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Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary form of glomerular disease worldwide and carries a high lifetime risk of kidney failure. The underlying pathogenesis of IgAN has been characterized to a sub-molecular level; immune complexes containing specific O-glycoforms of IgA1 are central. Kidney biopsy remains the gold-standard diagnostic test for IgAN and histological features (i.e. MEST-C score) have also been shown to independently predict outcome. Proteinuria and blood pressure are the main modifiable risk factors for disease progression. No IgAN-specific biomarker has yet been validated for diagnosis, prognosis or tracking response to therapy. There has been a recent resurgence of investigation into IgAN treatments. Optimized supportive care with lifestyle interventions and non-immunomodulatory drugs remains the backbone of IgAN management. The menu of available reno-protective medications is rapidly expanding beyond blockade of the renin-angiotensin-aldosterone system to include sodium-glucose cotransporter 2 and endothelin type A receptor antagonism. Systemic immunosuppression can further improve kidney outcomes, although recent randomized controlled trials have raised concerns regarding infectious and metabolic toxicity from systemic corticosteroids. Studies evaluating more refined approaches to immunomodulation in IgAN are ongoing: drugs targeting the mucosal immune compartment, B-cell promoting cytokines and the complement cascade are particularly promising. We review the current standards of treatment and discuss novel developments in pathophysiology, diagnosis, outcome prediction and management of IgAN.
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Affiliation(s)
- Patrick J Gleeson
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
- Department of Medicine, School of Microbiology, APC Microbiome Ireland, University College Cork, Cork, Ireland
| | | | - Jonathan Barratt
- The Mayer IgA Nephropathy Laboratories, University of Leicester, Leicester, UK
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2
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Krissberg JR, O'Shaughnessy MM, Smith AR, Helmuth ME, Almaani S, Aviles DH, Brathwaite KE, Cai Y, Cattran D, Gbadegesin R, Glenn DA, Greenbaum LA, Iragorri S, Jain K, Khalid M, Kidd J, Kopp J, Lafayette R, Lane JC, Lugani F, Nestor JG, Parekh RS, Reidy K, Selewski DT, Sethna CB, Sperati CJ, Tuttle K, Twombley K, Vasylyeva TL, Weaver DJ, Wenderfer SE, Gibson K. Racial and Ethnic Disparities in Acute Care Utilization Among Patients With Glomerular Disease. Am J Kidney Dis 2023; 81:318-328.e1. [PMID: 36191724 PMCID: PMC9974571 DOI: 10.1053/j.ajkd.2022.08.010] [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: 01/28/2022] [Accepted: 08/03/2022] [Indexed: 01/25/2023]
Abstract
RATIONALE & OBJECTIVE The effects of race, ethnicity, socioeconomic status (SES), and disease severity on acute care utilization in patients with glomerular disease are unknown. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 1,456 adults and 768 children with biopsy-proven glomerular disease enrolled in the Cure Glomerulonephropathy (CureGN) cohort. EXPOSURE Race and ethnicity as a participant-reported social factor. OUTCOME Acute care utilization defined as hospitalizations or emergency department visits. ANALYTICAL APPROACH Multivariable recurrent event proportional rate models were used to estimate associations between race and ethnicity and acute care utilization. RESULTS Black or Hispanic participants had lower SES and more severe glomerular disease than White or Asian participants. Acute care utilization rates were 45.6, 29.5, 25.8, and 19.2 per 100 person-years in Black, Hispanic, White, and Asian adults, respectively, and 55.8, 42.5, 40.8, and 13.0, respectively, for children. Compared with the White race (reference group), Black race was significantly associated with acute care utilization in adults (rate ratio [RR], 1.76 [95% CI, 1.37-2.27]), although this finding was attenuated after multivariable adjustment (RR, 1.31 [95% CI, 1.03-1.68]). Black race was not significantly associated with acute care utilization in children; Asian race was significantly associated with lower acute care utilization in children (RR, 0.32 [95% CI 0.14-0.70]); no significant associations between Hispanic ethnicity and acute care utilization were identified. LIMITATIONS We used proxies for SES and lacked direct information on income, household unemployment, or disability. CONCLUSIONS Significant differences in acute care utilization rates were observed across racial and ethnic groups in persons with prevalent glomerular disease, although many of these difference were explained by differences in SES and disease severity. Measures to combat socioeconomic disadvantage in Black patients and to more effectively prevent and treat glomerular disease are needed to reduce disparities in acute care utilization, improve patient wellbeing, and reduce health care costs.
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Affiliation(s)
- Jill R Krissberg
- Division of Pediatric Nephrology, Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Michelle M O'Shaughnessy
- Department of Renal Medicine, Cork University Hospital, Ireland; and School of Medicine, University College Cork, Ireland
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Salem Almaani
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Diego H Aviles
- Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Kaye E Brathwaite
- Division of Pediatric/Nephrology, Children's Hospital at Montefiore/Einstein, Bronx, New York
| | - Yi Cai
- Pediatric Nephrology, Dialysis and Transplantation, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Daniel Cattran
- Division of Nephrology, University Health Network, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Rasheed Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, North Carolina
| | - Dorey A Glenn
- Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Koyal Jain
- Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Myda Khalid
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jason Kidd
- Virginia Commonwealth University, Richmond, Virginia
| | - Jeffrey Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Richard Lafayette
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Jerome C Lane
- Division of Pediatric Nephrology, Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Francesca Lugani
- L'Unità Operativa Complessa Nefrology, Dialysis and Transplant, Laboratorio di Nefrologia Molecolare, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Jordan G Nestor
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York
| | - Rulan S Parekh
- Division of Nephrology, Department of Pediatrics and Medicine, Hospital for Sick Children, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Kimberly Reidy
- Division of Pediatric/Nephrology, Children's Hospital at Montefiore/Einstein, Bronx, New York
| | - David T Selewski
- Department of Pediatrics, Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Christine B Sethna
- Division of Pediatric Nephrology, Cohen Children's Medical Center, New Hyde Park, New York
| | - C John Sperati
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Katherine Tuttle
- Providence Health Care, Department of Medicine, Division of Nephrology, University of Washington, Spokane and Seattle, Washington
| | - Katherine Twombley
- Department of Pediatrics, Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Tetyana L Vasylyeva
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, Texas
| | - Donald J Weaver
- Division of Pediatric Nephrology and Hypertension, Atrium Health Levine Children's, Charlotte, North Carolina
| | - Scott E Wenderfer
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Keisha Gibson
- Department of Medicine and Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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3
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Mariani LH, Eddy S, AlAkwaa FM, McCown PJ, Harder JL, Nair V, Eichinger F, Martini S, Ademola AD, Boima V, Reich HN, El Saghir J, Godfrey B, Ju W, Tanner EC, Vega-Warner V, Wys NL, Adler SG, Appel GB, Athavale A, Atkinson MA, Bagnasco SM, Barisoni L, Brown E, Cattran DC, Coppock GM, Dell KM, Derebail VK, Fervenza FC, Fornoni A, Gadegbeku CA, Gibson KL, Greenbaum LA, Hingorani SR, Hladunewich MA, Hodgin JB, Hogan MC, Holzman LB, Jefferson JA, Kaskel FJ, Kopp JB, Lafayette RA, Lemley KV, Lieske JC, Lin JJ, Menon R, Meyers KE, Nachman PH, Nast CC, O'Shaughnessy MM, Otto EA, Reidy KJ, Sambandam KK, Sedor JR, Sethna CB, Singer P, Srivastava T, Tran CL, Tuttle KR, Vento SM, Wang CS, Ojo AO, Adu D, Gipson DS, Trachtman H, Kretzler M. Precision nephrology identified tumor necrosis factor activation variability in minimal change disease and focal segmental glomerulosclerosis. Kidney Int 2023; 103:565-579. [PMID: 36442540 DOI: 10.1016/j.kint.2022.10.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 11/27/2022]
Abstract
The diagnosis of nephrotic syndrome relies on clinical presentation and descriptive patterns of injury on kidney biopsies, but not specific to underlying pathobiology. Consequently, there are variable rates of progression and response to therapy within diagnoses. Here, an unbiased transcriptomic-driven approach was used to identify molecular pathways which are shared by subgroups of patients with either minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS). Kidney tissue transcriptomic profile-based clustering identified three patient subgroups with shared molecular signatures across independent, North American, European, and African cohorts. One subgroup had significantly greater disease progression (Hazard Ratio 5.2) which persisted after adjusting for diagnosis and clinical measures (Hazard Ratio 3.8). Inclusion in this subgroup was retained even when clustering was limited to those with less than 25% interstitial fibrosis. The molecular profile of this subgroup was largely consistent with tumor necrosis factor (TNF) pathway activation. Two TNF pathway urine markers were identified, tissue inhibitor of metalloproteinases-1 (TIMP-1) and monocyte chemoattractant protein-1 (MCP-1), that could be used to predict an individual's TNF pathway activation score. Kidney organoids and single-nucleus RNA-sequencing of participant kidney biopsies, validated TNF-dependent increases in pathway activation score, transcript and protein levels of TIMP-1 and MCP-1, in resident kidney cells. Thus, molecular profiling identified a subgroup of patients with either MCD or FSGS who shared kidney TNF pathway activation and poor outcomes. A clinical trial testing targeted therapies in patients selected using urinary markers of TNF pathway activation is ongoing.
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Affiliation(s)
- Laura H Mariani
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | - Sean Eddy
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Fadhl M AlAkwaa
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Phillip J McCown
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer L Harder
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Viji Nair
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Felix Eichinger
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sebastian Martini
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Adebowale D Ademola
- Department of Paediatrics, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Vincent Boima
- Department of Medicine and Therapeutics, University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Heather N Reich
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Jamal El Saghir
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Bradley Godfrey
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Wenjun Ju
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily C Tanner
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Virginia Vega-Warner
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Noel L Wys
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sharon G Adler
- Division of Nephrology and Hypertension at Harbor-UCLA Medical Center and The Lundquist Institute for Biomedical Innovation, Torrance, California, USA
| | - Gerald B Appel
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ambarish Athavale
- Division of Nephrology-Hypertension, University of San Diego, California, San Diego, California, USA
| | - Meredith A Atkinson
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Serena M Bagnasco
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laura Barisoni
- Department of Pathology and Medicine, Division of Nephrology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Elizabeth Brown
- Division of Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daniel C Cattran
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Gaia M Coppock
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine M Dell
- Center for Pediatric Nephrology, Cleveland Clinic, Case Western Reserve University, Cleveland, Ohio, USA
| | - Vimal K Derebail
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alessia Fornoni
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Crystal A Gadegbeku
- Department of Kidney Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Keisha L Gibson
- Pediatric Nephrology Division, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laurence A Greenbaum
- Division of Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sangeeta R Hingorani
- Division of Nephrology, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey B Hodgin
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Marie C Hogan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lawrence B Holzman
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Ashley Jefferson
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Frederick J Kaskel
- Division of Pediatric Nephrology, Montefiore Medical Center, Bronx, New York, USA
| | - Jeffrey B Kopp
- National Institute of Diabetes and Digestive Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Richard A Lafayette
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, California, USA
| | - Kevin V Lemley
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - John C Lieske
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jen-Jar Lin
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Rajarasee Menon
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Kevin E Meyers
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Patrick H Nachman
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cynthia C Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Edgar A Otto
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kimberly J Reidy
- Division of Pediatric Nephrology, Montefiore Medical Center, Bronx, New York, USA
| | - Kamalanathan K Sambandam
- Division of Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - John R Sedor
- Lerner Research Institutes, Cleveland Clinic, Cleveland, Ohio, USA; Department of Molecular Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Department of Physiology, Case Western Reserve University, Cleveland, Ohio, USA; Department of Biophysics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Christine B Sethna
- Division of Pediatric Nephrology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Pamela Singer
- Division of Pediatric Nephrology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Tarak Srivastava
- Section of Nephrology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Cheryl L Tran
- Pediatric Nephrology, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine R Tuttle
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA; Providence Medical Research Center, Providence Health Care, University of Washington, Spokane, Washington, USA
| | - Suzanne M Vento
- Division of Nephrology, Department of Pediatrics, New York University School of Medicine, New York, New York, USA
| | - Chia-Shi Wang
- Division of Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Akinlolu O Ojo
- Department of Population Health, School of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Dwomoa Adu
- Department of Medicine and Therapeutics, University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Debbie S Gipson
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Howard Trachtman
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthias Kretzler
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA.
