Decreased glomerular filtration rate is associated with mortality and cardiovascular events in patients with hypertension: a prospective study

Background

Few studies reported the associations between decreased glomerular filtration rate (GFR) and mortality, coronary heart disease (CHD), and stroke in hypertensive patients. We aim to assess the associations between GFR and mortality, CHD, and stroke in hypertensive patients and to evaluate whether low GFR can improve the prediction of these outcomes in addition to conventional cardiovascular risk factors.

Methods and Findings

This is an observational prospective study and 3,711 eligible hypertensive patients aged ≥5 years from rural areas of China were used for the present analysis. The associations between eGFR and outcomes, followed by a median of 4.9 years, were evaluated using Cox proportional hazards models adjusting for other potential confounders. Low eGFR was independently associated with risk of all-cause mortality, cardiovascular mortality, and incident stroke [multivariable adjusted hazard ratios (95% confidence intervals) for eGFR <60 ml/min/1.73 m² relative to eGFR ≥90 ml/min/1.73 m² were 1.824 (1.047–3.365), 2.371 (1.109–5.068), and 2.493 (1.193–5.212), respectively]. We found no independent association between eGFR and the risk of CHD. For 4-year all-cause and cardiovascular mortality, integrated discrimination improvement (IDI) was positive when eGFR were added to traditional risk factors (1.51%, P = 0.016, and 1.99%, P = 0.017, respectively). For stroke and CHD events, net reclassification improvements (NRI) were 5.9% (P = 0.012) and 1.8% (P = 0.083) for eGFR, respectively.

Conclusions

We have established an inversely independent association between eGFR and all-cause mortality, cardiovascular mortality, and stroke in hypertensive patients in rural areas of China. Further, addition of eGFR significantly improved the prediction of 4-year mortality and stroke over and above that of conventional risk factors. We recommend that eGFR be incorporated into prognostic assessment for patients with hypertension in rural areas of China.

Limitations

We did not have sufficient information on atrial fibrillation to control for the potential covariate. These associations should be further confirmed in future.     

Mechanisms of neonatal increase in glomerular filtration rate

To investigate the mechanisms responsible for the neonatal increase in glomerular filtration rate (GFR), renal function studies (whole kidney and micropuncture) were carried out in anesthesized fetal sheep (133-140 days gestation; term = 150 days) and lambs (12-18 days). Fetuses were delivered and placed in a water bath (39.5 degrees C), keeping the umbilical cord moist and intact. Lambs were studied on a thermostatically controlled heating pad. Animals were prepared for either blood flow studies or micropuncture measurements. Expected differences in blood composition and cardiovascular and renal function were observed between fetuses and lambs, and values obtained for most variables were similar to those measured in chronically catheterized unanesthetized animals. Fetal GFR was much lower than that of lambs (0.20 vs. 0.62 ml.min(-1).g kidney(-1), P < 0.001). Free-flow, stop-flow, and net filtration pressures (NFP) were lower in the fetuses than the lambs (NFP 20.8 vs. 23.8 mmHg, P < 0.001), as was the calculated ultrafiltration coefficient (0.014 vs. 0.022 ml.min(-1).g(-1).mmHg(-1), P < 0.001). Thus, we conclude that rises in both net filtration pressure and the ultrafiltration coefficient contribute to the large increase in GFR between fetal life and approximately 2 wk after birth.     

Increased male mating rate in Drosophila is associated with Wolbachia infection

The maternally inherited bacterium Wolbachia pipientis infects 25-75% of arthropods and manipulates host reproduction to improve its transmission. One way Wolbachia achieves this is by inducing cytoplasmic incompatibility (CI), where crosses between infected males and uninfected females are inviable. Infected males suffer reduced fertility through CI and reduced sperm production. However, Wolbachia induce lower levels of CI in nonvirgin males. We examined the impact of Wolbachia on mating behaviour in male Drosophila melanogaster and D. simulans, which display varying levels of CI, and show that infected males mate at a higher rate than uninfected males in both species. This may serve to increase the spread of Wolbachia, or alternatively, may be a behavioural adaptation employed by males to reduce the level of CI. Mating at high rate restores reproductive compatibility with uninfected females resulting in higher male reproductive success thus promoting male promiscuity. Increased male mating rates also have implications for the transmission of Wolbachia.     

