1
|
Canney M, Induruwage D, Tang M, Alencar de Pinho N, Er L, Zhao Y, Djurdjev O, Ahn YH, Behnisch R, Calice-Silva V, Chesnaye NC, de Borst MH, Dember LM, Dionne J, Ebert N, Eder S, Fenton A, Fukagawa M, Furth SL, Hoy WE, Imaizumi T, Jager KJ, Jha V, Kang HG, Kitiyakara C, Mayer G, Oh KH, Onu U, Pecoits-Filho R, Reichel H, Richards A, Schaefer F, Schaeffner E, Scheppach JB, Sola L, Ulasi I, Wang J, Yadav AK, Zhang J, Feldman HI, Taal MW, Stengel B, Levin A. Regional Variation in Hemoglobin Distribution Among Individuals With CKD: the ISN International Network of CKD Cohorts. Kidney Int Rep 2023; 8:2056-2067. [PMID: 37850014 PMCID: PMC10577366 DOI: 10.1016/j.ekir.2023.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/31/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction Despite recognized geographic and sex-based differences in hemoglobin in the general population, these factors are typically ignored in patients with chronic kidney disease (CKD) in whom a single therapeutic range for hemoglobin is recommended. We sought to compare the distribution of hemoglobin across international nondialysis CKD populations and evaluate predictors of hemoglobin. Methods In this cross-sectional study, hemoglobin distribution was evaluated in each cohort overall and stratified by sex and estimated glomerular filtration rate (eGFR). Relationships between candidate predictors and hemoglobin were assessed from linear regression models in each cohort. Estimates were subsequently pooled in a random effects model. Results A total of 58,613 participants from 21 adult cohorts (median eGFR range of 17-49 ml/min) and 3 pediatric cohorts (median eGFR range of 26-45 ml/min) were included with broad geographic representation. Hemoglobin values varied substantially among the cohorts, overall and within eGFR categories, with particularly low mean hemoglobin observed in women from Asian and African cohorts. Across the eGFR range, women had a lower hemoglobin compared to men, even at an eGFR of 15 ml/min (mean difference 5.3 g/l, 95% confidence interval [CI] 3.7-6.9). Lower eGFR, female sex, older age, lower body mass index, and diabetic kidney disease were all independent predictors of a lower hemoglobin value; however, this only explained a minority of variance (R2 7%-44% across cohorts). Conclusion There are substantial regional differences in hemoglobin distribution among individuals with CKD, and the majority of variance is unexplained by demographics, eGFR, or comorbidities. These findings call for a renewed interest in improving our understanding of hemoglobin determinants in specific CKD populations.
Collapse
Affiliation(s)
- Mark Canney
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ontario, Canada
| | | | - Mila Tang
- Division of Nephrology, Department of Pediatrics, University of British Columbia, Canada
| | | | - Lee Er
- Methodology and Analytics, BC Renal, Vancouver, British Columbia, Canada
| | - Yinshan Zhao
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ognjenka Djurdjev
- Methodology and Analytics, BC Renal, Vancouver, British Columbia, Canada
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Rouven Behnisch
- Institute of Medical Biometry, University Hospital Heidelberg, Germany
| | - Viviane Calice-Silva
- Research Department, Pro-rim Foundation, Joinville-SC, Brazil
- School of Medicine, UNIVILLE, Joinville-SC, Brazil
| | - Nicholas C. Chesnaye
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
- ERA Registry, Amsterdam UMC Location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
| | - Martin H. de Borst
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Laura M. Dember
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Janis Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia, Canada
| | - Natalie Ebert
- Institute of Public Health, Charité Universitätsmedizin Berlin, Germany
| | - Susanne Eder
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria
| | - Anthony Fenton
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Susan L. Furth
- Division of Nephrology, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wendy E. Hoy
- University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Anatomy and Cell Biology, Monash University, Clayton, Victoria, Australia
- Centre for Chronic Disease, University of Queensland, Brisbane, Queensland, Australia
| | - Takahiro Imaizumi
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan. Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Kitty J. Jager
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
