Targeting Uric Acid and the Inhibition of Progression to End-Stage Renal Disease--A Propensity Score Analysis

Approximation of Glomerular Filtration Rate after 1 Year Using Annual Medical Examination Data

Background: This cohort study was conducted to devise an approximation formula for predicting the glomerular filtration rate (GFR) after 1 year using annual medical examination data from the general population. Methods: Consecutive annual medical examination data were obtained for 41,337 inhabitants. Machine learning with the random forest method was used to assess the importance of each clinical parameter in terms of its association with estimated GFR (eGFR) after 1 year. An approximation formula was developed by multiple linear regression analysis based on the four most important clinical parameters. The relationship between the GFR after 1 year approximated by our formula and the eGFR after 1 year was analyzed using Pearson's correlation coefficient. Results: The following approximation formula was obtained by multiple linear regression analysis: approximate GFR after 1 year (mL/min/1.73 m2) = -0.054 × age + 0.162 × hemoglobin - 0.085 × uric acid + 0.849 × eGFR + 11.5. The approximate GFR after 1 year was significantly and strongly correlated with the eGFR at that time (r = 0.884; p < 0.001). Conclusions: An approximation formula including age, hemoglobin, uric acid, and eGFR may be useful for predicting GFR after 1 year among members of the general population.

The Efficacy and Safety of Dotinurad on Uric Acid and Renal Function in Patients with Hyperuricemia and Advanced Chronic Kidney Disease: A Single Center, Retrospective Analysis

Objective

We investigated the efficacy and safety of dotinurad, a selective urate reabsorption inhibitor, in hyperuricemic patients with advanced chronic kidney disease (CKD) (stage G3-5).

Patients and Methods

We retrospectively analyzed the cases of 34 patients (mean age, 68.6 ± 13.3 years; 17 men and 17 women) after 12 months of dotinurad treatment based on the changes in uric acid (UA) and the urine protein-to-creatinine ratio (UPCR) plus the annual change in estimated glomerular filtration rate (eGFR). Hyperuricemia (UA ≥6.0 mg/dL) and advanced CKD (mean eGFR: 32.0 ± 13.3 mL/min/1.73m2; stage G3, n=17; G4, n=13; G5, n=4) were present in all of the patients. The cases of 34 matched individuals with similar propensity scores (who were not taking dotinurad) were analyzed as a control group.

Results

UA values decreased significantly in the dotinurad group (7.1 ± 0.8 mg/dL to 5.9 ± 1.0 mg/dL, p<0.05) but those did not change in the control group. UPCR did not change in either group. Low-density lipoprotein cholesterol also decreased significantly in the dotinurad group (98.8 ± 43.4 mg/dL to 82.9 ± 33.1 mg/dL, p<0.05). With the 12-month dotinurad treatment, the annual change in the patients' eGFR was significantly improved from -6.0 ± 12.9 mL/min/1.73 m2/year to -0.9 ± 4.6 mL/min/1.73 m2/year (p<0.05), but there was no change in the control group.

Conclusion

Dotinurad can decrease UA levels and might attenuate renal function decline in individuals with hyperuricemia and advanced CKD.

Clinicopathological characteristics and associated factors of idiopathic membranous nephropathy with hyperuricemia: a single-centered cross-sectional study

PURPOSE

This study was designed to investigate the clinicopathological features of idiopathic membranous nephropathy (IMN) with hyperuricemia (HUA), together with associated factors within 10 years in a single centre in Shandong Province.

METHODS

In this cross-sectional study, we analysed the clinical and pathological data of 694 IMN patients in our hospital from January 2010 to December 2019. Based on serum uric acid (UA) level, the patients were divided into hyperuricemia (HUA) group (n = 213) and normal serum uric acid (NUA) group (n = 481). Multi-variate logistic regression analysis was conducted on to screen the associated factors of HUA.

RESULTS

213 (30.69%) IMN patient were complicated with HUA. Compared with the patients with NUA, significant increase was noticed in the proportion of patients showing edema, concurrent hypertensive disease or diabetes mellitus (DM), as well as the proportion of positive glomerular capillary loop IgM and positive C1q in the HUA group (P < 0.05). In addition, significant increase was noticed in the 24 h urine protein, serum creatinine, triglycerides, complement C3 and complement C4 in HUA group compared with those of NUA group (all P < 0.05). With gender as a control factor, multi-variate logistic regression analysis showed positive glomerular capillary loops C1q, serum albumin, serum phosphorus were associated with IMN combined with HUA in male, while triglycerides and serum creatinine were associated with IMN combined with HUA in female counterparts.

CONCLUSION

About 30.69% of IMN patients had HUA, with a male predominance than female. In male patients with IMN, higher serum albumin level and serum phosphorus level were associated with higher incidence of HUA, while in female IMN patients, higher serum triglyceridemia and serum creatinine level were associated with higher incidence of HUA. Therefore, it can be targeted to prevent the occurrence of HUA in IMN.

Association of uric acid with the decline in estimated glomerular filtration rate in middle-aged and elderly populations: evidence based on the China Health and Retirement Longitudinal Study

OBJECTIVE

Whether uric acid (UA) has an effect on renal function remains controversial. We aimed to investigate the association between serum UA with the decline in estimated glomerular filtration rate (eGFR) in middle-aged and elderly populations in the China Health and Retirement Longitudinal Study (CHARLS).

DESIGN

Longitudinal cohort study.

SETTING

This was a second analysis of a public dataset (CHARLS).

PARTICIPANTS

In this study, 4538 middle-aged and elderly individuals were screened after removing individuals younger than 45 years old, with kidney disease, malignant tumour and missing values.

OUTCOME MEASURES

Blood tests were performed both in 2011 and 2015. Decline in eGFR was defined as an eGFR decrease of more than 25% or deterioration of the eGFR stage during the 4-year follow-up period. Logistic models corrected for multiple covariables were used to analyse the association of UA with the decline in eGFR.

RESULTS

The median (IQR) concentrations of serum UA grouped by quartiles were 3.1 (0.6), 3.9 (0.3), 4.6 (0.4) and 5.7 (1.0) mg/dL, respectively. After multivariable adjustment, the OR of the decline in eGFR was higher for quartile 2 (3.5-<4.2 mg/dL: OR 1.44; 95% CI 1.07 to 1.64; p<0.01), quartile 3 (4.2-<5.0 mg/dL: OR 1.72; 95% CI 1.36 to 2.18; p<0.001) and quartile 4 (≥5.0 mg/dL: OR 2.04; 95% CI 1.58 to 2.63; p<0.001) when compared with quartile 1 (<3.5 mg/dL), and the p value for the trend was <0.001.

