Association between air pollutants and development of chronic kidney disease: A systematic review and meta-analysis
Graphical abstract
Forest plot and pooled estimates of the effect of air pollutants on the risk of chronic kidney disease.
(The size of the gray boxes for each point estimate represents the size of the included study.)
Introduction
Chronic kidney disease (CKD) is a prevalent disease globally with a high disease burden with numerous known risk factors (Levey et al., 2003; Lunyera et al., 2016). CKD is defined as at least three months of either reduced glomerular filtration rate (GFR < 60 mL/min/1.73m2) or evidence of kidney damage such as albuminuria or abnormal pathology (Eknoyan et al., 2013). Each of these can be stratified into further categories according to the GFR. Patients with CKD generally exhibit progressive deterioration in kidney function that would progress to end-stage renal disease (ESRD), requiring renal replacement therapy. Diabetes mellitus, hypertension, aging, and exposure to analgesic agents, heavy metals, and contrast medium are considered to be risk factors for CKD. The identification of modifiable risk factors for CKD such as avoidance of nephrotoxicity agents is crucial for reducing the high burden of CKD globally, but those studies investigating non-traditional risk factors are inadequate.
Exposure to air pollution, especially particulate matter with a diameter smaller than 10 μm (PM10) and 2.5 μm (PM2.5), has received substantial attention recently due to its potential associations with cardiovascular disease, diabetes mellitus, lung cancer, and chronic obstructive pulmonary disease (Arsalane et al., 1999; Fiorito et al., 2018; Hamra et al., 2015; He et al., 2017; Korhonen et al., 2004; Nangaku et al., 2008; Yang et al., 2018). However, data on the relationship between air pollutant exposure and the risk of CKD are scarce. Although the diesel exhaust particles, the major source of traffic related PM2.5, were found to induce nephrotoxicity and acute kidney injury in rodent models, resulting in increased urinary excretion of protein and N-acetyl-β-d-glucosaminidase, impaired renal function and increased severity of renal tubular necrosis (Nemmar et al., 2009; Waly et al., 2013), observational studies that have investigated the short- and long-term relationship between air pollutants and renal function trajectories were limited (Bowe et al., 2017; Bowe et al., 2018; Chin et al., 2018; Mehta et al., 2016; O'Neill et al., 2008). The diverse study design and methodologies of exposure assessment from these reports makes the comparability of results difficult. The potential heterogeneity may have originated from the quality of air pollutant assessment, which would varied by measurement frequency (daily or monthly measurement), air quality data source (ground-based and satellite-based monitoring data), and multivariate statistical techniques (kriging or land use regression modelling) (Zheng et al., 2014; Zou et al., 2015).
In this systematic review and meta-analysis, we attempted to summarize the current evidence on the association between long-term exposure to air pollutants and risk of incident CKD and impairments in renal function.
Section snippets
Data searches and sources
We searched Medline, Embase, and Cochrane Library (from inception until 20 October 2019) using detailed search terms, including “chronic kidney disease,” “end-stage renal disease,” “renal failure,” “renal dysfunction,” “ambient air pollution,” “air pollutants,” “carbon monoxide,” “sulfur dioxide,” “nitrogen dioxide,” “ozone,” and “particulate matter” (Appendix 1 details our search strategy). No filter was applied for the study design. A manual search of the bibliographies of identified studies
Literature search and study characteristics
We identified 4544 peer-reviewed articles from the literature, of which 27 were considered candidates for inclusion after their titles and abstracts were screened. Of the 27, 16 met our inclusion criteria after full texts were screened (Fig. 1). Table 1 details the main characteristics of 16 included studies in our meta-analysis. The 16 included studies that were published between 2008 and 2019 included seven from the United States (Bowe et al., 2017; Bowe et al., 2018; Bragg-Gresham et al.,
Discussion
This systematic review and meta-analysis identified that individuals exposed to higher levels of air pollutants had an increased risk of developing CKD. PM2.5, PM10, and NO2 exhibited a significant association with the incidence of CKD. To our knowledge, this is the first systematic review and meta-analysis of the long-term effects of air pollutant exposure on both renal function and CKD. We expect our findings to increase awareness of the pernicious effects of air pollution on the development
Conclusion
The evidence reviewed in this meta-analysis indicates that exposure to air pollutants, especially PM and NO2, is associated with an increased risk of CKD. Current epidemiologic data suggest that due to the exacerbation of CKD resulting from the pervasive exposure to air pollutants (especially in areas with high levels of PM), air pollution plays an instrumental role in the development of CKD. To reduce the heavy burden of CKD, policies for PM mitigation require careful consideration.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
This work was supported by grants from Taipei Medical University (TMU105-AE1-B33) and the Shuang Ho Hospital (W106HCP-01-1~3).
Authors' contributions
Mei-Yi Wu and Chih-Kang Chiang had full access to all data in this study and took responsibility for the integrity of the data and the accuracy of the related analysis.
Concept and design: Mei-Yi Wu, Mai-Szu Wu, and Chih-Kang Chiang.
Literature search and data analysis and interpretation: Mei-Yi Wu, Wei-Cheng Lo, and Chia-Ter Chao.
Statistical analysis: Mei-Yi Wu and Wei-Cheng Lo.
Drafting of the manuscript: Mei-Yi Wu, Wei-Cheng Lo, and Chia-Ter Chao.
Critical revision of the manuscript on important
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