- ERA Registry, Amsterdam UMC Location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Chagriya Kitiyakara
- Departments of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University, Seoul, South Korea
| | - Ugochi Onu
- Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Roberto Pecoits-Filho
- DOPPS Program Area, Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
- School of Medicine, Pontifica Universidade Catolica do Parana, Curitiba, Brazil
| | | | - Anna Richards
- Value Evidence and Outcomes, GSK, Brentford, Middlesex, UK
| | - Franz Schaefer
- Pediatric Nephrology Division, University Children's Hospital, Heidelberg, Germany
| | - Elke Schaeffner
- Institute of Public Health, Charité Universitätsmedizin Berlin, Germany
| | | | - Laura Sola
- Hemodialysis Unit, CASMU-IAMPP, Montevideo, Uruguay
| | - Ifeoma Ulasi
- Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
- Renal Unit, Department of Medicine, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
| | - Jinwei Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Peking University Institute of Nephrology, Peking University Health Science Center, Beijing, China
| | - Ashok K. Yadav
- Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jianzhen Zhang
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Harold I. Feldman
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Maarten W. Taal
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, University of Nottingham School of Medicine, Nottingham, UK
| | - Bénédicte Stengel
- CESP, University Paris-Saclay, UVSQ, Inserm, Clinical Epidemiology Team, Villejuif, France
| | - Adeera Levin
- Division of Nephrology, Department of Pediatrics, University of British Columbia, Canada
| |
Collapse
|
2
|
Scheppach JB, Wu A, Gottesman RF, Mosley TH, Arsiwala-Scheppach LT, Knopman DS, Grams ME, Sharrett AR, Coresh J, Koton S. Association of Kidney Function Measures With Signs of Neurodegeneration and Small Vessel Disease on Brain Magnetic Resonance Imaging: The Atherosclerosis Risk in Communities (ARIC) Study. Am J Kidney Dis 2023; 81:261-269.e1. [PMID: 36179945 PMCID: PMC9974563 DOI: 10.1053/j.ajkd.2022.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/21/2022] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Chronic kidney disease (CKD) is a risk factor for cognitive decline, but evidence is limited on its etiology and morphological manifestation in the brain. We evaluated the association of estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (UACR) with structural brain abnormalities visible on magnetic resonance imaging (MRI). We also assessed whether this association was altered when different filtration markers were used to estimate GFR. STUDY DESIGN Cross-sectional study nested in a cohort study. SETTING & PARTICIPANTS 1,527 participants in the Atherosclerosis Risk in Communities (ARIC) Study. PREDICTORS Log(UACR) and eGFR based on cystatin C, creatinine, cystatin C and creatinine in combination, or β2-microglobulin (B2M). OUTCOMES Brain volume reduction, infarcts, microhemorrhages, white matter lesions. ANALYTICAL APPROACH Multivariable linear and logistic regression models fit separately for each predictor based on a 1-IQR difference in the predictor value. RESULTS Each 1-IQR lower eGFR was associated with reduced cortex volume (regression coefficient: -0.07 [95% CI, -0.12 to-0.02]), greater white matter hyperintensity volume (logarithmically transformed; regression coefficient: 0.07 [95% CI, 0.01-0.15]), and lower white matter fractional anisotropy (regression coefficient: -0.08 [95% CI, -0.17 to-0.01]). The results were similar when eGFR was estimated with different equations based on cystatin C, creatinine, a combination of cystatin C and creatinine, or B2M. Higher log(UACR) was similarly associated with these outcomes as well as brain infarcts and microhemorrhages (odds ratios per 1-IQR-fold greater UACR of 1.31 [95% CI, 1.13-1.52] and 1.30 [95% CI, 1.12-1.51], respectively). The degree to which brain volume was lower in regions usually susceptible to Alzheimer disease and LATE (limbic-predominant age-related TDP-43 [Tar DNA binding protein 43] encephalopathy) was similar to that seen in the rest of the cortex. LIMITATIONS No inference about longitudinal effects due to cross-sectional design. CONCLUSIONS We found eGFR and UACR are associated with structural brain damage across different domains of etiology, and eGFR- and UACR-related brain atrophy is not selective for regions typically affected by Alzheimer disease and LATE. Hence, Alzheimer disease or LATE may not be leading contributors to neurodegeneration associated with CKD.
