Associations of interleukin-6, C-reactive protein and serum amyloid A with mortality in haemodialysis patients

BACKGROUND

Individuals with end-stage renal disease (ESRD) manifest a chronic inflammatory state. Serum albumin, C-reactive protein (CRP), interleukin-6 (IL-6) and serum amyloid A (SAA) have been associated with mortality in ESRD, although reports vary as to whether they are true independent markers of mortality. We undertook a prospective study to determine whether these markers could predict mortality in ESRD.

METHODS

A cohort of individuals on haemodialysis was followed prospectively for a mean of 2.1 years. Albumin, CRP, IL-6 and SAA were drawn at enrollment. Association between mortality and serum markers was assessed using Cox proportional hazards regression. A trend analysis was undertaken to establish the functional form of the association between serum markers and outcome.

RESULTS

After multivariable adjustment, IL-6 was most strongly associated with mortality, followed closely by albumin (P = 0.0002 and P = 0.0005, respectively). CRP was marginally associated with mortality (P = 0.046), and SAA was not independently associated with mortality. In the final model adjusting for the effects of both IL-6 and albumin simultaneously, both markers remained associated with mortality (P = 0.003 and P = 0.011).

CONCLUSION

IL-6 had the strongest independent association with mortality, followed closely by albumin. CRP and SAA were not associated with mortality when measured at single time points. Increasing levels of IL-6 and decreasing levels of albumin were associated with increased mortality. IL-6 and albumin may be capturing different aspects of the inflammatory burden observed in haemodialysis patients.

Correlates of self-efficacy among rural smokers

Self-efficacy has been related to intent to stop smoking, abstinence success, and risk for relapse. Because limited research exists regarding self-efficacy among rural smokers, the current study examined correlates of self-efficacy among rural primary care patients smoking > or =10 cigarettes per day. Participants completed a telephone survey assessing demographics, smoking history, and psychosocial variables (e.g. motivation, depression). Among the 750 participants, lower self-efficacy was correlated with high depression scores, shorter previous abstinence, lower autonomous motivation, younger age, higher nicotine dependence, readiness to quit, and being female. Future studies should examine the potential to improve self-efficacy by addressing depression and autonomous motivation.

Design and baseline characteristics from the KAN-QUIT disease management intervention for rural smokers in primary care

OBJECTIVE

To describe the design, implementation, baseline data, and feasibility of establishing a disease management program for smoking cessation in rural primary care.

METHOD

The study is a randomized clinical trial evaluating a disease management program for smoking cessation. The intervention combined pharmacotherapy, telephone counseling, and physician feedback, and repeated intervention over two years. The program began in 2004 and was implemented in 50 primary care clinics across the State of Kansas.

RESULTS

Of eligible patients, 73% were interested in study participation. 750 enrolled participants were predominantly Caucasian, female, employed, and averaged 47.2 years of age (SD=13.1). In addition to smoking, 427 (57%) had at least one additional major risk factor for cardiovascular disease (diabetes, hypertension, high cholesterol, heart disease or stroke). Participants smoked on average 23.7 (SD=10.4) cigarettes per day, were contemplating (61%) or preparing to quit (30%), were highly motivated and confident of their ability to quit smoking, and reported seeing their physicians multiple times in the past twelve months (Median=3.50; Mean=5.48; SD=6.58).

CONCLUSION

Initial findings demonstrate the willingness of patients to enroll in a two-year disease management program to address nicotine dependence, even among patients not ready to make a quit attempt. These findings support the feasibility of identifying and enrolling rural smokers within the primary care setting.

Reducing the effects of lead-time bias, length bias and over-detection in evaluating screening mammography: a censored bivariate data approach

Measuring the benefit of screening mammography is difficult due to lead-time bias, length bias and over-detection. We evaluated the benefit of screening mammography in reducing breast cancer mortality using observational data from the SEER-Medicare linked database. The conceptual model divided the disease duration into two phases: preclinical (T(0)) and symptomatic (T(1)) breast cancer. Censored information for the bivariate response vector ( T(0), T(1)) was observed and used to generate a likelihood function. However, the contribution to the likelihood function for some observations could not be calculated analytically, thus, censoring boundaries for these observations were modified. Inferences about the impact of screening mammography on breast cancer mortality were made based on maximum likelihood estimates derived from this likelihood function. Hazard ratios (95% confidence intervals) of 0.54 (0.48-0.61) and 0.33 (0.26- 0.42) for single and regular users (vs. non-users), respectively, demonstrated a protective effect of screening mammography among women 69 years and older. This method reduced the impact of lead-time bias, length bias and over-detection, which biased the estimated hazard ratios derived from standard survival models in favour of screening.

