Mortality risk of chronic kidney disease: A comparison between the adult populations in urban China and the United States

Interaction between the stage of chronic kidney disease and diabetes mellitus as factors associated with mortality in chronic kidney disease patients: An external cohort study

INTRODUCTION

Diabetic kidney disease is the main cause of chronic kidney disease (CKD) worldwide. Both CKD and diabetes mellitus (DMT2) are important risk factors for mortality. However, it is still unknown if the risk of death is modified by the simultaneous presence of these diseases.

OBJECTIVE

To evaluate the presence of an interaction between DMT2 and CKD for mortality in a representative population of a Latin American country.

METHODS

It is an analytical cohort study of patients with CKD, who were followed for 4 years (between 2004 and 2009). We calculated the incidence rate, progression, survival (using Kaplan-Meier curves), interaction (on the additive and multiplicative scales) and impact of the different stages of CKD in patients with and without DMT2 (using a cox proportional hazards model).

RESULTS

In this population of 5663 individuals, both DMT2 and CKD are risk factors for mortality (p<0.001). We found a statistically significant difference in mortality between individuals with and without DMT2, who also had CKD stages 3-4 -5 (Log-rank p=0.0076). Additionally, we found a statistically significant interaction for mortality in both the additive and multiplicative scales between DMT2 and CKD (p=0.005). DMT2 was found to be a risk factor for mortality (Hazard Ratio 1.61 p<0.001), but in individuals with DMT2, the only risks significantly associated with mortality, were age, dyslipidemia and nephroprotective drugs. CONCLUSIóN: The interaction between CKD and DMT2 negatively modifies the risk of death of both diseases. This means that when the two diseases are present, the risk of mortality is lower than expected.

Self-reported chronic kidney disease and the risk of all-cause and cause-specific mortality: outcome-wide association study of 54 causes of death in the National Health Interview Survey

Background

A diagnosis of chronic kidney disease has been strongly associated with cardiovascular disease and mortality in a number of studies, but the association with specific causes of death has not been assessed in detail. We analysed the association between chronic kidney disease and all-cause mortality and 54 causes of death in the National Health Interview Survey, a prospective study of 210,748 US adults.

Methods

We used multivariable Cox regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality associated with self-reported chronic kidney disease. Men and women aged 18–84 years were recruited between 1997 and 2004 and followed up for mortality through December 31, 2006.

Results

During an average of 6 years follow-up, 9564 deaths occurred. A history of chronic kidney disease vs. no chronic kidney disease was associated with increased risk of all-cause mortality (HR = 2.69, 95% CI: 2.38–3.04), and mortality from septicemia (5.65, 2.84–11.25), viral hepatitis (10.67, 2.43–46.95), other infectious parasitic diseases (10.58, 3.59–31.21), total cancer (1.48, 1.05–2.09), lung cancer (1.94, 1.10–3.44), kidney cancer (4.74, 1.81–12.41), diabetes mellitus (8.57, 5.60–13.11), circulatory disease overall (3.36, 2.70–4.18) and 11 specific circulatory diseases with the strongest associations observed for primary hypertension/renal disease (13.60, 6.42–28.84), hypertensive heart/renal disease (10.72, 2.47–46.49), and other diseases of circulatory system (7.36, 3.22–16.81). Elevated risk was also observed for alcoholic liver disease (5.63, 1.90–16.66), other chronic liver disease (4.41, 1.74–11.17), kidney failure (13.07, 8.23–20.77), and five other causes of death.

Conclusions

A history of chronic kidney disease was associated with increased risk of all-cause mortality and 27 out of 54 causes of death. Further studies are needed to clarify associations with less common causes of death.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02771-1.

Research progress on the relationship between IS and kidney disease and its complications

Indoxyl sulphate (IS) a representative uraemic toxin in the blood of patients with chronic kidney disease (CKD). Its accumulation may be closely related to CKD and the increasing morbidity and mortality of the disease's related complications. Timely and effective detection of the IS level and efficient clearance of IS may effectively prevent the progression of CKD and its related complications. Therefore, this article summarizes the research progress of IS related, including IS in CKD and its associated complications including chronic kidney disease, chronic kidney disease with cardiovascular disease, renal anemia, bone mineral metabolic disease and neuropsychiatric disorders, looking for IS accurate rapid detection methods, and explore the efficient treatment to reduce blood levels of indole phenol sulphate.

Chronic kidney disease biomarkers and mortality among older adults: A comparison study of survey samples in China and the United States

OBJECTIVES

Among older adults in China and the US, we aimed to compare the biomarkers of chronic-kidney-diseases (CKD), factors associated with CKD, and the correlation between CKD and mortality.

