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Assimon MM, Brookhart MA, Fine JP, Heiss G, Layton JB, Flythe JE. A Comparative Study of Carvedilol Versus Metoprolol Initiation and 1-Year Mortality Among Individuals Receiving Maintenance Hemodialysis. Am J Kidney Dis 2018; 72:337-348. [PMID: 29653770 PMCID: PMC6477681 DOI: 10.1053/j.ajkd.2018.02.350] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 02/04/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Carvedilol and metoprolol are the β-blockers most commonly prescribed to US hemodialysis patients, accounting for ∼80% of β-blocker prescriptions. Despite well-established pharmacologic and pharmacokinetic differences between the 2 medications, little is known about their relative safety and efficacy in the hemodialysis population. STUDY DESIGN A retrospective cohort study using a new-user design. SETTING & PARTICIPANTS Medicare-enrolled hemodialysis patients treated at a large US dialysis organization who initiated carvedilol or metoprolol therapy from January 1, 2007, through December 30, 2012. PREDICTOR Carvedilol versus metoprolol initiation. OUTCOMES All-cause mortality, cardiovascular mortality, and intradialytic hypotension (systolic blood pressure decrease ≥ 20mmHg during hemodialysis plus intradialytic saline solution administration) during a 1-year follow-up period. MEASUREMENTS Survival models were used to estimate HRs and 95% CIs in mortality analyses. Poisson regression was used to estimate incidence rate ratios (IRRs) and 95% CIs in intradialytic hypotension analyses. Inverse probability of treatment weighting was used to adjust for several demographic, clinical, laboratory, and dialysis treatment covariates in all analyses. RESULTS 27,064 individuals receiving maintenance hemodialysis were included: 9,558 (35.3%) carvedilol initiators and 17,506 (64.7%) metoprolol initiators. Carvedilol (vs metoprolol) initiation was associated with greater all-cause (adjusted HR, 1.08; 95% CI, 1.02-1.16) and cardiovascular mortality (adjusted HR, 1.18; 95% CI, 1.08-1.29). In subgroup analyses, similar associations were observed among patients with hypertension, atrial fibrillation, heart failure, and a recent myocardial infarction, the main cardiovascular indications for β-blocker therapy. During follow-up, carvedilol (vs metoprolol) initiators had a higher rate of intradialytic hypotension (adjusted IRR, 1.10; 95% CI, 1.09-1.11). LIMITATIONS Residual confounding may exist. CONCLUSIONS Relative to metoprolol initiation, carvedilol initiation was associated with higher 1-year all-cause and cardiovascular mortality. One potential mechanism for these findings may be the increased occurrence of intradialytic hypotension after carvedilol (vs metoprolol) initiation.
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Affiliation(s)
- Magdalene M Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC; Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC.
| | - M Alan Brookhart
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Jason P Fine
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Gerardo Heiss
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - J Bradley Layton
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC; RTI Health Solutions, Research Triangle Park, Chapel Hill, NC
| | - Jennifer E Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
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Königsbrügge O, Posch F, Antlanger M, Kovarik J, Klauser-Braun R, Kletzmayr J, Schmaldienst S, Auinger M, Zuntner G, Lorenz M, Grilz E, Stampfel G, Steiner S, Pabinger I, Säemann M, Ay C. Prevalence of Atrial Fibrillation and Antithrombotic Therapy in Hemodialysis Patients: Cross-Sectional Results of the Vienna InVestigation of AtriaL Fibrillation and Thromboembolism in Patients on HemoDIalysis (VIVALDI). PLoS One 2017; 12:e0169400. [PMID: 28052124 PMCID: PMC5213813 DOI: 10.1371/journal.pone.0169400] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 11/27/2016] [Indexed: 02/07/2023] Open
Abstract
Background Atrial fibrillation (AF) adds significant risk of stroke and thromboembolism in patients on hemodialysis (HD). The aim of this study was to investigate the prevalence of AF in a population-based cohort of HD patients and practice patterns of antithrombotic therapy for stroke prevention in AF. Methods The Vienna InVestigation of AtriaL fibrillation and thromboembolism in patients on hemodialysis (VIVALDI), an ongoing prospective observational cohort study, investigates the prevalence of AF and the risk of thromboembolic events in HD patients in Vienna, Austria. We analyzed cross-sectional data of 626 patients (63.4% men, median age 66 years, approx. 73% of HD patients in Vienna), who provided informed consent. A structured interview with each patient was performed, recent and archived ECGs were viewed and medical histories were verified with electronic records. Results The overall prevalence of AF was 26.5% (166 patients, 71.1% men, median age 72 years) of which 57.8% had paroxysmal AF, 3.0% persistent AF, 32.5% permanent AF, and 6.6% of patients had newly diagnosed AF. The median CHA2DS2-VASc Score was 4 [25th-75th percentile 3–5]. In multivariable analysis, AF was independently associated with age (odds ratio: 1.05 per year increase, 95% confidence interval: 1.03–1.07), male sex (1.7, 1.1–2.6), history of venous thromboembolism (2.0, 1.1–3.6), congestive heart failure (1.7, 1.1–2.5), history of or active cancer (1.5, 1.0–2.4) and time on HD (1.08 per year on HD, 1.03–1.13). Antithrombotic treatment was applied in 84.4% of AF patients (anticoagulant agents in 29.5%, antiplatelet agents in 33.7%, and both in 21.1%). In AF patients, vitamin-K-antagonists were used more often than low-molecular-weight heparins (30.1% and 19.9%). Conclusions The prevalence of AF is high amongst HD patients and is associated with age, sex, and distinct comorbidities. Practice patterns of antithrombotic treatment indicate a lack of consensus for stroke prevention in HD patients with AF.
