1
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Kim JE, Park J, Park S, Yu MY, Baek SH, Park SH, Han K, Kim YC, Kim DK, Oh KH, Joo KW, Kim YS, Lee H. De novo major cardiovascular events in kidney transplant recipients: a comparative matched cohort study. Nephrol Dial Transplant 2023; 38:499-506. [PMID: 35396847 DOI: 10.1093/ndt/gfac144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although cardiovascular disease is known to be one of the leading causes of death after kidney transplantation (KT), evidence on the risk difference of de novo major adverse cardiovascular events (MACEs) in kidney transplant recipients (KTRs) compared with that in dialysis patients or the general population (GP) remains rare. METHODS We identified KTRs using the nationwide health insurance database in South Korea and then 1:1 matched them with the dialysis and GP controls without a pre-existing MACE. The primary endpoint was defined as de novo MACEs consisting of myocardial infarction, coronary revascularization and ischemic stroke. The secondary endpoints were all-cause mortality and death-censored graft failure (DCGF) in KTRs. RESULTS We included 4156 individuals in each of the three groups and followed them up for 4.7 years. De novo MACEs occurred in 3.7, 21.7 and 2.5 individuals per 1000 person-years in the KTRs, dialysis controls and GP controls, respectively. KTRs showed a lower MACE risk {adjusted hazard ratio (aHR) 0.16 [95% confidence interval (CI) 0.12-0.20], P < .001} than dialysis controls, whereas a similar MACE risk to GP controls [aHR 0.81 (95% CI 0.52-1.27), P = .365]. In addition, KTRs showed a similar MACE risk compared with the GP group, regardless of age, sex and the presence of comorbidities, including hypertension, diabetes and dyslipidemia. Among KTRs, de novo MACEs were associated with an increased risk of all-cause mortality, but not with DCGF. CONCLUSIONS De novo MACEs in KTRs were much lower than that in dialysis patients and had a similar risk to the GP, but once it occurred it caused elevated mortality risk in KTRs.
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Affiliation(s)
- Ji Eun Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jina Park
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sehoon Park
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Mi-Yeon Yu
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Sang Hyun Park
- Department of Biostatistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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2
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Affiliation(s)
- Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, 143 Shimokasuya, Kanagawa 259-1193, Isehara, Japan
| | - Shinichi Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, 143 Shimokasuya, Kanagawa 259-1193, Isehara, Japan
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3
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Nanayakkara GL, Rai T, Kirincic L, Lightfoot R, Senaratne JM, Senaratne M. Differences in Clinical Measures and Outcomes in South Asians vs Caucasians Attending Cardiac Rehabilitation. CJC Open 2021; 3:1019-1024. [PMID: 34505041 PMCID: PMC8413229 DOI: 10.1016/j.cjco.2021.03.014] [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: 01/17/2021] [Accepted: 03/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background South Asians have a greater predisposition to cardiac events, compared to Caucasians. Although cardiac rehabilitation programs (CRPs) are known to improve outcomes, data are sparse regarding benefits acquired by South Asians vs Caucasians. The objective of the current study was to determine the outcomes of South Asian patients undergoing CRPs, compared to Caucasian patients. Methods This study compared baseline characteristics and outcomes in all patients attending a CRP in Edmonton, Canada with a proportionately large South Asian population. Results From 1998 to 2016, a total of 811 South Asians and 5406 Caucasians attended CRPs. Baseline characteristics revealed that there were more nonsmokers (73.4% vs 29.4%, P < 0.001), with a lower body mass index (26.8 ± 0.1 vs 29.6 ± 0.1, P < 0.001), but higher prevalence of diabetes (37.7% vs 20.5%, P < 0.001) in the South Asian population. Outcome measures revealed that South Asians spent less time in the CRP (6.9 weeks ± 0.1 vs 7.3 weeks ± 0.1, P < 0.001), attended the nutrition class less (36.2% vs 53.4%, P < 0.001), and had a lower 6-minute walk improvement (66.9 m vs 73.6 m, P < 0.001). Frequency of use of β-blockers (86.9% vs 86.1%, P > 0.05), antiplatelet agents (96.3% vs 97.1%, P > 0.05), angiotensin-converting enzyme inhibitors (79.9% vs 80.0%, P > 0.05), and cholesterol-lowering agents (91.4% vs 93.8%, P > 0.05) was not significantly different. Conclusions Although South Asians seem to be prescribed and use proven pharmacologic treatments to the same extent as Caucasians, they appeared to benefit less from CRPs. Given higher event rates in South Asians, consideration should be given to altering the delivery of CRPs to South Asians to improve their efficacy.
