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Fang X, Chen Y, Chen Y, Qiu M, Huang J, Ke B. Identification and characterization of two immune-related subtypes in human chronic kidney disease. Transpl Immunol 2024; 82:101983. [PMID: 38184215 DOI: 10.1016/j.trim.2023.101983] [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: 10/17/2023] [Revised: 12/09/2023] [Accepted: 12/31/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Immune response plays a vital role in the initiation and development of chronic kidney disease (CKD). Detailed mechanisms and specific immune-related biomarkers of CKD need further clarification. We aimed to identify and characterize immune-related infiltrates that are implicated in the CKD development using a bioinformatics method. METHODS The expression profiles of GSE66494 dataset were acquired from the Gene Expression Omnibus (GEO) database. Patients with CKD were divided into low- vs. high-immune subtypes based on their immune score. Based on such analysis, we identified differentially expressed genes (DEGs) of low- and high-immune subtypes. The weight gene co-expression network analysis (WGCNA) was used to identify immune-associated modules between two subtypes. The gene set enriched (GSEA) and variation (GSVA) analyses were correlated with their functional types using the molecular complex detection (MCODE) method. Finally, the immune infiltration landscape between subtypes was revealed using the xCell algorithm. RESULTS The total number of 131 differentially expressed immune-related genes (DEIRGs) were identified between low- vs. high-immune subtypes. Out of them GSEA/GSVA results identified and enriched immune- and inflammation-related pathways. In particular, GSVA results indicated that immune-related pathways were activated in high-immune subgroups. The core DEIRG genes that were identified to be involved in CKD development included: the protein tyrosine phosphatase receptor type C (PTPRC; also known as CD45) regulating cell growth and differentiation, an early activation marker (CD69), co-receptor for T cell receptor (CD8A), and T cell co-stimulatory signal (CD28). These core DEIRD genes were further verified by the GSE96804 dataset. We also found a higher proportion of immune cells infiltrating the high-immune subgroup. Furthermore, the four core genes were positively correlated with most immune cell types. CONCLUSION Among 131 DEIRG genes, four genes (PTPRC, CD69, CD8A, and CD28) were identified as potential biomarkers associated with the immune cell infiltration in CKD patients, which may provide a novel insight for immunotherapy for CKD.
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Affiliation(s)
- Xiangdong Fang
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yanxia Chen
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yan Chen
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Minzi Qiu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jinjing Huang
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Ben Ke
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.
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Myeloid leukocytes' diverse effects on cardiovascular and systemic inflammation in chronic kidney disease. Basic Res Cardiol 2022; 117:38. [PMID: 35896846 PMCID: PMC9329413 DOI: 10.1007/s00395-022-00945-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/24/2022] [Accepted: 07/11/2022] [Indexed: 01/31/2023]
Abstract
Chronic kidney disease's prevalence rises globally. Whereas dialysis treatment replaces the kidney's filtering function and prolongs life, dreaded consequences in remote organs develop inevitably over time. Even milder reductions in kidney function not requiring replacement therapy associate with bacterial infections, cardiovascular and heart valve disease, which markedly limit prognosis in these patients. The array of complications is diverse and engages a wide gamut of cellular and molecular mechanisms. The innate immune system is profoundly and systemically altered in chronic kidney disease and, as a unifying element, partakes in many of the disease's complications. As such, a derailed immune system fuels cardiovascular disease progression but also elevates the propensity for serious bacterial infections. Recent data further point towards a role in developing calcific aortic valve stenosis. Here, we delineate the current state of knowledge on how chronic kidney disease affects innate immunity in cardiovascular organs and on a systemic level. We review the role of circulating myeloid cells, monocytes and neutrophils, resident macrophages, dendritic cells, ligands, and cellular pathways that are activated or suppressed when renal function is chronically impaired. Finally, we discuss myeloid cells' varying responses to uremia from a systems immunology perspective.
