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Liu Y, Luo X, Deng S, Chen J, Zhang L, Huang Y, Hu H. Combined aerobic and resistance exercise in maintenance hemodialysis patients: A meta-analysis. Semin Dial 2023; 36:278-293. [PMID: 37313761 DOI: 10.1111/sdi.13162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/11/2023] [Accepted: 05/23/2023] [Indexed: 06/15/2023]
Abstract
Exercise brings many benefits to patients undergoing maintenance hemodialysis (MHD), but the effect of combined aerobic and resistance exercise remains unclear. English and Chinese databases (PubMed, Cochrane Library, Embase, Web of Science, CNKI, VIP, Wan Fang, and CBM) were searched from inception to January 2023 to retrieve qualified randomized controlled trials. The literature selection, data extraction, and risk of bias assessment of included studies were conducted independently by two reviewers. Meta-analysis was performed using RevMan 5.3 software. A total of 23 studies with 1214 participants were included, and 17 of the interventions were conducted during dialysis. Results showed that combined aerobic and resistance exercise (CARE) improved the peak oxygen uptake, six-minute walking test, 60 s sit-to-stand test (STS), 30 s STS, dialysis adequacy, five (out of eight) domains and physical component summary of health-related quality of life (HRQOL) measured by the Medical Outcomes Study Short Form-36, blood pressure, and hemoglobin for MHD patients compared with usual care. No significant changes were found in the mental component summary of HRQOL, C-reactive protein, creatinine, potassium, sodium, calcium, and phosphate. Subgroup analysis showed that intradialytic CARE ameliorated more outcomes, except for handgrip strength and hemoglobin, than non-intradialytic ones. CARE is an effective way to improve physical function, aerobic capacity, dialysis adequacy, and HRQOL for MHD patients. Strategies should be implemented by clinicians and policymakers to motivate patients to do more exercise. Well-designed clinical trials are warranted to explore the effectiveness of non-intradialytic CARE.
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Affiliation(s)
- Yixiu Liu
- School of Nursing, Suzhou Medical College of Soochow University, Suzhou, China
| | - Xiju Luo
- School of Nursing, Suzhou Medical College of Soochow University, Suzhou, China
| | - Siyan Deng
- School of Nursing, Suzhou Medical College of Soochow University, Suzhou, China
| | - Jing Chen
- School of Nursing, Suzhou Medical College of Soochow University, Suzhou, China
| | - Lu Zhang
- Xi'an Medical University, Xi'an, Shan'xi, China
| | - Ying Huang
- Hemodialysis Center, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Huagang Hu
- School of Nursing, Suzhou Medical College of Soochow University, Suzhou, China
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Nassar M, Nso N, Lakhdar S, Kondaveeti R, Buttar C, Bhangoo H, Awad M, Sheikh NS, Soliman KM, Munira MS, Radparvar F, Rizzo V, Daoud A. New onset hypertension after transplantation. World J Transplant 2022; 12:42-54. [PMID: 35433331 PMCID: PMC8968475 DOI: 10.5500/wjt.v12.i3.42] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/14/2021] [Accepted: 02/20/2022] [Indexed: 02/06/2023] Open
Abstract
It has been reported that up to 90% of organ transplant recipients have suboptimal blood pressure control. Uncontrolled hypertension is a well-known culprit of cardiovascular and overall morbidity and mortality. In addition, rigorous control of hypertension after organ transplantation is a crucial factor in prolonging graft survival. Nevertheless, hypertension after organ transplantation encompasses a broader range of causes than those identified in non-organ transplant patients. Hence, specific management awareness of those factors is mandated. An in-depth understanding of hypertension after organ transplantation remains a debatable issue that necessitates further clarification. This article provides a comprehensive review of the prevalence, risk factors, etiology, complications, prevention, and management of hypertension after organ transplantation.
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Affiliation(s)
- Mahmoud Nassar
- Department of Medicine, Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals: Queens), New York, NY 11432, United States
| | - Nso Nso
- Department of Medicine, Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals: Queens), New York, NY 11432, United States
| | - Sofia Lakhdar
- Department of Medicine, Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals: Queens), New York, NY 11432, United States
| | - Ravali Kondaveeti
- Department of Medicine, Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals: Queens), New York, NY 11432, United States
| | - Chandan Buttar
- Department of Medicine, Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals: Queens), New York, NY 11432, United States
| | - Harangad Bhangoo
- Department of Medicine, Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals: Queens), New York, NY 11432, United States
| | - Mahmoud Awad
- Department of Medicine, The Memorial Souad Kafafi University Hospital, 6th of October - Giza 0000, Egypt
| | - Naveen Siddique Sheikh
- Department of Physiology, CMH Lahore Medical College and Institute of Dentistry, Lahore - Punjab 0000, Pakistan
| | - Karim M Soliman
- Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Most Sirajum Munira
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals: Queens), New York, NY 11432, United States
| | - Farshid Radparvar
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals: Queens), New York, NY 11432, United States
| | - Vincent Rizzo
- Department of Medicine, Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals: Queens), New York, NY 11432, United States
| | - Ahmed Daoud
- Department of Medicine, Kasr Alainy Medical School, Cairo University, Cairo 11211, Egypt
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Moustafa BH, ElHatw MK, Shaheen IS. Update on Pediatric Hemodialysis Adequacy. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:323-329. [PMID: 37417185 DOI: 10.4103/1319-2442.379031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
The use of high reflux dialyzers to achieve a Kt/Vurea above 1.2 did not improve patient survival in most literature reports. After an electronic search in many sites, guidelines, systematic reviews, and review articles (cited references): We recommend (1) using the equilibrated double-pool, weekly rather than per session, Kt/Vurea, (2) Use of UF-dry weight to avoid V changes, (3) consider protein catabolic Rate (4) Use of double pool to avoid urea generation rebound effect. Beyond the urea model, other recommended parameters include the middle molecule clearance and patient clinical data as blood pressure control, normal ventricular morphology, and function, absence of anemia, bone mineral disease, vascular calcifications, good nutrition and growth, long-lasting vascular access, less intra-dialysis hypotension, fewer hospitalizations related to complications as infection, long-term patient survival with better life quality. All mentioned parameters are the good markers for adequate dialysis. Since (1) frequent short and (or) slow long dialysis sessions show better solute clearance and hemodynamic stability associated with better control of cardiovascular and bone disease, anemia, nutrition, and growth with better quality of life and survival. (2) The spare in the cost of the antihypertensive medications, erythroid-stimulating drugs, phosphate binders, and frequent hospitalization, compensates for the high dialysis cost. (3) The use of some advisable techniques can minimize access trauma; therefore, HD Model can be changeable according to each patient's clinical and biochemical follow-up dialysis adequacy progress pattern.
