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Wang H, Gao L, Zhao C, Fang F, Liu J, Wang Z, Zhong Y, Wang X. The role of PI3K/Akt signaling pathway in chronic kidney disease. Int Urol Nephrol 2024; 56:2623-2633. [PMID: 38498274 DOI: 10.1007/s11255-024-03989-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/12/2024] [Indexed: 03/20/2024]
Abstract
Chronic kidney disease (CKD), including chronic glomerulonephritis, IgA nephropathy and diabetic nephropathy, are common chronic diseases characterized by structural damage and functional decline of the kidneys. The current treatment of CKD is symptom relief. Several studies have reported that the phosphatidylinositol 3 kinases (PI3K)/protein kinase B (Akt) signaling pathway is a pathway closely related to the pathological process of CKD. It can ameliorate kidney damage by inhibiting this signal pathway which is involved with inflammation, oxidative stress, cell apoptosis, epithelial mesenchymal transformation (EMT) and autophagy. This review highlights the role of activating or inhibiting the PI3K/Akt signaling pathway in CKD-induced inflammatory response, apoptosis, autophagy and EMT. We also summarize the latest evidence on treating CKD by targeting the PI3K/Akt pathway, discuss the shortcomings and deficiencies of PI3K/Akt research in the field of CKD, and identify potential challenges in developing these clinical therapeutic CKD strategies, and provide appropriate solutions.
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Affiliation(s)
- Hongshuang Wang
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang, 050091, China
| | - Lanjun Gao
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang, 050091, China
| | - Chenchen Zhao
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang, 050091, China
| | - Fang Fang
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang, 050091, China
| | - Jiazhi Liu
- Graduate School, Hebei University of Chinese Medicine, Shijiazhuang, 050091, China
| | - Zheng Wang
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns Research, Shijiazhuang, 050091, China
- Institute of Integrative Medicine, College of Integrative Medicine, Hebei University of Chinese Medicine, Shijiazhuang, 050200, China
| | - Yan Zhong
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns Research, Shijiazhuang, 050091, China.
- Institute of Integrative Medicine, College of Integrative Medicine, Hebei University of Chinese Medicine, Shijiazhuang, 050200, China.
| | - Xiangting Wang
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns Research, Shijiazhuang, 050091, China.
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2
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Yuan S, Li S, Ruan J, Liu H, Jiang T, Dai H. Chronic kidney disease and pulmonary hypertension: Progress in diagnosis and treatment. Transl Res 2024; 273:16-22. [PMID: 38960282 DOI: 10.1016/j.trsl.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 06/13/2024] [Accepted: 06/18/2024] [Indexed: 07/05/2024]
Abstract
Pulmonary hypertension (PH) is a medical condition characterized by elevated pulmonary vascular resistance and pressure, resulting from different diseases. Due to their high occurrence of PH, intricate hemodynamic classification, and frequently multifactorial cause and mechanism, individuals suffering from chronic kidney disease (CKD) are categorized as the fifth primary group of PH. Based on both domestic and international research, this article provides information on the epidemiology, risk factors, pathogenesis, and targeted drug treatment of PH associated with CKD.
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Affiliation(s)
- Shanshan Yuan
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao 266011, PR China
| | - Shicheng Li
- Department of Cardiology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, PR China
| | - Jiangwen Ruan
- Department of Cardiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Institute of Cardiovascular Sciences, Guangxi Academy of Medical Sciences, Nanning 530021, PR China
| | - Hui Liu
- Division of Biology and Chemistry, Paul Scherrer Institut, 5232, Villigen, Switzerland; Department of Health Sciences and Technology, ETH Zurich, 8092, Zurich, Switzerland
| | - Tongmeng Jiang
- Key Laboratory of Emergency and Trauma of Ministry of Education, Key Laboratory of Haikou Trauma, Key Laboratory of Hainan Trauma and Disaster Rescue, The First Affiliated Hospital, Hainan Medical University, Haikou 571199, PR China; Engineering Research Center for Hainan Bio-Smart Materials and Bio-Medical Devices, Key Laboratory of Hainan Functional Materials and Molecular Imaging, College of Emergency and Trauma, Hainan Academy of Medical Sciences, Hainan Medical University, Haikou 571199, PR China.
| | - Hongyan Dai
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao 266011, PR China.
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3
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Günthner R, Lorenz G, Braunisch MC, Angermann S, Matschkal J, Hausinger R, Kuchler T, Glaser P, Schicktanz F, Haller B, Heemann U, Streese L, Hanssen H, Kotliar K, Schmaderer C. Endothelial dysfunction in retinal vessels of hemodialysis patients compared to healthy controls. Sci Rep 2024; 14:13948. [PMID: 38886448 PMCID: PMC11183144 DOI: 10.1038/s41598-024-64581-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 06/11/2024] [Indexed: 06/20/2024] Open
Abstract
Endothelial dysfunction is a key factor promoting atherosclerosis and cardiovascular complications. Hemodialysis patients typically show various cardiovascular complications and impaired retinal venular dilation has been described as a risk factor for mortality. Non-invasive retinal vessel analysis provides insight into the microvasculature and endothelial function. Static retinal vessel analysis determines arteriolar and venular vessel diameters and dynamic retinal vessel analysis measures microvascular function by flicker-light induced stimulation, which results in physiological dilation of retinal vessels. We measured 220 healthy individuals and compared them to our preexisting cohort of hemodialysis patients (275 for static and 214 for dynamic analysis). Regarding static vessel diameters, hemodialysis patients and healthy individuals did not significantly differ between vessel diameters. Dynamic retinal vessel analysis showed attenuated dilation of the arteriole of hemodialysis patients with 1.6% vs 2.3% in healthy individuals (p = 0.009). Case-control matching for age (mean 65.4 years) did not relevantly diminish the difference. Hemodialysis patients also exhibited reduced venular dilation after matching for age (3.2% vs 3.8%, p = 0.019). Hemodialysis patients showed microvascular dysfunction compared to healthy individuals when using dynamic retinal vessel analysis. Further studies should focus on dynamic retinal vessel analysis which can add insights into the microvascular function and risk factors in multimorbid patients.
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Affiliation(s)
- Roman Günthner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Georg Lorenz
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Matthias Christoph Braunisch
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Susanne Angermann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Julia Matschkal
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Renate Hausinger
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Timon Kuchler
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Patrizia Glaser
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Felix Schicktanz
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Haller
- School of Medicine, Klinikum Rechts der Isar, Institute of AI and Informatics in Medicine, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Lukas Streese
- Preventive Sports Medicine and Systems Physiology, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
- Faculty of Health Care, Niederrhein University of Applied Sciences, Krefeld, Germany
| | - Henner Hanssen
- Preventive Sports Medicine and Systems Physiology, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Konstantin Kotliar
- Aachen University of Applied Sciences, Heinrich-Mussmann-Str. 1, 52428, Jülich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
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Cozzolino M, Maffei Faccioli F, Cara A, Boni Brivio G, Rivela F, Ciceri P, Magagnoli L, Galassi A, Barbuto S, Speciale S, Minicucci C, Cianciolo G. Future treatment of vascular calcification in chronic kidney disease. Expert Opin Pharmacother 2023; 24:2041-2057. [PMID: 37776230 DOI: 10.1080/14656566.2023.2266381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/29/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION Cardiovascular disease (CVD) is one of the global leading causes of morbidity and mortality in chronic kidney disease (CKD) patients. Vascular calcification (VC) is a major cause of CVD in this population and is the consequence of complex interactions between inhibitor and promoter factors leading to pathological deposition of calcium and phosphate in soft tissues. Different pathological landscapes are associated with the development of VC, such as endothelial dysfunction, oxidative stress, chronic inflammation, loss of mineralization inhibitors, release of calcifying extracellular vesicles (cEVs) and circulating calcifying cells. AREAS COVERED In this review, we examined the literature and summarized the pathophysiology, biomarkers and focused on the treatments of VC. EXPERT OPINION Even though there is no consensus regarding specific treatment options, we provide the currently available treatment strategies that focus on phosphate balance, correction of vitamin D and vitamin K deficiencies, avoidance of both extremes of bone turnover, normalizing calcium levels and reduction of inflammatory response and the potential and promising therapeutic approaches liketargeting cellular mechanisms of calcification (e.g. SNF472, TNAP inhibitors).Creating novel scores to detect in advance VC and implementing targeted therapies is crucial to treat them and improve the future management of these patients.
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Affiliation(s)
- Mario Cozzolino
- Renal Division, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Federico Maffei Faccioli
- Renal Division, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Anila Cara
- Renal Division, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Giulia Boni Brivio
- Renal Division, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Francesca Rivela
- Renal Division, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Paola Ciceri
- Renal Division, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Lorenza Magagnoli
- Renal Division, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Andrea Galassi
- Renal Division, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Simona Barbuto
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Serena Speciale
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Carlo Minicucci
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Valera G, Figuer A, Caro J, Yuste C, Morales E, Ceprián N, Bodega G, Ramírez R, Alique M, Carracedo J. Plasma glycocalyx pattern: a mirror of endothelial damage in chronic kidney disease. Clin Kidney J 2023; 16:1278-1287. [PMID: 37529650 PMCID: PMC10387401 DOI: 10.1093/ckj/sfad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Indexed: 08/03/2023] Open
Abstract
Background Endothelial damage and cardiovascular disease complicate chronic kidney disease (CKD). The increased atherogenicity observed in patients with CKD can be linked to microinflammation and endothelial damage. Circulating endothelial glycocalyx degradation products, such as perlecan and decorin, tend to be elevated in CKD. We aimed to explore the association between the plasma perlecan and decorin levels and this pro-inflammatory and atherogenic state by studying monocyte subpopulations and intracellular adhesion molecule (ICAM)-1 expression in patients with CKD. Methods We studied 17 healthy controls, 23 patients with advanced CKD, 25 patients on haemodialysis, 23 patients on peritoneal dialysis and 20 patients who underwent kidney transplantation. Perlecan and decorin levels were evaluated using enzyme-linked immunosorbent assays, and the monocyte phenotype was analysed using direct immunofluorescence and flow cytometry. Results The plasma perlecan levels were higher in patients with CKD than in the healthy controls. These levels were associated with a higher prevalence of ICAM-1+ monocytes. Conversely, patients with advanced CKD (pre-dialysis) had higher plasma decorin levels, which were associated with a reduced ICAM-1 expression per monocyte. Conclusions Elevated perlecan levels in CKD may be associated with a higher prevalence of ICAM-1+ monocytes and a pro-inflammatory phenotype. Elevated decorin levels may act as a negative regulator of ICAM-1 expression in monocytes. Therefore, perlecan and decorin may be related to inflammation and monocyte activation in CKD and may act as potential markers of endothelial damage.
