Investigating the impact of lifestyle factors on kidney patients: insights from epidemiological studies

INTRODUCTION

Chronic kidney disease (CKD) has become a major global health issue, affecting millions of individuals worldwide and contributing to significant morbidity and mortality. It is a progressive condition in which the kidneys lose their ability to function properly, leading to an accumulation of waste and fluid in the body, which can have serious health consequences. While certain factors such as age, genetics, and pre-existing conditions like diabetes and hypertension are well-known contributors to CKD, increasing attention has been directed toward modifiable lifestyle factors that can influence the onset and progression of the disease.¹ This paper focuses on examining the impact of key lifestyle factors-namely diet, physical activity, smoking, alcohol consumption, and stress management-on kidney health. Epidemiological studies have been instrumental in identifying the relationships between these lifestyle factors and the risk of kidney disease, providing valuable insights that can be applied in both prevention and disease management strategies. For instance, dietary choices, particularly high sodium intake, and diets rich in animal protein have been associated with worsening kidney function, while plant-based diets may offer protective benefits. Similarly, regular physical activity has been shown to promote kidney health, whereas sedentary behavior increases the risk of kidney function decline. Smoking and excessive alcohol consumption are well-established risk factors for kidney disease, contributing to its progression by worsening inflammation and oxidative stress in the kidneys. Moreover, mental health, often overlooked in discussions about kidney disease, plays a critical role, with chronic stress exacerbating kidney dysfunction and contributing to poor patient outcomes.^2,3 The significance of these lifestyle factors in kidney disease management is underscored by their modifiability, making them important targets for early intervention and public health initiatives. Despite these advancements, there are still challenges in fully understanding the complex interactions between lifestyle factors and CKD due to limitations in epidemiological research, such as variability in lifestyle measurement, population diversity, and long-term follow-up. Nonetheless, the importance of addressing lifestyle factors in the context of kidney disease prevention and management cannot be overstated.⁸ This paper aims to review existing epidemiological evidence to explore the multifaceted impacts of lifestyle choices on kidney health and to provide recommendations for lifestyle modifications that can serve as effective strategies in mitigating the burden of CKD. By highlighting the critical role of lifestyle in kidney disease progression, this paper advocates for a comprehensive approach to CKD management that incorporates both medical and lifestyle interventions.

IMPORTANCE OF LIFESTYLE MODIFICATIONS

Lifestyle modifications are crucial in managing and preventing CKD due to their significant influence on both the onset and progression of the disease. Unlike non-modifiable risk factors such as age and genetics, lifestyle factors such as diet, physical activity, smoking, alcohol consumption, and stress are modifiable, offering a practical approach for reducing the risk of CKD and slowing its progression. A healthy diet, particularly one that reduces sodium intake and emphasizes plant-based foods, can alleviate the burden on the kidneys and lower blood pressure, one of the primary causes of kidney damage. Similarly, regular physical activity improves cardiovascular health, regulates body weight, and reduces the risk of developing conditions like hypertension and diabetes, both of which are major contributors to CKD.⁹ Smoking and excessive alcohol consumption are strongly linked to kidney damage, as they exacerbate inflammation and oxidative stress, accelerating the disease's progression. Quitting smoking and reducing alcohol intake are critical in preserving kidney function and enhancing overall health. Additionally, managing stress is essential, as chronic stress can raise blood pressure and increase the risk of kidney complications. Stress reduction techniques, such as mindfulness and therapy, have been shown to improve both mental and physical health outcomes in CKD patients. By adopting these lifestyle modifications, individuals can significantly reduce their risk of developing CKD or slow its progression, improving their quality of life and decreasing the likelihood of complications. Moreover, these changes can lessen the financial burden on healthcare systems by reducing the need for more intensive treatments like dialysis or kidney transplantation ^[6]. In conclusion, lifestyle modifications offer an accessible, effective, and holistic approach to managing CKD, empowering individuals to take control of their health through proactive behavioral changes.