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Affiliation(s)
- Bahia H Moustafa
- Department of Pediatric Nephrology, Dialysis/Transplantation Unit, Faculty of Medicine, Cairo University Children Hospital, Cairo University, Cairo, Egypt
| | - Mohamad Khaled ElHatw
- Department of Pediatrics, Northern Area Armed Forces Hospital, Hafr Al Batin, Saudi Arabia
| | - Ihab S Shaheen
- Department of Pediatric Nephrology, Royal Hospital for Children, Glasgow, United Kingdom
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Weissheimer R, Bucharles SGE, Truyts CAM, Jorgetti V, Figueiredo AE, Barrett P, Olandoski M, Pecoits-Filho R, Moraes TPD. High prevalence of biochemical disturbances of chronic kidney disease - mineral and bone disorders (CKD-MBD) in a nation-wide peritoneal dialysis cohort: are guideline goals too hard to achieve? J Bras Nefrol 2021; 43:173-181. [PMID: 33538758 PMCID: PMC8257285 DOI: 10.1590/2175-8239-jbn-2020-0147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/15/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Chronic kidney disease - mineral and bone disorders (CKD-MBD) are common in dialysis patients. Definition of targets for calcium (Ca), phosphorus (P), parathormone (iPTH), and alkaline phosphatase (ALP) and their treatment recommendations, are provided by international guidelines. There are few studies analyzing CKD-MBD in peritoneal dialysis (PD) patients and the impact of guidelines on mineral metabolism control. The aim of our study was to describe the prevalence of biomarkers for CKD-MBD in a large cohort of PD patients in Brazil. METHODS Data from the nation-wide prospective observational cohort BRAZPD II was used. Incident patients were followed between December 2004 and January 2011. According to KDOQI recommendations, reference ranges for total Ca were 8.4 to 9.5 mg/dL, for P, 3.5 to 5.5 mg/dL, for iPTH, 150-300 pg/mL, and for ALP, 120 U/L. RESULTS Mean age was 59.8 ± 16 years, 48% were male, and 43% had diabetes. In the beginning, Ca was 8.9 ± 0.9 mg/dL, and 48.3% were on the KODQI target. After 1 year, Ca increased to 9.1 ± 0.9 mg/dL and 50.4% were in the KDOQI preferred range. P at baseline was 5.2 ± 1.6 mg/dL, with 52.8% on target, declining to 4.9 ± 1.5 mg/dL after one year, when 54.7% were on target. Median iPTH at baseline was 238 (P25% 110 - P75% 426 pg/mL) and it remained stable throughout the first year; patients within target ranged from 26 to 28.5%. At the end of the study, 80% was in 3.5 meq/L Ca dialysate concentration, 66.9% of patients was taking any phosphate binder, and 25% was taking activated vitamin D. CONCLUSIONS We observed a significant prevalence of biochemical disorders related to CKD-MBD in this dialysis population.
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Affiliation(s)
- Rafael Weissheimer
- Pontifícia Universidade Católica do Paraná, Escola de Medicina, Curitiba, PR, Brasil
| | | | | | - Vanda Jorgetti
- Universidade de São Paulo, Escola de Medicina, São Paulo, SP, Brasil
| | - Ana Elizabeth Figueiredo
- Pontifícia Universidade Católica do Rio Grande do Sul, Programa de Pós-Graduação em Medicina e Ciências da Saúde, Porto Alegre, RS, Brasil
| | - Pasqual Barrett
- Universidade Estadual de São Paulo, Escola de Medicina, Botucatu, SP, Brasil
| | - Marcia Olandoski
- Pontifícia Universidade Católica do Paraná, Escola de Medicina, Curitiba, PR, Brasil
| | - Roberto Pecoits-Filho
- Pontifícia Universidade Católica do Paraná, Escola de Medicina, Curitiba, PR, Brasil
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Bowen IM, Redpath A, Dugdale A, Burford JH, Lloyd D, Watson T, Hallowell GD. BEVA primary care clinical guidelines: Analgesia. Equine Vet J 2020; 52:13-27. [PMID: 31657050 DOI: 10.1111/evj.13198] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 10/18/2019] [Indexed: 02/07/2023]
Abstract
Primary care guidelines provide a reference point to guide clinicians based on a systematic review of the literature, contextualised by expert clinical opinion. These guidelines develop a modification of the GRADE framework for assessment of research evidence (vetGRADE) and applied this to a range of clinical scenarios regarding use of analgesic agents. Key guidelines produced by the panel included recommendations that horses undergoing routine castration should receive intratesticular local anaesthesia irrespective of methods adopted and that horses should receive NSAIDs prior to surgery (overall certainty levels high). Butorphanol and buprenorphine should not be considered appropriate as sole analgesic for such procedures (high certainty). The panel recommend the continuation of analgesia for 3 days following castration (moderate certainty) and conclude that phenylbutazone provided superior analgesia to meloxicam and firocoxib for hoof pain/laminitis (moderate certainty), but that enhanced efficacy has not been demonstrated for joint pain. In horses with colic, flunixin and firocoxib are considered to provide more effective analgesia than meloxicam or phenylbutazone (moderate certainty). Given the risk of adverse events of all classes of analgesic, these agents should be used only under the control of a veterinary surgeon who has fully evaluated a horse and developed a therapeutic, analgesic plan that includes ongoing monitoring for such adverse events such as the development of right dorsal colitis with all classes of NSAID and spontaneous locomotor activity and potentially ileus with opiates. Finally, the panel call for the development of a single properly validated composite pain score for horses to allow accurate comparisons between medications in a robust manner.
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Affiliation(s)
- I M Bowen
- Oakham Veterinary Hospital/University of Nottingham, Sutton Bonington, Loughborough, UK
| | - A Redpath
- Oakham Veterinary Hospital/University of Nottingham, Sutton Bonington, Loughborough, UK
| | - A Dugdale
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, Loughborough, UK
| | - J H Burford
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, Loughborough, UK
| | - D Lloyd
- ChesterGates Veterinary Specialists, Chester, UK
| | - T Watson
- Waterlane Equine Vets, Stroud, UK
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Floege J, Covic AC, Ketteler M, Mann J, Rastogi A, Spinowitz B, Rakov V, Lisk LJ, Sprague SM. One-year efficacy and safety of the iron-based phosphate binder sucroferric oxyhydroxide in patients on peritoneal dialysis. Nephrol Dial Transplant 2018; 32:1918-1926. [PMID: 28339993 DOI: 10.1093/ndt/gfw460] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/09/2016] [Indexed: 01/24/2023] Open
Abstract
Background Sucroferric oxyhydroxide is a noncalcium, iron-based phosphate binder that demonstrated sustained serum phosphorus control, good tolerability and lower pill burden compared with sevelamer carbonate (sevelamer) in a Phase 3 study conducted in dialysis patients. This subanalysis examines the efficacy and tolerability of sucroferric oxyhydroxide and sevelamer in the peritoneal dialysis (PD) patient population. Methods The initial study (NCT01324128) and its extension (NCT01464190) were multicenter, Phase 3, open-label, randomized (2:1), active-controlled trials comparing sucroferric oxyhydroxide (1.0-3.0 g/day) with sevelamer (2.4-14.4 g/day) in dialysis patients over 52 weeks in total. Results In the overall study, 84/1055 (8.1%) patients received PD and were eligible for efficacy analysis (sucroferric oxyhydroxide, n = 56; sevelamer, n = 28). The two groups were broadly comparable to each other and to the overall study population. Serum phosphorus concentrations decreased comparably with both phosphate binders by week 12 (mean change from baseline - 0.6 mmol/L). Over 52 weeks, sucroferric oxyhydroxide effectively reduced serum phosphorus concentrations to a similar extent as sevelamer; 62.5% and 64.3% of patients, respectively, were below the Kidney Disease Outcomes Quality Initiative target range (≤1.78 mmol/L). This was achieved with a lower pill burden (3.4 ± 1.3 versus 8.1 ± 3.7 tablets/day) with sucroferric oxyhydroxide compared with sevelamer. Treatment adherence rates were 91.2% with sucroferric oxyhydroxide and 79.3% with sevelamer. The proportion of patients reporting at least one treatment-emergent adverse event was 86.0% with sucroferric oxyhydroxide and 93.1% with sevelamer. The most common adverse events with both treatments were gastrointestinal: diarrhea and discolored feces with sucroferric oxyhydroxide and nausea, vomiting and constipation with sevelamer. Conclusions Sucroferric oxyhydroxide is noninferior to sevelamer for controlling serum phosphorus in patients undergoing PD, while providing a relatively low pill burden and a high rate of adherence.
