A Newly Estimated Glomerular Filtration Rate Is Independently Associated with Arterial Stiffness in Japanese Patients

Kinetics of the hepatitis B core-related antigen and treatment responses in chronic hepatitis B patients treated with tenofovir alafenamide

AIM

An association between hepatitis B core-related antigen (HBcrAg) kinetics and hepatocarcinogenesis during nucleoside (t)id analog (NA) treatment has recently been reported. HBcrAg kinetics and factors associated with HBcrAg response during tenofovir alafenamide (TAF) administration remain unclear. In this multicenter retrospective study, we aimed to clarify the efficacy and safety of TAF in treatment-naïve patients with chronic hepatitis B, focusing on the reduction in HBcrAg levels.

METHODS

Patients were treated with TAF monotherapy for 96 weeks, and the kinetics of HBcrAg during treatment and the factors associated with HBcrAg response (defined as a change in HBcrAg of -1 log IU/mL from baseline) were evaluated.

RESULTS

The study population comprised 241 patients, 36.9% of whom were HBeAg-positive. The median baseline HBcrAg level was 4.7 log IU/mL. The median change in HBcrAg from baseline was -1.1 log IU/mL at 96 weeks after treatment. The HBcrAg response rate at 96 weeks was 56.6% (43/76). Multivariate analysis revealed high alanine transaminase level as an independent baseline factor associated with HBcrAg response at 96 weeks of treatment (p = 4.53 × 10-6). No correlation was found between the HBcrAg and hepatitis B surface antigen kinetics in patients treated with TAF monotherapy.

CONCLUSIONS

In TAF monotherapy for patients with chronic hepatitis B, HBcrAg levels were significantly decreased and baseline alanine transaminase level is an important factor associated with HBcrAg reduction. As no correlation was found between HBcrAg and reduced hepatitis B surface antigen levels in this study, HBcrAg kinetics in addition to hepatitis B surface antigen may need to be monitored during TAF treatment.

Effect of Congenital or Acquired Renal Mass Reduction on Arterial Stiffness

BACKGROUND

The changes in kidney functions, adversely affect the cardiovascular system. The aim of this study was to investigate whether arterial stiffness (AS), an indicator of subclinical atherosclerosis, was affected in patients with congenital or acquired reduced renal mass.

METHODS

In this prospective study, a total 135 patients (mean age 43.4±8.5 years and 71.9% female) with congenital unilateral small/non-functioning kidney or unilateral agenesis or with unilateral nephrectomy were included. As control group, 44 healthy individuals with similar age and gender (mean age, 42.5±7.1 year and 61.4% female) were included. Estimated glomerular filtration rate (eGFR) was calculated by Modification of Diet in Renal Disease formula. Official blood pressures (BP) and 24-h ambulatory non-invasive BP of both groups were measured. AS was assessed with pulse wave velocity (PWV) by using Mobile-O-Graph NG arteriograph device using oscillometrical method.

RESULTS

There was no difference in terms of BP parameters and body mass index between groups. eGFR values of control group and study group were 93±19ml/min/1.73m² and 89±28ml/min/1.73m², respectively (p=0.379). Compared with control group, the study group had higher PWV values (6.72±1.11m/sec vs 6.29±0.75m/sec, p=0.018). In linear regression analysis, PWV was found to be correlated with age (β=0.752, p<0.001), and daytime ambulatory systolic BP (β=0.345, p<0.001).

CONCLUSION

Our study showed that AS was increased in patients with reduced renal mass and this increase in AS was related to age and systolic BP. No relation was determined between AS and eGFR. This article is protected by copyright. All rights reserved.

Kidney Function and Aortic Stiffness, Pulsatility, and Endothelial Function in African Americans: The Jackson Heart Study

Rationale & Objective

The relation of vascular stiffness, endothelial function, and kidney function is incompletely elucidated in African Americans. Our hypothesis was that increased vascular stiffness and endothelial dysfunction are associated with low estimated glomerular filtration rate (eGFR) and albuminuria in African Americans.

Study Design

Cross-sectional cohort analysis of data from the Jackson Heart Study.

Settings & Patients

2,244 Jackson Heart Study participants (2012-2017 after Exam 3) who had undergone noninvasive hemodynamic assessment using arterial tonometry.

Predictors

Baseline carotid-femoral pulse wave velocity, pulsatile hemodynamics forward wave amplitude, and hyperemic brachial artery flow were measured. Reduced eGFR was defined as eGFR between 15 and 60 mL/min/1.73 m².

Outcomes

Prevalent albuminuria, urinary albumin-creatinine ratio.

Analytical Approach

2-sample t test for continuous variables and χ² test for categorical variables in addition to logistic and linear regression models to assess the risk for chronic kidney disease with each proposed hemodynamic variable.

Results

Among 2,244 participants, mean age was 66 ± 11 years and 64% were women. Reduced eGFR was present in 233 (10.4%), and elevated urinary albumin-creatinine ratio, in 232 (10.4%). In multivariable-adjusted analyses, higher carotid-femoral pulse wave velocity was associated with the presence of reduced eGFR (OR, 1.37 [95% CI, 1.08-1.75] per SD; P = 0.01) and with prevalent albuminuria (OR, 1.66 [95% CI, 1.32-2.11]; P < 0.001). Higher forward wave amplitude was significantly associated with prevalent albuminuria (OR, 1.37 [95% CI, 1.14-1.65]; P = 0.001).

Limitations

Cross-sectional analyses cannot inform causality.

Conclusions

Higher arterial stiffness and pulsatility are associated with higher odds of reduced eGFR in African Americans. Future studies should focus on whether improving arterial stiffness contributes to kidney protection in African Americans.

Utility of Geriatric Nutritional Risk Index in Patients with Chronic Kidney Disease: A Mini-Review

Chronic kidney disease (CKD) is one of the most significant risk factors for cardiovasculardisese. Malnutrition has been recognized as a significant risk factor for cardiovascular disease in patients with CKD, including those on chronic dialysis. Current studies showed higher all-cause and cardiovascular mortality rates in patients with CKD and malnutrition. Geriatric nutritional risk index (GNRI), a simple and validated nutritional screening measure for both elderly people and patients on dialysis, is based only on three objective parameters: body weight, height, and serum albumin level. Recently, we demonstrated that the cutoff GNRI for predicting all-cause and cardiovascular mortality was 96 in patients on hemodialysis. Moreover, together with left ventricular hypertrophy and low estimated glomerular filtration rate, the utility of GNRI as a significant determinant of cardiovascular events was demonstrated in non-dialysis-dependent patients with CKD. In the present review, we summarize available evidence regarding the relationship of GNRI with all-cause and cardiovascular mortality in patients with CKD including those on dialysis.

