Association of serum potassium with decline in residual kidney function in incident hemodialysis patients.

BACKGROUND: Hyperkalemia is associated with kidney function decline in patients with non-dialysis dependent chronic kidney disease, but this relationship is unclear for residual kidney function (RKF) among hemodialysis (HD) patients. METHODS: We conducted a retrospective cohort study of 6655 patients, who started HD January 2007 and December 2011 and who had data on renal urea clearance (KRU). Serum potassium levels were stratified into four groups (i.e. ≤4.0, >4.0 to ≤4.5, >4.5 to ≤5.0 and >5.0 mEq/L) and 1-year KRU slope for each group was estimated by a linear mixed-effects model. RESULTS: Higher serum potassium was associated with a greater decline in KRU, and the greatest decrease in KRU (-0.20, 95% confidence interval -0.50 to -0.06) was observed for baseline potassium >5.0 mEq/L in the fully adjusted model. Mediation analysis showed that KRU slope mediated 1.78% of the association between serum potassium and mortality. CONCLUSIONS: Hyperkalemia is associated with a decline in RKF amongst incident HD patients. These findings may have important clinical implications in the management of hyperkalemia in advanced CKD if confirmed in additional clinical trials.

Clinical characteristics and the diagnostic role of molecular tests in musculoskeletal infections caused by nontuberculous Mycobacterium: a single-center experience.

PURPOSE: We retrospectively investigated NTM musculoskeletal infections to understand the clinical characteristics as well as the diagnostic performance of molecular tests as a useful supplementary test. METHODS: A retrospective cohort study was conducted from January 2016 to December 2019. Intraoperative specimens for culture and pathological analysis were obtained during surgery under sterile conditions. AdvanSure TB/NTM real-time PCR (LG Life Sciences, Seoul, Korea) and PCR-reverse blot hybridization assay (REBA, REBA Myco-ID; YD Diagnostics, Yongin, Republic of Korea) was performed directly from tissue specimens for the rapid and accurate identification of 20 mycobacterial species. RESULTS: A series of 24 patients was identified during the study period. Agricultural/aquatic exposure were predisposing factors in 9 patients, trauma in 4 patients, but no predisposing host factor was identified for 11 patients. Twenty-two patients presented with tenosynovitis and two with arthritis with substantial delays between initial presentation of symptoms and microbiologic diagnosis, with a median of 147 days (range 5-396 days). Pathologic tissue examination of musculoskeletal NTM infections was positive for chronic granulomatous inflammation in 18 cases. Fifteen were positive in the culture study, and nine were positive only in the molecular study using tissue specimens. All 6 M. ulcerans/M. marinum isolates were identified only by PCR. CONCLUSIONS: This study is an important reminder that NTM infections should be a part of the differential diagnosis in patients with chronic musculoskeletal infections refractory to regular treatment. Although molecular test cannot replace the conventional smear and culture methods, it can be used as a useful supplementary test especially in diagnosing M. marinum infection.

Association of Pre-ESRD Serum Bicarbonate with Post-ESRD Mortality in Patients with Incident ESRD.

BACKGROUND: Serum bicarbonate or total carbon dioxide (CO2) concentrations decline as chronic kidney disease (CKD) progresses and rise after dialysis initiation. While metabolic acidosis accelerates the progression of CKD and is associated with higher mortality among patients with end stage renal disease (ESRD), there are scarce data on the association of CO2 concentrations before ESRD transition with post-ESRD mortality. METHODS: A historical cohort from the Transition of Care in CKD (TC-CKD) study includes 85,505 veterans who transitioned to ESRD from October 1, 2007, through March 31, 2014. After 1,958 patients without follow-up data, 3 patients with missing date of birth, and 50,889 patients without CO2 6 months prior to ESRD transition were excluded, the study population includes 32,655 patients. Associations between CO2 concentrations averaged over the last 6 months and its rate of decline during the 12 months prior to ESRD transition and post-ESRD all-cause, cardiovascular (CV), and non-CV mortality were examined by using hierarchical adjustment with Cox regression models. RESULTS: The cohort was on average 68 ± 11 years old and included 29% Black veterans. Baseline concentrations of CO2 were 23 ± 4 mEq/L, and median (interquartile range) change in CO2 were -1.8 [-3.4, -0.2] mEq/L/year. High (≥28 mEq/L) and low (<18 mEq/L) CO2 concentrations showed higher adjusted mortality risk while there was no clear trend in the middle range. Consistent associations were observed irrespective of sodium bicarbonate use. There was also a U-shaped association between the change in CO2 and all-cause, CV, and non-CV mortality with the lowest risk approximately at -2.0 and 0.0 mEq/L/year among sodium bicarbonate nonusers and users, respectively, and the highest mortality was among patients with decline in CO2 >4 mEq/L/year. CONCLUSION: Both high and low pre-ESRD CO2 levels (≥28 and <18 mEq/L) during 6 months prior to dialysis transition and rate of CO2 decline >4 mEq/L/year during 1 year before dialysis initiation were associated with greater post-ESRD all-cause, CV, and non-CV mortality. Further studies are needed to determine the optimal management of CO2 in patients with advanced CKD stages transitioning to ESRD.