Interhemispheric connections of the ventral premotor cortex in a new world primate

This study describes the pattern of interhemispheric connections of the ventral premotor cortex (PMv) distal forelimb representation (DFL) in squirrel monkeys. Our objectives were to describe qualitatively and quantitatively the connections of PMv with contralateral cortical areas. Intracortical microstimulation techniques (ICMS) guided the injection of the neuronal tract tracers biotinylated dextran amine or Fast blue into PMv DFL. We classified the interhemispheric connections of PMv into three groups. Major connections were found in the contralateral PMv and supplementary motor area (SMA). Intermediate interhemispheric connections were found in the rostral portion of the primary motor cortex, the frontal area immediately rostral and ventral to PMv (FR), cingulate motor areas (CMAs), and dorsal premotor cortex (PMd). Minor connections were found inconsistently across cases in the anterior operculum (AO), posterior operculum/inferior parietal cortex (PO/IP), and posterior parietal cortex (PP), areas that consistently show connections with PMv in the ipsilateral hemisphere. Within-case comparisons revealed that the percentage of PMv connections with contralateral SMA and PMd are higher than the percentage of PMv connections with these areas in the ipsilateral hemisphere; percentages of PMv connections with contralateral M1 rostral, FR, AO, and the primary somatosensory cortex are lower than percentages of PMv connections with these areas in the ipsilateral hemisphere. These studies increase our knowledge of the pattern of interhemispheric connection of PMv. They help to provide an anatomical foundation for understanding PMv's role in motor control of the hand and interhemispheric interactions that may underlie the coordination of bimanual movements.

Evaluating the Completeness of the SEER-Medicare Linked Database for Oral and Pharyngeal Cancer

Oral and pharyngeal cancer is a persistent oral health problem. Baseline and trend data to measure progress are lacking. Our long-term goal is to create an algorithm using Medicare claims to identify oral and pharyngeal cancer cases among those ages 65 and older. The goal of this project was to assess the completeness of the SEER-Medicare linked database for identifying incident oral and pharyngeal cancer cases. We compared incidence rates from the "gold-standard" SEER limited-use database to those from the SEER-Medicare linked database using a quasi-likelihood extension of Poisson regression, allowing for over-dispersion. Adjustment for age, sex, race and ethnicity, and interaction terms between these explanatory variables with data source were used to assess the completeness of the SEER-Medicare linked database among these subgroups. Approximately 6.4% of the cases were missing from the SEER-Medicare linked database. The completeness varied by race and ethnicity (p=0.066). Future development of an algorithm to identify oral and pharyngeal cancer cases using Medicare claims alone can potentially identify over 93% of the cases; however, Hispanic, non-Hispanic black, and non-Hispanic other race and ethnicity subgroups will be less likely than non-Hispanic whites to be identified in such future algorithms.

Neuromuscular Electrical Stimulation Improves Severe Hand Dysfunction for Individuals With Chronic Stroke

Restoring hand function is difficult post-stroke. We sought to determine if applying neuromuscular electrical stimulation (NMES) was beneficial for reducing severe hand impairments. Subjects with chronic stroke (N=8; 3 Fe, 5 M; 58.3 +/- 6.9 y/o) received 10 sessions of NMES using two different methods applied in a counterbalanced order. In one intervention, we applied NMES (active) in a novel fashion using multiple stimulators on the forearm flexors and extensors to assist subjects with grasping and releasing a tennis ball. In the other intervention, the NMES ('passive') stimulated repeated wrist extension and flexion. Motor performance was assessed prior to and immediately following the interventions and at retention. Upper extremity (UE) Fugl-Myer scores significantly improved (p < 0.002) immediately following either intervention. Significant improvement was also observed in the Modified Ashworth Spasticity Scale (MASS) (p < 0.03), immediately following intervention, primarily due to the NMESpassive treatment (p < 0.034). Subjects performed grasping tasks significantly faster (p < 0.0433) following interventions, with performance speeds on dexterous manipulation increasing approximately 10% for NMESactive immediately following intervention, compared to only 0.1% improvement following NMESpassive. Generally, improvements in motor speed remained 10 days following NMESactive intervention, although slightly diminished. In conclusion, severe hand impairment was reduced after a short duration of NMES therapy in this pilot data set for individuals with chronic stroke. NMES-assisted grasping trended towards greater functional benefit than traditional NMES-activation of wrist flexors/extensors.

