Adiposity and risk of decline in glomerular filtration rate: meta-analysis of individual participant data in a global consortium

doi:10.1136/bmj.k5301

Meta-Analysis

. 2019 Jan 10:364:k5301.

doi: 10.1136/bmj.k5301.

Adiposity and risk of decline in glomerular filtration rate: meta-analysis of individual participant data in a global consortium

Alex R Chang¹, Morgan E Grams², Shoshana H Ballew³, Henk Bilo⁴, Adolfo Correa⁵, Marie Evans⁶, Orlando M Gutierrez^{7

8}, Farhad Hosseinpanah⁹, Kunitoshi Iseki^{10

11}, Timothy Kenealy¹², Barbara Klein¹³, Florian Kronenberg¹⁴, Brian J Lee¹⁵, Yuanying Li¹⁶, Katsuyuki Miura¹⁷, Sankar D Navaneethan¹⁸, Paul J Roderick¹⁹, Jose M Valdivielso²⁰, Frank L J Visseren²¹, Luxia Zhang²², Ron T Gansevoort²³, Stein I Hallan^{24

25}, Andrew S Levey²⁶, Kunihiro Matsushita³, Varda Shalev²⁷, Mark Woodward^{3

28

29}; CKD Prognosis Consortium (CKD-PC)

Collaborators, Affiliations

Collaborators

CKD Prognosis Consortium (CKD-PC):
Brad Astor, Larry Appel, Tom Greene, Teresa Chen, John Chalmers, Hisatomi Arima, Vlado Perkovic, Hiroshi Yatsuya, Koji Tamakoshi, Yoshihisa Hirakawa, Josef Coresh, Yingying Sang, Kevan Polkinghorne, Steven Chadban, Robert Atkins, Adeera Levin, Ognjenka Djurdjev, Ron Klein, Kristine Lee, Lisheng Liu, Minghui Zhao, Fang Wang, Jinwei Wang, Mila Tang, Gunnar Heine, Insa Emrich, Adam Zawada, Lucie Bauer, Joseph Nally, Jesse Schold, Michael Shlipak, Mark Sarnak, Ronit Katz, Jade Hiramoto, Hiroyasu Iso, Kazumasa Yamagishi, Mitsumasa Umesawa, Isao Muraki, Masafumi Fukagawa, Shoichi Maruyama, Takayuki Hamano, Takeshi Hasegawa, Naohiko Fujii, Tazeen Jafar, Juanita Hatcher, Neil Poulter, Nish Chaturvedi, David Wheeler, John Emberson, John Townend, Martin Landray, Hermann Brenner, Ben Schöttker, Kai-Uwe Saum, Dietrich Rothenbacher, Caroline Fox, Shih-Jen Hwang, Anna Köttgen, Markus P Schneider, Kai-Uwe Eckardt, Jamie Green, H Lester Kirchner, Sadayoshi Ito, Mariko Miyazaki, Masaaki Nakayama, Gen Yamada, Massimo Cirillo, Solfrid Romundstad, Marius Øvrehus, Knut Asbjørn Langlo, Fujiko Irie, Toshimi Sairenchi, Casey M Rebholz, Bessie Young, L Ebony Boulware, Shizukiyo Ishikawa, Yuichiro Yano, Kazuhiko Kotani, Takeshi Nakamura, Sun Ha Jee, Heejin Kimm, Yejin Mok, Gabriel Chodick, Jack F M Wetzels, Peter J Blankestijn, Arjan D van Zuilen, M Bots, Mark Sarnak, Lesley Inker, Carmen Peralta, Barbara Kollerits, Eberhard Ritz, Dorothea Nitsch, Astrid Fletcher, Erwin Bottinger, Girish N Nadkarni, Stephen B Ellis, Rajiv Nadukuru, Elvira Fernandez, Angels Betriu, Marcelino Bermudez-Lopez, Benedicte Stengel, Marie Metzger, Martin Flamant, Pascal Houillier, Jean-Philippe Haymann, Marc Froissart, Hirotsugu Ueshima, Akira Okayama, Sachiko Tanaka, Tomonori Okamura, C Raina Elley, John F Collins, Paul L Drury, Takayoshi Ohkubo, Kei Asayama, Hirohito Metoki, Masahiro Kikuya, Masaaki Nakayama, Chiho Iseki, Robert G Nelson, William C Knowler, Stephan J L Bakker, Hiddo J L Heerspink, Nigel Brunskill, Rupert Major, David Shepherd, James Medcalf, Simerjot K Jassal, Jaclyn Bergstrom, Joachim H Ix, Elizabeth Barrett-Connor, Csaba Kovesdy, Kamyar Kalantar-Zadeh, Keiichi Sumida, Paul Muntner, David Warnock, Suzanne Judd, Bhupesh Panwar, Dick de Zeeuw, Barry Brenner, Sanaz Sedaghat, M Arfan Ikram, Ewout J Hoorn, Abbas Dehghan, Tien Yin Wong, Charumathi Sabanayagam, Ching-Yu Cheng, Riswana Banu, Mårten Segelmark, Maria Stendahl, Staffan Schön, Navdeep Tangri, Maneesh Sud, David Naimark, Chi-Pang Wen, Chwen-Keng Tsao, Min-Kugng Tsai, Chien-Hua Chen, Tsuneo Konta, Atsushi Hirayama, Kazunobu Ichikawa, Farzad Hadaegh, Mohammadhassan Mirbolouk, Fereidoun Azizi, Marit Dahl Solbu, Trond Geir Jenssen, Bjørn Odvar Eriksen, Anne Elise Eggen, Lars Lannfelt, Anders Larsson, Johan Ärnlöv, Gijs W D Landman, Kornelis J J van Hateren, Nanne Kleefstra, Jingsha Chen, Lucia Kwak, Aditya Surapaneni