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Affiliation(s)
| | - Tracey Rai
- Grey Nuns Community Hospital, Edmonton, Alberta, Canada
| | - Lena Kirincic
- Grey Nuns Community Hospital, Edmonton, Alberta, Canada
| | | | - Janek M Senaratne
- Grey Nuns Community Hospital, Edmonton, Alberta, Canada.,Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Manohara Senaratne
- Grey Nuns Community Hospital, Edmonton, Alberta, Canada.,Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
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4
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Lockridge JB, Pryor JB, Stack MN, Rehman SS, Norman DJ, DeMattos AM, Olyaei AJ. New onset diabetes after kidney transplantation in Asian Americans – Is there an increased risk? TRANSPLANTATION REPORTS 2021. [DOI: 10.1016/j.tpr.2021.100080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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5
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Prasad GVR, Bhamidi V. Managing cardiovascular disease risk in South Asian kidney transplant recipients. World J Transplant 2021; 11:147-160. [PMID: 34164291 PMCID: PMC8218347 DOI: 10.5500/wjt.v11.i6.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/12/2021] [Accepted: 05/22/2021] [Indexed: 02/06/2023] Open
Abstract
South Asians (SA) are at higher cardiovascular risk than other ethnic groups, and SA kidney transplant recipients (SA KTR) are no exception. SA KTR experience increased major adverse cardiovascular events both early and late post-transplantation. Cardiovascular risk management should therefore begin well before transplantation. SA candidates may require aggressive screening for pre-transplant cardiovascular disease (CVD) due to their ethnicity and comorbidities. Recording SA ethnicity during the pre-transplant evaluation may enable programs to better assess cardiovascular risk, thus allowing for earlier targeted peri- and post-transplant intervention to improve cardiovascular outcomes. Diabetes remains the most prominent post-transplant cardiovascular risk factor in SA KTR. Diabetes also clusters with other metabolic syndrome components including lower high-density lipoprotein cholesterol, higher triglycerides, hypertension, and central obesity in this population. Dyslipidemia, metabolic syndrome, and obesity are all significant CVD risk factors in SA KTR, and contribute to increased insulin resistance. Novel biomarkers such as adiponectin, apolipoprotein B, and lipoprotein (a) may be especially important to study in SA KTR. Focused interventions to improve health behaviors involving diet and exercise may especially benefit SA KTR. However, there are few interventional clinical trials specific to the SA population, and none are specific to SA KTR. In all cases, understanding the nuances of managing SA KTR as a distinct post-transplant group, while still screening for and managing each CVD risk factor individually in all patients may help improve the long-term success of all kidney transplant programs catering to multi-ethnic populations.
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Affiliation(s)
- G V Ramesh Prasad
- Kidney Transplant Program, St. Michael's Hospital, Toronto M5C 2T2, ON, Canada
| | - Vaishnavi Bhamidi
- Kidney Transplant Program, St. Michael's Hospital, Toronto M5C 2T2, ON, Canada
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6
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Deak AT, Ionita F, Kirsch AH, Odler B, Rainer PP, Kramar R, Kubatzki MP, Eberhard K, Berghold A, Rosenkranz AR. Impact of cardiovascular risk stratification strategies in kidney transplantation over time. Nephrol Dial Transplant 2021; 35:1810-1818. [PMID: 33022711 PMCID: PMC7538198 DOI: 10.1093/ndt/gfaa131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/22/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Kidney transplant recipients exhibit a dramatically increased cardiovascular (CV) risk. In 2007, Austrian centres implemented a consensus of comprehensive CV screening programme prior to kidney transplantation (KT). The consensus placed a particular emphasis on screening for coronary artery disease (CAD) with cardiac computed tomography (CT) or coronary angiography (CAG) in patients with diabetes mellitus, known CAD or those having multiple conventional CV risk factors. Here, we investigate if this affected risk stratification and post-transplant CV outcomes. METHODS In a retrospective chart review, we evaluated 551 KTs performed from 2003 to 2015 in our centre. Patients were categorized into three groups: KT before (2003-07), directly after (2008-11) and 5 years after (2012-15) implementation of the consensus. We analysed clinical characteristics, the rate of cardiac CTs and CAGs prior to KT as well as major adverse cardiac events (MACEs) during a 2-year follow-up after KT. RESULTS The three study groups showed a homogeneous distribution of comorbidities and age. Significantly more cardiac CTs (13.6% versus 10.2% versus 44.8%; P = 0.002) and CAGs (39.6% versus 43.9% versus 56.2%; P = 0.003) were performed after the consensus. Coronary interventions were performed during 42 out of 260 CAGs (16.2%), the cumulative 2-year MACE incidence was 8.7%. Regarding MACE occurrence, no significant difference between the three groups was found. CONCLUSION CV risk stratification has become more rigorous and invasive after the implementation of the consensus; however, this was not associated with an improvement in CV outcome.
