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      The global and national burden of chronic kidney disease attributable to ambient fine particulate matter air pollution: a modelling study

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          Abstract

          Introduction

          We aimed to integrate all available epidemiological evidence to characterise an exposure–response model of ambient fine particulate matter (PM 2.5) and the risk of chronic kidney disease (CKD) across the spectrum of PM 2.5 concentrations experienced by humans. We then estimated the global and national burden of CKD attributable to PM 2.5.

          Methods

          We collected data from prior studies on the association of PM 2.5 with CKD and used an integrative meta-regression approach to build non-linear exposure–response models of the risk of CKD associated with PM 2.5 exposure. We then estimated the 2017 global and national incidence, prevalence, disability-adjusted life-years (DALYs) and deaths due to CKD attributable to PM 2.5 in 194 countries and territories. Burden estimates were generated by linkage of risk estimates to Global Burden of Disease study datasets.

          Results

          The exposure–response function exhibited evidence of an increase in risk with increasing PM 2.5 concentrations, where the rate of risk increase gradually attenuated at higher PM 2.5 concentrations. Globally, in 2017, there were 3 284 358.2 (95% UI 2 800 710.5 to 3 747 046.1) incident and 122 409 460.2 (108 142 312.2 to 136 424 137.9) prevalent cases of CKD attributable to PM 2.5, and 6 593 134.6 (5 705 180.4 to 7 479 818.4) DALYs and 211 019.2 (184 292.5 to 236 520.4) deaths due to CKD attributable to PM 2.5. The burden was disproportionately borne by low income and lower middle income countries and exhibited substantial geographic variability, even among countries with similar levels of sociodemographic development. Globally, 72.8% of prevalent cases of CKD attributable to PM 2.5 and 74.2% of DALYs due to CKD attributable to PM 2.5 were due to concentrations above 10 µg/m 3, the WHO air quality guidelines.

          Conclusion

          The global burden of CKD attributable to PM 2.5 is substantial, varies by geography and is disproportionally borne by disadvantaged countries. Most of the burden is associated with PM 2.5 levels above the WHO guidelines, suggesting that achieving those targets may yield reduction in CKD burden.

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          Most cited references45

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          Global estimates of mortality associated with long-term exposure to outdoor fine particulate matter

          Significance Exposure to outdoor concentrations of fine particulate matter is considered a leading global health concern, largely based on estimates of excess deaths using information integrating exposure and risk from several particle sources (outdoor and indoor air pollution and passive/active smoking). Such integration requires strong assumptions about equal toxicity per total inhaled dose. We relax these assumptions to build risk models examining exposure and risk information restricted to cohort studies of outdoor air pollution, now covering much of the global concentration range. Our estimates are severalfold larger than previous calculations, suggesting that outdoor particulate air pollution is an even more important population health risk factor than previously thought.
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            Analysis of the Global Burden of Disease study highlights the global, regional, and national trends of chronic kidney disease epidemiology from 1990 to 2016

            The last quarter century witnessed significant population growth, aging, and major changes in epidemiologic trends, which may have shaped the state of chronic kidney disease (CKD) epidemiology. Here, we used the Global Burden of Disease study data and methodologies to describe the change in burden of CKD from 1990 to 2016 involving incidence, prevalence, death, and disability-adjusted-life-years (DALYs). Globally, the incidence of CKD increased by 89% to 21,328,972 (uncertainty interval 19,100,079- 23,599,380), prevalence increased by 87% to 275,929,799 (uncertainty interval 252,442,316-300,414,224), death due to CKD increased by 98% to 1,186,561 (uncertainty interval 1,150,743-1,236,564), and DALYs increased by 62% to 35,032,384 (uncertainty interval 32,622,073-37,954,350). Measures of burden varied substantially by level of development and geography. Decomposition analyses showed that the increase in CKD DALYs was driven by population growth and aging. Globally and in most Global Burden of Disease study regions, age-standardized DALY rates decreased, except in High-income North America, Central Latin America, Oceania, Southern Sub-Saharan Africa, and Central Asia, where the increased burden of CKD due to diabetes and to a lesser extent CKD due to hypertension and other causes outpaced burden expected by demographic expansion. More of the CKD burden (63%) was in low and lower-middle-income countries. There was an inverse relationship between age-standardized CKD DALY rate and health care access and quality of care. Frontier analyses showed significant opportunities for improvement at all levels of the development spectrum. Thus, the global toll of CKD is significant, rising, and unevenly distributed; it is primarily driven by demographic expansion and in some regions a significant tide of diabetes. Opportunities exist to reduce CKD burden at all levels of development.
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              Inhaled Nanoparticles Accumulate at Sites of Vascular Disease

              The development of engineered nanomaterials is growing exponentially, despite concerns over their potential similarities to environmental nanoparticles that are associated with significant cardiorespiratory morbidity and mortality. The mechanisms through which inhalation of nanoparticles could trigger acute cardiovascular events are emerging, but a fundamental unanswered question remains: Do inhaled nanoparticles translocate from the lung in man and directly contribute to the pathogenesis of cardiovascular disease? In complementary clinical and experimental studies, we used gold nanoparticles to evaluate particle translocation, permitting detection by high-resolution inductively coupled mass spectrometry and Raman microscopy. Healthy volunteers were exposed to nanoparticles by acute inhalation, followed by repeated sampling of blood and urine. Gold was detected in the blood and urine within 15 min to 24 h after exposure, and was still present 3 months after exposure. Levels were greater following inhalation of 5 nm (primary diameter) particles compared to 30 nm particles. Studies in mice demonstrated the accumulation in the blood and liver following pulmonary exposure to a broader size range of gold nanoparticles (2–200 nm primary diameter), with translocation markedly greater for particles <10 nm diameter. Gold nanoparticles preferentially accumulated in inflammation-rich vascular lesions of fat-fed apolipoproteinE-deficient mice. Furthermore, following inhalation, gold particles could be detected in surgical specimens of carotid artery disease from patients at risk of stroke. Translocation of inhaled nanoparticles into the systemic circulation and accumulation at sites of vascular inflammation provides a direct mechanism that can explain the link between environmental nanoparticles and cardiovascular disease and has major implications for risk management in the use of engineered nanomaterials.
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                2020
                25 March 2020
                : 5
                : 3
                : e002063
                Affiliations
                [1 ]departmentClinical Epidemiology Center , VA Saint Louis Health Care System , Saint Louis, Missouri, USA
                [2 ]departmentDepartment of Epidemiology and Biostatistics, College for Public Health and Social Justice , Saint Louis University , Saint Louis, Missouri, USA
                [3 ]departmentDivision of Public Health Sciences, Department of Surgery , Washington University in Saint Louis School of Medicine , Saint Louis, Missouri, USA
                [4 ]departmentDepartment of Medicine , Washington University in Saint Louis School of Medicine , Saint Louis, Missouri, USA
                [5 ]departmentNephrology Section, Medicine Service , VA Saint Louis Helath Care System , Saint Louis, Missouri, USA
                [6 ]departmentInstitute for Public Health , Washington University in Saint Louis , Saint Louis, Missouri, USA
                Author notes
                [Correspondence to ] Dr Ziyad Al-Aly; zalaly@ 123456gmail.com
                Author information
                http://orcid.org/0000-0002-2600-0434
                Article
                bmjgh-2019-002063
                10.1136/bmjgh-2019-002063
                7173767
                f694a643-e69f-4aee-9556-f2db17526fbc
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 07 October 2019
                : 10 February 2020
                : 15 February 2020
                Categories
                Original Research
                1506
                Custom metadata
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                environmental health,public health
                environmental health, public health

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