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Affiliation(s)
- Oliver Königsbrügge
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Posch
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Department of Medicine, Clinical Division of Oncology, Medical University of Graz, Austria
| | - Marlies Antlanger
- Clinical Division of Nephrology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Josef Kovarik
- Department of Medicine VI, Wilhelminenspital, Vienna, Austria
| | | | | | | | - Martin Auinger
- Department of Medicine III, Hietzing Hospital, Vienna, Austria
| | - Günther Zuntner
- Department of Medicine I, Rudolfstiftung Hospital, Vienna, Austria
| | | | - Ella Grilz
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Gerald Stampfel
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Stefan Steiner
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Marcus Säemann
- Clinical Division of Nephrology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Department of Medicine, Thrombosis and Hemostasis Program, McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- * E-mail:
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Shireman TI, Mahnken JD, Phadnis MA, Ellerbeck EF. Effectiveness comparison of cardio-selective to non-selective β-blockers and their association with mortality and morbidity in end-stage renal disease: a retrospective cohort study. BMC Cardiovasc Disord 2016; 16:60. [PMID: 27012911 PMCID: PMC4807583 DOI: 10.1186/s12872-016-0233-3] [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] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 03/19/2016] [Indexed: 11/10/2022] Open
Abstract
Background Within-class comparative effectiveness studies of β-blockers have not been performed in the chronic dialysis setting. With widespread cardiac disease in these patients and potential mechanistic differences within the class, we examined whether mortality and morbidity outcomes varied between cardio-selective and non-selective β-blockers. Methods Retrospective observational study of within class β-blocker exposure among a national cohort of new chronic dialysis patients (N = 52,922) with hypertension and dual eligibility (Medicare-Medicaid). New β-blocker users were classified according to their exclusive use of one of the subclasses. Outcomes were all-cause mortality (ACM) and cardiovascular morbidity and mortality (CVMM). The associations of cardio-selective and non-selective agents on outcomes were adjusted for baseline characteristics using Cox proportional hazards. Results There were 4938 new β-blocker users included in the ACM model and 4537 in the CVMM model: 77 % on cardio-selective β-blockers. Exposure to cardio-selective and non-selective agents during the follow-up period was comparable, as measured by proportion of days covered (0.56 vs. 0.53 in the ACM model; 0.56 vs 0.54 in the CVMM model). Use of cardio-selective β-blockers was associated with lower risk for mortality (AHR = 0.84; 99 % CI = 0.72–0.97, p = 0.0026) and lower risk for CVMM events (AHR = 0.86; 99 % CI = 0.75–0.99, p = 0.0042). Conclusion Among new β-blockers users on chronic dialysis, cardio-selective agents were associated with a statistically significant 16 % reduction in mortality and 14 % in cardiovascular morbidity and mortality relative to non-selective β-blocker users. A randomized clinical trial would be appropriate to more definitively answer whether cardio-selective β-blockers are superior to non-selective β-blockers in the setting of chronic dialysis.
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Affiliation(s)
- Theresa I Shireman
- Health Services Policy & Practice and the Center for Gerontology & Health Care Research, Brown University School of Public Health, 121 South Main St, Box-G-S121-6, Providence, RI, 02912, USA.
| | - Jonathan D Mahnken
- Biostatistics, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Milind A Phadnis
- Biostatistics, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Edward F Ellerbeck
- Preventive Medicine and Public Health, University of Kansas School of Medicine, Kansas City, KS, USA.,Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
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Clark EG, Akbari A, Hiebert B, Hiremath S, Komenda P, Lok CE, Moist LM, Schachter ME, Tangri N, Sood MM. Geographic and facility variation in initial use of non-tunneled catheters for incident maintenance hemodialysis patients. BMC Nephrol 2016; 17:20. [PMID: 26920700 PMCID: PMC4769546 DOI: 10.1186/s12882-016-0236-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 02/19/2016] [Indexed: 11/20/2022] Open
Abstract
Background Non-tunneled (temporary) hemodialysis catheters (NTHCs) are the least-optimal initial vascular access for incident maintenance hemodialysis patients yet little is known about factors associated with NTHC use in this context. We sought to determine factors associated with NTHC use and examine regional and facility-level variation in NTHC use for incident maintenance hemodialysis patients. Methods We analyzed registry data collected between January 2001 and December 2010 from 61 dialysis facilities within 12 geographic regions in Canada. Multi-level models and intra-class correlation coefficients were used to evaluate variation in NTHC use as initial hemodialysis access across facilities and geographic regions. Facility and patient characteristics associated with the lowest and highest quartiles of NTHC use were compared. Results During the study period, 21,052 patients initiated maintenance hemodialysis using a central venous catheter (CVC). This included 10,183 patients (48.3 %) in whom the initial CVC was a NTHC, as opposed to a tunneled CVC. Crude variation in NTHC use across facilities ranged from 3.7 to 99.4 % and across geographic regions from 32.4 to 85.1 %. In an adjusted multi-level logistic regression model, the proportion of total variation in NTHC use explained by facility-level and regional variation was 40.0 % and 34.1 %, respectively. Similar results were observed for the subgroup of patients who received greater than 12 months of pre-dialysis nephrology care. Patient-level factors associated with increased NTHC use were male gender, history of angina, pulmonary edema, COPD, hypertension, increasing distance from dialysis facility, higher serum phosphate, lower serum albumin and later calendar year. Conclusions There is wide variation in NTHC use as initial vascular access for incident maintenance hemodialysis patients across facilities and geographic regions in Canada. Identifying modifiable factors that explain this variation could facilitate a reduction of NTHC use in favor of more optimal initial vascular access.
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Affiliation(s)
- Edward G Clark
- Division of Nephrology, Department of Medicine, The Ottawa Hospital and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada. .,The Ottawa Hospital - Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7 W9, Canada.
| | - Ayub Akbari
- Division of Nephrology, Department of Medicine, The Ottawa Hospital and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
| | - Brett Hiebert
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, MB, Canada.
