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Kovesdy CP, Naseer A, Sumida K, Molnar MZ, Potukuchi PK, Thomas F, Streja E, Heung M, Abbott KC, Saran R, Kalantar-Zadeh K. Abrupt Decline in Kidney Function Precipitating Initiation of Chronic Renal Replacement Therapy. Kidney Int Rep 2018; 3:602-609. [PMID: 29854967 PMCID: PMC5976817 DOI: 10.1016/j.ekir.2017.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/12/2017] [Accepted: 12/18/2017] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Abrupt declines in kidney function often occur in patients with advanced chronic kidney disease and may exacerbate the need to initiate dialysis treatment. It is unclear how frequently such events occur in patients transitioning to chronic dialysis therapy, and what outcomes they are associated with. METHODS We examined a national cohort of 23,349 US veterans with incident end-stage renal disease (ESRD) and with available pre-ESRD estimated glomerular filtration rate (eGFR) to identify abrupt declines in kidney function, defined as an unexpected >50% decrease in eGFR at the time of chronic dialysis transition. Associations with all-cause mortality and with renal recovery were examined in Cox proportional hazard and competing risk regression models. RESULTS A total of 4804 (21%) patients experienced an abrupt decline in kidney function at dialysis transition. Renal recovery occurred in 586 (12.2%) and 297 (1.6%) patients with and without an abrupt decline, respectively (adjusted subhazard ratio: 4.42; 95% confidence interval [CI]: 3.72-5.27; P < 0.001). In the first 6 months after dialysis transition 1178 patients (24.5%) with abrupt decline died (annualized mortality rate 574/1000 patient-years), compared with 2354 deaths (12.7%) in patients without abrupt decline (274 deaths/1000 patient-years). An abrupt decline was associated with 45% higher mortality after multivariable adjustments (hazard ratio: 1.45; 95% CI: 1.33-1.57). CONCLUSION Abrupt declines in kidney function are common in patients transitioning to chronic dialysis, and are associated with higher mortality. Patients with abrupt declines also experience a higher rate of renal recovery; hence, careful attention to residual kidney function is warranted in these patients.
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Affiliation(s)
- Csaba P. Kovesdy
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adnan Naseer
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z. Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, Tennessee, USA
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Praveen K. Potukuchi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Michael Heung
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Rajiv Saran
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
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Crowley ST, Murphy K. Delivering a "New Deal" of Kidney Health Opportunities to Improve Outcomes Within the Veterans Health Administration. Am J Kidney Dis 2018; 72:444-450. [PMID: 29627134 DOI: 10.1053/j.ajkd.2018.01.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/22/2018] [Indexed: 11/11/2022]
Abstract
Just as the "New Deal" aimed to elevate the "forgotten man" of the Great Depression through governmental relief and reform, so does the Department of Veterans Affairs (VA) health care system aim to improve the health of veterans with the invisible illness of chronic kidney disease through a concerted series of health care delivery reforms. Augmenting its primary care platform with advances in informatics and health service delivery initiatives targeting kidney disease, the VA is changing how nephrology care is provided to veterans with the goal of optimized population kidney health. As the largest provider of kidney health services in the country, the VA offers an instructive case study of the value of comprehensive health care coverage for people with chronic kidney disease. Recent reports of kidney health outcomes among veterans support the benefit of the VA's integrated health care delivery system. Suggestions to optimize veterans' kidney health further may be equally applicable to other health systems caring for people afflicted with kidney disease.
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Affiliation(s)
- Susan T Crowley
- Veterans Health Administration, Specialty Care Services/Office of Policy and Services, West Haven, CT; Section of Nephrology, Department of Medicine, Yale University School of Medicine, West Haven, CT.
| | - Katherine Murphy
- Veterans Health Administration, Specialty Care Services/Office of Policy and Services, West Haven, CT
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Pre-end-stage renal disease visit-to-visit systolic blood pressure variability and post-end-stage renal disease mortality in incident dialysis patients. J Hypertens 2018; 35:1816-1824. [PMID: 28399042 DOI: 10.1097/hjh.0000000000001376] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Higher SBP visit-to-visit variability (SBPV) has been associated with increased risk of adverse events in patients with chronic kidney disease, but the association of SBPV in advanced nondialysis-dependent chronic kidney disease with mortality after the transition to end-stage renal disease (ESRD) remains unknown. METHODS Among 17 729 US veterans transitioning to dialysis between October 2007 and September 2011, we assessed SBPV calculated from the SD of at least three intraindividual outpatient SBP values during the last year prior to dialysis transition (prelude period). Outcomes included factors associated with higher prelude SBPV and post-transition all-cause, cardiovascular, and infection-related mortality, assessed using multivariable linear regression and Cox and competing risk regressions, respectively, adjusted for demographics, comorbidities, medications, cardiovascular medication adherence, SBP, BMI, estimated glomerular filtration rate, and type of vascular access. RESULTS Modifiable clinical factors associated with higher prelude SBPV included higher SBP, use of antihypertensive medications and erythropoiesis-stimulating agents, inadequate cardiovascular medication adherence, and catheter use. After multivariable adjustment, higher prelude SBPV was significantly associated with higher post-ESRD all-cause and infection-related mortality, but not cardiovascular mortality [hazard/subhazard ratios (95% confidence interval) for the highest (vs. lowest) quartile of SBPV, 1.08 (1.01-1.16), 1.02 (0.89-1.15), and 1.41 (1.10-1.80) for all-cause, cardiovascular, and infection-related mortality, respectively]. CONCLUSION High pre-ESRD SBPV is potentially modifiable and associated with higher all-cause and infection-related mortality following dialysis initiation. Further studies are needed to test whether modification of pre-ESRD SBPV can improve clinical outcomes in incident ESRD patients. VIDEO ABSTRACT:.
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Sumida K, Molnar MZ, Potukuchi PK, Hassan F, Thomas F, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Treatment of rheumatoid arthritis with biologic agents lowers the risk of incident chronic kidney disease. Kidney Int 2018; 93:1207-1216. [PMID: 29409725 DOI: 10.1016/j.kint.2017.11.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 11/05/2017] [Accepted: 11/30/2017] [Indexed: 02/06/2023]
Abstract
Rheumatoid arthritis is associated with reduced kidney function, possibly due to chronic inflammation or the use of nephrotoxic therapies. However, little is known about the effects of using the newer novel non-nephrotoxic biologic agents on the risk of incident chronic kidney disease (CKD). To study this we used a cohort of 20,757 United States veterans diagnosed with rheumatoid arthritis with an estimated glomerular filtration rate (eGFR) of 60 mL/min/1.73m2 or more, recruited between October 2004 and September 2006, and followed through 2013. The associations of biologic use with incident CKD (eGFR under 60 with a decrease of at least 25% from baseline, and eGFR under 45 mL/min/1.73m2) and change in eGFR (<-3, -3 to <0 [reference], and ≥0 mL/min/1.73m2/year) were examined in propensity-matched patients based on their likelihood to initiate biologic treatment, using Cox models and multinomial logistic regression models, respectively. Among 20,757 patients, 4,617 started biologic therapy. In the propensity-matched cohort, patients treated (versus not treated) with biologic agents had a lower risk of incident CKD (hazard ratios 0.95, 95% confidence interval [0.82-1.10] and 0.71 [0.53-0.94] for decrease in eGFR under 60 and under 45 mL/min/1.73m2, respectively) and progressive eGFR decline (multinomial odds ratios [95% CI] for eGFR slopes <-3 and ≥0 [versus -3 to <0] mL/min/1.73m2/year, 0.67 [0.58-0.79] and 0.76 [0.69-0.83], respectively). A significant deceleration of eGFR decline was also observed after biologic administration in patients treated with biologics (-1.0 versus -0.4 [mL/min/1.73m2/year] before and after biologic use). Thus, biologic agent administration was independently associated with lower risk of incident CKD and progressive eGFR decline.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan; Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary; Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, Tennessee, USA; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fatima Hassan
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA.
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Sumida K, Molnar MZ, Potukuchi PK, Thomas F, Lu JL, Ravel VA, Soohoo M, Rhee CM, Streja E, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Association between vascular access creation and deceleration of estimated glomerular filtration rate decline in late-stage chronic kidney disease patients transitioning to end-stage renal disease. Nephrol Dial Transplant 2018; 32:1330-1337. [PMID: 27242372 DOI: 10.1093/ndt/gfw220] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 05/01/2016] [Indexed: 11/13/2022] Open
Abstract
Background Prior studies have suggested that arteriovenous fistula (AVF) or graft (AVG) creation may be associated with slowing of estimated glomerular filtration rate (eGFR) decline. It is unclear if this is attributable to the physiological benefits of a mature access on systemic circulation versus confounding factors. Methods We examined a nationwide cohort of 3026 US veterans with advanced chronic kidney disease (CKD) transitioning to dialysis between 2007 and 2011 who had a pre-dialysis AVF/AVG and had at least three outpatient eGFR measurements both before and after AVF/AVG creation. Slopes of eGFR were estimated using mixed-effects models adjusted for fixed and time-dependent confounders, and compared separately for the pre- and post-AVF/AVG period overall and in patients stratified by AVF/AVG maturation. In all, 3514 patients without AVF/AVG who started dialysis with a catheter served as comparators, using an arbitrary 6-month index date before dialysis initiation to assess change in eGFR slopes. Results Of the 3026 patients with AVF/AVG (mean age 67 years, 98% male, 75% diabetic), 71% had a mature AVF/AVG at dialysis initiation. eGFR decline accelerated in the last 6 months prior to dialysis in patients with a catheter (median, from -6.0 to -16.3 mL/min/1.73 m2/year, P < 0.001), while a significant deceleration of eGFR decline was seen after vascular access creation in those with AVF/AVG (median, from -5.6 to -4.1 mL/min/1.73 m2/year, P < 0.001). Findings were independent of AVF/AVG maturation status and were robust in adjusted models. Conclusions The creation of pre-dialysis AVF/AVG appears to be associated with eGFR slope deceleration and, consequently, may delay the onset of dialysis initiation in advanced CKD patients.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan.,Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Praveen K Potukuchi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jun Ling Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vanessa A Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Melissa Soohoo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
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Peterson K, Anderson J, Boundy E, Ferguson L, McCleery E, Waldrip K. Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map. Am J Public Health 2018; 108:e1-e11. [PMID: 29412713 PMCID: PMC5803811 DOI: 10.2105/ajph.2017.304246] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Continued racial/ethnic health disparities were recently described as "the most serious and shameful health care issue of our time." Although the 2014 US Affordable Care Act-mandated national insurance coverage expansion has led to significant improvements in health care coverage and access, its effects on life expectancy are not yet known. The Veterans Health Administration (VHA), the largest US integrated health care system, has a sustained commitment to health equity that addresses all 3 stages of health disparities research: detection, understanding determinants, and reduction or elimination. Despite this, racial disparities still exist in the VHA across a wide range of clinical areas and service types. OBJECTIVES To inform the health equity research agenda, we synthesized evidence on racial/ethnic mortality disparities in the VHA. SEARCH METHODS Our research librarian searched MEDLINE and Cochrane Central Registry of Controlled Trials from October 2006 through February 2017 using terms for racial groups and disparities. SELECTION CRITERIA We included studies if they compared mortality between any racial/ethnic minority and nonminority veteran groups or between different minority groups in the VHA (PROSPERO# CRD42015015974). We made study selection decisions on the basis of prespecified eligibility criteria. They were first made by 1 reviewer and checked by a second and disagreements were resolved by consensus (sequential review). DATA COLLECTION AND ANALYSIS Two reviewers sequentially abstracted data on prespecified population, outcome, setting, and study design characteristics. Two reviewers sequentially graded the strength of evidence using prespecified criteria on the basis of 5 key domains: study limitations (study design and internal validity), consistency, directness, precision of the evidence, and reporting biases. We synthesized the evidence qualitatively by grouping studies first by racial/ethnic minority group and then by clinical area. For areas with multiple studies in the same population and outcome, we pooled their reported hazard ratios (HRs) using random effects models (StatsDirect version 2.8.0; StatsDirect Ltd., Altrincham, England). We created an evidence map using a bubble plot format to represent the evidence base in 5 dimensions: odds ratio or HR of mortality for racial/ethnic minority group versus Whites, clinical area, strength of evidence, statistical significance, and racial group. MAIN RESULTS From 2840 citations, we included 25 studies. Studies were large (n ≥ 10 000) and involved nationally representative cohorts, and the majority were of fair quality. Most studies compared mortality between Black and White veterans and found similar or lower mortality for Black veterans. However, we found modest mortality disparities (HR or OR = 1.07, 1.52) for Black veterans with stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, or stroke; for American Indian and Alaska Native veterans undergoing noncardiac major surgery; and for Hispanic veterans with HIV or traumatic brain injury (most low strength). AUTHOR'S CONCLUSIONS Although the VHA's equal access health care system has reduced many racial/ethnic mortality disparities present in the private sector, our review identified mortality disparities that have persisted mainly for Black veterans in several clinical areas. However, because most mortality disparities were supported by single studies with imprecise findings, we could not draw strong conclusions about this evidence. More disparities research is needed for American Indian and Alaska Native, Asian, and Hispanic veterans overall and for more of the largest life expectancy gaps. Public Health Implications. Because of the relatively high prevalence of diabetes in Black veterans, further research to better understand and reduce this mortality disparity may be prioritized as having the greatest potential impact. However, other mortality disparities affect thousands of veterans and cannot be ignored.