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Affiliation(s)
| | - Adrian C Covic
- Gr.T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | | | | | | | | | | | | | - Stuart M Sprague
- NorthShore University Health System, University of Chicago, Pritzker School of Medicine, Evanston, IL, USA
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Xie F, Liang Y, Guo SH. Application of PDCA cycle in gastroenterology disinfection supply: Effect on nursing quality. Shijie Huaren Xiaohua Zazhi 2017; 25:1214-1217. [DOI: 10.11569/wcjd.v25.i13.1214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To apply the Plan-Do-Check-Act (PDCA) cycle to gastroenterology disinfection supply and observe its effect on nursing quality.
METHODS From January 2014 to April 2014, 120 nurses at the Department of Gastroenterology, Traditional Chinese Medicine Hospital, Keqiao District, Shaoxing City, were randomly divided into either a control group (n = 60, January 2014-January 2015) or an observation group (n = 60, January 2015-January 2016) according to the implementation of PDCA management or not. The control group implemented routine management, and the observation group implemented PDCA management. Nursing quality was compared between the two groups.
RESULTS The nursing quality, service attitude, timely recovery, timely supply, and quality scores were significantly higher in the observation group than in the control group (P < 0.05). The rate of satisfaction was significantly higher in the observation group than in the control group (96.67% vs 75.00%, P < 0.05). The abilities of problem-solving, communication, and cooperation, self-confidence, cohesion and thinking ability of the cycle members were improved significantly after the quality control cycle was implemented. The implementation of quality control circle activities can greatly improve the nursing care and quality of care of the digestive disinfection supply center.
CONCLUSION Implementation of PDCA management has good nursing effect in gastroenterology disinfection supply center and can improve nursing quality.
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Perl J, Dember LM, Bargman JM, Browne T, Charytan DM, Flythe JE, Hickson LJ, Hung AM, Jadoul M, Lee TC, Meyer KB, Moradi H, Shafi T, Teitelbaum I, Wong LP, Chan CT. The Use of a Multidimensional Measure of Dialysis Adequacy-Moving beyond Small Solute Kinetics. Clin J Am Soc Nephrol 2017; 12:839-847. [PMID: 28314806 PMCID: PMC5477210 DOI: 10.2215/cjn.08460816] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Urea removal has become a key measure of the intensity of dialysis treatment for kidney failure. Small solute removal, exemplified by Kt/Vurea, has been broadly applied as a means to quantify the dose of thrice weekly hemodialysis. Yet, the reliance on small solute clearances alone as a measure of dialysis adequacy fails fully to quantify the intended clinical effects of dialysis therapy. This review aims to (1) understand the strengths and limitations of small solute kinetics as a surrogate marker of dialysis dose, and (2) present the prospect of a more comprehensive construct for dialysis dose, one that considers more broadly the goals of ESRD care to maximize both quality of life and survival. On behalf of the American Society of Nephrology Dialysis Advisory Group, we propose the need to ascertain the validity and utility of a multidimensional measure that moves beyond small solute kinetics alone to quantify optimal dialysis derived from both patient-reported and comprehensive clinical and dialysis-related measures.
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Affiliation(s)
- Jeffrey Perl
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Jiang LQ. Effect of continuous quality improvement in disinfection supply center on safety of patients undergoing gastroscopy. Shijie Huaren Xiaohua Zazhi 2017; 25:452-455. [DOI: 10.11569/wcjd.v25.i5.452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To observe the effect of continuous quality improvement in disinfection supply center on the safety of patients undergoing gastroscopy.
METHODS Eighty patients who would undergo painless endoscopy were enrolled in this study. From June 2014, continuous quality improvement was implemented in our disinfection supply center. The impact of continuous quality improvement in disinfection supply center on the safety of gastroscopic examination was analyzed, and the intangible results were evaluated.
RESULTS After implementation of continuous quality improvement in disinfection supply center, the incidence of nausea and vomiting and restlessness decreased significantly (P < 0.05), and the success rate of painless gastroscopy became significantly higher (P < 0.05). The quality of problem-solving, communication, cooperation, self-confidence, cohesion and thinking ability of the circle after the implementation of quality control circle was improved obviously. At the same time, the implementation of quality control circle activities can greatly improve the safety of patients who underwent painless gastroscopy.
CONCLUSION Continuous quality improvement in disinfection supply center can improve the safety of painless gastroscopy and the intangible results.
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Vikrant S, Parashar A. Prevalence and severity of disordered mineral metabolism in patients with chronic kidney disease: A study from a tertiary care hospital in India. Indian J Endocrinol Metab 2016; 20:460-467. [PMID: 27366711 PMCID: PMC4911834 DOI: 10.4103/2230-8210.183457] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Disordered mineral metabolism is common complications of chronic kidney disease (CKD). However, there are limited data on the pattern of these disturbances in Indian CKD population. MATERIALS AND METHODS This was a prospective observational study of CKD-mineral and bone disorder (CKD-MBD) over a period of 3 years. The biochemical markers of CKD-MBD, namely, calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone (iPTH), and 25-hydoxyvitamin Vitamin D3 (25OHD), were measured in newly diagnosed CKD Stage 3-5 and prevalent CKD Stage 5D adult patients. RESULTS A total of 462 patients of CKD Stage 3-5D were studied. The frequency of various biochemical abnormalities was hypocalcemia (23.8%), hypercalcemia (5.4%), hypophosphatemia (2.8%), hyperphosphatemia (55.4%), raised alkaline phosphatase (56.9%), secondary hyperparathyroidism (82.7%), and hypoparathyroidism (1.5%). 25OHD was done in 335 (72.5%) patients and 90.4% were found to have Vitamin D deficiency. About 70.6% of the patients had iPTH levels were above kidney disease outcomes quality initiative (KDOQI) target range. Nondiabetic CKD as compared to diabetic CKD had a higher alkaline phosphatase (P = 0.016), a higher iPTH (P = 0.001) a higher proportion of patients with iPTH above KDOQI target range (P = 0.09), and an elevated alkaline phosphatase (P = 0.004). The 25OHD levels were suggestive of severe Vitamin D deficiency in 33.7%, Vitamin D deficiency in 45.4%, and Vitamin D insufficiency in 11.3% patients. There was a significant positive correlation between iPTH with alkaline phosphatase (r = 0.572, P = 0.001), creatinine (r = 0.424, P = 0.001), and phosphorus (r = 0.241, P = 0.001) and a significant negative correlation with hemoglobin (r = -0.325, 0.001), age (r = -0.169, P = 0.002), and 25OHD (r = -0.126, P = 0.021). On multivariate logistic regression analysis, an elevated alkaline phosphatase was a significant predictor of hyperparathyroidism (odds ratio 9.7, 95% confidence interval 4.9-19.2, P = 0.001). CONCLUSIONS There was a high prevalence of CKD-MBD in Indian CKD patients. CKD-MBD is more common and more severe and has an early onset as compared to the western populations.
