Investigation of Metabolic Factors Associated with eGFR Decline Over 1 Year in a Japanese Population without CKD

Lifestyle factors associated with a rapid decline in the estimated glomerular filtration rate over two years in older adults with type 2 diabetes-Evidence from a large national database in Japan

BACKGROUND

The present study investigated lifestyle risk factors from metabolic syndrome-related lifestyles for a rapid decline in the estimated glomerular filtration rate (eGFR) among adults aged 40-74 years with treated and untreated type 2 diabetes.

METHODS AND RESULTS

This study analyzed data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan, encompassing the period from fiscal year (FY) 2017 to FY2020. We established FY2018 as our baseline year. The subjects of this study were adults aged 40-74 in FY2018(baseline) who had type 2 diabetes and underwent specific health checkups in FY2020. We excluded adults with a medical record of kidney dialysis between FY2017 and FY2018, records of suspected type 1 diabetes between FY2017 and FY2020, or a baseline eGFR >85 mL/min/1.73 m2 or missing eGFR data as of FY2020. Eventually we analyzed 573,860 individuals. The outcome variable was a rapid decline in eGFR (≥30%) during the follow-up. Exposure lifestyle factors included skipping breakfast, late-night dinners, regular smoking, a high alcohol intake, non-refreshing sleep, and a lack of habitual exercise. Logistic regression models were stratified by age (40-59 and 60-74 years) and baseline eGFR levels (60-85, 30-59, and <30 mL/min/1.73 m2). Covariates included sex, a history of heart disease, a history of stroke, a history of renal failure, anemia, low-density lipoprotein, systolic blood pressure, hemoglobin A1C, body mass index, antidiabetic medications, antihypertension drugs, lipid-lowering drugs, the oral adsorbent Kremezin, non-steroidal anti-inflammatory drugs, and drugs for the treatment of renal anemia. A rapid decline in eGFR was detected in approximately 1.3% of participants (7,683 cases). In the baseline eGFR >30 subgroups (60-85 or 30-59 mL/min/1.73 m2), skipping breakfast and regular smoking were associated with a rapid decline in eGFR in both age groups, while a lack of habitual exercise and late-night dinners in the 60-74 age group and non-refreshing sleep in the 40-59 age group were identified as risk factors. Additionally, skipping breakfast was a risk factor for a rapid decline in eGFR in the 60-74 age group regardless of baseline eGFR levels. In the baseline eGFR <30 mL/min/1.73 m2 subgroup, skipping breakfast and non-refreshed sleep were risk factors for a rapid decline in eGFR.

CONCLUSIONS

We found specific lifestyle risk factors were associated with a rapid eGFR decline among people with type 2 diabetes from a nationwide database in Japan. The associations varied by baseline eGFR level, age, and sex. Lifestyle modifications may effectively prevent the aggravation of diabetic kidney disease.

The Effect of Metabolic Syndrome and Its Individual Components on Renal Function: A Meta-Analysis

BACKGROUND

Observational studies have reported inconsistent findings in the relationship between metabolic syndrome (MetS), its components, and loss of renal function, mainly including eGFR decline, new-onset CKD, and ESRD. This meta-analysis was performed to investigate their potential associations.

METHODS

PubMed and EMBASE were systematically searched from their inception to 21 July 2022. Observational cohort studies in English assessing the risk of renal dysfunction in individuals with MetS were identified. Risk estimates and their 95% confidence intervals (CIs) were extracted and pooled using the random-effects approach.

RESULTS

A total of 32 studies with 413,621 participants were included in the meta-analysis. MetS contributed to higher risks of renal dysfunction (RR = 1.50, 95% CI = 1.39-1.61) and, specifically, rapid decline in eGFR (RR 1.31, 95% CI 1.13-1.51), new-onset CKD (RR 1.47, 95% CI 1.37-1.58), as well as ESRD (RR 1.55, 95% CI 1.08-2.22). Moreover, all individual components of MetS were significantly associated with renal dysfunction, while elevated BP conveyed the highest risk (RR = 1.37, 95% CI = 1.29-1.46), impaired fasting glucose with the lowest and diabetic-dependent risk (RR = 1.20, 95% CI = 1.09-1.33).

CONCLUSIONS

Individuals with MetS and its components are at higher risk of renal dysfunction.