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Affiliation(s)
- Kim Peterson
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Johanna Anderson
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Erin Boundy
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Lauren Ferguson
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Ellen McCleery
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Kallie Waldrip
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
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Molnar MZ, Eason JD, Gaipov A, Talwar M, Potukuchi PK, Joglekar K, Remport A, Mathe Z, Mucsi I, Novak M, Kalantar-Zadeh K, Kovesdy CP. History of psychosis and mania, and outcomes after kidney transplantation - a retrospective study. Transpl Int 2018; 31:554-565. [PMID: 29405487 DOI: 10.1111/tri.13127] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/11/2018] [Accepted: 01/29/2018] [Indexed: 11/29/2022]
Abstract
History of psychosis or mania, if uncontrolled, both represent relative contraindications for kidney transplantation. We examined 3680 US veterans who underwent kidney transplantation. The diagnosis of history of psychosis/mania was based on a validated algorithm. Measured confounders were used to create a propensity score-matched cohort (n = 442). Associations between pretransplantation psychosis/mania and death with functioning graft, all-cause death, graft loss, and rejection were examined in survival models and logistic regression models. Post-transplant medication nonadherence was assessed using proportion of days covered (PDC) for tacrolimus and mycophenolic acid in both groups. The mean ± SD age of the cohort at baseline was 61 ± 11 years, 92% were male, and 66% and 27% of patients were white and African-American, respectively. Compared to patients without history of psychosis/mania, patients with a history of psychosis/mania had similar risk of death with functioning graft [subhazard ratio (SHR) (95% confidence interval (CI)): 0.94(0.42-2.09)], all-cause death [hazard ratio (95% CI): 1.04 (0.51-2.14)], graft loss [SHR (95% CI): 1.07 (0.45-2.57)], and rejection [odds ratio(95% CI): 1.23(0.60-2.53)]. Moreover, there was no difference in immunosuppressive drug PDC in patients with and without history of psychosis/mania (PDC: 76 ± 21% vs. 78 ± 19%, P = 0.529 for tacrolimus; PDC: 78 ± 17% vs. 79 ± 18%, P = 0.666 for mycophenolic acid). After careful selection, pretransplantation psychosis/mania is not associated with adverse outcomes in kidney transplant recipients.
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Affiliation(s)
- Miklos Z Molnar
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - James D Eason
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Abduzhappar Gaipov
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Extracorporeal Hemocorrection, National Scientific Medical Research Center, Astana, Kazakhstan
| | - Manish Talwar
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kiran Joglekar
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adam Remport
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Zoltan Mathe
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Istvan Mucsi
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Marta Novak
- Centre for Mental Health, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
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Lack of Evidence for Racial Disparity in 30-Day All-Cause Readmission Rate for Older US Veterans Hospitalized with Heart Failure. Qual Manag Health Care 2018; 25:191-196. [PMID: 27749715 DOI: 10.1097/qmh.0000000000000108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Heart failure is the leading cause for 30-day all-cause readmission. Although racial disparities in health care are well documented, their impact on 30-day all-cause readmission rate is inconclusive. OBJECTIVE We examined the impact of racial disparity on 30-day readmission for hospitalized patients with heart failure. METHODS This is a retrospective secondary data analysis for a large veteran cohort in 130 Veterans Affairs Medical Centers. Propensity scores were used to reduce differences in age, gender, survival days, and comorbidities in index hospitalization among 46 524 whites and 14 124 African Americans (AA). RESULTS At index hospitalization, AA patients were younger (73.04 vs 67.10 years, t = -54.58, P < .000) and less likely to have myocardial infarcts (8.02% vs 9.80%, t = -6.36, P = .000), peripheral vascular disease (15.25% vs 22.51%, t = -18.68, P = .000), chronic obstructive pulmonary disease (39.59% vs 50.05%, t = -21.89, P < .000), and complicated diabetes (23.42% vs 26.24%, t = -6.73, P = .000). AA patients had lower mortality 30 days post-index hospitalization (3.51% vs 5.69%, t = -10.23, P = .000). In contrast, AA patients were more likely to have renal disease (44.03% vs 38.71%, t = 11.32, P < .000) and HIV/AIDS (1.56% vs 0.20%, t = 19.71, P < .000). The 30-day all-cause readmission rate before adjustments was 17.82% for AA patients versus 18.72% for white patients. There was no difference in the 2 rates after adjustments (18% vs 18%; odds of readmission = 1.002, z = 0.08, P = .937). CONCLUSIONS In a large Department of Veterans Affairs (VA) cohort, white and AA veterans hospitalized for heart failure had similar 30-day all-cause readmission rates after adjustments were made for age, gender, survival days, and comorbidities. However, the 30-day all-cause mortality rate was higher for white patients than for AA patients. Future prospective studies are needed to validate results and test generalizability outside the VA system of care.
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Arya S, Binney Z, Khakharia A, Brewster LP, Goodney P, Patzer R, Hockenberry J, Wilson PWF. Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease. J Am Heart Assoc 2018; 7:JAHA.117.007425. [PMID: 29330260 PMCID: PMC5850162 DOI: 10.1161/jaha.117.007425] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background Black race has been shown to be a risk factor for amputation in peripheral artery disease (PAD); however, race has been argued to be a marker for socioeconomic status (SES) rather than true disparity. The aim of this study is to study the impact of race and SES on amputation risk in PAD patients. Methods and Results Patients with incident PAD in the national Veterans Affairs Corporate Data Warehouse were identified from 2003 to 2014 (N=155 647). The exposures were race and SES (measured by median income in residential ZIP codes). The outcome was incident major amputation. Black veterans were significantly more likely to live in low‐SES neighborhoods and to present with advanced PAD. Black patients had a higher amputation risk in each SES stratum compared with white patients. In Cox models (adjusting for covariates), black race was associated with a 37% higher amputation risk compared with white race (hazard ratio: 1.37; 95% confidence interval, 1.30–1.45), whereas low SES was independently predictive of increased risk of amputation (hazard ratio: 1.12; 95% confidence interval, 1.06–1.17) and showed no evidence of interaction with race. In predicted amputation risk analysis, black race and low SES continued to be significant risk factors for amputation regardless of PAD presentation. Conclusions Black race significantly increases the risk of amputation within the same SES stratum compared with white race and has an independent effect on limb loss after controlling for comorbidities, severity of PAD at presentation, and use of medications.
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Affiliation(s)
- Shipra Arya
- Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA .,VA Palo Alto Health Care system, Palo Alto, CA
| | - Zachary Binney
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Anjali Khakharia
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Luke P Brewster
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA.,Surgical Service Line, Atlanta VA Medical Center, Decatur, GA
| | - Phil Goodney
- Section of Vascular Surgery Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Rachel Patzer
- Division of Transplant Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA.,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Jason Hockenberry
- Department of Health Policy, Emory University Rollins School of Public Health, Atlanta, GA
| | - Peter W F Wilson
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA.,Epidemiology and Genomic Medicine, Atlanta VA Medical Center, Decatur, GA
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Chan GC, Divers J, Russell GB, Langefeld CD, Wagenknecht LE, Hsu FC, Xu J, Smith SC, Palmer ND, Hicks PJ, Bowden DW, Register TC, Ma L, Carr JJ, Freedman BI. FGF23 Concentration and APOL1 Genotype Are Novel Predictors of Mortality in African Americans With Type 2 Diabetes. Diabetes Care 2018; 41:178-186. [PMID: 29113983 PMCID: PMC5741152 DOI: 10.2337/dc17-0820] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 10/05/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Cardiovascular and renal complications contribute to higher mortality in patients with diabetes. We assessed novel and conventional predictors of mortality in African American-Diabetes Heart Study (AA-DHS) participants. RESEARCH DESIGN AND METHODS Associations between mortality and subclinical atherosclerosis, urine albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), plasma fibroblast growth factor 23 (FGF23) concentration, African ancestry proportion, and apolipoprotein L1 genotypes (APOL1) were assessed in 513 African Americans with type 2 diabetes; analyses were performed using Cox proportional hazards models. RESULTS At baseline, participants were 55.6% female with median (25th, 75th percentile) age 55 years (49.0, 62.0), diabetes duration 8 years (5.0, 13.0), glycosylated hemoglobin 60.7 mmol/mol (48.6, 76.0), eGFR 91.3 mL/min/1.73 m2 (76.4, 111.3), UACR 12.5 mg/mmol (4.2, 51.2), and coronary artery calcium 28.5 mg Ca2+ (1.0, 348.6); 11.5% had two APOL1 renal-risk variants. After 6.6-year follow-up (5.8, 7.5), 54 deaths were recorded. Higher levels of coronary artery calcified plaque, carotid artery calcified plaque, albuminuria, and FGF23 were associated with higher mortality after adjustment for age, sex, and African ancestry proportion. A penalized Cox regression that included all covariates and predictors associated with mortality identified male sex (hazard ratio [HR] 4.17 [95% CI 1.96-9.09]), higher FGF23 (HR 2.10 [95% CI 1.59-2.78]), and absence of APOL1 renal-risk genotypes (HR 0.07 [95% CI 0.01-0.69]) as the strongest predictors of mortality. CONCLUSIONS Accounting for conventional risk factors, higher FGF23 concentrations and APOL1 non-renal-risk genotypes associated with higher mortality in African Americans with diabetes. These data add to growing evidence supporting FGF23 association with mortality; mechanisms whereby these novel predictors impact survival remain to be determined.
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Affiliation(s)
- Gary C Chan
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC.,Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Jasmin Divers
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Gregory B Russell
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Carl D Langefeld
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Lynne E Wagenknecht
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Fang-Chi Hsu
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Jianzhao Xu
- Department of Biochemistry, Center for Genomics and Personalized Medicine Research, and Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, NC
| | - S Carrie Smith
- Department of Biochemistry, Center for Genomics and Personalized Medicine Research, and Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, NC
| | - Nicholette D Palmer
- Department of Biochemistry, Center for Genomics and Personalized Medicine Research, and Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, NC
| | - Pamela J Hicks
- Department of Biochemistry, Center for Genomics and Personalized Medicine Research, and Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, NC
| | - Donald W Bowden
- Department of Biochemistry, Center for Genomics and Personalized Medicine Research, and Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, NC
| | - Thomas C Register
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Lijun Ma
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - J Jeffrey Carr
- Department of Radiology, Vanderbilt University School of Medicine, Nashville, TN
| | - Barry I Freedman
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
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Streja E, Kalantar-Zadeh K, Molnar MZ, Landman J, Arah OA, Kovesdy CP. Radical versus partial nephrectomy, chronic kidney disease progression and mortality in US veterans. Nephrol Dial Transplant 2018; 33:95-101. [PMID: 27798198 PMCID: PMC5837388 DOI: 10.1093/ndt/gfw358] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/06/2016] [Indexed: 01/25/2023] Open
Abstract
Background Partial nephrectomy is considered the preferred care for localized kidney tumors and may yield better patient and kidney survival and similar oncological outcomes compared with radical nephrectomy. We sought to reexamine these hypotheses in a large nationally representative cohort of US veterans who underwent radical or partial nephrectomy. Methods We identified 7073 US veterans who had a partial or radical nephrectomy between 2004 and 2013. We collected data on estimated glomerular filtration rate (eGFR) prior to admission for nephrectomy surgery, immediately after surgery and 180 days postsurgery. We evaluated the association of nephrectomy type and eGFR at different time points with long-term mortality risk in adjusted survival models. Results Patients who underwent radical (compared to partial) nephrectomy had a 2-fold greater decline in eGFR (-21.8 ± 17.7 versus -10.3 ± 17.4 mL/min/1.73 m2) immediately after surgery. This larger drop in eGFR resulted in a larger proportion of radical nephrectomy patients having an eGFR <60 mL/min/1.73 m2 at ≥180 days postsurgery. Radical (compared to partial) nephrectomy patients also exhibited a 2.2-fold higher mortality [adjusted death hazard ratio 2.21 (95% confidence interval 1.91-2.55)]. Low eGFRs prior to surgery and 180 days postsurgery were associated with higher risk of postnephrectomy death. Conclusions Worse postnephrectomy kidney function and higher mortality were observed with radical nephrectomy, and a low presurgical eGFR and a greater decrease in eGFR postsurgery were associated with worse mortality irrespective of the type of nephrectomy. Additional studies are needed to examine predictors of postnephrectomy outcomes.
