Abstracts
Introduction:
Chronic kidney disease (CKD) and smoking are public health problems.
Objective:
To assess smoking as a risk factor for progression of CKD.
Methods:
We conducted a systematic review in Medline, LILACS, SciELO, Google Scholar, Embase and Trials.gov with articles published until February/2013. Were included: cohort, clinical trials and case-control. Performed in humans, aged ≥ 18 years with smoking as a risk factor for progression of CKD. We excluded studies that reported no smoking and CKD in the title or had proposed to reduce smoking.
Results:
Among 94 citations, 12 articles were selected. Of these, six were multicenter conducted in developed countries, four were randomized. Males predominated 51-76%. There was associated with smoking progression in 11 studies. It was found that the consumption ≥ 15 packs/ year increases the risk of progression of CKD.
Conclusion:
Smoking is a risk factor for progression of CKD.
disease progression; kidney failure, chronic; renal insufficiency; review; risk factors; smoking
Introdução:
A doença renal crônica (DRC) e o tabagismo são problemas de saúde pública.
Objetivo:
Analisar o tabagismo como fator risco para a progressão da DRC.
Métodos:
Realizou-se uma revisão sistemática nas bases Medline, LILACS, SciELO, Google Acadêmico, Trials.gov e Embase com artigos publicados até fevereiro de 2013. Incluíram-se estudos: tipo coorte, ensaios clínicos e caso-controle. Realizados em seres humanos com idade ≥ 18 anos tendo tabagismo como fator de risco para progressão da DRC. Excluíram-se estudos que não referiam tabagismo e DRC no título ou tinham proposta de combate ao fumo.
Resultados:
Das 94 citações, 12 artigos foram selecionados. Destes, seis eram multicêntricos realizados em países desenvolvidos e quatro foram aleatorizados. Predominou o sexo masculino 51%-76%. Houve progressão associada ao tabagismo em 11 estudos. Identificou-se que o consumo ≥ 15 maços/ ano aumenta o risco de progressão da DRC.
Conclusão:
Tabagismo é fator de risco para progressão da DRC.
falência renal crônica; fatores de risco; insuficiência renal; progressão da doença; revisão; tabagismo
Introduction
Chronic kidney disease (CKD) and smoking are public health issues.11 National Kidney Foundation. K/DOQI clinical practice guidelines for
chronic kidney disease: evaluation, classification, and stratification. Am J Kidney
Dis 2002;39:S1-266.,22 Orth SR, Hallan SI. Smoking: a risk factor for progression of chronic
kidney disease and for cardiovascular morbidity and mortality in renal
patients-absence of evidence or evidence of absence? Clin J Am Soc Nephrol
2008;3:226-36. PMID: 18003763 The disturbances introduced in the health care system related to CKD
stem from the increasing incidence of this condition and the significant costs
involved in the treatment of individuals affected by it.33 Levey AS, Atkins R, Coresh J, Cohen EP, Collins AJ, Eckardt KU, et al.
Chronic kidney disease as a global public health problem: approaches and initiatives
- a position statement from Kidney Disease Improving Global Outcomes. Kidney Int
2007;72:247-59. PMID: 17568785 DOI:
http://dx.doi.org/10.1038/sj.ki.5002343
http://dx.doi.org/10.1038/sj.ki.5002343...
Although more resources have been made available to treat
patients with CKD, the conservative management of this disease still leads to high
rates of morbidity and mortality.44 Zoccali C. Traditional and emerging cardiovascular and renal risk
factors: an epidemiologic perspective. Kidney Int 2006;70:26-33. PMID: 16723985 DOI:
http://dx.doi.org/10.1038/sj.ki.5000417
http://dx.doi.org/10.1038/sj.ki.5000417...
Tobacco smoke contains over 4,000 particles and gases, some of which
nephrotoxic.55 Cooper RG. Effect of tobacco smoking on renal function. Indian J Med Res
2006;124:261-8. PMID: 17085829 Particles include heavy
metals known to cause tubular injury such as cadmium and lead, which may reach serum
concentrations above 40% in smokers.66 Satarug S, Moore MR. Adverse health effects of chronic exposure to
low-level cadmium in foodstuffs and cigarette smoke. Environ Health Perspect
2004;112:1099-103. PMID: 15238284 DOI:
http://dx.doi.org/10.1289/ehp.6751
http://dx.doi.org/10.1289/ehp.6751...
The
action of nicotine on specific cholinergic receptors causes hemodynamic changes such
as elevations in blood pressure, heart rate and peripheral vascular resistance.77 Hansen HP, Rossing K, Jacobsen P, Jensen BR, Parving HH. The acute
effect of smoking on systemic haemodynamics, kidney and endothelial functions in
insulin-dependent diabetic patients with microalbuminuria. Scand J Clin Lab Invest
1996;56:393-9. PMID: 8869661 DOI:
http://dx.doi.org/10.3109/00365519609088793
http://dx.doi.org/10.3109/00365519609088...
CKD patients are subject to the deleterious effects of inflammation, oxidative stress
and uremic toxins, which combined lead to rates of cardiovascular death 20-30 times
greater than the general population.88 Foley RN. Clinical epidemiology of cardiovascular disease in chronic
kidney disease. J Ren Care 2010;36:4-8. DOI:
http://dx.doi.org/10.1111/j.1755-6686.2010.00171.x
http://dx.doi.org/10.1111/j.1755-6686.20...
Additionally, smoking increases the incidence of heart failure, peripheral vascular
disease, and death in patients with CKD.99 Foley RN, Herzog CA, Collins AJ. Smoking and cardiovascular outcomes in
dialysis patients: the United States Renal Data System Wave 2 study. Kidney Int
2003;63:1462-7. PMID: 12631362 DOI:
http://dx.doi.org/10.1046/j.1523-1755.2003.00860.x
http://dx.doi.org/10.1046/j.1523-1755.20...
In spite of these shocking evidences, few studies have assessed smoking as a risk
factor for CKD. Two systematic reviews have been published to date on the matter. The
first, by Burton-Jones et al.,1010 Jones-Burton C, Seliger SL, Scherer RW, Mishra SI, Vessal G, Brown J, et
al. Cigarette smoking and incident chronic kidney disease: a systematic review. Am J
Nephrol 2007;27:342-51. DOI: http://dx.doi.org/10.1159/000103382
http://dx.doi.org/10.1159/000103382...
(2007) reviewed the incidence of CKD in smokers. The second systematic
review was published by Noborisaka1111 Noborisaka Y. Smoking and chronic kidney disease in healthy populations.
Nephrourol Mon 2013;5:655-67. DOI:
http://dx.doi.org/10.5812/numonthly.3527
http://dx.doi.org/10.5812/numonthly.3527...
(2013) to
look into the development of CKD in healthy populations and smokers. In Brazil, this
issue was discussed in 2002 in a narrative review by Oliveira et
al.,1212 Oliveira GR, Suh JI, Bérgamo RR. Tabagismo como fator de risco para
doença renal. In: Cruz J, Cruz HMM, Barros RT, eds. Atualidades em Nefrologia. 7a ed.
São Paulo: Sarvier; 2002. p.481-5. in which the knowledge then
available on smoking as a risk factor for kidney disease was summarized. The present
review1313 Petticrew M, Roberts H. Systematic reviews in the social sciences: a
practical guide. Oxford: Blackwell Publishing; 2006. aims to examine smoking as a risk
factor for progression of CKD.
Method
Search strategy
A systematic search for literature took place between November of 2011 and February of 2013. The following databases were used in this process: Medical Literature Analysis and Retrieval Online (Medline), Literature in the Health Sciences in Latin America and the Caribbean (LILACS), Google Scholar, Scientific Electronic Library Online (SciELO), EMBASE, and Trials.gov. A specific strategy was devised for each search portal to cross-reference descriptors and keywords in order to facilitate the retrieval of papers from the literature.