Role of increased central arterial stiffness in macro and microvascular damage in patients with coronary artery disease

BACKGROUND

Patients with heart disease frequently have renal dysfunction manifested by a decrease in glomerular filtration rate (GFR) and / or increase of albuminuria.

OBJECTIVES

The objective was to study the possible role of increased aortic stiffness in the presence and extent of coronary artery disease (CAD) and kidney dysfunction in a group of patients with suspected CAD.

PATIENTS AND METHODS

We studied forty-eight patients undergoing coronariography for suspected coronary disease (CAD). Using applanation tonometry on the radial artery and applying a transfer function, central blood pressure values were calculated. The study of aortic stiffness was done by determining the carotid-femoral pulse velocity (Pv_c-f).

RESULTS

Of the 48 patients, 11 had no significant coronary lesions, 24 showed significant lesions in 1 or 2 coronary arteries and 13 in ≥ 3 arteries. The group with a higher degree of CD had significantly higher cPP values than the group without CD. The Pv_c-f increased progressively and significantly with the degree of CD. The logistic regression showed that Pv_c-f independently predicted the presence of CD. The relative risk of CD increased 2.5 times for each meter of increase in Pv_c-f. The GFR was negatively and significantly correlated with age and Pv_c-f was associated with albuminuria.

CONCLUSIONS

In patients with stable CD, Pv_c-f, expression of aortic stiffness, is independently associated with the existence of CD and its degree of extension. The increase in arterial stiffness also participates in the decrease in GFR and in the increase in albuminuria.

Sequential therapy from entecavir to tenofovir alafenamide versus continuous entecavir monotherapy for patients with chronic hepatitis B

Background and Aim

Although tenofovir alafenamide (TAF), as well as entecavir (ETV), is widely used as first‐line treatment for patients with chronic hepatitis B, there are only a few studies comparing sequential therapy from ETV to TAF and continuous ETV monotherapy in patients with maintained virologic response to ETV.

Methods

In a retrospective multicenter study, we investigated the efficacy and safety of sequential therapy from ETV to TAF (ETV‐TAF group) and compared them with continuous ETV monotherapy (ETV group), using propensity score matching, in chronic hepatitis B patients.

Results

From 442 patients, we analyzed 142 patients from each group comprising 71 patients matched for several data, including age, HBV genotype, hepatitis B envelope antigen, cirrhosis, alanine aminotransferase, platelet count, prior ETV monotherapy period, and hepatitis B surface antigen (HBsAg) change during prior ETV monotherapy. In the ETV‐TAF group, HBsAg levels significantly decreased from baseline to 48 weeks after switching to TAF (−0.02 log IU/mL, P = 0.038). HBcrAg levels also significantly decreased after switching to TAF (−0.1 log IU/mL, P = 0.004). However, there were no significant differences in the reduction of HBsAg and HBcrAg levels between the ETV‐TAF and ETV groups. There was no significant difference in the change of estimated glomerular filtration rate levels from baseline to 48 weeks between the two groups.

Conclusions

The present study indicated that the efficacy, especially of the HBsAg‐reducing action, and safety of sequential therapy from ETV to TAF were similar to those of continuous ETV monotherapy among chronic hepatitis B patients with maintained virologic response to ETV.

Pulse wave velocity is a new predictor of acute kidney injury development after off-pump coronary artery bypass grafting

Background

Brachial-ankle pulse wave velocity (baPWV) is the simple, non-invasive, gold-standard method for assessing arterial stiffness. However, baPWV has been shown to be associated with renal dyfunction, with a few reports demonstrating an association between baPWV and postoperative acute kidney injury (AKI) among surgical patients.

Methods

We retrospectively analyzed preoperative baPWV data that were prospectively collected from 164 patients who underwent off-pump coronary artery bypass grafting (CABG) between April 2013 and July 2019 (mean age: 66.2 ± 10.3 years, 29.3% females). Primarily, baPWV was investigated as an independent predictor of postoperative AKI development; secondarily, the patients were divided into high and low PWV groups according to the optimal baPWV cut-off value. Postoperative complications, mortality, and mid-term survival were compared between the two groups.

Results

AKI developed in 30 patients (18.3%). Univariate analysis showed that AKI was significantly associated with baPWV (20.2±7.3 vs. 16.2±2.8 m/s, p < 0.001), age, preoperative serum creatinine, and EuroSCORE. Multivariable logistic regression analysis revealed baPWV as independently associated with postoperative AKI even after adjustment for preoperative creatinine, old age (> 75 years), hypertension, diabetes under insulin therapy, and EuroSCORE. Moreover, area under the curve (AUC) analysis indicated that PWV can predict AKI better than preoperative creatinine levels (AUC, 0.781 [95% confidence interval, 0.688–0.874] vs. 0.680 [0.568–0.792]). The group-dividing baPWV cut-off value for AKI was 19 m/s. There were no 30-day mortality. The in-hospital mortality rates in the high and the low PWV groups were 2.2% (n = 1) and 0.8% (n = 1), respectively (p = 0.484). Midterm survival rates were not different between the two groups, but the rate of composite neurologic complication composed of stroke and delirium, was higher, and rate of mechanical ventilatory support was longer, in the high PWV group.

Conclusion

Brachial-ankle pulse wave velocity was an independent predictor of postoperative AKI following off-pump CABG, and high baPWVs may affect the composite neurologic outcome and the duration of mechanical ventilatory support.

Switching from entecavir to tenofovir alafenamide versus maintaining entecavir for chronic hepatitis B

Tenofovir alafenamide (TAF) is a newly developed prodrug of tenofovir (TFV). We divided 48 chronic hepatitis B patients who had taken entecavir (ETV) for ≥2 years into two groups: the ETV continuation (n = 24) and the TAF switching (n = 24) groups, and compared the antiviral effects and safety until 48 weeks after the start of the study. There were no significant differences in the alterations in the serum levels of HBs antigen (HBsAg) level between the ETV continuation and the TAF switching groups at 24 or 48 weeks. We also examined the effect of baseline HBsAg level on the decrease of HBsAg during the treatment; in the TAF switching group, the decrease of HBsAg level at 48 weeks was more significant in patients with low baseline HBsAg (<800 IU/mL) than those with high baseline HBsAg ( >800 IU/mL) (change of HBsAg; - 0.029 vs - 0.132 for high and low baseline HBsAg, respectively, P = .007). Also, the effect on renal function was found to be comparable between the TAF switch group and the ETV continuation group. In this study, switching from ETV to TAF may represent higher efficacy for a decrease of HBsAg than a continuation of ETV among the patients with low baseline HBsAg level.