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Affiliation(s)
| | | | - Jara Caro
- Departamento de Nefrología del Hospital Universitario 12 de Octubre, Instituto de investigación i+12, Madrid, Spain
| | - Claudia Yuste
- Departamento de Nefrología del Hospital Universitario 12 de Octubre, Instituto de investigación i+12, Madrid, Spain
| | - Enrique Morales
- Departamento de Nefrología del Hospital Universitario 12 de Octubre, Instituto de investigación i+12, Madrid, Spain
- Departamento de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Noemí Ceprián
- Departamento de Genética, Fisiología y Microbiología, Facultad de Ciencias Biológicas, Universidad Complutense de Madrid/Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Guillermo Bodega
- Departamento de Biomedicina y Biotecnología, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Rafael Ramírez
- Departamento de Biología de Sistemas, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
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Cormican S, Negi N, Naicker SD, Islam MN, Fazekas B, Power R, Griffin TP, Dennedy MC, MacNeill B, Malone AF, Griffin MD. Chronic Kidney Disease Is Characterized by Expansion of a Distinct Proinflammatory Intermediate Monocyte Subtype and by Increased Monocyte Adhesion to Endothelial Cells. J Am Soc Nephrol 2023; 34:793-808. [PMID: 36799882 PMCID: PMC10125648 DOI: 10.1681/asn.0000000000000083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 12/13/2022] [Indexed: 01/27/2023] Open
Abstract
SIGNIFICANCE STATEMENT CKD is accompanied by abnormal inflammation, which contributes to progressive loss of functional renal tissue and accelerated cardiovascular disease. Although studies have documented that dysregulation of monocyte maturation and function is associated with CKD and its complications, it is not well characterized. This study reveals that a distinctive human monocyte subtype with high propensity for releasing proinflammatory mediators and activating endothelial cells is increased in adults with CKD compared with adults with high cardiovascular risk and normal kidney function. It also demonstrates that human monocyte adhesion to endothelial layers and responses to specific inflammatory migration signals are enhanced in CKD. These findings offer insights into the mechanisms of CKD-associated intravascular and localized inflammation and may suggest potential targets for therapeutic interventions. BACKGROUND Cardiovascular disease (CVD) in patients with CKD is associated with increased circulating intermediate monocytes (IMs). Dysregulation of monocyte maturation and function is associated with CKD and its complications, but it is incompletely characterized. METHODS To explore monocyte repertoire abnormalities in CKD, we studied properties of monocyte subpopulations, including IM subpopulations distinguished by HLA-DR expression level, in individuals with or without CKD. Using flow cytometry, we profiled monocyte populations in blood samples from adults with CKD, healthy volunteers (HVs), and patient controls (PCs) with high CVD risk. Monocyte subpopulations were also derived from single-cell RNA-sequencing profiles of paired blood and biopsy samples from kidney transplant recipients. We quantified intracellular cytokine production, migration, and endothelial adhesion in ex vivo assays of PBMCs. RESULTS Of four predefined blood monocyte subpopulations, only HLA-DR hi IMs were increased in individuals with CKD compared with HVs and PCs. In HVs and patients with CKD, LPS-stimulated HLA-DR hi IMs isolated from blood produced higher amounts of TNF and IL-1 β than other monocyte populations. Single-cell analysis revealed four monocyte clusters common to blood and kidneys, including an HLA-DR hi IM-like cluster that was enriched in kidneys versus blood. Migration toward CCL5 and CX3CL1 and adhesion to primary endothelial cell layers were increased in monocyte subpopulations in individuals with CKD compared with HVs. Monocyte adhesion to endothelial cells was partly dependent on CX3CR1/CX3CL1 interaction. CONCLUSIONS CKD is associated with an increased number of a distinctive proinflammatory IM subpopulation and abnormalities of monocyte migration and endothelial adhesion. Dysregulated monocyte maturation and function may represent targetable factors contributing to accelerated CVD in CKD.
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Affiliation(s)
- Sarah Cormican
- CÚRAM Centre for Research in Medical Devices, School of Medicine, Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
- Nephrology Department, Galway University Hospitals, Saolta University Health Care Group, Galway, Ireland
| | - Neema Negi
- CÚRAM Centre for Research in Medical Devices, School of Medicine, Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
| | - Serika D. Naicker
- CÚRAM Centre for Research in Medical Devices, School of Medicine, Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
| | - Md Nahidul Islam
- CÚRAM Centre for Research in Medical Devices, School of Medicine, Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
| | - Barbara Fazekas
- CÚRAM Centre for Research in Medical Devices, School of Medicine, Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
| | - Rachael Power
- CÚRAM Centre for Research in Medical Devices, School of Medicine, Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
| | - Tomás P. Griffin
- CÚRAM Centre for Research in Medical Devices, School of Medicine, Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
| | - M. Conall Dennedy
- Department of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway, Ireland
| | - Briain MacNeill
- Cardiology Department, Galway University Hospitals, Saolta University Health Care Group, Galway, Ireland
| | - Andrew F. Malone
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D. Griffin
- CÚRAM Centre for Research in Medical Devices, School of Medicine, Regenerative Medicine Institute (REMEDI), University of Galway, Galway, Ireland
- Nephrology Department, Galway University Hospitals, Saolta University Health Care Group, Galway, Ireland
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7
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Lano G, Sallée M, Pelletier M, Bataille S, Fraisse M, McKay N, Brunet P, Dou L, Burtey S. Neutrophil:lymphocyte ratio correlates with the uremic toxin indoxyl sulfate and predicts the risk of death in patients on hemodialysis. Nephrol Dial Transplant 2022; 37:2528-2537. [PMID: 35146525 DOI: 10.1093/ndt/gfab350] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a major public health issue associated with increased cardiovascular, infectious and all-cause mortality. The neutrophil:lymphocyte ratio (NLR) is a predictive marker of the risk of death and cardiovascular events. Uremic toxins, notably indoxyl sulfate (IS), are involved in immune deficiency and cardiovascular complications associated with CKD. The aim of this study was to assess whether the NLR was related to uremic toxins and could predict clinical outcome in hemodialysis (HD) patients. METHODS We conducted a prospective cohort study of 183 patients on chronic HD. The main objective was to study the correlation between the NLR and uremic toxin serum levels. The secondary objective was to test if the NLR can predict the incidence of mortality, cardiovascular events and infectious events. RESULTS Patients were separated into two groups according to the NLR median value (3.49). The NLR at inclusion was correlated with the NLR at the 6-month (r = 0.55, P < 0.0001) and 12-month (r = 0.62, P < 0.0001) follow-up. Among uremic toxins, IS levels were higher in the group with high NLR (104 µmol/L versus 81 µmol/L; P = 0.004). In multivariate analysis, the NLR remained correlated with IS (P = 0.03). The incidence of death, cardiovascular events and severe infectious events was higher in the group with high NLR [respectively, 38% versus 18% (P = 0.004), 45% versus 26% (P = 0.01) and 33% versus 21% (P = 0.02)] than in the low NLR group. Multivariate analysis showed an independent association of the NLR with mortality (P = 0.02) and cardiovascular events (P = 0.03) but not with severe infectious events. CONCLUSIONS In HD patients, the NLR predicted mortality and cardiovascular events but not severe infections and correlated positively with the level of the uremic toxin IS. The NLR could be an interesting marker for monitoring the risk of clinical events in CKD patients.
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Affiliation(s)
- Guillaume Lano
- Aix Marseille Université, INSERM, INRAE, C2VN, Marseille, France.,Centre de néphrologie et transplantation rénale, Hôpital de la conception AP-HM, Marseille, France
| | - Marion Sallée
- Aix Marseille Université, INSERM, INRAE, C2VN, Marseille, France.,Centre de néphrologie et transplantation rénale, Hôpital de la conception AP-HM, Marseille, France
| | - Marion Pelletier
- Centre de néphrologie et transplantation rénale, Hôpital de la conception AP-HM, Marseille, France
| | - Stanislas Bataille
- Aix Marseille Université, INSERM, INRAE, C2VN, Marseille, France.,Elsan, Phocean Institute of Nephrology, Clinique Bouchard, Marseille, France
| | - Megan Fraisse
- Aix Marseille Université, INSERM, INRAE, C2VN, Marseille, France
| | - Nathalie McKay
- Aix Marseille Université, INSERM, INRAE, C2VN, Marseille, France
| | - Philippe Brunet
- Aix Marseille Université, INSERM, INRAE, C2VN, Marseille, France.,Centre de néphrologie et transplantation rénale, Hôpital de la conception AP-HM, Marseille, France
| | - Laetitia Dou
- Aix Marseille Université, INSERM, INRAE, C2VN, Marseille, France
| | - Stéphane Burtey
- Aix Marseille Université, INSERM, INRAE, C2VN, Marseille, France.,Centre de néphrologie et transplantation rénale, Hôpital de la conception AP-HM, Marseille, France
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8
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Kaur R, Singh R. Mechanistic insights into CKD-MBD-related vascular calcification and its clinical implications. Life Sci 2022; 311:121148. [DOI: 10.1016/j.lfs.2022.121148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/22/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
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Vermeulen EA, Eelderink C, Hoekstra T, van Ballegooijen AJ, Raijmakers P, Beulens JW, de Borst MH, Vervloet MG. Reversal Of Arterial Disease by modulating Magnesium and Phosphate (ROADMAP-study): rationale and design of a randomized controlled trial assessing the effects of magnesium citrate supplementation and phosphate-binding therapy on arterial stiffness in moderate chronic kidney disease. Trials 2022; 23:769. [PMID: 36096824 PMCID: PMC9465140 DOI: 10.1186/s13063-022-06562-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Arterial stiffness and calcification propensity are associated with high cardiovascular risk and increased mortality in chronic kidney disease (CKD). Both magnesium and phosphate are recognized as modulators of vascular calcification and chronic inflammation, both features of CKD that contribute to arterial stiffness. In this paper, we outline the rationale and design of a randomized controlled trial (RCT) investigating whether 24 weeks of oral magnesium supplementation with or without additional phosphate-binding therapy can improve arterial stiffness and calcification propensity in patients with stage 3–4 CKD.
Methods
In this multi-center, placebo-controlled RCT, a total of 180 participants with an estimated glomerular filtration rate of 15 to 50 ml/min/1.73 m2 without phosphate binder therapy will be recruited. During the 24 weeks intervention, participants will be randomized to one of four intervention groups to receive either magnesium citrate (350 mg elemental magnesium/day) or placebo, with or without the addition of the phosphate binder sucroferric oxyhydroxide (1000 mg/day). Primary outcome of the study is the change of arterial stiffness measured by the carotid-femoral pulse wave velocity over 24 weeks. Secondary outcomes include markers of calcification and inflammation, among others calcification propensity (T50) and high-sensitivity C-reactive protein. As explorative endpoints, repeated 18F-FDG and 18F-NaF PET-scans will be performed in a subset of participants (n = 40). Measurements of primary and secondary endpoints are performed at baseline, 12 and 24 weeks.
Discussion
The combined intervention of magnesium citrate supplementation and phosphate-lowering therapy with sucroferric oxyhydroxide, in stage 3–4 CKD patients without overt hyperphosphatemia, aims to modulate the complex and deregulated mineral metabolism leading to vascular calcification and arterial stiffness and to establish to what extent this is mediated by T50 changes. The results of this combined intervention may contribute to future early interventions for CKD patients to reduce the risk of CVD and mortality.
Trial registration
Netherlands Trial Register, NL8252 (registered December 2019), EU clinical Trial Register 2019-001306-23 (registered November 2019).
