Dyslipidemia in Chronic Kidney Disease: Contemporary Concepts and Future Therapeutic Perspectives

The relationship between dietary niacin intake and the incidence of all-cause and cardiovascular mortality among chronic kidney disease patients

BACKGROUND

Chronic kidney disease (CKD) is a major cause of human mortality and cardiovascular disease (CVD)-related death. Niacin can treat dyslipidemia and can lower overall cardiovascular event incidence and mortality rates. The present study was designed to clarify the link between dietary consumption of niacin and cardiovascular mortality.

METHODS

This study enrolled subjects ≥18 years of age from the National Health and Nutrition Examination Survey 2009-2014 and excluded any individuals for whom data regarding their CKD status, dietary niacin intake, or other covariate information was unavailable. Relationships between dietary niacin intake levels and overall or CVD-related mortality among these CKD patients were assessed using univariate and multivariate Cox regression analyses.

RESULTS

The study included 1,798 subjects and recorded 514 and 186 instances of all-cause and cardiovascular death, respectively. Males comprised 51.8% of the study cohort, and the mean age of these subjects was 65. Cox proportional hazard model analyses revealed no relationship between dietary niacin intake and all-cause or cardiovascular death risk among the overall CKD patient population (P > 0.05). However, in age-stratified analyses, those subjects <60 years of age exhibiting the highest levels of dietary niacin consumption (≥ 38 mg/day) were found to face a significantly higher risk of all-cause mortality, and this association remained intact in sensitivity analyses.

CONCLUSION

These results do not support any link between the dietary intake of niacin and all-cause or cardiovascular mortality risk among patients with CKD. Age and niacin intake exhibited a significant interaction related to all-cause mortality.

Exploring therapeutic mechanisms of Chuan Huang Fang-II in the treatment of acute kidney injury on chronic kidney disease patients from the perspective of lipidomics

OBJECTIVE

This study aims to assess the clinical efficacy and safety of CHF-II in combination with RG for treating AKI on CKD (A on C), and to explore potential therapeutic mechanisms through lipidomics analysis.

METHODS

98 patients were enrolled and randomly assigned to the RG or RG + CHF groups. Both groups received RG therapy, with RG + CHF group additionally receiving CHF-II treatment over a duration of two weeks. Evaluation endpoints included changes in renal function, blood lipid profiles, urinary AKI biomarkers, and TCM symptoms before and after treatment. Serum samples were collected for lipid metabolite analysis.

RESULTS

The total clinical effective rate in RG + CHF group was 73.5%, and that of RG group was 40.8%. TCM syndrome scores in RG + CHF group showed a more pronounced decrease (p < 0.05). Scr, BUN, and UA levels decreased while eGFR levels increased in both groups (p < 0.05), with a greater magnitude of change observed in the RG + CHF group. Urinary AKI biomarkers decreased more in RG + CHF group (p < 0.05). No serious adverse events occurred during the trial. 58 different lipid metabolites and 48 lipid biomarkers were identified. According to the KEGG database, the possible metabolic pathways involved triglyceride metabolic pathway and fat digestion and absorption metabolic pathways.

CONCLUSION

CHF-II effectively alleviated kidney injury and improved TCM syndrome scores in patients with A on C. Lipid differential metabolites could serve as diagnostic indicators for AKI in patients with CKD. The possible metabolic pathways might be implicated in therapeutic action of CHF-II in the prevention and treatment of patients with A on C.

Atherogenic index of plasma: a new indicator for assessing the short-term mortality of patients with acute decompensated heart failure

Objective

Arteriosclerosis is a primary causative factor in cardiovascular diseases. This study aims to explore the correlation between the atherogenic index of plasma (AIP) and the 30-day mortality rate in patients with acute decompensated heart failure (ADHF).

Methods

A total of 1,248 ADHF patients recruited from the Jiangxi-Acute Decompensated Heart Failure1 (JX-ADHF1) cohort between 2019 and 2022 were selected for this study. The primary outcome was the 30-day mortality rate. Multivariable Cox regression, restricted cubic splines (RCS), and stratified analyses were utilized to assess the relationship between AIP and the 30-day mortality rate in ADHF patients. Mediation models were employed for exploratory analysis of the roles of inflammation, oxidative stress, and nutrition in the association between AIP and the 30-day mortality rate in ADHF patients.

