Network Analysis of Demographics, Dietary Intake, and Comorbidity Interactions

The aim of this study was to elucidate the complex interrelationships among dietary intake, demographics, and the risk of comorbidities. We applied a Gaussian graphical model to calculate the dietary scores of the participants. The network structure of dietary intake, demographics, and comorbidities was estimated in a mixed graphical model. The centrality indices of the nodes (strength (S), closeness (C), and betweenness (B)) were measured to identify the central node. Multinomial logistic regression was used to examine the association between the factors and comorbidities. Among 7423 participants, the strongest pairwise interactions were found between sex and smoking (1.56), sex and employment (0.66), sex and marital status (0.58), marital status and income (0.65), and age and employment (0.58). Among the factors in the network, sex played a central role (S = 4.63, C = 0.014, B = 41), followed by age (S = 2.81, C = 0.013, B = 18), smoking (S = 2.72, C = 0.013, B = 0), and employment (S = 2.17, C = 0.014, B = 22). While the odds of hypertension and diseases were significantly higher among females than males, an inverse association was observed between high cholesterol and moderate chronic kidney disease. Among these factors, dietary intake was not a strongly interacting factor in the network, whereas age was consistently associated with the comorbidities of hypertension, high cholesterol, diabetes, and chronic kidney disease.

SPRINT—A Kidney-Centric Narrative Review: Recent Advances in Hypertension

Hypertension is a potent cardiovascular risk factor with deleterious end-organ effects and is especially prevalent among patients with chronic kidney disease. The SPRINT (Systolic Blood Pressure Intervention Trial) enrolled patients at an elevated cardiac risk including patients with mild to moderate chronic kidney disease and found that an intensive systolic blood pressure goal of <120 mm Hg significantly reduced the rates of adverse cardiovascular events and all-cause mortality and nonsignificantly reduced the rates of probable dementia; these results were consistent whether one had chronic kidney disease or not. However, results of intensive blood pressure therapy on chronic kidney disease progression were inconclusive, and there was an increased risk of incident chronic kidney disease and acute kidney injury, but the declines in kidney function appear to be hemodynamically driven and reversible. Overall, an intensive blood pressure target is effective in reducing cardiovascular disease and all-cause mortality and may reduce the risk of probable dementia in patients with mild to moderate chronic kidney disease. More studies are needed to determine its long-term effects on kidney function.

Intestinal Phosphorus Absorption in Moderate CKD and Healthy Adults Determined Using a Radioisotopic Tracer

BackgroundReducing intestinal phosphorus absorption is a cornerstone in CKD-MBD management. Yet, knowledge gaps include how CKD pathophysiology affects intestinal phosphorus absorption. In vivo rodent studies suggest that intestinal phosphorus absorption remains inappropriately normal in early-moderate CKD, despite declining 1,25-dihydroxyvitamin D (1,25D). We measured intestinal phosphorus absorption in patients with moderate CKD versus healthy adults using a direct radiotracer method.MethodsPatients with CKD and healthy adults matched for age, sex, and race were enrolled in this 8-day controlled diet study: the first 6 days outpatient and the final 2 days inpatient. Oral and intravenous doses of 33P and serial blood and urine sampling determined intestinal phosphorus absorption during the final 2 days. Secondary outcomes included fasting biochemistries and 24-hour urine phosphorus (uP).ResultsIn total, n=8 patients with CKD (eGFR=29–55 ml/min per 1.73 m2) and n=8 matched healthy controls completed the study. On a controlled diet, no difference in fractional intestinal phosphorus absorption was detected between patients with CKD and healthy adults (0.69 versus 0.62, respectively; P=0.52), and this was similar for 24-hour uP (884 versus 935 mg/d, respectively; P=0.70). Fractional intestinal phosphorus absorption was not significantly related to 24-hour uP. Patients with CKD had higher serum intact PTH and intact FGF23 and lower 1,25D. The relationship between 1,25D and fractional intestinal phosphorus absorption was not statistically significant.ConclusionsIntestinal phosphorus absorption with typical dietary intake did not differ in patients with moderate CKD compared with controls, despite lower serum 1,25D levels. In this setting, a relationship between 24-hour uP and fractional or absolute intestinal absorption was not evident. Further investigation is needed to determine what factors influence intestinal phosphorus absorption in CKD and the apparent lack of compensation by the intestine to limit phosphorus absorption in the face of declining kidney function and reduced 1,25D. Whether this is evident across a range of dietary phosphorus intakes, as well as CKD severity, also needs to be determined.Clinical Trial registry name and registration number:Phosphorus Absorption in Healthy Adults and in Patients with Moderate Chronic Kidney Disease, NCT03108222

