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Amatruda JG, Katz R, Rebholz CM, Sarnak MJ, Gutierrez OM, Schrauben SJ, Greenberg JH, Coresh J, Cushman M, Waikar S, Parikh CR, Schelling JR, Jogalekar MP, Bonventre JV, Vasan RS, Kimmel PL, Ix JH, Shlipak MG. Urine Biomarkers of Kidney Tubule Health and Risk of Incident CKD in Persons Without Diabetes: The ARIC, MESA, and REGARDS Studies. Kidney Med 2024; 6:100834. [PMID: 38826568 PMCID: PMC11141432 DOI: 10.1016/j.xkme.2024.100834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
Rationale & Objective Tubulointerstitial damage is a feature of early chronic kidney disease (CKD), but current clinical tests capture it poorly. Urine biomarkers of tubulointerstitial health may identify risk of CKD. Study Design Prospective cohort (Atherosclerosis Risk in Communities [ARIC]) and case-cohort (Multi-Ethnic Study of Atherosclerosis [MESA] and Reasons for Geographic and Racial Differences in Stroke [REGARDS]). Setting & Participants Adults with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 and without diabetes in the ARIC, REGARDS, and MESA studies. Exposures Baseline urine monocyte chemoattractant protein-1 (MCP-1), alpha-1-microglobulin (α1m), kidney injury molecule-1, epidermal growth factor, and chitinase-3-like protein 1. Outcome Incident CKD or end-stage kidney disease. Analytical Approach Multivariable Cox proportional hazards regression for each cohort; meta-analysis of results from all 3 cohorts. Results 872 ARIC participants (444 cases of incident CKD), 636 MESA participants (158 cases), and 924 REGARDS participants (488 cases) were sampled. Across cohorts, mean age ranged from 60 ± 10 to 63 ± 8 years, and baseline eGFR ranged from 88 ± 13 to 91 ± 14 mL/min/1.73 m2. In ARIC, higher concentrations of urine MCP-1, α1m, and kidney injury molecule-1 were associated with incident CKD. In MESA, higher concentration of urine MCP-1 and lower concentration of epidermal growth factor were each associated with incident CKD. In REGARDS, none of the biomarkers were associated with incident CKD. In meta-analysis of all 3 cohorts, each 2-fold increase α1m concentration was associated with incident CKD (HR, 1.19; 95% CI, 1.08-1.31). Limitations Observational design susceptible to confounding; competing risks during long follow-up period; meta-analysis limited to 3 cohorts. Conclusions In 3 combined cohorts of adults without prevalent CKD or diabetes, higher urine α1m concentration was independently associated with incident CKD. 4 biomarkers were associated with incident CKD in at least 1 of the cohorts when analyzed individually. Kidney tubule health markers might inform CKD risk independent of eGFR and albuminuria.
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Affiliation(s)
- Jonathan G. Amatruda
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA
- Kidney Health Research Collaborative, San Francisco VA Medical Center & University of California, San Francisco, San Francisco, CA
| | - Ronit Katz
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Casey M. Rebholz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MA
| | - Mark J. Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Orlando M. Gutierrez
- Departments of Medicine and Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Sarah J. Schrauben
- Department of Medicine, Perelman School of Medicine, Center for Clinical Epidemiology and Biostatistics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jason H. Greenberg
- Section of Nephrology, Department of Pediatrics, Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
| | - Sushrut Waikar
- Section of Nephrology, Department of Medicine, Boston Medical Center, Boston, MA
| | - Chirag R. Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MA
| | - Jeffrey R. Schelling
- Division of Nephrology, Department of Internal Medicine, MetroHealth Campus, and Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Manasi P. Jogalekar
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Joseph V. Bonventre
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Ramachandran S. Vasan
- Departments of Medicine and Epidemiology, Boston University School of Medicine and School of Public Health, Boston, MA
| | - Paul L. Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Joachim H. Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, CA
- Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, CA
| | - Michael G. Shlipak
- Kidney Health Research Collaborative, San Francisco VA Medical Center & University of California, San Francisco, San Francisco, CA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA
| | - CKD Biomarkers Consortium
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA
- Kidney Health Research Collaborative, San Francisco VA Medical Center & University of California, San Francisco, San Francisco, CA
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
- Departments of Medicine and Epidemiology, University of Alabama at Birmingham, Birmingham, AL
- Department of Medicine, Perelman School of Medicine, Center for Clinical Epidemiology and Biostatistics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Section of Nephrology, Department of Pediatrics, Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
- Section of Nephrology, Department of Medicine, Boston Medical Center, Boston, MA
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MA
- Division of Nephrology, Department of Internal Medicine, MetroHealth Campus, and Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, OH
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Departments of Medicine and Epidemiology, Boston University School of Medicine and School of Public Health, Boston, MA
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, CA
- Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, CA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA
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Edrosolan KA, Shlipak MG, Scherzer R, Estrella MM, Gustafson D, Karim R, Fisher M, Cohen M, Kassaye S, Dumond J, Abraham A, McCulloch CE, Ascher SB. Mediation analysis of chronic kidney disease risk factors using kidney biomarkers in women living with HIV. AIDS 2024; 38:813-824. [PMID: 38224361 PMCID: PMC11025668 DOI: 10.1097/qad.0000000000003839] [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] [Indexed: 01/16/2024]
Abstract
OBJECTIVE Novel urinary biomarkers reflecting kidney tubule health are associated with chronic kidney disease (CKD) risk in persons living with HIV. However, it is unknown whether these biomarkers provide mechanistic insight into the associations between clinical risk factors for CKD and subsequent CKD risk. METHODS Among 636 women living with HIV in the Women's Interagency HIV Study with estimated glomerular filtration rate (eGFR) >60 ml/min/1.73 m 2 , we used a counterfactual approach to causal mediation analysis to evaluate the extent to which systolic blood pressure (SBP), diastolic blood pressure (DBP), hemoglobin a1c (Hba1c) and serum albumin associations with incident CKD were mediated by eight urine proteins. These biomarkers reflect proximal tubular reabsorptive dysfunction (α1-microglobulin [a1m], β2-microglobulin, trefoil factor 3); tubular injury (interleukin 18 [IL-18], kidney injury molecule 1 [KIM-1]); kidney repair (epidermal growth factor); tubular reserve (uromodulin); and glomerular injury (urinary albumin). Incident CKD was defined as eGFR <60 ml/min/1.73 m 2 measured at two consecutive 6-month visits with an average annual eGFR decline ≥3% per year. RESULTS During a median follow-up of 7 years, 11% developed CKD. Urinary albumin and KIM-1 mediated 32% (95% CI: 13.4%, 76.6%) and 23% (6.9%, 60.7%) of the association between SBP and incident CKD, respectively; and 19% (5.1%, 42.3%) and 22% (8.1%, 45.7%) of the association between DBP and incident CKD, respectively. Urinary albumin, α1m, and IL-18 were significant mediators of the association between Hba1c and incident CKD. None of the eight biomarkers mediated the association between serum albumin and incident CKD. CONCLUSIONS Among women living with HIV, several urinary biomarkers reflecting distinct dimensions of kidney health may partially explain the associations between SBP, DBP, and Hba1c and subsequent CKD risk.
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Affiliation(s)
- Kristienne A Edrosolan
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Healthcare System and University of California, San Francisco
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Healthcare System and University of California, San Francisco
| | - Rebecca Scherzer
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Healthcare System and University of California, San Francisco
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Healthcare System and University of California, San Francisco
- Department of Medicine, Division of Nephrology, University of California, San Francisco, CA
| | - Deborah Gustafson
- Department of Neurology, SUNY Downstate Health Sciences University, New York, NY
| | - Roksana Karim
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Molly Fisher
- Division of Nephrology, Albert Einstein College of Medicine, Bronx, NY
| | - Mardge Cohen
- Stroger Hospital of Cook County Health and Human Services, Chicago, IL
| | - Seble Kassaye
- Division of Infectious Diseases, Georgetown University, Washington DC
| | - Julie Dumond
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC
| | - Alison Abraham
- Department of Epidemiology, University of Colorado School of Public Health, Denver, CO
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco
| | - Simon B Ascher
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Healthcare System and University of California, San Francisco
- Division of Hospital Medicine, University of California Davis, Sacramento, CA, USA
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Lai M, Madden E, Shlipak MG, Scherzer R, Post WS, Vittinghoff E, Haberlen S, Brown TT, Wolinsky SM, Witt MD, Ho K, Abraham AG, Parikh CR, Budoff M, Estrella MM. Association of urine biomarkers of kidney health with subclinical cardiovascular disease among men with and without HIV. AIDS 2024; 38:465-475. [PMID: 37861689 PMCID: PMC10922264 DOI: 10.1097/qad.0000000000003761] [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] [Indexed: 10/21/2023]
Abstract
OBJECTIVE The aim of this study was to determine whether urine biomarkers of kidney health are associated with subclinical cardiovascular disease among men with and without HIV. DESIGN A cross-sectional study within the Multicenter AIDS Cohort Study (MACS) among 504 men with and without HIV infection who underwent cardiac computed tomography scans and had urine biomarkers measured within the preceding 2 years. METHODS Our primary predictors were four urine biomarkers of endothelial (albuminuria), proximal tubule dysfunction (alpha-1-microglobulin [A1 M] and injury (kidney injury molecule-1 [KIM-1]) and tubulointerstitial fibrosis (pro-collagen-III N-terminal peptide [PIIINP]). These were evaluated for association with coronary artery calcium (CAC) prevalence, CAC extent, total plaque score, and total segment stenosis using multivariable regression. RESULTS Of the 504 participants, 384 were men with HIV (MWH) and 120 were men without HIV. In models adjusted for sociodemographic factors, cardiovascular disease risk factors, eGFR, and HIV-related factors, each two-fold higher concentration of albuminuria was associated with a greater extent of CAC (1.35-fold higher, 95% confidence interval 1.11-1.65), and segment stenosis (1.08-fold greater, 95% confidence interval 1.01-1.16). Associations were similar between MWH and men without HIV in stratified analyses. The third quartile of A1 M showed an association with greater CAC extent, total plaque score, and total segment stenosis, compared with the lowest quartile. CONCLUSION Worse endothelial and proximal tubule dysfunction, as reflected by higher urine albumin and A1 M, were associated with greater CAC extent and coronary artery stenosis.