Results

During the 30-day follow-up, 42 (3.37%) of the ADHF patients died. The mortality rates corresponding to the quartiles of AIP were as follows: Q1: 1.28%, Q2: 2.88%, Q3: 2.88%, Q4: 6.41%. The multivariable Cox regression revealed a positive correlation between high AIP and the 30-day mortality rate in ADHF patients [Hazard ratio (HR) 3.94, 95% confidence interval (CI): 1.08-14.28], independent of age, gender, heart failure type, cardiac function classification, and comorbidities. It is important to note that there was a U-shaped curve association between AIP (<0.24) and the 30-day mortality rate before the fourth quartile, with the lowest 30-day mortality risk in ADHF patients around an AIP of -0.1. Furthermore, mediation analysis suggested significant mediating effects of inflammation and nutrition on the 30-day mortality rate in ADHF patients related to AIP, with inflammation accounting for approximately 24.29% and nutrition for about 8.16% of the mediation effect.

Conclusion

This retrospective cohort analysis reveals for the first time the association between AIP and the 30-day mortality rate in ADHF patients. According to our findings, maintaining an AIP around -0.1 in ADHF patients could be crucial for improving poor prognoses from a medical perspective. Additionally, for ADHF patients with high AIP, it is important to assess and, if necessary, enhance nutritional support and anti-inflammatory treatment.

A clustering approach to improve our understanding of the genetic and phenotypic complexity of chronic kidney disease

Chronic kidney disease (CKD) is a complex disorder that causes a gradual loss of kidney function, affecting approximately 9.1% of the world's population. Here, we use a soft-clustering algorithm to deconstruct its genetic heterogeneity. First, we selected 322 CKD-associated independent genetic variants from published genome-wide association studies (GWAS) and added association results for 229 traits from the GWAS catalog. We then applied nonnegative matrix factorization (NMF) to discover overlapping clusters of related traits and variants. We computed cluster-specific polygenic scores and validated each cluster with a phenome-wide association study (PheWAS) on the BioMe biobank (n = 31,701). NMF identified nine clusters that reflect different aspects of CKD, with the top-weighted traits signifying areas such as kidney function, type 2 diabetes (T2D), and body weight. For most clusters, the top-weighted traits were confirmed in the PheWAS analysis. Results were found to be more significant in the cross-ancestry analysis, although significant ancestry-specific associations were also identified. While all alleles were associated with a decreased kidney function, associations with CKD-related diseases (e.g., T2D) were found only for a smaller subset of variants and differed across genetic ancestry groups. Our findings leverage genetics to gain insights into the underlying biology of CKD and investigate population-specific associations.

Comprehensive proteomics of monocytes indicates oxidative imbalance functionally related to inflammatory response in chronic kidney disease-related atherosclerosis

Atherosclerosis-induced cardiovascular events are the leading cause of mortality in chronic kidney disease (CKD) patients. Monocytes are involved in the formation of atherosclerotic plaques and mediate in the overproduction of ROS, promoting inflammation and oxidative stress. However, the relationship between monocytes, inflammation, and oxidative status in CKD-associated atherosclerosis has not been thoroughly investigated. Monocytes and plasma derived from two groups of CKD patients with varying degrees of atherosclerosis and two groups of patients with cardiovascular disease (CVD) and non-CKD atherosclerosis were analyzed. This study was designed to perform a comprehensive proteomic analysis of monocytes in combination with functional bioinformatics. In addition, a targeted investigation of oxidative stress- and inflammatory-related factors to explore CKD-associated atherosclerosis was applied. Dysregulation of proteins involved in lipid oxidation, cell survival, ROS synthesis and metabolism, and inflammatory responses has been revealed. The characteristic disturbances in the monocyte proteome changed with the progression of CKD. A closer examination of oxidative stress's triggers, mediators, and effects on protein and lipid levels showed alterations in the oxidative imbalance between CKD and CVD. CKD monocytes demonstrated a significant increase of oxidized glutathione without changing the level of its reduced form. Evaluation of enzymatic antioxidants, sources of ROS, and modifications caused by ROS also revealed significant alterations between the study groups. In CKD, inflammation and oxidative imbalance correlated and drove each other. However, in CVD, oxidative stress-related factors were associated with each other but not to inflammatory proteins. Moreover, lipid abnormalities were more specific to classical CVD and unrelated to CKD. Such a comprehensive characterization of monocytes and oxidative stress in CKD and CVD patients has never been presented so far. Obtained results support the involvement of distinct mechanisms underlying the acceleration of atherosclerotic and non-atherosclerotic CKD.

