LABORATORY ASSESSMENT ON

IMMUNE SYSTEM DYSFUNCTION

C
AND
INFLAMMATION IN CHRONIC KIDNEY
DISEASE
DIAN ARININGRUM
CLINICAL PATHOLOGY DEPT.
FK UNS/ RSUD DR MOEWARDI SURAKARTA 2022
 OUTLINE

1. Innate and adaptive immune system and uremia

2. Risk factors of immune dysfunction in CKD
3. Immune response to bacterial and virus infection
4. Immune response to vaccination
5. Immune response to cancer
6. Low grade inflammatory state in CKD
7. Laboratory parameters to assess immune status in CKD

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 EPIDEMIOLOGY OF CKD

o KDIGO 2012 : Chronic kidney disease (CKD) is reduced renal function, which is
defined by glomerular filtration rate (GFR) < 60 mL/min per 1.73 m2, or with
present markers of kidney damage, or both, for more than 3 months.

o GBD Chronic Kidney Disease Collaboration, 2020 : the global prevalence of all-
stages CKD : 697.5 million or 9.1%, and 1.2 million people died from CKD in 2017.
The number of people receiving renal replacement therapy exceeds 2.5 million
and is projected to double to 5·4 million by 2030.

o Hojs et al, 2016; Mihai et al, 2018 : hallmarks of CKD is persistent, low-grade
inflammation  development, progression, and complication of disease.

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 4
Ref : Thompson et al., 2015, Cause of Death in Patients with Reduced Kidney Function, JASN , 26 (10) 2504-2511
 CKD AND PREMATURE CELLULAR
SENESCENCE

Ref : White et al, 2015, Aging and uremia: Is there cellular and molecular
crossover?, World J Nephrol 2015; 4(1): 19-30

SASP : senescence-associated secretory phenotype

• Inf!ammatory cytokines,
• Chemokines,
• Tissue-damaging proteases,
• Hemostatic factors
• Growth factors
SCAPS : senescent cell anti-apoptotic pathways
INFLAMMAGING p38 MAPK : p38 mitogen-activated protein kinases

Ref : Dai et al., 2019, Early Vascular Ageing and Cellular Senescence in Chronic Kidney
Disease, Computational and Structural Biotechnology Journal 17 (2019) 721–729
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 IMMUNE DYSFUNCTION IN CKD PATIENTS Chronic low
grade
Hemodynamic Metabolic Inflammatory Immunologic inflammatory
state
Comorbidities (DM, Activated
immune CKD
UREMIC TOXINS Hypertension, CHF, progression
autoimmunity) response
Uremia
Cardiovascular
disease
Oxidative stress Premature
Loss of renal Proinflammatory
function immunosen
milieu
Cytokines escence
accumulation Infections

Dialysis materials (virus-related)

“Leaky gut” Inhibited Neoplasma
immune
response Poor response
to vaccination
Ref : Anders et al., 2013; Cohen, 2020; Lioulios et al., 2021
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Uremia and epithelial barrier function

• Uremic skin  pruritus

 skin infection
• Uremic stomatitis

Leaky gut

Local inflammation

Systemic inflammation

PROGRESSION
OF CKD
Ref : Lau dan Vaziri, 2017 7
 LOW GRADE INFLAMMATORY STATE IN CKD
Diet Lifestyle Environment

Genetic and epigenetic factors CKD Primary disease

↓ cytokines Recurrent Oxydative Intestinal Periodontal Metabolic Vit D Dialysis-

elimination Infections and stress dysbiosis disease acidosis deficiency related
and ↑ thrombotic events
production

Low grade Inflammatory state

Early atherosclerosis Protein-energy Anemia and CKD-mineral and

and CVD wasting EPO resistance bone disease

Increased morbidity and mortality

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Ref : Ackchurin, 2015
 UREMIA AND INNATE IMMUNE SYSTEM

Ref : Syed-Ahmed & Narayanan, 2019, Immune Dysfunction and Risk of Infection in Chronic Kidney Disease, Adv Chronic Kidney Dis.
26(1):8-15
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 UREMIA AND ADAPTIVE IMMUNE SYSTEM

Ref : Syed-Ahmed & Narayanan, 2019, Immune Dysfunction and Risk of Infection in Chronic Kidney Disease, Adv Chronic Kidney Dis.
26(1):8-15
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 IMMUNE RESPONSE TO BACTERIAL INFECTION
Neutrophyl in CKD :
o Elevated ROS production,
degranulation, and basal neutrophil
extracellular trap (NET) formation 
spontaneous activation.
o Rise in the concentration of intracellular
calcium ([Ca2+]i)  reduced reactivity
upon stimulation.

