Clinical Implications of Estimating Glomerular Filtration Rate with Different Equations in Heart Failure Patients with Preserved Ejection Fraction.

INTRODUCTION: The prognostic values of estimated glomerular filtration rate (eGFR) calculated by different formulas have not been adequately compared in patients with heart failure with preserved ejection fraction (HFpEF). AIM: We compared the predictive values of serum creatinine-based eGFRs calculated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2009 equation, Modification of Diet in Renal Disease Study (MDRD) formula, and full-age-spectrum creatinine (FAS Cr) equation in 1751 HFpEF patients. METHODS: The area under the receiver-operating characteristic curve (AUC), integrated discrimination improvement (IDI) and net reclassification improvement (NRI) were employed. RESULTS: eGFR values were lowest calculated with FAS Cr equation (p < 0.001). When patients were classified into 4 subgroups (eGFR ≥ 90, 89-60, 59-30, and  < 30 ml/min/1.73 m2) or only 2 subgroups (≥ 60 or  < 60 ml/min/1.73 m2), the 3 formulas correlated significantly, with the best correlation found between the MDRD and CKD-EPI formulas (kappa = 0.871 and 0.963, respectively). The 3 formulas conveyed independent prognostic information. After adjusting for potential cofounders, risk prediction for all-cause mortality was more accurate (p = 0.001) using the CKD-EPI equation than MDRD formula as assessed by AUC. Compared with MDRD formula, CKD-EPI equation exhibited superior predictive ability assessed by IDI and NRI of 0.32% (p < 0.001)/10.4% (p = 0.010) for primary endpoint and 0.37% (p = 0.010)/10.8% (p = 0.010) for HF hospitalization. The risk prediction for deterioration of renal function was more accurate (p ≤ 0.040) using the CKD-EPI equation than FAS Cr equation as assessed by AUC, IDI, and NRI. CONCLUSION: The CKD-EPI formula might be the preferred creatinine-based equation in clinical risk stratification in HFpEF patients.

Association between systemic inflammatory indicators with the survival of chronic kidney disease: a prospective study based on NHANES.

Background: systemic inflammation disorders were observed in chronic kidney disease (CKD). Whether the systemic inflammatory indicators could be optimal predictors for the survival of CKD remains less studied. Methods: In this study, participants were selected from the datasets of the National Health and Nutrition Examination Survey (NHANES) between 1999 to 2018 years. Four systemic inflammatory indicators were evaluated by the peripheral blood tests including systemic immune-inflammation index (SII, platelet*neutrophil/lymphocyte), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR). Kaplan-Meier curves, restricted cubic spline (RCS), and Cox regression analysis were used to evaluate the association between the inflammatory index with the all-cause mortality of CKD. Receiver operating characteristic (ROC) and concordance index (C-index) were used to determine the predictive accuracy of varied systemic inflammatory indicators. Sensitive analyses were conducted to validate the robustness of the main findings. Results: A total of 6,880 participants were included in this study. The mean age was 67.03 years old. Among the study population, the mean levels of systemic inflammatory indicators were 588.35 in SII, 2.45 in NLR, 133.85 in PLR, and 3.76 in LMR, respectively. The systemic inflammatory indicators of SII, NLR, and PLR were all significantly positively associated with the all-cause mortality of CKD patients, whereas the high value of LMR played a protectable role in CKD patients. NLR and LMR were the leading predictors in the survival of CKD patients [Hazard ratio (HR) =1.21, 95% confidence interval (CI): 1.07-1.36, p = 0.003 (3rd quartile), HR = 1.52, 95%CI: 1.35-1.72, p<0.001 (4th quartile) in NLR, and HR = 0.83, 95%CI: 0.75-0.92, p<0.001 (2nd quartile), HR = 0.73, 95%CI: 0.65-0.82, p<0.001 (3rd quartile), and = 0.74, 95%CI: 0.65-0.83, p<0.001 (4th quartile) in LMR], with a C-index of 0.612 and 0.624, respectively. The RCS curves showed non-linearity between systemic inflammatory indicators and all-cause mortality risk of the CKD population. Conclusion: Our study highlights that systemic inflammatory indicators are important for predicting the survival of the U.S. population with CKD. The systemic inflammatory indicators would add additional clinical value to the health care of the CKD population.

Adherence to Plant-Based Diets and Risk of CKD Progression and All-Cause Mortality: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study.