The ACE polymorphism is associated with BMI in patients with metabolic syndrome

The angiotensin-converting enzyme (ACE) polymorphism is well known to be associated with cardiovascular diseases. Until now, however, evidence for the role of ACE polymorphism in susceptibility to metabolic syndrome (MS) has not been well studied. Thus, we investigated an association between ACE polymorphisms and Korean patients with MS. DNA samples from 214 MS patients and 193 age-matched non-MS subjects were amplified using the polymerase chain reaction for detection of the ACE insertion/deletion (I/D) and BstUI polymorphisms. Anthropometric and physiological parameters including body mass index (BMI), waist circumference, blood pressure, glucose, triglycerides, total cholesterol and HDL cholesterol were measured. The genotype frequencies of the ACE I/D and BstUI polymorphisms were not significantly different between the non-MS and the MS group. The BB genotype distribution of the BstUI polymorphism in the female subgroup, however, was associated with an increased risk of MS (P = 0.008). When the data were stratified by BMI values, the high BMI groups showed significant differences between the non-MS and the MS groups, compared to the low BMI group, in all genotype frequencies of the ACE I/D and BstUI polymorphisms. The trend remained even when the genotypes of the two polymorphisms were combined. Although no consistent results were obtained on the association between the ACE polymorphism and MS in the populations studied, the ACE polymorphism, at least in Koreans, may be a genetic determinant of BMI in MS patients. Therefore, further studies are required on the association between the ACE polymorphism and MS patients in other racial or ethnic groups.     

Increased metabolic potential of Rhizobium spp. is associated with bacterial competitiveness

Of 105 rhizobial isolates obtained from nodules of commonly cultivated legumes, we selected 19 strains on the basis of a high rate of symbiotic plant growth promotion. Individual strains within the species Rhizobium leguminosarum bv. trifolii, R. leguminosarum bv. viciae, and Rhizobium etli displayed variation not only in plasmid sizes and numbers but also in the chromosomal 16S-23S internal transcribed spacer. The strains were tagged with gusA gene and their competitiveness was examined in relation to an indigenous population of rhizobia under greenhouse conditions. A group of 9 strains was thus isolated that were competitive in relation to native rhizobia in pot experiments. Nineteen selected competitive and uncompetitive strains were examined with respect to their ability to utilize various carbon and energy sources by means of commercial Biolog GN2 microplate test. The ability of the selected strains to metabolize a wide range of nutrients differed markedly and the competitive strains were able to utilize more carbon and energy sources than uncompetitive ones. A major difference concerned the utilization of amino and organic acids, which were metabolized by most of the competitive and only a few uncompetitive strains, whereas sugars and their derivatives were commonly utilized by both groups of strains. A statistically significant correlation between the ability to metabolize a broad range of substrates and nodulation competitiveness was found, indicating that metabolic properties may be an essential trait in determining the competitiveness of rhizobia.     

Hepatic and renal cadmium accumulation is associated with mass-specific daily metabolic rate in the bank vole (Clethrionomys glareolus)

Previous study has shown that photoperiod and age affect tissue accumulation of cadmium (Cd) in a small rodent, the bank vole. Since the body mass is also influenced by these factors, the present study was designed to determine whether mass-specific daily metabolic rate might be responsible for differential accumulation of Cd in the liver and kidneys of the short- and long-photoperiod bank voles as well as of the young and old animals. One- and five-month old male bank voles were held under short (8 h light/16 h dark) or long (16 h light/8 h dark) photoperiods and exposed to dietary Cd (100 microg/g) for 6 weeks. The bank voles raised under the short photoperiod and those injected subcutaneously with melatonin (7 micromol/kg/day) under the long photoperiod showed significantly higher concentrations of Cd in the liver (43-60%) and kidneys (40-47%) than the age-matched long-photoperiod animals. The old bank voles accumulated significantly less Cd in both organs than the young animals. These differences in Cd accumulation appeared not to be associated with the relative Cd intake. However, the hepatic and renal Cd levels followed a pattern similar to that of the mass-specific daily metabolic rate (or energy expenditure) and energy assimilation efficiency. These data indicate that mass-specific daily metabolic rate and energy assimilation efficiency (an indicative of digestive and absorptive processes) may be responsible for differential tissue Cd accumulation in the bank vole.     

