Increased Proteinuria is Associated with Increased Aortic Arch Calcification, Cardio-Thoracic Ratio, Rapid Renal Progression and Increased Overall and Cardiovascular Mortality in Chronic Kidney Disease

Nonlinear association between proteinuria levels and the risk of cardiovascular disease events and all-cause mortality among chronic kidney disease patients

BACKGROUND

The association between proteinuria levels and cardiovascular disease (CVD) development and all-cause mortality in chronic kidney disease (CKD) patients remains controversial.

METHODS

In this investigation, we conducted a retrospective analysis involving 1138 patients who were registered in the CKD-Research of Outcomes in Treatment and Epidemiology (ROUTE) study. The primary outcome of this study was the composite of cardiovascular events or all-cause death. Cox proportional hazards regression, smooth curve fitting, piecewise linear regression, and subgroup analyses were used.

RESULTS

The mean age of the included individuals was 67.3 ± 13.6 years old. Adjusted hazard ratios (HRs) for UPCR in middle and high groups, compared to the low group, were 1.93 (95% CI: 1.28-2.91) and 4.12 (95% CI: 2.87-5.92), respectively, after multivariable adjustment. Further adjustments maintained significant associations; HRs for middle and high groups were 1.71 (95% CI: 1.12-2.61) and 3.07 (95% CI: 2.08-4.54). A nonlinear UPCR-primary outcome relationship was observed, with an inflection point at 3.93 g/gCr.

CONCLUSION

Among non-dialyzed patients with stage G2-G5 CKD, a nonlinear association between UPCR and the primary outcome was observed. A higher UPCR (when UPCR < 3.93 g/gCr) was an independent predictor of the primary outcome. Importantly, our study predates SGLT2 inhibitor use, showcasing outcomes achievable without these medications. Future research considerations will involve factors like SGLT-2 inhibitor utilization.

Yi-Shen-Hua-Shi regulates intestinal microbiota dysbiosis and protects against proteinuria in patients with chronic kidney disease: a randomized controlled study

CONTEXT

Yi-Shen-Hua-Shi (YSHS) is a traditional Chinese medicine that treats chronic kidney disease (CKD). However, its efficacy in reducing proteinuria and underlying mechanisms is unknown.

OBJECTIVE

This single-center randomized controlled trial explored whether YSHS could improve proteinuria and modulate the gut microbiota.

MATERIALS AND METHODS

120 CKD patients were enrolled and randomized to receive the renin-angiotensin-aldosterone system (RAAS) inhibitor plus YSHS (n = 56) or RAAS inhibitor (n = 47) alone for 4 months, and 103 patients completed the study. We collected baseline and follow-up fecal samples and clinical outcomes from participants. Total bacterial DNA was extracted, and the fecal microbiome was analyzed using bioinformatics.

RESULTS

Patients in the intervention group had a significantly higher decrease in 24-h proteinuria. After 4 months of the YSHS intervention, the relative abundance of bacteria that have beneficial effects on the body, such as Faecalibacterium, Lachnospiraceae, Lachnoclostridium, and Sutterella increased significantly, while pathogenic bacteria such as the Eggerthella and Clostridium innocuum group decreased. However, we could not find these changes in the control group. Redundancy analysis showed that the decline in 24-h proteinuria during follow-up was significantly correlated with various taxa of gut bacteria, such as Lachnospiraceae and the Lachnoclostridium genus in the YSHS group. KEGG analysis also showed the potential role of YSHS in regulating glycan, lipid, and vitamin metabolism.

DISCUSSION AND CONCLUSION

The YSHS granule reduced proteinuria associated with mitigating intestinal microbiota dysbiosis in CKD patients. The definite mechanisms of YSHS to improve proteinuria need to be further explored.

TRIAL REGISTRATION

ChiCTR2300076136, retrospectively registered.

