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Cho JM, Koh JH, Kim SG, Lee S, Kim Y, Cho S, Kim K, Kim YC, Han SS, Lee H, Lee JP, Joo KW, Lim CS, Kim YS, Kim DK, Park S. Associations of MRI-derived kidney volume, kidney function, body composition and physical performance in ≈38 000 UK Biobank participants: a population-based observational study. Clin Kidney J 2024; 17:sfae068. [PMID: 38660121 PMCID: PMC11040514 DOI: 10.1093/ckj/sfae068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Indexed: 04/26/2024] Open
Abstract
Background Kidney volume is used as a predictive and therapeutic marker for several clinical conditions. However, there is a lack of large-scale studies examining the relationship between kidney volume and various clinicodemographic factors, including kidney function, body composition and physical performance. Methods In this observational study, MRI-derived kidney volume measurements from 38 526 UK Biobank participants were analysed. Major kidney volume-related measures included body surface area (BSA)-adjusted total kidney volume (TKV) and the difference in bilateral kidneys. Multivariable-adjusted linear regression and cubic spline analyses were used to explore the association between kidney volume-related measures and clinicodemographic factors. Cox or logistic regression was used to identify the risks of death, non-kidney cancer, myocardial infarction, ischaemic stroke and chronic kidney disease (CKD). Results The median of BSA-adjusted TKV and the difference in kidney volume were 141.9 ml/m2 [interquartile range (IQR) 128.1-156.9] and 1.08-fold (IQR 1.04-1.15), respectively. Higher BSA-adjusted TKV was significantly associated with higher estimated glomerular filtration rate {eGFR; β = 0.43 [95% confidence interval (CI) 0.42-0.44]; P < .001}, greater muscle volume [β = 0.50 (95% CI 0.48-0.51); P < .001] and greater mean handgrip strength [β = 0.15 (95% CI 0.13-0.16); P < .001] but lower visceral adipose tissue volume [VAT; β = -0.09 (95% CI -0.11 to -0.07); P < .001] in adjusted models. A greater difference in bilateral kidney volumes was associated with lower eGFR, muscle volume and physical performance but with higher proteinuria and VAT. Higher BSA-adjusted TKV was significantly associated with a reduced risk of CKD [odds ratio (OR) 0.7 (95% CI 0.63-0.77); P < .001], while a greater difference in kidney volume was significantly associated with an increased risk of CKD [OR 1.13 (95% CI 1.07-1.20); P < .001]. Conclusion Higher BSA-adjusted TKV and lower differences in bilateral kidney volumes are associated with higher kidney function, muscle volume and physical performance and a reduced risk of CKD.
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Affiliation(s)
- Jeong Min Cho
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Gyeonggi-do, Korea
| | - Jung Hun Koh
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seong Geun Kim
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Soojin Lee
- Department of Internal Medicine, Uijeongbu Eulji University Medical Center, Uijeongbu, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yaerim Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Semin Cho
- Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Gyeonggi-do, Korea
| | - Kwangsoo Kim
- Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University, Seoul, Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University, Seoul, Korea
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University, Seoul, Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University, Seoul, Korea
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University, Seoul, Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University, Seoul, Korea
| | - Sehoon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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Klinkhammer BM, Buchtler S, Djudjaj S, Bouteldja N, Palsson R, Edvardsson VO, Thorsteinsdottir M, Floege J, Mack M, Boor P. Current kidney function parameters overestimate kidney tissue repair in reversible experimental kidney disease. Kidney Int 2022; 102:307-320. [PMID: 35483527 DOI: 10.1016/j.kint.2022.02.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 01/24/2022] [Accepted: 02/28/2022] [Indexed: 11/24/2022]
Abstract