RATIONALE & OBJECTIVE: Studies have shown that generally healthy individuals who consume diets rich in plant foods have a lower risk of incident chronic kidney disease (CKD) and cardiovascular disease. This study investigated the prospective associations of plant-based diets with the risk of CKD progression and all-cause mortality in individuals with CKD. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 2,539 participants with CKD recruited between 2003-2008 into the Chronic Renal Insufficiency Cohort (CRIC) Study. EXPOSURE: Responses on the Diet History Questionnaire were used to calculate scores for the overall plant-based diet index, healthy plant-based diet index, and unhealthy plant-based diet index. OUTCOME: (1) CKD progression defined as≥50% estimated glomerular filtration rate decline from baseline or kidney replacement therapy (dialysis, transplant) and (2) all-cause mortality. ANALYTICAL APPROACH: Cox proportional hazards models to compute hazard ratios and 95% confidence intervals adjusting for lifestyle, socioeconomic, and clinical covariates. RESULTS: There were 977 CKD progression events and 836 deaths during a median follow-up period of 7 and 12 years, respectively. Participants with the highest versus lowest adherence to overall plant-based diets and healthy plant-based diets had 26% (HR, 0.74 [95% CI, 0.62-0.88], P trend<0.001) and 21% (HR, 0.79 [95% CI, 0.66-0.95], P trend=0.03) lower risks of all-cause mortality, respectively. Each 10-point higher score of unhealthy plant-based diets was modestly associated with a higher risk of CKD progression (HR, 1.14 [95% CI, 1.03-1.25) and all-cause mortality (HR, 1.11 [95% CI, 1.00-1.23). LIMITATIONS: Self-reported diet may be subject to measurement error. CONCLUSIONS: Adherence to an overall plant-based diet and a healthy plant-based diet is associated with a reduced risk of all-cause mortality among individuals with CKD. An unhealthy plant-based was associated with an elevated risk of CKD progression and all-cause mortality. PLAIN-LANGUAGE SUMMARY: Plant-based diets are healthful dietary patterns that have been linked to a lower risk of chronic diseases. However, the impact of plant-based diets on clinical outcomes in patients with chronic kidney disease (CKD) is not well established. In 2,539 individuals with CKD, we examined the associations of adherence to 3 different types of plant-based diets with the risks of CKD progression and all-cause mortality. We found that following an overall plant-based diet and a healthy plant-based diet was associated with a lower risk of all-cause mortality. By contrast, following an unhealthy plant-based diet was associated with a higher risk of CKD progression and all-cause mortality. These results suggest that the quality of plant-based diets may be important for CKD management.

Functional iron deficiency anemia was associated with higher mortality in chronic kidney disease patients: the NHANES III follow-up study.

Anemia, a common complication of chronic kidney disease (CKD), is associated with poor prognosis. However, it is not completely clear whether this association is caused by anemia per se or other comorbidities. Whether different types of iron deficiency anemia can predict the outcomes of CKD remains unclear. The dataset from NHANES III was analyzed and Cox multivariate regression models and propensity score matching (PSM) method were used to evaluate the effect of anemia on mortality. Of 4103 patients with CKD, 14.6% had anemia. Among those with anemia, 38.8% had absolute iron deficiency (AID), and 19.8% had functional iron deficiency (FID). During the median follow-up time of 13.8 years, 2964 deaths and 804 cardiovascular deaths were observed. Anemia was robustly associated with a high risk of all-cause mortality in CKD patients after adjusting covariates by two multivariate regression models (Model 1: HR = 1.485, 95%CI:1.340-1.647, p < 0.001; Model 2: HR = 1.391, 95%CI:1.250-1.546, p < 0.001). In the PSM cohort, anemia was still an independent risk factor for all-cause mortality (Model 1: HR = 1.443, 95%CI: 1.256-1.656, p < 0.001; Model 2: HR = 1.357, 95%CI:1.177-1.564, p < 0.001). In the CKD population, anemia patients with FID had the highest risk of mortality than the other anemia groups (p < 0.05), while AID had a mortality rate similar to those without anemia (p > 0.05). In conclusion, anemia was associated with a worse prognosis in patients with CKD, which may be attributed to the higher mortality risk of FID rather than AID. AID wasn't associated with a higher mortality rate compared with CKD patients without anemia.

Mortality trend due to chronic kidney disease in Brazil: an ecological study.

OBJECTIVE: To analyze chronic kidney disease mortality in Brazil according to sex, age group and region of residence, from 2009 to 2020. METHODS: This was a time series study having deaths as its unit of analysis, based on Mortality Information System data. The mortality rate was standardized using the direct method and the temporal trend was analyzed using the Prais-Winsten method. RESULTS: There was a rising trend in chronic kidney disease mortality, ranging from 2.82, in 2009, to 3.24 in 2020 (average annual increase 1.29%; 95%CI 0.73;1.85), with a greater increase in males (1.14% per year; 95%CI 0.52;1.76), those aged 75 years and over (2.23% per year; 95%CI 1.87; 2.60) and in the Northern Region (3.86% per year; 95%CI 1.86;5.90) and Northeast Region (3.36% per year; 95%CI 2.24;4.50). CONCLUSION: Chronic kidney disease mortality showed a rising trend in the period, with sociodemographic disparities. MAIN RESULTS: A rising mortality trend was found for both sexes, with a greater increase in males, those aged over 75 years and in the North and Northeast regions of Brazil; mortality was highest in the Midwest region throughout the entire period. IMPLICATIONS FOR SERVICES: The results point to the need to implement public policies with guidelines for addressing chronic kidney disease, focused on strengthening Primary Health Care (PHC). PERSPECTIVES: Expanding access to health services, health education and integration between PHC, health surveillance and specialized care are strategies that would possibly prove to be efficient in managing this chronic health condition.

Estimating the association between systemic Interleukin-6 and mortality in the dialysis population. Re-analysis of the global fluid study, systematic review and meta-analysis.