Health Beliefs And Medication Taking Behaviour Of Individuals Living With Mild To Moderate Chronic Kidney Disease

The aims of this secondary analysis were to describe medication taking behaviour and health beliefs among people with mild to moderate CKD, examine differences in health beliefs according to age and gender, and examine relationships between health beliefs and medication taking behaviour. The sample consisted of 30 men and 30 women between19 and 72 years old. Forty-two participants reported they did not miss medication doses, but remembering to take all the pills was the most challenging. Women were more likely to believe their kidney function would improve in the future and to believe treatment would keep them from becoming ill. No statistically significant differences were found in health beliefs by age. Perceived barriers were the strongest indicator of medication taking behaviour. Findings from this study shed light on the complexity of the medication regimen in CKD, and could guide health care providers to better support medication taking behaviour.

Health Beliefs And Medication Taking Behaviour Of Individuals Living With Mild To Moderate Chronic Kidney Disease

The aims of this secondary analysis were to describe medication taking behaviour and health beliefs among people with mild to moderate CKD, examine differences in health beliefs according to age and gender, and examine relationships between health beliefs and medication taking behaviour. The sample consisted of 30 men and 30 women between19 and 72 years old. Forty-two participants reported they did not miss medication doses, but remembering to take all the pills was the most challenging. Women were more likely to believe their kidney function would improve in the future and to believe treatment would keep them from becoming ill. No statistically significant differences were found in health beliefs by age. Perceived barriers were the strongest indicator of medication taking behaviour. Findings from this study shed light on the complexity of the medication regimen in CKD, and could guide health care providers to better support medication taking behaviour.

Hypervitaminosis A: A Rare Cause of Hypercalcemia

Introduction: Hypercalcemia is a rather common clinical problem and a majority of cases are found to be secondary to primary hyperparathyroidism and malignancy. A rare cause of hypercalcemia is associated with high levels of vitamin A and thought to be secondary to the effect of vitamin A on bone to stimulate osteoclastic resorption or inhibit osteoblastic formation. Clinical Case: A 54 year-old male with a past medical history of CKD stage 3 secondary to medullary sponge kidney presented for hypercalcemia. He complained of chronic constipation, joint pain, mood changes and recurrent kidney stones. Reported multivitamin use (including 1000mcg of vitamin A) for years but was discontinued one year prior to visit. Lab work showed calcium of 11.5 mg/dL (8.7–10.2mg/dL), albumin 4.9 g/dL (3.8–4.9g/dL), elevated 24h urine calcium, eGFR 40 mL/min/1.73, parathyroid hormone 5 pg/mL (15-65pg/mL,) normal 1,25-OH vit D and 25-OH vit D, PTHrP &lt;2.0 pmol/L, serum protein electrophoresis unremarkable. His vitamin A level was elevated to 103 ug/dL (20.1–62.0ug/dL). CT chest showed no findings concerning for sarcoidosis. Bone density scan showed normal bone mineral density. Patient diagnosed with hypercalcemia secondary to elevated vitamin A levels. Current limited literature shows stopping the vitamin A supplement will normalize vitamin A levels and correct the hypercalcemia. This patient had discontinued his multivitamin 1 year prior and vitamin A remained elevated, thought to be due to his poor kidney function. Treatment was targeted at improving his hypercalcemia and reducing his symptoms. He was prescribed a one-week course of prednisone 40 mg daily. His calcium level improved to 10.5 mg/dL. Prednisone was reduced to 20 mg daily with normalization of calcium to 10.3 mg/dL (8.7–10.2mg/dL). Conclusion: Hypercalcemia is a rare but known complication of vitamin D toxicity. The liver, kidney and adrenal glands store vitamin A and it is excreted in the urine. Liver and kidney disease pose higher risk of vitamin A toxicity. We present a unique case of Hypercalcemia secondary to elevated vitamin A levels in a patient with moderate chronic kidney disease who was not taking excessive amounts of vitamin A and whose calcium and vitamin A did not normalize once vitamin A supplements were discontinued. The CKD 3 may have reduced vitamin A clearance and increased its toxicity. Hypercalcemia is not the only concern regarding vitamin A toxicity, the increasing use of dietary supplements and over the counter medications may pose significant risks for osteoporosis and bone fractures. A high clinical suspicion and thorough workup to exclude other causes of hypercalcemia is warranted to diagnose hypervitaminosis A as the etiology. Steroids can reduce gastrointestinal absorption of calcium, however, its role in vitamin A toxicity remains unclear. Further research is needed to investigate the appropriate treatment for these patients.