Although underlying mechanisms and the clinical course of kidney disease progression are well described, less is known about potential disease reversibility. Therefore, to analyze kidney recovery, we adapted a commonly used murine chronic kidney disease (CKD) model of 2,8- dihydroxyadenine (2,8-DHA) crystal-induced nephropathy to study disease recovery and efficacy of disease-modifying interventions. The recovery phase after CKD was characterized by improved kidney function after two weeks which remained stable thereafter. By contrast, even after eight weeks recovery, tubular injury and inflammation were only partially reduced and fibrosis persisted. Deep-learning-based histologic analysis of 8,604 glomeruli and 596,614 tubular cross sections revealed numerous tubules had undergone either prominent dilation or complete atrophy, leading to atubular glomeruli and irreversible nephron loss. We confirmed these findings in a second CKD model, reversible unilateral ureteral obstruction, in which a rapid improvement of glomerular filtration rate during recovery also did not reflect the permanent histologic kidney injury. In 2,8-DHA nephropathy, increased drinking volume was highly effective in disease prevention. However, in therapeutic approaches, high fluid intake was only effective in moderate but not severe CKD and established tissue injury was again poorly reflective of kidney function parameters. The injury was particularly localized in the medulla, which is often not analyzed. Thus, recovery after crystal- or obstruction-induced CKD is characterized by ongoing tissue injury, fibrosis, and nephron loss, but not reflected by standard measures of kidney function. Hence, our data might aid in designing kidney recovery studies and suggest the need for biomarkers specifically monitoring intra-kidney tissue injury.
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Affiliation(s)
| | - Simone Buchtler
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Sonja Djudjaj
- Institute of Pathology, RWTH University Hospital Aachen, Aachen, Germany
| | - Nassim Bouteldja
- Institute of Pathology, RWTH University Hospital Aachen, Aachen, Germany
| | - Runolfur Palsson
- Division of Nephrology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland; Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Vidar Orn Edvardsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland; Children´s Medical Center, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | | | - Jürgen Floege
- Division of Nephrology and Immunology, RWTH University Hospital Aachen, Aachen, Germany
| | - Matthias Mack
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Peter Boor
- Institute of Pathology, RWTH University Hospital Aachen, Aachen, Germany; Division of Nephrology and Immunology, RWTH University Hospital Aachen, Aachen, Germany; Department of Electron Microscopy, RWTH University Hospital Aachen, Aachen, Germany.
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3
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Schenk LK, Buchholz B, Henke SF, Michgehl U, Daniel C, Amann K, Kunzelmann K, Pavenstädt H. Nephron-specific knockout of TMEM16A leads to reduced number of glomeruli and albuminuria. Am J Physiol Renal Physiol 2018; 315:F1777-F1786. [PMID: 30156115 DOI: 10.1152/ajprenal.00638.2017] [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] [Indexed: 01/19/2023] Open
Abstract
TMEM16A is a transmembrane protein from a conserved family of calcium-activated proteins that is highly expressed in the kidney. TMEM16A confers calcium-activated chloride channel activity, which is of importance for various cellular functions in secretory epithelia and involved in secretion-dependent renal cyst growth. However, its specific function in renal physiology has remained elusive so far. Therefore, we generated conditional nephron-specific TMEM16A-knockout mice and found that these animals suffered from albuminuria. Kidney histology demonstrated an intact corticomedullary differentiation and absence of cysts. Electron microscopy showed a normal slit diaphragm. However, the total number of glomeruli and total nephron count was decreased in TMEM16A-knockout animals. At the same time, glomerular diameter was increased, presumably as a result of the hyperfiltration in the remaining glomeruli. TUNEL and PCNA stainings showed increased cell death and increased proliferation. Proximal tubular cilia were intact in young animals, but the number of properly ciliated cells was decreased in older, albuminuric animals. Taken together, our data suggest that TMEM16A may be involved in ureteric bud branching and proper nephron endowment. Loss of TMEM16A resulted in reduced nephron number and, subsequently, albuminuria and tubular damage.