EPIDEMIOLOGY OF KIDNEY DISEASES

Global burden of kidney disease

CKD has emerged as a major global health burden, affecting approximately 10% of the global population, with the prevalence varying significantly across regions. CKD is now recognized as one of the leading causes of death and disability worldwide, with over 1.2 million deaths annually attributed to the disease. The highest prevalence is observed in low- and middle-income countries, particularly in regions such as South Asia, sub-Saharan Africa, and Latin America, where access to healthcare is limited, and risk factors like diabetes and hypertension are prevalent. In high-income countries like the United States and Europe, CKD primarily affects older populations, as the incidence increases with age.⁴ The global economic burden of CKD is substantial, with treatment costs escalating, particularly for dialysis and kidney transplantation. Despite these alarming figures, awareness and early detection of CKD remain low, resulting in late diagnoses when the disease has already progressed to advanced stages. This contributes to poor outcomes and a higher risk of complications, including cardiovascular disease. Therefore, addressing the global burden of CKD through effective public health strategies and lifestyle modifications is critical to reducing its prevalence and improving patient outcomes.

Risk factors for kidney disease

The development and progression of kidney disease are influenced by a range of non-modifiable and modifiable risk factors. Non-modifiable factors include genetic predisposition, age, gender, and family history of kidney disease. For instance, individuals with a family history of CKD or other kidney-related issues are at a higher risk of developing the condition. Age is another critical factor, with older adults more susceptible to kidney function decline due to the natural aging process. Gender also plays a role, as men tend to be at a slightly higher risk than women for developing advanced stages of kidney disease. On the other hand, modifiable risk factors provide opportunities for prevention and intervention.⁷ These include lifestyle-related elements such as poor dietary habits, physical inactivity, smoking, excessive alcohol consumption, and unmanaged stress, all of which can contribute to kidney damage over time. Environmental factors like exposure to toxins and pollutants, as well as chronic conditions like diabetes, hypertension, and obesity, are also significant contributors.

Understanding these risk factors allows for targeted public health initiatives aimed at reducing the incidence of CKD through lifestyle modifications and early intervention.

Role of epidemiological studies

Epidemiological studies play a crucial role in understanding the complex relationship between lifestyle factors and kidney disease. These studies provide large-scale data on populations over extended periods, enabling researchers to identify trends and correlations between modifiable risk factors and the onset or progression of CKD. Through cohort studies, case-control studies, and cross-sectional research, epidemiological data has shed light on the significant impact of lifestyle choices such as diet, exercise, smoking, and alcohol use on kidney health. For example, findings from several epidemiological studies have established a strong link between high sodium intake and an increased risk of kidney damage, while regular physical activity is consistently associated with better kidney function and slower disease progression. Smoking and excessive alcohol consumption have been identified as major contributors to the decline in kidney health through inflammation and oxidative stress.^10,12

Additionally, these studies have highlighted the importance of mental health, revealing that chronic stress and anxiety can exacerbate CKD symptoms. The insights gained from epidemiological research are vital for developing public health policies and interventions aimed at reducing the global burden of CKD by promoting healthier lifestyle choices and enabling early detection and management of the disease.

LIFESTYLE FACTORS IMPACTING KIDNEY HEALTH

Diet

Certain food components have an immediate effect on kidney function, highlighting the need of a healthy diet in kidney maintenance. High blood pressure, caused by a diet high in salt, puts stress on the kidneys and speeds up the development of CKD, therefore this is one important aspect to consider. In order to control blood pressure and prevent kidney damage, it is often advised to cut back on salt consumption. Drinking enough of water helps the kidneys filter waste more effectively and keeps kidney stones at bay, so staying hydrated is just as important. Reduced kidney function and an increased risk of developing renal disease can result from inadequate hydration.^5,11 Due to their lower protein and phosphorus content, plant-based diets-which prioritize fruits, vegetables, and whole grains-have been demonstrated to be beneficial for kidney function.