The impact of accessibility to non-calcium-based phosphate binders and calcimimetics on mineral outcomes in patients receiving maintenance hemodialysis: A 10-year retrospective analysis of real-world data

INTRODUCTION

Hyperphosphatemia and hyperparathyroidism are common in end-stage kidney disease and are associated with poor outcomes. In addition to adequate dialysis, medications are usually required for optimum control of serum phosphate and parathyroid hormone (PTH) levels. The use of calcium-based phosphate binders (CBPBs) and active vitamin D is associated with an increase in serum calcium and worsening vascular calcification. To overcome these limitations, non-calcium-based phosphate binders (NCBPBs) and calcimimetics have been developed. However, the coverage for these new medications remains limited in several parts of the world due to the lack of patient-level outcome data and cost. The present study examined the differences in mineral outcomes between two main categories of healthcare programs that provided different coverage for medications used to control mineral and bone disorders (MBD). The Social Security/Universal Coverage (SS/UC) program covered only CBPBs and active vitamin D, whereas the Civil Servant/State Enterprise (CS/SE) program provided coverage of CBPBs, active vitamin D, NCBPBs, and calcimimetics.

METHODS

This 10-year retrospective cohort study examined the differences in mineral outcomes between two healthcare programs in maintenance hemodialysis patients. The differences in serum calcium, phosphate, and PTH levels, as well as the aortic arch calcification score, were analyzed according to dialysis vintage by linear mixed-effects regression analyses. The difference in the composite outcome of severe hyperparathyroidism and parathyroidectomy was analyzed by the Cox-proportional hazard regression model.

RESULTS

714 patients were included in the analyses (full cohort). Of these patients, 563 required at least one type of medication to control MBD (MBD medication subgroup). Serum calcium, phosphate, and the proportions of patients with hypercalcemia and hyperphosphatemia were substantially higher in the SS/UC group compared with the CS/SE group after appropriate adjustments for confounders in both the full cohort and the MBD medication subgroup. These findings were confirmed in propensity-score matched analyses. Higher parathyroid hormone levels and a higher rate of the composite endpoint of severe hyperparathyroidism and parathyroidectomy were also observed in the SS/UC group. A more rapid progression of aortic arch calcification was suggested in the SS/UC group, but between-group changes were not significant.

CONCLUSION

Patients under the healthcare program that did not cover the use of NCBPBs and calcimimetics showed higher serum calcium and phosphate levels and a more rapid progression of hyperparathyroidism. The difference in the progression of vascular calcification could not be confirmed in the present study.

Albuminuria: An Underappreciated Risk Factor for Cardiovascular Disease

Albuminuria, an established biomarker of the progression of chronic kidney disease, is also recognized as a biomarker for the risk of cardiovascular disease. Elevated urinary albumin excretion indicates kidney damage and systemic vascular disease, including myocardial capillary disease and arterial stiffness. Albuminuria is associated with an increased risk of coronary artery disease, stroke, heart failure, arrhythmias, and microvascular disease. There are now several therapeutic agents that can lead to albuminuria lowering and a reduction in cardiovascular risk. However, screening for albuminuria is still low. Considering the importance of multidisciplinary management of patients with cardiovascular disease, it is crucial that health care professionals managing such patients are aware of the benefits of albuminuria surveillance and management.

Parathyroidectomy is associated with slow progression of vascular calcification in maintenance haemodialysis patients: A propensity score-matched case-control study

Parathyroidectomy has been the mainstay of treatment of severe hyperparathyroidism in patients with kidney failure until the introduction of calcimimetic. Several large observational studies demonstrated the improvement in patient outcomes after parathyroidectomy. The benefit of parathyroidectomy on vascular calcification remains largely unexplored.

AIM

To examine the association between parathyroidectomy and the progression of vascular calcification as well as overall survival in maintenance haemodialysis patients.

METHOD

This is a matched case-control study undertaken between 2012 and 2020. Patients who underwent parathyroidectomy were identified and matched 1:1 to non-parathyroidectomized (non-PTX) haemodialysis patients using propensity score matching method resulting in 120 patients in each arm. Aortic arch calcification (AoAC) score was determined annually in the posteroanterior chest x-ray. The average follow-up period was 38 months.

