Proteinuria and the risk of developing end-stage renal disease

BACKGROUND: Dipstick urinalysis for proteinuria and hematuria has been used to screen renal disease, but evidence of the clinical impact of this test on development of end-stage renal disease (ESRD) is lacking. METHODS: We assessed development of ESRD through 2000 in 106,177 screened patients (50,584 men and 55,593 women), 20 to 98 years old, in Okinawa, Japan, who participated in community-based mass screening between April 1983 and March 1984. We used data from the Okinawa Dialysis Study Registry to identify ESRD patients. Multivariate logistic analyses were performed to calculate adjusted odds ratio and 95% confidence interval (95% CI) for the significance of proteinuria and hematuria on the risk of developing ESRD with confounding variables such as age, gender, blood pressure, and body mass index. A similar analysis was repeated in a subgroup of screened patients in whom serum creatinine data existed. RESULTS: During 17 years of follow-up, 420 screened persons (246 men and 174 women) entered the ESRD program. We identified a strong, graded relationship between ESRD and dipstick urinalysis positive for proteinuria; adjusted odds ratio (95% CI) was 2.71 (2.51 to 2.92, P < 0.001). Similar trends were observed after adding serum creatinine data. Compared with dipstick-negative proteinuria, adjusted odds ratio (95% CI) of proteinuria (1+) was 1.93 (1.53 to 2.41, P < 0.001) in men and 2.42 (1.91 to 3.06, P < 0.001) in women. CONCLUSION: Proteinuria was a strong, independent predictor of ESRD in a mass screening setting. Even a slight increase in proteinuria was an independent risk factor for ESRD. Therefore, asymptomatic proteinuria warrants further work-up and intervention.     

Factors influencing access to cardiovascular procedures in patients with chronic kidney disease: race, sex, and insurance.

Blacks and women are less likely to undergo invasive cardiac procedures than whites and men in patients with chronic renal disease. We determined the relationship between ethnic and sex differences in access to cardiac procedures as patients progress to ESRD and acquire Medicare insurance. We performed a cohort study of a nationwide random sample of 4,987 patients who progressed to ESRD in 1986 to 1987 and were followed up for 7 years was used. Data were collected from medical charts and Medicare administrative records. Pre-ESRD, the odds of cardiac procedure use were much lower for white women (adjusted odds 0.67 [95% confidence interval (CI) 0.49-0.92]), black men (adjusted odds 0.32 [95% CI 0.20-0.49]), and black women (adjusted odds 0.30 [95%CI 0.18-0.50]) compared with white men. After initiating dialysis therapy, the ethnic and sex differences decreased with odds of receiving a cardiac procedure compared with white men 0.88 (95% CI 0.63-1.21) for white women, 0.66 (95% CI 0.47-0.92) for black men, and 0.75 (95% CI 0.53-1.08) for black women. Patients uninsured pre-ESRD had the largest increase in procedure rates at follow-up. The wide pre-ESRD disparities in cardiac procedure use between white women, black men, and black women compared with white men narrowed substantially with acquisition of Medicare and entry into comprehensive dialysis care. Health insurance contributed to the narrowing of differences. Procedure use for black men still lagged behind the other groups, suggesting the need for closer examination of health needs in this potentially vulnerable group.     

Prevalence of high fasting plasma glucose and risk of developing end-stage renal disease in screened subjects in Okinawa,Japan

Background The number of diabetic dialysis patients is increasing worldwide. Only a few studies, however, have examined the effect of diabetes mellitus (DM) as a risk factor for the development of end-stage renal disease (ESRD) in the general population.Methods We examined the cumulative incidence of ESRD based on the results of community-based mass screening in Okinawa, Japan, performed in 1993 by the Okinawa General Health Maintenance Association. Fasting plasma glucose (FPG) data were available for 78529 screenees (37197 men and 41332 women). DM was diagnosed when the FPG was 126mg/dl or more. Screenees who developed ESRD by the end of 2000 were identified through the Dialysis Registry, Okinawa Dialysis Study.Results The mean (SD) FPG was 96.5 (22.8)mg/dl, ranging from 45 to 577mg/dl. The prevalence of DM among the screenees was 4089 (5.2%). A total of 133 screenees (82 men and 51 women) developed ESRD during the 7.75-year study period. The adjusted odds ratio (95% confidence interval [CI]) in the high-FPG group for the risk of developing ESRD was 3.098 (95% CI, 1.738–5.525; P = 0.0001), when adjusted for age, sex, systolic blood pressure, diastolic blood pressure, body mass index, total cholesterol, triglyceride, hematocrit, serum creatinine, hematuria, and proteinuria.Conclusions The results of the present study indicated that FPG is a significant, independent predictor of ESRD. FPG and proteinuria measurements are euqally important in detecting individuals at high risk for developing ESRD.     

