|Year : 2020 | Volume
| Issue : 2 | Page : 89-96
Diverse association between components of metabolic syndrome and chronic kidney disease in hypertension of different low-density lipoprotein cholesterol levels
Li-Wen Bao, Kun Xie, Li-Lian Bao, Ying Shan, Xin-Yu Zhuang, Hai-Ming Shi, Yong Li, Xiu-Fang Gao, for the UPPDATE collaboration
Department of Cardiovascular Disease, Huashan Hospital, Fudan University Shanghai, China
|Date of Submission||12-Feb-2020|
|Date of Acceptance||03-Jun-2020|
|Date of Web Publication||30-Jun-2020|
Department of Cardiovascular Disease, Huashan Hospital, Fudan University Shanghai
Source of Support: None, Conflict of Interest: None
Objectives: This study aimed to investigate the association between the metabolic syndrome (MetS) components and chronic kidney disease (CKD) in hypertension of different low-density lipoprotein cholesterol (LDL-C) levels. Methods: This national cross-sectional study was conducted in hospitals in 24 cities of China and comprised of 4792 eligible hypertensive participants with a recorded creatinine level between 2017 and 2018. All participants underwent a clinical survey and clinical assessment and were required to provide biomedical reports within 1 year from their outpatient visit. Student's t-test, log-rank, and Chi-square tests and receiver operating characteristic curve (ROC) analysis were used in data analysis. Results: Participants' average age was 65.82 ± 12.74 years; 54.65% were male. Overall, 52.73%, 63.29%, 26.84%, and 77.27% of participants had a high waist circumference, elevated triglyceride (TG) level, low high-density lipoprotein cholesterol level, and impaired fasting glucose/diabetes, respectively. The adjusted odds ratio (OR) for CKD with MetS was 1.67 (95% confidence interval [CI] 1.32–2.10, P < 0.001). The risk of CKD was associated with older age (OR: 1.05, 95% CI: 1.04–1.06, P < 0.001), female (OR: 1.25, 95% CI: 1.01–1.55, P < 0.001), higher LDL-C level (OR: 1.17, 95% CI: 1.08–1.27, P = 0.03), higher TG level (OR: 1.38, 95% CI: 1.13–1.68, P = 0.001), impaired fasting glucose/diabetes (OR 1.48, 95% CI: 1.2–1.85, P < 0.001), and a combination of two or more than three MetS components (OR: 1.7, 95% CI: 1.07–2.71, P = 0.025; OR: 2.03, 95% CI: 1.08–3.13, P = 0.008, respectively) (ROC curve: 0.7). MetS remained significantly associated with CKD in both LDL-C subgroups, but different associations between the MetS components and CKD were found. Conclusions: MetS and its components are less associated with CKD of LDL-C <2.6 mmol/L than LDL-C ≥2.6 mmol/L in hypertension. LDL-C is significantly associated with CKD in hypertension of LDL-C level ≥2.6 mmol/L subgroup.
Keywords: Chronic kidney disease, hypertension, low-density lipoprotein cholesterol, metabolic syndrome
|How to cite this article:|
Bao LW, Xie K, Bao LL, Shan Y, Zhuang XY, Shi HM, Li Y, Gao XF, for the UPPDATE collaboration. Diverse association between components of metabolic syndrome and chronic kidney disease in hypertension of different low-density lipoprotein cholesterol levels. Cardiol Plus 2020;5:89-96
|How to cite this URL:|
Bao LW, Xie K, Bao LL, Shan Y, Zhuang XY, Shi HM, Li Y, Gao XF, for the UPPDATE collaboration. Diverse association between components of metabolic syndrome and chronic kidney disease in hypertension of different low-density lipoprotein cholesterol levels. Cardiol Plus [serial online] 2020 [cited 2020 Sep 24];5:89-96. Available from: http://www.cardiologyplus.org/text.asp?2020/5/2/89/288507
| Introduction|| |
Although chronic kidney disease (CKD) is considered the major cause of morbidity and mortality in hypertension, the recognition and prevention of CKD remain deficient. In China, the incidence of CKD coexisting with hypertension is 6%–18%,,, and the prevalence of hypertension in CKD is estimated at 60%–80%.,,
Many risk factors are associated with CKD. Metabolic syndrome (MetS), which is closely linked to insulin resistance and manifests as central obesity, elevated blood pressure, impaired fasting glucose, and high triglyceride (TG) and low high-density lipoprotein (HDL) cholesterol levels, seems to aggravate these risk factors. Numerous studies have demonstrated that MetS is associated with CKD.,, According to the National Cholesterol Education Program Adult Treatment Panel III (ATPIII) guideline, beyond low-density lipoprotein cholesterol (LDL-C)-lowering therapy, MetS is a secondary therapy target for reducing CVD. The relationship between MetS and CKD in hypertension with different LDL-C levels requires further investigation. Therefore, this study aimed to investigate this question.
