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McGill RL, Weiner DE, Ruthazer R, Miskulin DC, Meyer KB, Lacson E. Transfers to Hemodialysis Among US Patients Initiating Renal Replacement Therapy With Peritoneal Dialysis. Am J Kidney Dis 2019; 74:620-628. [PMID: 31301926 DOI: 10.1053/j.ajkd.2019.05.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 05/08/2019] [Indexed: 12/28/2022]
Abstract
RATIONALE & OBJECTIVE Identifying patients who are likely to transfer from peritoneal dialysis (PD) to hemodialysis (HD) before transition could improve their subsequent care. This study developed a prediction tool for transition from PD to HD. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adults initiating PD between January 2008 and December 2011, followed up through June 2015, for whom data were available in the US Renal Data System (USRDS). PREDICTORS Clinical characteristics at PD initiation and peritonitis claims. OUTCOMES Transfer to HD, with the competing outcomes of death and kidney transplantation. ANALYTICAL APPROACH Outcomes were ascertained from USRDS treatment history files. Subdistribution hazards (competing-risk) models were fit using clinical characteristics at PD initiation. A nomogram was developed to classify patient risk at 1, 2, 3, and 4 years. These data were used to generate quartiles of HD transfer risk; this quartile score was incorporated into a cause-specific hazards model that additionally included a time-dependent variable for peritonitis. RESULTS 29,573 incident PD patients were followed up for a median of 21.6 (interquartile range, 9.0-42.3) months, during which 41.2% transferred to HD, 25.9% died, 17.1% underwent kidney transplantation, and the rest were followed up to the study end in June 2015. Claims for peritonitis were present in 11,733 (40.2%) patients. The proportion of patients still receiving PD decreased to <50% at 22.6 months and 14.2% at 5 years. Peritonitis was associated with a higher rate of HD transfer (HR, 1.82; 95% CI, 1.76-1.89; P < 0.001), as were higher quartile scores of HD transfer risk (HRs of 1.31 [95% CI, 1.25-1.37), 1.51 [95% CI, 1.45-1.58], and 1.78 [95% CI, 1.71-1.86] for quartiles 2, 3, and 4 compared to quartile 1 [P < 0.001 for all]). LIMITATIONS Observational data, reliant on the Medical Evidence Report and Medicare claims. CONCLUSIONS A large majority of the patients who initiated renal replacement therapy with PD discontinued this modality within 5 years. Transfer to HD was the most common outcome. Patient characteristics and comorbid diseases influenced the probability of HD transfer, death, and transplantation, as did episodes of peritonitis.
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Affiliation(s)
- Rita L McGill
- Section of Nephrology, University of Chicago, Chicago, IL.
| | | | - Robin Ruthazer
- Biostatistics, Epidemiology, and Research Design Center, Tufts Clinical and Translational Science Institute, Boston, MA
| | | | | | - Eduardo Lacson
- Division of Nephrology, Tufts Medical Center; Dialysis Clinic, Inc., Nashville, TN
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Drew DA, Tighiouart H, Duncan S, Rollins J, Gupta A, Scott T, Weiner DE, Sarnak MJ. Blood Pressure and Cognitive Decline in Prevalent Hemodialysis Patients. Am J Nephrol 2019; 49:460-469. [PMID: 31048586 PMCID: PMC6631042 DOI: 10.1159/000500041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/27/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Hypertension is associated with cognitive decline in the general population. It is unclear what impact blood pressure (BP) has on cognitive decline in patients receiving maintenance hemodialysis (HD). METHODS Using a longitudinal cohort of 314 prevalent HD patients without dementia at baseline, we examined the association of predialysis systolic BP (SBP) and diastolic BP (DBP), pulse pressure, and intradialytic SBP change (pre minus post), averaged for a month, with cognitive decline. Cognitive function was determined by a neurocognitive battery, administered yearly. Individual cognitive test results were reduced into 2 domain scores using principal components analysis (by definition mean of 0 and SD of 1), representing memory and executive function. Joint models, allowing for characterization of cognitive score slopes and including adjustment for potential confounders, were utilized to account for competing risks from death, dropout, or kidney transplantation. RESULTS Mean age was 62 years; 54% were men, 23% were black, and 90% had at least a high school education. During median follow-up of 2.1 years (25th-75th: 1.0-4.5), 191 had at least one follow-up test, 148 died, and 43 received kidney transplants. Low predialysis DBP and high pulse pressure were both associated with steeper executive function decline (each 10 mm Hg lower DBP = -0.03 SD [-0.01 to -0.05] per year steeper decline) in executive function (each 10 mm Hg higher pulse pressure = -0.03 SD [-0.06 to -0.01] steeper decline) but not for memory function. SBP and intradialytic change were not associated with steeper decline for either memory or executive function. CONCLUSIONS No relationship was seen between SBP or intradialytic change in BP with cognitive decline. In prevalent HD patients, lower predialysis DBP and wider predialysis pulse pressure are associated with steeper cognitive decline in executive function but not memory.
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Affiliation(s)
- David A Drew
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA,
| | - Hocine Tighiouart
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, USA
| | - Sarah Duncan
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jasmine Rollins
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Aditi Gupta
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Tammy Scott
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, Massachusetts, USA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Mark J Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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103
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Kramer HJ, Townsend RR, Griffin K, Flynn JT, Weiner DE, Rocco MV, Choi MJ, Weir MR, Chang TI, Agarwal R, Beddhu S. KDOQI US Commentary on the 2017 ACC/AHA Hypertension Guideline. Am J Kidney Dis 2019; 73:437-458. [PMID: 30905361 PMCID: PMC6740329 DOI: 10.1053/j.ajkd.2019.01.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
Hypertension is a modifiable risk factor for cardiovascular morbidity and mortality and reduction of elevated blood pressure (BP) remains an important intervention for slowing kidney disease progression. Over the past decade, the most appropriate BP target for initiation and titration of BP-lowering medications has been an area of intense research and debate within the clinical community. In 2017, the American College of Cardiology and the American Heart Association (ACC/AHA) in conjunction with several other professional societies released new hypertension guidelines based on data from a systematic review of clinical trials and observational data. While many of the recommendations in the ACC/AHA hypertension guideline are relevant to nephrology practice, BP targets and management strategies for patients receiving dialysis are not discussed. This Kidney Disease Outcomes Quality Initiative (KDOQI) commentary focuses largely on recommendations from the ACC/AHA hypertension guidelines that are pertinent to individuals at risk of chronic kidney disease or with non-dialysis-dependent chronic kidney disease. This KDOQI commentary also includes a brief discussion of the consensus statement regarding hypertension diagnosis and management for adults receiving maintenance dialysis published by the European Renal and Cardiovascular Medicine Working Group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension. Overall, we support the vast majority of the ACC/AHA recommendations and highlight select areas in which best diagnosis and treatment options remain controversial.
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Affiliation(s)
- Holly J Kramer
- Department of Public Health Sciences, Loyola University Chicago Stritch School of Medicine, Maywood; Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood; Hines VA Medical Center, Hines, IL.
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Karen Griffin
- Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood; Hines VA Medical Center, Hines, IL
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, Seattle WA
| | | | - Michael V Rocco
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael J Choi
- Department of Medicine, Johns Hopkins School of Medicine
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Tara I Chang
- Department of Medicine, Stanford Medical School, Palo Alto, CA
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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104
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Goyal N, Weiner DE, Levey AS. Kidney Transplantation in Lupus Nephritis: Can We Do Even Better? Ann Intern Med 2019; 170:266-267. [PMID: 30665233 DOI: 10.7326/m18-3721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Nitender Goyal
- Tufts Medical Center, Boston, Massachusetts (N.G., D.E.W., A.S.L.)
| | - Daniel E Weiner
- Tufts Medical Center, Boston, Massachusetts (N.G., D.E.W., A.S.L.)
| | - Andrew S Levey
- Tufts Medical Center, Boston, Massachusetts (N.G., D.E.W., A.S.L.)
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105
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Leonberg-Yoo AK, Wang W, Weiner DE, Lacson E. Oral nutritional supplements and 30-day readmission rate in hypoalbuminemic maintenance hemodialysis patients. Hemodial Int 2019; 23:93-100. [PMID: 30762294 DOI: 10.1111/hdi.12694] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 08/09/2018] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Hemodialysis (HD) patients are hospitalized nearly twice yearly, and 35% of these patients are rehospitalized within 30-days postdischarge. We hypothesized that monitored oral nutritional supplementation (ONS) during HD treatment may decrease readmissions. METHODS A cohort of maintenance HD patients, treated at a large dialysis organization, who were hospitalized with a postdischarge albumin of ≤3.5 g/dL, without documented ONS use 90 days prior to the index hospitalization were identified. Individuals who received monitored intradialytic ONS postdischarge were compared to those without receipt of ONS. The outcome of interest was 30-day hospital readmissions. Logistic regression was used to assess the association between ONS receipt and 30-day readmission events, with adjustment for case-mix and laboratory variables. FINDINGS Of 5479 eligible patients, ONS was prescribed to 1420 individuals. Mean age was 64.6 ± 14.1 (SD) years; median dialysis vintage was 3.9 years. There were 274 (19%) readmissions among ONS recipients vs. 1571 (38.7%) among controls during the 30-day follow-up period. Individuals who did not receive ONS had increased odds of readmission [OR 2.26 (95% CI 1.02, 2.53)] in 30 days, as compared to those who did receive ONS postdischarge. In sensitivity analyses using a propensity score matched cohort, the odds ratio of readmissions within 30 days postdischarge was 1.71 (95% CI: 1.42, 2.07) for individuals who did not receive ONS as compared to those who received ONS. DISCUSSION Consumption of ONS during HD sessions is associated with reduced hospital readmission rates among in-center maintenance HD with severe hypoalbuminemia at 30 days post-hospital discharge.
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Affiliation(s)
- Amanda K Leonberg-Yoo
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Weiling Wang
- Fresenius Medical Care, North America, Waltham, Massachusetts, USA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Eduardo Lacson
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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106
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Williamson JD, Pajewski NM, Auchus AP, Bryan RN, Chelune G, Cheung AK, Cleveland ML, Coker LH, Crowe MG, Cushman WC, Cutler JA, Davatzikos C, Desiderio L, Erus G, Fine LJ, Gaussoin SA, Harris D, Hsieh MK, Johnson KC, Kimmel PL, Tamura MK, Launer LJ, Lerner AJ, Lewis CE, Martindale-Adams J, Moy CS, Nasrallah IM, Nichols LO, Oparil S, Ogrocki PK, Rahman M, Rapp SR, Reboussin DM, Rocco MV, Sachs BC, Sink KM, Still CH, Supiano MA, Snyder JK, Wadley VG, Walker J, Weiner DE, Whelton PK, Wilson VM, Woolard N, Wright JT, Wright CB. Effect of Intensive vs Standard Blood Pressure Control on Probable Dementia: A Randomized Clinical Trial. JAMA 2019; 321:553-561. [PMID: 30688979 PMCID: PMC6439590 DOI: 10.1001/jama.2018.21442] [Citation(s) in RCA: 682] [Impact Index Per Article: 136.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE There are currently no proven treatments to reduce the risk of mild cognitive impairment and dementia. OBJECTIVE To evaluate the effect of intensive blood pressure control on risk of dementia. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted at 102 sites in the United States and Puerto Rico among adults aged 50 years or older with hypertension but without diabetes or history of stroke. Randomization began on November 8, 2010. The trial was stopped early for benefit on its primary outcome (a composite of cardiovascular events) and all-cause mortality on August 20, 2015. The final date for follow-up of cognitive outcomes was July 22, 2018. INTERVENTIONS Participants were randomized to a systolic blood pressure goal of either less than 120 mm Hg (intensive treatment group; n = 4678) or less than 140 mm Hg (standard treatment group; n = 4683). MAIN OUTCOMES AND MEASURES The primary cognitive outcome was occurrence of adjudicated probable dementia. Secondary cognitive outcomes included adjudicated mild cognitive impairment and a composite outcome of mild cognitive impairment or probable dementia. RESULTS Among 9361 randomized participants (mean age, 67.9 years; 3332 women [35.6%]), 8563 (91.5%) completed at least 1 follow-up cognitive assessment. The median intervention period was 3.34 years. During a total median follow-up of 5.11 years, adjudicated probable dementia occurred in 149 participants in the intensive treatment group vs 176 in the standard treatment group (7.2 vs 8.6 cases per 1000 person-years; hazard ratio [HR], 0.83; 95% CI, 0.67-1.04). Intensive BP control significantly reduced the risk of mild cognitive impairment (14.6 vs 18.3 cases per 1000 person-years; HR, 0.81; 95% CI, 0.69-0.95) and the combined rate of mild cognitive impairment or probable dementia (20.2 vs 24.1 cases per 1000 person-years; HR, 0.85; 95% CI, 0.74-0.97). CONCLUSIONS AND RELEVANCE Among ambulatory adults with hypertension, treating to a systolic blood pressure goal of less than 120 mm Hg compared with a goal of less than 140 mm Hg did not result in a significant reduction in the risk of probable dementia. Because of early study termination and fewer than expected cases of dementia, the study may have been underpowered for this end point. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01206062.
