Retard Chronic Kidney Disease Progression Research Articles

#2723 10-hydroxy-trans-2-decenoic and nonanoic acid delayed senescence in adult renal progenitor cells and increased the anti-aging Klotho protein secretion

Abstract Background and Aims Recent investigations have elucidated the complex system involving human adult renal stem/progenitor cells (ARPCs) and their pivotal role in maintaining homeostasis and in facilitating regenerative processes within the adult kidneys. CD133+/CD24+ ARPCs can repair several kinds of renal damage but their reparative properties can be compromised by the cell senescence, contributing to renal aging and impaired damage repair. The functional marker CD133 inversely correlates with cellular senescence and plays a crucial role in the ARPC regulation. Decreased protective factors, hypoxia, and microenvironmental stress drive increasingly cell senescence, disordered inflammation and renal fibrosis. The resulting fibrosis, senescence, and microvascular rarefaction exacerbate damage and promote chronic kidney disease (CKD) progression. In this study, we explore the impact of natural molecular compounds and drugs on slowing down and delaying ARPC senescence. Method ARPCs were treated with the following compounds for 48 hours: nonanoic acid (1 mM), 3-decenoic acid (1 mM), 10-hydroxy-trans-2-decenoic acid (10-HDA, 25uM), and Valproic acid (VPA, 1 mM), either individually or in combination. Lipid microvesicles were used to transmit the bioactive molecules. FACS was used to determine the CD133 levels. the β-galactosidase assays were used to determine cell senescence status. Western blots were performed to assess p16, p53 and p21 markers. Results Cytofluorimetry results demonstrated an increase in the expression of CD133, the inverse cell senescence marker, both following stimulation with decenoic (fold change = 1.8, p = 0.0053) and nonanoic acid (FC = 1.3, p = 0.0056), and with VPA (FC 2, p = 0.0036). Simultaneously, the number of senescent cells decreased, as confirmed by the β-galactosidase assay (FC = 0.13, p = 0.0005). The treatment with decenoic and nonanoic acid also restored high levels of the lncRNA HOTAIR (FC = 14.6 for nonanoic acid and 12.7 for 10-HDA; p = 0.05), that in turn promoted the secretion of the α-Klotho anti-aging protein (FC = 3.1; p = 0.01). Additionally, the western blot analysis revealed that the 10-HDA decreased the expression of cell senescence markers, p16 (FC = 1.6, p = 0.05), p53 (FC = 1.8, p = 0.05) and p21 (FC= 3.7, p = 0.05). Moreover, the nonanoic acid reduced the expression of p16 (FC = 1.8, p = 0.05), p53 (FC = 2, p = 0.05) and p21 (FC= 2.6, p = 0.0007). Also, their combination contributes to decrease p16 (FC = 1.9, p = 0.05), p53 (FC = 1.3, p = 0.05) and p21 (FC= 2.5, p = 0.05). Conclusion This study identifies specific molecules capable of reducing or delaying ARPC senescence. In particular, the two natural compounds 10-HDA and nonanoic acid can also enhance the capacity of renal progenitors to secrete the α-Klotho protein whose decline prevention by several mechanisms can attenuate renal injuries, retard CKD progression, ameliorate extrarenal complications, and improve renal function. These findings present potential therapeutic avenues for delaying or mitigating the progression of CKD.

Glomerular Hyperfiltration and Th17 Responses Promote Glomerulosclerosis Following Nephron Loss