Ultrafiltration Rate, Residual Kidney Function, and Survival Among Patients Treated With Reduced-Frequency Hemodialysis.

RATIONALE & OBJECTIVE: Patients receiving twice-weekly or less-frequent hemodialysis (HD) may need to undergo higher ultrafiltration rates (UFRs) to maintain acceptable fluid balance. We hypothesized that higher UFRs are associated with faster decline in residual kidney function (RKF) and a higher rate of mortality. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 1,524 patients with kidney failure who initiated maintenance HD at a frequency of twice or less per week for at least 6 consecutive weeks at some time between 2007 and 2011 and for whom baseline data for UFR and renal urea clearance were available. PREDICTOR: Average UFR during the first patient-quarter during less-frequent HD (<6, 6-<10, 10-<13, and≥13mL/h/kg). OUTCOME: Time to all-cause and cardiovascular death, slope of decline in RKF during the first year after initiation of less-frequent HD (with slopes above the median categorized as rapid decline). ANALYTICAL APPROACH: Cox proportional hazards regression for time to death and logistic regression for the analysis of rapid decline in RKF. RESULTS: Among 1,524 patients, higher UFR was associated with higher all-cause mortality; HRs were 1.43 (95% CI, 1.09-1.88), 1.51 (95% CI, 1.08-2.10), and 1.76 (95% CI, 1.23-2.53) for UFR of 6 to<10, 10 to<13, and≥13mL/h/kg, respectively (reference: UFR < 6mL/h/kg). Higher UFR was also associated with higher cardiovascular mortality. Baseline RKF modified the association between UFR and mortality; the association was attenuated among patients with renal urea clearance≥5mL/min/1.73m2. Higher UFR had a graded association with rapid decline in RKF; ORs were 1.73 (95% CI, 1.18-2.55), 1.89 (95% CI, 1.12-3.17), and 2.75 (95% CI, 1.46-5.18) at UFRs of 6 to<10, 10 to<13, and≥13mL/h/kg, respectively (reference: UFR < 6mL/h/kg). LIMITATIONS: Residual confounding from unobserved differences across exposure categories. CONCLUSIONS: Higher UFR was associated with worse outcomes, including shorter survival and more rapid loss of RKF, among patients receiving regular HD treatments at a frequency of twice or less per week.

Eosinophil count and mortality risk in incident hemodialysis patients.

BACKGROUND: Eosinophils are traditionally known as moderators of allergic reactions; however, they have now emerged as one of the principal immune-regulating cells as well as predictors of vascular disease and mortality in the general population. Although eosinophilia has been demonstrated in hemodialysis (HD) patients, associations of eosinophil count (EOC) and its changes with mortality in HD patients are still unknown. METHODS: In 107 506 incident HD patients treated by a large dialysis organization during 2007-11, we examined the relationships of baseline and time-varying EOC and its changes (ΔEOC) over the first 3 months with all-cause mortality using Cox proportional hazards models with three levels of hierarchical adjustment. RESULTS: Baseline median EOC was 231 (interquartile range 155-339) cells/µL and eosinophilia (>350 cells/µL) was observed in 23.4% of patients. There was a gradual increase in EOC over time after HD initiation with a median ΔEOC of 5.1 (IQR -53-199) cells/µL, which did not parallel the changes in white blood cell count. In fully adjusted models, mortality risk was highest in subjects with lower baseline and time-varying EOC (<100 cells/µL) and was also slightly higher in patients with higher levels (≥550 cells/µL), resulting in a reverse J-shaped relationship. The relationship of ΔEOC with all-cause mortality risk was also a reverse J-shape where both an increase and decrease exhibited a higher mortality risk. CONCLUSIONS: Both lower and higher EOCs and changes in EOC over the first 3 months after HD initiation were associated with higher all-cause mortality in incident HD patients.