Increased platelet thromboxane synthesis in renal glomerular diseases

Washed platelets were prepared from healthy children and adults, and patients with renal glomerular diseases, and incubated with [1-14C] arachidonate to measure the generation capacities of thromboxane (Tx) A2 and 12-hydroxyeicosatetraenoate (12-HETE). Tx generation capacity of platelets was significantly higher in patients with chronic glomerulonephritis, purpura nephritis and lupus nephritis than in healthy control subjects. There was no significant increase in minimal change nephrotic syndrome. 12-HETE showed a decreasing tendency in the glomerular diseases, which was restored to normal level by in vitro addition of indomethacin. Such increased Tx generation capacity of platelets may cause abnormal enhancement of platelet functions and conceivably constitute an aggravating factor of glomerular and microvascular damage in the affected kidney.     

Estimating glomerular filtration rate in diabetes using serum cystatin C

Chronic kidney disease (CKD) is a major public health problem, especially for people with diabetes. Not only is it a risk factor for end-stage renal disease (ESRD) but it is also a major cardiovascular disease (CVD) risk factor. Methods that accurately and simply estimate glomerular filtration rate (GFR) are therefore needed to optimise the detection and management of CKD in people with diabetes. One of the main failures of commonly used creatinine-based methods for estimating renal function is that they lack applicability across the full range of GFR values and underestimate GFR levels >60 mL/min/1.73m(2). Methods for accurately estimating an early pathological decline in GFR (i.e. ΔGFR >3.3 mL/min/year before reaching a GFR <60 mL/min/1.73m(2)) are especially needed as appropriate interventions have been shown to retard progression to ESRD and reduce CVD risk in people with diabetes. In contrast, recent studies have suggested that estimates of GFR based on serum cystatin C concentration might provide a simple and accurate method for detecting and monitoring an early decline in renal function.     

Basal metabolic rate in carnivores is associated with diet after controlling for phylogeny

Studies of basal metabolic rate (BMR), the minimum metabolic rate of postabsorptive, inactive endotherms while in their rest phase and thermal neutral zone, have contributed significantly to our understanding of animal energetics. Besides body mass, the main determinant of BMR, researchers have invoked diet and phylogenetic history as important factors that influence BMR, although their relative importance has been controversial. For 58 species within the Carnivora, we tested the hypothesis that BMR is correlated with home range size, a proxy for level of activity, and diet, using conventional least squares regression (CLSR) and regression based on phylogenetic independent contrasts (PIC). Results showed that BMR of Carnivora was positively correlated with home range size after controlling for body mass, regardless of the statistical method employed. We also found that diet and mass-adjusted home range size were correlated. When we simultaneously tested the effect of diet and mass-adjusted home range on mass-adjusted BMR, home range size was insignificant because of its colinearity with diet. Then we eliminated home range size from our model, and diet proved to be significant with both CLSR and PIC. We concluded that species that eat meat have larger home ranges and higher BMR than species that eat vegetable matter. To advance our understanding of the potential mechanisms that might explain our results, we propose the "muscle performance hypothesis," which suggests that selection for different muscle fiber types can account for the differences in BMR observed between meat eaters and vegetarian species within the Carnivora.     

Early glomerular filtration defect and severe renal disease in podocin-deficient mice

Podocytes are specialized epithelial cells covering the basement membrane of the glomerulus in the kidney. The molecular mechanisms underlying the role of podocytes in glomerular filtration are still largely unknown. We generated podocin-deficient (Nphs2-/-) mice to investigate the function of podocin, a protein expressed at the insertion of the slit diaphragm in podocytes and defective in a subset of patients with steroid-resistant nephrotic syndrome and focal and segmental glomerulosclerosis. Nphs2-/- mice developed proteinuria during the antenatal period and died a few days after birth from renal failure caused by massive mesangial sclerosis. Electron microscopy revealed the extensive fusion of podocyte foot processes and the lack of a slit diaphragm in the remaining foot process junctions. Using real-time PCR and immunolabeling, we showed that the expression of other slit diaphragm components was modified in Nphs2-/- kidneys: the expression of the nephrin gene was downregulated, whereas that of the ZO1 and CD2AP genes appeared to be upregulated. Interestingly, the progression of the renal disease, as well as the presence or absence of renal vascular lesions, depends on the genetic background. Our data demonstrate the crucial role of podocin in the establishment of the glomerular filtration barrier and provide a suitable model for mapping and identifying modifier genes involved in glomerular diseases caused by podocyte injuries.