Collapse
Affiliation(s)
- Johannes B Scheppach
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Aozhou Wu
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Rebecca F Gottesman
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Current affiliation: National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, Maryland
| | - Thomas H Mosley
- The MIND Center, University of Mississippi Medical Center, Jackson, Mississippi
| | | | | | - Morgan E Grams
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - A Richey Sharrett
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Josef Coresh
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Silvia Koton
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| |
Collapse
|
3
|
Tung S, Kendrick J, Surapaneni A, Scheppach JB, Coresh J, Gottesman R, Sharrett AR, Daya N, Grams ME. Association Between Acute Kidney Injury and Dementia in the Atherosclerosis Risk in Communities (ARIC) Study. Am J Kidney Dis 2022; 80:495-501. [PMID: 35390426 PMCID: PMC9509404 DOI: 10.1053/j.ajkd.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 02/05/2022] [Indexed: 02/02/2023]
Abstract
RATIONALE & OBJECTIVE Acute kidney injury (AKI) causes biochemical changes in the brain in animal models and is associated with adverse neurological complications in hospitalized patients. This study tested the association between AKI and incident dementia in a community-based cohort. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Adult participants in the Atherosclerosis Risk in Communities (ARIC) study who experienced hospitalized AKI compared with participants hospitalized for other reasons (primary analysis, mean follow-up period 4.3 years) or participants without hospitalized AKI (secondary analysis). PREDICTORS Incident AKI, defined by ICD codes from hospital records. OUTCOME Incident dementia, diagnosed based on a combination of neurocognitive testing, informant interviews, ICD codes, and death certificates. ANALYTICAL APPROACH In the primary analysis, we estimated the propensity for hospitalized AKI and matched these participants with those hospitalized for another reason to examine the association of AKI with subsequent onset of dementia (N = 1,708). In the secondary analysis, we estimated the association between time-varying hospitalized AKI and subsequent onset of dementia using multivariable Cox proportional hazards regression models, adjusted for age, sex, race/center, education, smoking status, body mass index, baseline estimated glomerular filtration rate, baseline urinary albumin-creatinine ratio, systolic blood pressure, coronary heart disease, diabetes, hypertension, apolipoprotein E (APOE) ε4 allele, and C-reactive protein. RESULTS The mean age in the propensity-matched cohort was 76.1 ± 6.5 (SD) years, and 53.2% of the participants were women. People who were hospitalized with AKI had a higher risk of dementia (HR, 1.25 [95% CI, 1.02-1.52]; P = 0.03) compared with those without a hospitalization for AKI. The associations were slightly stronger in the time-varying analysis (HR, 1.69 [95% CI, 1.48-1.92]; P < 0.001). Other risk factors for dementia included older age, male sex, higher albuminuria, diabetes, current smoker status, and presence of the APOE risk alleles. LIMITATIONS Observational study, with AKI identified through diagnosis codes. CONCLUSIONS Participants who experienced a hospitalization for AKI were at increased risk of dementia.