Estimated glomerular filtration rate and arterial stiffness in Japanese population: a secondary analysis based on a cross-sectional study

Background

Evidence regarding the relationship between estimated glomerular filtration rate (eGFR) and arterial stiffness is limited, and the data analysis is not sufficient to clarify the true relationship between the two. We aimed to investigate the relationship between eGFR and brachial-ankle pulse wave velocity (baPWV) in Japanese.

Methods

The present study was a cross-sectional study. Nine hundred twelve Japanese men and women, aging 24—84 years old, received a health medical check-up program including the results from baPWV inspection and various standardized questionnaires in a health examination center in Japan. The main outcome measures included eGFR, baPWV, fatty liver and postmenopausal status. Abdominal ultrasonography was used to diagnose fatty liver. Postmenopausal state was defined as beginning 1 year after the cessation of menses.

Results

The average age of the 912 selected participants was 51.5 ± 9.6 years old, and about 57.6% of them were male. The participants’ eGFR distribution was median 69.29 (min 39, max 122.28). The results of multivariate linear regression showed eGFR was not independently associated with baPWV after adjusting potential confounders (β = − 1.11, 95%CI -2.25 to 0.03), this is inconsistent with the result of eGFR (quartile) as a categorical variable (p for trend was 0.038). A non-linear relationship was detected between eGFR and baPWV, whose point was 77.05. The effect sizes and the confidence intervals of the left and right sides of inflection point were − 2.80 (− 4.41 to − 1.19) and 1.84 (− 0.50, 4.17), respectively. Subgroup analysis showed, the change in the elderly population is more pronounced (P for interaction = 0.018; − 2.83 with ≤60 year vs − 6.12 with > 60 year). The same trend was also seen in hypertensive people (P for interaction = 0.018; − 4.55 with hypertension vs − 0.82 with non-hypertension).

Conclusion

The relationship between eGFR and baPWV is non-linear. eGFR was negatively related to baPWV when eGFR is less than 77.05.

Impact of baseline estimated glomerular filtration rate on inhospital outcomes of patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: A China acute myocardial infarction registry study

OBJECTIVE

To explore the relationship between inhospital outcomes and different estimated glomerular filtration rates (eGFRs) and determine an optimal eGFR cutoff value for predicting risk in patients with renal insufficiency (RI).

BACKGROUND

RI is a predictor of poor prognosis in patients with myocardial infarction undergoing primary percutaneous coronary intervention (PCI). However, the cutoff value of the eGFR is questionable.

METHODS

We included 10,240 patients with ST segment elevation myocardial infarction (STEMI) undergoing primary PCI from January 2013 to January 2016 who participated in the China Acute Myocardial Infarction registry. RI was defined as eGFR <60 mL/min/1.73 m² . Patients were stratified into five eGFR groups to determine the optimal cutoff value: <30, 30-45, 45-60, 60-90, and > 90 mL/min/1.73 m² .

RESULTS

Overall, 1,112 (10.9%) patients had eGFR <60 mL/min/1.73 m² . Patients with eGFR<60 mL/min/1.73 m² had a significantly higher incidence of all-cause death and major adverse cardiovascular and cerebrovascular events (MACCEs) than those with eGFR >60 mL/min/1.73 m² . Occurrence trend test analysis revealed that the incidence of inhospital all-cause death and MACCEs increased as the eGFR decreased. In logistic multivariate-adjusted analysis, eGFR <45 mL/min/1.73 m² was associated with a higher incidence of all-cause death and MACCEs than eGFR >90 mL/min/1.73 m² .

CONCLUSIONS

RI is common among patients with STEMI undergoing primary PCI. A low eGFR is an indicator of worse inhospital prognosis. We suggest an eGFR cutoff value of 45 mL/min/1.73 m² to predict inhospital deaths and MACCEs.

Sex differences in associations of cardio-ankle vascular index with left ventricular function and geometry

The cardio-ankle vascular index (CAVI) is a measure of global arterial stiffness. We hypothesized that CAVI is associated with left ventricular (LV) function and geometry in individuals without structural heart disease. We measured CAVI in 600 participants (mean age 60.3±14.6 years, 54% men) without history of atherosclerotic cardiovascular disease who were referred for transthoracic echocardiography. Linear regression analysis was used to assess the association of CAVI with LV function (peak mitral annular systolic s' and early diastolic velocity e') and structure (LV mass index (LVMI) and relative wall thickness (RWT)). Older age, male sex, lower body mass index, history of hypertension, diabetes and chronic kidney disease were each associated with a higher CAVI (adjusted R² = 0.56, all p < 0.01). A higher CAVI was associated with lower s' and e', and greater RWT, independent of age, sex, systolic BP and other conventional cardiovascular risk factors (all p < 0.05); a borderline association of higher CAVI with greater LVMI ( p = 0.05) was present. Associations with e', s' and RWT were similar in women and men but the association with LVMI was stronger in women than in men ( p for interaction = 0.02, multivariable-adjusted β = 6.92, p < 0.001 in women; p > 0.1 in men). In conclusion, a higher CAVI, a measure of global arterial stiffness, is associated with worse LV systolic function, worse diastolic relaxation, and greater LV RWT in both men and women, and with LVMI in women.

Malnutrition, renal dysfunction and left ventricular hypertrophy synergistically increase the long-term incidence of cardiovascular events

Although malnutrition indicates an unfavorable prognosis in some clinical settings, the synergistic impact of nutritional state, renal dysfunction and left ventricular hypertrophy (LVH) on cardiovascular events is unknown. Among 338 patients aged 40-80 years who underwent echocardiographic evaluation between 2003 and 2005, 161 patients who were followed for >7 years were recruited. Malnutrition was defined as a geriatric nutritional risk index (GNRI) of ⩽96. The mean patient age was 63.5±9.2 years; the mean estimated glomerular filtration rate (eGFR) was 72.9±18.7 ml min(-1) per 1.73 m(2); the mean LV mass index was 114±33 g m(-)(2); and the mean GNRI was 100.4±6.0. Among the patients, 25% (n=40) had an eGFR of <60 ml min(-1) per 1.73 m(2), 29% (n=46) exhibited chronic kidney disease (CKD) and 37% (n=59) had LVH. During the follow-up period (median: 96 months), cardiovascular events were observed in 15 patients (9%). Kaplan-Meier curves showed a significantly higher incidence of cardiovascular events in patients with an eGFR of <60 ml min(-1) per 1.73 m(2) (log-rank P=0.007), a GNRI of ⩽96 (P=0.003) or LVH (P=0.010). In a Cox regression analysis, eGFR, LVH and GNRI were independent determinants of cardiovascular event incidence after adjusting for age, gender and the presence of hypertension and diabetes. Furthermore, the combination of LVH and lower GNRI was significantly associated with a higher rate of cardiovascular events not only in all patients but also in patients with CKD. In conclusion, malnutrition, low eGFR and LVH were independent determinants of cardiovascular event incidence; they synergistically increased rates of these events in the long term. The evaluation and management of LVH progression and the improvement of nutritional status are critical for preventing cardiovascular complications even in non-dialysis patients.