CONCLUSIONS

Over a 4-year follow-up period, we found that elevated UA was associated with a decline in eGFR in the middle-aged and elderly individuals with normal renal function.

Longitudinal uric acid has nonlinear association with kidney failure and mortality in chronic kidney disease

We investigated the shape of the relationship between longitudinal uric acid (UA) and the hazard of kidney failure and death in chronic kidney disease (CKD) patients, and attempted to identify thresholds associated with increased hazards. We included CKD stage 3-5 patients from the CKD-REIN cohort with one serum UA measurement at cohort entry. We used cause-specific multivariate Cox models including a spline function of current values of UA (cUA), estimated from a separate linear mixed model. We followed 2781 patients (66% men, median age, 69 years) for a median of 3.2 years with a median of five longitudinal UA measures per patient. The hazard of kidney failure increased with increasing cUA, with a plateau between 6 and 10 mg/dl and a sharp increase above 11 mg/dl. The hazard of death had a U-shape relationship with cUA, with a hazard twice higher for 3 or 11 mg/dl, compared to 5 mg/dl. In CKD patients, our results indicate that UA above 10 mg/dl is a strong risk marker for kidney failure and death and that low UA levels below 5 mg/dl are associated with death before kidney failure.

Lower bicarbonate level is associated with CKD progression and all-cause mortality: a propensity score matching analysis

Background

Although metabolic acidosis is known as a potential complication of chronic kidney disease (CKD), there is limited information concerning the association between metabolic acidosis and clinical outcomes.

Methods

Five hundred fifty-two patients referred to renal division of Iwata City Hospital from 2015 to 2017 were included as a retrospective CKD cohort, and finally 178 patients with CKD stage III or IV and 20 to 80 years of age were analyzed. We examined the association between serum bicarbonate (HCO₃⁻) levels and clinical outcomes using Kaplan-Meier methods after the matching of baseline characteristics by propensity scores.

Results

Of 178 patients with CKD, patients with lower HCO₃⁻ levels (N = 94), as compared with patients with higher HCO₃⁻ levels (N = 84), were more likely to be male (P < 0.05), had more severe CKD stages (P < 0.05), more frequent use of renin-angiotensin system inhibitor (P < 0.05) or uric acid lowering agent (P < 0.001), heavier body weight (P < 0.001) and lower estimated glomerular filtration rate (P < 0.05). In Kaplan-Meier analysis after propensity score matching, the incidence of composite outcome as the doubling of serum creatinine level from baseline, end-stage kidney disease requiring the initiation of dialysis, or death from any causes was significantly fewer in the higher HCO₃⁻ group than the lower HCO₃⁻ group (N = 57 each group, P = 0.016).

Conclusions

Lower HCO₃⁻ level is significantly associated with the doubling of serum creatinine level, end-stage kidney disease or all-cause mortality in patients with CKD.

Trial registration

This study was registered with the Clinical Trial Registry of the University Hospital Medical Information Network (http://www.umin.ac.jp/, study number: UMIN000044861).

Development of chronic kidney disease influenced by serum urate and body mass index based on young-to-middle-aged Japanese men: a propensity score-matched cohort study

OBJECTIVE

To investigate the association between serum uric acid (SUA) level and body mass index (BMI) on the development of chronic kidney disease (CKD) in working men aged 20-60 years.

DESIGN

Retrospective cohort study.

SETTING

Data from employees' annual health check-ups were collected from two companies in 2009 and 2014.

PARTICIPANTS

A total of 16 708 working men were recruited. We excluded participants with missing essential data (N=7801), who had basal estimated glomerular filtration rate (eGFR) <60.0 mL/min/1.73 m² and/or proteinuria (N=698) or with the absence of follow-up data (N=2).

PRIMARY OUTCOME

eGFR <60 mL/min/1.73 m² and/or proteinuria (≥1+) in 2014 (defined as incident CKD).

RESULTS

The cut-off values of SUA for incident CKD were 6.6 mg/dL in both young (20-39 years old) and middle-aged (40-60 years old) men analysed by receiver operator characteristics. ORs for incident CKD were assessed on propensity score-matched (1:1) cohorts. In young participants (N=1938), after propensity score matching, a coexistence of high-level SUA (≥6.6 mg/dL) and overweight (BMI ≥25 kg/m²) was a significant risk factor of incident CKD (OR=2.18, 95% CI 1.10 to 4.31, p=0.025), but high-level SUA was not an independent risk factor without overweight status (p=0.174). In middle-aged participants (N=2944) after propensity score matching, high-level SUA was a significant risk factor of incident CKD both with or without overweight (OR=1.44, 95% CI 1.02 to 2.04, p=0.037; OR=1.32, 95% CI 1.01 to 1.73, p=0.041, respectively).

CONCLUSION

These findings suggest that high-level SUA is strongly associated with incident CKD in overweight young adult men.

Hyperuricemia and Associated Factors in Children with Chronic Kidney Disease: A Cross-Sectional Study

Background: Hyperuricemia is increasingly recognized as a risk factor for chronic kidney disease (CKD) just in adults. The purpose of this study was to investigate the clinical characteristics of hyperuricemia and its associated factors in Chinese children with CKD at a single center. Methods: A cross-sectional study of 170 CKD children collected from the Department of Nephrology, The Zhejiang University Children’s Hospital was conducted. The clinical data, including anthropometric data, blood pressure measurements, and biochemical parameters, were recorded and analyzed retrospectively. The factors associated with hyperuricemia in CKD children were evaluated by Pearson and Spearman correlation analysis and multiple logistic regression analysis. Results: The mean age was 9.79 ± 4.10 years, and 72 (42.35%) were girls. Higher blood urea nitrogen (BUN), serum creatinine, cystatin C, D-dimer, lower hemoglobin, albumin, and estimated glomerular filtration rate (eGFR) were significantly associated with higher serum uric acid (SUA). In multiple logistic regression analysis, anemia and higher BUN were both positively associated factors, whereas eGFR ≥ 90 mL/min/1.73 m² was a negatively associated factor for subjects with SUA ≥ 390 µmol/L (6.5 mg/dL). Conclusions: SUA was significantly associated with kidney risk factors in CKD children. Monitoring and controlling SUA, Hb, BUN, and Scr levels in CKD children may help to prevent the progression of CKD.