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Affiliation(s)
- Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
- Department of Medicine, UC Irvine School of Medicine, Irvine, CA, USA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jaime Landman
- Department of Urology, UC Irvine School of Medicine, Irvine, CA, USA
| | - Onyebuchi A Arah
- Department of Epidemiology, School of Public Health, University of California, Los Angeles, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, 1030 Jefferson Ave., Memphis, TN 38104, USA
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62
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Sumida K, Molnar MZ, Potukuchi PK, George K, Thomas F, Lu JL, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Changes in Albuminuria and Subsequent Risk of Incident Kidney Disease. Clin J Am Soc Nephrol 2017; 12:1941-1949. [PMID: 28893924 PMCID: PMC5718265 DOI: 10.2215/cjn.02720317] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 08/02/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Albuminuria is a robust predictor of CKD progression. However, little is known about the associations of changes in albuminuria with the risk of kidney events outside the settings of clinical trials. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a nationwide cohort of 56,946 United States veterans with an eGFR≥60 ml/min per 1.73 m2, we examined the associations of 1-year fold changes in albuminuria with subsequent incident CKD (>25% decrease in eGFR reaching <60 ml/min per 1.73 m2) and rapid eGFR decline (eGFR slope <-5 ml/min per 1.73 m2 per year) assessed using Cox models and logistic regression, respectively, with adjustment for confounders. RESULTS The mean age was 64 (SD, 10) years old; 97% were men, and 91% were diabetic. There was a nearly linear association between 1-year fold changes in albuminuria and incident CKD. The multivariable-adjusted hazard ratios (95% confidence intervals) of incident CKD associated with more than twofold decrease, 1.25- to twofold decrease, 1.25- to twofold increase, and more than twofold increase (versus <1.25-fold decrease to <1.25-fold increase) in albuminuria were 0.82 (95% confidence interval, 0.77 to 0.89), 0.93 (95% confidence interval, 0.86 to 1.00), 1.12 (95% confidence interval, 1.05 to 1.20), and 1.29 (95% confidence interval, 1.21 to 1.38), respectively. Qualitatively similar associations were present for rapid eGFR decline (adjusted odds ratios; 95% confidence intervals for corresponding albuminuria changes: adjusted odds ratio, 0.86; 95% confidence interval, 0.78 to 0.94; adjusted odds ratio, 0.98; 95% confidence interval, 0.89 to 1.07; adjusted odds ratio, 1.18; 95% confidence interval, 1.08 to 1.29; and adjusted odds ratio, 1.67; 95% confidence interval, 1.54 and 1.81, respectively). CONCLUSIONS Relative changes in albuminuria over a 1-year interval were linearly associated with subsequent risk of kidney outcomes. Additional studies are warranted to elucidate the underlying mechanisms of the observed associations and test whether active interventions to lower elevated albuminuria can improve kidney outcomes.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine and
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z. Molnar
- Division of Nephrology, Department of Medicine and
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | | | - Koshy George
- Division of Nephrology, Department of Medicine and
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine and
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California; and
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine and
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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63
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Sumida K, Diskin CD, Molnar MZ, Potukuchi PK, Thomas F, Lu JL, Rhee CM, Streja E, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Pre-End-Stage Renal Disease Hemoglobin Variability Predicts Post-End-Stage Renal Disease Mortality in Patients Transitioning to Dialysis. Am J Nephrol 2017; 46:397-407. [PMID: 29130991 DOI: 10.1159/000484356] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 10/12/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hemoglobin variability (Hb-var) has been associated with increased mortality both in non-dialysis dependent chronic kidney disease (NDD-CKD) and end-stage renal disease (ESRD) patients. However, the impact of Hb-var in advanced NDD-CKD on outcomes after dialysis initiation remains unknown. METHODS Among 11,872 US veterans with advanced NDD-CKD transitioning to dialysis between October 2007 through September 2011, we assessed Hb-var calculated from the residual SD of at least 3 Hb values during the last 6 months before dialysis initiation (prelude period) using within-subject linear regression models, and stratified into quartiles. Outcomes included post-transition all-cause, cardiovascular, and infection-related mortality, assessed in Cox proportional hazards models and adjusted for demographics, comorbidities, length of hospitalization, medications, estimated glomerular filtration rate (eGFR), type of vascular access, Hb parameters (baseline Hb [i.e., intercept] and change in Hb [i.e., slope]), and number of Hb measurements. RESULTS Higher prelude Hb-var was associated with use of iron and antiplatelet agents, tunneled dialysis catheter use, higher levels of baseline Hb, change in Hb, eGFR, and serum ferritin. After multivariable adjustment, higher prelude Hb-var was associated with higher post-ESRD all-cause and infection-related mortality, but not cardiovascular mortality (adjusted hazard ratios [95% CI] for the highest [vs. lowest] quartile of Hb-var, 1.10 [1.02-1.19], 1.28 [0.93-1.75], and 0.93 [0.79-1.10], respectively). CONCLUSIONS High pre-ESRD Hb-var is associated with higher mortality, particularly from infectious causes rather than cardiovascular causes. Further research is required to clarify the underlying mechanisms and true causal nature of the observed association.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Charles Dyer Diskin
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
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Szatmari S, Bereczki D, Fornadi K, Kalantar-Zadeh K, Kovesdy CP, Molnar MZ. Association of Restless Legs Syndrome With Incident Parkinson's Disease. Sleep 2017; 40:2667757. [PMID: 28364505 DOI: 10.1093/sleep/zsw065] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Study Objectives The association between restless legs syndrome (RLS) and Parkinson's disease (PD) has been extensively studied with inconclusive results; therefore, we prospectively examined the associations of the presence of RLS with development of incident PD. Methods From a nationally representative prospective cohort of almost 3.5 million US veterans (age: 60 ± 14 years, 93% male, median follow-up time of 7.8 years [interquartile range: 6.4-8.4 years]), we created a propensity-matched cohort of 100882 PD-free patients and examined the association between prevalent RLS and incident PD. This association was also assessed in the entire cohort. Associations were examined using Cox models. Results There were 68 incident PD events (0.13%, incidence rate 1.87 [1.48-2.37]/10000 patient-years) in the RLS-negative group, and 185 incident PD events (0.37%, incidence rate 4.72 [4.09-5.45]/10000 patient-years) in the RLS-positive group in the propensity-matched cohort. Prevalent RLS was associated with more than twofold higher risk of incident PD (hazard ratio [HR]: 2.57, 95% confidence interval [CI]: 1.95-3.39) compared to RLS-negative patients. Qualitatively similar results were found when we examined the entire 3.5 million cohort: Prevalent RLS was associated with more than twofold higher risk of incident PD (multivariable adjusted HR: 2.81, 95%CI: 2.41-3.27). Conclusion RLS and PD share common risk factors. In this large cohort of US veterans, we found that prevalent RLS is associated with higher risk of incident PD during 8 years of follow-up, suggesting that RLS could be an early clinical feature of incident PD.
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Affiliation(s)
- Szabolcs Szatmari
- Department of Neurology, Sibiu County Emergency Hospital, Sibiu, Romania.,2nd Department of Neurology, Targu Mures Emergency Clinical County Hospital, Targu Mures, Romania.,Szentágothai Doctoral School, Semmelweis University, Budapest, Hungary
| | - Daniel Bereczki
- Szentágothai Doctoral School, Semmelweis University, Budapest, Hungary.,Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Katalin Fornadi
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | | | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
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Kshirsagar AV, Manickam RN, Mu Y, Flythe JE, Chin AI, Bang H. Area-level poverty, race/ethnicity & dialysis star ratings. PLoS One 2017; 12:e0186651. [PMID: 29040342 PMCID: PMC5645143 DOI: 10.1371/journal.pone.0186651] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/25/2017] [Indexed: 11/25/2022] Open
Abstract
The Centers for Medicare and Medicaid Services recently released a five star rating system as part of ‘Dialysis Facility Compare’ to help patients identify and choose high performing clinics in the US. Eight dialysis-related measures determine ratings. Little is known about the association between surrounding community sociodemographic characteristics and star ratings. Using data from the U.S. Census and over 6000 dialysis clinics across the country, we examined the association between dialysis clinic star ratings and characteristics of the local population: 1) proportion of population below the federal poverty level (FPL); 2) proportion of black individuals; and 3) proportion of Hispanic individuals, by correlation and regression analyses. Secondary analyses with Quality Incentive Program (QIP) scores and population characteristics were also performed. We observed a negligible correlation between star ratings and the proportion of local individuals below FPL; Spearman coefficient, R = -0.09 (p<0.0001), and a stronger correlation between star ratings and the proportion of black individuals; R = -0.21 (p<0.0001). Ordered logistic regression analyses yielded adjusted odds ratio of 0.91 (95% confidence interval [0.80–1.30], p = 0.12) and 0.55 ([0.48–0.63], p<0.0001) for high vs. low level of proportion below FPL and proportion of black individuals, respectively. In contrast, a near-zero correlation was observed between star ratings and the proportion of Hispanic individuals. Correlations varied substantially by country region, clinic profit status and clinic size. Analyses using clinic QIP scores provided similar results. Sociodemographic characteristics of the surrounding community, factors typically outside of providers’ direct control, have varying levels of association with clinic dialysis star ratings.
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Affiliation(s)
- Abhijit V. Kshirsagar
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Raj N. Manickam
- Graduate Group in Epidemiology, University of California, Davis, Davis, California, United States of America
| | - Yi Mu
- Graduate Group in Epidemiology, University of California, Davis, Davis, California, United States of America
| | - Jennifer E. Flythe
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Andrew I. Chin
- Division of Nephrology, University of California, Davis School of Medicine, Sacramento, California, United States of America
- Division of Nephrology, Sacramento VA Medical Center, VA Northern California Health Care Systems, Mather Field, California, United States of America
| | - Heejung Bang
- Graduate Group in Epidemiology, University of California, Davis, Davis, California, United States of America
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, Davis, California, United States of America
- Center for Healthcare Policy and Research, School of Medicine, University of California, Sacramento, Sacramento, California, United States of America
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66
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Gyamlani G, Molnar MZ, Lu JL, Sumida K, Kalantar-Zadeh K, Kovesdy CP. Association of serum albumin level and venous thromboembolic events in a large cohort of patients with nephrotic syndrome. Nephrol Dial Transplant 2017; 32:157-164. [PMID: 28391310 DOI: 10.1093/ndt/gfw227] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/04/2016] [Indexed: 11/13/2022] Open
Abstract
Background Prior small studies have suggested an association between low serum albumin and increased risk of venous thromboembolic (VTE) events in patients with nephrotic syndrome (NS). Methods From a nationally representative prospective cohort of over 3 million US veterans with baseline estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m 2 , we identified 7037 patients with NS based on ICD-9 codes. Association between serum albumin and risk of incident VTE was assessed using Cox regression analysis with adjustments for age, gender, race, comorbidities, eGFR, body mass index and anticoagulant treatment. Results Mean age was 57 ± 11 years, patients were 96% male, 32% African-American and 60% diabetic. There were a total of 158 VTE events over a median follow-up of 8.1 years; 16 events [absolute event rate (AER) 4.1%, event rate 8.5/1000 patient-years (PY)] in patients with albumin <2.5 g/dL, 18 events (AER 3.4%, event rate 5.7/1000 patient-years) in patients with albumin 2.5-2.99 g/dL, 89 events (AER 2.5%, event rate 3.4/1000 patient-years) in patients with albumin 3-3.99 g/dL and 35 events (AER 1.4%, event rate 1.9/1000 patient-years) in patients with albumin ≥4 g/dL. Compared with patients with albumin ≥4 g/dL, those with albumin levels of 3-3.99 g/dL [adjusted hazard ratio (HR): 1.51, 95% confidence interval (CI): 1.01-2.26], 2.5-2.99 g/dL (HR: 2.24, 95% CI: 1.24-4.05) and <2.5 g/dL (HR: 2.79, 95% CI: 1.45-5.37) experienced a linearly higher risk of VTE events. Conclusions Lower serum albumin is a strong independent predictor for VTE events in NS. The risk increases proportionately with declining albumin levels. Clinical trials are needed to determine benefit of prophylactic anticoagulation in NS patients with moderately lower serum albumin levels.
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Affiliation(s)
- Geeta Gyamlani
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jun L Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA.,Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
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67
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Molnar MZ, Streja E, Sumida K, Soohoo M, Ravel VA, Gaipov A, Potukuchi PK, Thomas F, Rhee CM, Lu JL, Kalantar-Zadeh K, Kovesdy CP. Pre-ESRD Depression and Post-ESRD Mortality in Patients with Advanced CKD Transitioning to Dialysis. Clin J Am Soc Nephrol 2017; 12:1428-1437. [PMID: 28679562 PMCID: PMC5586564 DOI: 10.2215/cjn.00570117] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 05/26/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVES Depression in patients with nondialysis-dependent CKD is often undiagnosed, empirically overlooked, and associated with higher risk of death, progression to ESRD, and hospitalization. However, there is a paucity of evidence on the association between the presence of depression in patients with advanced nondialysis-dependent CKD and post-ESRD mortality, particularly among those in the transition period from late-stage nondialysis-dependent CKD to maintenance dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS From a nation-wide cohort of 45,076 United States veterans who transitioned to ESRD over 4 contemporary years (November of 2007 to September of 2011), we identified 10,454 (23%) patients with a depression diagnosis during the predialysis period. We examined the association of pre-ESRD depression with all-cause mortality after transition to dialysis using Cox proportional hazards models adjusted for sociodemographics, comorbidities, and medications. RESULTS Patients were 72±11 years old (mean±SD) and included 95% men, 66% patients with diabetes, and 23% blacks. The crude mortality rate was similar in patients with depression (289/1000 patient-years; 95% confidence interval, 282 to 297) versus patients without depression (286/1000 patient-years; 95% confidence interval, 282 to 290). Compared with patients without depression, patients with depression had a 6% higher all-cause mortality risk in the adjusted model (hazard ratio, 1.06; 95% confidence interval, 1.03 to 1.09). Similar results were found across all selected subgroups as well as in sensitivity analyses using alternate definitions of depression. CONCLUSION Pre-ESRD depression has a weak association with post-ESRD mortality in veterans transitioning to dialysis.