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Hüsing AM, Wulfmeyer VC, Gaedcke S, Fleig SV, Rong S, DeLuca D, Haller H, Schmitt R, von Vietinghoff S. Myeloid CCR2 Promotes Atherosclerosis after AKI. J Am Soc Nephrol 2022; 33:1487-1500. [PMID: 35537780 PMCID: PMC9342642 DOI: 10.1681/asn.2022010048] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/10/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The risk of cardiovascular events rises after AKI. Leukocytes promote atherosclerotic plaque growth and instability. We established a model of enhanced remote atherosclerosis after renal ischemia-reperfusion (IR) injury and investigated the underlying inflammatory mechanisms. METHODS Atherosclerotic lesions and inflammation were investigated in native and bone marrow-transplanted LDL receptor-deficient (LDLr-/- ) mice after unilateral renal IR injury using histology, flow cytometry, and gene expression analysis. RESULTS Aortic root atherosclerotic lesions were significantly larger after renal IR injury than in controls. A gene expression screen revealed enrichment for chemokines and their cognate receptors in aortas of IR-injured mice in early atherosclerosis, and of T cell-associated genes in advanced disease. Confocal microscopy revealed increased aortic macrophage proximity to T cells. Differential aortic inflammatory gene regulation in IR-injured mice largely paralleled the pattern in the injured kidney. Single-cell analysis identified renal cell types that produced soluble mediators upregulated in the atherosclerotic aorta. The analysis revealed a marked early increase in Ccl2, which CCR2+ myeloid cells mainly expressed. CCR2 mediated myeloid cell homing to the post-ischemic kidney in a cell-individual manner. Reconstitution with Ccr2-/- bone marrow dampened renal post-ischemic inflammation, reduced aortic Ccl2 and inflammatory macrophage marker CD11c, and abrogated excess aortic atherosclerotic plaque formation after renal IR. CONCLUSIONS Our data introduce an experimental model of remote proatherogenic effects of renal IR and delineate myeloid CCR2 signaling as a mechanistic requirement. Monocytes should be considered as mobile mediators when addressing systemic vascular sequelae of kidney injury.
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Affiliation(s)
- Anne M. Hüsing
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Hannover, Germany
| | - Vera C. Wulfmeyer
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Hannover, Germany
| | - Svenja Gaedcke
- German Centre for Lung Research, Hannover Medical School, Hannover, Germany
| | - Susanne V. Fleig
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Hannover, Germany,Nephrology Section, Medical Clinic 1, University Hospital Bonn, Rheinische Friedrich Wilhelm University of Bonn, Bonn, Germany
| | - Song Rong
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Hannover, Germany
| | - David DeLuca
- German Centre for Lung Research, Hannover Medical School, Hannover, Germany
| | - Hermann Haller
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Hannover, Germany
| | - Roland Schmitt
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Hannover, Germany
| | - Sibylle von Vietinghoff
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Hannover, Germany,Nephrology Section, Medical Clinic 1, University Hospital Bonn, Rheinische Friedrich Wilhelm University of Bonn, Bonn, Germany
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11
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Rroji M, Figurek A, Viggiano D, Capasso G, Spasovski G. Phosphate in the Context of Cognitive Impairment and Other Neurological Disorders Occurrence in Chronic Kidney Disease. Int J Mol Sci 2022; 23:ijms23137362. [PMID: 35806367 PMCID: PMC9266940 DOI: 10.3390/ijms23137362] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/25/2022] [Accepted: 06/28/2022] [Indexed: 02/01/2023] Open
Abstract
The nervous system and the kidneys are linked under physiological states to maintain normal body homeostasis. In chronic kidney disease (CKD), damaged kidneys can impair the central nervous system, including cerebrovascular disease and cognitive impairment (CI). Recently, kidney disease has been proposed as a new modifiable risk factor for dementia. It is reported that uremic toxins may have direct neurotoxic (astrocyte activation and neuronal death) and/or indirect action through vascular effects (cerebral endothelial dysfunction, calcification, and inflammation). This review summarizes the evidence from research investigating the pathophysiological effects of phosphate toxicity in the nervous system, raising the question of whether the control of hyperphosphatemia in CKD would lower patients’ risk of developing cognitive impairment and dementia.
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Affiliation(s)
- Merita Rroji
- Department of Nephrology, Faculty of Medicine, University of Medicine Tirana, 1001 Tirana, Albania
- Correspondence:
| | - Andreja Figurek
- Department of Internal Medicine, Medical Faculty, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina;
- Institute of Anatomy, University of Zurich, 8057 Zurich, Switzerland
| | - Davide Viggiano
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (D.V.); (G.C.)
- BioGeM, Institute of Molecular Biology and Genetics, 83031 Ariano Irpino, Italy
| | - Giovambattista Capasso
- Department of Translational Medical Sciences, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (D.V.); (G.C.)
- BioGeM, Institute of Molecular Biology and Genetics, 83031 Ariano Irpino, Italy
| | - Goce Spasovski
- University Clinic for Nephrology, Medical Faculty, University St. Cyril and Methodius, 1000 Skopje, North Macedonia;
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12
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Romano G, Mioni R, Danieli N, Bertoni M, Croatto E, Merla L, Alcaro L, Pedduzza A, Metcalf X, Rigamonti A, Catena C, Sechi LA, Colussi G. Elevated Intrarenal Resistive Index Predicted Faster Renal Function Decline and Long-Term Mortality in Non-Proteinuric Chronic Kidney Disease. J Clin Med 2022; 11:jcm11112995. [PMID: 35683384 PMCID: PMC9181195 DOI: 10.3390/jcm11112995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/19/2022] [Accepted: 05/24/2022] [Indexed: 12/19/2022] Open
Abstract
Background. Intrarenal resistive index (RI) ≥ 0.80 predicts renal outcomes in proteinuric chronic kidney disease (CKD). However, this evidence in non-proteinuric patients with CKD of unknown etiology is lacking. In this study, we assessed the effect of intrarenal RI on renal function and all-cause mortality in non-proteinuric patients with CKD of unknown etiology despite an extensive diagnostic work-up. Methods. Non-proteinuric CKD patients were evaluated in a retrospective longitudinal study. Progression of renal disease was investigated by checking serum creatinine levels at 1, 3, and 5 years and defined by a creatinine level increase of at least 0.5 mg/dL. The discrimination performance of intrarenal RI in predicting the 5-year progression of renal disease was assessed by calculating the area under the receiver operating characteristic curve (AUROC). Results. One-hundred-thirty-one patients (76 ± 9 years, 56% males) were included. The median follow-up was 7.5 years (interquartile range 4.3−10.5) with a cumulative mortality of 53%, and 5-year renal disease progression occurred in 25%. Patients with intrarenal RI ≥ 0.80 had a faster increase of serum creatinine levels compared to those with RI < 0.80 (+0.06 mg/dL each year, 95% CI 0.02−0.10, p < 0.010). Each 0.1-unit increment of intrarenal RI was an independent determinant of 5-year renal disease progression (odds ratio 4.13, 95% CI 1.45−12.9, p = 0.010) and predictor of mortality (hazards ratio 1.80, 95% CI 1.05−3.09, p = 0.034). AUROCs of intrarenal RI for predicting 5-year renal disease progression and mortality were 0.66 (95% CI 0.57−0.76) and 0.67 (95% CI 0.58−0.74), respectively. Conclusions. In non-proteinuric patients with CKD of unknown etiology, increased intrarenal RI predicted both a faster decline in renal function and higher long-term mortality, but as a single marker, it showed poor discrimination performance.
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Affiliation(s)
- Giulio Romano
- Nephrology, Department of Medicine, University of Udine, 33100 Udine, Italy; (G.R.); (N.D.); (M.B.)
| | - Roberto Mioni
- Division of Nephrology, Academic Hospital of Udine “Santa Maria della Misericordia”, 33100 Udine, Italy;
| | - Nicola Danieli
- Nephrology, Department of Medicine, University of Udine, 33100 Udine, Italy; (G.R.); (N.D.); (M.B.)
| | - Martina Bertoni
- Nephrology, Department of Medicine, University of Udine, 33100 Udine, Italy; (G.R.); (N.D.); (M.B.)
| | - Elisa Croatto
- Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy; (E.C.); (L.M.); (L.A.); (A.P.); (X.M.); (C.C.); (L.A.S.)
| | - Lucia Merla
- Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy; (E.C.); (L.M.); (L.A.); (A.P.); (X.M.); (C.C.); (L.A.S.)
| | - Lucia Alcaro
- Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy; (E.C.); (L.M.); (L.A.); (A.P.); (X.M.); (C.C.); (L.A.S.)
| | - Antonio Pedduzza
- Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy; (E.C.); (L.M.); (L.A.); (A.P.); (X.M.); (C.C.); (L.A.S.)
| | - Xenia Metcalf
- Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy; (E.C.); (L.M.); (L.A.); (A.P.); (X.M.); (C.C.); (L.A.S.)
| | - Alessandra Rigamonti
- Department of Radiology, Academic Hospital of Udine “Santa Maria della Misericorida”, 33100 Udine, Italy;
| | - Cristiana Catena
- Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy; (E.C.); (L.M.); (L.A.); (A.P.); (X.M.); (C.C.); (L.A.S.)
| | - Leonardo A. Sechi
- Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy; (E.C.); (L.M.); (L.A.); (A.P.); (X.M.); (C.C.); (L.A.S.)
| | - GianLuca Colussi
- Internal Medicine, Department of Medicine, University of Udine, 33100 Udine, Italy; (E.C.); (L.M.); (L.A.); (A.P.); (X.M.); (C.C.); (L.A.S.)
- Correspondence: ; Tel.: +39-0432-559-829; Fax: +39-0432-559-490
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13
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The Mediterranean Diet Protects Renal Function in Older Adults: A Prospective Cohort Study. Nutrients 2022; 14:nu14030432. [PMID: 35276791 PMCID: PMC8839505 DOI: 10.3390/nu14030432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Chronic kidney disease entails a high disease burden that is progressively increasing due to population aging. However, evidence on the effect of the Mediterranean diet on renal function is limited, in particular among older adults in Mediterranean countries. Methods: Prospective cohort study with 975 community-dwelling adults aged ≥ 60 recruited during 2008–2010 in Spain and followed up to 2015. At baseline, food consumption was obtained using a validated dietary history. Two Mediterranean dietary patterns were used: (i) An a priori-defined pattern, the Mediterranean Diet Adherence Screener (MEDAS score: low adherence: 0–5 points; moderate: 6–8 points; high: 9–14 points); (ii) An a posteriori Mediterranean-like dietary pattern, based on 36 food groups, which was generated using factor analysis. Renal function decline was calculated as an estimated glomerular filtration rate (eGFR) decrease ≥1 mL/min/1.73 m2 per year of follow-up. Results: A total of 104 cases of renal function decline occurred. Compared with participants with a low MEDAS adherence, the multivariable-adjusted odds ratios (95% confident interval) for renal function decline risk were 0.63 (0.38–1.03) for moderate adherence, and 0.52 (0.29–0.95) for high adherence (p-trend: 0.015). Multivariable-adjusted odds ratios (95% confidence interval) for renal function decline risk according to increasing quartiles of the adherence to the a posteriori Mediterranean-like dietary pattern were 1.00, 0.67 (0.38–1.20), 0.65 (0.35–1.19), and 0.47 (0.23–0.96) (p-trend: 0.042). Conclusion: A higher adherence to a Mediterranean diet was associated with a lower risk of renal function decline in older adults, suggesting benefits to health of this dietary pattern in Mediterranean countries.