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, The Ottawa Hospital and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
| | - Paul Komenda
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada.
| | - Charmaine E Lok
- Division of Nephrology, Department of Medicine, Toronto General Hospital and University of Toronto, Toronto, ON, Canada.
| | - Louise M Moist
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University and Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada.
| | | | | | - Manish M Sood
- Division of Nephrology, Department of Medicine, The Ottawa Hospital and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
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Roberts MA, Pilmore HL, Ierino FL, Badve SV, Cass A, Garg AX, Isbel NM, Krum H, Pascoe EM, Perkovic V, Scaria A, Tonkin AM, Vergara LA, Hawley CM. The β-Blocker to Lower Cardiovascular Dialysis Events (BLOCADE) Feasibility Study: A Randomized Controlled Trial. Am J Kidney Dis 2015; 67:902-11. [PMID: 26717861 DOI: 10.1053/j.ajkd.2015.10.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/27/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND β-Blocking agents reduce cardiovascular mortality in patients with heart disease, but their potential benefit in dialysis patients is unclear. We aimed to determine the feasibility of a randomized controlled trial (RCT). STUDY DESIGN Pilot RCT. SETTING & PARTICIPANTS Patients who received dialysis for 3 or more months and were 50 years or older (or ≥18 years with diabetes or cardiovascular disease) were recruited from 11 sites in Australia and New Zealand. We aimed to recruit 150 participants. INTERVENTION After a 6-week run-in with the β-blocker carvedilol, we randomly assigned participants to treatment with carvedilol or placebo for 12 months. OUTCOMES & MEASUREMENTS The prespecified primary outcome was the proportion of participants who tolerated carvedilol, 6.25mg, twice daily during the run-in period. After randomization, we report participant withdrawal and the incidence of intradialytic hypotension (IDH). RESULTS Of 1,443 patients screened, 354 were eligible, 91 consented, and 72 entered the run-in stage. 49 of 72 run-in participants (68%; 95% CI, 57%-79%) achieved the primary outcome. 5 of the 23 withdrawals from run-in were attributable to bradycardia or hypotension. After randomization, 10 of 26 allocated to carvedilol and 4 of 23 allocated to placebo withdrew. 4 participants randomly assigned to carvedilol withdrew because of bradycardia or hypotension. Overall, there were 4 IDH events per 100 hemodialysis sessions; in participants allocated to carvedilol versus placebo, respectively, there were 7 versus 2 IDH events per 100 hemodialysis sessions (P=0.1) in the 2 weeks immediately following a dose increase and 4 versus 3 IDH events per 100 hemodialysis sessions after no dose increase (P=0.7). LIMITATIONS Unable to recruit planned sample size. CONCLUSIONS Recruiting patients receiving dialysis to an RCT of β-blocker versus placebo will prove challenging. Possible solutions include international collaboration and exploring novel trial designs such as a registry-based RCT.
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Affiliation(s)
- Matthew A Roberts
- Department of Renal Medicine, Eastern Health Clinical School, Monash University, Melbourne, Australia.
| | - Helen L Pilmore
- Department of Renal Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Francesco L Ierino
- Department of Nephrology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Sunil V Badve
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia; Department of Nephrology, St George Hospital, Sydney, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, Canada
| | - Nicole M Isbel
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Henry Krum
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Vlado Perkovic
- George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Anish Scaria
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Andrew M Tonkin
- Cardiovascular Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Liza A Vergara
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Carmel M Hawley
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
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Tang Y, Brooks JM, Wetmore JB, Shireman TI. Association between higher rates of cardioprotective drug use and survival in patients on dialysis. Res Social Adm Pharm 2015; 11:824-43. [PMID: 25657171 PMCID: PMC4490138 DOI: 10.1016/j.sapharm.2014.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/22/2014] [Accepted: 12/22/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND While cardiovascular (CV) disease is a leading cause of morbidity and mortality in patients on chronic dialysis, utilization rates of cardioprotective drugs for dialysis patients remain low. This study sought to determine whether higher rates of cardioprotective drug use among dialysis patients might increase survival. METHODS A retrospective cohort of incident dialysis patients (n = 50,468) with dual eligibility for U.S. Medicare and Medicaid was constructed using USRDS data linked with billing claims. Medication exposures included angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), β-blockers, calcium channel blockers (CCBs), and HMG-CoA reductase inhibitors (statins) prescribed within 90 days of dialysis initiation. The outcomes were one- and two-year survival and CV event-free survival. Variation in treatment rates based on local area practice styles were used as instruments in instrumental variable (IV) estimation, yielding average treatment effect estimates for patients whose treatment choices were affected by local area practice styles. RESULTS Patients aged 65 years and older comprised 47.4% of the sample, while 59.5% were female and 35.0% were white. The utilization rate was 40.7% for ACEIs/ARBs, 43.0% for β-blockers, 50.7% for CCBs and 26.4% for statins. The local area practice style instruments were highly significantly related to cardioprotective drug use in dialysis patients (Chow-F values > 10). IV estimates showed only that higher rates of β-blockers increased one-year survival (β = 0.161, P-value = 0.020) and CV event-free survival (β = 0.189, P-value = 0.033), but that higher rates of CCBs decreased two-year CV event-free survival (β = -0.520, P-value = 0.009). CONCLUSIONS This study suggests that higher utilization rates of β-blockers might yield higher survival rates for dialysis patients. However, higher rates of the other drugs studied had no correlations with survival, and higher CCB rates might actually reduce CV-event free survival. Since the benefits of cardioprotective drugs may vary across dialysis patients, the study findings should be interpreted only with respect to changes of utilization rates around the rates observed in this study.
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Affiliation(s)
- Yuexin Tang
- Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA, USA
| | - John M Brooks
- Department of Health Services Policy & Management and the Center for Rehabilitation and Reconstruction Sciences, University of South Carolina Arnold School of Public Health, Columbia, SC, USA
| | - James B Wetmore
- Department of Medicine, Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Theresa I Shireman
- Department of Preventive Medicine and Public Health, University of Kansas School of Medicine, Kansas City, KS, USA; The Kidney Institute, University of Kansas School of Medicine, Kansas City, KS, USA.