Affiliations

¹ Kidney Health Research Institute, and Department of Epidemiology and Health Services Research, Geisinger Health System, Danville, PA, USA.
² Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA ckdpc@jhmi.edu.
³ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁴ Diabetes Centre, Isala, and Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
⁵ Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
⁶ Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden and Swedish Renal Registry, Jönköping, Sweden.
⁷ Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
⁸ Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.
⁹ Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
¹⁰ Dialysis Unit, University of the Ryukyus Hospital, Nishihara, Japan.
¹¹ Yuuaikai Tomishiro Central Hospital, Tomigusuku, Okinawa, Japan.
¹² Departments of Medicine and General Practice & Primary Health Care, School of Population Health, University of Auckland, Auckland, New Zealand.
¹³ Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
¹⁴ Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University of Innsbruck, Innsbruck, Austria.
¹⁵ Kaiser Permanente, Hawaii Region, Moanalua Medical Center, Honolulu, HI, USA.
¹⁶ Department of Public Health, Fujita Health University School of Medicine, Aichi, Japan.
¹⁷ Department of Public Health, Shiga University of Medical Science, Otsu, Japan.
¹⁸ Section of Nephrology, Baylor College of Medicine, Houston, TX, USA.
¹⁹ Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
²⁰ Vascular and Renal Translational Research Group, REDinREN del ISCIII, IRBLleida, Lleida, Spain.
²¹ Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, Netherlands.
²² Peking University Institute of Nephrology, Division of Nephrology, Peking University First Hospital, Beijing, China.
²³ Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
²⁴ Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science Technology, Trondheim, Norway.
²⁵ Division of Nephrology, Department of Medicine, St Olav University Hospital, Trondheim, Norway.
²⁶ Division of Nephrology at Tufts Medical Center, Boston, MA, USA.
²⁷ Medical Division, Maccabi Healthcare Services, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
²⁸ George Institute for Global Health, University of Oxford, Oxford, UK.
²⁹ George Institute for Global Health, University of New South Wales, Sydney, Australia.

PMID: 30630856
PMCID: PMC6481269
DOI: 10.1136/bmj.k5301

Meta-Analysis

Adiposity and risk of decline in glomerular filtration rate: meta-analysis of individual participant data in a global consortium

Alex R Chang et al. BMJ. 2019.

. 2019 Jan 10:364:k5301.

doi: 10.1136/bmj.k5301.