Development of a Contemporary Bleeding Risk Model for Elderly Warfarin Recipients

BACKGROUND AND PURPOSE

Develop and validate a contemporary bleeding risk model to guide the clinical use of warfarin in the elderly atrial fibrillation (AF) population.

METHODS

Chart-abstracted data from the National Registry of Atrial Fibrillation was combined with Medicare part A claims to identify major bleeding events requiring hospitalization. Using a split-sample technique, candidate variables that provided statistically stable relationships with major bleeding events were selected for model development. Three risk categories were created and validated. The new model was compared to existing bleeding risk models using c-statistics and Kaplan-Meier curves.

RESULTS

Model development and validation was conducted on 26,345 AF patients who were > 65 years of age and had been discharged from the hospital while receiving warfarin therapy. The following eight variables were included in the final risk score model: age > or = 70 years; gender; remote bleeding; recent (ie, during index hospitalization) bleeding; alcohol/drug abuse; diabetes; anemia; and antiplatelet use. Bleeding rates were 0.9%, 2.0%, and 5.4%, respectively, for the groups with low, moderate, and high risk, compared to the bleeding rates for groups with moderate risk (1.5% and 1.0%) and high risk (1.8% and 2.5%) from other models.

CONCLUSIONS

Using a nationally derived data set, we developed a model based on contemporary practice standards for determining major bleeding risk among AF patients receiving warfarin therapy. The larger sample size afforded the opportunity to incorporate additional risk factors. In addition, since the majority of our population was > 65 years of age, we had greater ability to stratify risk among the elderly.

Effects of small ischemic lesions in the primary motor cortex on neurophysiological organization in ventral premotor cortex

After a cortical lesion, cortical areas distant from the site of injury are known to undergo physiological and anatomical changes. However, the mechanisms through which reorganization of distant cortical areas is initiated are poorly understood. In a previous publication, we showed that the ventral premotor cortex (PMv) undergoes physiological reorganization after a lesion destroying the majority of the primary motor cortex (M1) distal forelimb representation (DFL). After large lesions destroying >50% of the M1 DFL, the PMv DFL invariably increased in size, and the amount of the increase was positively correlated with the size of lesion. To determine whether lesions destroying <50% of the M1 DFL followed a similar trajectory, we documented PMv reorganization using intracortical microstimulation techniques after small, ischemic lesions targeting subregions within the M1 DFL. In contrast to earlier results, lesions resulted in a reduction of the PMv DFL regardless of their location. Further, because recent anatomical findings suggest a segregation of PMv connectivity with M1, we examined two lesion characteristics that may drive alterations in PMv physiological reorganization: location of the lesion with respect to PMv connectivity and relative size of the lesion. The results suggest that after a lesion in the M1 DFL, the induction of representational plasticity in PMv, as evaluated using intracortical microstimulation, is related more to the size of the lesion than to the disruption of its intracortical connections.

Risk factors for lung cancer in Iowa women: implications for prevention

BACKGROUND

Multiple risk factors possibly associated with lung cancer were examined as part of a large-scale residential radon case-control study conducted in Iowa between 1994 and 1997. We were particularly interested in stratifying risk factors by smoking status. Relatively little risk factor information is available for Midwestern rural women.

METHODS

Four hundred thirteen female lung cancer cases and 614 controls aged 40-84, who were residents of their current home for at least 20 years, were included. Risk factors examined included cigarette smoking, passive smoking, occupation, chemical exposure, previous lung disease, family history of cancer, and urban residence. Multiple logistic regression analysis was conducted after adjusting for age, education, and cumulative radon exposure.

RESULTS

As expected, active cigarette smoking was the major risk factor for lung cancer. While cessation of smoking was significantly associated with a reduced risk for lung cancer, the risk remained significantly elevated for 25 years. Among all cases, asbestos exposure was a significant risk. Among ex-smokers, pack-year history predominated as the major risk. Among never smokers, a family history of kidney or bladder cancer were significant risk factors (OR=7.34, 95% CI=1.91-28.18; and OR=5.02, 95% CI=1.64-15.39, respectively), as was a history of previous lung disease (OR=2.28, 95% CI=1.24-4.18) and asbestos exposure. No statistically significant increase in lung cancer risk was found for occupation or urban residence.