Arterial stiffness and increased cardiovascular risk in chronic kidney disease

Chronic kidney disease (CKD) is a global public health problem. Cardiovascular disease (CVD) is a common comorbidity and a major cause of mortality in CKD population. While CVD-related mortality is relatively uncommon in young population, it accounts for most deaths in young CKD adults. There are numerous risk factors for CVD in CKD patients including conventional (hypertension, diabetes, dyslipidemia) and nonconventional (oxidative stress, inflammation, anemia, mineral metabolism disorder) factors. Recent studies have placed great emphasis on the association of arterial stiffness (AS) and CVD. AS is traditionally known as an aging marker of the artery; however, increased AS is observed in young and even in pediatric CKD patients; it is also shown that AS progresses in consistent with kidney function decline. Unparallel AS in young CKD population and excessive risk of CVD in young CKD adults show an indication that AS probably offers one of the underlying mechanisms for linking CKD and CVD. AS in CKD patients has multifactorial causes. Comorbidities such as hypertension, diabetes, dyslipidemia, and mineral metabolism disorder which are risk factors for CVD also show great contribution to AS in CKD patients. Increased systolic blood pressure and decreased diastolic blood pressure resulting from AS cause elevated ventricular afterload, lead to impaired coronary perfusion, myocardial ischemia, and ventricular hypertrophy, and consequently develop into CVD event. In this review, we summarized the role of AS in CKD and CVD, aiming to explore the linkage of AS between CKD and CVD.

Association between urinary 8-OHdG and pulse wave velocity in hypertensive patients with type 2 diabetes mellitus

INTRODUCTION

Oxidative stress, assessed using 8-hydroxy-2'-deoxyguanosine (8-OHdG), can be associated with arterial stiffness in patients with type 2 diabetes mellitus (T2DM) and/or hypertension (HT). We investigated the correlation between urinary 8-OHdG and pulse wave velocity (PWV) in hypertensive and non-hypertensive T2DM patients with fair glycaemic control to determine the clinical significance of HT as a comorbidity in the diabetic state.

METHODS

Clinical data, including traditional cardiovascular risk factors, diabetic complications, prescribed agents, urinary 8-OHdG level and brachial-ankle PWV, was collected from T2DM patients with and without HT.

RESULTS

There were 76 patients (45 men, 31 women; mean age 61 years; mean haemoglobin A1c level 6.5%) in the study cohort. T2DM patients with HT had significantly higher mean PWV than patients without HT (1,597 cm/s vs 1,442 cm/s; p < 0.05). Patients with HT showed no significant difference in 8-OHdG levels relative to those without HT (median 7.9 ng/mg creatinine vs 8.8 ng/mg creatinine; p > 0.05). Simple linear correlation and stepwise multiple linear regression analyses revealed that 8-OHdG levels correlated independently, significantly and positively with PWV among T2DM patients with HT (r = 0.33, p < 0.05; β= 0.23, p < 0.05). No significant correlation was observed between 8-OHdG levels and PWV among T2DM patients without HT.

CONCLUSION

In the hypertensive state, oxidative stress can be responsible for the development of arterial stiffness, even in patients with fairly well controlled T2DM. Oxidative stress management may be necessary for the prevention of cardiovascular disease in this population.

The association of metabolic syndrome and its components with brachial-ankle pulse wave velocity in south China

BACKGROUND

Brachial-ankle pulse wave velocity (baPWV) can reflect both central and peripheral arterial stiffness. Metabolic syndrome (MS) and its components may increase arterial stiffness and the risks of cardiovascular diseases. However, the correlation of MS and its components with arterial stiffness has not been not well studied. The aim of this study was to investigate the correlation between MS/its components and arterial stiffness by the measurement of baPWV in south China population.

METHODS

A total of 8599 subjects were selected from those who underwent health examination in our hospital. MS was defined by Joint Scientific Statement. BaPWV, waist circumference, blood pressure (BP), fasting plasma glucose (FPG), lipid profile and serum uric acid (UA) were measured. The relationship between baPWV and MS/its components was analyzed.

RESULTS

BaPWV was significantly higher in the subjects with MS than in those without MS (P < 0.001 for both genders). By multivariate regression analysis, all the metabolic components were correlated to baPWV in the male and female subjects except low HDL-C and high UA in the male group. BP and FPG had the strongest correlation factors. The values of baPWV were positively correlated with the advanced age (P < 0.001) and the values of the MS components, and this correlation was stronger in the females than in the males (P < 0.001).

CONCLUSION

Metabolic syndrome and its individual components were positively correlated with baPWV. Monitoring baPWV is helpful to identify early stage of arterial stiffness in those people with MS.

Ankle-brachial blood pressure index predicts cardiovascular events and mortality in Japanese patients with chronic kidney disease not on dialysis

The ankle-brachial blood pressure index (ABPI) has been recognized to have a predictive value for cardiovascular (CV) events and mortality in general or dialysis populations. However, the associations between ABPI and those outcomes have not been fully investigated in predialysis patients. The present study aimed to clarify the relationships between ABPI and both CV events and mortality in Japanese chronic kidney disease (CKD) patients not on dialysis. In this prospective observational study, we enrolled 320 patients with CKD stages 3-5 who were not on dialysis. At baseline, ABPI was examined and a low ABPI was defined as <0.9. CV events and all-cause deaths were examined in each patient. A Cox proportional hazards model was applied to determine the risk factors for CV events, as well as for mortality from CV and all causes. The median follow-up period was 30 months. CV events occurred in 56 patients and all-cause deaths occurred in 48, including 20 CV deaths. Multivariate analysis showed that age and low ABPI were risk factors for CV events. It was demonstrated that age, a history of cerebrovascular disease and low ABPI were determined as independent risk factors for CV mortality. In addition, age, body mass index and low ABPI were independently associated with all-cause mortality. In patients with CKD, low ABPI during the predialysis period is independently associated with poor survival and CV events, suggesting the usefulness of measuring ABPI for predicting CV events and patient survival in CKD.