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Wetmore JB, Mahnken JD, Phadnis MA, Ellerbeck EF, Shireman TI. Relationship between calcium channel blocker class and mortality in dialysis. Pharmacoepidemiol Drug Saf 2015; 24:1249-58. [PMID: 26371369 DOI: 10.1002/pds.3869] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/20/2015] [Accepted: 08/11/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVE The comparative effectiveness of dihydropyridine (DHP) and non-DHP calcium channel blockers (CCBs) in maintenance dialysis patients has not been well-studied. METHODS A retrospective cohort of hypertensive patients initiating dialysis was created. New CCB initiators, defined as individual who had no evidence of CCB use in the first 90 days of dialysis but who were initiated by day 180, were followed from their first day of medication exposure until event or censoring; events consisted of all-cause mortality (ACM) and a combined endpoint of cardiovascular morbidity or mortality (CVMM). Cox proportional hazards models were used to determine adjusted hazard ratios (AHRs) comparing the effect of DHPs vs. non-DHPs. RESULTS There were 2900 and 2704 new initiators of CCBs in the ACM and CVMM models, respectively. Adjusted for other factors, use of DHPs, compared to non-DHPs, was associated with an AHR of 0.77 (99% confidence intervals, 0.64 - 0.93, P = 0.0004) for ACM and 0.86 (0.72 - 1.02, P = 0.024) for CVMM. Results were similar when individuals who initiated therapy at any point after the cohort inception were included, with AHRs of 0.60 (0.53 - 0.69, P < 0.0001) and 0.77 (0.67 - 0.89, P < 0.0001) for ACM and CVMM, respectively. Further, elimination of individuals with chronic atrial fibrillation resulted in AHRs of 0.71 and 0.70 for ACM and CVVM, respectively. CONCLUSION DHPs, as compared to non-DHPs, were associated with reduced hazard of death or cardiovascular morbidity and mortality; potential mechanisms of action require further study.
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Affiliation(s)
- James B Wetmore
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN, USA.,Chronic Disease Research Group, Minneapolis, MN, USA
| | | | | | | | - Theresa I Shireman
- Preventive Medicine and Public Health, Kansas City, KS, USA.,The Kidney Institute, University of Kansas School of Medicine, Kansas City, KS, USA
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Folt DA, Evans KL, Brahmandam S, He W, Brewster PS, Yu S, Murphy TP, Cutlip DE, Dworkin LD, Jamerson K, Henrich W, Kalra PA, Tobe S, Thomson K, Holden A, Rayner BL, Grinfeld L, Haller ST, Cooper CJ. Regional and physician specialty-associated variations in the medical management of atherosclerotic renal-artery stenosis. ACTA ACUST UNITED AC 2015; 9:443-52. [PMID: 26051926 DOI: 10.1016/j.jash.2015.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/16/2015] [Accepted: 03/21/2015] [Indexed: 11/18/2022]
Abstract
For people enrolled in Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL), we sought to examine whether variation exists in the baseline medical therapy of different geographic regions and if any variations in prescribing patterns were associated with physician specialty. Patients were grouped by location within the United States (US) and outside the US (OUS), which includes Canada, South America, Europe, South Africa, New Zealand, and Australia. When comparing US to OUS, participants in the US took fewer anti-hypertensive medications (1.9 ± 1.5 vs. 2.4 ± 1.4; P < .001) and were less likely to be treated with an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (46% vs. 62%; P < .001), calcium channel antagonist (37% vs. 58%; P < .001), and statin (64% vs. 75%; P < .05). In CORAL, the identification of variations in baseline medical therapy suggests that substantial opportunities exist to improve the medical management of patients with atherosclerotic renal-artery stenosis.
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Affiliation(s)
- David A Folt
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Kaleigh L Evans
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Sravya Brahmandam
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Wencan He
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Pamela S Brewster
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Shipeng Yu
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Timothy P Murphy
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Donald E Cutlip
- Department of Medicine, Harvard Clinical Research Institute, Boston, MA, USA
| | - Lance D Dworkin
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Kenneth Jamerson
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - William Henrich
- The University of Texas Health Science Center, San Antonio, TX, USA
| | - Philip A Kalra
- Department of Medicine, Salford Royal Hospital NHS Foundation Trust, Greater Manchester, United Kingdom
| | - Sheldon Tobe
- Sunnybrook and Women's College Health Sciences Centre, Toronto, Canada
| | - Ken Thomson
- Department of Radiology, Alfred Hospital, Melbourne, Australia
| | - Andrew Holden
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Brian L Rayner
- Department of Medicine, University of Cape Town/Groote Schuur Hospital, Cape Town, South Africa
| | - Liliana Grinfeld
- Department of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Steven T Haller
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA.