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Chronic Kidney Disease-Associated Inflammation Increases the Risks of Acute Kidney Injury and Mortality after Cardiac Surgery. Int J Mol Sci 2020; 21:ijms21249689. [PMID: 33353159 PMCID: PMC7766561 DOI: 10.3390/ijms21249689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 01/12/2023] Open
Abstract
Cardiovascular mortality increases with decreasing renal function although the cause is yet unknown. Here, we have investigated whether low chronic inflammation in chronic kidney diseases (CKD) could contribute to increased risk for coronary artery diseases (CAD). Thus, a prospective case–control study was conducted in patients with CAD and CKD undergoing coronary artery bypass graft surgery with the aim of detecting differences in cardiovascular outcomes, epicardial adipose tissue volume, and inflammatory marker activity associated with renal dysfunction. Expression of membrane CD14 and CD16, inflammatory cytokines and chemokines, mitogen-activated protein (MAP) kinases and hsa-miR-30a-5p were analyzed in peripheral blood mononuclear cells (PBMCs). Epicardial fat volume and tissue inflammation in perivascular adipose tissue and in the aorta were also studied. In the present study, 151 patients were included, 110 with CAD (51 with CKD) and 41 nonCAD controls (15 with CKD). CKD increased the risk of cardiac surgery–associated acute kidney injury (CSA-AKI) as well as the 30-day mortality after cardiac surgery. Higher counts of CD14++CD16+ monocytes were associated with vascular inflammation, with an increased expression of IL1β, and with CKD in CAD patients. Expression of hsa-miR-30a-5p was correlated with hypertension. We conclude that CKD patients show an increased risk of CSA-AKI and mortality after cardiovascular surgery, associated with the expansion of the CD14++CD16+ subset of proinflammatory monocytes and with IL1β expression. We propose that inflammation associated with CKD may contribute to atherosclerosis (ATH) pathogenesis.
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Daub S, Lutgens E, Münzel T, Daiber A. CD40/CD40L and Related Signaling Pathways in Cardiovascular Health and Disease-The Pros and Cons for Cardioprotection. Int J Mol Sci 2020; 21:E8533. [PMID: 33198327 PMCID: PMC7697597 DOI: 10.3390/ijms21228533] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/03/2020] [Accepted: 11/08/2020] [Indexed: 02/07/2023] Open
Abstract
The CD40-CD40 ligand (CD40L) dyad represents a scientific and clinical field that has raised many controversies in the past and cannot be clearly defined as being an either beneficial or harmful pathway. Being crucially involved in physiological immunological processes as well as pathological inflammatory reactions, the signaling pathway has been recognized as a key player in the development of both autoimmune and cardiovascular disease. Even though the possibilities of a therapeutic approach to the dyad were recognized decades ago, due to unfortunate events, detailed in this review, pharmacological treatment targeting the dyad, especially in patients suffering from atherosclerosis, is not available. Despite the recent advances in the treatment of classical cardiovascular risk factors, such as arterial hypertension and diabetes mellitus, the treatment of the associated low-grade inflammation that accounts for the progression of atherosclerosis is still challenging. Low-grade inflammation can be detected in a significant portion of patients that suffer from cardiovascular disease and it is therefore imperative to develop new therapeutic strategies in order to combat this driver of atherosclerosis. Of note, established cardiovascular drugs such as angiotensin-converting enzyme inhibitors or statins have proven beneficial cardiovascular effects that are also related to their pleiotropic immunomodulatory properties. In this review, we will discuss the setbacks encountered as well as new avenues discovered on the path to a different, inflammation-centered approach for the treatment of cardiovascular disease with the CD40-CD40L axis as a central therapeutic target.
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Affiliation(s)
- Steffen Daub
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (S.D.); (T.M.)
| | - Esther Lutgens
- Experimental Vascular Biology Division, Department of Medical Biochemistry, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands;
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians Universität, 80336 Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany and Partner Site Munich Heart Alliance, 80336 Munich, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (S.D.); (T.M.)
- German Center for Cardiovascular Research (DZHK), Partnersite Rhine-Main, 55131 Mainz, Germany
| | - Andreas Daiber
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (S.D.); (T.M.)