Lipid and Bone Effects of Heparin Use During Hemodialysis

Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly prescribed anticoagulants for chronic hemodialysis (HD). The dialysis population comprises a unique group that receives heparin three times per week for a long period, with potential long-term cumulative metabolic effects such as osteoporosis and worsening lipid profile. HD patients have approximately half the number of lipases as healthy individuals, and their lipid metabolism is limited because of this decrease as well as partially inhibited function. Administration of UFH or LMWHs for anticoagulation can lead to metabolic starvation despite high triglyceride levels at the end of HD. In vitro studies indicate that UFH and LMWHs inhibit osteoblasts and promote osteoclasts. In patients on HD, long-term use of UFH or LMWHs did not worsen chronic kidney disease-mineral bone disease. Further investigation is needed to elucidate the underlining mechanisms of UFH and LMWHs and their possible influences on maintenance HD patients.

A clustering approach to improve our understanding of the genetic and phenotypic complexity of chronic kidney disease

Chronic kidney disease (CKD) is a complex disorder that causes a gradual loss of kidney function, affecting approximately 9.1% of the world's population. Here, we use a soft-clustering algorithm to deconstruct its genetic heterogeneity. First, we selected 322 CKD-associated independent genetic variants from published genome-wide association studies (GWAS) and added association results for 229 traits from the GWAS catalog. We then applied nonnegative matrix factorization (NMF) to discover overlapping clusters of related traits and variants. We computed cluster-specific polygenic scores and validated each cluster with a phenome-wide association study (PheWAS) on the BioMe biobank (n=31,701). NMF identified nine clusters that reflect different aspects of CKD, with the top-weighted traits signifying areas such as kidney function, type 2 diabetes (T2D), and body weight. For most clusters, the top-weighted traits were confirmed in the PheWAS analysis. Results were found to be more significant in the cross-ancestry analysis, although significant ancestry-specific associations were also identified. While all alleles were associated with a decreased kidney function, associations with CKD-related diseases (e.g., T2D) were found only for a smaller subset of variants and differed across genetic ancestry groups. Our findings leverage genetics to gain insights into the underlying biology of CKD and investigate population-specific associations.

A clustering approach to improve our understanding of the genetic and phenotypic complexity of chronic kidney disease

Chronic kidney disease (CKD) is a complex disorder that causes a gradual loss of kidney function, affecting approximately 9.1% of the world's population. Here, we use a soft-clustering algorithm to deconstruct its genetic heterogeneity. First, we selected 322 CKD-associated independent genetic variants from published genome-wide association studies (GWAS) and added association results for 229 traits from the GWAS catalog. We then applied nonnegative matrix factorization (NMF) to discover overlapping clusters of related traits and variants. We computed cluster-specific polygenic scores and validated each cluster with a phenome-wide association study (PheWAS) on the BioMe biobank (n=31,701). NMF identified nine clusters that reflect different aspects of CKD, with the top-weighted traits signifying areas such as kidney function, type 2 diabetes (T2D), and body weight. For most clusters, the top-weighted traits were confirmed in the PheWAS analysis. Results were found to be more significant in the cross-ancestry analysis, although significant ancestry-specific associations were also identified. While all alleles were associated with a decreased kidney function, associations with CKD-related diseases (e.g., T2D) were found only for a smaller subset of variants and differed across genetic ancestry groups. Our findings leverage genetics to gain insights into the underlying biology of CKD and investigate population-specific associations.