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Affiliation(s)
- Mason Lai
- Kidney Health Research Collaborative, Department of Medicine, University of California San Francisco
- Department of Medicine, University of California San Francisco
| | - Erin Madden
- Kidney Health Research Collaborative, Department of Medicine, University of California San Francisco
- San Francisco VA Healthcare System, San Francisco, California
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, University of California San Francisco
- Department of Medicine, University of California San Francisco
- San Francisco VA Healthcare System, San Francisco, California
| | - Rebecca Scherzer
- Kidney Health Research Collaborative, Department of Medicine, University of California San Francisco
- San Francisco VA Healthcare System, San Francisco, California
| | - Wendy S Post
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health
| | - Eric Vittinghoff
- Kidney Health Research Collaborative, Department of Medicine, University of California San Francisco
| | - Sabina Haberlen
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health
| | - Todd T Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven M Wolinsky
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mallory D Witt
- Lundquist Institute of Biomedical Research at Harbor-UCLA Medical Center, Torrance, California
| | - Ken Ho
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alison G Abraham
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
| | - Chirag R Parikh
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew Budoff
- Lundquist Institute of Biomedical Research at Harbor-UCLA Medical Center, Torrance, California
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, University of California San Francisco
- San Francisco VA Healthcare System, San Francisco, California
- Department of Medicine, Division of Nephrology, University of California San Francisco, San Francisco, California, USA
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Lai M, Scherzer R, Shlipak MG, Madden E, Vittinghoff E, Tse W, Parikh CR, Villalobos CPC, Monroy-Trujillo JM, Moore RD, Estrella MM. Ambulatory urine biomarkers associations with acute kidney injury and hospitalization in people with HIV. AIDS 2023; 37:2339-2348. [PMID: 37650762 PMCID: PMC10843826 DOI: 10.1097/qad.0000000000003705] [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] [Indexed: 09/01/2023]
Abstract
BACKGROUND People with HIV (PWH) generally have worse ambulatory levels of kidney injury biomarkers and excess risk of acute kidney injury (AKI) compared to persons without HIV. We evaluated whether ambulatory measures of subclinical kidney injury among PWH are associated with subsequent AKI. METHODS In the Predictors of Acute Renal Injury Study (PARIS), which enrolled 468 PWH from April 2016 to August 2019, we measured 10 urine biomarkers of kidney health (albumin, a1m, b2M, NGAL, IL18, KIM-1, EGF, UMOD, MCP-1, YKL40) at baseline and annually during follow-up. Using multivariable Cox regression models, we evaluated baseline and time-updated biomarker associations with the primary outcome of AKI (≥0.3 mg/dl or ≥1.5-times increase in serum creatinine from baseline) and secondary outcome of all-cause hospitalization. RESULTS At baseline, the mean age was 53 years old, and 45% self-identified as female. In time-updated models adjusting for sociodemographic factors, comorbidities, albuminuria, estimated glomerular filtration rate, and HIV-associated factors, higher KIM-1 [hazard ratio (HR) = 1.30 per twofold higher; 95% confidence interval (CI) 1.03-1.63] and NGAL concentrations (HR = 1.24, 95% CI 1.06-1.44) were associated with higher risk of hospitalized AKI. Additionally, in multivariable, time-updated models, higher levels of KIM-1 (HR = 1.19, 95% CI 1.00, 1.41), NGAL (HR = 1.13, 95% CI 1.01-1.26), and MCP-1 (HR = 1.20, 95% CI 1.00, 1.45) were associated with higher risk of hospitalization. CONCLUSIONS Urine biomarkers of kidney tubular injury, such as KIM-1 and NGAL, are strongly associated with AKI among PWH, and may hold potential for risk stratification of future AKI.
