the risk of premature death compared with the general population but also the risk of developing chronic kidney disease and progressing towards kidney failure. Currently, no specific therapy exists for preventing or treating AKI other than mitigating further injury and supportive care. To address this unmet need, novel therapeutic interventions targeting the underlying pathophysiology must be developed. New and well-designed clinical trials with appropriate end points must be subsequently designed and implemented to test the efficacy of such new interventions. Herein, we discuss predictive and prognostic enrichment strategies for patient selection, as well as primary and secondary end points that can be used in different clinical trial designs (specifically, prevention and treatment trials) to evaluate novel interventions and improve the outcomes of patients at a high risk of AKI or with established AKI.
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Affiliation(s)
- Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Münster, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Lui G Forni
- Department of Critical Care, Royal Surrey Hospital Foundation Trust, Guildford, UK
- School of Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy
- International Renal Research Institute of Vicenza, Vicenza, Italy
- Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Ravindra L Mehta
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - John A Kellum
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Nalesso F, Martino FK, Bogo M, Bettin E, Alessi M, Stefanelli LF, Silvestre C, Furian L, Calò LA. The Ultrasound Renal Stress Test for the Assessment of Functional Renal Reserve in Kidney Transplantation: A Pilot Study in Living Donors. J Clin Med 2024; 13:525. [PMID: 38256658 PMCID: PMC10816091 DOI: 10.3390/jcm13020525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
In the evolving landscape of nephrology and kidney transplants, assessing renal functional reserve (RFR) in living kidney donors is essential for ensuring donor safety and successful transplantation. This study explores the use of the Intra-Parenchymal Renal Resistive Index Variation (IRRIV) test, a novel non-invasive method, to measure RFR in living donors. Our observational study included 11 participants undergoing living kidney donations, evaluated using the IRRIV-based Renal Stress Test (RST) before and 12 months post-nephrectomy. The study demonstrated significant changes in creatinine and eGFR CKD-EPI levels post-donation, with an average creatinine rise from 69 to 97 µmol/L and a reduction in eGFR from 104 to 66 mL/min/1.73 m2. These variations align with the expected halving of nephron mass post-nephrectomy and the consequent recruitment of RFR and hyperfiltration in the remaining nephrons. This pilot study suggests that the IRRIV-based RST is a practical, safe, and reproducible tool, potentially revolutionizing the assessment of RFR in living kidney donors, with implications for broader clinical practice in donor eligibility evaluation, even in borderline renal cases. Furthermore, it confirms the feasibility of RST in living kidney donors and allows us to assess the sample size in 48 donors for a future study.
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Affiliation(s)
- Federico Nalesso
- Department of Medicine, Nephrology-Dialysis-Kidney Transplant Unit, University of Padua, 35128 Padua, Italy; (F.K.M.); (M.B.); (L.F.S.); (L.A.C.)
| | - Francesca K. Martino
- Department of Medicine, Nephrology-Dialysis-Kidney Transplant Unit, University of Padua, 35128 Padua, Italy; (F.K.M.); (M.B.); (L.F.S.); (L.A.C.)
| | - Marco Bogo
- Department of Medicine, Nephrology-Dialysis-Kidney Transplant Unit, University of Padua, 35128 Padua, Italy; (F.K.M.); (M.B.); (L.F.S.); (L.A.C.)
| | - Elisabetta Bettin
- Department of Medicine, Nephrology-Dialysis-Kidney Transplant Unit, University of Padua, 35128 Padua, Italy; (F.K.M.); (M.B.); (L.F.S.); (L.A.C.)
| | - Marianna Alessi
- Department of Medicine, Nephrology-Dialysis-Kidney Transplant Unit, University of Padua, 35128 Padua, Italy; (F.K.M.); (M.B.); (L.F.S.); (L.A.C.)
| | - Lucia F. Stefanelli
- Department of Medicine, Nephrology-Dialysis-Kidney Transplant Unit, University of Padua, 35128 Padua, Italy; (F.K.M.); (M.B.); (L.F.S.); (L.A.C.)
| | - Cristina Silvestre
- Department of Surgical Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplant Unit, University of Padua, 35128 Padua, Italy; (C.S.); (L.F.)
| | - Lucrezia Furian
- Department of Surgical Oncological and Gastroenterological Sciences, Kidney and Pancreas Transplant Unit, University of Padua, 35128 Padua, Italy; (C.S.); (L.F.)
| | - Lorenzo A. Calò
- Department of Medicine, Nephrology-Dialysis-Kidney Transplant Unit, University of Padua, 35128 Padua, Italy; (F.K.M.); (M.B.); (L.F.S.); (L.A.C.)
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Taylor KM, Au AYM, Herath S, Succar L, Wong J, Erlich JH, Endre ZH. Kidney functional reserve and damage biomarkers in subclinical chronic kidney disease and acute kidney injury. Am J Physiol Renal Physiol 2023; 325:F888-F898. [PMID: 37733876 DOI: 10.1152/ajprenal.00133.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/01/2023] [Accepted: 09/15/2023] [Indexed: 09/23/2023] Open
Abstract
Significant loss of kidney function is not easily identified by serum creatinine (sCr)-based measurements. In the presence of normal sCr, decreased kidney functional reserve (KFR) may identify a significant loss of function. We evaluated KFR in experimental subclinical chronic kidney disease (sCKD) before and after brief ischemia-reperfusion injury (IRI). Using fluorescein isothiocyanate-labeled sinistrin, glomerular filtration rate (GFR) was measured transcutaneously before and after adenine-induced sCKD, and 1 and 2 wk after brief IRI, and compared with urinary kidney damage biomarkers. sCKD reduced stimulated and unstimulated GFR by ∼20% while reducing KFR by 50%. IRI reduced unstimulated GFR for 14 days, but KFR remained relatively unchanged in sCKD and transiently increased in control kidneys at 7 days. sCr increased and creatinine clearance (CrCl) decreased only immediately after IRI; sCr and CrCl correlated poorly with measured GFR except on day 1 after IRI. Heterogeneity in sCr and CrCl resulted from variation in tubular creatinine secretion. The increase in damage biomarker concentrations persisted for up to 14 days after IRI, allowing retrospective detection of sCKD before AKI by urine clusterin/urine kidney injury molecule-1 with an area under the curve of 1.0. sCr and CrCl are unreliable unless sCr is acutely elevated. Measurement of KFR and urine damage biomarker excretion detected sCKD despite normal sCr and CrCl. After IRI, the urine clusterin-to-urine kidney injury molecule-1 ratio may identify prior sCKD.NEW & NOTEWORTHY Early kidney function loss is poorly identified by serum creatinine (sCr)-based measurements. Direct kidney functional reserve (KFR) measurement before kidney injury and elevated urinary biomarkers clusterin and kidney injury molecule-1 detect subclinical chronic kidney disease (sCKD) after kidney injury despite normal range sCr and creatinine clearance. Reliance on sCr masks underlying sCKD. Acute kidney injury risk evaluation requires direct glomerular filtration rate measurement and KFR, whereas kidney damage biomarkers facilitate identification of prior subclinical injury.
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Affiliation(s)
- Kylie M Taylor
- Faculty of Medicine and Health, School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Amy Y M Au
- Faculty of Medicine and Health, School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Sanjeeva Herath
- Faculty of Medicine and Health, School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Lena Succar
- Faculty of Medicine and Health, School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Jasmine Wong
- Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Jonathan H Erlich
- Faculty of Medicine and Health, School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Zoltán H Endre
- Faculty of Medicine and Health, School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
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Noel S, Parikh CR. Kidney functional reserve helps early detection of subclinical chronic kidney disease. Am J Physiol Renal Physiol 2023; 325:F885-F887. [PMID: 37943940 DOI: 10.1152/ajprenal.00327.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Sanjeev Noel
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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Murakoshi M, Kobayashi T, Kihara M, Ueda S, Suzuki Y, Gohda T. The proteinuria-lowering effects of dapagliflozin are associated with an initial decline in estimated glomerular filtration rate in patients with chronic kidney disease. Nephrology (Carlton) 2023; 28:540-547. [PMID: 37357381 DOI: 10.1111/nep.14207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/05/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023]
Abstract
AIM Sodium-glucose co-transporter-2 inhibitor, dapagliflozin (DAPA) reduced albuminuria and slowed down the decline in estimated glomerular filtration rate (eGFR) in patients with chronic kidney disease (CKD) in the DAPA-CKD trial. However, proteinuria (albuminuria) does not necessarily decrease in all patients in real-world clinical settings. Therefore, we aimed to identify the clinical characteristics of patients with CKD and decreased proteinuria in response to DAPA treatment. METHODS Of 106 patients with CKD, 54 patients were finally included who received 10 mg of DAPA once daily. Patients whose urinary protein-to-creatinine ratio (UPCR) decreased by >30% or ≤30% from baseline after 1 month of treatment were defined as responders and non-responders, respectively. RESULTS At baseline, median eGFR and UPCR were 45.3 mL/min/1.73 m2 (interquartile range [IQR], 29.7, 54.6) and 1.09 g/gCr (IQR, 0.52, 1.91), respectively. After 1 month of treatment, the mean decline in eGFR and reduction in UPCR was 6.5% (standard deviation [SD], 7.2%) and 6.6% (SD, 42.1%) from baseline, respectively. Moreover, the blood pressure, eGFR, and uric acid decreased significantly from baseline, but haemoglobin and serum potassium did not change. The median UPCR decreased significantly in patients with UPCR ≥0.5 g/gCr, but not <0.5 g/gCr at baseline. UPCR responders had a greater initial decline in eGFR at 1 month than non-responders. CONCLUSION The percent changes in UPCR were positively associated with the initial decline rate in eGFR in patients with CKD with a UPCR ≥0.5 g/gCr at baseline after 1 month of DAPA treatment.
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Affiliation(s)
- Maki Murakoshi
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Takashi Kobayashi
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Masao Kihara
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Seiji Ueda
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Tomohito Gohda
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
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Fourniol C, Dariane C, Correas J, Audenet F, Pinar U, Anract J, Hostettler A, Panthier F, Timsit MO, Mejean A. Volumetric and functional outcomes at 1-year between percutaneous-ablation and partial-nephrectomy for T1b renal tumors. Prog Urol 2023; 33:509-518. [PMID: 37633733 DOI: 10.1016/j.purol.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/16/2023] [Accepted: 08/01/2023] [Indexed: 08/28/2023]
Abstract
INTRODUCTION Indication for percutaneous-ablation (PA) is gradually expanding to renal tumors T1b (4-7cm). Few data exist on the alteration of renal functional volume (RFV) post-PA. Yet, it is a surrogate marker of post partial-nephrectomy (PN) glomerular filtration rate (GFR) impairment. The objective was to compare RFV and GFR at 1-year post-PN or PA, in this T1b population. METHODS Patients with unifocal renal tumor≥4cm treated between 2014 and 2019 were included. Tumor, homolateral (RFVh), contralateral RFV, and total volumes were assessed by manual segmentation (3D Slicer) before and at 1 year of treatment, as was GFR. The loss of RFV, contralateral hypertrophy, and preservation of GFR were compared between both groups (PN vs. PA). RESULTS 144 patients were included (87PN, 57PA). Preoperatively, PA group was older (74 vs. 59 years; P<0.0001), had more impaired GFR (73 vs. 85mL/min; P=0.0026) and smaller tumor volume(31.1 vs. 55.9cm3; P=0.0007) compared to PN group. At 1 year, the PN group had significantly more homolateral RFV loss (-19 vs. -14%; P=0.002), and contralateral compensatory hypertrophy (+4% vs. +1,8%; P=0.02, respectively). Total-RFV loss was similar between both (-21.7 vs. -19cm3; P=0.07). GFR preservation was better in the PN group (95.9 vs. 90.7%; P=0.03). In multivariate analysis, age and tumor size were associated with loss of RFVh. CONCLUSION For renal tumors T1b, PN is associated with superior compensatory hypertrophy compared with PA, compensating for the higher RFVh loss, resulting in similar ΔRFV-total between both groups. The superior post-PN GFR preservation suggests that the preserved quantitative RFV factor is insufficient. Therefore, the underlying quality of the parenchyma would play a major role in postoperative GFR.