SETTING

China and the US.

STUDY DESIGN

Cross-sectional and prospective cohorts.

PARTICIPANTS

We included 2019 participants aged 65 and above from the Chinese Longitudinal Healthy Longevity Study (CLHLS) in 2012, and 2177 from US National Health and Nutrition Examination Survey (NHANES) in 2011-2014.

OUTCOMES

Urinary albumin, urinary creatinine, albumin creatinine ratio (ACR), serum creatinine, blood urea nitrogen, plasma albumin, uric acid, and estimated glomerular filtration rate (eGFR). CKD (ACR ≥ 30 mg/g or eGFR< 60 ml/min/1.73m2) and mortality.

ANALYTICAL APPROACH

Logistic regression and Cox proportional hazard models. Covariates included age, sex, race, education, income, marital status, health condition, smoking and drinking status, physical activity and body mass index.

RESULTS

Chinese participants had lower levels of urinary albumin, ACR, and uric acid than the US (mean: 25.0 vs 76.4 mg/L, 41.7 vs 85.0 mg/g, 292.9 vs 341.3 μmol/L). In the fully-adjusted model, CKD was associated with the risk of mortality only in the US group (hazard ratio [HR], 95% CI: 2.179, 1.561-3.041 in NHANES, 1.091, 0.940-1.266 in CLHLS). Compared to eGFR≥90, eGFR ranged 30-44 ml/min/1.73m2 was only associated with mortality in the US population (HR, 95% CI: 2.249, 1.141-4.430), but not in the Chinese population (HR, 95% CI: 1.408, 0.884-2.241).

CONCLUSIONS

The elderly participants in the US sample had worse CKD-related biomarker levels than in China sample, and the association between CKD and mortality was also stronger among the US older adults. This may be due to the biological differences, or co-morbid conditions.

Interaction between the stage of chronic kidney disease and diabetes mellitus as factors associated with mortality in chronic kidney disease patients: An external cohort study

INTRODUCTION

Diabetic kidney disease is the main cause of chronic kidney disease (CKD) worldwide. Both CKD and diabetes mellitus (DMT2) are important risk factors for mortality. However, it is still unknown if the risk of death is modified by the simultaneous presence of these diseases.

OBJECTIVE

To evaluate the presence of an interaction between DMT2 and CKD for mortality in a representative population of a Latin American country.

METHODS

It is an analytical cohort study of patients with CKD, who were followed for 4 years (between 2004 and 2009). We calculated the incidence rate, progression, survival (using Kaplan-Meier curves), interaction (on the additive and multiplicative scales) and impact of the different stages of CKD in patients with and without DMT2 (using a cox proportional hazards model).

RESULTS

In this population of 5663 individuals, both DMT2 and CKD are risk factors for mortality (P < 0.001). We found a statistically significant difference in mortality between individuals with and without DMT2, who also had CKD stages 3 - 4 - 5 (Log-rank P = 0.0076). Additionally, we found a statistically significant interaction for mortality in both the additive and multiplicative scales between DMT2 and CKD (P = 0.005). DMT2 was found to be a risk factor for mortality (Hazard Ratio 1.61 P < 0.001), but in individuals with DMT2, the only risks significantly associated with mortality, were age, dyslipidemia and nephroprotective drugs. CONCLUSIóN: The interaction between CKD and DMT2 negatively modifies the risk of death of both diseases. This means that when the two diseases are present, the risk of mortality is lower than expected.

Links Between Mortality and Socioeconomic Characteristics, Disease Burden, and Biological and Physical Functioning in the Aging Chinese Population

OBJECTIVES

Determinants of mortality may depend on the time and place where they are examined. China provides an important context in which to study the determinants of mortality at older ages because of its unique social, economic, and epidemiological circumstances. This study uses a nationally representative sample of persons in China to determine how socioeconomic characteristics, early-life conditions, biological and physical functioning, and disease burden predict 4-year mortality after age 60.

METHODS

We used data from the China Health and Retirement Longitudinal Study. We employed a series of Cox proportional hazard models based on exact survival time to predict 4-year all-cause mortality between the 2011 baseline interview and the 2015 interview.

RESULTS

We found that rural residence, poor physical functioning ability, uncontrolled hypertension, diabetes, cancer, a high level of systemic inflammation, and poor kidney functioning are strong predictors of mortality among older Chinese.