Objective: Chronic kidney disease (CKD) affects 37 million Americans resulting in $87 billion healthcare cost annually. Impaired renal autoregulation in obesity, diabetes and hypertension causes elevated glomerular capillary pressure and whole-kidney hyperfiltration, leading to progressive glomerulosclerosis and CKD. In advanced CKD with less than 50% functional nephron mass, single-nephron hyperfiltration causes further nephron loss, ultimately leading to hypofiltration and end-state kidney disease. Increased renal perfusion pressure directly drives T cell infiltration to the kidney. We and others have shown that T helper (Th) 17 cells promote vascular stiffening in hypertension and renal interstitial fibrosis after ischemia-reperfusion injury, but their roles in glomerulosclerosis and CKD are poorly understood. We hypothesized that glomerular hypertension and hyperfiltration promote renal fibrosis through Th17-mediated immune responses. Methods: We investigated the causal roles of glomerular hyperfiltration and Th17 responses in a mouse CKD model induced by reduced kidney mass (RKM), which involved right kidney nephrectomy and partial renal artery ligation in the left kidney such that the functional renal mass is reduced by ~ 5/6. Male 129/S6 mice received sham or RKM surgery at 8 weeks of age, and blood pressure (BP, by radiotelemetry), glomerular filtration rate (GFR, by transcutaneous FITC-sinistrin) and serum/urine CKD markers were assessed at baseline (BL) and week 1, 2, 3, 4, 8, and 12 post-surgery. Results: BP and GFR of RKM mice were identical to sham controls at BL (n=4-6). Immediately after the RKM procedure, GFR dropped to 22% of BL, consistent with the extent of renal mass ablation. BP increased by 29 mmHg first week after 5/6 ablation (144 ± 8 vs BL 112 ± 2 mmHg, p<0.05, 2-way ANOVA), exposing the remnant nephrons to increased renal perfusion pressure. Serum creatinine, blood urea nitrogen and urinary albumin were significantly elevated by week 2. BP and CKD markers remained elevated through week 12 in the 5/6 ablation mice. The GFR of ablated mice gradually increased to 38% of BL at day 3, 57% at week 1 and 68% at week 2, suggesting that systemic hypertension and impaired renal autoregulation may have caused substantial single-nephron hyperfiltration in the remnant kidney mass. GFR plateaued at ~ 70% of BL in week 3-4 then declined to 48% at week 8-12 when glomerular, interstitial, and microvascular fibrosis developed as evidence by Periodic Acid Schiff and Picro Sirius Red staining. Supporting a causal role of hemodynamic derangements in CKD progression, calcium channel blocker amlodipine, a potent vasodilator, dose dependently (5-10 mg/kg/day, n=7-9) exacerbated glomerular hyperfiltration, glomerulosclerosis and mortality despite marked BP-lowering effects. Importantly, the adaptive increase of GFR in the first 2 weeks post 5/6 ablation was accompanied by significant increase of renal Th17 cells, which not only preceded the infiltration of CD11b+ myeloid cells, F4/80+ monocyte/macrophages and T regulatory cells, but also the glomerulosclerosis and GFR decline in week 8. Conclusions: Our data suggest that glomerular hyperfiltration causes progressive nephron loss and kidney fibrosis, at least in part, through Th17-mediated renal inflammation. To further establish causality, ongoing studies will assess if Th17 blockade ameliorates glomerulosclerosis and retard CKD progression. Funding: This work was supported by NIDDK R01 DK094907, R01 DK113632, R01 DK128677 to THL, and K01 DK126972 to JW. JW is also supported by an American Heart Association Second Century Early Faculty Independence Award (23SCEFIA1148464), a University of Rochester Environmental Health Science Center pilot award (Prime sponsor: NIEHS P30ES001247), and a University of Rochester Program for Advanced Immune Bioimaging Pilot Award (Prime Sponsor: NIAID P01AI102851). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Retard chronic kidney disease progression

Chronic kidney disease (CKD) poses a substantial global health burden. It is classified according to estimated glomerular filtration rate (eGFR) (G1-G5) and albuminuria (A1-A3). In recent years the clinicians' therapeutic options for slowing CKD progression and mitigating cardiovascular disease has been significantly expanded:For CKD with albuminuria, concomitant cardiovascular disease or diabetes mellitus, a target blood pressure <130/80mmHg should be aspired. Apart from the geriatric population and those with a life expectancy below one year a blood pressure <140/90mmHg should be targeted. Renin-angiotensin-system inhibitors (RASi) and sodium-glucose-cotransporter 2 inhibitors (SGLT2i) are the basis of CKD therapy. SGLT2i can be prescribed in most cases of CKD with an eGFR >20ml/min/1.73m2 apart from a few exceptions. Once started, patients should stay on SGLT2i until dialysis. Finerenon is a novel option for diabetic nephropathy with an ACR >30mg/g [3mg/mmol] and an eGFR >25ml/min/1.73m2. Finerenon slows CKD progression and reduces cardiovascular events.

Metabolomics study reveals blood biomarkers for early diagnosis of chronic kidney disease and IgA nephropathy: A retrospective cross-sectional study

Background and aimsChronic kidney disease (CKD) causes low quality of life and alarming morbidity and mortality. The crucial to retard CKD progression is to diagnose early for timely treatment. IgA nephropathy (IgAN) is a typical CKD and the most common glomerulonephritis. Both CKD and IgAN lack accurate and sensitive blood biomarkers for early diagnosis. Here we report the potential of plasma biomarkers for early diagnosis of CKD and IgAN. Materials and methodsPlasma levels of metabolites derived from tryptophan were quantified with an LC-MS/MS-based metabolomics for two cohorts. Based on the predictive probability of each metabolite, multivariate models including logistic regression and random forest were used to establish the early diagnostic biomarkers for CKD and IgAN. ResultsThe plasma melatonin diagnosed early CKD (stages Ⅰ−Ⅱ) with an accuracy exceeding 95%, and a panel of melatonin and tryptophan achieved a remarkable 100% accuracy in diagnosing early CKD. Furthermore, indole-3-lactic acid had an excellent ability to distinguish IgAN among CKD patients. Based on the CKD screening and IgAN diagnosis primarily contributed by melatonin and indole-3-lactic acid, early IgAN could be diagnosed with an accuracy of over 85%. ConclusionsThis study provides promising plasma biomarkers for early diagnosis of CKD and IgAN.