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Affiliation(s)
- C Fourniol
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, centre, université de Paris, 20, rue Leblanc, 75015 Paris, France.
| | - C Dariane
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, centre, université de Paris, 20, rue Leblanc, 75015 Paris, France
| | - J Correas
- Service de radiologie adulte, hôpital Necker-Enfants-Malades, AP-HP, centre, université de Paris, 245, rue de Sèvres, 75015 Paris, France
| | - F Audenet
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, centre, université de Paris, 20, rue Leblanc, 75015 Paris, France
| | - U Pinar
- Service d'urologie, hôpital Pitié-Salpêtrière, AP-HP-centre, Sorbonne université, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J Anract
- Service d'urologie, hôpital Cochin, AP-HP-centre, université de Paris, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - A Hostettler
- Département de recherche et développement, IRCAD France, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - F Panthier
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, centre, université de Paris, 20, rue Leblanc, 75015 Paris, France
| | - M O Timsit
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, centre, université de Paris, 20, rue Leblanc, 75015 Paris, France
| | - A Mejean
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, centre, université de Paris, 20, rue Leblanc, 75015 Paris, France
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McArdle Z, Singh R, Bielefeldt-Ohmann H, Moritz K, Denton K, Schreuder M. Beneficial effects of brief early life angiotensin-converting enzyme inhibition wane with time in sheep with solitary functioning kidney. Clin Sci (Lond) 2023; 137:603-615. [PMID: 37018071 PMCID: PMC10116343 DOI: 10.1042/cs20220811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/26/2023] [Accepted: 04/05/2023] [Indexed: 04/23/2023]
Abstract
A child with a congenital solitary functioning kidney (SFK) may develop kidney disease from early in life due to hyperfiltration injury. Previously, we showed in a sheep model of SFK that brief angiotensin-converting enzyme inhibition (ACEi) early in life is reno-protective and increases renal functional reserve (RFR) at 8 months of age. Here we investigated the long-term effects of brief early ACEi in SFK sheep out to 20 months of age. At 100 days gestation (term = 150 days) SFK was induced by fetal unilateral nephrectomy, or sham surgery was performed (controls). SFK lambs received enalapril (SFK+ACEi; 0.5 mg/kg, once daily, orally) or vehicle (SFK) from 4 to 8 weeks of age. At 8, 14 and 20 months of age urinary albumin excretion was measured. At 20 months of age, we examined basal kidney function and RFR via infusion of combined amino acid and dopamine (AA+D). SFK+ACEi resulted in lower albuminuria (∼40%) at 8 months, but not at 14 or 20 months of age compared with vehicle-SFK. At 20 months, basal GFR (∼13%) was lower in SFK+ACEi compared with SFK, but renal blood flow (RBF), renal vascular resistance (RVR) and filtration fraction were similar to SFK. During AA+D, the increase in GFR was similar in SFK+ACEi and SFK animals, but the increase in RBF was greater (∼46%) in SFK+ACEi than SFK animals. Brief ACEi in SFK delayed kidney disease in the short-term but these effects were not sustained long-term.
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Affiliation(s)
- Zoe McArdle
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Reetu R. Singh
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Helle Bielefeldt-Ohmann
- School of Chemistry & Molecular Biosciences, The University of Queensland, St Lucia, Queensland, Australia
| | - Karen M. Moritz
- Child Health Research Centre and School of Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Kate M. Denton
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
- Correspondence: Kate M. Denton ()
| | - Michiel F. Schreuder
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
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Gohda T, Murakoshi M. Sodium-Glucose Cotransporter-2 Inhibitors-Miracle Drugs for the Treatment of Chronic Kidney Disease Irrespective of the Diabetes Status: Lessons from the Dedicated Kidney Disease-Focused CREDENCE and DAPA-CKD Trials. Int J Mol Sci 2022; 23:ijms232213749. [PMID: 36430228 PMCID: PMC9696577 DOI: 10.3390/ijms232213749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease worldwide. In Japan, the proportion of new patients requiring dialysis due to DKD has remained unchanged over the past five years. Early diagnosis and treatment are extremely important for the prevention of DKD progression. Albuminuria is the most promising biomarker currently available for diagnosing DKD and predicting its prognosis at an early stage; however, it has relatively poor specificity and sensitivity for DKD. Measuring the serum levels of tumor necrosis factor receptors (TNFRs; TNFR1 and TNFR2) is an alternative for predicting the prognosis of patients with CKD, irrespective of their diabetes status. Cardiorenal risk factor management and renin-angiotensin system inhibitor usage are effective in slowing the DKD progression, although the residual risk remains high in patients with DKD. Recently, two classes of antihyperglycemic agents, sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists, in addition to nonsteroidal selective mineralocorticoid receptor antagonists, which are less potent blood pressure-lowering and potassium-sparing agents, have emerged as cardiorenal disease-modifying therapies for preventing the DKD progression. This review focused on the SGLT2 inhibitor-based therapeutic strategies that have demonstrated cardiorenal benefits in patients with type 2 diabetes.
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Tsai MH, Lin MY, Hsu CY, Yen AMF, Chen THH, Chiu SYH, Hwang SJ. Factors associated with renal function state transitions: A population-based community survey in Taiwan. Front Public Health 2022; 10:930798. [PMID: 36159292 PMCID: PMC9493090 DOI: 10.3389/fpubh.2022.930798] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/27/2022] [Indexed: 01/24/2023] Open
Abstract
Background Understanding renal function state transition risk and associated factors in community residences is vital for appropriate preventive and care actions. We aim to investigate factors affecting renal function state transitions through 10-year longitudinal community screening surveys. Methods The prospective cohort study included participants who attended the screening program ≥2 times from 2001 to 2009 and were divided into two cohorts: those with baseline estimated glomerular filtration rate (eGFR) ≥60 (n = 46,278) and those with eGFR 59-30 mL/min/1.73 m2 (n = 4,656). We applied the illness-death model to identify associated factors with eGFR <60 and death for the cohort with baseline eGFR ≥60 and eGFR <30 and death for that with baseline eGFR ≥59-30. Results Among the followed-up participants, 3,018 (6.5%) in the cohort of baseline eGFR ≥60 mL/min/1.73 m2 and 322 (6.9%) in the cohort of eGFR 59-30 mL/min/1.73 m2 experienced renal function state transition during a median over 7-year follow-up. Besides eGFR and grade of proteinuria, diabetes mellitus (adding nearly 50% hazard rate) is the main factor associated with both state transitions. Other early-phase eGFR state transition risk factors were metabolic syndrome score, triglyceride, uric acid, fasting blood sugar, and high-density lipoprotein cholesterol. Males, poor hemoglobin, high triglyceride, and high low-density lipoprotein cholesterol were all linked with the late-phase eGFR state transition hazard rate. Conclusion The study developed the state transition functions for community participants with varying renal function levels. Further actions to develop precision screening plans and services that incorporate personal risk factors and state transition risks are necessary.
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Affiliation(s)
- Ming-Hsien Tsai
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan,Division of Biostatistics, Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Ming-Yen Lin
- Master of Public Health Degree Program, College of Public Health, National Taiwan University, Taipei, Taiwan,Department of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan,Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chen-Yang Hsu
- Division of Biostatistics, Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan,Master of Public Health Degree Program, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Amy Ming-Fang Yen
- Master of Public Health Degree Program, College of Public Health, National Taiwan University, Taipei, Taiwan,School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tony Hsiu-Hsi Chen
- Division of Biostatistics, Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan,Master of Public Health Degree Program, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Sherry Yueh-Hsia Chiu
- Department of Health Care Management, College of Management, Chang Gung University, Taoyuan, Taiwan,Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Shang-Jyh Hwang
- Department of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan,Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan,Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan,*Correspondence: Shang-Jyh Hwang
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11
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Abstract
Circulating blood is filtered across the glomerular barrier to form an ultrafiltrate of plasma in the Bowman's space. The volume of glomerular filtration adjusted by time is defined as the glomerular filtration rate (GFR), and the total GFR is the sum of all single-nephron GFRs. Thus, when the single-nephron GFR is increased in the context of a normal number of functioning nephrons, single glomerular hyperfiltration results in 'absolute' hyperfiltration in the kidney. 'Absolute' hyperfiltration can occur in healthy people after high protein intake, during pregnancy and in patients with diabetes, obesity or autosomal-dominant polycystic kidney disease. When the number of functioning nephrons is reduced, single-nephron glomerular hyperfiltration can result in a GFR that is within or below the normal range. This 'relative' hyperfiltration can occur in patients with a congenitally reduced nephron number or with an acquired reduction in nephron mass consequent to surgery or kidney disease. Improved understanding of the mechanisms that underlie 'absolute' and 'relative' glomerular hyperfiltration in different clinical settings, and of whether and how the single-nephron haemodynamic and related biomechanical forces that underlie glomerular hyperfiltration promote glomerular injury, will pave the way toward the development of novel therapeutic interventions that attenuate glomerular hyperfiltration and potentially prevent or limit consequent progressive kidney injury and loss of function.
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12
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Abstract
An exploration of the normal limits of physiologic responses and how these responses are lost when the kidney is injured rarely occurs in clinical practice. However, the differences between "resting" and "stressed" responses identify an adaptive reactiveness that is diminished before baseline function is impaired. This functional reserve is important in the evaluation of prognosis and progression of kidney disease. Here, we discuss stress tests that examine protein-induced hyperfiltration, proximal tubular secretion, urea-selective concentration defects, and acid retention. We discuss diseases in which these tests have been used to diagnose subclinical injury. The study and follow-up of abnormal functional reserve may add considerable understanding to the natural history of CKD.
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Affiliation(s)
- Armando Armenta
- Department of Nephrology, National Institute of Cardiology “Ignacio Chavez,” Mexico City, Mexico
| | - Magdalena Madero
- Department of Nephrology, National Institute of Cardiology “Ignacio Chavez,” Mexico City, Mexico
| | - Bernardo Rodriguez-Iturbe
- Department of Nephrology, National Institute of Cardiology "Ignacio Chavez," Mexico City, Mexico .,Department of Nephrology and Mineral Metabolism, National Institute of Health Sciences and Nutrition "Salvador Zubirán," Mexico City, Mexico
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13
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Kimweri D, Ategeka J, Ceasor F, Muyindike W, Nuwagira E, Muhindo R. Incidence and risk predictors of acute kidney injury among HIV-positive patients presenting with sepsis in a low resource setting. BMC Nephrol 2021; 22:238. [PMID: 34187389 PMCID: PMC8243728 DOI: 10.1186/s12882-021-02451-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 06/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequently encountered clinical condition in critically ill patients and is associated with increased morbidity and mortality. In our resource-limited setting (RLS), the most common cause of AKI is sepsis and volume depletion. Sepsis alone, accounts for up to 62 % of the AKI cases in HIV-positive patients. OBJECTIVE The major goal of this study was to determine the incidence and risk predictors of AKI among HIV-infected patients admitted with sepsis at a tertiary hospital in Uganda. METHODS In a prospective cohort study, we enrolled adult patients presenting with sepsis at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda between March and July 2020. Sepsis was determined using the qSOFA criteria. Patients presenting with CKD or AKI were excluded. Sociodemographic characteristics, physical examination findings, and baseline laboratory values were recorded in a data collection tool. The serum creatinine and urea were done at admission (0-hour) and at the 48-hour mark to determine the presence of AKI. We performed crude and multivariable binomial regression to establish the factors that predicted developing AKI in the first 48 h of admission. Variables with a p < 0.01 in the adjusted analysis were considered as significant predictors of AKI. RESULTS Out of 384 patients screened, 73 (19 %) met our inclusion criteria. Their median age was 38 (IQR 29-46) years and 44 (60.3 %) were male. The median CD4 T-cell count was 67 (IQR 35-200) cells, median MUAC was 23 (IQR 21-27) cm and 54 (74.0 %) participants were on a regimen containing Tenofovir Disoproxil Fumarate (TDF). The incidence of AKI in 48 h was 19.2 % and in the adjusted analysis, thrombocytopenia (Platelet count < 150) (adjusted risk ratio 8.21: 95 % CI: 2.0-33.8, p = 0.004) was an independent predictor of AKI. CONCLUSIONS There is a high incidence of AKI among HIV-positive patients admitted with sepsis in Uganda. Thrombocytopenia at admission may be a significant risk factor for developing AKI. The association of thrombocytopenia in sepsis and AKI needs to be investigated.
