The Role of Klotho G395A Gene Polymorphism in Atherosclerotic Cardiovascular Disease and Mortality Risk Scores in Non-dialysis Chronic Kidney Disease

Hendri Susilo, Budi Susetyo Pikir, Mochammad Thaha, Mochamad Yusuf Alsagaff, Satriyo Dwi Suryantoro, Citrawati Dyah Kencono Wungu, David Setyo Budi, Laurentius Andre, Cennikon Pakpahan


BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in patients with chronic kidney disease (CKD). Klotho expression was reduced in patients with CKD, leading to vascular calcification, endothelial dysfunction, and atherosclerosis. We investigated the role of the klotho G395A gene polymorphism and plasma klotho level in the ten-year risk of atherosclerotic cardiovascular disease (ASCVD) and CVD mortality in CKD patients.

METHODS: We used the PCR-CTPP assay method to genotype klotho G395A single nucleotide polymorphism (SNP) in 72 non-dialysis CKD patients. The klotho level was determined using the enzyme-linked immunoassay (ELISA) method. Path analysis was used to determine the relationship between the klotho G395A SNP, plasma klotho level, ASCVD risk score, and CVD mortality risk score.

RESULTS: Our results showed that the GA genotype had lower plasma klotho levels than the GG genotype (path coefficient=-0.185, p=0.000). There was a significant negative correlation between plasma klotho level and the ASCVD risk score (r=-0.243, p=0.040), but no significant correlation was found between plasma klotho level and the CVD mortality risk score (r=-0.145, p=0.225). Path analysis showed that plasma klotho level had a significant negative direct effect on ASCVD risk score (path coefficient=-0.272, p=0.000) and an indirect effect on CVD mortality risk score (path coefficient=0.187, p=0.005).

CONCLUSION: Klotho G395A SNP might reduce lower plasma klotho levels, which increased ASCVD and CVD mortality risk scores in non-dialysis CKD patients. However, other risk factors such as age, CKD stages, hypertension, and smoking should be taken into consideration. Therefore, large-scale genetic association studies with adjusted variables could be conducted in various ethnic groups for a more robust result.

KEYWORDS: klotho, single nucleotide polymorphism, cardiovascular disease, chronic kidney disease

Full Text:



Jankowski J, Floege J, Fliser D, Böhm M, Marx N. Cardiovascular disease in chronic kidney disease: pathophysiological insights and therapeutic options. Circulation. 2021: 143(11): 1157-72, CrossRef.

Ramadhanti R, Helda H. Association of hypertension and chronic kidney disease in population aged ≥18 years old. Mol Cell Biomed Sci. 2021; 5(3): 137-44, CrossRef.

Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019; 139(10): e56-528, CrossRef.

Ridwan R, Febriza A, Linggi EB, Natzir R, Tazlim NA. Correlation between blood pressure and obesity parameter against cystatin-C and adiponectin levels in serum of obese adolescent. Mol Cell Biomed Sci. 2020; 4(3): 105-12, CrossRef.

Alsagaff MY, Pikir BS, Thaha M, Susilo H. Correlations between total antioxidant capacity and 8-hydroxydeoxyguanosine with carotid-femoral pulse wave velocity in chronic kidney disease. Indones Biomed J. 2020; 12(3): 267-74, CrossRef.

Kadariswantiningsih IN, Thaha M, Nugroho CW, Hamidah B, Rasyid H, el Hakim Z, et al. Could complete blood count parameters and non-fasting cholesterol profile describe inflammation and oxidative stress in chronic kidney disease? Indones Biomed J. 2018; 10(3): 270-7, CrossRef.

Rutsch F, Nitschke Y, Terkeltaub R. Genetics in arterial calcification: Pieces of a puzzle and cogs in a wheel. Circ Res. 2011; 109(5): 578-92, CrossRef.

Vervloet MG, Adema AY, Larsson TE, Massy ZA. The role of klotho on vascular calcification and endothelial function in chronic kidney disease. Semin Nephrol. 2014; 34(6): 578-85, CrossRef.