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Affiliation(s)
- Andras T Deak
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Francesca Ionita
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Alexander H Kirsch
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Balazs Odler
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Peter P Rainer
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Reinhard Kramar
- Austrian Dialysis and Transplant Registry, Innsbruck, Austria
| | - Michael P Kubatzki
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Katharina Eberhard
- Core Facility Computational Bioanalytics, Medical University of Graz, Graz, Austria
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Alexander R Rosenkranz
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
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7
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Association of Race and Major Adverse Cardiac Events (MACE): The Atherosclerosis Risk in Communities (ARIC) Cohort. J Aging Res 2020; 2020:7417242. [PMID: 32280543 PMCID: PMC7114773 DOI: 10.1155/2020/7417242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/19/2020] [Indexed: 12/20/2022] Open
Abstract
Background and Aims To evaluate the association of self-reported race with major adverse cardiac events (MACE) and modification of this association by paraoxonase gene (PON1, PON2, and PON3) single nucleotide polymorphisms (SNPs). Methods Included in this longitudinal study were 12,770 black or white participants from the Atherosclerosis Risk in Communities (ARIC) cohort who completed a baseline visit (1987–1989) with PON genotyping. Demographic, behavioral, and health information was obtained at baseline. MACE was defined as first occurrence of myocardial infarction, stroke, or CHD-related death through 2004. Cox proportional hazards regression was used to evaluate the association between race and MACE after adjustment for age, gender, and other demographic and cardiovascular risk factors such as diabetes and hypertension. Modification of the association between PON SNPs and MACE was also assessed. Results Blacks comprised 24.6% of the ARIC cohort; overall, 14.0% of participants developed MACE. Compared with whites, blacks had 1.24 times greater hazard of MACE (OR = 1.24,95%CI = 1.10,1.39) than whites after adjusting for age, gender, BMI, cigarette and alcohol use, educational and marital status, and aspirin use. This association became nonsignificant after further adjustment for high cholesterol, diabetes, and hypertension. None of the evaluated SNPs met the significance level (p < 0.001) after Bonferroni correction for multiple comparisons. Conclusions No association between race and MACE was identified after adjusting for high cholesterol, diabetes, and hypertension, suggesting that comorbidities are major determinants of MACE; medical intervention with focus on lifestyle and health management could ameliorate the development of MACE. Further studies are needed to confirm this observation.
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8
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Yoo KD, Kim CT, Kim MH, Noh J, Kim G, Kim H, An JN, Park JY, Cho H, Kim KH, Kim H, Ryu DR, Kim DK, Lim CS, Kim YS, Lee JP. Superior outcomes of kidney transplantation compared with dialysis: An optimal matched analysis of a national population-based cohort study between 2005 and 2008 in Korea. Medicine (Baltimore) 2016; 95:e4352. [PMID: 27537562 PMCID: PMC5370789 DOI: 10.1097/md.0000000000004352] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Data regarding kidney transplantation (KT) and dialysis outcomes are rare in Asian populations. In the present study, we evaluated the clinical outcomes associated with KT using claims data from the Korean national public health insurance program. Among the 35,418 adult patients with incident dialysis treated between 2005 and 2008 in Korea, 1539 underwent KT. An optimal balanced risk set matching was attempted to compare the transplant group with the control group in terms of the overall survival and major adverse cardiac event-free survival. Before matching, the dialysis group was older and had more comorbidities. After matching, there were no differences in age, sex, dialysis modalities, or comorbidities. Patient survival was significantly better in the transplant group than in the matched control group (P < 0.001). In addition, the transplant group showed better major adverse cardiac event-free survival than the dialysis group (P < 0.001; hazard ratio, 0.49; 95% confidence interval, 0.32-0.75). Korean patients with incident dialysis who underwent long-term dialysis had significantly more cardiovascular events and higher all-cause mortality rates than those who underwent KT. Thus, KT should be more actively recommended in Korean populations.