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Affiliation(s)
- Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Anupam Parashar
- Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
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Lu JR, Yi Y, Xiong ZX, Cheng XF, Hu J, Hang HY, Cheng J, Peng W. The Study of Low Calcium Dialysate on Elderly Hemodialysis Patients with Secondary Hypoparathyroidism. Blood Purif 2016; 42:3-8. [PMID: 26905433 DOI: 10.1159/000443470] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/15/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The study aimed to study the safety and efficacy of 1.25 mmol/l calcium dialysate on maintenance hemodialysis (MHD) in elderly patients who suffered from secondary hypoparathyroidism. METHODS Eighty-two elderly patients (ages ≥65) who had been in MHD with dialysate calcium at 1.5 mmol/l over 6 months and had 2 consecutive serum intact parathyroid hormone (iPTH) measurements at level below 100 pg/ml were selected and randomized into 2 groups: treatment group (41 patients, with dialysate calcium at 1.25 mmol/l) and control group (41 patients, still with dialysate calcium at 1.5 mmol/l). Both groups were studied for the duration of 12 months. The changes of serum iPTH, calcium, phosphorus, calcium and phosphorus product and other indicators as well as related adverse reactions were recorded at the following time points: before the study and 1, 3, 6 and 12 months into the study. In addition, the intimal media thickness (IMT) of carotid artery and abdominal aorta calcification score (AACS) were measured in the 0, 6 and 12 months during the study. RESULTS (1) In the treatment group, the levels of serum corrected calcium, phosphorus and calcium-phosphate product began to decline after 1 month and exhibited further decrease 3 months later. Serum iPTH level increased significantly after 1 month into the study and the trend continued. The above markers stabilized after month 6. Compared with pre-study markers, the changes of the above markers were significant after study (p < 0.05). (2) The average IMT and AACS were evidently decreased during the 6 and 12 months of study in the treatment group. There was statistical significance (p < 0.05) when compared with the above indexes of the pre-study and the control group. (3) In the control group, there were no significant differences in above laboratory markers over the 12-month study period. (4) There was no significant difference in the adverse events observed between the 2 groups. CONCLUSION Safety of low calcium dialysate (dialysate calcium 1.25 mmol/l) in elderly MHD patients with iPTH <100 pg/ml is good, as well as improving carotid IMT, resistance index and AACS as indexes of vascular calcification in the small study group and warrants further investigation.
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Affiliation(s)
- Jian-Rao Lu
- Department of Nephrology, Affiliated Seventh People's Hospital, Shanghai University of TCM, Shanghai, China
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Holden RM, Booth SL, Day AG, Clase CM, Zimmerman D, Moist L, Shea MK, McCabe KM, Jamal SA, Tobe S, Weinstein J, Madhumathi R, Adams MA, Heyland DK. Inhibiting the progression of arterial calcification with vitamin K in HemoDialysis patients (iPACK-HD) trial: rationale and study design for a randomized trial of vitamin K in patients with end stage kidney disease. Can J Kidney Health Dis 2015; 2:17. [PMID: 26075081 PMCID: PMC4465015 DOI: 10.1186/s40697-015-0053-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 03/23/2015] [Indexed: 11/16/2022] Open
Abstract
Background Cardiovascular disease, which is due in part to progressive vascular calcification, is the leading cause of death among patients with end stage kidney disease (ESKD) on dialysis. A role for vitamin K in the prevention of vascular calcification is plausible based on the presence of vitamin K dependent proteins in vascular tissue, including matrix gla protein (MGP). Evidence from animal models and observational studies support a role for vitamin K in the prevention of vascular calcification. A large-scale study is needed to investigate the effect of vitamin K supplementation on the progression of vascular calcification in patients with ESKD, a group at risk for sub-clinical vitamin K deficiency. Methods/Design We plan a prospective, randomized, double-blind, multicenter controlled trial of incident ESKD patients on hemodialysis in centers within North America. Eligible subjects with a baseline coronary artery calcium score of greater than or equal to 30 Agatston Units, will be randomly assigned to either the treatment group (10 mg of phylloquinone three times per week) or to the control group (placebo administration three times per week). The primary endpoint is the progression of coronary artery calcification defined as a greater than 15% increase in CAC score over baseline after 12 months. Discussion Vitamin K supplementation is a simple, safe and cost-effective nutritional strategy that can easily be integrated into patient care. If vitamin K reduces the progression of coronary artery calcification it may lead to decreased morbidity and mortality in men and women with ESKD. Trial registration NCT 01528800.
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Affiliation(s)
- Rachel M Holden
- Department of Medicine, Queen's University, 3048C Etherington Hall, Kingston, Ontario K7L 3 V6 Canada ; Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario Canada
| | - Sarah L Booth
- USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA USA
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario Canada
| | - Catherine M Clase
- Department of Medicine, McMaster University, Hamilton, Ontario Canada
| | - Deborah Zimmerman
- Department of Nephrology, University of Ottawa, Ottawa, Ontario Canada
| | - Louise Moist
- Department of Medicine, Western University, London, Ontario Canada
| | - M Kyla Shea
- USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA USA
| | - Kristin M McCabe
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario Canada
| | - Sophie A Jamal
- Women's College Research Institute and Department of Endocrinology, University of Toronto, Toronto, Ontario Canada
| | - Sheldon Tobe
- Department of Medicine, University of Toronto, Toronto, Ontario Canada
| | - Jordan Weinstein
- Department of Medicine, University of Toronto, Toronto, Ontario Canada
| | - Rao Madhumathi
- Department of Medicine, Tufts University, Boston, MA USA
| | - Michael A Adams
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario Canada
| | - Daren K Heyland
- Department of Medicine, Queen's University, 3048C Etherington Hall, Kingston, Ontario K7L 3 V6 Canada ; Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario Canada
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Paniagua R, Ventura MDJ, Ávila-Díaz M, Hinojosa-Heredia H, Méndez-Duran A, Cisneros A, Gómez AM, Cueto-Manzano A, Trinidad P, Obrador GT, García-López E, Lindholm B. Reaching Targets for Mineral Metabolism Clinical Practice Guidelines and Its Impact on Outcomes Among Mexican Chronic Dialysis Patients. Arch Med Res 2013; 44:229-34. [DOI: 10.1016/j.arcmed.2013.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 01/23/2013] [Indexed: 11/30/2022]
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Kim JK, Kwon YJ, Kim SW, Kim YH, Park CW, Choi KB, Hwang SD, Choi KH. Rapid decrease of intact parathyroid hormone could be a predictor of better response to cinacalcet in hemodialysis patients. Yonsei Med J 2013; 54:453-63. [PMID: 23364981 PMCID: PMC3575968 DOI: 10.3349/ymj.2013.54.2.453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Cinacalcet is effective for treating refractory secondary hyperparathyroidism (SHPT), but little is known about the response rates and clinical factors influencing the response. MATERIALS AND METHODS A prospective, single-arm, multi-center study was performed for 24 weeks. Cinacalcet was administered to patients with intact parathyroid hormone (iPTH) level greater than 300 pg/mL. Cinacalcet was started at a dose of 25 mg daily and titrated until 100 mg to achieve a serum iPTH level<300 pg/mL (primary end point). Early response to cinacalcet was defined as a decrease of iPTH more than 50% within one month. RESULTS Fifty-seven patients were examined. Based on the magnitude of iPTH decrease, patients were divided into responder (n=47, 82.5%) and non-responder (n=10, 17.5%) groups. Among the responders, 38 achieved the primary end point, whereas 9 patients showed a reduction in serum iPTH of 30% or more, but did not reach the primary end point. Compared to non-responders, responders were significantly older (p=0.026), female (p=0.041), and diabetics (p<0.001). Additionally, early response was observed more frequently in the responders (30/47, 63.8%), of whom the majority (27/30, 90.0%) achieved the primary end point. Multivariate analysis showed that lower baseline iPTH levels [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.93-0.99], the presence of diabetes (OR 46.45, CI 1.92-1125.6) and early response (OR 21.54, CI 2.94-157.7) were significant clinical factors affecting achievement of iPTH target. CONCLUSION Cinacalcet was effective in most hemodialysis patients with refractory SHPT. The presence of an early response was closely associated with the achievement of target levels of iPTH.