MO563: Effect of Probiotics on Uremic Toxins Production and Inflammation in Patients Suffering from CKD Stage 3 and 4

Abstract BACKGROUND AND AIMS Probiotics are being coprescribed in the management of chronic kidney disease (CKD). Few studies have reported that probiotics could slow down the progression of CKD by regulating the intestinal flora and by reducing the uremic toxins. [1,2] Objective of our study is to assess the effect of probiotics on uremic toxins production and inflammation in patient suffering from CKD stage 3 and 4. METHOD Patients of either sex, aged 18–75 years, suffering from CKD stage 3 and 4 were enrolled. Study was conducted at Department of Nephrology, Guwahati Medical College and Hospital (GMCH), Guwahati, Assam. Patients received 1 capsule containing 45 billion of colony forming units of probiotics twice a day for 180 days. Patients were evaluated at day 0, 90 and 180. Parameters such as serum creatinine, blood urea, uric acid, C-reactive protein (CRP), hemoglobin and albumin were recorded at each visit. RESULTS During period of May 2019 to May 2020, 102 patients were enrolled and followed for 180 days. Significantly higher number of males 67 (66%) than 35 (34%) females is reported (P = 0.024). CKD stage 3 and 4 is reported in 41 (40% ) and 61 (60%), respectively. Insignificant drop of serum creatinine of -0.17 (on day 90, P = 0.146) and -0.23 (on day 180, P = 0.135) compared with baseline Sr. creatinine 2.53 ± 0.56 (mean ± SD) is reported. Significant drop in blood urea is reported on day 90 (-2.97, P = 0.014) and on day 180 (-3.60, P &amp;lt; 0.001) compared with baseline 52.11 ± 26.90 (mean ± SD). The reduction in CRP on day 90 and day 180 from baseline was found to be statistically significant (P = 0.037, 0.011). However, reduction in uric acid and increase in hemoglobin and albumin did not reach significance on day 90 and day 180. CONCLUSION Probiotics supplementation lead to decrease in blood urea and CRP. However, its effect on serum creatinine, hemoglobin, uric acid and albumin did not reach statistical significance. More randomized controlled trials are required to prove the efficacy of probiotics to retard CKD progression.

A Podcast Discussing Aldosterone and Mineralocorticoid Receptor Antagonists in 2021: A Paradigm Shift.

The classic focus on the mechanisms of action of aldosterone was directed primarily on its role in modulating renal excretory function and maintaining volume homeostasis. In contrast, many recent studies have demonstrated a much wider and expanded role for aldosterone and for the mineralocorticoid receptor (MR). Activation of the MR promotes inflammation, collagen formation, fibrosis, and necrosis with consequent renal injury. Increasing evidence has accrued that implicates the pathophysiological overactivation of the MR as a major determinant of progression of both diabetic and nondiabetic chronic kidney disease (CKD). By promoting cascades of injury encompassing inflammation and fibrosis, MR overactivation constitutes a pivotal determinant of CKD progression and consequently its associated morbidity and mortality. Based on this mechanism of action, blockade of the MR with the nonsteroidal MR antagonist finerenone is currently being investigated as a novel treatment regimen to slow the progression of CKD. The recently reported FIDELIO-DKD (FInerenone in reducing kiDnEy faiLure and dIsease prOgression in Diabetic Kidney Disease) study demonstrated that patients with CKD and type 2 diabetes (T2D) who were treated with finerenone manifested a lower risk of a composite primary outcome event compared with patients in the placebo arm (defined as kidney failure or a sustained decrease of ≥ 40% in the estimated glomerular filtration rate from baseline, or death from renal causes). In addition, patients in the finerenone group also manifested a lower risk of a key secondary outcome event (defined as death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure). Based on the success of these major clinical trials, finerenone was approved by the FDA on 9 July 2021 as a novel treatment for retarding CKD progression in patients with T2D (https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-drug-reduce-risk-serious-kidney-and-heart-complications-adults-chronic-kidney-disease). Podcast Video (MP4 258973 KB)Supplementary InformationThe online version contains supplementary material available at 10.1007/s13300-022-01236-w.