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14
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Myeloid leukocytes' diverse effects on cardiovascular and systemic inflammation in chronic kidney disease. Basic Res Cardiol 2022; 117:38. [PMID: 35896846 PMCID: PMC9329413 DOI: 10.1007/s00395-022-00945-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/24/2022] [Accepted: 07/11/2022] [Indexed: 01/31/2023]
Abstract
Chronic kidney disease's prevalence rises globally. Whereas dialysis treatment replaces the kidney's filtering function and prolongs life, dreaded consequences in remote organs develop inevitably over time. Even milder reductions in kidney function not requiring replacement therapy associate with bacterial infections, cardiovascular and heart valve disease, which markedly limit prognosis in these patients. The array of complications is diverse and engages a wide gamut of cellular and molecular mechanisms. The innate immune system is profoundly and systemically altered in chronic kidney disease and, as a unifying element, partakes in many of the disease's complications. As such, a derailed immune system fuels cardiovascular disease progression but also elevates the propensity for serious bacterial infections. Recent data further point towards a role in developing calcific aortic valve stenosis. Here, we delineate the current state of knowledge on how chronic kidney disease affects innate immunity in cardiovascular organs and on a systemic level. We review the role of circulating myeloid cells, monocytes and neutrophils, resident macrophages, dendritic cells, ligands, and cellular pathways that are activated or suppressed when renal function is chronically impaired. Finally, we discuss myeloid cells' varying responses to uremia from a systems immunology perspective.
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15
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Bonato FOB, Karohl C, Canziani MEF. Diagnosis of vascular calcification related to mineral and bone metabolism disorders in chronic kidney disease. J Bras Nefrol 2021; 43:628-631. [PMID: 34910796 PMCID: PMC8823916 DOI: 10.1590/2175-8239-jbn-2021-s104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/24/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Cristina Karohl
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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16
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van Zonneveld AJ, Kölling M, Bijkerk R, Lorenzen JM. Circular RNAs in kidney disease and cancer. Nat Rev Nephrol 2021; 17:814-826. [PMID: 34381199 DOI: 10.1038/s41581-021-00465-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 02/07/2023]
Abstract
Circular RNAs (circRNAs) are a class of endogenously expressed regulatory RNAs with a single-stranded circular structure. They are generated by back splicing and their expression can be tightly regulated by RNA binding proteins. Cytoplasmic circRNAs can function as molecular sponges that inhibit microRNA-target interactions and protein function or as templates for the efficient generation of peptides via rolling circle amplification. They can also act as molecular scaffolds that enhance the reaction kinetics of enzyme-substrate interactions. In the nucleus, circRNAs might facilitate chromatin modifications and promote gene expression. CircRNAs are resistant to degradation and can be packaged in extracellular vesicles and transported in the circulation. Initial studies suggest that circRNAs have roles in kidney disease and associated cardiovascular complications. They have been implicated in hypertensive nephropathy, diabetic kidney disease, glomerular disease, acute kidney injury and kidney allograft rejection, as well as in microvascular and macrovascular complications of chronic kidney disease, including atherosclerotic vascular disease. In addition, several circRNAs have been reported to have oncogenic or tumour suppressor roles or to regulate drug resistance in kidney cancer. The available data suggest that circRNAs could be promising diagnostic and/or prognostic biomarkers and potential therapeutic targets for kidney disease, cardiovascular disease and kidney cancer.
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Affiliation(s)
- Anton Jan van Zonneveld
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Malte Kölling
- Division of Nephrology, University Hospital Zürich, Zürich, Switzerland
| | - Roel Bijkerk
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Johan M Lorenzen
- Division of Nephrology, University Hospital Zürich, Zürich, Switzerland.
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17
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Navaneethan SD, Walther CP, Gregg LP, Bansal S, Winkelmayer WC, Nambi V, Niu J. Mortality, Kidney Failure, and Hospitalization Among Medicare Beneficiaries With CKD and Pulmonary Hypertension. Am J Kidney Dis 2021; 78:700-708.e1. [PMID: 33905766 PMCID: PMC8542055 DOI: 10.1053/j.ajkd.2021.02.336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/23/2021] [Indexed: 02/02/2023]
Abstract
RATIONALE & OBJECTIVE Pulmonary hypertension (PH) is highly prevalent among patients with chronic kidney disease (CKD) not requiring kidney replacement therapy. We studied the associations of PH with mortality, kidney failure, as well as cardiovascular (CV) and non-CV hospitalization among Medicare beneficiaries with a CKD diagnosis. STUDY DESIGN Retrospective, observational study using a matched cohort design. SETTING & PARTICIPANTS Patients with PH (based on 2 claims within 2 years) and patients without PH matched on CKD stage from the Medicare 5% CKD sample (1996-2016). PREDICTOR Presence of pulmonary hypertension. OUTCOME Mortality, kidney failure, and all-cause, CV, and non-CV hospitalization. ANALYTICAL APPROACH Cox proportional hazards models to assess the association between PH and mortality, adjusting for age, sex, race, and comorbidities. Death was considered as a competing event in Fine-Gray models to assess the association between PH and kidney failure. Negative binomial model was used to evaluate the relationship between PH and all-cause, CV, and non-CV hospitalizations. RESULTS 30,052 patients with PH and CKD and 150,260 CKD stage-matched patients without diagnosed PH were studied. The median age of the study population was 80.7 years, 57.8% were women, and 10.3% were African Americans. The presence of PH was associated with an increased risk of mortality after 1 (HR, 2.87 [95% CI, 2.79-2.95]), 2-3 (HR, 1.56 [95% CI, 1.51-1.61]), and 4-5 (HR, 1.47 [95% CI, 1.40-1.53]) years of follow-up, and a higher risk of all-cause, CV, and non-CV hospitalization during the same period. PH was also associated with kidney failure in after 1 and 2-3 years but not after 4-5 years of follow-up evaluation. Patients with PH also experienced higher rates of acute kidney injury (AKI), and AKI requiring dialysis support within 30 and 90 days of AKI. LIMITATIONS Reliance on billing codes and lack of echocardiogram or right heart catheterization data CONCLUSIONS: Among older Medicare beneficiaries with a CKD diagnosis not requiring kidney replacement therapy, the presence of PH was associated with an increased risk of mortality, kidney failure, and hospitalization. Understanding of the mechanism of these associations, especially the increased risk of kidney failure, requires further study.
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Affiliation(s)
- Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, Texas; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas.
| | - Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - L Parker Gregg
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas
| | - Shweta Bansal
- Division of Nephrology, UT Health at San Antonio, San Antonio, Texas
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Vijay Nambi
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Jingbo Niu
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
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18
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Ceprian N, Valera G, Caro J, Yuste C, Serroukh N, González de Pablos I, Oliva C, Figuer A, Praga M, Alique M, Ramirez R, Morales E, Carracedo J. Effect of Kidney Transplantation on Accelerated Immunosenescence and Vascular Changes Induced by Chronic Kidney Disease. Front Med (Lausanne) 2021; 8:705159. [PMID: 34646838 PMCID: PMC8502880 DOI: 10.3389/fmed.2021.705159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
Kidney transplantation is the best option for patients with end-stage renal disease. Despite the improvement in cardiovascular burden (leading cause of mortality among patients with chronic kidney disease), cardiovascular adverse outcomes related to the inflammatory process remain a problem. Thus, the aim of the present study was to characterize the immune profile and microvesicles of patients who underwent transplantation. We investigated the lymphocyte phenotype (CD3, CD4, CD8, CD19, and CD56) and monocyte phenotype (CD14, CD16, CD86, and CD54) in peripheral blood, and endothelium-derived microvesicles (annexin V+CD31+CD41–) in plasma of patients with advanced chronic kidney disease (n = 40), patients with transplantation (n = 40), and healthy subjects (n = 18) recruited from the University Hospital “12 de Octubre” (Madrid, Spain). Patients with kidney transplantation had B-cell lymphopenia, an impairment in co-stimulatory (CD86) and adhesion (CD54) molecules in monocytes, and a reduction in endothelium-derived microvesicles in plasma. The correlations between those parameters explained the modifications in the expression of co-stimulatory and adhesion molecules in monocytes caused by changes in lymphocyte populations, as well as the increase in the levels of endothelial-derived microvesicles in plasma caused by changes in lymphocyte and monocytes populations. Immunosuppressive treatment could directly or indirectly induce those changes. Nevertheless, the particular characteristics of these cells may partly explain the persistence of cardiovascular and renal alterations in patients who underwent transplantation, along with the decrease in arteriosclerotic events compared with advanced chronic kidney disease. In conclusion, the expression of adhesion molecules by monocytes and endothelial-derived microvesicles is related to lymphocyte alterations in patients with kidney transplantation.
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Affiliation(s)
- Noemi Ceprian
- Departamento de Genética, Fisiología y Microbiología, Universidad Complutense de Madrid, Instituto de Investigacin Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Gemma Valera
- Departamento Biología de Sistemas (Unidad Fisiología), Facultad de Medicina, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Jara Caro
- Departamento de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria 12 de Octubre, Madrid, Spain
| | - Claudia Yuste
- Departamento de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria 12 de Octubre, Madrid, Spain
| | - Nadia Serroukh
- Departamento de Genética, Fisiología y Microbiología, Universidad Complutense de Madrid, Instituto de Investigacin Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | | | - Carlos Oliva
- Departamento de Genética, Fisiología y Microbiología, Universidad Complutense de Madrid, Madrid, Spain
| | - Andrea Figuer
- Departamento Biología de Sistemas (Unidad Fisiología), Facultad de Medicina, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Manuel Praga
- Departamento de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria 12 de Octubre, Madrid, Spain
| | - Matilde Alique
- Departamento Biología de Sistemas (Unidad Fisiología), Facultad de Medicina, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Rafael Ramirez
- Departamento Biología de Sistemas (Unidad Fisiología), Facultad de Medicina, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Enrique Morales
- Departamento de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria 12 de Octubre, Madrid, Spain
| | - Julia Carracedo
- Departamento de Genética, Fisiología y Microbiología, Universidad Complutense de Madrid, Instituto de Investigacin Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
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Inflammation: a putative link between phosphate metabolism and cardiovascular disease. Clin Sci (Lond) 2021; 135:201-227. [PMID: 33416083 PMCID: PMC7796315 DOI: 10.1042/cs20190895] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023]
Abstract
Dietary habits in the western world lead to increasing phosphate intake. Under physiological conditions, extraosseous precipitation of phosphate with calcium is prevented by a mineral buffering system composed of calcification inhibitors and tight control of serum phosphate levels. The coordinated hormonal regulation of serum phosphate involves fibroblast growth factor 23 (FGF23), αKlotho, parathyroid hormone (PTH) and calcitriol. A severe derangement of phosphate homeostasis is observed in patients with chronic kidney disease (CKD), a patient collective with extremely high risk of cardiovascular morbidity and mortality. Higher phosphate levels in serum have been associated with increased risk for cardiovascular disease (CVD) in CKD patients, but also in the general population. The causal connections between phosphate and CVD are currently incompletely understood. An assumed link between phosphate and cardiovascular risk is the development of medial vascular calcification, a process actively promoted and regulated by a complex mechanistic interplay involving activation of pro-inflammatory signalling. Emerging evidence indicates a link between disturbances in phosphate homeostasis and inflammation. The present review focuses on critical interactions of phosphate homeostasis, inflammation, vascular calcification and CVD. Especially, pro-inflammatory responses mediating hyperphosphatemia-related development of vascular calcification as well as FGF23 as a critical factor in the interplay between inflammation and cardiovascular alterations, beyond its phosphaturic effects, are addressed.
