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Kim T, Surapaneni AL, Schmidt IM, Eadon MT, Kalim S, Srivastava A, Palsson R, Stillman IE, Hodgin JB, Menon R, Otto EA, Coresh J, Grams ME, Waikar SS, Rhee EP. Plasma Proteins associated with Chronic Histopathologic Lesions on Kidney Biopsy. J Am Soc Nephrol 2024:00001751-990000000-00298. [PMID: 38656806 DOI: 10.1681/asn.0000000000000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 04/17/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND The severity of chronic histopathologic lesions on kidney biopsy is independently associated with higher risk of progressive chronic kidney disease (CKD). Because kidney biopsies are invasive, identification of blood markers that report on underlying kidney histopathology has the potential to enhance CKD care. METHODS We examined the association between 6592 plasma protein levels measured by aptamers and the severity of interstitial fibrosis and tubular atrophy (IFTA), glomerulosclerosis, arteriolar sclerosis, and arterial sclerosis among 434 participants of the Boston Kidney Biopsy Cohort. For proteins significantly associated with at least one histologic lesion, we assessed renal arteriovenous protein gradients among 21 individuals who had undergone invasive catheterization and assessed the expression of the cognate gene among 47 individuals with single cell RNA sequencing data in the Kidney Precision Medicine Project. RESULTS In models adjusted for estimated glomerular filtration rate (eGFR), proteinuria, and demographic factors, we identified 35 proteins associated with one or more chronic histologic lesions, including 20 specific for IFTA, 8 specific for glomerulosclerosis, and 1 specific for arteriolar sclerosis. In general, higher levels of these proteins were associated with more severe histologic score and lower eGFR. Exceptions included testican-2 and NELL1, which were associated with less glomerulosclerosis and IFTA, respectively, and higher eGFR; notably, both of these proteins demonstrated significantly higher levels from artery to renal vein, demonstrating net kidney release. In the Kidney Precision Medicine Project, 13 of the 35 protein hits had cognate gene expression enriched in one or more cell types in the kidney, including podocyte expression of select glomerulosclerosis markers (including testican-2) and tubular expression of several IFTA markers (including NELL1). CONCLUSIONS Proteomic analysis identified circulating proteins associated with chronic histopathologic lesions, some of which have concordant site-specific expression within the kidney.
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Affiliation(s)
- Taesoo Kim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Aditya L Surapaneni
- Department of Medicine, New York University Langone School of Medicine, New York, NY
| | - Insa M Schmidt
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
| | - Michael T Eadon
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Sahir Kalim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Anand Srivastava
- Division of Nephrology, University of Illinois Chicago, Chicago, IL
| | - Ragnar Palsson
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Isaac E Stillman
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Rajasree Menon
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI
| | - Edgar A Otto
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Morgan E Grams
- Department of Medicine, New York University Langone School of Medicine, New York, NY
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
| | - Eugene P Rhee
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
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Srivastava A, Amodu A, Liu J, Verma A, Mothi SS, Palsson R, Stillman IE, Kestenbaum BR, Waikar SS. The Associations of Urine Albumin-Protein Ratio With Histopathologic Lesions and Clinicopathologic Diagnoses in Individuals With Kidney Disease. Am J Kidney Dis 2024; 83:557-560. [PMID: 37827424 DOI: 10.1053/j.ajkd.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 08/03/2023] [Accepted: 08/20/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Anand Srivastava
- Division of Nephrology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois.
| | - Afolarin Amodu
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Jing Liu
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Ashish Verma
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Suraj Sarvode Mothi
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ragnar Palsson
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Isaac E Stillman
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bryan R Kestenbaum
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, Washington
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts
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Verma A, Schmidt IM, Claudel S, Palsson R, Waikar SS, Srivastava A. Association of Albuminuria With Chronic Kidney Disease Progression in Persons With Chronic Kidney Disease and Normoalbuminuria : A Cohort Study. Ann Intern Med 2024; 177:467-475. [PMID: 38560911 DOI: 10.7326/m23-2814] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Albuminuria is a major risk factor for chronic kidney disease (CKD) progression, especially when categorized as moderate (30 to 300 mg/g) or severe (>300 mg/g). However, there are limited data on the prognostic value of albuminuria within the normoalbuminuric range (<30 mg/g) in persons with CKD. OBJECTIVE To estimate the increase in the cumulative incidence of CKD progression with greater baseline levels of albuminuria among persons with CKD who had normoalbuminuria (<30 mg/g). DESIGN Multicenter prospective cohort study. SETTING 7 U.S. clinical centers. PARTICIPANTS 1629 participants meeting criteria from the CRIC (Chronic Renal Insufficiency Cohort) study with CKD (estimated glomerular filtration rate [eGFR], 20 to 70 mL/min/1.73 m2) and urine albumin-creatinine ratio (UACR) less than 30 mg/g. MEASUREMENTS Baseline spot urine albumin divided by spot urine creatinine to calculate UACR as the exposure variable. The 10-year adjusted cumulative incidences of CKD progression (composite of 50% eGFR decline or kidney failure [dialysis or kidney transplantation]) from confounder adjusted survival curves using the G-formula. RESULTS Over a median follow-up of 9.8 years, 182 of 1629 participants experienced CKD progression. The 10-year adjusted cumulative incidences of CKD progression were 8.7% (95% CI, 5.9% to 11.6%), 11.5% (CI, 8.8% to 14.3%), and 19.5% (CI, 15.4% to 23.5%) for UACR levels of 0 to less than 5 mg/g, 5 to less than 15 mg/g, and 15 mg/g or more, respectively. Comparing persons with UACR 15 mg/g or more to those with UACR 5 to less than 15 mg/g and 0 to less than 5 mg/g, the absolute risk differences were 7.9% (CI, 3.0% to 12.7%) and 10.7% (CI, 5.8% to 15.6%), respectively. The 10-year adjusted cumulative incidence increased linearly based on baseline UACR levels. LIMITATION UACR was measured once. CONCLUSION Persons with CKD and normoalbuminuria (<30 mg/g) had excess risk for CKD progression, which increased in a linear fashion with higher levels of albuminuria. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Ashish Verma
- Boston Medical Center and Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts (A.V., S.S.W.)
| | - Insa M Schmidt
- Boston Medical Center and Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts; and Hamburg Center for Kidney Health, University Medical Center Hamburg, Hamburg, Germany (I.M.S.)
| | - Sophie Claudel
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts (S.C.)
| | - Ragnar Palsson
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (R.P.)
| | - Sushrut S Waikar
- Boston Medical Center and Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts (A.V., S.S.W.)
| | - Anand Srivastava
- Division of Nephrology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois (A.S.)
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Srivastava A, Schmidt IM, Palsson R. Combined Angiotensin Inhibition for CKD: The Truth Is Rarely Pure and Never Simple. Am J Kidney Dis 2024; 83:130-132. [PMID: 38069999 DOI: 10.1053/j.ajkd.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/22/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Anand Srivastava
- Division of Nephrology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Insa M Schmidt
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts; Hamburg Center for Kidney Health, University Medical Center Hamburg, Hamburg, Germany
| | - Ragnar Palsson
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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Buckley L, Palsson R, Waikar SS. Linking Kidney Vessel Scarring to Cardiovascular Risk-Reply. JAMA Cardiol 2023; 8:1000. [PMID: 37672259 DOI: 10.1001/jamacardio.2023.2755] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Affiliation(s)
- Leo Buckley
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ragnar Palsson
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Boston
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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Liu J, Bankir L, Verma A, Waikar SS, Palsson R. Association of the Urine-to-Plasma Urea Ratio With CKD Progression. Am J Kidney Dis 2023; 81:394-405. [PMID: 36356680 DOI: 10.1053/j.ajkd.2022.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 03/19/2022] [Accepted: 09/01/2022] [Indexed: 11/09/2022]
Abstract
RATIONALE & OBJECTIVES The urine-to-plasma (U/P) ratio of urea is correlated with urine-concentrating capacity and associated with progression of autosomal dominant polycystic kidney disease. As a proposed biomarker of tubular function, we hypothesized that the U/P urea ratio would also be associated with progression of more common forms of chronic kidney disease (CKD). STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 3,723 adults in the United States with estimated glomerular filtration rate (eGFR) of 20-70 mL/min/1.73 m2, enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study. EXPOSURE U/P urea ratio, calculated from 24-hour urine collections and plasma samples at baseline. OUTCOME Associations of U/P urea ratio with eGFR slope, initiation of kidney replacement therapy (KRT), and CKD progression, defined as 50% decline in eGFR or incident KRT. ANALYTICAL APPROACH Multivariable linear mixed-effects models tested associations with eGFR slope. Cox proportional hazards models tested associations with dichotomous CKD outcomes. RESULTS The median U/P urea ratio was 14.8 (IQR, 9.5-22.2). Compared with participants in the highest U/P urea ratio quintile, those in the lowest quintile had a greater eGFR decline by 1.06 mL/min/1.73 m2 per year (P < 0.001) over 7.0 (IQR, 3.0-11.0) years of follow-up observation. Each 1-SD lower natural log-transformed U/P urea ratio was independently associated with CKD progression (HR, 1.22 [95% CI, 1.12-1.33]) and incident KRT (HR, 1.22 [95% CI, 1.10-1.33]). Associations differed by baseline eGFR (P interaction = 0.009). Among those with an eGFR ≥30 mL/min/1.73 m2, each 1-SD lower in ln(U/P urea ratio) was independently associated with CKD progression (HR, 1.30 [95% CI, 1.18-1.45]), but this was not significant among those with eGFR <30 mL/min/1.73 m2 (HR, 1.00 [95% CI, 0.84-1.20]). LIMITATIONS Possibility of residual confounding. Single baseline 24-hour urine collection for U/P urea ratio. CONCLUSIONS In a large and diverse cohort of patients with common forms of CKD, U/P urea was independently associated with disease progression and incident kidney failure. Associations were not significant among those with advanced CKD at baseline.
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Affiliation(s)
- Jing Liu
- Kidney Research Institute, Renal Division, West China Hospital of Sichuan University, Chengdu, People's Republic of China; Section of Nephrology, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Lise Bankir
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France; CNRS, ERL 8228, Laboratoire de Physiologie Rénale et Tubulopathies, Paris, France
| | - Ashish Verma
- Section of Nephrology, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Sushrut S Waikar
- Section of Nephrology, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ragnar Palsson
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Medical School, Harvard University, Boston, Massachusetts.