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Affiliation(s)
| | - Jeff D Williamson
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Alexander P Auchus
- Department of Neurology, University of Mississippi Medical Center, Jackson
| | - R Nick Bryan
- Department of Radiology, University of Pennsylvania, Philadelphia
| | - Gordon Chelune
- Department of Neurology, University of Utah School of Medicine, Salt Lake City
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City
| | - Maryjo L Cleveland
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Laura H Coker
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael G Crowe
- Department of Psychology, University of Alabama at Birmingham
| | - William C Cushman
- Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, Tennessee
| | - Jeffrey A Cutler
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Lisa Desiderio
- Department of Radiology, University of Pennsylvania, Philadelphia
| | - Guray Erus
- Department of Radiology, University of Pennsylvania, Philadelphia
| | - Larry J Fine
- Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Sarah A Gaussoin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Darrin Harris
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Meng-Kang Hsieh
- Department of Radiology, University of Pennsylvania, Philadelphia
| | - Karen C Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
| | - Paul L Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Disorders, Bethesda, Maryland
| | | | - Lenore J Launer
- Neuroepidemiology Section, Intramural Research Program, National Institute on Aging, Bethesda, Maryland
| | - Alan J Lerner
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Cora E Lewis
- Department of Epidemiology, University of Alabama at Birmingham
| | | | - Claudia S Moy
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Ilya M Nasrallah
- Department of Radiology, University of Pennsylvania, Philadelphia
| | - Linda O Nichols
- Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, Tennessee
| | - Suzanne Oparil
- Department of Medicine, University of Alabama at Birmingham
| | - Paula K Ogrocki
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mahboob Rahman
- Department of Medicine, Louis Stokes Cleveland Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Stephen R Rapp
- Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David M Reboussin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael V Rocco
- Section of Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Bonnie C Sachs
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kaycee M Sink
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Carolyn H Still
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
| | - Mark A Supiano
- Division of Geriatrics, University of Utah School of Medicine, Salt Lake City
| | - Joni K Snyder
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Jennifer Walker
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Valerie M Wilson
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nancy Woolard
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jackson T Wright
- Division of Nephrology and Hypertension, Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Clinton B Wright
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
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107
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Affiliation(s)
- Taimur Dad
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Daniel E Weiner
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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108
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Weiner DE, Drew DA, Gordon CE, Tighiouart H, Frank EA. Kidney Medicine: What’s in a Name? Kidney Med 2019; 1:1-2. [PMID: 32734177 PMCID: PMC7380389 DOI: 10.1016/j.xkme.2019.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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109
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Dad T, Tighiouart H, Lacson E, Meyer KB, Weiner DE, Richardson MM. Hemodialysis patient characteristics associated with better experience as measured by the In-center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey. BMC Nephrol 2018; 19:340. [PMID: 30486811 PMCID: PMC6264620 DOI: 10.1186/s12882-018-1147-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 11/21/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Patient experience in hemodialysis (HD) is measured twice yearly in all in-center HD patients in the United States using the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey. Survey scores are publically available and incorporated into the dialysis payment system. Despite its importance, little is known about factors associated with better experience scores. We studied the association between patient-level characteristics and experience scores in a large real-world cohort of HD patients. METHODS This is a cross-sectional analysis of ICH CAHPS administration in 2012. All in-center HD patients in Dialysis Clinic, Incorporated facilities nationally over 18 years old and receiving HD at their facility for at least 3 months were eligible. Predictors include patient demographic, clinical, and treatment-related characteristics. Outcomes include high global rating scores across three domains (Nephrologist, Dialysis Staff, Dialysis Center) and high composite scores across three domains (Nephrologists' Communication and Caring, Quality of Dialysis Center Care and Operations, and Providing Information to Patients). RESULTS Among 3369 respondents, older age and telephone (vs. mail) administration of the survey were associated with higher global ratings, while shortened HD treatments were associated with lower global ratings. Lower education and telephone administration were associated with higher composite scores, while older age, and shortened HD treatments were associated with lower composite scores. CONCLUSIONS Several patient characteristics and mode of survey administration are associated with higher experience scores. Future research should assess HD facility characteristics associated with higher scores and interventions that might improve experience accounting for these associations.
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Affiliation(s)
- Taimur Dad
- Tufts Medical Center, 800 Washington Street Box 391, Boston, MA 02111 USA
- Sackler School of Graduate Biomedical Sciences, Tufts University, Boston, USA
| | - Hocine Tighiouart
- Tufts Medical Center, 800 Washington Street Box 391, Boston, MA 02111 USA
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA USA
- Biostatistics, Epidemiology and Research Design (BERD) Center, Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA USA
| | - Eduardo Lacson
- Tufts Medical Center, 800 Washington Street Box 391, Boston, MA 02111 USA
- Dialysis Clinic Incorporated, Nashville, TN USA
| | - Klemens B. Meyer
- Tufts Medical Center, 800 Washington Street Box 391, Boston, MA 02111 USA
| | - Daniel E. Weiner
- Tufts Medical Center, 800 Washington Street Box 391, Boston, MA 02111 USA
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110
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Ladin K, Buttafarro K, Hahn E, Koch-Weser S, Weiner DE. "End-of-Life Care? I'm not Going to Worry About That Yet." Health Literacy Gaps and End-of-Life Planning Among Elderly Dialysis Patients. Gerontologist 2018; 58:290-299. [PMID: 28329829 DOI: 10.1093/geront/gnw267] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/31/2016] [Indexed: 11/14/2022] Open
Abstract
Purpose Between 2000 and 2012, the incident dialysis population in the United States increased by nearly 60%, most sharply among adults 75 years and older. End-of-life (EOL) conversations among dialysis patients are associated with better patient-centered outcomes and lower use of aggressive interventions in the last month of life. This study examined how health literacy may affect engagement, comprehension, and satisfaction with EOL conversations among elderly dialysis patients. Design and Methods Qualitative/descriptive study with semi-structured interviews about health literacy, EOL conversations, and goals of care with 31 elderly dialysis patients at 2 centers in Boston. Themes were interpreted in the context of Nutbeam's health literacy framework. Results Despite high mortality risk in this population, only 13% of patients had discussed EOL preferences with physicians, half had discussed EOL with their social network, and 25% of participants explicitly stated that they had never considered EOL preferences. Less than 30% of participants could correctly define terminology commonly used in EOL conversations. Analyses yielded 5 themes: (1) Misunderstanding EOL terminology; (2) Nephrologists reluctant to discuss EOL; (3) Patients conforming to socially constructed roles; (4) Discordant expectations and dialysis experiences; and (5) Reconciling EOL values and future care. Patients had limited understanding of EOL terminology, lacked of opportunities for meaningful EOL discussion with providers and family, resulting in uncertainty about future care. Implications Limited health literacy presents a substantial barrier to communication and could lead to older adults committing to an intensive pattern of care without adequate information. Clinicians should consider health literacy when discussing dialysis initiation.
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Affiliation(s)
- Keren Ladin
- Department of Occupational Therapy, Tufts University, Medford, Massachusetts.,Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts
| | - Katie Buttafarro
- Department of Occupational Therapy, Tufts University, Medford, Massachusetts.,Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts
| | - Emily Hahn
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts
| | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Daniel E Weiner
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
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111
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Miskulin DC, Weiner DE, Tighiouart H, Lacson EK, Meyer KB, Dad T, Manley HJ. High-Dose Seasonal Influenza Vaccine in Patients Undergoing Dialysis. Clin J Am Soc Nephrol 2018; 13:1703-1711. [PMID: 30352787 PMCID: PMC6237058 DOI: 10.2215/cjn.03390318] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/24/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES High-dose influenza vaccine, which contains fourfold more antigen than standard dose, is associated with fewer cases of influenza and less influenza-related morbidity in the elderly general population. Whether the high-dose influenza vaccine benefits patients on dialysis, whose immune response to vaccination is less robust than that of healthy patients, is uncertain. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We compared hospitalizations and deaths during the 2015-2016 and 2016-2017 influenza seasons by vaccine type (standard trivalent, standard quadrivalent, and high-dose trivalent influenza vaccine) administered within a national dialysis organization. The association of vaccine type with outcomes was estimated using Cox proportional hazards regression with adjustment for patient factors and "center effect." Analyses were stratified by age and dialysis modality. RESULTS Between September 1 and December 31, 2015, standard dose trivalent, standard dose quadrivalent, and high-dose trivalent influenza vaccines were administered to 3057 (31%), 5981 (61%), and 805 (8%) patients, respectively. The adjusted rates of first hospitalizations by vaccine type during the influenza season were 8.43, 7.88, and 7.99 per 100 patient-months, respectively, and the adjusted rates of death were 1.00, 0.97, and 1.04, respectively. These differences were not significant. In 2016, 3614 (39%) received quadrivalent vaccine, and 5700 (61%) received high-dose trivalent vaccine. The adjusted rates of first hospitalization by vaccine type were 8.71 and 8.04 per 100 patient-months, respectively, and the adjusted rates of death were 0.98 and 1.02, respectively. Receipt of high dose was associated with a significant reduction in hospitalization (hazard ratio, 0.93; 95% confidence interval, 0.86 to 1.00; P=0.04); there was no significant association with death. There was no significant heterogeneity of either association by age group or dialysis modality. CONCLUSIONS Receipt of high-dose compared with standard dose influenza vaccine in 2016-2017 was associated with lower rates of hospitalization in patients on dialysis, although that was not seen in 2015-2016.
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Affiliation(s)
| | | | - Hocine Tighiouart
- Biostatistics, Epidemiology, and Research Design Center, Tufts University School of Medicine, Boston, Massachusetts; and
| | - Eduardo K. Lacson
- Division of Nephrology, Tufts Medical Center and
- Dialysis Clinic Inc., Nashville, Tennessee
| | | | - Taimur Dad
- Division of Nephrology, Tufts Medical Center and
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Dad T, Tighiouart H, Fenton JJ, Lacson E, Meyer KB, Miskulin DC, Weiner DE, Richardson MM. Evaluation of non-response to the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey. BMC Health Serv Res 2018; 18:790. [PMID: 30340585 PMCID: PMC6194668 DOI: 10.1186/s12913-018-3618-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 10/10/2018] [Indexed: 11/14/2022] Open
Abstract
Background The In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Survey is the first patient reported outcome measure included in the U.S. Medicare End Stage Renal Disease Quality Incentive Program. Administered twice yearly, it assesses in-center dialysis experience and survey responses are tied to dialysis facility payments. Low response rates, currently approximately 35%, raise concern for possible underrepresentation of patient groups. Methods Cross-sectional analysis of survey administration in 2012 to all in-center hemodialysis patients in Dialysis Clinic, Inc. (DCI) facilities nationally over 18 years old who received hemodialysis at their facility for at least 3 months. Patient-level covariates included demographic, clinical, laboratory, and functional characteristics. Random effects multivariable logistic regression was used to assess survey non-response. Results Among 11,055 eligible patients 6541 (59%) were non-responders. Of the remaining 4514 responders, 549 (14%) surveys were not usable due to presence of proxy help or incomplete responses. Non-responders were more likely to be men, non-white, younger, single, dual Medicare/Medicaid eligible, less educated, non-English speaking, and not active on the transplant list; non-responders had longer ESRD vintage, lower body mass index, lower serum albumin, worse functional status, and more hospitalizations, missed treatments, and shortened treatments. Similar associations were found using more parsimonious multivariable analyses and after imputing missing data. Conclusions Non-responders to the ICH CAHPS significantly differed from responders, broadly spanning individuals with fewer socioeconomic advantages and greater illness burden, raising limitations in interpreting facility survey results. Future research should assess reasons for non-response to improve ICH CAHPS generalizability and utility. Electronic supplementary material The online version of this article (10.1186/s12913-018-3618-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Taimur Dad
- Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Box 391, Boston, MA, 02111, USA.
| | - Hocine Tighiouart
- Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Box 391, Boston, MA, 02111, USA.,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.,Biostatistics, Epidemiology and Research Design (BERD) Center, Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - Joshua J Fenton
- Department of Family and Community Medicine, Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
| | - Eduardo Lacson
- Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Box 391, Boston, MA, 02111, USA.,Dialysis Clinic Incorporated, Nashville, TN, USA
| | - Klemens B Meyer
- Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Box 391, Boston, MA, 02111, USA
| | - Dana C Miskulin
- Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Box 391, Boston, MA, 02111, USA
| | - Daniel E Weiner
- Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Box 391, Boston, MA, 02111, USA
| | - Michelle M Richardson
- Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Box 391, Boston, MA, 02111, USA
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113
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Kupferman J, Ramírez-Rubio O, Amador JJ, López-Pilarte D, Wilker EH, Laws RL, Sennett C, Robles NV, Lau JL, Salinas AJ, Kaufman JS, Weiner DE, Scammell MK, McClean MD, Brooks DR, Friedman DJ. Acute Kidney Injury in Sugarcane Workers at Risk for Mesoamerican Nephropathy. Am J Kidney Dis 2018; 72:475-482. [PMID: 30042041 DOI: 10.1053/j.ajkd.2018.04.014] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 04/11/2018] [Indexed: 01/05/2023]
Abstract
RATIONALE & OBJECTIVE Mesoamerican nephropathy (MeN), a form of chronic kidney disease (CKD) of unknown cause in Central America, affects young individuals working in physically strenuous occupations. Repeated episodes of work-related kidney injury may lead to CKD in this setting. We aimed to better understand the burden and natural history of acute kidney injury (AKI) in workers at risk for MeN. STUDY DESIGN Cross-sectional study of active sugarcane workers, followed by prospective follow-up of individuals with AKI. SETTING & PARTICIPANTS 326 sugarcane workers with normal preharvest serum creatinine (Scr) values and no history of CKD in an MeN hotspot in Nicaragua near the end of the harvest, and prospective follow-up of workers with AKI. PREDICTOR AKI during the harvest, as defined by Scr level increase ≥ 0.3mg/dL over baseline to a level ≥ 1.3mg/dL. OUTCOMES Kidney function trajectory and development of CKD over 12 months. ANALYTICAL APPROACH Linear regression models were used to analyze the association between job category and kidney function. For workers with AKI, the effect of time on Scr level was evaluated using linear mixed effects. RESULTS 34 of 326 participants were found to have AKI, with a median late-harvest Scr level of 1.64mg/dL in the AKI group. Workers without AKI had a median Scr level of 0.88mg/dL. AKI was more common among cane cutters compared with other field workers. Participants with AKI had variable degrees of kidney function recovery, with median 6- and 12-month Scr values of 1.25 and 1.27mg/dL, respectively (P < 0.001 for each follow-up value compared to late-harvest Scr). When we compared workers' kidney function before the AKI episode to their kidney function at last follow-up, 10 participants with AKI developed de novo estimated glomerular filtration rate < 60mL/min/1.73m2 and 11 had a >30% decrease in estimated glomerular filtration rate. LIMITATIONS Follow-up limited to 1 year and some loss to follow-up in the prospective component of the study. Broad definition of AKI that includes both acute and subacute kidney injury. CONCLUSIONS In a group of sugarcane workers with normal preharvest kidney function, newly decreased kidney function developing during the harvest season was common. Of those with kidney injury, nearly half had established CKD 12 months later.