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20
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Roy-Chowdhury E, Brauns N, Helmke A, Nordlohne J, Bräsen JH, Schmitz J, Volkmann J, Fleig SV, Kusche-Vihrog K, Haller H, von Vietinghoff S. Human CD16+ monocytes promote a pro-atherosclerotic endothelial cell phenotype via CX3CR1-CX3CL1 interaction. Cardiovasc Res 2021; 117:1510-1522. [PMID: 32717023 DOI: 10.1093/cvr/cvaa234] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/17/2020] [Accepted: 07/22/2020] [Indexed: 12/31/2022] Open
Abstract
AIMS Monocytes are central for atherosclerotic vascular inflammation. The human non-classical, patrolling subtype, which expresses high levels of CD16 and fractalkine receptor CX3CR1, strongly associates with cardiovascular events. This is most marked in renal failure, a condition with excess atherosclerosis morbidity. The underlying mechanism is not understood. This study investigated how human CD16+ monocytes modulate endothelial cell function. METHODS AND RESULTS In patients with kidney failure, CD16+ monocyte counts were elevated and dynamically decreased within a year after transplantation, chiefly due to a drop in CD14+CD16+ cells. The CX3CR1 ligand CX3CL1 was similarly elevated in the circulation of humans and mice with renal impairment. CX3CL1 up-regulation was also observed close to macrophage rich human coronary artery plaques. To investigate a mechanistic basis of this association, CD16+CX3CR1HIGH monocytes were co-incubated with primary human endothelium in vitro. Compared to classical CD14+ monocytes or transwell cocultures, CD16+ monocytes enhanced endothelial STAT1 and NF-κB p65 phosphorylation, up-regulated expression of CX3CL1 and interleukin-1β, numerous CCL and CXCL chemokines and molecules promoting leucocyte patrolling and adhesion such as ICAM1 and VCAM1. Genes required for vasodilatation including endothelial nitric oxide synthase decreased while endothelial collagen production increased. Uraemic patients' monocytes enhanced endothelial CX3CL1 even more markedly. Their receptor CX3CR1 was required for enhanced aortic endothelial stiffness in murine atherosclerosis with renal impairment. CX3CR1 dose-dependently modulated monocyte-contact-dependent gene expression in human endothelium. CONCLUSION By demonstrating endothelial proatherosclerotic gene regulation in direct contact with CD16+ monocytes, in part via cellular CX3CR1-CX3CL1 interaction, our data delineate a mechanism how this celltype can increase cardiovascular risk.
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Affiliation(s)
- Eva Roy-Chowdhury
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany
| | - Nicolas Brauns
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany
| | - Alexandra Helmke
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany
| | - Johannes Nordlohne
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany
| | | | - Jessica Schmitz
- Department of Pathology, Hannover Medical School, Hannover, Germany
| | - Julia Volkmann
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany
| | - Susanne V Fleig
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany
| | | | - Hermann Haller
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany
| | - Sibylle von Vietinghoff
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany
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21
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Falconi CA, Junho CVDC, Fogaça-Ruiz F, Vernier ICS, da Cunha RS, Stinghen AEM, Carneiro-Ramos MS. Uremic Toxins: An Alarming Danger Concerning the Cardiovascular System. Front Physiol 2021; 12:686249. [PMID: 34054588 PMCID: PMC8160254 DOI: 10.3389/fphys.2021.686249] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/19/2021] [Indexed: 12/14/2022] Open
Abstract
The kidneys and heart share functions with the common goal of maintaining homeostasis. When kidney injury occurs, many compounds, the so-called "uremic retention solutes" or "uremic toxins," accumulate in the circulation targeting other tissues. The accumulation of uremic toxins such as p-cresyl sulfate, indoxyl sulfate and inorganic phosphate leads to a loss of a substantial number of body functions. Although the concept of uremic toxins is dated to the 1960s, the molecular mechanisms capable of leading to renal and cardiovascular injuries are not yet known. Besides, the greatest toxic effects appear to be induced by compounds that are difficult to remove by dialysis. Considering the close relationship between renal and cardiovascular functions, an understanding of the mechanisms involved in the production, clearance and overall impact of uremic toxins is extremely relevant for the understanding of pathologies of the cardiovascular system. Thus, the present study has as main focus to present an extensive review on the impact of uremic toxins in the cardiovascular system, bringing the state of the art on the subject as well as clinical implications related to patient's therapy affected by chronic kidney disease, which represents high mortality of patients with cardiac comorbidities.
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Affiliation(s)
- Carlos Alexandre Falconi
- Laboratory of Cardiovascular Immunology, Center of Natural and Human Sciences (CCNH), Federal University of ABC, Santo André, Brazil
| | - Carolina Victoria da Cruz Junho
- Laboratory of Cardiovascular Immunology, Center of Natural and Human Sciences (CCNH), Federal University of ABC, Santo André, Brazil
| | - Fernanda Fogaça-Ruiz
- Laboratory of Cardiovascular Immunology, Center of Natural and Human Sciences (CCNH), Federal University of ABC, Santo André, Brazil
| | - Imara Caridad Stable Vernier
- Laboratory of Cardiovascular Immunology, Center of Natural and Human Sciences (CCNH), Federal University of ABC, Santo André, Brazil
| | - Regiane Stafim da Cunha
- Experimental Nephrology Laboratory, Basic Pathology Department, Universidade Federal do Paraná, Curitiba, Brazil
| | | | - Marcela Sorelli Carneiro-Ramos
- Laboratory of Cardiovascular Immunology, Center of Natural and Human Sciences (CCNH), Federal University of ABC, Santo André, Brazil
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22
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Hoogeveen RM, Verweij SL, Kaiser Y, Kroon J, Verberne HJ, Vogt L, Moens SJB, Stroes ESG. Atorvastatin treatment does not abolish inflammatory mediated cardiovascular risk in subjects with chronic kidney disease. Sci Rep 2021; 11:4126. [PMID: 33602971 PMCID: PMC7892998 DOI: 10.1038/s41598-021-83273-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/27/2021] [Indexed: 11/26/2022] Open
Abstract
Individuals with chronic kidney disease are at an increased risk for cardiovascular disease. This risk may partially be explained by a chronic inflammatory state in these patients, reflected by increased arterial wall and cellular inflammation. Statin treatment decreases cardiovascular risk and arterial inflammation in non-CKD subjects. In patients with declining kidney function, cardiovascular benefit resulting from statin therapy is attenuated, possibly due to persisting inflammation. In the current study, we assessed the effect of statin treatment on arterial wall and cellular inflammation. Fourteen patients with chronic kidney disease stage 3 or 4, defined by an estimated Glomerular Filtration Rate between 15 and 60 mL/min/1.73 m2, without cardiovascular disease were included in a single center, open label study to assess the effect of atorvastatin 40 mg once daily for 12 weeks (NTR6896). At baseline and at 12 weeks of treatment, we assessed arterial wall inflammation by 18F-fluoro-deoxyglucose positron-emission tomography computed tomography (18F-FDG PET/CT) and the phenotype of circulating monocytes were assessed. Treatment with atorvastatin resulted in a 46% reduction in LDL-cholesterol, but this was not accompanied by an attenuation in arterial wall inflammation in the aorta or carotid arteries, nor with changes in chemokine receptor expression of circulating monocytes. Statin treatment does not abolish arterial wall or cellular inflammation in subjects with mild to moderate chronic kidney disease. These results imply that CKD-associated inflammatory activity is mediated by factors beyond LDL-cholesterol and specific anti-inflammatory interventions might be necessary to further dampen the inflammatory driven CV risk in these subjects.
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Affiliation(s)
- Renate M Hoogeveen
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Simone L Verweij
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Yannick Kaiser
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jeffrey Kroon
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Nephrology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Sophie J Bernelot Moens
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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23
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Abstract
Phosphorus plays a vital role in diverse biological processes including intracellular signaling, membrane integrity, and skeletal biomineralization; therefore, the regulation of phosphorus homeostasis is essential to the well-being of the organism. Cells and whole organisms respond to changes in inorganic phosphorus (Pi) concentrations in their environment by adjusting Pi uptake and altering biochemical processes in cells (local effects) and distant organs (endocrine effects). Unicellular organisms, such as bacteria and yeast, express specific Pi-binding proteins on the plasma membrane that respond to changes in ambient Pi availability and transduce intracellular signals that regulate the expression of genes involved in cellular Pi uptake. Multicellular organisms, including humans, respond at a cellular level to adapt to changes in extracellular Pi concentrations and also have endocrine pathways which integrate signals from various organs (e.g., intestine, kidneys, parathyroid glands, bone) to regulate serum Pi concentrations and whole-body phosphorus balance. In mammals, alterations in the concentrations of extracellular Pi modulate type III sodium-phosphate cotransporter activity on the plasma membrane, and trigger changes in cellular function. In addition, elevated extracellular Pi induces activation of fibroblast growth factor receptor, Raf/mitogen-activated protein kinase/ERK kinase (MEK)/extracellular signal-regulated kinase (ERK) and Akt pathways, which modulate gene expression in various mammalian cell types. Excessive Pi exposure, especially in patients with chronic kidney disease, leads to endothelial dysfunction, accelerated vascular calcification, and impaired insulin secretion.
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Affiliation(s)
- Kittrawee Kritmetapak
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
- Division of Nephrology and Hypertension, Departments of Medicine, Biochemistry and Molecular Biology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55902, USA
| | - Rajiv Kumar
- Division of Nephrology and Hypertension, Departments of Medicine, Biochemistry and Molecular Biology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55902, USA.
- Nephrology Research, Medical Sciences 1-120, 200 First Street Southwest, Rochester, MN, 55902, USA.
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24
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The prognostic value of platelet-to-lymphocyte ratio on the long-term renal survival in patients with IgA nephropathy. Int Urol Nephrol 2020; 53:523-530. [PMID: 33113085 PMCID: PMC7906929 DOI: 10.1007/s11255-020-02651-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 09/14/2020] [Indexed: 02/06/2023]
Abstract
Purpose Platelet-to-lymphocyte ratio (PLR) was established showing the poor prognosis in several diseases, such as malignancies and cardiovascular diseases. But limited study has been conducted about the prognostic value of PLR on the long-term renal survival of patients with Immunoglobulin A nephropathy (IgAN). Methods We performed an observational cohort study enrolling patients with biopsy-proven IgAN recorded from November 2011 to March 2016. The definition of composite endpoint was eGFR decrease by 50%, eGFR < 15 mL/min/1.73 m2, initiation of dialysis, or renal transplantation. Patients were categorized by the magnitude of PLR tertiles into three groups. The Kaplan–Meier curves and multivariate Cox models were performed to determine the association of PLR with the renal survival of IgAN patients. Results 330 patients with a median age of 34.0 years were followed for a median of 47.4 months, and 27 patients (8.2%) had reached the composite endpoints. There were no differences among the three groups (PLR < 106, 106 ≤ PLR ≤ 137, and PLR > 137) in demographic characteristics, mean arterial pressure (MAP), proteinuria, and estimated glomerular filtration rate (eGFR) at baseline. The Kaplan–Meier curves showed that the PLR > 137 group was significantly more likely to poor renal outcomes than the other two groups. Using univariate and multivariate cox regression analyses, we found that PLR > 137 was an independent prognostic factor for poor renal survival in patients with IgAN. Subgroup analysis revealed that the PLR remained the prognostic value for female patients or patients with eGFR less than 60 mL/min/1.73 m2. Conclusions Our results underscored that baseline PLR was an independent prognostic factor for poor renal survival in patients with IgAN, especially for female patients or those patients with baseline eGFR less than 60 mL/min/1.73 m2.