Collapse
Affiliation(s)
- Sarah Tung
- Whiting School of Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado
| | - Aditya Surapaneni
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Johannes B Scheppach
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Josef Coresh
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca Gottesman
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - A Richey Sharrett
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Natalie Daya
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Morgan E Grams
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| |
Collapse
|
4
|
Scheppach JB, Coresh J, Wu A, Gottesman RF, Mosley TH, Knopman DS, Grams ME, Sharrett AR, Koton S. Albuminuria and Estimated GFR as Risk Factors for Dementia in Midlife and Older Age: Findings From the ARIC Study. Am J Kidney Dis 2020; 76:775-783. [PMID: 32428540 PMCID: PMC7669634 DOI: 10.1053/j.ajkd.2020.03.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 03/08/2020] [Indexed: 01/22/2023]
Abstract
RATIONALE & OBJECTIVE Evidence is limited on how estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (UACR) relate to dementia at different ages. We evaluated eGFR and UACR in midlife and older age as risk factors for dementia. Additionally, we assessed whether the association between eGFR and dementia is altered when cystatin C and β2-microglobulin (B2M) levels are used for GFR estimation. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Two baselines from the Atherosclerosis Risk in Communities (ARIC) Study were used: visit 4 (1996-1998), including 9,967 participants 54 to 74 years old, and visit 5 (2011-2013), including 4,626 participants 70 to 90 years old. Participants were followed up until 2017. PREDICTORS Log(UACR); eGFR based on creatinine, cystatin C, creatinine and cystatin C, or B2M levels (denoted as eGFRcr, eGFRcys, eGFRcr-cys, and eGFRB2M). OUTCOME Incident dementia. ANALYTICAL APPROACH Multivariable Cox proportional hazards regression models fit separately for each of the 5 predictors and based on a change in the predictor equivalent to the interquartile range for that predictor at visit 4 (IQRV4). eGFR models were adjusted for log(UACR) and log(UACR) models were adjusted for eGFRcys. RESULTS We observed 1,821 dementia cases after visit 4 and 438 cases after visit 5. Dementia risk increased with higher albuminuria levels (HRs per IQRV4 [equivalent to 4.2-fold greater log albuminuria] of 1.15 [95% CI, 1.09-1.21] after visit 4 and 1.27 [95% CI, 1.13-1.42] after visit 5). An association with lower eGFR was seen for only eGFRcys (HRs per IQRV4 [equivalent to 24.3mL/min/1.73m2 lesser eGFRcys] of 1.12 [95% CI, 1.04-1.21] after visit 4 and 1.30 [95% CI, 1.12-1.52] after visit 5) and eGFRB2M (HRs per IQRV4 [equivalent to 18.3mL/min/1.73m2 lesser eGFRB2M] of 1.15 [95% CI, 1.07-1.23] after visit 4 and 1.34 [95% CI, 1.17-1.55] after visit 5). Differences between these associations in midlife and older age were not statistically significant. LIMITATIONS Changes in potentially time-varying covariates were not measured. Dementia was not subclassified by cause. CONCLUSIONS Albuminuria was consistently associated with dementia incidence. Lower eGFR based on cystatin C or B2M, but not creatinine, levels was also associated with dementia. Risk associations were similar when kidney measures were assessed at midlife and older age.
Collapse
Affiliation(s)
- Johannes B Scheppach
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Josef Coresh
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Aozhou Wu
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Rebecca F Gottesman
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Thomas H Mosley
- The MIND Center, University of Mississippi Medical Center, Jackson, MS
| | | | - Morgan E Grams
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Richey Sharrett
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Silvia Koton
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| |
Collapse
|
5
|
Scheppach JB, Raff U, Toncar S, Ritter C, Klink T, Störk S, Wanner C, Schlieper G, Saritas T, Reinartz SD, Floege J, Janka R, Uder M, Schmieder RE, Eckardt KU, Schneider MP. Blood Pressure Pattern and Target Organ Damage in Patients With Chronic Kidney Disease. Hypertension 2019; 72:929-936. [PMID: 30354716 DOI: 10.1161/hypertensionaha.118.11608] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In patients with chronic kidney disease, data on blood pressure (BP) pattern and its association with target organ damage, which indicates elevated cardiovascular risk, are sparse. In 305 treated hypertensive chronic kidney disease patients, we assessed BP pattern, left ventricular mass (magnetic resonance imaging), intima-media thickness (ultrasound), 24-hour-pulse wave velocity and 24-hour-central augmentation index (Mobil-O-Graph). Controlled hypertension (normal office and ambulatory BP) was found in 41% and sustained uncontrolled hypertension (elevated office and ambulatory BP) in 30% of patients. Misclassification of BP status occurred in 29%: white coat uncontrolled hypertension (elevated office but normal ambulatory BP) was detected in 11% and masked uncontrolled hypertension (normal office but elevated ambulatory BP) in 18% of patients. Left ventricular mass was increased in white coat uncontrolled hypertension (+11.2 g), masked uncontrolled hypertension (+9.4 g), and sustained uncontrolled hypertension (+16.6 g) compared with controlled hypertension. Intima-media thickness was similar across all 4 BP groups. Twenty-four hour-pulse wave velocity and 24-hour-central augmentation index were increased in masked uncontrolled hypertension (+0.5 m/sec and +2.5%) and sustained uncontrolled hypertension (+0.5 m/sec and +2.9%) compared with controlled hypertension. In conclusion, based on office BP measurements, misclassification of true BP status occurred in almost one-third of chronic kidney disease patients. Both types of misclassification (white coat uncontrolled hypertension and masked uncontrolled hypertension) were associated with parameters of target organ damage. Ambulatory BP monitoring should be used routinely to identify chronic kidney disease patients at high cardiovascular risk.