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Affiliation(s)
- Joseph Kupferman
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Oriana Ramírez-Rubio
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Juan José Amador
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | | | - Elissa H Wilker
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
| | - Rebecca L Laws
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | - Caryn Sennett
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | | | - Jorge Luis Lau
- Especialistas en Medicina Interna, Chichigalpa, Nicaragua
| | | | - James S Kaufman
- Research Service, VA New York Harbor Healthcare System and Department of Medicine, New York University School of Medicine, New York, NY
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - Madeleine K Scammell
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | - Michael D McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | - Daniel R Brooks
- Department of Epidemiology, Boston University School of Public Health, Boston, MA.
| | - David J Friedman
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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114
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Supiano MA, Lovato L, Ambrosius WT, Bates J, Beddhu S, Drawz P, Dwyer JP, Hamburg NM, Kitzman D, Lash J, Lustigova E, Miracle CM, Oparil S, Raj DS, Weiner DE, Taylor A, Vita JA, Yunis R, Chertow GM, Chonchol M. Pulse wave velocity and central aortic pressure in systolic blood pressure intervention trial participants. PLoS One 2018; 13:e0203305. [PMID: 30256784 PMCID: PMC6157848 DOI: 10.1371/journal.pone.0203305] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 08/16/2018] [Indexed: 12/14/2022] Open
Abstract
Arterial stiffness, typically assessed as the aortic pulse wave velocity (PWV), and central blood pressure levels may be indicators of cardiovascular disease (CVD) risk. This ancillary study to the Systolic Blood Pressure Intervention Trial (SPRINT) obtained baseline assessments (at randomization) of PWV and central systolic blood pressure (C-SBP) to: 1) characterize these vascular measurements in the SPRINT cohort, and 2) test the hypotheses that PWV and C-SBP are associated with glucose homeostasis and markers of chronic kidney disease (CKD). The SphygmoCor® CPV device was used to assess carotid-femoral PWV and its pulse wave analysis study protocol was used to obtain C-SBP. Valid results were obtained from 652 participants. Mean (±SD) PWV and C-SBP for the SPRINT cohort were 10.7 ± 2.7 m/s and 132.0 ± 17.9 mm Hg respectively. Linear regression analyses for PWV and C-SBP results adjusted for age, sex, and race/ethnicity in relation to several markers of glucose homeostasis and CKD did not identify any significant associations with the exception of a marginally statistically significant and modest association between PWV and urine albumin-to-creatinine ratio (linear regression estimate ± SE, 0.001 ± 0.0006; P-value 0.046). In a subset of SPRINT participants, PWV was significantly higher than in prior studies of normotensive persons, as expected. For older age groups in the SPRINT cohort (age > 60 years), PWV was compared with a reference population of hypertensive individuals. There were no compelling associations noted between PWV or C-SBP and markers of glucose homeostasis or CKD. Clinical Trial Registration: NCT01206062.
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Affiliation(s)
- Mark A. Supiano
- Geriatrics Division University of Utah School of Medicine and VA Salt Lake City Geriatric Research, Education and Clinical Center, Salt Lake City, Utah, United States of America
- * E-mail:
| | - Laura Lovato
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Walter T. Ambrosius
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Jeffrey Bates
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, United States of America
| | - Srinivasan Beddhu
- Nephrology Division University of Utah and Salt Lake City VA Medical Center, Salt Lake City, Utah, United States of America
| | - Paul Drawz
- Division of Renal Diseases & Hypertension, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Jamie P. Dwyer
- Division of Nephrology/Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Naomi M. Hamburg
- Section of Vascular Biology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Dalane Kitzman
- Sections on Cardiovascular Medicine and Geriatrics, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - James Lash
- Section of Nephrology, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Eva Lustigova
- Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
| | - Cynthia M. Miracle
- Division of Nephrology and Hypertension, University of California San Diego and VA San Diego Healthcare System, San Diego, California, United States of America
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Dominic S. Raj
- Division of Kidney Diseases and Hypertension, George Washington University, Washington, DC, United States of America
| | - Daniel E. Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - Addison Taylor
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, United States of America
| | - Joseph A. Vita
- Section of Vascular Biology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Reem Yunis
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Denver, Colorado, United States of America
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Scott TM, Rogers G, Weiner DE, Livingston K, Selhub J, Jacques PF, Rosenberg IH, Troen AM. B-Vitamin Therapy for Kidney Transplant Recipients Lowers Homocysteine and Improves Selective Cognitive Outcomes in the Randomized FAVORIT Ancillary Cognitive Trial. J Prev Alzheimers Dis 2018; 4:174-182. [PMID: 29182708 DOI: 10.14283/jpad.2017.15] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Objectives: Elevated plasma total homocysteine (tHcy) is associated with increased risk of cardiovascular disease, stroke and dementia. Results of clinical trials using B-vitamins to reduce the cognitive risks attributed to tHcy have been inconsistent. The high prevalence of both hyperhomocysteinemia and cognitive impairment among kidney transplant recipients makes them an important population in which to evaluate the effect of lowering homocysteine on cognitive function. We therefore evaluated whether B-vitamin therapy to lower tHcy would prevent cognitive-decline in a cohort of stable kidney transplant recipients. DESIGN The study was a longitudinal ancillary of the FAVORIT trial, a randomized, placebo-controlled multi-site trial of high-dose B vitamins to reduce cardiovascular and cerebrovascular events in clinically stable kidney transplant recipients with elevated tHcy. PARTICIPANTS 584 participants from 18 sites across North America. INTERVENTION The intervention consisted of a daily multivitamin containing high-doses of folate (5.0 mg), vitamin B12 (1.0 mg) and vitamin B6 (50 mg). The placebo consisted of a daily multi-vitamin containing no folate and recommended daily allowances of vitamins B12 and B6 (0 mg folate; 2.0 µg vitamin B12; 1.4 mg vitamin B6). MEASUREMENTS Annual neuropsychological assessment for up to 5 years (mean 3.3 years) using a standardized test battery. Efficacy was analyzed on an intention-to-treat basis using end-of-trial data. Subgroup analyses included stratification for baseline plasma B-vitamin and tHcy concentrations. RESULTS At baseline, cognitive impairment was common with 61% of participants falling more than one standard deviation below published norms for at least one cognitive test. Fewer than 1% of participants had insufficient plasma folate < 5 ng/ml or vitamin B12 < 148 pmol/L. However, 44.6% had plasma B6 concentrations < 30 nmol/L. At follow-up, processing speed and memory scores were modestly but significantly better in the B-vitamin supplement group than in controls (p≤0.05). There was no interaction between baseline tHcy, B-vitamin status and treatment on the cognitive outcomes. CONCLUSIONS High-dose B-vitamin supplementation provided modest cognitive benefit for kidney transplant recipients with elevated baseline tHcy. Since nearly all participants were folate and vitamin B12 sufficient at baseline, the potential cognitive benefits of folate and B12 supplementation in individuals with poor B-vitamin status remains to be determined.
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Affiliation(s)
- T M Scott
- Prof. Aron M. Troen, Director, Nutrition and Brain Health Laboratory, Institute of Biochemistry, Food Science and Nutrition, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, P.O. Box 12, Rehovot 76100, Israel, Phone ++972-54-8820420, E-mail:
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Affiliation(s)
- Scott D. Bieber
- Division of Nephrology, University of Washington Medicine, Harborview Medical Center, Seattle, Washington; and
| | - Daniel E. Weiner
- William B. Schwartz Division of Nephrology. Tufts Medical Center, Boston, Massachusetts
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117
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Ladin K, Pandya R, Perrone RD, Meyer KB, Kannam A, Loke R, Oskoui T, Weiner DE, Wong JB. Characterizing Approaches to Dialysis Decision Making with Older Adults: A Qualitative Study of Nephrologists. Clin J Am Soc Nephrol 2018; 13:1188-1196. [PMID: 30049850 PMCID: PMC6086704 DOI: 10.2215/cjn.01740218] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/15/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite guidelines recommending shared decision making, nephrologists vary significantly in their approaches to discussing conservative management for kidney replacement therapy with older patients. Many older patients do not perceive dialysis initiation as a choice or receive sufficient information about conservative management for reasons incompletely understood. We examined how nephrologists' perceptions of key outcomes and successful versus failed treatment discussions shape their approach and characterized different models of decision making, patient engagement, and conservative management discussion. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our qualitative study used semistructured interviews with a sample of purposively sampled nephrologists. Interviews were conducted from June 2016 to May 2017 and continued until thematic saturation. Data were analyzed using typological and thematic analyses. RESULTS Among 35 nephrologists from 18 practices, 20% were women, 66% had at least 10 years of nephrology experience, and 80% were from academic medical centers. Four distinct approaches to decision making emerged: paternalist, informative (patient led), interpretive (navigator), and institutionalist. Five themes characterized differences between these approaches, including patient autonomy, engagement and deliberation (disclosing all options, presenting options neutrally, eliciting patient values, and offering explicit treatment recommendation), influence of institutional norms, importance of clinical outcomes (e.g., survival and dialysis initiation), and physician role (educating patients, making decisions, pursuing active therapies, and managing symptoms). Paternalists and institutionalists viewed initiation of dialysis as a measure of success, whereas interpretive and informative nephrologists focused on patient engagement, quality of life, and aligning patient values with treatment. In this sample, only one third of providers presented conservative management to patients, all of whom followed either informative or interpretive approaches. The interpretive model best achieved shared decision making. CONCLUSIONS Differences in nephrologists' perceptions of their role, patient autonomy, and successful versus unsuccessful encounters contribute to variation in decision making for patients with kidney disease.
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Affiliation(s)
- Keren Ladin
- Department of Occupational Therapy and
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts; and
| | - Renuka Pandya
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts; and
| | | | - Klemens B. Meyer
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Allison Kannam
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts; and
| | - Rohini Loke
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts; and
| | - Tira Oskoui
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, Massachusetts; and
| | - Daniel E. Weiner
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - John B. Wong
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
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Weiner DE, Park M, Tighiouart H, Joseph AA, Carpenter MA, Goyal N, House AA, Hsu CY, Ix JH, Jacques PF, Kew CE, Kim SJ, Kusek JW, Pesavento TE, Pfeffer MA, Smith SR, Weir MR, Levey AS, Bostom AG. Albuminuria and Allograft Failure, Cardiovascular Disease Events, and All-Cause Death in Stable Kidney Transplant Recipients: A Cohort Analysis of the FAVORIT Trial. Am J Kidney Dis 2018; 73:51-61. [PMID: 30037726 DOI: 10.1053/j.ajkd.2018.05.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 05/23/2018] [Indexed: 12/30/2022]
Abstract
RATIONALE & OBJECTIVE Cardiovascular disease (CVD) is common and overall graft survival is suboptimal among kidney transplant recipients. Although albuminuria is a known risk factor for adverse outcomes among persons with native chronic kidney disease, the relationship of albuminuria with cardiovascular and kidney outcomes in transplant recipients is uncertain. STUDY DESIGN Post hoc longitudinal cohort analysis of the Folic Acid for Vascular Outcomes Reduction in Transplantation (FAVORIT) Trial. SETTING & PARTICIPANTS Stable kidney transplant recipients with elevated homocysteine levels from 30 sites in the United States, Canada, and Brazil. PREDICTOR Urine albumin-creatinine ratio (ACR) at randomization. OUTCOMES Allograft failure, CVD, and all-cause death. ANALYTICAL APPROACH Multivariable Cox models adjusted for age; sex; race; randomized treatment allocation; country; systolic and diastolic blood pressure; history of CVD, diabetes, and hypertension; smoking; cholesterol; body mass index; estimated glomerular filtration rate (eGFR); donor type; transplant vintage; medications; and immunosuppression. RESULTS Among 3,511 participants with complete data, median ACR was 24 (Q1-Q3, 9-98) mg/g, mean eGFR was 49±18 (standard deviation) mL/min/1.73m2, mean age was 52±9 years, and median graft vintage was 4.1 (Q1-Q3, 1.7-7.4) years. There were 1,017 (29%) with ACR < 10mg/g, 912 (26%) with ACR of 10 to 29mg/g, 1,134 (32%) with ACR of 30 to 299mg/g, and 448 (13%) with ACR ≥ 300mg/g. During approximately 4 years, 282 allograft failure events, 497 CVD events, and 407 deaths occurred. Event rates were higher at both lower eGFRs and higher ACR. ACR of 30 to 299 and ≥300mg/g relative to ACR < 10mg/g were independently associated with graft failure (HRs of 3.40 [95% CI, 2.19-5.30] and 9.96 [95% CI, 6.35-15.62], respectively), CVD events (HRs of 1.25 [95% CI, 0.96-1.61] and 1.55 [95% CI, 1.13-2.11], respectively), and all-cause death (HRs of 1.65 [95% CI, 1.23-2.21] and 2.07 [95% CI, 1.46-2.94], respectively). LIMITATIONS No data for rejection; single ACR assessment. CONCLUSIONS In a large population of stable kidney transplant recipients, elevated baseline ACR is independently associated with allograft failure, CVD, and death. Future studies are needed to evaluate whether reducing albuminuria improves these outcomes.