| Methods|| |
This research complies with the guidelines for human studies according to Helsinki Declaration of 1975. The patients enrolled in this study have given their informed consent and that the study protocol has been approved by the institute's committee on human research from our hospital (2017 to 282).
Study design and population
In this national cross-sectional study, primary hypertensive patients older than 18 years of age with a recorded creatinine level were enrolled from outpatient departments in community hospitals and tertiary first-class hospitals in 24 cities in China between 2017 and 2018 using a convenience sampling method. Subjects were excluded if they had confirmed secondary hypertension, active cancer, or recognition disorder. After each participant provided consent, they completed a questionnaire regarding demographic characteristics (age and sex), medical history (whether they were comorbid with coronary heart disease, stroke, CKD, peripheral arterial occlusive, heart failure, and atrial fibrillation), lifestyle features (smoking and alcohol abuse status), current medical treatment, and imaging and biochemical test report results (e.g., the serum biochemical index, echocardiography results, ambulatory blood pressure measurement, and home blood pressure measurement) within 1 year from their visit. Besides, participants also underwent clinical assessments of their clinical blood pressure, waist circumference, height, weight, and body mass index, which was calculated by dividing the weight in kilograms by height in meters squared.
The diagnosis of MetS includes any three of the five criteria according to the National Cholesterol Education Program ATP III guideline: waist circumference ≥90 cm in men or ≥80 cm in women (for Asians); TG level ≥ 1.7 mmol/L or drug treatment for an elevated TG level; HDL-C level <1.03 mmol/L in men or <1.3 mmol/L in women; blood pressure ≥130/85 mmHg or antihypertensive treatment with a history of hypertension; and fasting blood glucose (FBG) ≥5.6 mmol/L or treatment for an elevated FBG level.
CKD was defined by the estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2, which was calculated using the Modification of Diet in Renal Disease Study equation for each enrolled participant in addition to the history of CKD.
High waist circumference was defined as waist circumference ≥90 cm in men or ≥80 cm in women. High TG level was defined as TG level ≥1.7 mmol/L or drug treatment for an elevated TG level. Low HDL-C level was defined as an HDL-C level <1.03 mmol/L in men or <1.3 mmol/L in women. Diabetes mellitus (DM) was defined as a self-report history of treatment for diabetes or FBG level ≥6.1 mmol/L. Impaired glucose was defined as FBG level ≥5.6 mmol/L or the presence of DM.
Baseline data are presented as mean ± standard deviation for symmetric continuous variables, as median (25% quartile to 75% quartile) for skewed continuous variables, and as proportion for categorical variables. The Student t-test and log-rank test were used to analyze symmetric and skewed continuous data, and the Chi-square test was used to compare categorical variables to their baseline. The receiver operating characteristic (ROC) curve was used to analyze the different models in terms of the association between CKD and MetS/MetS components. Odds ratios (ORs) were calculated by univariate/multivariate logistic regression analyses in unadjusted and adjusted models and 95% confident intervals (CIs) were used to determine the association between MetS and CKD. Stata 13.0 (StataCorp, College Station, TX, USA) was used to perform statistical analysis in all participants or those with an LDL-C level at a threshold of 2.6 mmol/L with respect to CKD. A P < 0.05 was considered statistically significant.
| Results|| |
Overall, 4792 hypertensive patients with a recorded creatinine were enrolled [Table 1]. Measured systolic and diastolic blood pressures were much higher in the hospital than at home, and 88.15% of participants were treated with antihypertensive medication regularly. Approximately 78.9% of participants were comorbid with MetS in this study.