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Affiliation(s)
- Miklos Z. Molnar
- Division of Nephrology, Department of Medicine and
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | | | - Melissa Soohoo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Vanessa A. Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Abduzhappar Gaipov
- Division of Nephrology, Department of Medicine and
- Department of Extracorporeal Hemocorrection, National Scientific Medical Research Center, Astana, Kazakhstan; and
| | | | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Connie M. Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine and
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine and
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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Shaw LJ, Pepine CJ, Xie J, Mehta PK, Morris AA, Dickert NW, Ferdinand KC, Gulati M, Reynolds H, Hayes SN, Itchhaporia D, Mieres JH, Ofili E, Wenger NK, Bairey Merz CN. Quality and Equitable Health Care Gaps for Women: Attributions to Sex Differences in Cardiovascular Medicine. J Am Coll Cardiol 2017; 70:373-388. [PMID: 28705320 DOI: 10.1016/j.jacc.2017.05.051] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/17/2017] [Accepted: 05/17/2017] [Indexed: 12/20/2022]
Abstract
The present review synthesizes evidence and discusses issues related to health care quality and equity for women, including minority population subgroups. The principle of "sameness" or women and men receiving equitable, high-quality care is a near-term target, but optimal population health cannot be achieved without consideration of the unique, gendered structural determinants of health and the development of unique care pathways optimized for women. The aim of this review is to promote enhanced awareness, develop critical thinking in sex and gender science, and identify strategic pathways to improve the cardiovascular health of women. Delineation of the components of high-quality health care, including a women-specific research agenda, remains a vital part of strategic planning to improve the lives of women at risk for or living with cardiovascular disease.
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Affiliation(s)
- Leslee J Shaw
- Emory University School of Medicine, Atlanta, Georgia.
| | | | - Joe Xie
- Emory University School of Medicine, Atlanta, Georgia
| | - Puja K Mehta
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | - Martha Gulati
- University of Arizona College of Medicine, Phoenix, Arizona
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Sumida K, Molnar MZ, Potukuchi PK, Thomas F, Lu JL, Ravel VA, Soohoo M, Rhee CM, Streja E, Sim JJ, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Blood Pressure Before Initiation of Maintenance Dialysis and Subsequent Mortality. Am J Kidney Dis 2017; 70:207-217. [PMID: 28291617 PMCID: PMC5526740 DOI: 10.1053/j.ajkd.2016.12.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/19/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Mortality is extremely high immediately after the transition to dialysis therapy, but the association of blood pressure (BP) before dialysis therapy initiation with mortality after dialysis therapy initiation remains unknown. STUDY DESIGN Observational study. SETTING & PARTICIPANTS 17,729 US veterans transitioning to dialysis therapy in October 2007 to September 2011, with a median follow-up of 2.0 years. PREDICTOR Systolic (SBP) and diastolic BP (DBP) averaged over the last 1-year predialysis transition period as 6 (<120 to ≥160mmHg in 10-mmHg increments) and 5 (<60 to ≥90mmHg in 10-mmHg increments) categories, respectively, and as continuous measures. OUTCOMES & MEASUREMENTS Postdialysis all-cause mortality, assessed over different follow-up periods (ie, <3, 3-<6, 6-<12, and ≥12 months after dialysis therapy initiation) using Cox regressions adjusted for demographics, comorbid conditions, medications, cardiovascular medication adherence, body mass index, estimated glomerular filtration rate, and type of vascular access. RESULTS Mean predialysis SBP and DBP were 141.2±16.1 (SD) and 73.7±10.6mmHg, respectively. There was a reverse J-shaped association of SBP with all-cause mortality, with significantly higher mortality seen with SBP<140mmHg. Mortality risks associated with lower SBP were greatest in the first 3 months after dialysis therapy initiation, with multivariable-adjusted HRs of 2.40 (95% CI, 1.96-2.93), 1.99 (95% CI, 1.66-2.40), 1.35 (95% CI, 1.13-1.62), 0.98 (95% CI, 0.78-1.22), and 0.76 (95% CI, 0.57-1.00) for SBP <120, 120 to <130, 130 to <140, 150 to <160, and ≥160 (vs 140-<150) mmHg, respectively. No consistent association was observed between predialysis DBP and postdialysis mortality. LIMITATIONS Results cannot be inferred to show causality and may not be generalizable to women or the general US population. CONCLUSIONS Lower predialysis SBP is associated with higher all-cause mortality in the immediate postdialysis period. Predialysis DBP showed no consistent association with postdialysis mortality. Further studies are needed to clarify ideal predialysis SBP levels among incident dialysis patients as a potential means to improve the excessively high early dialysis mortality.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa; Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Vanessa A Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange
| | - Melissa Soohoo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis VA Medical Center, Memphis, TN.
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70
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McLean NO, Robinson TW, Freedman BI. APOL1 Gene Kidney Risk Variants and Cardiovascular Disease: Getting to the Heart of the Matter. Am J Kidney Dis 2017; 70:281-289. [PMID: 28143671 PMCID: PMC5526726 DOI: 10.1053/j.ajkd.2016.11.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 11/01/2016] [Indexed: 12/12/2022]
Abstract
Apolipoprotein L1 gene (APOL1) renal risk variants exhibit strong genetic associations with a spectrum of nondiabetic kidney diseases in individuals with recent African ancestry. Relationships between APOL1 kidney risk variants and cardiovascular disease (CVD) susceptibility and CVD-related death remain controversial. Some studies detected an increased risk for CVD, whereas others support protection from death and subclinical CVD and cerebrovascular disease. Because treatments for nondiabetic kidney disease may target this gene and its protein products, it remains critical to clarify the potential extrarenal effects of APOL1 kidney risk variants. This review addresses the current literature on APOL1 associations with CVD, cerebrovascular disease, and death. Potential causes of disparate results between studies are discussed.
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Affiliation(s)
- Nicholas O McLean
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Todd W Robinson
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Barry I Freedman
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
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71
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George LK, Koshy SKG, Molnar MZ, Thomas F, Lu JL, Kalantar-Zadeh K, Kovesdy CP. Heart Failure Increases the Risk of Adverse Renal Outcomes in Patients With Normal Kidney Function. Circ Heart Fail 2017; 10:e003825. [PMID: 28765150 PMCID: PMC5557387 DOI: 10.1161/circheartfailure.116.003825] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 07/03/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heart failure (HF) is associated with poor cardiac outcomes and mortality. It is not known whether HF leads to poor renal outcomes in patients with normal kidney function. We hypothesized that HF is associated with worse long-term renal outcomes. METHODS AND RESULTS Among 3 570 865 US veterans with estimated glomerular filtration rate (eGFR) ≥60 mL min-1 1.73 m-2 during October 1, 2004 to September 30, 2006, we identified 156 743 with an International Classification of Diseases, Ninth Revision, diagnosis of HF. We examined the association of HF with incident chronic kidney disease (CKD), the composite of incident CKD or mortality, and rapid rate of eGFR decline (slopes steeper than -5 mL min-1 1.73 m-2 y-1) using Cox proportional hazard analyses and logistic regression. Adjustments were made for various confounders. The mean±standard deviation baseline age and eGFR of HF patients were 68±11 years and 78±14 mL min-1 1.73 m-2 and in patients without HF were 59±14 years and 84±16 mL min-1 1.73 m-2, respectively. HF patients had higher prevalence of hypertension, diabetes mellitus, cardiac, peripheral vascular and chronic lung diseases, stroke, and dementia. Incidence of CKD was 69.0/1000 patient-years in HF patients versus 14.5/1000 patient-years in patients without HF, and 22% of patients with HF had rapid decline in eGFR compared with 8.5% in patients without HF. HF patients had a 2.12-, 2.06-, and 2.13-fold higher multivariable-adjusted risk of incident CKD, composite of CKD or mortality, and rapid eGFR decline, respectively. CONCLUSIONS HF is associated with significantly higher risk of incident CKD, incident CKD or mortality, and rapid eGFR decline. Early diagnosis and management of HF could help reduce the risk of long-term renal complications.
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Affiliation(s)
- Lekha K George
- From the Division of Nephrology, Department of Medicine (L.K.G., M.Z.M., J.L.L., C.P.K.), Division of Cardiology, Department of Medicine (S.K.G.K.), and Division of Biostatistics and Epidemiology, Department of Preventive Medicine (F.T.), University of Tennessee Health Sciences Center, Memphis; Regional One Health, Memphis, TN (S.K.G.K.); Division of Nephrology, University of California, Irvine (K.K.-Z.); and Nephrology Section, Memphis Veterans Affairs Medical Center, TN (C.P.K.)
| | - Santhosh K G Koshy
- From the Division of Nephrology, Department of Medicine (L.K.G., M.Z.M., J.L.L., C.P.K.), Division of Cardiology, Department of Medicine (S.K.G.K.), and Division of Biostatistics and Epidemiology, Department of Preventive Medicine (F.T.), University of Tennessee Health Sciences Center, Memphis; Regional One Health, Memphis, TN (S.K.G.K.); Division of Nephrology, University of California, Irvine (K.K.-Z.); and Nephrology Section, Memphis Veterans Affairs Medical Center, TN (C.P.K.)
| | - Miklos Z Molnar
- From the Division of Nephrology, Department of Medicine (L.K.G., M.Z.M., J.L.L., C.P.K.), Division of Cardiology, Department of Medicine (S.K.G.K.), and Division of Biostatistics and Epidemiology, Department of Preventive Medicine (F.T.), University of Tennessee Health Sciences Center, Memphis; Regional One Health, Memphis, TN (S.K.G.K.); Division of Nephrology, University of California, Irvine (K.K.-Z.); and Nephrology Section, Memphis Veterans Affairs Medical Center, TN (C.P.K.)
| | - Fridtjof Thomas
- From the Division of Nephrology, Department of Medicine (L.K.G., M.Z.M., J.L.L., C.P.K.), Division of Cardiology, Department of Medicine (S.K.G.K.), and Division of Biostatistics and Epidemiology, Department of Preventive Medicine (F.T.), University of Tennessee Health Sciences Center, Memphis; Regional One Health, Memphis, TN (S.K.G.K.); Division of Nephrology, University of California, Irvine (K.K.-Z.); and Nephrology Section, Memphis Veterans Affairs Medical Center, TN (C.P.K.)
| | - Jun L Lu
- From the Division of Nephrology, Department of Medicine (L.K.G., M.Z.M., J.L.L., C.P.K.), Division of Cardiology, Department of Medicine (S.K.G.K.), and Division of Biostatistics and Epidemiology, Department of Preventive Medicine (F.T.), University of Tennessee Health Sciences Center, Memphis; Regional One Health, Memphis, TN (S.K.G.K.); Division of Nephrology, University of California, Irvine (K.K.-Z.); and Nephrology Section, Memphis Veterans Affairs Medical Center, TN (C.P.K.)
| | - Kamyar Kalantar-Zadeh
- From the Division of Nephrology, Department of Medicine (L.K.G., M.Z.M., J.L.L., C.P.K.), Division of Cardiology, Department of Medicine (S.K.G.K.), and Division of Biostatistics and Epidemiology, Department of Preventive Medicine (F.T.), University of Tennessee Health Sciences Center, Memphis; Regional One Health, Memphis, TN (S.K.G.K.); Division of Nephrology, University of California, Irvine (K.K.-Z.); and Nephrology Section, Memphis Veterans Affairs Medical Center, TN (C.P.K.)
| | - Csaba P Kovesdy
- From the Division of Nephrology, Department of Medicine (L.K.G., M.Z.M., J.L.L., C.P.K.), Division of Cardiology, Department of Medicine (S.K.G.K.), and Division of Biostatistics and Epidemiology, Department of Preventive Medicine (F.T.), University of Tennessee Health Sciences Center, Memphis; Regional One Health, Memphis, TN (S.K.G.K.); Division of Nephrology, University of California, Irvine (K.K.-Z.); and Nephrology Section, Memphis Veterans Affairs Medical Center, TN (C.P.K.).