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Wang L, Smith-Salzberg B, Meyers KE, Glenn DA, Tuttle KR, Derebail VK, Brady TM, Gibson K, Smith AR, O'Shaughnessy MM, Srivastava T, Hall G, Zee J, Bitzer M, Sethna CB. Tobacco exposure in adults and children with proteinuric glomerulopathies: a NEPTUNE cohort study. BMC Nephrol 2023; 24:30. [PMID: 36759756 PMCID: PMC9912673 DOI: 10.1186/s12882-023-03073-w] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Tobacco exposure has been recognized as a risk factor for cardiovascular disease (CVD) and progression of kidney disease. Patients with proteinuric glomerulopathies are at increased risk for cardiovascular morbidity and mortality. Multiple studies have linked tobacco exposure to CVD and chronic kidney disease, but the relationships between smoking and proteinuric glomerulopathies in adults and children have not been previously explored. METHODS Data from the Nephrotic Syndrome Study Network (NEPTUNE), a multi-center prospective observational study of participants with proteinuric glomerulopathies, was analyzed. 371 adults and 192 children enrolled in NEPTUNE were included in the analysis. Self-reported tobacco exposure was classified as non-smoker, active smoker, former smoker, or exclusive passive smoker. Baseline serum cotinine levels were measured in a sub-cohort of 178 participants. RESULTS The prevalence of active smokers, former smokers and exclusive passive smoking among adults at baseline was 14.6%, 29.1% and 4.9%, respectively. Passive smoke exposure was 16.7% among children. Active smoking (reference non-smoking) was significantly associated with greater total cholesterol among adults (β 17.91 95% CI 0.06, 35.76, p = 0.049) while passive smoking (reference non-smoking) was significantly associated with greater proteinuria over time among children (β 1.23 95% CI 0.13, 2.33, p = 0.03). Higher cotinine levels were associated with higher baseline eGFR (r = 0.17, p = 0.03). CONCLUSION Tobacco exposure is associated with greater risk for CVD and worse kidney disease outcomes in adults and children with proteinuric glomerulopathies. Preventive strategies to reduce tobacco exposure may help protect against future cardiovascular and kidney morbidity and mortality in patients with proteinuric glomerulopathies.
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Affiliation(s)
- Linda Wang
- Cohen Children's Medical Center of NY, New Hyde Park, NY, USA
| | | | | | - Dorey A Glenn
- Division of Nephrology and Hypertension, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, WA, USA
- Nephrology Division and Kidney Research Institute, University of Washington, Seattle, WA, USA
| | - Vimal K Derebail
- Division of Nephrology and Hypertension, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tammy M Brady
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Keisha Gibson
- Division of Nephrology and Hypertension, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | - Gentzon Hall
- Division of Nephrology, Duke University School of Medicine, 269-01 76th Avenue, 11040, Durham, NC, USA
| | - Jarcy Zee
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Christine B Sethna
- Cohen Children's Medical Center of NY, New Hyde Park, NY, USA.
- Division of Nephrology, Duke University School of Medicine, 269-01 76th Avenue, 11040, Durham, NC, USA.
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Ziolkowski S, Liu S, Montez-Rath ME, Denburg M, Winkelmayer WC, Chertow GM, O'Shaughnessy MM. Association between cause of kidney failure and fracture incidence in a national US dialysis population cohort study. Clin Kidney J 2022; 15:2245-2257. [PMID: 36381373 PMCID: PMC9664571 DOI: 10.1093/ckj/sfac193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background Whether fracture rates, overall and by fracture site, vary by cause of kidney failure in patients receiving dialysis is unknown. Methods Using the US Renal Data System, we compared fracture rates across seven causes of kidney failure in patients who started dialysis between 1997 and 2014. We computed unadjusted and multivariable adjusted proportional sub-distribution hazard models, with fracture events (overall, and by site) as the outcome and immunoglobulin A nephropathy as the reference group. Kidney transplantation and death were competing events. Results Among 491 496 individuals, with a median follow-up of 2.0 (25%, 75% range 0.9–3.9) years, 62 954 (12.8%) experienced at least one fracture. Patients with diabetic nephropathy, vasculitis or autosomal polycystic kidney disease (ADPKD) had the highest (50, 46 and 40 per 1000 person-years, respectively), and patient with lupus nephritis had the lowest (20 per 1000 person-years) fracture rates. After multivariable adjustment, diabetic nephropathy [hazard ratio (HR) 1.43, 95% confidence interval 1.33–1.53], ADPKD (HR 1.37, 1.26–1.48), vasculitis (HR 1.22, 1.09–1.34), membranous nephropathy (HR 1.16, 1.02–1.30) and focal segmental glomerulosclerosis (FSGS) (HR 1.13, 1.02–1.24) were associated with a significantly higher, and lupus nephritis with a significantly lower (HR 0.85, 0.71–0.98) fracture hazard. The hazards for upper extremity and lower leg fractures were significantly higher in diabetic nephropathy, ADPKD, FSGS and membranous nephropathy, while the hazard for vertebral fracture was significantly higher in vasculitis. Our findings were limited by the lack of data on medication use and whether fractures were traumatic or non-traumatic, among other factors. Conclusions Fracture risk, overall and by fracture site, varies by cause of end-stage kidney disease. Future work to determine underlying pathogenic mechanisms contributing to differential risks might inform more tailored treatment strategies. Our study was limited by lack of data regarding numerous potential confounders or mediators including medications and measures or bone biomarkers.
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Affiliation(s)
- Susan Ziolkowski
- Department of Medicine, Stanford University School of Medicine , Stanford, CA , USA
| | - Sai Liu
- Department of Medicine, Stanford University School of Medicine , Stanford, CA , USA
| | - Maria E Montez-Rath
- Department of Medicine, Stanford University School of Medicine , Stanford, CA , USA
| | - Michelle Denburg
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Division of Nephrology, Children's Hospital of Philadelphia , Philadelphia, PA , USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine , Houston, TX , USA
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine , Stanford, CA , USA
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Al Khalaf S, Bodunde E, Maher GM, O'Reilly ÉJ, McCarthy FP, O'Shaughnessy MM, O'Neill SM, Khashan AS. Chronic kidney disease and adverse pregnancy outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol 2022; 226:656-670.e32. [PMID: 34736915 DOI: 10.1016/j.ajog.2021.10.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Limited evidence exists on the role that the cause of chronic kidney disease plays in determining pregnancy outcomes. The aim of this systematic review and meta-analysis was to examine the association between chronic kidney disease and adverse pregnancy outcomes by the cause and severity of chronic kidney disease where reported. The protocol was registered under the International Prospective Register of Systematic Reviews (CRD42020211925). DATA SOURCES PubMed, Embase, and Web of Science were searched until May 24, 2021, supplemented with reference list checking. STUDY ELIGIBILITY CRITERIA Studies that compared the pregnancy outcomes in women with or without chronic kidney disease were included. Two reviewers independently screened titles, abstracts, and full-text articles according to a priori defined inclusion criteria. METHODS Data extraction and quality appraisal were performed independently by 3 reviewers. The grading of recommendations, assessment, development, and evaluation approach was used to assess the overall certainty of the evidence. Random-effects meta-analyses were used to calculate the pooled estimates using the generic inverse variance method. The primary outcomes included preeclampsia, cesarean delivery, preterm birth (<37 weeks' gestation), and small for gestational age babies. RESULTS Of 4076 citations, 31 studies were included. Prepregnancy chronic kidney disease was significantly associated with a higher odds of preeclampsia (pooled crude odds ratio, 8.13; [95% confidence interval, 4.41-15], and adjusted odds ratio, 2.58; [1.33-5.01]), cesarean delivery (adjusted odds ratio, 1.65; [1.21-2.25]), preterm birth (adjusted odds ratio, 1.73; [1.31-2.27]), and small for gestational age babies (adjusted odds ratio, 1.93; [1.06-3.52]). The association with stillbirth was not statistically significant (adjusted odds ratio, 1.67; [0.96-2.92]). Subgroup analyses indicated that different causes of chronic kidney disease might confer different risks and that the severity of chronic kidney disease is associated with a risk of adverse pregnancy outcomes, as pregnancies with later stages of chronic kidney disease had higher odds of preeclampsia, preterm birth, and small for gestational age babies than those at earlier stages. The grading of recommendations, assessment, development, and evaluation certainty of the evidence overall was "very low". CONCLUSION This meta-analysis quantified the associations between prepregnancy chronic kidney disease and adverse pregnancy outcomes, both overall and according to the cause and severity of the disease. These findings might support the clinicians aiming to counsel women having chronic kidney disease by allowing them to tailor their advice according to cause and severity of the chronic kidney disease. We identified the gaps in the literature, and further studies examining the effect of specific kidney diseases and other clinical characteristics (eg, proteinuria, hypertension) on adverse pregnancy outcomes are warranted.
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Affiliation(s)
- Sukainah Al Khalaf
- School of Public Health, College of Medicine and Health, University College Cork, Cork, Ireland; The Irish Centre for Maternal and Child Health Research, University College Cork, Cork, Ireland.
| | - Elizabeth Bodunde
- School of Public Health, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Gillian M Maher
- School of Public Health, College of Medicine and Health, University College Cork, Cork, Ireland; The Irish Centre for Maternal and Child Health Research, University College Cork, Cork, Ireland
| | - Éilis J O'Reilly
- School of Public Health, College of Medicine and Health, University College Cork, Cork, Ireland; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Fergus P McCarthy
- The Irish Centre for Maternal and Child Health Research, University College Cork, Cork, Ireland; Department of Obstetrics and Gynaecology, Cork University Hospital, Cork, Ireland
| | | | | | - Ali S Khashan
- School of Public Health, College of Medicine and Health, University College Cork, Cork, Ireland; The Irish Centre for Maternal and Child Health Research, University College Cork, Cork, Ireland.