| | - Christopher J Cooper
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
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Roberts MA, Pilmore HL, Ierino FL, Badve SV, Cass A, Garg AX, Hawley CM, Isbel NM, Krum H, Pascoe EM, Tonkin AM, Vergara LA, Perkovic V. The rationale and design of the Beta-blocker to LOwer CArdiovascular Dialysis Events (BLOCADE) Feasibility Study. Nephrology (Carlton) 2015; 20:140-7. [DOI: 10.1111/nep.12362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Matthew A Roberts
- Department of Renal Medicine; Eastern Health Clinical School; Monash University; Melbourne Victoria Australia
| | - Helen L Pilmore
- Department of Renal Medicine; Auckland City Hospital; Auckland New Zealand
| | - Francesco L Ierino
- Department of Nephrology; Austin Health; Melbourne Victoria Australia
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
| | - Sunil V Badve
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Alan Cass
- Menzies School of Health Research; Charles Darwin University; Darwin Northern Territory Australia
| | - Amit X Garg
- Division of Nephrology; Department of Medicine; Western University; London Ontario Canada
| | - Carmel M Hawley
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Nicole M Isbel
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Henry Krum
- Centre of Cardiovascular Research and Education in Therapeutics; Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Queensland Australia
| | - Andrew M Tonkin
- Cardiovascular Research Unit; Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Liza A Vergara
- Australasian Kidney Trials Network; The University of Queensland; Brisbane Queensland Australia
| | - Vlado Perkovic
- The George Institute for Global Health; University of Sydney; Sydney New South Wales Australia
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Wetmore JB, Phadnis MA, Ellerbeck EF, Shireman TI, Rigler SK, Mahnken JD. Relationship between stroke and mortality in dialysis patients. Clin J Am Soc Nephrol 2014; 10:80-9. [PMID: 25318759 DOI: 10.2215/cjn.02900314] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND OBJECTIVES Stroke is common in patients undergoing long-term dialysis, but the implications for mortality after stroke in these patients are not fully understood. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A large cohort of dually-eligible (Medicare and Medicaid) patients initiating dialysis from 2000 to 2005 and surviving the first 90 days was constructed. Medicare claims were used to ascertain ischemic and hemorrhagic strokes occurring after 90-day survival. A semi-Markov model with additive hazard extension was generated to estimate the association between stroke and mortality, to calculate years of life lost after a stroke, and to determine whether race was associated with differential survival after stroke. RESULTS The cohort consisted of 69,371 individuals representing >112,000 person-years of follow-up. Mean age±SD was 60.8±15.5 years. There were 21.1 (99% confidence interval [99% CI], 20.0 to 22.3) ischemic strokes and 4.7 (99% CI, 4.2 to 5.3) hemorrhagic strokes after cohort entry per 1000 patient-years. At 30 days, mortality was 17.9% for ischemic stroke and 53.4% for hemorrhagic stroke. The adjusted hazard ratio (AHR) depended on time since entry into the cohort; for patients who experienced a stroke at 1 year after cohort entry, for example, the AHR of hemorrhagic stroke for mortality was 25.4 (99% CI, 22.4 to 28.4) at 1 week, 9.9 (99% CI, 8.4 to 11.6) at 3 months, 5.9 (99% CI, 5.0 to 7.0) at 6 months, and 1.8 (99% CI, 1.5 to 2.1) at 24 months. The corresponding AHRs for ischemic stroke were 11.7 (99% CI, 10.2 to 13.1) at 1 week, 6.6 (99% CI, 6.4 to 6.7) at 3 months, and 4.7 (99% CI, 4.5 to 4.9) at 6 months, remaining significantly >1.0 even at 48 months. Median months of life lost were 40.7 for hemorrhagic stroke and 34.6 for ischemic stroke. For both stroke types, mortality did not differ by race. CONCLUSIONS Dialysis recipients have high mortality after a stroke with corresponding decrements in remaining years of life. Poststroke mortality does not differ by race.
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Affiliation(s)
- James B Wetmore
- Department of Medicine, Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota; and
| | | | | | | | - Sally K Rigler
- Department of Medicine, University of Kansas School of Medicine, Kansas City, Kansas
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Sood MM, Manns B, Dart A, Hiebert B, Kappel J, Komenda P, Molzahn A, Naimark D, Nessim S, Rigatto C, Soroka S, Zappitelli M, Tangri N. Variation in the level of eGFR at dialysis initiation across dialysis facilities and geographic regions. Clin J Am Soc Nephrol 2014; 9:1747-56. [PMID: 25248743 DOI: 10.2215/cjn.12321213] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The relative influence of facilities and regions on the timing of dialysis initiation remains unknown. The purpose of the study is to determine the variation in eGFR at dialysis initiation across dialysis facilities and geographic regions in Canada after accounting for patient-level factors (case mix). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In total, 33,263 dialysis patients with an eGFR measure at dialysis initiation between January of 2001 and December of 2010 representing 63 dialysis facilities and 14 geographic regions were included in the study. Multilevel models and intraclass correlation coefficients were used to evaluate the variation in timing of dialysis initiation by eGFR at the patient, facility, and geographic levels. RESULTS The proportion initiating dialysis with an eGFR≥10.5 ml/min per 1.73 m(2) was 35.3%, varying from 20.1% to 57.2% across geographic regions and from 10% to 67% across facilities. In an unadjusted, intercept-only linear model, 90.7%, 6.6%, and 2.7% of the explained variability were attributable to patient, facility, and geography, respectively. After adjustment for patient and facility factors, 96.9% of the explained variability was attributable to patient case mix, 3.1% was attributable to the facility, and 0.0% was attributable to the geographic region. These findings were consistent when the eGFR was categorized as a binary variable (≥10.5 ml/min per 1.73 m(2)) or in an analysis limited to patients with >3 months of predialysis care. CONCLUSIONS Patient characteristics accounted for the majority of the explained variation regarding the eGFR at the initiation of dialysis. There was a small amount of variation at the facility level and no variation among geographic regions that was independent of patient- and facility-level factors.
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Affiliation(s)
- Manish M Sood
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada;
| | - Braden Manns
- Foothills Hospital, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Joanne Kappel
- Saskatoon Health Region, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Paul Komenda
- Seven Oaks Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anita Molzahn
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - David Naimark
- Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sharon Nessim
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Claudio Rigatto
- Seven Oaks Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Steven Soroka
- Department of Medicine, Section of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada; and
| | - Michael Zappitelli
- McGill University Health Centre, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Navdeep Tangri
- Seven Oaks Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
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Miller LM, Vercaigne LM, Moist L, Lok CE, Tangri N, Komenda P, Rigatto C, Mojica J, Sood MM. The association between geographic proximity to a dialysis facility and use of dialysis catheters. BMC Nephrol 2014; 15:40. [PMID: 24576140 PMCID: PMC3974066 DOI: 10.1186/1471-2369-15-40] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 02/21/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Residing remotely from health care resources appears to impact quality of care delivery. It remains unclear if there are differences in vascular access based on distance of one's residence to dialysis centre at time of dialysis initiation, and whether region or duration of pre-dialysis care are important effect modifiers. METHODS We studied the association of distance from a patients' residence to the nearest dialysis centre and central venous catheter (CVC) use in an observational study of 26,449 incident adult dialysis patients registered in the Canadian Organ Replacement Registry between 2000-2009. Multivariate logistic regression was used to assess the association between distance in tertiles and CVC use, adjusted for patient demographics and comorbidities. Geographic region and duration of pre-dialysis care were examined as potential effect modifiers. RESULTS Eighty percent of patients commenced dialysis with a CVC. Incident CVC use was highest among those living > 20 km from the dialysis centre (OR 1.29 (1.24-1.34)) compared to those living < 5 km from centre. The length of pre-dialysis care and geographic region were significant effect modifiers; among patients residing in the furthest tertile (>20 km) from the nearest dialysis centre, incident CVC use was more common with shorter length of pre-dialysis care (< 1 year) and residence in central regions of the country. CONCLUSION Residing further from a dialysis centre is associated with increased CVC use, an effect modified by shorter pre-dialysis care and the geographic region of the country. Efforts to reduce geographical disparities in pre dialysis care may decrease CVC use.