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Buckley LF, Schmidt IM, Verma A, Palsson R, Adam D, Shah AM, Srivastava A, Waikar SS. Associations Between Kidney Histopathologic Lesions and Incident Cardiovascular Disease in Adults With Chronic Kidney Disease. JAMA Cardiol 2023; 8:357-365. [PMID: 36884237 PMCID: PMC9996453 DOI: 10.1001/jamacardio.2023.0056] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 01/06/2023] [Indexed: 03/09/2023]
Abstract
Importance Histologic lesions in the kidney may reflect or contribute to systemic processes that may lead to adverse cardiovascular events. Objective To assess the association between kidney histopathologic lesion severity and the risk of incident major adverse cardiovascular events (MACE). Design, Setting, and Participants This prospective observational cohort study included participants without a history of myocardial infarction, stroke, or heart failure from the Boston Kidney Biopsy Cohort recruited from 2 academic medical centers in Boston, Massachusetts. Data were collected from September 2006 and November 2018, and data were analyzed from March to November 2021. Exposures Semiquantitative severity scores for kidney histopathologic lesions adjudicated by 2 kidney pathologists, a modified kidney pathology chronicity score, and primary clinicopathologic diagnostic categories. Main Outcomes and Measures The main outcome was the composite of death or incident MACE, which included myocardial infarction, stroke, and heart failure hospitalization. All cardiovascular events were independently adjudicated by 2 investigators. Cox proportional hazards models estimated associations of histopathologic lesions and scores with cardiovascular events adjusted for demographic characteristics, clinical risk factors, estimated glomerular filtration rate (eGFR), and proteinuria. Results Of 597 included participants, 308 (51.6%) were women, and the mean (SD) age was 51 (17) years. The mean (SD) eGFR was 59 (37) mL/min per 1.73 m2, and the median (IQR) urine protein to creatinine ratio was 1.54 (0.39-3.95). The most common primary clinicopathologic diagnoses were lupus nephritis, IgA nephropathy, and diabetic nephropathy. Over a median (IQR) of 5.5 (3.3-8.7) years of follow-up, the composite of death or incident MACE occurred in 126 participants (37 per 1000 person-years). Compared with the reference group of individuals with proliferative glomerulonephritis, the risk of death or incident MACE was highest in individuals with nonproliferative glomerulopathy (hazard ratio [HR], 2.61; 95% CI, 1.30-5.22; P = .002), diabetic nephropathy (HR, 3.56; 95% CI, 1.62-7.83; P = .002), and kidney vascular diseases (HR, 2.86; 95% CI, 1.51-5.41; P = .001) in fully adjusted models. The presence of mesangial expansion (HR, 2.98; 95% CI, 1.08-8.30; P = .04) and arteriolar sclerosis (HR, 1.68; 95% CI, 1.03-2.72; P = .04) were associated with an increased risk of death or MACE. Compared with minimal chronicity, greater chronicity was significantly associated with an increased risk of death or MACE (severe: HR, 2.50; 95% CI, 1.06-5.87; P = .04; moderate: HR, 1.66; 95% CI, 0.74-3.75; P = .22; mild: HR, 2.22; 95% CI, 1.01-4.89; P = .047) in fully adjusted models. Conclusions and Relevance In this study, specific kidney histopathological findings were associated with increased risks of CVD events. These results provide potential insight into mechanisms of the heart-kidney relationship beyond those provided by eGFR and proteinuria.
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Affiliation(s)
- Leo F. Buckley
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Insa M. Schmidt
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ashish Verma
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ragnar Palsson
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Boston
| | - Debbie Adam
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Amil M. Shah
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Anand Srivastava
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago
| | - Sushrut S. Waikar
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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Schmidt IM, Myrick S, Liu J, Verma A, Srivastava A, Palsson R, Onul IF, Stillman IE, Avillach C, Patil P, Waikar SS. The use of plasma biomarker-derived clusters for clinicopathologic phenotyping: results from the Boston Kidney Biopsy Cohort. Clin Kidney J 2023; 16:90-99. [PMID: 36726432 PMCID: PMC9871860 DOI: 10.1093/ckj/sfac202] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Indexed: 02/04/2023] Open
Abstract
Background Protein biomarkers may provide insight into kidney disease pathology but their use for the identification of phenotypically distinct kidney diseases has not been evaluated. Methods We used unsupervised hierarchical clustering on 225 plasma biomarkers in 541 individuals enrolled into the Boston Kidney Biopsy Cohort, a prospective cohort study of individuals undergoing kidney biopsy with adjudicated histopathology. Using principal component analysis, we studied biomarker levels by cluster and examined differences in clinicopathologic diagnoses and histopathologic lesions across clusters. Cox proportional hazards models tested associations of clusters with kidney failure and death. Results We identified three biomarker-derived clusters. The mean estimated glomerular filtration rate was 72.9 ± 28.7, 72.9 ± 33.4 and 39.9 ± 30.4 mL/min/1.73 m2 in Clusters 1, 2 and 3, respectively. The top-contributing biomarker in Cluster 1 was AXIN, a negative regulator of the Wnt signaling pathway. The top-contributing biomarker in Clusters 2 and 3 was Placental Growth Factor, a member of the vascular endothelial growth factor family. Compared with Cluster 1, individuals in Cluster 3 were more likely to have tubulointerstitial disease (P < .001) and diabetic kidney disease (P < .001) and had more severe mesangial expansion [odds ratio (OR) 2.44, 95% confidence interval (CI) 1.29, 4.64] and inflammation in the fibrosed interstitium (OR 2.49 95% CI 1.02, 6.10). After multivariable adjustment, Cluster 3 was associated with higher risks of kidney failure (hazard ratio 3.29, 95% CI 1.37, 7.90) compared with Cluster 1. Conclusion Plasma biomarkers may identify clusters of individuals with kidney disease that associate with different clinicopathologic diagnoses, histopathologic lesions and adverse outcomes, and may uncover biomarker candidates and relevant pathways for further study.
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Affiliation(s)
- Insa M Schmidt
- Boston University School of Medicine and Boston Medical Center, Department of Medicine, Section of Nephrology, Boston, MA, USA
| | - Steele Myrick
- Boston University School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Jing Liu
- Division of Nephrology and National Clinical Research Center for Geriatrics, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China
| | - Ashish Verma
- Boston University School of Medicine and Boston Medical Center, Department of Medicine, Section of Nephrology, Boston, MA, USA
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ragnar Palsson
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ingrid F Onul
- Boston University School of Medicine and Boston Medical Center, Department of Medicine, Section of Nephrology, Boston, MA, USA
| | - Isaac E Stillman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Pathology, Boston, MA, USA
| | - Claire Avillach
- Boston Medical Center, Department of Pathology, Boston, MA, USA
| | - Prasad Patil
- Boston University School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Sushrut S Waikar
- Boston University School of Medicine and Boston Medical Center, Department of Medicine, Section of Nephrology, Boston, MA, USA
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Palsson R, Riella LV. Dessensibilização no transplante: a imunoglobulina intravenosa é o Santo Graal? J Bras Nefrol 2022. [DOI: 10.1590/2175-8239-jbn-2022-e010pt] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ragnar Palsson
- Massachusetts General Hospital, USA; Harvard Medical School, USA
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Garimella PS, Katz R, Waikar SS, Srivastava A, Schmidt I, Hoofnagle A, Palsson R, Rennke HG, Stillman IE, Wang K, Kestenbaum BR, Ix JH. Kidney Tubulointerstitial Fibrosis and Tubular Secretion. Am J Kidney Dis 2022; 79:709-716. [PMID: 34571064 PMCID: PMC8973399 DOI: 10.1053/j.ajkd.2021.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 02/16/2021] [Accepted: 08/13/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Tubular secretion plays an important role in the efficient elimination of endogenous solutes and medications, and lower secretory clearance is associated with risk of kidney function decline. We evaluated whether histopathologic quantification of interstitial fibrosis and tubular atrophy (IFTA) is associated with lower tubular secretory clearance in persons undergoing kidney biopsy. STUDY DESIGN Cross-sectional. SETTINGS & PARTICIPANTS The Boston Kidney Biopsy Cohort is a study of persons undergoing native kidney biopsies for clinical indications. EXPOSURES Semiquantitative score of IFTA reported by 2 trained pathologists. OUTCOMES We measured plasma and urine concentrations of 9 endogenous secretory solutes using a targeted liquid chromatography/mass spectrometry assay. We used linear regression to test associations of urine-to-plasma ratios (UPRs) of these solutes with IFTA score after controlling for estimated glomerular filtration rate (eGFR) and albuminuria. RESULTS Among 418 participants, mean age was 53 years, 51% were women, 64% were White, and 18% were Black. Mean eGFR was 50mL/min/1.73m2, and median urinary albumin-creatinine ratio was 819mg/g. Compared with individuals with≤25% IFTA, those with>50% IFTA had 12%-37% lower UPRs for all 9 secretory solutes. Adjusting for age, sex, race, eGFR, and urine albumin and creatinine levels attenuated the associations, yet a trend of lower secretion across groups remained statistically significant (P<0.05 for trend) for 7 of 9 solutes. A standardized composite secretory score incorporating UPR for all 9 secretory solutes using the min-max method showed similar results (P<0.05 for trend). LIMITATIONS Single time point and spot measures of secretory solutes. CONCLUSIONS Greater IFTA severity is associated with lower clearance of endogenous secretory solutes even after adjusting for eGFR and albuminuria.
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Affiliation(s)
- Pranav S Garimella
- Division of Nephrology-Hypertension, University of California San Diego, La Jolla; Kidney Health, Research and Innovation Hub of San Diego, San Diego, CA.
| | - Ronit Katz
- Departments of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Anand Srivastava
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Insa Schmidt
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | | | - Ragnar Palsson
- Division of Nephrology, Landspitali-The National University Hospital of Iceland, Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - Isaac E Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ke Wang
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, WA; Kidney Research Institute, Seattle, WA
| | - Bryan R Kestenbaum
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, WA; Kidney Research Institute, Seattle, WA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California San Diego, La Jolla
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Palsson R, Riella LV. Desensitization in transplantation: is intravenous immunoglobulin the holy grail? J Bras Nefrol 2022; 44:470. [PMID: 36524965 PMCID: PMC9838657 DOI: 10.1590/2175-8239-jbn-2022-e010en] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 08/08/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ragnar Palsson
- Massachusetts General Hospital, Department of Medicine, Nephrology
Division, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Leonardo V. Riella
- Massachusetts General Hospital, Department of Medicine, Nephrology
Division, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
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Schmidt IM, Sarvode Mothi S, Wilson PC, Palsson R, Srivastava A, Onul IF, Kibbelaar ZA, Zhuo M, Amodu A, Stillman IE, Rennke HG, Humphreys BD, Waikar SS. Circulating Plasma Biomarkers in Biopsy-Confirmed Kidney Disease. Clin J Am Soc Nephrol 2022; 17:27-37. [PMID: 34759008 PMCID: PMC8763150 DOI: 10.2215/cjn.09380721] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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: 07/09/2021] [Accepted: 11/02/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Biomarkers for noninvasive assessment of histopathology and prognosis are needed in patients with kidney disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using a proteomics assay, we measured a multimarker panel of 225 circulating plasma proteins in a prospective cohort study of 549 individuals with biopsy-confirmed kidney diseases and semiquantitative assessment of histopathology. We tested the associations of each biomarker with histopathologic lesions and the risks of kidney disease progression (defined as ≥40% decline in eGFR or initiation of KRT) and death. RESULTS After multivariable adjustment and correction for multiple testing, 46 different proteins were associated with histopathologic lesions. The top-performing markers positively associated with acute tubular injury and interstitial fibrosis/tubular atrophy were kidney injury molecule-1 (KIM-1) and V-set and Ig domain-containing protein 2 (VSIG2), respectively. Thirty proteins were significantly associated with kidney disease progression, and 35 were significantly associated with death. The top-performing markers for kidney disease progression were placental growth factor (hazard ratio per doubling, 5.4; 95% confidence interval, 3.4 to 8.7) and BMP and activin membrane-bound inhibitor (hazard ratio, 3.0; 95% confidence interval, 2.1 to 4.2); the top-performing markers for death were TNF-related apoptosis-inducing ligand receptor-2 (hazard ratio, 2.9; 95% confidence interval, 2.0 to 4.0) and CUB domain-containing protein-1 (hazard ratio, 2.4; 95% confidence interval, 1.8 to 3.3). CONCLUSION We identified several plasma protein biomarkers associated with kidney disease histopathology and adverse clinical outcomes in individuals with a diverse set of kidney diseases. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_12_28_CJN09380721.mp3.