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Glenn DA, Zee J, Hegde A, Henderson C, O'Shaughnessy MM, Bomback A, Gibson K, Greenbaum LA, Mansfield S, Hu Y, Mariani L, Falk R, Hogan S, Denburg M, Mottl A. Validation of Diagnosis Codes to Identify Infection-Related Acute Care Events in Patients With Glomerular Disease. Kidney Int Rep 2021; 6:3079-3082. [PMID: 34901577 PMCID: PMC8640562 DOI: 10.1016/j.ekir.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Dorey A Glenn
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jarcy Zee
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anisha Hegde
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Candace Henderson
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Andrew Bomback
- Division of Nephrology, Columbia University, New York, New York, USA
| | - Keisha Gibson
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Sarah Mansfield
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Yichun Hu
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura Mariani
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ronald Falk
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan Hogan
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michelle Denburg
- Division of Nephrology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amy Mottl
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Krissberg JR, Helmuth ME, Almaani S, Cai Y, Cattran D, Chatterjee D, Gbadegesin RA, Gibson KL, Glenn DA, Greenbaum LA, Iragorri S, Jain K, Khalid M, Kidd JM, Kopp JB, Lafayette R, Nestor JG, Parekh RS, Reidy KJ, David T Selewski, John Sperati C, Tuttle KR, Twombley K, Vasylyeva TL, Weaver DJ, Wenderfer SE, O'Shaughnessy MM. Racial-ethnic differences in health-related quality of life among adults and children with glomerular disease. Glomerular Dis 2021; 1:105-117. [PMID: 34723246 DOI: 10.1159/000516832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction Disparities in health-related quality of life (HRQOL) have been inadequately studied in patients with glomerular disease. The aim of this study was to identify relationships between race/ethnicity, socioeconomic status, disease severity, and HRQOL in an ethnically and racially diverse cohort of patients with glomerular disease. Methods Cure Glomerulonephropathy (CureGN) is a multinational cohort study of patients with biopsy-proven glomerular disease. Associations between race/ethnicity and HRQOL were determined by the following: 1. Missed school or work due to kidney disease; 2. Responses to Patient Reported Outcomes Measurement Information System (PROMIS) questionnaires. We adjusted for demographics, socioeconomic status, and disease characteristics using multivariable logistic and linear regression. Results Black and Hispanic participants had worse socioeconomic status and more severe glomerular disease than White or Asian participants. Black adults missed work or school most frequently due to kidney disease (30% versus 16-23% in the other three groups, p=0.04), and had the worst self-reported global physical health (median score 44.1 versus 48.0-48.2, p<0.001) and fatigue (53.8 versus 48.5-51.1, p=0.002), compared to other racial/ethnic groups. However, these findings were not statistically significant with adjustment for socioeconomic status and disease severity, both of which were strongly associated with HRQOL in adults. Among children, disease severity but not race/ethnicity or socioeconomic status were associated with HRQOL. Conclusions Among patients with glomerular disease enrolled in CureGN, the worse HRQOL reported by Black adults was attributable to lower socioeconomic status and more severe glomerular disease. No racial/ethnic differences in HRQOL were observed in children.
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Affiliation(s)
- Jill R Krissberg
- Division of Nephrology, Department of Pediatrics, Stanford University, Stanford, California, United States
| | - Margaret E Helmuth
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States
| | - Salem Almaani
- Department of Nephrology, The Ohio State University, Columbus, Ohio, United States
| | - Yi Cai
- Division of Pediatric Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, United States
| | - Daniel Cattran
- Division of Nephrology, University Health Network, University of Toronto, Ontario, Canada
| | - Debanjana Chatterjee
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York, United States
| | - Rasheed A Gbadegesin
- Department of Pediatrics, Duke University, Durham, North Carolina, United States
| | - Keisha L Gibson
- Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Dorey A Glenn
- Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Laurence A Greenbaum
- Division of Nephrology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Sandra Iragorri
- Division of Nephrology and Hypertension, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, United States
| | - Koyal Jain
- Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Myda Khalid
- Division of Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Jason M Kidd
- Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia, United States
| | - Jeffrey B Kopp
- Kidney Disease Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, United States
| | - Richard Lafayette
- Division of Nephrology and Hypertension, Stanford University, Stanford, California, United States
| | - Jordan G Nestor
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York, United States
| | - Rulan S Parekh
- Division of Nephrology, Department of Paediatrics, Hospital for Sick Children, University Health Network and University of Toronto, Toronto, Canada
| | - Kimberly J Reidy
- Department of Pediatric Nephrology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, United States
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States
| | - C John Sperati
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Katherine R Tuttle
- Division of Nephrology, University of Washington, Seattle, Washington, United States
| | - Katherine Twombley
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Tetyana L Vasylyeva
- Division of Nephrology, Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Donald Jack Weaver
- Division of Pediatric Nephrology, Atrium Health Levine Children's, Charlotte, North Carolina, United States
| | - Scott E Wenderfer
- Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
| | - Michelle M O'Shaughnessy
- Department of Renal Medicine, Cork University Hospital and University College Cork, Cork, Ireland
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Ng MSY, Charu V, Johnson DW, O'Shaughnessy MM, Mallett AJ. National and international kidney failure registries: characteristics, commonalities, and contrasts. Kidney Int 2021; 101:23-35. [PMID: 34736973 DOI: 10.1016/j.kint.2021.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/02/2021] [Accepted: 09/16/2021] [Indexed: 12/23/2022]
Abstract
Registries are essential for health infrastructure planning, benchmarking, continuous quality improvement, hypothesis generation, and real-world trials. To date, data from these registries have predominantly been analyzed in isolated "silos," hampering efforts to analyze "big data" at the international level, an approach that provides wide-ranging benefits, including enhanced statistical power, an ability to conduct international comparisons, and greater capacity to study rare diseases. This review serves as a valuable resource to clinicians, researchers, and policymakers, by comprehensively describing kidney failure registries active in 2021, before proposing approaches for inter-registry research under current conditions, as well as solutions to enhance global capacity for data collaboration. We identified 79 kidney-failure registries spanning 77 countries worldwide. International Society of Nephrology exemplar initiatives, including the Global Kidney Health Atlas and Sharing Expertise to support the set-up of Renal Registries (SharE-RR), continue to raise awareness regarding international healthcare disparities and support the development of universal kidney-disease registries. Current barriers to inter-registry collaboration include underrepresentation of lower-income countries, poor syntactic and semantic interoperability, absence of clear consensus guidelines for healthcare data sharing, and limited researcher incentives. This review represents a call to action for international stakeholders to enact systemic change that will harmonize the current fragmented approaches to kidney-failure registry data collection and research.
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Affiliation(s)
- Monica S Y Ng
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Kidney Health Service, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; Faculty of Medicine and Institute for Molecular Biosciences, University of Queensland, Brisbane, Queensland, Australia
| | - Vivek Charu
- Department of Pathology, Stanford University School of Medicine, Palo Alto, California, USA
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Translational Research Institute, Brisbane, Queensland, Australia; Centre for Kidney Disease Research, University of Queensland, Brisbane, Queensland, Australia
| | | | - Andrew J Mallett
- Faculty of Medicine and Institute for Molecular Biosciences, University of Queensland, Brisbane, Queensland, Australia; Department of Renal Medicine, Townsville University Hospital, Townsville, Queensland, Australia; College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.
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10
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Sim JJ, Shu YH, Hever A, O'Shaughnessy MM, Jacobsen SJ. Rates of Biopsy-Proven Pediatric Glomerulopathies in a Large Health System, 2000-2014. Am J Kidney Dis 2021; 79:453-455. [PMID: 34332008 DOI: 10.1053/j.ajkd.2021.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/06/2021] [Indexed: 11/11/2022]
Affiliation(s)
- John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine.
| | - Yu-Hsiang Shu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Aviv Hever
- Department of Renal Pathology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | | | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
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11
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Shah PP, Brady TM, Meyers KEC, O'Shaughnessy MM, Gibson KL, Srivastava T, Zee J, Cattran D, Tuttle KR, Gadegbeku C, Glenn D, Derebail V, Smith A, Wang CS, Gillespie BW, Bitzer M, Sethna CB. Association of Obesity with Cardiovascular Risk Factors and Kidney Disease Outcomes in Primary Proteinuric Glomerulopathies. Nephron Clin Pract 2021; 145:245-255. [PMID: 33677435 DOI: 10.1159/000513869] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 08/14/2020] [Accepted: 12/16/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS Obesity is a known risk factor for cardiovascular disease and contributes to the development and progression of kidney disease. However, the specific influence of obesity on outcomes in primary glomerular disease has not been well characterized. METHODS In this prospective cohort study, data were from 541 participants enrolled in the Nephrotic Syndrome Study Network (NEPTUNE), between 2010 and 2019, at 23 sites across North America. Blood pressure, lipids, and kidney disease outcomes including complete proteinuria remission, kidney failure, and chronic kidney disease progression were evaluated. Data were analyzed using linear and logistic regression with generalized estimating equations and time-varying Cox regression with Kaplan-Meier plots. RESULTS The prevalence of obesity at baseline was 43.3% (N = 156) in adults and 37.6% (N = 68) in children. In adults, obesity was longitudinally associated with higher systolic BP (β = 6.49, 95% CI: 2.41, 10.56, p = 0.002), dyslipidemia (OR = 1.74, 95% CI: 1.30, 2.32, p < 0.001), triglycerides (β = 41.92, 95% CI: 17.12, 66.71, p = 0.001), and lower HDL (β = -6.92, 95% CI: -9.32, -4.51, p < 0.001). In children, obesity over time was associated with higher systolic BP index (β = 0.04, 95% CI: 0.02, 0.06, p < 0.001) and hypertension (OR = 1.43, 95% CI: 1.04, 1.98, p = 0.03). In both adults and children, obesity was associated with a significantly lower hazard of achieving complete remission of proteinuria (adult HR = 0.80, 95% CI: 0.69, 0.88, p < 0.001; pediatric HR = 0.72, 95% CI: 0.61, 0.84, p < 0.001). CONCLUSION Obesity was associated with higher cardiovascular risk and less proteinuria remission from nephrotic syndrome in adults and children with proteinuric glomerulopathies. Weight-loss strategies may forestall cardiovascular disease and progressive kidney function decline in this high-risk patient group.
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Affiliation(s)
- Paras P Shah
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Tammy M Brady
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin E C Meyers
- The Children Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Keisha L Gibson
- UNC Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Daniel Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Katherine R Tuttle
- Providence Health Care, University of Washington, Spokane, Washington, USA
| | - Crystal Gadegbeku
- Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dorey Glenn
- UNC Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Vimal Derebail
- UNC Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Abigail Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Chia-Shi Wang
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brenda W Gillespie
- Consulting for Statistics, Computing and Analytics Research and School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Markus Bitzer
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Christine B Sethna
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA, .,Cohen Children's Medical Center of NY, New Hyde Park, New York, USA,
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12
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Medjeral-Thomas NR, O'Shaughnessy MM. Complement in IgA Nephropathy: The Role of Complement in the Pathogenesis, Diagnosis, and Future Management of IgA Nephropathy. Adv Chronic Kidney Dis 2020; 27:111-119. [PMID: 32553243 DOI: 10.1053/j.ackd.2019.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022]
Abstract
Immunoglobulin A (IgA) nephropathy (IgAN) is an important cause of chronic and end-stage kidney disease. IgAN pathogenesis is incompletely understood. In particular, we cannot adequately explain the heterogeneity in clinical and histologic features and severities that characterizes IgAN. This limits patient stratification to appropriate and effective treatments and the development of disease-targeted therapies. Studies of the role of the alternative, lectin, and terminal complement pathways in IgAN have enhanced our understanding of disease pathogenesis and inform the development of novel diagnostic and therapeutic strategies. For example, recent genetic, serologic, and immunohistologic evidence suggests that imbalances between the main alternative complement pathway regulator protein (factor H) and competitor proteins that deregulate complement activity (factor H-related proteins 1 and 5, FHR1, and FHR5) associate with IgAN severity: a relative abundance of FHR1 and FHR5 amplifies complement-dependent inflammation and exacerbates kidney injury. Ongoing characterization of the mechanisms by which complement activity contributes to IgAN pathogenesis will facilitate the development of complement-based diagnostic techniques, biomarkers of disease activity and severity, and novel targeted therapies.