DISCUSSION

The results show that the objectively measured indicators of physical functioning and biomarkers are independent and strong predictors of mortality risk after accounting for several additional self-reported health measures, confirming the value of incorporating biological and performance measurements in population health surveys to help understand health changes and aging processes that lead to mortality. This study also highlights the importance of social and historical context in the study of old-age mortality.

Costs and Healthcare Resource Use Associated with Risk of Cardiovascular Morbidity in Patients with Chronic Kidney Disease: Evidence from a Systematic Literature Review

Introduction

The management of chronic kidney disease (CKD) costs in excess of $114 billion in the USA and £1.45 billion in the UK annually and is projected to increase alongside the increasing disease prevalence. The aim of this review was to evaluate the risks of cardiovascular (CV) morbidity, CV mortality or all-cause mortality based on KDIGO (Kidney Disease: Improving Global Outcomes) 2012 categorisations and estimate the additional costs and healthcare resource utilisation associated with CV morbidity linked to CKD severity in US and UK settings.

Methods

A systematic literature review was conducted of studies reporting on the risk of CV morbidity, CV mortality or all-cause mortality characterised by CKD severity (published between January 2000 and September 2018). Additional costs and bed days associated with CKD severity in the USA and UK were estimated on the basis of median hazard ratios for CV morbidity risk at each CKD and albuminuria stage.

Results

Twenty-nine studies reported risk of adverse clinical outcomes based on KDIGO categorisations. Compared to stage 1 (or without) CKD, patients with stage 5 CKD and macroalbuminuria experienced a relative risk increase of 11.77–12.46 across all outcomes. Additional costs and bed days associated with stage 5 CKD and macroalbuminuria (versus stage 1 (or without) CKD) per 1000 patient years were US$3.93 million and 803 bed days and £435,000 and 1017 bed days, in the USA and UK, respectively.

Conclusion

Risks of adverse clinical outcomes increase with CKD and albuminuria severity and are associated with substantial additional costs and resource utilisation. Thus, early diagnosis and proactive management of CKD and its complications should be a priority for healthcare providers to alleviate the burden of CV morbidity and its management on healthcare resources.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-020-01607-4.

Prediction of Mortality Incidence in Patients with Chronic Kidney Disease Based on Influential Prognostic Factors with Competing Risks Approach

BACKGROUND

Chronic Kidney Disease (CKD) is a disease in which the kidney's functionality declines gradually. The aim of this study was to identify significant laboratory prognostic factors on death due to CKD in a clinical complex.

MATERIALS AND METHODS

A retrospective study including 109 patients with the end-stage renal disease treated at Iran Helal pharmaceutical and the clinical complex was conducted between 2014-2018. The survival time was set as the time interval between starting dialysis until death due to CKD. Also, the transplantation was considered as competing risk, which was occurred for a few patients. A three-parameter Gompertz model was used that considers both the event of interest and the competing event simultaneously.

RESULTS

Death due to CKD occurred in 29 (26.6%) of the patients and 19(17.4%) with transplantation. Serum uric acid was a significant prognostic factor that decreased the hazard of mortality by 21%. Serum phosphorus and age by increasing the risk of death, were poor prognoses for the event of interest. Serum uric acid and phosphorus 6.9-9.9 (mg/dl) were associated with 72% and 4.05- fold increased hazard of transplant, respectively. The 4-year cumulative incidence of death and transplant was 48.4% and 29.2%, respectively.

CONCLUSION

We have deduced that high serum phosphorus levels and increased levels of age were associated with worse outcomes. High serum uric acid level was related to better survival, which could be explained by having a better protein-rich diet alongside the high albumin level.

Optimized Identification of Advanced Chronic Kidney Disease and Absence of Kidney Disease by Combining Different Electronic Health Data Resources and by Applying Machine Learning Strategies