Medline was accessed via search portal Pubmed, using the following syntax: (("kidney failure, chronic" [Majr]) AND/OR ("renal insufficiency, chronic" [Majr]) AND "smoking" [Majr]). Descriptors "tabagismo" AND "doença renal crônica" AND "insuficiência renal crônica" were used in LILACS and SciELO. In Embase, the sarch was made via portal Evidence Based Medicine using the following syntax: ‘smoking'/ exp/mj AND ‘chronickidneydisease'/exp/mj. In Trials.gov, the syntax category was chronic kidney failure -> refine results -> smoking. In Google Scholar, the syntax was "allintitle kidney chronic smoking insufficiency OR failure OR disease."
The resulting list of papers was then submitted to eligibility, inclusion, and
exclusion criteria. Original articles in which smoking was deemed as a risk factor
for chronic kidney disease, without linguistic or time restrictions were
considered eligible. The PICOS (Population, Intervention, Comparison, Outcome,
Study Design) search strategy was used.1010 Jones-Burton C, Seliger SL, Scherer RW, Mishra SI, Vessal G, Brown J, et
al. Cigarette smoking and incident chronic kidney disease: a systematic review. Am J
Nephrol 2007;27:342-51. DOI: http://dx.doi.org/10.1159/000103382
http://dx.doi.org/10.1159/000103382...
Selected papers included: (1) prospective/retrospective cohort studies, randomized
and non-randomized clinical trials, and case-control studies; (2) studies in which
smoking was considered a risk factor for CKD progression; (3) studies in humans
aged 18 years and older; (4) studies in which CKD patients were offered
conservative treatment, studies enrolling smokers with or without CKD who
progressed to CKD as a result of smoking, and (5) studies comparing the outcomes
of smokers and nonsmokers with CKD. Papers with no reference in their titles to
smoking and CKD or studies proposing measures to combat smoking were excluded.
Data analysis
Paper selection was carried out in three steps. In the first step, independent researchers VML and MAL read the papers blinded for their authors and journals on which they were published. Disagreements were resolved by consensus or, when needed, with the aid of a third researcher (UFEJ) called in to break the tie.
Papers failing to meet the inclusion criteria were excluded. In the second step, the independent researchers read the abstracts from the studies selected in the first step and excluded additional articles that did not meet the inclusion criteria. In the third step, the studies still remaining from the first two steps were read in full and selected to be included in this review (Figure 1).
Flowchart showing the steps taken in the selection of the papers included in the systematic review. Source: designed by the authors.
Results
Twelve of 94 papers were deemed potentially relevant, and were retrieved with their texts in full to be included in the review. On Medline, 27 of the 37 papers found via Pubmed were excluded based on their titles or due to duplicated occurrence of the reference. Another three were excluded after their abstracts were read, and seven were read in full. The two citations found on LILACS were excluded because of their titles. The six listed on SciELO were ruled out for the same reason. Thirteen of the papers listed on Embase were excluded because of their titles or due to duplicated occurrence of the reference. Seventeen of the 33 citations from Google Scholar were excluded because of their titles or due to reference duplicates, ten were left out after their abstracts were read, one after it was red in full, and four were included in the review.
The three references found on Trials.gov were excluded because of their titles.
Chart 1 shows the data and the results of the
12 included studies and reveals that the first study on smoking as a risk factor for
progression of CKD was published in 1998. Most of the papers contained accounts of
observational case-control or cohort studies designed to assess relative risk (RR) or
odds ratios (OR).1414 Shankar A, Klein R, Klein BE. The association among smoking, heavy
drinking, and chronic kidney disease. Am J Epidemiol 2006;164:263-71. PMID: 16775042
DOI: http://dx.doi.org/10.1093/aje/kwj173
http://dx.doi.org/10.1093/aje/kwj173...
15 Stengel B, Couchoud C, Cénée S, Hémon D. Age, blood pressure and smoking
effects on chronic renal failure in primary glomerular nephropathies. Kidney Int
2000;57:2519-26. PMID: 10844621
16 Orth SR, Stöckmann A, Conradt C, Ritz E, Ferro M, Kreusser W, et al.
Smoking as a risk factor for end-stage renal failure in men with primary renal
disease. Kidney Int 1998;54:926-31. PMID: 9734618 DOI:
http://dx.doi.org/10.1046/j.1523-1755.1998.00067.x
http://dx.doi.org/10.1046/j.1523-1755.19...
17 Yacoub R, Habib H, Lahdo A, Al Ali R, Varjabedian L, Atalla G, et al.
Association between smoking and chronic kidney disease: a case control study. BMC
Public Health 2010;10:731. DOI:
http://dx.doi.org/10.1186/1471-2458-10-731
http://dx.doi.org/10.1186/1471-2458-10-7...
-1818 Ejerblad E, Fored CM, Lindblad P, Fryzek J, Dickman PW, Elinder CG, et
al. Association between smoking and chronic renal failure in a nationwide
population-based case-control study. J Am Soc Nephrol 2004;15:2178-85. DOI:
http://dx.doi.org/10.1097/01.ASN.0000135048.35659.10
http://dx.doi.org/10.1097/01.ASN.0000135...
Multicenter trials carried out in developed
nations prevailed over other study types.1414 Shankar A, Klein R, Klein BE. The association among smoking, heavy
drinking, and chronic kidney disease. Am J Epidemiol 2006;164:263-71. PMID: 16775042
DOI: http://dx.doi.org/10.1093/aje/kwj173
http://dx.doi.org/10.1093/aje/kwj173...
,1515 Stengel B, Couchoud C, Cénée S, Hémon D. Age, blood pressure and smoking
effects on chronic renal failure in primary glomerular nephropathies. Kidney Int
2000;57:2519-26. PMID: 10844621,1818 Ejerblad E, Fored CM, Lindblad P, Fryzek J, Dickman PW, Elinder CG, et
al. Association between smoking and chronic renal failure in a nationwide
population-based case-control study. J Am Soc Nephrol 2004;15:2178-85. DOI:
http://dx.doi.org/10.1097/01.ASN.0000135048.35659.10
http://dx.doi.org/10.1097/01.ASN.0000135...
19 Orth SR. Smoking-a risk factor for progression of renal disease. Kidney
Blood Press Res 2000;23:202-4.
20 Hellemons ME, Agarwal PK, van der Bij W, Verschuuren EA, Postmus D,
Erasmus ME, et al. Former smoking is a risk factor for chronic kidney disease after
lung transplantation. Am J Transplant 2011;11:2490-8. DOI:
http://dx.doi.org/10.1111/j.1600-6143.2011.03701.x
http://dx.doi.org/10.1111/j.1600-6143.20...
-2121 Hallan SI, Orth SR. Smoking is a risk factor in the progression to
kidney failure. Kidney Int 2011;80:516-23. PMID: 21677635 DOI:
http://dx.doi.org/10.1038/ki.2011.157
http://dx.doi.org/10.1038/ki.2011.157...
No papers from Latin America were included. Four were randomized
controlled trials.1414 Shankar A, Klein R, Klein BE. The association among smoking, heavy
drinking, and chronic kidney disease. Am J Epidemiol 2006;164:263-71. PMID: 16775042
DOI: http://dx.doi.org/10.1093/aje/kwj173
http://dx.doi.org/10.1093/aje/kwj173...
,1717 Yacoub R, Habib H, Lahdo A, Al Ali R, Varjabedian L, Atalla G, et al.
Association between smoking and chronic kidney disease: a case control study. BMC
Public Health 2010;10:731. DOI:
http://dx.doi.org/10.1186/1471-2458-10-731
http://dx.doi.org/10.1186/1471-2458-10-7...
,1818 Ejerblad E, Fored CM, Lindblad P, Fryzek J, Dickman PW, Elinder CG, et
al. Association between smoking and chronic renal failure in a nationwide
population-based case-control study. J Am Soc Nephrol 2004;15:2178-85. DOI:
http://dx.doi.org/10.1097/01.ASN.0000135048.35659.10
http://dx.doi.org/10.1097/01.ASN.0000135...