Potassium intake, skeletal muscle mass, and effect modification by sex: data from the 2008-2011 KNHANES.

BACKGROUND: A loss of muscle mass may be influenced by multiple factors. Insulin sensitivity and metabolic acidosis are associated with muscle wasting and may be improved with potassium intake. This study evaluated the association between dietary potassium intake and skeletal muscle mass. METHODS: We performed a cross-sectional study with data obtained from the Korean National Health and Nutrition Examination Survey (KNHANES) (2008-2011). Participant's daily food intake was assessed using a 24-h recall method. Appendicular skeletal muscle mass (ASM) was calculated as the sum of muscle mass in both arms and legs, measured using dual energy X-ray absorptiometry. The skeletal muscle index (SMI) was calculated as ASM divided by height2 (kg/m2). Low muscle mass was defined as a SMI < 7.0 kg/m2 for men and < 5.4 kg/m2 for women. RESULTS: Data from 16,558 participants (age ≥ 19 years) were analyzed. Participants were categorized into quintiles according to their potassium intake. Sex-specific differences were found in the association between potassium intake and muscle mass (PInteraction < 0.001). In men, higher potassium intake was associated with lower odds for low muscle mass; the fully adjusted odds ratios (95% confidence intervals) were 0.78 (0.60-1.03), 0.71 (0.54-0.93), 0.68 (0.51-0.90), and 0.71 (0.51-0.98) for the top four quintiles (referenced against the lowest quintile), respectively. However, this association was attenuated in women after adjusting for total energy intake. Higher potassium intakes were also associated with a greater SMI. CONCLUSIONS: Higher dietary potassium intake decreased the odds of low muscle mass in men but not in women.

Ultrafiltration Rate Effects Declines in Residual Kidney Function in Hemodialysis Patients.

BACKGROUND: High ultrafiltration rate (UFR) has been associated with increased mortality in hemodialysis (HD) patients. However, the impact of UFR on decline of residual kidney function (RKF) has not been elucidated among patients receiving conventional HD. METHODS: We performed a retrospective cohort study of 7,753 patients who initiated conventional HD from 2007 to 2011 and survived the first year of dialysis with baseline UFR and renal urea clearance (KRU) data at baseline and 1 year (5th patient-quarter). The primary exposure was average UFR at the 1st patient-quarter from dialysis initiation (<4, 4 to <6, 6 to <9, 9 to <13, and ≥13 mL/h/kg). Decline in RKF was defined as the percent change in KRU and decline in urine output during the first year after initiation of dialysis. We used a logistic regression model for rapid decline in RKF and a linear regression model for change in urine volume. RESULTS: In our HD cohort, mean baseline UFR was 7.0 ± 3.1 mL/h/kg, and median (interquartile range) baseline KRU was 3.5 (2.1-5.3) mL/min/1.73 m2. There was a graded association between UFR and a rapid decline in RKF; the expanded case mix-adjusted ORs and 95% CIs were 1.21 (1.04-1.40), 1.34 (1.16-1.55), 1.73 (1.46-2.04), and 1.93 (1.48-2.52) for baseline UFR 4 to <6, 6 to <9, 9 to <13, and ≥13  mL/h/kg, respectively (reference: <4 mL/h/kg). KRU trajectories showed a greater KRU decline over time in higher UFR categories. Higher UFR was also associated with a greater decline in urine output after 1 year. CONCLUSION: Higher UFR was associated with a rapid decline in RKF among conventional HD patients. Further clinical trials are needed to elucidate a causal effect of UFR on RKF among HD patients.

Metronidazole therapy as initial treatment of Clostridium difficile infection in patients with chronic kidney disease in Korea.