Eating less acid, which can be hard on the kidneys, is another benefit of plant-based diets. In contrast, those who are already at risk of or experiencing CKD may find that their renal function declines more rapidly if they consume an excessive amount of protein, particularly from animal sources. Consequently, maintaining healthy kidney function is greatly enhanced by following a low-sodium diet coupled with adequate hydration and a well-balanced protein consumption.

Physical activity

Physical activity is crucial in maintaining kidney health, as regular exercise has been shown to improve overall health and reduce the risk of chronic diseases, including CKD. Engaging in regular physical activity can help regulate blood pressure, improve cardiovascular health, and enhance insulin sensitivity, all of which are essential in preventing kidney damage. Exercise also helps manage body weight and reduce the risk of obesity, a major risk factor for CKD. Sedentary behavior, on the other hand, is associated with an increased risk of kidney function decline. Studies suggest that individuals who lead inactive lifestyles are more likely to develop conditions such as hypertension and diabetes, which are leading causes of CKD. Moreover, sedentary behavior can lead to muscle wasting and metabolic imbalances, further contributing to kidney damage over time.

Regular aerobic exercise, such as walking, cycling, or swimming, along with strength training, has been shown to slow the progression of CKD by improving circulation, reducing inflammation, and promoting better kidney filtration. Incorporating regular physical activity into daily routines is a modifiable factor that can have a profound positive effect on kidney health and overall well-being.¹⁷

Smoking and alcohol consumption

Smoking and excessive alcohol consumption are significant lifestyle factors that have been linked to the progression of CKD. Epidemiological studies have consistently shown that smoking accelerates kidney function decline, exacerbates hypertension, and increases the risk of kidney disease progression. The harmful chemicals in tobacco lead to oxidative stress and inflammation, damaging the kidneys' delicate filtering structures. Smokers are also at a higher risk of developing cardiovascular diseases, which further strain the kidneys. Additionally, smoking can impair the effectiveness of medications used to treat CKD, making disease management more challenging. Similarly, excessive alcohol consumption is associated with negative kidney outcomes. Chronic alcohol use can lead to dehydration, which reduces kidney function over time. Alcohol also contributes to high blood pressure and liver disease, both of which can aggravate kidney problems. Epidemiological evidence suggests that heavy alcohol consumption leads to a higher risk of kidney failure and end-stage renal disease (ESRD).¹⁴

However, moderate alcohol consumption has been shown to have a neutral or slightly protective effect on kidney health in some studies. Reducing or eliminating smoking and limiting alcohol intake are essential preventive measures for individuals at risk of or already suffering from CKD.

Stress management

Psychological stress plays a critical role in the progression and management of kidney disease. Chronic stress can lead to a cascade of negative physiological effects, including increased blood pressure, inflammation, and metabolic imbalances, all of which strain the kidneys and contribute to the development of CKD. When individuals experience stress, the body's response involves the release of hormones such as cortisol, which, when elevated over time, can impair kidney function. Stress is also linked to poor health behaviors, such as smoking, overeating, and physical inactivity, which further exacerbate kidney disease. Additionally, stress can interfere with the management of existing kidney conditions, making it harder for patients to adhere to treatment plans and lifestyle modifications. Mental health conditions such as anxiety and depression are commonly seen in individuals with CKD and are associated with worse health outcomes.²²

Studies have shown that managing stress through techniques such as mindfulness, meditation, and cognitive behavioral therapy (CBT) can improve kidney health by lowering blood pressure and reducing the impact of stress on the body. Addressing mental health and implementing stress management strategies are essential components of a holistic approach to preventing and managing kidney disease.