Although the self-report history of CKD was 2.87%, the total proportion of participants with eGFR <60 ml/min/1.73 m2 was 22.8% (n = 1092). Compared with subjects without CKD, those with CKD were older and of the female, had higher systolic and diastolic blood pressures measured in the hospital or at home, used antihypertensive medication less, had higher LDL-C and TG levels despite undergoing more lipid-lowering therapy, had similar history of DM but a higher FBG level, and had a higher prevalence of coronary heart disease, chronic heart failure, and atrial fibrillation but a similar prevalence of cerebral infarction.
ORs for CKD according to different components of MetS in all participants are shown in [Table 2]. Older age and female remained significantly associated with CKD prevalence in models 1 and 2. The receiver operating characteristic (ROC) curve was 0.7 for model 2 in terms of the association between CKD and MetS/MetS components [Figure 1]. ORs for CKD by specific components of MetS are shown in [Table 3]. Besides, a high TG level (OR: 1.38, 95% CI: 1.13–1.68, P = 0.001), impaired glucose (OR: 1.48, 95% CI: 1.2–1.85, P < 0.001), and older age (OR: 1.05, 95% CI: 1.04–1.06, P < 0.001), female (OR: 1.37, 95% CI: 1.11–1.71, P = 0.004), and LDL-C level (OR: 1.16, 95% CI: 1.06–1.26, P < 0.001) also remained significantly associated with CKD when separating the MetS components in model 2 [Table 3]. The ROC curve was 0.7 [Figure 2].
|Table 2: Odds ratios for chronic kidney disease according to different components of metabolic syndrome in all participants|
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|Table 3: Odds ratios for chronic kidney disease by specific components of metabolic syndrome|
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|Figure 2: ROC for odds ratio of CKD with respect to different MetS components|
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The LDL-C level was associated with CKD in the subgroup with LDL-C level >2.6 mmol/L but not in the subgroup with LDL-C level <2.6 mmol/L. Although MetS was associated with the prevalence of CKD in both LDL-C subgroups, the LDL-C level showed a significant association with CKD in only the subgroup with LDL-C >2.6 mmol/L (P interaction, <0.001). In the subgroup with LDL-C level >2.6 mmol/L, participants with two or more than three components of MetS (OR: 2.16, 95% CI: 1.06–4.39, P = 0.03 and OR: 2.33, 95% CI: 1.14–4.76, P = 0.02), lower waist circumference (OR: 0.68, 95% CI: 0.52–0.89, P = 0.006), higher TG level (OR: 1.42, 95% CI: 1.1–1.83, P = 0.008), and impaired glucose (OR: 1.54, 95% CI: 1.14–2.09, P = 0.005) had a significant association with CKD. In the subgroup with LDL-C level <2.6 mmol/L, only impaired glucose (OR: 1.49, 95% CI: 1.08–2.08, P = 0.017) remained significantly associated with CKD in the adjusted model because the OR for CKD with other variables had a positive relationship but no statistical association [Figure 3], [Figure 4], [Figure 5] and [Table 4], [Table 5].