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25
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Zhao WM, Tao SM, Liu GL. Neutrophil-to-lymphocyte ratio in relation to the risk of all-cause mortality and cardiovascular events in patients with chronic kidney disease: a systematic review and meta-analysis. Ren Fail 2020; 42:1059-1066. [PMID: 33081569 PMCID: PMC7668415 DOI: 10.1080/0886022x.2020.1832521] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Aim To systematically evaluate the relationship between the neutrophil-to-lymphocyte ratio (NLR) and the risk of all-cause mortality or cardiovascular events in patients with chronic kidney disease (CKD). Methods PubMed, Embase, and Web of Science databases were searched for cohort studies that were published since the databases were launched, until 1 April 2020. We selected papers according to specific inclusion and exclusion criteria, extracted data, and evaluated the quality of the citations. Data from eligible studies were used to calculate the combined hazard ratios (HRs) and 95% confidence intervals (CI). Results The search identified 1048 potentially eligible records, and 10 studies (n = 1442) were selected. Eight studies reported all-cause mortality, and two studies reported cardiovascular events. The combined HR of all-cause mortality was 1.45 (95% CI 1.20–1.75) and the HR of cardiovascular events was 1.52 (95% CI 1.33–1.72) when NLR was considered as a categorical variable. Similarly, the association between NLR and all-cause mortality was confirmed (HR 1.35; 95% CI 1.23–1.48) when NLR was used as a continuous variable. Conclusion NLR is a predictor of all-cause mortality and cardiovascular events in patients with chronic kidney disease.
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Affiliation(s)
- Wen-Man Zhao
- Department of Nephrology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shu-Man Tao
- Department of Nephrology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Gui-Ling Liu
- Department of Nephrology, The Second Hospital of Anhui Medical University, Hefei, China
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26
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Vogt L, Bangalore S, Fayyad R, Melamed S, Hovingh GK, DeMicco DA, Waters DD. Atorvastatin Has a Dose-Dependent Beneficial Effect on Kidney Function and Associated Cardiovascular Outcomes: Post Hoc Analysis of 6 Double-Blind Randomized Controlled Trials. J Am Heart Assoc 2020; 8:e010827. [PMID: 31020900 PMCID: PMC6512126 DOI: 10.1161/jaha.118.010827] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Kidney function decreases during the lifetime, and this decline is a powerful predictor of both kidney and cardiovascular outcomes. Statins lower cardiovascular risk, which may relate to beneficial effects on kidney function. We studied whether atorvastatin influences kidney function decline and assessed the association between individual kidney function slopes and cardiovascular outcome. Methods and Results Data were collected from 6 large atorvastatin cardiovascular outcome trials conducted in patients not selected for having kidney disease. Slopes of serum creatinine reciprocals representing measures of kidney function change ([mg/dL]−1/y), were analyzed in 30 621 patients. Based on treatment arms, patients were categorized into 3 groups: placebo (n=10 057), atorvastatin 10 mg daily (n=12 763), and 80 mg daily (n=7801). To assess slopes, mixed‐model analyses were performed for each treatment separately, including time in years and adjustment for study. These slopes displayed linear improvement over time in all 3 groups. Slope estimates for patients randomized to placebo or atorvastatin 10 mg and 80 mg were 0.009 (0.0008), 0.011 (0.0006), and 0.014 (0.0006) (mg/dL)−1/y, respectively. A head‐to‐head comparison of atorvastatin 10 and 80 mg based on data from 1 study (TNT [Treating to New Targets]; n=10 001) showed a statistically significant difference in slope between the 2 doses (P=0.0009). From a Cox proportional hazards model using slope as a predictor, a significant (P<0.0001) negative association between kidney function and cardiovascular outcomes was found. Conclusions In patients at risk of or with cardiovascular disease, atorvastatin improved kidney function over time in a dose‐dependent manner. In the 3 treatment groups, kidney function improvement was strongly associated with lower cardiovascular risk. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00327418; NCT00147602; NCT00327691.
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Affiliation(s)
- Liffert Vogt
- 1 Department of Internal Medicine Amsterdam Cardiovascular Sciences Amsterdam University Medical Centre University of Amsterdam The Netherlands
| | - Sripal Bangalore
- 2 Division of Cardiology New York University School of Medicine New York NY
| | | | | | - G Kees Hovingh
- 1 Department of Internal Medicine Amsterdam Cardiovascular Sciences Amsterdam University Medical Centre University of Amsterdam The Netherlands
| | | | - David D Waters
- 4 Division of Cardiology San Francisco General Hospital San Francisco CA
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27
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Chade AR, Williams ML, Engel JE, Williams E, Bidwell GL. Molecular targeting of renal inflammation using drug delivery technology to inhibit NF-κB improves renal recovery in chronic kidney disease. Am J Physiol Renal Physiol 2020; 319:F139-F148. [PMID: 32538151 DOI: 10.1152/ajprenal.00155.2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Inflammation is a major determinant for the progression of chronic kidney disease (CKD). NF-κB is a master transcription factor upregulated in CKD that promotes inflammation and regulates apoptosis and vascular remodeling. We aimed to modulate this pathway for CKD therapy in a swine model of CKD using a peptide inhibitor of the NF-κB p50 subunit (p50i) fused to a protein carrier [elastin-like polypeptide (ELP)] and equipped with a cell-penetrating peptide (SynB1). We hypothesized that intrarenal SynB1-ELP-p50i therapy would inhibit NF-κB-driven inflammation and induce renal recovery. CKD was induced in 14 pigs. After 6 wk, pigs received single intrarenal SynB1-ELP-p50i therapy (10 mg/kg) or placebo (n = 7 each). Renal hemodynamics were quantified in vivo using multidetector computed tomography before and 8 wk after treatment. Pigs were then euthanized. Ex vivo experiments were performed to quantify renal activation of NF-κB, expression of downstream mediators of NF-κB signaling, renal microvascular density, inflammation, and fibrosis. Fourteen weeks of CKD stimulated NF-κB signaling and downstream mediators (e.g., TNF-α, monocyte chemoattractant protein-1, and IL-6) accompanying loss of renal function, inflammation, fibrosis, and microvascular rarefaction versus controls. All of these were improved after SynB1-ELP-p50i therapy, accompanied by reduced circulating inflammatory cytokines as well, which were evident up to 8 wk after treatment. Current treatments for CKD are largely ineffective. Our study shows the feasibility of a new treatment to induce renal recovery by offsetting inflammation at a molecular level. It also supports the therapeutic potential of targeted inhibition of the NF-κB pathway using novel drug delivery technology in a translational model of CKD.
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Affiliation(s)
- Alejandro R Chade
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi.,Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi.,Department of Radiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Maxx L Williams
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Jason E Engel
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Erika Williams
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Gene L Bidwell
- Department of Neurology, University of Mississippi Medical Center, Jackson, Mississippi.,Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, Mississippi.,Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi
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28
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Plasma Leucine-Rich α-2-Glycoprotein 1 Predicts Cardiovascular Disease Risk in End-Stage Renal Disease. Sci Rep 2020; 10:5988. [PMID: 32249825 PMCID: PMC7136266 DOI: 10.1038/s41598-020-62989-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 03/17/2020] [Indexed: 11/17/2022] Open
Abstract
Plasma leucine-Rich α-2-glycoprotein 1 (LRG1) is an innovative biomarker for inflammation and angiogenesis. Many adverse pathophysiological changes including inflammation, atherosclerosis, and premature mortality is associated with End-stage renal disease (ESRD). However, whether levels of plasma LRG1 correlate with the co-morbidities of ESRD patients is unknown. Plasma LRG1 and high-sensitivity C-reactive protein (hsCRP) were analyzed by ELISA in 169 hemodialysis patients from the Immunity in ESRD (iESRD) study. Patient demographics and comorbidities at the time of enrollment were recorded. Peripheral blood monocyte and T cell subsets were assessed by multicolor flow cytometry. In the univariate analysis, a higher level of LRG1 was associated with the presence of cardiovascular disease (CVD) and peripheral arterial occlusive disease (PAOD). In multivariate logistic regression models, higher LRG1 tertile was significantly associated with PAOD (odds ratio = 3.49) and CVD (odds ratio = 1.65), but not with coronary artery disease, history of myocardial infarction, or stroke after adjusting for gender, diabetes, hemoglobin, albumin, calcium-phosphate product, and level of hsCRP. In addition, the level of LRG1 had a positive correlation with IL-6, hsCRP, and also more advanced T cell differentiation. The association suggests that LRG1 participates in the progression of atherosclerosis by inducing inflammation. Therefore, the role of LRG1 in coexisting inflammatory response should be further investigated in the pathogenesis of cardiovascular morbidity and mortality in patients with ESRD.
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29
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Nelson AJ, Raggi P, Wolf M, Gold AM, Chertow GM, Roe MT. Targeting Vascular Calcification in Chronic Kidney Disease. JACC Basic Transl Sci 2020; 5:398-412. [PMID: 32368697 PMCID: PMC7188874 DOI: 10.1016/j.jacbts.2020.02.002] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/24/2020] [Accepted: 02/03/2020] [Indexed: 12/22/2022]
Abstract
Cardiovascular (CV) disease remains an important cause of morbidity and mortality for patients with chronic kidney disease (CKD). Although clustering of traditional risk factors with CKD is well recognized, kidney-specific mechanisms are believed to drive the disproportionate burden of CV disease. One perturbation that is frequently observed at high rates in patients with CKD is vascular calcification, which may be a central mediator for an array of CV sequelae. This review summarizes the pathophysiological bases of intimal and medial vascular calcification in CKD, current strategies for diagnosis and management, and posits vascular calcification as a risk marker and therapeutic target.
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Key Words
- CAC, coronary artery calcification
- CI, confidence interval
- CKD, chronic kidney disease
- CT, computed tomography
- CV, cardiovascular
- CVD, cardiovascular disease
- ESKD, end-stage kidney disease
- FGF, fibroblast growth factor
- HR, hazard ratio
- LDL-C, low-density lipoprotein cholesterol
- MGP, matrix Gla protein
- PTH, parathyroid hormone
- VSMC, vascular smooth muscle cell
- chronic kidney disease
- dialysis
- eGFR, estimated glomerular filtration rate
- medial calcification
- vascular calcification
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Affiliation(s)
- Adam J. Nelson
- Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| | - Paolo Raggi
- Division of Cardiology, Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Alexander M. Gold
- Research and Development, Sanifit Therapeutics, San Diego, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Glenn M. Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Matthew T. Roe
- Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
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30
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Walther CP, Nambi V, Hanania NA, Navaneethan SD. Diagnosis and Management of Pulmonary Hypertension in Patients With CKD. Am J Kidney Dis 2020; 75:935-945. [PMID: 32199709 DOI: 10.1053/j.ajkd.2019.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022]
Abstract
Pulmonary hypertension (PH) is a highly prevalent and important condition in adults with chronic kidney disease (CKD). In this review, we summarize the definition of PH, discuss its pathophysiology and classifications, and describe diagnostic and management strategies in patients with CKD, including those with kidney failure treated by kidney replacement therapy. In the general population, PH is classified into 5 groups based on clinical presentation, pathology, hemodynamics, and management strategies. In this classification system, PH in CKD is placed in a diverse group with unclear or multifactorial mechanisms, although underlying cardiovascular disease may account for most cases. CKD may itself directly incite pulmonary circulatory dysfunction and remodeling through uremic toxins, inflammation, endothelial dysfunction, and altered vasoregulation. Despite several studies describing the higher prevalence of PH in CKD and kidney failure, along with an association with poor outcomes, high-quality evidence is not available for its diagnostic and management strategies in those with CKD. In CKD not requiring kidney replacement therapy, volume management along with treatment of underlying risk factors for PH are critical. In those receiving hemodialysis, options are limited and transition to peritoneal dialysis may be considered if recurrent hypotension precludes optimal volume control.