,2222 Regalado M, Yang S, Wesson DE. Cigarette smoking is associated with
augmented progression of renal insufficiency in severe essential hypertension. Am J
Kidney Dis 2000;35:687-94. DOI:
http://dx.doi.org/10.1016/S0272-6386(00)70017-5
http://dx.doi.org/10.1016/S0272-6386(00)...
Characteristics of observational studies and association between chronic kidney disease and smoking
Male patients were predominantly enrolled in the included studies, and accounted for
51%-77% of the subjects. Six studies2020 Hellemons ME, Agarwal PK, van der Bij W, Verschuuren EA, Postmus D,
Erasmus ME, et al. Former smoking is a risk factor for chronic kidney disease after
lung transplantation. Am J Transplant 2011;11:2490-8. DOI:
http://dx.doi.org/10.1111/j.1600-6143.2011.03701.x
http://dx.doi.org/10.1111/j.1600-6143.20...
21 Hallan SI, Orth SR. Smoking is a risk factor in the progression to
kidney failure. Kidney Int 2011;80:516-23. PMID: 21677635 DOI:
http://dx.doi.org/10.1038/ki.2011.157
http://dx.doi.org/10.1038/ki.2011.157...
22 Regalado M, Yang S, Wesson DE. Cigarette smoking is associated with
augmented progression of renal insufficiency in severe essential hypertension. Am J
Kidney Dis 2000;35:687-94. DOI:
http://dx.doi.org/10.1016/S0272-6386(00)70017-5
http://dx.doi.org/10.1016/S0272-6386(00)...
23 Lash JP, Go AS, Appel LJ, He J, Ojo A, Rahman M, et al.; Chronic Renal
Insufficiency Cohort (CRIC) Study Group. Chronic Renal Insufficiency Cohort (CRIC)
Study: baseline characteristics and associations with kidney function. Clin J Am Soc
Nephrol 2009;4:1302-11. DOI: http://dx.doi.org/10.2215/CJN.00070109
http://dx.doi.org/10.2215/CJN.00070109...
24 Míguez-Burbano MJ, Wyatt C, Lewis JE, Rodríguez A, Duncan R. Ignoring
the obvious missing piece of chronic kidney disease in HIV: cigarette smoking. J
Assoc Nurses AIDS Care 2010;21:16-24. DOI:
http://dx.doi.org/10.1016/j.jana.2009.07.005
http://dx.doi.org/10.1016/j.jana.2009.07...
-2525 U.S. Renal Data System. USRDS 1998 Annual Data Report National
Institutes of Health, National Institute of Diabetes and Digestive and Kidney
Diseases. U.S. Renal Data System: Bethesda; 1998. reported increased
rates of CKD progression among smokers. Differently from others, one paper identified
a transient increase of 0.32 ml/min/1.73 m2/year in the glomerular
filtration rate (GFR) of female smokers versus female nonsmokers.
However, this difference disappeared seven years after they started smoking. This
change in GFR was not statistically significant in males.2626 Kronborg J, Solbu M, Njølstad I, Toft I, Eriksen BO, Jenssen T.
Predictors of change in estimated GFR: a population-based 7-year follow-up from the
Tromso study. Nephrol Dial Transplant 2008;23:2818-26. DOI:
http://dx.doi.org/10.1093/ndt/gfn148
http://dx.doi.org/10.1093/ndt/gfn148...
Five studies1515 Stengel B, Couchoud C, Cénée S, Hémon D. Age, blood pressure and smoking
effects on chronic renal failure in primary glomerular nephropathies. Kidney Int
2000;57:2519-26. PMID: 10844621
16 Orth SR, Stöckmann A, Conradt C, Ritz E, Ferro M, Kreusser W, et al.
Smoking as a risk factor for end-stage renal failure in men with primary renal
disease. Kidney Int 1998;54:926-31. PMID: 9734618 DOI:
http://dx.doi.org/10.1046/j.1523-1755.1998.00067.x
http://dx.doi.org/10.1046/j.1523-1755.19...
17 Yacoub R, Habib H, Lahdo A, Al Ali R, Varjabedian L, Atalla G, et al.
Association between smoking and chronic kidney disease: a case control study. BMC
Public Health 2010;10:731. DOI:
http://dx.doi.org/10.1186/1471-2458-10-731
http://dx.doi.org/10.1186/1471-2458-10-7...
-1818 Ejerblad E, Fored CM, Lindblad P, Fryzek J, Dickman PW, Elinder CG, et
al. Association between smoking and chronic renal failure in a nationwide
population-based case-control study. J Am Soc Nephrol 2004;15:2178-85. DOI:
http://dx.doi.org/10.1097/01.ASN.0000135048.35659.10
http://dx.doi.org/10.1097/01.ASN.0000135...
,2727 Shankar A, Klein R, Klein BE. The association among smoking, heavy
drinking, and chronic kidney disease. Am J Epidemiol 2006;164:263-71. PMID: 16775042
DOI: http://dx.doi.org/10.1093/aje/kwj173
http://dx.doi.org/10.1093/aje/kwj173...
reported a dose-effect relationship in which
higher risk of CKD progression was associated with heavier smoking, particularly when
individuals smoked more than 15 packs of cigarettes a year.
Discussion
The relationship between smoking and CKD
The perception that smoking may cause renal injury is recent in the history of
nephrology and, therefore, deserves some contextualization. The first causal
association between smoking and CKD was discussed by Orth et
al.1616 Orth SR, Stöckmann A, Conradt C, Ritz E, Ferro M, Kreusser W, et al.
Smoking as a risk factor for end-stage renal failure in men with primary renal
disease. Kidney Int 1998;54:926-31. PMID: 9734618 DOI:
http://dx.doi.org/10.1046/j.1523-1755.1998.00067.x
http://dx.doi.org/10.1046/j.1523-1755.19...
in 1998, with the
publication of a multicenter trial involving nine research centers. This study
looked into the outcomes of patients with primary IgA nephropathy (inflammatory
model of CKD) and subjects with autosomal dominant polycystic kidney disease
(non-inflammatory genetic model) all the way to stage-5 CKD. The authors concluded
that male smokers with IgA nephropathy or autosomal dominant polycystic kidney
disease were at a higher risk of progressing to stage-5 CKD when compared to
nonsmoking patients.1616 Orth SR, Stöckmann A, Conradt C, Ritz E, Ferro M, Kreusser W, et al.
Smoking as a risk factor for end-stage renal failure in men with primary renal
disease. Kidney Int 1998;54:926-31. PMID: 9734618 DOI:
http://dx.doi.org/10.1046/j.1523-1755.1998.00067.x
http://dx.doi.org/10.1046/j.1523-1755.19...
The United States
Renal Data Systems (USRDS) published a paper that same year alerting the
scientific community to the growth of a global epidemic of CKD.2525 U.S. Renal Data System. USRDS 1998 Annual Data Report National
Institutes of Health, National Institute of Diabetes and Digestive and Kidney
Diseases. U.S. Renal Data System: Bethesda; 1998. Since this publication, expert committees
from around the world have begun to scale up the attention given to the risk
factors associated with CKD progression. In 2002, the guidelines from the National
Kidney Foundation11 National Kidney Foundation. K/DOQI clinical practice guidelines for
chronic kidney disease: evaluation, classification, and stratification. Am J Kidney
Dis 2002;39:S1-266. already considered
smoking as a factor in CKD progression.
This review found five case-control1515 Stengel B, Couchoud C, Cénée S, Hémon D. Age, blood pressure and smoking
effects on chronic renal failure in primary glomerular nephropathies. Kidney Int
2000;57:2519-26. PMID: 10844621
16 Orth SR, Stöckmann A, Conradt C, Ritz E, Ferro M, Kreusser W, et al.
Smoking as a risk factor for end-stage renal failure in men with primary renal
disease. Kidney Int 1998;54:926-31. PMID: 9734618 DOI:
http://dx.doi.org/10.1046/j.1523-1755.1998.00067.x
http://dx.doi.org/10.1046/j.1523-1755.19...