Authors

Collaborators

CKD Prognosis Consortium (CKD-PC):
Brad Astor, Larry Appel, Tom Greene, Teresa Chen, John Chalmers, Hisatomi Arima, Vlado Perkovic, Hiroshi Yatsuya, Koji Tamakoshi, Yoshihisa Hirakawa, Josef Coresh, Yingying Sang, Kevan Polkinghorne, Steven Chadban, Robert Atkins, Adeera Levin, Ognjenka Djurdjev, Ron Klein, Kristine Lee, Lisheng Liu, Minghui Zhao, Fang Wang, Jinwei Wang, Mila Tang, Gunnar Heine, Insa Emrich, Adam Zawada, Lucie Bauer, Joseph Nally, Jesse Schold, Michael Shlipak, Mark Sarnak, Ronit Katz, Jade Hiramoto, Hiroyasu Iso, Kazumasa Yamagishi, Mitsumasa Umesawa, Isao Muraki, Masafumi Fukagawa, Shoichi Maruyama, Takayuki Hamano, Takeshi Hasegawa, Naohiko Fujii, Tazeen Jafar, Juanita Hatcher, Neil Poulter, Nish Chaturvedi, David Wheeler, John Emberson, John Townend, Martin Landray, Hermann Brenner, Ben Schöttker, Kai-Uwe Saum, Dietrich Rothenbacher, Caroline Fox, Shih-Jen Hwang, Anna Köttgen, Markus P Schneider, Kai-Uwe Eckardt, Jamie Green, H Lester Kirchner, Sadayoshi Ito, Mariko Miyazaki, Masaaki Nakayama, Gen Yamada, Massimo Cirillo, Solfrid Romundstad, Marius Øvrehus, Knut Asbjørn Langlo, Fujiko Irie, Toshimi Sairenchi, Casey M Rebholz, Bessie Young, L Ebony Boulware, Shizukiyo Ishikawa, Yuichiro Yano, Kazuhiko Kotani, Takeshi Nakamura, Sun Ha Jee, Heejin Kimm, Yejin Mok, Gabriel Chodick, Jack F M Wetzels, Peter J Blankestijn, Arjan D van Zuilen, M Bots, Mark Sarnak, Lesley Inker, Carmen Peralta, Barbara Kollerits, Eberhard Ritz, Dorothea Nitsch, Astrid Fletcher, Erwin Bottinger, Girish N Nadkarni, Stephen B Ellis, Rajiv Nadukuru, Elvira Fernandez, Angels Betriu, Marcelino Bermudez-Lopez, Benedicte Stengel, Marie Metzger, Martin Flamant, Pascal Houillier, Jean-Philippe Haymann, Marc Froissart, Hirotsugu Ueshima, Akira Okayama, Sachiko Tanaka, Tomonori Okamura, C Raina Elley, John F Collins, Paul L Drury, Takayoshi Ohkubo, Kei Asayama, Hirohito Metoki, Masahiro Kikuya, Masaaki Nakayama, Chiho Iseki, Robert G Nelson, William C Knowler, Stephan J L Bakker, Hiddo J L Heerspink, Nigel Brunskill, Rupert Major, David Shepherd, James Medcalf, Simerjot K Jassal, Jaclyn Bergstrom, Joachim H Ix, Elizabeth Barrett-Connor, Csaba Kovesdy, Kamyar Kalantar-Zadeh, Keiichi Sumida, Paul Muntner, David Warnock, Suzanne Judd, Bhupesh Panwar, Dick de Zeeuw, Barry Brenner, Sanaz Sedaghat, M Arfan Ikram, Ewout J Hoorn, Abbas Dehghan, Tien Yin Wong, Charumathi Sabanayagam, Ching-Yu Cheng, Riswana Banu, Mårten Segelmark, Maria Stendahl, Staffan Schön, Navdeep Tangri, Maneesh Sud, David Naimark, Chi-Pang Wen, Chwen-Keng Tsao, Min-Kugng Tsai, Chien-Hua Chen, Tsuneo Konta, Atsushi Hirayama, Kazunobu Ichikawa, Farzad Hadaegh, Mohammadhassan Mirbolouk, Fereidoun Azizi, Marit Dahl Solbu, Trond Geir Jenssen, Bjørn Odvar Eriksen, Anne Elise Eggen, Lars Lannfelt, Anders Larsson, Johan Ärnlöv, Gijs W D Landman, Kornelis J J van Hateren, Nanne Kleefstra, Jingsha Chen, Lucia Kwak, Aditya Surapaneni