Tangled relationship between insulin resistance and microalbuminuria in children with obesity

Childhood obesity represents a complex disease with a well-known cardiometabolic burden including fatty liver, type 2 diabetes, metabolic syndrome, and cardiovascular disease. From a pathogenic point of view, insulin resistance (IR) represents the key factor underlying the spectrum of these obesity consequences. As observed in adults, recent data supported the occurrence of microalbuminuria (MA) as marker of early kidney dysfunction and its potential link with cardiometabolic factors also in children with obesity. In fact, a well-documented pathophysiological hypothesis both in adults and children supported an intimate correlation with the major feature of obesity such as IR through the influence of insulin on renal hemodynamics. Based on the clinical and prognostic relevance of this relationship in daily practice (including an increased risk of chronic kidney disease development overtime), more scientific attention needs to be paid to the evaluation of early kidney damage in children with obesity. In this paper, we attempt to address three debated questions regarding the intriguing liaison between IR and MA in children with obesity: (1) What is the prevalence of pediatric MA? (2) What is the state of art of MA in children with obesity? and (3) Is there a link between IR and MA in children with obesity?

Association between recovery/occurrence of metabolic syndrome and rapid estimated glomerular filtration rate decline in middle-aged and older populations: evidence from the China Health and Retirement Longitudinal Study

OBJECTIVES

Few studies have explored correlations between metabolic syndrome (MetS) alterations and renal deterioration in longitudinal cohorts. We aim to investigate associations between MetS recovery/development and rapid estimated glomerular filtration rate (eGFR) decline in the China Health and Retirement Longitudinal Study (CHARLS).

DESIGN

Longitudinal cohort study.

SETTING

This study is a secondary analysis of CHARLS.

PARTICIPANTS

After excluding individuals with age <45 years old, eGFR <60 mL/min/1.73 m² and clinician-reported malignant tumour, heart disease, stroke or kidney disease at baseline, 4142 participants with complete data were selected from the CHARLS during the 4-year follow-up period (2011-2015).

OUTCOME MEASURES

MetS were measured at 2011 and 2015 in CHARLS. A rapid eGFR decline was defined as an average annual eGFR decline of >3 mL/min/1.73 m². The associations between rapid eGFR decline and MetS recovery/development were analysed using multivariable adjusted logistic models.

RESULTS

According to MetS baseline status and follow-up, participants were divided into four groups: (1) 2460 (59.4%) in the MetS-free group, (2) 361 (8.7%) in the MetS-developed group, (3) 499 (12.0%) in the MetS recovery group and (4) 822 (19.8%) in the MetS chronic group. When compared with the MetS chronic group, the multivariable adjusted OR of rapid eGFR decline in the MetS recovery group was 0.64 (OR: 0.64; 95% CI 0.45 to 0.90, p=0.01). In contrast, when compared with the MetS-free group, the multivariable adjusted OR of rapid eGFR decline in the MetS-developed group was 1.00 (OR: 1.00; 95% CI 0.73 to 1.38, p=0.98).

CONCLUSIONS

Over the 4-year follow-up period, we found that MetS recovery was associated with a reduced risk of rapid eGFR decline in middle-aged and older adults, while MetS occurrence was not related to rapid eGFR decline. Recovery from MetS appeared to protect against a rapid decline in eGFR.

Identification of core genes and pathways between geriatric multimorbidity and renal insufficiency: potential therapeutic agents discovered using bioinformatics analysis

Background

Geriatric people are prone to suffer from multiple chronic diseases, which can directly or indirectly affect renal function. Through bioinformatics analysis, this study aimed to identify key genes and pathways associated with renal insufficiency in patients with geriatric multimorbidity and explore potential drugs against renal insufficiency.

Methods

The text mining tool Pubmed2Ensembl was used to detect genes associated with the keywords including "Geriatric", "Multimorbidity" and "Renal insufficiency". The GeneCodis program was used to specify Gene Ontology (GO) biological process terms and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. Protein–protein interaction (PPI) networks were constructed using STRING and visualized in Cytoscape. Module analysis was performed using CytoHubba and Molecular Complex Detection (MCODE) plugins. GO and KEGG analysis of gene modules was performed using the Database for Annotation, Visualization and Integrated Discover (DAVID) platform database. Genes clustered in salient modules were selected as core genes. Then, the functions and pathways of core genes were visualized using ClueGO and CluePedia. Finally, the drug-gene interaction database was used to explore drug-gene interactions of the core genes to identify drug candidates for renal insufficiency in patients with geriatric multimorbidity.

Results

Through text mining, 351 genes associated with "Geriatric", "Multimorbidity" and "Renal insufficiency" were identified. A PPI network consisting of 216 nodes and 1087 edges was constructed and CytoHubba was used to sequence the genes. Five gene modules were obtained by MCODE analysis. The 26 genes clustered in module1 were selected as core candidate genes primarily associated with renal insufficiency in patients with geriatric multimorbidity. The HIF-1, PI3K-Akt, MAPK, Rap1, and FoxO signaling pathways were enriched. We found that 21 of the 26 selected genes could be targeted by 34 existing drugs.