Protein-Bound Uremic Toxins Lowering Effect of Sevelamer in Pre-Dialysis Chronic Kidney Disease Patients with Hyperphosphatemia: A Randomized Controlled Trial.

P-cresyl sulfate and indoxyl sulfate are strongly associated with cardiovascular events and all-cause mortality in chronic kidney disease (CKD). This randomized controlled trial was conducted to compare the effects between sevelamer and calcium carbonate on protein-bound uremic toxins in pre-dialysis CKD patients with hyperphosphatemia. Forty pre-dialysis CKD patients with persistent hyperphosphatemia were randomly assigned to receive either 2400 mg of sevelamer daily or 1500 mg of calcium carbonate daily for 24 weeks. A significant decrease of total serum p-cresyl sulfate was observed in sevelamer therapy compared to calcium carbonate therapy (mean difference between two groups −5.61 mg/L; 95% CI −11.01 to −0.27 mg/L; p = 0.04). There was no significant difference in serum indoxyl sulfate levels (p = 0.36). Sevelamer had effects in terms of lowering fibroblast growth factor 23 (p = 0.01) and low-density lipoprotein cholesterol levels (p = 0.04). Sevelamer showed benefits in terms of retarding CKD progression. Changes in vascular stiffness were not found in this study.

Bioactive peptide apelin rescues acute kidney injury by protecting the function of renal tubular mitochondria.

Mitochondrial dysfunction in proximal tubular epithelial cells is a key event in acute kidney injury (AKI), which is a risk factor for the development of chronic kidney disease (CKD). Apelin is a bioactive peptide that protects against AKI by alleviating inflammation, inhibiting apoptosis, and preventing lipid oxidation, but its role in protecting against mitochondrial damage remains unknown. Herein, we examined the protective effects of apelin on mitochondria in cisplatin-stimulated human renal proximal tubular epithelial cells and evaluated its therapeutic efficacy in cisplatin-induced AKI mice. In vitro, apelin inhibited the cisplatin-induced mitochondrial fission factor (MFF) upregulation and the fusion-promoting protein optic atrophy 1 (OPA1) downregulation. Apelin co-treatment reversed the decreased levels of the deacetylase, Sirt3, and the increased levels of protein acetylation in mitochondria of cisplatin-stimulated cells. Overall, apelin improved the mitochondrial morphology and membrane potential in vitro. In the AKI model, apelin administration significantly attenuated mitochondrial damage, as evidenced by longer mitochondrial profiles and increased ATP levels in the renal cortex. Suppression of MFF expression, and maintenance of Sirt3 and OPA1 expression in apelin-treated AKI mice was also observed. Finally, exogenous administration of apelin normalized the serum level of creatinine and urea nitrogen and the urine levels of NGAL and Kim-1. We also confirmed a regulatory pathway that drives mitochondrial homeostasis including PGC-1α, ERRα and Sirt3. In conclusion, we demonstrated that apelin ameliorates renal functions by protecting tubular mitochondria through Sirt3 upregulation, which is a novel protective mechanism of apelin in AKI. These results suggest that apelin has potential renoprotective effects and may be an effective agent for AKI treatment to significantly retard CKD progression.

Cardiovascular Protection With Sodium-Glucose Cotransporter-2 Inhibitors and Mineralocorticoid Receptor Antagonists in Chronic Kidney Disease: A Milestone Achieved.

Chronic kidney disease (CKD) and cardiovascular disease are intimately linked. They share major risk factors, including age, hypertension, and diabetes, and common pathogenetic mechanisms. Furthermore, reduced renal function and kidney injury documented with albuminuria are independent risk factors for cardiovascular events and mortality. In major renal outcome trials and subsequent meta-analyses in patients with CKD, ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin II receptor blockers) were shown to effectively retard CKD progression but not to significantly reduce cardiovascular events or mortality. Thus, a high residual risk for cardiovascular disease progression under standard-of-care treatment is still present for patients with CKD. In contrast to the above, several outcome trials with SGLT-2 (sodium-glucose cotransporter-2) inhibitors and MRAs (mineralocorticoid receptor antagonists) clearly suggest that these agents, apart from nephroprotection, offer important cardioprotection in this population. This article discusses existing evidence on the effects of SGLT-2 inhibitors and MRAs on cardiovascular outcomes in patients with CKD that open new roads in cardiovascular protection of this heavily burdened population.