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Affiliation(s)
- Insa M. Schmidt
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Renal Division, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Suraj Sarvode Mothi
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Parker C. Wilson
- Department of Pathology and Immunology, Washington University, St. Louis, Missouri
| | - Ragnar Palsson
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anand Srivastava
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ingrid F. Onul
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Renal Division, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Zoe A. Kibbelaar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Renal Division, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Min Zhuo
- Renal Division, Brigham & Women’s Hospital, Boston, Massachusetts
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Afolarin Amodu
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Renal Division, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Isaac E. Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Helmut G. Rennke
- Department of Pathology, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Benjamin D. Humphreys
- Division of Nephrology, Department of Medicine, Washington University, St. Louis, Missouri
| | - Sushrut S. Waikar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Renal Division, Brigham & Women’s Hospital, Boston, Massachusetts
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13
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Onundarson PT, Palsson R, Witt DM, Gudmundsdottir BR. Replacement of traditional prothrombin time monitoring with the new Fiix prothrombin time increases the efficacy of warfarin without increasing bleeding. A review article. Thromb J 2021; 19:72. [PMID: 34654442 PMCID: PMC8520310 DOI: 10.1186/s12959-021-00327-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 10/06/2021] [Indexed: 12/13/2022] Open
Abstract
The antithrombotic effect of vitamin K antagonists (VKA) depends on controlled lowering of the activity of factors (F) II and X whereas reductions in FVII and FIX play little role. PT-INR based monitoring, however, is highly influenced by FVII, which has the shortest half-life of vitamin K-dependent coagulation factors. Hence, variability in the anticoagulant effect of VKA may be partly secondary to an inherent flaw of the traditional monitoring test itself. The Fiix prothrombin time (Fiix-PT) is a novel test that is only sensitive to reductions in FII and FX and is intended to stabilize the VKA effect. Two clinical studies have now demonstrated that when warfarin is monitored with the Fiix-PT based normalized ratio (Fiix-NR) instead of PT-INR, anticoagulation is stabilized and less testing and fewer dose adjustments are needed. Furthermore, the relative risk of thromboembolism was reduced by 50-56% in these studies without an increase in major bleeding.
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Affiliation(s)
- Pall T Onundarson
- Central Laboratory/Hematology, Landspitali National University Hospital of Iceland and University of Iceland Faculty of Medicine, Hringbraut, 101 Reykjavik, Reykjavik, Iceland.
| | - Ragnar Palsson
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Brynja R Gudmundsdottir
- Central Laboratory/Hematology, Landspitali National University Hospital of Iceland , Reykjavik, Iceland
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Emilsdottir AR, Palsson R. Global Dialysis Perspective: Iceland. Kidney360 2021; 2:1632-1637. [PMID: 35372966 PMCID: PMC8785792 DOI: 10.34067/kid.0002332021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/08/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Arna R. Emilsdottir
- Division of Nephrology, Landspitali—The National University Hospital of Iceland, Reykjavik, Iceland
| | - Ragnar Palsson
- Division of Nephrology, Landspitali—The National University Hospital of Iceland, Reykjavik, Iceland,Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
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Schmidt IM, Srivastava A, Sabbisetti V, McMahon GM, He J, Chen J, Kusek J, Taliercio J, Ricardo AC, Hsu CY, Kimmel PL, Liu KD, Mifflin TE, Nelson RG, Ramachandran VS, Xie D, Zhang X, Palsson R, Stillman IE, Rennke HG, Feldman HI, Bonventre JV, Waikar SS. Plasma Kidney Injury Molecule 1 in CKD: Findings From the Boston Kidney Biopsy Cohort and CRIC Studies. Am J Kidney Dis 2021; 79:231-243.e1. [PMID: 34175376 DOI: 10.1053/j.ajkd.2021.05.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 05/03/2021] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE Plasma kidney injury molecule-1 (KIM-1) is a sensitive marker of proximal tubule injury, but its association with risks of adverse clinical outcomes across a spectrum of kidney diseases is unknown. STUDY DESIGN Prospective, observational cohort study. SETTING & PARTICIPANTS 524 individuals undergoing clinically indicated native kidney biopsy with biopsy specimens adjudicated for semiquantitative scores of histopathology by two kidney pathologists enrolled into the Boston Kidney Biopsy Cohort (BKBC) Study and 3,800 individuals with common forms of chronic kidney disease (CKD) enrolled into the Chronic Renal Insufficiency Cohort (CRIC) Study. EXPOSURE Histopathologic lesions and clinicopathologic diagnosis in cross-sectional analyses, baseline plasma KIM-1 in prospective analyses. OUTCOMES Baseline plasma KIM-1 in cross-sectional analyses, kidney failure (defined as initiation of kidney replacement therapy) and death in prospective analyses. ANALYTICAL APPROACH Multivariable-adjusted linear regression models tested associations of plasma KIM-1 with histopathologic lesions and clinicopathologic diagnoses. Cox proportional hazards models tested associations of plasma KIM-1 with future kidney failure and death. RESULTS In the BKBC Study, higher plasma KIM-levels were associated with more severe acute tubular injury, tubulointerstitial inflammation, and more severe mesangial expansion after multivariable adjustment. Participants with diabetic nephropathy, glomerulopathies, and tubulointerstitial disease had significantly higher plasma KIM-1 levels after multivariable adjustment. In the BKBC Study, 124 participants progressed to kidney failure and 85 participants died during a median follow-up time of 5 years. In the CRIC Study, 1153 participants progressed to kidney failure and 1356 participants died during a median follow-up time of 11.5 years. In both cohorts, each doubling of plasma KIM-1 was associated with an increased risk of kidney failure after multivariable adjustment (BKBC: HR 1.19, 95% CI 1.03 to 1.38 and CRIC: HR 1.10, 95% CI 1.06 to 1.15). There was no statistically significant association of plasma KIM-1 with death in either cohort. LIMITATIONS Generalizability and unmeasured confounding. CONCLUSIONS Plasma KIM-1 is associated with underlying tubulointerstitial and mesangial lesions and progression to kidney failure in two cohort studies of individuals with kidney diseases.
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Affiliation(s)
- Insa M Schmidt
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA; Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Anand Srivastava
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Venkata Sabbisetti
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gearoid M McMahon
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jiang He
- Department of Epidemiology and Medicine, Tulane University School of Public Health and Tropical Medicine, and Tulane University School of Medicine, New Orleans, LA
| | - Jing Chen
- Department of Epidemiology and Medicine, Tulane University School of Public Health and Tropical Medicine, and Tulane University School of Medicine, New Orleans, LA
| | - John Kusek
- Department for Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan Taliercio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois Hospital and Health Sciences Center, Chicago, IL
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California San Francisco School of Medicine, San Francisco, CA
| | - Paul L Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Kathleen D Liu
- Division of Nephrology, University of California San Francisco School of Medicine, San Francisco, CA
| | - Theodore E Mifflin
- Department for Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert G Nelson
- Chronic Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ
| | | | - Dawei Xie
- Department for Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Xiaoming Zhang
- Department for Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ragnar Palsson
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Isaac E Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Helmut G Rennke
- Pathology Department, Brigham & Women's Hospital, Boston, MA
| | - Harold I Feldman
- Department for Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Joseph V Bonventre
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA; Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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16
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Schmidt IM, Colona MR, Kestenbaum BR, Alexopoulos LG, Palsson R, Srivastava A, Liu J, Stillman IE, Rennke HG, Vaidya VS, Wu H, Humphreys BD, Waikar SS. Cadherin-11, Sparc-related modular calcium binding protein-2, and Pigment epithelium-derived factor are promising non-invasive biomarkers of kidney fibrosis. Kidney Int 2021; 100:672-683. [PMID: 34051265 PMCID: PMC8384690 DOI: 10.1016/j.kint.2021.04.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/25/2021] [Accepted: 04/30/2021] [Indexed: 02/06/2023]
Abstract
Kidney fibrosis constitutes the shared final pathway of nearly all chronic nephropathies, but biomarkers for the non-invasive assessment of kidney fibrosis are currently not available. To address this, we characterize five candidate biomarkers of kidney fibrosis: Cadherin-11 (CDH11), Sparc-related modular calcium binding protein-2 (SMOC2), Pigment epithelium-derived factor (PEDF), Matrix-Gla protein, and Thrombospondin-2. Gene expression profiles in single-cell and single-nucleus RNA-sequencing (sc/snRNA-seq) datasets from rodent models of fibrosis and human chronic kidney disease (CKD) were explored, and Luminex-based assays for each biomarker were developed. Plasma and urine biomarker levels were measured using independent prospective cohorts of CKD: the Boston Kidney Biopsy Cohort, a cohort of individuals with biopsy-confirmed semiquantitative assessment of kidney fibrosis, and the Seattle Kidney Study, a cohort of patients with common forms of CKD. Ordinal logistic regression and Cox proportional hazards regression models were used to test associations of biomarkers with interstitial fibrosis and tubular atrophy and progression to end-stage kidney disease and death, respectively. Sc/snRNA-seq data confirmed cell-specific expression of biomarker genes in fibroblasts. After multivariable adjustment, higher levels of plasma CDH11, SMOC2, and PEDF and urinary CDH11 and PEDF were significantly associated with increasing severity of interstitial fibrosis and tubular atrophy in the Boston Kidney Biopsy Cohort. In both cohorts, higher levels of plasma and urinary SMOC2 and urinary CDH11 were independently associated with progression to end-stage kidney disease. Higher levels of urinary PEDF associated with end-stage kidney disease in the Seattle Kidney Study, with a similar signal in the Boston Kidney Biopsy Cohort, although the latter narrowly missed statistical significance. Thus, we identified CDH11, SMOC2, and PEDF as promising non-invasive biomarkers of kidney fibrosis.
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Affiliation(s)
- Insa M Schmidt
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachussetts, USA; Renal Division, Brigham & Women's Hospital, Department of Medicine, Harvard Medical School, Boston, Massachussetts, USA
| | - Mia R Colona
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachussetts, USA; Renal Division, Brigham & Women's Hospital, Department of Medicine, Harvard Medical School, Boston, Massachussetts, USA
| | - Bryan R Kestenbaum
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Leonidas G Alexopoulos
- School of Mechanical Engineering, National Technical University of Athens, Athens Greece; ProtATonce, Ltd., Athens, Greece
| | - Ragnar Palsson
- Division of Nephrology, Landspitali-The National University Hospital of Iceland, Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Anand Srivastava
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jing Liu
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachussetts, USA; Division of Nephrology and National Clinical Research Center for Geriatrics, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China
| | - Isaac E Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachussetts, USA
| | - Helmut G Rennke
- Department of Pathology, Brigham & Women's Hospital, Boston, Massachussetts, USA
| | - Vishal S Vaidya
- Renal Division, Brigham & Women's Hospital, Department of Medicine, Harvard Medical School, Boston, Massachussetts, USA; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachussetts, USA
| | - Haojia Wu
- Division of Nephrology, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Benjamin D Humphreys
- Division of Nephrology, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachussetts, USA; Renal Division, Brigham & Women's Hospital, Department of Medicine, Harvard Medical School, Boston, Massachussetts, USA.