Automated identification of advanced chronic kidney disease (CKD ≥ III) and of no known kidney disease (NKD) can support both clinicians and researchers. We hypothesized that identification of CKD and NKD can be improved, by combining information from different electronic health record (EHR) resources, comprising laboratory values, discharge summaries and ICD-10 billing codes, compared to using each component alone. We included EHRs from 785 elderly multimorbid patients, hospitalized between 2010 and 2015, that were divided into a training and a test (n = 156) dataset. We used both the area under the receiver operating characteristic (AUROC) and under the precision-recall curve (AUCPR) with a 95% confidence interval for evaluation of different classification models. In the test dataset, the combination of EHR components as a simple classifier identified CKD ≥ III (AUROC 0.96[0.93-0.98]) and NKD (AUROC 0.94[0.91-0.97]) better than laboratory values (AUROC CKD 0.85[0.79-0.90], NKD 0.91[0.87-0.94]), discharge summaries (AUROC CKD 0.87[0.82-0.92], NKD 0.84[0.79-0.89]) or ICD-10 billing codes (AUROC CKD 0.85[0.80-0.91], NKD 0.77[0.72-0.83]) alone. Logistic regression and machine learning models improved recognition of CKD ≥ III compared to the simple classifier if only laboratory values were used (AUROC 0.96[0.92-0.99] vs. 0.86[0.81-0.91], p < 0.05) and improved recognition of NKD if information from previous hospital stays was used (AUROC 0.99[0.98-1.00] vs. 0.95[0.92-0.97]], p < 0.05). Depending on the availability of data, correct automated identification of CKD ≥ III and NKD from EHRs can be improved by generating classification models based on the combination of different EHR components.

Clinical predictors of all-cause mortality in patients presenting to specialist heart failure clinic with raised NT-proBNP and no heart failure

AIMS

Clinical outcomes for patients suspected of having heart failure (HF) who do not meet the diagnostic criteria of any type of HF by echocardiography remain unknown. The aim of this study was to investigate the clinical predictors of all-cause mortality in patients with suspected HF, a raised N-terminal pro-b-type natriuretic peptide (NTproBNP) and who do not meet the diagnostic criteria of any type of HF by echocardiography.

METHODS AND RESULTS

Relevant data were taken from the Sheffield HEArt Failure (SHEAF) registry (222349P4). The inclusion criteria were presence of symptoms raising suspicion of HF, NTproBNP > 400 pg/mL, and preserved left ventricular function. Exclusion criteria were any type of HF by echocardiography. The outcome was defined as all-cause mortality. Cox proportional-hazards regression model was used to investigate the association between the survival time of patients and clinical variables; 1031 patients were identified with NTproBNP > 400 pg/mL but who did not have echocardiographic evidence of HF. All-cause mortality was 21.5% (222 deaths) over the mean follow-up (FU) period of 6 ± 2 years. NTproBNP was similar in patients who were alive or dead (P = 0.96). However, age (HR 1, P < 0.01), chronic kidney disease (CKD, HR 1.2, P < 0.01), chronic pulmonary obstructive disease (COPD, HR 1.6, P < 0.01), dementia (HR 5.9, P < 0.01), male gender (HR 1.4, P < 0.01), first-degree atrioventricular block (HR 2.1, P < 0.01), left axis deviation (HR 1.6, P = 0.04), and diabetes (HR 1.4, P = 0.03) were associated with all-cause mortality. In multivariate regression, age, gender, CKD stage, COPD, and dementia were independently associated with mortality. In patients with NTproBNP > 627 pg/mL, NYHA class predicted death (II, 19.6%; III, 27.4%; IV, 66.7%; P < 0.01).

CONCLUSIONS

Patients with no HF on echocardiography but raised NTproBNP suffer excess mortality particularly in the presence of certain clinical variables. Age, male gender, worsening CKD stage, presence of COPD, and dementia are independently associated with all-cause mortality in these patients. An NTproBNP > 627 pg/mL coupled with NYHA class could identify patients at greatest risk of death.

Chronic Kidney Disease After Partial Nephrectomy in Patients With Preoperative Inconspicuous Renal Function - Curiosity or Relevant Issue?

BACKGROUND

Chronic kidney disease (CKD) is a severe long-term complication after partial nephrectomy (PN). Clinical and scientific focus lies on patients with impaired renal function at the time of surgery. Little data is available on patients with normal preoperative renal function (NPRF).

PATIENTS AND METHODS

Patients who underwent PN with a preoperative estimated glomular filtration rate > 60 mL/min/1.73m² were retrospectively examined at 8 European urologic centers. The occurrence of new onset CKD ≥ stage III after surgery (sCKD) was defined as the primary endpoint. Group comparisons and risk correlations were determined. Based on this data, a risk stratification model for sCKD was developed.

RESULTS

Of the 1315 patients with NPRF included, 249 (18.9%) developed sCKD after a median follow-up of 44 months (range, 6-255 months). Pair analysis and univariable regression revealed age, arterial hypertension, American Society of Anesthesiologists score, tumor stage, surgical approach, intraoperative blood loss, perioperative blood transfusions and preoperative CKD stage as predictors for sCKD development. Multivariate analysis confirmed perioperative blood transfusion (hazard ratio [HR], 2.96; P ≤ .0001), age (≥ 55 years; HR, 2.60; P = .0002), tumor stage (> pT1; HR, 2.15; P = .025), and preoperative CKD stage (stage II vs. I; HR, 3.85; P ≤ .0001) as independent risk factors. A model that stratified patient risk for new onset CKD was highly significant (P < .0001).