SAT-288 Trends in pharmacotherapy for diabetes in a large Australian cohort: results from the EXTEND45 study

Aim: We sought to examine temporal trends in the prescribing patterns of glucose lowering agents in Australia in patients with diabetes. Background Rising diabetes rates are increasing the global burden of chronic kidney disease (CKD). Glycemic control remains a key strategy for retarding CKD progression. Multiple factors may influence prescribing practice of glucose lowering pharmacotherapies including health provider restrictions on therapy combinations, patient factors such as age, comorbidities and level of renal function, and contemporary recommendations in national and international guidelines. The EXTEND45 cohort study links health information on consenting participants of the 45 and Up Study (2006-2009) with administrative health information from the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (provided by the Department of Human Services), community pathology providers and other routinely collected health information sources. Linkage was performed by the Centre for Health Record Linkage and the Sax Institute (PBS and MBS). We identified a population-based cohort (2006-2014) of people aged ≥45 years who met pre-specified criteria for diabetes: self-report of diabetes, a HbA1c result ≥6.5%, a fasting serum glucose result >7.0 mmol/L, a random serum glucose >11.1 mmol/L, dispensed oral glucose lowering (OGL) medication and/or insulin analogue. Persons were considered to have prevalent diabetes if they had any of the diagnostic criteria prior to their 45 and Up Study recruitment date, and incident diabetes if they met the criteria after this date. OGL treatment episodes were analysed from the date of recruitment into the study or the date of diabetes diagnosis, until death, relocation outside the state of NSW, or June 30 2014. Treatment episodes were defined as the period a patient adhered to a particular regimen of pharmacotherapy without any breaks in treatment of two or more standard coverage days (SCD). SCDs relate to the number of treatment days covered by a single script and vary by drug agent. Episodes were attributed to the calendar year in which they commenced and were categorised into six pre-defined patterns of glucose lowering medication use:1. Never treated with pharmacotherapy2. Monotherapy (one OGL agent)3. Dual therapy (two OGL agents)4. Triple or more therapy (three or more OGL agents)5. Insulin treatment (+/- one or more OGL agent)6. Treatment break We identified 24,236 participants with diabetes who experienced 149,532 treatment episodes over a mean follow-up period of 4.97 years. Treatment episodes included: never treated (4.4%), monotherapy (33.1%), dual therapy (17.0%), triple or more therapy (4.0%), insulin-based therapy (21.7%) and treatment break (20.3%). Metformin (a biguanide) accounted for the majority (68.5%) of monotherapy episodes, followed by sulfonlyureas (23.1%). The combination of metformin and a sulfonylurea was the most common dual therapy treatment episode (56.1%) but became less common over the study period, falling from 75.5% of episodes in 2006 to 41.1% in 2014. Most treatment episodes in our cohort were for monotherapy-based regimens. There was a temporal change in the specific OGL agents prescribed within a dual therapy regimen, likely related to the availability of newer OGL agents in Australia.

Huangqi-Danshen Decoction Ameliorates Adenine-Induced Chronic Kidney Disease by Modulating Mitochondrial Dynamics.

Chronic kidney disease (CKD) is a leading public health problem with high morbidity and mortality. However, the therapies remain limited. Traditional Chinese medicine (TCM) has been used for treating kidney disease for thousands of years and is an effective alternative treatment for CKD patients in China and other Asian countries. In the present study, we aimed to investigate the effect and mechanism of Huangqi-Danshen decoction (HDD), a TCM herbal decoction, on treating CKD. CKD rat model was induced by adding 0.75% adenine to the diet for 4 weeks. HDD extract was administrated orally to CKD rats at the dose of 4.7 g/kg/d for consecutive 4 weeks in adenine-induced CKD rats. Kidney function was evaluated by the levels of serum creatinine (Scr) and blood urea nitrogen (BUN). The pathological changes of kidney tissues were observed by periodic acid-Schiff (PAS) and Masson's trichrome staining. The proteins expression of renal fibrosis and mitochondrial dynamics were determined and quantified by Western blot analysis. CKD rats showed obvious decline in renal function as evidenced by increased levels of Scr and BUN, which were blunted by HDD treatment. HDD could also improve tubular atrophy and interstitial fibrosis of CKD rats. Moreover, HDD downregulated fibronectin, type IV collagen, and α-smooth muscle actin expression in CKD rats. Furthermore, mitochondrial dynamics was disturbed in CKD rats, which manifested as increased mitochondrial fission and decreased mitochondrial fusion. HDD treatment restored mitochondrial dynamics in CKD rats by repressing dynamin-related protein 1 and Mid 49/51 expression, promoting mitofusin 2 expression, and suppressing optic atrophy 1 proteolysis. In conclusion, HDD could significantly retard CKD progression through modulating mitochondrial dynamics.