Predictors of diabetic end‐stage renal disease in Japan

SUMMARY: Diabetes mellitus (DM) has been the leading cause of incident dialysis in Japan since 1998, according to the Japanese Society for Dialysis Therapy (JSDT). In particular, the number of male DM dialysis patients is increasing. DM is becoming a worldwide epidemic in both developed and developing countries. Strategies to detect individuals at high‐risk of developing CKD and end‐stage renal disease (ESRD) are needed that can be implemented on a population‐basis. Among the commonly measured variables, dipstick urinalysis (proteinuria, haematuria), blood pressure, serum creatinine, body mass index (BMI), and serum uric acid are significant predictors of ESRD. Recently, we evaluated the effect of DM as a risk factor of developing ESRD. DM was diagnosed when the fasting plasma glucose (FPG) was 126 mg/dL or more in participants (n = 78529) of the 1993 screening program in Okinawa. The prevalence of DM was 5.2%. The odds ratio (95% CI) of DM for developing ESRD was 3.098 (1.738–5.525, P = 0.0001) after adjusting for possible confounding variables. Early detection and treatment of DM might prevent DM‐related ESRD. We examined 7125 non‐DM screenees who underwent a 1‐day health check between April 1997 and March 1998. They were followed‐up until March 2000 to determine whether they developed DM. Over the 2 years, the cumulative incidence of DM was 2.3%, 2.9% in men and 1.3% in women. Proteinuria was the most robust predictor of the development of DM; the adjusted relative risk (95% CI) was 1.90 (1.14–3.17). Obesity, per se, is also recognized as a risk factor for developing proteinuria. The higher the BMI, the higher the risk of developing ESRD; the adjusted odds ratio (95% CI) was 1.273 (1.121–1.446, P = 0.0002) for men. Other than being overweight (BMI = 25.0 kg/m²), a smoking habit was a significant predictor of developing proteinuria. The prevalence of obesity and DM is increasing in Japan. It is possible that the impact of obesity and complications of DM are different among races and ethnicities. Public relations regarding the risk of DM and its complications are especially important in Asian countries. Asians have more fat than non‐Asians, even at the same BMI levels. Knowledge of the predictors of DM‐ESRD is crucial as a first step toward prevention. Consistent with this notion, initiatives on the management of CKD and ESRD were recently organized in Japan and internationally.     

Metabolic syndrome and chronic kidney disease in Okinawa, Japan

We assessed the prevalence of chronic kidney disease (CKD) in a hospital-based screening program in Okinawa, Japan. The significance of metabolic syndrome as a determinant of CKD was examined using multivariate logistic regression analysis. A total of 6980 participants, aged 30-79 years, participated in a screening program in Tomishiro Chuo Hospital. Metabolic syndrome was defined according to the criteria of the Adult Treatment Panel III (ATP III). Data were also analyzed according to the modified criteria of the National Cholesterol Education Program (NCEP) that defines abdominal obesity as a waist circumference of > oe =85 cm in men and > or =90 cm in women. CKD was defined as dipstick proteinuria (> or =1+) or a reduced glomerular filtration rate (GFR). GFR was estimated using the abbreviated Modification of Diet in Renal Disease (MDRD) formula. The prevalence of metabolic syndrome and CKD was 12.8 and 13.7%, respectively. Metabolic syndrome was a significant determinant of CKD (adjusted odds ratio (OR) 1.537 and 95% confidence interval (CI) 1.277-1.850, P<0.0001). The adjusted OR (95% CI) was 1.770 (1.215-2.579, P=0.0029) for those with four metabolic syndrome risk factors compared to those with no metabolic syndrome risk factors. Metabolic syndrome was a significant determinant for younger participants (<60 years; OR 1.686, 95% CI 1.348-2.107, P<0.0001), but not for older participants (> or =60 years; OR 1.254, 95% CI 0.906-1.735, NS). The relationship between the number of metabolic syndrome risk factors and the prevalence of CKD was linear using the modified criteria. The results suggest that metabolic syndrome is a significant determinant of CKD in men under 60 years of age, in Okinawa, Japan.     