|Figure 3: Forest plot of odds ratio for chronic kidney disease with metabolic syndrome components with respect to different LDL-C levels MetS: metabolic syndrome, LDL-C: low-density lipoprotein cholesterol|
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|Figure 4: Forest plot of odds ratio for chronic kidney disease by specific components of metabolic syndrome with respect to different levels LDL-C: low-density lipoprotein cholesterol, HDL: high-density lipoprotein, TG: triglyceride|
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|Figure 5: The prevalence of chronic kidney disease by number of metabolic syndrome components in our study (linear trend, P < 0.001; each bar represents the proportion of different components of metabolic syndrome in hypertension)|
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|Table 4: Odds ratios for chronic kidney disease according to metabolic syndrome and its components with respect to different low-density lipoprotein cholesterol levels|
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|Table 5: Odds ratios for chronic kidney disease by specific components of metabolic syndrome with respect to different low-density lipoprotein cholesterol levels|
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| Discussion|| |
We performed the UPPDATE study, a national cross-sectional study of hypertension from 2017, to investigate the status of the current blood pressure control, related MetS control status, and comorbid diseases with hypertension in China, and we plan to perform this survey in China for at least 10 years. This study showed that overall, in addition to age and female, both MetS and elevated LDL-C level were significantly associated with a higher prevalence of CKD and increased OR of CKD, and this corresponded to the MetS components. When considering the specific components of MetS, a high TG level and impaired glucose but not a low HDL-C level or elevated waist circumference were associated with an increased risk of CKD. For different LDL-C levels (<2.6 and >2.6 mmol/L), the results were dispersed. In the subgroup with LDL-C level >2.6 mmol/L, the LDL-C level, MetS, and older age rather than female were significantly associated with the prevalence of CKD. Elevated TG level, impaired glucose, or subjects with a combination of two or more than three MetS components were found to be associated with the prevalence of CKD. Interestingly, lower waist circumference was also significantly associated with CKD in the subgroup with LDL-C level >2.6 mmol/L. However, the subgroup with LDL-C <2.6 mmol/L, MetS, older age, and female rather than the LDL-C level were associated with CKD; furthermore, only impaired glucose showed a significant relationship with CKD when analyzing separate components of MetS.
As the National Cholesterol Education Program ATPIII guideline recommended, stringent LDL-C control has been proven to be fundamentally important in the prevention of atherosclerotic cardiovascular disease (ASCVD). Furthermore, MetS is considered as a secondary therapy target. In addition to ASCVD, CKD is another concerning issue with regard to mortality in hypertensive patients. Besides glomerulonephritis or pyelonephritis, the etiologies of CKD including glomerulosclerosis attributed to hypertension, diabetic nephropathy, or gout nephritis are increasing dramatically recently because of the increased prevalence of metabolic disorders. The capture of LDL-C by scavenger receptors and macrophages leads to the progression of atherosclerosis, and oxidative LDL-C is associated with glomerulosclerosis and arteriosclerosis by the infiltration of monocytes/macrophages and overexpression of adhesion molecules. In addition, researchers have considered MetS as a major contribution to the development of CKD and reported that the pathophysiologic link between MetS and CKD is obesity. Inflammation, unstable renal hemodynamics, endothelial dysfunction, sympathetic nervous system, and renin-angiotensin aldosterone system activation induced by an enlarged mass of adipocytes along with an increased level of leptin leads to insulin resistance, which is responsible for renal vascular remodeling, renal fibrosis, and impaired renal function through transforming growth factor-ß production and reduction of insulin-like growth factor-1.,,,
Although some researchers have already demonstrated the association of LDL-C or MetS with CKD in the general population or some specific patients, the integrated concerns of these two major causes of CKD remain unclear. Kang et al. demonstrated a positive association between the presence of MetS and CKD (OR: 1.364, 95% CI: 1.355–1.373, P < 0.001), and specific components of MetS were also associated with an increased CKD risk. Li et al. discovered an increased risk of CKD that corresponded to the number of MetS components in 1724 Southern Chinese general participants (three components: OR: 2.9, 95% CI: 1.7–4.96; four/five components: OR: 3.64, 95% CI: 1.95–6.8). A higher prevalence of MetS was associated with CKD than with non-CKD in diabetic patients according to Kittiskulnam et al.'s study in Thailand. In Italy, MetS was also associated with an increased risk of CKD (OR: 1.33, 95% CI: 1.03–1.71) in 2916 hypertensive subjects. In the Jackson heart study, participants with MetS had a 2.22-fold increased risk of CKD (OR: 2.22, 95% CI: 1.78–2.78) compared to those without MetS, and the combination of an elevated FBG level, elevated TG level, and abdominal obesity was associated with the highest odds for CKD, which is consistent with our findings. Kuma et al. demonstrated a positive association between elevated LDL-C level and the incidence of CKD in 14 510 healthy male workers without hypertension and diabetes in Japan. Using data from the Global Lipids Genetics Consortium including data from 60 studies with 188,577 participants and the CKD Genetics Consortium comprising of 133,814 patients, Lanktree et al. found that there was no causal relationship between LDL-C and CKD, but a genetically elevated HDL-C level was associated with a higher eGFR and lower odds of CKD.