Jian-Pi-Yi-Shen Formula ameliorates chronic kidney disease: involvement of mitochondrial quality control network

BackgroundJian-Pi-Yi-Shen Formula (JPYSF), a Chinese herbal decoction with the efficacies of ‘fortify the spleen and tonify the kidney’ and ‘activate blood and resolve stasis’, is effective for the treatment of chronic kidney disease in clinic. However, the underlying mechanism remains unclear. The aim of this study was to investigate the therapeutic effects and possible mechanisms of JPYSF on retarding chronic kidney disease progression in 5/6 nephrectomized (5/6 Nx) rats.MethodsPerindopril (4 mg/kg/d) and JPYSF (2.72 g/kg/d) were administrated by gavage to 5/6 Nx rats daily for 6 weeks. The therapeutic effects of JPYSF were evaluated by renal function, pathological injury, and fibrosis. The protein levels associated with mitochondrial quality control network were measured by Western blot and immunofluorescence analysis.Results5/6 Nx rats showed obvious decline in renal function as evidenced by increased serum creatinine, blood urea nitrogen, and urinary protein excretion, and significant injury in kidney structure as evidenced by glomerular hypertrophy, tubular atrophy, and interstitial fibrosis. Administration of JPYSF for 6 weeks could improve renal function and ameliorate kidney structure injury in 5/6 Nx rats. Furthermore, the remnant kidneys of 5/6 Nx rats showed unbalanced mitochondrial quality control network manifested as decreased mitochondrial biogenesis, fusion, and mitophagy, and increased mitochondrial fission. Treatment of JPYSF could restore aforesaid aspects of mitochondrial quality control network.ConclusionsThese results indicate that JPYSF can notably ameliorate 5/6 Nx-induced chronic kidney disease, which may be related with modulation of mitochondrial quality control network.

Long-Term Effects of Spironolactone on Kidney Function and Hyperkalemia-Associated Hospitalization in Patients with Chronic Kidney Disease.

Background: Spironolactone, a non-selective mineralocorticoid receptor antagonist, can protect against cardiac fibrosis and left ventricular dysfunction, and improve endothelial dysfunction and proteinuria. However, the safety and effects of spironolactone on patient-centered cardiovascular and renal endpoints remain unclear. Methods: We identified predialysis stage 3–4 chronic kidney disease (CKD) patients between 2000 and 2013 from the Longitudinal Health Insurance Database 2005 (LHID 2005). The outcomes of interest were end-stage renal disease (ESRD), major adverse cardiovascular events (MACE), hospitalization for heart failure (HHF), hyperkalemia-associated hospitalization (HKAH), all-cause mortality and cardiovascular mortality. The Fine and Gray sub-distribution hazards approach was adopted to adjust for the competing risk of death. Results: After the propensity score matching, 693 patients with stage 3–4 CKD were spironolactone users and 1386 were nonusers. During the follow-up period, spironolactone users had a lower incidence rate for ESRD than spironolactone non-users (39.2 vs. 53.69 per 1000 person-years) and a higher incidence rate for HKAH (54.79 vs. 18.57 per 1000 person-years). The adjusted hazard ratios for ESRD of spironolactone users versus non-users were 0.66 (95% CI, 0.51–0.84; p value < 0.001) and 3.17 (95% CI, 2.41–4.17; p value < 0.001) for HKAH. A dose-response relationship was found between spironolactone use and risk of ESRD and HKAH. There were no statistical differences in MACE, HHF, all-cause mortality and cardiovascular mortality between spironolactone users and non-users. Conclusion: Spironolactone represented a promising treatment option to retard CKD progression to ESRD amongst stage 3–4 CKD patients, but strategic treatments to prevent hyperkalemia should be enforced.

Jian-Pi-Yi-Shen Formula Regulates Inflammatory Cytokines Production in 5/6 Nephrectomized Rats via Suppression of NF-κB Activation

Jian-Pi-Yi-Shen formula (JPYSF) is a Chinese herbal decoction used for treating chronic kidney disease (CKD) for over 20 years with good efficiency. However, the mechanism lacks solid evidence. In the present study, we tested the hypothesis that JPYSF may retard CKD progression via inhibition of inflammation in 5/6 nephrectomy (5/6 Nx) rat model. The 5/6 Nx rats were randomly divided into 2 groups: 5/6 Nx group and JPYSF group. Sham-operated rats served as control. JPYSF (2.06 g/kg/d) were administrated by gavage to 5/6 Nx rats daily for 6 weeks. Results showed that JPYSF treatment significantly improved kidney function and pathological injury in 5/6 Nx rats. Multiplex analysis of cytokines revealed that JPYSF reduced proinflammatory cytokines and increased anti-inflammatory cytokine production. Furthermore, JPYSF inhibited the activation of nuclear factor-kappa B (NF-κB) signaling pathway. In conclusion, our data demonstrated that JPYSF remarkably retards development and progression of CKD in a 5/6 Nx rat model, which may be associated with inhibition of inflammation via NF-κB signaling pathway.