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Affiliation(s)
- Kyung Don Yoo
- Department of Internal Medicine, Division of Nephrology, Dongguk University Medical Center
| | | | - Myoung-Hee Kim
- Department of Dental Hygiene, College of Health Science, Eulji University, Daejeon
| | - Junhyug Noh
- College of Engineering, Seoul National University
| | - Gunhee Kim
- College of Engineering, Seoul National University
| | - Ho Kim
- School of Public Health, Seoul National University, Seoul
| | - Jung Nam An
- Department of Internal Medicine, Seoul National University Boramae Medical Center
| | - Jae Yoon Park
- Department of Internal Medicine, Division of Nephrology, Dongguk University Medical Center
| | - Hyunjeong Cho
- Department of Internal Medicine, Seoul National University College of Medicine
| | - Kyoung Hoon Kim
- Department of Public Health, Graduate School, Korea University, Seoul
| | - Hyunwook Kim
- Department of Internal Medicine, Wonkwang University College of Medicine, Sanbon Hospital, Gyeonggi-do
| | - Dong-Ryeol Ryu
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University Boramae Medical Center
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center
- Correspondence: Jung Pyo Lee, Department of Internal Medicine, Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 156-707, Republic of Korea (e-mail: )
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9
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Peracha J, Nath J, Ready A, Tahir S, Parekh K, Hodson J, Ferro CJ, Borrows R, Sharif A. Risk of post-transplantation diabetes mellitus is greater in South Asian versus Caucasian kidney allograft recipients. Transpl Int 2016; 29:727-39. [PMID: 27062063 DOI: 10.1111/tri.12782] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/19/2015] [Accepted: 04/06/2016] [Indexed: 12/14/2022]
Abstract
South Asians have increased risk for type 2 diabetes mellitus compared with Caucasians in the general population, but data for the development of post-transplantation diabetes mellitus (PTDM) is scarce. In this retrospective analysis, data was extracted from electronic patient records at a single centre (2004-2014). Caucasians were more likely to be male, with higher age and BMI than South Asians. Case-control matching was therefore undertaken to remove this bias, resulting in 102 recipient pairs. Median follow-up was 50 months (range 4-127 months). Matched groups had similar baseline characteristics, although South Asians compared with Caucasians received more deceased-donor kidneys (74% vs. 43%, respectively, P < 0.001) and were more likely to be CMV positive (77% vs. 43%, respectively, P < 0.001). PTDM incidence was significantly higher in South Asians versus Caucasians (35% vs. 10%, respectively, subhazard ratio 4.2 [95% CI: 2.1-8.5, P < 0.001]). Donor type had significant interaction with ethnicity, with the observed difference in PTDM rates between ethnicities most visible with receipt of deceased-donor kidneys. No significant difference was detected in allograft function, rejection episodes, adverse cardiovascular events or patient/graft survival. South Asians have increased risk of PTDM, especially recipients of deceased kidneys, and recognition of this allows appropriate patient counselling and development of targeted strategies.
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Affiliation(s)
- Javeria Peracha
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Jay Nath
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| | - Andrew Ready
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - James Hodson
- Institute of Translational Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Charles J Ferro
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Richard Borrows
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
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10
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Agarwal A, Prasad GVR. Post-transplant dyslipidemia: Mechanisms, diagnosis and management. World J Transplant 2016; 6:125-134. [PMID: 27011910 PMCID: PMC4801788 DOI: 10.5500/wjt.v6.i1.125] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/26/2015] [Accepted: 02/17/2016] [Indexed: 02/05/2023] Open
Abstract
Post-transplant dyslipidemia is highly prevalent and presents unique management challenges to the clinician. The two major outcomes to consider with post-transplant therapies for dyslipidemia are preserving or improving allograft function, and reducing cardiovascular risk. Although there are other cardiovascular risk factors such as graft dysfunction, hypertension, and diabetes, attention to dyslipidemia is warranted because interventions for dyslipidemia have an impact on reducing cardiac events in clinical trials specific to the transplant population. Dyslipidemia is not synonymous with hyperlipidemia. Numerous mechanisms exist for the occurrence of post-transplant dyslipidemia, including those mediated by immunosuppressive drug therapy. Statin therapy has received the most attention in all solid organ transplant recipient populations, although the effect of proper dietary advice and adjuvant pharmacological and non-pharmacological agents should not be dismissed. At all stages of treatment appropriate monitoring strategies for side effects should be implemented so that the benefits from these therapies can be achieved. Clinicians have a choice when there is a conflict between various transplant society and lipid society guidelines for therapy and targets.