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Wetmore JB, Phadnis MA, Mahnken JD, Ellerbeck EF, Rigler SK, Zhou X, Shireman TI. Race, ethnicity, and state-by-state geographic variation in hemorrhagic stroke in dialysis patients. Clin J Am Soc Nephrol 2014; 9:756-63. [PMID: 24458073 DOI: 10.2215/cjn.06980713] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. A similar pattern of geographic variation in ischemic strokes has also recently been reported in patients undergoing long-term dialysis, but whether this is also the case for hemorrhagic stroke is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Medicare claims from 2000 to 2005 were used to ascertain hemorrhagic stroke events in a large cohort of incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios (ARRs) for stroke. RESULTS A total of 265,685 Medicare-eligible incident dialysis patients were studied. During a median follow-up of 15.5 months, 2397 (0.9%) patients sustained a hemorrhagic stroke. African Americans (ARR, 1.43; 95% confidence interval [CI], 1.30 to 1.57), Hispanics (ARR, 1.78; 95% CI, 1.57 to 2.03), and individuals of other races (ARR, 1.51; 95% CI, 1.26 to 1.80) had a significantly higher risk for hemorrhagic stroke compared with whites. In models adjusted for age and sex, four states had O/E ARRs for hemorrhagic stroke that were significantly greater than 1.0 (California, 1.15; Maryland, 1.25; North Carolina, 1.25; Texas, 1.19), while only 1 had an ARR less than 1.0 (Wisconsin, 0.79). However, after adjustment for race and ethnicity, no states had ARRs that varied significantly from 1.0. CONCLUSION Race and ethnicity, or other factors that covary with these, appear to explain a substantial portion of state-by-state geographic variation in hemorrhagic stroke. This finding suggests that the factors underlying the high rate of hemorrhagic strokes in dialysis patients are likely to be system-wide and that further investigations into regional variations in clinical practices are unlikely to identify large opportunities for preventive interventions for this disorder.
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Affiliation(s)
- James B Wetmore
- Department of Medicine, Division of Nephrology and Hypertension,, †The Kidney Institute,, ‡Department of Biostatistics,, §Department of Preventive Medicine and Public Health,, ‖Department of Medicine, and, ¶The Landon Center on Aging, University of Kansas School of Medicine, Kansas City, Kansas
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St Peter WL, Sozio SM, Shafi T, Ephraim PL, Luly J, McDermott A, Bandeen-Roche K, Meyer KB, Crews DC, Scialla JJ, Miskulin DC, Tangri N, Jaar BG, Michels WM, Wu AW, Boulware LE. Patterns in blood pressure medication use in US incident dialysis patients over the first 6 months. BMC Nephrol 2013; 14:249. [PMID: 24219348 PMCID: PMC3840675 DOI: 10.1186/1471-2369-14-249] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 11/04/2013] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Several observational studies have evaluated the effect of a single exposure window with blood pressure (BP) medications on outcomes in incident dialysis patients, but whether BP medication prescription patterns remain stable or a single exposure window design is adequate to evaluate effect on outcomes is unclear. METHODS We described patterns of BP medication prescription over 6 months after dialysis initiation in hemodialysis and peritoneal dialysis patients, stratified by cardiovascular comorbidity, diabetes, and other patient characteristics. The cohort included 13,072 adult patients (12,159 hemodialysis, 913 peritoneal dialysis) who initiated dialysis in Dialysis Clinic, Inc., facilities January 1, 2003-June 30, 2008, and remained on the original modality for at least 6 months. We evaluated monthly patterns in BP medication prescription over 6 months and at 12 and 24 months after initiation. RESULTS Prescription patterns varied by dialysis modality over the first 6 months; substantial proportions of patients with prescriptions for beta-blockers, renin angiotensin system agents, and dihydropyridine calcium channel blockers in month 6 no longer had prescriptions for these medications by month 24. Prescription of specific medication classes varied by comorbidity, race/ethnicity, and age, but little by sex. The mean number of medications was 2.5 at month 6 in hemodialysis and peritoneal dialysis cohorts. CONCLUSIONS This study evaluates BP medication patterns in both hemodialysis and peritoneal dialysis patients over the first 6 months of dialysis. Our findings highlight the challenges of assessing comparative effectiveness of a single BP medication class in dialysis patients. Longitudinal designs should be used to account for changes in BP medication management over time, and designs that incorporate common combinations should be considered.
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Affiliation(s)
- Wendy L St Peter
- University of Minnesota College of Pharmacy, Minneapolis, MN, USA.