Anemia and atrial fibrillation as independent risk factors for new-onset chronic kidney disease: the TAMA-MED Project-CKD and AF

Background

Various risk factors have been identified for the new onset or rapid deterioration of chronic kidney disease (CKD). However, it is thought that many risk factors that have not yet been clarified remain.

Methods

Based on the results of specific annual health checkups at Tama City (n = 18 383) in 2017 and 2018, we analyzed the factors that cause new-onset CKD and the risk factors that rapidly worsen renal function. For new-onset CKD, proteinuria and estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² were examined separately. Rapid deterioration of renal function was defined as an eGFR ≥25% less than the previous year.

Results

Multivariate analysis showed that in addition to age and impaired glucose tolerance, anemia and atrial fibrillation (AF) were risk factors for the new appearance of proteinuria. Risk factors for a decrease in eGFR to <60 mL/min/1.73 m² were age and hyperuricemia. Age, systolic hypertension, urinary protein and urinary occult blood, high triglycerides and anemia were significant risk factors for the rapid deterioration of renal function in patients with CKD Stage ≥3.

Conclusions

From the results of specific annual health checkups at Tama City, AF, anemia and hyperuricemia were identified as risk factors for new-onset CKD over a short period of 1 year. Anemia was also a factor for the rapid deterioration of kidney function in subjects with renal dysfunction.

Effectiveness of Drug Treatments for Lowering Uric Acid on Renal Function in Patients With Chronic Kidney Disease and Hyperuricemia: A Network Meta-Analysis of Randomized Controlled Trials

Background: Hyperuricemia is very common in patients with chronic kidney disease (CKD); the role of hyperuricemia in the occurrence and progression of kidney disease remains an interesting and unresolved issue for nephrologists, and whether urate-lowering therapy (ULT) is warranted in CKD patients is still in controversy. To summarize and compare the clinical outcomes and adverse events (AEs) of three common ULT drugs, we performed a systematic review and network meta-analysis of randomized clinical trials (RCTs). Method: PubMed, MEDLINE, Clinical Trials.gov, EMBASE, and the Cochrane Central Register of Controlled Trials electronic databases were searched. The network meta-analysis was performed using the "gemtc 0.8-7" and its dependent packages in R software. The primary outcome was the change of renal function and uric acid; creatinine, proteinuria, blood pressure, and adverse events were assessed as the secondary outcomes. Results: 16 RCTs involving 1,943 patients were included in the final network analysis. Febuxostat, allopurinol, and benzbromarone were not found to exert superior effects over placebo upon renoprotective effect. With respect to lowering urate, the three drugs showed to be statistically superior to placebo, while febuxostat could better lower urate than allopurinol (MD: -1.547; 95% CrI: -2.473 to -0.626). It is also indicated that febuxostat was superior to placebo at controlling blood pressure, while no differences were observed when allopurinol and benzbromarone were compared to placebo. These results are stable in subgroup analysis. Conclusion: There is insufficient evidence to support the renoprotective effects of the three urate-lowering agents in CKD patients with hyperuricemia; febuxostat shows a tendency to be superior to allopurinol on lowering the decline of eGFR and increment of proteinturia, but the difference does not reach a statistical significance. Regarding its urate-lowering effect, febuxostat appears to be a satisfactory alternative to allopurinol and benzbromarone, and can control blood pressure better.

Asymptomatic hyperuricemia: is it really asymptomatic?

PURPOSE OF REVIEW

Hyperuricemia is highly prevalent, affecting approximately 38 million individuals in the United States. However, the significance of asymptomatic hyperuricemia - hyperuricemia in the absence of gout - continues to be debated.

RECENT FINDINGS

Asymptomatic hyperuricemia results in monosodium urate crystal deposition in tissues, which may promote chronic inflammation. Intracellularly, hyperuricemia inhibits the master regulator adenosine monophosphate (AMP)-associated protein kinase and may condition innate immune responses through durable epigenetic modifications. At the population level, asymptomatic hyperuricemia is associated with multiple comorbidities, including hypertension, chronic kidney disease, coronary artery disease, and diabetes; limitations of these studies include that most are retrospective and some do not rigorously distinguish between asymptomatic hyperuricemia and gout. Treatment studies suggest that urate lowering may reduce the risk of incidence or progression of some of these comorbidities; unfortunately, many of these treatment studies are small or flawed, and not all study results are consistent.

SUMMARY

Accumulating evidence suggests that asymptomatic hyperuricemia contributes to the comorbidities with which it associates and that proper asymptomatic hyperuricemia treatment may reduce future risk. Additional prospective trials are needed to definitely establish causality and support decision-making as to whether, and which patients with asymptomatic hyperuricemia would warrant urate-lowering treatment.

Xanthine oxidase inhibitors are associated with reduced risk of cardiovascular disease

As previous studies have reported finding an association between hyperuricemia and the development of cardiovascular and chronic kidney disease, hyperuricemia is thought to be an independent risk factor for hypertension and diabetic mellitus. However, we have not been able to determine whether the use of xanthine oxidase inhibitors can reduce cardiovascular disease. The present study used the longitudinal data of the Fukushima Cohort Study to investigate the relationship between the use of xanthine oxidase inhibitors and cardiovascular events in patients with cardiovascular risks. During the 3-year period between 2012 and 2014, a total of 2724 subjects were enrolled in the study and followed. A total of 2501 subjects had hypertension, diabetic mellitus, dyslipidemia, or chronic kidney disease, and were identified as having cardiovascular risks. The effects of xanthine oxidase inhibitor use on the development of cardiovascular events was evaluated in these patients using a time to event analysis. During the observational periods (median 2.7 years), the incidence of cardiovascular events was 20.7 in subjects with xanthine oxidase inhibitor and 11.2 (/1000 person-years, respectively) in those without. Although a univariate Cox regression analysis showed that the risk of cardiovascular events was significantly higher in subjects administered xanthine oxidase inhibitors (HR = 1.87, 95% CI 1.19–2.94, p = 0.007), the risk was significantly lower in subjects administered a xanthine oxidase inhibitor after adjustment for covariates (HR = 0.48, 95% CI 0.26–0.91; p = 0.024) compared to those without. Xanthine oxidase inhibitor use was associated with reduced risk of cardiovascular disease in patients with cardiovascular risk factors.

[Asymptomatic Hyperuricemia and Risk Of Cardiovascular and Renal Diseases]

Asymptomatic hyperuricemia (HU) is common in the population and significantly contributes to the general cardiovascular risk. Despite extensive study of this condition there is still no conclusive answers to questions about detection of asymptomatic HU and its effect on the risk for development and progression of cardiovascular and kidney diseases. This review summarizes key information about these issues, which has been accumulated by the present time.