Affiliations

¹ Kidney Health Research Institute, and Department of Epidemiology and Health Services Research, Geisinger Health System, Danville, PA, USA.
² Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA ckdpc@jhmi.edu.
³ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁴ Diabetes Centre, Isala, and Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
⁵ Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
⁶ Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden and Swedish Renal Registry, Jönköping, Sweden.
⁷ Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
⁸ Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.
⁹ Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
¹⁰ Dialysis Unit, University of the Ryukyus Hospital, Nishihara, Japan.
¹¹ Yuuaikai Tomishiro Central Hospital, Tomigusuku, Okinawa, Japan.
¹² Departments of Medicine and General Practice & Primary Health Care, School of Population Health, University of Auckland, Auckland, New Zealand.
¹³ Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
¹⁴ Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University of Innsbruck, Innsbruck, Austria.
¹⁵ Kaiser Permanente, Hawaii Region, Moanalua Medical Center, Honolulu, HI, USA.
¹⁶ Department of Public Health, Fujita Health University School of Medicine, Aichi, Japan.
¹⁷ Department of Public Health, Shiga University of Medical Science, Otsu, Japan.
¹⁸ Section of Nephrology, Baylor College of Medicine, Houston, TX, USA.
¹⁹ Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
²⁰ Vascular and Renal Translational Research Group, REDinREN del ISCIII, IRBLleida, Lleida, Spain.
²¹ Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, Netherlands.
²² Peking University Institute of Nephrology, Division of Nephrology, Peking University First Hospital, Beijing, China.
²³ Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
²⁴ Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science Technology, Trondheim, Norway.
²⁵ Division of Nephrology, Department of Medicine, St Olav University Hospital, Trondheim, Norway.
²⁶ Division of Nephrology at Tufts Medical Center, Boston, MA, USA.
²⁷ Medical Division, Maccabi Healthcare Services, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
²⁸ George Institute for Global Health, University of Oxford, Oxford, UK.
²⁹ George Institute for Global Health, University of New South Wales, Sydney, Australia.

PMID: 30630856
PMCID: PMC6481269
DOI: 10.1136/bmj.k5301

Abstract

Objective: To evaluate the associations between adiposity measures (body mass index, waist circumference, and waist-to-height ratio) with decline in glomerular filtration rate (GFR) and with all cause mortality.

Design: Individual participant data meta-analysis.

Setting: Cohorts from 40 countries with data collected between 1970 and 2017.

Participants: Adults in 39 general population cohorts (n=5 459 014), of which 21 (n=594 496) had data on waist circumference; six cohorts with high cardiovascular risk (n=84 417); and 18 cohorts with chronic kidney disease (n=91 607).

Main outcome measures: GFR decline (estimated GFR decline ≥40%, initiation of kidney replacement therapy or estimated GFR <10 mL/min/1.73 m²) and all cause mortality.

Results: Over a mean follow-up of eight years, 246 607 (5.6%) individuals in the general population cohorts had GFR decline (18 118 (0.4%) end stage kidney disease events) and 782 329 (14.7%) died. Adjusting for age, sex, race, and current smoking, the hazard ratios for GFR decline comparing body mass indices 30, 35, and 40 with body mass index 25 were 1.18 (95% confidence interval 1.09 to 1.27), 1.69 (1.51 to 1.89), and 2.02 (1.80 to 2.27), respectively. Results were similar in all subgroups of estimated GFR. Associations weakened after adjustment for additional comorbidities, with respective hazard ratios of 1.03 (0.95 to 1.11), 1.28 (1.14 to 1.44), and 1.46 (1.28 to 1.67). The association between body mass index and death was J shaped, with the lowest risk at body mass index of 25. In the cohorts with high cardiovascular risk and chronic kidney disease (mean follow-up of six and four years, respectively), risk associations between higher body mass index and GFR decline were weaker than in the general population, and the association between body mass index and death was also J shaped, with the lowest risk between body mass index 25 and 30. In all cohort types, associations between higher waist circumference and higher waist-to-height ratio with GFR decline were similar to that of body mass index; however, increased risk of death was not associated with lower waist circumference or waist-to-height ratio, as was seen with body mass index.

Conclusions: Elevated body mass index, waist circumference, and waist-to-height ratio are independent risk factors for GFR decline and death in individuals who have normal or reduced levels of estimated GFR.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

PubMed Disclaimer

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: part support from the US National Kidney Foundation and the National Institute of Diabetes and Digestive and Kidney Diseases for the submitted work; ARC was supported by the NIDDK; no other financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activites that could appear to have influenced the submitted work.