The risk of metronidazole treatment failure in Clostridium difficile infection (CDI) patients with chronic kidney disease (CKD) or end-stage renal disease in Korea has not been established. We evaluated 481 patients who had been admitted to two secondary hospitals with a diagnosis of, and treatment for, CDI during 2010-2016. CDI patients were divided into three groups according to CKD status: non-CKD (n = 363), CKD (n = 55) and those requiring dialysis (n = 63). Logistic regression analyses were performed to examine the association of CKD status with treatment failure. CDI patients receiving dialysis tended to have increased odds of metronidazole and overall treatment failure compared to non-CKD patients; adjusted odds ratios and 95% confidence intervals were 2.09 (1.03-4.21) and 2.18 (1.11-4.32) for metronidazole and overall treatment failure, respectively. However, CKD patients did not have increased odds of metronidazole or overall treatment failure compared to non-CKD patients, even where severe CDI was more prevalent in CKD patients. The incidence of symptomatic ileus or toxic megacolon did not differ among groups. Our results suggest that initial metronidazole therapy may be considered in CDI patients with non-dialysis CKD, but should not be considered in CDI patients undergoing dialysis.

The association of dialysis adequacy, body mass index, and mortality among hemodialysis patients.

BACKGROUND: Although hemodialysis (HD) adequacy, single-pool Kt/Vurea (spKt/V), is inversely correlated with body size, each is known to affect patient survival in the same direction. Therefore, we sought to examine the relationship between HD adequacy and mortality according to body mass index (BMI) in HD patients and explore a combination effect of BMI and HD adequacy on mortality risk. METHODS: We retrospectively reviewed patient data from the Korean Society of Nephrology registry, a nationwide database of medical records of HD patients, from January 2001 to June 2017. We included patients ≥18 years old who were receiving maintenance HD. Patients were categorized into three groups according to baseline BMI (< 20 (low), 20 to < 23 (normal), and ≥ 23 (high) kg/m2). Baseline spKt/V was divided into six categories. RESULTS: Among 18,242 patients on HD, the median follow-up duration was 5.2 (IQR, 1.9-8.9) years. Cox regression analysis showed that, compared to the reference (spKt/V 1.2-1.4), lower and higher baseline spKt/V were associated with greater and lower risks for all-cause mortality, respectively. However, among patients with high BMI (n = 5588), the association between higher spKt/V and lower all-cause mortality was attenuated in all adjusted models (Pinteraction < 0.001). Compared to patients with normal BMI and spKt/V within the target range (1.2-1.4), those with low BMI had a higher risk for all-cause mortality at all spKt/V levels. However, the gap in mortality risk became narrower for higher values of spKt/V. Compared to patients with normal BMI and spKt/V in the target range, those with high BMI and spKt/V < 1.2 were not at increased risk for mortality despite low dialysis adequacy. CONCLUSIONS: The association between spKt/V and mortality in HD patients may be modified by BMI.

Association between colistin dose and development of nephrotoxicity.

OBJECTIVE: To investigate the development of nephrotoxicity associated with colistin dose, and whether this relationship differs depending on renal function. DESIGN: A retrospective cohort study of patients who received intravenous colistin to treat infections caused by extensively drug-resistant Gram-negative microorganisms. Adult patients receiving colistin for 72 hours or longer were included in this study. Patients who received renal replacement therapy at baseline or were administered colistin for less than 3 days were excluded. Colistin-induced nephrotoxicity was defined as a doubling of baseline serum creatinine. Colistin dosing was evaluated based on both actual body weight and ideal body weight. SETTING: Single general hospital between 2010 and 2013. PATIENTS: A total number of 475 patients received colistin therapy. Of these patients, 329 met the inclusion criteria and were included in the analysis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred forty-three patients (43.5%) experienced nephrotoxicity during colistin treatment. The median onset time of nephrotoxicity was 6 days (interquartile range, 4-8 days). The patients with nephrotoxicity were older. Hematocrit and serum albumin levels were lower in patients with nephrotoxicity. Median daily dosing of colistin based on ideal body weight was significantly higher in patients with nephrotoxicity than in those without nephrotoxicity (4.55 vs 4.43 mg/kg/d, respectively; p=0.021). The cumulative dose was not different between patients with and without nephrotoxicity. In multiple logistic regression analysis, daily colistin dosing based on ideal body weight was only significantly associated with the development of nephrotoxicity in patients with an estimated glomerular filtration rate<60 mL/min/1.73 m2 (odds ratio, 2.34; 95% CI, 1.22-4.5). In these affected patients, based on a receiver operating characteristic plot, the optimal predictive cutoff of colistin dose for the development of nephrotoxicity was 2.87 mg/kg/d of colistin, with a sensitivity of 92.3% and a specificity of 76.7%. In patients with estimated glomerular filtration rate≥60 mL/min/1.73 m, age, serum albumin, hematocrit, and use of glycopeptide were associated with the development of nephrotoxicity. CONCLUSIONS: Development of nephrotoxicity was significantly more strongly associated with the dose of colistin, but only in patients with an estimated glomerular filtration rate<60 mL/min/1.73 m2 and not in those with normal renal function.