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14
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Sun AZ, Shu YH, Harrison TN, Hever A, Jacobsen SJ, O'Shaughnessy MM, Sim JJ. Identifying Patients with Rare Disease Using Electronic Health Record Data: The Kaiser Permanente Southern California Membranous Nephropathy Cohort. Perm J 2020; 24:19.126. [PMID: 32069207 DOI: 10.7812/tpp/19.126] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Developing a reliable means to identify and study real-world populations of patients with membranous nephropathy (MN) using electronic health records (EHRs) would help advance glomerular disease research. Identifying MN cases using EHRs is limited by the need for manual reviews of biopsy reports. OBJECTIVE To evaluate the accuracy of identifying patients with biopsy-proven MN using the EHR in a large, diverse population of an integrated health system. METHODS A retrospective cohort study was performed between June 28, 1999, and June 25, 2015, among patients with kidney biopsy results (N = 4723), which were manually reviewed and designated as MN or non-MN. The sensitivity, specificity, and positive predictive value (PPV) of International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes were determined using 2 approaches: 1) clinical (MN-specific codes 581.1, 582.1, or 583.1) and 2) agnostic/data-derived (codes selected from supervised learning at the highest predictive performance). RESULTS One year after biopsy, the sensitivity and specificity of an MN diagnosis were 86% and 76%, respectively, but the PPV was 26%. The data-driven approach detected that using only 2 codes (581.1 or 583.1) improved specificity to 94% and PPV to 58%, with a small decrease in sensitivity to 83%. When any code was reported at least 3 times, specificity was 98%; PPV, 78%; and sensitivity, 64%. DISCUSSION Our findings suggest that ICD-9 diagnosis codes might be a convenient tool to identify patients with MN using EHR and/or administrative claims information. Codes selected from supervised learning achieved better overall performance, suggesting the potential of developing data-driven methods.
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Affiliation(s)
- Amy Z Sun
- Division of Nephrology and Hypertension, Los Angeles Medical Center, CA
| | - Yu-Hsiang Shu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Aviv Hever
- Department of Renal Pathology, Los Angeles Medical Center, CA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - John J Sim
- Division of Nephrology and Hypertension, Los Angeles Medical Center, CA
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15
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Chin KK, Charu V, O'Shaughnessy MM, Troxell ML, Cheng XS. Histologic Case Definition of an Atypical Glomerular Immune-Complex Deposition Following Kidney Transplantation. Kidney Int Rep 2020; 5:632-642. [PMID: 32405585 PMCID: PMC7210607 DOI: 10.1016/j.ekir.2020.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/15/2019] [Revised: 01/01/2020] [Accepted: 01/27/2020] [Indexed: 01/04/2023] Open
Abstract
Introduction Immune-complex deposition in the transplanted kidney can present as well-phenotyped recurrent or de novo glomerular disease. However, a subset, herein termed immune-complex glomerulopathy not otherwise specified (ICG-NOS), defies classification. We quantified, categorized, and characterized cases of transplant ICG-NOS occurring at a single US academic medical center. Methods We retrospectively reviewed our single-institution pathology database (July 2007–July 2018) to identify and categorize all cases of immune-complex deposition in kidney allografts (based on immunofluorescence microscopy). We extracted clinicopathologic and outcome data for ICG-NOS (i.e., immune complex deposition not conforming to any well-characterized glomerular disease entity). Results Of 104 patients with significant immune deposits, 28 (27%) were classified as ICG-NOS. We created 5 mutually exclusive ICG-NOS categories: Full-house, Quasi-full-house, IgA-rich, C1q-rich, and C1q-poor. Overall, 16 (57%) patients met criteria for definite or possible allograft rejection, including 9 (32%) with antibody-mediated rejection (ABMR), 3 (11%) suspicious for ABMR, 1 (4%) with T-cell–mediated rejection (TCMR), and 9 (32%) with borderline TCMR. After a median follow-up of 2.3 (range, 0.1–14.0) years after biopsy, 7 (25%) allografts had failed and an additional 8 (29%) had persistent renal dysfunction (hematuria, 14%; proteinuria, 21%; and estimated glomerular filtration rate <60 ml/min per 1.73 m2, 11%). Conclusion In contrast to prior studies, our findings suggest that ICG-NOS is not necessarily a benign glomerular process and that there may be an association between ICG-NOS and alloimmunity. Our immunofluorescence-based classification provides a framework for future studies aiming to further elucidate ICG-NOS pathogenesis and prognosis.
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Affiliation(s)
- Kuo-Kai Chin
- Stanford University School of Medicine, Stanford University, Stanford, California, USA.,Department of Medicine, Brigham and Women's Hospital, Brookline, Massachusetts, USA
| | - Vivek Charu
- Department of Pathology, Stanford University Medical Center, Stanford, California, USA
| | - Michelle M O'Shaughnessy
- Department of Medicine, Division of Nephrology, Stanford University Medical Center, Stanford, California, USA.,Department of Nephrology, Cork University Hospital, Cork, Ireland
| | - Megan L Troxell
- Department of Pathology, Stanford University Medical Center, Stanford, California, USA
| | - Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University Medical Center, Stanford, California, USA
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Uffing A, Pérez-Sáez MJ, Mazzali M, Manfro RC, Bauer AC, de Sottomaior Drumond F, O'Shaughnessy MM, Cheng XS, Chin KK, Ventura CG, Agena F, David-Neto E, Mansur JB, Kirsztajn GM, Tedesco-Silva H, Neto GMV, Arias-Cabrales C, Buxeda A, Bugnazet M, Jouve T, Malvezzi P, Akalin E, Alani O, Agrawal N, La Manna G, Comai G, Bini C, Muhsin SA, Riella MC, Hokazono SR, Farouk SS, Haverly M, Mothi SS, Berger SP, Cravedi P, Riella LV. Recurrence of FSGS after Kidney Transplantation in Adults. Clin J Am Soc Nephrol 2020; 15:247-256. [PMID: 31974287 PMCID: PMC7015092 DOI: 10.2215/cjn.08970719] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [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: 07/31/2019] [Accepted: 11/29/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES FSGS recurrence after kidney transplantation is a major risk factor for graft loss. However, the natural history, clinical predictors, and response to treatment remain unclear because of small sample sizes and poor generalizability of single-center studies, and disease misclassification in registry-based studies. We therefore aimed to determine the incidence, predictors, and treatment response of recurrent FSGS in a large cohort of kidney transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Post-Transplant Glomerular Disease (TANGO) project is an observational, multicenter, international cohort study that aims to investigate glomerular disease recurrence post-transplantation. Transplant recipients were screened for the diagnosis of idiopathic FSGS between 2005 and 2015 and details were recorded about the transplant, clinical outcomes, treatments, and other risk factors. RESULTS Among 11,742 kidney transplant recipients screened for FSGS, 176 had a diagnosis of idiopathic FSGS and were included. FSGS recurred in 57 patients (32%; 95% confidence interval [95% CI], 25% to 39%) and 39% of them lost their graft over a median of 5 (interquartile range, 3.0-8.1) years. Multivariable Cox regression revealed a higher risk for recurrence with older age at native kidney disease onset (hazard ratio [HR], 1.37 per decade; 95% CI, 1.09 to 1.56). Other predictors were white race (HR, 2.14; 95% CI, 1.08 to 4.22), body mass index at transplant (HR, 0.89 per kg/m2; 95% CI, 0.83 to 0.95), and native kidney nephrectomies (HR, 2.76; 95% CI, 1.16 to 6.57). Plasmapheresis and rituximab were the most frequent treatments (81%). Partial or complete remission occurred in 57% of patients and was associated with better graft survival. CONCLUSIONS Idiopathic FSGS recurs post-transplant in one third of cases and is associated with a five-fold higher risk of graft loss. Response to treatment is associated with significantly better outcomes but is achieved in only half of the cases.
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Affiliation(s)
- Audrey Uffing
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maria José Pérez-Sáez
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Marilda Mazzali
- Division of Nephrology, School of Medical Sciences, University of Campinas (UNICAMP), Sao Paulo, Brazil
| | - Roberto C Manfro
- Division of Nephrology, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Andrea Carla Bauer
- Division of Nephrology, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Michelle M O'Shaughnessy
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kuo-Kai Chin
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Carlucci G Ventura
- Kidney Transplant Service, Hospital das Clinicas-University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Fabiana Agena
- Kidney Transplant Service, Hospital das Clinicas-University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Elias David-Neto
- Kidney Transplant Service, Hospital das Clinicas-University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Juliana B Mansur
- Division of Nephrology, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Helio Tedesco-Silva
- Division of Nephrology, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Gilberto M V Neto
- Division of Nephrology, Hospital do Rim, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Anna Buxeda
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Mathilde Bugnazet
- Service de Néphrologie Dialyse, Aphérèses et Transplantation, Grenoble University Hospital, Grenoble, France
| | - Thomas Jouve
- Service de Néphrologie Dialyse, Aphérèses et Transplantation, Grenoble University Hospital, Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie Dialyse, Aphérèses et Transplantation, Grenoble University Hospital, Grenoble, France
| | - Enver Akalin
- Montefiore Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Omar Alani
- Montefiore Einstein Center for Transplantation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Nikhil Agrawal
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Claudia Bini
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Saif A Muhsin
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Samira S Farouk
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Meredith Haverly
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Suraj Sarvode Mothi
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stefan P Berger
- Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paolo Cravedi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Leonardo V Riella
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts;
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Rovin BH, Caster DJ, Cattran DC, Gibson KL, Hogan JJ, Moeller MJ, Roccatello D, Cheung M, Wheeler DC, Winkelmayer WC, Floege J, Alpers CE, Ayoub I, Bagga A, Barbour SJ, Barratt J, Chan DT, Chang A, Choo JCJ, Cook HT, Coppo R, Fervenza FC, Fogo AB, Fox JG, Glassock RJ, Harris D, Hodson EM, Hogan JJ, Hoxha E, Iseki K, Jennette JC, Jha V, Johnson DW, Kaname S, Katafuchi R, Kitching AR, Lafayette RA, Li PK, Liew A, Lv J, Malvar A, Maruyama S, Mejía-Vilet JM, Mok CC, Nachman PH, Nester CM, Noiri E, O'Shaughnessy MM, Özen S, Parikh SM, Park HC, Peh CA, Pendergraft WF, Pickering MC, Pillebout E, Radhakrishnan J, Rathi M, Ronco P, Smoyer WE, Tang SC, Tesař V, Thurman JM, Trimarchi H, Vivarelli M, Walters GD, Wang AYM, Wenderfer SE, Wetzels JF. Management and treatment of glomerular diseases (part 2): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 95:281-295. [PMID: 30665569 DOI: 10.1016/j.kint.2018.11.008] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023]
Abstract
In November 2017, the Kidney Disease: Improving Global Outcomes (KDIGO) initiative brought a diverse panel of experts in glomerular diseases together to discuss the 2012 KDIGO glomerulonephritis guideline in the context of new developments and insights that had occurred over the years since its publication. During this KDIGO Controversies Conference on Glomerular Diseases, the group examined data on disease pathogenesis, biomarkers, and treatments to identify areas of consensus and areas of controversy. This report summarizes the discussions on primary podocytopathies, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated nephritis, complement-mediated kidney diseases, and monoclonal gammopathies of renal significance.