CONCLUSION

Every fifth patient with NPRF developed sCKD following PN. Elderly patients with higher tumor stage and who require blood transfusion appear to be at increased risk. Based on our risk stratification, patients with ≥ 2 risk factors are candidates for an early, nephrologic follow-up.

Integrin-Linked Kinase Deficiency in Collecting Duct Principal Cell Promotes Necroptosis of Principal Cell and Contributes to Kidney Inflammation and Fibrosis

BACKGROUND

Necroptosis is a newly discovered cell death pathway that plays a critical role in AKI. The involvement of integrin-linked kinase (ILK) in necroptosis has not been studied.

METHODS

We performed experiments in mice with an Ilk deletion in collecting duct (CD) principal cells (PCs), and cultured tubular epithelial cells treated with an ILK inhibitor or ILK siRNA knockdown.

RESULTS

Ilk deletion in CD PCs resulted in acute tubular injury and early mortality in mice. Progressive interstitial fibrosis and inflammation associated with the activation of the canonical TGF-β signaling cascade were detected in the kidneys of the mice lacking ILK in the CD PCs. In contrast to the minimal apoptosis detected in the animals' injured CDs, widespread necroptosis was present in ILK-deficient PCs, characterized by cell swelling, deformed mitochondria, and rupture of plasma membrane. In addition, ILK deficiency resulted in increased expression and activation of necroptotic proteins MLKL and RIPK3, and membrane translocation of MLKL in CD PCs. ILK inhibition and siRNA knockdown reduced cell survival in cultured tubular cells, concomitant with increased membrane accumulation of MLKL and/or phospho-MLKL. Administration of a necroptosis inhibitor, necrostatin-1, blocked cell death in vitro and significantly attenuated inflammation, interstitial fibrosis, and renal failure in ILK-deficient mice.

CONCLUSIONS

The study demonstrates the critical involvement of ILK in necroptosis through modulation of the RIPK3 and MLKL pathway and highlights the contribution of CD PC injury to the development of inflammation and interstitial fibrosis of the kidney.

[Estimated glomerular filtration rate and post-hospital mortality after discharge from an acute care for the elderly unit]

OBJECTIVE

To determine the relationship between estimated glomerular filtration rate (eGFR) and mortality in a retrospective cohort of older adults admitted to an acute care for the elderly (ACE) unit.

MATERIALS AND METHODS

The study included 1,678 patients aged 60 years and over admitted to an AEC, in Cali, Colombia, from 2012 to 2015, and followed- up until 2016. The primary outcome was mortality. Renal function (eGFR) was estimated using Modification of Diet in Renal Disease Study (MDRD-4) equation. The renal function was grouped according to the eGFR (ml/min/1.73m²) as follows: slightly decreased (≥60), moderately decreased (30-59), and severely decreased (<30). Bivariate survival and multivariate Cox regression analyses were performed.

RESULTS

In the univariate analysis, patients with severely decreased eGFR had higher mortality than those with a higher eGFR (P=.046). In the group with severely decreased eGFR, survival was lower in the functionally dependent group (Barthel index [IB]<60) than in the independent group (IB≥60) (log rank test; P=.001). In the multivariate analysis, there was a significant increase in the risk of death in the elderly with severely decreased eGFR (<30) compared with slightly decreased eGFR (≥60) (hazard ratio [HR], 1.44; 95% confidence interval [CI]; 1.02-2.05, P=.039). There was also a significant increase in the risk of death in the dependent elderly compared to the independent ones [HR 1.72; 95% CI; 1.26-2.34, P=.000], those who had the high morbidity (≥4) with low albumin (<3.2g/dL) compared with those with low morbidity (0-3) and high albumin (≥3.2) [HR 1.77; 95% CI; 1.18-2.65, P=.005], and in those with a high (16-102mg/dL) C-reactive protein (CRP) compared with those with low CRP (0-15) [HR 1.42; 95% CI; 1.01-2.01, P=.043].

CONCLUSIONS

The risk of mortality after hospital admission to an AEC unit is greater in patients with eGFR<30. Poor functional status performance, high comorbidity, low plasma albumin, and increased inflammation markers are additional prognostic factors to be taken into account. The improvement in the functional status could improve the survival after hospitalisation.