Biotics (Pre-, Pro-, Post-) and Uremic Toxicity: Implications, Mechanisms, and Possible Therapies

In recent years, more scientific data have pointed out the close connection between intestinal microbial community, nutritional habits, lifestyle, and the appearance of various affections located at certain anatomical systems. Gut dysbiosis enhances the formation and accumulation of specific metabolites with toxic potential that induce the appearance of kidney-associated illnesses. Intestinal microbes are involved in the degradation of food, drugs, or other ingested products that lead to the formation of various metabolites that end up in renal tissue. Over the last few years, the possibilities of modulating the gut microbiota for the biosynthesis of targeted compounds with bioactive properties for reducing the risk of chronic illness development were investigated. In this regard, the present narrative review provides an overview of the scientific literature across the last decade considering the relationship between bioactive compounds, pre-, pro-, and post-biotics, uremic toxicity, and kidney-associated affections, and the possibility of alleviating the accumulation and the negative effects of uremic toxins into the renal system.

Novel therapeutic approaches in the management of chronic kidney disease: a narrative review

Chronic kidney disease (CKD) remains a pathologic entity with constantly rising incidence and high rates of morbidity and mortality, which are associated with serious cardiovascular complications. Moreover, the incidence of end-stage renal disease tends to increase. The epidemiological trends of CKD warrant the development of novel therapeutic approaches aiming to prevent its development or retard its progression through the control of major risk factors: type 2 diabetes mellitus, arterial hypertension, and dyslipidemia. Contemporary therapeutics such as sodium-glucose cotransporter-2 inhibitors and second-generation mineralocorticoid receptor antagonists are utilized in this direction. Additionally, experimental and clinical studies present novel drug categories that could be employed in managing CKD, such as aldosterone synthesis inhibitors or activators guanylate cyclase, while the role of melatonin should be further tested in the clinical setting. Finally, in this patient population, the use of hypolipidemic agents may provide incremental benefits.

A comprehensive risk factor analysis using association rules in people with diabetic kidney disease

Association rule is a transparent machine learning method expected to share information about risks for chronic kidney disease (CKD) among diabetic patients, but its findings in clinical data are limited. We used the association rule to evaluate the risk for kidney disease in General and Worker diabetic cohorts. The absence of risk factors was examined for association with stable kidney function and worsening kidney function. A confidence value was used as an index of association, and a lift of > 1 was considered significant. Analyses were applied for individuals stratified by KDIGO's (Kidney Disease: Improving Global Outcomes) CKD risk categories. A General cohort of 4935 with a mean age of 66.7 years and a Worker cohort of 2153 with a mean age of 47.8 years were included in the analysis. Good glycemic control was significantly related to stable kidney function in low-risk categories among the General cohort, and in very-high risk categories among the Worker cohort; confidences were 0.82 and 0.77, respectively. Similar results were found with poor glycemic control and worsening kidney function; confidences of HbA1c were 0.41 and 0.27, respectively. Similarly, anemia, obesity, and hypertension showed significant relationships in the low-risk General and very-high risk Worker cohorts. Stratified risk assessment using association rules revealed the importance of the presence or absence of risk factors.

Relationship between lipoprotein(a) levels, cardiovascular outcomes and death in patients with chronic kidney disease: a systematic review of prospective studies

INTRODUCTION AND AIM

In the general population, high levels of lipoprotein(a) (Lp(a)) are an independent risk factor for atherosclerotic cardiovascular diseases. However, the information available in patients with chronic kidney disease (CKD) is less robust. The main objective of this updated systematic review of prospective studies was to analyze the association between elevated Lp(a) levels and cardiovascular outcomes or death in patients with CKD.

METHODS

The PRISMA guidelines were used to carry out this systematic review. Randomized clinical trials or prospective observational studies that evaluated the association between Lp(a) levels and cardiovascular outcomes or death in CKD patients were searched in the current literature.

RESULTS

Fifteen studies including 12,260 individuals were identified and considered eligible for this systematic review. In total, 14 prospective cohorts and one post-hoc analysis of a randomized clinical trial were analyzed. Eight studies evaluated hemodialysis patients, one study analyzed patients on peritoneal dialysis, while six studies evaluated subjects with different stages of CKD. Median follow-up duration ranged from 1 to 8.6 years. Our findings showed that elevated Lp(a) values were associated with a higher risk of cardiovascular events or death in most studies, despite adjusting for traditional risk factors.