17 Yacoub R, Habib H, Lahdo A, Al Ali R, Varjabedian L, Atalla G, et al.
Association between smoking and chronic kidney disease: a case control study. BMC
Public Health 2010;10:731. DOI:
http://dx.doi.org/10.1186/1471-2458-10-731
http://dx.doi.org/10.1186/1471-2458-10-7...
-1818 Ejerblad E, Fored CM, Lindblad P, Fryzek J, Dickman PW, Elinder CG, et
al. Association between smoking and chronic renal failure in a nationwide
population-based case-control study. J Am Soc Nephrol 2004;15:2178-85. DOI:
http://dx.doi.org/10.1097/01.ASN.0000135048.35659.10
http://dx.doi.org/10.1097/01.ASN.0000135...
,2525 U.S. Renal Data System. USRDS 1998 Annual Data Report National
Institutes of Health, National Institute of Diabetes and Digestive and Kidney
Diseases. U.S. Renal Data System: Bethesda; 1998. and seven
cohort studies1414 Shankar A, Klein R, Klein BE. The association among smoking, heavy
drinking, and chronic kidney disease. Am J Epidemiol 2006;164:263-71. PMID: 16775042
DOI: http://dx.doi.org/10.1093/aje/kwj173
http://dx.doi.org/10.1093/aje/kwj173...
,2020 Hellemons ME, Agarwal PK, van der Bij W, Verschuuren EA, Postmus D,
Erasmus ME, et al. Former smoking is a risk factor for chronic kidney disease after
lung transplantation. Am J Transplant 2011;11:2490-8. DOI:
http://dx.doi.org/10.1111/j.1600-6143.2011.03701.x
http://dx.doi.org/10.1111/j.1600-6143.20...
21 Hallan SI, Orth SR. Smoking is a risk factor in the progression to
kidney failure. Kidney Int 2011;80:516-23. PMID: 21677635 DOI:
http://dx.doi.org/10.1038/ki.2011.157
http://dx.doi.org/10.1038/ki.2011.157...
22 Regalado M, Yang S, Wesson DE. Cigarette smoking is associated with
augmented progression of renal insufficiency in severe essential hypertension. Am J
Kidney Dis 2000;35:687-94. DOI:
http://dx.doi.org/10.1016/S0272-6386(00)70017-5
http://dx.doi.org/10.1016/S0272-6386(00)...
-2323 Lash JP, Go AS, Appel LJ, He J, Ojo A, Rahman M, et al.; Chronic Renal
Insufficiency Cohort (CRIC) Study Group. Chronic Renal Insufficiency Cohort (CRIC)
Study: baseline characteristics and associations with kidney function. Clin J Am Soc
Nephrol 2009;4:1302-11. DOI: http://dx.doi.org/10.2215/CJN.00070109
http://dx.doi.org/10.2215/CJN.00070109...
,2626 Kronborg J, Solbu M, Njølstad I, Toft I, Eriksen BO, Jenssen T.
Predictors of change in estimated GFR: a population-based 7-year follow-up from the
Tromso study. Nephrol Dial Transplant 2008;23:2818-26. DOI:
http://dx.doi.org/10.1093/ndt/gfn148
http://dx.doi.org/10.1093/ndt/gfn148...
,2828 Noborisaka Y, Ishizaki M, Yamada Y, Honda R, Yokoyama H, Miyao M, et al.
The effects of continuing and discontinuing smoking on the development of chronic
kidney disease (CKD) in the healthy middle-aged working population in Japan. Environ
Health Prev Med 2013;18:24-32. DOI:
http://dx.doi.org/10.1007/s12199-012-0285-7
http://dx.doi.org/10.1007/s12199-012-028...
with the
analytical robustness required to produce risk assessments. Nonetheless, the
subjects in the case and control groups of the case-control studies were not given
equal odds1515 Stengel B, Couchoud C, Cénée S, Hémon D. Age, blood pressure and smoking
effects on chronic renal failure in primary glomerular nephropathies. Kidney Int
2000;57:2519-26. PMID: 10844621
16 Orth SR, Stöckmann A, Conradt C, Ritz E, Ferro M, Kreusser W, et al.
Smoking as a risk factor for end-stage renal failure in men with primary renal
disease. Kidney Int 1998;54:926-31. PMID: 9734618 DOI:
http://dx.doi.org/10.1046/j.1523-1755.1998.00067.x
http://dx.doi.org/10.1046/j.1523-1755.19...
-1717 Yacoub R, Habib H, Lahdo A, Al Ali R, Varjabedian L, Atalla G, et al.
Association between smoking and chronic kidney disease: a case control study. BMC
Public Health 2010;10:731. DOI:
http://dx.doi.org/10.1186/1471-2458-10-731
http://dx.doi.org/10.1186/1471-2458-10-7...
,2121 Hallan SI, Orth SR. Smoking is a risk factor in the progression to
kidney failure. Kidney Int 2011;80:516-23. PMID: 21677635 DOI:
http://dx.doi.org/10.1038/ki.2011.157
http://dx.doi.org/10.1038/ki.2011.157...
,2424 Míguez-Burbano MJ, Wyatt C, Lewis JE, Rodríguez A, Duncan R. Ignoring
the obvious missing piece of chronic kidney disease in HIV: cigarette smoking. J
Assoc Nurses AIDS Care 2010;21:16-24. DOI:
http://dx.doi.org/10.1016/j.jana.2009.07.005
http://dx.doi.org/10.1016/j.jana.2009.07...
,2626 Kronborg J, Solbu M, Njølstad I, Toft I, Eriksen BO, Jenssen T.
Predictors of change in estimated GFR: a population-based 7-year follow-up from the
Tromso study. Nephrol Dial Transplant 2008;23:2818-26. DOI:
http://dx.doi.org/10.1093/ndt/gfn148
http://dx.doi.org/10.1093/ndt/gfn148...
,2828 Noborisaka Y, Ishizaki M, Yamada Y, Honda R, Yokoyama H, Miyao M, et al.
The effects of continuing and discontinuing smoking on the development of chronic
kidney disease (CKD) in the healthy middle-aged working population in Japan. Environ
Health Prev Med 2013;18:24-32. DOI:
http://dx.doi.org/10.1007/s12199-012-0285-7
http://dx.doi.org/10.1007/s12199-012-028...
, as they were
not randomized. Additionally, most of the studies enrolled patients with
established kidney disease, indicating the need for a prospective cohort study
with CKD-free individuals. Two studies were designed with this method in
mind,2121 Hallan SI, Orth SR. Smoking is a risk factor in the progression to
kidney failure. Kidney Int 2011;80:516-23. PMID: 21677635 DOI:
http://dx.doi.org/10.1038/ki.2011.157
http://dx.doi.org/10.1038/ki.2011.157...
,2828 Noborisaka Y, Ishizaki M, Yamada Y, Honda R, Yokoyama H, Miyao M, et al.
The effects of continuing and discontinuing smoking on the development of chronic
kidney disease (CKD) in the healthy middle-aged working population in Japan. Environ
Health Prev Med 2013;18:24-32. DOI:
http://dx.doi.org/10.1007/s12199-012-0285-7
http://dx.doi.org/10.1007/s12199-012-028...
but their outcomes are questionable due to methodological
flaws.
In 2011, Hallan & Orth2121 Hallan SI, Orth SR. Smoking is a risk factor in the progression to
kidney failure. Kidney Int 2011;80:516-23. PMID: 21677635 DOI:
http://dx.doi.org/10.1038/ki.2011.157
http://dx.doi.org/10.1038/ki.2011.157...
carried out a
study on CKD and smoking based on the population of the HUNT-2 cross-sectional
study. However, the HUNT-2 study was not conceived to assess the habit of smoking.