Monocyte in CKD :
o ↑ intermediate monocytes (CD14++
CD16+ )  pro-inflammatory properties .

Dendritic cells in CKD :

o Terminal differentiation of monocyte-
derived dendritic cells is compromised
o Binding to glomerular antigens 
progression of renal failure.
Ref : Pindjakova dan Griffin, 2011, Defective neutrophil rolling and Ref : Cohen, 2020, Immune Dysfunction in Uremia, 13
transmigration in acute uremia , Kidney International (2011) 80, 447–450 Toxins 2020, 12, 439
 IMMUNE RESPONSE TO VIRUS INFECTION

Ref : Betjes, 2021, Uremia-Associated Immunological Aging and Severity of COVID-19 Infection, Front. Med. 8:675573. 14
 IMMUNE RESPONSE TO CANCER

Kitchlu et al., The cumulative incidence of cancer ranged between 10.8 to

2022 15.3% in patients with kidney disease

Wong et al., Reduced renal function is associated with an increased risk of

2016 urinary tract, digestive tract and thyroid cancers

Increased risk of certain cancer related to DNA damage due to

Schupp et prolonged uremic state, the presence of chronic infection and
al., 2010 inflammation, a weakened immune system, nutritional deficiencies,
and impaired mechanisms of DNA repair.

Ref :
• Kitchlu et al, 2022, Cancer Risk and Mortality in Patients With Kidney Disease: A Population-Based Cohort Study, https://doi.org/10.1053/j.ajkd.2022.02.020
• Wong et al., 2016, Chronic kidney disease and the risk of cancer: an individual patient data meta-analysis of 32,057 participants from six prospective studies, BMC
Cancer 16:488 15
• Schupp et al, 2010, Genomic Damage in Endstage Renal Disease—Contribution of Uremic Toxins, Toxins 2010, 2, 2340-2358
 IMMUNE RESPONSE TO VACCINATION

Ref : Hou et al, 2021, The Efficacy of COVID-19 Vaccines in Chronic Kidney Disease and Kidney Transplantation
Patients: A Narrative Review, Vaccines 2021, 9, 885. https://doi.org/10.3390/ vaccines9080885
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 LABORATORY PARAMETERS TO ASSESS IMMUNE STATUS IN CKD

1) Biomarkers to assess inflammation

Sundin et al, 2014 ESR in adolescents has been shown to be predictive of ESRD in middle-
aged men.
Bezeley et al, 2011 CRP predicted mortality in hemodialysis (HD) patients

Zadeh et al, 2005 Hypoalbuminemia is strongly associated with mortality in dialysis patients.

WBC(HR = 2.665, 95% CI: 1.39–5.12), serum iron (HR = 8.396, 95% CI: 2.02–
34.96), serum calcium (HR = 4.102, 95% CI: 1.35–12.46) and serum protein
Fereira et al, 2020 (HR = 4.630, 95% CI: 2.07–10.34) as an independent risk factor for the survival
time, while high ferritin values (HR = 0.392, 95% CI: 0.19–0.80), serum
phosphorus (HR = 0.290, 95% CI: 0.19–0.61) and serum albumin (HR = 0.230,
95% CI: 0.10–0.54) were less risk to die.
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LABORATORY PARAMETERS TO ASSESS IMMUNE STATUS IN CKD

1) Biomarkers to assess inflammation

Neutrophyl to lymphocyte ratio was higher in CKD than healthy
Okyay et al, 2012 controls, positively correlated with IL6 (r=0.4) and hsCRP (r=0.3),
negatively correlated with Hb (r=0.3) and HDL (r=0.4).

Neutrophyl to lymphocyte ratio >2.09 is associated with the risk of

Yuan et al, 2019 ESRD in Chinese patients with stage 4 CKD (HR 2.11, 95% CI 1.18,
3.76)

CRP, fibrinogen, IL-6, TNF-α, IL-1β, and IL-1 receptor antagonist were
Gupta et al, 2012 inversely associated with the measures of kidney function and
positively with albuminuria.

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LABORATORY PARAMETERS TO ASSESS IMMUNE STATUS IN CKD

1) Biomarkers to assess inflammation

Honda et al, 2006; IL-6 predicts all-cause and cardiovascular mortality in ESRD better
Tripepi et al, 2005 than CRP and other cytokines

Serum vitamin D are lower in children with ESRD than in age-

Youssef et al, 2012
matched controls & significantly positively related to the anti-
inflammatory IL-10 and negatively related to the pro-inflammatory
SIL-2R.

De Oliveira et al, Significant negative association between low vitamin D levels

2017 (≤30 nmol/l) and CRP (OR 1.23, 95 % CI 1.00-1.51) and WBC (OR 1.35,
95 % CI 1.13-1.60).