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72
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George J, Mathur R, Shah AD, Pujades-Rodriguez M, Denaxas S, Smeeth L, Timmis A, Hemingway H. Ethnicity and the first diagnosis of a wide range of cardiovascular diseases: Associations in a linked electronic health record cohort of 1 million patients. PLoS One 2017; 12:e0178945. [PMID: 28598987 PMCID: PMC5466321 DOI: 10.1371/journal.pone.0178945] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/22/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND While the association of ethnic group with individual cardiovascular diseases has been studied, little is known about ethnic differences in the initial lifetime presentation of clinical cardiovascular disease in contemporary populations. METHODS AND RESULTS We studied 1,068,318 people, aged ≥30 years and free from diagnosed CVD at baseline (90.9% White, 3.6% South Asian and 2.9% Black), using English linked electronic health records covering primary care, hospital admissions, acute coronary syndrome registry and mortality registry (CALIBER platform). During 5.7 years median follow-up between 1997-2010, 95,224 people experienced an incident cardiovascular diagnosis. 69.9% (67.2%-72.4%) of initial presentation in South Asian <60 yrs were coronary heart disease presentations compared to 47.8% (47.3%-48.3%) in White and 40.1% (36.3%-43.9%) in Black patients. Compared to White patients, Black patients had significantly lower age-sex adjusted hazard ratios (HRs) for initial lifetime presentation of all the coronary disease diagnoses (stable angina HR 0.80 (95% CI 0.68-0.93); unstable angina- 0.75 (0.59-0.97); myocardial infarction 0.49 (0.40-0.62)) while South Asian patients had significantly higher HRs (stable angina- 1.67 (1.52-1.84); unstable angina 1.82 (1.56-2.13); myocardial infarction- 1.67 (1.49-1.87). We found no ethnic differences in initial presentation with heart failure (Black 0.97 (0.79-1.20); S Asian 1.04(0.87-1.26)). Compared to White patients, Black patients were more likely to present with ischaemic stroke (1.24 (0.97-1.58)) and intracerebral haemorrhage (1.44 (0.97-2.12)). Presentation with peripheral arterial disease was less likely for Black (0.63 (0.50-0.80)) and South Asian patients (0.70 (0.57-0.86)) compared with White patients. DISCUSSION While we found the anticipated substantial predominance of coronary heart disease presentations in South Asian and predominance of stroke presentations in Black patients, we found no ethnic differences in presentation with heart failure. We consider the public health and research implications of our findings. TRIAL REGISTRATION NCT02176174, www.clinicaltrials.gov.
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Affiliation(s)
- Julie George
- The Farr Institute of Health Informatics Research and the National Institute for Health Research, Biomedical Research Centre, University College London, London, United Kingdom
| | - Rohini Mathur
- Electronic Health Records Group, Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anoop Dinesh Shah
- The Farr Institute of Health Informatics Research and the National Institute for Health Research, Biomedical Research Centre, University College London, London, United Kingdom
| | - Mar Pujades-Rodriguez
- The Farr Institute of Health Informatics Research and the National Institute for Health Research, Biomedical Research Centre, University College London, London, United Kingdom
- Leeds Institute of Biomedical and Clinical Science, University of Leeds, Leeds, United Kingdom
| | - Spiros Denaxas
- The Farr Institute of Health Informatics Research and the National Institute for Health Research, Biomedical Research Centre, University College London, London, United Kingdom
| | - Liam Smeeth
- Electronic Health Records Group, Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Adam Timmis
- NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, London, United Kingdom
| | - Harry Hemingway
- The Farr Institute of Health Informatics Research and the National Institute for Health Research, Biomedical Research Centre, University College London, London, United Kingdom
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73
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Abstract
PURPOSE OF REVIEW The prevalence of cardiovascular disease differs among ethnic groups and along geographic boundaries. At present, most of the projected increase in mortality from cardiovascular disease occurs in sub-Saharan African, Chinese and Southeast Asian populations. Ethnic disparities in the prevalence of cardiovascular disease coincide with quantitative and qualitative differences in risk factors for cardiovascular disease. High plasma cholesterol is one of the most important preventable causes of ischemic heart disease. RECENT FINDINGS The current review summarizes recent evidence on ethnic differences in ischemic heart disease and its correlates with genetic and acquired differences in plasma lipid and lipoprotein levels. The nature of ethnic differences in plasma lipid levels, apolipoprotein L1 en lipoprotein(a) [Lp(a)] is outlined, and the effects of lipid-lowering therapy and future efforts and challenges regarding implementation are discussed. SUMMARY Ethnic differences in HDL-cholesterol (HDL-C), triglyceride levels and Lp(a) may impact ethnic differences in cardiovascular disease and result in higher residual risk during lipid-lowering therapy. Further efforts should be made to stimulate the use of statins in both high-income and low-income countries and study their effects in individuals with different ethnic backgrounds.
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Affiliation(s)
- Katia Gazzola
- aDepartment of Medical Sciences, University of Ferrara, Ferrara, Italy bDepartment of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
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74
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Saleh T, Sumida K, Molnar MZ, Potukuchi PK, Thomas F, Lu JL, Gyamlani GG, Streja E, Kalantar-Zadeh K, Kovesdy CP. Effect of Age on the Association of Vascular Access Type with Mortality in a Cohort of Incident End-Stage Renal Disease Patients. Nephron Clin Pract 2017; 137:57-63. [PMID: 28514785 DOI: 10.1159/000477271] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/03/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND/AIMS All hemodialysis (HD) patients are generally recommended to create a fistula first; but to create a mature arteriovenous fistula (AVF) can be challenging in elderly individuals. It is unclear if elderly incident HD patients derive a survival benefit from an AVF over an arteriovenous graft (AVG) or a tunneled central venous catheter (TDC). METHODS We examined the association of vascular access type (AVF, AVG, and TDC with and without a maturing AVF/AVG at dialysis transition) at HD initiation with all-cause, cardiovascular (CV), and infection-related mortality in 46,786 US veterans using Cox models with adjustment for confounders. Effect modification by age was examined by examining associations in pre-specified age subgroups (<60, 60-<70, 70-<80, and ≥80 years old), and by including interaction terms. RESULTS Patients numbering 8,940 (19%) started HD with an AVF, 1,090 (3%) with an AVG, 8,262 (18%) with a TDC and a maturing AVF/AVG and 28,494 (61%) with a TDC without a maturing AVF/AVG. A total of 13,303 all-cause, 4,392 CV, and 1,058 infection-related deaths were observed in the first year after HD transition. Compared to patients with AVF, those with AVG and TDC with and without maturing AVF/AVG had incrementally higher overall risk of all-cause mortality and CV mortality. Only TDC use was associated with higher infection-associated mortality. These associations were not modified by age. CONCLUSION Although most of our patients consisted of male veterans and the results may not be generalized to the general population, the use of TDCs is associated with poor outcomes even in the most elderly incident HD patients.
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Affiliation(s)
- Tarek Saleh
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
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75
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Erqou S, Echouffo-Tcheugui JB, Kip KE, Aiyer A, Reis SE. Association of cumulative social risk with mortality and adverse cardiovascular disease outcomes. BMC Cardiovasc Disord 2017; 17:110. [PMID: 28482797 PMCID: PMC5422978 DOI: 10.1186/s12872-017-0539-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 04/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quantifying the cumulative effect of social risk factors on cardiovascular disease (CVD) risk can help to better understand the sources of disparities in health outcomes. METHOD AND RESULTS Data from the Heart Strategies Concentrating on Risk Evaluation (HeartSCORE) study were used to create an index of cumulative social risk (CSR) and quantify its association with incident CVD and all-cause mortality. CSR was defined by assigning a score of 1 for the presence of each of 4 social factors: i) racial minority status (Black race), ii) single living status, iii) low income, and iv) low educational level. Hazard ratios (HRs) were computed using Cox-regression models, adjusted for CVD risk factors. Over a median follow-up period of 8.3 years, 127 incident events were observed. The incidence of the primary outcome for subgroups of participants with 0, 1, and ≥2 CSR scores was 5.31 (95% CI, 3.40-7.22), 10.32 (7.16-13.49) and 17.80 (12.94-22.67) per 1000 person-years, respectively. Individuals with CSR score of 1 had an adjusted HR of 1.85 (1.15-2.97) for incident primary outcomes, compared to those with score of 0. The corresponding HR for individuals with CSR score of 2 or more was 2.58 (1.60-4.17). CONCLUSION An accumulation of social risk factors independently increased the likelihood of CVD events and deaths in a cohort of White and Black individuals.
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Affiliation(s)
- Sebhat Erqou
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | | | - Kevin E. Kip
- College of Nursing, University of South Florida, Tampa, FL USA
| | - Aryan Aiyer
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Steven E. Reis
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA USA
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76
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Norris KC, Williams SF, Rhee CM, Nicholas SB, Kovesdy CP, Kalantar-Zadeh K, Boulware LE. Hemodialysis Disparities in African Americans: The Deeply Integrated Concept of Race in the Social Fabric of Our Society. Semin Dial 2017; 30:213-223. [PMID: 28281281 PMCID: PMC5418094 DOI: 10.1111/sdi.12589] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
End-stage renal disease (ESRD) is one of the starkest examples of racial/ethnic disparities in health. Racial/ethnic minorities are 1.5 to nearly 4 times more likely than their non-Hispanic White counterparts to require renal replacement therapy (RRT), with African Americans suffering from the highest rates of ESRD. Despite improvements over the last 25 years, substantial racial differences are persistent in dialysis quality measures such as RRT modality options, dialysis adequacy, anemia, mineral and bone disease, vascular access, and pre-ESRD care. This report will outline the current status of racial disparities in key ESRD quality measures and explore the impact of race. While the term race represents a social construct, its association with health is more complex. Multiple individual and community level social determinants of health are defined by the social positioning of race in the U.S., while biologic differences may reflect distinct epigenetic changes and linkages to ancestral geographic origins. Together, these factors conspire to influence dialysis outcomes among African Americans with ESRD.
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Affiliation(s)
- Keith C. Norris
- Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Sandra F. Williams
- Department of Integrated Medical Science, Florida Atlantic University, Florida
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
| | - Susanne B. Nicholas
- Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Csaba P. Kovesdy
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
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77
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Kalantar-Zadeh K, Crowley ST, Beddhu S, Chen JLT, Daugirdas JT, Goldfarb DS, Jin A, Kovesdy CP, Leehey DJ, Moradi H, Navaneethan SD, Norris KC, Obi Y, O’Hare A, Shafi T, Streja E, Unruh ML, Vachharajani T, Weisbord S, Rhee CM. Renal Replacement Therapy and Incremental Hemodialysis for Veterans with Advanced Chronic Kidney Disease. Semin Dial 2017; 30:251-261. [PMID: 28421638 PMCID: PMC5418081 DOI: 10.1111/sdi.12601] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Each year approximately 13,000 Veterans transition to maintenance dialysis, mostly in the traditional form of thrice-weekly hemodialysis from the start. Among >6000 dialysis units nationwide, there are currently approximately 70 Veterans Affairs (VA) dialysis centers. Given this number of VA dialysis centers and their limited capacity, only 10% of all incident dialysis Veterans initiate treatment in a VA center. Evidence suggests that, among Veterans, the receipt of care within the VA system is associated with favorable outcomes, potentially because of the enhanced access to healthcare resources. Data from the United States Renal Data System Special Study Center "Transition-of-Care-in-CKD" suggest that Veterans who receive dialysis in a VA unit exhibit greater survival compared with the non-VA centers. Substantial financial expenditures arise from the high volume of outsourced care and higher dialysis reimbursement paid by the VA than by Medicare to outsourced providers. Given the exceedingly high mortality and abrupt decline in residual kidney function (RKF) in the first dialysis year, it is possible that incremental transition to dialysis through an initial twice-weekly hemodialysis regimen might preserve RKF, prolong vascular access longevity, improve patients' quality of life, and be a more patient-centered approach, more consistent with "personalized" dialysis. Broad implementation of incremental dialysis might also result in more Veterans receiving care within a VA dialysis unit. Controlled trials are needed to examine the safety and efficacy of incremental hemodialysis in Veterans and other populations; the administrative and health care as well as provider structure within the VA system would facilitate the performance of such trials.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Los Angeles Biomedical Research Institute, Harbor-UCLA Med. Center, Torrance, California
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California
| | - Susan T. Crowley
- VHA National Program Director for Kidney Disease; and Renal Section, VA Connecticut Healthcare System, and Yale University, New Haven, Connecticut
| | - Srinivasan Beddhu
- University of Utah Health Sciences Center, and VA Salt Lake City, Salt Lake City, Utah
| | - Joline LT Chen
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | | | | | - Anna Jin
- VA Long Beach Healthcare System, Long Beach, California
| | - Csaba P. Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, and Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Hamid Moradi
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Sankar D Navaneethan
- Michael E. Debakey VA Medical center and Baylor College of Medicine, Houston, Texas
| | - Keith C Norris
- Department of Medicine, David Geffen UCLA School of Medicine, Los Angeles, California
| | - Yoshitsugu Obi
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Ann O’Hare
- Puget Sounds VA Healthcare System, and University of Washington Seattle, Washington
| | - Tariq Shafi
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Elani Streja
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Los Angeles Biomedical Research Institute, Harbor-UCLA Med. Center, Torrance, California
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California
| | - Mark L. Unruh
- New Mexico VA Health Care System, and University of New Mexico; Albuquerque, New Mexico
| | - Tushar Vachharajani
- W. G. (Bill) Hefner VA Medical Center, and Edwards Via College of Osteopathic Medicine, Salisbury, North Carolina
| | - Steven Weisbord
- VA Pittsburgh Healthcare System; and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Connie M. Rhee
- VA Long Beach Healthcare System, Long Beach, California
- Harold Simmons Center for Kidney Disease Research and Epidemiology; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Los Angeles Biomedical Research Institute, Harbor-UCLA Med. Center, Torrance, California
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78
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Arif FM, Sumida K, Molnar MZ, Potukuchi PK, Lu JL, Hassan F, Thomas F, Siddiqui OA, Gyamlani GG, Kalantar-Zadeh K, Kovesdy CP. Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease. Nephron Clin Pract 2017; 137:15-22. [PMID: 28445893 DOI: 10.1159/000473704] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/27/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Mortality in the immediate post-hemodialysis transition period is extremely high. Many end-stage renal disease (ESRD) patients in the US start dialysis in an inpatient setting, but the characteristics of patients starting dialysis as inpatients, and the association of inpatient hemodialysis transition with mortality remain unclear. METHODS We examined 48,261 US veterans who transitioned to hemodialysis between October 2007 and September 2011. Associations of inpatient hemodialysis starting with all-cause mortality were examined in Cox proportional hazard models, with adjustments for demographics, comorbidities, vascular access type, pre-dialysis nephrology care and medication use, and last pre-ESRD estimated glomerular filtration rate and hemoglobin. RESULTS A total of 22,338 (46.3%) patients received the first hemodialysis treatment in an inpatient setting. Inpatient hemodialysis transition was associated with older age, presence of a tunneled catheter, higher comorbidity burden, and lack of pre-dialysis nephrology care. A total of 8,674 patients died (mortality rate 405/1,000 patient-years, 95% CI 397-413) during the first 6 months after transition to hemodialysis. The starting of inpatient vs. outpatient hemodialysis was associated with significantly higher crude all-cause mortality, but this association was attenuated after multivariable adjustments. CONCLUSIONS Transition to hemodialysis in an inpatient setting is more common in older and sicker individuals, and in patients without pre-dialysis nephrology care and those who used a catheter for vascular access. Future studies are needed to determine if a higher proportion of patients could start hemodialysis treatment in outpatient clinics, through interventions targeting modifiable risk factors such as timely vascular access placement or earlier nephrology referrals.