RESULTS

Baseline demographic, laboratory data and AoAC score were comparable among the two groups of patients. The prevalence of AoAC was 59% in the PTX group and 54% in the non-PTX group (p = .43). Progression of AoAC occurred in 33% in the PTX group and 47% in the non-PTX group (p = .04). Multivariate generalized linear model revealed parathyroidectomy as an independent protective factor [β (95% CI) -1.04 (-1.68, -0.41)] and increased serum calcium as a potentiating factor [β (95% CI) 0.62 (0.25, 0.1)] for progression of AoAC. Linear mixed models revealed an increase in AoAC score in both groups but between group comparisons indicated substantially slower progression in the PTX group. Rapid progression of AoAC was also observed more frequently among non-PTX patients. Death occurred in 7 and 16% in the PTX and non-PTX groups, respectively. Kaplan-Meier survival curve revealed better survival associated with parathyroidectomy (p = .01). More rapid progression of AoAC also correlated with worse survival.

CONCLUSION

Parathyroidectomy was associated with slow progression of vascular calcification in maintenance haemodialysis patients.

Low Albumin, Low Bilirubin, and High Alfa-Fetoprotein Are Associated with a Rapid Renal Function Decline in a Large Population Follow-Up Study

A rapid decline in renal function is associated with high cardiovascular morbidity and mortality, and therefore it is important to identify those at high-risk of rapid renal function decline. The relationship between liver function and renal function is unclear. Therefore, in this longitudinal study, we aimed to investigate associations between liver function and rapid renal function decline. A total of 27,116 participants were enrolled from the Taiwan Biobank and followed for 3.8 years. A rapid decline in renal function was defined as a decline in estimated glomerular filtration rate (eGFR) of ≥25%. Binary logistic regression analysis was used to identify associations between liver function parameters (glutamic-oxalacetic transaminase, glutamic-pyruvic transaminase, albumin, α-fetoprotein [AFP], total bilirubin, and gamma-glutamyl transpeptidase) and eGFR decline ≥ 25%. The rate of eGFR decline of ≥25% was 4.7%. Multivariable analysis showed that low albumin (odds ratio [OR], 0.173; p < 0.001), high AFP (OR, 1.006; p = 0.010), and low total bilirubin (OR, 0.588; p < 0.001) were significantly associated with eGFR decline ≥ 25% in all study participants. After excluding abnormal liver function, low albumin (OR, 0.189; p < 0.001), high AFP (OR, 1.007; p = 0.011), and low total bilirubin (OR, 0.569; p = 0.001) were still significantly associated with an eGFR decline of ≥25%. The results of this large population-based cohort study showed associations between low albumin, low bilirubin, and high AFP with a rapid renal function decline. A greater understanding of potential risk factors for a rapid decline in renal function may help to reduce the burden of renal failure in this high-risk population.

Contribution of Gut Microbiota-Derived Uremic Toxins to the Cardiovascular System Mineralization

Chronic kidney disease (CKD) affects more than 10% of the world population and leads to excess morbidity and mortality (with cardiovascular disease as a leading cause of death). Vascular calcification (VC) is a phenomenon of disseminated deposition of mineral content within the media layer of arteries preceded by phenotypic changes in vascular smooth muscle cells (VSMC) and/or accumulation of mineral content within the atherosclerotic lesions. Medial VC results in vascular stiffness and significantly contributes to increased cardio-vascular (CV) morbidity, whereas VC of plaques may rather increase their stability. Mineral and bone disorders of CKD (CKD-MBD) contribute to VC, which is further aggravated by accumulation of uremic toxins. Both CKD-MBD and uremic toxin accumulation affect not only patients with advanced CKD (glomerular filtration rate (GFR) less than 15 mL/min/1.72 m², end-stage kidney disease) but also those on earlier stages of a disease. The key uremic toxins that contribute to VC, i.e., p-cresyl sulphate (PCS), indoxyl sulphate (IS) and trimethylamine-N-oxide (TMAO) originate from bacterial metabolism of gut microbiota. All mentioned toxins promote VC by several mechanisms, including: Transdifferentiation and apoptosis of VSMC, dysfunction of endothelial cells, oxidative stress, interaction with local renin–angiotensin–aldosterone system or miRNA profile modification. Several attractive methods of gut microbiota manipulations have been proposed in order to modify their metabolism and to limit vascular damage (and VC) triggered by uremic toxins. Unfortunately, to date no such method was demonstrated to be effective at the level of “hard” patient-oriented or even clinically relevant surrogate endpoints.