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Smoking and Chronic Kidney Disease 10.5152/turkjnephrol.2019.3440 Review Smoking and Chronic Kidney Disease Bülent Yardımcı1, Tevfik Ecder2 1İstanbul Florence Nightingale Hospital, İstanbul, Turkey 75 2Division of Nephrology, Department of Internal Medicine, İstanbul Bilim University School of Medicine, İstanbul, Turkey Abstract Smoking is the leading preventable cause of death worldwide. Smoking affects all systems of the organism. Smoking stim- ulates the sympathetic nervous system, increases blood pressure and albuminuria, and decreases renal function. Smoking increases renal functional loss in patients with chronic kidney disease. Moreover, smoking accelerates the course of athero- sclerosis, causing cardiovascular complications and premature death. Smoking decreases graft survival in kidney transplant patients. As a result, all physicians and health care providers should acknowledge all patients who smoke about the deleteri- ous effects of smoking and continuously motivate them to stop smoking. Keywords: Chronic kidney disease, diabetes, hypertension, smoking Corresponding Author: Tevfik Ecder [email protected] Received: 19.06.2018 Accepted: 27.07.2018 Cite this article as: Yardımcı B, Ecder T. Smoking and Chronic Kidney Disease. Turk J Nephrol 2019; 28(1): 75-80. INTRODUCTION such as coronary circulation. Smoking causes acute and Smoking is one of the leading and preventable causes chronic changes in the kidney even in normal individu- of death. It has a large number of harmful effects on all als. In a study conducted with 15 volunteers with normal systems in the organism. It has a negative impact on blood pressure, Ritz et al. (3) investigated renal hemody- the cardiovascular system and respiratory system in namic changes developing after smoking a single ciga- the foreground. As a result, it is well known that it may rette. In their study, it was noted that the mean arterial lead to cardiovascular diseases, chronic obstructive pressure and pulse rate increase significantly after smok- pulmonary diseases, and lung carcinomas. It also has ing. In addition, it was observed that plasma adrenaline carcinogenic effects on the urinary tract. It shows a facil- concentration and arginine vasopressin concentration itating effect on the development of kidney, kidney pel- increase significantly. In the same study, it was found that vis, ureter, and bladder carcinomas. In addition, it has renovascular resistance increases by 11% along with cig- been found that smoking has negative effects on kidney arette smoking, glomerular filtration rate (GFR) decreases function and may accelerate the development of renal by 15%, and filtration fraction decreases by 18%. These failure in renal patients (1, 2). acute effects of smoking on the cardiovascular system are probably due to nicotine because similar findings may Effects of Smoking on The Kidney in The General also develop with nicotine chewing (3). In addition, Gam- Population baro et al. (4) found in their cross-sectional study that Smoking activates the sympathetic nervous system, renal plasma flow is lower in smokers than in non-smok- causing increased blood pressure and tachycardia. As ers. Furthermore, plasma endothelin concentration was a result, vasoconstriction may occur in certain areas, found to be increased in these individuals. This work is licensed under a Creative Commons Attribution 4.0 International License. Turk J Nephrol 2019; 28(1): 75-80 Yardımcı and Ecder. Smoking and Chronic Kidney Disease In the Prevention of Renal and Vascular End-stage Disease study smoking and an increased risk of chronic kidney disease in the that was conducted in the Netherlands and in which albumin- general population. This relationship was independent of age, uria was investigated in 40,856 people aged between 28 and 75 hypertension, diabetes, and body mass index, which are risk years in the general population, smoking was shown to increase factors for chronic kidney disease. This risk, which was high for albuminuria (5, 6). Additionally, this study reported a close re- the development of chronic kidney disease, was markedly de- lationship between the number of cigarettes smoked and an creased, though it continued for years after smoking cessation. increase in albuminuria and a decrease in GFR (7). Effects of Smoking on The Kidneys in Patients with Hypertension In a cross-sectional study in which 28,409 volunteers in the Smoking makes it difficult to control blood pressure in pa- general population were included, it was shown that smoking tients with hypertension. In addition, it increases the risk of could irreversibly lead to proteinuria (8). target organ damage in patients with hypertension. The prev- alence of microalbuminuria is approximately two-fold high- In Australia, a total of 11,247 adults from the normal popula- er in patients who smoked with primary hypertension than tion were included in the Australian Diabetes, Obesity and Life- in patients who had never smoked with hypertension (15). style study, and a significant relationship was found between Smoking has been found to