RESEARCH ARTICLE
Increased Risk of Chronic Kidney Disease in Rheumatoid Arthritis Associated with Cardiovascular Complications – A National Population-Based Cohort Study a11111
OPEN ACCESS Citation: Chiu H-Y, Huang H-L, Li C-H, Chen H-A, Yeh C-L, Chiu S-H, et al. (2015) Increased Risk of Chronic Kidney Disease in Rheumatoid Arthritis Associated with Cardiovascular Complications – A National Population-Based Cohort Study. PLoS ONE 10(9): e0136508. doi:10.1371/journal.pone.0136508 Editor: Emmanuel A Burdmann, University of Sao Paulo Medical School, BRAZIL Received: June 1, 2015 Accepted: August 4, 2015 Published: September 25, 2015 Copyright: © 2015 Chiu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper. Funding: This work was funded by the Cathay General Hospital (Grant number: MR-A10324; http:// www.cgh.org.tw/index.html), the National Science Council of Taiwan under contract number MOST-1032221-E-009-117-, and the Center forBioinformatics Research of Aiming for the Top University Program of the National Chiao Tung University and Ministry of Education, Taiwan, R.O.C. for the project 104W962. This work was also supported in part by UST-UCSD International Center of Excellence in Advanced
Hsien-Yi Chiu1,2,3,4☯, Hui-Ling Huang5,6☯, Chien-Hsun Li5,7, Hung-An Chen5, ChiaLun Yeh5, Shih-Hsiang Chiu5, Wei-Chun Lin5, Yu-Pin Cheng8, Tsen-Fang Tsai3*, ShinnYing Ho5,6* 1 Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan, 2 Department of Dermatology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan, 3 Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, 4 School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, 5 Institute of Bioinformatics and Systems Biology, National Chiao Tung University, Hsinchu, Taiwan, 6 Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan, 7 Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan, 8 Department of Dermatology, Cathay General Hospital, Taipei, Taiwan ☯ These authors contributed equally to this work. * [email protected] (T-FT); [email protected] (S-YH)
Abstract Background and Objectives There have been few large population-based studies of the association between rheumatoid arthritis (RA) and chronic kidney disease (CKD) and glomerulonephritis. This nationwide cohort study investigated the risks of developing CKD and glomerulonephritis in patients with RA, and the associated risks for cardiovascular complications.
Methods From the Taiwan National Health Insurance Research Database, we identified a study cohort of 12,579 patients with RA and randomly selected 37,737 subjects without RA as a control cohort. Each subject was individually followed for up for 5 years, and the risk of CKD was analyzed using Cox proportional hazards regression models.
Results During the follow-up period, after adjusting for traditional cardiovascular risk factors RA was independently associated with a significantly increased risk of CKD (adjusted hazard ratio [aHR] 1.31; 95% confidence interval [CI] 1.23–1.40) and glomerulonephritis (aHR 1.55; 95% CI 1.37–1.76). Increased risk of CKD was also associated with the use of non-steroidal anti-inflammatory drugs, cyclosporine, glucocorticoids, mycophenolate mofetil, and cyclophosphamide. Patients with comorbidities had even greater increased risk of CKD.
PLOS ONE | DOI:10.1371/journal.pone.0136508 September 25, 2015
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Chiu et al. Chronic Kidney Disease in RA
Bioengineering, sponsored by the Ministry of Science and Technology with I-RiCE Program under Grant Number: MOST 103-2911-I-009-101. 2. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: Dr. Tsai has conducted clinical trials or received honoraria for serving as a consultant for Pfizer Pharmaceuticals, Serono International SA (now Merck Serono International), UniPharma/Biogen Idec, Novartis Pharmaceuticals and Janssen-Cilag Pharmaceutical and has received speaking fees from AbbVie. Other authors have no conflicts of interest to declare. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.
Moreover, RA patients with concurrent CKD had significantly higher likelihood of developing ischemic heart disease and stroke.
Conclusions RA patients had higher risk of developing CKD and glomerulonephritis, independent of traditional cardiovascular risk factors. Their increased risk of CKD may be attributed to glomerulonephritis, chronic inflammation, comorbidities, and renal toxicity of antirheumatic drugs. Careful monitoring of renal function in RA patients and tight control of their comorbid diseases and cardiovascular risk factors are warranted.