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Affiliation(s)
- Brad H Rovin
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
| | - Dawn J Caster
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Keisha L Gibson
- University of North Carolina Kidney Center at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marcus J Moeller
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany
| | - Dario Roccatello
- CMID (Center of Research of Immunopathology and Rare Diseases), and Division of Nephrology and Dialysis (ERK-Net member), University of Turin, Italy
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jürgen Floege
- Division of Nephrology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany.
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18
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O'Shaughnessy MM, Troost JP, Bomback AS, Hladunewich MA, Ashoor IF, Gibson KL, Matar RB, Selewski DT, Srivastava T, Rheault MN, Al-Uzri A, Kogon AJ, Khalid M, Vento S, Sanghani NS, Gillespie BW, Gipson DS, Wang CS, Parsa A, Guay-Woodford L, Laurin LP. Treatment Patterns Among Adults and Children With Membranous Nephropathy in the Cure Glomerulonephropathy Network (CureGN). Kidney Int Rep 2019; 4:1725-1734. [PMID: 31844809 PMCID: PMC6895579 DOI: 10.1016/j.ekir.2019.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 05/23/2019] [Revised: 08/21/2019] [Accepted: 09/02/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for Glomerulonephritis recommend that patients with membranous nephropathy (MN) at risk for progression receive immunosuppressive therapy (IST), usually after 6 months of observation. A cyclophosphamide (CYC) or calcineurin inhibitor (CNI)–based regimen is recommended as first-line IST. However, the extent to which KDIGO recommendations are adopted in practice remains largely unknown. Methods We evaluated prescribing practice among patients with primary MN (diagnosed 2010–2018) enrolled in the Cure Glomerulonephropathy Network (CureGN) cohort study. We also evaluated the availability of testing for phospholipase A2 receptor (PLA2R) in the contemporary era. Results Among 361 patients (324 adults and 37 children) with MN who were IST-naïve at biopsy and had at least 6 months of follow-up, 55% of adults and 58% of children initiated IST <6 months after biopsy. Of these, 1 in 5 had no indication for (i.e., urine protein-to-creatinine ratio [uPCR] <4 g/g) or an apparent contraindication to (i.e., an estimated glomerular filtration rate [eGFR] <30 ml/min per 1.73 m2) IST. As first-line IST, half of treated patients received either CYC (16% of adults; 0% of children) or a CNI (40% and 46%, respectively), whereas 1 in 5 received corticosteroid monotherapy (20% and 27%, respectively) and 1 in 6 rituximab (15% and 15%, respectively). More than 80% of surveyed centers had access to PLA2R testing. Conclusion These findings suggest that providers are not aware of, or lack confidence in, current KDIGO guidelines for MN. Treatment patterns observed in this cohort might critically inform the drafting of planned updates to KDIGO guidelines.
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Affiliation(s)
| | - Jonathan P Troost
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew S Bomback
- Division of Nephrology, Columbia University, New York, New York, USA
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Isa F Ashoor
- Division of Nephrology, Department of Pediatrics, LSU Health and Children's Hospital, New Orleans, Louisiana, USA
| | - Keisha L Gibson
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Raed Bou Matar
- Center for Pediatric Nephrology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Michelle N Rheault
- Division of Pediatric Nephrology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Amira Al-Uzri
- Division of Pediatric Kidney Services and Hypertension, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Amy J Kogon
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Wynnewood, Pennsylvania, USA
| | - Myda Khalid
- JW Riley Hospital for Children, Indiana University School of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Suzanne Vento
- Division of Nephrology, Department of Pediatrics, New York University School of Medicine, New York, New York, USA
| | - Neil S Sanghani
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brenda W Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Debbie S Gipson
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Chia-Shi Wang
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Afshin Parsa
- Division of Kidney, Urologic, and Hematologic Diseases, The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Lisa Guay-Woodford
- Center for Translational Research, Children's National Health System, Washington, DC, USA
| | - Louis-Philippe Laurin
- Division of Nephrology, Maisonneuve-Rosemont Hospital, Department of Medicine, University of Montreal, Montreal, Quebec, Canada
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19
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Falasinnu T, O'Shaughnessy MM, Troxell ML, Charu V, Weisman MH, Simard JF. A review of non-immune mediated kidney disease in systemic lupus erythematosus: A hypothetical model of putative risk factors. Semin Arthritis Rheum 2019; 50:463-472. [PMID: 31866044 DOI: 10.1016/j.semarthrit.2019.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/08/2019] [Accepted: 10/30/2019] [Indexed: 12/13/2022]
Abstract
About half of patients with systemic lupus erythematosus (SLE) are diagnosed with lupus nephritis (LN). Patients with SLE are also at increased risk for diabetes, hypertension and obesity, which together account for >70% of end-stage renal disease in the general population. The frequencies of non-LN related causes of kidney disease, and their contribution to kidney disease development and progression among patients with SLE have been inadequately studied. We hypothesize that a substantial, and increasing proportion of kidney pathology in patients with SLE might not directly relate to LN but instead might be explained by non-immune mediated factors such as diabetes, hypertension, and obesity. The goal of the manuscript is to draw attention to hypertension, diabetes and obesity as potential alternative causes of kidney damage in patients with SLE. Further, we suggest that misclassification of kidney disease etiology in patients with SLE might have important ramifications for clinical trial recruitment, epidemiologic investigation, and clinical care. Future studies aiming to elucidate and distinguish discrete causes of kidney disease - both clinically and histologically - among patients with SLE are desperately needed as improved understanding of disease mechanisms is paramount to advancing therapeutic discovery. Collaboration among rheumatologists, pathologists, nephrologists, and endocrinologists, and the availability of dedicated research funding, will be critical to the success of such efforts.
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Affiliation(s)
- Titilola Falasinnu
- Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Lane Stanford, Palo Alto, CA 94305, United States
| | | | - Megan L Troxell
- Department of Pathology, Stanford University Medical Center, Palo Alto, CA. United States
| | - Vivek Charu
- Department of Pathology, Stanford University Medical Center, Palo Alto, CA. United States
| | - Michael H Weisman
- Division of Rheumatology, Cedars-Sinai Medical Center, David Geffen School of Medicine, UCLA, United States
| | - Julia F Simard
- Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Lane Stanford, Palo Alto, CA 94305, United States; Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, United States.
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20
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O'Shaughnessy MM, Hogan SL, Thompson BD, Coppo R, Fogo AB, Jennette JC. Glomerular disease frequencies by race, sex and region: results from the International Kidney Biopsy Survey. Nephrol Dial Transplant 2019; 33:661-669. [PMID: 29106637 DOI: 10.1093/ndt/gfx189] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/19/2017] [Indexed: 12/14/2022] Open
Abstract
Background Large-scale studies comparing glomerular disease frequencies across continents are lacking. Methods We surveyed 29 nephropathology laboratories in four continents using a standardized data collection form. We obtained recent consecutive kidney biopsy diagnosis frequencies at each center and summary demographics for each diagnosis. This report focuses on glomerular disease frequencies by region and race/ethnicity. Results Among 42 603 glomerular disease diagnoses reported (median age 47 years, 52% male, 57% white), from a total of 60 340 diagnoses, glomerular disease subtype frequencies differed considerably by continent. Diabetic glomerulosclerosis (GS; 19.1%) and focal segmental glomerulosclerosis (FSGS; 19.1%) predominated in North America; lupus nephritis (38.1%) and FSGS (15.8%) predominated in Latin America; IgA nephropathy (IgAN; 22.1%) and FSGS (14.9%) predominated in Europe; and IgAN (39.5%) and lupus nephritis (16.8%) predominated in Asia. After stratifying by race, diabetic GS (17.4% versus 4.3%, P < 0.001) and FSGS (17.3% versus 11.8%, P < 0.001) were more, and lupus nephritis less (15.8% versus 45.6%, P < 0.001), frequent among Latinos in North versus Latin America; FSGS was more (13.1% versus 7.1%, P < 0.001), and IgAN less (27.4% versus 40.5%, P < 0.001), frequent among Asians in North America versus Asia; and FSGS (18.9% versus 13.5%, P < 0.001) and diabetic GS (18.7% versus 6.5%, P < 0.001) were more, and IgAN less (14.4% versus 25.4%, P < 0.001), frequent among whites in North America versus Europe. Conclusions We determined that glomerular disease frequencies differed by continent, even among patients of similar race/ethnicity. Regional environmental and lifestyle factors, and local biopsy policies, might influence glomerular disease epidemiology independently of race/ethnicity.
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Affiliation(s)
- Michelle M O'Shaughnessy
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA.,Division of Nephrology and Hypertension, Department of Medicine and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Susan L Hogan
- Division of Nephrology and Hypertension, Department of Medicine and the Kidney Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Bawana D Thompson
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Division of Renal Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J Charles Jennette
- Division of Nephropathology, Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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21
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Ashoor IF, Mansfield SA, O'Shaughnessy MM, Parekh RS, Zee J, Vasylyeva TL, Kogon AJ, Sethna CB, Glenn DA, Chishti AS, Weaver DJ, Helmuth ME, Fernandez HE, Rheault MN. Prevalence of Cardiovascular Disease Risk Factors in Childhood Glomerular Diseases. J Am Heart Assoc 2019; 8:e012143. [PMID: 31286821 PMCID: PMC6662122 DOI: 10.1161/jaha.119.012143] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Cardiovascular disease is a major cause of morbidity and mortality in children with chronic kidney disease. We sought to determine the prevalence of cardiovascular risk factors in children with glomerular disease and to describe current practice patterns regarding risk factor identification and management. Methods and Results Seven-hundred sixty-one children aged 0 to 17 years with any of 4 biopsy-confirmed primary glomerular diseases (minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, and IgA nephropathy/vasculitis) were enrolled at a median of 16 months from glomerular disease diagnosis in the multicenter prospective Cure Glomerulonephropathy Network study. Prevalence of traditional (hypertension, hypercholesterolemia, and obesity) and novel (proteinuria, prematurity, and passive smoke exposure) cardiovascular risk factors were determined at enrollment and compared across glomerular disease subtypes. Frequency of screening for dyslipidemia and prescribing of lipid-lowering or antihypertensive medications were compared across glomerular disease subtype, steroid exposure, and remission status groups. Compared with the general population, all traditional risk factors were more frequent: among those screened, 21% had hypertension, 51% were overweight or obese, and 71% had dyslipidemia. Children who were not in remission at enrollment were more likely to have hypertension and hypercholesterolemia. Fourteen percent of hypertensive children were not receiving antihypertensives. Only 49% underwent screening for dyslipidemia and only 9% of those with confirmed dyslipidemia received lipid-lowering medications. Conclusions Children with primary glomerular diseases exhibit a high frequency of modifiable cardiovascular risk factors, particularly untreated dyslipidemia. Lipid panels should be routinely measured to better define the burden of dyslipidemia in this population. Current approaches to screening for and treating cardiovascular risk factors are not uniform, highlighting a need for evidence-based, disease-specific guidelines.