CONCLUSION

The findings of this systematic review show that there is a positive association between Lp(a) levels and fatal and non-fatal cardiovascular events in patients with CKD.

Dyslipidemia is associated with inflammation and organ involvement in systemic lupus erythematosus

INTRODUCTION

Disturbed lipid metabolism was observed in systemic lupus erythematosus (SLE) patients. This study aimed to evaluate the relationships between dyslipidemia and visceral organ involvement, disease severity, inflammatory factors, and drug intake in SLE patients.

METHOD

Inpatients with SLE (n = 105) and healthy controls (HC) (n = 75) were recruited in this study. Clinical and laboratory data were collected from patient records. The concentrations of tumor necrosis factor receptors superfamily member1A (TNFRSF1A), member1B (TNFRSF1B) and adipokine angiopoietin-like 4 (ANGPTL4) in plasma were measured by ELISA.

RESULT

Compared to HC, serum levels of triglyceride (TG), total cholesterol (TC), low-density lipoprotein (LDL), and apolipoprotein B (ApoB) were significantly increased, while high-density lipoprotein (HDL) and apolipoprotein A1 (ApoA1) were decreased in SLE patients. Patients with higher disease activity and renal damage suffered from more severe dyslipidemia. Renal functional parameters were closely correlated with serum lipid levels. Inflammatory factors were associated with dyslipidemia. The levels of TNFRSF1A and TNFRSF1B were obviously increased and associated with kidney involvement in SLE patients. Patients with high-dose glucocorticoid intake showed more severe dyslipidemia.

CONCLUSIONS

Attention should be paid to the dyslipidemia of SLE. Dyslipidemia is associated with inflammation and organ involvement in SLE. These findings might provide a new strategy for the treatment of SLE. Key Points • Serum levels of TG, TC, LDL, and ApoB were significantly increased, while HDL and ApoA1 were decreased in SLE patients. • Patients with higher disease activity and renal damage suffered from more severe dyslipidemia. Renal functional parameters and inflammatory factors were closely correlated with serum lipid levels. • Patients with high-dose glucocorticoid intake showed more severe dyslipidemia. • These findings might provide a new strategy for the treatment of SLE.

Cardiovascular Risk Stratification and Appropriate Use of Statins in Patients with Chronic Kidney Disease According to Different Strategies

INTRODUCTION

Different strategies were proposed to stratify cardiovascular risk and assess the appropriate use of statins in patients with chronic kidney disease (CKD).

AIM

(1) To apply two strategies on the management of lipids in patients with CKD, analyzing what proportion of patients received lipid-lowering treatment and how many patients without statin therapy would be candidates for receiving them; (2) to identify how many patients achieve the lipid goals.

METHODS

A cross-sectional study was performed. Patients aged between 18 to 70 years and CKD with an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m² (without hemodialysis) were included. The indications for statin therapy according to 2019 ESC/EAS and 2013 KDIGO guidelines were analyzed as well as the achievement of LDL-C goals.

RESULTS

A total of 300 patients were included. According to ESC/EAS guidelines, 62.3 and 37.7% of the population was classified at high or very high cardiovascular risk. In total, 52% of patients received statins. Applying the 2013 KDIGO and the 2019 ESC/EAS guidelines, 92.4 and 95.8% of the population without lipid-lowering treatment were eligible for statin therapy, respectively. Globally, only 9.1 and 10.6% of the patients with high or very high risk achieved the suggested lipid goals.

CONCLUSION

A large proportion of patients with CKD showed considerable cardiovascular risk and were eligible for statin therapy according to the two strategies evaluated. However, observed statin use was deficient and current lipid goals were not achieved in most cases.

Triglycerides-glucose index and the risk of cardiovascular events in persons with non-diabetic chronic kidney disease

Background

Chronic kidney disease (CKD) is associated with high rates of cardiovascular events. We here explored whether the recently described triglycerides-glucose index (TyG) predicted the incidence of major adverse cardiovascular events (MACE) in these patients.

Methods

This observationa study was undertaken of 1142 persons with CKD and free from diabetes and 460 controls from the prospective NEFRONA study. The study exposure was the TyG index at cohort inclusion. The study outcome was MACE (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke and hospitalization for unstable angina). Covariates included demographics, comorbidities, lipid profile, renal function and glycaemic control. Cox regression models evaluated the association between TyG index and 4-point MACE in patients with CKD.

