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Microscopic Hematuria Is a Risk Factor for End-Stage Kidney Disease In

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Microscopic Hematuria Is a Risk Factor for End-Stage Kidney Disease In Pathophysiology/complications Open access Original research BMJ Open Diab Res Care: first published as 10.1136/bmjdrc-2020-001863 on 4 November 2020. Downloaded from Microscopic hematuria is a risk factor for end- stage kidney disease in patients with biopsy- proven diabetic nephropathy Sadanori Okada,1,2 Ken- ichi Samejima ,3 Masaru Matsui,4 Katsuhiko Morimoto,5 Riri Furuyama,3 Kaori Tanabe,3 Masahiro Eriguchi,3 Yasuhiro Akai,1,3 Yoshihiko Saito,6 Kazuhiko Tsuruya3 To cite: Okada S, Samejima K, ABSTRACT Matsui M, et al. Microscopic Introduction There are fewer reports about whether the Significance of this study hematuria is a risk factor for presence of hematuria affects the progression of chronic end- stage kidney disease kidney disease in patients with diabetic nephropathy. What is already known about this subject? in patients with biopsy- We analyzed whether microscopic hematuria in diabetic ► The presence of hematuria has been considered a proven diabetic nephropathy. nephropathy is a risk factor for end-sta ge kidney disease clinical sign of non- diabetic kidney disease in pa- BMJ Open Diab Res Care tients with diabetes. 2020;8:e001863. doi:10.1136/ (ESKD). ► There are fewer reports about whether microscopic bmjdrc-2020-001863 Research design and methods The present study was a retrospective cohort study of patients with biopsy- proven hematuria affects the progression of chronic kidney diabetic nephropathy. We recruited 397 patients with diabetic disease in patients with diabetic nephropathy. SO and K-iS contributed nephropathy, which was confirmed by renal biopsy between What are the new findings? equally. June 1981 and December 2014 and followed them until ► The presence of microscopic hematuria is a risk fac- October 2018 or death. Patients with microscopic hematuria Received 26 August 2020 tor for end- stage kidney disease (ESKD) in diabetic before renal biopsy were defined as the hematuria group Revised 12 September 2020 nephropathy, independent of proteinuria and renal copyright. (n=91), and the remainder as the no-hema turia group Accepted 17 September 2020 pathology. (n=306). The main outcome was the occurrence of ESKD, which was defined by the requirement of permanent renal How might these results change the focus of replacement therapies. research or clinical practice? Results The systolic and diastolic blood pressure, serum ► We should treat patients with diabetic nephropathy creatinine and proteinuria were significantly higher, and the and microscopic hematuria as high-risk patients for © Author(s) (or their estimated glomerular filtration rate was significantly lower ESKD. employer(s)) 2020. Re- use in the hematuria group compared with the no-hema turia permitted under CC BY- NC. No group. Pathological evaluations revealed that glomerular, commercial re- use. See rights tubulointerstitial and vascular lesions in the hematuria 1 and permissions. Published group were significantly more severe. During a median function. Recently, several studies reported by BMJ. of 10.1 years, 44 and 52 patients developed ESKD in the that the presence of hematuria was associated http://drc.bmj.com/ 1Center for Postgraduate hematuria group and the no-hema turia group, respectively. with a faster decline in renal function and an Training, Nara Medical Survival analyses showed that the incidence of ESKD was increase in development of end-stage kidney University, Kashihara, Nara, significantly higher in the hematuria group compared disease (ESKD) in healthy people2 3 and Japan with the no- hematuria group (log- rank, p<0.0001). The 4 2 patients with chronic kidney disease (CKD). Department of Diabetes and multivariable Cox proportional hazards models revealed Endocrinology, Nara Medical Although diabetic nephropathy is the leading a significant association between hematuria and the University, Kashihara, Nara, on September 25, 2021 by guest. Protected incidence of ESKD after adjusting for clinically relevant cause of ESKD, the clinical assessment of Japan diabetic nephropathy includes the level of 3Department of Nephrology, factors, including proteinuria and renal pathology (adjusted Nara Medical University, HR 1.64, 95% CI 1.03 to 2.60). The subgroups of men, albuminuria and estimated glomerular filtra- Kashihara, Nara, Japan proteinuria ≥0.5 g/day, and systolic blood pressure tion rate (eGFR), and it does not consider 5 4Department of Nephrology, ≥132 mm Hg showed a stronger association between the presence of hematuria. The presence Nara Prefecture General hematuria and ESKD than their opposing subgroups. of hematuria has been considered a clinical Medical Center, Nara, Japan Conclusions Microscopic hematuria is a