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15
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Wetmore JB, Ellerbeck EF, Mahnken JD, Phadnis MA, Rigler SK, Spertus JA, Zhou X, Mukhopadhyay P, Shireman TI. Stroke and the "stroke belt" in dialysis: contribution of patient characteristics to ischemic stroke rate and its geographic variation. J Am Soc Nephrol 2013; 24:2053-61. [PMID: 23990675 DOI: 10.1681/asn.2012111077] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. ESRD is a potent risk factor for stroke, but whether regional variations in stroke risk exist among dialysis patients is unknown. Medicare claims from 2000 to 2005 were used to ascertain ischemic stroke events in a large cohort of 265,685 incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios for stroke. Older age, female sex, African American race and Hispanic ethnicity, unemployed status, diabetes, hypertension, history of stroke, and permanent atrial fibrillation were positively associated with ischemic stroke, whereas body mass index >30 kg/m(2) was inversely associated with stroke (P<0.001 for each). After full multivariable adjustment, the three states with O/E rate ratios >1.0 were all in the South: North Carolina, Mississippi, and Oklahoma. Regional efforts to increase primary prevention in the "stroke belt" or to better educate dialysis patients on the signs of stroke so that they may promptly seek care may improve stroke care and outcomes in dialysis patients.
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Affiliation(s)
- James B Wetmore
- Department of Medicine, Division of Nephrology and Hypertension
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16
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Wetmore JB, Mahnken JD, Rigler SK, Ellerbeck EF, Mukhopadhyay P, Hou Q, Shireman TI. Impact of race on cumulative exposure to antihypertensive medications in dialysis. Am J Hypertens 2013; 26:234-42. [PMID: 23382408 DOI: 10.1093/ajh/hps019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Racial minorities typically have less exposure than non-minorities to antihypertensive medications across an array of cardiovascular conditions in the general population. However, cumulative exposure has not been investigated in dialysis patients. METHODS In a longitudinal analysis of 38,381 hypertensive dialysis patients, prescription drug data from Medicaid was linked to Medicare data contained in United States Renal Data System core data, creating a national cohort of dialysis patients dually eligible for Medicare and Medicaid services. The proportion of days covered (PDC) was calculated to determine cumulative exposure to angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), β-blockers, and calcium-channel blockers (CCDs). The factors associated with use of these medications were modeled through weighted linear regression, with derivation of the adjusted odds ratios (AORs) for exposure. RESULTS Relative to non-Hispanic Caucasians, African-American, Hispanic, or Other race/ethnicity were significantly associated with less exposure to β-blockers (AOR 0.56-0.69, P < 0.001 in each case) and CCBs (AOR 0.84-0.85, P < 0.001 in each case); African-American race and Hispanic ethnicity had AORs of 0.78 and 0.73 for ACEIs and ARBs, respectively (P < 0.001 in both cases). Collectively, the odds of exposure to each class of medication for minorities was about three-quarters of that for Caucasians. CONCLUSIONS Given that dually Medicare-and-Medicaid-eligible dialysis patients have insurance coverage for prescription medications as well as regular contact with health care providers, differences by race in exposure to antihypertensive medications should with time be minimal among patients who are candidates for these drugs. The causes of differences by race in exposure to antihypertensive medications over the course of time should be further examined.
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Affiliation(s)
- James B Wetmore
- Department of Medicine, Division of Nephrology and Hypertension, University of Kansas School of Medicine, Kansas City, KS, USA
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Wetmore JB, Ellerbeck EF, Mahnken JD, Phadnis M, Rigler SK, Mukhopadhyay P, Spertus JA, Zhou X, Hou Q, Shireman TI. Atrial fibrillation and risk of stroke in dialysis patients. Ann Epidemiol 2013; 23:112-8. [PMID: 23332588 DOI: 10.1016/j.annepidem.2012.12.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 11/23/2012] [Accepted: 12/11/2012] [Indexed: 02/07/2023]
Abstract
PURPOSE Both stroke and chronic atrial fibrillation (AF) are common in dialysis patients, but uncertainty exists in the incidence of new strokes and the risk conferred by chronic AF. METHODS A cohort of dually eligible (Medicare and Medicaid) incident dialysis patients was constructed. Medicare claims were used to determine the onset of chronic AF, which was specifically treated as a time-dependent covariate. Cox proportional hazards models were used to model time to stroke. RESULTS Of 56,734 patients studied, 5629 (9.9%) developed chronic AF. There were 22.8 ischemic and 5.0 hemorrhagic strokes per 1000 patient-years, a ratio of approximately 4.5:1. Chronic AF was independently associated with time to ischemic (hazard ratio [HR], 1.26; 99% confidence interval [CI], 1.06-1.49; P = .0005), but not hemorrhagic, stroke. Race was strongly associated with hemorrhagic stroke: African Americans (HR, 1.46; 99% CI, 1.08-1.96), Hispanics (HR, 1.64; 99% CI, 1.16-2.31), and others (HR, 1.76; 99% CI, 1.16-2.78) had higher rates than did Caucasians (all P < .001). CONCLUSIONS Chronic AF has a significant, but modest, association with ischemic stroke. Race/ethnicity is strongly associated with hemorrhagic strokes. The proportion of strokes owing to hemorrhage is much higher than in the general population.
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Affiliation(s)
- James B Wetmore
- Department of Medicine, Division of Nephrology and Hypertension, University of Kansas School of Medicine, Kansas City, KS, USA.
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Tomaszuk-Kazberuk A, Kozuch M, Malyszko J, Bachorzewska-Gajewska H, Dobrzycki S, Musial WJ. Pharmacologic treatment in dialysis patients hospitalized for cardiovascular reasons: do we follow the guidelines? Ren Fail 2012; 35:235-42. [PMID: 23176538 DOI: 10.3109/0886022x.2012.745119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM The aim was to assess if the pharmacological treatment due to cardiovascular causes in dialysis patients is compliant with the European Guidelines. METHODS In total, 110 consecutive end-stage renal disease (ESRD) patients on regular dialysis were enrolled into the study. We divided the population into subgroups with coronary artery disease (CAD), chronic heart failure (CHF) and diabetes mellitus (DM). RESULTS We gathered information about drugs from 99 patients. The mean age was 61.8 ± 12.9 years (70% of males). There were 37 patients with CAD. Acetylsalicylic acid (ASA) was taken by 89% of the patients with CAD, clopidogrel by 25%, beta-blockers by 70%, angiotensin converting enzyme inhibitors (ACEIs) by 50%, angiotensin receptor blockers (ARBs) by 8%, and statins by 41%. Dual antiplatelet therapy was used after stent implantation (35%). There were 24 patients with CHF. Beta-blockers were taken by 71% of the patients, ACEIs by 45%, statins by 54%, and diuretics by 21% with CHF. There were 36 patients with DM. ASA was taken by 89% of the patients, clopidogrel and ticlopidine by 34%, beta-blockers were taken by 67%, ACE-inhibitors by 55%, and statins by 38% of the population with DM. The patients with DM were taking more ACEIs than those without DM (p = 0.033). DM was associated with a statistically 21% higher odds of ACEI/ARB use, but CHF was associated with no increase in the odds of beta-blocker use and no increase in ACEI/ARB use. CONCLUSIONS Dialysis patients with cardiovascular diseases are given less cardioprotective drugs such as ASA, beta-blockers, ACEIs, ARBs, and statins than they should be given according to the guidelines.