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Affiliation(s)
- Faisal M Arif
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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Gaffney A, McCormick D. The Affordable Care Act: implications for health-care equity. Lancet 2017; 389:1442-1452. [PMID: 28402826 DOI: 10.1016/s0140-6736(17)30786-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 12/17/2016] [Accepted: 01/09/2017] [Indexed: 10/19/2022]
Abstract
Inequalities in medical care are endemic in the USA. The Affordable Care Act (ACA), passed in 2010 and fully implemented in 2014, was intended to expand coverage and bring about a new era of health-care access. In this review, we evaluate the legislation's impact on health-care equity. We consider the law's coverage expansion, insurance market reforms, cost and affordability provisions, and delivery-system reforms. Although the ACA improved coverage and access-particularly for poorer Americans, women, and minorities-its overall impact was modest in comparison with the gaps present before the law's implementation. Today, 29 million people in the USA remain uninsured, and substantial inequalities in access along economic, gender, and racial lines persist. Although most Americans agree that further reform is needed, the proper direction for reform-especially following the 2016 presidential election-is highly contentious. We discuss proposals for change from opposite sides of the political spectrum, together with their potential impact on health equity.
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Affiliation(s)
- Adam Gaffney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Danny McCormick
- Division of Social and Community Medicine, Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA; Harvard Medical School, Boston, MA, USA
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80
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Laster M, Soohoo M, Hall C, Streja E, Rhee CM, Ravel VA, Reddy U, Norris KC, Salusky IB, Kalantar-Zadeh K. Racial-ethnic disparities in mortality and kidney transplant outcomes among pediatric dialysis patients. Pediatr Nephrol 2017; 32:685-695. [PMID: 27796622 PMCID: PMC5392236 DOI: 10.1007/s00467-016-3530-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/05/2016] [Accepted: 09/25/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Previous studies in adult hemodialysis patients have shown that African-American and Hispanic patients have a lower risk of mortality in addition to a lower likelihood of kidney transplantation. However, studies of the association between race and outcomes in pediatric dialysis are sparse and often do not examine outcomes in Hispanic children. The objective was to determine if racial-ethnic disparities in mortality and kidney transplantation outcomes exist in pediatric dialysis patients. METHODS This was a retrospective cohort analysis of 2,697 pediatric dialysis patients (aged 0-20 years) from a large national dialysis organization (entry period 2001-2011) of non-Hispanic white, African-American, and Hispanic race-ethnicity. Associations between race-ethnicity with mortality and kidney transplantation outcomes were examined separately using competing risks methods. Logistic regression analyses were used to examine the association between race-ethnicity, with outcomes within 1 year of dialysis initiation. RESULTS Of the 2,697 pediatric patients in this cohort, 895 were African-American, 778 were Hispanic, and 1,024 were non-Hispanic white. After adjusting for baseline demographics, competing risk survival analysis revealed that compared with non-Hispanic whites, African-Americans had a 64 % higher mortality risk (hazards ratio [HR] = 1.64; 95 % CI 1.24-2.17), whereas Hispanics had a 31 % lower mortality risk (HR = 0.69; 95 % CI 0.47-1.01) that did not reach statistical significance. African-Americans also had higher odds of 1-year mortality after starting dialysis (odds ratio [OR] = 2.08; 95 % CI 0.95-4.58), whereas both African-Americans and Hispanics had a lower odds of receiving a transplant within 1 year of starting dialysis (OR = 0.28; 95 % CI 0.19-0.41 and OR = 0.43; 95 % CI 0.31-0.59 respectively). CONCLUSION In contrast to adults, African-American pediatric dialysis patients have worse survival than their non-Hispanic white counterparts, whereas Hispanics have a similar to lower mortality risk. Both African-American and Hispanic pediatric dialysis patients had a lower likelihood of kidney transplantation than non-Hispanic whites, similar to observations in the adult dialysis population.
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Affiliation(s)
- Marciana Laster
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, School of Medicine, University of California Irvine, 101 The City Drive South, City Tower, Suite 400, ZOT: 4088, Orange, CA, 92868-3217, USA
| | - Clinton Hall
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, School of Medicine, University of California Irvine, 101 The City Drive South, City Tower, Suite 400, ZOT: 4088, Orange, CA, 92868-3217, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, School of Medicine, University of California Irvine, 101 The City Drive South, City Tower, Suite 400, ZOT: 4088, Orange, CA, 92868-3217, USA
- Division of Nephrology and Hypertension, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Vanessa A Ravel
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, School of Medicine, University of California Irvine, 101 The City Drive South, City Tower, Suite 400, ZOT: 4088, Orange, CA, 92868-3217, USA
| | - Uttam Reddy
- Division of Nephrology and Hypertension, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Keith C Norris
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Kamyar Kalantar-Zadeh
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, School of Medicine, University of California Irvine, 101 The City Drive South, City Tower, Suite 400, ZOT: 4088, Orange, CA, 92868-3217, USA.
- Division of Nephrology and Hypertension, School of Medicine, University of California Irvine, Orange, CA, USA.
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81
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Chen Y, Sang Y, Ballew SH, Tin A, Chang AR, Matsushita K, Coresh J, Kalantar-Zadeh K, Molnar MZ, Grams ME. Race, Serum Potassium, and Associations With ESRD and Mortality. Am J Kidney Dis 2017; 70:244-251. [PMID: 28363732 DOI: 10.1053/j.ajkd.2017.01.044] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/07/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recent studies suggest that potassium levels may differ by race. The basis for these differences and whether associations between potassium levels and adverse outcomes differ by race are unknown. STUDY DESIGN Observational study. SETTING & PARTICIPANTS Associations between race and potassium level and the interaction of race and potassium level with outcomes were investigated in the Racial and Cardiovascular Risk Anomalies in Chronic Kidney Disease (RCAV) Study, a cohort of US veterans (N=2,662,462). Associations between African ancestry and potassium level were investigated in African Americans in the Atherosclerosis Risk in Communities (ARIC) Study (N=3,450). PREDICTORS Race (African American vs non-African American and percent African ancestry) for cross-sectional analysis; serum potassium level for longitudinal analysis. OUTCOMES Potassium level for cross-sectional analysis; mortality and end-stage renal disease for longitudinal analysis. RESULTS The RCAV cohort was 18% African American (N=470,985). Potassium levels on average were 0.162mmol/L lower in African Americans compared with non-African Americans, with differences persisting after adjustment for demographics, comorbid conditions, and potassium-altering medication use. In the ARIC Study, higher African ancestry was related to lower potassium levels (-0.027mmol/L per each 10% African ancestry). In both race groups, higher and lower potassium levels were associated with mortality. Compared to potassium level of 4.2mmol/L, mortality risk associated with lower potassium levels was lower in African Americans versus non-African Americans, whereas mortality risk associated with higher levels was slightly greater. Risk relationships between potassium and end-stage renal disease were weaker, with no difference by race. LIMITATIONS No data for potassium intake. CONCLUSIONS African Americans had slightly lower serum potassium levels than non-African Americans. Consistent associations between potassium levels and percent African ancestry may suggest a genetic component to these differences. Higher and lower serum potassium levels were associated with mortality in both racial groups.
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Affiliation(s)
- Yan Chen
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Adrienne Tin
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Alex R Chang
- Division of Nephrology, Geisinger Health System, Danville, PA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA; Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD.
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82
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Molnar MZ, Sumida K, Gaipov A, Potukuchi PK, Fülöp T, Joglekar K, Lu JL, Streja E, Kalantar-Zadeh K, Kovesdy CP. Pre-ESRD Dementia and Post-ESRD Mortality in a Large Cohort of Incident Dialysis Patients. Dement Geriatr Cogn Disord 2017; 43:281-293. [PMID: 28448971 PMCID: PMC5705007 DOI: 10.1159/000471761] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Conservative management may be a desirable option for elderly, fragile, or demented patients who reach end-stage renal disease (ESRD), yet some patients with dementia are placed on renal replacement therapy nonetheless. METHODS From a nationwide cohort of 45,076 US veterans who transitioned to ESRD over 4 contemporary years (October 1, 2007 to September 30, 2011), we identified 1,336 (3.0%) patients with International Classification of Diseases, Ninth Revision, Clinical Modification code-based dementia diagnosis during the prelude (predialysis) period. We examined the association of prelude dementia with all-cause mortality within the first 6 months following transition to dialysis, using a propensity-matched cohort and Cox proportional hazards models. RESULTS In the entire cohort, the overall mean ± standard deviation age at baseline was 72 ± 11 years, 95% were male, 23% were African-American, and 66% were diabetic. There were 8,080 (18.5%) deaths (mortality rate, 412; 95% confidence interval [CI], 403-421/1,000 patient-years) in the dementia-negative group, and 396 (29.6%) deaths (mortality rate, 708; 95% CI, 642-782/1,000 patient-years) in the dementia-positive group in the entire cohort in the first 6 months after dialysis initiation. Presence of dementia was associated with higher risk of all-cause mortality (adjusted hazard ratio, 1.25; 95% CI, 1.12-1.38) compared to dementia-free patients in the first 6 months after dialysis initiation. CONCLUSION Pre-ESRD dementia is associated with increased risk of early post-ESRD mortality in veterans transitioning to dialysis.
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Affiliation(s)
- Miklos Z. Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Abduzhappar Gaipov
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States,Department of Extracorporeal Hemocorrection, National Scientific Medical Research Center, Astana, Kazakhstan
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Tibor Fülöp
- FMC Extracorporeal Life Support Center, Fresenius Medical Care; Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Kiran Joglekar
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, United States
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, United States
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States,Nephrology Section, Memphis VA Medical Center, Memphis, TN, United States
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83
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Lu JL, Molnar MZ, Ma JZ, George LK, Sumida K, Kalantar-Zadeh K, Kovesdy CP. Racial Differences in Association of Serum Calcium with Mortality and Incident Cardio- and Cerebrovascular Events. J Clin Endocrinol Metab 2016; 101:4851-4859. [PMID: 27631543 PMCID: PMC5155693 DOI: 10.1210/jc.2016-1802] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Abnormalities in calcium metabolism may potentially contribute to the development of vascular disease. Calcium metabolism may be different in African American (AA) vs white individuals, but the effect of race on the association of serum calcium with clinical outcomes remains unclear. OBJECTIVE This study sought to examine race-specific associations of serum calcium levels with mortality and with major incident cardiovascular events. DESIGN AND SETTING This was a historical cohort study in the U.S. Department of Veterans Affairs health care facilities. PARTICIPANTS Participants included veterans (n = 1 967 622) with estimated glomerular filtration rate ≥ 60 mL/min/1.73 m2. MAIN OUTCOME MEASURES The association between serum calcium levels with all-cause mortality, incident coronary heart disease (CHD), and ischemic stroke incidence was examined in multivariable adjusted Cox proportional hazards models, including an interaction term for calcium and race. RESULTS The association of calcium with all-cause mortality was U-shaped in both AA and white patients, but race modified the association of calcium with all-cause mortality. Compared with white patients, AA patients experienced lower risk of mortality when calcium was ≥ 8.8 mg/dL, with a statistically significant interaction (P < .001). Conversely, AA vs white race was associated with higher mortality when calcium was < 8.8 mg/dL. Calcium showed no significant association with ischemic stroke or CHD in both races; and race did not modify these associations (P = .37 and 0.11, respectively for interaction term). CONCLUSIONS Race modified the U-shaped association between calcium and all-cause mortality. Serum calcium is not associated with incident stroke or CHD in either AA or white patients. The race-specific difference in the association of calcium levels with mortality warrants further examination.