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Affiliation(s)
- Davis Kimweri
- Department of Internal Medicine, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda.
| | - Julian Ategeka
- Department of Internal Medicine, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda
| | - Faustine Ceasor
- Department of Internal Medicine, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda
| | - Winnie Muyindike
- Department of Internal Medicine, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda
- Immunosuppression Clinic, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Edwin Nuwagira
- Department of Internal Medicine, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda
| | - Rose Muhindo
- Department of Internal Medicine, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda
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14
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Christiadi D, Simpson C, O'brien K, Taylor K, Luxton G, Rossleigh M, Erlich J, Endre ZH. Cystatin C kidney functional reserve: a simple method to predict outcome in chronic kidney disease. Nephrol Dial Transplant 2021; 37:1118-1124. [PMID: 34043011 DOI: 10.1093/ndt/gfab188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Kidney Functional Reserve (KFR), the only clinical kidney stress test, is not routinely measured because complexity of measurement has limited clinical application. We investigated the utility of plasma cystatin C (CysC) after oral protein loading to determine KFR in stage 3 and 4 CKD. METHODS Following a 24 hour low protein diet, KFR was measured after oral protein by hourly plasma CysC and compared with simultaneous creatinine clearance (CrCl) and radionuclide Tc-99m-DTPA (mGFR) measurement in an observational, single-centre cohort study of adults with CKD 3 and CKD 4. Subjects were followed for three years for fast (F) or slow (S) CKD progression, dialysis requirement or death or a combination of major adverse kidney events (MAKE-F or -S). RESULT CysC, CrCl and Tc-99m DPTA mGFR measurements of KFR in 19 CKD 3 and 21 CKD 4 patients yielded good agreement. KFR was not correlated with baseline kidney function. Eight CKD 3 (42%) and 11 CKD 4 (52%) subjects reached their lowest serum CysC concentration four hours after protein loading. CysC KFR and baseline serum creatinine (sCr) predicted (death or dialysis) or MAKE-F with respective AUC = 0.73 (95% CI: 0.48 to 0.89) and 0.71 (95% CI: 0.51 to 0.84). Including CysC KFR, age, baseline sCr and nadir CysC predicted a decrease in sCr-eGFR greater than 1.2 mL/min per year (MAKE-S) with AUC = 0.89. CONCLUSIONS Serial CysC avoided timed urine collection and radionuclide exposure and yielded equivalent estimates of KFR. Serial CysC may facilitate monitoring of KFR in clinical practice.
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Affiliation(s)
- Daniel Christiadi
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Charles Simpson
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Kate O'brien
- Nutrition and Dietetics Services, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Kylie Taylor
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Grant Luxton
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Monica Rossleigh
- Department of Nuclear Medicine, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Jonathan Erlich
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Zoltán H Endre
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
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15
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van Duijl TT, Soonawala D, de Fijter JW, Ruhaak LR, Cobbaert CM. Rational selection of a biomarker panel targeting unmet clinical needs in kidney injury. Clin Proteomics 2021; 18:10. [PMID: 33618665 PMCID: PMC7898424 DOI: 10.1186/s12014-021-09315-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/30/2021] [Indexed: 12/01/2022] Open
Abstract
The pipeline of biomarker translation from bench to bedside is challenging and limited biomarkers have been adopted to routine clinical care. Ideally, biomarker research and development should be driven by unmet clinical needs in health care. To guide researchers, clinical chemists and clinicians in their biomarker research, the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) has developed a structured questionnaire in which the clinical gaps in current clinical pathways are identified and desirable performance specifications are predefined. In kidney injury, the high prevalence of the syndrome acute kidney injury (AKI) in the hospital setting has a significant impact on morbidity, patient survival and health care costs, but the use of biomarkers indicating early kidney injury in daily patient care remains limited. Routinely, medical labs measure serum creatinine, which is a functional biomarker, insensitive for detecting early kidney damage and cannot distinguish between renal and prerenal AKI. The perceived unmet clinical needs in kidney injury were identified through the EFLM questionnaire. Nephrologists within our tertiary care hospital emphasized that biomarkers are needed for (1) early diagnosis of in-hospital AKI after a medical insult and in critically ill patients, (2) risk stratification for kidney injury prior to a scheduled (elective) intervention, (3) kidney injury monitoring in patients scheduled to receive nephrotoxic medication and after kidney transplantation and (4) differentiation between prerenal AKI and structural kidney damage. The biomarker search and selection strategy resulted in a rational selection of an eleven-protein urinary panel for kidney injury that target these clinical needs. To assess the clinical utility of the proposed biomarker panel in kidney injury, a multiplexed LC-MS test is now in development for the intended translational research.
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Affiliation(s)
- T T van Duijl
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Postzone E2-P, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - D Soonawala
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - J W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - L R Ruhaak
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Postzone E2-P, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - C M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Postzone E2-P, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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16
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Abstract
Renal functional reserve (RFR) is described as the difference between a glomerular filtration rate (GFR) measured at baseline and after protein stimulation. The percent change in GFR after a protein load varies based on differences in experimental conditions, with the use of an oral meat protein stimulus and a creatinine clearance method to quantify GFR showing the greatest RFR. A decline in RFR has been found in numerous patient groups. Recent investigations have suggested that a lower RFR may be associated with an increased risk of acute kidney injury and eventual chronic kidney disease.
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Affiliation(s)
- Dana Y Fuhrman
- Pediatrics, Critical Care Medicine, and Nephrology, Department of Critical Care Medicine, The Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Children's Hospital Drive, Faculty Pavilion, Suite 2000, Pittsburgh, PA 15224, USA.
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17
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Sasamoto Y, Endo N, Kanazawa K, Utsumi T, Takahashi T, Endo Y, Nanba M, Takeda H, Takano T, Takahashi K, Tanji M, Kohzuki M. Outpatient Cardiac Rehabilitation Suppresses Deterioration of Renal Function in Patients ≥75 Years of Age With Heart Disease. Circ J 2021; 85:612-622. [PMID: 33536402 DOI: 10.1253/circj.cj-20-0970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study investigated the effect of outpatient cardiac rehabilitation (OCR) and physical activity on the estimated glomerular filtration rate based on serum cystatin C (eGFRcys) in patients with heart disease (HD) aged ≥75 years.Methods and Results:This non-randomized prospective intervention study involved 136 patients (non-OCR group, n=66; OCR group, n=70), 55 of whom were aged ≥75 years (non-OCR group, n=29; OCR group, n=26). Renal function (eGFRcys) was evaluated at discharge and 3 months thereafter. A linear mixed model (LMM) was used to assess changes in renal function over time. The hospital readmission rate within 3 months after discharge was also evaluated. LMM analysis showed that the change in eGFRcys was -2.27 and +0.48 mL/min/1.73 m2in the non-OCR and OCR groups, respectively (F=2.960, P=0.022). Further, among patients aged ≥75 years in the non-OCR and OCR groups, the change in eGFRcys was -3.83 and -1.08 mL/min/1.73 m2, respectively (F=2.719, P=0.039). The proportion of patients aged ≥75 years who were rehospitalized due to exacerbation of HD was 16.9% (n=10) and 6.7% (n=2) in the non-OCR and OCR groups, respectively. CONCLUSIONS Among patients with HD aged ≥75 years, participation in OCR reduces the decline in renal function and hospital readmission rates.
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Affiliation(s)
- Yuichiro Sasamoto
- Department of Internal Medicine & Rehabilitation Science Disability Science, Tohoku University Graduate School of Medicine.,Department of Rehabilitation, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital
| | - Noriko Endo
- Department of Public Health, Fukushima Medical University.,Department of Cardiology & Cardiac Rehabilitation, Choja-2-chome Kaoriyama Clinic
| | - Kohko Kanazawa
- Department of Cardiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital
| | - Taeko Utsumi
- Department of Rehabilitation, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital
| | - Tomomi Takahashi
- Department of Rehabilitation, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital
| | - Yosuke Endo
- Department of Rehabilitation, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital
| | - Makoto Nanba
- Department of Rehabilitation, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital
| | - Hiroto Takeda
- Department of Cardiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital
| | - Tomohiro Takano
- Department of Cardiovascular Surgery, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital
| | - Koki Takahashi
- Department of Cardiovascular Surgery, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital
| | - Masahiro Tanji
- Department of Cardiovascular Surgery, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital
| | - Masahiro Kohzuki
- Department of Internal Medicine & Rehabilitation Science Disability Science, Tohoku University Graduate School of Medicine
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18
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Real-time glomerular filtration rate: improving sensitivity, accuracy and prognostic value in acute kidney injury. Curr Opin Crit Care 2021; 26:549-555. [PMID: 33002974 DOI: 10.1097/mcc.0000000000000770] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) is common and associated with high patient mortality, and accelerated progression to chronic kidney disease. Our ability to diagnose and stratify patients with AKI is paramount for translational progress. Unfortunately, currently available methods have major pitfalls. Serum creatinine is an insensitive functional biomarker of AKI, slow to register the event and influenced by multiple variables. Cystatin C, a proposed alternative, requires long laboratory processing and also lacks specificity. Other techniques are either very cumbersome (inuline, iohexol) or involve administration of radioactive products, and are therefore, not applicable on a large scale. RECENT FINDINGS The development of two optical measurement techniques utilizing novel minimally invasive techniques to quantify kidney function, independent of serum or urinary measurements is advancing. Utilization of both one and two compartmental models, as well as continuous monitoring, are being developed. SUMMARY The clinical utility of rapid GFR measurements in AKI patients remains unknown as these disruptive technologies have not been tested in studies exploring clinical outcomes. However, these approaches have the potential to improve our understanding of AKI and clinical care. This overdue technology has the potential to individualize patient care and foster therapeutic success in AKI.