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Affiliation(s)
- Isa F Ashoor
- 1 Louisiana State University Health Sciences Center New Orleans LA
| | | | | | - Rulan S Parekh
- 4 Division of Nephrology Department of Pediatrics and Medicine Hospital for Sick Children University Health Network, and University of Toronto Toronto Canada
| | - Jarcy Zee
- 2 Arbor Research Collaborative for Health Ann Arbor MI
| | | | - Amy J Kogon
- 6 Children's Hospital of Philadelphia Philadelphia PA
| | | | - Dorey A Glenn
- 8 University of North Carolina at Chapel Hill School of Medicine Chapel Hill NC
| | | | - Donald J Weaver
- 10 Levine Children's Hospital at Carolinas Medical Center Charlotte NC
| | | | - Hilda E Fernandez
- 11 Columbia University College of Physicians and Surgeons New York NY
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22
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Hendren EM, Reynolds ML, Mariani LH, Zee J, O'Shaughnessy MM, Oliverio AL, Moore NW, Hill-Callahan P, Rizk DV, Almanni S, Twombley KE, Herreshoff E, Nester CM, Hladunewich MA. Confidence in Women's Health: A Cross Border Survey of Adult Nephrologists. J Clin Med 2019; 8:jcm8020176. [PMID: 30717445 PMCID: PMC6406323 DOI: 10.3390/jcm8020176] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [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: 01/09/2019] [Revised: 01/26/2019] [Accepted: 01/30/2019] [Indexed: 12/28/2022] Open
Abstract
A range of women’s health issues are intimately related to chronic kidney disease, yet nephrologists’ confidence in counseling or managing these issues has not been evaluated. The women’s health working group of Cure Glomerulonephropathy (CureGN), an international prospective cohort study of glomerular disease, sought to assess adult nephrologists’ training in, exposure to, and confidence in managing women’s health. A 25-item electronic questionnaire was disseminated in the United States (US) and Canada via CureGN and Canadian Society of Nephrology email networks and the American Society of Nephrology Kidney News. Response frequencies were summarized using descriptive statistics. Responses were compared across provider age, gender, country of practice, and years in practice using Pearson’s chi-squared test or Fisher’s exact test. Among 154 respondents, 53% were women, 58% practiced in the US, 77% practiced in an academic setting, and the median age was 41–45 years. Over 65% of respondents lacked confidence in women’s health issues, including menstrual disorders, preconception counseling, pregnancy management, and menopause. Most provided contraception or preconception counseling to less than one woman per month, on average. Only 12% had access to interdisciplinary pregnancy clinics. Finally, 89% felt that interdisciplinary guidelines and/or continuing education seminars would improve knowledge. Participants lacked confidence in both counseling and managing women’s health. Innovative approaches are warranted to improve the care of women with kidney disease and might include the expansion of interdisciplinary clinics, the development of case-based teaching materials, and interdisciplinary treatment guidelines focused on this patient group.
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Affiliation(s)
- Elizabeth M Hendren
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada.
| | - Monica L Reynolds
- Division of Nephrology, Department of Internal Medicine, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Laura H Mariani
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
- Arbor Research Collaborative for Health, Ann Arbor, MI 48104, USA.
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI 48104, USA.
| | - Michelle M O'Shaughnessy
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94305-5101, USA.
| | - Andrea L Oliverio
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Nicholas W Moore
- Arbor Research Collaborative for Health, Ann Arbor, MI 48104, USA.
| | | | - Dana V Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| | - Salem Almanni
- Division of Nephrology, Department of Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.
| | - Katherine E Twombley
- Division of Nephrology, Department of Pediatric, Medical University of South Carolina, Charleston, SC 29425, USA.
| | - Emily Herreshoff
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Carla M Nester
- Divisions of Nephrology, Departments of Internal Medicine and Pediatrics, University of Iowa, Iowa City, IA 52242, USA.
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada.
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Selewski DT, Ambruzs JM, Appel GB, Bomback AS, Matar RB, Cai Y, Cattran DC, Chishti AS, D'Agati VD, D'Alessandri-Silva CJ, Gbadegesin RA, Hogan JJ, Iragorri S, Jennette JC, Julian BA, Khalid M, Lafayette RA, Liapis H, Lugani F, Mansfield SA, Mason S, Nachman PH, Nast CC, Nester CM, Noone DG, Novak J, O'Shaughnessy MM, Reich HN, Rheault MN, Rizk DV, Saha MK, Sanghani NS, Sperati CJ, Sreedharan R, Srivastava T, Swiatecka-Urban A, Twombley K, Vasylyeva TL, Weaver DJ, Yin H, Zee J, Falk RJ, Gharavi AG, Gillespie BW, Gipson DS, Greenbaum LA, Holzman LB, Kretzler M, Robinson BM, Smoyer WE, Flessner M, Guay-Woodford LM, Kiryluk K. Clinical Characteristics and Treatment Patterns of Children and Adults With IgA Nephropathy or IgA Vasculitis: Findings From the CureGN Study. Kidney Int Rep 2018; 3:1373-1384. [PMID: 30450464 PMCID: PMC6224619 DOI: 10.1016/j.ekir.2018.07.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [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: 04/19/2018] [Revised: 04/27/2018] [Accepted: 07/30/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction The Cure Glomerulonephropathy Network (CureGN) is a 66-center longitudinal observational study of patients with biopsy-confirmed minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, or IgA nephropathy (IgAN), including IgA vasculitis (IgAV). This study describes the clinical characteristics and treatment patterns in the IgA cohort, including comparisons between IgAN versus IgAV and adult versus pediatric patients. Methods Patients with a diagnostic kidney biopsy within 5 years of screening were eligible to join CureGN. This is a descriptive analysis of clinical and treatment data collected at the time of enrollment. Results A total of 667 patients (506 IgAN, 161 IgAV) constitute the IgAN/IgAV cohort (382 adults, 285 children). At biopsy, those with IgAV were younger (13.0 years vs. 29.6 years, P < 0.001), more frequently white (89.7% vs. 78.9%, P = 0.003), had a higher estimated glomerular filtration rate (103.5 vs. 70.6 ml/min per 1.73 m2, P < 0.001), and lower serum albumin (3.4 vs. 3.8 g/dl, P < 0.001) than those with IgAN. Adult and pediatric individuals with IgAV were more likely than those with IgAN to have been treated with immunosuppressive therapy at or prior to enrollment (79.5% vs. 54.0%, P < 0.001). Conclusion This report highlights clinical differences between IgAV and IgAN and between children and adults with these diagnoses. We identified differences in treatment with immunosuppressive therapies by disease type. This description of baseline characteristics will serve as a foundation for future CureGN studies.
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Affiliation(s)
- David T. Selewski
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
- Correspondence: David T. Selewski, University of Michigan, 1540 East Hospital Drive, Room 12-250, Ann Arbor, Michigan 48109-4297, USA.
| | | | - Gerald B. Appel
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Andrew S. Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Raed Bou Matar
- Center for Pediatric Nephrology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yi Cai
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Daniel C. Cattran
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aftab S. Chishti
- Division of Nephrology, Hypertension and Renal Transplantation, University of Kentucky, Lexington, Kentucky, USA
| | - Vivette D. D'Agati
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York, USA
| | | | - Rasheed A. Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan J. Hogan
- Renal Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sandra Iragorri
- Division of Nephrology and Hypertension, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Bruce A. Julian
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Myda Khalid
- Division of Nephrology, Department of Pediatrics, JW Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richard A. Lafayette
- Division of Nephrology and Hypertension, Stanford University, Stanford, California, USA
| | | | | | | | - Sherene Mason
- Section of Pediatric Nephrology, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Patrick H. Nachman
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Cynthia C. Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carla M. Nester
- Division of Pediatric Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
- Molecular Otolaryngology and Renal Research Laboratory, University of Iowa, Iowa City, Iowa, USA
| | - Damien G. Noone
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jan Novak
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Heather N. Reich
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Rheault
- Division of Nephrology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Dana V. Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Manish K. Saha
- Division of Nephrology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Neil S. Sanghani
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C. John Sperati
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rajasree Sreedharan
- Division of Nephrology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Tarak Srivastava
- Children's Mercy Hospital and University of Missouri−Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Agnieszka Swiatecka-Urban
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Katherine Twombley
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tetyana L. Vasylyeva
- Department of Pediatrics, Division of Nephrology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Donald J. Weaver
- Division of Nephrology and Hypertension, Levine Children's Hospital at Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Hong Yin
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Ronald J. Falk
- Division of Nephrology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ali G. Gharavi
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Brenda W. Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Debbie S. Gipson
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Larry A. Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Lawrence B. Holzman
- Department of Medicine, University of Pennsylvania Medical School, Philadelphia, Pennsylvania, USA
| | - Matthias Kretzler
- Department of Computational Medicine and Bioinformatics, University of Michigan School of Medicine, Ann Arbor, Michigan USA
- Division of Nephrology, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | | | - William E. Smoyer
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Michael Flessner
- Division of Kidney, Urology, and Hematology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa M. Guay-Woodford
- Center for Translational Science, Children’s National Health System, Washington, DC, USA
| | - Krzysztof Kiryluk
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Krzysztof Kiryluk, Columbia University, Department of Medicine, Division of Nephrology, 1150 St Nicholas Avenue, Russ Berrie Pavilion #412, New York, New York 10032, USA.
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Affiliation(s)
| | - Richard A Lafayette
- Glomerular Disease Center, Stanford University School of Medicine, Palo Alto, California
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O'Shaughnessy MM, Jobson MA, Sims K, Liberty AL, Nachman PH, Pendergraft WF. Pregnancy Outcomes in Patients with Glomerular Disease Attending a Single Academic Center in North Carolina. Am J Nephrol 2017; 45:442-451. [PMID: 28445873 DOI: 10.1159/000471894] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/16/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Contemporary data regarding pregnancy outcomes in US patients with primary glomerular diseases are lacking. We aimed to report fetal and maternal outcomes among women with biopsy-proven primary glomerular disease who received obstetric care at a single large academic US center. METHODS All women with a biopsy-confirmed primary glomerular disease diagnosis and without end-stage kidney disease who received obstetric care at the University of North Carolina (UNC) Hospitals (1996-2015) were identified using the Glomerular Disease Collaborative Network registry and the UNC Hospitals Perinatal Database. The primary study outcome was perinatal death (stillbirth at >20 weeks or neonatal death). Secondary outcomes included premature birth (<37 weeks), birth weight, preeclampsia, and kidney function changes (postpartum vs. baseline). Demographics, clinical characteristics, and outcomes were compared across glomerular disease subtypes. RESULTS Among 48 pregnancies in 43 women (IgA nephropathy n = 17, focal segmental glomerulosclerosis [FSGS] n = 16, membranous nephropathy n = 6, minimal change disease n = 4), 13% of pregnancies resulted in perinatal death and 48% of babies were born prematurely. From a maternal perspective, 33% of pregnancies were complicated by preeclampsia, 39% by a doubling of urinary protein, and 27% by a ≥50% increase in serum creatinine. Outcome differences across glomerular disease subtypes were not statistically significant, although decline in kidney function appeared most frequent in FSGS. CONCLUSION Adverse pregnancy outcomes are frequently observed in women with glomerular disease. The independent influence of glomerular disease subtype on outcomes requires further study. More widespread reporting and analysis of pregnancy outcomes in women with glomerular disease are urgently needed.