BACKGROUND: Systemic inflammation, measured as circulating Interleukin-6 (IL-6) levels, is associated with cardiovascular and all-cause mortality in chronic kidney disease. However, this has not been convincingly demonstrated in a systematic review or a meta-analysis in the dialysis population. We provide such evidence, including a re-analysis of the GLOBAL Fluid Study. METHODS: Mortality in the GLOBAL fluid study was re-analysed using Cox proportional hazards regression with IL-6 levels as a covariate using a continuous non-logarithmic scale. Literature searches of the association of IL-6 levels with mortality were conducted on MEDLINE, EMBASE, PyschINFO and CENTRAL. All studies were assessed for risk of bias using the QUIPS tool. To calculate a pooled effect size, studies were grouped by use of IL-6 scale and included in the meta-analysis if IL-6 was analysed as a continuous linear covariate, either per unit or per 10 pg/ml, in both unadjusted or adjusted for other patient characteristics (e.g. age, comorbidity) models. Funnel plot was used to identify potential publication bias. RESULTS: Of 1886 citations identified from the electronic search, 60 were included in the qualitative analyses, and 12 had sufficient information to proceed to meta-analysis after full paper screening. Random effects meta-analysis of 11 articles yielded a pooled hazard ratio (HR) per pg/ml of 1.03, (95% CI 1.01, 1.03), [Formula: see text]= 81%. When the analysis was confined to seven articles reporting a non-adjusted HR the result was similar: 1.03, per pg/ml (95% CI: 1.03, 1.06), [Formula: see text]=92%. Most of the heterogeneity could be attributed to three of the included studies. Publication bias could not be determined due to the limited number of studies. CONCLUSION: This systematic review confirms the adverse association between systemic IL-6 levels and survival in people treated with dialysis. The heterogeneity that we observed may reflect differences in study case mix. SYSTEMATIC REVIEW REGISTRATION: PROSPERO - CRD42020214198.

Long-term follow-up of HCV-infected patients with end-stage chronic kidney disease after sustained virological response with direct-acting antiviral therapy / Seguimiento a largo plazo de pacientes infectados por el virus de la hepatitis C con insuficiencia renal crónica terminal tras una respuesta virológica sostenida con tratamiento antiviral de acción directa

Background and aim: Patients with chronic kidney disease (CKD) and hepatitis C infection can be safely and effectively treated with direct-acting antivirals (DAAs). However, there is scarce data on the long-term impact of hepatitis C cure on CKD. The aim of this study was to assess the long-term mortality, morbidity and hepatic/renal function outcomes in a cohort of HCV-infected individuals with CKD treated with DAAs. Methods: 135 HCV patients with CKD stage 3b-5 who received ombitasvir/paritaprevir/ritonavir±dasabuvir in a multicenter study were evaluated for long-term hepatic and renal outcomes and their associated mortality. Results: 125 patients achieved SVR and 66 were included. Prior to SVR, 53 were under renal replacement therapy (RRT) and 25 (37.8%) had liver cirrhosis. After a follow-up of 4.5 years, 25 (38%) required kidney transplantation but none combined liver–kidney. No changes in renal function were observed among the 51 patients who did not receive renal transplant although eGFR values improved in those with baseline CKD stage 3b-4. Three (5.6%) subjects were weaned from RRT. Eighteen (27.3%) patients died, mostly from cardiovascular events; 2 developed liver decompensation and 1 hepatocellular carcinoma. No HCV reinfection was observed. Conclusions: Long-term mortality remained high among end-stage CKD patients despite HCV cure. Overall, no improvement in renal function was observed and a high proportion of patients required kidney transplantation. However, in CKD stage 3b-4 HCV cure may play a positive role in renal function. (AU)

Introducción y objetivo: Los pacientes con insuficiencia renal crónica (IRC) e infección por el virus de la hepatitis C (VHC) pueden ser tratados de forma efectiva y segura con antivirales de acción directa (AAD). El objetivo de este estudio fue evaluar la mortalidad y la evolución de la función renal y hepática a largo plazo en una cohorte de pacientes con infección por VHC e IRC tratados con AAD. Métodos: Se analizó la evolución de la función hepática y renal, así como la mortalidad en 135 pacientes con infección por VHC e IRC estadio 3b-5 que recibieron ombitasvir/paritaprevir/ritonavir±dasabuvir en un estudio multicéntrico. Resultados: Ciento veinticinco pacientes se curaron (RVS), y 66 de ellos fueron incluidos. Antes de RVS, 53 estaban bajo terapia renal sustitutiva (TRS) y 25 (37,8%) tenían cirrosis hepática. Tras un seguimiento medio de 4,5 años, 25 (38%) requirieron trasplante renal, pero ninguno combinado renal-hepático. No se observaron cambios en la función renal entre aquellos 51 pacientes que no recibieron trasplante renal a pesar de que los valores de eFGR mejoraron en aquellos pacientes con IRC estadio 3b-4 de base. Tres (5,6%) pacientes pudieron dejar la TRS. Dieciocho (27,3%) pacientes fallecieron, principalmente por eventos cardiovasculares, 2 presentaron descompensación hepática y uno carcinoma hepatocelular. No se observó ninguna reinfección por VHC. Conclusiones: La mortalidad a largo-plazo fue alta. Globalmente no se objetivó una mejora en la función renal. A pesar de ello, en estadios 3b-4, la curación del VHC podría tener un papel positivo en la función renal. (AU)

Association of dietary total antioxidant capacity with all-cause and cardiovascular mortality in patients with chronic kidney disease: based on two retrospective cohort studies of NHANES.