Instead, the Norwegian study was designed to evaluate the status of public health
issues such as cardiovascular disease (CVD), diabetes mellitus
(DM), chronic obstructive pulmonary disease (COPD), osteoporosis, and mental
health. As a consequence of methodological carelessness, patients with multiple
cardiovascular comorbidities were included in the study on smoking and CKD,2121 Hallan SI, Orth SR. Smoking is a risk factor in the progression to
kidney failure. Kidney Int 2011;80:516-23. PMID: 21677635 DOI:
http://dx.doi.org/10.1038/ki.2011.157
http://dx.doi.org/10.1038/ki.2011.157...
a decision that introduced selection and
survival biases in the studied sample of the population.
In 2013, Noborisaka et al.2828 Noborisaka Y, Ishizaki M, Yamada Y, Honda R, Yokoyama H, Miyao M, et al.
The effects of continuing and discontinuing smoking on the development of chronic
kidney disease (CKD) in the healthy middle-aged working population in Japan. Environ
Health Prev Med 2013;18:24-32. DOI:
http://dx.doi.org/10.1007/s12199-012-0285-7
http://dx.doi.org/10.1007/s12199-012-028...
evaluated 6,998 Japanese active workers without CKD, although with
the following selection biases: (1) subjects who reported to have stopped smoking
at baseline were categorized as former smokers; (2) the time for which the
subjects had smoked was not accounted for; (3) patients with CKD were categorized
from a single evaluation;2929 Kidney Disease. Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO
2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney
Disease. Kidney Inter Suppl 2013;3:1-150. additionally,
the KDIGO2929 Kidney Disease. Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO
2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney
Disease. Kidney Inter Suppl 2013;3:1-150. was reported to have been the
basis for categorization but its criteria were not followed; (4) proteinuria
(indicative of kidney damage) was ruled out from the examination of a single
sample tested with a reagent strip, a method subject to selection and information
biases.
The countries of origin of the studies
This review predominantly included studies carried out in developed nations,
possibly because of the greater number of epidemiologic surveillance efforts in
effect in these countries and the longer life expectancy of their
populations,3030 Kalache A, Veras RP, Ramos LR. O envelhecimento da população mundial. Um
desafio novo. Rev Saúde Pública 1987;21:200-10. DOI:
http://dx.doi.org/10.1590/S0034-89101987000300005
http://dx.doi.org/10.1590/S0034-89101987...
as is the case in
Germany,2020 Hellemons ME, Agarwal PK, van der Bij W, Verschuuren EA, Postmus D,
Erasmus ME, et al. Former smoking is a risk factor for chronic kidney disease after
lung transplantation. Am J Transplant 2011;11:2490-8. DOI:
http://dx.doi.org/10.1111/j.1600-6143.2011.03701.x
http://dx.doi.org/10.1111/j.1600-6143.20...
Austria,1616 Orth SR, Stöckmann A, Conradt C, Ritz E, Ferro M, Kreusser W, et al.
Smoking as a risk factor for end-stage renal failure in men with primary renal
disease. Kidney Int 1998;54:926-31. PMID: 9734618 DOI:
http://dx.doi.org/10.1046/j.1523-1755.1998.00067.x
http://dx.doi.org/10.1046/j.1523-1755.19...
Sweden,1818 Ejerblad E, Fored CM, Lindblad P, Fryzek J, Dickman PW, Elinder CG, et
al. Association between smoking and chronic renal failure in a nationwide
population-based case-control study. J Am Soc Nephrol 2004;15:2178-85. DOI:
http://dx.doi.org/10.1097/01.ASN.0000135048.35659.10
http://dx.doi.org/10.1097/01.ASN.0000135...
the United
States,2323 Lash JP, Go AS, Appel LJ, He J, Ojo A, Rahman M, et al.; Chronic Renal
Insufficiency Cohort (CRIC) Study Group. Chronic Renal Insufficiency Cohort (CRIC)
Study: baseline characteristics and associations with kidney function. Clin J Am Soc
Nephrol 2009;4:1302-11. DOI: http://dx.doi.org/10.2215/CJN.00070109
http://dx.doi.org/10.2215/CJN.00070109...
Norway,2626 Kronborg J, Solbu M, Njølstad I, Toft I, Eriksen BO, Jenssen T.
Predictors of change in estimated GFR: a population-based 7-year follow-up from the
Tromso study. Nephrol Dial Transplant 2008;23:2818-26. DOI:
http://dx.doi.org/10.1093/ndt/gfn148
http://dx.doi.org/10.1093/ndt/gfn148...
and Japan.2828 Noborisaka Y, Ishizaki M, Yamada Y, Honda R, Yokoyama H, Miyao M, et al.
The effects of continuing and discontinuing smoking on the development of chronic
kidney disease (CKD) in the healthy middle-aged working population in Japan. Environ
Health Prev Med 2013;18:24-32. DOI:
http://dx.doi.org/10.1007/s12199-012-0285-7
http://dx.doi.org/10.1007/s12199-012-028...
Projections for 2015 developed by the World Bank and the World Health Organization
indicate that 6.4 million people will die of causes related to smoking - the
equivalent to 10% of the deaths for all causes and a figure 50% greater than the
number of deaths attributed to the human immunodeficiency virus (HIV).3131 Mathers CD, Loncar D. Projections of global mortality and burden of
disease from 2002 to 2030. PLoS Med 2006;3:e442. DOI:
http://dx.doi.org/10.1371/journal.pmed.0030442
http://dx.doi.org/10.1371/journal.pmed.0...
Despite the preoccupying nature of this data and the impact smoking potentially has on the progression of CKD, no studies have been published on this matter in Latin America to date. The intersection between CKD and smoking must not be neglected. These issues combined may overwhelm health systems worldwide, particularly in poorer or developing nations such as Brazil.
Controversies over CKD and gender
The higher prevalence seen in male populations is consistent with the
epidemiologic findings of other populations.1717 Yacoub R, Habib H, Lahdo A, Al Ali R, Varjabedian L, Atalla G, et al.
Association between smoking and chronic kidney disease: a case control study. BMC
Public Health 2010;10:731. DOI:
http://dx.doi.org/10.1186/1471-2458-10-731
http://dx.doi.org/10.1186/1471-2458-10-7...
,3232 Sesso RC, Lopes AA, Thomé FS, Lugon JR, Burdmann EA. Brazilian Dialysis
Census, 2009. J Bras Nefrol 2010;32(4):374-8. For yet unknown
reasons, males are at a higher risk of developing CKD.3333 Crews DC, Charles RF, Evans MK, Zonderman AB, Powe NR. Poverty, race,
and CKD in a racially and socioeconomically diverse urban population. Am J Kidney Dis
2010;55:992-1000. DOI: http://dx.doi.org/10.1053/j.ajkd.2009.12.032
http://dx.doi.org/10.1053/j.ajkd.2009.12...
Evidence suggests that estrogen offers protection against
renal disorders as it affects the conservation of nitric oxide - an important
regulator of glomerular ultrafiltration - by modulating mesangial cells and
afferent arterioles,3434 Baylis C. Sexual dismorphism, the aging, and involvement of nitric oxid
deficiency. Semin Nephrol 2009;29:569-78. DOI:
http://dx.doi.org/10.1016/j.semnephrol.2009.07.003
http://dx.doi.org/10.1016/j.semnephrol.2...
an effect not
observed in postmenopausal women.3535 Neugarten J, Acharya A, Silbiger SR. Effect of gender on the progression
of nondiabetic renal disease: a meta-analysis. J Am Soc Nephrol
2000;11:319-29.
However, data from the USRDS3636 Collins AJ, Foley RN, Herzog C, Chavers B, Gilbertson D, Herzog C, et
al. US Renal Data System 2012 Annual Data Report. Am J Kidney Dis 2013;61:A7,e1-476.
DOI: http://dx.doi.org/10.1053/j.ajkd.2012.11.031
http://dx.doi.org/10.1053/j.ajkd.2012.11...
have shown
that the female population with CKD has grown between 1988 and 2010 and achieved a
prevalence rate of 10.2% - versus 8.6% in males - due to
increases in female life expectancy, obesity, and a greater number of cases of
systemic hypertension and DM.3737 Rychlik I, Miltenberger-Miltenyi G, Ritz E. The drama of the continuous
increase in end-stage renal failure in patients with type II diabetes mellitus.