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11
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Palepu S, Prasad GVR. Screening for cardiovascular disease before kidney transplantation. World J Transplant 2015; 5:276-286. [PMID: 26722655 PMCID: PMC4689938 DOI: 10.5500/wjt.v5.i4.276] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/31/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Pre-kidney transplant cardiac screening has garnered particular attention from guideline committees as an approach to improving post-transplant success. Screening serves two major purposes: To more accurately inform transplant candidates of their risk for a cardiac event before and after the transplant, thereby informing decisions about proceeding with transplantation, and to guide pre-transplant management so that post-transplant success can be maximized. Transplant candidates on dialysis are more likely to be screened for coronary artery disease than those not being considered for transplantation. Thorough history and physical examination taking, resting electrocardiography and echocardiography, exercise stress testing, myocardial perfusion scintigraphy, dobutamine stress echocardiography, cardiac computed tomography, cardiac biomarker measurement, and cardiac magnetic resonance imaging all play contributory roles towards screening for cardiovascular disease before kidney transplantation. In this review, the importance of each of these screening procedures for both coronary artery disease and other forms of cardiac disease are discussed.
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12
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Palepu S, Prasad GVR. New-onset diabetes mellitus after kidney transplantation: Current status and future directions. World J Diabetes 2015; 6:445-455. [PMID: 25897355 PMCID: PMC4398901 DOI: 10.4239/wjd.v6.i3.445] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/14/2014] [Accepted: 01/12/2015] [Indexed: 02/05/2023] Open
Abstract
A diagnosis of new-onset diabetes after transplantation (NODAT) carries with it a threat to the renal allograft, as well as the same short- and long-term implications of type 2 diabetes seen in the general population. NODAT usually occurs early after transplantation, and is usually diagnosed according to general population guidelines. Non-modifiable risk factors for NODAT include advancing age, African American, Hispanic, or South Asian ethnicity, genetic background, a positive family history for diabetes mellitus, polycystic kidney disease, and previously diagnosed glucose intolerance. Modifiable risk factors for NODAT include obesity and the metabolic syndrome, hepatitis C virus and cytomegalovirus infection, corticosteroids, calcineurin inhibitor drugs (especially tacrolimus), and sirolimus. NODAT affects graft and patient survival, and increases the incidence of post-transplant cardiovascular disease. The incidence and impact of NODAT can be minimized through pre- and post-transplant screening to identify patients at higher risk, including by oral glucose tolerance tests, as well as multi-disciplinary care, lifestyle modification, and the use of modified immunosuppressive regimens coupled with glucose-lowering therapies including oral hypoglycemic agents and insulin. Since NODAT is a major cause of post-transplant morbidity and mortality, measures to reduce its incidence and impact have the potential to greatly improve overall transplant success.
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13
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Prasad GVR, Huang M, Silver SA, Al-Lawati AI, Rapi L, Nash MM, Zaltzman JS. Metabolic syndrome definitions and components in predicting major adverse cardiovascular events after kidney transplantation. Transpl Int 2014; 28:79-88. [PMID: 25207680 DOI: 10.1111/tri.12450] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 09/19/2014] [Accepted: 09/05/2014] [Indexed: 02/06/2023]
Abstract
Metabolic syndrome (MetS) associates with cardiovascular risk post-kidney transplantation, but its ambiguity impairs understanding of its diagnostic utility relative to components. We compared five MetS definitions and the predictive value of constituent components of significant definitions for major adverse cardiovascular events (MACE) in a cohort of 1182 kidney transplant recipients. MetS definitions were adjusted for noncomponent traditional Framingham risk factors and relevant transplant-related variables. Kaplan-Meier, logistic regression, and Cox proportional hazards analysis were utilized. There were 143 MACE over 7447 patient-years of follow-up. Only the World Health Organization (WHO) 1998 definition predicted MACE (25.3 vs 15.5 events/1000 patient-years, P = 0.019). Time-to-MACE was 5.5 ± 3.5 years with MetS and 6.8 ± 3.9 years without MetS (P < 0.0001). MetS was independent of pertinent MACE risk factors except age and previous cardiac disease. Among MetS components, dysglycemia provided greatest hazard ratio (HR) for MACE (1.814 [95% confidence interval 1.26-2.60]), increased successively by microalbuminuria (HR 1.946 [1.37-2.75]), dyslipidemia (3.284 [1.72-6.26]), hypertension (4.127 [2.16-7.86]), and central obesity (4.282 [2.09-8.76]). MetS did not affect graft survival. In summary, although the WHO 1998 definition provides greatest predictive value for post-transplant MACE, most of this is conferred by dysglycemia and is overshadowed by age and previous cardiac disease.