BACKGROUND: The relationship between dietary total antioxidant capacity (DTAC) and death risk among CKD populations remains unclear. METHODS: Based on vitamin C equivalent antioxidant capacity (VCEAC) and the component dietary antioxidant index (CDAI) indices, we analyzed two cohorts to investigate the association of DTAC with all-cause and CVD mortality in CKD patients using data from National Health and Nutrition Examination Survey (2007-2018). VCEAC (n = 6330) and CDAI (n = 6300) cohorts with mortality follow-up data available through 2018 were included. Cox models with restricted cubic splines was used to model the nonlinear association between VCEAC/CDAI and outcomes in CKD patients. RESULTS: Our results showed L-shaped associations of DTAC with all-cause mortality among individuals with CKD stages 1-2 in both cohorts. Compared to the lowest quartile, higher dietary total antioxidant intake was associated with lower all-cause mortality risks among CKD stages 1-2 after adjustment for covariates, with HRs (95%CI) of 1.00, 0.91 (0.71,1.17), 0.69 (0.53,0.90), and 0.70 (0.54,0.91) in VCEAC, and similar respective estimate trends in CDAI. After sensitivity and subgroup analyses, there were no benefits for patients with stage 3-5 CKD or albuminuria. Mediation analysis revealed that the proportions mediated in both cohorts were less consistent. CONCLUSIONS: Moderate dietary total antioxidants intake has potential benefits for early-stage CKD patients. However, further evidence is needed to confirm whether patients with worsening CKD can benefit in the long term.

Effects of anthropometric changes on hospitalization and mortality among patients on hemodialysis.

BACKGROUND: Low values for anthropometric indicators are risk factors for adverse clinical outcomes among patients on hemodialysis. Nonetheless, little is known about the association between the trajectory of anthropometric indicators and prognosis. We examined the association between a one-year change in anthropometric indicators and hospitalization and mortality in patients undergoing hemodialysis. METHODS: This retrospective cohort study collected data on five anthropometric indicators from patients undergoing maintenance hemodialysis: body mass index, mid-upper arm circumference, triceps skinfold, mid-arm muscle circumference, and calf circumference. We calculated their trajectories over one year. The outcomes were all-cause death and the number of all-cause hospitalizations. Negative binomial regressions were used to examine these associations. RESULTS: We included 283 patients (mean age, 67.3 years; 60.4% males). During the follow-up period (median, 2.7 years), 30 deaths and 200 hospitalizations occurred. Body mass index (incident rate ratio [IRR]: 0.87; 95% confidence interval [CI] 0.85-0.90), mid-upper arm circumference (IRR: 0.94; 95% CI 0.88-0.99), triceps skinfold (IRR: 0.92; 95% CI 0.84-0.99), and mid-arm muscle circumference (IRR: 0.99; 95% CI 0.98-0.99) increases over one year were associated with a lower risk of all-cause hospitalizations and death regardless of their value at any one point in time. However, the calf circumference trajectory was not associated with clinical events (IRR: 0.94; 95% CI 0.83-1.07). CONCLUSIONS: Body mass index, mid-upper arm circumference, triceps skinfold, and mid-arm muscle circumference trajectories were independently associated with clinical events. Routinely assessing these simple measures in clinical practice may provide additional prognostic information for managing patients undergoing hemodialysis.

Calcifilaxis en una paciente en hemodiálisis: complicación grave con elevada mortalidad / Calciphylaxis in a hemodialysis patient: a serious complication with high mortality

Descripción del caso: Paciente con enfermedad renal crónica terminal en tratamiento de hemodiálisis desde hace 1 año. Acude a sesión de hemodiálisis refiriendo lesiones cutáneas muy dolorosas con aspecto necrótico de 2 semanas de evolu-ción en extremidades inferiores distales sugestivas de calcifi-laxis. Dados los antecedentes clínicos de fibrilación auricular paroxística, anticoagulada con acenocumarol y los factores de riesgo que presenta, se inician medidas inmediatas dado el mal pronóstico de dicha enfermedad. Descripción/evaluación del plan de cuidados: Se suspende tratamiento con acenocumarol iniciando anticoagulación con heparina de bajo peso molecular, también se suspenden los suplementos de vitamina D. Se inicia administración de bifos-fonatos como inhibidores del calcio, de tiosulfato de sodio como vasodilatador y quelante del fósforo. Se instaura pauta de analgesia siendo uno de los objetivos más importantes del plan de cuidados, el control del dolor, con la administración de opiáceos, antiinflamatorios no esteroideos o mórficos. Aunque fue de difícil manejo, el papel de enfermería ha sido fundamental para procurar el máximo confort. También fue muy importante la vigilancia y el cuidado de las lesiones para prevenir infecciones y controlar la enfermedad observándose una adversa y rápida evolución a pesar de las terapias coad-yuvantes, puesto que cuando se diagnosticó ya presentaba lesiones necróticas. Conclusiones: La calcifilaxis es una complicación poco fre-cuente pero grave que suele observarse en pacientes con enfermedad renal crónica, sobre todo en hemodiálisis. Eltratamiento es multidisciplinar y es importante identificar precozmente a estos pacientes. Desgraciadamente, como en nuestro caso, los resultados no son siempre favorables.(AU)