Conclusion

This study indicated that CST3, SERPINA1, FN1, PF4, IGF1, KNG1, IL6, VEGFA, ALB, TIMP1, TGFB1, HGF, SERPINE1, APOA1, APOB, FGF23, EGF, APOE, VWF, TF, CP, GAS6, APP, IGFBP3, P4HB, and SPP1 were key genes potentially involved with renal insufficiency in patients with geriatric multimorbidity. In addition, 34 drugs were identified as potential agents for the treatment and management of renal insufficiency.

Plasma ST6GAL1 regulates IgG sialylation to control IgA nephropathy progression

Background:

Our previous study revealed that plasma levels of a-2,6-sialyltransferase 1 (ST6GAL1) were increased in patients with IgA nephropathy (IgAN). ST6GAL1 catalyzes terminal sialylation of IgG to shift the antibody effector function to the anti-inflammatory pattern. However, the role of plasma ST6GAL1 in the progression of IgAN and underlying mechanisms are still unknown.

Methods:

A total of 180 IgAN patients were included. The kidney outcomes were defined as the eGFR decline or proteinuria remission. Peripheral blood mononuclear cells (PBMCs) were either stimulated with purified sialylated IgG (SA-IgG) or with non-sialylated IgG (NSA-IgG) from IgAN patients to detect the levels of interleukin (IL)-6 and tumor necrosis factor-α (TNF-α) in supernatant.

Results:

Compared with the lower ST6GAL1 (reference), the risk of eGFR decline decreased for the higher ST6GAL1 group after adjustment for baseline eGFR, systolic blood pressure (SBP), and proteinuria. The results showed that patients with higher ST6GAL1 levels had a higher rate of proteinuria remission. ST6GAL1, expressed as a continuous variable, was a protective factor for eGFR decline and proteinuria remission. An in vitro study showed that the administration of recombinant ST6GAL1 (rST6GAL1) decreased the levels of IL-6 and TNF-α in PBMCs. Furthermore, the administration of rST6GAL1 resulted in the enrichment of SA-IgG in a concentration-dependent manner. In addition, as compared to control, purified SA-IgG-treated PBMCs showed a significant decrease in the expression of IL-6 and TNF-α.

Conclusion:

Our study indicated that elevated ST6GAL1 was associated with a slower progression of IgAN, which may play a protective effect by increasing IgG sialylation to inhibit the production of proinflammatory cytokines in PBMCs.

Denosumab Improves Glomerular Filtration Rate in Osteoporotic Patients With Normal Kidney Function by Lowering Serum Phosphorus

Higher serum phosphorus (Pi) increases the risk for chronic kidney disease (CKD). It was reported that a single administration of denosumab or zoledronate significantly suppressed serum Pi levels as well as those of bone resorption markers in serum. Also, previous evidences suggest a link between bone anti-resorptive therapy and vasoprotective/renoprotective effects through mechanisms that remain unexplored. The aim of this study is to assess the renoprotective effect of denosumab and involvement of denosumab-induced reduction in serum Pi in osteoporotic patients. Osteoporotic patients (n = 73) without overt proteinuria in dipstick test results were treated with denosumab (60 mg) every 6 months during the study period (24 months). Estimated glomerular filtration rate based on serum cystatin C (eGFRcys) was used as a filtration marker and tartrate-resistant acid phosphatase-5b (TRACP-5b) as a bone resorption marker. For analysis of non-CKD patients (n = 56), those with eGFRcys <60 mL/min/1.73 m² were excluded. A single injection of denosumab suppressed serum Pi as well as TRACP-5b during the first 6 months, whereas age-related decline in eGFRcys was significantly reversed, with an increase of 2.75 ± 1.2 mL/min/1.73 m² after 24 months noted. Multivariate analysis showed that serum Pi reduction following the initial denosumab injection was positively associated with serum TRACP-5b suppression during that same period (β = 0.241, p = 0.049). In addition, a positive association of serum Pi suppression, but not of corrected calcium or TRACP-5b, with eGFRcys increase after 24 months (β = 0.321, p = 0.014) was found after adjustments for gender, age, BMI, antihypertensive drug use, albumin, and eGFRcys. The same was observed in osteoporotic cases restricted to non-CKD patients. In conclusion, serum Pi reduction resulting from phosphorus load decrement from bone induced by denosumab is a determinant for eGFRcys increase. Early introduction of bone antiresorptive therapy can retain glomerular filtration in osteoporosis cases, including non-CKD patients. © 2019 American Society for Bone and Mineral Research.