Pulse wave velocity and neutrophil gelatinase-associated lipocalin as predictors of acute kidney injury following aortic valve replacement

BACKGROUND

Accurate prediction, early detection and treatment of acute kidney injury (AKI) are essential for improving post-operative outcomes. This study aimed to examine the role of aortic stiffness and neutrophil gelatinase-associated lipocalin (NGAL) as predictors of AKI or need for early medical renal intervention following aortic valve replacement (AVR).

METHODS

Aortic pulse wave velocity and plasma NGAL were measured pre-operatively in recruited patients undergoing AVR for aortic stenosis (AS). Plasma NGAL was also measured at 3 and 18-24 hours after cardiopulmonary bypass (CPB). AKI was defined using RIFLE criteria. Early medical renal intervention included diuretics or dopamine infusion exclusively for renal causes.

RESULTS

Fifty-three patients aged 71 ± 9 years were included. Sixteen (30%) developed AKI (AKI-Yes) and 24 patients (45%) received early medical intervention (Intervention-Yes). There was no significant difference in the demographic, clinical or operative characteristics between the two groups for either outcome. PWV did not significantly correlate with AKI (r = 0.12, P = 0.13) or early intervention (r = 0.18, P = 0.18). At 3 h post-CPB, plasma NGAL was a much stronger predictor of both AKI and the need for early medical intervention than conventional markers such as creatinine (AKI: AUC 83%, 95% CI 0.70-0.95 vs. AUC 65%, 95% CI 0.47- 0.82; Medical intervention: AUC 84%, 95% CI 0.72-0.96 vs. AUC 56%, 95% CI 0.38-0.73). Post-CPB (3 hr) plasma NGAL was also significantly associated with AKI (r = 0.68, P < 0.001) at levels above 150 ng/ml; and significantly associated with early intervention (r = 0.64, P < 0.001) above 136 ng/ml. Simple linear regression showed no relationship between PWV and NGAL levels.

CONCLUSION

Aortic PWV does not correlate significantly with post-operative AKI or plasma NGAL levels in surgical AS patients. Post-operative NGAL is however an early and powerful predictive biomarker of both post-operative AKI and the need for early medical renal intervention and should consequently be considered in prediction models for AKI after cardiac surgery.

Deterioration in renal function is associated with increased arterial stiffness

BACKGROUND

Higher levels of baseline pulse wave velocity (PWV) have been associated with longitudinal decline in renal function in patients with kidney disease. We examined longitudinal decline in renal function in relation to levels of PWV. We hypothesized that longitudinal decline in renal function in a community-based, nonclinic sample would be associated with higher levels of PWV.

METHODS

We conducted a 4-5 year longitudinal study with 482 community-living individuals free from acute stroke, dementia, and end-stage renal disease (mean age = 60.9 years; 59% women; 93.2% white; 10% with diabetes mellitus; mean estimated glomerular filtration rate (eGFR) = 79.2 ml/min/1.73 m2). Multiple linear regression analyses were used to examine the association between changes in renal function (eGFR and serum creatinine) from baseline to follow-up and PWV levels at follow-up, the outcome measure. Regression coefficients were adjusted for age, sex, education, race/ethnicity, weight, activity level, mean arterial pressure, treatment of hypertension, and cardiovascular risk factors.

RESULTS

With adjustment for covariables, decline in renal function was associated with higher levels of PWV over a mean follow-up of 4.68 years.

CONCLUSIONS

Decline in renal functioning from baseline levels measured 4-5 years before measurement of PWV is related to higher levels of PWV in a community sample.

The Prevalence of the Risk Factors for Atherosclerosis among Type 2 Diabetic Patients Is Greater in the Progressive Stages of Chronic Kidney Disease

BACKGROUND/AIMS

The prevalence of the risk factors for atherosclerosis, other than diabetes mellitus, among type 2 diabetic patients with different stages of chronic kidney disease (CKD) determined by glomerular filtration rate (GFR) was investigated.

METHODS

The prevalence of ten risk factors (age ≥65 years, history of smoking, male gender, obesity, albuminuria, hypertension, hypercholesterolemia, hypo-HDL-cholesterolemia, hyperuricemia and anemia) was determined in 2,107 Japanese type 2 diabetic patients with different stages of CKD (six stages according to GFR).

RESULTS

The risk factors for age ≥65 years and male gender were found in 49 and 62% of the study subjects, respectively. The percentages of subjects with a current history of smoking, obesity, albuminuria, hypertension, hypercholesterolemia, hypo-HDL-cholesterolemia, hyperuricemia and anemia were 35, 44, 47, 70, 61, 13, 21 and 26%, respectively. The prevalence of age ≥65 years, male gender, albuminuria, hypertension, hypo-HDL-cholesterolemia, hyperuricemia and anemia was greater in the later stages of GFR, whereas the prevalence of hypercholesterolemia and obesity did not differ between stages. The prevalence of a current history of smoking was lower in the later stages of GFR. The cumulative number of risk factors increased from 3.1 to 6.8 in the later stages of GFR.

CONCLUSION

Among type 2 diabetic patients with CKD, the total number of risk factors increases with the progression of renal dysfunction. It is important to pay attention to newly recognized risk factors for hyperuricemia and anemia, in addition to hypertension, albuminuria and hypo-HDL-cholesterolemia, in monitoring diabetic patients with later stages of CKD.

Brachial-ankle pulse wave velocity and systolic time intervals in risk stratification for progression of renal function decline

BACKGROUND

Cardiovascular dysfunction was associated with progression of renal function decline. This study was to assess whether combination of brachial-ankle pulse wave velocity (baPWV) and the ratio of brachial pre-ejection period (bPEP) to brachial ejection time (bET) was independently associated with progression of renal function decline.

METHODS

We included 363 patients and classified them into four groups according to median values of bPEP/bET and baPWV. Groups 1, 2, 3, and 4 were patients with bPEP/bET and baPWV below the median, bPEP/bET above but baPWV below the median, bPET/bET below but baPWV above the median, and bPET/bET and baPWV above the median, respectively. The decline in renal function was assessed by the estimated glomerular filtration rate (eGFR) slope and the renal end points were defined as commencement of dialysis or ≥25% decline in eGFR. The relative risk of renal end points was analyzed by Cox regression method.