- German Center for Cardiovascular Research (DZHK), Partnersite Rhine-Main, 55131 Mainz, Germany
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Hueso M, Cruzado JM, Torras J, Navarro E. An Exonic Switch Regulates Differential Accession of microRNAs to the Cd34 Transcript in Atherosclerosis Progression. Genes (Basel) 2019; 10:genes10010070. [PMID: 30669689 PMCID: PMC6356495 DOI: 10.3390/genes10010070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/07/2019] [Accepted: 01/14/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND CD34⁺ Endothelial Progenitor Cells (EPCs) play an important role in the recovery of injured endothelium and contribute to atherosclerosis (ATH) pathogenesis. Previously we described a potential atherogenic role for miR-125 that we aimed to confirm in this work. METHODS Microarray hybridization, TaqMan Low Density Array (TLDA) cards, qPCR, and immunohistochemistry (IHC) were used to analyze expression of the miRNAs, proteins and transcripts here studied. RESULTS Here we have demonstrated an increase of resident CD34-positive cells in the aortic tissue of human and mice during ATH progression, as well as the presence of clusters of CD34-positive cells in the intima and adventitia of human ATH aortas. We introduce miR-351, which share the seed sequence with miR-125, as a potential effector of CD34. We show a splicing event at an internal/cryptic splice site at exon 8 of the murine Cd34 gene (exonic-switch) that would regulate the differential accession of miRNAs (including miR-125) to the coding region or to the 3'UTR of Cd34. CONCLUSIONS We introduce new potential mediators of ATH progression (CD34 cell-clusters, miR-351), and propose a new mechanism of miRNA action, linked to a cryptic splicing site in the target-host gene, that would regulate the differential accession of miRNAs to their cognate binding sites.
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Affiliation(s)
- Miguel Hueso
- Department of Nephrology, Hospital Universitari Bellvitge and Bellvitge Research Institute (IDIBELL), L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
| | - Josep M Cruzado
- Department of Nephrology, Hospital Universitari Bellvitge and Bellvitge Research Institute (IDIBELL), L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
| | - Joan Torras
- Department of Nephrology, Hospital Universitari Bellvitge and Bellvitge Research Institute (IDIBELL), L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
| | - Estanis Navarro
- Independent Researcher, Esplugues de Llobregat, 08950 Barcelona, Spain.
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Vascular Calcification in Chronic Kidney Disease: The Role of Inflammation. Int J Nephrol 2018; 2018:4310379. [PMID: 30186632 PMCID: PMC6109995 DOI: 10.1155/2018/4310379] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 07/24/2018] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular complications are extremely frequent in patients with chronic kidney disease (CKD) and death from cardiac causes is the most common cause of death in this particular population. Cardiovascular disease is approximately 3 times more frequent in patients with CKD than in other known cardiovascular risk groups and cardiovascular mortality is approximately 10-fold more frequent in patients on dialysis compared to the age- and sex-matched segments of the nonrenal population. Among other structural and functional factors advanced calcification of atherosclerotic plaques as well as of the arterial and venous media has been described as potentially relevant for this high cardiovascular morbidity and mortality. One potential explanation for this exceedingly high vascular calcification in animal models as well as in patients with CKD increased systemic and most importantly local (micro)inflammation that has been shown to favor the development of calcifying particles by multiple ways. Of note, local vascular upregulation of proinflammatory and proosteogenic molecules is already present at early stages of CKD and may thus be operative for vascular calcification. In addition, increased expression of costimulatory molecules and mast cells has also been documented in patients with CKD pointing to a more inflammatory and potentially less stable phenotype of coronary atherosclerotic plaques in CKD.