Association between serum bicarbonate levels and albuminuria in stage 3 and stage 4 chronic kidney disease: a cross-sectional study.

AIMS: Metabolic acidosis is a common manifestation of chronic kidney disease (CKD) and appears to be associated with CKD progression and mortality. We evaluated whether serum bicarbonate level is associated with albuminuria in patients with stage 3 and 4 CKD. METHODS: This was a retrospective cross-sectional study of outpatients with CKD stages 3 - 4 (estimated glomerular filtration rate 15 - 59 mL/minutes/1.73 m2). Serum bicarbonate levels, serum creatinine levels, and random urinary albumin-to-creatinine ratios (UA/Cr) examined on the same day were required for enrollment. Significant albuminuria was defined as UA/Cr >= 300 mg/g. Serum bicarbonate was analyzed as both a continuous variable and a categorical variable after it was divided into categories of < 23, 23 - 25.9, and >= 26 mmol/L. RESULTS: 151 patients were included in this study. Their mean age was 59.1 ± 13.9 years, and 60.9% were men. The mean serum bicarbonate level was 23.7 ± 3.3 mmol/L. In a multiple logistic regression analysis to determine the factors associated with significant albuminuria, the serum bicarbonate categories were independent factors associated with significant albuminuria after adjustments were made for relevant covariates (p = 0.028). In a subgroup analysis according to CKD stage, the association between bicarbonate categories and significant albuminuria was significant only for patients with stage 3 disease, regardless of renal function or blood pressure (p = 0.014 and 0.706 in stage 3 and 4 diseases, respectively). CONCLUSIONS: Low serum bicarbonate levels were ssociated with significant albuminuria, even at levels in the normal range, in CKD patients, especially with stage 3 disease.

Unilateral and bilateral acute pyelonephritis: differences in clinical presentation, progress and outcome.

PURPOSE: Acute pyelonephritis (APN) generally involves a single kidney, but it can be bilateral. The aim of the present study was to evaluate differences in clinical presentation, progress and outcome for bilateral APN compared with unilateral APN. STUDY DESIGN: The medical records of all patients over 19 years of age, hospitalised for APN and who underwent abdominal enhanced CT at Samsung Changwon Hospital between January 2009 and August 2012 were retrospectively reviewed. Patients were divided into two groups according to whether unilateral or bilateral lesions were identified on the CT scan. RESULTS: Of the 296 patients, 99 had bilateral APN. Only 64/86 (74.4%) patients with clear tenderness in the bilateral APN group had bilateral tenderness. Patients with bilateral APN had more severe abnormalities, based on the results of laboratory tests. Leukocytosis, thrombocytopenia, bacteraemia, acute kidney injury, shock and death occurred more frequently in bilateral than in unilateral APN. In the bilateral APN group, broad spectrum antibiotics were used more frequently as an initial antibiotic treatment. A history of stroke or diabetes mellitus, and duration of symptoms before admission, were independent risk factors associated with bilateral APN. CONCLUSIONS: Patients with bilateral APN experienced more severe clinical and laboratory manifestations and had a poorer outcome than those with unilateral APN. Early imaging tests can be considered to discriminate unilateral from bilateral APN, especially in those with a history of stroke or diabetes and with a longer duration of symptoms. Moreover, initial use of broader spectrum antibiotics can be considered in patients with bilateral APN.

