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Net Letter
87 (
2
); 321-321
doi:
10.25259/IJDVL_372_19

Prevalence and stages of chronic kidney disease in psoriasis and psoriatic arthritis: A cross-sectional study

Department of Dermatology Germans Trias i Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
Department of Rheumatology, Germans Trias i Pujol University Hospital, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
Corresponding author: Dr. Mónica Munera-Campos, Department of Dermatology, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, S/N, 08916 Badalona, Barcelona, Spain. monicamunera@hotmail.com
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This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Munera-Campos M, Ferrándiz C, Mateo L, Prior-Español A, Carrascosa JM. Prevalence and stages of chronic kidney disease in psoriasis and psoriatic arthritis: A cross-sectional study. Indian J Dermatol Venereol Leprol 2021;87:321-321.

Sir,

A few retrospective cohort studies have reported an increased incidence of chronic kidney disease (CKD) in patients with psoriasis, independent of traditional cardiovascular risk factors and nephrotoxic drugs.1,2 However, those studies have relied mainly on secondary data which makes it impossible to stratify patients. Additionally, mild-to-moderate declines in estimated glomerular filtration rate (eGFR) were not reported.

Our aim was to describe the prevalence of eGFR stages and CKD in a representative cohort of patients with moderate-to-severe psoriasis, and to explore predictors of CKD.

We conducted a prospective, cross-sectional study in patients aged 20 or above who had been diagnosed with moderate-to-severe psoriasis on the basis of their need for phototherapy or systemic treatment (≥6 months) and/or psoriatic arthropathy. Participants were recruited from dermatology and rheumatology outpatient clinics at a tertiary University Hospital between October 2007 and May 2018. This study was approved by the Ethics Committee of our hospital.

We examined laboratory data of serum creatinine and eGFR using the Chronic Kidney Disease-Epidemiology Collaboration (CDK-EPI) formula. The criteria for CKD were an eGFR value under 60mL/min/1.73m2 on at least 2 occasions separated by at least 3 months. Acute kidney impairment was ruled out. To identify the risk factors associated with comorbid CKD, we performed univariate and multivariate logistic regression analyses (SPSS, v25). A P value of less than 0.05 was considered statistically significant.

Our study population included 558 patients: 221 (39.6%) had purely cutaneous psoriasis, 108 (19.4%) had only psoriatic arthropathy whereas 229 (41%) had both. Three patients with psoriatic arthropathy had concomitant renal amyloidosis. Characteristics and potential confounders have been summarised in Table 1.

Table 1:: Demographic, clinical and treatment characteristics of the study population (n=558)
Feature n(%)
Sex
Male 315 (56.5)
Female 243 (43.5)
Age (years) range
20-39 71 (12.7)
40-64 353 (63.3)
>64 134 (24)
Smoking status
Current smoker 135 (24.2)
Ex-smoker 63 (11.3)
Non-smoker 360 (64.5)
Alcohol intake
Alcohol consumer 117 (21)
Non-consumer 441 (79)
BMI
Obesity (BMI >30 kg/m2) 144 (25.8)
Overweight (BMI 2530 kg/m2) 135 (24.2)
Normal weight (BMI 18.5-24.9kg/m2) 279 (50)
Comorbidities
Hypertension 158 (28.3)
Dyslipidaemia 206 (36.9)
Ischaemic heart disease 21 (3.8)
Diabetes 82 (14.7)
Psoriasis duration (years)
Duration >10 339 (60.8)
Clinical characteristics
Psoriasis 450 (80.7)
Chronic plaque psoriasis 422 (93.8)
Guttate psoriasis 12 (2.7)
Erythrodermic psoriasis 5 (1.1)
Generalized pustular psoriasis 6 (0.1)
Palmoplantar pustular psoriasis 23 (5.1)
Psoriatic arthritis (all subtypes) 337 (60.4)
Subtypes
Oligoarthritis 145 (43)
Polyarthritis 94 (27.9)
Axial 22 (6.5)
Oligoarthritis with axial involvement 31 (9.2)
Polyarthritis with axial involvement 34 (10.1)
Distant interphalangeal arthritis 11 (3.3)
Comorbid manifestations
Dactylitis 116 (34.4)
Tendonitis 129 (38.3)
Plantar fasciitis 34 (10.1)
Enthesitis 88 (26.1)
Coexisting renal amyloidosis 3 (0.9)
Use of NSAIDs
Non-user 106 (19)
Low frequency user(<2 prescriptions/year) 390 (69.9)
Moderately frequent user (2-5 prescriptions/year) 50 (9)
Highly frequent user (>5 prescriptions/year) 12 (2.2)
Treatments received >6 months
Phototherapy 155 (27.8)
Methotrexate 372 (66.7)
Leflunomide 108 (19.4)
Salazopyrin 20 (3.6)
Hydroxychloroquine 16 (2.9)
Cyclosporin 47 (8.4)
Acitretin 44 (7.9)
Apremilast 13 (2.3)
Adalimumab 74 (13.3)
Etanercept 80 (14.3)
Infliximab 28 (5)
Golimumab 8 (1.4)
Certolizumab 4 (0.7)
Ustekinumab 50 (9)
Secukinumab 16 (2.9)
Ixekizumab 6 (1.1)
Efalizumab 25 (4.5)