A longitudinal analysis of the relationship between serum uric acid and residual renal function loss in peritoneal dialysis patients

Background: Hyperuricemia occurs frequently in patients with continuous ambulatory peritoneal dialysis (CAPD). This study aimed to evaluate the impact of serum uric acid (UA) over time on residual renal function (RRF) loss in a cohort of patients with CAPD.Methods: A total of 201 patients who started CAPD therapy between January 1, 2008 and April 30, 2016 were included in this single-center, retrospective cohort study. All patients were followed up until December 31, 2016. The median follow-up time was 23.43 ± 16.60 months. RRF loss was represented as the time to anuria.Results: Eighty-six patients developed anuria within 5 years. Multivariate Cox regression analysis showed that time-averaged serum UA and peritonitis were independent risk factors for RRF loss, while weekly Kt/V urea was a protective factor. Cox proportional hazard regression models showed that both patients with time-averaged uric acid (TA-UA) < 6.77 mg/dL [hazard ratio (HR) = 1.165, 95% confidence interval (CI) 1.054-1.387; p < 0.05] and those with TA-UA≥ 7.64 mg/dL (HR = 1.184, 95% CI 1.045-2.114; p < 0.05) had a higher risk of RRF than those with TA-UA in the range of 6.77-7.64 mg/dL. Penalized spline smoothing also showed a U-shaped relationship between continuous UA and RRF loss.Conclusion: The present study demonstrated that both high and low serum UA over time were associated with RRF loss in patients with CAPD.

Renal effects of uric acid: hyperuricemia and hypouricemia

The prevalence of chronic kidney disease (CKD) is increasing worldwide. Although hyperuricemia has been associated with CKD in many studies, it remains controversial whether this is the cause or the result of decreased renal function. Recent observational studies of healthy populations and patients with CKD have reported that uric acid (UA) has an independent role in the development or progression of CKD. Experimental studies have shown several potential mechanisms by which hyperuricemia may cause or promote CKD. However, other reports have indicated an association between hypouricemia and CKD. This opposing effect is hypothesized to occur because UA is a major antioxidant in human plasma and is associated with oxidative stress. In this article, we discuss the potential association between UA imbalance and CKD and how they can be treated.

A treat-to-target approach for gout confers renoprotective effect in patients with chronic kidney disease stage 3

The aim of this study was to assess changes in the estimated glomerular filtration rate (eGFR) in gouty patients with chronic kidney disease (CKD) using a "treat-to-target" (T2T) approach in gout. This multicenter observational retrospective study included patients diagnosed with gout and CKD stage 3 taking xanthine oxidase inhibitors (XOIs) (allopurinol or febuxostat) for at least 12 months. All patients were treated using a T2T strategy according to national gout guidelines to achieve the target levels of serum uric acid (sUA; < 5-6 mg/dl) within 6 months of the first visit. The primary outcome was to assess changes in eGFR. The effects of independent variables were analyzed over eGFR in a linear mixed-effects (LME) model. Fifty patients with gout and CKD stage 3 treated with XOIs with a T2T strategy for 12 months were included. Eighty-two percent of the patients achieved the sUA target during the study period. The improvement seen in eGFR was higher during the first 6 months, showing a median increase of 7.54 ml/min/m² (SE = 1.25) and trending towards stability over 12 months. For every 1 mg/dl of decrease in sUA, an improvement of 1.5 ml/min/m² in eGFR was observed (coefficient ± SE: - 1.58 ± 0.26) (p < 0.001) with no differences between type and dosage of XOIs treatment, colchicine administration, age, sex, and smoking status. A reduction in sUA levels using a T2T approach with XOIs at an optimal dose is possible and could help conserve and improve renal function in gouty patients with CKD stage 3.

Renal disorders in rheumatologic diseases: the spectrum is changing (part 2. Arthridides)

This review is devoted to rheumatologic diseases mainly characterized by different types of arthritis. They may involve also different organs, including the kidney, but renal disease is more frequently caused by the nephrotoxicity of drugs to relieve pain or to interfere with the pathophysiology of the underlying disease. Rheumatoid arthritis is the prototype of arthropathies. This autoimmune disease mainly attacks joints, tendons and ligaments but can also involve internal organs including the kidney. Psoriatic arthritis is a complex disease in which psoriasis, a chronic inflammatory disease, is associated with the development of peripheral arthritis or spondylitis. The disease or its treatment may lead to kidney complications. Gout is a form of inflammatory arthritis which is characterized by an increase in the serum uric acid deposits in and around the joints of the extremities, the so called tophi. The disease is often associated with a metabolic syndrome with diabetes, obesity, hypertension, and cardiovascular disease. Kidney injury is frequent. It may be caused by kidney stones, urinary tract obstruction, tubulointerstitial and vascular lesions leading to CKD and renal failure.

The association of renal tubular inflammatory and injury markers with uric acid excretion in chronic kidney disease patients

AIM

To investigate the correlation of renal tubular inflammatory and injury markers with renal uric acid excretion in chronic kidney disease (CKD) patients.

METHODS

Seventy-three patients with CKD were enrolled. Fasting blood and morning urine sample were collected for routine laboratory measurements. At the same time, 24 h of urine was collected for urine biochemistry analyses, and 10 ml was extracted from the 24-h urine sample to further detect renal tubular inflammatory and injury markers, including interleukin-18 (IL-18), interleukin 1β (IL-1β), neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1). The patients were divided into three tertile groups according to their 24-h urinary uric acid (24-h UUA) levels (UUA1: 24-h UUA ≤ 393.12 mg; UUA2: 393.12 < 24-h UUA ≤ 515.76 mg; UUA3: 24-h UUA > 515.76 mg). The general clinical and biochemical indexes were compared. Multivariable linear regression models were used to test the association of IL-18/Urinary creatinine concentration (IL-18/CR), IL-1β/CR, NGAL/CR and KIM-1/CR with renal uric acid excretion indicators.

RESULTS

All of tested renal tubular inflammation- and injury-related urinary markers were negatively associated with 24-h UUA and UEUA, and the negative correlation still persisted after adjusting for multiple influencing factors including urinary protein and eGFR. Further group analyses showed that these makers were significantly higher in the UUA1 than in the UUA3 group.

CONCLUSIONS

Our findings suggest that markers of urinary interstitial inflammation and injury in CKD patients are significantly correlated with 24-h UUA and Urinary excretion of uric acid (UEUA), and those with high 24-h UUA have lower levels of these markers. Renal uric acid excretion may also reflect the inflammation and injury of renal tubules under certain conditions.