REVIEW LITERATURE

Orth and Hallan studied “Smoking: A risk factor for progression of CKD and for cardiovascular morbidity and mortality in renal patients-absence of evidence or evidence of absence” and said that despite being the top cause of death worldwide, the impact of smoking on the progression of kidney disease has been questioned due to a lack of research based on data. Recent clinical and experimental evidence have linked tobacco smoking to an increased risk of renal function deterioration. This investigation shows that smoking significantly raises the risk of kidney disease, so nephrologists should make quitting smoking a top priority for their patients.¹⁵

Dungey et al studied “inflammatory factors and exercise in CKD” and said that patients with chronic renal illness are more likely to have malnutrition and protein loss, as well as elevated levels of inflammatory markers. The primary killer of this population is heart disease, which is linked to this inflammation. Research indicates that increasing levels of habitual movement might assist remedy systemic inflammation, and training is especially beneficial for those with high inflammation levels.⁶

Gansevoort et al studied “CKD and cardiovascular risk: epidemiology, mechanisms, and prevention” and said that in the absence of kidney-specific risk factors or diminished kidney function, the risk of cardiovascular disease is increased twofold or fourfold in patients with chronic renal disease. Misdiagnoses and under treatment are common in this population, further highlighting the need for personalized medical care. Prevention methods, research goals, and guidelines should all keep this in mind.⁷

Reutens studied “epidemiology of diabetic kidney disease” and said that unless measures are put in place, the economic expenses would continue to climb due to diabetes-related kidney disease (DKD), which ranks high among the causes of ESRD in numerous nations. Diagnosis of renal failure and mortality is more likely in patients with microalbuminuria or macroalbuminuria. Both the number of cases and the number of deaths caused by DKD have been decreasing, according to recent studies. Important issues include detecting DKD early, reducing its progression, and improving global results.¹⁸

Wang et al studied “investigating factors associated with depressive symptoms of CKDs in China with type 2 diabetes” and said that with 210 patients diagnosed with type 2 diabetes, researchers from Nantong, China, sought to understand the root reasons of depression. The likelihood of feeling depressed symptoms was enhanced in patients who were female, had hypertension, and were in stage IV or V of the disease. The quality of life was much better for people whose HAD-D scores were less than 11 compared to those whose scores were 11 or above. Optimal care should be provided to this population by clinicians, as stated in the study.²³

Bowden et al studied “a Mediterranean lifestyle is associated with favourable cardiometabolic markers in people with non-dialysis dependent CKD” and said that a Mediterranean diet and lifestyle may help lower the risk of CKD, according to an Australian study. The age range of the 99 participants was 73-95 years, and they all had non-dialysis dependent CKD. Scores ranging from 11 to 33 on the MEDLIFE index showed a moderate to poor level of commitment to the Mediterranean diet and way of life. There was a correlation between a Mediterranean diet and cardiometabolic indicators, such as controlling comorbidities, eating moderate quantities, and reducing sugar in beverages. Having social meals also decreased the occurrence of depressive episodes.³

Jones et al studied “Do lifestyle factors including Smoking, alcohol, and exercise impact your risk of developing kidney stone disease? Outcomes of a systematic review” and said that this research aims to examine the relationship between KSD and other lifestyle factors, including smoking, alcohol intake, and physical activity levels. Out of 4921 articles, 14 fulfilled the inclusion criteria. The findings disprove the hypothesis that cigarette smoking, alcohol consumption, and exercise are causally related. Drinking alcohol decreased the risk of nephrolithiasis, according to one study. Based on the results of four investigations, it is clear that cigarette smoking greatly increases the likelihood of developing kidney stones. Being hydrated and cognizant of the risks of smoking are of the utmost importance.¹⁰

Kurniawan et al studied “association of nutrition education and its interaction with lifestyle factors on kidney function parameters and cardiovascular risk factors among CKD patients in Taiwan” and said that a study conducted in Taiwan with 2,176 patients with CKD found that lifestyle factors and nutrition education (NE) significantly impacted renal function measurements and cardiovascular risk factors. Regardless of smoking status or level of physical activity, patients who received NE had improved glomerular filtration rates and reduced risks of elevated glycated hemoglobin A1c, LDL-C, and C-Ca. The findings suggest that NE has the potential to reduce cardiovascular risk factors and stop the decline of renal function in individuals with CKD.¹¹