Collapse
Affiliation(s)
- Johannes B Scheppach
- From the Department of Nephrology and Hypertension (J.B.S., U.R., R.E.S., K.-U.E., M.P.S.), Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany
| | - Ulrike Raff
- From the Department of Nephrology and Hypertension (J.B.S., U.R., R.E.S., K.-U.E., M.P.S.), Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany
| | - Sebastian Toncar
- Division of Nephrology, Department of Medicine, University of Würzburg, Germany (S.T., C.W.)
| | - Christian Ritter
- Department of Diagnostic and Interventional Radiology, University Medicine Göttingen, Germany (C.R.)
| | - Thorsten Klink
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Germany (T.K.)
| | - Stefan Störk
- Comprehensive Heart Failure Center, University of Würzburg and Department of Medicine I, Cardiology, University Hospital Würzburg, Germany (S.S.)
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University of Würzburg, Germany (S.T., C.W.)
| | - Georg Schlieper
- Division of Nephrology and Clinical Immunology (G.S., T.S., J.F.), University Hospital RWTH Aachen, Germany
| | - Turgay Saritas
- Division of Nephrology and Clinical Immunology (G.S., T.S., J.F.), University Hospital RWTH Aachen, Germany
| | - Sebastian D Reinartz
- Department of Diagnostic and Interventional Radiology (S.D.R.), University Hospital RWTH Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology (G.S., T.S., J.F.), University Hospital RWTH Aachen, Germany
| | - Rolf Janka
- Department of Radiology (R.J., M.U.), Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany
| | - Michael Uder
- Department of Radiology (R.J., M.U.), Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany
| | - Roland E Schmieder
- From the Department of Nephrology and Hypertension (J.B.S., U.R., R.E.S., K.-U.E., M.P.S.), Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany
| | - Kai-Uwe Eckardt
- From the Department of Nephrology and Hypertension (J.B.S., U.R., R.E.S., K.-U.E., M.P.S.), Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany.,Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Germany (K.-U.E.)
| | - Markus P Schneider
- From the Department of Nephrology and Hypertension (J.B.S., U.R., R.E.S., K.-U.E., M.P.S.), Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany.,Department of Nephrology and Hypertension, Klinikum Nürnberg, Paracelsus Private Medical University, Germany (M.P.S.)