Nephrol Dial Transplant 1998;13:6-10. PMID: 9870418 DOI:
http://dx.doi.org/10.1093/ndt/13.suppl_8.6
http://dx.doi.org/10.1093/ndt/13.suppl_8...
,3838 Ritz E, Koleganova N. Obesity and chronic kidney disease. Semin Nephrol
2009;29:504-11. DOI:
http://dx.doi.org/10.1016/j.semnephrol.2009.06.007
http://dx.doi.org/10.1016/j.semnephrol.2...
Only the study by Kronborg et al.2626 Kronborg J, Solbu M, Njølstad I, Toft I, Eriksen BO, Jenssen T.
Predictors of change in estimated GFR: a population-based 7-year follow-up from the
Tromso study. Nephrol Dial Transplant 2008;23:2818-26. DOI:
http://dx.doi.org/10.1093/ndt/gfn148
http://dx.doi.org/10.1093/ndt/gfn148...
reported improved GFR in female smokers based on the follow-up of
the cohort enrolled in the Tromsø Study,3939 Jacobsen BK, Eggen AE, Mathiesen EB, Wilsgaard T, Njølstad I. Cohort
profile: the Tromso Study. Int J Epidemiol 2012;41:961-7. DOI:
http://dx.doi.org/10.1093/ije/dyr049
http://dx.doi.org/10.1093/ije/dyr049...
designed by its authors to determine high risk factors for cardiovascular death
and develop strategies for the prevention of acute myocardial infarction (AMI) and
stroke. However, it should be noted that the authors2626 Kronborg J, Solbu M, Njølstad I, Toft I, Eriksen BO, Jenssen T.
Predictors of change in estimated GFR: a population-based 7-year follow-up from the
Tromso study. Nephrol Dial Transplant 2008;23:2818-26. DOI:
http://dx.doi.org/10.1093/ndt/gfn148
http://dx.doi.org/10.1093/ndt/gfn148...
had difficulties explaining this finding. The improvement
observed in the GFR of the female patients was attributed to hyperfiltration and
smoking-induced loss of muscle mass. This transient improvement disappears after
seven years and the GFR then decreases progressively.2626 Kronborg J, Solbu M, Njølstad I, Toft I, Eriksen BO, Jenssen T.
Predictors of change in estimated GFR: a population-based 7-year follow-up from the
Tromso study. Nephrol Dial Transplant 2008;23:2818-26. DOI:
http://dx.doi.org/10.1093/ndt/gfn148
http://dx.doi.org/10.1093/ndt/gfn148...
Loss of muscle mass and hyperfiltration are physiologically
associated with decreases in serum creatinine, either by decreased synthesis or
increased clearance. However, this explanation is far from being biologically
plausible, particularly when the vascular alterations introduced by smoking are
considered.3939 Jacobsen BK, Eggen AE, Mathiesen EB, Wilsgaard T, Njølstad I. Cohort
profile: the Tromso Study. Int J Epidemiol 2012;41:961-7. DOI:
http://dx.doi.org/10.1093/ije/dyr049
http://dx.doi.org/10.1093/ije/dyr049...
Despite the difference introduced by the transient improvement in the GFR of
females, the Norwegian team3939 Jacobsen BK, Eggen AE, Mathiesen EB, Wilsgaard T, Njølstad I. Cohort
profile: the Tromso Study. Int J Epidemiol 2012;41:961-7. DOI:
http://dx.doi.org/10.1093/ije/dyr049
http://dx.doi.org/10.1093/ije/dyr049...
concluded
that gender differences affect the interactions between predictors of GFR decline.
Alcohol consumption at any level had a protective effect over the renal function
of men, whereas in women such correlation was not statistically significant.
Physical activity has been positively correlated with GFR increases in females,
while DM and CVD have led to renal function deterioration in both genders.3939 Jacobsen BK, Eggen AE, Mathiesen EB, Wilsgaard T, Njølstad I. Cohort
profile: the Tromso Study. Int J Epidemiol 2012;41:961-7. DOI:
http://dx.doi.org/10.1093/ije/dyr049
http://dx.doi.org/10.1093/ije/dyr049...
Most studies have shown that smoking more than 15 packs a year increases the risk
of renal disorder progression.1616 Orth SR, Stöckmann A, Conradt C, Ritz E, Ferro M, Kreusser W, et al.
Smoking as a risk factor for end-stage renal failure in men with primary renal
disease. Kidney Int 1998;54:926-31. PMID: 9734618 DOI:
http://dx.doi.org/10.1046/j.1523-1755.1998.00067.x
http://dx.doi.org/10.1046/j.1523-1755.19...
17 Yacoub R, Habib H, Lahdo A, Al Ali R, Varjabedian L, Atalla G, et al.
Association between smoking and chronic kidney disease: a case control study. BMC
Public Health 2010;10:731. DOI:
http://dx.doi.org/10.1186/1471-2458-10-731
http://dx.doi.org/10.1186/1471-2458-10-7...
-1818 Ejerblad E, Fored CM, Lindblad P, Fryzek J, Dickman PW, Elinder CG, et
al. Association between smoking and chronic renal failure in a nationwide
population-based case-control study. J Am Soc Nephrol 2004;15:2178-85. DOI:
http://dx.doi.org/10.1097/01.ASN.0000135048.35659.10
http://dx.doi.org/10.1097/01.ASN.0000135...
,2121 Hallan SI, Orth SR. Smoking is a risk factor in the progression to
kidney failure. Kidney Int 2011;80:516-23. PMID: 21677635 DOI:
http://dx.doi.org/10.1038/ki.2011.157
http://dx.doi.org/10.1038/ki.2011.157...
,2727 Shankar A, Klein R, Klein BE. The association among smoking, heavy
drinking, and chronic kidney disease. Am J Epidemiol 2006;164:263-71. PMID: 16775042
DOI: http://dx.doi.org/10.1093/aje/kwj173
http://dx.doi.org/10.1093/aje/kwj173...
This finding
appears to be similar to what has been reported for other diseases such as lung
cancer in relation to the cumulative effects of smoking.4040 Lubin JH, Caporaso N, Wichmann HE, Schaffrath-Rosario A, Alavanja MC.
Cigarette smoking and lung cancer: modeling effect modification of total exposure and
intensity. Epidemiology 2007;18:639-48. DOI:
http://dx.doi.org/10.1097/EDE.0b013e31812717fe
http://dx.doi.org/10.1097/EDE.0b013e3181...
A statistically significant correlation between the
cumulative effects of smoking and renal function decline1515 Stengel B, Couchoud C, Cénée S, Hémon D. Age, blood pressure and smoking
effects on chronic renal failure in primary glomerular nephropathies. Kidney Int
2000;57:2519-26. PMID: 10844621
16 Orth SR, Stöckmann A, Conradt C, Ritz E, Ferro M, Kreusser W, et al.
Smoking as a risk factor for end-stage renal failure in men with primary renal
disease. Kidney Int 1998;54:926-31. PMID: 9734618 DOI:
http://dx.doi.org/10.1046/j.1523-1755.1998.00067.x
http://dx.doi.org/10.1046/j.1523-1755.19...
17 Yacoub R, Habib H, Lahdo A, Al Ali R, Varjabedian L, Atalla G, et al.
Association between smoking and chronic kidney disease: a case control study. BMC
Public Health 2010;10:731. DOI:
http://dx.doi.org/10.1186/1471-2458-10-731
http://dx.doi.org/10.1186/1471-2458-10-7...
-1818 Ejerblad E, Fored CM, Lindblad P, Fryzek J, Dickman PW, Elinder CG, et
al. Association between smoking and chronic renal failure in a nationwide
population-based case-control study. J Am Soc Nephrol 2004;15:2178-85. DOI:
http://dx.doi.org/10.1097/01.ASN.0000135048.35659.10
http://dx.doi.org/10.1097/01.ASN.0000135...