Ghelichi-Ghojogh et al studied “CKD and its health-related factors: a case-control study” and said that finding health-related and behavioral characteristics in Iranian patients with CKD was the main objective of this study. CKD is more likely among people with a family history of renal disease, diabetes, low birth weight, or chemotherapy, according to hospital case-control research. The importance of preventive measures is shown by the results, which highlight the critical need for collaborative monitoring of kidney function among patients with different illnesses.⁸

Schuett et al studied “the cardio-kidney patient: epidemiology, clinical characteristics and therapy” and said that a higher incidence of cardiovascular complications, such as heart failure, arrhythmias, coronary artery disease, and sudden cardiac death, is linked to CKD. There is a higher probability of illness and mortality for patients suffering from these disorders. Since there aren't always many options for treating severe CKD, researchers often extrapolate drugs from studies that don't include CKD.²⁰

INSIGHTS FROM EPIDEMIOLOGICAL STUDIES

Major epidemiological studies

Several major epidemiological studies have explored the impact of lifestyle factors on kidney disease. The chronic renal insufficiency cohort (CRIC) study and the modification of diet in renal disease (MDRD) study both provided extensive data on how dietary habits, physical activity, smoking, and alcohol consumption affect kidney function. Additionally, population-based studies like the atherosclerosis risk in communities (ARIC) study and the nurses' health study have linked lifestyle factors such as high sodium intake, low physical activity, and smoking with accelerated kidney function decline, helping shape preventive strategies.¹¹

Findings on diet and kidney disease

Dietary patterns play a crucial role in kidney health, with high sodium intake and diets rich in animal proteins consistently linked to worsening kidney function. Epidemiological studies reveal that individuals who consume high amounts of processed foods and sodium are at greater risk for developing CKD. Conversely, plant-based diets rich in fruits, vegetables, and whole grains have been shown to protect against kidney disease progression by reducing acid load and improving blood pressure regulation, thereby mitigating the risk of CKD.^13,16

Physical activity and kidney health

Epidemiological research has consistently demonstrated that regular physical activity is associated with better kidney health. Studies like the CRIC have shown that individuals who engage in moderate to vigorous physical activity experience slower kidney function decline compared to sedentary individuals. Exercise helps manage blood pressure, reduce inflammation, and improve overall cardiovascular health, all of which are important in preventing or slowing the progression of CKD. Sedentary lifestyles, on the other hand, have been linked to higher rates of kidney disease progression and complications.²¹

Long-term effects of smoking and alcohol

Long-term smoking and excessive alcohol consumption are well-established risk factors for kidney disease. Epidemiological studies, including the Framingham heart study, have found that smokers are more likely to develop CKD and experience faster progression to end-stage renal disease (ESRD). Alcohol, when consumed in excess, exacerbates kidney dysfunction by contributing to dehydration, high blood pressure, and liver damage. However, some studies suggest that light to moderate alcohol consumption may have a neutral or slightly protective effect on kidney health, but more research is needed.¹⁴

Mental health and kidney disease

Recent epidemiological studies have highlighted the significant link between mental health and kidney disease. Chronic stress, depression, and anxiety are associated with worse outcomes in CKD patients, as these conditions can lead to poor treatment adherence and elevated blood pressure, further straining the kidneys. Studies like the CRIC and the dialysis outcomes and practice patterns study (DOPPS) have shown that psychological stress can accelerate kidney function decline. Implementing stress management techniques, such as mindfulness and therapy, has been found to improve kidney health by reducing blood pressure and inflammation levels.