Uric acid in CKD: has the jury come to the verdict?

Epidemiological studies show that hyperuricemia independently predicts the development of chronic kidney disease (CKD) in individuals with normal kidney function both in the general population and in subjects with diabetes. As a matter of fact, an unfavorable role of uric acid may somewhat be harder to identify in the context of multiple risk factors and pathogenetic mechanisms typical of overt CKD such as proteinuria and high blood pressure. Although the discrepancy in clinical results could mean that urate lowering treatment does not provide a constant benefit in all patients with hyperuricemia and CKD, we believe that the inconsistency in the results from available meta-analysis is mainly due to inadequate sample size, short follow-up times and heterogeneity in study design characterizing the randomized controlled trials included in the analyses. Therefore, available data support the view that hyperuricemia has a damaging impact on kidney function, while preliminary evidence suggests that treatment of so-called asymptomatic hyperuricemia may be helpful to slow or delay the progression of chronic kidney.

Decline in serum uric acid predicts higher risk for mortality in peritoneal dialysis patients-a propensity score analysis

BACKGROUND

The level of serum uric acid (SUA) in treatment follow-up is associated with mortality in peritoneal dialysis (PD) patients, but it remains unknown if the longitudinal change in SUA affects mortality.

METHODS

309 PD patients who were not using UA-lowering agents were enrolled. The longitudinal change in SUA was estimated by comparing the values between the run-in and follow-up periods. Based the calculated values, the patients were divided into SUA decliner and SUA non-decliner. A propensity score (PS) was calculated using the parameters measured in run-in period. After PS matching, the time-to-event analysis was performed for all-cause death.

RESULTS

After PS matching, 86 patients of each group were left. A higher mortality of 19/86 existed in SUA decliner compared with SUA non-decliner which is 3/86 (p < 0.001). Kaplan-Meier analysis in sub-cohort showed worse survival in the SUA decliner. Standard and stratified Cox regression analysis both showed SUA decline to be an independent risk factor for all-cause death in PD patients.

CONCLUSIONS

The decline in SUA in the follow-up may predict the all-cause mortality of PD patients, the reason of which may result from reducing scavenging effects of SUA or may reflect general condition. More studies need to be done.

High Serum Uric Acid is Highly Associated with a Reduced Left Ventricular Ejection Fraction Rather than Increased Plasma B-type Natriuretic Peptide in Patients with Cardiovascular Diseases

High serum uric acid (UA) has been reported to be associated with left ventricular (LV) dysfunction; however, the relationship between UA and plasma B-type natriuretic peptide (BNP), a sensitive biomarker of heart failure, is still unclear. This study investigated their relationship to provide an accurate assessment of high UA. The study patients consisted of 3,077 subjects who underwent cardiac catheterization because of various cardiovascular disorders. Since the explanatory factors of multiple regression analysis were mostly confounding with each other, subgroup analysis was performed by quartering the study population using the respective risk factors and by covariance structure analysis. This analysis revealed that UA was almost always well associated with a reduced LV ejection fraction (LVEF), but generally not with BNP. UA was significantly associated with BNP in lean aged females, but not in obese adolescent males, although LVEF was significantly reduced in response to a high UA in both groups. A high UA is a direct risk factor for cardiac dysfunction from the perspective of BNP; however, augmentation of BNP in response to a high UA would likely be restricted among obese adolescent males. On the other hand, the observed LV systolic dysfunction, such as LVEF, reflects a high UA on an almost constant basis.

Urate-Lowering Therapy in Moderate to Severe Chronic Kidney Disease

CONTEXT

Hyperuricemia is an independent risk factor for progression of kidney disease.

OBJECTIVE

To determine whether lowering serum uric acid level (sUA) to below 6 mg/dL (target) improves mild to moderate chronic kidney disease (CKD) and whether CKD stage influences the benefit of lowering sUA to target.

DESIGN

Retrospective epidemiologic cohort study conducted over 8 years. Estimated glomerular filtration rate (eGFR) was required in the 6 months preceding the index date (defined as first occurrence of sUA < 7 mg/dL), and at least 1 sUA and eGFR were required during follow-up. Patients were urate-lowering therapy (ULT) naïve, aged 18 years or older, and had CKD Stages 2 to 4 at baseline. Health Plan enrollment with drug benefit was required. Exclusions included active cancer, dialysis, or other kidney disease.

MAIN OUTCOME MEASURES

A 30% decrease or 30% improvement in eGFR from baseline.

RESULTS

A total of 12,751 patients met inclusion criteria; 2690 patients received ULT during follow-up and 10,061 did not. Target sUA was achieved in 1118 patients (42%) receiving ULT. A 30% improvement in eGFR was likelier in patients who achieved the target (odds ratio [OR] = 1.78, p < 0.001). Pairwise comparison of CKD stages showed a 30% improvement in eGFR in CKD Stage 2 (OR = 2.26, p = 0.017) and Stage 3 (OR = 2.23, p < 0.001) but not Stage 4 (OR = 1.50, p = 0.081).

CONCLUSION

Patients who achieve an American College of Rheumatology target sUA below 6 mg/dL during ULT have higher rates of eGFR improvement, especially in CKD Stages 2 and 3.

The association between time-mean serum uric acid levels and the incidence of chronic kidney disease in the general population: a retrospective study

Background

Investigations on the role of the time-mean serum uric acid (SUA) value in determining the risk of chronic kidney disease (CKD) are limited. We investigated whether the time-mean SUA value indicates the risk of CKD, and explored associations of the baseline and time-mean SUA levels with kidney function decline and incident CKD in a healthy population.

Methods

We initiated an inhabitant-based cohort study between January 2011 and December 2016. All participants completed a yearly medical check-up at the Zhejiang Province People’s Hospital and had baseline estimated glomerular filtration rates (eGFR) > 60 ml/min/1.73m². The SUA level and eGFR were assessed every year in the follow-up period. A multivariate adjusted binary logistic regression analysis and Cox proportional hazards models were used to evaluate the risk of newly-developed CKD among different stratified groups.

Results

During the 6-year follow-up period, 227 (4.4%) participants developed CKD. In multivariable-adjusted analyses, the odds ratio (OR) for new-onset CKD increased, with higher time-mean SUA levels than at baseline (OR: 1.00 [reference], 2.709 [95% confidence interval: 1.836–5.293], 3.754 [1.898–7.428], and 7.462 [3.694–15.073]). After adjustment for potential cofounders, a multivariate Cox proportional hazard model showed that a higher SUA increased the risk of developing CKD (the adjusted hazard ratios of the highest and lowest quartiles for the baseline and time-mean SUA levels were 1.689 [1.058–2.696] and 6.320 [3.285–12.159], respectively).