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O'Shaughnessy MM, Hogan SL. Distinguishing the Signals From the Noise: Can Epidemiologic Studies Inform Our Understanding of Glomerular Disease? Am J Kidney Dis 2016; 68:503-507. [PMID: 27664473 DOI: 10.1053/j.ajkd.2016.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 05/22/2016] [Indexed: 11/11/2022]
Affiliation(s)
| | - Susan L Hogan
- University of North Carolina, Chapel Hill, North Carolina
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O'Shaughnessy MM, Liu S, Montez-Rath ME, Lenihan CR, Lafayette RA, Winkelmayer WC. Kidney Transplantation Outcomes across GN Subtypes in the United States. J Am Soc Nephrol 2016; 28:632-644. [PMID: 27432742 DOI: 10.1681/asn.2016020126] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [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: 02/02/2016] [Accepted: 05/28/2016] [Indexed: 12/28/2022] Open
Abstract
Differences in kidney transplantation outcomes across GN subtypes have rarely been studied. From the US Renal Data System, we identified all adult (≥18 years) first kidney transplant recipients (1996-2011) with ESRD attributed to one of six GN subtypes or two comparator kidney diseases. We computed hazard ratios (HRs) for death, all-cause allograft failure, and allograft failure excluding death as a cause (competing risks framework) using Cox proportional hazards regression. Among the 32,131 patients with GN studied, patients with IgA nephropathy (IgAN) had the lowest mortality rates and patients with IgAN or vasculitis had the lowest allograft failure rates. After adjusting for patient- and transplant-related factors, compared with IgAN (referent), FSGS, membranous nephropathy, membranoproliferative GN, lupus nephritis, and vasculitis associated with HRs (95% confidence intervals) for death of 1.57 (1.43 to 1.72), 1.52 (1.34 to 1.72), 1.76 (1.55 to 2.01), 1.82 (1.63 to 2.02), and 1.56 (1.34 to 1.81), respectively, and with HRs for allograft failure excluding death as a cause of 1.20 (1.12 to 1.28), 1.27 (1.14 to 1.41), 1.50 (1.36 to 1.66), 1.11 (1.02 to 1.20), and 0.94 (0.81 to 1.09), respectively. Considering external comparator groups, and comparing with IgAN, autosomal dominant polycystic kidney disease (ADPKD) and diabetic nephropathy associated with higher HRs for mortality [1.22 (1.12 to 1.34) and 2.57 (2.35 to 2.82), respectively], but ADPKD associated with a lower HR for allograft failure excluding death as a cause [0.85 (0.79 to 0.91)]. Reasons for differential outcomes by GN subtype and cause of ESRD should be examined in future research.
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Affiliation(s)
| | - Sai Liu
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Colin R Lenihan
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Richard A Lafayette
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Wolfgang C Winkelmayer
- Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
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O'Shaughnessy MM, Montez-Rath ME, Zheng Y, Lafayette RA, Winkelmayer WC. Differences in Initial Hemodialysis Vascular Access Use Among Glomerulonephritis Subtypes in the United States. Am J Kidney Dis 2016; 67:638-47. [PMID: 26774466 DOI: 10.1053/j.ajkd.2015.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 10/19/2015] [Accepted: 11/19/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND The type of vascular access used for hemodialysis affects patient morbidity and mortality. Whether vascular access types differ by glomerulonephritis (GN) subtype in the US hemodialysis population has not been investigated. STUDY DESIGN Cross-sectional observational study. SETTING & PARTICIPANTS We identified all adult (aged ≥ 18 years) patients within the US Renal Data System who initiated hemodialysis therapy from July 2005 through December 2011 with a diagnosis of end-stage renal disease attributed to any of 4 primary (focal segmental glomerulosclerosis, immunoglobulin A nephropathy [reference group], membranous nephropathy, and membranoproliferative GN) or 2 secondary (lupus nephritis and vasculitis) GN subtypes. PREDICTOR GN subtype. OUTCOMES ORs with 95% CIs for arteriovenous fistula versus central venous catheter (CVC) use and for arteriovenous graft versus CVC use were computed using multinomial logistic regression, with adjustment for demographic, socioeconomic, comorbidity, and duration of nephrology care covariates. RESULTS Among 29,015 patients, CVC use at initiation of hemodialysis therapy was substantially higher in patients with lupus nephritis (89.2%) or vasculitis (91.2%) compared with patients with primary GN subtypes (72.7%-79.8%). After adjustment and compared with patients with immunoglobulin A nephropathy, patients with lupus nephritis or vasculitis were as likely to have used an arteriovenous graft (ORs of 0.94 [95% CI, 0.70-1.27] and 0.80 [95% CI, 0.56-1.13], respectively) but significantly less likely to have used an arteriovenous fistula (ORs of 0.66 [95% CI, 0.57-0.76] and 0.54 [95% CI, 0.45-0.63], respectively), whereas patients with any comparator primary GN subtype were at least as likely to have used either of these 2 access types. LIMITATIONS Potential misclassification of exposure; residual confounding by unmeasured covariates; inability to determine causes of observed associations; lacking longitudinal data for vascular access use. CONCLUSIONS Significant differences in vascular access distributions at initiation of hemodialysis therapy are apparent among GN subtypes. The unacceptably high use of CVCs in patients with lupus nephritis and vasculitis is particularly concerning. Further studies are needed to identify any potentially modifiable factors underlying these findings.
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Affiliation(s)
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Yuanchao Zheng
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Richard A Lafayette
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX
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O'Shaughnessy MM, Montez-Rath ME, Lafayette RA, Winkelmayer WC. Differences in initial treatment modality for end-stage renal disease among glomerulonephritis subtypes in the USA. Nephrol Dial Transplant 2015; 31:290-8. [PMID: 26610594 DOI: 10.1093/ndt/gfv386] [Citation(s) in RCA: 6] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/12/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Kidney transplantation is the preferred treatment for end-stage renal disease (ESRD), while peritoneal dialysis affords certain benefits over hemodialysis. Distributions and determinants of first ESRD treatment modality have not been compared across glomerulonephritis (GN) subtypes. METHODS We identified all adult (18-75 years) patients with ESRD attributed to any of six GN subtypes [focal segmental glomerulosclerosis (FSGS), IgA nephropathy (IgAN), membranous nephropathy (MN), membranoproliferative GN (MPGN), lupus nephritis (LN) and vasculitis] who were first registered in the US Renal Data System (USRDS) between 1996 and 2011. We used multinomial logistic regression--adjusting for temporal, geographic, demographic, socioeconomic and comorbid factors--to determine odds ratios (ORs) with 95% confidence intervals (CIs) for transplantation versus hemodialysis, and for peritoneal dialysis versus hemodialysis, comparing other GN subtypes to IgAN. RESULTS Among the 75 278 patients studied, patients with comparator GN subtypes were significantly less likely than those with IgAN to receive either transplantation or peritoneal dialysis. After adjusting for potentially confounding covariates, patients with comparator primary GN subtypes (FSGS, MN, MPGN) were at least as likely to receive transplantation [FSGS OR 0.98 (95% CI 0.93-1.15), MN OR 1.19 (95% CI 1.01-1.39), MPGN OR 1.08 (95% CI 0.93-1.26)] or peritoneal dialysis [FSGS OR 1.05 (95% CI 0.98-1.12), MN OR 1.30 (95% CI 1.18-1.43), MPGN OR 0.95 (95% CI 0.85-1.06)] as patients with IgAN. Conversely, patients with the secondary GN subtypes LN and vasculitis remained significantly less likely to receive either modality [transplantation OR 0.49 (95% CI 0.43-0.56) for LN and 0.27 (95% CI 0.22-0.34) for vasculitis, peritoneal dialysis OR 0.76 (95% CI 0.70-0.82) for LN and 0.54 (95% CI 0.48-0.60) for vasculitis]. CONCLUSIONS Significant differences in ESRD treatment practice patterns are apparent among GN subtypes. To ensure equitable care for all patients, regardless of GN subtype, reasons for observed disparities should be elucidated and-if appropriate-eliminated.
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Affiliation(s)
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Richard A Lafayette
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX, USA
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O'Shaughnessy MM, Montez-Rath ME, Lafayette RA, Winkelmayer WC. Patient characteristics and outcomes by GN subtype in ESRD. Clin J Am Soc Nephrol 2015; 10:1170-8. [PMID: 26092830 DOI: 10.2215/cjn.11261114] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [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: 11/12/2014] [Accepted: 02/26/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Outcomes-based research rarely focuses on patients with ESRD caused by GN. The hypotheses were that the GN subtype would clinically discriminate patient groups and independently associate with survival after ESRD therapy initiation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were extracted from the US Renal Data System for adult patients with incident (1996-2011) ESRD attributed to six GN subtypes: FSGS, IgA nephropathy (IgAN), membranous nephropathy, membranoproliferative glomeruonephritis, lupus nephritis (LN), and vasculitis. ESRD attributed to diabetes and autosomal dominant polycystic kidney disease served as non-GN comparators. Unadjusted and adjusted mortality hazard ratios (aHRs) with 95% confidence intervals (95% CIs) were estimated using Cox regression (reference, IgAN). Models sequentially adjusted for sociodemographic (model 2), comorbidity/laboratory (model 3), and ESRD treatment modality (model 4) variables. RESULTS Among 84,301 patients with ESRD attributed to GN, the median age ranged from 39 (LN) to 66 (vasculitis) years, male sex ranged from 18% (LN) to 68% (IgAN), and black race ranged from 7% (IgAN) to 49% (LN). Patients with IgAN had the fewest comorbidities and lowest use of hemodialysis (70.1%). After a median follow-up of 2.5 (interquartile range, 1.0-4.9) years, crude mortality was lowest in IgAN (3.7 deaths/100 person years). Compared to IgAN, adjusted mortality was highest in LN (model 4 aHR=1.75; 95% CI, 1.68 to 1.83) and in diabetes (aHR=1.73; 95% CI, 1.67 to 1.79), and was also higher in all other GN subtypes (membranous nephropathy: aHR=1.23; 95% CI, 1.17 to 1.29; FSGS: aHR=1.37; 95% CI, 1.32 to 1.42; membranoproliferative GN: aHR=1.38; 95% CI, 1.31 to 1.45; vasculitis: aHR=1.51; 95% CI, 1.45 to 1.58) and in autosomal dominant polycystic kidney disease (aHR=1.22; 95% CI, 1.18 to 1.27). CONCLUSIONS This study exposes substantial heterogeneity across GN subtypes at ESRD therapy initiation and identifies independent associations between GN subtype and post-ESRD mortality. These survival discrepancies warrant further study, and the utility of current research practice to group GN subtypes together when evaluating ESRD outcomes should be questioned.
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Affiliation(s)
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Richard A Lafayette
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
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O'Shaughnessy MM, O'Regan JA, Lavin PJ. Prevention of sudden cardiac death in hemodialysis patients. Cardiovasc Hematol Disord Drug Targets 2014; 14:195-204. [PMID: 24720456 DOI: 10.2174/1871529x14666140401112956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/22/2014] [Accepted: 03/25/2014] [Indexed: 06/03/2023]
Abstract
One quarter of all hemodialysis patients will succumb to sudden cardiac death (SCD), a rate far exceeding that observed in the general population. A high prevalence of atherosclerotic coronary artery disease amongst patients with end-stage kidney disease (ESKD) partly explains this exaggerated risk. However, uremia and dialysis related factors are also of critical importance. Interventions aimed at preventing SCD have been inadequately studied in patients with ESKD. Data extrapolated from non-renal populations cannot necessarily be applied to hemodialysis patients, who possess relatively unique risk factors for SCD including "uremic cardiomyopathy", electrolyte shifts, fluctuations in intravascular volume and derangements of mineral and bone metabolism. Pending data derived from proposed randomized controlled clinical trials, critical appraisal of existing evidence and the selective application of guidelines developed for the general population to dialysis patients are required if therapeutic nihilism, or excessive intervention, are to be avoided. We discuss the evidence supporting a role for medical therapies, dialysis prescription refinements, revascularization procedures and electrical therapies as potential interventions to prevent SCD amongst hemodialysis patients. Based on current best available evidence, we present suggested strategies for the prevention of arrhythmia-mediated death in this highly vulnerable patient population.