Case description: Patient with end-stage renal disease undergoing hemodialysis treatment for 1 year. The patient presents to the hemodialysis session with extremely painful necrotic-looking skin lesions on the distal lower extremities, suggestive of calciphylaxis, which have been present for 2 weeks. Given the patient’s medical history of paroxysmal atrial fibrillation and anticoagulation with acenocoumarol, along with the risk factors present, immediate measures are initiated due to the poor prognosis of this condition. Description/evaluation of the care plan: Acenocoumarol treatment is discontinued, and anticoagulation with low molecular weight heparin is initiated. Vitamin D supplements are also discontinued. Bisphosphonates are started as calcium inhibitors, sodium thiosulfate is administered as a vasodilator, and phosphate binder. An analgesic regimen is established, with pain control being one of the most important goals of he care plan. This includes the administration of opioids, nonsteroidal anti-inflammatory drugs, or morphine. Although challenging, the nursing role has been crucial in providing maximum comfort. Close monitoring and wound care are also important to prevent infections and control the disease, although an adverse and rapid progression was observed despite the adjunctive therapies, as necrotic lesions were already present at the time of diagnosis. Conclusions: Calciphylaxis is a rare but serious complication often observed in patients with chronic kidney disease, especially in those undergoing hemodialysis. Treatment is multidisciplinary, and early identification of these patients is important. Unfortunately, as in our case, the outcomes are not always favorable.(AU)

Comparison of CG, CKD-EPI[AS] and CKD-EPI[ASR] equations to estimate glomerular filtration rate and predict mortality in treatment naïve people living with HIV in Zimbabwe.

BACKGROUND: Renal impairment in people living with HIV (PWH) in Sub-Saharan Africa is common and associated with increased morbidity and mortality. The ideal equation to estimate glomerular filtration rate (eGFR) in this population remains unclear. That which best predicts clinical risk may be the most appropriate while validation studies are awaited. Here we compare the Cockcroft-Gault (CG), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI[ASR]) and the CKD-EPI equation with the race coefficient removed (CKD-EPI[AS]), in a population of anti-retroviral therapy (ART) naïve PWH in Zimbabwe to assess which equation best predicts mortality. METHODS: A retrospective cohort study of treatment naïve PWH at the Newlands Clinic in Harare, Zimbabwe was completed. The study included all patients commencing ART between 2007 and 2019. Predictors of mortality were assessed by multivariable logistic regression. RESULTS: A total of 2991 patients were followed-up for a median of 4.6 years. The cohort was 62.1% female, with 26.1% of patients having at least one comorbidity. The CG equation identified 21.6% of patients as having renal impairment compared with 17.6% with CKD-EPI[AS] and 9.3% with CKD-EPI[ASR]. There was a mortality rate of 9.1% across the study period. The highest mortality risk was seen in those with renal impairment as determined by the CKD-EPI[ASR] equation for both eGFR < 90 and eGFR < 60 with OR 2.97 (95%CI 1.86-4.76) and OR 10.6 (95%CI 3.15-18.04) respectively. CONCLUSION: In treatment naïve PWH in Zimbabwe, the CKD-EPI[ASR] equation identifies patients at highest risk of mortality when compared to the CKD-EPI[AS] and CG equations.

Long-term exposure to elemental components of fine particulate matter and all-natural and cause-specific mortality in a Danish nationwide administrative cohort study.

BACKGROUND: Fine particulate matter (PM2.5) is a well-recognized risk factor for premature death. However, evidence on which PM2.5 components are most relevant is unclear. METHODS: We evaluated the associations between mortality and long-term exposure to eight PM2.5 elemental components [copper (Cu), iron (Fe), zinc (Zn), sulfur (S), nickel (Ni), vanadium (V), silicon (Si), and potassium (K)]. Studied outcomes included death from diabetes, chronic kidney disease (CKD), dementia, and psychiatric disorders as well as all-natural causes, cardiovascular disease (CVD), respiratory diseases (RD), and lung cancer. We followed all residents in Denmark (aged ≥30 years) from January 1, 2000 to December 31, 2017. We used European-wide land-use regression models at a 100 × 100 m scale to estimate the residential annual mean levels of exposure to PM2.5 components. The models were developed with supervised linear regression (SLR) and random forest (RF). The associations were evaluated by Cox proportional hazard models adjusting for individual- and area-level socioeconomic factors and total PM2.5 mass. RESULTS: Of 3,081,244 individuals, we observed 803,373 death from natural causes during follow-up. We found significant positive associations between all-natural mortality with Si and K from both exposure modeling approaches (hazard ratios; 95% confidence intervals per interquartile range increase): SLR-Si (1.04; 1.03-1.05), RF-Si (1.01; 1.00-1.02), SLR-K (1.03; 1.02-1.04), and RF-K (1.06; 1.05-1.07). Strong associations of K and Si were detected with most causes of mortality except CKD and K, and diabetes and Si (the strongest associations for psychiatric disorders mortality). In addition, Fe was relevant for mortality from RD, lung cancer, CKD, and psychiatric disorders; Zn with mortality from CKD, RD, and lung cancer, and; Ni and V with lung cancer mortality. CONCLUSIONS: We present novel results of the relevance of different PM2.5 components for different causes of death, with K and Si seeming to be most consistently associated with mortality in Denmark.