Serum cholesterol and risk of end-stage renal disease in a cohort of mass screening

Background To evaluate the relative risk of end-stage renal disease (ESRD), indicated by basal serum cholesterol levels, we examined data from the 1983 community-based, mass screening registry and chronic dialysis program in Okinawa, Japan. Methods Data on serum cholesterol were available for a total of 38,053 subjects (17,859 men and 20,194 women), in addition to dipstick urinalysis and blood pressure data. Between 1983 and the end of 1995, we identified 99 ESRD dialysis patients (62 men and 37 women) among the screening participants. Results The cumulative incidence and risk of ESRD were calculated for the following quartile definitions of serum cholesterol level: ≤167 mg/dL, 168 to 191 mg/dL, 192 to 217 mg/dL, and ≥218 mg/dL. The cumulative incidence of ESRD was 179, 216, 315, and 334 per 100,000 screened subjects in the respective serum cholesterol level quartiles. Logistic regression analysis on the prediction of ESRD by serum cholesterol level quartile was done, and the odds ratio (95% confidence interval) was 1.25 (1.04–1.49). However, the significance was lost when adjusted for the results of urinalysis or blood pressure measurements. Serum cholesterol levels were dependent on the degree of proteinuria by dipstick and blood pressure findings. Conclusion The present study suggests that serum cholesterol may not be an independent predictor of ESRD. Whether the result was due to racial difference or was organ specific remains to be determined.     

Outcome study of renal biopsy patients in Okinawa, Japan

Here we report a community-based epidemiologic study of patients who received renal biopsy in Okinawa, Japan between 1967 and 1994. The total number of cases was 2832 (1395 men and 1437 women), and the mean (SD) age at biopsy was 30.0 (10.0) years (range 1.0 to 88.0 years). The most common clinical indications for renal biopsy were proteinuria/hematuria (46.7%), nephrotic syndrome (21.2%), acute glomerulonephritis (10.1%), and systemic lupus erythematosus (7.5%). Patients who received renal biopsy between 1985 and 1994 (N= 1480) were much less likely to have acute glomerulonephritis than patients treated between 1967 and 1984 (N= 1352); the rates of proteinuria/hematuria, renal failure, and diabetes mellitus were slightly higher in the later period. Okinawa patients who began dialysis between 1971 and 2000 (N= 5246) were also studied. Among them, a total of 468 patients (260 men and 208 women) began dialysis after renal biopsy. The cumulative incidence of end-stage renal disease (ESRD) among these patients was 17% in 17 years. Half of these patients developed ESRD in the 5.8 years after renal biopsy. Among the dialysis patients, the biopsy rate was 12.6% in chronic glomerulonephritis, 1.7% in diabetes mellitus, 2.6% in nephrosclerosis, and 52.1% in systemic lupus erythematosus. The diagnoses of primary renal diseases were primarily made clinically. The survival rate after starting dialysis therapy was slightly better in those with than in those without renal biopsy but this finding was not statistically significant (adjusted hazards ratio 0.855, 95% CI 0.711-1.028, P= 0.095). The clinical significance of renal biopsy, other than its provision of histologic evidence, remains to be shown.     

Smoking, gender and rheumatoid arthritis-epidemiological clues to etiology. Results from the behavioral risk factor surveillance system

OBJECTIVES: This study was undertaken to confirm and extend our earlier observation that gender is a biological effect modifier of smoking-rheumatoid arthritis (RA) relationship in a diverse national survey sample in the United States. METHODS: Smoking history of 644 cases of RA and 1509 geographically matched general population controls were compared using weighted logistic regression. RESULTS: There were 644 respondents with RA (cases) and 1509 geographically matched controls. Cases were significantly younger, less educated, more likely to be single and female than controls. Among cases 57% were smokers while among controls 49% smoked. Among women, after adjusting for age, hysterectomy had an age adjusted odds ratio 1.45, (95% CI 0.99-2.10) and menopause an adjusted odds ratio 1.18 (95% CI 0.99-2.10) were associated with smoking. In univariable analysis ever-smoking was associated with increased risk of RA (odds ratio 1.34, 95% CI 1.0-1.81). Among the strata of smokers, there was an increasing gradient of risk with increasing exposure to smoking (P = 0.041). In separate multivariable models, smoking increased the risk in men (odds ratio 2.29, 95% CI 1.35-3.90) while in women the risk was not elevated (odds ratio 0.98, 95% CI 0.67-1.42). After adjusting for the statistically significant interaction both female gender (odds ratio 2.30, 95% CI 1.39-3.83) and having ever smoked (odds ratio 2.31, 95% CI 1.36-3.94) emerged as significant risk factors for RA. CONCLUSIONS: Gender interacts with smoking in by an unknown mechanism to lead to differential risk of RA.     