Introduction Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that affects many body tissues and leads to joint destruction and other major morbidity and mortality. In particular, previous reports have indicated that patients with RA also have considerable incidence of renal disease. Specifically, there is accruing evidence that a substantial proportion of patients with early RA have proteinuria, hematuria and renal dysfunction [1,2]. Renal disease in RA is clinically important because it not only restricts the management of primary disease, but also increases mortality. In one study, RA patients with renal disease had significantly increased mortality compared to those with normal renal function, with a hazard ratio (HR) of 2.77–4.45 [3]. Other investigators have shown that subjects hospitalized for RA were significantly more likely to die from renal failure than the general population: HR 3.1 (95% confidence interval [CI]: 2.5–3.9) for males, and HR 3.5 (95% CI: 3.0–4.0) for females [2,4]. Autopsy findings in patients with RA have shown that renal failure is a major cause of death in 3–20% of cases [5,6]. However, previous studies evaluated a variety of kidney disorders or used different criteria to define renal abnormality in RA. Further major limitations were small sample sizes, crosssectional design, sampling frame at consecutive times from a single rheumatology clinic, lack of a comparison group, and short follow-up, all of which make it difficult to determine the true magnitude of risk and potentially limit the generalizability of their results. Few studies have specifically investigated the chronic kidney disease (CKD) in patients with RA and despite evidence that Asians have higher prevalence of CKD than Caucasians, such research focusing on Asian subjects is lacking [7]. Furthermore, as treatment patterns for RA have changed over the years, the true incidence of CKD may be different nowadays and remains unclear. This study was conducted to determine the risk of CKD and glomerulonephritis (GN) and the associated risk for cardiovascular (CV) complications in a nationally-representative cohort of patients with RA from Taiwan.
Materials and Methods Dataset This retrospective cohort study used data from the Taiwan Longitudinal Health Insurance Database (LHID) 2005, which is a subset of the National Health Insurance Research Database (NHIRD). NHIRD data are compiled from the Taiwan National Health Insurance (NHI) system, which was launched in 1995 to finance health care for all citizens and provides care for approximately 99% of the Taiwanese population of more than 23 million. In the LHID 2005,
PLOS ONE | DOI:10.1371/journal.pone.0136508 September 25, 2015
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Chiu et al. Chronic Kidney Disease in RA
approximately 1,000,000 representative individuals were randomly sampled from among all of those in NHIRD that year. The database includes inpatient care, outpatient care, ambulatory care and prescription drugs from 1 January 2000 through 31 December 2010. A multistage stratified systematic sampling design was used and there were no statistically significant differences in gender, age, or average insured payroll-related amount, between the LHID sample and the whole NHIRD population [8]. The disease diagnoses used in our study were coded using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The local Investigational Research Bureau approved the study (HCH 103-024-E).
Study Population The RA study cohort comprised 12,579 patients newly diagnosed with RA (ICD-9-CM 714.0, 714.2, and 720.0) between 1 January 2001, and 31 December 2005. The initial diagnosis date was defined as the index date of entry into the RA cohort. Patients who were younger than 18 or who had CKD within 1 year before the index date were excluded. A control cohort of 37,737 subjects who had not been diagnosed with RA from year 2000 through 2010, were selected to match each RA patient for gender and age.
Study Outcomes The primary study outcomes were new-onset CKD (ICD-9-CM 580, 581, 582, 583, 584, 585, 586, 587, 588, 589, 753, 403, 404, 2504, 2741, 4401, 4421, 4473, 5724, 6421, 6462) and GN (ICD-9-CM codes: 580.0, 580.1, 580.2, 580.3, 580.4, 580.9, 590.81, 582.0, 582.1, 582.4, 582.81, 582.89, 582.9, 583.0, 583.1, 583.2, 583.4, and 583.9); final-stage CKD (end-stage renal disease [ESRD]) (ICD-9-CM 585) was the secondary outcome. Patients were followed-up for 5 years from the index date or until the development of CKD (Fig 1). Comorbidities included diabetes mellitus (ICD-9-CM 250.xx), hypertension (ICD-9-CM 362.11, 401–405, and 437.2), hyperlipidemia (ICD-9-CM 272.x), CV disease (ICD-9-CM 410–429), and obesity (ICD-9-CM 278.0x).