Mortality in hemodialysis patients in Ethiopia: a retrospective follow-up study in three centers.

BACKGROUND: The prevalence of chronic kidney disease (CKD) is between 10 and 15% worldwide. Ethiopia is seeing a consistent increase in the number of dialysis patients. Patients on chronic hemodialysis have high mortality rates, but there is little information available in Ethiopia. Thus, this study looked into patient mortality and the factors that contributed to it at three dialysis centers in Addis Ababa for hemodialysis patients. METHOD: A facility-based retrospective follow-up study was employed among End-Stage Renal Disease patients on hemodialysis from 2016 to 2020 at St. Paul Millennium Medical College (SPMMC), Zewditu Memorial Hospital (ZMH), and Menelik II Hospital. The proportional hazard assumption was checked by using the Log (-log (St)) plots and tests. Life-table analysis was fitted to estimate the one and five-year's survival probability of these patients and Cox Proportional regression analysis to model the predictors of mortality at p-value < 0.05. RESULT: Over the course of 2772 person-months, 139 patients were tracked. Of these patients, 88 (63.3%) were male and the mean age (± SD) of the patients was 36.8 (± 11.9) years. During the follow-up period, 24 (17%) of the patients died, 67 (48.2%) were alive, 43 (30.9%) received a kidney transplant, and 5 (3.6%) were lost to follow-up. The mean survival time was 46.2 months (95% CI: 41.8, 50.5). According to estimates, there were 104 deaths per 1000 person-years at the end of the follow-up period. The likelihood that these patients would survive for one and 5 years was 91%% and 65%, respectively. Our analysis showed that patients with hypertension (Adjusted Hazard Rate (AHR) = 4.33; 95% CI: 1.02, 34.56), cardiovascular disease (AHR = 4.69; 95% CI: 1.32, 16.80), and infection during dialysis (AHR = 3.89; 95% CI: 1.96, 13.80) were more likely to die. CONCLUSION: The hemodialysis patients' death rate in the chosen dialysis facilities was high. Preventing and treating comorbidities and complications during dialysis would probably reduce the mortality of CKD patients. Furthermore, the best way to avoid and manage chronic kidney disease is to take a complete and integrated approach to manage hypertension, diabetes, and obesity.

Elevated Crude Mortality in Obese Chronic Kidney Disease Patients with Loss of Exercise Habit: A Cohort Study of the Japanese General Population.

Objective The relationship between obesity and risk of death in chronic kidney disease (CKD) patients remains controversial. In addition, no clear evidence has been accumulated regarding whether or not exercise improves mortality in CKD patients. Methods The original cohort was based on a Japanese general population of 685,889 people from 40 to 74 years old who had undergone annual specific health checkups. The number of all-cause deaths during follow-up (mean, 4.7 years) in this study was 1,490. Information on walking and exercise habits was obtained by questionnaires. The study population was divided into 4 categories by the combination of CKD and obesity [body mass index (BMI) ≥25.0 kg/m2]. Changes in the BMI and walking and exercise habits were determined by results for the first year and following year. Results Obese CKD patients with weight gain (BMI increase by more than +1.0 kg/m2/year) showed a higher crude mortality (1.32%) than those with a stable BMI (within ±1.0 kg/m2/year; 0.69%). In the obese CKD population, mortality was higher with loss of exercise habits (0.96%) than in those continuously maintaining exercise habits (0.52%). The age- and sex-adjusted hazard ratio for all-cause death was 2.23 in the group with weight gain compared to the group with stable weight (p<0.01) and 2.08 in the group with loss of exercise habits compared to those who maintained exercise habits (p<0.01). Conclusion This observational cohort study suggested that loss of exercise habits as well as weight gain of more than 1 kg/m2/year might worsen all-cause mortality in the obese CKD population.

Interacción entre el estadio de la enfermedad renal crónica y la diabetes mellitus como factores asociados con mortalidad en pacientes con enfermedad renal crónica: un estudio de cohortes externas / Interaction between the stage of chronic kidney disease and diabetes mellitus as factors associated with mortality in chronic kidney disease patients: An external cohort study