Figures

**Fig 1**
Association between body mass index and risk of decline in glomerular filtration rate in general population cohorts, as shown by meta-analysed hazard ratios and 95% confidence intervals related to body mass index. Association is modelled by linear splines with knots at body mass indices 20, 25, 30, and 35. Circles indicate points with significant differences in risk from the reference point at body mass index 25

**Fig 2**
Association between body mass index and risk of decline in glomerular filtration rate in general population cohorts, as shown by hazard ratios in individual studies at body mass index 35 versus 25, sorted by average follow-up time (shortest to longest). Study acronyms/abbreviations are listed in eAppendix 2 in the supplementary materials

**Fig 3**
Body mass index interactions with risk of decline in glomerular filtration rate in general population cohorts, by estimated GFR (eGFR) category, sex, diabetes status, and Asian ethnicity. Meta-analysed hazard ratios and 95% confidence intervals are related to body mass index, modelled by linear splines with knots at body mass indices of 20, 25, 30, and 35 (reference is body mass index 25 in each category)

**Fig 4**
Association of body mass index with risk of decline in glomerular filtration rate in high cardiovascular risk cohorts, as shown by meta-analysed hazard ratios and 95% confidence intervals related to body mass index, modelled by linear splines with knots at body mass indices 20, 25, 30, and 35. Circles indicate points with significant differences in risk from the reference point at body mass index 25

**Fig 5**
Association of body mass index with risk of decline in glomerular filtration rate in high cardiovascular risk cohorts, as shown by hazard ratios in individual studies at body mass index 35 versus 25, sorted by average follow-up time (shortest to longest). Study acronyms/abbreviations are listed in eAppendix 2 in the supplementary materials

**Fig 6**
Association of body mass index with risk of decline in glomerular filtration rate in cohorts with chronic kidney disease, as shown by meta-analysed hazard ratios and 95% confidence interval related to body mass index, modelled by linear splines with knots at body mass indices 20, 25, 30, and 35. Circles indicate points with significant differences in risk from the reference point at body mass index 25

**Fig 7**
Association of body mass index with risk of decline in glomerular filtration rate in cohorts with chronic kidney disease, as shown by hazard ratios in individual studies at body mass index 35 v 25, sorted by average follow-up time (shortest to longest). Study acronyms/abbreviations are listed in eAppendix 2 in the supplementary materials

**Fig 8**
Association of waist circumference and waist-to-height ratio with risk of decline in glomerular filtration rate in general population cohorts, as shown by meta-analysed hazard ratios and 95% confidence intervals. Circles indicate points with significant differences in risk from the reference point (sex specific reference point for waist circumference (92 cm for men (M), 78 cm for women (F)); common reference point 0.5 cm/m for waist-to-height ratio)

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References

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[1] Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384:766-81. 10.1016/S0140-6736(14)60460-8. - DOI - PMC - PubMed

[2] Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384:766-81. 10.1016/S0140-6736(14)60460-8. - DOI - PMC - PubMed

[3] Forouzanfar MH, Liu P, Roth GA, et al. Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015. JAMA 2017;317:165-82. 10.1001/jama.2016.19043. - DOI - PubMed

[4] Forouzanfar MH, Liu P, Roth GA, et al. Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015. JAMA 2017;317:165-82. 10.1001/jama.2016.19043. - DOI - PubMed

[5] Whaley-Connell A, Sowers JR. Obesity and kidney disease: from population to basic science and the search for new therapeutic targets. Kidney Int 2017;92:313-23. 10.1016/j.kint.2016.12.034. - DOI - PubMed

[6] Whaley-Connell A, Sowers JR. Obesity and kidney disease: from population to basic science and the search for new therapeutic targets. Kidney Int 2017;92:313-23. 10.1016/j.kint.2016.12.034. - DOI - PubMed

[7] United States Renal Data System 2017 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2017.

[8] United States Renal Data System 2017 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2017.

[9] Hsu CY, McCulloch CE, Iribarren C, Darbinian J, Go AS. Body mass index and risk for end-stage renal disease. Ann Intern Med 2006;144:21-8. - PubMed

[10] Hsu CY, McCulloch CE, Iribarren C, Darbinian J, Go AS. Body mass index and risk for end-stage renal disease. Ann Intern Med 2006;144:21-8. - PubMed

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Adiposity and risk of decline in glomerular filtration rate: meta-analysis of individual participant data in a global consortium

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Adiposity and risk of decline in glomerular filtration rate: meta-analysis of individual participant data in a global consortium

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Conflict of interest statement

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