Family history of end-stage renal disease among hemodialyzed patients in Poland

BACKGROUND: In previous reports of end-stage renal disease (ESRD) patients, family history of ESRD was associated with race, younger age, higher education levels and ESRD etiology. This study aimed to analyze how often Polish caucasian dialysis patients reported relatives with ESRD, and to evaluate which risk factors are associated with family history of ESRD. METHODS: 4808 ESRD patients provided data about renal disease etiology, diabetes and hypertensive status of first- and second-degree relatives, socioeconomic status and education level. RESULTS: Reported ESRD etiologies were: chronic glomerular disease, 19.4 %; diabetic nephropathy, 11.3%; interstitial nephritris, 11.2%; hypertension, 7.8%; polycystic kidney disease (PKD), 7.1%; other or no response, 40.0%. Positive ESRD family history was reported by 745 patients (15.5%); positive history of diabetes, 932 (19.4%); hypertension, 1904 (39%). Positive ESRD family history according to kidney disease etiology was: PKD, 53.1%; glomerulonephritis, 12%; diabetic nephropathy, 11.9%; hypertension, 11.8%; interstitial nephritis, 10.8%. PKD as ESRD etiology (odds ratio (OR) 8.06, 95% confidence interval (CI) 6.35-10.23, p < 0.0001), positive family history of diabetes (OR 1.64, 95% CI 1.34-1.99, p < 0.0001) and positive history of hypertension (OR 1.64, 95% CI 1.39-1.95, p < 0.0001), were independently associated with positive ESRD history. Patients with later ESRD onset had a less frequent positive ESRD family history: for ESRD < 45 yrs, 16% (OR 1.0); 45-64 yrs, 14.4% (OR 0.83, 95% CI 0.70-0.99); > or = 65 yrs, 9.2 % (OR 0.5, 95% CI 0.35-0.72). CONCLUSIONS: Results of our study strongly support the contention that familial predisposition contributes to ESRD development.     

Chronic proteinuric nephropathies. II. Outcomes and response to treatment in a prospective cohort of 352 patients: differences between women and men in relation to the ACE gene polymorphism. Gruppo Italiano di Studi Epidemologici in Nefrologia (Gisen)

In the Ramipril Efficacy in Nephropathy study, ramipril decreased the rate of GFR decline (deltaGFR) and progression to end-stage renal disease (ESRD) in 352 patients with proteinuric chronic nephropathies. This study investigated whether in these patients disease outcome and response to treatment were affected by gender or insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene. deltaGFR (0.43 +/- 0.05 versus 0.48 +/- 0.08 ml/min per 1.73 m2) and incidence of ESRD (23 and 22%, respectively) were comparable in male and female patients. However, compared to conventional treatment, ramipril decreased deltaGFR (-52% versus -19%) and progression to ESRD (-74% versus -40%) more effectively in women than in men. Thus, the relative risk (95% confidence interval [CI]) of events (ESRD) between conventional and ramipril treatment was 5.52 (1.59 to 19.17, P = 0.003) in women, but only 1.80 (1.08 to 2.97, P = 0.02) in men. This gender-related effect of ramipril was associated with more reduction in proteinuria (-7.8 +/- 4.2% versus -21.9 +/- 5.7%, P = 0.05) and was still evident even after correction for potentially confounding factors such as baseline GFR, daily sodium intake, ramipril dose, BP control, and concomitant treatment with diuretics or dihydropyridinic calcium channel blockers (adjusted RR [95% CI]: women, 5.07 [1.26 to 20.38], P = 0.02; men, 1.44 [0.85 to 2.44], P = 0.17). Ramipril uniformly decreased deltaGFR and incidence of ESRD in women with either DD (-39% and - 100%) or II + ID (-71% and -82%) genotype, and in men (-25% and -50%) with the DD genotype, but had no beneficial effect in men with the II + ID genotype (+18% and +34%). Thus, the relative risk of events (ESRD) between conventional and ramipril-treated men was higher in subjects with the DD genotype (1.85; 0.69 to 4.94) and lower in those with the II +/- ID genotype (0.71; 0.28 to 1.80). Again, in parallel with deltaGFR and events, proteinuria decreased in women with DD (-23.3 +/-8.0%) or II + ID (-16.0 +/- 9.5%) genotype and in men with the DD genotype (-14.8 +/- 7.0%), but did not change in men with II + ID genotype (+ 1.0 +/- 7.8%). Of note, the ACE genotype-related effect of ramipril was still evident even after correction for the above potentially confounding factors (adjusted RR [95% CI]: DD, 2.52 [0.83 to 7.63], P = 0.10; II + ID, 0.35 [0.12 to 1.01], P = 0.05). Thus, among patients with chronic proteinuric nephropathies, men are at increased risk of progression due to their lower response to ACE inhibitor treatment. ACE inhibition is uniformly renoprotective in women regardless of the ACE polymorphism, and in men with the DD genotype, but is virtually devoid of beneficial effects in men with the II or ID genotype. This information may help to guide therapeutic interventions in clinical practice and to interpret the results of prospective trials in chronic renal disease.     