RESULTS

The eGFR slope was significantly associated with baPWV, bPEP/bET, and patients in groups 2, 3, and 4 (vs. group 1) (P < 0.006). Multivariate forward Cox regression analysis showed that high baPWV, high bPEP/bET, and patients in groups 2, 3, and 4 (vs. group 1) (P ≤ 0.047) were independent predictors of renal end points.

CONCLUSIONS

Our results demonstrated higher baPWV and bPEP/bET were associated with faster renal function decline and adverse renal end points. Dividing patients into four groups using these two parameters might be useful in risk stratification for progression of renal function decline.

Structural and biochemical characteristics of arterial stiffness in patients with atherosclerosis and in healthy subjects

Arterial stiffness is an independent predictor of vascular morbidity and mortality in patients with atherosclerosis. Angiographic score (ASc) reflects severity of atherosclerosis in patients with peripheral arterial disease (PAD). Osteopontin (OPN) and oxidized low-density lipoprotein (oxLDL) are involved in the pathogenesis of atherosclerosis. The aim of the present study was to evaluate the association between arterial stiffness, ASc, serum OPN and oxLDL in patients with symptomatic PAD, and in clinically healthy subjects. We studied 79 men with symptomatic PAD (mean age 64±7 years) and 84 healthy men (mean age 63±8 years). Calculation of the ASc was based on severity and location of atherosclerotic lesions in the arteries of the lower extremities. Aortic pulse wave velocity (aPWV) was evaluated by applanation tonometry using the Sphygmocor device. Serum OPN and oxLDL levels were determined by enzyme-linked immunosorbent assay. The aPWV (10±2.4 vs. 8.4±1.7 (m s(-1)); P<0.001), OPN (75 (62.3-85.8) vs. 54.8 (47.7-67.9) (ng ml(-1)); P<0.001) and oxLDL (67 (52.5-93.5) vs. 47.5 (37-65.5); P<0.001) were different for the patients and for the controls. In multiple regression models, aPWV was independently determined by ASc, log-OPN, log-oxLDL and estimated glomerular filtration rate in the patients (R2=0.44; P<0.001) and by log-OPN, log-oxLDL, age and heart rate in the controls (R2=0.38; P<0.001). The independent relationship of a PWV with serum levels of OPN and oxLDL in the patients with PAD and in the controls indicates that OPN and oxLDL might influence arterial stiffening in patients with atherosclerosis and in clinically healthy subjects.

Arterial stiffness in patients with chronic kidney disease

INTRODUCTION

Brachial-ankle pulse wave velocity (baPWV) was a marker of arterial stiffness, and increased baPWV was associated with renal function progression in patients with chronic kidney disease (CKD). However, there was no study to evaluate the longitudinal change of baPWV in patients with CKD. The aims of this study were to assess whether there was a longitudinal change in baPWV and to find out the determinants of this change in patients with CKD.

METHODS

This study enrolled 52 patients with CKD stages 3 to 5 from outpatient Department of Internal Medicine. The values of baPWV were measured by an ankle-brachial index-form device at baseline and at 2-year follow-up. Changes of parameters (Δ) were used to evaluate the relationship between biological markers, blood pressures, medications and baPWV.

RESULTS

The values of baPWV decreased during the 2-year follow-up (2108.4 ± 893.9 and 1897.1 ± 472.4; P = 0.016). There were also significant reductions in systolic and diastolic blood pressures during the 2-year follow-up, and Δsystolic blood pressure and baseline baPWV were the major determinants of ΔbaPWV.

CONCLUSIONS

The present longitudinal study showed that the values of baPWV decreased during the 2-year follow-up, and the major determinants of ΔbaPWV were Δsystolic blood pressure and baseline baPWV in patients with CKD. Good control of systolic blood pressure may be associated with the regression of baPWV in patients with CKD.

Impact of decreased estimated glomerular filtration rate on Japanese acute stroke and its subtype

OBJECTIVE

Patients with chronic kidney disease (CKD) are at a high risk for cardiovascular diseases including stroke. However, the characteristics of the stroke subtypes in patients with CKD remain to be determined.

METHODS

We investigated the associations between stroke subtypes and estimated glomerular filtration rate (eGFR), and traditional risk factors in 451 (males, 239; mean age, 71.1 y) acute stroke patients at our hospital between 2006 and 2010.

RESULTS

The stroke subtype was cardiogenic cerebral embolism in 129 (29%), cerebral hemorrhage in 104 (23%), unclassified cerebral infarction in 65 (14%), lacunar infarction in 65 (14%), subarachnoid hemorrhage in 41 (9%), atherothrombosis in 30 (7%), and transient ischemic attacks in 17 (4%). Among the 451 patients, 134 (30%) had CKD with eGFR <60 mL/min/1.73 m². Compared with a group without CKD, mean age (75.9 vs. 69.0 years, p<0.05), the prevalence of atrial fibrillation (AF) (44% vs. 21%, p<0.01) and a history of cardiovascular disease (37% vs. 19%, p<0.01) were significantly higher in that with CKD. A comparison of stroke subtypes revealed a significantly higher incidence of cardiogenic cerebral embolism (36% vs. 26%, p<0.05) in the group with, than without CKD.

CONCLUSION

We showed the prevalence of CKD in about 30% of acute stroke patients, and those patients were older, had a significantly higher prevalence of AF and a higher rate of cardiogenic cerebral embolism compared with patients without CKD. Thus, strict control of blood pressure and management of AF should be important to prevent stroke among patients with CKD.

The balance of fetuin-A and osteoprotegerin is independently associated with diastolic dysfunction in hemodialysis patients

Fetuin-A and osteoprotegerin (OPG) are arterial calcification regulators, which are related to cardiovascular survival in hemodialysis patients. We hypothesized that a balance of these calcification regulators might mediate the progression of left ventricular (LV) diastolic dysfunction in hemodialysis patients. We recruited 63 hemodialysis patients and measured their serum fetuin-A, OPG, arterial stiffness, aortic calcification and echocardiographic parameters, including the transmitral early diastolic velocity/tissue Doppler mitral annular early diastolic velocity ratio (E/E'), and analyzed the relationships between these variables. Fetuin-A levels were significantly and negatively correlated with the ankle-brachial pulse wave velocity (baPWV), aortic calcification score (AOCS), left atrial volume index (LAVI), LV mass index (LVMI) and E/E'. OPG levels and the ratio of OPG to fetuin-A levels were significantly and positively correlated with the baPWV, AOCS, LAVI and E/E'. A stepwise multiple regression analysis revealed that E/E' was independently correlated with fetuin-A levels (β=-0.334, P=0.02), OPG levels (β=0.367, P=0.01) and the ratio of OPG to fetuin-A (β=0.295, P=0.04). Categorizing the patients according to their serum fetuin-A and OPG levels revealed that patients with low fetuin-A and high OPG levels had the highest LAVI, LVMI and E/E' values after adjusting for potential confounders. Serum fetuin-A levels negatively reflected, whereas OPG levels and the ratio of OPG to fetuin-A positively reflected an increase in vascular and ventricular stiffness, leading to the aggravation of diastolic dysfunction. Therefore, based on our results, the balance of the tissue calcification regulators fetuin-A and OPG could mediate the progression of LV diastolic dysfunction in hemodialysis patients.