risk factor for sign of non- diabetic kidney disease in patients 5Department of Nephrology, ESKD in diabetic nephropathy, independent of proteinuria with diabetes6–8; however, a recent report of Nara Prefecture Seiwa Medical and renal pathology. Center, Nara, Japan biopsy-proven diabetic nephropathy showed 6Department of Cardiology, that patients with advanced diabetic nephrop- Nara Medical University, INTRODUCTION athy were accompanied by a high prevalence Kashihara, Nara, Japan Glomerular hematuria has been classically of hematuria.9 There are fewer reports about Correspondence to considered a hallmark of glomerular filtra- whether the presence of hematuria affects the Dr Ken- ichi Samejima; tion barrier dysfunction or damage, but with progression of CKD in patients with diabetic ksame@ naramed- u. ac. jp less effect on the progressive decline in renal nephropathy. BMJ Open Diab Res Care 2020;8:e001863. doi:10.1136/bmjdrc-2020-001863 1 Pathophysiology/complications BMJ Open Diab Res Care: first published as 10.1136/bmjdrc-2020-001863 on 4 November 2020. Downloaded from A previous study reported that patients with hematuria patient or her/his family. As the secondary end point, we had more advanced glomerular and vascular lesions in evaluated all- cause death in the follow- up period. renal pathology than those without hematuria.10 There- fore, we hypothesized that glomerular hematuria in Pathological evaluations diabetic nephropathy is a risk factor for the progression Histological examinations were performed inde- of CKD. In the present study, we assessed whether the pendently by at least two renal pathologists, with differ- presence of microscopic hematuria was associated with ences resolved by consensus. The detailed method of the incidence of ESKD in patients with biopsy- proven pathological evaluations was previously described.11 diabetic nephropathy. Briefly, glomerular lesions were classified based on the criteria of the Research Committee of Renal Patholog- ical Society15: class I, characterized by thickening of the RESEARCH DESIGN AND METHODS glomerular basement membrane as detected by electron Study design microscopy; classes IIa and IIb, mild and severe mesangial This study was a retrospective cohort study of patients expansion, respectively; class III, nodular sclerosis with with biopsy- proven diabetic nephropathy.11 Informed <50% global glomerulosclerosis and class IV, >50% global consent was obtained from each patient. glomerulosclerosis. We did not include class I because the renal tissues were not examined by electron micros- Study population copy. Severity of interstitial fibrosis and tubular atrophy A total of 408 patients with type 2 diabetes, who were (IFTA) was graded as follows: 0, no IFTA; 1, <25% IFTA; proven to have diabetic nephropathy by renal biopsy at 2, 25%─50% IFTA; 3, >50% IFTA. Vascular lesions were Nara Medical University Hospital between June 1981 classified by arteriolar hyalinosis and arteriosclerosis to December 2014, completed the follow-up study. We (intimal thickening). Arteriolar hyalinosis was graded excluded 11 patients whose prerenal biopsy urinary as follows: 0, absent; 1, at least one area; 2, more than sediment data were missing. Eventually, we followed 397 one area. The severity of arteriosclerosis was presented as patients until October 2018 or death. 0, no intimal thickening; 1, intimal thickening less than The following clinical data were obtained at the renal thickness of media and 2: intimal thickening greater than biopsy: age, sex, body mass index (BMI), smoking status, thickness of media.15 presence of diabetic retinopathy, systolic and diastolic copyright. blood pressure, serum creatinine, hemoglobin A1c Statistical analyses (HbA1c), proteinuria and hematuria. Serum creati- Categorical variables were expressed as numbers and nine values (mg/dL) measured by the Jaffe method percentages and were compared with the χ2 test. Contin- were converted to values for the enzymatic method by uous variables were expressed as mean±SD or median subtracting 0.207 mg/dL.12 The eGFR (mL/min/1.73 m2 (IQR). Based on their distribution, continuous variables of body surface area) was calculated using the new three- were compared using the Student’s t- test or Wilcoxon variable Japanese equation for eGFR: eGFR=194×serum rank sum test as appropriate. creatinine (mg/dL)−1.094×age−0.287×0.739 (if female).13 Survival curves were obtained using the Kaplan- Meier HbA1c values measured by the Japan Diabetes Society method and compared by a log-rank test. The Cox values were converted to the National Glycohemo- proportional hazards model was used to calculate the HR http://drc.bmj.com/ globin Standardization Program values.14 Proteinuria and 95% CI for the impact of hematuria on ESKD. In was measured by 24- hour urine protein (or spot urine the multivariable models, model 1 was
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