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Affiliation(s)
- Laura K Schenk
- Internal Medicine D University Hospital of Muenster , Muenster Germany
| | - Bjoern Buchholz
- Department of Nephrology and Hypertension, Friedrich-Alexander University of Erlangen-Nürnberg , Erlangen , Germany
| | - Sebastian F Henke
- Internal Medicine D University Hospital of Muenster , Muenster Germany
| | - Ulf Michgehl
- Internal Medicine D University Hospital of Muenster , Muenster Germany
| | - Christoph Daniel
- Institute for Nephropathology, Friedrich-Alexander University of Erlangen-Nürnberg , Erlangen , Germany
| | - Kerstin Amann
- Institute for Nephropathology, Friedrich-Alexander University of Erlangen-Nürnberg , Erlangen , Germany
| | - Karl Kunzelmann
- Department of Physiology, University of Regensburg , Regensburg Germany
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Effect of Chronic Kidney Disease on Changes in Vasopressin System Expression in the Kidney Cortex in Rats with Nephrectomy. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2607928. [PMID: 30013980 PMCID: PMC6022316 DOI: 10.1155/2018/2607928] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/18/2018] [Accepted: 05/21/2018] [Indexed: 02/01/2023]
Abstract
It is believed that the vasopressinergic system plays an important role in the pathogenesis of chronic kidney disease (CKD). The aim of this study was to evaluate the effect of CKD on changes in vasopressin system expression in the kidney cortex in rats with nephrectomy. The study was performed on 4 groups of Sprague Dawley (SPRD) rats: a control group (CN), 1/2 nephrectomy (N1/2), 2/3 nephrectomy (N2/3), and 5/6 nephrectomy (N5/6). Blood and the kidney cortex were collected to evaluate plasma copeptin concentrations and mRNA expressions of V1a vasopressin receptors (V1aR) and V2 vasopressin receptors (V2R) and V1aR, V2R, and aquaporin 2 (AQP2) protein levels. V1aR and V2R mRNA expression in the kidney cortex was significantly lower in the CN group compared with the other groups. In contrast, the V1aR, V2R, and AQP2 protein levels were significantly higher in the CN group compared with all of the nephrectomized groups. Plasma copeptin concentration was significantly lower in the CN group than in the nephrectomized groups. CKD caused significant changes in the expression of the vasopressinergic system. Further research is needed to explain the mechanisms of the impact of the vasopressinergic system on the kidney in CKD.
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Nakazato T, Ikehira H, Imasawa T. An equation to estimate the renal cortex volume in chronic kidney disease patients. Clin Exp Nephrol 2017; 22:603-612. [PMID: 29071505 DOI: 10.1007/s10157-017-1492-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 09/24/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The renal cortex volume is associated with the kidney function and chronic kidney disease (CKD) risk factors, and it may also be a prognostic factor. We aimed to create an equation to estimate the renal cortex volume of CKD patients in day-to-day clinical practice. METHODS The subjects included 116 ethnic Japanese CKD patients who were ≥ 18 years of age. The renal size (length, width and thickness) was measured by ultrasound. The body height, weight, year of age, sex, birth weight, gestational age, diabetes status, hypertension status, family history of CKD and dialysis and estimated glomerular filtration rate (eGFR) were collected as expected dependent variables. We made models for the equation regarding the renal cortex volume measured by non-contrast magnetic resonance imaging as a true renal cortex volume. Stepwise multiple linear regression analyses were performed with the log-transformation of dependent and independent variables. The accuracy of the models was compared using the leave one out cross-validation method. RESULTS The estimated volume of the renal cortex (cm3) = 0.012 × renal length (cm)0.92 × width (cm)0.53 × body weight (kg)0.40 × body height (cm)0.67 × eGFR (ml/min/1.73 m2)0.22 × 1.12 if diabetes. The adjusted R 2 value and the accuracy within 30 and 50% were 0.73, 0.94 and 0.99, respectively. CONCLUSIONS This study provided a new method for estimating the renal cortex volume in day-to-day clinical practice.