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ALUminating the Path of Atherosclerosis Progression: Chaos Theory Suggests a Role for Alu Repeats in the Development of Atherosclerotic Vascular Disease. Int J Mol Sci 2018; 19:ijms19061734. [PMID: 29895733 PMCID: PMC6032270 DOI: 10.3390/ijms19061734] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 06/04/2018] [Accepted: 06/09/2018] [Indexed: 12/12/2022] Open
Abstract
Atherosclerosis (ATH) and coronary artery disease (CAD) are chronic inflammatory diseases with an important genetic background; they derive from the cumulative effect of multiple common risk alleles, most of which are located in genomic noncoding regions. These complex diseases behave as nonlinear dynamical systems that show a high dependence on their initial conditions; thus, long-term predictions of disease progression are unreliable. One likely possibility is that the nonlinear nature of ATH could be dependent on nonlinear correlations in the structure of the human genome. In this review, we show how chaos theory analysis has highlighted genomic regions that have shared specific structural constraints, which could have a role in ATH progression. These regions were shown to be enriched with repetitive sequences of the Alu family, genomic parasites that have colonized the human genome, which show a particular secondary structure and are involved in the regulation of gene expression. Here, we show the impact of Alu elements on the mechanisms that regulate gene expression, especially highlighting the molecular mechanisms via which the Alu elements alter the inflammatory response. We devote special attention to their relationship with the long noncoding RNA (lncRNA); antisense noncoding RNA in the INK4 locus (ANRIL), a risk factor for ATH; their role as microRNA (miRNA) sponges; and their ability to interfere with the regulatory circuitry of the (nuclear factor kappa B) NF-κB response. We aim to characterize ATH as a nonlinear dynamic system, in which small initial alterations in the expression of a number of repetitive elements are somehow amplified to reach phenotypic significance.
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Bansal S, Friedrichs WE, Velagapudi C, Feliers D, Khazim K, Horn D, Cornell JE, Werner SL, Fanti P. Spleen contributes significantly to increased circulating levels of fibroblast growth factor 23 in response to lipopolysaccharide-induced inflammation. Nephrol Dial Transplant 2018; 32:960-968. [PMID: 27836924 DOI: 10.1093/ndt/gfw376] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 09/20/2016] [Indexed: 12/19/2022] Open
Abstract
Background Circulating levels of fibroblast growth factor 23 (FGF23) increase progressively and correlate with systemic inflammation in chronic kidney disease (CKD). The aim of this study was to identify and characterize the causal relationship between FGF23 and inflammation in CKD. Methods Circulating FGF23 and inflammatory cytokines were correlated in healthy subjects and patients with varying levels of CKD. In addition, FGF23 expression in blood and solid organs was measured in normal mice that were exposed acutely (one time) or chronically (2-week) to low-dose lipopolysaccharide (LPS); chronic exposure being either sustained (subcutaneous pellets), intermittent (daily injections) or combined sustained plus acute (subcutaneous pellets plus acute injection on the day of sacrifice). Blood was analyzed for both terminal (cFGF23) and intact (iFGF23) FGF23 levels. Solid tissues were investigated with immunohistochemistry, enzyme-linked immunosorbent assay and reverse transcription polymerase chain reaction. Results FGF23 levels correlated significantly with neutrophil gelatinase-associated lipocalin ( r = 0.72, P < 0.001), C-reactive protein ( r = 0.38, P < 0.001), tumor necrosis factor-α ( r = 0.32, P = 0.001) and interleukin-6 ( r = 0.48, P < 0.001). Acute LPS administration increased tissue FGF23 mRNA and plasma levels of cFGF23 but not iFGF23. Neither chronic sustained nor chronic pulsatile LPS increased the tissue or circulating levels of FGF23. However, acute on chronic LPS raised tissue FGF23 mRNA and both circulating cFG23 and iFGF23. Interestingly, the spleen was the major source of FGF23. Conclusion Acute on chronic exposure to LPS stimulates FGF23 production in a normal mouse model of inflammation. We provide the first evidence that the spleen, under these conditions, contributes substantially to elevated circulating FGF23 levels.