Statistical Analysis SPSS software version 19.0 (SPSS Inc., Chicago, IL, USA) was used for all statistical analyses. A two-sided p-value
Increased Risk of Chronic Kidney Disease in Rheumatoid Arthritis Associated with Cardiovascular Complications – A National Population-Based Cohort Study a11111
OPEN ACCESS Citation: Chiu H-Y, Huang H-L, Li C-H, Chen H-A, Yeh C-L, Chiu S-H, et al. (2015) Increased Risk of Chronic Kidney Disease in Rheumatoid Arthritis Associated with Cardiovascular Complications – A National Population-Based Cohort Study. PLoS ONE 10(9): e0136508. doi:10.1371/journal.pone.0136508 Editor: Emmanuel A Burdmann, University of Sao Paulo Medical School, BRAZIL Received: June 1, 2015 Accepted: August 4, 2015 Published: September 25, 2015 Copyright: © 2015 Chiu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper. Funding: This work was funded by the Cathay General Hospital (Grant number: MR-A10324; http:// www.cgh.org.tw/index.html), the National Science Council of Taiwan under contract number MOST-1032221-E-009-117-, and the Center forBioinformatics Research of Aiming for the Top University Program of the National Chiao Tung University and Ministry of Education, Taiwan, R.O.C. for the project 104W962. This work was also supported in part by UST-UCSD International Center of Excellence in Advanced
Hsien-Yi Chiu1,2,3,4☯, Hui-Ling Huang5,6☯, Chien-Hsun Li5,7, Hung-An Chen5, ChiaLun Yeh5, Shih-Hsiang Chiu5, Wei-Chun Lin5, Yu-Pin Cheng8, Tsen-Fang Tsai3*, ShinnYing Ho5,6* 1 Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan, 2 Department of Dermatology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan, 3 Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, 4 School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, 5 Institute of Bioinformatics and Systems Biology, National Chiao Tung University, Hsinchu, Taiwan, 6 Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan, 7 Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan, 8 Department of Dermatology, Cathay General Hospital, Taipei, Taiwan ☯ These authors contributed equally to this work. * [email protected] (T-FT); [email protected] (S-YH)
Abstract Background and Objectives There have been few large population-based studies of the association between rheumatoid arthritis (RA) and chronic kidney disease (CKD) and glomerulonephritis. This nationwide cohort study investigated the risks of developing CKD and glomerulonephritis in patients with RA, and the associated risks for cardiovascular complications.
Methods From the Taiwan National Health Insurance Research Database, we identified a study cohort of 12,579 patients with RA and randomly selected 37,737 subjects without RA as a control cohort. Each subject was individually followed for up for 5 years, and the risk of CKD was analyzed using Cox proportional hazards regression models.
Results During the follow-up period, after adjusting for traditional cardiovascular risk factors RA was independently associated with a significantly increased risk of CKD (adjusted hazard ratio [aHR] 1.31; 95% confidence interval [CI] 1.23–1.40) and glomerulonephritis (aHR 1.55; 95% CI 1.37–1.76). Increased risk of CKD was also associated with the use of non-steroidal anti-inflammatory drugs, cyclosporine, glucocorticoids, mycophenolate mofetil, and cyclophosphamide. Patients with comorbidities had even greater increased risk of CKD.
PLOS ONE | DOI:10.1371/journal.pone.0136508 September 25, 2015
1 / 13
Chiu et al. Chronic Kidney Disease in RA
Bioengineering, sponsored by the Ministry of Science and Technology with I-RiCE Program under Grant Number: MOST 103-2911-I-009-101. 2. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: Dr. Tsai has conducted clinical trials or received honoraria for serving as a consultant for Pfizer Pharmaceuticals, Serono International SA (now Merck Serono International), UniPharma/Biogen Idec, Novartis Pharmaceuticals and Janssen-Cilag Pharmaceutical and has received speaking fees from AbbVie. Other authors have no conflicts of interest to declare. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.
Moreover, RA patients with concurrent CKD had significantly higher likelihood of developing ischemic heart disease and stroke.
Conclusions RA patients had higher risk of developing CKD and glomerulonephritis, independent of traditional cardiovascular risk factors. Their increased risk of CKD may be attributed to glomerulonephritis, chronic inflammation, comorbidities, and renal toxicity of antirheumatic drugs. Careful monitoring of renal function in RA patients and tight control of their comorbid diseases and cardiovascular risk factors are warranted.
