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For Peer Review Only BMJ Open BMJ Open: first published as 10.1136/bmjopen-2015-008634 on 24 November 2015. Downloaded from The effect of increased water intake on plasma copeptin in patients with chronic kidney disease ForJournal: peerBMJ Open review only Manuscript ID: bmjopen-2015-008634 Article Type: Research Date Submitted by the Author: 30-Apr-2015 Complete List of Authors: Sontrop, Jessica; London Health Sciences Centre, Nephrology Huang, Shih-Han; Western University, Medicine; London Health Sciences Centre - Victoria Hospital, Medicine - Nephrology Garg, Amit; University of Western Ontario Moist, Louise; Western University, Medicine; London Health Sciecnes Centre - Victoria Hospital, Medicine - Nephrology House, Andrew; London Health Sciences Centre - University Hospital, Medicine - Nephrology Gallo, Kerri; London Health Sciences Centre - Victoria Hospital, Medicine - Nephrology Clark, William; University of Western Ontario, Medicine <b>Primary Subject Renal medicine Heading</b>: Secondary Subject Heading: Renal medicine http://bmjopen.bmj.com/ coeptin, water intake, glomerular filtration rate, 24-hour urine volume, Keywords: chronic kidney disease on September 28, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 21 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2015-008634 on 24 November 2015. Downloaded from 1 2 3 The effect of increased water intake on plasma copeptin in patients with chronic kidney 4 5 disease: results from a pilot randomized controlled trial 6 1,2 1 1,2 7 Jessica M. Sontrop PhD, Shi-Han Huang MSc MD, Amit X. Garg MD PhD, Louise Moist 1,2 1 1 1 8 MSc MD, Andrew A. House MD, Kerri Gallo RN, William F. Clark MD * 9 10 1. Division of Nephrology, Department of Medicine, London Health Sciences Centre, London 11 ON, Canada N6A 4G5 12 13 2. Department of Epidemiology & Biostatistics, Western University, London ON, Canada 14 N6A 5C1 15 For peer review only 16 *Corresponding Author 17 Dr. William F. Clark 18 Victoria Hospital 19 20 800 Commissioner’s Road East, A2-343 21 London ON, Canada N6A 5W9 22 Phone: 519-685-8361 23 Fax: 519-685-8047 24 Email: [email protected] 25 26 27 28 29 30 Word count: main body: 2293 words; abstract: 250 words 31 32 33 Key words: 24-hour urine volume, chronic kidney disease, copeptin, randomized controlled 34 trial, vasopressin http://bmjopen.bmj.com/ 35 36 37 38 DISCLOSURES 39 40 Dr. William Clark and Dr. Louise Moist have received consulting fees and/or honorarium and 41 42 support to travel to meetings with Danone Research. No other authors have relevant conflicts of on September 28, 2021 by guest. Protected copyright. 43 interest to declare. 44 45 This study was funded by Danone Research and the Program of Experimental Medicine, Western 46 University, Canada. The study sponsors had no direct role in the data collection, statistical 47 analysis, interpretation of the results or drafting of the manuscript. Dr. Garg is supported by the 48 Dr. Adam Linton Chair in Kidney Health Analytics. 49 50 51 An abstract of this work was presented at the World Congress of Nephrology, March 13-17, 52 2015, Cape Town, South Africa. 53 54 55 56 57 58 59 60 1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 21 BMJ Open: first published as 10.1136/bmjopen-2015-008634 on 24 November 2015. Downloaded from 1 2 3 ABSTRACT 4 5 6 7 Objectives: Increased water intake may have a beneficial effect on the kidney through 8 9 suppression of plasma vasopressin. We examined the effect of increased oral water intake on 10 11 plasma copeptin (a marker of vasopressin) over six weeks in patients with stage 3 chronic kidney 12 13 14 disease. 15 For peer review only 16 17 Design: Secondary analysis of a randomized controlled parallel-group pilot trial. 18 19 20 Setting: Canada, 2012-2013. 21 22 23 Participants: Twenty-nine patients with stage 3 Chronic Kidney Disease randomized (2:1) to a 24 25 26 hydration (n=18) or control group (n=11). 27 28 29 Intervention: The hydration group was coached to increase water intake by up to 1.5 L/day for 6 30 31 weeks (in addition to usual intake, depending on sex and weight). The control group was asked 32 33 to maintain regular water intake. 34 http://bmjopen.bmj.com/ 35 36 37 Measures and Outcomes: Participants provided blood and 24-hr urine samples at baseline and 6 38 39 weeks after randomization. Change in plasma copeptin was compared within and between study 40 41 42 groups. on September 28, 2021 by guest. Protected copyright. 