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Affiliation(s)
| | - Meyeon Park
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
| | | | - Alin A Joseph
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Myra A Carpenter
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC
| | - Nitender Goyal
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Andrew A House
- Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California, San Diego, San Diego, CA
| | - Paul F Jacques
- Human Nutrition Research Center on Aging, Tufts University, Boston, MA
| | - Clifton E Kew
- Division of Nephrology, University of Alabama, Birmingham, AL
| | - S Joseph Kim
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | | | - Matthew R Weir
- Division of Nephrology, University of Maryland, Baltimore, MD
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Andrew G Bostom
- Division of Hypertension and Kidney Diseases, Rhode Island Hospital, Providence, RI
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119
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Affiliation(s)
- Nitender Goyal
- Division of Nephrology, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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120
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Ladin K, Pandya R, Kannam A, Loke R, Oskoui T, Perrone RD, Meyer KB, Weiner DE, Wong JB. Discussing Conservative Management With Older Patients With CKD: An Interview Study of Nephrologists. Am J Kidney Dis 2018; 71:627-635. [PMID: 29396240 PMCID: PMC5916578 DOI: 10.1053/j.ajkd.2017.11.011] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 11/06/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management. Barriers and facilitators to discussions about conservative management and nephrologists' decisions to present the option of conservative management may vary within the nephrology provider community. STUDY DESIGN Interview study of nephrologists. SETTING & PARTICIPANTS National sample of US nephrologists sampled based on sex, years in practice, practice type, and region. METHODOLOGY Qualitative semistructured interviews continued until thematic saturation. ANALYTICAL APPROACH Thematic and narrative analysis of recorded and transcribed interviews. RESULTS Among 35 semistructured interviews with nephrologists from 18 practices, 37% described routinely discussing conservative management ("early adopters"). 5 themes and related subthemes reflected issues that influence nephrologists' decisions to discuss conservative management and their approaches to these discussions: struggling to define nephrologists' roles (determining treatment, instilling hope, and improving patient symptoms), circumventing end-of-life conversations (contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, and tailoring information), confronting institutional barriers (time constraints, care coordination, incentives for dialysis, and discomfort with varied conservative management approaches), conservative management as "no care," and moral distress. Nephrologists' approaches to conservative management discussions were shaped by perceptions of their roles and by a common view of conservative management as no care. Their willingness to pursue conservative management was influenced by provider- and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress). Early adopters routinely discussed conservative management as a way of relieving moral distress, whereas others who were more selective in discussing conservative management experienced greater distress. LIMITATIONS Participants' views are likely most transferable to large academic medical centers, due to oversampling of academic clinicians. CONCLUSIONS Our findings clarify how moral distress serves as a catalyst for conservative management discussion and highlight points of intervention and mechanisms potentially underlying low conservative management use in the United States.
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Affiliation(s)
- Keren Ladin
- Department of Occupational Therapy, Tufts University, Medford, MA; Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA.
| | - Renuka Pandya
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Allison Kannam
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Rohini Loke
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | - Tira Oskoui
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA
| | | | | | | | - John B Wong
- Department of Medicine, Tufts Medical Center, Boston, MA
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Weinrauch LA, Claggett B, Liu J, Finn PV, Weir MR, Weiner DE, D'Elia JA. Smoking and outcomes in kidney transplant recipients: a post hoc survival analysis of the FAVORIT trial. Int J Nephrol Renovasc Dis 2018; 11:155-164. [PMID: 29760559 PMCID: PMC5937486 DOI: 10.2147/ijnrd.s161001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background Tobacco use remains an international health problem with between 10% and 40% of adults currently using tobacco. Given the rising number of patients either awaiting or having received a kidney transplant and the absence of smoking cessation as the criterion for transplantation in guidelines, we explored the association between smoking status and clinical outcomes in kidney transplant recipients. Patients and methods In this post hoc analysis of the Folic Acid for Vascular Outcome Reduction in Transplant trial, the associations between smoking status, defined as never having smoked, formerly or currently smoking, and both all-cause mortality and graft survival were assessed using Cox proportional hazards models. Fatal events were centrally adjudicated into prespecified categories: all-cause, cardiovascular and non-cardiovascular causes. Graft loss was defined as return to dialysis or retransplantation. Clinical Trials URL: http://www.clinicaltrials.gov/show/NCT00064753. Results Among 4110 transplant recipients, there were 451 current smokers and 1611 former smokers. The mortality rate per 100 patient-years was 4.0 (71 deaths) for smokers, 3.5 (226 deaths) for former smokers and 2.4 (116 deaths) for never smokers. Hazard ratio for mortality for current smokers was 1.70 (CI=1.26–2.29, p=0.001) and for former smokers was 1.21 (0.98–1.50, p=0.08) with 1.0 representing never smokers. As the number of cardiovascular deaths was similar in each group (all p>0.3), the differences between groups was driven by non-cardiovascular death rates. Current smokers (2.39; 1.62–3.61, p<0.001) and former smokers (1.50; 1.12–2.01, p=0.007) had increased hazard of non-cardiovascular death. Kidney allograft failure was more likely in current smokers than in either former or never smokers (3.5, 2.1 and 2.0 per 100 patient-years, p<0.001, adjusted hazard ratio 1.49 and 1.05, respectively). Conclusion Continued smoking was associated with >100% increased risk of non-cardiovascular death, 70% greater risk of all-cause mortality and a 50% greater risk of graft loss, a risk not seen in former smokers. These findings confirm previous non-adjudicated observations that smoking is associated with adverse clinical outcomes and suggest that more emphasis should be placed on smoking cessation prior to kidney transplantation.
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Affiliation(s)
- Larry A Weinrauch
- Cardiovascular Division, Brigham and Women's Hospital.,Kidney and Hypertension Section, Joslin Diabetes Center.,Department of Medicine, Beth Israel Deaconess Hospital.,Harvard Medical School, Boston, MA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital.,Harvard Medical School, Boston, MA
| | - Jiankang Liu
- Cardiovascular Division, Brigham and Women's Hospital
| | - Peter V Finn
- Cardiovascular Division, Brigham and Women's Hospital
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland, College Park, MD
| | - Daniel E Weiner
- Division of Nephrology, Tufts University School of Medicine, Boston, MA, USA
| | - John A D'Elia
- Kidney and Hypertension Section, Joslin Diabetes Center.,Department of Medicine, Beth Israel Deaconess Hospital.,Harvard Medical School, Boston, MA
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122
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Bostom A, Steubl D, Garimella PS, Franceschini N, Roberts MB, Pasch A, Ix JH, Tuttle KR, Ivanova A, Shireman T, Kim SJ, Gohh R, Weiner DE, Levey AS, Hsu CY, Kusek JW, Eaton CB. Serum Uromodulin: A Biomarker of Long-Term Kidney Allograft Failure. Am J Nephrol 2018; 47:275-282. [PMID: 29698955 DOI: 10.1159/000489095] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/04/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Uromodulin is a kidney-derived glycoprotein and putative tubular function index. Lower serum uromodulin was recently associated with increased risk for kidney allograft failure in a preliminary, longitudinal single-center -European study involving 91 kidney transplant recipients (KTRs). METHODS The Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) trial is a completed, large, multiethnic controlled clinical trial cohort, which studied chronic, stable KTRs. We conducted a case cohort analysis using a randomly selected subset of patients (random subcohort, n = 433), and all individuals who developed kidney allograft failure (cases, n = 226) during follow-up. Serum uromodulin was determined in this total of n = 613 FAVORIT trial participants at randomization. Death-censored kidney allograft failure was the study outcome. RESULTS The 226 kidney allograft failures occurred during a median surveillance of 3.2 years. Unadjusted, weighted Cox proportional hazards modeling revealed that lower serum uromodulin, tertile 1 vs. tertile 3, was associated with a threefold greater risk for kidney allograft failure (hazards ratio [HR], 95% CI 3.20 [2.05-5.01]). This association was attenuated but persisted at twofold greater risk for allograft failure, after adjustment for age, sex, smoking, allograft type and vintage, prevalent diabetes mellitus and cardiovascular disease (CVD), total/high-density lipoprotein cholesterol ratio, systolic blood pressure, estimated glomerular filtration rate, and natural log urinary albumin/creatinine: HR 2.00, 95% CI (1.06-3.77). CONCLUSIONS Lower serum uromodulin, a possible indicator of less well-preserved renal tubular function, remained associated with greater risk for kidney allograft failure, after adjustment for major, established clinical kidney allograft failure and CVD risk factors, in a large, multiethnic cohort of long-term, stable KTRs.
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Affiliation(s)
- Andrew Bostom
- Center For Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island, USA
| | - Dominik Steubl
- Klinikum rechts der Isar, Technische Universität, München, Germany
| | - Pranav S Garimella
- Division of Nephrology-Hypertension, Department of Medicine, University of California, San Diego, California, USA
| | - Nora Franceschini
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mary B Roberts
- Center For Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island, USA
| | | | - Joachim H Ix
- Division of Nephrology-Hypertension, Department of Medicine, University of California, San Diego, California, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, University of Washington, Spokane, Washington, USA
| | - Anastasia Ivanova
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Theresa Shireman
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - S Joseph Kim
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Reginald Gohh
- Division of Hypertension and Kidney Diseases, Department of Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Andrew S Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California-San Francisco, San Francisco, California, USA
| | - John W Kusek
- National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Charles B Eaton
- Department of Family Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
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123
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Johnson RJ, Bakris GL, Borghi C, Chonchol MB, Feldman D, Lanaspa MA, Merriman TR, Moe OW, Mount DB, Sanchez Lozada LG, Stahl E, Weiner DE, Chertow GM. Hyperuricemia, Acute and Chronic Kidney Disease, Hypertension, and Cardiovascular Disease: Report of a Scientific Workshop Organized by the National Kidney Foundation. Am J Kidney Dis 2018; 71:851-865. [PMID: 29496260 DOI: 10.1053/j.ajkd.2017.12.009] [Citation(s) in RCA: 315] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 12/03/2017] [Indexed: 12/21/2022]
Abstract
Urate is a cause of gout, kidney stones, and acute kidney injury from tumor lysis syndrome, but its relationship to kidney disease, cardiovascular disease, and diabetes remains controversial. A scientific workshop organized by the National Kidney Foundation was held in September 2016 to review current evidence. Cell culture studies and animal models suggest that elevated serum urate concentrations can contribute to kidney disease, hypertension, and metabolic syndrome. Epidemiologic evidence also supports elevated serum urate concentrations as a risk factor for the development of kidney disease, hypertension, and diabetes, but differences in methodologies and inpacts on serum urate concentrations by even subtle changes in kidney function render conclusions uncertain. Mendelian randomization studies generally do not support a causal role of serum urate in kidney disease, hypertension, or diabetes, although interpretation is complicated by nonhomogeneous populations, a failure to consider environmental interactions, and a lack of understanding of how the genetic polymorphisms affect biological mechanisms related to urate. Although several small clinical trials suggest benefits of urate-lowering therapies on kidney function, blood pressure, and insulin resistance, others have been negative, with many trials having design limitations and insufficient power. Thus, whether uric acid has a causal role in kidney and cardiovascular diseases requires further study.
