Relationships of race and ethnicity to progression of kidney dysfunction and clinical outcomes in patients with chronic kidney failure

Slowing the progression of diabetic and non-diabetic kidney disease: A summary of the current evidence base for sodium-glucose co-transporter-2 inhibitors

The global prevalence of chronic kidney disease (CKD) is approximately 9%. CKD is predicted to become the fifth largest global cause of death by 2040. Moreover, CKD causes disability, diminished quality of life and poses a high cost to healthcare systems. Delaying the development and progression of CKD is therefore of the utmost importance. Several kidney-specific outcome trials on sodium-glucose co-transporter-2 inhibitors (SGLT-2s) have recently provided a paradigm shift in the treatment of people with CKD, with or without diabetes, as these agents have been shown to reduce the progression of CKD on top of maximally tolerated renin-angiotensin-aldosterone system (RAAS) blockade. The relative benefit and safety of SGLT-2is seems to be consistent across ethnicities, ages and frailty categories; however, this needs to be tested in dedicated clinical trials. Guidelines make clear recommendations for the prescription of SGLT-2is and RAAS inhibitors as standard of care for people with CKD. Their combination with other newer antidiabetic agents may provide further benefits by targeting different components of CKD mechanisms. Dedicated randomized controlled trials are needed to test whether combination with other agents could extend the use of SGLT2is and identify people in whom a combination of drugs may be most effective. Increased efforts to implement the guidelines on treatment with SGLT-2is for people with CKD are needed, particularly in those at the highest risk of adverse outcomes and without type 2 diabetes. Moreover, strategies to target the equitable use of SGLT-2is are needed.

Rates of Reporting and Analyzing Race and Ethnicity in Athlete-Specific Sports Medicine Research: A Systematic Review

Background

Race- and ethnicity-based differences in treatment access and outcomes have been reported in the orthopaedic sports medicine literature. However, the rate at which race and ethnicity are reported and incorporated into the statistical analysis of sports medicine studies remains unclear.

Purpose

To determine the rate at which race and ethnicity are reported and analyzed in athlete-specific sports medicine literature.

Study Design

Systematic review; Level of evidence, 4.

Methods

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, articles published by the 3 journals of the American Orthopaedic Society for Sports Medicine between 2017 and 2021 were considered for inclusion. Original sports medicine research studies that focused on athletes were included. Outcome measures included reporting and analysis of patient demographics (age, sex, race, ethnicity). Studies that included demographic variables in a multivariate analysis or that performed a race-/ethnicity-based stratified analyses were considered to have analyzed that variable. Studies that reported and/or analyzed patient demographics were examined. Chi-square tests were performed to determine statistical significance.

Results

A total of 5140 publications were screened, and 842 met the inclusion criteria. Age and sex were well reported (84.1% and 87.0%, respectively), while race (3.8%) and ethnicity (2.0%) were poorly reported. There was no difference in rates of reporting age, sex, race, or ethnicity between the American Journal of Sports Medicine (AJSM), the Orthopaedic Journal of Sports Medicine (OJSM), or Sports Health: A Multidisciplinary Approach (Sports Health). The rate of analysis was also calculated as a percentage of the studies that reported that variable. Of the studies that reported age, 38.5% analyzed age. Using this method, 26.2% of studies analyzed sex, 40.6% analyzed race, and 17.6% analyzed ethnicity. Although there was no difference in the overall rate at which studies from the 3 journals analyzed ethnicity, Sports Health studies analyzed age (P = .044), sex (P = .001), and race (P = .027) more frequently than studies published in AJSM and OJSM. Of the studies that analyzed race, most of those studies (8/13, 61.5%) found significant race-based differences in reported outcomes.

Conclusion

This systematic review demonstrated that race and ethnicity are poorly reported and analyzed in athlete-specific sports medicine literature, despite the fact that a majority of studies analyzing race found significant differences between racial groups. Improved reporting of race and ethnicity can determine whether race- and ethnicity-based differences exist in patient interventions to ameliorate disparities in patient outcomes.

Ten years trajectories of estimated glomerular filtration rate (eGFR) in a multiethnic cohort of people with type 1 diabetes and preserved renal function

OBJECTIVES

We aim to evaluate estimated glomerular filtration rate (eGFR) patterns of progression in a multiethnic cohort of people with type I diabetes mellitus and with baseline eGFR ≥45 mL/min/1.73 m2.

DESIGN

Observational cohort.

SETTING

People with a clinical diagnosis of type 1 diabetes, attending two university hospital-based outpatient diabetes clinics, in South London between 2004 and 2018.

PARTICIPANTS

We studied 1495 participants (52% females, 81% white, 12% African-Caribbean and 7% others).