Outcome of subjects with elevated serum creatinine in a community-based mass screening

Background The outcome and prognosis of screened subjects with elevated levels of serum creatinine (>-176.8 μmol/L [≥2.0 mg/dL]) in a community-based mass health screening were examined in Okinawa, Japan. Methods From 1983 to 1992, a total of more than 1.24 million people had received at least 1 screening by the Okinawa General Health Maintenance Association. The status of 250,091 individuals for whom data on serum creatine levels was available, as of January 1, 1996, was examined by using information from the Okinawa Dialysis Study registry, which included data on the end-stage renal disease (ESRD) program, and by reviewing the medical charts. Results A total of 289 screened subjects (187 men and 102 women) were investigated in this study. The total duration of observation was 1081.8 person-years. Clinical demographics and the incidence of ESRD, and the death of patients with ESRD before starting dialysis therapy (ESRD+death) were compared in 2 consecutive periods: A (1983 to 1987) and B (1988 to 1992). The incidence of ESRD and ESRD+death was 122.4 (161.5) per 1000 person-years in period A, whereas that of period B was 143.8 (170.2) per 1000 person-years. In the period 1988 to 1992, the hazards ratio for ESRD and ESRD+death was 1.50 and 1.38, respectively. The 95% confidence interval was 1.05 to 2.15 and 0.99 to 1.91, respectively, when compared to the period of 1983 to 1987. Conclusion This study shows that the risk of ESRD and ESRD+death is not decreasing, therefore the current strategy for the prevention of ESRD is not satistactory. Further study is needed to determine the underlying causes and mechanisms of the progression of renal disease.     

Scleroderma at end stage renal disease in the United States: patient characteristics and survival

BACKGROUND: The patient characteristics and mortality associated with scleroderma have not been characterized for a national sample of end stage renal disease (ESRD) patients. METHODS: 364,317 patients in the United States Renal Data System initiated on ESRD therapy between 1 January 1992 and 30 June 1997 with valid causes of ESRD were analyzed in an historical cohort study of scleroderma. RESULTS: Of the study population, 820 (0.22%) had scleroderma. The mean age of patients with scleroderma was 56.38 +/- 13.93 years vs. 60.48 +/- 16.51 years for patients with other causes of ESRD (p<0.01 by Student's t-test). In histogram analysis, there were two age peaks: 45-49 and 65-69. In logistic regression, patients with scleroderma, compared to patients with other causes of ESRD, were significantly more likely to be women, Caucasian, younger, and more likely to have congestive heart failure but less likely to have ischemic heart disease, stroke, and receive predialysis erythropoietin. The unadjusted two-year survival of patients with scleroderma during the study period was 49.3% vs. 63.8% in all other patients (adjusted hazard ratio, 1.96, 95% CI 1.70-2.26, p=0.0001 by Cox Regression). CONCLUSIONS: Among patients with ESRD, the demographics of patients with scleroderma were similar to those of patients with scleroderma in the general population. Patients with scleroderma had decreased survival compared to patients with other causes of ESRD, despite being equally likely to be wait listed and receive renal transplantation adjusted for other factors.     