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Palsson R, Chandraker AK, Curhan GC, Rennke HG, McMahon GM, Waikar SS. The association of calcium oxalate deposition in kidney allografts with graft and patient survival. Nephrol Dial Transplant 2021; 36:747. [PMID: 30590582 PMCID: PMC8008363 DOI: 10.1093/ndt/gfy364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Helgason D, Eythorsson E, Olafsdottir LB, Agustsson T, Ingvarsdottir S, Sverrisdottir S, Ragnarsdottir ED, Gottfredsson M, Gudlaugsson O, Palsson R, Ingvarsson RF. Beating the odds with systematic individualized care: Nationwide prospective follow-up of all patients with COVID-19 in Iceland. J Intern Med 2021; 289:255-258. [PMID: 32558969 PMCID: PMC7323355 DOI: 10.1111/joim.13135] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 11/27/2022]
Affiliation(s)
- D Helgason
- From the, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - E Eythorsson
- From the, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - L B Olafsdottir
- From the, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - T Agustsson
- From the, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - S Ingvarsdottir
- From the, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - S Sverrisdottir
- From the, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - E D Ragnarsdottir
- From the, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - M Gottfredsson
- From the, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - O Gudlaugsson
- From the, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - R Palsson
- From the, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - R F Ingvarsson
- From the, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
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19
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Srivastava A, Schmidt IM, Palsson R, Weins A, Bonventre JV, Sabbisetti V, Stillman IE, Rennke HG, Waikar SS. The Associations of Plasma Biomarkers of Inflammation With Histopathologic Lesions, Kidney Disease Progression, and Mortality-The Boston Kidney Biopsy Cohort Study. Kidney Int Rep 2021; 6:685-694. [PMID: 33732983 PMCID: PMC7938082 DOI: 10.1016/j.ekir.2020.12.025] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/20/2020] [Accepted: 12/22/2020] [Indexed: 12/18/2022] Open
Abstract
Background Soluble tumor necrosis factor receptor (sTNFR)-1, sTNFR-2, YKL-40, monocyte chemoattractant protein (MCP)-1, and soluble urokinase plasminogen activator receptor (suPAR) have emerged as promising biomarkers of inflammation but have not been evaluated across diverse types of kidney diseases. Methods We measured these plasma biomarkers in 523 individuals enrolled into a prospective, observational cohort study of patients undergoing clinically indicated native kidney biopsy at 3 tertiary care hospitals. Two kidney pathologists adjudicated biopsy specimens for semiquantitative scores of histopathology. Proportional hazard models tested associations between biomarkers and risks of kidney disease progression (composite of ≥40% estimated glomerular filtration rate [eGFR] decline or end-stage kidney disease [ESKD]) and death. Results Mean eGFR was 56.4±36 ml/min per 1.73 m2 and the median proteinuria (interquartile range) was 1.6 (0.4, 3.9) g/g creatinine. The most common primary clinicopathologic diagnoses were proliferative glomerulonephritis (29.2%), nonproliferative glomerulopathy (18.1%), advanced glomerulosclerosis (11.3%), and diabetic kidney disease (11.1%). sTNFR-1, sTNFR-2, MCP-1, and suPAR were associated with tubulointerstitial and glomerular lesions. YKL-40 was not associated with any histopathologic lesions after multivariable adjustment. During a median follow-up of 65 months, 182 participants suffered kidney disease progression and 85 participants died. After multivariable adjustment, each doubling of sTNFR-1, sTNFR-2, YKL-40, and MCP-1 was associated with increased risks of kidney disease progression, with hazard ratios ranging from 1.21 to 1.47. Each doubling of sTNFR-2, YKL-40, and MCP-1 was associated with increased risks of death, with hazard ratios ranging from 1.33 to 1.45. suPAR was not significantly associated with kidney disease progression or death. Conclusions sTNFR-1, sTNFR-2, YKL-40, MCP-1, and suPAR are associated with underlying histopathologic lesions and adverse clinical outcomes across a diverse set of kidney diseases.
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Affiliation(s)
- Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Insa M. Schmidt
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
- Renal Division, Brigham & Women’s Hospital, Boston, Massachusetts, USA
| | - Ragnar Palsson
- Renal Division, Brigham & Women’s Hospital, Boston, Massachusetts, USA
- Division of Nephrology, Landspitali–The National University Hospital of Iceland, Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Astrid Weins
- Pathology Department, Brigham & Women’s Hospital, Boston, Massachusetts, USA
| | | | | | - Isaac E. Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Helmut G. Rennke
- Pathology Department, Brigham & Women’s Hospital, Boston, Massachusetts, USA
| | - Sushrut S. Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
- Renal Division, Brigham & Women’s Hospital, Boston, Massachusetts, USA
- Correspondence: Sushrut S. Waikar, Evans Biomedical Research Center, 650 Albany St, X504, Boston, Massachusetts 02118, USA.
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Abstract
IMPORTANCE Urine sediment microscopy is commonly performed during the evaluation of kidney disease. Interobserver reliability of nephrologists' urine sediment examination has not been well studied. OBJECTIVE Assess interobserver reliability of the urine sediment examination. DESIGN, SETTING, AND PARTICIPANTS In this diagnostic test study, urine samples were prospectively collected from a convenience sample of adult patients from an academic hospital in the United States undergoing kidney biopsy from July 11, 2018, to March 20, 2019. Digital images and videos of urine sediment findings were captured using a bright-field microscope. These images and videos along with urine dipstick results were incorporated in online surveys and sent to expert nephrologists at 15 US teaching hospitals. They were asked to identify individual sediment findings and the most likely underlying disease process. EXPOSURES Urine dipstick results and urine sediment images from patients undergoing native kidney biopsy. MAIN OUTCOMES AND MEASURES Interobserver reliability of urine sediment microscopy findings estimated by overall percent agreement and Fleiss κ coefficients. Secondary outcomes included concordance of diagnoses suspected by nephrologists with corresponding kidney biopsy results. RESULTS In total, 10 surveys from 10 patients containing 76 study questions on individual features were sent to 21 nephrologists, 14 (67%) of whom completed them all. Their combined 1064 responses were analyzed. Overall percent agreement for casts was an estimated 59% (95% CI, 50%-69%), κ = 0.52 (95% CI, 0.42-0.62). For other sediment findings, overall percent agreement was an estimated 69% (95% CI, 61%-77%), κ = 0.65 (95% CI, 0.56-0.73). The κ estimates ranged from 0.13 (95% CI, 0.10-0.17) for mixed cellular casts to 0.90 (95% CI, 0.87-0.94) for squamous epithelial cells. CONCLUSIONS AND RELEVANCE In this study, substantial variability occurred in the interpretation of urine sediment findings, even among expert nephrologists. Educational or technological innovations may help improve the urine sediment as a diagnostic tool.
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Affiliation(s)
- Ragnar Palsson
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Nephrology, National University Hospital of Iceland, Reykjavik, Iceland
| | - Mia R. Colona
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Melanie P. Hoenig
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Andrew L. Lundquist
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - James E. Novak
- Division of Nephrology, Henry Ford Hospital, Detroit, Michigan
| | - Mark A. Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Sushrut S. Waikar
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
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21
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McMahon GM, Amodu A, Sise ME, Mothi SS, Palsson R, Waikar SS. Physician Attitudes on Kidney Biopsies for Research: A Survey Study. Kidney Med 2020; 2:82-84. [PMID: 32734230 PMCID: PMC7380349 DOI: 10.1016/j.xkme.2019.10.009] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Gearoid M McMahon
- Renal Division, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Afolarin Amodu
- Renal Division, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA
| | - Meghan E Sise
- Harvard Medical School, Boston, MA.,Renal Division, Massachusetts General Hospital, Boston, MA
| | - Suraj Sarvode Mothi
- Renal Division, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Ragnar Palsson
- Renal Division, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Sushrut S Waikar
- Renal Division, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA
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22
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Palsson R, Chandraker AK, Curhan GC, Rennke HG, McMahon GM, Waikar SS. The association of calcium oxalate deposition in kidney allografts with graft and patient survival. Nephrol Dial Transplant 2020; 35:888-894. [PMID: 30165691 PMCID: PMC7849934 DOI: 10.1093/ndt/gfy271] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 06/04/2018] [Accepted: 07/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Whether calcium oxalate (CaOx) deposition in kidney allografts following transplantation (Tx) adversely affects patient outcomes is uncertain, as are its associated risk factors. METHODS We performed a retrospective cohort study of patients who had kidney allograft biopsies performed within 3 months of Tx at Brigham and Women's Hospital and examined the association of CaOx deposition with the composite outcome of death or graft failure within 5 years. RESULTS Biopsies from 67 of 346 patients (19.4%) had CaOx deposition. In a multivariable logistic regression model, higher serum creatinine [odds ratio (OR) = 1.28 per mg/dL, 95% confidence interval (CI) 1.15-1.43], longer time on dialysis (OR = 1.11 per additional year, 95% CI 1.01-1.23) and diabetes (OR = 2.26, 95% CI 1.09-4.66) were found to be independently associated with CaOx deposition. CaOx deposition was strongly associated with delayed graft function (DGF; OR = 11.31, 95% CI 5.97-21.40), and with increased hazard of the composite outcome after adjusting for black recipient race, donor type, time on dialysis before Tx, diabetes and borderline or acute rejection (hazard ratio 1.90, 95% CI 1.13-3.20). CONCLUSIONS CaOx deposition is common in allografts with poor function and portends worse outcomes up to 5 years after Tx. The extent to which CaOx deposition may contribute to versus result from DGF, however, cannot be determined based on our retrospective and observational data. Future studies should examine whether reducing plasma and urine oxalate prevents CaOx deposition in the newly transplanted kidney and whether this has an effect on clinical outcomes.
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Affiliation(s)
- Ragnar Palsson
- Renal Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Gary C Curhan
- Renal Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Helmut G Rennke
- Renal Pathology Service, Brigham and Women's Hospital, Boston, MA, USA
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23
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Palsson R, Short SAP, Kibbelaar ZA, Amodu A, Stillman IE, Rennke HG, McMahon GM, Waikar SS. Bleeding Complications After Percutaneous Native Kidney Biopsy: Results From the Boston Kidney Biopsy Cohort. Kidney Int Rep 2020; 5:511-518. [PMID: 32274455 PMCID: PMC7136322 DOI: 10.1016/j.ekir.2020.01.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/18/2020] [Accepted: 01/20/2020] [Indexed: 02/07/2023] Open
Abstract
Background The major risk of kidney biopsy is severe bleeding. Numerous risk factors for bleeding after biopsy have been reported, but findings have been inconsistent. Methods We retrospectively reviewed medical records of adult patients enrolled in a native kidney biopsy cohort study to identify major bleeding events (red blood cell [RBC] transfusions, invasive procedures, kidney loss, or death). We used logistic and linear regression models to identify characteristics associated with postbiopsy RBC transfusions and decline in hemoglobin within a week after the procedure. Results Major bleeding events occurred in 28 of 644 (4.3%) patients (28 required an RBC transfusion, 4 underwent angiographic intervention, and 1 had open surgery to control bleeding). No patient lost a kidney or died because of the biopsy. Postbiopsy RBC transfusion risk was driven by the baseline hemoglobin level (odds ratio [OR] 13.6; 95% confidence interval [CI] 5.4–34.1 for hemoglobin <10 vs. ≥10 g/dl). After adjusting for hemoglobin, no other patient characteristics were independently associated with RBC transfusions. Female sex (β = 0.18; 95% CI: 0.04–0.32), estimated glomerular filtration rate (eGFR) <30 ml/min per 1.73 m2 (β = 0.32; 95% CI: 0.14–0.49), and baseline hemoglobin (β = 0.09; 95% CI: 0.05–0.13, per g/dl increase) were independently associated with a larger drop in hemoglobin. Histopathologic lesions were not independently associated with major bleeding after biopsy. Conclusion Biopsies were generally well tolerated. Baseline hemoglobin was the dominant risk factor for RBC transfusions, but female sex and eGFR <30 ml/min per 1.73 m2 were also associated with a larger decline in hemoglobin after the procedure.