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Affiliation(s)
- Jwa-Kyung Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University College of Medicine, Anyang, Korea
| | - Young Joo Kwon
- Department of Internal Medicine, Korea University Medical School, Seoul, Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangjuv, Korea
| | - Yeong-Hoon Kim
- Department of Nephrology, College of Medicine, Busan Paik Hospital, Inje University, Busan, Korea
| | - Cheol Whee Park
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyu Bok Choi
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Seung Duk Hwang
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Kyu Hun Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Palomares I, Ramos R, Martin-Malo A, Merello J, Praga M, Luño J, de Francisco A, NIL A. Compliance with Mineral Metabolism Targets in Haemodialysis Patients: Moving Backwards. Blood Purif 2013; 36:122-31. [DOI: 10.1159/000353418] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 05/09/2013] [Indexed: 11/19/2022]
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Fouque D, Roth H, Pelletier S, London GM, Hannedouche T, Jean G, Bouchet JL, Drüeke T. Control of mineral metabolism and bone disease in haemodialysis patients: which optimal targets? Nephrol Dial Transplant 2012; 28:360-7. [PMID: 23136211 DOI: 10.1093/ndt/gfs404] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is a high drug treatment burden on patients receiving long-term dialysis therapy. Abnormalities of calcium and phosphate metabolism are associated with increased mortality, and attempts to correct these disturbances may improve survival. METHODS We prospectively evaluated the targets of the currently used Kidney Disease: Improving Global Outcomes (KDIGO) guidelines in 8377 prevalent patients receiving intermittent haemodialysis therapy in France from July 2007 to December 2009. RESULTS Adjusted Cox analyses showed that only one among six targets was predictive of mortality, i.e. a serum intact parathyroid hormone (iPTH) <130 pg/mL. A continuous risk analysis using fractional polynomials showed a 10% increase in hazard ratio (HR) for mortality for a serum phosphate <0.71 (2.2) and >1.98 (6.14) mmol/L (mg/dL), a non-corrected serum calcium <1.59 (6.37) and >2.41 (9.66) mmol/L (mg/dL) and a serum iPTH <100 and >1090 pg/mL. CONCLUSION The findings of our observational study confirm the existence of a grey zone, in which precise biochemical targets are difficult to define, with the exception of avoiding extreme values. Given the absence of intervention trials proving the clinical usefulness of phosphorus control, and pending the results of large clinical trials on the effect of optimal PTH and calcium control on hard outcomes, the present findings may help to refine future recommendations for the treatment of chronic haemodialysis patients.
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Affiliation(s)
- Denis Fouque
- Department of Nephrology, Hôpital Edouard Herriot, Université de Lyon, CENS, Lyon, France.
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Kong X, Zhang L, Zhang L, Chen N, Gu Y, Yu X, Liu W, Chen J, Peng L, Yuan W, Wu H, Chen W, Fan M, He L, Ding F, Chen X, Xiong Z, Zhang J, Jia Q, Shi W, Xing C, Tang X, Hou F, Shu G, Mei C, Wang L, Xu D, Ni Z, Zuo L, Wang M, Wang H. Mineral and bone disorder in Chinese dialysis patients: a multicenter study. BMC Nephrol 2012; 13:116. [PMID: 22994525 PMCID: PMC3507668 DOI: 10.1186/1471-2369-13-116] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 09/14/2012] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Mineral and bone disorder (MBD) in patients with chronic kidney disease is associated with increased morbidity and mortality. Studies regarding the status of MBD treatment in developing countries, especially in Chinese dialysis patients are extremely limited. METHODS A cross-sectional study of 1711 haemodialysis (HD) patients and 363 peritoneal dialysis (PD) patients were enrolled. Parameters related to MBD, including serum phosphorus (P), calcium (Ca), intact parathyroid hormone (iPTH) were analyzed. The achievement of MBD targets was compared with the results from the Dialysis Outcomes and Practice Study (DOPPS) 3 and DOPPS 4. Factors associated with hyperphosphatemia were examined. RESULTS Total 2074 dialysis patients from 28 hospitals were involved in this study. Only 38.5%, 39.6% and 26.6% of them met the Kidney Disease Outcomes Quality Initiative (K/DOQI) defined targets for serum P, Ca and iPTH levels. Serum P and Ca levels were statistically higher (P < 0.05) in the HD patients compared with those of PD patients, which was (6.3 ± 2.1) mg/dL vs (5.7 ± 2.0) mg/dL and (9.3 ± 1.1) mg/dL vs (9.2 ± 1.1) mg/dL, respectively. Serum iPTH level were statistically higher in the PD patients compared with those of HD patients (P = 0.03). The percentage of patients reached the K/DOQI targets for P (37.6% vs 49.8% vs 54.5%, P < 0.01), Ca (38.6% vs 50.4% vs 56.0%, P < 0.01) and iPTH (26.5% vs 31.4% vs 32.1%, P < 0.01) were lower among HD patients, compared with the data from DOPPS 3 and DOPPS 4. The percentage of patients with serum phosphorus level above 5.5 mg/dL was 57.4% in HD patients and 47.4% in PD patients. Age, dialysis patterns and region of residency were independently associated with hyperphosphatemia. CONCLUSIONS Status of MBD is sub-optimal among Chinese patients receiving dialysis. The issue of hyperphosphatemia is prominent and needs further attention.