Infection-related hospitalization rates in pediatric versus adult patients with end-stage renal disease in the United States

Infection is a common cause of morbidity and mortality in patients with ESRD. Infection-related hospitalization (IH) incidence among US Medicare incident pediatric and adult dialysis and transplant patients within 3 yr of presentation was compared from 1996 to 2001: Hemodialysis (HD) patients (pediatric n = 1469; adult n = 305,323); peritoneal dialysis (PD) patients (pediatric n=982; adult n=27,119), and kidney transplant (KTx) patients (pediatric n=1108; adult n=31,663). IH were identified from principal diagnosis codes; IH cumulative incidence and rates were calculated from claims data. Cumulative incidence of IH at 36 mo for incident pediatric patients with ESRD during 1996 to 2001 was 39.9% in HD, 51.2% in PD, and 47.4% in KTx patients (HD or PD versus KTx, P<0.0001). Cumulative incidence for adults was 52.6% in HD, 51.8% in PD, and 39.8% in KTx patients (HD or PD versus KTx, P<0.0001). IH rates per 1000 patient-months were highest for pediatric KTx patients (adjusted rate ratio 1.53 versus HD and 1.90 versus PD, P<0.001 for each) and adult HD patients (adjusted rate ratio 1.20 versus KTx and 1.11 versus PD, P < 0.001 for each). Within the first 36 mo of incidence, IH rates are highest for incident pediatric KTx patients compared with HD and PD patients, in contrast to findings for adult patients with ESRD. Pediatric KTx patients require infection surveillance after transplantation.     

Polycystic kidney disease at end-stage renal disease in the United States: patient characteristics and survival

BACKGROUND: The patient characteristics and mortality associated with autosomal dominant polycystic kidney disease have not been characterized for a national sample of end-stage renal disease (ESRD) patients. METHODS: 375,152 patients in the United States Renal Data System were initiated on ESRD therapy (including patients who eventually received renal transplants) between January 1, 1992 and June 30, 1997 and analyzed in an historical cohort study of polycystic kidney disease. RESULTS: Of the study population, 5,799 (1.5%) had polycystic kidney disease. In logistic regression, polycystic kidney disease was associated with Caucasian race (odds ratio 3.31, 95% CI, 3.09-3.54), women (1.10, 1.04-1.16), receipt of renal transplant (4.15, 3.87-4.45), peritoneal dialysis (vs. hemodialysis, 1.37, 1.27-1.49), younger age, and more recent year of first treatment for ESRD. Use of pre-dialysis EPO but not the level of serum hemoglobin at initiation of ESRD was significantly higher in patients with polycystic kidney disease. Patients with polycystic kidney disease had lower mortality compared to patients with other causes of ESRD, but patients with polycystic kidney disease had a higher adjusted risk of mortality associated with hemodialysis (vs. peritoneal dialysis) compared to patients with other causes of ESRD (hazard ratio 1.40, 1.13-1.75). CONCLUSIONS: Hematocrit at presentation to ESRD was not significantly different in patients with polycystic kidney disease compared with patients with other causes of ESRD. Peritoneal dialysis is a more frequent modality than hemodialysis in patients with polycystic kidney disease, and patients with polycystic kidney disease had an adjusted survival benefit associated with peritoneal dialysis, compared to patients with other causes of renal disease.     

Tobacco smoking and pulmonary tuberculosis

BACKGROUND: The prevalence of tuberculosis in adult men in India is 2-4 times higher than in women. Tobacco smoking is prevalent almost exclusively among men, so it is possible that tobacco smoking may be a risk factor for developing pulmonary tuberculosis. A nested case control study was carried out to study the association between tobacco smoking and pulmonary tuberculosis. METHODS: A tuberculosis disease survey was carried out in two Panchayat unions in the Tiruvallur district of Tamil Nadu in India. Eighty five men aged 20-50 years with bacteriological tuberculosis (smear and/or culture positive) were selected as cases and 459 age matched men without tuberculosis were selected randomly as controls. Information on smoking status, type of tobacco smoked, quantity of tobacco smoked, and duration of tobacco smoking was collected from cases and controls using a questionnaire. RESULTS: The estimated crude odds ratio (OR) of the association between tobacco smoking and bacillary tuberculosis was 2.48 (95% confidence interval (CI) 1.42 to 4.37), p<0.001.The age adjusted OR (Mantel-Hanszel estimate) was 2.24.(95% CI 1.27 to 3.94), p<0.05. The ORs for mild (1-10 cigarettes/day), moderate (11-20/day), and heavy (>20/day) smokers were 1.75, 3.17, and 3.68, respectively (p<0.0001 test for linear trend). The ORs for smokers with <10 years, 11-20 years, and >20 years of smoking were 1.72, 2.45, and 3.23, respectively (p<0.0001 test for linear trend). CONCLUSION: There is a positive association between tobacco smoking and pulmonary (bacillary) tuberculosis (OR 2.5). The association also shows a strong dose-response relationship.     