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Affiliation(s)
- Ragnar Palsson
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Division of Nephrology, National University Hospital of Iceland, Reykjavik, Iceland
| | - Samuel A P Short
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zoe A Kibbelaar
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Renal Section, Boston University Medical Center, Boston, Massachusetts, USA
| | - Afolarin Amodu
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Renal Section, Boston University Medical Center, Boston, Massachusetts, USA
| | - Isaac E Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gearoid M McMahon
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sushrut S Waikar
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Renal Section, Boston University Medical Center, Boston, Massachusetts, USA
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24
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Waikar SS, Srivastava A, Palsson R, Shafi T, Hsu CY, Sharma K, Lash JP, Chen J, He J, Lieske J, Xie D, Zhang X, Feldman HI, Curhan GC. Association of Urinary Oxalate Excretion With the Risk of Chronic Kidney Disease Progression. JAMA Intern Med 2019; 179:542-551. [PMID: 30830167 PMCID: PMC6450310 DOI: 10.1001/jamainternmed.2018.7980] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Oxalate is a potentially toxic terminal metabolite that is eliminated primarily by the kidneys. Oxalate nephropathy is a well-known complication of rare genetic disorders and enteric hyperoxaluria, but oxalate has not been investigated as a potential contributor to more common forms of chronic kidney disease (CKD). OBJECTIVE To assess whether urinary oxalate excretion is a risk factor for more rapid progression of CKD toward kidney failure. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study assessed 3123 participants with stages 2 to 4 CKD who enrolled in the Chronic Renal Insufficiency Cohort study from June 1, 2003, to September 30, 2008. Data analysis was performed from October 24, 2017, to June 17, 2018. EXPOSURES Twenty-four-hour urinary oxalate excretion. MAIN OUTCOMES AND MEASURES A 50% decline in estimated glomerular filtration rate (eGFR) and end-stage renal disease (ESRD). RESULTS This study included 3123 participants (mean [SD] age, 59.1 [10.6] years; 1414 [45.3%] female; 1423 [45.6%] white). Mean (SD) eGFR at the time of 24-hour urine collection was 42.9 (16.8) mL/min/1.73 m2. Median urinary excretion of oxalate was 18.6 mg/24 hours (interquartile range [IQR], 12.9-25.7 mg/24 hours) and was correlated inversely with eGFR (r = -0.13, P < .001) and positively with 24-hour proteinuria (r = 0.22, P < .001). During 22 318 person-years of follow-up, 752 individuals reached ESRD, and 940 individuals reached the composite end point of ESRD or 50% decline in eGFR (CKD progression). Higher oxalate excretion was independently associated with greater risks of both CKD progression and ESRD: compared with quintile 1 (oxalate excretion, <11.5 mg/24 hours) those in quintile 5 (oxalate excretion, ≥27.8 mg/24 hours) had a 33% higher risk of CKD progression (hazard ratio [HR], 1.33; 95% CI, 1.04-1.70) and a 45% higher risk of ESRD (HR, 1.45; 95% CI, 1.09-1.93). The association between oxalate excretion and CKD progression and ESRD was nonlinear and exhibited a threshold effect at quintiles 3 to 5 vs quintiles 1 and 2. Higher vs lower oxalate excretion (at the 40th percentile) was associated with a 32% higher risk of CKD progression (HR, 1.32; 95% CI, 1.13-1.53) and 37% higher risk of ESRD (HR, 1.37; 95% CI, 1.15-1.63). Results were similar when treating death as a competing event. CONCLUSIONS AND RELEVANCE Higher 24-hour urinary oxalate excretion may be a risk factor for CKD progression and ESRD in individuals with CKD stages 2 to 4.
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Affiliation(s)
- Sushrut S Waikar
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anand Srivastava
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ragnar Palsson
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tariq Shafi
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California, San Francisco
| | - Kumar Sharma
- Division of Nephrology, University of Texas, San Antonio
| | - James P Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Jing Chen
- Department of Medicine, Tulane University, New Orleans, Louisiana.,Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Jiang He
- Department of Medicine, Tulane University, New Orleans, Louisiana.,Department of Medicine, Tulane University, New Orleans, Louisiana
| | - John Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Xiaoming Zhang
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Harold I Feldman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gary C Curhan
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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25
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Palsson R, Srivastava A, Waikar SS. Performance of the Automated Urinalysis in Diagnosis of Proliferative Glomerulonephritis. Kidney Int Rep 2019; 4:723-727. [PMID: 31080928 PMCID: PMC6506710 DOI: 10.1016/j.ekir.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 01/10/2019] [Accepted: 02/04/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ragnar Palsson
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sushrut S. Waikar
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Correspondence: Sushrut S. Waikar, 75 Francis Street, MRB4, Boston, Massachusetts 02115, USA.
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26
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Srivastava A, Palsson R, Leaf DE, Higuera A, Chen ME, Palacios P, Baron RM, Sabbisetti V, Hoofnagle AN, Vaingankar SM, Palevsky PM, Waikar SS. Uric Acid and Acute Kidney Injury in the Critically Ill. Kidney Med 2019; 1:21-30. [PMID: 32734180 PMCID: PMC7380422 DOI: 10.1016/j.xkme.2019.01.003] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rationale & Objective Uric acid is excreted by the kidney and accumulates in acute kidney injury (AKI). Whether higher plasma uric acid level predisposes to AKI or its complications is not known. Study Design Prospective observational cohort study. Setting & Participants 2 independent cohorts of critically ill patients: (1) 208 patients without AKI admitted to the intensive care unit (ICU) at Brigham & Women's Hospital between October 2008 and December 2016; and (2) 250 participants with AKI requiring renal replacement therapy (RRT) who had not yet initiated RRT enrolled in the Acute Renal Failure Trial Network (ATN) Study. Exposure Plasma uric acid level upon ICU admission and before RRT initiation in the ICU and ATN Study cohorts, respectively. Outcomes Incident AKI and 60-day mortality in the ICU and ATN Study cohorts, respectively. Analytical Approach Logistic regression models were used to test the association of plasma uric acid level with incident AKI and 60-day mortality. Results In the ICU cohort, median plasma uric acid level was 4.7 (interquartile range [IQR], 3.6-6.4) mg/dL, and 40 patients (19.2%) developed AKI. Higher plasma uric acid levels associated with incident AKI, but this association was confounded by serum creatinine level and was not significant after multivariable adjustment (adjusted OR per doubling of uric acid, 1.50; 95% CI, 0.80-2.81). In the ATN Study cohort, median plasma uric acid level was 11.1 (IQR, 8.6-14.2) mg/dL, and 125 participants (50.0%) died within 60 days. There was no statistically significant association between plasma uric acid levels and 60-day mortality in either unadjusted models or after multivariable adjustment for demographic, severity-of-illness, and kidney-specific covariates (adjusted OR per doubling of uric acid, 1.15; 95% CI, 0.71-1.86). Limitations Heterogeneity of ICU patients. Conclusions Plasma uric acid levels upon ICU admission or before RRT initiation are not independently associated with adverse clinical outcomes in critically ill patients.
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Affiliation(s)
- Anand Srivastava
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.,Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Ragnar Palsson
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Angelica Higuera
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Margaret E Chen
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Polly Palacios
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Rebecca M Baron
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | | | - Andrew N Hoofnagle
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | | | - Paul M Palevsky
- Renal Section, Veterans Affairs Pittsburgh Healthcare System and Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Sushrut S Waikar
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
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27
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Ocak G, Noordzij M, Rookmaaker MB, Cases A, Couchoud C, Heaf JG, Jarraya F, De Meester J, Groothoff JW, Waldum-Grevbo BE, Palsson R, Resic H, Remón C, Finne P, Stendahl M, Verhaar MC, Massy ZA, Dekker FW, Jager KJ. Mortality due to bleeding, myocardial infarction and stroke in dialysis patients. J Thromb Haemost 2018; 16:1953-1963. [PMID: 30063819 DOI: 10.1111/jth.14254] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 04/01/2018] [Accepted: 07/21/2018] [Indexed: 01/13/2023]
Abstract
Essentials Mortality due to bleeding vs. arterial thrombosis in dialysis patients is unknown. We compared death causes of 201 918 dialysis patients with the general population. Dialysis was associated with increased mortality risks of bleeding and arterial thrombosis. Clinicians should be aware of the increased bleeding and thrombosis risks. SUMMARY Background Dialysis has been associated with both bleeding and thrombotic events. However, there is limited information on bleeding as a cause of death versus arterial thrombosis as a cause of death. Objectives To investigate the occurrence of bleeding, myocardial infarction and stroke as causes of death in the dialysis population as compared with the general population. Methods We included 201 918 patients from 11 countries providing data to the ERA-EDTA Registry who started dialysis treatment between 1994 and 2011, and followed them for 3 years. Age-standardized and sex-standardized mortality rate ratios for bleeding, myocardial infarction and stroke as causes of death were calculated in dialysis patients as compared with the European general population. Associations between potential risk factors and these causes of death in dialysis patients were investigated by calculating hazard ratios (HRs) with 95% confidence intervals (CIs) by the use of Cox proportional-hazards regression. Results As compared with the general population, the age-standardized and sex-standardized mortality rate ratios in dialysis patients were 12.8 (95% CI 11.9-13.7) for bleeding as a cause of death (6.2 per 1000 person-years among dialysis patients versus 0.3 per 1000 person-years in the general population), 13.4 (95% CI 13.0-13.9) for myocardial infarction (22.5 versus 0.9 per 1000 person-years), and 12.4 (95% CI 11.9-12.9) for stroke (14.3 versus 0.7 per 1000 person-years). Conclusion Dialysis patients have highly increased risks of death caused by bleeding and arterial thrombosis as compared with the general population. Clinicians should be aware of the increased mortality risks caused by these conditions.
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Affiliation(s)
- G Ocak
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M Noordzij
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - M B Rookmaaker
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A Cases
- Registre de Malalts Renals de Catalunya, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - C Couchoud
- REIN Registry, Agence de Biomedecine, Saint Denis La Plaine, France
| | - J G Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - F Jarraya
- Department of Nephrology, Sfax University Hospital and Research Unit, Faculty of Medicine, Sfax University, Sfax, Tunisia
| | - J De Meester
- Department of Nephrology, Dialysis and Hypertension, Dutch-Speaking Belgian Renal Registry, Sint-Niklaas, Belgium
| | - J W Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - B E Waldum-Grevbo
- Department of Nephrology, Oslo University Hospital Ullevål, Oslo, Norway
| | - R Palsson
- Division of Nephrology, Internal Medicine Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - H Resic
- Clinic for Hemodialysis, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - C Remón
- SICATA (The Information System of the Andalusian Transplant Autonomic Coordination Registry), Andalusia, Spain
| | - P Finne
- Finnish Registry for Kidney Diseases, Helsinki, Finland
| | - M Stendahl
- Swedish Renal Registry, Department of Internal Medicine, Ryhov County Hospital, Jönköping, Sweden
| | - M C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Z A Massy
- Division of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne Billancourt/Paris, France
- INSERM Unit 1018, CESP, Team 5, UVSQ, Villejuif, France
| | - F W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - K J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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28
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Srivastava A, Palsson R, Kaze AD, Chen ME, Palacios P, Sabbisetti V, Betensky RA, Steinman TI, Thadhani RI, McMahon GM, Stillman IE, Rennke HG, Waikar SS. The Prognostic Value of Histopathologic Lesions in Native Kidney Biopsy Specimens: Results from the Boston Kidney Biopsy Cohort Study. J Am Soc Nephrol 2018; 29:2213-2224. [PMID: 29866798 DOI: 10.1681/asn.2017121260] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [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: 12/07/2017] [Accepted: 04/18/2018] [Indexed: 11/03/2022] Open
Abstract
Background Few studies have evaluated whether histopathologic lesions on kidney biopsy provide prognostic information beyond clinical and laboratory data.Methods We enrolled 676 individuals undergoing native kidney biopsy at three tertiary care hospitals into a prospective, observational cohort study. Biopsy specimens were adjudicated for semiquantitative scores in 13 categories of histopathology by two experienced renal pathologists. Proportional hazards models tested the association between histopathologic lesions and risk of kidney disease progression (≥40% eGFR decline or RRT).Results Mean baseline eGFR was 57.5±36.0 ml/min per 1.73 m2 During follow-up (median, 34.3 months), 199 individuals suffered kidney disease progression. After adjustment for demographics, clinicopathologic diagnosis, and laboratory values, the following lesions (hazard ratio; 95% confidence interval) were independently associated with progression: inflammation in nonfibrosed interstitium (0.52; 0.32 to 0.83), moderate and severe versus minimal interstitial fibrosis/tubular atrophy (2.14; 1.24 to 3.69 and 3.42; 1.99 to 5.87, respectively), moderate and severe versus minimal global glomerulosclerosis (2.17; 1.36 to 3.45 and 3.31; 2.04 to 5.38, respectively), moderate and severe versus minimal arterial sclerosis (1.78; 1.15 to 2.74 and 1.64; 1.04 to 2.60, respectively), and moderate and severe versus minimal arteriolar sclerosis (1.63; 1.08 to 2.46 and 2.33; 1.42 to 3.83, respectively). An 11-point chronicity score derived from semiquantitative assessments of chronic lesions independently associated with higher risk of kidney disease progression (hazard ratio per one-point increase, 1.19; 95% confidence interval, 1.12 to 1.27).Conclusions Across a diverse group of kidney diseases, histopathologic lesions on kidney biopsy provide prognostic information, even after adjustment for proteinuria and eGFR.