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Affiliation(s)
- Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX.
| | - Vijay Nambi
- Micheal E DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX; Sections of Atherosclerosis and Vascular Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Nicola A Hanania
- Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.
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31
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Meyer F, Seibert FS, Nienen M, Welzel M, Beisser D, Bauer F, Rohn B, Westhoff TH, Stervbo U, Babel N. Propionate supplementation promotes the expansion of peripheral regulatory T-Cells in patients with end-stage renal disease. J Nephrol 2020; 33:817-827. [PMID: 32144645 PMCID: PMC7381474 DOI: 10.1007/s40620-019-00694-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/26/2019] [Indexed: 12/14/2022]
Abstract
Patients with end-stage renal disease (ESRD) suffer from a progressively increasing low-grade systemic inflammation, which is associated with higher morbidity and mortality. Regulatory T cells (Tregs) play an important role in regulation of the inflammatory process. Previously, it has been demonstrated that short-chain fatty acids reduce inflammation in the central nervous system in a murine model of multiple sclerosis through an increase in tissue infiltrating Tregs. Here, we evaluated the effect of the short-chain fatty acid propionate on the chronic inflammatory state and T-cell composition in ESRD patients. Analyzing ESRD patients and healthy blood donors before, during, and 60 days after the propionate supplementation by multiparametric flow cytometry we observed a gradual and significant expansion in the frequencies of CD25highCD127- Tregs in both groups. Phenotypic characterization suggests that polarization of naïve T cells towards Tregs is responsible for the observed expansion. In line with this, we observed a significant reduction of inflammatory marker CRP under propionate supplementation. Of interest, the observed anti-inflammatory surroundings did not affect the protective pathogen-specific immunity as demonstrated by the stable frequencies of effector/memory T cells specific for tetanus/diphtheria recall antigens. Collectively, our data suggest that dietary supplements with propionate have a beneficial effect on the elevated systemic inflammation of ESRD patients. The effect can be achieved through an expansion of circulating Tregs without affecting the protective pathogen-reactive immunity.
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Affiliation(s)
- Fabian Meyer
- Medical Department I , Centre for Translational Medicine, Marienhospital Herne, Universitätsklinikum Der Ruhr-Universität Bochum, Ruhr-Universität Bochum, Hölkeskampring 40, 44623, Herne, Germany
| | - Felix S Seibert
- Medical Department I , Centre for Translational Medicine, Marienhospital Herne, Universitätsklinikum Der Ruhr-Universität Bochum, Ruhr-Universität Bochum, Hölkeskampring 40, 44623, Herne, Germany
| | - Mikalai Nienen
- Medical Department I , Centre for Translational Medicine, Marienhospital Herne, Universitätsklinikum Der Ruhr-Universität Bochum, Ruhr-Universität Bochum, Hölkeskampring 40, 44623, Herne, Germany
| | - Marius Welzel
- Biodiversity, University of Duisburg-Essen, Essen, Germany
| | | | - Frederic Bauer
- Medical Department I , Centre for Translational Medicine, Marienhospital Herne, Universitätsklinikum Der Ruhr-Universität Bochum, Ruhr-Universität Bochum, Hölkeskampring 40, 44623, Herne, Germany
| | - Benjamin Rohn
- Medical Department I , Centre for Translational Medicine, Marienhospital Herne, Universitätsklinikum Der Ruhr-Universität Bochum, Ruhr-Universität Bochum, Hölkeskampring 40, 44623, Herne, Germany
| | - Timm H Westhoff
- Medical Department I , Centre for Translational Medicine, Marienhospital Herne, Universitätsklinikum Der Ruhr-Universität Bochum, Ruhr-Universität Bochum, Hölkeskampring 40, 44623, Herne, Germany
| | - Ulrik Stervbo
- Medical Department I , Centre for Translational Medicine, Marienhospital Herne, Universitätsklinikum Der Ruhr-Universität Bochum, Ruhr-Universität Bochum, Hölkeskampring 40, 44623, Herne, Germany.
| | - Nina Babel
- Medical Department I , Centre for Translational Medicine, Marienhospital Herne, Universitätsklinikum Der Ruhr-Universität Bochum, Ruhr-Universität Bochum, Hölkeskampring 40, 44623, Herne, Germany.
- Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin-Brandenburg Center for Regenerative Therapies, Berlin, Germany.
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Wenstedt EF, Verberk SG, Kroon J, Neele AE, Baardman J, Claessen N, Pasaoglu ÖT, Rademaker E, Schrooten EM, Wouda RD, de Winther MP, Aten J, Vogt L, Van den Bossche J. Salt increases monocyte CCR2 expression and inflammatory responses in humans. JCI Insight 2019; 4:130508. [PMID: 31672939 DOI: 10.1172/jci.insight.130508] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 09/26/2019] [Indexed: 01/03/2023] Open
Abstract
Inflammation may play a role in the link between high salt intake and its deleterious consequences. However, it is unknown whether salt can induce proinflammatory priming of monocytes and macrophages in humans. We investigated the effects of salt on monocytes and macrophages in vitro and in vivo by performing a randomized crossover trial in which 11 healthy human subjects adhered to a 2-week low-salt and high-salt diet. We demonstrate that salt increases monocyte expression of CCR2, a chemokine receptor that mediates monocyte infiltration in inflammatory diseases. In line with this, we show a salt-induced increase of plasma MCP-1, transendothelial migration of monocytes, and skin macrophage density after high-salt diet. Macrophages demonstrate signs of an increased proinflammatory phenotype after salt exposure, as represented by boosted LPS-induced cytokine secretion of IL-6, TNF, and IL-10 in vitro, and by increased HLA-DR expression and decreased CD206 expression on skin macrophages after high-salt diet. Taken together, our data open up the possibility for inflammatory monocyte and macrophage responses as potential contributors to the deleterious effects of high salt intake.
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Affiliation(s)
- Eliane Fe Wenstedt
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Section of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Sanne Gs Verberk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Molecular Cell Biology and Immunology, Amsterdam Cardiovascular Sciences, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jeffrey Kroon
- Amsterdam UMC, University of Amsterdam, Department of Experimental Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Annette E Neele
- Amsterdam UMC, University of Amsterdam, Department of Medical Biochemistry, Section of Experimental Vascular Biology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Jeroen Baardman
- Amsterdam UMC, University of Amsterdam, Department of Medical Biochemistry, Section of Experimental Vascular Biology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Nike Claessen
- Amsterdam UMC, University of Amsterdam, Department of Pathology, Amsterdam, Netherlands
| | - Özge T Pasaoglu
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Section of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Emma Rademaker
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Section of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Esmee M Schrooten
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Section of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Rosa D Wouda
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Section of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Menno Pj de Winther
- Amsterdam UMC, University of Amsterdam, Department of Medical Biochemistry, Section of Experimental Vascular Biology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands.,Institute for Cardiovascular Prevention (IPEK), Munich, Germany
| | - Jan Aten
- Amsterdam UMC, University of Amsterdam, Department of Pathology, Amsterdam, Netherlands
| | - Liffert Vogt
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Section of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Jan Van den Bossche
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Molecular Cell Biology and Immunology, Amsterdam Cardiovascular Sciences, Cancer Center Amsterdam, Amsterdam, Netherlands.,Amsterdam UMC, University of Amsterdam, Department of Medical Biochemistry, Section of Experimental Vascular Biology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
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33
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Prevalence of Early Chronic Kidney Disease and Main Associated Factors in Spanish Population: Populational Study. J Clin Med 2019; 8:jcm8091384. [PMID: 31487800 PMCID: PMC6780839 DOI: 10.3390/jcm8091384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 12/12/2022] Open
Abstract
The aim of this study was to determine the prevalence of early chronic kidney disease (EKD) (stages 1 and 2) and the factors associated. This was a populational study including individuals from 18–75 years randomly selected from 18 Primary Healthcare centers in the area of Barcelonès Nord and Maresme (Catalunya, Spain). Variables: anamnesis, physical examination, blood pressure, and analysis. EKD was defined with by a glomerular filtration rate (GFR) ≥60 mL/min/1.73 m2 and albumin/creatinine ratio (ACR) ≥17 mg/g in men and ≥25 mg/g in women confirmed with two determinations. 2871 individuals: 43% men, mean age 55 years (19–75), 32.2% obese, 50.5% abdominal obesity, 21.1% hypertensive, and 10.6% diabetic. Prevalence of EKD: With one determination 157 individuals (5.5%), 110 men (9%) and 47 women (2.8%); with two determinations 109 individuals (3.8%), 85 men (7%), and 24 women (1.5%). Factors independently associated with the multivariate logistic regression model: Man (OR 3.35), blood pressure ≥ 135/85 mmHg (OR 2.29), BMI ≥ 30 kg/m2 (OR 2.48), glycemia ≥ 100 mg/dL (OR 1.73), smoker (OR 1.67) and age (OR 1.04). The prevalence varies if the diagnosis is established based on one or two analytical determinations, overestimated if only one determination is made and depends on the value chosen to define urine albumin excretion.
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Verweij SL, Duivenvoorden R, Stiekema LCA, Nurmohamed NS, van der Valk FM, Versloot M, Verberne HJ, Stroes ESG, Nahrendorf M, Bekkering S, Bernelot Moens SJ. CCR2 expression on circulating monocytes is associated with arterial wall inflammation assessed by 18F-FDG PET/CT in patients at risk for cardiovascular disease. Cardiovasc Res 2019; 114:468-475. [PMID: 29186373 DOI: 10.1093/cvr/cvx224] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 11/23/2017] [Indexed: 01/08/2023] Open
Abstract
Aims Circulating monocytes infiltrate the plaque and differentiate into macrophages, contributing to an inflammatory environment which is associated with higher risk of cardiovascular events. Although the pivotal role of circulating monocytes in plaque inflammation has been firmly established, the search continues to identify specific monocyte subsets that may be especially atherogenic. Therefore, we evaluated the relation between monocyte phenotype, particularly surface receptor expression, and arterial wall inflammation in patients at increased cardiovascular risk. Methods and results We performed a multivariate linear regression analysis in 79 patients at increased cardiovascular risk who had both an 18F-fluorodeoxyglucose positron emission tomography/computed tomography to assess arterial wall inflammation and extensive monocyte characterization (using flow cytometry). We found that CCR2, a monocyte chemokine receptor essential for transmigration, significantly correlates with arterial wall inflammation. This relationship was independent of traditional cardiovascular risk factors and statin use (β = 0.429, P = 0.015). We found no relation between arterial wall inflammation and monocyte count or monocyte subsets, namely CD14+CD16-, CD14+CD16+, CD14+CD16 ++, CCR5+, CD18+, CD11b+, or CD11c+ monocytes. Conclusion Monocyte CCR2 expression is associated with arterial wall inflammation in patients at increased cardiovascular risk. Our data warrant further studies to assess if inhibition of CCR2 may attenuate atherosclerotic plaque inflammation.