How to Retard Progression of Chronic Kidney Disease

End stage chronic kidney disease (CKD) requiring renal replacement therapy is related to poor quality of life and high mortality. Thus, slowing the progression of CKD is an important purpose of therapy. Some general therapeutic approaches aim to slow the decline of renal function and they can be applied in all patients with CKD - irrespective of the underlying cause of CKD. A key intervention is lowering blood pressure (target: ≤ 140/90 mmHg, and in patients with albuminuria ≤ 130/80 mmHg). Inhibitors of the renin angiotensin system preferentially should be used in case of albuminuria, depending on the diabetic status and the level of albuminuria: in diabetics with albuminuria ≥ 30 mg/d, in non-diabetics with albuminuria > 300 mg/d. Mineralocorticoid receptor blockers and endothelin receptors blockers promise novel anti-proteinuric strategies - but still validation of their positive effects on retarding CKD progression is necessary. In patients with diabetic kidney disease, glycemic control aiming for an HbA1c of ≈7.0 % has been established to slow CKD progression. Furthermore, SGLT-2 inhibition with empagliflozin may be considered as a new therapeutic approach that provides additional cardiovascular and renal protection. Finally, recent studies suggest: correction of metabolic acidosis and avoidance of episodes of acute renal failure may provide protection against the progression of CKD.

Dietary protein intake and chronic kidney disease

High-protein intake may lead to increased intraglomerular pressure and glomerular hyperfiltration. This can cause damage to glomerular structure leading to or aggravating chronic kidney disease (CKD). Hence, a low-protein diet (LPD) of 0.6-0.8 g/kg/day is often recommended for the management of CKD. We reviewed the effect of protein intake on incidence and progression of CKD and the role of LPD in the CKD management. Actual dietary protein consumption in CKD patients remains substantially higher than the recommendations for LPD. Notwithstanding the inconclusive results of the 'Modification of Diet in Renal Disease' (MDRD) study, the largest randomized controlled trial to examine protein restriction in CKD, several prior and subsequent studies and meta-analyses appear to support the role of LPD on retarding progression of CKD and delaying initiation of maintenance dialysis therapy. LPD can also be used to control metabolic derangements in CKD. Supplemented LPD with essential amino acids or their ketoanalogs may be used for incremental transition to dialysis especially on nondialysis days. The LPD management in lieu of dialysis therapy can reduce costs, enhance psychological adaptation, and preserve residual renal function upon transition to dialysis. Adherence and adequate protein and energy intake should be ensured to avoid protein-energy wasting. A balanced and individualized dietary approach based on LPD should be elaborated with periodic dietitian counseling and surveillance to optimize management of CKD, to assure adequate protein and energy intake, and to avoid or correct protein-energy wasting.

Time to target uric acid to retard CKD progression.

Uric acid (UA) remains a possible risk factor of chronic kidney disease (CKD) but its potential role should be elucidated given a fact that multidisciplinary treatments assure a sole strategy to inhibit the progression to end-stage renal disease (ESRD). In clinical setting, most observational studies showed that elevation of serum uric acid (SUA) independently predicts the incidence and the development of CKD. The meta-analysis showed that SUA-lowering therapy with allopurinol may retard the progression of CKD but did not reach conclusive results due to small-sized studies. Larger scale, randomized placebo-controlled trials to assess SUA-lowering therapy are needed. Our recent analysis by propensity score methods has shown that the threshold of SUA should be less than 6.5mg/dL to abrogate ESRD. In animal models an increase in SUA by the administration of oxonic acid, uricase inhibitor, or nephrectomy can induce glomerular hypertension, arteriolosclerosis including afferent arteriolopathy and tubulointerstitial fibrosis. The ever-growing discoveries of urate transporters prompt us to learnUA metabolism in the kidney and intestine. One example is that the intestinal ABCG2 may play a compensatory role at face of decreased renal clearance of UA in nephrectomized rats, the trigger of which is not a uremic toxin but SUA itself. This review will summarize the recent knowledge on the relationship between SUA and the kidney and try to draw a conclusion when and how to treat asymptomatic hyperuricemia accompanied by CKD. Finally we will address a future perspective onUA study including a Mendelian randomization approach.