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Affiliation(s)
- Anand Srivastava
- Renal Division and.,Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | | | | | - Rebecca A Betensky
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Ravi I Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; and.,Departments of Biomedical Sciences and.,Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Isaac E Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Helmut G Rennke
- Pathology Department, Brigham and Women's Hospital, Boston, Massachusetts
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Abstract
Kidney function, like the function of other organs, is dynamic and continuously adjusts to changes in the internal environment to maintain homeostasis. The glomerular filtration rate, which serves as the primary index of kidney function in clinical practice, increases in response to various physiological and pathological stressors including oral protein intake. The difference between the glomerular filtration rate in the resting state and at maximum capacity has been termed renal functional reserve (RFR). RFR could provide additional information on kidney health and renal function prognosis. Despite longstanding interest in RFR as a biomarker in nephrology, its underlying mechanisms remain inadequately understood. Moreover, no consensus has been reached on how it should be quantified. Previous studies on RFR have used various measurement methods and yielded heterogeneous results. A standardized and clinically feasible approach to quantifying RFR would allow for more rigorous appraisal of its value as a biomarker and could pave the way for adoption of "renal stress tests" into clinical practice.
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30
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Helgadottir S, Sigurdsson MI, Palsson R, Helgason D, Sigurdsson GH, Gudbjartsson T. The importance of recovery of renal function following acute kidney injury after CABG. Acta Anaesthesiol Scand 2016; 60:1483. [PMID: 27594609 DOI: 10.1111/aas.12782] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S. Helgadottir
- Department of Cardiothoracic Surgery; Landspitali University Hospital; Reykjavik Iceland
- Department of Anesthesiology and Intesive care Medicine; Landspitali University Hospital; Reykjavik Iceland
| | - M. I. Sigurdsson
- Department of Anesthesiology, Perioperative and Pain Medicine; Brigham and Women's Hospital; Boston MA USA
| | - R. Palsson
- Department of Nephrology; Landspitali University Hospital; Reykjavik Iceland
- Faculty of Medicine; University of Iceland; Reykjavik Iceland
| | - D. Helgason
- Department of Cardiothoracic Surgery; Landspitali University Hospital; Reykjavik Iceland
| | - G. H. Sigurdsson
- Department of Anesthesiology and Intesive care Medicine; Landspitali University Hospital; Reykjavik Iceland
- Faculty of Medicine; University of Iceland; Reykjavik Iceland
| | - T. Gudbjartsson
- Department of Cardiothoracic Surgery; Landspitali University Hospital; Reykjavik Iceland
- Faculty of Medicine; University of Iceland; Reykjavik Iceland
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31
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Helgadottir S, Sigurdsson MI, Palsson R, Helgason D, Sigurdsson GH, Gudbjartsson T. Renal recovery and long-term survival following acute kidney injury after coronary artery surgery: a nationwide study. Acta Anaesthesiol Scand 2016; 60:1230-40. [PMID: 27378715 DOI: 10.1111/aas.12758] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/31/2016] [Accepted: 06/01/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a relatively common complication following CABG and is associated with adverse outcomes. Nonetheless, we hypothesized that the majority of patients make a good long-term recovery of their renal function. We studied the incidence and risk factors of AKI together with renal recovery and long-term survival in patients who developed AKI following CABG. METHODS This nationwide study examined AKI among 1754 consecutive patients undergoing CABG in 2001-2013. AKI was defined according to the KDIGO criteria. RESULTS Postoperatively 184 (11%) patients developed AKI; 121 (7%), 27 (2%), and 36 (2%) at stages 1, 2, and 3, respectively. AKI was an independent risk factor for chronic kidney disease (CKD) and AKI patients had worse post-operative outcomes. Lower pre-operative glomerular filtration rate, higher EuroSCORE and BMI, diabetes, reoperation, and units of red blood cells transfused were independent risk factors of AKI. At post-operative day 10, renal recovery rates, defined as serum creatinine ratio <1.25 of baseline, were 96 (95% CI 91-99%), 78 (95% CI 53-90%), and 94% (95% CI 77-98%) for AKI stages 1, 2, and 3, respectively. Long-term survival was predicted by AKI with 10-year survival of patients without AKI being 76% and those with AKI stages 1, 2, and 3 being 63%, 56%, and 49%, respectively (P < 0.001). CONCLUSION Depending on the severity of the initial AKI, 78-97% of patients made good recovery of their kidney function. However, AKI was significantly linked to progression to CKD and long-term survival remained markedly affected by the severity of the initial kidney injury.
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Affiliation(s)
- S. Helgadottir
- Department of Cardiothoracic Surgery; Landspitali University Hospital; Reykjavik Iceland
| | - M. I. Sigurdsson
- Department of Anesthesiology, Perioperative and Pain Medicine; Brigham and Women's Hospital; Boston MA USA
| | - R. Palsson
- Faculty of Medicine; University of Iceland; Reykjavik Iceland
- Department of Nephrology; Landspitali University Hospital; Reykjavik Iceland
| | - D. Helgason
- Department of Cardiothoracic Surgery; Landspitali University Hospital; Reykjavik Iceland
| | - G. H. Sigurdsson
- Faculty of Medicine; University of Iceland; Reykjavik Iceland
- Department of Anesthesia and Intensive Care Medicine; Landspitali University Hospital; Reykjavik Iceland
| | - T. Gudbjartsson
- Department of Cardiothoracic Surgery; Landspitali University Hospital; Reykjavik Iceland
- Faculty of Medicine; University of Iceland; Reykjavik Iceland
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Bjorgvinsdottir L, Indridason OS, Heidarsdottir R, Skogstrand K, Arnar DO, Torfason B, Hougaard DM, Palsson R, Skuladottir GV. Inflammatory response following heart surgery and association with n-3 and n-6 long-chain polyunsaturated fatty acids in plasma and red blood cell membrane lipids. Prostaglandins Leukot Essent Fatty Acids 2013; 89:189-94. [PMID: 23999253 DOI: 10.1016/j.plefa.2013.07.007] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 07/12/2013] [Accepted: 07/26/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Open heart surgery is associated with a systemic inflammatory response. The n-3 long-chain polyunsaturated fatty acids (LC-PUFA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and the n-6 LC-PUFA arachidonic acid (AA) may contribute to modulation of the inflammatory response. OBJECTIVE We investigated whether the preoperative levels of EPA, DHA and AA in plasma phospholipids (PL) and red blood cell (RBC) membrane lipids in patients (n=168) undergoing open heart surgery were associated with changes in the plasma concentration of selected inflammatory mediators in the immediate postoperative period. RESULTS AND CONCLUSIONS The postoperative concentration of TNF-β was lower (P<0.05) and those of hs-CRP, IL-6, IL-8, IL-18 and IL-10 higher (P<0.05) than the respective preoperative concentrations. We observed that the preoperative levels of EPA and AA in plasma PL and RBC membrane lipids were associated with changes in the concentration of pro-inflammatory and anti-inflammatory mediators, suggesting a complex role in the postoperative inflammatory process.
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Affiliation(s)
- L Bjorgvinsdottir
- Faculty of Medicine, School of Health Sciences, University of Iceland, Vatnsmyrarvegur 16, IS-101 Reykjavik, Iceland
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Palsson R, Vidarsson B, Gudmundsdottir BR, Larsen OH, Ingerslev J, Sorensen B, Onundarson PT. Complementary effect of fibrinogen and rFVIIa on clottingex vivoin Bernard-Soulier syndrome and combined use during three deliveries. Platelets 2013; 25:357-62. [DOI: 10.3109/09537104.2013.819971] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ocak G, van Stralen KJ, Rosendaal FR, Verduijn M, Ravani P, Palsson R, Leivestad T, Hoitsma AJ, Ferrer-Alamar M, Finne P, De Meester J, Wanner C, Dekker FW, Jager KJ. Mortality due to pulmonary embolism, myocardial infarction, and stroke among incident dialysis patients. J Thromb Haemost 2012; 10:2484-93. [PMID: 22970891 DOI: 10.1111/j.1538-7836.2012.04921.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [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: 08/31/2023]
Abstract
BACKGROUND It is has been suggested that dialysis patients have lower mortality rates for pulmonary embolism than the general population, because of platelet dysfunction and bleeding tendency. However, there is limited information whether dialysis is indeed associated with a decreased mortality risk from pulmonary embolism. OBJECTIVE The aim of our study was to evaluate whether mortality rate ratios for pulmonary embolism were lower than for myocardial infarction and stroke in dialysis patients compared with the general population. METHODS Cardiovascular causes of death for 130,439 incident dialysis patients registered in the ERA-EDTA Registry were compared with the cardiovascular causes of death for the European general population. RESULTS The age- and sex-standardized mortality rate (SMR) from pulmonary embolism was 12.2 (95% CI 10.2-14.6) times higher in dialysis patients than in the general population. The SMRs in dialysis patients compared with the general population were 11.0 (95% CI 10.6-11.4) for myocardial infarction, 8.4 (95% CI 8.0-8.8) for stroke, and 8.3 (95% CI 8.0-8.5) for other cardiovascular diseases. In dialysis patients, primary kidney disease due to diabetes was associated with an increased mortality risk due to pulmonary embolism (HR 1.9; 95% CI 1.0-3.8), myocardial infarction (HR 4.1; 95% CI 3.4-4.9), stroke (HR 3.5; 95% CI 2.8-4.4), and other cardiovascular causes of death (HR 3.4; 95% CI 2.9-3.9) compared with patients with polycystic kidney disease. CONCLUSIONS Dialysis patients were found to have an unexpected highly increased mortality rate for pulmonary embolism and increased mortality rates for myocardial infarction and stroke.