Geriatric Nutritional Risk Index as a Possible Predictor of Decline in Kidney Function in Older People.

BACKGROUND: The Geriatric Nutritional Risk Index (GNRI) is associated with morbidity and mortality in older individuals. Our study explored the relationship between GNRI, decline in kidney function, and all-cause mortality in older individuals. METHODS: This retrospective cohort study analyzed data from participants aged ≥60 years who underwent a general health checkup between 2002 and 2018. The primary exposure was the GNRI, divided into quartiles. The primary and secondary outcomes were a decline in kidney function assessed using the 5-year estimated glomerular filtration rate (eGFR) and all-cause mortality, respectively. RESULTS: The analysis included a total of 1,599 participants (median age, 63 years; interquartile range [IQR], 61-67; 54% males). The mean±standard deviation of GNRI was 114±7. Compared with the highest GNRI quartile, the lower GNRI quartiles were associated with steeper 5-year slopes in eGFR, with a fully adjusted beta coefficient and 95% confidence intervals (CIs) of -0.50 (-0.86, -0.14), -0.29 (-0.63, 0.05), and -0.19 (-0.53, 0.14) for the first, second, and third GNRI quartiles, respectively. The median follow-up duration was 7.4 years (IQR, 4.6-12.4). During this period, we identified 108 deaths (7.8 per 1,000 person-years). The first GNRI quartile was associated with all-cause mortality compared to the highest GNRI quartile (hazard ratio of 2.20; 95% CI 1.23, 3.95). CONCLUSION: Nutritional status, as evaluated using the GNRI, was associated with 5-year changes in kidney function and all-cause mortality in older individuals.

Interaction of malnutrition, N-terminal pro-B-type natriuretic peptide and ventricular remodeling in patients on maintenance hemodialysis.

AIMS: The aim of the present study was to investigate the interaction of nutritional status, N-terminal probrain-type natriuretic peptide (NT-proBNP) and ventricular remodeling in hemodialysis patients. METHODS: NT-proBNP was measured by immunoassay. Nutritional status was assessed using the subjective global assessment (SGA) and malnutrition-inflammation score (MIS). Transthoracic echocardiographic examinations were performed on all patients. RESULTS: 44 patients undergoing maintenance hemodialysis were enrolled in this study. Malnourished patients had higher levels of extracellular water (ECW) per kg body weight (BWt) than well-nourished patients and higher levels of NT-proBNP. MIS was positively correlated with left ventricular mass index (LVMI), log NT-proBNP and ECW/BWt, and negatively correlated with fat mass and LV systolic dysfunction. LV systolic dysfunction, LVMI and MIS were independently associated with log NT-proBNP levels. Multiple regression analysis showed that log NT-proBNP, mean arterial pressure and ECW/BWt were independently associated with LVMI. However, MIS did not have an independent relationship to LVMI. CONCLUSIONS: Malnutrition in hemodialysis patients is accompanied by volume overload and associated with increased log NT-proBNP levels independent of volume status, and these levels are independently associated with increased LVMI. This suggests a possibility that nutritional status may affect ventricular remodeling in hemodialysis patients.

Effect of Orthostatic Hypotension on Kidney Function.

BACKGROUND: The association between orthostatic hypotension (OH) and long-term changes in kidney function in the general population is not yet well known. METHODS: We performed a population-based cohort study based on data from the Korean Genome and Epidemiology Study (KoGES). The primary exposure was the presence of classic OH, defined as a postural drop in blood pressure (systolic blood pressure ≥20 mm Hg and/or diastolic blood pressure ≥10 mm Hg) at 2 min of standing after 5 min of supine rest. The primary outcome was a 12-year change in kidney function, assessed by subtracting the baseline estimated glomerular filtration rate (eGFR) from the eGFR at 12 years of follow-up. RESULTS: Our study included 5,905 participants (median [interquartile range] age, 49 [44-58] years; 46% males) who met inclusion and exclusion criteria. Classic OH was detected in 268 (4.5%) of the total participants. In the regression analyses, participants with classic OH had a greater decline in eGFR over 12 years compared with those without classic OH; the fully adjusted beta coefficient and 95% confidence intervals (95% CIs) were -1.74 (-3.07, -0.40). Furthermore, classic OH was associated with 27% greater risk of a 30% decline in kidney function compared with those without classic OH; fully adjusted hazard ratio and 95% CIs were 1.27 (1.07, 1.49). CONCLUSIONS: Classic OH can negatively affect long-term kidney function in the general population.