,2121 Hallan SI, Orth SR. Smoking is a risk factor in the progression to
kidney failure. Kidney Int 2011;80:516-23. PMID: 21677635 DOI:
http://dx.doi.org/10.1038/ki.2011.157
http://dx.doi.org/10.1038/ki.2011.157...
,2727 Shankar A, Klein R, Klein BE. The association among smoking, heavy
drinking, and chronic kidney disease. Am J Epidemiol 2006;164:263-71. PMID: 16775042
DOI: http://dx.doi.org/10.1093/aje/kwj173
http://dx.doi.org/10.1093/aje/kwj173...
has also been
observed when patients with other comorbidities such as HIV2424 Míguez-Burbano MJ, Wyatt C, Lewis JE, Rodríguez A, Duncan R. Ignoring
the obvious missing piece of chronic kidney disease in HIV: cigarette smoking. J
Assoc Nurses AIDS Care 2010;21:16-24. DOI:
http://dx.doi.org/10.1016/j.jana.2009.07.005
http://dx.doi.org/10.1016/j.jana.2009.07...
and lung transplant recipients were assessed, even more
than six months after smoking cessation.2020 Hellemons ME, Agarwal PK, van der Bij W, Verschuuren EA, Postmus D,
Erasmus ME, et al. Former smoking is a risk factor for chronic kidney disease after
lung transplantation. Am J Transplant 2011;11:2490-8. DOI:
http://dx.doi.org/10.1111/j.1600-6143.2011.03701.x
http://dx.doi.org/10.1111/j.1600-6143.20...
Smoking cessation was assessed in ten studies included in this review and was
shown to have been statistically correlated with renal function improvement.
However, particularly among heavy smokers - defined as individuals who smoke more
than 15 packs of cigarettes a year - the risk of progression persisted, with a
relative risk of 8.84.4141 Hallan SI, Orth SR. Smoking is a risk factor in the progression to
kidney failure. Kidney Int 2011;80:516-23. PMID: 21677635 DOI:
http://dx.doi.org/10.1038/ki.2011.157
http://dx.doi.org/10.1038/ki.2011.157...
The method used in the studies that looked into the association between smoking
and CKD may have introduced selection and information biases to the analysis. A
great deal of these studies was designed to establish the risk factors for
conditions such as severe hypertension,2222 Regalado M, Yang S, Wesson DE. Cigarette smoking is associated with
augmented progression of renal insufficiency in severe essential hypertension. Am J
Kidney Dis 2000;35:687-94. DOI:
http://dx.doi.org/10.1016/S0272-6386(00)70017-5
http://dx.doi.org/10.1016/S0272-6386(00)...
lung transplant associated with use of calcineurin inhibitors, COPD,2020 Hellemons ME, Agarwal PK, van der Bij W, Verschuuren EA, Postmus D,
Erasmus ME, et al. Former smoking is a risk factor for chronic kidney disease after
lung transplantation. Am J Transplant 2011;11:2490-8. DOI:
http://dx.doi.org/10.1111/j.1600-6143.2011.03701.x
http://dx.doi.org/10.1111/j.1600-6143.20...
and HIV.2424 Míguez-Burbano MJ, Wyatt C, Lewis JE, Rodríguez A, Duncan R. Ignoring
the obvious missing piece of chronic kidney disease in HIV: cigarette smoking. J
Assoc Nurses AIDS Care 2010;21:16-24. DOI:
http://dx.doi.org/10.1016/j.jana.2009.07.005
http://dx.doi.org/10.1016/j.jana.2009.07...
Smoking was one of the data points collected from enrolled
individuals. Smoking and CKD were not among the main objectives of these studies,
although they were retrospectively identified as risk factors.1818 Ejerblad E, Fored CM, Lindblad P, Fryzek J, Dickman PW, Elinder CG, et
al. Association between smoking and chronic renal failure in a nationwide
population-based case-control study. J Am Soc Nephrol 2004;15:2178-85. DOI:
http://dx.doi.org/10.1097/01.ASN.0000135048.35659.10
http://dx.doi.org/10.1097/01.ASN.0000135...
19 Orth SR. Smoking-a risk factor for progression of renal disease. Kidney
Blood Press Res 2000;23:202-4.
20 Hellemons ME, Agarwal PK, van der Bij W, Verschuuren EA, Postmus D,
Erasmus ME, et al. Former smoking is a risk factor for chronic kidney disease after
lung transplantation. Am J Transplant 2011;11:2490-8. DOI:
http://dx.doi.org/10.1111/j.1600-6143.2011.03701.x
http://dx.doi.org/10.1111/j.1600-6143.20...
-2121 Hallan SI, Orth SR. Smoking is a risk factor in the progression to
kidney failure. Kidney Int 2011;80:516-23. PMID: 21677635 DOI:
http://dx.doi.org/10.1038/ki.2011.157
http://dx.doi.org/10.1038/ki.2011.157...
,2727 Shankar A, Klein R, Klein BE. The association among smoking, heavy
drinking, and chronic kidney disease. Am J Epidemiol 2006;164:263-71. PMID: 16775042
DOI: http://dx.doi.org/10.1093/aje/kwj173
http://dx.doi.org/10.1093/aje/kwj173...
This review identified the need for studies to determine the pathophysiological
mechanisms of kidney injury associated with smoking and the establishment of
smoking as both a triggering agent and a risk factor for the progression of CKD.
There still is no evidence as to whether the hemodynamic hypothesis (linked to
nicotine)88 Foley RN. Clinical epidemiology of cardiovascular disease in chronic
kidney disease. J Ren Care 2010;36:4-8. DOI:
http://dx.doi.org/10.1111/j.1755-6686.2010.00171.x
http://dx.doi.org/10.1111/j.1755-6686.20...
or tubular toxicity (linked
to heavy metals)99 Foley RN, Herzog CA, Collins AJ. Smoking and cardiovascular outcomes in
dialysis patients: the United States Renal Data System Wave 2 study. Kidney Int
2003;63:1462-7. PMID: 12631362 DOI:
http://dx.doi.org/10.1046/j.1523-1755.2003.00860.x
http://dx.doi.org/10.1046/j.1523-1755.20...
are the only mechanisms
of renal injury. Perhaps there is a specific substance responsible for the entire
process as in the bladder cancer model, in which a mutagen - 3,4-benzopyrene -
acts as the initiator of damage to cell DNA.4242 Feng Z, Hu W, Rom WN, Beland FA, Tang MS. 4-aminobiphenyl is a major
etiological agent of human bladder cancer: evidence from its DNA binding spectrum in
human p53 gene. Carcinogenesis 2002;23:1721-7. DOI:
http://dx.doi.org/10.1093/carcin/23.10.1721
http://dx.doi.org/10.1093/carcin/23.10.1...
New pathophysiological frontiers to explain old histopathological processes
In 2012, researchers from the University of Alabama at Birmingham (Nephrology and Pathology) showed that rats submitted to 5/6 nephrectomies had an oligomer known as α7 nicotinic acetylcholine receptor (α7nAChR) and changed the understanding of how nicotine acts on the kidneys. This protein led to increases of 100% in proteinuria but not in albuminuria, thus revealing impaired tubular reabsorption. The levels of NADPH oxidase 4 (NOX4), the main marker of oxidative stress in the renal cortex, were increased by 100%. Markers of fibrosis such as fibronectin and transforming growth factor beta (TGF-β) increased by 50% and 200%, respectively. Expression of α7nAChR was more pronounced in the proximal tubule and decreased toward the distal tubules. Levels of α7nAChR were not detected in glomeruli or in the intrarenal vasculature. The administration of methyllycaconitine (MLA), a specific α7nAChR blocker, led to reversals in proteinuria, hypertension, and expression of fibronectin, TGF-β, and NOX4 in rats submitted to 5/6 nephrectomy.