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19
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Zitouni K, Steyn MRCP, Lyka E, Kelly FJ, Cook P, Ster IC, Earle KA. Derepression of glomerular filtration, renal blood flow and antioxidant defence in patients with type 2 diabetes at high-risk of cardiorenal disease. Free Radic Biol Med 2020; 161:283-289. [PMID: 33039650 DOI: 10.1016/j.freeradbiomed.2020.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/28/2020] [Accepted: 10/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The role of antioxidant status on microvascular blood flow and glomerular filtration (eGFR) in patients with type 2 diabetes and hypertension whose risk of progressive renal disease varies by ethnicity is unknown. METHODS Adult, non-Caucasian (n = 101) and Caucasian (n = 69) patients with type 2 diabetes, hypertension and/or microalbuminuria and an eGFR > 45 mL/min/1.73 m2 were randomised to receive 400 IU vitamin E and/or 20 μg selenium daily or matching placebo. eGFR (CKD-EPI) was measured at baseline, 3,6 and 12 months and renal blood flow by contrast-enhanced ultrasonography in a sub-group (n = 9) at baseline and 3 months by assessing the area under the time intensity curve (TIC). Circulating glutathione peroxidase 3 (GPx-3) activity was measured as a biomarker of oxidative defence status. RESULTS The time to change in eGFR was shortest with combined vitamin E and selenium than usual care (5.6 [4.0-7.0] vs 8.9 [6.8-10.9 months]; p = 0.006). Area under the TIC was reduced compared to baseline (38.52 [22.41-90.49] vs 123 [86.98-367.03]dB.s; P ≤ 0.05 and 347 [175.88-654.92] vs 928.03 [448.45-1683]dB.s; P ≤ 0.05, respectively] at 3 months suggesting an increase in rate of perfusion. The proportional change in eGFR at 12 months was greater in the group whose GPx-3 activity was above, compared with those below the cohort median (360 U/L) in the non-Caucasian and the Caucasian groups (19.1(12.5-25.7] % vs 6.5[-3.5 to 16.5] % and 12.8 [0.7 to 24] % vs 0.2 [-6.1 to 6.5] %). CONCLUSION In these patients with type 2 diabetes and early CKD, antioxidant treatment derepresses renal blood flow and a rise in eGFR correlated directly with GPx-3 activity. SIGNIFICANCE Diabetes mellitus is the world's leading cause of end-stage renal disease which has a predilection for black and minor ethnic groups compared with Caucasians. The differences in risk despite the benefits of conventional care may be related to oxidative stress. We found that glomerular filtration and renal blood flow is suppressed when renal function is preserved in high-risk patients with type 2 diabetes. Conventional care supplemented with selenium - the co-factor for glutathione peroxidase-3 (GPx-3) - improves renal perfusion and increase glomerular filtration according to host antioxidant defence determined by GPx-3 activity. Circulating GPx-3 activity warrants further investigation as a novel biomarker of reversible haemodynamic changes in early diabetic kidney disease to better enable targeting of renoprotective strategies.
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Affiliation(s)
- Karima Zitouni
- St Georges University of London, Institute of Infection and Immunity, London, UK
| | - M R C P Steyn
- St Georges University Hospitals NHS Foundation Trust, Thomas Addison Unit, London, UK
| | - Eliza Lyka
- St Georges University of London, Institute of Biomedical & Medical Education, London, UK
| | - Frank J Kelly
- Kings College London, Analytical, Environmental and Forensic Sciences Department, London, UK
| | - Paul Cook
- University Hospital Southampton NHS Foundation Trust, Trace Element Unit, Southampton, UK
| | - Irina Chis Ster
- St Georges University of London, Institute of Infection and Immunity, London, UK
| | - Kenneth Anthony Earle
- St Georges University Hospitals NHS Foundation Trust, Thomas Addison Unit, London, UK; St Georges University of London, Institute of Biomedical & Medical Education, London, UK.
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20
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Vilskersts R, Vilks K, Videja M, Cirule H, Zharkova‐Malkova O, Sevostjanovs E, Dambrova M, Liepinsh E. Rats with congenital hydronephrosis show increased susceptibility to renal ischemia-reperfusion injury. Physiol Rep 2020; 8:e14638. [PMID: 33207081 PMCID: PMC7673629 DOI: 10.14814/phy2.14638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 11/24/2022] Open
Abstract
Many drug candidates have shown significant renoprotective effects in preclinical models; however, there is no clinically used effective pharmacotherapy for acute kidney injury. The failure to translate from bench to bedside could be due to misleading results from experimental animals with undetected congenital kidney defects. This study was performed to assess the effects of congenital hydronephrosis on the functional capacity of tubular renal transporters as well as kidney sensitivity to ischemia-reperfusion (I-R)-induced injury in male Wistar rats. Ultrasonography was used to distinguish healthy control rats from rats with hydronephrosis. L-carnitine or furosemide was administered, and serial blood samples were collected and analyzed to assess the effects of hydronephrosis on the pharmacokinetic parameters. Renal injury was induced by clamping the renal pedicles of both kidneys for 30 min with subsequent 24 hr reperfusion. The prevalence of hydronephrosis reached ~30%. The plasma concentrations after administration of L-carnitine or furosemide were similar in both groups. I-R induced more pronounced renal injury in the hydronephrotic rats than the control rats, which was evident by a significantly higher kidney injury molecule-1 concentration and lower creatinine concentration in the urine of the hydronephrotic rats than the control rats. After I-R, the gene expression levels of renal injury markers were significantly higher in the hydronephrotic kidneys than in the kidneys of control group animals. In conclusion, our results demonstrate that hydronephrotic kidneys are more susceptible to I-R-induced damage than healthy kidneys. Unilateral hydronephrosis does not affect the pharmacokinetics of substances secreted or absorbed in the renal tubules.
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Affiliation(s)
- Reinis Vilskersts
- Latvian Institute of Organic SynthesisRigaLatvia
- Rigas Stradins UniversityRigaLatvia
| | - Karlis Vilks
- Latvian Institute of Organic SynthesisRigaLatvia
- University of LatviaRigaLatvia
| | - Melita Videja
- Latvian Institute of Organic SynthesisRigaLatvia
- Rigas Stradins UniversityRigaLatvia
| | | | | | | | - Maija Dambrova
- Latvian Institute of Organic SynthesisRigaLatvia
- Rigas Stradins UniversityRigaLatvia
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21
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Bellomo R, Evans RG. Renal functional reserve: from physiological phenomenon to clinical biomarker and beyond. Am J Physiol Regul Integr Comp Physiol 2020; 319:R690-R702. [PMID: 33074016 DOI: 10.1152/ajpregu.00237.2020] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Glomerular filtration rate (GFR) is acutely increased following a high-protein meal or systemic infusion of amino acids. The mechanisms underlying this renal functional response remain to be fully elucidated. Nevertheless, they appear to culminate in preglomerular vasodilation. Inhibition of the tubuloglomerular feedback signal appears critical. However, nitric oxide, vasodilator prostaglandins, and glucagon also appear important. The increase in GFR during amino acid infusion reveals a "renal reserve," which can be utilized when the physiological demand for single nephron GFR increases. This has led to the concept that in subclinical renal disease, before basal GFR begins to reduce, renal functional reserve can be recruited in a manner that preserves renal function. The extension of this concept is that once a decline in basal GFR can be detected, renal disease is already well progressed. This concept likely applies both in the contexts of chronic kidney disease and acute kidney injury. Critically, its corollary is that deficits in renal functional reserve have the potential to provide early detection of renal dysfunction before basal GFR is reduced. There is growing evidence that the renal response to infusion of amino acids can be used to identify patients at risk of developing either chronic kidney disease or acute kidney injury and as a treatment target for acute kidney injury. However, large multicenter clinical trials are required to test these propositions. A renewed effort to understand the renal physiology underlying the response to amino acid infusion is also warranted.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
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22
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Damianaki K, Burnier M, Dimitriadis K, Tsioufis C, Petras D. Renal Functional Reserve Is Related to the Nondipping Phenotype and to the Exercise Heart Rate Response in Patients with Essential Hypertension and Preserved Renal Function. Kidney Blood Press Res 2020; 45:737-747. [PMID: 32784307 DOI: 10.1159/000508939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/25/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Renal functional reserve (RFR), defined as the difference between stress and resting glomerular filtration rate (GFR), may constitute a diagnostic tool to identify patients at higher risk of developing acute kidney injury or chronic kidney disease. Blunted RFR has been demonstrated in early stages of hypertension and has been attributed to impaired vascular reactivity due to an overactive sympathetic nervous system (SNS). OBJECTIVE The purpose of this study was to investigate whether RFR correlates with other phenotypes expressing overactivity of the SNS in patients with essential hypertension and preserved renal function. METHODS Thirty-six patients with untreated essential hypertension and a GFR >60 mL/min/1.73 m2 were enrolled. The following parameters were measured: RFR, 24-h ambulatory blood pressure (BP) profile, a treadmill stress test, and an echocardiographic examination. Urine and venous samples were obtained at specific time points for the determination of clinical parameters, and both resting and stress GFR were calculated by using endogenous creatinine clearance for the measurement of RFR after an acute oral protein load (1 g/kg). RESULTS Twenty-one patients had a RFR <30 mL/min/1.73 m2 and 15 had a RFR above this cutoff. A nondipping pattern of 24-h BP was significantly more frequent in patients with low RFR (57.1 vs. 25.0%, p < 0.05 for systolic BP and 52.3 vs. 10.0%, p < 0.02 for diastolic BP). Moreover, patients with lower RFR values showed a blunted heart rate (HR) response to exercise during treadmill test (r = 0.439, p < 0.05). None of the echocardiographic parameters differed between the two groups of patients. CONCLUSIONS In hypertensive patients with preserved GFR, reduced RFR is related to nondipping BP phenotype as well as to attenuated exercise HR response. Overactivity of the SNS may be a common pathway. Since loss of RFR may represent a risk factor for acute or chronic kidney injury, hypertensive patients with blunted RFR might need a more careful renal follow-up.
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Affiliation(s)
- Katerina Damianaki
- Service of Nephrology, University Hospital of Athens, Hippokration Hospital, Athens, Greece,
| | - Michel Burnier
- Service of Nephrology and Hypertension, University Hospital of Lausanne, Lausanne, Switzerland
| | - Kyriakos Dimitriadis
- First Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece
| | - Dimitrios Petras
- Service of Nephrology, University Hospital of Athens, Hippokration Hospital, Athens, Greece
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Rivero J, Rodríguez F, Soto V, Macedo E, Chawla LS, Mehta RL, Vaingankar S, Garimella PS, Garza C, Madero M. Furosemide stress test and interstitial fibrosis in kidney biopsies in chronic kidney disease. BMC Nephrol 2020; 21:87. [PMID: 32143585 PMCID: PMC7060600 DOI: 10.1186/s12882-020-01721-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 02/11/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Interstitial fibrosis (IF) on kidney biopsy is one of the most potent risk factors for kidney disease progression. The furosemide stress test (FST) is a validated tool that predicts the severity of acute kidney injury (especially at 2 h) in critically ill patients. Since furosemide is secreted through the kidney tubules, the response to FST represents the tubular secretory capacity. To our knowledge there is no data on the correlation between functional tubular capacity assessed by the FST with IF on kidney biopsies from patients with chronic kidney disease (CKD). The aim of this study was to determine the association between urine output (UO), Furosemide Excreted Mass (FEM) and IF on kidney biopsies after a FST. METHODS This study included 84 patients who underwent kidney biopsy for clinical indications and a FST. The percentage of fibrosis was determined by morphometry technique and reviewed by a nephropathologist. All patients underwent a FST prior to the biopsy. Urine volume and urinary sodium were measured in addition to urine concentrations of furosemide at different times (2, 4 and 6 h). We used an established equation to determine the FEM. Values were expressed as mean, standard deviation or percentage and Pearson Correlation. RESULTS The mean age of the participants was 38 years and 44% were male. The prevalence of diabetes mellitus, hypertension and diuretic use was significantly higher with more advanced degree of fibrosis. Nephrotic syndrome and acute kidney graft dysfunction were the most frequent indications for biopsy. eGFR was inversely related to the degree of fibrosis. Subjects with the highest degree of fibrosis (grade 3) showed a significant lower UO at first hour of the FST when compared to lower degrees of fibrosis (p = 0.015). Likewise, the total UO and the FEM was progressively lower with higher degrees of fibrosis. An inversely linear correlation between FEM and the degree of fibrosis (r = - 0.245, p = 0.02) was observed. CONCLUSIONS Our findings indicate that interstitial fibrosis correlates with total urine output and FEM. Further studies are needed to determine if UO and FST could be a non-invasive tool to evaluate interstitial fibrosis. TRIAL REGISTRATION ClinicalTrials.gov NCT02417883.