Wang Y, Sun Z. Current understanding of klotho. Ageing Res Rev. 2009; 8(1): 43-51, CrossRef.

Ahmad H, Muzasti RA, Nasution S. Association between KLOTHO gene G395A polymorphism and carotid artery calcification in regular hemodialysis patients. Open Access Maced J Med Sci. 2020; 8(A): 208-13, CrossRef.

Lanzani C, Citterio L, Vezzoli G. Klotho: A link between cardiovascular and non-cardiovascular mortality. Clin Kidney J. 2020; 13(6): 926-32, CrossRef.

Rhee EJ, Oh KW, Yun EJ, Jung CH, Lee WY, Kim SW, et al. Relationship between polymorphisms G395A in promoter and C1818T in exon 4 of the KLOTHO gene with glucose metabolism and cardiovascular risk factors in Korean women. J Endocrinol Invest. 2006; 29(7): 613-8, CrossRef.

Lang F, Leibrock C, Pelzl L, Gawaz M, Pieske B, Alesutan I, et al. Therapeutic interference with vascular calcification-Lessons from klotho-hypomorphic mice and beyond. Front Endocrinol (Lausanne). 2018; 9: 207, CrossRef.

Zwakenberg SR, de Jong PA, Hendriks EJ, Westerink J, Spiering W, de Borst GJ, et al. Intimal and medial calcification in relation to cardiovascular risk factors. PLoS One. 2020; 15(7): e0235228, CrossRef.

Zhai C, Tang G, Qian G, Hu H, Gu A, Fang Y, et al. Polymorphism of klotho G-395A and susceptibility of coronary artery disease in East-Asia population: a meta-analysis. Int J Clin Exp Med. 2015; 8(2): 1582-8, PMID.

Nazarian A, Hasankhani M, Aghajany-Nasab M, Monfared A. Association between klotho gene polymorphism and markers of bone metabolism in patients receiving maintenance hemodialysis in Iran. Iran J Kidney Dis. 2017; 11(6): 456-60, PMID.

Shimoyama Y, Nishio K, Hamajima N, Niwa T. KLOTHO gene polymorphisms G-395A and C1818T are associated with lipid and glucose metabolism, bone mineral density and systolic blood pressure in Japanese healthy subjects. Clin Chim Acta. 2009; 406(1-2): 134-8, CrossRef.

Susilo H, Pikir BS, Thaha M, Alsagaff MY, Suryantoro SD, Wungu CDK, et al. The effect of angiotensin converting enzyme (ACE) I/D polymorphism on atherosclerotic cardiovascular disease and cardiovascular mortality risk in non-hemodialyzed chronic kidney disease: the mediating role of plasma ACE level. Genes (Basel) 2022; 13: 1121, CrossRef.

Levey AS, Stevens LA, Schmid CH, Zhang Y (Lucy), Castro AF, Feldman HI, et al. A new equation to estimate glomerular filtration rate. ann intern med. 2009; 150(9): 604-12, CrossRef.

Matsushita K, Jassal SK, Sang Y, Ballew SH, Grams ME, Surapaneni A, et al. Incorporating kidney disease measures into cardiovascular risk prediction: development and validation in 9 million adults from 72 datasets. EClinicalMedicine 2020; 27: 100552, CrossRef.

Merck [Internet]. Recommended Standard Method for Isolating Mononuclear Cells 2022 [cited 2022 May 30]. Available from:

Shimoyama Y, Taki K, Mitsuda Y, Tsuruta Y, Hamajima N, Niwa T. KLOTHO gene polymorphisms G-395A and C1818T are associated with low-density lipoprotein cholesterol and uric acid in Japanese hemodialysis patients. Am J Nephrol. 2009; 30(4): 383-8, CrossRef.