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Affiliation(s)
- Simone L Verweij
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Raphaël Duivenvoorden
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.,Department of Nephrology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Lotte C A Stiekema
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Nick S Nurmohamed
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Fleur M van der Valk
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Miranda Versloot
- Department of Experimental Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Matthias Nahrendorf
- Center for Systems Biology and Department of Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Siroon Bekkering
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.,Department of Experimental Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Sophie J Bernelot Moens
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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35
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Cozzolino M, Ciceri P, Galassi A, Mangano M, Carugo S, Capelli I, Cianciolo G. The Key Role of Phosphate on Vascular Calcification. Toxins (Basel) 2019; 11:toxins11040213. [PMID: 30970562 PMCID: PMC6521180 DOI: 10.3390/toxins11040213] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/05/2019] [Accepted: 04/07/2019] [Indexed: 01/19/2023] Open
Abstract
Vascular calcification (VC) is common in dialysis and non-dialysis chronic kidney disease (CKD) patients, even in the early stage of the disease. For this reason, it can be considered a CKD hallmark. VC contributes to cardiovascular disease (CVD) and increased mortality among CKD patients, although it has not been proven. There are more than one type of VC and every form represents a marker of systemic vascular disease and is associated with a higher prevalence of CVD in CKD patients, as shown by several clinical studies. Major risk factors for VC in CKD include: Increasing age, dialysis vintage, hyperphosphatemia (particularly in the setting of intermittent or persistent hypercalcemia), and a positive net calcium and phosphate balance. Excessive oral calcium intake, including calcium-containing phosphate binders, increases the risk for VC. Moreover, it has been demonstrated that there is less VC progression with non-calcium-containing phosphate binders. Unfortunately, until now, a specific therapy to prevent progression or to facilitate regression of VC has been found, beyond careful attention to calcium and phosphate balance.
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Affiliation(s)
- Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, 20142 Milan, Italy.
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico & Fondazione D'Amico per la Ricerca sulle Malattie Renali, 20122 Milan, Italy.
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, 20142 Milan, Italy.
| | - Michela Mangano
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, 20142 Milan, Italy.
| | - Stefano Carugo
- Cardiology Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, 20142 Milan, Italy.
| | - Irene Capelli
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40138 Bologna, Italy.
| | - Giuseppe Cianciolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40138 Bologna, Italy.
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36
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Lipids, inflammation, and chronic kidney disease: a SHARP perspective. Kidney Int 2018; 93:784-786. [PMID: 29571452 DOI: 10.1016/j.kint.2017.11.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 11/24/2022]
Abstract
Accumulating evidence indicates that inflammation plays a role in the initiation and progression of chronic kidney disease. In the Study of Heart and Renal Protection (SHARP) trial, higher baseline C-reactive protein and higher baseline low-density lipoprotein cholesterol levels were both associated with a higher risk of cardiovascular events, but higher baseline C-reactive protein levels were also associated with a higher risk of nonvascular events. Simvastatin/ezetimibe reduced cardiovascular events independent of baseline C-reactive protein levels. However, this observation does not exclude inflammation as a causal factor for cardiovascular disease development in chronic kidney disease patients.
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37
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Yoon HE, Kim Y, Kim SD, Oh JK, Chung YA, Shin SJ, Yang CW, Seo SM. A Pilot Trial to Examine the Changes in Carotid Arterial Inflammation in Renal Transplant Recipients as Assessed by 18F-Fluorodeoxyglucose (18F-FDG) Positron Emission Tomography Computed Tomography (PET/CT). Ann Transplant 2018; 23:412-421. [PMID: 29904040 PMCID: PMC6248031 DOI: 10.12659/aot.909212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Inflammatory activity of the artery can be assessed by measuring 18F-fluorodeoxyglucose (18F-FDG) uptake with positron emission tomography computed tomography (PET/CT). Improvement in vascular function after renal transplantation has been reported, but no studies have used 18F-FDG PET/CT to examine the changes in vascular inflammation. This study investigated the changes in the inflammatory activity in the carotid artery after renal transplantation in patients with chronic kidney disease (CKD). MATERIAL AND METHODS 18F-FDG PET/CT was performed before and at 4 months after transplantation. We quantified 18F-FDG uptake as the target-to-background ratio (TBR) in the carotid artery in 10 CKD patients. TBR was evaluated in the whole carotid artery (WH) and most-diseased segment (MDS), and the mean and maximum values were analyzed. The concentrations of inflammatory cytokines, including tumor necrosis factor-alpha, interleukin-6, plasminogen activator inhibitor-1, and endothelin-1, were measured. RESULTS Eight patients showed a decrease in mean or maximum TBR. The average mean or maximum TBRs in the WH and MDS of the right and left arteries were all reduced after transplantation. The average mean TBR for the right WH decreased significantly (% reduction [95% CI]) by -5.74% [-15.37, -0.02] (p=0.047). TBRs did not correlate significantly with cytokine concentrations. The changes in cytokine concentrations after transplantation varied. CONCLUSIONS 18F-FDG uptake by the WH and MDS tended to reduce after renal transplantation. Therefore, renal transplantation may confer an anti-inflammatory effect on carotid atherosclerosis in patients with CKD; however, this effect is not large enough to be demonstrated in this study with small sample size.
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Affiliation(s)
- Hye Eun Yoon
- Department of Internal Medicine, Incheon St. Mary's Hospital, Incheon, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yaeni Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, Incheon, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sang Dong Kim
- Department of Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Jin Kyoung Oh
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Yong-An Chung
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Seok Joon Shin
- Department of Internal Medicine, Incheon St. Mary's Hospital, Incheon, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Internal Medicine, Seoul St. Mary's Hospital, Seoul, Korea; , , South Korea
| | - Suk Min Seo
- Cardiovascular Center and Cardiology Division, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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38
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Nordlohne J, Helmke A, Ge S, Rong S, Chen R, Waisman A, Haller H, von Vietinghoff S. Aggravated Atherosclerosis and Vascular Inflammation With Reduced Kidney Function Depend on Interleukin-17 Receptor A and Are Normalized by Inhibition of Interleukin-17A. JACC Basic Transl Sci 2018; 3:54-66. [PMID: 30062194 PMCID: PMC6058956 DOI: 10.1016/j.jacbts.2017.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/18/2017] [Accepted: 08/22/2017] [Indexed: 12/25/2022]
Abstract
Moderate renal impairment significantly increases atherosclerotic lesion size and leukocyte numbers, most markedly macrophages and T cells, in LDLr–/– mice. IL-17 receptor A–deficient LDLr–/– mice are protected from the growth in lesion size and leukocyte infiltrate in renal impairment. Monocytes, especially Ly6C/GR1HIGH cells, express high levels of IL-17 receptor A. IL-17A increases monocyte adhesion to the aortic wall and enhances endothelial cell pro-inflammatory cytokine production. Ablation of IL-17A or IL-17A blockade normalizes the inflammatory aortic wall infiltrate even in established atherosclerosis.
Effective therapy of atherosclerotic complications in patients with chronic kidney disease (CKD) is an unmet clinical need. Cardiovascular events are the most common cause of death. At a glomerular filtration rate ≤60 ml/min, these events are increased also after correction for common risk factors. Previous studies have reported enhanced vascular inflammation in mice and recently also in humans. Our current data show, in a mouse model of atherosclerosis in moderate renal impairment, that interleukin-17 receptor A is instrumental in this condition, and blockade of this pathway can normalize arterial inflammation even in advanced atherosclerosis.
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Affiliation(s)
- Johannes Nordlohne
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Alexandra Helmke
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Shuwang Ge
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany.,Department of Nephrology, Tongji Hospital, Huazhong University of Science and Technology, Huazhong, People's Republic of China
| | - Song Rong
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Rongjun Chen
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Ari Waisman
- Institute for Molecular Medicine, University of Mainz, Mainz, Germany
| | - Hermann Haller
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Sibylle von Vietinghoff
- Department of Internal Medicine, Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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39
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Buscher K, Marcovecchio P, Hedrick CC, Ley K. Patrolling Mechanics of Non-Classical Monocytes in Vascular Inflammation. Front Cardiovasc Med 2017; 4:80. [PMID: 29312957 PMCID: PMC5742122 DOI: 10.3389/fcvm.2017.00080] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/23/2017] [Indexed: 12/13/2022] Open
Abstract
Non-classical monocytes have emerged as the preeminent vascular housekeepers. Continuous intravascular screening is enabled by slow patrolling on the endothelium and allows a rapid response to local perturbations. Intravital imaging has been crucial to elucidate the molecular mechanisms and migratory phenotype of patrolling. In this review, we discuss technical requirements of intravital microscopy such as imaging modalities, labeling strategies, and data analysis. We further focus on patrolling kinetics and adhesion receptors in different organs and vascular beds including arteries during homeostasis and vascular inflammation and define pertinent questions in the field.
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Affiliation(s)
- Konrad Buscher
- Division of Inflammation Biology, La Jolla Institute for Allergy and Immunology, La Jolla, CA, United States.,Department of Internal Medicine, Nephrology and Rheumatology, University Hospital Münster, Münster, Germany
| | - Paola Marcovecchio
- Division of Inflammation Biology, La Jolla Institute for Allergy and Immunology, La Jolla, CA, United States
| | - Catherine C Hedrick
- Division of Inflammation Biology, La Jolla Institute for Allergy and Immunology, La Jolla, CA, United States
| | - Klaus Ley
- Division of Inflammation Biology, La Jolla Institute for Allergy and Immunology, La Jolla, CA, United States
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40
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Catabay C, Obi Y, Streja E, Soohoo M, Park C, Rhee CM, Kovesdy CP, Hamano T, Kalantar-Zadeh K. Lymphocyte Cell Ratios and Mortality among Incident Hemodialysis Patients. Am J Nephrol 2017; 46:408-416. [PMID: 29130984 DOI: 10.1159/000484177] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 10/06/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been previously suggested as oncologic prognostication markers. These are associated with malnutrition and inflammation, and hence, may provide benefit in predicting mortality among hemodialysis patients. METHODS Among 108,548 incident hemodialysis patients in a large U.S. dialysis organization (2007-2011), we compared the mortality predictability of NLR and PLR with baseline and time-varying covariate Cox models using the receiver operating characteristic curve (AUROC), net reclassification index (NRI), and adjusted R2. RESULTS During the median follow-up period of 1.4 years, 28,618 patients died. Median (IQR) NLR and PLR at baseline were 3.64 (2.68-5.00) and 179 (136-248) respectively. NLR was associated with higher mortality, which appeared stronger in the time-varying versus baseline model. PLR exhibited a J-shaped association with mortality in both models. NLR provided better mortality prediction in addition to demographics, comorbidities, and serum albumin; ΔAUROC and NRI for 1-year mortality (95% CI) were 0.010 (0.009-0.012) and 6.4% (5.5-7.3%) respectively. Additionally, adjusted R2 (95% CI) for the Cox model increased from 0.269 (0.262-0.276) to 0.283 (0.276-0.290) in the non-time-varying model and from 0.467 (0.461-0.472) to 0.505 (0.500-0.512) in the time-varying model. There was little to no benefit of adding PLR to predict mortality. CONCLUSIONS High NLR in incident hemodialysis patients predicted mortality, especially in the short-term period. NLR, but not PLR, added modest benefit in predicting mortality along with demographics, comorbidities, and serum albumin, and should be included in prognostication approaches.
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Affiliation(s)
- Christina Catabay
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
| | - Takayuki Hamano
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
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