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Affiliation(s)
- Jesús Rivero
- Nephrology Department, National Institute of Lung Disease Ismael Cosio Villegas , Mexico City, Mexico
| | - Francisco Rodríguez
- Nephrology Department, National Institute Cardiology Ignacio Chávez, Juan Badiano No. 1, 14080-Tlalpan, Mexico City, Mexico
| | - Virgilia Soto
- Nephrology Department, National Institute Cardiology Ignacio Chávez, Juan Badiano No. 1, 14080-Tlalpan, Mexico City, Mexico
| | - Etienne Macedo
- Division of Nephrology, University of California, San Diego, CA, USA
| | - Lakhmir S Chawla
- Division of Nephrology, University of California, San Diego, CA, USA
| | - Ravindra L Mehta
- Division of Nephrology, University of California, San Diego, CA, USA
| | - Sucheta Vaingankar
- Nephrology Department, National Institute Cardiology Ignacio Chávez, Juan Badiano No. 1, 14080-Tlalpan, Mexico City, Mexico
| | | | - Carlos Garza
- Nephrology Department, National Institute Cardiology Ignacio Chávez, Juan Badiano No. 1, 14080-Tlalpan, Mexico City, Mexico
| | - Magdalena Madero
- Nephrology Department, National Institute Cardiology Ignacio Chávez, Juan Badiano No. 1, 14080-Tlalpan, Mexico City, Mexico.
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Renal safety in 3264 HCV patients treated with DAA-based regimens: Results from a large Italian real-life study. Dig Liver Dis 2020; 52:190-198. [PMID: 31813755 DOI: 10.1016/j.dld.2019.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sofosbuvir (SOF)-based regimens have been associated with renal function worsening in HCV patients with estimated glomerular filtration rate (eGFR) ≤ 45 ml/min, but further investigations are lacking. AIM To assess renal safety in a large cohort of DAA-treated HCV patients with any chronic kidney disease (CKD). METHODS All HCV patients treated with DAA in Lombardy (December 2014-November 2017) with available kidney function tests during and off-treatment were included. RESULTS Among 3264 patients [65% males, 67% cirrhotics, eGFR 88 (9-264) ml/min], CKD stage was 3 in 9.5% and 4/5 in 0.7%. 79% and 73% patients received SOF and RBV, respectively. During DAA, eGFR declined in CKD-1 (p < 0.0001) and CKD-2 (p = 0.0002) patients, with corresponding rates of CKD stage reduction of 25% and 8%. Conversely, eGFR improved in lower CKD stages (p < 0.0001 in CKD-3a, p = 0.0007 in CKD-3b, p = 0.024 in CKD-4/5), with 33-45% rates of CKD improvement. Changes in eGFR and CKD distribution persisted at SVR. Baseline independent predictors of CKD worsening at EOT and SVR were age (p < 0.0001), higher baseline CKD stages (p < 0.0001) and AH (p = 0.010 and p < 0.0001, respectively). CONCLUSIONS During DAA, eGFR significantly declined in patients with preserved renal function and improved in those with lower CKD stages, without reverting upon drug discontinuation.
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25
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Kluger AY, Tecson KM, Lee AY, Lerma EV, Rangaswami J, Lepor NE, Cobble ME, McCullough PA. Class effects of SGLT2 inhibitors on cardiorenal outcomes. Cardiovasc Diabetol 2019; 18:99. [PMID: 31382965 PMCID: PMC6683461 DOI: 10.1186/s12933-019-0903-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To summarize the four recent sodium-glucose cotransporter 2 inhibitor (SGLT2i) trials: Dapagliflozin Effect on CardiovascuLAR Events (DECLARE-TIMI 58), CANagliflozin CardioVascular Assessment Study (CANVAS) Program, Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose (EMPA-REG OUTCOME), Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE), and explore the potential determinants for their cardiovascular, renal, and safety outcomes. RESULTS The composite renal outcome event rates per 1000 patient-years for drug and placebo, as well as the corresponding relative risk reductions, were 3.7, 7.0, 47%; 5.5, 9.0, 40%; 6.3, 11.5, 46%; 43.2, 61.2, 30% for DECLARE-TIMI 58, CANVAS, EMPA-REG OUTCOME, and CREDENCE, respectively (event definitions varied across trials). The major adverse cardiovascular (CV) event rates per 1000 patient-years for drug and placebo, as well as the corresponding relative risk reductions, were 22.6, 24.2, 7%; 26.9, 31.5, 14%; 37.4, 43.9, 14%; 38.7, 48.7, 20% for DECLARE-TIMI 58, CANVAS, EMPA-REG OUTCOME, and CREDENCE, respectively. DECLARE-TIMI 58 had the fewest cardiorenal events and CREDENCE the most. These differences were presumably due to varying inclusion criteria resulting in DECLARE-TIMI 58 having the best baseline renal filtration function and CREDENCE the worst (mean estimated glomerular filtration rate 85.2, 76.5, 74, 56.2 mL/min/1.73 m2 for DECLARE-TIMI 58, CANVAS, EMPA-REG OUTCOME, and CREDENCE, respectively). Additionally, CREDENCE had considerably higher rates of albuminuria (median urinary albumin-creatinine ratios (UACR) were 927, 12.3, and 13.1 mg/g for CREDENCE, CANVAS, and DECLARE-TIMI 58, respectively; EMPA-REG OUTCOME had 59.4% UACR < 30, 28.6% UACR > 30-300, 11.0% UACR > 300 mg/g). CONCLUSIONS Dapagliflozin, empagliflozin, and canagliflozin have internally and externally consistent and biologically plausible class effects on cardiorenal outcomes. Baseline renal filtration function and degree of albuminuria are the most significant indicators of risk for both CV and renal events. Thus, these two factors also anticipate the greatest clinical benefit for SGLT2i.
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Affiliation(s)
- Aaron Y Kluger
- Baylor Heart and Vascular Institute, 621 N. Hall #H030, Dallas, TX, 75226, USA.
- Baylor Scott & White Research Institute, Dallas, TX, USA.
| | - Kristen M Tecson
- Baylor Heart and Vascular Institute, 621 N. Hall #H030, Dallas, TX, 75226, USA
- Baylor Scott & White Research Institute, Dallas, TX, USA
- Texas A&M College of Medicine Health Science Center, Dallas, TX, USA
| | - Andy Y Lee
- Baylor University Medical Center, Dallas, TX, USA
- Baylor Heart and Vascular Hospital, Dallas, TX, USA
| | - Edgar V Lerma
- UIC/Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Janani Rangaswami
- Einstein Medical Center, Philadelphia, PA, USA
- Sidney Kimmel College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Norman E Lepor
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Peter A McCullough
- Baylor Heart and Vascular Institute, 621 N. Hall #H030, Dallas, TX, 75226, USA
- Texas A&M College of Medicine Health Science Center, Dallas, TX, USA
- Baylor University Medical Center, Dallas, TX, USA
- Baylor Heart and Vascular Hospital, Dallas, TX, USA
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Abstract
Acute kidney injury (AKI) is a frequent complication in hospitalised patients and is diagnosed by urinary output and serum creatinine. Serum creatinine is an indirect marker for renal glomerular filtration, but lacks specificity for damage to kidney tissue and the relatively late response to injury precludes early recognition of AKI. Timely diagnosis of kidney injury using biomarkers that provide information about the aetiology of kidney injury is an unmet clinical need. To overcome the suboptimal performance of serum creatinine, injury biomarkers have been proposed that predict AKI in diverse clinical settings. The clinical performance of these markers is considered moderate due to the lack of specificity for kidney tissue or the underlying injury mechanisms, poor test specificity and confounding by interventions or comorbidities. Hence, it is not unequivocally beneficial to implement current kidney injury biomarkers in the clinical laboratory for diagnostic purposes. In this article we review biomarkers that might fulfil AKI-related unmet clinical needs in the academic hospital setting.
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Messchendorp AL, van Londen M, Taylor JM, de Borst MH, Navis G, Casteleijn NF, Gaillard CA, Bakker SJ, Gansevoort RT. Kidney Function Reserve Capacity in Early and Later Stage Autosomal Dominant Polycystic Kidney Disease. Clin J Am Soc Nephrol 2018; 13:1680-1692. [PMID: 30254028 PMCID: PMC6237049 DOI: 10.2215/cjn.03650318] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/20/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES It is assumed that in autosomal dominant polycystic kidney disease (ADPKD), kidney function remains in the normal range for several decades because of hyperfiltration of remnant nephrons. In this study, we investigate the extent to which patients with ADPKD hyperfilter. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this cross-sectional study, we measured GFR as urinary clearance using continuous infusion of 125I-iothalamate. Kidney function reserve capacity was determined as increase in measured GFR after adding a dopamine infusion of 4.4-6 mg/h. Potential kidney donors were used as healthy controls and matched by age and sex to patients with ADPKD for comparisons across age groups and CKD stages. Hyperfiltration was defined by a loss of kidney function reserve capacity compared with healthy controls. RESULTS A total of 300 participants were studied. In the youngest age group (18-29 years), measured GFR was not different between patients with ADPKD and healthy controls (103±21 versus 111±9 ml/min per 1.73 m2; P=0.14). In this age group kidney function reserve capacity was higher compared with healthy controls (11.1%±8.3% versus 5.3%±6.5%; P=0.04). Moreover, kidney function reserve capacity was similar to healthy controls in patients with ADPKD with early-stage disease (eGFR≥60 ml/min per 1.73 m2), either overall or when divided into fast or slow progressors according to their Mayo height-adjusted total kidney volume class. However, in patients with ADPKD, lower measured GFR was associated with lower kidney function reserve capacity (β=1.0 [95% confidence interval, 0.5 to 1.5] % per 10 ml/min per 1.73 m2; P<0.001). Kidney function reserve capacity was therefore lower compared with healthy controls at older age and later CKD stages. CONCLUSIONS Patients with early-stage ADPKD, either classified as having rapidly or slowly progressive disease, are able to increase their GFR in response to dopamine. Hyperfiltration, defined by a loss of kidney function reserve capacity, may therefore not be an early phenomenon in ADPKD.
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Affiliation(s)
| | | | | | | | | | - Niek F. Casteleijn
- Urology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; and
| | - Carlo A.J.M. Gaillard
- Division of Internal Medicine and Dermatology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | | | | | - on behalf of the DIPAK Consortium
- Departments of Nephrology and
- Urology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; and
- Division of Internal Medicine and Dermatology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
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De Moor B, Vanwalleghem JF, Swennen Q, Stas KJ, Meijers BKI. Haemodynamic or metabolic stimulation tests to reveal the renal functional response: requiem or revival? Clin Kidney J 2018; 11:623-654. [PMID: 30288259 PMCID: PMC6165749 DOI: 10.1093/ckj/sfy022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/26/2018] [Indexed: 12/24/2022] Open
Abstract
Renal stimulation tests document the dynamic response of the glomerular filtration rate (GFR) after a single or a combination of stimuli, such as an intravenous infusion of dopamine or amino acids or an oral protein meal. The increment of the GFR above the unstimulated state has formerly been called the renal functional reserve (RFR). Although the concept of a renal reserve capacity has not withstood scientific scrutiny, the literature documenting renal stimulation merits renewed interest. An absent or a blunted response of the GFR after a stimulus indicates lost or diseased nephrons. This information is valuable in preventing, diagnosing and prognosticating acute kidney injury and pregnancy-related renal events as well as chronic kidney disease. However, before renal function testing is universally practiced, some shortcomings must be addressed. First, a common nomenclature should be decided upon. The expression of RFR should be replaced by renal functional response. Second, a simple protocol must be developed and propagated. Third, we suggest designing prospective studies linking a defective stimulatory response to emergence of renal injury biomarkers, to histological or morphological renal abnormalities and to adverse renal outcomes in different renal syndromes.