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Affiliation(s)
| | | | | | | | | | | | | | - Orson W Moe
- University of Texas Southwestern Medical Center, Dallas, TX
| | - David B Mount
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Eli Stahl
- Mount Sinai School of Medicine, New York City, NY
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124
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Roehm B, Vest AR, Weiner DE. Left Ventricular Assist Devices, Kidney Disease, and Dialysis. Am J Kidney Dis 2018; 71:257-266. [DOI: 10.1053/j.ajkd.2017.09.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/20/2017] [Indexed: 12/19/2022]
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125
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Li Q, Trivedi AN, Galarraga O, Chernew ME, Weiner DE, Mor V. Medicare Advantage Ratings And Voluntary Disenrollment Among Patients With End-Stage Renal Disease. Health Aff (Millwood) 2018; 37:70-77. [PMID: 29309223 PMCID: PMC6021124 DOI: 10.1377/hlthaff.2017.0974] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Populations with intensive health care needs and high care costs may be attracted to insurance plans that have high quality ratings, but patients may be likely to disenroll from a plan if their care needs are not met. We assessed the association between publicly reported Medicare Advantage plan star ratings and voluntary disenrollment of incident dialysis patients in the following year over the period 2007-13. We found that Medicare Advantage (MA) plans with lower star ratings had significantly higher rates of disenrollment by incident dialysis patients in the following year. Compared to MA plans with 4.0 or more stars, adjusted disenrollment rates were 3.9 percentage points higher for plans with 3.5 stars, 5.0 percentage points higher for those with 3.0 stars, and 12.1 percentage points higher for those with 2.5 or fewer stars. These findings suggest that low plan quality may lead to increased expenditures, as this high-cost population generally must shift from Medicare Advantage to traditional Medicare upon disenrollment.
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Affiliation(s)
- Qijuan Li
- Qijuan Li ( ) is an adjunct professor of health services research at the Brown University School of Public Health, in Providence, Rhode Island, and director of innovation analytics at SCIO Health Analytics, in West Hartford, Connecticut
| | - Amal N Trivedi
- Amal N. Trivedi is an associate professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health
| | - Omar Galarraga
- Omar Galarraga is an associate professor in the Department of Health Services, Policy, and Practice, Brown University School of Public Health
| | - Michael E Chernew
- Michael E. Chernew is the Leonard D. Schaeffer Professor of Health Care Policy in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Daniel E Weiner
- Daniel E. Weiner is an associate professor of medicine at Tufts Medical Center, in Boston
| | - Vincent Mor
- Vincent Mor is a professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health and a health scientist at the Providence Veterans Affairs Medical Center, in Rhode Island
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126
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Isakova T, Nickolas TL, Denburg M, Yarlagadda S, Weiner DE, Gutiérrez OM, Bansal V, Rosas SE, Nigwekar S, Yee J, Kramer H. KDOQI US Commentary on the 2017 KDIGO Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD). Am J Kidney Dis 2017; 70:737-751. [DOI: 10.1053/j.ajkd.2017.07.019] [Citation(s) in RCA: 199] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 07/29/2017] [Indexed: 12/25/2022]
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127
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Babyak JM, Weiner DE, Noubary F, Sharp CR. Prevalence of Elevated Serum Creatinine Concentration in Dogs Presenting to a Veterinary Academic Medical Center (2010-2014). J Vet Intern Med 2017; 31:1757-1764. [PMID: 28891088 PMCID: PMC5697188 DOI: 10.1111/jvim.14823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/22/2017] [Accepted: 08/03/2017] [Indexed: 12/16/2022] Open
Abstract
Background The epidemiology of kidney disease is not extensively described in dogs. Hypothesis/Objectives To better understand the prevalence of elevated serum creatinine concentration in dogs. Animals Client‐owned dogs. Methods A retrospective, observational cross‐sectional study design was used. We made a dataset of 115,631 hospital visits of all dogs presenting from October 2010 to October 2014. We estimated the prevalence and risk of elevated serum creatinine, defined as >1.6 mg/dL, in evaluated dogs. Results Of 115,631 visits, 98,693 were outpatient visits and 16,938 were hospital admissions. Among outpatient visits, 9,983 (10.1%) had serum creatinine assessment (4,423 [44.3%] visits were first visits), whereas, among hospital admissions, 12,228 (60.0%) had at least 1 serum creatinine (7,731 [75.6%] admissions were first admissions). The prevalence of elevated serum creatinine concentration in all evaluated dogs was 11.5% (95% CI: 11.0%, 11.9%); 10.2% (95% CI: 9.6%, 10.8%) of inpatients and 12.9% (95% CI: 12.1%, 13.8%) of outpatients had elevated serum creatinine concentration. The relative risk (RR) of elevated serum creatinine concentration was significantly higher in geriatric dogs (outpatient RR 1.45 [95% CI: 1.23, 1.70], inpatient RR 1.43 [95% CI: 1.16, 1.76]) and lower in young dogs (outpatient RR 0.39 [95% CI: 0.26, 0.59], inpatient RR 0.44 [95% CI: 0.32, 0.62]) when compared to the measured population risk. Conclusions and Clinical Importance When selected for laboratory evaluation, the proportion of dogs presenting to an academic medical center with evidence of kidney injury is high compared to previous reports and might reflect a population of sicker dogs.
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Affiliation(s)
- J M Babyak
- Tufts Cummings School of Veterinary Medicine, North Grafton, MA
| | - D E Weiner
- Tufts University School of Medicine, Boston, MA.,Tufts Medical Center, Boston, MA.,Tufts Clinical and Translational Institute, Boston, MA
| | - F Noubary
- Tufts Clinical and Translational Institute, Boston, MA.,Tufts Sackler School of Biomedical Sciences, Boston, MA
| | - C R Sharp
- College of Veterinary Medicine, Murdoch University, Murdoch, WA, Australia
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128
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Berlowitz DR, Foy CG, Kazis LE, Bolin LP, Conroy MB, Fitzpatrick P, Gure TR, Kimmel PL, Kirchner K, Morisky DE, Newman J, Olney C, Oparil S, Pajewski NM, Powell J, Ramsey T, Simmons DL, Snyder J, Supiano MA, Weiner DE, Whittle J. Effect of Intensive Blood-Pressure Treatment on Patient-Reported Outcomes. N Engl J Med 2017; 377:733-744. [PMID: 28834483 PMCID: PMC5706112 DOI: 10.1056/nejmoa1611179] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The previously published results of the Systolic Blood Pressure Intervention Trial showed that among participants with hypertension and an increased cardiovascular risk, but without diabetes, the rates of cardiovascular events were lower among those who were assigned to a target systolic blood pressure of less than 120 mm Hg (intensive treatment) than among those who were assigned to a target of less than 140 mm Hg (standard treatment). Whether such intensive treatment affected patient-reported outcomes was uncertain; those results from the trial are reported here. METHODS We randomly assigned 9361 participants with hypertension to a systolic blood-pressure target of less than 120 mm Hg or a target of less than 140 mm Hg. Patient-reported outcome measures included the scores on the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Veterans RAND 12-Item Health Survey, the Patient Health Questionnaire 9-item depression scale (PHQ-9), patient-reported satisfaction with their blood-pressure care and blood-pressure medications, and adherence to blood-pressure medications. We compared the scores in the intensive-treatment group with those in the standard-treatment group among all participants and among participants stratified according to physical and cognitive function. RESULTS Participants who received intensive treatment received an average of one additional antihypertensive medication, and the systolic blood pressure was 14.8 mm Hg (95% confidence interval, 14.3 to 15.4) lower in the group that received intensive treatment than in the group that received standard treatment. Mean PCS, MCS, and PHQ-9 scores were relatively stable over a median of 3 years of follow-up, with no significant differences between the two treatment groups. No significant differences between the treatment groups were noted when participants were stratified according to baseline measures of physical or cognitive function. Satisfaction with blood-pressure care was high in both treatment groups, and we found no significant difference in adherence to blood-pressure medications. CONCLUSIONS Patient-reported outcomes among participants who received intensive treatment, which targeted a systolic blood pressure of less than 120 mm Hg, were similar to those among participants who received standard treatment, including among participants with decreased physical or cognitive function. (Funded by the National Institutes of Health; SPRINT ClinicalTrials.gov number, NCT01206062 .).
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Affiliation(s)
- Dan R Berlowitz
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Capri G Foy
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Lewis E Kazis
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Linda P Bolin
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Molly B Conroy
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Peter Fitzpatrick
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Tanya R Gure
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Paul L Kimmel
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Kent Kirchner
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Donald E Morisky
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Jill Newman
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Christine Olney
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Suzanne Oparil
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Nicholas M Pajewski
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - James Powell
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Thomas Ramsey
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Debra L Simmons
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Joni Snyder
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Mark A Supiano
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Daniel E Weiner
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
| | - Jeff Whittle
- From the Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs (VA) Hospital, Bedford (D.R.B., L.E.K.), and Boston University Schools of Medicine and Public Health (D.R.B., L.E.K.) and Tufts Medical Center (D.E.W.), Boston - all in Massachusetts; Wake Forest School of Medicine, Winston-Salem (C.G.F., J.N., N.M.P.), and East Carolina University College of Nursing (L.P.B.) and Brody School of Medicine (J.P.), East Carolina University, Greenville - both in North Carolina; the University of Pittsburgh, Pittsburgh (M.B.C.); Mayo Clinic Florida, Jacksonville (P.F.); the Ohio State Wexner Medical Center, Columbus (T.R.G.); the National Institute of Diabetes and Digestive and Kidney Diseases (P.L.K.) and the National Heart, Lung, and Blood Institute (J.S.), Bethesda, MD; the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS (K.K.); UCLA Fielding School of Public Health, Los Angeles (D.E.M.); Minneapolis VA Medical Center, Minneapolis (C.O.); University of Alabama at Birmingham, Birmingham (S.O., T.R.); University of Utah School of Medicine (D.L.S., M.A.S.) and VA Geriatric Research, Education and Clinical Center (M.A.S.), Salt Lake City; and the Clement J. Zablocki VA Medical Center, Milwaukee (J.W.)
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Stallings TL, Riefkohl A, Ma Y, Weiner DE, Aschengrau A, Kaufman JS, Ramirez-Rubio O, Amador JJ, Lopez D, Laws R, Winter M, McSorley VE, Brooks D, Applebaum KM. Cane Cutting and Dysuria among male Sugarcane Workers in Nicaragua. Ann Epidemiol 2017. [DOI: 10.1016/j.annepidem.2017.07.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ladin K, Lin N, Hahn E, Zhang G, Koch-Weser S, Weiner DE. Engagement in decision-making and patient satisfaction: a qualitative study of older patients' perceptions of dialysis initiation and modality decisions. Nephrol Dial Transplant 2017; 32:1394-1401. [PMID: 27576590 PMCID: PMC5837335 DOI: 10.1093/ndt/gfw307] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/01/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although shared decision-making (SDM) can better align patient preferences with treatment, barriers remain incompletely understood and the impact on patient satisfaction is unknown. METHODS This is a qualitative study with semistructured interviews. A purposive sample of prevalent dialysis patients ≥65 years of age at two facilities in Greater Boston were selected for diversity in time from initiation, race, modality and vintage. A codebook was developed and interrater reliability was 89%. Codes were discussed and organized into themes. RESULTS A total of 31 interviews with 23 in-center hemodialysis patients, 1 home hemodialysis patient and 7 peritoneal dialysis patients were completed. The mean age was 76 ± 9 years. Two dominant themes (with related subthemes) emerged: decision-making experiences and satisfaction, and barriers to SDM. Subthemes included negative versus positive decision-making experiences, struggling for autonomy, being a 'good patient' and lack of choice. In spite of believing that dialysis initiation should be the patient's choice, no patients perceived that they had made a choice. Patients explained that this is due to the perception of imminent death or that the decision to start dialysis belonged to physicians. Clinicians and family frequently overrode patient preferences, with patient autonomy honored mostly to select dialysis modality. Poor decision-making experiences were associated with low treatment satisfaction. CONCLUSIONS Despite recommendations for SDM, many older patients were unaware that dialysis initiation was voluntary, held mistaken beliefs about their prognosis and were not engaged in decision-making, resulting in poor satisfaction. Patients desired greater information, specifically focusing on the acuity of their choice, prognosis and goals of care.
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Affiliation(s)
- Keren Ladin
- Department of Occupational Therapy, Tufts University, Medford, MA, USA
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA, USA
| | - Naomi Lin
- Department of Occupational Therapy, Tufts University, Medford, MA, USA
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA, USA
| | - Emily Hahn
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA, USA
| | - Gregory Zhang
- Research on Aging, Ethics, and Community Health, Tufts University, Medford, MA, USA
| | - Susan Koch-Weser
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
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Drew DA, Koo BB, Bhadelia R, Weiner DE, Duncan S, la Garza MMD, Gupta A, Tighiouart H, Scott T, Sarnak MJ. White matter damage in maintenance hemodialysis patients: a diffusion tensor imaging study. BMC Nephrol 2017; 18:213. [PMID: 28676035 PMCID: PMC5497357 DOI: 10.1186/s12882-017-0628-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/21/2017] [Indexed: 11/22/2022] Open
Abstract
Background Patients treated with dialysis have high rates of brain infarcts, brain atrophy, and white matter disease. There are limited data regarding the presence of more subtle damage to brain white matter. Methods In the Cognition and Dialysis Study, we compared brain structure using diffusion tensor imaging in hemodialysis (HD) patients to individuals without known kidney disease, using tract based spatial statistics (TBSS) to compare Fractional Anisotropy (FA) and Mean Diffusivity (MD). Statistical comparison of each overlaid voxel was age controlled using a permutation based corrected p value of <0.05. Results Thirty-four HD patients and twenty six controls (52 vs 51 years for HD vs control) had adequate magnetic resonance imaging for analysis. The HD group had fewer women (38% vs 23%) and a higher prevalence of diabetes (29% vs 8%), heart failure (29% vs 0%) and clinical stroke (15% vs 0%). Hemodialysis patients had significantly lower FA across multiple white matter fiber tracts, with fronto-temporal connections, the genu of the corpus callosum and the fornix more significantly affected than posterior regions of the brain. Similarly, HD patients had significantly higher mean diffusivity in multiple anterior brain regions. Results remained similar when those with a prior history of stroke were excluded. Conclusions In HD patients, there is more white matter disease in the anterior than posterior parts of the brain compared to controls without kidney disease. This pattern of injury is most similar to that seen in aging, suggesting that developing chronic kidney disease and ultimately kidney failure may result in a phenotype consistent with accelerated aging.