BMI: Body mass index, NSAIDs: Nonsteroidal anti-inflammatory drugs

The overall prevalence of CKD was 15.2% (1.4% for age 20-39 years; 9.4% for age 40-64 years and 38.1% for age >64 years). In patients who had only skin disease, the prevalence of CKD was 9.5% compared with 18.8% in the group with skin disease and psoriatic arthropathy. Prevalence of eGFR as per staging is shown in Table 2. Unadjusted associations for CKD are shown in Table 3. On multivariate analysis, only age >64 years, hypertension and psoriatic arthropathy remained as independent predictors of CKD [Table 4].

Table 2:: Prevalence of estimated glomerular filtration rate stages and overall chronic kidney disease (stages 3-5) in the study population (n=558)
Prevalence of eGFR (mL/min/1.73 m2) distributed in categories and overall CKD. Expressed by n(%)
Normal (≥90) Stage 2 (60-89) Stage 3a (45-59) Stage 3b (30-44) Stage 4 (15-29) Stage 5 (<15) CKD (Stages 3-5) (overall <60)
Total (n=558) 219 (39.3) 254 (45.5) 58 (10.4) 16 (2.9) 9 (1.6) 2 (0.4) 85 (15.2)
Age (years)
20-39 (n=71) 45 (63.4) 25 (35.2) - - 1 (1.4) - 1 (1.4)
40-64 (n=353) 164 (46.5) 156 (44.2) 26 (7.4) 5 (1.4) 1 (0.3) 1 (0.3) 33 (9.4)
>64 (n=134) 10 (7.5) 73 (54.5) 32 (23.9) 11 (8.2) 7 (5.2) 1 (0.8) 51 (38.1)
Sex
Male (n=315) 124 (39.4) 147 (46.7) 34 (10.8) 6 (1.9) 4 (1.3) - 44 (14)
Female (n=243) 95 (39.1) 107 (44) 24 (9.9) 10 (4.1) 5 (2.1) 2 (0.8) 41 (16.9)

eGFR: Estimated glomerular filtration rate, CKD: Chronic kidney disease

Table 3:: Unadjusted associations (univariate analysis) between demographic, clinical and systemic therapies, and the presence of chronic kidney disease (estimated glomerular filtration rate <60 ml/min/1.73m2)
Characteristic (reference) OR (95% CI) P
Age >64 years (v/s ≤64 years) 6.6 (4-10.7) <0.001
Age >64 years (v/s 20-39 years) 43 (5.8-319.3) <0.001
Age 40-64 years (v/s 20-39 years) 7.22 (1-53.7) 0.02
Men (v/s women) 1.3 (0.8-2) 0.344
Alcohol consumer (v/s non-consumer) 0.6 (0.3-1.2) 0.163
Current smoker (v/s non-smoker) 1 (0.5-1.7) 0.855
Ex-smoker (v/s non-smoker) 1.5 (0.8-3) 0.233
Obesity, BMI >30 kg/m2(v/s normal, 18.5-25 kg/m2) 1.2 (0.7-2) 0.538
Overweight, BMI 25-30 kg/m2(v/s normal, 18.5-25 kg/m2) 0.8 (0.5-1.5) 0.510
Hypertension (v/s absence) 4.3 (2.7-6.9) <0.001
Dyslipidaemia (v/s absence) 1.7 (1.1-2.8) 0.019
Ischaemic heat disease (v/s absence) 2.9 (1.2-7.5) 0.019
Diabetes (v/s absence) 2.8 (1.6-4.9) <0.001
Psoriatic arthritis (v/s absence) 2.2 (1.3-3.8) 0.002
Disease duration >10 years (v/s ≤10 years) 1 (0.6-1.5) 0.877
NSAIDs frequent user (2-5 prescriptions/y) (v/s nonuser) 1 (0.4-2.4) 0.991
NSAIDs high-frequent user (>5 prescriptions/years) (v/s nonuser) 0.9 (0.2-4.5) 0.914
Methotrexate (v/s absence) 0.8 (0.5-1.3) 0.359
Leflunomide (v/s absence) 1.1 (0.7-2) 0.644
Salazopyrin (v/s absence) 0.8 (0.8-1) 0.503
Hydroxychloroquine (v/s absence) 0.8 (0.2-3.5) 0.758
Cyclosporin (v/s absence) 0.8 (0.3-2) 0.623
Acitretin (v/s absence) 0.9 (0.4-2.1) 0.759