The combination of chronic kidney disease and increased arterial stiffness is a predictor for stroke and cardiovascular disease in hypertensive patients

To clarify the clinical utility of pulse wave velocity (PWV) and chronic kidney disease (CKD) in hypertension, we analyzed the prognostic impact of PWV and CKD on cerebrocardiovascular disease in hypertensive patients. This study consisted of 531 patients with essential hypertension (male/female=292/239, mean age=61.7±12.3, mean follow-up=7.0±3.0 years) and was performed between January 1998 and June 2004. We used questionnaires to assess stroke (n=57), cardiovascular diseases (CVDs; myocardial infarction, angina and congestive heart failure; n=44) and death (n=53) as primary end points. At baseline, we evaluated the carotid-femoral PWV (9.1±1.8 m s(-1)), the glomerular filtration rate and urinary protein excretions. We divided these subjects into those in the highest quartile of PWV and other subjects and into CKD (n=149) and non-CKD (n=458). We evaluated the prognostic influences of PWV and CKD with Kaplan-Meier analysis and Cox's proportional hazard model. PWV in CKD (9.6±1.9 m s(-1)) was higher than in non-CKD (8.8±1.6 m s(-1); P<0.0001), and creatinine was slightly decreased in the highest PWV group (1.09±0.35 mg dl(-1), P<0.0001). On the basis of Kaplan-Meier analysis, the highest PWV group (PWV>10.1 m s(-1); P=0.0003) and the CKD group (P=0.0005) showed significantly higher proportions of stroke and CVD events. In addition, the highest PWV group showed the highest percentage of stroke (P=0.0007), and the CKD group showed the highest proportion of CVD (P<00001). High PWV and CKD were independent predictors for stroke and CVD (P=0.0332) by Cox's proportional hazard model. These data suggest that increased aortic stiffness and CKD may be predictors for stroke and cardiovascular events in hypertensive patients.

Risk of macrovascular disease stratified by stage of chronic kidney disease in type 2 diabetic patients: critical level of the estimated glomerular filtration rate and the significance of hyperuricemia

BACKGROUND

Although a high prevalence of macrovascular disease (MVD) has been reported in patients with stage 3 chronic kidney disease (CKD), few studies have reported its risk with respect to the underlying cause of kidney disease. This study investigated the prevalence of MVD in type 2 diabetic patients with CKD stratified by CKD stage, as defined by estimated glomerular filtration rate (eGFR), as well as the risk factors for MVD.

METHODS

1493 patients with diabetic CKD (1273 males, 220 females) were stratified by CKD stage (stage 1: 39, stage 2: 272, stage 3: 1052, stage 4: 101, stage 5: 29) based on eGFR calculated by the Japanese formula and averaged over 8 months. MVD was defined as one of the following: coronary heart disease (CHD), stroke or arteriosclerosis obliterans (ASO).

RESULTS

The prevalence of MVD was 18.6%. A significant increasing trend in MVD prevalence was observed from stage 3 (17.78%) to 4 (52.48%). According to a receiver operating characteristic curve analysis on MVD prevalence in stage 3 patients, an eGFR of 46.4 ml/min/1.73 m(2) was determined to be a critical cut-off level. Proteinuria, eGFR <60 ml/min/1.73 m(2) and hyperuricemia were independent risk factors for MVD.

CONCLUSIONS

In patients with diabetic CKD, a significant increase in MVD prevalence was observed from stage 3 to 4. An eGFR of 46.4 ml/min/1.73 m(2) is a critical level that affects MVD prevalence. From the perspective of cardiorenal association, CKD stage 3 should be divided into two substages. As hyperuricemia is related to an increased risk of MVD, uric acid control may be important in reducing MVD risk in diabetic CKD.

Echocardiographic assessment of the cardio-renal connection: is left ventricular hypertrophy or diastolic function more closely correlated with estimated glomerular filtration rate in patients with cardiovascular risk factors?

Although left ventricular (LV) hypertrophy and diastolic function assessed by echocardiography and chronic kidney disease (CKD) have been established as predictors of cardiovascular events in hypertensive patients, the relationships between the echocardiographic parameters and renal function have not been fully examined. We examined which echocardiographic parameter correlates best with estimated glomerular filtration rate (eGFR) in patients with cardiovascular risk factors. Enrolled in the study were 309 patients (mean age 67 +/- 13 y) with cardiovascular risk factors. Echocardiography was performed to measure left ventricular mass index (LVMI) as an index of LV hypertrophy. Transmitral early to atrial velocity (E/A) ratio and peak early diastolic mitral annular velocity (E') were measured as indexes of LV diastolic function. E/E' was calculated as a parameter of LV preload. eGFR was measured using the equation proposed by the Japanese Society of Nephrology. The correlations of LVMI (r = -0.333, p < 0.001) and hypertension (r = -0.326, p < 0.001) to eGFR were closer than those of E' (r = 0.276, p < 0.001) and E/A (r = 0.224, p < 0.001) to eGFR. Stepwise regression analysis showed that hypertension (beta coefficient = -0.211, p < 0.001) and LVMI (beta coefficient = -0.206, p < 0.001) were independently associated with eGFR. The E/E' increased with a decrease in eGFR, and E/E' in CKD stage 5 (16.0 +/- 6.8) was significantly higher than that in patients in whom eGFR > or = 90 mL/min/1.73 m(2) (10.5 +/- 4.5) (p < 0.001). Left ventricular diastolic function may be influenced by the increase in LV preload due to progression of CKD stage. Therefore, LV hypertrophy may be superior to LV diastolic dysfunction in predicting low eGFR in patients with CKD using echocardiography.