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Affiliation(s)
- Mason Lai
- Kidney Health Research Collaborative, Department of Medicine
- Department of Medicine, University of California San Francisco
| | | | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine
- Department of Medicine, University of California San Francisco
- San Francisco VA Healthcare System
- Department of Epidemiology and Biostatistics
| | - Erin Madden
- Kidney Health Research Collaborative, Department of Medicine
- San Francisco VA Healthcare System
| | - Eric Vittinghoff
- Kidney Health Research Collaborative, Department of Medicine
- Department of Epidemiology and Biostatistics
| | - Warren Tse
- Kidney Health Research Collaborative, Department of Medicine
- San Francisco VA Healthcare System
| | - Chirag R Parikh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine
- Department of Medicine, University of California San Francisco
- San Francisco VA Healthcare System
- Department of Medicine, Division of Nephrology, University of California San Francisco, San Francisco, California
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Amatruda JG, Estrella MM, Garg AX, Thiessen-Philbrook H, McArthur E, Coca SG, Parikh CR, Shlipak MG. Urine Alpha-1-Microglobulin Levels and Acute Kidney Injury, Mortality, and Cardiovascular Events following Cardiac Surgery. Am J Nephrol 2021; 52:673-683. [PMID: 34515046 DOI: 10.1159/000518240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/20/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Urine alpha-1-microglobulin (Uα1m) elevations signal proximal tubule dysfunction. In ambulatory settings, higher Uα1m is associated with acute kidney injury (AKI), progressive chronic kidney disease (CKD), cardiovascular (CV) events, and mortality. We investigated the associations of pre- and postoperative Uα1m concentrations with adverse outcomes after cardiac surgery. METHODS In 1,464 adults undergoing cardiac surgery in the prospective multicenter Translational Research Investigating Biomarker Endpoints for Acute Kidney Injury (TRIBE-AKI) cohort, we measured the pre-and postoperative Uα1m concentrations and calculated the changes from pre- to postoperative concentrations. Outcomes were postoperative AKI during index hospitalization and longitudinal risks for CKD incidence and progression, CV events, and all-cause mortality after discharge. We analyzed Uα1m continuously and categorically by tertiles using multivariable logistic regression and Cox proportional hazards regression adjusted for demographics, surgery characteristics, comorbidities, baseline estimated glomerular filtration rate, urine albumin, and urine creatinine. RESULTS There were 230 AKI events during cardiac surgery hospitalization; during median 6.7 years of follow-up, there were 212 cases of incident CKD, 54 cases of CKD progression, 269 CV events, and 459 deaths. Each 2-fold higher concentration of preoperative Uα1m was independently associated with AKI (adjusted odds ratio [aOR] = 1.36, 95% confidence interval 1.14-1.62), CKD progression (adjusted hazard ratio [aHR] = 1.46, 1.04-2.05), and all-cause mortality (aHR = 1.19, 1.06-1.33) but not with incident CKD (aHR = 1.21, 0.96-1.51) or CV events (aHR = 1.01, 0.86-1.19). Postoperative Uα1m was not associated with AKI (aOR per 2-fold higher = 1.07, 0.93-1.22), CKD incidence (aHR = 0.90, 0.79-1.03) or progression (aHR = 0.79, 0.56-1.11), CV events (aHR = 1.06, 0.94-1.19), and mortality (aHR = 1.01, 0.92-1.11). CONCLUSION Preoperative Uα1m concentrations may identify patients at high risk of AKI and other adverse events after cardiac surgery, but postoperative Uα1m concentrations do not appear to be informative.