Conclusion

An increased time-mean and single SUA value were independently associated with an increased likelihood of eGFR decline and development of new-onset CKD in the general population.

The impact of serum uric acid reduction on renal function and blood pressure in chronic kidney disease patients with hyperuricemia

BACKGROUND

Febuxostat is tolerable in chronic kidney disease (CKD) patients with hyperuricemia. However, the long-term effect of lowering uric acid with febuxostat on renal function and blood pressure has not been elucidated.

METHODS

This was a 2 years retrospective observational study. 86 CKD patients with hyperuricemia who continued with allopurinol (allopurinol group, n = 30), switched from allopurinol to febuxostat (switched group, n = 25), or were newly prescribed febuxostat (febuxostat group, n = 31) were included in this study. Serum uric acid, estimated glomerular filtration rate (eGFR), blood pressure, and urinary protein were analyzed. Moreover, the impact of serum uric acid reduction on renal function and blood pressure was assessed.

RESULTS

Serum uric acid in the switched and febuxostat groups was significantly reduced at 6 months (switched group; 8.49 ± 1.32-7.19 ± 1.14 mg/dL, p < 0.0001, febuxostat group; 9.43 ± 1.63-6.31 ± 0.90 mg/dL, p < 0.0001). In the allopurinol group, serum uric acid was increased (6.86 ± 0.87-7.10 ± 0.85 mg/dL, p = 0.0213). eGFR was significantly increased (35.2 ± 12.8-37.3 ± 13.9 mL/min/1.73 m², p = 0.0232), while mean arterial pressure (93.1 ± 10.8-88.2 ± 9.5 mmHg, p = 0.0039) was significantly decreased at 6 months in the febuxostat group, resulting in the retention of eGFR for 2 years.

CONCLUSIONS

The impact of serum uric acid reduction might have beneficial effects on CKD progression and blood pressure. However, a large prospective study is needed to determine the long-term efficacy of febuxostat therapy in CKD patients with hyperuricemia.

Uric Acid in the Follow-Up Determines 30% Decline in Estimated GFR Over 2 Years: a Propensity Score Analysis

BACKGROUND/AIMS

Higher level of serum uric acid (SUA) predicts early entry to dialysis in chronic kidney disease (CKD) patients. However, a short-term effect of SUA remains to be elucidated using a novel surrogate endpoint.

METHODS

Japanese CKD stage 3 to 4 patients were retrospectively examined (n= 701). The follow-up level of SUA was estimated as time-averaged uric acid (TA-UA). A propensity score for 6.0, 6.5 or 7.0 mg/dL of TA-UA was respectively calculated using baseline 23 covariates. The time-to-event analysis was performed for 30% decline in estimated GFR over 2 years.

RESULTS

Incidence rates over 2 years were 90 of 440 in men and 36 of 261 in women (p = 0.03). Despite the negative result of baseline SUA, stratified Cox regression on the quintiles of the estimated propensity score showed that higher TA-UA of the three thresholds were all significant (crude HR 2.10 to 2.44) even after adjusting for the confounders. Kaplan-Meier analysis after propensity score matching likewise showed worse survival in the patients with the higher TA-UA (HR 3.11 to 4.26).

CONCLUSION

Higher SUA increases likelihood of reaching a surrogate endpoint over 2 years. Early intervention for SUA less than 6.0 mg/dL is recommended for slowing CKD progression.

Asymptomatic hyperuricemia and chronic kidney disease: Narrative review of a treatment controversial

Today there is plausible evidence both on experimental and epidemiological basis, that hyperuricemia represents a risk factor for the development and progression of chronic kidney disease (CKD). Nevertheless, the role of serum uric acid lowering treatment in CKD is still a matter of serious controversy. Review of randomised controlled trials, suggests that there may be an improvement of renal function with allopurinol treatment in CKD stage 3-5. However, these studies have included a relatively limited number of participants and provide insufficient information on adverse events and on the incidence of the end stage renal disease. Therefore, before adequately powered randomised, placebo-controlled trials are completed we cannot recommend treating asymptomatic hyperuricemia in patients with CKD.

Uric acid in the pathogenesis of metabolic, renal, and cardiovascular diseases: A review

The association between uric acid (UA) on one side and systemic hypertension (Htn), dyslipidemia, glucose intolerance, overweight, fatty liver, renal disease and cardiovascular disease (CVD) on the other side is well recognized. However, the causal relationship between UA and these different clinical problems is still debatable. The recent years have witnessed hundreds of experimental and clinical trials that favored the opinion that UA is a probable player in the pathogenesis of these disease entities. These studies disclosed the strong association between hyperuricemia and metabolic syndrome (MS), obesity, Htn, type 2 diabetes mellitus (DM), non-alcoholic fatty liver disease, hypertriglyceridemia, acute kidney injury, chronic kidney disease (CKD), coronary heart disease (CHD), heart failure and increased mortality among cardiac and CKD patients. The association between UA and nephrolithiasis or preeclampsia is a non-debatable association. Recent experimental trials have disclosed different changes in enzyme activities induced by UA. Nitric oxide (NO) synthase, adenosine monophosphate kinase (AMPK), adenosine monophosphate dehydrogenase (AMPD), and nicotinamide adenine dinucleotide phosphate (NADPH)-oxidase are affected by UA. These changes in enzymatic activities can lead to the observed biochemical and pathological changes associated with UA. The recent experimental, clinical, interventional, and epidemiologic trials favor the concept of a causative role of UA in the pathogenesis of MS, renal, and CVDs.

Hyperuricemia, Hypertension, and Chronic Kidney Disease: an Emerging Association

Uric acid is a product of purine metabolism and has been linked to gout and kidney calculi. Chronic kidney disease (CKD) and hypertension (HTN) are two major public health problems, and both are associated with increased risk of cardiovascular events. Emerging evidence suggests a pathogenic role of hyperuricemia in the development of HTN and CKD, in addition to progression of CKD, by inducing renal inflammation, endothelial dysfunction, and activation of the renin-angiotensin system. In addition, several epidemiological studies have linked hyperuricemia with an increased risk of HTN and CKD. A few clinical trials have assessed the use of uric acid-lowering therapies such as allopurinol and febuxostat in the management of HTN and delaying progression of CKD. To date, most of these trials are short-term with a small sample size; however, their results are encouraging and provide a rationale for larger randomized controlled trials to establish the role of uric acid-lowering therapies in the management of HTN, in addition to prevention of CKD progression and cardiovascular events.