Greater Severity of Steatosis Is Associated with a Higher Risk of Incident Diabetes: A Retrospective Longitudinal Study.

BACKGRUOUND: Fatty liver is associated with increased risk of developing type 2 diabetes. We aimed to evaluate whether the severity of hepatic steatosis is associated with incident diabetes. METHODS: We conducted a longitudinal analysis using data from 1,798 participants who underwent a comprehensive health checkup and abdominal computed tomography (CT). We assessed the association between baseline liver attenuation value on non-contrast CT images and risk of incident diabetes. All the participants were categorized into three groups based on the baseline liver attenuation value on non-contrast CT images: without hepatic steatosis (>57 Hounsfield unit [HU]), mild hepatic steatosis (41-57 HU), and moderate to severe hepatic steatosis (≤40 HU). RESULTS: During a median follow-up period of 5 years, 6.0% of the study participants progressed to diabetes. The incidence of diabetes was 17.3% in the moderate to severe hepatic steatosis group, 9.0% in the mild steatosis group, and 2.9% in those without hepatic steatosis. In a multivariate adjustment model, as compared with participants without hepatic steatosis, those with moderate to severe steatosis had a hazard ratio (HR) of 3.24 (95% confidence interval [CI], 1.64 to 4.2) for the development of diabetes, and those in the mild steatosis group had a HR of 2.33 (95% CI, 1.42 to 3.80). One standard deviation decrease in mean CT attenuation values of the liver was associated with a 40% increase in the development of diabetes (multivariate adjusted HR, 1.40; 95% CI, 1.2 to 1.63). CONCLUSION: We found a positive association between severity of hepatic steatosis and risk of incident diabetes. Greater severity of steatosis was associated with a higher risk of incident diabetes.

Health-related quality of life in adults with metabolic syndrome: the Korea national health and nutrition examination survey, 2007-2008.

BACKGROUND/AIMS: An association between metabolic syndrome and impaired health-related quality of life (HRQoL) is still controversial. We investigated the association between metabolic syndrome in itself and HRQoL in the Korean adult population. METHODS: The study is a cross-sectional analysis of 8,941 adults ≥19 years of age who participated in the 2007 and 2008 Korean National Health and Nutrition Examination Survey. EuroQoL five-dimension (EQ-5D), the EQ-5D index and the EQ visual analogue scale (EQ VAS) were used to assess HRQoL. RESULTS: The prevalence of metabolic syndrome was 26.2%. Compared to the participants without metabolic syndrome, those with metabolic syndrome were older and comprised a higher proportion of men. Moreover, participants with metabolic syndrome were more likely to have a lower education level, to be current smokers, to have activity limitation and to have more frequent metabolic abnormalities and comorbidities. Metabolic syndrome was associated with HRQoL based on EQ-5D and EQ VAS in simple regression analysis. However, metabolic syndrome was not significantly associated with HRQoL after adjusting for age, sex, smoking status, income, education level, marital status, obesity, diabetes mellitus, stroke, history of heart disease and chronic kidney disease for EQ-5D, and in addition history of depression for EQ VAS. CONCLUSION: Metabolic syndrome in itself was not associated with impaired HRQoL after adjusting for confounding variables such as socio-demographic factors, medical comorbidities and obesity.

Potential role of urinary angiotensinogen in predicting antiproteinuric effects of angiotensin receptor blocker in non-diabetic chronic kidney disease patients: a preliminary report.