Augmentation pressure and subendocardial viability ratio are associated with microalbuminuria and with poor renal function in type 1 diabetes

In this report we explore the hypothesis that arterial stiffness indices, which predict cardiovascular disease, might also correlate with microalbuminuria (MA) in type 1 diabetes (T1D), and thus have potential for risk assessment. Three pulse wave analysis (PWA) indices, measured using the SphygmoCor device, were evaluated on 144 participants with childhood-onset T1D. These variables, augmentation index (AIx), augmentation pressure (AP) and subendocardial viability ratio (SEVR, an estimate of myocardial perfusion) (an estimate of myocardial perfusion), were each analysed cross-sectionally in relation to both prevalent MA (defined as albuminuria excretion rate (AER) = 20-199 microg/min) and renal function (assessed by both eGFR and serum cystatin C). AP and SEVR were each univariately associated with AER, estimated glomerular filtration rate (eGFR) and cystatin C. Lower SEVR was also independently related to the presence of MA and degree of albuminuria within normo- and microalbuminuric participants. SEVR, not AP, was independently and negatively associated with both measures of renal function. SEVR is a better predictor of AER than brachial blood pressure measures in those without clinical proteinuria, indicating a potential use for PWA in the early detection of individuals at risk for cardiovascular and renal complications of T1D.

Selective association of endogenous ouabain with subclinical organ damage in treated hypertensive patients

According to previous studies endogenous ouabain (EO) closely correlates with high blood pressure, congestive heart failure and kidney disease in humans. Our aims were to analyse associations between plasma, urinary EO level and various markers of cardiovascular damage in treated hypertensive patients. Forty-one adult patients with hypertension and/or diabetes mellitus (DM) and/or chronic kidney disease (CKD) were studied. We assessed plasma and urinary EO, pro-brain natriuretic peptide and catecholamines, profile of ambulatory blood pressure monitor and cardiovascular status by echocardiography and echo-tracking. The highest level of plasma EO (19.7±9.5 pmol l⁻¹) was measured in hypertensive patients with DM and CKD. The nighttime mean arterial blood pressure independently correlated with the level of plasma EO (P=0.004), while independent predictor of the β-stiffness of carotid artery was the urinary EO (P=0.011). Elevated level of EO was associated with nighttime blood pressure and subclinical organ damage in treated hypertensive patients, suggesting possible role of EO in the pathogenesis of impaired diurnal blood pressure rhythm and arterial stiffness.

Association between arterial stiffness and estimated glomerular filtration rate in the Japanese general population

AIM

Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular disease, although it has yet to be established whether CKD is an independent risk factor for arterial stiffness in community residents. The purpose of this study was to determine the correlation between the cardio-ankle vascular index (CAVI) and estimated glomerular filtration rate (eGFR) in the general population.

METHODS

We studied 881 consecutively enrolled subjects undergoing health checkups. CAVI was calculated automatically from the pulse volume record, blood pressure and the vascular length from the heart to the ankle. CKD was evaluated by the eGFR.

RESULTS

The distribution of eGFR was as follows: 241 with eGFR (mL/min/1.73m(2)) > or =90; 572 with eGFR 60-89; 65 with eGFR 30-59; 3 with eGFR 15-29; 0 with eGFR <15. Linear regression analysis showed that CAVI was negatively correlated significantly with eGFR, while multiple regression analysis using CAVI as an objective variable, adjusted for conventional atherosclerotic risk factors and eGFR as explanatory variables, demonstrated that CAVI was an independent determinant of eGFR. We also showed that stepwise increments of CAVI occurred with progressive deterioration of CKD.

CONCLUSION

CAVI was independently correlated with eGFR indicating that CKD is associated with arterial stiffness in the general population.

Arterial stiffness in mild-to-moderate CKD

Whether arterial stiffness correlates with mild-to-moderate CKD and albuminuria in the community is unclear. We studied the association between arterial stiffness and mild-to-moderate CKD and albuminuria in the Framingham Heart Study. CKD was present in 6.7% (181 of 2682) of participants and microalbuminuria was present in 8.2% (479 of 5818). The measures of arterial stiffness were the carotid femoral pulse wave velocity, forward pressure wave amplitude, central pulse pressure, augmentation pressure, augmentation index, and mean arterial pressure. In cross-sectional analyses, arterial stiffness did not associate with CKD (defined by estimated GFR <60 ml/min/1.73 m(2)) in either age- and gender-adjusted or multivariable-adjusted linear regression models. Carotid femoral pulse wave velocity associated with both urinary albumin-to-creatinine ratio and microalbuminuria (P < 0.0001 after multivariable adjustment). In longitudinal analyses, we used logistic regression models to examine the associations between baseline arterial stiffness measures (exposure variables) and incident CKD or microalbuminuria (n = 1675 for CKD analyses and n = 1252 for microalbuminuria analyses). Baseline arterial measures did not associate with incident CKD or incident microalbuminuria. In summary, arterial stiffness correlates with albuminuria but not with mild-to-moderate CKD.

Inflammation as a cardiovascular risk factor and pulse wave velocity as a marker of early-stage atherosclerosis in the Japanese population

Inflammation and pulse wave velocity (PWV) are a potential risk factor and marker, respectively, for atherosclerosis in the primary prevention setting. Atherosclerosis is now generally accepted to be an inflammatory disorder of the arterial wall, and the high-sensitivity C-reactive protein (hs-CRP) level has been reported to be a strong predictor of cardiovascular events. High-sensitivity-CRP is associated with two factors related to inflammation: (1) the local production of CRP by atheromatous tissue or coronary artery smooth muscle cells and (2) adipose tissue as a potent source of inflammatory cytokines. Based on studies in North America and Europe, hs-CRP has been established as a cardiovascular risk factor and a cut-off value has been recommended. However, Japanese have lower hs-CRP values than their Western counterparts, partly because Japanese have a lower body mass index (BMI), which correlates positively to hs-CRP, and partly because lifestyle and genetic factors can affect hs-CRP values. Therefore, a cut-off value needs to be established by cohort studies for the Japanese population. Carotid-femoral PWV is most commonly measured by applanation tonometry, particularly in Europe, but this method is critically dependent upon the accurate placing of transducers over the arteries and is both time-consuming and complex. A novel device has been recently developed in Japan that measures brachial-ankle PWV (baPWV) using a volume-rendering method. Brachian-ankle PWV is a suitable screening method because of its technical simplicity and shorter measurement time. It is associated not only with conventional cardiovascular risk factors but also with new risk factors, such as inflammation, gamma-glutamyltransferase, chronic kidney disease, and psychosocial factors. However, a suitable cut-off value has yet to be established.