Close linkage between serum uric acid and cardiac dysfunction in patients with ischemic heart disease according to covariance structure analysis

High serum uric acid (UA) level has been assumed to be a risk factor for left ventricular (LV) dysfunction; however, the precise relationship between these conditions has not been fully examined because many confounding factors are associated with UA level. We herein examined the precise relationship by proposing structural equation models. The study population consisted of 1432 cases with ischemic heart disease who underwent cardiac catheterization. Multiple regression analyses and covariance structure analyses were performed to elucidate the cause-and-effect relationship between UA level and LV ejection fraction (LVEF). A path model exploring the factors contributing to LVEF showed that high UA was a significant cause of reduced LVEF (P = 0.004), independent of other significant factors. The degree of atherosclerosis, as estimated by the number of diseased coronary vessels, was significantly affected by high UA (P = 0.005); and the number of diseased coronary vessels subsequently led to reduced LVEF (P < 0.001). Another path model exploring the factors contributing to UA level showed that LVEF was a significant cause of high UA (P = 0.001), while other risk factors were also independent contributing factors. This study clearly demonstrated that there was a close link between high UA and LV dysfunction, which was represented by possible cause-and-effect relationship.

Management of Gout and Hyperuricemia in CKD

Hyperuricemia and gout, the clinical manifestation of monosodium urate crystal deposition, are common in patients with chronic kidney disease (CKD). Although the presence of CKD poses additional challenges in gout management, effective urate lowering is possible for most patients with CKD. Initial doses of urate-lowering therapy are lower than in the non-CKD population, whereas incremental dose escalation is guided by regular monitoring of serum urate levels to reach the target level of <6mg/dL (or <5mg/dL for patients with tophi). Management of gout flares with presently available agents can be more challenging due to potential nephrotoxicity and/or contraindications in the setting of other common comorbid conditions. At present, asymptomatic hyperuricemia is not an indication for urate-lowering therapy, though emerging data may support a potential renoprotective effect.

Podocyte Injury and Albuminuria in Experimental Hyperuricemic Model Rats

Although hyperuricemia is shown to accelerate chronic kidney disease, the mechanisms remain unclear. Accumulating studies also indicate that uric acid has both pro- and antioxidant properties. We postulated that hyperuricemia impairs the function of glomerular podocytes, resulting in albuminuria. Hyperuricemic model was induced by oral administration of 2% oxonic acid, a uricase inhibitor. Oxonic acid caused a twofold increase in serum uric acid levels at 8 weeks when compared to control animals. Hyperuricemia in this model was associated with the increase in blood pressure and the wall-thickening of afferent arterioles as well as arcuate arteries. Notably, hyperuricemic rats showed significant albuminuria, and the podocyte injury marker, desmin, was upregulated in the glomeruli. Conversely, podocin, the key component of podocyte slit diaphragm, was downregulated. Structural analysis using transmission electron microscopy confirmed podocyte injury in this model. We found that urinary 8-hydroxy-2'-deoxyguanosine levels were significantly increased and correlated with albuminuria and podocytopathy. Interestingly, although the superoxide dismutase mimetic, tempol, ameliorated the vascular changes and the hypertension, it failed to reduce albuminuria, suggesting that vascular remodeling and podocyte injury in this model are mediated through different mechanisms. In conclusion, vasculopathy and podocytopathy may distinctly contribute to the kidney injury in a hyperuricemic state.

Serum Uric Acid and Progression of Kidney Disease: A Longitudinal Analysis and Mini-Review

Background

Increasing evidence supports the association between hyperuricemia and incident chronic kidney disease (CKD); however, there are conflicting data regarding the role of hyperuricemia in the progression of CKD. This study retrospectively assessed the longitudinal association between uric acid (UA) level and CKD progression in a Chinese population lived in Taiwan.

Methods

Patients with physician diagnosis of hyperuricemia or receiving urate-lowering therapy between 2003 and 2005 were identified in the electronic medical records (EMR) of a tertiary medical center and were followed up until December 31, 2011. Patients were divided into four UA categories at the cut-off 6, 8, and 10 mg/dL. CKD progression was estimated by the change of estimated glomerular filtration rate (eGFR) in the linear mixed models. Kidney failure was defined as an eGFR less than 15 mL/min/1.73 m² or requiring renal replacement therapy.

Results

A total of 739 patients were analyzed. In the full-adjusted model, patients with a baseline UA level ≥6 mg/dL had greater decline in eGFR ((β = -9.6, 95% CI -16.1, -3.1), comparing to those with a UA level less than 6 mg/dL. When stratifying patients into four UA categories, all three hyperuricemia categories (UA6-8, 8–10, ≥10 mg/dL) associated with a greater decline in eGFR over the follow-up period with an increasing dose-response, comparing to the lowest UA category. The risk of progression to renal failure increased 7% (hazard ratio 1.07, 95% CI 1.00, 1.14) for each 1mg/dL increase in baseline UA level. The influences of hyperuricemia on eGFR decline and the risk of kidney failure were more prominent in patients without proteinuria than those with proteinuria.

Conclusion

Our study showed a higher uric acid level is associated with a significant rapid decline in eGFR and a higher risk of kidney failure, particularly in patients without proteinuria. Our findings suggest hyperuricemia is a potential modifiable factor of CKD progression.

Clinical Effects of Topiroxostat on Renal and Endothelial Function in A Patient with Chronic Kidney Disease and Hyperuricemic Arteriolopathy: A Case Report

Hyperuricemia is associated with the progression of chronic kidney disease (CKD) and cardiovascular diseases. Topiroxostat, a selective xanthine oxidase inhibitor, effectively reduces serum uric acid (UA) levels and urinary albumin excretion (UAE) in CKD patients. A 50-year-old Japanese man was referred to our hospital due to albuminuria and hyperuricemia, and renal biopsy showed a typical hyperuricemic arteriolopathy. Treatment with topiroxostat decreased serum UA levels (9.2 mg/dL at baseline to 6.4 mg/dL after 6 months), UAE (388 to 88 mg/g.cr), and urinary level of liver-type fatty acid-binding protein (28.8 to 19.8 µg/g.cr). Interestingly, topiroxostat treatment was associated with a trend towards improved flow-mediated dilation (5.4 to 5.8%). These results suggested that topiroxostat in CKD patients with hyperuricemia is potentially effective, not only for ameliorating renal damages but also for improving endothelial function beyond its UA-lowering action.