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Affiliation(s)
- Bart De Moor
- Faculty of Medicine and Life Sciences, University of Hasselt, Diepenbeek, Belgium
- Department of Nephrology, Jessa Hospital of Hasselt, Hasselt, Belgium
| | | | - Quirine Swennen
- Faculty of Medicine and Life Sciences, University of Hasselt, Diepenbeek, Belgium
| | - Koen J Stas
- Department of Nephrology, Jessa Hospital of Hasselt, Hasselt, Belgium
| | - Björn K I Meijers
- Department of Nephrology, Universitair Ziekenhuis Leuven, Leuven, Belgium
- Department of Immunology and Microbiology, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
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29
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Suyoto PST. Effect of low-carbohydrate diet on markers of renal function in patients with type 2 diabetes: A meta-analysis. Diabetes Metab Res Rev 2018; 34:e3032. [PMID: 29904998 DOI: 10.1002/dmrr.3032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 05/27/2018] [Accepted: 06/06/2018] [Indexed: 12/31/2022]
Abstract
Meta-analysis was conducted to clarify the effect of low-carbohydrate diet (LCD) on renal function in patients with type 2 diabetes. An extensive literature search was conducted on scientific databases including PubMed, Scopus, and Cochrane Library until September 2017. Only controlled trials on human subjects written in English were included in this meta-analysis. Several markers of renal function were compared between subjects who adopted an LCD or control diet, including estimated glomerular filtration rate, creatinine clearance, urinary albumin, serum creatinine, and serum uric acid. Random effect model was used in the analysis of each marker. In this meta-analysis, 12 controlled trials were selected, which involved 942 participants (500 received LCD and 442 received a control diet). The pooled standardized mean difference (SMD) of estimated glomerular filtration rate from LCD vs control diet was not different (pooled SMD: 0.26; 95% CI, -0.03 to 0.55; P = .08). Investigation on creatinine clearance also showed no significant difference (pooled SMD: 0.51; 95% CI, -0.38 to 1.40; P = .26). Other comparisons from urinary albumin (pooled SMD: -0.04; 95% CI, -0.75 to 0.67; P = .90), serum creatinine (pooled SMD: -0.57; 95% CI, -1.51 to 0.38; P = .24), and serum uric acid (pooled SMD: -0.86; 95% CI, -4.00 to 2.28; P = .59) also showed no significant difference in the results. In the present meta-analysis, no effect on markers of renal function was found after provision of a LCD compared with a control diet in patients with type 2 diabetes.
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Affiliation(s)
- Perdana Samekto Tyasnugroho Suyoto
- Department of Nutrition and Health, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Center for Health and Human Nutrition, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
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30
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Muroya Y, He X, Fan L, Wang S, Xu R, Fan F, Roman RJ. Enhanced renal ischemia-reperfusion injury in aging and diabetes. Am J Physiol Renal Physiol 2018; 315:F1843-F1854. [PMID: 30207168 DOI: 10.1152/ajprenal.00184.2018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The incidence and severity of acute kidney injury is increased in patients with diabetes and with aging. However, the mechanisms involved have not been clearly established. The present study examined the effects of aging and diabetes on the severity of renal ischemia-reperfusion (IR) injury in Sprague-Dawley (SD) and type 2 diabetic (T2DN) rats. T2DN rats develop diabetes at 3 mo of age and progressive proteinuria and diabetic nephropathy as they age from 6 to 18 mo. Plasma creatinine levels after bilateral IR were significantly higher (3.4 ± 0.1 mg/dl) in 18-mo-old elderly T2DN rats than in middle-aged (12 mo) T2DN rats with less severe diabetic nephropathy or young (3 mo) and elderly (18 mo) control SD rats (1.5 ± 0.2, 1.8 ± 0.1, and 1.7 ± 0.1 mg/dl, respectively). Elderly T2DN rats exhibited a greater fall in medullary blood flow 2 h following renal IR and a more severe and prolonged decline in glomerular filtration rate than middle-aged T2DN and young or elderly SD rats. The basal expression of the adhesion molecules ICAM-1 and E-selectin and the number of infiltrating immune cells was higher in the kidney of elderly T2DN than age-matched SD rats or young and middle-aged T2DN rats before renal IR. These results indicate that elderly T2DN rats with diabetic nephropathy are more susceptible to renal IR injury than diabetic animals with mild injury or age-matched control animals. This is associated with increased expression of ICAM-1, E-selectin and immune cell infiltration, renal medullary vasocongestion, and more prolonged renal medullary ischemia.
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Affiliation(s)
- Yoshikazu Muroya
- Faculty of Medicine, Tohoku Medical and Pharmaceutical University , Sendai , Japan.,Department of Pharmacology and Toxicology, The University of Mississippi Medical Center , Jackson, Mississippi
| | - Xiaochen He
- Department of Pharmacology and Toxicology, The University of Mississippi Medical Center , Jackson, Mississippi
| | - Letao Fan
- Department of Pharmacology and Toxicology, The University of Mississippi Medical Center , Jackson, Mississippi
| | - Shaoxun Wang
- Department of Pharmacology and Toxicology, The University of Mississippi Medical Center , Jackson, Mississippi
| | - Rui Xu
- Department of Pharmacology and Toxicology, The University of Mississippi Medical Center , Jackson, Mississippi
| | - Fan Fan
- Department of Pharmacology and Toxicology, The University of Mississippi Medical Center , Jackson, Mississippi
| | - Richard J Roman
- Department of Pharmacology and Toxicology, The University of Mississippi Medical Center , Jackson, Mississippi
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van Londen M, Schaeffers AWMA, de Borst MH, Joles JA, Navis G, Lely AT. Overweight young female kidney donors have low renal functional reserve postdonation. Am J Physiol Renal Physiol 2018; 315:F454-F459. [PMID: 29357424 DOI: 10.1152/ajprenal.00492.2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Maintenance of adequate renal function after living kidney donation is important for donor outcome. Overweight donors, in particular, may have an increased risk for end-stage kidney disease (ESKD), and young female donors have an increased preeclampsia risk. Both of these risks may be associated with low postdonation renal functional reserve (RFR). Because we previously found that higher body mass index (BMI) was associated with lower postdonation RFR, we now studied the relationship between BMI and RFR in young female donors. RFR, the rise in glomerular filtration rate (GFR) (125I-iothalamate clearance) during dopamine, was measured in female donors (<45 yr) before and after kidney donation. Donors who are overweight (BMI >25) and nonoverweight donors were compared by Student's t-test; the association was subsequently explored with regression analysis. We included 105 female donors [age 41 (36-44) median(IQR)] with a BMI of 25 (22-27) kg/m2. Predonation GFR was 118 (17) ml/min [mean(SD)] rising to 128 (19) ml/min during dopamine; mean RFR was 10 (10) ml/min. Postdonation GFR was 76 (13) ml/min, rising to 80 (12); RFR was 4 (6) ml/min ( P < 0.001 vs. predonation). In overweight donors, RFR was fully lost after donation (1 ml/min vs. 10 ml/min predonation, P < 0.001), and BMI was inversely associated with RFR after donation, independent of confounders (standardized β 0.37, P = 0.02). Reduced RFR might associate with the risk of preeclampsia and ESKD in kidney donors. Prospective studies should explore whether RFR is related to preeclampsia and whether BMI reduction before conception is of benefit to overweight female kidney donors during and after pregnancy.
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Affiliation(s)
- Marco van Londen
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Anouk W M A Schaeffers
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Martin H de Borst
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Gerjan Navis
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - A Titia Lely
- Department of Obstetrics and Gynecology, Division of Women and Baby, University Medical Center Utrecht , Utrecht , The Netherlands
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Abstract
Kidney function, like the function of other organs, is dynamic and continuously adjusts to changes in the internal environment to maintain homeostasis. The glomerular filtration rate, which serves as the primary index of kidney function in clinical practice, increases in response to various physiological and pathological stressors including oral protein intake. The difference between the glomerular filtration rate in the resting state and at maximum capacity has been termed renal functional reserve (RFR). RFR could provide additional information on kidney health and renal function prognosis. Despite longstanding interest in RFR as a biomarker in nephrology, its underlying mechanisms remain inadequately understood. Moreover, no consensus has been reached on how it should be quantified. Previous studies on RFR have used various measurement methods and yielded heterogeneous results. A standardized and clinically feasible approach to quantifying RFR would allow for more rigorous appraisal of its value as a biomarker and could pave the way for adoption of "renal stress tests" into clinical practice.
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Abstract
PURPOSE OF REVIEW The kidney, like most other organs, has a reserve capacity that can be utilized in times of increased physiologic demand. The ability to quantify this renal reserve function across various parts of the nephron (glomerular and tubular) has been an area of increased investigation over the past several years. In this review, we discuss several techniques that have been developed to interrogate the maximal physiologic capacity of the injured kidney. RECENT FINDINGS Although protein loading has been established as an ideal method to investigate glomerular filtration capacity in healthy kidneys, other methods such as the antagonism of the renin-angiotensin-aldosterone system have demonstrated promise as a method to determine underlying glomerular disease in those with acute kidney injury and other comorbidities (e.g., congestive heart failure and chronic kidney disease). The furosemide stress test has been demonstrated to be a useful clinical tool to ascertain tubular integrity in the setting of acute kidney injury. SUMMARY Although various methods to interrogate the reserve capacity of the several nephron segments (glomerulus and tubules) have been investigated, none of these techniques have had wide-spread clinical implementation. Further research into acute kidney injury stress testing is warranted.
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Gestational bisphenol S impairs placental endocrine function and the fusogenic trophoblast signaling pathway. Arch Toxicol 2018; 92:1861-1876. [PMID: 29550860 DOI: 10.1007/s00204-018-2191-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/13/2018] [Indexed: 02/07/2023]
Abstract
Exposure to bisphenolic chemicals during pregnancy occurs in > 90% of pregnancies. Bisphenolic compounds can cross the placental barrier reaching fetal circulation. However, the effects of emerging bisphenolic compounds, such as bisphenol S (BPS), on placental function remain untested. The aim was to determine if bisphenol A (BPA) or BPS, at an environmentally relevant dose, impairs placental function. Pregnant sheep were randomly distributed into three treatment groups (n = 7-8/group): control, BPA, and BPS. All animals received daily injections of corn oil (control), BPA, or BPS (0.5 mg/kg; s.c.; internal fetal doses were ~ 2.6 ng/mL unconjugated BPA and ~ 7.7 ng/mL of BPS) from gestational day 30-100. After a 20-day washout period, placentas were weighed and placentomes collected. Placental endocrine function was assessed on biweekly maternal blood samples. Gestational exposure to BPS, but not BPA, reduced maternal circulating pregnancy-associated glycoproteins without change in placental weight or placental stereology. BPS-exposed placentas had 50% lower e-cadherin protein expression, ~ 20% fewer binucleate cells, and ~ threefold higher glial cell missing-1 protein expression. BPA placentas were not affected highlighting the intrinsic differences among bisphenolic chemicals. This is the first study to demonstrate that gestational BPS can result in placental endocrine dysfunction and points to a dysregulation in the fusogenic trophoblast signaling pathway.
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Rowland J, Akbarov A, Maan A, Eales J, Dormer J, Tomaszewski M. Tick-Tock Chimes the Kidney Clock - from Biology of Renal Ageing to Clinical Applications. Kidney Blood Press Res 2018; 43:55-67. [PMID: 29402805 DOI: 10.1159/000486907] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 01/18/2018] [Indexed: 11/19/2022] Open
Abstract
Ageing of the kidney is a multi-dimensional process that occurs simultaneously at the molecular, cellular, histological, anatomical and physiological level. Nephron number and renal cortical volume decline, renal tubules become atrophic and glomeruli become sclerotic with age. These structural changes are accompanied by a decline in glomerular filtration rate, decreased sodium reabsorption and potassium excretion, reduced urinary concentrating capacity and alterations in the endocrine activity of the kidney. However, the pace of progression of these changes is not identical in everyone - individuals of the same age and seemingly similar clinical profile often exhibit stark differences in the age-related decline in renal health. Thus, chronological age poorly reflects the time-dependent changes that occur in the kidney. An ideal measure of renal vitality is biological kidney age - a measure of the age-related changes in physiological function. Replacing chronological age with biological age could provide numerous clinical benefits including improved prognostic accuracy in renal transplantation, better stratification of risk and identification of those who are on a fast trajectory to an age-related drop in kidney health.