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Affiliation(s)
- David A Drew
- Division of Nephrology, Department of Medicine, Tufts Medical Center, 800 Washington Street, Box 391, Boston, MA, 02111, USA.
| | - Bang-Bon Koo
- Department of Neurobiology and Anatomy, Boston University School of Medicine, Boston, MA, USA
| | - Rafeeque Bhadelia
- Department of Radiology, Beth-Israel Deaconess Medical Center, Boston, MA, USA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, 800 Washington Street, Box 391, Boston, MA, 02111, USA
| | - Sarah Duncan
- Division of Nephrology, Department of Medicine, Tufts Medical Center, 800 Washington Street, Box 391, Boston, MA, 02111, USA
| | | | - Aditi Gupta
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Hocine Tighiouart
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.,Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - Tammy Scott
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA
| | - Mark J Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, 800 Washington Street, Box 391, Boston, MA, 02111, USA
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Weiner DE, Gaussoin SA, Nord J, Auchus AP, Chelune GJ, Chonchol M, Coker L, Haley WE, Killeen AA, Kimmel PL, Lerner AJ, Oparil S, Saklayen MG, Slinin YM, Wright CB, Williamson JD, Kurella Tamura M. Cognitive Function and Kidney Disease: Baseline Data From the Systolic Blood Pressure Intervention Trial (SPRINT). Am J Kidney Dis 2017; 70:357-367. [PMID: 28606731 DOI: 10.1053/j.ajkd.2017.04.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 04/13/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chronic kidney disease is common and is associated with cardiovascular disease, cerebrovascular disease, and cognitive function, although the nature of this relationship remains uncertain. STUDY DESIGN Cross-sectional cohort using baseline data from the Systolic Blood Pressure Intervention Trial (SPRINT). SETTING & PARTICIPANTS Participants in SPRINT, a randomized clinical trial of blood pressure targets in older community-dwelling adults with cardiovascular disease, chronic kidney disease, or high cardiovascular disease risk and without diabetes or known stroke, who underwent detailed neurocognitive testing in the cognition substudy, SPRINT-Memory and Cognition in Decreased Hypertension (SPRINT-MIND). PREDICTORS Urine albumin-creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR). OUTCOMES Cognitive function, a priori defined as 5 cognitive domains based on 11 cognitive tests using z scores, and abnormal white matter volume quantified by brain magnetic resonance imaging. RESULTS Of 9,361 SPRINT participants, 2,800 participated in SPRINT-MIND and 2,707 had complete data; 637 had brain imaging. Mean age was 68 years, 37% were women, 30% were black, and 20% had known cardiovascular disease. Mean eGFR was 70.8±20.9mL/min/1.73m2 and median urine ACR was 9.7 (IQR, 5.7-22.5) mg/g. In adjusted analyses, higher ACR was associated with worse global cognitive function, executive function, memory, and attention, such that each doubling of urine ACR had the same association with cognitive performance as being 7, 10, 6, and 14 months older, respectively. Lower eGFR was independently associated with worse global cognitive function and memory. In adjusted models, higher ACR, but not eGFR, was associated with larger abnormal white matter volume. LIMITATIONS Cross-sectional only, no patients with diabetes were included. CONCLUSIONS In older adults, higher urine ACR and lower eGFR have independent associations with global cognitive performance with different affected domains. Albuminuria concurrently identifies a higher burden of abnormal brain white matter disease, suggesting that vascular disease may mediate these relationships.
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Affiliation(s)
| | - Sarah A Gaussoin
- Department of Biostatistical Sciences, Wake Forest University School of Medicine, Winston-Salem, NC
| | - John Nord
- University of Utah and George E. Wahlen VAMC, Salt Lake City, UT
| | | | | | | | - Laura Coker
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | | | - Paul L Kimmel
- National Institutes of Health, National Institute of Diabetes Digestive and Kidney Diseases, Bethesda, MD
| | - Alan J Lerner
- Case Western Reserve University and University Hospitals Case Medical Center, Cleveland, OH
| | | | | | - Yelena M Slinin
- Minneapolis Veteran's Administration Healthcare System and University of Minnesota, Minneapolis, MN
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Merhi B, Shireman T, Carpenter MA, Kusek JW, Jacques P, Pfeffer M, Rao M, Foster MC, Kim SJ, Pesavento TE, Smith SR, Kew CE, House AA, Gohh R, Weiner DE, Levey AS, Ix JH, Bostom A. Serum Phosphorus and Risk of Cardiovascular Disease, All-Cause Mortality, or Graft Failure in Kidney Transplant Recipients: An Ancillary Study of the FAVORIT Trial Cohort. Am J Kidney Dis 2017; 70:377-385. [PMID: 28579423 DOI: 10.1053/j.ajkd.2017.04.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 04/03/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Mild hyperphosphatemia is a putative risk factor for cardiovascular disease [CVD], loss of kidney function, and mortality. Very limited data are available from sizable multicenter kidney transplant recipient (KTR) cohorts assessing the potential relationships between serum phosphorus levels and the development of CVD outcomes, transplant failure, or all-cause mortality. STUDY DESIGN Cohort study. SETTING & PARTICIPANTS The Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) Trial, a large, multicenter, multiethnic, controlled clinical trial that provided definitive evidence that high-dose vitamin B-based lowering of plasma homocysteine levels did not reduce CVD events, transplant failure, or total mortality in stable KTRs. PREDICTOR Serum phosphorus levels were determined in 3,138 FAVORIT trial participants at randomization. RESULTS During a median follow-up of 4.0 years, the cohort had 436 CVD events, 238 transplant failures, and 348 deaths. Proportional hazards modeling revealed that each 1-mg/dL higher serum phosphorus level was not associated with a significant increase in CVD risk (HR, 1.06; 95% CI, 0.92-1.22), but increased transplant failure (HR, 1.36; 95% CI, 1.15-1.62) and total mortality risk associations (HR, 1.21; 95% CI, 1.04-1.40) when adjusted for treatment allocation, traditional CVD risk factors, kidney measures, type of kidney transplant, transplant vintage, and use of calcineurin inhibitors, steroids, or lipid-lowering drugs. These associations were strengthened in models without kidney measures: CVD (HR, 1.14; 95% CI, 1.00-1.31), transplant failure (HR, 1.72; 95% CI, 1.46-2.01), and mortality (HR, 1.34; 95% CI, 1.15-1.54). LIMITATIONS We lacked data for concentrations of parathyroid hormone, fibroblast growth factor 23, or vitamin D metabolites. CONCLUSIONS Serum phosphorus level is marginally associated with CVD and more strongly associated with transplant failure and total mortality in long-term KTRs. A randomized controlled clinical trial in KTRs that assesses the potential impact of phosphorus-lowering therapy on these hard outcomes may be warranted.
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Affiliation(s)
- Basma Merhi
- Division of Hypertension and Kidney Diseases, Department of Medicine, Rhode Island Hospital, Providence, RI
| | - Theresa Shireman
- Center for Gerontology and Healthcare Research, Brown University, Providence, RI
| | - Myra A Carpenter
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC
| | - John W Kusek
- National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Paul Jacques
- Nutritional Epidemiology Program, USDA Human Nutrition Research Center on Aging, Boston, MA
| | - Marc Pfeffer
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Madhumathi Rao
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Meredith C Foster
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - S Joseph Kim
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Todd E Pesavento
- Division of Nephrology, Department of Medicine, Ohio State University, Columbus, OH
| | - Stephen R Smith
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Clifton E Kew
- Division of Nephrology, Department of Medicine, University of Alabama-Birmingham, Birmingham, AL
| | - Andrew A House
- Division of Nephrology, Department of Medicine, London Health Sciences Center, London, Ontario, Canada
| | - Reginald Gohh
- Division of Hypertension and Kidney Diseases, Department of Medicine, Rhode Island Hospital, Providence, RI
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Andrew S Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, Department of Medicine, University of California, San Diego, CA
| | - Andrew Bostom
- Division of Hypertension and Kidney Diseases, Department of Medicine, Rhode Island Hospital, Providence, RI.
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Shea MK, Booth SL, Weiner DE, Brinkley TE, Kanaya AM, Murphy RA, Simonsick EM, Wassel CL, Vermeer C, Kritchevsky SB. Circulating Vitamin K Is Inversely Associated with Incident Cardiovascular Disease Risk among Those Treated for Hypertension in the Health, Aging, and Body Composition Study (Health ABC). J Nutr 2017; 147:888-895. [PMID: 28356433 PMCID: PMC5404216 DOI: 10.3945/jn.117.249375] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 02/23/2017] [Accepted: 03/03/2017] [Indexed: 01/07/2023] Open
Abstract
Background: A role for vitamin K in coronary artery calcification (CAC), a subclinical manifestation of cardiovascular disease (CVD), has been proposed because vitamin K-dependent proteins, including the calcification inhibitor matrix Gla protein (MGP), are present in vascular tissue. Observational studies found that low circulating phylloquinone (vitamin K-1) was associated with increased CAC progression, especially in persons treated for hypertension. It is unknown whether hypertension treatment modifies this putative role of vitamin K in clinical CVD risk.Objective: We determined the association between vitamin K status and incident clinical CVD in older adults in the Health ABC (Health, Aging, and Body Composition Study) and whether the association differed by hypertension treatment status.Methods: Plasma phylloquinone was measured in 1061 participants free of CVD (70-79 y of age, 58% women, 39% black). Plasma uncarboxylated MGP [(dp)ucMGP] was measured in a subset of 635 participants. Multivariate Cox models estimated the HR for incident CVD over 12.1 follow-up years. Effect modification by hypertension was tested with the use of interaction terms.Results: Neither low plasma phylloquinone (<0.2 nmol/L) nor elevated (dp)ucMGP (≥574 pmol/L) was significantly associated with incident CVD [respective HRs (95% CIs): 1.27 (0.75, 2.13) and 1.02 (0.72, 1.45)]. In participants treated for hypertension (n = 489; 135 events), low plasma phylloquinone was associated with higher CVD risk overall (HR: 2.94; 95% CI: 1.41, 6.13). In those with untreated hypertension (n = 153; 48 events) and without hypertension (n = 418; 92 events), low plasma phylloquinone was not associated with incident CVD. The association between high (dp)ucMGP did not differ by hypertension treatment status (P-interaction = 0.72).Conclusions: Vitamin K status was not significantly associated with CVD risk overall, but low plasma phylloquinone was associated with a higher CVD risk in older adults treated for hypertension. Additional evidence from larger clinical studies is needed to clarify the importance of vitamin K to CVD in persons treated for hypertension, a segment of the population at high risk of clinical CVD events.
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Affiliation(s)
- M Kyla Shea
- USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA;
| | - Sarah L Booth
- USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Tina E Brinkley
- Sticht Center on Aging, Wake Forest School of Medicine, Winston-Salem, NC
| | - Alka M Kanaya
- University of California-San Francisco, San Francisco, CA
| | - Rachel A Murphy
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Christina L Wassel
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; and
| | - Cees Vermeer
- VitaK, University of Maastricht, Maastricht, Netherlands
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Affiliation(s)
- Dana C. Miskulin
- Department of Medicine; Tufts University School of Medicine; Boston Massachusetts
| | - Daniel E. Weiner
- Department of Medicine; Tufts University School of Medicine; Boston Massachusetts
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Ix JH, Katz R, Bansal N, Foster M, Weiner DE, Tracy R, Jotwani V, Hughes-Austin J, McKay D, Gabbai F, Hsu CY, Bostom A, Levey AS, Shlipak MG. Urine Fibrosis Markers and Risk of Allograft Failure in Kidney Transplant Recipients: A Case-Cohort Ancillary Study of the FAVORIT Trial. Am J Kidney Dis 2017; 69:410-419. [PMID: 28024930 PMCID: PMC7321838 DOI: 10.1053/j.ajkd.2016.10.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 10/05/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Kidney tubulointerstitial fibrosis marks risk for allograft failure in kidney transplant recipients, but is poorly captured by estimated glomerular filtration rate (eGFR) or urine albumin-creatinine ratio (ACR). Whether urinary markers of tubulointerstitial fibrosis can noninvasively identify risk for allograft failure above and beyond eGFR and ACR is unknown. STUDY DESIGN Case-cohort study. SETTING & PARTICIPANTS The FAVORIT (Folic Acid for Vascular Outcome Reduction in Transplantation) Trial was a randomized double-blind trial testing vitamin therapy to lower homocysteine levels in stable kidney transplant recipients. We selected a subset of participants at random (n=491) and all individuals with allograft failure during follow-up (cases; n=257). PREDICTOR Using spot urine specimens from the baseline visit, we measured 4 urinary proteins known to correlate with tubulointerstitial fibrosis on biopsy (urine α1-microglobulin [A1M], monocyte chemoattractant protein 1 [MCP-1], and procollagen type III and type I amino-terminal amino pro-peptide). OUTCOME Death-censored allograft failure. RESULTS In models adjusted for demographics, chronic kidney disease risk factors, eGFR, and ACR, higher concentrations of urine A1M (HR per doubling, 1.73; 95% CI, 1.43-2.08) and MCP-1 (HR per doubling, 1.60; 95% CI, 1.32-1.93) were strongly associated with allograft failure. When additionally adjusted for concentrations of other urine fibrosis and several urine injury markers, urine A1M (HR per doubling, 1.76; 95% CI, 1.27-2.44]) and MCP-1 levels (HR per doubling, 1.49; 95% CI, 1.17-1.89) remained associated with allograft failure. Urine procollagen type III and type I levels were not associated with allograft failure. LIMITATIONS We lack kidney biopsy data, BK titers, and HLA antibody status. CONCLUSIONS Urine measurement of tubulointerstitial fibrosis may provide a noninvasive method to identify kidney transplant recipients at higher risk for future allograft failure, above and beyond eGFR and urine ACR.