CONCLUSIONS

Smoking prevention activities are urgently needed in rural areas of the United States. Relatives of individuals with smoking-related cancers are potentially at increased risk. Genetic risk factors should be more fully investigated in never smokers.

Heparin-bonded cardiopulmonary bypass circuits reduce the rate of red blood cell transfusion during elective coronary artery bypass surgery

OBJECTIVE

This study compared the transfusion rates of patients treated with heparin-bonded circuits with the transfusion rates of patients treated with standard bypass circuits with and without -aminocaproic acid (EACA).

DESIGN

Prospective double-blind (drugs), open trial (cardiopulmonary bypass circuits).

SETTING

University medical center.

PARTICIPANTS

Seventy-one patients undergoing elective am admission coronary artery bypass graft surgery.

MEASUREMENTS AND MAIN RESULTS

Patients were randomized to receive either heparin-coated cardiopulmonary bypass circuits (HBCPB), nonheparin-coated cardiopulmonary bypass circuits and EACA (EACPB), or nonheparin-coated bypass circuits and placebo (control). Patients were transfused if their hematocrit was <18% while on cardiopulmonary bypass or <25% at any time after the cardiopulmonary bypass period. The rate and number of transfused packed red blood cells (pRBCs), platelets, fresh frozen plasma, and cryoprecipitate were measured. A Fisher exact test showed that the transfusion rate was as follows: the HBCPB group (5.0%), the EACPB group (18.2%), and the control group (36%), (p = 0.034).

CONCLUSIONS

The heparin-bonded cardiopulmonary bypass-treated patients in this study received fewer pRBCs than did the control group. A nonsignificant reduction in the pRBC transfusion rate was found between those with heparin-bonded bypass circuits and those with standard circuits who received epsilon-aminocaproic acid.

Neighborhood composition and incidence of cancer among Hispanics in the United States

BACKGROUND

Hispanics in the United States have a 33% lower age-adjusted incidence of cancer and a 38% lower cancer mortality rate compared with non-Hispanic whites. This may be secondary to health behaviors that vary with residential and economic assimilation. The authors investigated whether cancer incidence among Hispanics increased with residential and economic assimilation into mainstream culture.

METHODS

Data from the Surveillance, Epidemiology, and End Results program (SEER) and the U.S. Census Bureau were used to compare cancer incidence rates and rate ratios as a function of percentage of Hispanics and income of Hispanics in a census tract. Type of cancer was identified with a site recode variable in the SEER data set. Cases with in situ prostate and cervical carcinoma were excluded. Hispanic ethnicity in SEER was identified by medical record review and Hispanic surname lists. The study also used income of Hispanics living in the census tract, age at diagnosis, and stratification by gender.

RESULTS

The incidence of breast, colorectal, and lung carcinoma among Hispanics increased as the percentage of Hispanics in the census tract decreased and as tract Hispanic income increased. For example, there was a 39% reduction in breast carcinoma and a 38% reduction in male colorectal carcinoma when the Hispanic population in high-density Hispanic neighborhoods in the lowest income quartile was contrasted to Hispanics living in tracts with the lowest total percentage of Hispanics in the highest income quartile.

CONCLUSIONS

The lower cancer rates among Hispanics relative to non-Hispanic whites in the United States may dissipate as Hispanics become more assimilated into the mainstream society.

Decreasing variation in the use of hospice among older adults with breast, colorectal, lung, and prostate cancer

BACKGROUND

Utilization of hospice services has been shown to vary by place of residence and patient characteristics.

OBJECTIVES

The purpose of this study was to examine whether such variation has changed over time. Hospice utilization is examined as a function of sociodemographic characteristics, geographic location, type of insurance, and year of death.

RESEARCH DESIGN

This study used a retrospective cohort design.

SUBJECTS

We used data from the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database to study hospice utilization in subjects aged 67 and older diagnosed with breast, colorectal, lung, or prostate cancer from 1991 to 1996 and who died between 1991 and 1999.

RESULTS

Of the 170,136 subjects aged 67 and older who died from 1991 through 1999, 51,345 (30.2%) were enrolled in hospice before they died. Hospice utilization varied significantly by patient characteristics, including type of insurance, age, marital status, race and ethnicity, gender, urban versus rural residence, type of cancer, income level, and education level. This variation, however, decreased over time for subgroups defined by type of insurance, marital status, urban residence, and income. Variation in hospice use increased over time as a function of age and type of cancer. There was no change in variation in use in blacks compared with non-Hispanic whites over time.