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Affiliation(s)
- Joshua Rowland
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester, Manchester, United Kingdom
| | - Artur Akbarov
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester, Manchester, United Kingdom
| | - Akhlaq Maan
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester, Manchester, United Kingdom
| | - James Eales
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester, Manchester, United Kingdom
| | - John Dormer
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester, Manchester, United Kingdom.,Division of Medicine, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
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[New kidney function tests: Renal functional reserve and furosemide stress test]. Med Klin Intensivmed Notfmed 2018; 115:37-42. [PMID: 29327197 DOI: 10.1007/s00063-017-0400-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/06/2017] [Accepted: 12/09/2017] [Indexed: 12/21/2022]
Abstract
Acute kidney injury (AKI) occurs in 30-50% of all intensive care patients. Renal replacement therapy (RRT) has to be initiated in 10-15%. The early in-hospital mortality is about 50%. Up to 20% of all survivors develop chronic kidney disease after intensive care discharge and progress to end-stage kidney disease within the next 10 years. For timely initiation of prophylactic or therapeutic interventions, it is crucial to exactly determine the actual kidney function, i. e., glomerular filtration rate (GFR), and to gain insight into the further development of kidney function. Traditionally, renal function has been estimated using serum levels of creatinine or urea. Unfortunately, both are notoriously unreliable and insensitive in intensive care patients. Cystatin C has fewer non-GFR determinants when compared to creatinine and is more sensitive and accurate to detect early decreases of GFR. At present, new functional tests are discussed, namely the furosemide stress test (FST) and renal functional reserve (RFR). The FST consists of an intravenous infusion of 1.0-1.5 mg/kgBW furosemide to critically ill patients with AKI. An increase in urine output to >100 ml/h is indicative of a GFR >20 ml/min and almost certainly excludes progression to AKI stage III and need for RRT. Estimation of RFR can be made by short-term oral or intravenous administration of a high protein load. A subsequent increase in GFR defines the presence and the magnitude of functional reserve which can be activated. Loss of RFR is an indicator of loss of functioning nephron mass and incomplete recovery following AKI. Both FST and RFR can help to improve diagnosis and care of high-risk patients with acute and chronic kidney disease.
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The role of renal response to amino acid infusion and oral protein load in normal kidneys and kidney with acute and chronic disease. Curr Opin Nephrol Hypertens 2018; 27:23-29. [DOI: 10.1097/mnh.0000000000000380] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Alaini A, Malhotra D, Rondon-Berrios H, Argyropoulos CP, Khitan ZJ, Raj DSC, Rohrscheib M, Shapiro JI, Tzamaloukas AH. Establishing the presence or absence of chronic kidney disease: Uses and limitations of formulas estimating the glomerular filtration rate. World J Methodol 2017; 7:73-92. [PMID: 29026688 PMCID: PMC5618145 DOI: 10.5662/wjm.v7.i3.73] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/17/2017] [Accepted: 05/30/2017] [Indexed: 02/06/2023] Open
Abstract
The development of formulas estimating glomerular filtration rate (eGFR) from serum creatinine and cystatin C and accounting for certain variables affecting the production rate of these biomarkers, including ethnicity, gender and age, has led to the current scheme of diagnosing and staging chronic kidney disease (CKD), which is based on eGFR values and albuminuria. This scheme has been applied extensively in various populations and has led to the current estimates of prevalence of CKD. In addition, this scheme is applied in clinical studies evaluating the risks of CKD and the efficacy of various interventions directed towards improving its course. Disagreements between creatinine-based and cystatin-based eGFR values and between eGFR values and measured GFR have been reported in various cohorts. These disagreements are the consequence of variations in the rate of production and in factors, other than GFR, affecting the rate of removal of creatinine and cystatin C. The disagreements create limitations for all eGFR formulas developed so far. The main limitations are low sensitivity in detecting early CKD in several subjects, e.g., those with hyperfiltration, and poor prediction of the course of CKD. Research efforts in CKD are currently directed towards identification of biomarkers that are better indices of GFR than the current biomarkers and, particularly, biomarkers of early renal tissue injury.
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Affiliation(s)
- Ahmed Alaini
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Deepak Malhotra
- Division of Nephrology, Department of Medicine, University of Toledo School of Medicine, Toledo, OH 43614-5809, United States
| | - Helbert Rondon-Berrios
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, United States
| | - Christos P Argyropoulos
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Zeid J Khitan
- Division of Nephrology, Department of Medicine, Joan C. Edwards School of Medicine, Huntington, WV 25701, United States
| | - Dominic S C Raj
- Division of Nephrology, Department of Medicine, George Washington University, Washington, DC 20037, United States
| | - Mark Rohrscheib
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Joseph I Shapiro
- Marshall University Joan C. Edwards School of Medicine, Huntington, WV 25701, United States
| | - Antonios H Tzamaloukas
- Nephrology Section, Medicine Service, Raymond G. Murphy VA Medical Center, Albuquerque, NM 87108, United States
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
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Succar L, Pianta TJ, Davidson T, Pickering JW, Endre ZH. Subclinical chronic kidney disease modifies the diagnosis of experimental acute kidney injury. Kidney Int 2017; 92:680-692. [DOI: 10.1016/j.kint.2017.02.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 02/01/2017] [Accepted: 02/23/2017] [Indexed: 12/19/2022]
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Ronco C, Chawla LS. Glomerular and Tubular Kidney Stress Test: New Tools for a Deeper Evaluation of Kidney Function. Nephron Clin Pract 2016; 134:191-194. [PMID: 27577054 DOI: 10.1159/000449235] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/13/2016] [Indexed: 11/19/2022] Open
Abstract
Kidney function has been traditionally identified with glomerular filtration rate (GFR). However, the kidney has multiple functions beyond filtration and a careful evaluation of its whole spectrum of activities should be carried out. Furthermore, the kidney presents a functional reserve capacity both at glomerular and tubular level. In presence of appropriate stimuli, patients with intact nephron mass can increase their GFR and tubular secretion. The difference between maximal capacity and baseline function represents the renal functional reserve (RFR). Glomerular and tubular kidney stress test may help to evaluate RFR and improve the clinicians' ability to better diagnose and prognosticate both acute and chronic kidney disease. © 2016 S. Karger AG, Basel.
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Affiliation(s)
- Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
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41
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Gaipov A, Solak Y, Zhampeissov N, Dzholdasbekova A, Popova N, Molnar MZ, Tuganbekova S, Iskandirova E. Renal functional reserve and renal hemodynamics in hypertensive patients. Ren Fail 2016; 38:1391-1397. [DOI: 10.1080/0886022x.2016.1214052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Chawla LS, Ronco C. Renal Stress Testing in the Assessment of Kidney Disease. Kidney Int Rep 2016; 1:57-63. [PMID: 29142914 PMCID: PMC5678605 DOI: 10.1016/j.ekir.2016.04.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 11/02/2022] Open
Abstract
As part of human evolutionary development, many human organ systems have innate mechanisms to adapt to increased "work demand" or stress. This reserve capacity can be informative and is used commonly in cardiology to assess cardiac function (e.g., treadmill test). Similarly, the kidney possesses reserve capacity, which can be demonstrated in at least 2 of the following renal domains: glomerular and tubular. When appropriate stimulants are used, healthy patients with intact kidneys can significantly increase their glomerular filtration rate and their tubular secretion. This approach has been used to develop diagnostics for the assessment of renal function. This article reviews both glomerular and tubular kidney stress tests and their respective diagnostic utility.
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Affiliation(s)
- Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA.,Department of Medicine, George Washington University, Washington, DC, USA
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy.,International Renal Research Institute of Vicenza, Vicenza, Italy
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Bahler CD, Sundaram CP. Effect of Renal Reconstruction on Renal Function After Partial Nephrectomy. J Endourol 2016; 30 Suppl 1:S37-41. [DOI: 10.1089/end.2016.0055] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Clinton D. Bahler
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chandru P. Sundaram
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana
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Fujimi K, Miura SI, Matsuda T, Fujita M, Ura Y, Kaino K, Sakamoto M, Horita T, Arimura T, Shiga Y, Saku K. Influence of a Cardiac Rehabilitation Program on Renal Function in Patients With Cardiovascular Disease in a One-Year Follow-Up. Cardiol Res 2015; 6:311-315. [PMID: 28197248 PMCID: PMC5295569 DOI: 10.14740/cr440e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2015] [Indexed: 11/11/2022] Open
Abstract
Background Exercise training may improve renal function in patients with chronic kidney disease (CKD). The effect of cardiac rehabilitation (CR) with exercise training on renal function has not yet been established. We evaluated the effects of CR on renal function in patients with cardiovascular disease (CVD). Methods Twenty-three CVD patients in a 1-year CR program (CR group) who had ischemic heart disease (IHD) and/or heart failure were compared with 26 age- and gender-matched CVD patients without CR (non-CR group, standard pharmacological care alone). At baseline and after 1 year, urea nitrogen (UN), creatinine (Cr), potassium (K), estimated glomerular filtration rate (eGFR) and hematocrit (Hct) in blood were assessed. Results There were no differences in the patient characteristics at baseline between the CR and non-CR groups except for the percentages of heart failure and the use of calcium channel blocker. After 1 year, there were no significant changes in UN, Cr, K, eGFR or Hct in either the CR or non-CR groups. The patients in the CR group were divided into two groups according to the eGFR level at baseline: low (n = 12, eGFR < 51 mL/minute/1.73 m2, indicating mild-to-moderate CKD) and high (n = 11, eGFR ≥ 51 mL/minute/1.73 m2) eGFR groups. Although there were no differences in the patient characteristics at baseline between the low and high eGFR groups, the low eGFR group showed a significant increase in eGFR after the 1-year CR program. Conclusions CR may improve renal function in patients with mild-to-moderate CKD.
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Affiliation(s)
- Kanta Fujimi
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Shin-Ichiro Miura
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan; Department of Molecular Cardiovascular Therapeutics, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Takuro Matsuda
- Department of Rehabilitation, Fukuoka University Hospital, Fukuoka, Japan
| | - Masaomi Fujita
- Department of Rehabilitation, Fukuoka University Hospital, Fukuoka, Japan
| | - Yoshiyuki Ura
- Department of Rehabilitation, Fukuoka University Hospital, Fukuoka, Japan
| | - Kouji Kaino
- Department of Rehabilitation, Fukuoka University Hospital, Fukuoka, Japan
| | - Maya Sakamoto
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Tomoe Horita
- Division of Nutrition, Fukuoka University Hospital, Fukuoka, Japan
| | - Tadaaki Arimura
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Yuhei Shiga
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Keijiro Saku
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan; Department of Molecular Cardiovascular Therapeutics, Fukuoka University School of Medicine, Fukuoka, Japan
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Tseng CL, Lafrance JP, Lu SE, Soroka O, Miller DR, Maney M, Pogach LM. Variability in estimated glomerular filtration rate values is a risk factor in chronic kidney disease progression among patients with diabetes. BMC Nephrol 2015; 16:34. [PMID: 25885708 PMCID: PMC4377072 DOI: 10.1186/s12882-015-0025-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 02/24/2015] [Indexed: 12/22/2022] Open
Abstract
Background It is unknown whether variability of estimated Glomerular Filtration Rate (eGFR) is a risk factor for dialysis or death in patients with chronic kidney disease (CKD). This study aimed to evaluate variability of estimated Glomerular Filtration Rate (eGFR) as a risk factor for dialysis or death to facilitate optimum care among high risk patients. Methods A longitudinal retrospective cohort study of 70,598 Veterans Health Administration veteran patients with diabetes and CKD (stage 3–4) in 2000 with up to 5 years of follow-up. VHA and Medicare files were linked to derive study variables. We used Cox proportional hazards models to evaluate association between time to initial dialysis/death and key independent variables: time-varying eGFR variability (measured by standard deviation (SD)) and eGFR means and slopes while adjusting for prior hospitalizations, and comorbidities. Results There were 76.7% older than 65 years, 97.5% men, and 81.9% Whites. Patients were largely in early stage 3 (61.2%), followed by late stage 3 (28.9%), and stage 4 (9.9%); 29.1%, 46.8%, and 73.3%, respectively, died or had dialysis during the follow-up. eGFR SDs (median: 5.8, 5.1, and 4.0 ml/min/1.73 m2 ) and means (median: 54.1, 41.0, 27.2 ml/min/1.73 m2) from all two-year moving intervals decreased as CKD advanced; eGFR variability (relative to the mean) increased when CKD progressed (median coefficient of variation: 10.9, 12.8, and 15.4). Cox regressions revealed that one unit increase in a patient’s standard deviation of eGFRs from prior two years was significantly associated with about 7% increase in risk of dialysis/death in the current year, similarly in all three CKD stages. This was after adjusting for concurrent means and slopes of eGFRs, demographics, prior hospitalization, and comorbidities. For example, the hazard of dialysis/death increased by 7.2% (hazard ratio:1.072; 95% CI = 1.067, 1.080) in early stage 3. Conclusion eGFR variability was independently associated with elevated risk of dialysis/death even after controlling for eGFR means and slopes. Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0025-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chin-Lin Tseng
- Department of Veteran Affairs-New Jersey Health Care System, 385 Tremont Avenue, Mail Stop#15, East Orange, NJ, 07018, USA. .,Department of Preventive Medicine and Community Health, Rutgers University, New Jersey Medical School, Newark, NJ, USA.