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Affiliation(s)
- Xianglei Kong
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, China
| | - Luxia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Ling Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Nan Chen
- Department of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yong Gu
- Renal Division, Xinhua Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xueqing Yu
- Department of Nephrology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenhu Liu
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jianghua Chen
- Kidney Diseases Center, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Liren Peng
- Department of Nephrology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Weijie Yuan
- Department of Nephrology, Shanghai First People s Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Hua Wu
- Department of Nephrology, Beijing Hospital, Beijing, China
| | - Wei Chen
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Minhua Fan
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Liqun He
- Department of Nephrology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Feng Ding
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiangmei Chen
- Department of Nephrology, The General Hospital of the People's Liberation Army, Beijing, China
| | - Zuying Xiong
- Renal Division, Hospital Peking of Shenzhen, Shenzhen, China
| | - Jinyuan Zhang
- Department of Nephrology, The 455th Hospital of PLA, Shanghai, China
| | - Qiang Jia
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Shi
- Department of Nephrology, Guangdong General Hospital, Guangzhou, China
| | - Changying Xing
- Renal Division, Jiangsu Provincial Hospital, Nanjing, China
| | - Xiaoling Tang
- Department of internal medicine, Shantou Central Hospital, Shantou, China
| | - Fanfan Hou
- Department of Nephrology, Nanfang Hospital, The Southern Medical University, Guangzhou, China
| | - Guiyang Shu
- Department of Nephrology, Fujian Provincial Hospital, Fuzhou, China
| | - Changlin Mei
- Department of Nephrology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Li Wang
- Department of Nephrology, Sichuan Provincial People’ s Hospital, Chengdu, China
| | - Dongmei Xu
- Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, China
| | - Zhaohui Ni
- Renal Division, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Zuo
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Mei Wang
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
- Institute of Nephrology and Division of Nephrology, and Key Laboratory of Ministry of Health, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Haiyan Wang
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
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18
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Reporting of the estimated glomerular filtration rate decreased creatinine clearance testing. Kidney Int 2012; 81:1245-7. [PMID: 22336989 DOI: 10.1038/ki.2011.483] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines suggest that clinicians use the estimated glomerular filtration rate (eGFR) measurements and minimize the use of timed urine creatinine clearance collection. The intent of this change was to improve recognition of chronic kidney disease. Here we used time-series modeling and intervention analyses to determine the effect of publication of the K/DOQI guidelines and the introduction of widespread eGFR reporting with prompts on physician ordering of 24-h urine collection for creatinine clearance. In this setting, clinical practice guidelines did not influence creatinine clearance testing; however, the direct introduction of eGFR reporting with prompts into physician workflow resulted in a sudden and significant 23.5% decrease in creatinine clearance collection over the 43 months analyzed. Thus, eGFR reporting with prompts may have produced a clinical practice change because it is integrated directly into physician workflow. Changing physician practice patterns may require more than publishing guidelines; rather it is more likely to occur through educational and structural changes to practice.
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Spasovski G, Zdravkovska V, Zabzun M, Antarorov R, Ivanovski K, Janakievska P, Neskovski J, Karceva-Sarajlia E, Panova B, Petrovska T, Zulbeari L, Masin-Spasovska J, Taleska-Matovska N, Gelev S. Achievements in CKD-MBD guidelines targets: is there a progress in the implementation practice? Int Urol Nephrol 2011; 44:1791-8. [PMID: 22173961 DOI: 10.1007/s11255-011-0092-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 11/09/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Guidelines should help the practicing nephrologists to reduce the variability in diagnostic and treatment strategies, and achieve the best possible patients' outcomes. The aim of our study was to look at the treatment strategies and the shortcomings in the implementation of the chronic kidney disease mineral and bone disorder (CKD-MBD) KDOQI guidelines in dialysis units across the Republic of Macedonia in 2009, and to analyze trends with regard to our previous analysis from 2005. METHODS A questionnaire was sent in 2009 to all dialysis units in our country for data concerning CKD-MBD in dialysis patients. This study included 742 patients, comparable with the reply we got on the same our 2005 survey, with a total of 588 patients. We collected the last 6 months mean values of biochemical parameters [calcium (Ca), phosphate (P), and intact parathyroid hormone (iPTH)], as well as treatment data including dialysate Ca concentration, phosphate binding agents, and vitamin D doses. RESULTS The majority of patients in both surveys had values within the target ranges for all parameters, except for iPTH, which was <150 pg/ml in most patients, in both reports. Compared to the 2005 study, in 2009 we found a significantly improved control of all four biochemical parameters, but a greater proportion of patients within guidelines targets was found only for serum Ca (79 vs. 67.4%, P<0.05). Treatment with low Ca dialysate concentration of 1.25 mmol/L continued to be an underused option (3.7 vs. 6.1%), while the 1.75 mmol/L was still the standard dialysate in the majority of patients (57.7 vs. 64.2%). The dose of calcium carbonate was significantly reduced (2.77±1.71 vs. 3.06±1.54, P<0.01) in 2009 compared to 2005. The mean of the achieved targets increased significantly in 2009 (2.33±1.05 vs. 2.13±1.03, P<0.01). CONCLUSION There was an improved control of all bone and mineral parameters in our dialysis units, following the publication of the CKD-MBD KDOQI guidelines. In order to improve the iPTH values, a more frequent use of low Ca dialysate (1.25 mmol/L) and of non-calcium-based phosphate binders in this small subset of patients should be implemented, as recommended by the guidelines. Individualization of the CKD-MBD management may be successful, even when newer treatment options are not available. Finally, the guidelines implementation process should be a continuous and self-monitored process, with the help of periodic surveys.
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Affiliation(s)
- G Spasovski
- Department of Nephrology, Medical Faculty, University of Skopje, Dialysis Unit, Military Hospital Skopje, Vodnjanska 17, 1000, Skopje, Republic of Macedonia.
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Allen N, Schwartz D, Sood AR, Mendelssohn D, Verrelli M, Tanna G, Schiff J, Komenda P, Rigatto C, Sood MM. Perceived barriers to guidelines in peritoneal dialysis. Nephrol Dial Transplant 2010; 26:1683-9. [PMID: 20959345 DOI: 10.1093/ndt/gfq623] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Little is known regarding barriers to guideline adherence in the nephrology community. We set out to identify perceived barriers to evidence-based medicine (EBM) and measurement of continuous quality indicators (CQI) in an international cohort of peritoneal dialysis (PD) practitioners. METHODS Subscribers to an online nephrology education site (Nephrology Now) were invited to participate in an online survey. Nephrology Now is a non-profit, monthly mailing list that highlights clinically relevant articles in nephrology. Four hundred and seventy-five physicians supplying PD care participated in an online survey assessing their use of EBM and CQI in their PD practice. Ordinal logistic regression was utilized to determine relationships between baseline characteristics and EBM and CQI practices. RESULTS The majority of physicians were nephrologists (89.7%), and 50.4% worked in an academic centre. Respondents were from the following geographic regions: 13.5% Canadian, 24% American, 23.8% European, 4.4% Australian, 5.3% South American, 10.7% African and 12.2% Asian. Adherence to PD clinical practice guidelines were generally strong; however, lower adherence was associated with countries with lower healthcare expenditure, not using personal digital assistant (PDA), the longer the physician had been practising and smaller (< 20 patients per centre) PD practice. CONCLUSIONS International variation in guideline adherence may be influenced by a country's healthcare expenditure, physician's PDA use and experience, and size of PD practice which may impact future guideline development and implementation.