Retarding CKD Progression: Readily Available through Comprehensive Nutritional Management?

This manuscript is aimed at summarising the evidences raised by the 2nd International conference of the European Renal Nutrition (ERN) working group at the ERA-EDTA “Retarding CKD progression: readily available through comprehensive nutritional management?” This project is focused on everyday nutritional issues related to non-dialysis-dependent chronic kidney disease (CKD) condition. A non-dialysis CKD clinical case of common presentation in the daily clinical practice will be reported and thereafter several key aspects of the comprehensive nutritional management which nephrologists face daily in clinics will be addressed; definitely, baseline nutritional assessment, basic nutritional concerns, major nutritional targets, nutritional strategies to improve renal outcomes, and modalities of nutritional follow-up will be discussed in relation to follow-up of the case report.

Retarding Chronic Kidney Disease (CKD) Progression: A Practical Nutritional Approach for Non-Dialysis CKD

This is a case report on a patient with non-dialysis chronic kidney disease (CKD) in whom several nutritional issues are briefly discussed from a practical point of view. The article is accompanied by an editorial published in this Journal in relation to the 2nd International Conference of the European Renal Nutrition working group at ERA-EDTA—“Retarding CKD progression: readily available through comprehensive nutritional management?”— and focuses on several practical topics associated with the nutritional approach for the conservative treatment of non-dialysis CKD. The article is divided into 3 sections—basic nutritional assessment, nutritional targets, and nutritional follow-up in non-dialysis CKD—linked to 3 consecutive steps of the clinical follow-up of the patient and the related nutritional concerns and intervention. First visit: Baseline nutritional assessment and basic nutritional considerations in non-dialysis chronic kidney disease (CKD) • What nutritional assessment/monitoring for protein-energy wasting (PEW) should be employed? • Is a body mass index (BMI) of 21 kg/m2 adequate? • What phosphate target should be pursued? • What are the nutritional habits in patients with incident CKD? • What protein needs and amount of dietary protein should be pursued? • Does the quality of protein matter? • What amount of dietary salt should be employed? How should this be obtained? • How should normal serum phosphate be achieved? • What diet should be recommended? Is a vegetarian diet an option? Second visit: Major nutritional targets in non-dialysis CKD • Consequences of unintentional weight loss • What is the role of the renal dietitian in helping the patient adhere to a renal diet? Intermediate visits: Nutritional follow-up in non-dialysis CKD • What treatment for calcium/parathyroid hormone (PTH) will affect CKD progression? Final visits: • Would a dietary recall/intensive dietary education improve adherence with the diet? • Would a very-low-protein diet (VLPD)/ketodiet be indicated for this patient?

Kidney Disease in Adenine Phosphoribosyltransferase Deficiency

Adenine phosphoribosyltransferase (APRT) deficiency is a purine metabolism disorder causing kidney stones and chronic kidney disease (CKD). The course of nephrolithiasis and CKD has not been well characterized. The objective of this study was to examine long-term kidney outcomes in patients with APRT deficiency. An observational cohort study. All patients enrolled in the APRT Deficiency Registry of the Rare Kidney Stone Consortium. Kidney stones, acute kidney injury (AKI), stage of CKD, end-stage renal disease, estimated glomerular filtration rate (eGFR), and changes in eGFR. Serum creatinine and eGFR calculated using creatinine-based equations. Of 53 patients, 30 (57%) were females and median age at diagnosis was 37.0 (range, 0.6-67.9) years. Median duration of follow-up was 10.3 (range, 0.0-31.5) years. At diagnosis, kidney stones had developed in 29 (55%) patients and 20 (38%) had CKD stages 3 to 5, including 11 (21%) patients with stage 5. At latest follow-up, 33 (62%) patients had experienced kidney stones; 18 (34%), AKI; and 22 (42%), CKD stages 3 to 5. Of 14 (26%) patients with stage 5 CKD, 12 had initiated renal replacement therapy. Kidney stones recurred in 18 of 33 (55%) patients. The median eGFR slope was -0.38 (range, -21.99 to 1.42) mL/min/1.73m(2) per year in patients receiving treatment with an xanthine dehydrogenase inhibitor and -5.74 (range, -75.8 to -0.10) mL/min/1.73m(2) per year in those not treated prior to the development of stage 5 CKD (P=0.001). Use of observational registry data. Progressive CKD and AKI episodes are major features of APRT deficiency, whereas nephrolithiasis is the most common presentation. Advanced CKD without a history of kidney stones is more prevalent than previously reported. Our data suggest that timely therapy may retard CKD progression.