| | | | - Shou-En Lu
- Department of Biostatistics, Rutgers School of Public Health, Piscataway, NJ, USA.
| | - Orysya Soroka
- Department of Veteran Affairs-New Jersey Health Care System, 385 Tremont Avenue, Mail Stop#15, East Orange, NJ, 07018, USA.
| | - Donald R Miller
- Bedford VA Medical Center, Center for Health Quality, Outcomes and Economic Research, Bedford, MA, USA. .,Boston University, School of Public Health, Boston, MA, USA.
| | - Miriam Maney
- Department of Veteran Affairs-New Jersey Health Care System, 385 Tremont Avenue, Mail Stop#15, East Orange, NJ, 07018, USA.
| | - Leonard M Pogach
- Department of Veteran Affairs-New Jersey Health Care System, 385 Tremont Avenue, Mail Stop#15, East Orange, NJ, 07018, USA. .,Department of Preventive Medicine and Community Health, Rutgers University, New Jersey Medical School, Newark, NJ, USA.
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Fesler P, Mourad G, du Cailar G, Ribstein J, Mimran A. Arterial stiffness: an independent determinant of adaptive glomerular hyperfiltration after kidney donation. Am J Physiol Renal Physiol 2015; 308:F567-71. [PMID: 25568135 DOI: 10.1152/ajprenal.00524.2014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
After kidney donation, the remaining kidney tends to hyperfiltrate, thus limiting the initial loss of renal function. The potential determinants of this adaptive glomerular hyperfiltration (GHF) and specifically the influence of arterial function are poorly known. In 45 normotensive healthy kidney donors [51 ± 10 yr (mean ± SD), 39 females], glomerular filtration rate (GFR) was measured as the clearance of continuously infused (99m)Tc-DTPA and timed urine collections at baseline, i.e., before donation, and 1 yr after donation. GHF was computed as postdonation GFR minus half of baseline GFR. Arterial function was assessed as baseline carotid-femoral pulse wave velocity (PWV) and carotid augmentation index (AIx). After kidney donation, no significant change in blood pressure (BP) was observed, but two subjects developed hypertension. GFR decreased from 107 ± 19 to 73 ± 15 ml·min(-1)·1.73 m(-2), and mean GHF was 20 ± 10 ml·min(-1)·1.73 m(-2). In univariate analysis, GHF was inversely correlated to age (r(2) = 0.24, P = 0.01), baseline PWV (r(2) = 0.23, P = 0.001), and Aix (r(2) = 0.11, P = 0.031). Nevertheless, GHF was not correlated to baseline peripheral or central BP. In multivariate analysis, baseline PWV, but not AIx, remained inversely correlated to GHF, independently of age, baseline mean BP, and GFR (model r(2) = 0.34, P < 0.001). In healthy subjects selected for renal donation, increased arterial stiffness is associated with decreased postdonation compensatory hyperfiltration.
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Affiliation(s)
- Pierre Fesler
- Department of Internal Medicine, Hopital Lapeyronie, Montpellier, France; Université Montpellier 1, Montpellier, France
| | - Georges Mourad
- Department of Nephrology, Hôpital Lapeyronie, Montpellier, France; and Université Montpellier 1, Montpellier, France
| | - Guilhem du Cailar
- Department of Internal Medicine, Hopital Lapeyronie, Montpellier, France
| | - Jean Ribstein
- Department of Internal Medicine, Hopital Lapeyronie, Montpellier, France; Université Montpellier 1, Montpellier, France
| | - Albert Mimran
- Department of Internal Medicine, Hopital Lapeyronie, Montpellier, France; Université Montpellier 1, Montpellier, France
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Sharma A, Mucino MJ, Ronco C. Renal functional reserve and renal recovery after acute kidney injury. Nephron Clin Pract 2014; 127:94-100. [PMID: 25343829 DOI: 10.1159/000363721] [Citation(s) in RCA: 183] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Renal functional reserve (RFR) represents the capacity of the kidney to increase glomerular filtration rate (GFR) in response to certain physiological or pathological stimuli or conditions. Once baseline GFR is determined, RFR can be assessed clinically after an oral protein load or intravenous amino acid infusion. In clinical practice, baseline GFR displays variable levels due to diet or other factors. RFR is the difference between peak 'stress' GFR induced by the test (p.o. or i.v.) and the baseline GFR. In clinical scenarios where hyperfiltration is present (high baseline GFR due to pregnancy, hypertension or diabetic nephropathy, in solitary kidney or kidney donors), RFR may be fully or partially used to achieve normal or supranormal renal function. Since commonly used renal function markers, such as GFR, may remain within normal ranges until 50% of nephrons are lost or in patients with a single remnant kidney, the RFR test may represent a sensitive and early way to assess the functional decline in the kidney. RFR assessment may become an important tool to evaluate the ability of the kidney to recover completely or partially after a kidney attack. In case of healing with a defect and progressive fibrosis, recovery may appear complete clinically, but a reduced RFR may be a sign of a maladaptive repair or subclinical loss of renal mass. Thus, a reduction in RFR may represent the equivalent of renal frailty or susceptibility to insults. The main aim of this article is to review the concept of RFR, its utility in different clinical scenarios, and future perspective for its use.
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Affiliation(s)
- Aashish Sharma
- International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy
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Bridges CC, Joshee L, Zalups RK. Aging and the disposition and toxicity of mercury in rats. Exp Gerontol 2014; 53:31-9. [PMID: 24548775 DOI: 10.1016/j.exger.2014.02.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 02/04/2014] [Accepted: 02/10/2014] [Indexed: 10/25/2022]
Abstract
Progressive loss of functioning nephrons, secondary to age-related glomerular disease, can impair the ability of the kidneys to effectively clear metabolic wastes and toxicants from blood. Additionally, as renal mass is diminished, cellular hypertrophy occurs in functional nephrons that remain. We hypothesize that these nephrons are exposed to greater levels of nephrotoxicants, such as inorganic mercury (Hg(2+)), and thus are at an increased risk of becoming intoxicated by these compounds. The purpose of the present study was to characterize the effects of aging on the disposition and renal toxicity of Hg(2+) in young adult and aged Wistar rats. Paired groups of animals were injected (i.v.) with either a 0.5μmol·kg(-1) non-nephrotoxic or a 2.5μmol·kg(-1) nephrotoxic dose of mercuric chloride (HgCl2). Plasma creatinine and renal biomarkers of proximal tubular injury were greater in both groups of aged rats than in the corresponding groups of young adult rats. Histologically, evidence of glomerular sclerosis, tubular atrophy, interstitial inflammation and fibrosis were significant features of kidneys from aged animals. In addition, proximal tubular necrosis, especially along the straight segments in the inner cortex and outer stripe of the outer medulla was a prominent feature in the renal sections from both aged and young rats treated with the nephrotoxic dose of HgCl2. Our findings indicate 1) that overall renal function is significantly impaired in aged rats, resulting in chronic renal insufficiency and 2) the disposition of HgCl2 in aging rats is significantly altered compared to that of young rats.
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Affiliation(s)
- Christy C Bridges
- Mercer University School of Medicine, Division of Basic Medical Sciences, Macon, GA 31207, United States.
| | - Lucy Joshee
- Mercer University School of Medicine, Division of Basic Medical Sciences, Macon, GA 31207, United States
| | - Rudolfs K Zalups
- Mercer University School of Medicine, Division of Basic Medical Sciences, Macon, GA 31207, United States
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Takaya Y, Kumasaka R, Arakawa T, Ohara T, Nakanishi M, Noguchi T, Yanase M, Takaki H, Kawano Y, Goto Y. Impact of Cardiac Rehabilitation on Renal Function in Patients With and Without Chronic Kidney Disease After Acute Myocardial Infarction. Circ J 2014; 78:377-84. [DOI: 10.1253/circj.cj-13-0779] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoichi Takaya
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Reon Kumasaka
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tetsuo Arakawa
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takahiro Ohara
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Michio Nakanishi
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Teruo Noguchi
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masanobu Yanase
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroshi Takaki
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yuhei Kawano
- Hypertension and Nephrology, National Cerebral and Cardiovascular Center
| | - Yoichi Goto
- Departments of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Histogram analysis of renal arterial spin labeling perfusion data reveals differences between volunteers and patients with mild chronic kidney disease. Invest Radiol 2012; 47:490-6. [PMID: 22766911 DOI: 10.1097/rli.0b013e318257063a] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The spatial heterogeneity of renal perfusion data was analyzed with arterial spin labeling (ASL) data sets in a cohort of subjects with moderately impaired kidney function (ie, glomerular filtration rate >30 mL/min/1.73 m) versus a cohort of healthy volunteers. The potential diagnostic value of a detailed histogram analysis of such perfusion data for detection of mild renal dysfunction was investigated. MATERIALS AND METHODS Eight healthy volunteers and 9 patients with mild renal dysfunction (chronic kidney disease stages 1-3) were included in the study. All subjects underwent ASL perfusion measurements with a 1.5-T magnetic resonance scanner using a flow-sensitive alternating inversion recovery labeling scheme with true fast imaging in steady-state precession data readout. Quantitative perfusion maps were generated using extended Bloch equations. Histogram analysis was performed to quantify the metrics of the perfusion of the renal cortex and the entire parenchyma, respectively. Mean perfusion value (μ), SD of the mean value (σ), peak height (PH), peak position (PP), skewness (s), and kurtosis (k) were computed to describe the distribution of the perfusion values. RESULTS A significant difference was found in the mean perfusion values computed for the cortex and the parenchyma between healthy volunteers (cortex, 329 ± 53 mL/100 g/min; parenchyma, 301 ± 51 mL/100 g/min) and patients (cortex, 263 ± 81 mL/100 g/min; parenchyma, 244 ± 77 mL/100 g/min). The histogram analysis of the cortical perfusion values also showed a significant difference (P < 0.05) in the main histogram measures between healthy volunteers (PP = 368 ± 65 mL/100 g/min; s = -0.543 ± 0.298; k = 0.371 ± 0.590) and patients (PP = 237 ± 115 mL/100 g/min; s = -0.125 ± 0.581; k = -0.151 ± 0.561). CONCLUSION Moderate renal dysfunction is associated with a significant change in the distribution of cortical perfusion values and a reduction of blood perfusion for both the parenchyma and the cortex. The preliminary results reported in this study suggest the importance of a regional assessment of renal perfusion. Histogram analysis of ASL data may help to detect chronic kidney disorders and to monitor their progression in a clinical setting.
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