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Affiliation(s)
- Jonathan G Amatruda
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA,
- Kidney Health Research Collaborative, San Francisco VA Health Care System & University of California, San Francisco, San Francisco, California, USA,
| | - Michelle M Estrella
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Kidney Health Research Collaborative, San Francisco VA Health Care System & University of California, San Francisco, San Francisco, California, USA
- Division of Nephrology, Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
| | - Amit X Garg
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | | | | | - Steven G Coca
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chirag R Parikh
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco VA Health Care System & University of California, San Francisco, San Francisco, California, USA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
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Muiru AN, Scherzer R, Ascher SB, Jotwani V, Grunfeld C, Shigenaga J, Spaulding KA, Ng DK, Gustafson D, Spence AB, Sharma A, Cohen MH, Parikh CR, Ix JH, Estrella MM, Shlipak MG. Associations of CKD risk factors and longitudinal changes in urine biomarkers of kidney tubules among women living with HIV. BMC Nephrol 2021; 22:296. [PMID: 34461840 PMCID: PMC8406753 DOI: 10.1186/s12882-021-02508-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Novel urine biomarkers have enabled the characterization of kidney tubular dysfunction and injury among persons living with HIV, a population at an increased risk of kidney disease. Even though several urine biomarkers predict progressive kidney function decline, antiretroviral toxicity, and mortality in the setting of HIV infection, the relationships among the risk factors for chronic kidney disease (CKD) and urine biomarkers are unclear. METHODS We assessed traditional and infection-related CKD risk factors and measured 14 urine biomarkers at baseline and at follow-up among women living with HIV in the Women's Interagency Health Study (WIHS). We then used simultaneously adjusted multivariable linear regression models to evaluate the associations of CKD risk factors with longitudinal changes in biomarker levels. RESULTS Of the 647 women living with HIV in this analysis, the majority (67%) were Black, the median age was 45 years and median follow-up time was 2.5 years. Each traditional and infection-related CKD risk factor was associated with a unique set of changes in urine biomarkers. For example, baseline hemoglobin a1c was associated with worse tubular injury (higher interleukin [IL]-18), proximal tubular reabsorptive dysfunction (higher α1-microglobulin), tubular reserve (lower uromodulin) and immune response to injury (higher chitinase-3-like protein-1 [YKL-40]). Furthermore, increasing hemoglobin a1c at follow-up was associated with further worsening of tubular injury (higher kidney injury molecule-1 [KIM-1] and IL-18), as well as higher YKL-40. HCV co-infection was associated with worsening proximal tubular reabsorptive dysfunction (higher β2-microglobulin [β2m]), and higher YKL-40, whereas HIV viremia was associated with worsening markers of tubular and glomerular injury (higher KIM-1 and albuminuria, respectively). CONCLUSIONS CKD risk factors are associated with unique patterns of biomarker changes among women living with HIV, suggesting that serial measurements of multiple biomarkers may help in detecting and monitoring kidney disease in this setting.
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Affiliation(s)
- Anthony N Muiru
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, CA, USA.
- Department of Medicine, Division of Nephrology, University of California, 533 Parnassus Avenue, U404, Box 0532, San Francisco, CA, 94143, USA.
| | - Rebecca Scherzer
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, CA, USA
| | - Simon B Ascher
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, CA, USA
- Division of Hospital Medicine, University of California Davis, Sacramento, CA, USA
| | - Vasantha Jotwani
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, CA, USA
- Department of Medicine, Division of Nephrology, University of California, 533 Parnassus Avenue, U404, Box 0532, San Francisco, CA, 94143, USA
| | - Carl Grunfeld
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, CA, USA
| | - Judy Shigenaga
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, CA, USA
| | - Kimberly A Spaulding
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, CA, USA
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Deborah Gustafson
- Department of Neurology, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Amanda B Spence
- Division of Infectious Diseases, Department of Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Anjali Sharma
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Mardge H Cohen
- Department of Medicine, Stroger Hospital and Rush University, Chicago, IL, USA
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California, San Diego, CA, USA
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, CA, USA
- Department of Medicine, Division of Nephrology, University of California, 533 Parnassus Avenue, U404, Box 0532, San Francisco, CA, 94143, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, CA, USA
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7
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Ascher SB, Scherzer R, Estrella MM, Jotwani VK, Shigenaga J, Spaulding KA, Ng DK, Gustafson D, Spence AB, Sharma A, Cohen MH, Parikh CR, Ix JH, Shlipak MG. Urine Biomarkers of Kidney Tubule Health and Incident CKD Stage 3 in Women Living With HIV: A Repeated Measures Study. Kidney Med 2021; 3:395-404.e1. [PMID: 34136786 PMCID: PMC8178470 DOI: 10.1016/j.xkme.2021.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale & Objective Single measurements of urinary biomarkers reflecting kidney tubule health are associated with chronic kidney disease (CKD) risk in HIV infection, but the prognostic value of repeat measurements over time is unknown. Study Design Cohort study. Setting & Participants 647 women living with HIV infection enrolled in the Women’s Interagency Health Study. Exposures 14 urinary biomarkers of kidney tubule health measured at 2 visits over a 3-year period. Outcome Incident CKD, defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 at two 6-month visits and an average eGFR decline ≥ 3% per year. Analytical Approach We used multivariable generalized estimating equations adjusting for CKD risk factors to evaluate baseline, time-updated, and change-over-time biomarker associations with incident CKD. We compared CKD discrimination between models with and without a parsimoniously selected set of biomarkers. Results During a median 7 years of follow-up, 9.7% (63/647) developed CKD. In multivariable-adjusted analyses, 3 of 14 baseline biomarkers associated with incident CKD. In contrast, 10 of 14 time-updated biomarkers and 9 of 14 biomarkers modeled as change over time associated with incident CKD. Urinary epidermal growth factor (EGF), α1-microglobulin (A1M), and albumin were selected using penalized regression methods. In the time-updated model, lower urinary EGF (risk ratio [RR] per 2-fold higher time-updated biomarker levels, 0.69; 95% CI, 0.58-0.81), higher urinary A1M (RR, 1.47; 95% CI, 1.25-1.73), and higher urinary albumin excretion (RR, 1.21; 95% CI, 1.03-1.42) were jointly associated with increased risk for CKD. Compared with a base model (C statistic, 0.75), CKD discrimination improved after adding urinary EGF, A1M, and albumin values across baseline (C = 0.81), time-updated (C = 0.83), and change-over-time (C = 0.83) models (P < 0.01 for all). Limitations Observational design, incident CKD definition limited to eGFR. Conclusions Repeat urinary biomarker measurements for kidney tubule health have stronger associations with incident CKD compared with baseline measurements and moderately improve CKD discrimination in women living with HIV infection.