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Affiliation(s)
- Jun Ling Lu
- Division of Nephrology (J.L.L., M.Z.M., L.K.G., K.S., C.P.K.), University of Tennessee Health Science Center, Memphis Tennessee 38163; Department of Public Health Sciences and Division of Nephrology, Department of Medicine (J.Z.M.), University of Virginia, Charlottesville, Virginia 22908; Nephrology Center (K.S.), Toranomon Hospital Kajigaya, Kanagawa 213-8587, Japan; Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension (K.K.-Z.), University of California-Irvine Medical Center, Orange, California 92868; and Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104
| | - Miklos Z Molnar
- Division of Nephrology (J.L.L., M.Z.M., L.K.G., K.S., C.P.K.), University of Tennessee Health Science Center, Memphis Tennessee 38163; Department of Public Health Sciences and Division of Nephrology, Department of Medicine (J.Z.M.), University of Virginia, Charlottesville, Virginia 22908; Nephrology Center (K.S.), Toranomon Hospital Kajigaya, Kanagawa 213-8587, Japan; Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension (K.K.-Z.), University of California-Irvine Medical Center, Orange, California 92868; and Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104
| | - Jennie Z Ma
- Division of Nephrology (J.L.L., M.Z.M., L.K.G., K.S., C.P.K.), University of Tennessee Health Science Center, Memphis Tennessee 38163; Department of Public Health Sciences and Division of Nephrology, Department of Medicine (J.Z.M.), University of Virginia, Charlottesville, Virginia 22908; Nephrology Center (K.S.), Toranomon Hospital Kajigaya, Kanagawa 213-8587, Japan; Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension (K.K.-Z.), University of California-Irvine Medical Center, Orange, California 92868; and Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104
| | - Lekha K George
- Division of Nephrology (J.L.L., M.Z.M., L.K.G., K.S., C.P.K.), University of Tennessee Health Science Center, Memphis Tennessee 38163; Department of Public Health Sciences and Division of Nephrology, Department of Medicine (J.Z.M.), University of Virginia, Charlottesville, Virginia 22908; Nephrology Center (K.S.), Toranomon Hospital Kajigaya, Kanagawa 213-8587, Japan; Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension (K.K.-Z.), University of California-Irvine Medical Center, Orange, California 92868; and Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104
| | - Keiichi Sumida
- Division of Nephrology (J.L.L., M.Z.M., L.K.G., K.S., C.P.K.), University of Tennessee Health Science Center, Memphis Tennessee 38163; Department of Public Health Sciences and Division of Nephrology, Department of Medicine (J.Z.M.), University of Virginia, Charlottesville, Virginia 22908; Nephrology Center (K.S.), Toranomon Hospital Kajigaya, Kanagawa 213-8587, Japan; Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension (K.K.-Z.), University of California-Irvine Medical Center, Orange, California 92868; and Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology (J.L.L., M.Z.M., L.K.G., K.S., C.P.K.), University of Tennessee Health Science Center, Memphis Tennessee 38163; Department of Public Health Sciences and Division of Nephrology, Department of Medicine (J.Z.M.), University of Virginia, Charlottesville, Virginia 22908; Nephrology Center (K.S.), Toranomon Hospital Kajigaya, Kanagawa 213-8587, Japan; Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension (K.K.-Z.), University of California-Irvine Medical Center, Orange, California 92868; and Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104
| | - Csaba P Kovesdy
- Division of Nephrology (J.L.L., M.Z.M., L.K.G., K.S., C.P.K.), University of Tennessee Health Science Center, Memphis Tennessee 38163; Department of Public Health Sciences and Division of Nephrology, Department of Medicine (J.Z.M.), University of Virginia, Charlottesville, Virginia 22908; Nephrology Center (K.S.), Toranomon Hospital Kajigaya, Kanagawa 213-8587, Japan; Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension (K.K.-Z.), University of California-Irvine Medical Center, Orange, California 92868; and Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104
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84
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Grams ME, Wilson FP. Lifetime Probabilities of ESRD: A Decade of Disparity. Am J Kidney Dis 2016; 68:831-832. [DOI: 10.1053/j.ajkd.2016.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/09/2016] [Indexed: 11/11/2022]
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85
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Sumida K, Molnar MZ, Potukuchi PK, Thomas F, Lu JL, Matsushita K, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Constipation and Incident CKD. J Am Soc Nephrol 2016; 28:1248-1258. [PMID: 28122944 DOI: 10.1681/asn.2016060656] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 09/11/2016] [Indexed: 12/12/2022] Open
Abstract
Constipation is one of the most prevalent conditions in primary care settings and increases the risk of cardiovascular disease, potentially through processes mediated by altered gut microbiota. However, little is known about the association of constipation with CKD. In a nationwide cohort of 3,504,732 United States veterans with an eGFR ≥60 ml/min per 1.73 m2, we examined the association of constipation status and severity (absent, mild, or moderate/severe), defined using diagnostic codes and laxative use, with incident CKD, incident ESRD, and change in eGFR in Cox models (for time-to-event analyses) and multinomial logistic regression models (for change in eGFR). Among patients, the mean (SD) age was 60.0 (14.1) years old; 93.2% of patients were men, and 24.7% were diabetic. After multivariable adjustments, compared with patients without constipation, patients with constipation had higher incidence rates of CKD (hazard ratio, 1.13; 95% confidence interval [95% CI], 1.11 to 1.14) and ESRD (hazard ratio, 1.09; 95% CI, 1.01 to 1.18) and faster eGFR decline (multinomial odds ratios for eGFR slope <-10, -10 to <-5, and -5 to <-1 versus -1 to <0 ml/min per 1.73 m2 per year, 1.17; 95% CI, 1.14 to 1.20; 1.07; 95% CI, 1.04 to 1.09; and 1.01; 95% CI, 1.00 to 1.03, respectively). More severe constipation associated with an incrementally higher risk for each renal outcome. In conclusion, constipation status and severity associate with higher risk of incident CKD and ESRD and with progressive eGFR decline, independent of known risk factors. Further studies should elucidate the underlying mechanisms.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California; and
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; .,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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86
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Novak M, Mucsi I, Rhee CM, Streja E, Lu JL, Kalantar-Zadeh K, Molnar MZ, Kovesdy CP. Increased Risk of Incident Chronic Kidney Disease, Cardiovascular Disease, and Mortality in Patients With Diabetes With Comorbid Depression. Diabetes Care 2016; 39:1940-1947. [PMID: 27311494 PMCID: PMC5079613 DOI: 10.2337/dc16-0048] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 05/26/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE It is not known if patients with diabetes with depression have an increased risk of chronic kidney disease (CKD). We examined the association between depression and incident CKD, mortality, and incident cardiovascular events in U.S. veterans with diabetes. RESEARCH DESIGN AND METHODS Among a nationally representative prospective cohort of >3 million U.S. veterans with baseline estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2, we identified 933,211 patients with diabetes. Diabetes was ascertained by an ICD-9-CM code for diabetes, an HbA1c >6.4%, or receiving antidiabetes medication during the inclusion period. Depression was defined by an ICD-9-CM code for depression or by antidepressant use during the inclusion period. Incident CKD was defined as two eGFR levels <60 mL/min/1.73 m2 separated by ≥90 days and a >25% decline in baseline eGFR. The associations between depression and outcomes were assessed using Cox proportional regression. RESULTS Depression was present in 340,806 patients at enrollment. Depressed patients were younger (61 ± 11 vs. 65 ± 11 years), had higher eGFR (84 ± 15 vs. 81 ± 14 mL/min/1.73 m2), but had more comorbidities. Incident CKD developed in 180,343 patients. Depression was associated with 20% higher risk of incident CKD (adjusted hazard ratio [aHR] and 95% CI: 1.20 [1.19-1.21]). Similarly, depression was associated with increased all-cause mortality (aHR and 95% CI: 1.25 [1.24-1.26]). CONCLUSIONS The presence of depression in patients with diabetes is associated with higher risk of developing CKD compared with nondepressed patients. Intervention studies should determine if effective treatment of depression in patients with diabetes would prevent major renal and cardiovascular complications.
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Affiliation(s)
- Marta Novak
- Centre for Mental Health, University Health Network, and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Istvan Mucsi
- Division of Nephrology and Multiorgan Transplant Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Connie M Rhee
- Division of Nephrology, University of California, Irvine, CA
| | - Elani Streja
- Division of Nephrology, University of California, Irvine, CA
| | - Jun L Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | | | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
- Nephrology Section, Memphis VA Medical Center, Memphis, TN
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87
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Gosmanova EO, Mikkelsen MK, Molnar MZ, Lu JL, Yessayan LT, Kalantar-Zadeh K, Kovesdy CP. Association of Systolic Blood Pressure Variability With Mortality, Coronary Heart Disease, Stroke, and Renal Disease. J Am Coll Cardiol 2016; 68:1375-1386. [PMID: 27659458 PMCID: PMC5117818 DOI: 10.1016/j.jacc.2016.06.054] [Citation(s) in RCA: 199] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 06/13/2016] [Accepted: 06/21/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Intraindividual blood pressure (BP) fluctuates dynamically over time. Previous studies suggested an adverse link between greater visit-to-visit variability in systolic blood pressure (SBP) and various outcomes. However, these studies have significant limitations, such as a small size, inclusion of selected populations, and restricted outcomes. OBJECTIVES This study investigated the association of increased visit-to-visit variability and all-cause mortality, cardiovascular events, and end-stage renal disease (ESRD) in a large cohort of U.S. veterans. METHODS From among 3,285,684 U.S. veterans with and without hypertension and normal estimated glomerular filtration rates (eGFR) during 2005 and 2006, we identified 2,865,157 patients who had 8 or more outpatient BP measurements. Systolic blood pressure variability (SBPV) was measured using the SD of all SBP values (normally distributed) in 1 individual. Associations of SD quartiles (<10.3, 10.3 to 12.7, 12.7 to 15.6, and ≥15.6 mm Hg) with all-cause mortality, incident coronary heart disease (CHD), stroke, and ESRD was examined using Cox models adjusted for sociodemographic characteristics, baseline eGFR, comorbidities, body mass index, SBP, diastolic BP, and antihypertensive medication use. RESULTS Several sociodemographic variables (older age, male sex, African-American race, divorced or widowed status) and clinical characteristics (lower baseline eGFR, higher SBP and diastolic BP), and comorbidities (presence of diabetes, hypertension, cardiovascular disease, and lung disease) were all associated with higher intraindividual SBPV. The multivariable adjusted hazard ratios and 95% confidence intervals for SD quartiles 2 through 4 (compared with the first quartile) associated with all-cause mortality, CHD, stroke, and ESRD were incrementally higher. CONCLUSIONS Higher SBPV in individuals with and without hypertension was associated with increased risks of all-cause mortality, CHD, stroke, and ESRD. Further studies are needed to determine interventions that can lower SBPV and their impact on adverse health outcomes.
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Affiliation(s)
- Elvira O Gosmanova
- Nephrology Section, Stratton Veterans Affairs (VA) Medical Center, Albany, New York; Division of Nephrology, Albany Medical College, Albany, New York
| | | | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jun L Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Lenar T Yessayan
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, California
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee; Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee.
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88
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Ma L, Langefeld CD, Comeau ME, Bonomo JA, Rocco MV, Burkart JM, Divers J, Palmer ND, Hicks PJ, Bowden DW, Lea JP, Krisher JO, Clay MJ, Freedman BI. APOL1 renal-risk genotypes associate with longer hemodialysis survival in prevalent nondiabetic African American patients with end-stage renal disease. Kidney Int 2016; 90:389-395. [PMID: 27157696 PMCID: PMC4946964 DOI: 10.1016/j.kint.2016.02.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 01/13/2023]
Abstract
Relative to European Americans, evidence supports that African Americans with end-stage renal disease (ESRD) survive longer on dialysis. Renal-risk variants in the apolipoprotein L1 gene (APOL1), associated with nondiabetic nephropathy and less subclinical atherosclerosis, may contribute to dialysis outcomes. Here, APOL1 renal-risk variants were assessed for association with dialytic survival in 450 diabetic and 275 nondiabetic African American hemodialysis patients from Wake Forest and Emory School of Medicine outpatient facilities. Outcomes were provided by the ESRD Network 6-Southeastern Kidney Council Standardized Information Management System. Dates of death, receipt of a kidney transplant, and loss to follow-up were recorded. Outcomes were censored at the date of transplantation or through 1 July 2015. Multivariable Cox proportional hazards models were computed separately in patients with nondiabetic and diabetic ESRD, adjusting for the covariates age, gender, comorbidities, ancestry, and presence of an arteriovenous fistula or graft at dialysis initiation. In nondiabetic ESRD, patients with 2 (vs. 0/1) APOL1 renal-risk variants had significantly longer dialysis survival (hazard ratio 0.57), a pattern not observed in patients with diabetes-associated ESRD (hazard ratio 1.29). Thus, 2 APOL1 renal-risk variants are associated with longer dialysis survival in African Americans without diabetes, potentially relating to presence of renal-limited disease or less atherosclerosis.