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Affiliation(s)
- G Ocak
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
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Letavernier E, Letavernier E, Rodenas A, Guerrot D, Haymann JP, Quaglia M, Quaglia M, Merlotti G, Fenoglio R, Menegotto A, Izzo C, Airoldi A, Guarnieri V, Stratta P, Edvardsson V, Haroarson S, Palsson R, Thorens B, Muriel A, Olivier B, Froeder L, Calabria Baxmann A, Pfeferman Heilberg I. Mineral homeostasis and nephrolithiasis. Nephrol Dial Transplant 2012. [DOI: 10.1093/ndt/gfs201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Koopman JJE, Rozing MP, Kramer A, de Jager DJ, Ansell D, De Meester JMJ, Prütz KG, Finne P, Heaf JG, Palsson R, Kramar R, Jager KJ, Dekker FW, Westendorp RGJ. Senescence rates in patients with end-stage renal disease: a critical appraisal of the Gompertz model. Aging Cell 2011; 10:233-8. [PMID: 21108732 DOI: 10.1111/j.1474-9726.2010.00659.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [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: 12/12/2022] Open
Abstract
The most frequently used model to describe the exponential increase in mortality rate over age is the Gompertz equation. Logarithmically transformed, the equation conforms to a straight line, of which the slope has been interpreted as the rate of senescence. Earlier, we proposed the derivative function of the Gompertz equation as a superior descriptor of senescence rate. Here, we tested both measures of the rate of senescence in a population of patients with end-stage renal disease. It is clinical dogma that patients on dialysis experience accelerated senescence, whereas those with a functional kidney transplant have mortality rates comparable to the general population. Therefore, we calculated the age-specific mortality rates for European patients on dialysis (n=274 221; follow-up=594 767 person-years), for European patients with a functioning kidney transplant (n=61 286; follow-up=345 024 person-years), and for the general European population. We found higher mortality rates, but a smaller slope of logarithmic mortality curve for patients on dialysis compared with both patients with a functioning kidney transplant and the general population (P<0.001). A classical interpretation of the Gompertz model would imply that the rate of senescence in patients on dialysis is lower than in patients with a functioning transplant and lower than in the general population. In contrast, the derivative function of the Gompertz equation yielded the highest senescence rates for patients on dialysis, whereas the rate was similar in patients with a functioning transplant and the general population. We conclude that the rate of senescence is better described by the derivative function of the Gompertz equation.
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Affiliation(s)
- J J E Koopman
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
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Abstract
The European Board of Internal Medicine is working towards enhancing the training in Internal Medicine in Europe. One of the most important tasks is to ensure that training programmes reach an acceptable level of quality. The Board does not accredit training centres as this is the responsibility of national authorities. The purpose of this paper is to provide guidance for the accreditation process. The content of the paper has been developed from a publication on medical education produced by the World Federation for Medical Education. Basic standards which should be met by all training centres are outlined. Quality development describes standards which centres should aim for although progress will to some extent be influenced by resources, stage of development and local circumstances.
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Affiliation(s)
- C Semple
- Diabetes Centre, Southern General Hospital, Glasgow G51 4TF, UK.
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Dores H, Ferreira R, Cardiga R, Araujo I, Marques F, Leitao A, Fonseca C, Ceia F, Alegret Colome JM, Vinolas X, Martinez JG, Pachon N, Crespo F, Freire F, Gonzalez Ruiz J, Garcia Sacristan JF, Deering TF, Epstein A, Goldman D, Greeberg S, Dalal Y, Castellant P, Vinsonneau U, Vinsonneau A, Valls-Bertault V, Desvignes O, Fatemi M, Etienne Y, Blanc JJ, Heidarsdottir R, Indridason OS, Arnar DO, Torfason B, Palsson R, Edvardsson V, Gottskalksson G, Skuladottir GV, Guglin M, Chen R, Curtis AB. Abstracts: Associated risk in atrial fibrillation patients. Europace 2009. [DOI: 10.1093/europace/euq251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
BACKGROUND Several types of replacement fluid and methods of anticoagulation have been employed for continuous renal replacement therapy, but there is no consensus on a preferred approach. We evaluated the indications for the selection of replacement fluid and anticoagulant among critically ill patients receiving continuous venovenous hemofiltration (CVVH) and assessed the effect of the selection on the efficacy of anticoagulation and complications. METHODS We retrospectively studied 29 consecutive patients who received CVVH in the Medical Intensive Care Unit at Massachusetts General Hospital. There were 3 types of replacement solution available, an isotonic citrate solution which was also used for regional anticoagulation of the extracorporeal circuit, and bicarbonate and lactate solutions which were used with low-dose heparin or no anticoagulant. Blood flow rate was set at 120 ml/min when citrate replacement fluid was used and at 200 ml/min with bicarbonate or lactate. The replacement fluid was administered proximal to the hemofilter at a constant rate of 1,600 ml/h. RESULTS There were 22 patients who received citrate replacement fluid which was mainly chosen for the purpose of anticoagulation in the setting of contraindications to heparin. 12 patients received bicarbonate, predominantly when citrate was considered contraindicated due to liver failure or high-anion gap metabolic acidosis, and 2 received lactate; 8 of these 14 patients were anticoagulated with heparin and 6 were managed without anticoagulation. There were 44 filters used in the patients receiving citrate with a median filter life of 42.0 (interquartile range 22.2 - 70.7) hours. Only 8 of the 44 filters were lost due to clotting. Heparin was used for anticoagulation of 17 filters and no anticoagulation was used in the case of 15 filters, resulting in a median filter life of 43.0 (13.5 - 75.0) and 12.0 (4.0 - 33.0) hours, respectively. Clinically significant bleeding occurred in 2 patients, 1 receiving citrate and another receiving heparin. No patient had evidence for citrate toxicity, metabolic alkalosis or hypernatremia. 14 (48.3%) patients survived. CONCLUSIONS The use of regional citrate anticoagulation of the CVVH circuit appears advantageous in patients with increased risk of bleeding and bicarbonate-based replacement fluid seems desirable in patients with lactic acidosis due to shock and/or severe liver failure. Tailoring the type of replacement fluid and method of anticoagulation to the individual patient leads to long filter lives, excellent metabolic control and minimal complications.
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Affiliation(s)
- R Palsson
- Division of Nephrology and Department of Medicine, Landspitali University Hospital, Reykjavik, Iceland
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Abstract
AIMS Diabetic nephropathy is an uncommon cause of end-stage renal disease in Iceland in contrast to most industrialized countries. The aim of this study was to examine the incidence of diabetic nephropathy in Iceland. METHODS All patients diagnosed with Type 1 diabetes in Iceland before 1992 were studied retrospectively. Patients diagnosed before age 30, who were insulin dependent from the onset, were defined as having Type 1 diabetes. Diabetic nephropathy was defined as persistent proteinuria measured with a dipstick test (Albustix) on three consecutive clinic visits at least 2 months apart. Patients were followed to the end of year 1998, to their last recorded outpatient visit, or until death. The cumulative incidence of diabetic nephropathy was calculated with the Kaplan-Meier method and presented according to the duration of diabetes divided into 5-year intervals. RESULTS A total of 343 patients with Type 1 diabetes were identified. The mean follow-up period was 20.2 +/- 11.4 (mean +/- sd) years. Only 9.3% of patients were lost to follow-up. Sixty-five patients developed diabetic nephropathy. The cumulative incidence was 22.6% at 20 years and levelled off at 40.3% after approximately 35 years of diabetes duration. No significant changes in cumulative incidence were observed over time. Mean glycated haemoglobin was 8.4% in patients with proteinuria and 7.8% in a group of patients without proteinuria that was matched for age, gender and duration of diabetes (P = 0.04). CONCLUSIONS The cumulative incidence of diabetic nephropathy in Iceland is comparable with previously reported cumulative incidence rates and has remained unchanged. Glycaemic control was significantly better in patients without proteinuria.
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Affiliation(s)
- G Tryggvason
- University of Iceland Faculty of Medicine, Reykjavik, Iceland
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Asmundsson P, Leifsson AS, Palsson R. Kidney transplantation in Icelandic patients 1970 to 2000. Transplant Proc 2003; 35:785. [PMID: 12644136 DOI: 10.1016/s0041-1345(03)00043-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- P Asmundsson
- Renal Unit, Landspitali University Hospital, Reykjavik, Iceland.
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Edvardsson V, Palsson R, Olafsson I, Hjaltadottir G, Laxdal T. Clinical features and genotype of adenine phosphoribosyltransferase deficiency in iceland. Am J Kidney Dis 2001; 38:473-80. [PMID: 11532677 DOI: 10.1053/ajkd.2001.26826] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.7] [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: 01/05/2023]
Abstract
The purpose of this study was to characterize the clinical, diagnostic, and prognostic features of adenine phosphoribosyltransferase (APRT) deficiency in Icelandic patients, as well as determine their genotype. Medical records of all known patients in Iceland were reviewed. Urinalysis and polymerase chain reaction-based DNA mutation analysis were performed in all patients, siblings, and living parents of index cases. Twenty-three individuals homozygous for type I APRT deficiency were identified in 16 families from 1983 to 1998. There were 12 males and 11 females, and the median age at diagnosis was 37 years (range, 0.5 to 62 years). Seventeen patients were index cases and 6 patients were diagnosed during screening of first-degree relatives. Eighteen patients had symptomatic disease, 15 of whom experienced nephrolithiasis; 4 patients had mild to moderate renal insufficiency, 1 patient had advanced renal failure, and 1 patient died of uremic complications. Six patients experienced recurrent urinary tract infections and 3 infants had a history of reddish-brown diaper stains. Five patients were asymptomatic; 3 of these patients were diagnosed during routine urinalysis and 2 patients were identified during family screening. Urinary 2,8-dihydroxyadenine crystals were detected in all cases, except for the patient who died of end-stage renal failure. All 23 patients were homozygous for the same mutation (D65V) in the APRT gene. Allopurinol therapy successfully prevented further stone formation and significantly improved renal function in most patients with renal insufficiency. Our results suggest that APRT deficiency may be more common than previously recognized and can lead to severe renal failure if left untreated.
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Affiliation(s)
- V Edvardsson
- Department of Pediatrics, Landspitali-University Hospital, Reykjavik, Iceland.
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Palsson R, Jonasson JG, Kristjansson M, Bodvarsson A, Goldin RD, Cox DW, Olafsson S. Genotype-phenotype interactions in Wilson's disease: insight from an Icelandic mutation. Eur J Gastroenterol Hepatol 2001; 13:433-6. [PMID: 11338076 DOI: 10.1097/00042737-200104000-00023] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Wilson's disease, an autosomal recessive disorder of copper transport, usually presents with symptoms from the liver or central nervous system. Rarely, the initial manifestation is fulminant hepatic failure. The abnormal gene (ATP7B) is located on chromosome 13q and encodes a copper-transporting ATPase. A large number of mutations have been reported. We describe a previously healthy 16-year-old girl who presented with fulminant hepatic failure. The girl died within 24 h of admission to a hospital from refractory shock. Autopsy revealed cirrhosis and widespread necrosis of the liver. The copper content of the liver was markedly increased (975 micrograms/g dry weight), strongly suggesting a diagnosis of Wilson's disease. Genetic studies revealed that the girl was homozygous for the mutation 2007 del7, which is the mutation found in all Wilson's disease patients previously identified in Iceland. This is the first known case of fulminant hepatic failure due to Wilson's disease in Iceland. Despite the same mutation, the clinical picture is vastly different from other Icelandic patients with Wilson's disease, who all presented with relatively late-onset neurological disease. This suggests that factors other than the specific mutation have significant impact on the phenotype of the disease.