Introducción: La enfermedad renal diabética es la principal causa de enfermedad renal crónica (ERC) en el mundo y tanto la diabetes mellitus (DMT2) como la ERC son importantes factores de riesgo para mortalidad. Sin embargo, se desconoce si la presencia simultánea de ambas enfermedades modifica el riesgo de muerte. Objetivo: Evaluar la presencia de interacción entre DMT2 y estadio ERC respecto a la mortalidad en una población representativa de un país latinoamericano. Métodos: Estudio analítico en dos cohortes de pacientes con diagnóstico de ERC con cuatro años de seguimiento entre 2004 y 2008. Se calculó la tasa de incidencia, progresión, supervivencia (Kaplan-Meier), interacción (aditiva y multiplicativa) e impacto de la presencia de los diferentes estadios de ERC en pacientes con y sin DMT2 mediante un análisis de riesgos proporcionales de Cox. Resultados: En esta población de estudio de 5.663 pacientes, tanto la DMT2 como el estadio de ERC son factores de riesgo para mortalidad (p < 0,001). La diferencia en la supervivencia entre diabéticos y no diabéticos en estadios 3 – 4 – 5 fue estadísticamente significativa (Log-rank p = 0,0076). Se encontró una interacción estadísticamente significativa en las escalas aditiva y multiplicativa entre la presencia de DMT2 y el estadio de ERC, con respecto a la mortalidad (p = 0,005). Se confirmó el impacto de la diabetes como factor de riesgo de mortalidad (Hazard Ratio 1,61 p < 0,001), pero en los pacientes con DMT2 solamente la edad, la dislipidemia y los nefroprotectores estuvieron asociados significativamente con la mortalidad. Conclusión: La interacción entre ERC y DMT2 modifica de forma negativa el riesgo de muerte de ambas enfermedades. Es decir que el efecto conjunto observado es menor al esperado. (AU)

Introduction: Diabetic kidney disease is the main cause of chronic kidney disease (CKD) worldwide. Both CKD and diabetes mellitus (DMT2) are important risk factors for mortality. However, it is still unknown if the risk of death is modified by the simultaneous presence of these diseases. Objective: To evaluate the presence of an interaction between DMT2 and CKD for mortality in a representative population of a Latin American country. Methods: It is an analytical cohort study of patients with CKD, who were followed for 4 years (between 2004 and 2009). We calculated the incidence rate, progression, survival (using Kaplan–Meier curves), interaction (on the additive and multiplicative scales) and impact of the different stages of CKD in patients with and without DMT2 (using a cox proportional hazards model). Results: In this population of 5663 individuals, both DMT2 and CKD are risk factors for mortality (P < 0.001). We found a statistically significant difference in mortality between individuals with and without DMT2, who also had CKD stages 3 – 4 – 5 (Log-rank P = 0.0076). Additionally, we found a statistically significant interaction for mortality in both the additive and multiplicative scales between DMT2 and CKD (P = 0.005). DMT2 was found to be a risk factor for mortality (Hazard Ratio 1.61 P < 0.001), but in individuals with DMT2, the only risks significantly associated with mortality, were age, dyslipidemia and nephroprotective drugs. Conclusión: The interaction between CKD and DMT2 negatively modifies the risk of death of both diseases. This means that when the two diseases are present, the risk of mortality is lower than expected. (AU)

Mortality from chronic kidney disease secondary to hypertension in Brazil: a study of the "Global Burden of Disease" / Mortalidade por doença renal crônica secundária à hipertensão no Brasil: um estudo do "Global Burden of Disease" / Mortalidad por enfermedad renal crónica secundaria a hipertensión en Brasil: un estudio de la "Global Burden of Disease"

Background and Objectives: Chronic kidney disease (CKD) is one of the main complications resulting from arterial hypertension, and a recent increase in the incidence and prevalence of the disease has been reported, which can lead to an increase in mortality and complications resulting from the disease. Thus, the objective of study is to describe the variations in mortality from CKD secondary to arterial hypertension, in Brazil, between the years 1990 to 2019. Methods: Epidemiological study, with a quantitative approach and descriptive character, which analyzed data from the "Global Burden of Disease Study" (GBD) tool. Results: In all of Brazil's federative units, the estimate of deaths from CKD secondary to hypertension increased, with the Southeast region having the highest estimates. The States of Rio de Janeiro, Rio Grande do Sul, and Paraíba lead with the highest mortality rates. Regarding sex, in all years, higher rates were observed in males, however, over the years, this difference has been reduced. The age group of ≥70 years was the most affected, standing out with the highest death rates. Conclusion: the burden of CKD in Brazil has increased in the last 30 years; among the regions of the country, the Southeast recorded the highest estimates of deaths in all the years analyzed, being mainly higher among men.(AU)

Justificativa e objetivos: A doença renal crônica (DRC) é uma das principais complicações decorrentes da hipertensão arterial. Nos últimos anos, tem sido relatado um aumento na incidência e prevalência da doença, o que pode levar ao aumento da mortalidade e das complicações decorrentes da doença. Assim, o objetivo deste estudo foi descrever as variações da mortalidade por DRC secundária à hipertensão arterial no Brasil entre 1990 e 2019. Métodos: Trata-se de um estudo epidemiológico, de abordagem quantitativa e caráter descritivo, que analisou dados da ferramenta Global Burden of Disease Study (GBD). Resultados: Em todas as unidades da federação, a estimativa de mortes por DRC secundária à hipertensão apresentou aumento, a região Sudeste apresentando as maiores estimativas. Os estados do Rio de Janeiro, Rio Grande do Sul e Paraíba lideram as pesquisas com as maiores taxas de mortalidade. No que diz respeito ao sexo, em todos os anos foram observadas maiores taxas de DRC em indivíduos do sexo masculino; contudo, nota-se que tem ocorrido uma redução dessa diferença. A faixa etária de ≥70 anos foi a mais acometida, destacando-se com as maiores taxas de mortes. Conclusão: a carga de DRC no Brasil aumentou nos últimos 30 anos. Entre as regiões do país, o Sudeste registrou as maiores estimativas de mortes em todos os anos analisados, principalmente de homens.(AU)