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Affiliation(s)
- Simon B Ascher
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, San Francisco, CA.,Department of Medicine, University of California, Davis, Sacramento, CA
| | - Rebecca Scherzer
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, San Francisco, CA
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, San Francisco, CA
| | - Vasantha K Jotwani
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, San Francisco, CA
| | - Judy Shigenaga
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, San Francisco, CA
| | - Kimberly A Spaulding
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, San Francisco, CA
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Deborah Gustafson
- Department of Neurology, The State University of New York Downstate Health Sciences University, Brooklyn, NY
| | - Amanda B Spence
- Division of Infectious Diseases, Department of Medicine, Georgetown University Medical Center, Washington, DC
| | - Anjali Sharma
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Mardge H Cohen
- Department of Medicine, Stroger Hospital and Rush University, Chicago, IL
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California, San Diego, San Diego, CA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, San Francisco, CA
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8
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Danjuma MI, Al Shokri S, Bakhsh N, Alamin MA, Mohamedali MG, Tamuno I. The utility of kidney injury molecule-1 as an early biomarker of kidney injury in people living with HIV. Int J STD AIDS 2020; 31:1228-1237. [PMID: 32951563 PMCID: PMC7754827 DOI: 10.1177/0956462420918515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
There are increasing reports of antiretroviral therapy (ART) drug-related kidney dysfunction. Traditional markers of kidney dysfunction such as urine protein/creatinine ratio and estimated glomerular filtration rate (eGFR) have thus far proven ineffective at detecting some sub-clinical forms of ART-related kidney injury. This is a cross-sectional examination of 114 people living with HIV (PLWH), either naïve (N =104) or treatment experienced (N =10). Urinary kidney injury molecule-1 (KIM-1 ng/mg) thresholds were estimated using electrochemiluminescent assays from stored urine samples and normalised for urinary creatinine excretion (KIM-1/Cr). Correlation coefficients and predictors of kidney tubular injury were compared and derived for both adjusted and unadjusted urinary KIM-1/CR (ng/mg). In PLWH (both ART-naïve and treatment experienced) had a higher baseline unadjusted and adjusted median (≥3.7 ng/mg) and upper tertile (≥6.25 ng/mg) urinary KIM-1/Cr levels compared to either non-normal volunteers (0.39 ng/mg) or those with acute kidney injury in the general population (0.57 ng/mg). When upper tertile KIM-1/Cr (≥6.25 ng/mg) was utilised as a marker of kidney injury, eGFR (ml/min/1.73 m2), white Caucasian ethnicity, and protease inhibitor exposure were significantly associated with increased risk of kidney injury in multivariate analyses (odds ratio 0.91, confidence interval [CI] 0.68–0.98, P = 0.02; odds ratio 8.9, CI 1.6–48.6, p = 0.01; and odds ratio 0.05, CI 0.03–0.9, p =0.04, respectively). We found a significant degree of sub-clinical kidney injury (high unadjusted and adjusted KIM-1/Cr) in PLWH with normal kidney function (eGFR ≥60 ml/min/1.73 m2). We also found a higher baseline KIM-1/Cr (ng/mg) in our study cohort than reported both in normal volunteers and patients with kidney injury in the general population.