Increased Risk of Chronic Kidney Diseases in Patients with Metabolic Syndrome: A 3-year Prospective Cohort Study

The relationship of metabolic syndrome (MS) and its components with incident chronic kidney disease (CKD) and rapid decline of estimated glomerular filtration rate (eGFR) was investigated. A total of 10 140 patients participating in the epidemiological study (Risk Evaluation of Cancers in Chinese Diabetic Individuals, REACTION) of risk factors of type 2 diabetes in China were followed up for 3 years, with MS being diagnosed by adult treatment panel III (ATPIII) combined with waist circumference in Asian population and renal function being evaluated by eGFR <60 mL·min^-1(1.73 m^2)-1 and rapid decline of eGFR ≤30%. The results showed that as compared with the non-MS group, the adjusted odds ratios (ORs) of CKD and rapid decline of eGFR were 1.64 (OR: 1.64; 95% CI: 1.20-2.25, P<0.05) and 1.23 (OR: 1.23; 95% CI: 1.05-1.43, P<0.05) respectively in MS group. With the increase in the number (0, 1, 2, 3 and ≥4) of MS components, the prevalence of CKD was 1.42%, 1.44%, 2.80%, 3.42%, and 4.03% (P<0.001), respectively. The ORs of incident CKD were 1.67 (OR: 1.67; 95% CI: 1.22-2.27, P<0.05) for high TG, 1.50 (OR: 1.50; 95% CI: 1.10-2.05, P<0.05) for low HDL-C, and 1.39 (OR: 1.39; 95% CI: 1.02-1.91, P<0.05) for hyperglycemia. The risk for developing incident CKD was higher in the group with the highest HOMA-IR than in the group with the lowest HOMA-IR (OR: 1.83; 95% CI: 1.16-2.89, P<0.05). It is suggested that MS is an independent risk factor for incident CKD. The occurrence and development of CKD is closely related to insulin resistance.

Serum Triglycerides Are Related to Chronic Kidney Disease (CKD) Stage 2 in Young and Middle-Aged Chinese Individuals During Routine Health Examination

BACKGROUND The aim of this study was to determine the risk factors for early chronic kidney disease (CKD) (GFR 60-89 ml/min/1.73 m²; CKD stage 2) in asymptomatic Chinese individuals undergoing routine health examination. MATERIAL AND METHODS This cross-sectional study enrolled 9100 individuals who received voluntary medical examinations between 10/01/2011 and 09/30/2017. Demographic data, clinical history, clinical examination, medication, smoking, alcohol, blood biochemistry, urinalysis, and carotid ultrasound were extracted from the medical records. All laboratory analyses were performed routinely. Multivariable logistic regression for factors predicting CKD stage 2 was performed. RESULTS A total of 9100 individuals were enrolled (age of 18-65 and 65.4% male). CKD stage 2 was found in 1989/9100 individuals (21.9%). Male gender (OR=6.711, 95%CI: 5.376-8.403, P<0.001), older age (OR=1.077, 95%CI: 1.068-1.086, P<0.001), hemoglobin levels (OR=1.051, 95%CI: 1.046-1.057, P<0.001), triglycerides levels (OR=1.174, 95%CI: 1.067-1.292, P=0.001), HDL-C (OR=0.539, 95%CI: 0.380-0.763, P<0.001), Lp(a) levels (OR=1.000, 95%CI: 1.000-1.001, P=0.03), and carotid atherosclerosis (OR=1.248, 95%CI: 1.005-1.550, P=0.045) were associated with CKD stage 2 among all subjects. Serum triglycerides levels were associated with CKD stage 2 in the 18-45 and 45-65 years of age subgroups. CONCLUSIONS Factors that are routinely assessed during routine health examinations (male gender, age, hemoglobin levels, triglycerides levels, HDL-C, Lp(a) levels, and carotid atherosclerosis) can help identify individuals at higher risk of having CKD stage 2. The Chinese dyslipidemia is characterized by high triglycerides and low HDL-C and occurs in young and middle-aged individuals. Those factors could help identify individuals at higher risk for CKD stage 2 and who could benefit from preventive treatments.

Frequency and Risk Factors of Kidney Alterations in Children and Adolescents who Are Overweight and Obese in a Primary Health-care Setting

OBJECTIVE

Obesity is clearly associated to kidney disease in adult population; however, there is scarce evidence in children and adolescents. The aim was to compare frequency of renal damage according to the presence of overweight-obesity in children and adolescents, as well as to compare nutritional and biochemical risk factors, according to the presence of kidney alterations.