PRIMARY AND SECONDARY OUTCOME MEASURES

Clinical measures including weight and height, systolic blood pressure, diastolic blood pressure and laboratory results (such as serum creatinine, urine albumin to creatinine ratio (ACR), HbA1c were collected from electronic health records (EHRs) and eGFR was estimated by the Chronic Kidney Disease-Epidemiology Collaboration. Ethnicity was self-reported.

RESULTS

Five predominantly linear patterns/groups of eGFR trajectories were identified. Group I (8.5%) had a fast eGFR decline (>3 mL/min/1.73 m2 year). Group II (23%) stable eGFR, group III (29.8%), groups IV (26.3%) and V (12.4%) have preserved eGFR with no significant fall. Group I had the highest proportion (27.6%) of African-Caribbeans. Significant differences between group I and the other groups were observed in age, gender, HbA1C, systolic and diastolic blood pressure, body mass index, cholesterol and urine ACR, p<0.05 for all. At 10 years of follow-up, 33% of group I had eGFR <30 and 16.5%<15 (mL/min/1.73 m2).

CONCLUSIONS

Distinct trajectories of eGFR were observed in people with type 1 diabetes. The group with the highest risk of eGFR decline had a greater proportion of African-Caribbeans compared with others and has higher prevalence of traditional modifiable risk factors for kidney disease.

Exploring the Role of Phenolic Compounds in Chronic Kidney Disease: A Systematic Review

Chronic kidney disease (CKD) presents a formidable global health concern, affecting one in six adults over 25. This review explores the potential of phenolic compounds in managing CKD and its complications. By examining the existing research, we highlight their diverse biological activities and potential to combat CKD-related issues. We analyze the nutritional benefits, bioavailability, and safety profile of these compounds. While the clinical evidence is promising, preclinical studies offer valuable insights into underlying mechanisms, optimal dosages, and potential side effects. Further research is crucial to validate the therapeutic efficacy of phenolic compounds for CKD. We advocate for continued exploration of their innovative applications in food, pharmaceuticals, and nutraceuticals. This review aims to catalyze the scientific community's efforts to leverage phenolic compounds against CKD-related challenges.

African Caribbean Ethnicity Is an Independent Predictor of Significant Decline in Kidney Function in People With Type 1 Diabetes

OBJECTIVE

The aim of the study was to identify the demographic and clinical features in an urban cohort of people with type 1 diabetes who developed a ≥50% decline in estimated glomerular filtration rate (eGFR).

RESEARCH DESIGN AND METHODS

We evaluated 5,261 people with type 1 diabetes (51% female, 13.4% African Caribbean) with baseline eGFR >45 mL/min/1.73 m2 between 2004 and 2018. The primary end point was an eGFR decline of ≥50% from baseline with a final eGFR <30 mL/min/1.73 m2. eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation.

RESULTS

Of the cohort, 263 (5%) reached the primary end point. These individuals were more likely to be of African Caribbean ethnicity, be older, have a longer duration of diabetes, have higher systolic blood pressure and HbA1c, have more prevalent retinopathy, and have higher albuminuria (all P < 0.05). In multivariable Cox regression models, African Caribbean ethnicity emerged as a significant risk factor for the primary end point (hazard ratio 1.57, 95% CI 1.19, 2.08) compared with other ethnicities and independent of established risk factors (P < 0.01). The incidence rate for the primary end point in African Caribbean people was double that in non-African Caribbean people (16 vs. 7.7 per 1000 patient-years, P < 0.001). A similar significant independent impact of African Caribbean ethnicity for secondary end points (≥40% and ≥30% fall in eGFR) was observed.

CONCLUSIONS

We report a novel observation that African Caribbean ethnicity increased the risk of kidney function loss in people with type 1 diabetes, an effect that was independent of traditional risk factors. Further studies are needed to examine the associated pathophysiology that may explain this observation.

Sex-age-specific handgrip strength and mortality in an incident hemodialysis cohort: The risk explained by nutrition and comorbidities

OBJECTIVE:

To investigate associations of sex-age-specific handgrip strength by a dynamometer with all-cause mortality and the percent excess risk explained (%ERE) by comorbidities and nutritional indicators in incident maintenance hemodialysis patients.

METHODS:

Prospective cohort of 413 adult patients (165 women, 248 men, 299 <60 years and 114 ⩾60 years) with <6 months (82% <3 months) on dialysis enrolled in PROHEMO in Salvador, Brazil. Low and high handgrip strength groups were based on sex-age-specific cutoffs (17.8 kg for women <60 years, 13.8 kg for women ⩾60 years, 29.5 kg for men <60 years, and 21.9 kg for men ⩾60 years). We used Cox regression to estimate the mortality hazard ratio. The %ERE was determined by the equation (HR1 - HR2)/(HR1 - 1) × 100, in which HR1 represented the hazard ratio in a model with a smaller number of covariates and HR2 represented the hazard ratio in a subsequent model with the inclusion of new covariates plus the variables included in the previous model.