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MESH Headings
- Animals
- Arrhythmias, Cardiac/complications
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/etiology
- Coronary Artery Disease/complications
- Coronary Artery Disease/epidemiology
- Coronary Artery Disease/etiology
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Humans
- Kidney Failure, Chronic/complications
- Kidney Failure, Chronic/therapy
- Practice Guidelines as Topic
- Prevalence
- Renal Dialysis
- Risk Factors
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Affiliation(s)
| | | | - Peter J Lavin
- Trinity Health Kidney Centre, Tallaght Hospital, Trinity College, Dublin, Ireland.
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Medjeral-Thomas NR, O'Shaughnessy MM, O'Regan JA, Traynor C, Flanagan M, Wong L, Teoh CW, Awan A, Waldron M, Cairns T, O'Kelly P, Dorman AM, Pickering MC, Conlon PJ, Cook HT. C3 glomerulopathy: clinicopathologic features and predictors of outcome. Clin J Am Soc Nephrol 2013; 9:46-53. [PMID: 24178974 DOI: 10.2215/cjn.04700513] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES The term C3 glomerulopathy describes renal disorders characterized by the presence of glomerular deposits composed of C3 in the absence of significant amounts of Ig. On the basis of electron microscopy appearance, subsets of C3 glomerulopathy include dense deposit disease (DDD) and C3 glomerulonephritis (C3GN). The full spectrum of histologic change observed in C3 glomerulopathy has yet to be defined and pathologic predictors of renal outcome within this patient population remain largely unknown. This study thus characterized a large C3 glomerulopathy cohort and identified clinicopathologic predictors of renal outcome. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All patients with kidney biopsies fulfilling criteria for C3 glomerulopathy from two quaternary renal centers within the United Kingdom and Ireland between 1992 and 2012 were retrospectively reviewed. We recorded histologic, demographic, and clinical data and determined predictors of ESRD using the Cox proportional hazards model. RESULTS Eighty patients with C3 glomerulopathy were identified: 21 with DDD and 59 with C3GN. Patients with DDD were younger, more likely to have low serum C3 levels, and more likely to have crescentic GN than patients with C3GN. Patients with C3GN were older and had more severe arteriolar sclerosis, glomerular sclerosis, and interstitial scarring than patients with DDD. Of 70 patients with available follow-up data, 20 (29%) progressed to ESRD after a median of 28 months. Age >16 years, DDD subtype, and crescentic GN were independent predictors of ESRD within the entire cohort. Renal impairment at presentation predicted ESRD only among patients with DDD. CONCLUSIONS Although detailed serologic and genetic data are lacking, this study nevertheless identifies important clinicopathologic distinctions between patients with DDD and C3GN. These include independent predictors of renal outcome. If replicated in other cohorts, these predictors could be used to stratify patients, enabling application of emerging mechanism-based therapies to patients at high risk for poor renal outcome.
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Affiliation(s)
- Nicholas R Medjeral-Thomas
- West London Renal and Transplant Centre, Imperial College Healthcare National Health Service Trust, London, United Kingdom;, †Centre for Complement and Inflammation Research, Imperial College, London, United Kingdom;, ‡Department of Transplant, Urology and Nephrology, Beaumont Hospital, Dublin, Ireland;, §Children's University Hospital, Temple Street, Dublin, Ireland;, ‖Our Lady's Children's Hospital, Crumlin, Dublin, Ireland, ¶Department of Renal Pathology, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
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O'Shaughnessy MM, Durcan M, Kinsella SM, Griffin MD, Reddan DN, Lappin DW. Blood pressure measurement in peritoneal dialysis: which method is best? Perit Dial Int 2013; 33:544-51. [PMID: 23547279 DOI: 10.3747/pdi.2012.00027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [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: 11/15/2022] Open
Abstract
BACKGROUND The optimal approach to monitoring blood pressure (BP) in the peritoneal dialysis (PD) population is unclear. Ambulatory BP monitoring reliably predicts prognosis, but can be inconvenient. The accuracy of home BP monitoring in this population is unproven. The automated BpTRU device (BpTRU Medical Devices, Coquitlam, BC, Canada), which provides an average of up to 6 successive in-office BP measurements, has not been studied in this patient group. METHODS We studied 17 patients (average age: 54 ± 12 years; 12 men, 5 women; 94% on automated PD) attending a single center. All patients underwent office, home, BpTRU, and ambulatory BP measurement. The reference standard for analysis was daytime ambulatory BP. Correlation between the referent method and each comparator method was determined (Pearson correlation coefficient), and Bland-Altman scatter plots depicting the differences in the BP measurements were constructed. RESULTS Mean office BP (126.4 ± 16.9/78.8 ± 11.6 mmHg) and BpTRU BP (123.8 ± 13.7/80.7 ± 11.1 mmHg) closely approximated mean daytime ambulatory BP (129.3 ± 14.8/78.2 ± 7.9 mmHg). Mean home BP (143.8 ± 15.0/89.9 ± 28.1 mmHg) significantly overestimated mean daytime systolic BP by 14.2 mmHg (95% confidence interval: 4.3 mmHg to 24.1 mmHg; p = 0.008). Bland-Altman plots demonstrated poorest agreement between home BP and daytime ambulatory BP. No patient had "white-coat hypertension," and only 1 patient had false-resistant hypertension. Most patients showed abnormal nocturnal dipping patterns (non-dipping: n = 11; reverse-dipping: n = 5; normal dipping: n = 1). CONCLUSIONS We report a novel finding that BP measurement using the BpTRU device is more accurate than home BP measurement in a PD population. Potential explanations for this observation include poor home BP measurement technique, use of poorly validated home BP measurement devices, or a reduced prevalence of white-coat effect among PD patients. Our study also confirms that, in the PD population, BP measurements vary considerably with patient location, time of day, and measurement technique.
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Affiliation(s)
- Michelle M O'Shaughnessy
- Nephrology Services,1 Galway University Hospitals, and College of Medicine Nursing and Health Sciences,2 National University of Ireland, Galway, Ireland
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O'Shaughnessy MM, O'Regan JA, Murray FE, Connell JA, Duffy MP, Francis VM, Dwyer S, Thornton LM, Conlon PJ. Re-infection following sustained virological response with a different hepatitis C virus genotype: implications for infection control policy. Clin Kidney J 2012; 5:250-3. [PMID: 26069778 PMCID: PMC4400513 DOI: 10.1093/ckj/sfs040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [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: 01/09/2012] [Accepted: 03/08/2012] [Indexed: 11/23/2022] Open
Abstract
We report the case of a 45-year-old haemodialysis patient who achieved a sustained virological response (SVR) following pegylated interferon therapy for hepatitis C virus (HCV) genotype 2 infection. He was subsequently cohorted with other HCV-infected dialysis patients and became re-infected with HCV genotype 3a. Epidemiological and molecular investigations identified a highly viraemic HCV genotype 3a-infected dialysis patient as the likely source of this infection. This critical incident informed a revision to local and national infection control policy regarding the dialysis management of patients who achieve an SVR following anti-viral treatment.
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Affiliation(s)
| | - John A O'Regan
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland
| | - Frank E Murray
- Department of Hepatology, Beaumont Hospital, Dublin, Ireland
| | - Jeff A Connell
- National Virus Reference Laboratory, University College Dublin, Dublin, Ireland
| | - Margaret P Duffy
- National Virus Reference Laboratory, University College Dublin, Dublin, Ireland
| | | | - Sharon Dwyer
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland
| | | | - Peter J Conlon
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland
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O'Shaughnessy MM, Lappin DW, Reddan DN. Sudden cardiac death in dialysis: do current guidelines for implantable cardioverter defibrillator therapy apply to patients with end-stage kidney disease? Semin Dial 2012; 25:272-6. [PMID: 22452711 DOI: 10.1111/j.1525-139x.2012.01067.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Arrhythmic mechanisms account for one in four deaths in end-stage kidney disease. Large-scale randomized controlled trials have demonstrated a mortality benefit from implantable cardioverter defibrillator therapy in carefully selected patient groups at high risk for sudden cardiac death. Unfortunately, patients with end-stage kidney disease were systematically excluded from these trials. Consequently, the applicability of American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) guidelines on implantable cardioverter defibrillator therapy to dialysis patients remains uncertain. Observational data suggest that secondary preventative implantable cardioverter defibrillator therapy following resuscitated cardiac arrest prolongs the lives of dialysis patients. This intervention may also offer a survival advantage as a primary preventative strategy in end-stage kidney disease. However, competing risk from co-morbidity can negate any perceived benefit. Device-related complications also negatively impact outcome. The recommendation that primary preventative device implantation be reserved for patients with severely impaired left ventricular function may be excessively restrictive in this high-risk population. Trials of implantable cardioverter defibrillator therapy that include dialysis patients are required to validate existing device eligibility criteria in this unique population. Novel indications for this intervention in dialysis patients should also be identified.
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Peter FW, Franken RJ, Wang WZ, Anderson GL, Schuschke DA, O'Shaughnessy MM, Banis JC, Steinau HU, Barker JH. Effect of low dose aspirin on thrombus formation at arterial and venous microanastomoses and on the tissue microcirculation. Plast Reconstr Surg 1997; 99:1112-21. [PMID: 9091911 DOI: 10.1097/00006534-199704000-00030] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In free flap/replantation surgery, failure is usually associated with thrombotic occlusion of a microvascular anastomosis (risk zone I) or, on occasion, flow impairment in the microcirculation of the transferred or replanted tissue (risk zone II). The objective of this study is to describe the effect of low dose aspirin on blood flow at both risk zones in microvascular surgery. Risk zone I: In rat femoral arteries and veins, thrombus formation was measured at the anastomoses using transillumination and videomicroscopy. Forty male Wistar rats were assigned in equal numbers to four groups: either arterial or venous injury with either aspirin (5 mg/kg systemically) or saline treatment. We found that aspirin significantly reduces thrombus formation at the venous anastomosis (p = 0.001). Risk zone II: In the isolated rat cremaster muscle downstream from an arterial anastomosis, we measured capillary perfusion, arteriolar diameters, and the appearance of platelet emboli for 6 hours in the muscle microcirculation. Sixteen male Wistar rats in two equal groups received either aspirin (5 mg/kg systemically) or saline. We found that in aspirin-treated animals, capillary perfusion is significantly (p = 0.002) improved, whereas arteriolar diameters and emboli only slightly increased. In conclusion, low dose aspirin inhibits anastomotic venous thrombosis and improves microcirculatory perfusion in our rat model. These studies provide quantitative data confirming and clarifying the beneficial effects of low dose aspirin in microvascular surgery.
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Affiliation(s)
- F W Peter
- Department of Physiology and Biophysics, University of Louisville School of Medicine, Kentucky, USA
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