METHODS

Cross-sectional study; 172 children and adolescents, 6-16 years old, without malnutrition, diabetes mellitus, hypertension and independent comorbid conditions associated to obesity or kidney disease, as well as transitory causes of microalbuminuria (MA) from a Primary Health-Care Unit were included. Clinical, biochemical, anthropometric and dietetic evaluations were measured in all subjects; subsequently they were classified as normal weight, overweight and obesity groups according to sex- and age-adjusted body mass index (BMI). Glomerular filtration rate (GFR, estimated by Schwartz equation) and albuminuria (albumin/creatinine ratio) were determined. Presence of kidney alterations was measured as decreased GFR (<90 mL/min/1.73m²), hyperfiltration (>170 mL/min/1.73m²) and MA (30-300 mg/g).

RESULTS

Compared with controls, subjects with overweight-obesity had significantly (P<.05) abdominal obesity (0 vs 69%), hypertension (19 vs 26%), hypertriglyceridemia (11 vs 47%), high low-density lipoprotein cholesterol (2 vs 8%) and low high-density lipoprotein cholesterol (HDL-cholesterol; 2 vs 28%), hyperuricemia (11 vs 28%) and hyperinsulinemia (8 vs 70%). Hyperfiltration and MA were present in 5 and 4 subjects with overweight/obesity, respectively, whereas decreased GFR was present in only 1 subject with obesity. Normal weight subjects had no kidney alterations. In multivariate analysis, kidney alterations were significantly predicted by higher BMI and lower HDL-cholesterol.

CONCLUSIONS

Kidney alterations were observed only in subjects with overweight (3.6%) and obesity (9.9%), who additionally, displayed cardiometabolic and kidney disease risk factors more frequently than normal weight subjects.

Rationale and Descriptive Analysis of Specific Health Guidance: the Nationwide Lifestyle Intervention Program Targeting Metabolic Syndrome in Japan

AIM

All health insurers in Japan are mandated to provide Specific Health Checkups and Specific Health Guidance (SHG) focusing on metabolic syndrome (MetS) in middle-aged adults, beginning in 2008; intensive HG for individuals who have abdominal obesity and two or more additional MetS risk factors, and motivational HG for individuals with one risk factor. The aim of this study is to describe medium-term changes in health indexes for intensive and motivational HG groups using the National Database.

METHODS

We compared changes of risk factors and initiation of pharmacological therapy over 3 yr between participants (n=31,790) and nonparticipants (n=189,726) who were eligible for SHG in 2008.

RESULTS

Body weight reduction in intensive HG was 1.98 kg (participants) vs 0.42 kg (nonparticipants) in men (p＜0.01) and 2.25 vs 0.68 kg in women (p＜0.01) after 1 yr. In motivational HG, the respective reduction was 1.40 vs 0.30 kg in men (p＜0.01) and 1.53 vs 0.42 kg in women (p＜0.01). Waist circumference reduction was also greatest among participants in intensive HG (2.34 cm in men and 2.98 cm in women). These reductions were fairly unchanged over 3 yr and accompanied greater improvements in MetS risk factors in participants. We also detected significantly smaller percentages of SHG participants who initiated pharmacological therapy compared with nonparticipants.

CONCLUSION

Participants in SHG showed greater improvements in MetS profiles with proportionally smaller pharmacological treatment initiations than did nonparticipants for 3 yr. Although selection bias may be present, this study suggests SHG would be a feasible strategy to prevent MetS and its sequelae.

HDL in CKD-The Devil Is in the Detail

The picture of HDL cholesterol (HDL-C) as the "good" cholesterol has eroded. This is even more surprising because there exists strong evidence that HDL-C is associated with cardiovascular disease (CVD) in the general population as well as in patients with impairment of kidney function and/or progression of CKD. However, drugs that dramatically increase HDL-C have mostly failed to decrease CVD events. Furthermore, genetic studies took the same line, as genetic variants that have a pronounced influence on HDL-C concentrations did not show an association with cardiovascular risk. For many, this was not surprising, given that an HDL particle is highly complex and carries >80 proteins and several hundred lipid species. Simply measuring cholesterol might not reflect the variety of biologic effects of heterogeneous HDL particles. Therefore, functional studies and the involvement of HDL components in the reverse cholesterol transport, including the cholesterol efflux capacity, have become a further focus of study during recent years. As also observed for other aspects, CKD populations behave differently compared with non-CKD populations. Although clear disturbances have been observed for the "functionality" of HDL particles in patients with CKD, this did not necessarily translate into clear-cut associations with outcomes.