OBJECTIVES: Many chronic kidney disease (CKD) patients have persistent overt proteinuria despite angiotensin receptor blocker (ARB) treatment. This study investigated whether the initial difference in intrarenal renin-angiotensin system activity measured with urinary angiotensinogen would affect the antiproteinuric effects of ARB. METHODS: Between September 2005 and September 2008, in 50 non-diabetic proteinuric CKD patients not taking renin-angiotensin system inhibitors, the urinary protein/creatinine ratio (P/Cr), angiotensinogen/creatinine ratio (AGT/Cr), plasma renin and aldosterone were measured before starting valsartan, and were followed for 18 months. RESULTS: Patients were divided into three groups according to their initial urinary AGT/Cr. The urinary P/Cr was lower in the low angiotensinogen group, but similar in the high and extremely high angiotensinogen groups (1.3±0.38 vs 2.0±0.92 vs 2.2±0.78). In all groups, the urinary P/Cr was decreased most for the first 6 months. The urinary P/Cr reduction at 6 months was greatest in the high angiotensinogen group (-24.2% vs -46.2% vs -16.4%). The urinary AGT/Cr was decreased most in the high angiotensinogen group. Renal functional deterioration was attenuated in the high angiotensinogen group compared with the extremely high angiotensinogen group. CONCLUSIONS: The antiproteinuric effects of ARB were different according to the initial urinary angiotensinogen levels. These results suggest the potential value of the initial urinary AGT/Cr for predicting the therapeutic effect of ARB in proteinuric non-diabetic CKD patients.

Depression is a main determinant of health-related quality of life in patients with diabetic kidney disease.

Low health-related quality of life (HRQOL) is associated with adverse outcomes in diabetic kidney disease (DKD) patients. We examined the modifiable factors associated with low HRQOL in these patients. We enrolled 141 DKD patients. HRQOL was assessed with the Short Form 36 (SF-36) questionnaire. Low HRQOL was defined as a score > one standard deviation below the mean. Depression and anxiety were assessed with the Hospital Anxiety and Depression Scale (HADS-D and HDAS-A, respectively). The patients' median age was 65 years, and 73% were men. The prevalence rates of anxiety and depression were 8% (n = 11) and 17% (n = 24), respectively. Forty (28%) patients were identified as poor sleepers, and 40 (28%) had low physical activity levels. Anxiety, depression, and poor sleep quality were negatively correlated with SF-36 scores. Higher levels of physical activity and the estimated glomerular filtration rate (eGFR) were correlated with higher SF-36 scores, which indicated better health status. Higher depression scores (HADS-D scores) were associated with low HRQOL, independent of factors including age, sex, smoking status, comorbidities, eGFR, anemia, sleep quality, anxiety levels, and physical activity levels (odds ratio, 1.43; 95% confidence interval, 1.17-1.75). Among the clinical and psycho-physical factors, depression was a main determinant of low HRQOL in DKD patients.

Renoprotective efficacy of valsartan in chronic non-diabetic proteinuric nephropathies with renin-angiotensin system gene polymorphisms.

AIM: The renoprotective effects of angiotensin receptor blockers vary considerably among individuals. We investigated the renoprotective effects of valsartan according to polymorphisms of the renin-angiotensin system and transforming growth factor-b1 (TGFB1) genes in patients with chronic non-diabetic proteinuric nephropathies. METHODS: Two hundred and thirty-nine non-diabetic patients with proteinuria of at least 1 g/day were enrolled. Patients received 80 g of valsartan daily, followed by 160 mg/day after 6 weeks. The follow-up period was 18 months. The status of the angiotensin-converting enzyme (ACE) insertion/deletion, angiotensinogen (AGT) M235T, type 1 angiotensin II receptor (ATR1) A1166C, and TGFB1 C509 and T869C polymorphisms was determined in 162 patients. RESULTS: Valsartan treatment caused a significant reduction in proteinuria from baseline throughout the study in patients with each genotype of the ACE, AGT and TGFB1 genes. However, patients with the ATR1 AC genotype had no significant reduction in proteinuria from baseline throughout the study course. The median reductions in proteinuria after 6 months were 45.7% and 10.8% in the patients with the ATR1 AA and AC genotypes, respectively (P = 0.034). The annual change in the estimated glomerular filtration rate did not differ significantly among the genotypes for each gene. On multiple regression analysis, the change in proteinuria after 6 months of treatment was independently associated with the ATR1 genotype and the change in blood pressure (P = 0.005 and 0.019, respectively). CONCLUSION: Valsartan treatment significantly reduced the blood pressure and urinary protein excretion of patients with chronic non-diabetic proteinuric nephropathies. Interindividual differences in the anti-proteinuric effect of valsartan may be related partly to the ATR1 A1166C polymorphism.