be an independent predictor of smoking and proteinuria and renal dysfunction (9). Similarly, albuminuria development in the Heart Outcome Prevention in a study in which the data of 4142 individuals without diabe- Evaluation study in which patients with diabetes and without tes aged ≥65 years in the Cardiovascular Health Study cohort diabetes with high cardiovascular risk were included (16). In 76 were evaluated retrospectively, it was shown that there was a addition, in the analysis of the Losartan Intervention for End- parallelism between the number of cigarettes smoked and the point Reduction in Hypertension study, which included pa- increase in serum creatinine level (10). tients with hypertension with left ventricular hypertrophy, it was reported that the prevalence of microalbuminuria was 1.6 In a prospective study conducted by Maeda et al. (11), 10,118 times higher in patients who smoked >20 cigarettes/day than Japanese men who were aged between 40 and 55 years and in non-smokers, and the prevalence of macroalbuminuria was who did not have proteinuria and renal dysfunction were fol- 3.7 times higher (17). lowed up for a total of 6 years. At the end of this period, the risk of glomerular hyperfiltration development was found to be In a prospective study conducted in 51 patients with prima- 1.32 times higher in smokers than in non-smokers. In addition, ry hypertension, it was found that smoking was the strongest the risk of proteinuria development was found to be 1.51 times determinant in the development of renal insufficiency even if higher in smokers than in non-smokers. Hyperfiltration and blood pressure was controlled (18). proteinuria caused by smoking may result in long-term glomer- ular damage. Effects of Smoking on The Kidney in Patients with Chronic Renal Disease In a case-control study conducted in the general population The first studies showing the negative effects of smoking on by Ejerblad et al. (12), 926 patients who were aged between 18 kidney patients were conducted in patients with type 1 diabe- and 74 years and had a serum creatinine level >3.4 mg/dL (in tes mellitus (19-21). It has been found in studies that the risk men) or 2.8 mg/dL (in women) were examined in Sweden. It was of nephropathy is higher in patients who smoked with type 1 noted that in renal diseases, nephrosclerosis had the strongest diabetes mellitus than in non-smokers. Smoking significantly relationship with smoking. There was also a significant relation- increases the risk of microalbuminuria development in patients ship between smoking and chronic glomerulonephritis. with type 1 diabetes mellitus (19). It also accelerates the transi- tion from microalbuminuria to macroalbuminuria (21). For a median of 10.3 years, Hallan and Orth (13) examined the data of the second Nord-Trøndelag Health study in which 65,589 In a prospective study conducted in 794 patients with type 2 di- people in the general population were included in the study. As abetes, the risk of transition from microalbuminuria to macro- a result of the study, they reported that the risks of renal fail- albuminuria was found to be 2-2.5 times higher in smokers than ure development are 3.32 and 4.01, respectively, times higher in non-smokers (22). in those who had previously smoked or were still smoking than in those who had never smoked. In a study conducted by Sawicki et al. (23), it was reported that the rate of decrease in glomerular filtration was significantly Xia et al. (14) published a meta-analysis that examined 65,064 lower in patients with type 1 diabetes mellitus who quit smok- patients newly determined to have chronic kidney disease in ing and whose blood pressure and blood sugar were well con- 15 prospective cohort studies in order to investigate the rela- trolled than in those who continued to smoke. This finding is tionship between smoking and chronic kidney disease in the important in terms of demonstrating that patients can benefit general population. In this meta-analysis, it was noteworthy from smoking cessation even after the development of diabetic that there was a statistically significant relationship between nephropathy. Yardımcı and Ecder. Smoking and Chronic Kidney Disease Turk J Nephrol 2019; 28(1): 75-80 In a study conducted in 33 patients with type 2 diabetes ne- Effects of Smoking on Dialysis Patients phropathy, although good blood pressure control and good Patients in whom dialysis treatment has been started due to glucose control were provided with antihypertensive treatment end-stage renal failure should also be encouraged to make an including angiotensin-converting enzyme inhibitor in all pa- effort to quit smoking. In dialysis patients, in whom the most tients, it was noted after a 5-year follow-up that renal function common cause of death is cardiovascular diseases, smoking was impaired faster in smokers than in non-smokers (24). can significantly increase morbidity and mortality (38, 39). In the United States Renal Data System Wave 2 study, which was Smoking is also known to have negative effects on other kid- conducted by Foley et al.
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