Results

TyG was higher [median 8.63 (interquartile range 8.32-8.95)] in patients with CKD compared with controls (P < 0.001). TyG increased across albuminuria categories but was similar for glomerular filtration rate categories among patients with CKD stages 3-5. During 46 ± 13 months of follow-up, 49 (4.3%) MACE were registered. TyG predicted the occurrence of MACE {hazard ratio (HR) 1.95 [95% confidence interval (CI) 1.11-3.40] per TyG unit increase; and HR 2.29 (95% CI 1.24-4.20] for TyG values above the median of 8.63 units}. Sensitivity analysis for subgroups of participants according to age, kidney function, body mass index and imaging evidence of atherosclerosis yielded similar results, as did adjusted analysis. Neither triglycerides nor glucose alone was associated with MACE.

Conclusions

The TyG index is associated with the occurrence of major cardiovascular events in persons free from diabetes with non-dialysis dependent CKD.

COVID-19 and Kidney Disease: A Clinical Perspective

Coronavirus disease-19 (COVID-19), caused by severe acute respiratory syndrome Coronavirus- 2 (SARS-CoV-2), has caused a global pandemic with high morbidity and mortality. The presence of several comorbidities has been associated with a worse prognosis, with chronic kidney disease being a critical risk factor. Regarding COVID-19 complications, other than classical pneumonia and thromboembolism, acute kidney injury (AKI) is highly prevalent and represents a poor prognostic indicator linked to increased disease severity and mortality. Its pathophysiology is multifactorial, revolving around inflammation, endothelial dysfunction, and activation of coagulation, while the direct viral insult of the kidney remains a matter of controversy. Indirectly, COVID-19 AKI may stem from sepsis, volume depletion, and administration of nephrotoxic agents, among others. Several markers have been proposed for the early detection of COVID-19 AKI, including blood and urinary inflammatory and kidney injury biomarkers, while urinary SARS-CoV-2 load may also be an early prognostic sign. Concerning renal replacement therapy (RRT), general principles apply to COVID-19 AKI, but sudden RRT surges may mandate adjustments in resources. Following an episode of COVID-19 AKI, there is a gradual recovery of kidney function, with pre-existing renal impairment and high serum creatinine at discharge being associated with kidney disease progression and long-term dialysis dependence. Finally, kidney transplant recipients represent a special patient category with increased susceptibility to COVID- 19 and subsequent high risk of severe disease progression. Rates of mortality, AKI, and graft rejection are significantly elevated in the presence of COVID-19, highlighting the need for prevention and careful management of the disease in this subgroup.

Clustering Inflammatory Markers with Sociodemographic and Clinical Characteristics of Patients with Diabetes Type 2 Can Support Family Physicians' Clinical Reasoning by Reducing Patients' Complexity

Diabetes mellitus type 2 (DM2) is a complex disease associated with chronic inflammation, end-organ damage, and multiple comorbidities. Initiatives are emerging for a more personalized approach in managing DM2 patients. We hypothesized that by clustering inflammatory markers with variables indicating the sociodemographic and clinical contexts of patients with DM2, we could gain insights into the hidden phenotypes and the underlying pathophysiological backgrounds thereof. We applied the k-means algorithm and a total of 30 variables in a group of 174 primary care (PC) patients with DM2 aged 50 years and above and of both genders. We included some emerging markers of inflammation, specifically, neutrophil-to-lymphocyte ratio (NLR) and the cytokines IL-17A and IL-37. Multiple regression models were used to assess associations of inflammatory markers with other variables. Overall, we observed that the cytokines were more variable than the marker NLR. The set of inflammatory markers was needed to indicate the capacity of patients in the clusters for inflammatory cell recruitment from the circulation to the tissues, and subsequently for the progression of end-organ damage and vascular complications. The hypothalamus–pituitary–thyroid hormonal axis, in addition to the cytokine IL-37, may have a suppressive, inflammation-regulatory role. These results can help PC physicians with their clinical reasoning by reducing the complexity of diabetic patients.