Sublytic C5b-9 Induces Glomerular Mesangial Cell Apoptosis through the Cascade Pathway of MEKK2-p38 MAPK-IRF-1-TRADD-Caspase 8 in Rat Thy-1 Nephritis

The apoptosis of glomerular mesangial cells (GMCs) in the early phase of rat Thy-1 nephritis (Thy-1N), a model of human mesangioproliferative glomerulonephritis (MsPGN), is primarily triggered by sublytic C5b-9. However, the mechanism of GMC apoptosis induced by sublytic C5b-9 remains unclear. In this study, we demonstrate that expressions of TNFR1-associated death domain-containing protein (TRADD) and IFN regulatory factor-1 (IRF-1) were simultaneously upregulated in the renal tissue of Thy-1N rats (in vivo) and in GMCs under sublytic C5b-9 stimulation (in vitro). In vitro, TRADD was confirmed to be a downstream gene of IRF-1, because IRF-1 could bind to TRADD gene promoter to promote its transcription, leading to caspase 8 activation and GMC apoptosis. Increased phosphorylation of p38 MAPK was verified to contribute to IRF-1 and TRADD production and caspase 8 activation, as well as to GMC apoptosis induced by sublytic C5b-9. Furthermore, phosphorylation of MEK kinase 2 (MEKK2) mediated p38 MAPK activation. More importantly, three sites (Ser^153/164/239) of MEKK2 phosphorylation were identified and demonstrated to be necessary for p38 MAPK activation. In addition, silencing of renal MEKK2, IRF-1, and TRADD genes or inhibition of p38 MAPK activation in vivo had obvious inhibitory effects on GMC apoptosis, secondary proliferation, and urinary protein secretion in rats with Thy-1N. Collectively, these findings indicate that the cascade axis of MEKK2-p38 MAPK-IRF-1-TRADD-caspase 8 may play an important role in GMC apoptosis following exposure to sublytic C5b-9 in rat Thy-1N.

Time to target uric acid to retard CKD progression

Uric acid (UA) remains a possible risk factor of chronic kidney disease (CKD) but its potential role should be elucidated given a fact that multidisciplinary treatments assure a sole strategy to inhibit the progression to end-stage renal disease (ESRD). In clinical setting, most observational studies showed that elevation of serum uric acid (SUA) independently predicts the incidence and the development of CKD. The meta-analysis showed that SUA-lowering therapy with allopurinol may retard the progression of CKD but did not reach conclusive results due to small-sized studies. Larger scale, randomized placebo-controlled trials to assess SUA-lowering therapy are needed. Our recent analysis by propensity score methods has shown that the threshold of SUA should be less than 6.5 mg/dL to abrogate ESRD. In animal models an increase in SUA by the administration of oxonic acid, uricase inhibitor, or nephrectomy can induce glomerular hypertension, arteriolosclerosis including afferent arteriolopathy and tubulointerstitial fibrosis. The ever-growing discoveries of urate transporters prompt us to learn UA metabolism in the kidney and intestine. One example is that the intestinal ABCG2 may play a compensatory role at face of decreased renal clearance of UA in nephrectomized rats, the trigger of which is not a uremic toxin but SUA itself. This review will summarize the recent knowledge on the relationship between SUA and the kidney and try to draw a conclusion when and how to treat asymptomatic hyperuricemia accompanied by CKD. Finally we will address a future perspective on UA study including a Mendelian randomization approach.

The Impact of Normal Range of Serum Phosphorus on the Incidence of End-Stage Renal Disease by A Propensity Score Analysis

Background

Although hyperphosphatemia is deemed a risk factor of the progression of chronic kidney disease (CKD), it remains unclear whether the normal range of serum phosphorus likewise deteriorates CKD. A propensity score analysis was applied to examine the causal effect of the normal range of serum phosphorus on the incidence of end-stage renal disease (ESRD).

Methods

A retrospective CKD cohort of 803 participants in a single institution was analyzed. Propensity score was estimated using 22 baseline covariates by multivariate binary logistic regression for the different thresholds of time-averaged phosphorus (TA-P) in the normal range of serum phosphorus incremented by 0.1 mg/dL from 3.3 to 4.5 mg/dL.

Results

The incidence rate of ESRD was 33.9 per 1,000 person-years over median follow-up of 4.3 years. Total patients showed the mean baseline phosphorus of 3.37 mg/dL and were divided to quartile. The higher quartile was associated with the parameters consistent with the advancement of CKD. A stratified Cox regression showed the highest hazard ratio (HR) at TA-P 3.4 mg/dL (HR 17.60, 95% CI 3.92–78.98) adjusted for baseline covariates such as sex, age, diabetic nephropathy, estimated GFR, serum albumin, Na-Cl, phosphorus, LDL-C and proteinuria. Adjusted HRs remained high up to TA-P 4.2 mg/dL (HR 2.22, 95% CI 1.33–3.71). After propensity score matching conducted at the thresholds of TA-P 3.4, 3.6, 3.8 and 4.0 mg/dL, the higher levels of TA-P showed the higher HRs by Kaplan-Meier analysis (p < 0.05 by stratified log-rank test). The numbers needed to treat were calculated as 3.9 to 5.3 over 5 years.

Conclusions

The propensity score analysis shows that even the normal range of serum phosphorus clearly accelerates CKD progression to ESRD. Our results encourage clinicians to target serum phosphorus to inhibit CKD progression in the manner of ‘the lower the better.’

Differential pharmacology and clinical utility of empagliflozin in type 2 diabetes

With rates of obesity and diabetes rising across the world, effective therapies to treat hyperglycemia and its associated comorbidities continue to be in demand. Empagliflozin is a highly selective sodium glucose transporter-2 inhibitor that improves serum glucose levels by inducing glucosuria. Taken orally, it is rapidly absorbed with linear pharmacokinetics consistent in Asian and Caucasian populations. Empagliflozin treatment demonstrates consistent reductions in hemoglobin A1c, fasting plasma glucose, body weight, and blood pressure in individuals with type 2 diabetes. Improvements in glycemic control and metabolic end points are evident with empagliflozin monotherapy, as add-on to oral hypoglycemics or add-on to insulin. The nonglycemic effects of empagliflozin with consistent improvements in blood pressure, body weight, and waist circumference provide additional rationale for use in patients with type 2 diabetes. Moreover, treatment with empagliflozin has recently shown significant reductions in both microvascular and macrovascular complications of diabetes.