BMI: Body mass index, CI: confidence interval, OR: Odds ratio, NSAIDs: Nonsteroidal anti-inflammatory drugs

Table 4:: Multivariable logistic regression analysis of epidemiological and clinical factors: Independent predictors of chronic kidney disease (estimated glomerular filtration rate <60 ml/min/1.73 m2) in the multivariate logistic regression model
Predictor OR (95 CI) P
Age >64 years (v/s ≤64 years) 4.7 (2.7-8.1) <0.001
Hypertension (v/s absence) 2.3 (1.3-4) 0.005
Psoriatic arthritis 2.5 (1.4-4.5) 0.002
Men (v/s woman) 0.9 (0.5-1.5) 0.682
Alcohol consumer (v/s nonconsumer) 1.4 (0.2-9.2) 0.755
Currently smoker (v/s nonsmoker) 0.6 (0.1-4.4) 0.581
Exsmoker (v/s nonsmoker) 1 (0.6-1.8) 0.897
Obesity, BMI >30 kg/m2(v/s normal, 18.5-25 kg/m2) 0.9 (0.5-1.6) 0.658
Overweight, BMI 25-30 kg/m2(v/s normal, 18.5-25 kg/m2) 0.5 (0.2-1.1) 0.172
Dyslipidaemia (v/s absence) 1.3 (0.8-2.4) 0.310
Ischaemic heat disease (v/s absence) 1.2 (0.4-3.8) 0.719
Diabetes (v/s absence) 1.4 (0.7-2.8) 0.306
Disease duration >10 years (v/s ≤10 years) 1.6 (0.9-2.8) 0.147
NSAIDs frequent user (2-5 prescriptions/years) (v/s nonuser) 1.6 (0.8-3.3) 0.164
NSAIDs high-frequent user (>5 prescriptions/years) (v/s nonuser) 1.4 (0.3-7.3) 0.686
Methotrexate (v/s absence) 0.7 (0.4-1.2) 0.189
Leflunomide (v/s absence) 0.6 (0.3-1.2) 0.160
Salazopyrin (v/s absence) 0.5 (0.2-1.1) 0.078
Hydroxychloroquine (v/s absence) 1.6 (0.8-3.2) 0.208
Cyclosporin (v/s absence) 1.3 (0.5-3.5) 0.663
Acitretin (v/s absence) 1.9 (0.7-5.4) 0.238

BMI: Body mass index, CI: confidence interval, OR: Odds ratio, NSAIDs: Nonsteroidal anti-inflammatory drugs

A total of 85 patients (15.2%) had CKD. Although the study lacks a control group, the prevalence of CKD and of mildly decreased eGFR found are higher than those in the general population.3 We also found an overall prevalence of 45.5% for stage 2 eGFR, a relatively high percentage compared to data from the general population, particularly in younger individuals (35.2% for age 20-39 years). Cardiovascular mortality increased linearly when eGFR decreased to below 75 mL/min/1.73m2, independent of traditional cardiovascular risk factors and albuminuria.4 In this study group, 30.7% patients had results below this threshold (5.6% for age 20-39 years; 24.6% for age 40-64 years; and 59.7% for age >64 years), a finding that could be associated with an increased cardiovascular risk.

The three independent predictors of CKD were age >64 years, hypertension and psoriatic arthropathy. Although eGFR decreases with age, the prevalence of CKD over 64 years of age in our study group (38.1%) is higher than what is reported for the general population (21.4%).

It has been hypothesised that the decrease in eGFR in patients with psoriasis may be due to an increase in systemic cytokines (tumor necrosis factor-α and interleukin-6) and endothelial dysfunction, which has been associated with an increase in fibroblast growth factor-23.2 In our study group, the presence of psoriatic arthropathy increased the risk of CKD (odds ratio, 2.5) after adjustment for conventional risk factors and nephrotoxic drugs. Psoriatic arthropathy may increase chronic inflammation more than psoriasis without arthropathy.

This study is limited by the small sample size and the lack of a control group. Nonetheless, it includes a cohort undergoing close monitoring, which allowed us to stratify eGFR stages and to obtain the prevalence of CKD defined by eGFR (using the CKD-EPI equation, which has been shown to be more accurate than other formulae).5 Moreover, the eGFR classification was based on 2 values obtained more than 90 days apart and acute renal impairment was systematically ruled out.

To conclude, the prevalence of CKD among patients with moderate-to-severe psoriasis and/or psoriatic arthropathy is high. Age over 64 years and the presence of hypertension may predict an increased likelihood of CKD. In other words, psoriasis could increase the likelihood of renal impairment in patients with conventional cardiovascular risk factors and the presence of psoriatic arthropathy may be associated with additional risk. Mildly decreased eGFR was highly prevalent and could increase cardiovascular risk in these patients. Our findings suggest that renal and cardiovascular risk factors should be taken into consideration in cases of moderate-to-severe forms of psoriasis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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