Decreased body mass index as an independent risk factor for developing chronic kidney disease

BACKGROUND: Obesity and metabolic syndrome are risk factors for the development of chronic kidney disease (CKD). Few studies have examined the effect of change in body mass index (DeltaBMI) on CKD incidence in a general screening setting. METHODS: Subjects of this study were screenees that participated in the screening program of the Okinawa General Health Maintenance Association in 1993 and 2003 in Okinawa, Japan. Using identification number, birth date, sex, and other recorded identifiers, we identified 33,389 subjects among the 1993 screening participants (N = 143,948) who also participated in the 2003 screening. CKD was defined as estimated glomerular filtration rate <60 ml/min/1.73 m(2), according to the modification of diet in renal disease study equation. Obesity was defined as BMI > or = 25 kg/m(2). RESULTS: CKD prevalence was 13.8% in 1993 and 22.4% in 2003. The incidence of developing CKD in 10 years was 15.5%. The effect of DeltaBMI on CKD incidence was evaluated after considering other confounding factors such as age, sex, blood pressure, BMI, fasting plasma glucose, and proteinuria. Median DeltaBMI was 1.0%. The adjusted odds ratio (95% CI) for the effect of DeltaBMI on CKD incidence was 1.111 (1.026-1.204, P < 0.01; entire study population), 1.271 (1.116-1.448, P = 0.0030; men), and 1.030 (0.931-1.139, NS; women), when DeltaBMI > or = 1% was taken as a reference. DeltaBMI was an independent predictor of CKD incidence. CONCLUSIONS: The present results suggest that there was an inverse relationship between DeltaBMI and CKD incidence among screened subjects. The reasons for this observation are not clear, but careful follow-up for DeltaBMI is necessary, particularly in obese men with proteinuria.     

Use of the albumin/creatinine ratio to detect microalbuminuria: implications of sex and race

The recommended albumin (microg)/creatinine (mg) ratio (ACR) (30 microg/mg) to detect microalbuminuria does not account for sex or racial differences in creatinine excretion. In a nationally representative sample of subjects, the distribution of urine albumin and creatinine concentrations was examined by using one ACR value (> or =30 microg/mg) and sex-specific cutpoints (> or =17 microg/mg in men and > or =25 microg/mg in women) measured in spot urine specimens. Mean urine albumin concentrations were not significantly different between men and women, but urine creatinine concentrations were significantly higher (P < 0.0001). Compared with non-Hispanic whites, urine creatinine concentrations were significantly higher in non-Hispanic blacks (NHB) and Mexican Americans, whereas urine albumin concentrations were significantly higher in NHB (P < 0.0001) but not Mexican Americans. When a single ACR is used, the prevalence of microalbuminuria was significantly lower among the men compared with women (6.0 versus 9.2%; P < 0.0001) and among non-Hispanic whites compared with NHB (7.2 versus 10.2%; P < 0.0001). No significant difference in the prevalence of microalbuminuria between men and women was noted when sex-specific ACR cutpoints were used. In the multivariate adjusted model, female sex (odds ratio, 1.62; 95% confidence interval, 1.29 to 2.05) and NHB race/ethnicity (odds ratio, 1.34; 95% confidence interval, 1.12 to 1.61) were independently associated with microalbuminuria when a single ACR threshold was used. When a sex-specific ACR was used, NHB race/ethnicity remained significantly associated with microalbuminuria but sex did not. The use of one ACR value to define microalbuminuria may underestimate microalbuminuria in subjects with higher muscle mass (men) and possibly members of certain racial/ethnic groups.     

A Population‐Based Cross‐Sectional Study Comparing Breast Cancer Stage at Diagnosis between Immigrant and Canadian‐Born Women in Ontario