In accordance with our findings, we suggest that (1) LDL-C level >2.6 mmol/L but not <2.6 mmol/L is a strong predictor of CKD progression in Chinese hypertensive patients. (2) Although the overall presence of MetS was significantly associated with CKD in different LDL-C subgroups, different combinations of components of MetS or separate components of MetS had diverse associations with CKD. (3) Treatment for an elevated TG level, impaired glucose, and decreased waist circumference should be considered to prevent the development of CKD in Chinese hypertensive patients with LDL-C level >2.6 mmol/L. (4) If the LDL-C level is controlled to <2.6 mmol/L, therapy for impaired glucose and CKD prevention should be the focus of any intervention.
This study has some limitations. First, this national cross-sectional study could only determine the association between MetS and CKD rather than a cause-and-effect relationship. Second, we conducted this study in hypertensive participants; although we assessed MetS and the prevalence of CKD, hypertension is one of the causes of CKD progression, which may weaken the power of the association between MetS and CKD.
| Conclusions|| |
MetS and its components are less associated with an increased risk of CKD in hypertensive patients with LDL-C level <2.6 mmol/L than in those with LDL-C level >2.6 mmol/L, and LDL-C is significantly associated with CKD only in those with LDL-C level >2.6 mmol/L. In hypertensive patients with LDL-C level >2.6 mmol/L, elevated TG level, low waist circumference, impaired fasting glucose/diabetes, or a combination of two or more than three MetS components were also associated with an increased risk of CKD. Further prospective cohort study would be recommended to investigate the causal association between MetS and CKD in hypertension.
Group Information: The UPPDATE collaboration investigators who come from the following institutes in China participated in the patient recruitment and data collection. The investigators include Jianping Bin (Nanfang Hospital, Southern Medical University), Zhenyun Chen (The 113th Hospital of the Chinese People's Liberation Army), Hong Chen (Peking University people's Hospital), Jiangtian Chen (Peking University People's Hospital), Yugang Dong (TheFirst Affiliated Hospital, Sun Yat-sen University), Danchen Gao (TheFirst Affiliated Hospital, College of Medicine, Zhejiang University), Weijian Huang (TheFirst Affiliated Hospital, Wenzhou Medical School), Tingbo Jiang (TheFirst Affiliated Hospital of Soochow University), Jiangang Jiang (Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology), Suxin Luo (TheFirst Affiliated Hospital of Chongqing Medical University), Yan Li (Ruijing Hospital), Jinchao Lu (The Second Hospital of Hebei Medical University), Jiehua Li (TheFirst Affiliated Hospital, Anhui Medical University), Xiaoping Ji (Qilu Hospital of Shandong University), Wei Mao (Zhejiang Province Chinese Medicine Hospital), Daoquan Peng (Second Xiangya Hospital, Central South University), Peng Qu (The Second Hospital of Dalian Medical University), Shangming Song (Shandong Province Hospital), Yan Tang (TheFirst People's Hospital of Guiyang), Junkui Wang (Shanxi Provincial Peopleci Hospital), Hui Wang (Jiangsu Province Hospital), Yongxin Wu (TheFirst People's Hospital of Yunnan Province), Huichao Wang (Wuhan Union Hospital), Biao Xu (Nanjing Drum Tower Hospital), Zaixin Yu (First Xiangya Hospital, Central South University), Xinhua Yin (TheFirst Affiliated Hospital, Harbin Medical University), Fang Yuan (Qilu Hospital of Shandong University), Xinjun Zhang (West China Hospital of Sichuan University), Min Zhang (TheFirst Affiliated Hospital of Kunming Medical University), Zixin Zhang (TheFirst Affiliated Hospital, China Medical University), Zhiming Zhu (Daping Hospital of Army Medical University).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]