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Affiliation(s)
- R Palsson
- Department of Medicine, Reykjavik Hospital, Fossvogur, 108 Reykjavik, Iceland
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Abstract
BACKGROUND Systemic heparinization is associated with a high rate of bleeding when used to maintain patency of the extracorporeal circuit during continuous renal replacement therapy (CRRT) in critically ill patients. Regional anticoagulation can be achieved with citrate, but previously described techniques are cumbersome and associated with metabolic complications. METHODS We designed a simplified system for delivering regional citrate anticoagulation during continuous venovenous hemofiltration (CVVH). We evaluated filter life and hemorrhagic complications in the first 17 consecutive patients who received this therapy at our institution. Blood flow rate was set at 180 ml/min. Ultrafiltration rate was maintained at 2.0 liters/hr and citrate-based replacement fluid (trisodium citrate 13.3 mM, sodium chloride 100 mM, magnesium chloride 0.75 mM, dextrose 0.2%) was infused proximal to the filter to maintain the desired fluid balance. Calcium gluconate was infused through a separate line to maintain a serum-ionized calcium level of 1.0 to 1.1 mM. RESULTS All patients were critically ill and required mechanical ventilation and vasopressor therapy. Systemic heparin anticoagulation was judged to be contraindicated in all of the patients. A total of 85 filters were used, of which 64 were lost because of clotting, with a mean life span of 29.5 +/- 17.9 hours. The remaining 21 filters were discontinued for other reasons. Control of fluid and electrolyte balance and azotemia was excellent (mean serum creatinine after 48 to 72 hr of treatment was 2.4 +/- 1.2 mg/dl). No bleeding episodes occurred. Two patients, one with septic shock and the other with fulminant hepatic failure, developed evidence for citrate toxicity without a significant alteration in clinical status. Nine patients survived (52.9%). CONCLUSION Our simplified technique of regional anticoagulation with citrate is an effective and safe form of anticoagulation for CVVH in critically ill patients with a high risk of bleeding.
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Affiliation(s)
- R Palsson
- Renal Unit, Massachusetts General Hospital, Boston, USA
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Fossdal R, Bodvarsson M, Asmundsson P, Ragnarsson J, Palsson R. [Autosomal dominant polycystic kidney disease in Iceland - genetic study.]. LAEKNABLADID 1999; 85:33-42. [PMID: 19321914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE Autosomal dominand polycystic kidney disease (ADPKD) is one of the most common genetic diseases in humans and accounts for 8-10% of end-stage renal failure. The disease is caused by mutations in at least three different genes. About 85% of families with ADPKS have a mutation in a gene (PKD1) on chromosome 16p, whereas 10-15% have a mutation in a gene (PKD2) on chromosom 4q. In a few families, a third gene (PKD3) of unkonown location appears to be involved. The purpose of this study was to determine the genotype of Icelandic families with ADPKD. MATERIAL AND METHODS We isloated DNA from 229 family members and generated genotypes for polymorphic markers with conventional methods. Linkage analysis and haplotype analysis weere performed in 14 ADPKD families, employing merkers from the PKD1 and PKD2 regions. RESULTS The abnormal gene could be located in 13 families. Eleven families demonstrated linkage to the PKD2 locus. Comparison of the haplotypes of the PKD1 families indicates that nine different mutations cause ADPKD1 in Iceland, including one de novo mutation. The two ADPKD2 families each have a distinct haplotype. Thererfor, at least 11 different mutations cause ADPKD in Icelnad. In cooperation with Dutch scientists, one mutation in the PKD2 gene was defined, a 16 bp deletion of a spice site between intron 1 and exon 2. CONCLUSIONS Our results demonstrate marked genetic heterogeneity of ADPKD in the Icelandic population. As expected, most of the families have evidence for mutation in the PKD1 gene. The stage has been set for future work, which will focus on detecting mutations in the PKD genes and defining the correlation between mutations and phenotype of the disease.
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Asmundsson P, Palsson R. [Treatment of end-stage renal disease in Iceland 1968-1997 heart disease in Iceland?]. LAEKNABLADID 1999; 85:9-24. [PMID: 19321912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE Renal replacement therapy for end-stage renal disease (ESRD) jas been provided in Iceland since 1968 when hemodialysis was begun. Kidney transplantation in Iceland patients has benn performed abroad since 1970 mainly in Copenhagen, Gothenburg and Boston. The purpose of theis retrospective study was to determine the changes in incidencs, prevalence, and outcome of ESRD treatment during the period 1968-1997 and compare the results with other ESRD programs, mainly in the Nordic countries. MATERIAL AND METHODS Included in this study were all patients who began renal replacement therapy for ESRD during the study period and remained on therapy for at least six weeks. Data were obtained from the registry of ESRD, compiled by the Dialysis Service of the National University Hospital. The data were used to determine the annual incidence and prevalence of treated ESRD. Changes in parameters, such as age at the beginning of renal replacement therapy, gender distribution, causes of ESRD, treatment modalities, and survival were evaluated. Annual mortality rate was calculated as deaths per 100 life-years. Comparison of means was done by the twö sample t-test, survival was estimated by the Kaplan-Meier method and survival differences weere determined with the Mantel-Cox test. RESULTS A total of 201 patients began therapy for ESRD during this 30 year period. The number of patients beginning renal replacement therapy in each of the three consecutive decades was 27, 59 and 115, respectively, which corresponds to 12.8, 25.1 and 44 per million population per year. The mean age rose throughout hte study period nad was 54.8 in the final decade. The prevalence per million population was 72 in 1977, 182 in 1987 nad 356 in 1997. Diabetic nephropathy was not observed as a cause of ESRD until the last decade when it accounted for 12% of new patiens. Hemodialysis was the sole dialysis modality undtil 1985. Peritoneal dialysis has since provided approximately one third of the dialysis treatment. The number of renal transplants was 13, 30 and 58 for each decade, respectively. At the end of 1997 htere were 59 functioning allografts and of these 45 were from living donors. Patients with a functioning allograft were 70% of all ESRD patients at the end of 1997. Allografts came predominantly from cadveric donors during the first two decades but living donors were 65% in the final decade. The five year survival of transplanted patients (81%) was markedly superior to that of dialyzed patients (16%). The annual mortality rate declined for the whole period, during the last decade it was 10.7 per 100 life-years for all patients, 27.9 for hemodialysis patients, 15.3 for peritonial dialysis patients and 2.1 for transplanted patients. Death was mainly from cardiovascular causes and infections. CONCLUSIONS There has been marked increase in the incidence and prevalence of treated ESRD in Iceland during the last 30 years. However, the incidence is low compared to the other Nordic countries, mainly as a rresult of low incidence of ESRD due to glomerulonephritis and diabetic nephropathy. Nearly half the ESRD population has recieved a renal transplant. Only Norway has a higher prevalence of transplanted patients among the ESRD pool. The percentage of living donor grafts among the transplanted patients is the highest the auhtors are aware of. Five year patient survival and renal allograft survival in Iceland were comparable to other countries.
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Abstract
BACKGROUND In clinical transplantation, "passenger" dendritic cells (DCs) in the allograft have been thought to induce allograft rejection. However, the presence of DCs in the normal human kidney is controversial. Most reports have relied on the examination of MHC class I and II antigen expression in combination with DC morphology for identification of DCs. METHODS The distribution of the p55 antigen (fascin), which is selectively expressed by human blood and lymphoid DCs, was investigated by immunohistochemistry. RESULTS Our study demonstrates that p55-positive DCs are absent from the normal human kidney and CD1a- and S100-positive cells are absent or very rare. Furthermore, HLA-DR and factor VIII-related antigen show almost complete colocalization in capillaries. In contrast, all 16 kidney biopsies from patients with inflammatory processes demonstrated p55-positive DCs in the cellular infiltrates. CONCLUSIONS These results suggest that DCs are not present or are very rare in normal renal tissues but may migrate into the renal interstitium with inflammatory changes.
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Affiliation(s)
- L Sonderbye
- Department of Medicine/Nephrology, The Milton S. Hershey Medical Center, Penn State University, Hershey 17033, USA
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Hsu CY, Palsson R, Niles JL. Continuous hemofiltration. N Engl J Med 1997; 337:713; author reply 713-4. [PMID: 9280826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Palsson R, Sharma CP, Kim K, McLaughlin M, Brown D, Arnaout MA. Characterization and cell distribution of polycystin, the product of autosomal dominant polycystic kidney disease gene 1. Mol Med 1996; 2:702-11. [PMID: 8972485 PMCID: PMC2230129] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND In a majority of cases, autosomal dominant polycystic kidney disease (ADPKD) is caused by mutations within a putative open reading frame of the PKD1 gene. The encoded protein, polycystin, is predicted to span the plasma membrane several times and contains extracellular domains, suggestive of a role in cell adhesion. The cellular distribution and function of polycystin is not known. MATERIALS AND METHODS We selected as immunogens two conserved 15 amino acid peptides: P1, located in a predicted extracellular region of polycystin, and P2, located in the C-terminal putative cytoplasmic tail. The anti-peptide antibodies from immunized rabbits were affinity purified on peptide-coupled resins and their specificity confirmed by their selective binding to recombinant polycystin fusion proteins. Western blotting and immunohistochemistry were used to characterize the size, tissue, and cell distribution of polycystin. RESULTS A high-molecular mass protein (about 642 kD) was detected by Western blotting in rat brain tissue. A few additional bands, in the 100- to 400-kD range, probably representing tissue-specific variants and/or proteolytic fragments, were recognized in human and rat tissues. Polycystin was abundantly expressed in fetal kidney epithelia, where it displayed basolateral and apical membrane distribution in epithelial cells of the ureteric buds, collecting ducts, and glomeruli. In normal human adult kidney, polycystin was detected at moderate levels and in a cell surface-associated distribution in cortical collecting ducts and glomerular visceral epithelium. Expression of polycystin was significantly increased in cyst-lining epithelium in ADPKD kidneys, but was primarily intracellular. CONCLUSIONS Polycystin appears to be a developmentally regulated and membrane-associated glycoprotein. Its intracellular localization in the cyst-lining epithelium of ADPKD kidneys suggests an abnormality in protein sorting in this disease.
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Affiliation(s)
- R Palsson
- Renal Unit, Massachusetts General Hospital, Charlestown 02129, USA
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Abstract
Detection of circulating antineutrophil cytoplasmic antibodies (ANCA) to the neutrophil serine proteinase, proteinase 3 (PR3), has proven valuable for the diagnosis of Wegener's granulomatosis (WG). However, the importance of these autoantibodies in the pathogenesis of WG remains unknown. It was recently reported that anti-PR3 autoantibodies (PR3-ANCA) from some patients with WG inhibit the proteolytic activity of PR3 and interfere with the inactivation of PR3 by the physiologic inhibitor, alpha 1-proteinase inhibitor (alpha 1-PI). We have studied the effect of PR3-ANCA on the enzymatic activity of PR3 and its correlation with disease activity in patients with WG. We purified IgG from 21 PR3-ANCA positive sera obtained from 17 patients with WG, and determined its effect on the esterolytic and proteolytic activity of purified human PR3 using Boc-Ala-O-Nitrophenyl ester and fluoresceinated-elastin as enzyme substrates. Controls included seven sera containing anti-MPO autoantibodies (MPO-ANCA) from patients with systemic vasculitis and seven ANCA-negative sera obtained from healthy individuals. We found that PR3-ANCA from 9 of the 17 patients significantly inhibited the activity of PR3. There was no correlation between the titers of PR3-ANCA and their inhibitory activity. For one extensively characterized autoantibody, the inhibition reached 70 to 95% at 20-fold molar excess of IgG to enzyme, with an apparent Kiapp of 56.5 microM. This inhibition was non-competitive in nature, and was additive to that produced by alpha 1-PI. A review of the clinical histories of the patients revealed a strong association between active WG and inhibitory autoantibodies.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G H Daouk
- Leukocyte Biology and Inflammation Program, Massachusetts General Hospital, Charlestown, USA
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