CONCLUSIONS

The variation in hospice use by several patient characteristics is decreasing over time, a finding consistent with the manner in which new medical technologies diffuse.

Discrepancy between consensus recommendations and actual community use of adjuvant chemotherapy in women with breast cancer

BACKGROUND

Although the efficacy of adjuvant chemotherapy in prolonging survival for women with breast cancer has been well documented, limited population-based information is available on the actual use of chemotherapy.

OBJECTIVE

To examine the relationship between age and chemotherapy use.

DESIGN

Cohort study.

SETTING

New Mexico.

PATIENTS

5101 women 20 years of age or older receiving a diagnosis of stage I, stage II, or stage IIIA breast cancer from 1991 through 1997.

MEASUREMENTS

Pattern of chemotherapy use by age; logistic regression analysis to generate the odds and probabilities of receiving chemotherapy; and sensitivity analysis to estimate potential effects of unmeasured confounders.

RESULTS

Overall, 29% of women received chemotherapy. The rate of chemotherapy use for women with stage I, stage II, or stage IIIA breast cancer was 11%, 47%, and 68%, respectively. Across all tumor stages, the use of chemotherapy decreased substantially with increasing age (P < 0.001). Overall, 66% of women younger than 45 years of age received chemotherapy compared with 44% of women between 50 and 54 years of age, 31% of women between 55 and 59 years of age, and 18% of women between 60 and 64 years of age. The decreasing pattern of chemotherapy use with age continued after adjustment for prognostic factors and was relatively insensitive to changes in unmeasured factors.

CONCLUSIONS

There is considerable discrepancy between the 1990 National Institutes of Health Consensus Conference recommendations for chemotherapy administration in women with breast cancer and the actual use of chemotherapy in the community. The decrease in use with age may relate to the decreasing efficacy of chemotherapy with age, as reported in clinical trials. Outcomes studies should address whether the recommendations are overly aggressive or whether practicing oncologists are too conservative in their use of chemotherapy.

Using Medicare data to estimate the prevalence of breast cancer screening in older women: comparison of different methods to identify screening mammograms

OBJECTIVES

To compare different methods for defining screening mammograms with Medicare claims and their impact on estimates of breast cancer screening rates.

METHODS

Medicare outpatient facility and physician claims for 61,962 women in 1993 and 59,652 women in 1998 were reviewed for evidence of receipt of screening mammography. We compared the estimates of screening mammography use derived from CPT (Current Procedure Terminology) codes to categorize mammograms as screening or diagnostic versus using an algorithm that uses CPT codes plus breast-related diagnoses in the prior two years. We also compared estimates obtained from review of physician claims alone, facility claims alone, or the combination of the two sources of claims.

RESULTS

Use of physician claims alone produced estimates of screening rates similar to rates calculated from use of both physician and outpatient (facility) claims. In 1993, the CPT code for screening mammography underestimated the rate of screening compared to estimates generated by using the algorithm (8.3 percent versus 18.0 percent prevalence, p<0.001). By 1998, the screening prevalence rate generated from using the CPT code for screening mammography more closely approximated the rate generated by the algorithm (23.0 percent versus 25.1 percent). By all methods of estimating screening mammography with Medicare claims, its prevalence increased substantially between 1993 and 1998.

CONCLUSION

Providers increased their use of the screening mammography code in their charges to Medicare during the 1990s. This has improved the claims' ability to distinguish screening from diagnostic mammograms, but screening rates computed with claims continue to fall below those generated from self-reports of mammography use among general populations of older women.

Regular mammography use is associated with elimination of age-related disparities in size and stage of breast cancer at diagnosis

BACKGROUND

There is little consensus about recommending mammography for women 75 years of age and older. These women have mammography less frequently and are more likely to receive a diagnosis of advanced breast cancer.

OBJECTIVE

To examine the relationship between use of screening mammography and size and stage of cancer at diagnosis in older women.

DESIGN

Retrospective cohort study.

SETTING

Tumor registries in the Surveillance, Epidemiology, and End Results (SEER) program.

PATIENTS

12 038 women who were Medicare beneficiaries, were at least 69 years of age, resided in a SEER area, and received a new diagnosis of breast cancer in 1995 through 1996.