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Affiliation(s)
- G V Ramesh Prasad
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON, Canada; Renal Transplant Program, St. Michael's Hospital, Toronto, ON, Canada
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14
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Rana A, de Souza RJ, Kandasamy S, Lear SA, Anand SS. Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis. CMAJ Open 2014; 2:E183-91. [PMID: 25295238 PMCID: PMC4183167 DOI: 10.9778/cmajo.20130064] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND South Asians represent about 3% of the Canadian population and have a higher burden of certain cardiovascular risk factors and cardiovascular disease (CVD) compared with white people. The objective of this study was to review the literature to compare cardiovascular risk factors and disease management practices among adult South Asian and white Canadians. METHODS We searched MEDLINE, Embase, Cochrane and Cumulative Index to Nursing and Allied Health Literature databases from their inception through Feb. 17, 2014 and the reference lists of the selected articles. English-language studies of interventions and observational studies of biological mechanisms underlying CVD risk in South Asians conducted in Canada were eligible for inclusion. Where appropriate, we used random-effects meta-analyses to integrate results comparing the CVD risk profiles of South Asian and white Canadians. RESULTS We included 50 articles (n = 5 805 313 individuals) in this review. Compared with white Canadians, South Asian Canadians had a higher prevalence and incidence of CVD, an increased prevalence of diabetes (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.81 to 2.80, p < 0.001) and hypertension (OR 1.11, 95% CI 1.02 to 1.22, p = 0.02), lower high-density lipoprotein cholesterol levels (mean difference -0.19 mmol/L, 95% CI -0.25 to -0.13 mmol/L, p < 0.001) and a higher percentage of body fat (men: absolute mean difference 3.23%, 95% CI 0.83% to 5.62%, p = 0.008; women: absolute mean difference 4.09%, 95% CI 3.46% to 4.72%, p < 0.001). South Asian people are also more sedentary, consume higher levels of carbohydrates and are less likely to smoke tobacco (OR 0.38, 95% CI 0.24 to 0.60, p < 0.001]) than white Canadians. No differences in access to diagnostic tests, outcomes following cardiovascular surgery or use of cardiac rehabilitation programs were apparent. INTERPRETATION Compared with white people, South Asian people living in Canada have a higher prevalence and incidence of CVD and possess a unique cardiovascular risk profile.
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Affiliation(s)
- Ayesha Rana
- Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ont. ; Chanchlani Research Centre, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ont
| | - Russell J de Souza
- Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ont. ; Chanchlani Research Centre, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ont. ; Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont
| | - Sujane Kandasamy
- Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ont. ; Chanchlani Research Centre, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ont
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC ; Division of Cardiology, Providence Health Care, Vancouver, BC
| | - Sonia S Anand
- Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ont. ; Chanchlani Research Centre, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ont. ; Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ont
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Glick L, Shamy F, Nash M, Sokwala A, Malavade T, Prasad GR, Zaltzman JS. A prospective cohort conversion study of twice-daily to once-daily extended-release tacrolimus: role of ethnicity. Transplant Res 2014; 3:7. [PMID: 24606676 PMCID: PMC3995788 DOI: 10.1186/2047-1440-3-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 02/25/2014] [Indexed: 12/23/2022] Open
Abstract
Background Tacrolimus is a widely used calcineurin inhibitor in kidney transplantation. It is available as twice-daily Prograf® (Tac-BID) and once-daily Advagraf® (Tac-OD). Although therapeutically equivalent, some patients require dose adjustments to achieve similar trough concentrations [C0] after conversion. Tacrolimus exposure is affected by ethnicity in the de novo setting but the role of ethnicity in determining dose requirements and adjustments after conversion is unknown. Methods In this study, 496 renal transplant recipients (RTRs) were prospectively converted from Tac-BID to Tac-OD, with dose adjustments targeted to achieve similar [C0] at 12 months post-conversion. Renal function, acute rejection and Tac dose adjustments by ethnicity were analyzed. Results There were similar numbers of recipients from living and deceased donors. The mean transplant duration was 7 years. Of the RTRs, 60% were Caucasian and 40% were identified as belonging to an ethnic minority. There was no change in estimated renal function (eGFR) post-conversion to Tac-OD. At 12 months, 35/488 (7%) RTRs were receiving a reduced dose, 101/488 (21%) required a dose increase of which 77 (16%) were receiving at least a 30% increase in dose over baseline. The percentage of those in ethnic groups requiring a dose increase of >30% varied from 8.0% for South Asians to 27.5% for East Asians (P = 0.03), despite East Asians having a similar baseline dose of Tac-BID (3.59 mg/day) compared to the entire cohort (3.53 mg/day). Conclusions Ethnicity may play an important role in dosing requirements when converting from Tac-BID to Tac-OD, unrelated to baseline dose. Further investigation is required to determine the reasons for ethnic variability when patients are converted between tacrolimus preparations.