| |
Collapse
|
6
|
Schneider MP, Scheppach JB, Raff U, Toncar S, Ritter C, Klink T, Störk S, Wanner C, Schlieper G, Saritas T, Reinartz SD, Floege J, Friedrich N, Janka R, Uder M, Schmieder RE, Eckardt KU. Left Ventricular Structure in Patients With Mild-to-Moderate CKD-a Magnetic Resonance Imaging Study. Kidney Int Rep 2018; 4:267-274. [PMID: 30775623 PMCID: PMC6365352 DOI: 10.1016/j.ekir.2018.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/23/2018] [Accepted: 10/02/2018] [Indexed: 01/19/2023] Open
Abstract
Introduction The high burden of left ventricular (LV) abnormalities in patients with advanced chronic kidney disease (CKD) is well established. However, less is known about the prevalence, patterns, and determinants of LV abnormalities in patients with early CKD. Methods We examined LV structure in 290 patients with a median estimated glomerular filtration rate (eGFR) of 51 ml/min per 1.73 m2 by magnetic resonance imaging (MRI). We explored associations with clinical and hemodynamic parameters, hydration (bioimpedance), endothelial function, inflammation (including C-reactive protein and tumor necrosis factor−α and its soluble receptors) and mineral bone disease (MBD) markers (including vitamin D, parathyroid hormone, α-klotho and fibroblast growth factor−23). Results Normal geometry was found in 56% of patients, dilation in 4%, concentric remodeling in 10%, and LV hypertrophy in 29%. Linear regression analysis revealed that greater LV mass was independently associated with male sex, greater body mass index (BMI), and higher 24-hour systolic blood pressure (24-hour SBP). Concentric remodeling was independently associated with age, male sex, higher 24-hour SBP, and greater hemoglobin levels. Surprisingly, neither hydration status, nor endothelial function, nor any of the inflammatory or MBD parameters added significantly to these models. Conclusion Abnormal LV structure was found in almost one-half of the patients. Reducing BMI and 24-hour SBP and avoiding high hemoglobin concentrations appear to be the key factors to prevent abnormal LV remodeling in patients with mild-to-moderate CKD.
Collapse
Affiliation(s)
- Markus P Schneider
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Nephrology and Hypertension, Klinikum Nürnberg, Paracelsus Medical University, Nürnberg, Germany
| | - Johannes B Scheppach
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ulrike Raff
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian Toncar
- Division of Nephrology, Department of Medicine, University of Würzburg, Würzburg, Germany
| | - Christian Ritter
- Department of Diagnostic and Interventional Radiology, University Medicine Göttingen, Göttingen, Germany
| | - Thorsten Klink
- Department of Diagnostic and Interventional Radiology, University of Würzburg, Würzburg, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University and Department of Medicine I, Cardiology, University Hospital Würzburg, Würzburg, Germany
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University of Würzburg, Würzburg, Germany
| | - Georg Schlieper
- Division of Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Aachen, Germany
| | - Turgay Saritas
- Division of Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sebastian D Reinartz
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Aachen, Germany
| | - Nele Friedrich
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Rolf Janka
- Department of Radiology, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Uder
- Department of Radiology, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
7
|
Bosch A, Scheppach JB, Harazny JM, Raff U, Eckardt KU, Schmieder RE, Schneider MP. Retinal capillary and arteriolar changes in patients with chronic kidney disease. Microvasc Res 2018; 118:121-127. [PMID: 29559377 DOI: 10.1016/j.mvr.2018.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 01/29/2018] [Accepted: 03/16/2018] [Indexed: 01/25/2023]
Abstract
RATIONALE Premature cardiovascular disease is a leading cause of death in patients with chronic kidney disease (CKD). In animal models CKD has been shown to cause renal and extrarenal vascular remodeling and capillary rarefaction, but data in humans with CKD are sparse. Retinal arteriolar wall-to-lumen ratio (WLR) is an established marker of early end-organ damage and there is evidence that arteriolar and capillary changes in the retinal circulation mirror those in the general and in particular the cerebrovascular microcirculation. OBJECTIVE The aim of this study was to compare retinal capillary density and arteriolar structure between patients with CKD and healthy individuals. METHODS We compared 76 patients with CKD stage 3+ or proteinuria >500 mg/g creatinine in the presence of a normal GFR from the German Chronic Kidney Disease cohort to 53 healthy control subjects, who participated in clinical trials during 2007 and 2015 in our Clinical Research Center. Retinal vascular parameters were measured non-invasively in vivo by scanning laser Doppler Flowmetry (SLDF, Heidelberg Engineering, Germany). Capillary rarefaction was assessed by intercapillary distance. RESULTS Patients with CKD showed greater WLR (0.403 ± 0.11 vs 0.351 ± 0.11, p = 0.010) and greater wall thickness (WT) (15.1 ± 4.1 vs 13.5 ± 3.8, p = 0.026) compared to healthy individuals. Intercapillary distance (ICD) (22.4 ± 5.7 vs 20.2 ± 4.1, p = 0.008) was greater in the CKD group compared to the healthy control group. After adjustment for differences in clinical characteristics of the groups (age, gender, BMI, serum cholesterol) WLR (p = 0.046), WT (p = 0.025) and ICD (p = 0.003) remained significantly different between the two groups. There was a correlation between serum phosphate level and WLR in the CKD group (r = 0.288, p = 0.013). CONCLUSION Patients with moderately severe CKD show retinal signs of end-organ damage indicated by an increased wall-to-lumen ratio and capillary rarefaction.