These findings have redirected research perspectives around the progression of CKD
in smokers. Apparently, we are beginning to solve the puzzle of how nicotine acts
on the kidneys. Experimental data indicate that nicotine activates α7nAChR in the
proximal tubule and triggers the biosynthesis of profibrotic and proinflammatory
cytokines.4343 Rezonzew G, Chumley P, Feng W, Hua P, Siegal GP, Jaimes EA. Nicotine
exposure and the progression of chronic kidney disease: role of the α7-nicotinic
acetylcholine receptor. Am J Physiol Renal Physiol 2012;303:304-12. DOI:
http://dx.doi.org/10.1152/ajprenal.00661.2011
http://dx.doi.org/10.1152/ajprenal.00661...
According to this theory, smoking not only causes substance production and
deregulation in the endothelium, release of endothelin-1 (efferent arteriole
vasoconstrictor), and decreased levels of nitric oxide (efferent arteriole
vasodilator)1010 Jones-Burton C, Seliger SL, Scherer RW, Mishra SI, Vessal G, Brown J, et
al. Cigarette smoking and incident chronic kidney disease: a systematic review. Am J
Nephrol 2007;27:342-51. DOI: http://dx.doi.org/10.1159/000103382
http://dx.doi.org/10.1159/000103382...
as previously thought,
but it may also accelerate the progression of CKD through profibrotic and
proinflammatory cytokines. Higher levels of vasoconstrictors would consequently
cause intrarenal hypoxia, neovascularization, and formation of microaneurysms. The
mesangial cells targeted by these cytokines would produce too much mesangial
matrix, leading to the formation of focal nodules similar to what is found in
diabetic nephropathy.4444 Markowitz GS, Lin J, Valeri AM, Avila C, Nasr SH, D'Agati VD. Idiopathic
nodular glomerulosclerosis is a distinct clinicopathologic entity linked to
hypertension and smoking. Hum Pathol 2002;33:826-35. PMID: 12203216 DOI:
http://dx.doi.org/10.1053/hupa.2002.126189
http://dx.doi.org/10.1053/hupa.2002.1261...
If the theory involving proximal tubule inflammation and α7nAChR4343 Rezonzew G, Chumley P, Feng W, Hua P, Siegal GP, Jaimes EA. Nicotine
exposure and the progression of chronic kidney disease: role of the α7-nicotinic
acetylcholine receptor. Am J Physiol Renal Physiol 2012;303:304-12. DOI:
http://dx.doi.org/10.1152/ajprenal.00661.2011
http://dx.doi.org/10.1152/ajprenal.00661...
is proven valid in humans, Science will be
able to explain the findings identified in the study of idiopathic nodular
glomerulosclerosis associated with smoking and hypertension.4444 Markowitz GS, Lin J, Valeri AM, Avila C, Nasr SH, D'Agati VD. Idiopathic
nodular glomerulosclerosis is a distinct clinicopathologic entity linked to
hypertension and smoking. Hum Pathol 2002;33:826-35. PMID: 12203216 DOI:
http://dx.doi.org/10.1053/hupa.2002.126189
http://dx.doi.org/10.1053/hupa.2002.1261...
Perhaps in the coming years the discussion of the toxic inflammatory effects of nicotine on the proximal tubule might guide further research for a selective receptor blocker or renal nicotine-acetylcholine receptors. In the future, it will be possible to stabilize or reverse the progression of CKD with drug therapy.
Smoking and clinical practice
Regardless of the mechanism of renal injury, the evidence derived from
observational studies indicates that CKD patients with comorbidities (primary
glomerulonephritis,1616 Orth SR, Stöckmann A, Conradt C, Ritz E, Ferro M, Kreusser W, et al.
Smoking as a risk factor for end-stage renal failure in men with primary renal
disease. Kidney Int 1998;54:926-31. PMID: 9734618 DOI:
http://dx.doi.org/10.1046/j.1523-1755.1998.00067.x
http://dx.doi.org/10.1046/j.1523-1755.19...
COPD,2020 Hellemons ME, Agarwal PK, van der Bij W, Verschuuren EA, Postmus D,
Erasmus ME, et al. Former smoking is a risk factor for chronic kidney disease after
lung transplantation. Am J Transplant 2011;11:2490-8. DOI:
http://dx.doi.org/10.1111/j.1600-6143.2011.03701.x
http://dx.doi.org/10.1111/j.1600-6143.20...
hypertension,2525 U.S. Renal Data System. USRDS 1998 Annual Data Report National
Institutes of Health, National Institute of Diabetes and Digestive and Kidney
Diseases. U.S. Renal Data System: Bethesda; 1998. HIV,2424 Míguez-Burbano MJ, Wyatt C, Lewis JE, Rodríguez A, Duncan R. Ignoring
the obvious missing piece of chronic kidney disease in HIV: cigarette smoking. J
Assoc Nurses AIDS Care 2010;21:16-24. DOI:
http://dx.doi.org/10.1016/j.jana.2009.07.005
http://dx.doi.org/10.1016/j.jana.2009.07...
proteinuria2828 Noborisaka Y, Ishizaki M, Yamada Y, Honda R, Yokoyama H, Miyao M, et al.
The effects of continuing and discontinuing smoking on the development of chronic
kidney disease (CKD) in the healthy middle-aged working population in Japan. Environ
Health Prev Med 2013;18:24-32. DOI:
http://dx.doi.org/10.1007/s12199-012-0285-7
http://dx.doi.org/10.1007/s12199-012-028...
) tend to experience
faster declines in GFR and increased risk of death.4444 Markowitz GS, Lin J, Valeri AM, Avila C, Nasr SH, D'Agati VD. Idiopathic
nodular glomerulosclerosis is a distinct clinicopathologic entity linked to
hypertension and smoking. Hum Pathol 2002;33:826-35. PMID: 12203216 DOI:
http://dx.doi.org/10.1053/hupa.2002.126189
http://dx.doi.org/10.1053/hupa.2002.1261...
,4545 Perkins RM, Bucaloiu ID, Kirchner HL, Ashouian N, Hartle JE, Yahya T.
GFR decline and mortality risk among patients with chronic kidney disease. Clin J Am
Soc Nephrol 2011;6:1879-86. DOI:
http://dx.doi.org/10.2215/CJN.00470111
http://dx.doi.org/10.2215/CJN.00470111...
The
evidence on CKD progression, mortality, tobacco dose-effect, and renal function
deterioration leaves no doubt over the need to combat smoking. The main tool
available for smoking cessation is a combination between treatment with a
multidisciplinary team and drug therapy.
In our opinion, antismoking medications such as bupropion hydrochloride (Bup®) and varenicline tartrate (Champix®) combined with chewing gum and nicotine patches (Niquitin®) should be added to the therapeutic arsenal of nephrologists.
A new perspective in nephrology
In our view, physicians - nephrologists in particular - should change their approach to smoking. Smoking needs to be seen as a public health issue, as the treatment of smokers does not lie only in the hands of psychiatrists and pulmonologists. We need to intervene upon this modifiable element in the progression of CKD. To that end, the following are needed: 1) guidelines and refresher courses to train nephrologists on how to combat smoking; 2) change our perspectives in relation to smoking; 3) offer antismoking medication in CKD units; 4) address smoking cessation responsibly during patient visits to the CKD unit.
In short, smoking cessation should be valued and treated in the same manner in which one deals with other renal disease progression factors such as anemia, hyperphosphatemia, hypertension, proteinuria, and secondary hyperparathyroidism.
Conclusion
This systematic review revealed a correlation between smoking and progression of CKD. This positive correlation became more pronounced for individuals smoking 15 of more packs of cigarettes a year.
Acknowledgement
The authors would like to thank Dr. Michel Pompeu Barros de Oliveira Sá for his help in organizing and designing this review; Dr. Lais Guimarães Vieira for the technical support and corrections made to the manuscript of this review; and the Coordination of Postgraduate and Masters Programs on Health Sciences at the Federal University of Pernambuco for their academic support.
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Publication Dates
-
Publication in this collection
Oct-Dec 2014
History
-
Received
09 Apr 2014 -
Accepted
18 July 2014