PREVENTION AND MANAGEMENT STRATEGIES BASED ON LIFESTYLE MODIFICATIONS

Prevention and management of CKD through lifestyle modifications are essential strategies for improving patient outcomes and reducing the burden of kidney-related complications. Dietary interventions are among the most effective ways to prevent CKD progression. Reducing sodium intake is a crucial step, as excessive sodium contributes to high blood pressure, a leading cause of kidney damage. Replacing sodium-heavy, processed foods with fresh fruits, vegetables, and whole grains can mitigate this risk. A plant-based diet, which is naturally lower in protein and phosphorus, has been shown to reduce kidney workload and prevent the buildup of harmful waste products. Hydration is equally important, with adequate fluid intake supporting kidney filtration and preventing kidney stone formation.²³ Alongside dietary changes, physical activity plays a critical role in kidney disease management. Regular exercise helps to regulate blood pressure, manage body weight, and improve cardiovascular health, all of which are vital for slowing CKD progression. Even moderate levels of physical activity, such as walking or swimming, can significantly improve kidney function. Smoking cessation is another essential component of kidney health management. Smoking not only accelerates the progression of CKD but also increases the risk of cardiovascular disease, a common complication among kidney patients. Quitting smoking reduces inflammation, improves blood flow to the kidneys, and helps manage blood pressure more effectively. Similarly, limiting alcohol consumption is advised, as excessive drinking can lead to dehydration, hypertension, and liver damage, all of which negatively affect kidney function. On the mental health front, managing stress and anxiety is critical, as psychological stress can elevate blood pressure and exacerbate kidney damage. Stress reduction techniques, such as mindfulness meditation, yoga, and cognitive behavioral therapy (CBT), can help patients better manage their stress levels, leading to improved treatment adherence and overall health outcomes.^19,22 Additionally, routine screenings and early detection are key to preventing CKD from advancing to more severe stages. Individuals at risk for CKD, such as those with hypertension, diabetes, or a family history of kidney disease, should engage in regular check-ups to monitor their kidney function and take preventive measures early. Education about the importance of lifestyle modifications in managing kidney health should be widely promoted, empowering patients to take proactive steps in preventing disease progression. Overall, combining dietary changes, regular exercise, smoking cessation, limited alcohol intake, stress management, and regular health monitoring forms a comprehensive approach to CKD prevention and management.