Collapse
Affiliation(s)
- Agnes Bosch
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany
| | - Johannes B Scheppach
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany
| | - Joanna M Harazny
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany; Department of Pathophysiology, University of Warmia and Mazury, Olsztyn, Poland
| | - Ulrike Raff
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Germany
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany.
| | - Markus P Schneider
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany
| |
Collapse
|
8
|
Schneider MP, Raff U, Kopp C, Scheppach JB, Toncar S, Wanner C, Schlieper G, Saritas T, Floege J, Schmid M, Birukov A, Dahlmann A, Linz P, Janka R, Uder M, Schmieder RE, Titze JM, Eckardt KU. Skin Sodium Concentration Correlates with Left Ventricular Hypertrophy in CKD. J Am Soc Nephrol 2017; 28:1867-1876. [PMID: 28154199 DOI: 10.1681/asn.2016060662] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 11/25/2016] [Indexed: 12/24/2022] Open
Abstract
The pathogenesis of left ventricular hypertrophy in patients with CKD is incompletely understood. Sodium intake, which is usually assessed by measuring urinary sodium excretion, has been inconsistently linked with left ventricular hypertrophy. However, tissues such as skin and muscle may store sodium. Using 23sodium-magnetic resonance imaging, a technique recently developed for the assessment of tissue sodium content in humans, we determined skin sodium content at the level of the calf in 99 patients with mild to moderate CKD (42 women; median [range] age, 65 [23-78] years). We also assessed total body overhydration (bioimpedance spectroscopy), 24-hour BP, and left ventricular mass (cardiac magnetic resonance imaging). Skin sodium content, but not total body overhydration, correlated with systolic BP (r=0.33, P=0.002). Moreover, skin sodium content correlated more strongly than total body overhydration did with left ventricular mass (r=0.56, P<0.001 versus r=0.35, P<0.001; P<0.01 between the two correlations). Linear regression analysis demonstrated that skin sodium content is a strong explanatory variable for left ventricular mass, unaffected by BP and total body overhydration. In conclusion, we found skin sodium content to be closely linked to left ventricular mass in patients with CKD. Interventions that reduce skin sodium content might improve cardiovascular outcomes in these patients.
Collapse
Affiliation(s)
| | - Ulrike Raff
- Departments of *Nephrology and Hypertension, and
| | | | | | - Sebastian Toncar
- Division of Nephrology, Department of Medicine, University of Würzburg, Würzburg, Germany
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University of Würzburg, Würzburg, Germany
| | - Georg Schlieper
- Division of Nephrology and Clinical Immunology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Turgay Saritas
- Division of Nephrology and Clinical Immunology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Matthias Schmid
- Department of Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany; and
| | - Anna Birukov
- Departments of *Nephrology and Hypertension, and.,Radiology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | | | - Peter Linz
- Radiology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Rolf Janka
- Radiology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Uder
- Radiology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | | | - Jens M Titze
- Departments of *Nephrology and Hypertension, and.,Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | | |
Collapse
|