Introduction Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that affects many body tissues and leads to joint destruction and other major morbidity and mortality. In particular, previous reports have indicated that patients with RA also have considerable incidence of renal disease. Specifically, there is accruing evidence that a substantial proportion of patients with early RA have proteinuria, hematuria and renal dysfunction [1,2]. Renal disease in RA is clinically important because it not only restricts the management of primary disease, but also increases mortality. In one study, RA patients with renal disease had significantly increased mortality compared to those with normal renal function, with a hazard ratio (HR) of 2.77–4.45 [3]. Other investigators have shown that subjects hospitalized for RA were significantly more likely to die from renal failure than the general population: HR 3.1 (95% confidence interval [CI]: 2.5–3.9) for males, and HR 3.5 (95% CI: 3.0–4.0) for females [2,4]. Autopsy findings in patients with RA have shown that renal failure is a major cause of death in 3–20% of cases [5,6]. However, previous studies evaluated a variety of kidney disorders or used different criteria to define renal abnormality in RA. Further major limitations were small sample sizes, crosssectional design, sampling frame at consecutive times from a single rheumatology clinic, lack of a comparison group, and short follow-up, all of which make it difficult to determine the true magnitude of risk and potentially limit the generalizability of their results. Few studies have specifically investigated the chronic kidney disease (CKD) in patients with RA and despite evidence that Asians have higher prevalence of CKD than Caucasians, such research focusing on Asian subjects is lacking [7]. Furthermore, as treatment patterns for RA have changed over the years, the true incidence of CKD may be different nowadays and remains unclear. This study was conducted to determine the risk of CKD and glomerulonephritis (GN) and the associated risk for cardiovascular (CV) complications in a nationally-representative cohort of patients with RA from Taiwan.
Materials and Methods Dataset This retrospective cohort study used data from the Taiwan Longitudinal Health Insurance Database (LHID) 2005, which is a subset of the National Health Insurance Research Database (NHIRD). NHIRD data are compiled from the Taiwan National Health Insurance (NHI) system, which was launched in 1995 to finance health care for all citizens and provides care for approximately 99% of the Taiwanese population of more than 23 million. In the LHID 2005,
PLOS ONE | DOI:10.1371/journal.pone.0136508 September 25, 2015
2 / 13
Chiu et al. Chronic Kidney Disease in RA
approximately 1,000,000 representative individuals were randomly sampled from among all of those in NHIRD that year. The database includes inpatient care, outpatient care, ambulatory care and prescription drugs from 1 January 2000 through 31 December 2010. A multistage stratified systematic sampling design was used and there were no statistically significant differences in gender, age, or average insured payroll-related amount, between the LHID sample and the whole NHIRD population [8]. The disease diagnoses used in our study were coded using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The local Investigational Research Bureau approved the study (HCH 103-024-E).
Study Population The RA study cohort comprised 12,579 patients newly diagnosed with RA (ICD-9-CM 714.0, 714.2, and 720.0) between 1 January 2001, and 31 December 2005. The initial diagnosis date was defined as the index date of entry into the RA cohort. Patients who were younger than 18 or who had CKD within 1 year before the index date were excluded. A control cohort of 37,737 subjects who had not been diagnosed with RA from year 2000 through 2010, were selected to match each RA patient for gender and age.
Study Outcomes The primary study outcomes were new-onset CKD (ICD-9-CM 580, 581, 582, 583, 584, 585, 586, 587, 588, 589, 753, 403, 404, 2504, 2741, 4401, 4421, 4473, 5724, 6421, 6462) and GN (ICD-9-CM codes: 580.0, 580.1, 580.2, 580.3, 580.4, 580.9, 590.81, 582.0, 582.1, 582.4, 582.81, 582.89, 582.9, 583.0, 583.1, 583.2, 583.4, and 583.9); final-stage CKD (end-stage renal disease [ESRD]) (ICD-9-CM 585) was the secondary outcome. Patients were followed-up for 5 years from the index date or until the development of CKD (Fig 1). Comorbidities included diabetes mellitus (ICD-9-CM 250.xx), hypertension (ICD-9-CM 362.11, 401–405, and 437.2), hyperlipidemia (ICD-9-CM 272.x), CV disease (ICD-9-CM 410–429), and obesity (ICD-9-CM 278.0x).
Statistical Analysis SPSS software version 19.0 (SPSS Inc., Chicago, IL, USA) was used for all statistical analyses. A two-sided p-value