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Affiliation(s)
- Takashi Nakazato
- Department of Medical Information Management, National Hospital Organization Chiba Medical Center, 4-1-2 Tsubakimori Chuouku, Chiba, 260-8606, Japan.
| | - Hiroo Ikehira
- Department of Radiology, National Hospital Organization Chiba East Hospital, 673 Nitona Chuouku, Chiba, 260-8712, Japan
| | - Toshiyuki Imasawa
- Department of Internal Medicine, National Hospital Organization Chiba East Hospital, 673 Nitona Chuouku, Chiba, 260-8712, Japan
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6
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Rosenberg AZ, Palmer M, Merlino L, Troost JP, Gasim A, Bagnasco S, Avila-Casado C, Johnstone D, Hodgin JB, Conway C, Gillespie BW, Nast CC, Barisoni L, Hewitt SM. The Application of Digital Pathology to Improve Accuracy in Glomerular Enumeration in Renal Biopsies. PLoS One 2016; 11:e0156441. [PMID: 27310011 PMCID: PMC4911144 DOI: 10.1371/journal.pone.0156441] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 05/14/2016] [Indexed: 12/02/2022] Open
Abstract
Background In renal biopsy reporting, quantitative measurements, such as glomerular number and percentage of globally sclerotic glomeruli, is central to diagnostic accuracy and prognosis. The aim of this study is to determine the number of glomeruli and percent globally sclerotic in renal biopsies by means of registration of serial tissue sections and manual enumeration, compared to the numbers in pathology reports from routine light microscopic assessment. Design We reviewed 277 biopsies from the Nephrotic Syndrome Study Network (NEPTUNE) digital pathology repository, enumerating 9,379 glomeruli by means of whole slide imaging. Glomerular number and the percentage of globally sclerotic glomeruli are values routinely recorded in the official renal biopsy pathology report from the 25 participating centers. Two general trends in reporting were noted: total number per biopsy or average number per level/section. Both of these approaches were assessed for their accuracy in comparison to the analogous numbers of annotated glomeruli on WSI. Results The number of glomeruli annotated was consistently higher than those reported (p<0.001); this difference was proportional to the number of glomeruli. In contrast, percent globally sclerotic were similar when calculated on total glomeruli, but greater in FSGS when calculated on average number of glomeruli (p<0.01). The difference in percent globally sclerotic between annotated and those recorded in pathology reports was significant when global sclerosis is greater than 40%. Conclusions Although glass slides were not available for direct comparison to whole slide image annotation, this study indicates that routine manual light microscopy assessment of number of glomeruli is inaccurate, and the magnitude of this error is proportional to the total number of glomeruli.
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MESH Headings
- Biopsy
- Glomerulonephritis, IGA/diagnostic imaging
- Glomerulonephritis, IGA/pathology
- Glomerulonephritis, IGA/surgery
- Glomerulonephritis, Membranous/diagnostic imaging
- Glomerulonephritis, Membranous/pathology
- Glomerulonephritis, Membranous/surgery
- Glomerulosclerosis, Focal Segmental/diagnostic imaging
- Glomerulosclerosis, Focal Segmental/pathology
- Glomerulosclerosis, Focal Segmental/surgery
- Humans
- Kidney Glomerulus/diagnostic imaging
- Kidney Glomerulus/pathology
- Kidney Glomerulus/surgery
- Microscopy/methods
- Nephrotic Syndrome/diagnostic imaging
- Nephrotic Syndrome/pathology
- Nephrotic Syndrome/surgery
- Signal Processing, Computer-Assisted
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Affiliation(s)
- Avi Z. Rosenberg
- Department of Pathology, Children’s National Medical Center, Washington, DC, United States of America
- National Institute of Digestive Diseases and Kidney, National Institutes of Health, Bethesda, MD, United States of America
| | - Matthew Palmer
- Department of Pathology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Lino Merlino
- Department of Pathology, University of Miami, Miami, FL, United States of America
| | - Jonathan P. Troost
- Department of Pediatrics, Division of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, United States of America
| | - Adil Gasim
- Department of Pathology, University of North Carolina, Chapel Hill, NC, United States of America
| | - Serena Bagnasco
- Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | | | - Duncan Johnstone