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 LABORATORY PARAMETERS TO ASSESS IMMUNE STATUS IN CKD

1. Interferon-gamma-based in vitro assays (IGRA)

2) Immune 2. Lymphocyte proliferation
functional assay 3. TNF⍺ secretion
4. Cytokine profile evaluation
(IFA) 5. Intracellular ATP production
Albert-Vega et al, 2018

Monitoring of IFN-γ production after stimulation of innate and adaptive

immunity may identify ESKD patients with high risk of infection. Patients
with stimulated IFN-γ levels measured by QuantiFERON Monitor below
Suavet et al, 2019
63.55 IU/mL (n = 21) had a hazard ratio of 10.71 ([3.68–31.13], p < 0.0001)
for the development of subsequent infections.

Ref :
• Albert-Vega et al, 2018, Immune Functional Assay, from Custon to Standardized test for Precision Medicine, Front. Immunol. 9:2367.
• Suavet et al, 2019, Functional immune assay using interferon-gamma could predict infectious events in end-stage kidney disease, Clinica Chimica Acta, 21
https://doi.org/10.1016/j.cca.2019.11.018
 LABORATORY PARAMETERS TO ASSESS IMMUNE STATUS IN CKD

3) Oxydative stress and antioxidant level

Antioxidant Lipid peroxidation products Protein peroxidation products
GSH (reduced glutathione) MDA (malondialdehyde) AOPP (advanced-oxidation protein
products)
GSSG (oxidized glutathione) TBARS (thiobarbituric acid-reactive Oxydized LDL
substances
TAS (total antioxidant status) HNE (4-hydroxynonenal) AGE-pentoside
Vitamin C, E, A F2-isoprostanes
Enzymes DNA oxidation products
GPx (glutathione peroxidase) GR (glutathione reductase) 8-OH-dG (8-hydroxy
deoxyguanosine)
CAT (catalase) SOD (superoxide dismuthase)
Ref : Carracedo et al, 2020, Mechanisms of cardiovascular Disorders in Patients with Chronic Kidney Disease-a process related to Accelerated 22
Senescense, Front. Cell Dev. Biol. 8:185, doi: 10.3389/fcell.2020.00185
 LABORATORY PARAMETERS TO ASSESS IMMUNE STATUS IN CKD

Monocyte subsets 4) Analysis of specific

lymphocyte/ monocyte subsets
Duni et al, 2021
Lymphocyte subsets
• PD patients : lower total lymphocytes
B cells (CD3- CD19+),
NK cells
(CD3+CD
and B-lymphocytes (CD3- CD19+),
16+56+)
higher intermediate monocytes
(CD14++ CD16+).
• PD patients with prevalent CAD had
Tregs (CD4+CD25+
higher NK cells (CD3+ CD16+56+) and
FoxP3+) lower B cells counts.
• Patients with increased NK cells had
T cells T cells
(CD3+ (CD3+
CD4+) CD8+)
3.8 times higher risk of CAD and more
likely to be rapid transporters.

Ref : Duni et al, 2021, The Association of Circulating CD14++CD16+ Monocytes, Natural Killer Cells and Regulatory T Cells
Subpopulations With Phenotypes of Cardiovascular Disease in a Cohort of Peritoneal Dialysis Patients. Front. Med. 8:724316.
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LABORATORY PARAMETERS TO ASSESS IMMUNE STATUS IN CKD

5) Post-vaccination antibody titers

• Vaccination in dialysis patients : hepatitis B, influenza, Streptococcus

pneumonia, and Covid-19 vaccine.
• Quantitative antibody measurement.
• Seroconversion rates after 2 doses of the mRNA-1273 COVID-19
vaccine are almost comparable to that in healthy controls, except in
kidney transplant recipients.

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 IMMUNE RESPONSE TO VACCINATION

Ref : Sanders et al, 2022, The RECOVAC Immune-response Study: The Immunogenicity, Tolerability, and Safety of COVID-19 Vaccination in
Patients With Chronic Kidney Disease, on Dialysis, or Living With a Kidney Transplant, Transplantation 106: 821–834

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 CONCLUSION

1. Chronic kidney disease (CKD) is simultaneously associated with immune

activation and immune deficiency.

2. Immune activation, marked by systemic inflammation, contributes to

cardiovascular disease, cachexia and anemia, while immune deficiency leads
to susceptibility to infections and cancer and impaired response to
vaccination.

3. Laboratory tests that can be used to assess the immunological status of CKD
patients are: 1) inflammatory biomarkers, 2) changes in immune cell
phenotype, 3) immune functional assay (IFA), 4) oxidative stress marker, 5) post-
vaccination antibody titers.

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TERIMA KASIH…
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