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Affiliation(s)
| | | | | | | | | | | | - Jeffrey S Zaltzman
- Department of Medicine, Division of Nephrology, Keenan Research Institute, St, Michael's, 30 Bond St, Toronto, Ontario M5B1W8, Canada.
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16
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Paraoxonase 1 Phenotype and Mass in South Asian versus Caucasian Renal Transplant Recipients. J Lipids 2012; 2012:608580. [PMID: 22701797 PMCID: PMC3371753 DOI: 10.1155/2012/608580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 03/09/2012] [Accepted: 03/11/2012] [Indexed: 11/18/2022] Open
Abstract
South Asian renal transplant recipients have a higher incidence of cardiovascular disease compared with Caucasian renal transplant recipients. We carried out a study to determine whether paraoxonase 1, a novel biomarker for cardiovascular risk, was decreased in South Asian compared with Caucasian renal transplant recipients. Subjects were matched two to one on the basis of age and sex for a total of 129 subjects. Paraoxonase 1 was measured by mass, arylesterase activity, and two-substrate phenotype assay. Comparisons were made by using a matched design. The frequency of PON1 QQ, QR and RR phenotype was 56%, 37%, and 7% for Caucasian subjects versus 35%, 44%, and 21% for South Asian subjects (χ(2) = 7.72, P = 0.02). PON1 mass and arylesterase activity were not significantly different between South Asian and Caucasian subjects. PON1 mass was significantly associated with PON1 phenotype (P = 0.0001), HDL cholesterol (P = 0.009), LDL cholesterol (P = 0.02), and diabetes status (P < 0.05). Arylesterase activity was only associated with HDL cholesterol (P = 0.003). Thus the frequency of the PON1 RR phenotype was higher and that of the QQ phenotype was lower in South Asian versus Caucasian renal transplant recipients. However, ethnicity was not a significant factor as a determinant of PON1 mass or arylesterase activity, with or without analysis including PON1 phenotype. The two-substrate method for determining PON1 phenotype may be of value for future studies of cardiovascular complications in renal transplant recipients.
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Lo YC, Ho HC, Wu MJ, Chen CH, Cheng CH, Yu TM, Chuang YW, Huang ST, Yang CK, Shu KH. Interleukin-2 Receptor Antagonist Does Not Decrease Biopsy-Proven Acute Rejection among Adult Chinese Kidney Transplant Recipients. Ren Fail 2012; 34:856-61. [DOI: 10.3109/0886022x.2012.684032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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18
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Prasad GVR, Vorobeichik L, Nash MM, Huang M, Rapi L, Maguire G, Mamdani M, Yan AT, Connelly PW. Lower total and percent of high-molecular-weight adiponectin concentration in South Asian kidney transplant recipients. Clin Kidney J 2012; 5:124-129. [PMID: 24744849 PMCID: PMC3989851 DOI: 10.1093/ckj/sfs033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 02/28/2012] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Ethnicity is an important determinant of post-renal transplant outcomes. Limited data are available on cardiovascular risk differences in kidney transplant recipients (KTR) based on ethnicity. METHODS A group of 129 clinically stable age-matched KTR [43 South Asian (SA), 86 Caucasian]) were assessed for plasma total and high-molecular-weight (HMW) adiponectin, cystatin C, apolipoproteins A1 and B, C-reactive protein, uric acid, urine albumin-to-creatinine ratio, estimated glomerular filtration rate (eGFR) and transplant-specific plus traditional Framingham risk factors. SA and Caucasians were compared by t-tests, Wilcoxon rank-sum or chi-square testing. Accounting for the matched design, multivariable linear regression was performed to determine predictors of adiponectin concentrations. RESULTS SA did not differ from Caucasians in background cardiac disease or cardioprotective medication use or risk factors other than smoking (26 versus 56%, P = 0.001). Total adiponectin (9.5 ± 3.5 versus 12.9 ± 6.7 μmg/mL, P < 0.001) and HMW adiponectin (22 ± 9 versus 29 ± 11%, P < 0.001) were significantly lower in SA. Determinants of total adiponectin included SA ethnicity (P = 0.02), cystatin C-eGFR (P < 0.001), high-density lipoprotein (HDL) cholesterol (P < 0.0001) and waist-to-hip ratio (P < 0.001), while those of HMW adiponectin included SA ethnicity (P < 0.001), cystatin C-eGFR (P = 0.03) and HDL cholesterol (P = 0.001). There were no important differences in the other measured biomarkers. CONCLUSION Total and HMW adiponectin concentrations are lower in SA KTR and may be promising exploratory biomarkers of post-transplant cardiovascular risk.