- Department of Medicine, Section of Nephrology, Hypertension and Kidney Transplantation Temple University, Philadelphia, PA, United States of America
| | - Jeffrey B. Hodgin
- Department of Pathology, University of Michigan, Ann Arbor, MI, United States of America
| | - Catherine Conway
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States of America
| | - Brenda W. Gillespie
- Biostatistics Department, School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
| | - Cynthia C. Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Laura Barisoni
- Department of Pathology, University of Miami, Miami, FL, United States of America
| | - Stephen M. Hewitt
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States of America
- * E-mail:
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7
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Determinants of renal shape in chronic kidney disease patients. Clin Exp Nephrol 2016; 20:748-756. [DOI: 10.1007/s10157-015-1220-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 12/13/2015] [Indexed: 10/22/2022]
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8
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Charlton JR, Beeman SC, Bennett KM. MRI-detectable nanoparticles: the potential role in the diagnosis of and therapy for chronic kidney disease. Adv Chronic Kidney Dis 2013; 20:479-87. [PMID: 24206600 DOI: 10.1053/j.ackd.2013.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/23/2013] [Accepted: 06/03/2013] [Indexed: 12/30/2022]
Abstract
Chronic kidney disease (CKD) is a common, deadly, and expensive threat to public health. Patients susceptible to the development of CKD are difficult to identify because there are few noninvasive clinical techniques and markers to assess early kidney dysfunction. Noninvasive imaging techniques are being developed to quantitatively measure kidney morphology and function in preclinical research and in clinical trials. Magnetic resonance imaging (MRI) techniques in particular have the potential to provide structural and functional information in the kidney. Novel molecular imaging techniques, using targeted magnetic nanoparticles that exploit the characteristics of the endogenous protein, ferritin, have been developed in conjunction with MRI to count every perfused glomerulus in the kidney and measure their individual volumes. This technique could open the door to the possibility of prospectively assessing and eventually reducing a patient's risk for progression to CKD. This review highlights the potential clinical benefits of early detection in patients predisposed to CKD and discusses technologic and regulatory hurdles to the translation of these molecular MRI techniques to provide early diagnosis of CKD.
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Imasawa T, Fukuda N, Hirose S, Kato N, Suganuma S, Yamamoto R, Kimura H, Kadomura M, Nishimura M, Yoshimura M, Ikei S. Hemodialysis patients born with a low birth weight should have a different time course of kidney diseases than those born with a normal birth weight. Ther Apher Dial 2013; 17:293-7. [PMID: 23735144 DOI: 10.1111/1744-9987.12002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Low birth weight (LBW) is thought to be one of the risk factors for the progression of kidney diseases. This study hypothesized that the onset age of kidney disease, the rate of progression of kidney disease, or the age at the time of hemodialysis (HD) induction among HD patients that were born with LBW is different from those without a history of LBW. A questionnaire survey in nine dialysis units in Japan was performed and 427 answer sheets were collected. There were statistically significant differences in the present age, the age of kidney disease onset, and the age of HD induction between LBW group and normal birth weight group (NBW). An analysis limited to participants whose underlying disease was diabetic nephropathy revealed that the duration from the onset of nephropathy to HD induction was much shorter in HD patients with a history of LBW than those with a NBW history. In addition, the Pearson's correlation coefficient between the birth weight and the period from onset of diabetic nephropathy to HD induction was 0.283. Although these results might partly support the primary hypothesis, the necessity to perform other clinical studies is also emphasized.
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Affiliation(s)
- Toshiyuki Imasawa
- National Hospital Organization Chiba-East National Hospital, 673 Nitona-cho, Chuoh-ku, Chiba-city, Chiba 260-8712, Japan.
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