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Affiliation(s)
- Joachim H Ix
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA; Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA; Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA.
| | - Ronit Katz
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA
| | - Meredith Foster
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Russell Tracy
- Department of Pathology, University of Vermont, Burlington, VT
| | - Vasantha Jotwani
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jan Hughes-Austin
- Department of Orthopedic Surgery, University of California San Diego, San Diego, CA
| | - Dianne McKay
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA
| | - Francis Gabbai
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA; Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | | | - Andrew S Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Michael G Shlipak
- General Internal Medicine Section, San Francisco Veterans Affairs Hospital, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
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138
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Abstract
Dialysate composition is a critical aspect of the hemodialysis prescription. Despite this, trial data are almost entirely lacking to help guide the optimal dialysate composition. Often, the concentrations of key components are chosen intuitively, and dialysate composition may be determined by default based on dialysate manufacturer specifications or hemodialysis facility practices. In this review, we examine the current epidemiological evidence guiding selection of dialysate bicarbonate, calcium, magnesium, and potassium, and identify unresolved issues for which pragmatic clinical trials are needed.
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Affiliation(s)
- Rita L McGill
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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139
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Liu CK, Milton J, Hsu FC, Beavers KM, Yank V, Church T, Shegog JD, Kashaf S, Nayfield S, Newman A, Stafford RS, Nicklas B, Weiner DE, Fielding RA. The Effect of Chronic Kidney Disease on a Physical Activity Intervention: Impact on Physical Function, Adherence, and Safety. ACTA ACUST UNITED AC 2017; 3. [PMID: 29745380 PMCID: PMC5937279 DOI: 10.23937/2572-3286.1510021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background Because chronic kidney disease (CKD) is associated with muscle wasting, older adults with CKD are likely to have physical function deficits. Physical activity can improve these deficits, but whether CKD attenuates the benefits is unknown. Our objective was to determine if CKD modified the effect of a physical activity intervention in older adults. Methods This is an exploratory analysis of the LIFE-P study, which compared a 12-month physical activity program (PA) to a successful aging education program (SA) in older adults. CKD was defined as a baseline eGFR < 60 mL/min/1.73 m2. We examined the Short Physical Performance Battery (SPPB) at baseline, 6 and 12 months. Secondary outcomes included serious adverse events (SAE) and adherence to intervention frequency. Linear mixed models were adjusted for age, sex, diabetes, hypertension, CKD, intervention, site, visit, baseline SPPB, and interactions of intervention and visit and of intervention, visit, and baseline CKD. Results The sample included 368 participants. CKD was present in 105 (28.5%) participants with a mean eGFR of 49.2 ± 8.1 mL/min/1.73 m2. Mean SPPB was 7.38 ± 1.41 in CKD participants; 7.59 ± 1.44 in those without CKD (p = 0.20). For CKD participants in PA, 12-month SPPBs increased to 8.90 (95% CI 8.32, 9.47), while PA participants without CKD increased to 8.40 (95% CI 8.01, 8.79, p = 0.43). For CKD participants in SA, 12-month SPPBs increased to 7.67 (95% CI 7.07, 8.27), while participants without CKD increased to 8.12 (95% CI 7.72, 8.52, p = 0.86). Interaction between CKD and intervention was non-significant (p = 0.88). Number and type of SAEs were not different between CKD and non-CKD participants (all p > 0.05). In PA, adherence for CKD participants was 65.5 ± 25.4%, while for those without CKD was 74.0 ± 22.2% (p = 0.12). Conclusion Despite lower adherence, older adults with CKD likely derive clinically meaningful benefits from physical activity with no apparent impact on safety, compared to those without CKD.
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Affiliation(s)
- C K Liu
- Nutrition, Exercise Physiology, and Sarcopenia Laboratory, Jean Mayer Human Nutrition Research Center in Aging, Tufts University, Boston, MA, USA.,Boston University School of Medicine, Boston, MA, USA
| | - J Milton
- Boston University School of Public Health, Boston, MA, USA
| | - F-C Hsu
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - K M Beavers
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - V Yank
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - T Church
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | - J D Shegog
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - S Kashaf
- Yale University School of Medicine, New Haven, CT, USA
| | - S Nayfield
- University of Florida College of Medicine, Gainesville, FL, USA
| | - A Newman
- University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - R S Stafford
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - B Nicklas
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - D E Weiner
- Tufts University School of Medicine, Boston, MA, USA
| | - R A Fielding
- Nutrition, Exercise Physiology, and Sarcopenia Laboratory, Jean Mayer Human Nutrition Research Center in Aging, Tufts University, Boston, MA, USA
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Drew DA, Weiner DE, Tighiouart H, Duncan S, Gupta A, Scott T, Sarnak MJ. Cognitive Decline and Its Risk Factors in Prevalent Hemodialysis Patients. Am J Kidney Dis 2017; 69:780-787. [PMID: 28131531 DOI: 10.1053/j.ajkd.2016.11.015] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 11/11/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cognitive impairment is common in patients treated with hemodialysis. The trajectory of cognitive function and risk factors for cognitive decline remain uncertain in this population. STUDY DESIGN Longitudinal cohort. SETTING & PARTICIPANTS 314 prevalent hemodialysis patients. PREDICTORS Age, sex, race, education level, hemodialysis vintage, cause of end-stage renal disease, and baseline history of cardiovascular disease. OUTCOMES Cognitive function as determined by a comprehensive neurocognitive battery, administered at baseline and yearly when possible. Individual cognitive test results were reduced into 2 domain scores using principal components analysis, representing memory and executive function, which were used as our coprimary outcomes and by definition have a mean of zero and SD of 1. RESULTS Mean age was 63 years; 54% were men, 22% were black, and 90% had at least a high school education. During a median follow-up of 2.1 (IQR, 0.9-4.2) years, 196 had at least 1 follow-up test, 156 died, and 43 received a kidney transplant. Linear mixed models and joint models, which accounted for competing risks from death, dropout, or kidney transplantation, showed nearly identical results. The joint model demonstrated a decline in executive function (-0.09 [95% CI, -0.13 to -0.05] SD per year), whereas memory improved slightly (0.05 [95% CI, 0.02 to 0.08] SD per year). A significant yearly decline was also seen in the Mini-Mental State Examination score (median change, -0.41; 95% CI, -0.57 to -0.25). Older age was the only significant risk factor for steeper executive function decline (-0.04 [95% CI, -0.06 to -0.02] SD steeper annual decline for each 10 years of age). LIMITATIONS Prevalent hemodialysis patients only, limited follow-up testing due to high mortality rate, and exclusion of participants with severe cognitive deficits or dementia. CONCLUSIONS Prevalent hemodialysis patients demonstrate significant cognitive decline, particularly within tests of executive function. Older age was the only statistically significant risk factor for steeper cognitive decline, which may have important clinical consequences for patient management and education. Future studies should evaluate strategies to maintain or improve cognitive function.
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Affiliation(s)
- David A Drew
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA.
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Sarah Duncan
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Aditi Gupta
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Tammy Scott
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA
| | - Mark J Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
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Riefkohl A, Ramírez-Rubio O, Laws RL, McClean MD, Weiner DE, Kaufman JS, Galloway RL, Shadomy SV, Guerra M, Amador JJ, Sánchez JM, López-Pilarte D, Parikh CR, Leibler JH, Brooks DR. Leptospira seropositivity as a risk factor for Mesoamerican Nephropathy. Int J Occup Environ Health 2017; 23:1-10. [PMID: 28209095 PMCID: PMC6060841 DOI: 10.1080/10773525.2016.1275462] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 12/08/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Leptospirosis is postulated as a possible cause of Mesoamerican Nephropathy (MeN) in Central American workers. OBJECTIVES Investigate job-specific Leptospira seroprevalence and its association with kidney disease biomarkers. METHODS In 282 sugarcane workers, 47 sugarcane applicants and 160 workers in other industries, we measured anti-leptospiral antibodies, serum creatinine, and urinary injury biomarkers, including neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), and N-acetyl-D-glucosaminidase (NAG). RESULTS Leptospira seroprevalence differed among job categories and was highest among sugarcane cutters (59%). Seropositive sugarcane workers had higher NGAL concentrations (relative mean: 1.28; 95% CI: 0.94-1.75) compared to those who were seronegative, with similar findings among field and non-field workers. CONCLUSIONS Leptospira seroprevalence varied by job category. There was some indication that seropositivity was associated with elevated biomarker levels, but results were inconsistent. Additional studies may help establish whether Leptospira infection plays any role in MeN among Central American workers.
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Affiliation(s)
- Alejandro Riefkohl
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Oriana Ramírez-Rubio
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Preventive Medicine and Public Health Department, Universidad Autónoma de Madrid, Madrid, Spain
| | - Rebecca L. Laws
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Michael D. McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Daniel E. Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - James S. Kaufman
- Research Service, VA New York Harbor Healthcare System and New York University School of Medicine, New York, NY, USA
| | - Renee L. Galloway
- Bacterial Special Pathogens Branch, Division of High-Consequence Pathogens & Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sean V. Shadomy
- Bacterial Special Pathogens Branch, Division of High-Consequence Pathogens & Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Marta Guerra
- Bacterial Special Pathogens Branch, Division of High-Consequence Pathogens & Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Juan José Amador
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - José Marcel Sánchez
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Damaris López-Pilarte
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Chirag R. Parikh
- Section of Nephrology, Department of Medicine, Yale University, New Haven, CT, USA
- Program of Applied Translational Research, Department of Medicine, Yale University, New Haven, CT, USA
| | - Jessica H. Leibler
- Department of Environmental Health, Boston University School of Public Health, Boston, MA, USA
| | - Daniel R. Brooks
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Levey AS, Weiner DE, Gilbert SJ, Dorman NM. Ten Years Atop the Masthead. Am J Kidney Dis 2016; 68:825-827. [DOI: 10.1053/j.ajkd.2016.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/09/2016] [Indexed: 11/11/2022]
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143
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Abstract
INTRODUCTION Central venous catheters (CVC) increase risks associated with hemodialysis (HD), but may be necessary until an arteriovenous fistula (AVF) or graft (AVG) is achieved. The impact of vascular imaging on achievement of working AVF and AVG has not been firmly established. METHODS Retrospective cohort of patients initiating HD with CVC in 2010-2011, classified by exposure to venography or Doppler vein mapping, and followed through December 31, 2012. Standard and time-dependent Cox models were used to determine hazard ratios (HRs) of death, working AVF, and any AVF or AVG. Logistic regression was used to assess the association of preoperative imaging with successful AVF or AVG among 18,883 individuals who had surgery. Models were adjusted for clinical and demographic factors. FINDINGS Among 33,918 patients followed for a median of 404 days, 39.1% had imaging and 55.7% had surgery. Working AVF or AVG were achieved in 40.6%; 46.2% died. Compared to nonimaged patients, imaged patients were more likely to achieve working AVF (HR = 1.45 [95% confidence interval [CI] 1.36, 1.55], P < 0.001]), any AVF or AVG (HR = 1.63 [1.58, 1.69], P > 0.001), and less likely to die (HR = 0.88 [0.83-0.94], P < 0.001). Among patients who had surgery, the odds ratio for any successful AVF or AVG was 1.09 (1.02-1.16, P = 0.008). DISCUSSION Fewer than half of patients who initiated HD with a CVC had vascular imaging. Imaged patients were more likely to have vascular surgery and had increased achievement of working AV fistulas and grafts. Outcomes of surgery were similar in patients who did and did not have imaging.