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Affiliation(s)
- G V Ramesh Prasad
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada ; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Leon Vorobeichik
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle M Nash
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michael Huang
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Lindita Rapi
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Graham Maguire
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Andrew T Yan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada ; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Philip W Connelly
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada ; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Jafar TH, Islam M, Jessani S, Bux R, Inker LA, Mariat C, Levey AS. Level and determinants of kidney function in a South Asian population in Pakistan. Am J Kidney Dis 2011; 58:764-72. [PMID: 21840098 DOI: 10.1053/j.ajkd.2011.06.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 06/01/2011] [Indexed: 01/21/2023]
Abstract
BACKGROUND People of South Asian origin are at high risk of chronic kidney disease. Some have suggested that the usual level of glomerular filtration rate (GFR) in South Asians may be lower than in populations of European origin. However, measured GFR in a general adult population of South Asian origin has not been studied. DESIGN Cross-sectional observational study. SETTING & PARTICIPANTS 530 patients 40 years or older randomly selected from communities in Karachi, Pakistan, using multistage cluster sampling. Patients with both diabetes and hypertension were excluded. PREDICTOR Age, sex, diabetes, and hypertension. OUTCOME Measured GFR using urinary clearance of inulin. RESULTS Mean age of participants was 49.7 ± 9.5 (standard deviation [SD]) years, 51% were men, 34.9% had hypertension, and 30.5% had diabetes. Mean measured GFR was 94.1 ± 28.6 mL/min/1.73 m(2). GFR was lower by 0.79 ± 0.11 mL/min/1.73 m(2) for each 1-year older age. The 5-year age- and sex-specific mean GFR of the study population generally was within 1 SD of the mean of previously reported values for US adults. Factors independently associated with GFR were younger age (β coefficient, -3.84 [95% CI, -5.46 to -2.21] mL/min/1.73 m(2) per 5 years older), higher serum albumin level (4.58 [95% CI, 0.74-8.42] mL/min/1.73 m(2) per 0.5-g/dL increase), higher fasting plasma glucose level (0.81 [95% CI, 0.44-1.18] mL/min/1.73 m(2) per 10-mg/dL increase), high versus low meat intake (7.81 [95% CI, 1.14-14.48] mL/min/1.73 m(2) for ≥11 vs ≤5 servings/wk), and higher estimated protein intake (1.46 [95% CI, 0.41-2.51] mL/min/1.73 m(2) per 1.0-g/d increase) from urine urea nitrogen. LIMITATIONS Moderate sample size, lack of validation of some items in the dietary assessment for this study population. CONCLUSIONS Mean measured GFR in South Asian adults from the general population in Karachi, Pakistan, is only modestly lower than in European-origin counterparts, with similar age association. This may reflect lower dietary protein intake in South Asians.
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Affiliation(s)
- Tazeen H Jafar
- Clinical Epidemiology Unit, Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
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Siezenga MA, Shaw PKC, Daha MR, Rabelink TJ, Berger SP. Low Mannose-Binding Lectin (MBL) genotype is associated with future cardiovascular events in type 2 diabetic South Asians. A prospective cohort study. Cardiovasc Diabetol 2011; 10:60. [PMID: 21729275 PMCID: PMC3157421 DOI: 10.1186/1475-2840-10-60] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 07/05/2011] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND South Asians have a high burden of type 2 diabetes and vascular complications. Vascular inflammation is considered central in the pathophysiology of atherosclerosis, and the complement system is thought to play an important role. Mannose-Binding Lectin (MBL), which activates the lectin pathway of complement activation, has been introduced as a risk marker of vascular damage. The present study explores the association of MBL levels, genotype and cardiovascular events in type 2 diabetic South Asians. METHODS We conducted a prospective observational study. A cohort consisting of 168 type 2 diabetic South Asians was followed for a median duration of 7.66 years. At baseline, MBL levels and genotype were determined. The association with future cardiovascular events was assessed by Cox proportional hazard regression. RESULTS During follow-up, 31 cardiovascular events occurred in 22 subjects (11 men, 11 women). The O/O genotype was significantly associated with the occurrence of cardiovascular events (hazard ratio 3.42, 95%CI 1.24-9.49, P = 0.018). However, log MBL levels were not associated with the occurrence of cardiovascular events (hazard ratio 0.93, 95% CI 0.50-1.73). CONCLUSIONS In type 2 diabetic South Asians, the O/O MBL genotype is associated with cardiovascular events, although single serum MBL levels are not.
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Affiliation(s)
- Machiel A Siezenga
- Department of Nephrology, Leiden University Medical Center, the Netherlands.
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