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Affiliation(s)
- Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Center for Public Health Genomics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Carl D Langefeld
- Center for Public Health Genomics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mary E Comeau
- Center for Public Health Genomics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jason A Bonomo
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael V Rocco
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - John M Burkart
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jasmin Divers
- Center for Public Health Genomics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicholette D Palmer
- Center for Public Health Genomics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Center for Genomics and Personalized Medicine Research, Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Pamela J Hicks
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Donald W Bowden
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Center for Genomics and Personalized Medicine Research, Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Janice P Lea
- Division of Renal Medicine, Department of Internal Medicine, Emory School of Medicine, Atlanta, Georgia, USA
| | - Jenna O Krisher
- Southeastern Kidney Council Inc.-ESRD Network 6, Raleigh, North Carolina, USA
| | - Margo J Clay
- Southeastern Kidney Council Inc.-ESRD Network 6, Raleigh, North Carolina, USA
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Center for Public Health Genomics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Center for Genomics and Personalized Medicine Research, Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
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89
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Kovesdy CP, Norris KC, Boulware LE, Lu JL, Ma JZ, Streja E, Molnar MZ, Kalantar-Zadeh K. Response to Letter Regarding Article, "Association of Race With Mortality and Cardiovascular Events in a Large Cohort of US Veterans". Circulation 2016; 133:e453. [PMID: 27002093 DOI: 10.1161/circulationaha.116.021164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Keith C Norris
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Jun L Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Jennie Z Ma
- Department of Public Health Sciences, Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA
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90
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Kuller LH, Neaton JD. Letter by Kuller and Neaton Regarding Article, "Association of Race With Mortality and Cardiovascular Events in a Large Cohort of US Veterans". Circulation 2016; 133:e452. [PMID: 27002092 DOI: 10.1161/circulationaha.115.020379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lewis H Kuller
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
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91
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Norris KC, Mensah GA, Boulware LE, Lu JL, Ma JZ, Streja E, Molnar MZ, Kalantar-Zadeh K, Kovesdy CP. Age, Race and Cardiovascular Outcomes in African American Veterans. Ethn Dis 2016; 26:305-14. [PMID: 27440969 DOI: 10.18865/ed.26.3.305] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND In the general population, compared wtih their White peers, African Americans suffer premature all-cause and cardiovascular (CV) deaths, attributed in part to reduced access to care and lower socioeconomic status. Prior reports indicated younger (aged 35 to 44 years) African Americans had a signficantly greater age-adjusted risk of death. Recent studies suggest that in a more egalitarian health care structure than typical United States (US) health care structures, African Americans may have similar or even better CV outcomes, but the impact of age is less well-known. METHODS We examined age stratified all-cause mortality, and incident coronary heart disease (CHD) and ischemic stroke in 3,072,966 patients (547,441 African American and 2,525,525 White) with an estimated glomerular filtration rate (eGFR)>60 mL/min/1.73m(2) receiving care from the US Veterans Health Administration. Outcomes were examined in Cox models adjusted for demographics, comorbidities, kidney function, blood pressure, socioeconomics and indicators of the quality of health care delivery. RESULTS African Americans had an overall 30% lower all-cause mortality (P<.001) and 29% lower incidence of CHD (P<.001) and higher incidence of ischemic stroke (aHR, 95%CI: 1.16, 1.13-1.18, P<.001). The lower rates of mortality and CHD were strongest in younger African Americans and attenuated across patients aged ≥70 years. Stroke rates did not differ by race in persons aged <70 years. CONCLUSIONS Among patients with normal eGFR and receiving care in the Veterans Health Administration, younger African Americans had lower all-cause mortality and incidence of CHD and similar rates of stroke, independent of demographic, comorbidity and socioeconomic differences. The lower all-cause mortality persisted but attenuated with increasing age and the lower incidence of CHD ended at aged ≥80 years. The higher incidence of ischemic stroke in African Americans was driven by increasing risk in patients aged ≥70 years suggesting that the improved cardiovascular outcomes were most dramatic for younger African Americans.
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Affiliation(s)
- Keith C Norris
- David Geffen School of Medicine; University of California, Los Angeles
| | - George A Mensah
- National Heart, Lung, and Blood Institute, National Institutes of Health
| | | | - Jun L Lu
- University of Tennessee Heath Science Center
| | | | | | | | | | - Csaba P Kovesdy
- University of Tennessee Heath Science Center; Memphis VA Medical Center
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92
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93
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Kovesdy CP, Alrifai A, Gosmanova EO, Lu JL, Canada RB, Wall BM, Hung AM, Molnar MZ, Kalantar-Zadeh K. Age and Outcomes Associated with BP in Patients with Incident CKD. Clin J Am Soc Nephrol 2016; 11:821-831. [PMID: 27103623 PMCID: PMC4858482 DOI: 10.2215/cjn.08660815] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 02/01/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Hypertension is the most important treatable risk factor for cardiovascular outcomes. Many patients with CKD are elderly, but the ideal BP in these individuals is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS From among 339,887 patients with incident eGFR<60 ml/min per 1.73 m(2), we examined associations of systolic BP (SBP) and diastolic BP (DBP) with all-cause mortality, incident coronary heart disease (CHD), ischemic strokes, and ESRD from the time of developing CKD until the end of follow-up (July 26, 2013, for mortality, CHD, and stroke, and December 31, 2011, for ESRD) in multivariable-adjusted survival models categorized by patients' age. RESULTS Of the total cohort, 300,424 (88%) had complete data for multivariable analysis. Both SBP and DBP showed a U-shaped association with mortality. SBP displayed a linear association with CHD, stroke, and ESRD, whereas DBP showed no consistent association with either. SBP>140 mmHg was associated with higher incidence of all examined outcomes, but with an incremental attenuation of the observed risk in older compared with younger patients (P<0.05 for interaction) The adjusted hazard ratios and 95% confidence intervals associated with SBP≥170 mmHg (compared with 130-139 mmHg) in patients <50, 50-59, 60-69, 70-79, and ≥80 years were 1.95 (1.34 to 2.84), 2.01 (1.75 to 2.30), 1.68 (1.49 to 1.89), 1.39 (1.25 to 1.54), and 1.30 (1.17 to 1.44), respectively. The risk of incident CHD, stroke, and ESRD was incrementally higher with higher SBP in patients aged <80 years but showed no consistent association in those aged ≥80 years (P<0.05 for interaction for all outcomes). CONCLUSIONS In veterans with incident CKD, SBP showed different associations in older versus younger patients. The association of higher SBP with adverse outcomes was present but markedly reduced in older individuals, especially in those aged ≥80 years. Elevated DBP showed no consistent association with vascular outcomes in patients with incident CKD.
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Affiliation(s)
- Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Ahmed Alrifai
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Elvira O. Gosmanova
- Nehphrology Section, Straton Veterans Affairs Medical Center, Albany, New York
- Department of Medicine, Albany Medical College, Albany, New York
| | - Jun Ling Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Robert B. Canada
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Barry M. Wall
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Adriana M. Hung
- Nephrology Section, Nashville Veterans Affairs Medical Center, Nashville, Tennessee
- Division of Nephrology, Vanderbilt University, Nashville, Tennessee; and
| | - Miklos Z. Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California
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94
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Gosmanov AR, Lu JL, Sumida K, Potukuchi PK, Rhee CM, Kalantar-Zadeh K, Molnar MZ, Kovesdy CP. Synergistic association of combined glycemic and blood pressure level with risk of complications in US veterans with diabetes. J Hypertens 2016; 34:907-13. [PMID: 26928222 PMCID: PMC5705006 DOI: 10.1097/hjh.0000000000000864] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Hemoglobin A1c levels less than 7.0% and systolic blood pressure (SBP) less than 140 mmHg are each associated with lower risk of vascular complications in patients with diabetes mellitus. Associations between combined A1c level and SBP categories and risk of mortality and morbidity in diabetic patients are not well characterized. METHODS We examined 891 670 US diabetic veterans with baseline estimated glomerular filtration rates more than 60 ml/min per 1.73 m (mean age 67 ± 11 years, 97% men, 17% African-Americans). The associations of mutually exclusive combined categories of A1c (<6.5, 6.5-6.9, 7.0-7.9, 8.0-8.9, 9.0-9.9, and ≥10%) and SBP (<100, 100-119, 120-139, 140-159, 160-179, and ≥180 mmHg) with the risk of all-cause mortality and incident chronic kidney disease (CKD), coronary heart disease, and stroke were examined in Cox models adjusted for baseline characteristics using patients with concomitant A1c 6.5-6.9% and SBP of 120-139 mmHg as the referent group. RESULTS A total of 221 529 (25%) patients died, and 178 588 (20%), 43 373 (5%) and 36 935 (4%) developed CKD, coronary heart disease and stroke, respectively, during a median follow-up of 7.4 years. SBP displayed a J-shaped association with each outcome except CKD risk that was linearly associated with SBP across all A1c categories. A1c above 7.0% was associated with monotonically worse outcomes for all end points in all SBP categories. Patients with the combined highest A1c and SBP levels experienced the worst outcomes. CONCLUSION SBP greater than 120-139 mmHg and A1c greater than 7.0% are associated with higher mortality and vascular complications in diabetic patients, independent of each other. Combined efforts to improve both glycemic and blood pressure control may synergistically improve outcomes in patients with normal kidney function.
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Affiliation(s)
- Aidar R. Gosmanov
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Jun L. Lu
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Connie M. Rhee
- Division of Nephrology and Hypertension, Department of Medicine, University of California, Irvine, CA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Department of Medicine, University of California, Irvine, CA
| | - Miklos Z. Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
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95
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Grams ME, Sang Y, Coresh J, Ballew SH, Matsushita K, Levey AS, Greene TH, Molnar MZ, Szabo Z, Kalantar-Zadeh K, Kovesdy CP. Candidate Surrogate End Points for ESRD after AKI. J Am Soc Nephrol 2016; 27:2851-9. [PMID: 26857682 DOI: 10.1681/asn.2015070829] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 01/06/2016] [Indexed: 11/03/2022] Open
Abstract
AKI, a frequently transient condition, is not accepted by the US Food and Drug Association as an end point for drug registration trials. We assessed whether an intermediate-term change in eGFR after AKI has a sufficiently strong relationship with subsequent ESRD to serve as an alternative end point in trials of AKI prevention and/or treatment. Among 161,185 United States veterans undergoing major surgery between 2004 and 2011, we characterized in-hospital AKI by Kidney Disease Improving Global Outcomes creatinine criteria and decline in eGFR from prehospitalization to postdischarge time points and quantified associations of these values with ESRD and mortality over a median of 3.8 years. An eGFR decline of ≥30% at 30, 60, and 90 days after discharge occurred in 3.1%, 2.5%, and 2.6%, of survivors without AKI and 15.9%, 12.2%, and 11.7%, of survivors with AKI. For patients with in-hospital AKI compared with those with no AKI and stable eGFR, a 30% decline in eGFR at 30, 60, and 90 days after discharge demonstrated adjusted hazard ratios (95% confidence intervals) of ESRD of 5.60 (4.06 to 7.71), 6.42 (4.76 to 8.65), and 7.27 (5.14 to 10.27), with corresponding estimates for 40% decline in eGFR of 6.98 (5.21 to 9.35), 8.03 (6.11 to 10.56), and 10.95 (8.10 to 14.82). Risks for mortality were smaller but consistent in direction. A 30%-40% decline in eGFR after AKI could be a surrogate end point for ESRD in trials of AKI prevention and/or treatment, but additional trial evidence is needed.
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Affiliation(s)
- Morgan E Grams
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Departments of Epidemiology and
| | | | - Josef Coresh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Departments of Epidemiology and Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Tom H Greene
- Division of Clinical Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Zoltan Szabo
- Department of Cardiothoracic Surgery and Cardiothoracic Anesthesia, Linköping University Hospital, Linköping, Sweden; Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology and Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California; and
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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96
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Ajayi TA, Edmonds KP, Thornberry K, Atayee RA. Palliative Care Teams as Advocates for Adults with Sickle Cell Disease. J Palliat Med 2016; 19:195-201. [DOI: 10.1089/jpm.2015.0268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Toluwalase A. Ajayi
- Department of Pediatrics, Rady Children's Hospital, San Diego, California
- Scripps Translational Science Institute, La Jolla, California
| | - Kyle P. Edmonds
- Doris A. Howell Palliative Care Service, University of California San Diego, La Jolla, California
| | - Kathryn Thornberry
- Doris A. Howell Palliative Care Service, University of California San Diego, La Jolla, California
| | - Rabia A. Atayee
- Doris A. Howell Palliative Care Service, University of California San Diego, La Jolla, California
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California
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97
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Affiliation(s)
- Nakela L Cook
- From National Heart, Lung, and Blood Institute, Bethesda, MD.
| | - George A Mensah
- From National Heart, Lung, and Blood Institute, Bethesda, MD
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