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Toussaint ND, Pedagogos E, Beavis J, Becker GJ, Polkinghorne KR, Kerr PG. Improving CKD-MBD management in haemodialysis patients: barrier analysis for implementing better practice. Nephrol Dial Transplant 2010; 26:1319-26. [DOI: 10.1093/ndt/gfq602] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Goldsmith DJA, Covic A, Fouque D, Locatelli F, Olgaard K, Rodriguez M, Spasovski G, Urena P, Zoccali C, London GM, Vanholder R. Endorsement of the Kidney Disease Improving Global Outcomes (KDIGO) Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Guidelines: a European Renal Best Practice (ERBP) commentary statement. Nephrol Dial Transplant 2010; 25:3823-31. [PMID: 20829401 DOI: 10.1093/ndt/gfq513] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Under the auspices of the European Renal Best Practice, a group of European nephrologists, not serving on the Kidney Disease Improving Global Outcomes (KDIGO) working group, but with significant clinical and research interests and expertise in these areas, was invited to examine and critique the Chronic Kidney Disease-Mineral and Bone Disorder KDIGO document published in August 2009. The final form of this paper in Nephrology Dialysis Transplantation, as a commentary, not as a position statement, reflects the fact that we have had no more evidence to review, discuss and debate available to us than was available to the KDIGO working group. However, we have felt that we were able to comment on specific areas where we feel that further clinical guidance would be helpful, thereby going beyond the KDIGO position as reflected in their document. This present paper, we hope, will be of most use to the practising kidney specialist and those allied to the clinical team.
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Irving MJ, Johnson DW, McDonald S, Walker RG, Frommer MS, Fetherstonhaugh D, Deans P, Craig JC. Opinions on the content and effects of the Caring for Australasians with Renal Impairment (CARI) Guidelines: a survey of renal nurses and comparison with the opinions of nephrologists in Australasia. Nephrology (Carlton) 2010; 15:48-53. [PMID: 20377771 DOI: 10.1111/j.1440-1797.2009.01191.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Renal nurses in Australia and New Zealand are critical to the care of patients with chronic kidney disease (CKD), especially those on dialysis. We aimed to obtain the opinions of renal nurses in Australia and New Zealand on the Caring for Australasians with Renal Impairment (CARI) Guidelines. METHODS A self-administered survey was distributed to all members of the professional organisation for renal nurses (Renal Society of Australasia) in 2006. The results were compared with those from a similar survey in 2002 and an identical 2006 survey of Australian and New Zealand nephrologists. RESULTS Of the 173 respondents, more than 95% considered the Guidelines to be a good synthesis of the available evidence, 80% indicated that the Guidelines had significantly influenced their practice and 86% considered that the Guidelines had improved patient outcomes. Older respondents were less likely to perceive that the Guidelines had improved patient outcomes, and renal nurse educators were more likely to consider that the Guidelines were based on the best available evidence than other respondents. Respondents were generally more positive about the Guidelines in 2006 than in 2002. Although nephrologists were generally positive about the CARI Guidelines, renal nurses were more positive, especially regarding the effect of the Guidelines on practice and the improvement in health outcomes. CONCLUSION Australian and New Zealand renal nurses valued the CARI Guidelines highly, used them in practice and considered that they led to improved patient outcomes. Positive responses towards the Guidelines increased between 2002 and 2006.
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Affiliation(s)
- Michelle J Irving
- Centre for Kidney Research, Children's Hospital at Westmead, Australia.
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Walsh M, Manns BJ, Klarenbach S, Tonelli M, Hemmelgarn B, Culleton B. The effects of nocturnal compared with conventional hemodialysis on mineral metabolism: A randomized-controlled trial. Hemodial Int 2009; 14:174-81. [PMID: 20041960 DOI: 10.1111/j.1542-4758.2009.00418.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hyperphosphatemia is common among patients receiving dialysis and is associated with increased mortality. Nocturnal hemodialysis (NHD) is a long, slow dialytic modality that may improve hyperphosphatemia and disorders of mineral metabolism. We performed a randomized-controlled trial of NHD compared with conventional hemodialysis (CvHD); in this paper, we report detailed results of mineral metabolism outcomes. Prevalent patients were randomized to receive NHD 5 to 6 nights per week for 6to 10 hours per night or to continue CvHD thrice weekly for 6 months. Oral phosphate binders and vitamin D analogs were adjusted to maintain phosphate, calcium and parathyroid hormone (PTH) levels within recommended targets. Compared with CvHD patients, patients in the NHD group had a significant decrease in serum phosphate over the course of the study (0.49 mmol/L, 95% confidence interval 0.24-0.74; P=0.002) despite a significant reduction in the use of phosphate binders. Sixty-one percent of patients in the NHD group compared with 20% in the CvHD group had a decline in intact PTH (P=0.003). Nocturnal hemodialysis lowers serum phosphate, calcium-phosphate product and requirement for phosphate binders. The effects of NHD on PTH are variable. The impact of these changes on long-term cardiovascular and bone-related outcomes requires further investigation.
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Affiliation(s)
- Michael Walsh
- Department of Medicine, University of Calgary, Alberta, Canada
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JEAN G, VANEL T, TERRAT JC, HUROT JM, LORRIAUX C, MAYOR B, CHAZOT C. Treating mineral metabolism disorders in patients undergoing long hemodialysis: A search for an optimal strategy. Hemodial Int 2009; 13:526-32. [DOI: 10.1111/j.1542-4758.2009.00394.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Irving MJ, Johnson DW, McDonald S, Walker RG, Frommer MS, Craig JC. Opinions on the Content and Effects of Clinical Practice Guidelines for CKD: A Survey of Nephrologists in Australia and New Zealand. Am J Kidney Dis 2009; 53:1082-90. [DOI: 10.1053/j.ajkd.2008.12.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Accepted: 12/11/2008] [Indexed: 11/11/2022]
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Palmer SC, Craig JC, Strippoli GFM. Taking aim at targets. Nephrol Dial Transplant 2009; 24:1358-61. [DOI: 10.1093/ndt/gfp025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Labriola L, Wallemacq P, Gulbis B, Jadoul M. The impact of the assay for measuring albumin on corrected ('adjusted') calcium concentrations. Nephrol Dial Transplant 2009; 24:1834-8. [DOI: 10.1093/ndt/gfn747] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Interpreting observational studies of disordered mineral metabolism and mortality in patients on hemodialysis. ACTA ACUST UNITED AC 2008; 5:16-7. [DOI: 10.1038/ncpneph0992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Accepted: 10/14/2008] [Indexed: 11/09/2022]
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Wald R, Sarnak MJ, Tighiouart H, Cheung AK, Levey AS, Eknoyan G, Miskulin DC. Disordered mineral metabolism in hemodialysis patients: an analysis of cumulative effects in the Hemodialysis (HEMO) Study. Am J Kidney Dis 2008; 52:531-40. [PMID: 18657891 DOI: 10.1053/j.ajkd.2008.05.020] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Accepted: 05/23/2008] [Indexed: 11/11/2022]
Abstract
BACKGROUND Serum markers of disordered mineral metabolism have been associated with adverse outcomes in patients requiring long-term dialysis therapy. Although the values of these markers often evolve over time, no study has examined the accumulated effects of these abnormalities on important clinical end points. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 1,846 prevalent hemodialysis patients randomly assigned in the Hemodialysis (HEMO) Study. PREDICTORS Serum phosphorus, calcium, calcium-phosphorus (Ca x P) product, and intact parathyroid hormone, each analyzed at the time of randomization (baseline), as a standard time-dependent covariate and as a cumulative time-dependent covariate. OUTCOMES All-cause mortality and the composite of all-cause mortality and first cardiac hospitalization. MEASUREMENTS Cox proportional hazards models. RESULTS In all analyses, serum phosphorus level greater than 6 mg/dL was associated with a heightened risk of mortality of approximately 25% compared with phosphorus values of 4.1 to 5 mg/dL. Serum calcium level greater than 11 mg/dL was associated with a 60% greater risk of death, but only when this parameter was analyzed as either a time-dependent or cumulative time-dependent variable. Ca x P product greater than 50 mg(2)/dL(2) was strongly associated with mortality, but only when assessed cumulatively. Similar relationships were observed when phosphorus, calcium, and Ca x P product values were related to the composite end point of all-cause mortality and first cardiac hospitalization. No relationships between baseline, time-dependent, and cumulative time-dependent intact parathyroid hormone levels and the outcomes of interest were observed. LIMITATIONS Residual confounding, lack of access to patient information before randomization in the HEMO Study, and concerns regarding generalizability given changes in practice patterns since the completion of the HEMO Study. CONCLUSIONS Cumulative time-dependent analyses provide a different framework for analyzing the impact of factors that may mediate adverse events in hemodialysis patients. Our findings support maintaining serum phosphorus levels at less than 6 mg/dL, calcium levels at less than 11 mg/dL, and Ca x P product at less than 50 mg(2)/dL(2).