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Affiliation(s)
| | - Shaikha Al Shokri
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
| | - Nadia Bakhsh
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed A Alamin
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
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9
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Chazot R, Botelho-Nevers E, Mariat C, Frésard A, Cavalier E, Lucht F, Delanaye P, Maillard N, Gagneux-Brunon A. Cystatin C and Urine Albumin to Creatinine Ratio Predict 5-Year Mortality and Cardiovascular Events in People Living With HIV. J Infect Dis 2020; 223:885-892. [PMID: 32691827 DOI: 10.1093/infdis/jiaa433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/15/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Identifying people with HIV (PWH) at risk for chronic kidney disease, cardiovascular events, and death is crucial. We evaluated biomarkers to predict all-cause mortality and cardiovascular events, and measured glomerular filtration rate (mGFR) slope. METHODS Biomarkers were measured at enrollment. Baseline and 5-year mGFR were measured by plasma iohexol clearance. Outcomes were a composite criterion of all-cause mortality and/or cardiovascular events, and mGFR slope. RESULTS Of 168 subjects, 146 (87.4%) had undetectable HIV load. Median follow-up was 59.1 months (interquartile range, 56.2-62.1). At baseline, mean age was 49.5 years (± 9.8) and mean mGFR 98.9 mL/min/1.73m2 (± 20.6). Seventeen deaths and 10 cardiovascular events occurred during 5-year follow-up. Baseline mGFR was not associated with mortality/cardiovascular events. In multivariable analysis, cystatin C (hazard ratio [HR], 5.978; 95% confidence interval [CI], 2.774-12.88; P < .0001) and urine albumin to creatinine ratio (uACR) at inclusion (HR, 1.002; 95% CI, 1.001-1.004; P < .001) were associated with mortality/cardiovascular events. Area under receiver operating curve of cystatin C was 0.67 (95% CI, .55-.79) for mortality/cardiovascular event prediction. Biomarkers were not associated with GFR slope. CONCLUSIONS uACR and cystatin C predict all-cause mortality and/or cardiovascular events in PWH independently of mGFR.
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Affiliation(s)
- Robin Chazot
- Department of Nephrology, Dialysis and Transplantation, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Elisabeth Botelho-Nevers
- Department of Infectious and Tropical Diseases, University Hospital of Saint-Etienne, Saint-Etienne, France.,Groupe Immunité des Muqueuses et Agents Pathogènes, University of Jean Monnet and Université de Lyon, Saint-Etienne, France
| | - Christophe Mariat
- Department of Nephrology, Dialysis and Transplantation, University Hospital of Saint-Etienne, Saint-Etienne, France.,Groupe Immunité des Muqueuses et Agents Pathogènes, University of Jean Monnet and Université de Lyon, Saint-Etienne, France
| | - Anne Frésard
- Department of Infectious and Tropical Diseases, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Etienne Cavalier
- Department of Clinical Biology, University Hospital Sart Tilman, Liège, Belgium
| | - Frédéric Lucht
- Department of Infectious and Tropical Diseases, University Hospital of Saint-Etienne, Saint-Etienne, France.,Groupe Immunité des Muqueuses et Agents Pathogènes, University of Jean Monnet and Université de Lyon, Saint-Etienne, France
| | | | - Nicolas Maillard
- Department of Nephrology, Dialysis and Transplantation, University Hospital of Saint-Etienne, Saint-Etienne, France.,Groupe Immunité des Muqueuses et Agents Pathogènes, University of Jean Monnet and Université de Lyon, Saint-Etienne, France
| | - Amandine Gagneux-Brunon
- Department of Infectious and Tropical Diseases, University Hospital of Saint-Etienne, Saint-Etienne, France.,Groupe Immunité des Muqueuses et Agents Pathogènes, University of Jean Monnet and Université de Lyon, Saint-Etienne, France
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10
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Johnston CD, Ifeagwu KCC, Siegler EL, Derry H, Burchett CO, Rice MC, Gupta SK, Choi ME, Glesby MJ. Elevated cardiac risk score by Atherosclerotic Cardiovascular Disease calculation is associated with albuminuria in older people living with HIV. AIDS 2020; 34:947-949. [PMID: 32271253 PMCID: PMC7321911 DOI: 10.1097/qad.0000000000002492] [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] [Indexed: 11/26/2022]
Abstract
: Globally, the proportion of older people living with HIV (PLWH) is growing and the burden of noncommunicable diseases, including cardiac and renal disease, is increasing. There are few studies of renal disease and cardiac risk in older PLWH. This study investigates the relationship between albuminuria and cardiac risk as estimated by the Atherosclerotic Cardiovascular Disease 10-year risk calculator. We report that albuminuria is associated with a higher Atherosclerotic Cardiovascular Disease risk score in both diabetic and nondiabetic older PLWH.