MEASUREMENTS

Screening mammograms obtained in the 2 years before breast cancer diagnosis (none, one, or at least two) and stage and size of tumor at diagnosis.

RESULTS

Older women (> or =75 years of age) had larger tumors at diagnosis and were less likely to have undergone screening mammography than younger women (69 to 74 years of age). The association between increased mammography use and smaller tumor size and stage was significantly greater in older women than in younger women (P = 0.010 for stage; P = 0.001 for size). The percentage of regular mammography users who received a diagnosis of high-stage disease (28% vs. 26%; P > 0.2) and the mean size of the tumors (15.0 mm vs. 15.1 mm; P > 0.2) did not significantly differ between younger and older women, respectively. These findings remained constant after controlling for factors that might contribute to biases.

CONCLUSION

Mammography in older women is associated with elimination of age-related disparities in size and stage of breast cancer at diagnosis.

Geographic variations in breast cancer survival among older women: implications for quality of breast cancer care

BACKGROUND

Breast cancer care, such as utilization of screening procedures and types of treatment received, varies substantially by geographic region of the United States. However, little is known about variations in survival with breast cancer.

METHODS

We examined breast cancer incidence, survival, and mortality in the 66 health service areas covered by the Surveillance, Epidemiology, and End Results (SEER) program for women aged 65 and older at diagnosis. Incidence and survival data were derived from SEER, while breast cancer mortality data were from Vital Statistics data.

RESULTS

There was considerable variation in breast cancer survival among the 66 health service areas (chi2 = 202.7, p <.0001). There was also significant variation in incidence and mortality from breast cancer. In a partial correlation weighted for the size of the health service area, both incidence (r =.812) and percent 5-year survival (r = -.587) correlate with mortality. In a Poisson regression analysis, the combination of variation in incidence and variation in survival explains 90.9% of the variation in mortality.

CONCLUSIONS

There is considerable geographic variation in survival from breast cancer among older women, and this contributes to variation in breast cancer mortality. Geographic variations in breast cancer mortality should diminish as the quality of breast cancer care becomes more standardized.

Predictors of the development of hyperkalemia in patients using angiotensin-converting enzyme inhibitors

BACKGROUND/AIMS

Angiotensin-converting enzyme inhibitors (ACEI) are the antihypertensives of choice in patients with chronic renal failure (CRF). ACEI by decreasing the synthesis of aldosterone, the main regulator of serum potassium, predispose to the development of hyperkalemia. Although hyperkalemia with administration of ACEI is uncommon in patients with a normal renal function, a preexisting abnormality in potassium hemostasis, as seen in patients with chronic renal failure, may increase the risk of hyperkalemia.

METHOD

To determine the predictors of development of hyperkalemia (K >5.1 mEq/l) in patients on ACEI, we retrospectively reviewed medical records of 119 patients followed in our renal clinic.

RESULTS

The mean age of the patients was 56 +/- (SD) 13 (range 20-84) years. Sixty-three percent were males, and 37% were females. Sixty-seven percent had a history of diabetes. Eighty five percent of the patients had CRF [creatinine clearance (CrCl) <80 ml/min]. The baseline serum Cr was 2.3 +/- 1.2 (range 0.6-6.9) mg/dl, and the CrCl was 50 +/- 27.5 ml/min. Of the 119 patients 46 (38.6%) developed hyperkalemia (mean K 5.68 +/- 0.3, range 5.2-6.7 mEq/l). Ninety-six percent of the patients who developed hyperkalemia had CRF, and 84% were diabetics. Pearson product-moment correlation revealed a significant positive correlation of hyperkalemia with Cr and a negative correlation of hyperkalemia with CrCl and HCO(3) (Cr: r = 0.42, p < 0.0001; CrCl: r = -0.34, p < 0.0001; HCO(3): r = -0.41, p < 0.0001). Multivariate logistic regression analysis revealed diabetes and serum creatinine to be the main predictors of hyperkalemia. In 31 patients hyperkalemia resolved either with a low-potassium (2 g/day) diet or with diet and a decrease in the dose of ACEI. In 15 patients ACEI had to be discontinued due to persistent hyperkalemia.

CONCLUSIONS

We conclude that hyperkalemia is common in patients with CRF on ACEI. The majority of the patients who develop hyperkalemia on ACEI have CRF and diabetes. A large number of patients with CRF require discontinuation of ACEI due to hyperkalemia and are deprived of their renoprotective effects.