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Affiliation(s)
- Rita L McGill
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Robin Ruthazer
- Biostatistics, Epidemiology, and Research Design Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA
| | - Eduardo Lacson
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Klemens B Meyer
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Dana C Miskulin
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
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144
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Karaboyas A, Zee J, Brunelli SM, Usvyat LA, Weiner DE, Maddux FW, Nissenson AR, Jadoul M, Locatelli F, Winkelmayer WC, Port FK, Robinson BM, Tentori F. Dialysate Potassium, Serum Potassium, Mortality, and Arrhythmia Events in Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2016; 69:266-277. [PMID: 27866964 DOI: 10.1053/j.ajkd.2016.09.015] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 09/08/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Sudden death is a leading cause of death in patients on maintenance hemodialysis therapy. During hemodialysis sessions, the gradient between serum and dialysate levels results in rapid electrolyte shifts, which may contribute to arrhythmias and sudden death. Controversies exist about the optimal electrolyte concentration in the dialysate; specifically, it is unclear whether patient outcomes differ among those treated with a dialysate potassium concentration of 3 mEq/L compared to 2 mEq/L. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 55,183 patients from 20 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 1 to 5 (1996-2015). PREDICTOR Dialysate potassium concentration at study entry. OUTCOMES Cox regression was used to estimate the association between dialysate potassium concentration and both all-cause mortality and an arrhythmia composite outcome (arrhythmia-related hospitalization or sudden death), adjusting for potential confounders. RESULTS During a median follow-up of 16.5 months, 24% of patients died and 7% had an arrhythmia composite outcome. No meaningful difference in clinical outcomes was observed for patients treated with a dialysate potassium concentration of 3 versus 2 mEq/L (adjusted HRs were 0.96 [95% CI, 0.91-1.01] for mortality and 0.98 [95% CI, 0.88-1.08] for arrhythmia composite). Results were similar across predialysis serum potassium levels. As in prior studies, higher serum potassium level was associated with adverse outcomes. However, dialysate potassium concentration had only minimal impact on serum potassium level measured predialysis (+0.09 [95% CI, 0.05-0.14] mEq/L serum potassium per 1 mEq/L greater dialysate potassium concentration). LIMITATIONS Data were not available for delivered (vs prescribed) dialysate potassium concentration and postdialysis serum potassium level; possible unmeasured confounding. CONCLUSIONS In combination, these results suggest that approaches other than altering dialysate potassium concentration (eg, education on dietary potassium sources and prescription of potassium-binding medications) may merit further attention to reduce risks associated with high serum potassium levels.
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Affiliation(s)
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Len A Usvyat
- Fresenius Medical Care North America, Waltham, MA
| | | | | | - Allen R Nissenson
- DaVita Healthcare Partners, Inc, El Segundo, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Michel Jadoul
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | | | - Friedrich K Port
- Arbor Research Collaborative for Health, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | - Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, MI; Vanderbilt University, Nashville, TN
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145
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Kupferman J, Amador JJ, Lynch KE, Laws RL, López-Pilarte D, Ramírez-Rubio O, Kaufman JS, Lau JL, Weiner DE, Robles NV, Verma KP, Scammell MK, McClean MD, Brooks DR, Friedman DJ. Characterization of Mesoamerican Nephropathy in a Kidney Failure Hotspot in Nicaragua. Am J Kidney Dis 2016; 68:716-725. [PMID: 27575010 DOI: 10.1053/j.ajkd.2016.06.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 06/07/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mesoamerican nephropathy (MeN) is a kidney disease of unknown cause that mainly affects working-age men in Central America. Despite being a major cause of morbidity and mortality in this region, its clinical characteristics have not been well defined. STUDY DESIGN Cross-sectional family-based study. SETTING & PARTICIPANTS 266 members of 24 families with high chronic kidney disease (CKD) burdens in a MeN hotspot in Northwestern Nicaragua. We compared clinical and biochemical characteristics of affected individuals first with their unaffected relatives and then with NHANES (National Health and Nutrition Examination Survey) participants with CKD in order to reveal identifying features of MeN. PREDICTOR CKD defined as serum creatinine level ≥ 1.5mg/dL in men and ≥1.4mg/dL in women. OUTCOMES Clinical and biochemical parameters, including serum sodium, potassium, bicarbonate, calcium, magnesium, phosphorus, and uric acid. RESULTS Hyperuricemia, in many cases severe, was common among patients with MeN. Uric acid levels in patients with MeN were higher than those in NHANES participants (mean, 9.6 vs 7.4mg/dL for men in each group) despite more frequent use of uric acid-lowering medications in Nicaraguan individuals (71.7% vs 11.2%). In multivariable linear mixed-effects regression analysis, uric acid levels were 2.0mg/dL (95% CI, 1.0-3.0; P<0.001) higher in patients with MeN compared with their NHANES counterparts after adjusting for age, estimated glomerular filtration rate, and uric acid-lowering therapies. In contrast to prior reports, hyponatremia and hypokalemia were not common. LIMITATIONS CKD defined by single serum creatinine measurement; population likely not representative of full MeN phenotype spectrum across Central America; major differences between MeN and NHANES groups in important characteristics such as age, ancestry, and recruitment method. CONCLUSIONS Hyperuricemia out of proportion to the degree of decreased kidney function was common among Nicaraguan patients with MeN. Our results suggest that rather than being solely a consequence of CKD, hyperuricemia may play a role in MeN pathogenesis, a hypothesis that deserves further study.
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Affiliation(s)
- Joseph Kupferman
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Juan José Amador
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Katherine E Lynch
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Rebecca L Laws
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | | | - Oriana Ramírez-Rubio
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - James S Kaufman
- Research Service, VA New York Harbor Healthcare System and Department of Medicine, New York University School of Medicine, New York, NY
| | - Jorge Luis Lau
- Universidad Nacional Autónoma de Nicaragua, León, Nicaragua
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - Ninoska Violeta Robles
- Centro Nacional de Diagnóstico y Referencia, Nicaraguan Ministry of Health, Managua, Nicaragua
| | - Karina P Verma
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Madeleine K Scammell
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | - Michael D McClean
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | - Daniel R Brooks
- Department of Epidemiology, Boston University School of Public Health, Boston, MA.
| | - David J Friedman
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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146
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McGill RL, Ruthazer R, Meyer KB, Miskulin DC, Weiner DE. Peripherally Inserted Central Catheters and Hemodialysis Outcomes. Clin J Am Soc Nephrol 2016; 11:1434-1440. [PMID: 27340280 PMCID: PMC4974875 DOI: 10.2215/cjn.01980216] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 04/21/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Use of peripherally inserted central catheters has expanded rapidly, but the consequences for patients who eventually require hemodialysis are undefined. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our national, population-based analysis included 33,918 adult Medicare beneficiaries from the US Renal Data System who initiated hemodialysis with central venous catheters as their sole vascular access in 2010 and 2011. We used linked Medicare claims to identify peripherally inserted central catheter exposures and evaluate the associations of peripherally inserted central catheter placement with transition to working arteriovenous fistulas or grafts and patient survival using a Cox model with time-dependent variables. RESULTS Among 33,918 individuals initiating hemodialysis with a catheter as sole access, 12.6% had received at least one peripherally inserted central catheter. Median follow-up was 404 days (interquartile range, 103-680 days). Among 6487 peripherally inserted central catheters placed, 3435 (53%) were placed within the 2 years before hemodialysis initiation, and 3052 (47%) were placed afterward. Multiple peripherally inserted central catheters were placed in 30% of patients exposed to peripherally inserted central catheters. Recipients of peripherally inserted central catheters were more likely to be women and have comorbid diagnoses and less likely to have received predialysis nephrology care. After adjustment for clinical and demographic factors, peripherally inserted central catheters placed before or after hemodialysis initiation were independently associated with lower likelihoods of transition to any working fistula or graft (hazard ratio for prehemodialysis peripherally inserted central catheter, 0.85; 95% confidence interval, 0.79 to 0.91; hazard ratio for posthemodialysis peripherally inserted central catheter, 0.81; 95% confidence interval, 0.73 to 0.89). CONCLUSIONS Peripherally inserted central catheter placement was common and associated with adverse vascular access outcomes. Recognition of potential long-term adverse consequences of peripherally inserted central catheters is essential for clinicians caring for patients with CKD.
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Affiliation(s)
- Rita L. McGill
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts; and
| | - Robin Ruthazer
- Biostatistics, Epidemiology, and Research Design Center, Department of Medicine, Tufts Clinical and Translational Science Institute, Boston, Massachusetts
| | - Klemens B. Meyer
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts; and
| | - Dana C. Miskulin
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts; and
| | - Daniel E. Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts; and
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147
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Affiliation(s)
- Daniel E Weiner
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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148
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Shrestha D, Liu S, Hammond SK, LaValley MP, Weiner DE, Eisen EA, Applebaum KM. Risk of renal cell carcinoma following exposure to metalworking fluids among autoworkers. Occup Environ Med 2016; 73:656-62. [PMID: 27484955 DOI: 10.1136/oemed-2016-103769] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/01/2016] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Metalworking fluids (MWF), used to cool and lubricate metal in occupational settings, are linked to several cancers but data on kidney cancer are limited. We examine how MWF influence the rate of renal cell carcinoma (RCC) in a large prospective study. METHODS A cohort of Michigan autoworkers consisting of 33 421 individuals was followed from 1985 to 2009. The cohort was linked to the Michigan Cancer Registry to identify new cases of RCC. We analysed RCC in relation to cumulative exposure to each specific type of MWF (straight, soluble and synthetic) and all 3 types pooled into a single MWF variable, with a 15-year lag. Cox proportional hazards regression with splines were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), controlling for age, gender, race, calendar year, year hired, time since hire, plant and other MWF types. RESULTS There were 135 incident cases. A linear increase in the log-HR was observed for RCC with increasing cumulative exposure to each MWF type and total MWF exposure. At the mean of total MWF exposure (18.80 mg/m(3)-year), the estimated HR was 1.11 (95% CI 1.04 to 1.19). CONCLUSIONS Our results provide evidence for a dose-dependent association between MWF exposure and RCC. The influence of components of oil-based and water-based MWF needs further examination.
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Affiliation(s)
- Deepika Shrestha
- Department of Environmental and Occupational Health, George Washington University, Milken Institute School of Public Health, Washington, DC, USA
| | - Sa Liu
- Department of Environmental Health Sciences, University of California Berkeley, Berkeley, California, USA
| | - S Katharine Hammond
- Department of Environmental Health Sciences, University of California Berkeley, Berkeley, California, USA
| | - Michael P LaValley
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ellen A Eisen
- Department of Environmental Health Sciences, University of California Berkeley, Berkeley, California, USA
| | - Katie M Applebaum
- Department of Environmental and Occupational Health, George Washington University, Milken Institute School of Public Health, Washington, DC, USA
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149
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Kramer H, Yee J, Weiner DE, Bansal V, Choi MJ, Brereton L, Berns JS, Samaniego-Picota M, Scheel P, Rocco M. Ultrafiltration Rate Thresholds in Maintenance Hemodialysis: An NKF-KDOQI Controversies Report. Am J Kidney Dis 2016; 68:522-532. [PMID: 27449697 DOI: 10.1053/j.ajkd.2016.06.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 06/02/2016] [Indexed: 11/11/2022]
Abstract
High hemodialysis ultrafiltration rate (UFR) is increasingly recognized as an important and modifiable risk factor for mortality among patients receiving maintenance hemodialysis. Recently, the Kidney Care Quality Alliance (KCQA) developed a UFR measure to assess dialysis unit care quality. The UFR measure was defined as UFR≥13mL/kg/h for patients with dialysis session length less than 240 minutes and was endorsed by the National Quality Forum as a quality measure in December 2015. Despite this, implementation of a UFR threshold remains controversial. In this NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) Controversies Report, we discuss the concept of the UFR, which is governed by patients' interdialytic weight gain, body weight, and dialysis treatment time. We also examine the potential benefits and pitfalls of adopting a UFR threshold as a clinical performance measure and outline several aspects of UFR thresholds that require further research.
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Affiliation(s)
- Holly Kramer
- Division of Nephrology, Department of Medicine, Loyola University Chicago, Maywood, IL; Department of Public Health Sciences, Loyola University Chicago, Maywood, IL.
| | - Jerry Yee
- Division of Nephrology, Department of Medicine, Henry Ford Medical Center, Detroit, MI
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Vinod Bansal
- Division of Nephrology, Department of Medicine, Loyola University Chicago, Maywood, IL
| | - Michael J Choi
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Jeffrey S Berns
- Renal, Electrolyte, and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Paul Scheel
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Rocco
- Division of Nephrology, Department of Medicine, Wake Forest University, Winston-Salem, NC
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150
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Abstract
Cerebrovascular disease and stroke are very common at all stages of chronic kidney disease (CKD), likely representing both shared risk factors as well as synergy among risk factors. More subtle ischemic brain lesions may be particularly common in the CKD population, with subtle manifestations including cognitive impairment. For individuals with nondialysis CKD, the prevention, approach to, diagnosis, and management of stroke is similar to the general, non-CKD population. For individuals with end-stage renal disease, far less is known regarding strategies to prevent stroke. Stroke prophylaxis using warfarin in dialysis patients with atrial fibrillation in particular remains of uncertain benefit. End-stage renal disease patients can be managed aggressively in the setting of acute stroke. Outcomes after stroke at all stages of CKD are poor, and improving these outcomes should be the subject of future clinical trials.
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Affiliation(s)
- Taimur Dad
- Division of Nephrology, Tufts Medical Center, Boston, MA
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