NIH National Library of Medicine [Internet]. Reference SNP (rs) Report: rs1207568 [cited 2022 Jun 21]. Available from:

Yang K, Yang J, Bi X, Yu Z, Xiao T, Huang Y, et al. Serum klotho, cardiovascular events, and mortality in nondiabetic chronic kidney disease. Cardiorenal Med. 2020; 10(3): 175-87, CrossRef.

Liu Q, Yu L, Yin X, Ye J, Li S. Correlation between soluble klotho and vascular calcification in chronic kidney disease: a meta-analysis and systematic review. Front Physiol. 2021; 12: 711904, CrossRef.

Said S, Hernandez GT. The link between chronic kidney disease and cardiovascular disease. J Nephropathol. 2014; 3(3): 99-104, CrossRef.

Memmos E, Sarafidis P, Pateinakis P, Tsiantoulas A, Faitatzidou D, Giamalis P, et al. Soluble klotho is associated with mortality and cardiovascular events in hemodialysis. BMC Nephrol. 2019; 20: 217, CrossRef.

Roumeliotis S, Mallamaci F, Zoccali C. Endothelial dysfunction in chronic kidney disease, from biology to clinical outcomes: A 2020 update. J Clin Med. 2020; 9(8): 2359, CrossRef.

Oh HJ, Nam BY, Lee MJ, Kim CH, Koo HM, Doh FM, et al. Decreased circulating klotho levels in patients undergoing dialysis and relationship to oxidative stress and inflammation. Perit Dial Int. 2015; 35(1): 43-51, CrossRef.

Donfrancesco C, Palleschi S, Palmieri L, Rossi B, lo Noce C, Pannozzo F, et al. Estimated glomerular filtration rate, all-cause mortality and cardiovascular diseases incidence in a low risk population: the MATISS study. PLoS One 2013; 8(10): e78475, CrossRef.

Empitu MA, Kadariswantiningsih IN, Thaha M, Nugroho CW, Cahyaning Putri EA, el Hakim Z, et al. Determiner of poor sleep quality in chronic kidney disease patients links to elevated diastolic blood pressure, hs-CRP, and blood-count-based inflammatory predictors. Indones Biomed J. 2019; 11(1): 100-6, CrossRef.

Dalrymple LS, Katz R, Kestenbaum B, Shlipak MG, Sarnak MJ, Stehman-Breen C, et al. Chronic kidney disease and the risk of end-stage renal disease versus death. J Gen Intern Med. 2011 Apr; 26(4): 379-85, CrossRef.

Ensembl Asia [Internet]. Human (GRCh38.p13): rs1207568 (SNP) [cited 2022 May 1]. Available from:

Ko GJ, Lee YM, Lee EA, Lee JE, Bae SY, Park SW, et al. The association of Klotho gene polymorphism with the mortality of patients on maintenance dialysis. Clin Nephrol. 2013; 80(4): 263-9, CrossRef.

Xu Y, Sun Z. Molecular basis of klotho: From gene to function in aging. Endocr Rev. 2015; 36(2): 174-93, CrossRef.

Kim Y, Jeong SJ, Lee HS, Kim EJ, Song YR, Kim SG, et al. Polymorphism in the promoter region of the klotho gene (G-395A) is associated with early dysfunction in vascular access in hemodialysis patients. Korean J Intern Med. 2008; 23(4): 201-7, CrossRef.

Kawano K, Ogata N, Chiano M, Molloy H, Kleyn P, Spector TD, et al. Klotho gene polymorphisms associated with bone density of aged postmenopausal women. J Bone Miner Res. 2002; 17(10): 1744-51, CrossRef.

Pereira RMR, Freitas TQ, Franco AS, Takayama L, Caparbo VF, Domiciano DS, et al. KLOTHO polymorphisms and age-related outcomes in community-dwelling older subjects: The São Paulo Ageing & Health (SPAH) Study. Sci Rep. 2020; 10(1): 8574, CrossRef.


Copyright (c) 2022 The Prodia Education and Research Institute

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.


Indexed by:






The Prodia Education and Research Institute