CONCLUSION

In conclusion, lifestyle modifications play a critical role in the prevention and management of CKD. Diet, physical activity, smoking cessation, alcohol moderation, and stress management are all essential in slowing disease progression and improving patient outcomes. Epidemiological studies underscore the importance of these factors in kidney health, providing evidence-based strategies for mitigating CKD risks. By adopting healthier lifestyle habits and engaging in regular health screenings, individuals can significantly reduce the likelihood of developing or worsening kidney disease. Integrating these strategies into public health policies will further enhance CKD prevention efforts globally.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Babagana-Kyari M, Kazeem MK, Jajere AA. The chronic kidney disease of unknown aetiology (CKDU) epidemics in northern yobe state. AJHSE. 2022;3(2):31-45.
2. 2. Bay B, Blaum C, Kellner C, Bei Der Kellen R, Ojeda F, Waibel J. Inflammatory burden, lifestyle and atherosclerotic cardiovascular disease: insights from a population based cohort study. Sci Rep. 2023;13(1):21761.
3. 3. Bowden K, Gray NA, Swanepoel E, Wright HH. A Mediterranean lifestyle is associated with favourable cardiometabolic markers in people with non-dialysis dependent chronic kidney disease. J Nutr Sci. 2021;10:e42.
4. 4. Neuen BL, Bello AK, Levin A, Lunney M, Osman MA, Ye F, Ashuntantang GE. National health policies and strategies for addressing chronic kidney disease: Data from the International Society of Nephrology Global Kidney Health Atlas. PLOS Glob Public Health. 2023;3(2):0001467.
5. 5. Brosius FC, Hostetter TH, Kelepouris E, Mitsnefes MM, Moe SM, Moore MA. Detection of chronic kidney disease in patients with or at increased risk of cardiovascular disease: a science advisory from the american heart association kidney and cardiovascular disease council; the councils on high blood pressure research, cardiovascular disease in the young, and epidemiology and prevention; and the quality of care and outcomes research interdisciplinary working group: developed in collaboration with the national kidney foundation. circulation. Hypertension. 2006;48(4):751-5.
6. 6. Dungey M, Hull KL, Smith AC, Burton JO, Bishop NC. Inflammatory factors and exercise in chronic kidney disease. Int J Endocrinol. 2013;2013:569831.
7. 7. Gansevoort RT, Correa-Rotter R, Hemmelgarn BR, Jafar TH, Heerspink HJL, Mann JF. Chronic kidney disease and cardiovascular risk: Epidemiology, mechanisms, and prevention. The Lancet, 2013;382(9889):339-52.
8. 8. Ghelichi-Ghojogh M, Fararouei M, Seif M, Pakfetrat M. Chronic kidney disease and its health-related factors: A case-control study. BMC Nephrol. 2022;23(1):24.
9. 9. Go AS, Fang MC, Udaltsova N, Chang Y, Pomernacki NK, Borowsky. Impact of Proteinuria and Glomerular Filtration Rate on Risk of Thromboembolism in Atrial Fibrillation: The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. Circulation, 2006;119(10):1363-9.
10. 10. Jones P, Karim Sulaiman S, Gamage KN, Tokas T, Jamnadass E, Somani BK. Do lifestyle factors including smoking, alcohol, and exercise impact your risk of developing kidney stone disease? Outcomes of a systematic review. J Endourol. 2021;35(1):1-7.
11. 11. Kurniawan AL, Yang YL, Chin MY, Hsu CY, Paramastri R, Lee HA. Association of nutrition education and its interaction with lifestyle factors on kidney function parameters and cardiovascular risk factors among chronic kidney disease patients in Taiwan. Nutrients. 2021;13(2):298.
12. 12. Mantovani A, Lombardi R, Cattazzo F, Zusi C, Cappelli D, Dalbeni A. MAFLD and CKD: an updated narrative review. Int J Mol Sci. 2022;23(13):7007.
13. 13. Mende C. Management of chronic kidney disease: the relationship between serum uric acid and development of nephropathy. Adv Ther. 2015;32(12):1177-91.
14. 14. Myette RL, Lamarche C, Odutayo A, Verdin N, Canney M. Cardiovascular risk in patients with glomerular disease: a narrative review of the epidemiology, mechanisms, management, and patient priorities. Can J Kidney Health Dis. 2024;11:20543581241232472.
15. 15. 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(1):226-36.
16. 16. Pattaro C, Teumer A, Gorski M, Chu AY, Li M, Mijatovic V. Genetic associations at 53 loci highlight cell types and biological pathways relevant for kidney function. Nat Commun. 2016;7:10023.
17. 17. Pilz S, Iodice S, Zittermann A, Grant WB, Gandini S. Vitamin D status and mortality risk in CKD: a meta-analysis of prospective studies. Am J Kidney Dis. 2011;58(3):374-82.
18. 18. Reutens AT. Epidemiology of diabetic kidney disease. Med Clin North Am. 2013;97(1):1-18.
19. 19. Said MA, Van De Vegte YJ, Zafar MM, Van Der Ende MY, Raja. Contributions of interactions between lifestyle and genetics on coronary artery disease risk. Curr Cardiol Rep. 2019;21(9):89.
20. 20. Schuett K, Marx N, Lehrke M. The cardio-kidney patient: epidemiology, clinical characteristics and therapy. Circ Res. 2023;132(8):902-14.
21. 21. Tang L, Yang L, Chen W, Li C, Zeng Y, Yang H. Sex-specific association between coffee consumption and incident chronic kidney disease: A population-based analysis of 359,906 participants from the UK Biobank. Chin Med J (Engl). 2022;135(12):1414-24.
22. 22. Vanholder R, Massy Z, Argiles A, Spasovski G, Verbeke F, Lameire N. Chronic kidney disease as cause of cardiovascular morbidity and mortality. Nephrol Dial Transplant. 2005;20(6):1048-56.
23. 23. Wang X, Shen B, Zhuang X, Wang X, Weng W. Investigating factors associated with depressive symptoms of chronic kidney diseases in china with type 2 diabetes. J Diabetes Res. 2017;2017:1769897.