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Affiliation(s)
- Shweta Bansal
- Division of Nephrology, Department of Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, TX 78229, USA.,Renal Section, South Texas Veterans Healthcare System, San Antonio, TX, USA
| | - William E Friedrichs
- Division of Nephrology, Department of Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, TX 78229, USA
| | - Chakradhar Velagapudi
- Division of Nephrology, Department of Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, TX 78229, USA.,Renal Section, South Texas Veterans Healthcare System, San Antonio, TX, USA
| | - Denis Feliers
- Division of Nephrology, Department of Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, TX 78229, USA
| | - Khaled Khazim
- Faculty of Medicine, Galilee Medical Center, Bar-Ilan University, Safed, Israel
| | - Diane Horn
- Department of Pathology, University of Texas Health Sciences Center at San Antonio and South Texas Veterans Healthcare System, San Antonio, TX, USA
| | - John E Cornell
- Department of Epidemiology & Biostatistics, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA
| | - Sherry L Werner
- Department of Pathology, University of Texas Health Sciences Center at San Antonio and South Texas Veterans Healthcare System, San Antonio, TX, USA
| | - Paolo Fanti
- Division of Nephrology, Department of Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, TX 78229, USA
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Hueso M, De Ramon L, Navarro E, Ripoll E, Cruzado JM, Grinyo JM, Torras J. Silencing of CD40 in vivo reduces progression of experimental atherogenesis through an NF-κB/miR-125b axis and reveals new potential mediators in the pathogenesis of atherosclerosis. Atherosclerosis 2016; 255:80-89. [DOI: 10.1016/j.atherosclerosis.2016.11.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 10/06/2016] [Accepted: 11/01/2016] [Indexed: 02/08/2023]
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Paul K, Franke S, Nadal J, Schmid M, Yilmaz A, Kretzschmar D, Bärthlein B, Titze S, Koettgen A, Wolf G, Busch M. Inflammation, vitamin D and dendritic cell precursors in chronic kidney disease. Clin Exp Immunol 2016; 186:86-95. [PMID: 27414487 DOI: 10.1111/cei.12844] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2016] [Indexed: 01/14/2023] Open
Abstract
Decreased blood dendritic cell precursors (DCP) count is linked with atherosclerotic disease, while reduction of circulating DCP is also seen in patients with chronic kidney disease (CKD). As poor vitamin D status could be linked to a compromised innate immune response, we hypothesized that vitamin D status might be involved in the decrease in circulating DCP in CKD. Moreover, the potential role of inflammation was considered. Circulating myeloid (mDCP), plasmacytoid (pDCP) and total DCP (tDCP) were analysed using flow cytometry in 287 patients with CKD stage 3. Serum 25(OH)D and 1,25(OH)2D levels were measured using enzyme-linked immunosorbent assays (ELISA), interleukin (IL)-6, IL-10 and tumour necrosis factor (TNF)-α using cytometric bead array, C-reactive protein (CRP) using a high-sensitivity (hs) ELISA. Contrary to our hypothesis, there was no association between vitamin D levels and DCP, although their number was decreased significantly in CKD (P < 0·001). Instead, mDCP (r = -0·211) and tDCP (r = -0·188,) were associated slightly negatively with hsCRP but positively with the estimated glomerular filtration rate (eGFR, r = 0·314 for tDCP). According to multivariate linear regression, only higher hsCRP concentration and the presence of diabetes mellitus had a significant negative influence on DCP count (P < 0·03, respectively) but not vitamin D, age and eGFR. A significant impact of vitamin D on the reduction of circulating DCP in CKD 3 patients can be neglected. Instead, inflammation as a common phenomenon in CKD and diabetes mellitus had the main influence on the decrease in DCP. Thus, a potential role for DCP as a sensitive marker of inflammation and cardiovascular risk should be elucidated in future studies.
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Affiliation(s)
- K Paul
- Department of Internal Medicine III, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - S Franke
- Department of Internal Medicine III, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - J Nadal
- Institute of Medical Biometry, Informatics and Epidemiology at Rhenish Friedrich-Wilhelm University, Bonn, Germany
| | - M Schmid
- Institute of Medical Biometry, Informatics and Epidemiology at Rhenish Friedrich-Wilhelm University, Bonn, Germany
| | - A Yilmaz
- Department of Internal Medicine II, Division of Cardiology, Elisabeth Klinikum Schmalkalden GmbH, Schmalkalden, Germany
| | - D Kretzschmar
- Department of Internal Medicine I, Division of Cardiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - B Bärthlein
- Chair of Medical Informatics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - S Titze
- Department of Nephrology and Hypertension, University of Erlangen-Nürnberg, Erlangen, Germany
| | - A Koettgen
- Department of Medicine IV, University Hospital Freiburg, Freiburg, Germany
| | - G Wolf
- Department of Internal Medicine III, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - M Busch
- Department of Internal Medicine III, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
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