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Affiliation(s)
- Ron Wald
- Division of Nephrology and The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada.
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Shastri J, Tran A, Covit A, Pepe J, Sherman RA. Adherence to K/DOQI guidelines for calcium-based phosphate binders in clinical practice. J Ren Nutr 2008; 18:370-4. [PMID: 18558302 DOI: 10.1053/j.jrn.2008.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2007] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guidelines for bone metabolism in chronic kidney disease recommend that calcium-based phosphate binders (CBPBs) be used in limited doses and be reduced or withheld when albumin-adjusted serum calcium exceeds target values, or when parathyroid hormone is below the target range. We sought to assess the pattern of CBPB use in a clinical practice setting. DESIGN This was a retrospective review. PATIENTS We reviewed 283 patients at three hemodialysis units in New York and New Jersey in which 39 physicians practice. METHODS Data collected included intact parathyroid hormone levels (from February and May, 2006), blood chemistries (from April and May, 2006), and the use of CBPBs, vitamin D, and cinacalcet. The use of CBPBs was classified as "consistent" or "inconsistent" with the guidelines 1 month after the blood tests of May 2006 (to allow time for dosing adjustments). Because cinacalcet was not available when the K/DOQI guidelines were published, a failure to reduce or stop CBPBs in the presence of elevated calcium levels was still considered to be "consistent" use if cinacalcet was initiated in the appropriate time frame (5 patients). RESULTS CBPBs were used in 172 of 283 patients (61%). In 10% (17 patients), doses exceeded the 1500-mg limit for calcium. Adjusted serum calcium levels exceeded 2.5 mmol/L (10.2 mg/dL) in 8 cases; CBPBs were not reduced or stopped in any of these. Similarly, CBPBs were reduced in only 2 of 27 patients on vitamin D, with an adjusted serum calcium level of 2.38 to 255 mmol/L (9.5 to 10.2 mg/dL). In all 10 patients with consecutive intact parathyroid hormone values of less than 150 ng/L (150 pg/mL), CBPBs were not discontinued or reduced. CONCLUSIONS Overall, 50 of 172 patients (29%) receiving CBPBs did so in a manner inconsistent with K/DOQI guidelines. The reasons for this inconsistency are speculative, and may include disagreement with the opinion-based recommendations, insufficient knowledge of the guidelines, or individual patient considerations (including cost, tolerance, and effectiveness).
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Affiliation(s)
- Jay Shastri
- Division of Nephrology, Department of Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08903-0019, USA
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Tentori F, Blayney MJ, Albert JM, Gillespie BW, Kerr PG, Bommer J, Young EW, Akizawa T, Akiba T, Pisoni RL, Robinson BM, Port FK. Mortality risk for dialysis patients with different levels of serum calcium, phosphorus, and PTH: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2008; 52:519-30. [PMID: 18514987 DOI: 10.1053/j.ajkd.2008.03.020] [Citation(s) in RCA: 721] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 03/24/2008] [Indexed: 11/11/2022]
Abstract
BACKGROUND Abnormalities in serum calcium, phosphorus, and parathyroid hormone (PTH) concentrations are common in patients with chronic kidney disease and have been associated with increased morbidity and mortality. No clinical trials have been conducted to clearly identify categories of calcium, phosphorus, and PTH levels associated with the lowest mortality risk. Current clinical practice guidelines are based largely on expert opinions, and clinically relevant differences exist among guidelines across countries. We sought to describe international trends in calcium, phosphorus, and PTH levels during 10 years and identify mortality risk categories in the Dialysis Outcomes and Practice Patterns Study (DOPPS), an international study of hemodialysis practices and associated outcomes. STUDY DESIGN Prospective cohort study. PARTICIPANTS 25,588 patients with end-stage renal disease on hemodialysis therapy for longer than 180 days at 925 facilities in DOPPS I (1996-2001), DOPPS II (2002-2004), or DOPPS III (2005-2007). PREDICTORS Serum calcium, albumin-corrected calcium (Ca(Alb)), phosphorus, and PTH levels. OUTCOMES Adjusted hazard ratios for all-cause and cardiovascular mortality calculated using Cox models. RESULTS Distributions of mineral metabolism markers differed across DOPPS countries and phases, with lower calcium and phosphorus levels observed in the most recent phase of DOPPS. Survival models identified categories with the lowest mortality risk for calcium (8.6 to 10.0 mg/dL), Ca(Alb) (7.6 to 9.5 mg/dL), phosphorus (3.6 to 5.0 mg/dL), and PTH (101 to 300 pg/mL). The greatest risk of mortality was found for calcium or Ca(Alb) levels greater than 10.0 mg/dL, phosphorus levels greater than 7.0 mg/dL, and PTH levels greater than 600 pg/mL and in patients with combinations of high-risk categories of calcium, phosphorus, and PTH. LIMITATIONS Because of the observational nature of DOPPS, this study can only indicate an association between mineral metabolism categories and mortality. CONCLUSIONS Our results provide important information about mineral metabolism trends in hemodialysis patients in 12 countries during a decade. The risk categories identified in the DOPPS cohort may be relevant to efforts at international harmonization of existing clinical guidelines for mineral metabolism.
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Affiliation(s)
- Francesca Tentori
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI 48103, USA.
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Massart A, Wissing KM, Debelle FD. Did the Release of KDOQI Guidelines Really Improve the Control of Bone Mineral Metabolism in Hemodialysis Patients? Am J Kidney Dis 2007; 50:686; author reply 686-7. [PMID: 17900471 DOI: 10.1053/j.ajkd.2007.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Accepted: 07/09/2007] [Indexed: 11/11/2022]
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