Justificación y objetivos: La enfermedad renal crónica (ERC) es una de las principales complicaciones derivadas de la hipertensión arterial, y en los últimos años se ha reportado un aumento en la incidencia y prevalencia de la enfermedad, lo que puede conducir a un aumento de la mortalidad y de las complicaciones derivadas de esta, por lo tanto, el objetivo del estudio es describir las variaciones en la mortalidad por ERC secundaria a la hipertensión arterial en Brasil entre los años 1990 a 2019. Métodos: Estudio epidemiológico, con enfoque cuantitativo y carácter descriptivo, que analizó datos de la herramienta Global Burden of Disease Study (GBD). Resultados: En todas las unidades de la federación, aumentó la estimación de muertes por ERC secundaria a la hipertensión arterial, con la región Sudeste presentando las estimaciones más altas. Los estados de Rio de Janeiro, Rio Grande do Sul y Paraíba lideran con las tasas de mortalidad más altas. Con respecto al sexo, en todos los años se observaron mayores tasas en los varones, sin embargo, con el paso de los años, esta diferencia se ha ido reduciendo. El grupo de edad de ≥70 años fue el más afectado, destacándose con las tasas de mortalidad más altas. Conclusión: la carga de ERC en Brasil ha aumentado en los últimos 30 años; de las regiones del país, el Sudeste registró las mayores estimaciones de muertes en todos los años registrados entre los analizados, siendo principalmente mayor entre los hombres.(AU)

Association of Estimated GFR Calculated Using Race-Free Equations With Kidney Failure and Mortality by Black vs Non-Black Race.

Importance: At a given estimated glomerular filtration rate (eGFR), individuals who are Black have higher rates of mortality and kidney failure with replacement therapy (KFRT) compared with those who are non-Black. Whether the recently adopted eGFR equations without race preserve racial differences in risk of mortality and KFRT at a given eGFR is unknown. Objective: To assess whether eGFR equations with and without race and cystatin C document racial differences in risk of KFRT and mortality in populations including Black and non-Black participants. Design, Setting, and Participants: Retrospective individual-level data analysis of 62 011 participants from 5 general population and 3 chronic kidney disease (CKD) US-based cohorts with serum creatinine, cystatin C, and follow-up for KFRT and mortality from 1988 to 2018. Exposures: Chronic Kidney Disease Epidemiology Collaboration equation with serum creatinine (eGFRcr with and without race), cystatin C (eGFRcys without race), or both markers (eGFRcr-cys without race). Main Outcomes and Measures: The prevalence of decreased eGFR at baseline and hazard ratios of KFRT and mortality in Black vs non-Black participants were calculated, adjusted for age and sex. Analyses were performed within each cohort and with random-effect meta-analyses of the models. Results: Among 62 011 participants (20 773 Black and 41 238 non-Black; mean age, 63 years; 53% women), the prevalence ratio (95% CI; percent prevalences) of eGFR less than 60 mL/min/1.73 m2 comparing Black with non-Black participants was 0.98 (95% CI, 0.93-1.03; 11% vs 12%) for eGFRcr with race, 0.95 (95% CI, 0.91-0.98; 17% vs 18%) for eGFRcys, and 1.2 (95% CI, 1.2-1.3; 13% vs 11%) for eGFRcr-cys but was 1.8 (95% CI, 1.7-1.8; 15% vs 9%) for eGFRcr without race. During a mean follow-up of 13 years, 8% and 4% of Black and non-Black participants experienced KFRT and 34% and 39% died, respectively. Decreased eGFR was associated with significantly greater risk of both outcomes for all equations. At an eGFR of 60 mL/min/1.73 m2, the hazard ratios for KFRT comparing Black with non-Black participants were 2.8 (95% CI, 1.6-4.9) for eGFRcr with race, 3.0 (95% CI, 1.5-5.8) for eGFRcys, and 2.8 (95% CI, 1.4-5.4) for eGFRcr-cys vs 1.3 (95% CI, 0.8-2.1) for eGFRcr without race. The 5-year absolute risk differences for KFRT comparing Black with non-Black participants were 1.4% (95% CI, 0.2%-2.6%) for eGFRcr with race, 1.1% (95% CI, 0.2%-1.9%) for eGFRcys, and 1.3% (95% CI, 0%-2.6%) for eGFRcr-cys vs 0.37% (95% CI, -0.32% to 1.05%) for eGFRcr without race. Similar patterns were observed for mortality. Conclusions and Relevance: In this retrospective analysis of 8 US cohorts including Black and non-Black individuals, the eGFR equation without race that included creatinine and cystatin C, but not the eGFR equation without race that included creatinine without cystatin C, demonstrated racial differences in the risk of KFRT and mortality throughout the range of eGFR. The eGFRcr-cys equation may be preferable to the eGFRcr equation without race for assessing racial differences in the risk of KFRT and mortality associated with low eGFR.