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Geographic variation in HMG-CoA reductase inhibitor use in dialysis patients. J Gen Intern Med 2012; 27:1475-83. [PMID: 22696256 PMCID: PMC3475809 DOI: 10.1007/s11606-012-2112-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 04/09/2012] [Accepted: 04/18/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite uncertainty about their effectiveness in chronic dialysis patients, statin use has increased in recent years. Little is known about the demographic, clinical, and geographic factors associated with statin exposure in end-stage renal disease (ESRD) patients. OBJECTIVE To analyze the demographic, clinical, and geographic factors associated with use of statins among chronic dialysis patients. DESIGN Cross-sectional analysis. SETTING Prevalent dialysis patients across the U.S. PARTICIPANTS 55,573 chronic dialysis patients who were dually eligible for Medicaid and Medicare services during the last four months of 2005. METHODS Using Medicaid prescription drug claims and United States Renal Data System core data, we examined demographics, comorbid conditions, and state of residence using hierarchical logistic regression models to determine their associations with statin use. INTERVENTION Prescription for a statin. OUTCOME MEASURES Factors associated with a prescription for a statin. RESULTS Statin exposure was significantly associated with older age, female sex, Caucasian (versus African-American) race, body mass index, use of self-care dialysis, diabetes, and comorbidity burden. Moreover, there was substantial state-by-state variation in statin use, with a greater than 2.3-fold difference in adjusted odds ratios between the highest- and lowest-prescribing states. CONCLUSIONS Among publicly insured chronic dialysis patients, there were marked differences between states in the use of HMG-CoA reductase inhibitors above and beyond patient characteristics. This suggests substantial clinical uncertainty about the utility of these medications. Understanding how such regional variations impact patient care in this high-risk population is an important focus for future work.
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Abstract
PURPOSE OF REVIEW Geographic variation in the occurrence and outcomes of chronic kidney disease (CKD) is major area of study in epidemiology and health services and outcomes research. Geographic attributes may be as diverse as the physical, socioeconomic, and medical care characteristics of an environment. This review summarizes the recent literature pertaining to geographic risk factors and CKD. RECENT FINDINGS Studies have reported on the association between CKD and physical attributes of place (ambient temperature and altitude), the impact of disasters on CKD populations, new diseases characterized by regional localization, national variations in CKD incidence and prevalence, regional variation in end-stage renal disease incidence, residential mobility and CKD risk factors, and geographic variations in CKD care. The emerging role of tools for geospatial studies - including multilevel analytical designs, which reduce the likelihood of an ecologically biased inference, and geographic information systems, which allow the simultaneous linkage, analysis, and mapping of geospatial data - is illustrated by these studies. SUMMARY Our understanding of the occurrence and outcomes of CKD will continue to be expanded and deepened by the explicit study of attributes associated with place as a potential risk factor. Many of the studies reviewed are largely hypothesis generating, and a better understanding of the role of geography in the study of CKD awaits investigations that probe the mechanisms that link attributes of place to disease processes.
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Otiniano M, Wood RC. Exploring the importance of identifying geographic variation to improve diabetes treatment. J Diabetes Complications 2012; 26:255-6. [PMID: 22673567 DOI: 10.1016/j.jdiacomp.2012.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Wetmore JB, Mahnken JD, Rigler SK, Ellerbeck EF, Mukhopadhyay P, Hou Q, Shireman TI. Association of race with cumulative exposure to statins in dialysis. Am J Nephrol 2012; 36:90-6. [PMID: 22739257 DOI: 10.1159/000339626] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 05/21/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients on dialysis have high rates of cardiovascular disease and are frequently treated with HMG-CoA reductase inhibitors. Given that these patients have insurance coverage for medications as well as regular contact with health care providers, differences by race in exposure to statins over time should be minimal among patients who are candidates for the drug. METHODS We created a cohort of incident dialysis patients who were dually eligible for Medicare and Medicaid services. We determined the proportion of days covered (or PDC, a marker of cumulative medication exposure) by a statin prescription over a mean of 2.0 ± 1.4 years. Ordinary least squares regression was used to determine the factors associated with cumulative drug exposure. RESULTS Of the 18,727 patients who filled at least one prescription for a statin, mean PDC was 0.57 ± 0.32. The unadjusted PDC was higher for Caucasians (0.63 ± 0.31) than for African-Americans (0.51 ± 0.32), Hispanics (0.54 ± 0.31), and individuals of other race/ethnicity (0.58 ± 0.32). In multivariable modeling, Caucasian race was independently associated with greater exposure to statins. Relative to Caucasians, the adjusted odds ratios for the PDC for African-Americans was 0.47 (95% confidence interval, CI, 0.43-0.50), for Hispanics 0.52 (0.48-0.56) and for others, 0.72 (0.64-0.81). CONCLUSIONS Despite insurance coverage, regular contact with health care providers, and at least one prescription for a statin, there are large differences by race in statin exposure over time. The provider- and patient-associated factors related to this phenomenon should be further examined.
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Affiliation(s)
- James B Wetmore
- Division of Nephrology and Hypertension, Department of Medicine, University of Kansas School of Medicine, Kansas City, USA
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