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Affiliation(s)
- Carrie D Johnston
- Infectious Diseases Division, Department of Medicine, Weill Cornell Medical College, New York
| | | | | | | | | | - Michelle C Rice
- Nephrology Division, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Samir K Gupta
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mary E Choi
- Nephrology Division, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Marshall J Glesby
- Infectious Diseases Division, Department of Medicine, Weill Cornell Medical College, New York
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11
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Ascher SB, Scherzer R, Estrella MM, Shigenaga J, Spaulding KA, Glidden DV, Mehrotra ML, Defechereux P, Gandhi M, Grant RM, Shlipak MG, Jotwani V. HIV preexposure prophylaxis with tenofovir disoproxil fumarate/emtricitabine and changes in kidney function and tubular health. AIDS 2020; 34:699-706. [PMID: 31794523 PMCID: PMC7071971 DOI: 10.1097/qad.0000000000002456] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To evaluate the effects of HIV preexposure prophylaxis (PrEP) with tenofovir disoproxial fumurate (TDF)/emtricitabine (FTC) on kidney function and kidney tubular health. DESIGN The Iniciativa Profilaxis Pre-Exposicion open-label extension (iPrEx-OLE) study enrolled former PrEP trial participants to receive open-label TDF/FTC. This study included 123 iPrEx-OLE participants who demonstrated PrEP adherence. METHODS We compared estimated glomerular filtration rate calculated using serum creatinine (eGFRcr), serum cystatin C (eGFRcys), and in combination (eGFRcr-cys), and a panel of 14 urine biomarkers reflecting kidney tubular health before and 6 months after PrEP initiation. RESULTS At baseline, mean eGFRcr, eGFRcys, and eGFRcr-cys were 108.3, 107.0, and 111.1 ml/min per 1.73 m, respectively. Six months after PrEP initiation, eGFRcr declined by -4% (95% CI: -5.7 to -2.4%), eGFRcys declined by -3.3% (95% CI: -8.3 to 1.9%), and eGFRcr-cys declined by -4.1% (95% CI: -7.5 to -0.7%). From the urine biomarker panel, α1-microglobulin and β2-microglobulin increased by 22.7% (95% CI: 11.8--34.7%) and 14.1% (95% CI: -6.1 to 38.6%), whereas chitinase-3-like 1 protein and monocyte chemoattractant protein-1 decreased by -37.7% (95% CI: -53.0 to -17.3%) and -15.6% (95% CI: -31.6 to 4.2%), respectively. Ten of the 14 urine biomarkers, including albumin, had estimated changes of less than 12% with wide confidence intervals. CONCLUSION Six months of PrEP with TDF/FTC was associated with decreases in eGFRcr and eGFRcys. We also observed for the first time changes in flour of 14 urine biomarkers reflecting kidney tubular health. These findings demonstrate that PrEP has direct effects on eGFR and the proximal tubule.
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Affiliation(s)
- Simon B Ascher
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
- Department of Medicine, University of California, Davis, Sacramento
| | - Rebecca Scherzer
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
| | - Judy Shigenaga
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
| | - Kimberly A Spaulding
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
| | | | | | | | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine
| | - Robert M Grant
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
| | - Vasantha Jotwani
- Kidney Health Research Collaborative, Department of Medicine, San Francisco Veterans Affairs Health Care System and University of California, San Francisco
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12
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Chen TK, Parikh CR. Management of Presumed Acute Kidney Injury during Hypertensive Therapy: Stay Calm and Carry on? Am J Nephrol 2020; 51:108-115. [PMID: 31940606 DOI: 10.1159/000505447] [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: 12/12/2019] [Accepted: 12/13/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Recent studies have demonstrated that intensive blood pressure control is associated with improved cardiovascular outcomes. Acute kidney injury (AKI), however, was more common in the intensive treatment group prompting concern in the nephrology community. SUMMARY Clinical trials on hypertension control have traditionally defined AKI by changes in serum creatinine. However, serum creatinine has several inherent limitations as a marker of kidney injury, with various factors influencing its production, secretion, and elimination. Urinary biomarkers of kidney injury and repair have the potential to provide insight on the presence and phenotype of kidney injury. In both the Systolic Blood Pressure Intervention Trial and the Action to Control Cardiovascular Risk in Diabetes study, urinary biomarkers have suggested that the increased risk of AKI associated with intensive treatment was due to hemodynamic changes rather than structural kidney injury. As such, clinicians who encounter rises in serum creatinine during intensification of hypertension therapy should "stay calm and carry on." Alternative explanations for serum creatinine elevation should be considered and addressed if appropriate. When the rise in serum creatinine is limited, particularly if albuminuria is stable or improving, intensive blood pressure control should be continued for its potential long-term benefits. Key Messages: Increases in serum creatinine during intensification of blood pressure control may not necessarily reflect kidney injury. Clinicians should evaluate for other contributing factors before stopping therapy. Urinary biomarkers may address limitations of serum creatinine as a marker of kidney injury.
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Affiliation(s)
- Teresa K Chen
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA,
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