43 44 45 Results: Participants (n=28) were 63% male with a mean age of 61 years and had an estimated 46 47 glomerular filtration rate (eGFR) of 40 ml/min/1.73 m<sup>2</sup>. Between baseline and 6 48 49 50 weeks, 24-hr unrine volume increased by 0.7 L/d in the hydration group, rising from 2.3 to 3.0 51 52 L/d, while decreasing by 0.3 L/d among controls, from 2.0 to 1.7 L/d (p=0.002 for the between- 53 54 group change). In the hydration group, median copeptin decreased by 3.6 pmol/L, from 15.0 to 55 56 57 58 59 60 2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 21 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2015-008634 on 24 November 2015. Downloaded from 1 2 3 10.8 pmol/L (p=0.005), while remaining stable among controls at 19 pmol/L (p=0.76) (p=0.19 4 5 6 for the between-group change). 7 8 9 Conclusions: Adults with stage 3 chronic kidney disease can be successfully randomized to 10 11 drink approximately 1 L more per day than controls. This increased water intake caused a 12 13 14 significant decrease in plasma copeptin concentration. Future trials should examine whether 15 For peer review only 16 increased water intake can slow renal decline in patients with chronic kidney disease. 17 18 19 20 21 22 23 24 25 26 Strengths and Limitations 27 28 29 • In this randomized controlled pilot trial, 28 patients with stage 3 chronic kidney disease were 30 31 successfully randomized to drink approximately 1 L more per day than controls for six 32 33 34 weeks, as verified by 24-hour urine collections. This increased water intake caused a http://bmjopen.bmj.com/ 35 36 significant decrease in plasma copeptin concentration. 37 38 39 • Patients were followed for only six weeks. Whether the effect of increased water intake on 40 41 plasma copeptin concentration is clinically significant, beneficial, or sustainable over time is 42 on September 28, 2021 by guest. Protected copyright. 43 unknown. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 21 BMJ Open: first published as 10.1136/bmjopen-2015-008634 on 24 November 2015. Downloaded from 1 2 3 INTRODUCTION 4 5 6 Vasopressin is an essential antidiuretic hormone in mammals that regulates thirst and urine 7 8 water.1 However, chronically elevated levels of vasopressin may have adverse health effects. 9 10 Until recently, it was not possible to reliably measure vasopressin due to the limited sensitivity of 11 12 13 available assays; however, in 2006, Morgenthaler et al. developed an immunoassay for 14 15 copeptin—a glycosylatedFor peptide peer that is co-released review with vasopressin only from the hypothalamus.2 16 17 Copeptin can be measured from blood samples and is demonstrated to be a reliable marker of 18 19 2,3 20 vasopressin. The availability of this assay has renewed scientific interest into the role of 21 22 vasopressin and copeptin in chronic illness. In longitudinal studies, a higher baseline 23 24 25 concentration of plasma copeptin predicts kidney function decline patients with autosomal 26 4,5 27 dominant polycystic kidney disease, and other studies have linked copeptin to the development 28 29 of diabetes,6 the metabolic syndrome,7 and heart failure.8,9 In cohort studies, elevated plasma 30 31 10,11 32 copeptin at baseline is strongly predictive of subsequent myocardial infarction and end-stage 33 12 34 kidney disease. http://bmjopen.bmj.com/ 35 36 37 Many factors are known to activate vasopressin, including acute stress and illness.13 Other 38 39 40 stimuli include high plasma osmolality and dehydration—vasopressin is the first hormone 41 42 released during dehydration.1 In experimental studies of rats, increased water intake was shown on September 28, 2021 by guest. Protected copyright. 43 44 to suppress vasopressin, reduce proteinuria, and improve creatinine clearance.14,15 In large cohort 45 46 16–18 47 studies, renal decline was slower in those with greater water inake, but evidence from 48 49 clinical trials is lacking. Copeptin may be an intermediate variable in the relationship between 50 51 water intake and renal decline; however, it is not known whether copeptin can be adequately 52 53 54 suppressed by water intake in patients with Chronic Kidney Disease. In 2012, we launched the 55 56 pilot phase of a randomized controlled trial that will test whether increased water intake can slow 57 58 59 60 4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 21 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2015-008634 on 24 November 2015.
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