There is limited information on stage at breast cancer diagnosis in Canadian immigrant women. We compared stage at diagnosis between immigrant women and Canadian‐born women, and determined whether ethnicity was an independent factor associated with stage. 41,213 women with invasive breast cancer from 2007 to 2012 were identified from the Ontario Cancer Registry. Women were classified as either immigrants or Canadian‐born by linkage with the Immigration, Refugees, and Citizenship Canada's Permanent Resident database. Women's ethnicity was classified as Chinese, South Asian, or remaining women in Ontario. Logistic regression was performed to calculate the odds ratio (OR) of being diagnosed at stage I breast cancer (versus stage II–IV). 4,353 (10.6%) women were immigrants and 36,860 (89.4%) were Canadian‐born women. The mean age at breast cancer diagnosis was 53.5 years for immigrants versus 62.3 years for Canadian‐born women (p < 0.0001). Immigrant women were less likely than Canadian‐born women to be diagnosed with stage I breast cancers (adjusted OR = 0.85; 95% CI: 0.79–0.91; p < 0.0001). The adjusted OR of being stage I was 1.28 (95% CI: 1.14–1.43; p < 0.0001) for women of Chinese ethnicity and was 0.82 (95% CI: 0.70–0.96; p = 0.01) for women of South Asian ethnicity, compared to the remaining women in Ontario. Canadian immigrant women were less likely than Canadian‐born women to be diagnosed with early‐stage breast cancers. Ethnicity was a greater contributor to the stage disparity than was immigrant status. South Asian women, regardless of immigration status, might benefit from increased breast cancer awareness programs.     

Adverse events in ambulatory surgery. A comparison between elderly and younger patients

PURPOSE: An increasing number of elderly patients are undergoing ambulatory surgery. We examined whether ambulatory surgery carries a higher risk for the elderly than for younger patients. METHODS: A total of 17,638 consecutive ambulatory surgical patients were enrolled in a prospective cohort study during a three-year period. Preoperative, intraoperative, and postoperative information was collected. Twenty-seven percent of the enrolled patients were 65 yr or older. Incidence rates of intraoperative and postoperative adverse events among the elderly were compared with those among younger patients; we controlled for sex, ASA physical status, body mass index, type of surgery, and duration of procedure, using multiple logistic regression models. RESULTS: Elderly patients had a higher incidence of any intraoperative event (adjusted odds ratio, 1.4; 99.7% confidence interval [CI], 1.0-2.0) and of intraoperative cardiovascular events (adjusted odds ratio, 2.0; 99.7% CI, 1.3-3.0). They also had a lower incidence of any postoperative event (adjusted odds ratio, 0.4; 99.7% CI, 0.3-0.6) and of postoperative pain (adjusted odds ratio, 0.2; 99.7% CI, 0.1-0.4), nausea and vomiting (adjusted odds ratio, 0.3; 99.7% CI, 0.1-0.6), and dizziness (adjusted odds ratio, 0.4; 99.7% CI, 0.2-1.0). CONCLUSION: The risks reported do not constitute a contraindication for elderly patients to undergo ambulatory surgery but this population may require more careful intraoperative cardiovascular management.     

Assessment of incident spine and hip fractures in women and men using finite element analysis of CT scans

Finite element analysis of computed tomography (CT) scans provides noninvasive estimates of bone strength at the spine and hip. To further validate such estimates clinically, we performed a 5‐year case‐control study of 1110 women and men over age 65 years from the AGES‐Reykjavik cohort (case = incident spine or hip fracture; control = no incident spine or hip fracture). From the baseline CT scans, we measured femoral and vertebral strength, as well as bone mineral density (BMD) at the hip (areal BMD only) and lumbar spine (trabecular volumetric BMD only). We found that for incident radiographically confirmed spine fractures (n = 167), the age‐adjusted odds ratio for vertebral strength was significant for women (2.8, 95% confidence interval [CI] 1.8 to 4.3) and men (2.2, 95% CI 1.5 to 3.2) and for men remained significant (p = 0.01) independent of vertebral trabecular volumetric BMD. For incident hip fractures (n = 171), the age‐adjusted odds ratio for femoral strength was significant for women (4.2, 95% CI 2.6 to 6.9) and men (3.5, 95% CI 2.3 to 5.3) and remained significant after adjusting for femoral neck areal BMD in women and for total hip areal BMD in both sexes; fracture classification improved for women by combining femoral strength with femoral neck areal BMD (p = 0.002). For both sexes, the probabilities of spine and hip fractures were similarly high at the BMD‐based interventional thresholds for osteoporosis and at corresponding preestablished thresholds for “fragile bone strength” (spine: women ≤ 4500 N, men ≤ 6500 N; hip: women ≤ 3000 N, men ≤ 3500 N). Because it is well established that individuals over age 65 years who have osteoporosis at the hip or spine by BMD criteria should be considered at high risk of fracture, these results indicate that individuals who have fragile bone strength at the hip or spine should also be considered at high risk of fracture. © 2014 American Society for Bone and Mineral Research.