RESULTS:

The mortality hazard ratio comparing low and high handgrip strength was 2.58 (95% confidence interval: 1.73, 3.85) in the model with sociodemographic factors and vintage and 2.25 (95% confidence interval: 1.49, 3.43) with addition of comorbidities, corresponding to a %ERE of 21%. The hazard ratio was 1.98 (95% confidence interval: 1.29, 3.06) after addition of nutritional indicators corresponding to %ERE of 38%. Results stratified by age and gender followed similar patterns.

CONCLUSION:

These results provide support for the assessment of handgrip strength in all maintenance hemodialysis patients for early identification of those who may require special care to improve nutritional status and survival.

Diabetes and risk of renal cell carcinoma

Background and objectives: There is evidence that the incidence of solid tumors is markedly increased in patients with diabetes mellitus. In the current study, we investigate the association between diabetes and renal cancer.

Patients and Methods: A single-center retrospective analysis of 473 patients who underwent nephrectomy for renal cell carcinoma (RCC) was performed. Diabetic RCC patients were screened for age, gender, ethnicity, HgA1C, glucose levels and renal function.

Results: Of the 473 cases with RCC, we identified 120 patients (25.4%) with a history of diabetes. The incidence of diabetes in RCC patients was higher in female than male subjects and in Hispanic compared to White and Other ethnic backgrounds. At diagnosis, the majority of diabetic RCC patients were 50-59 years of age. In diabetic RCC cases, clear cell type histology (92.0%), nuclear grade 2 (56.1%) and tumor size range from 1-5 cm (65.7%) were the most common in each category.

Conclusion: Our findings indicate that diabetic RCC patients have a predominance of localized, small clear cell RCC. In addition, females with a history of RCC have a higher frequency of diabetes compared to males. This is the first report of clinical and histopathological features of RCC associated with diabetes.

Essential hypertension and risk of nephropathy: a reappraisal

PURPOSE OF REVIEW

Treating mild-to-moderate essential hypertension in nondiabetic African Americans fails to halt nephropathy progression, whereas hypertension control slows nephropathy progression in European Americans. The pathogenesis of these disparate renal syndromes is reviewed.

RECENT FINDINGS

The nonmuscle myosin heavy chain 9 gene (MYH9) is associated with a spectrum of kidney diseases in African Americans, including idiopathic focal global glomerulosclerosis historically attributed to hypertension, idiopathic focal segmental glomerulosclerosis, and the collapsing variant of focal segmental glomerulosclerosis [HIV-associated nephropathy (HIVAN)]. Risk variants in MYH9 likely contribute to the failure of hypertension control to slow progressive kidney disease in nondiabetic African Americans.

SUMMARY

Early and intensive hypertension control fails to halt progression of 'hypertensive nephropathy' in African Americans. Genetic analyses in patients with essential hypertension and nephropathy attributed to hypertension, focal segmental glomerulosclerosis and HIVAN reveal that MYH9 gene polymorphisms are associated with a spectrum of kidney diseases in this ethnic group. Mild to moderate hypertension may cause nephropathy in European Americans with intrarenal vascular disease improved by the treatment of hypertension, hyperlipidemia and smoking cessation.

Advance care planning among Asian Americans and Native Hawaiians receiving haemodialysis

AIM

To explore the attitudes about death and dying, advance care planning (ACP), and completion of ACP among Asian Americans (AAs) and Native Hawaiians (NHs) receiving haemodialysis. This study was a descriptive, cross-sectional survey design.

METHOD

A convenience sample of 50 participants aged 30-82 years was recruited from four outpatient dialysis centers in Honolulu, Hawaii and interviewed face-to-face using a 43-item end-of-life community survey. A majority of participants perceived dying as an important part of life and were comfortable talking about death, but expressed concerns and fears about end-of-life issues. Aspects of ACP, such as planning a funeral service, getting finances in order, and completing the will were important. While most participants' attitudes about ACP were positive, less than half (40%) had completed ACP. Most participants preferred initiating end-of-life conversations with family.

CONCLUSIONS

The main conclusions drawn from this study are that there is a need for ACP and secondly that AAs and NHs would prefer to discuss ACP with family members rather than health or legal professionals. Findings from this preliminary study build on the need to use a theoretical framework in which to develop sound instruments and effective interventions to promote ACP completion among AAs and NHs receiving haemodialysis.

The effects of race on patient preferences and spouse substituted judgments

Knowledge about the ways in which race affects decision-making at the end of life is minimal, yet this information is critical for providing culturally sensitive care at the end of life. Data matching socio-demographic characteristics of 34 black and 34 white patients with end-stage renal disease and their spouses reveal that there are no significant differences in the preferences to continue dialysis on the part of black and white patients. However, the substituted judgments of black and white spouses differ from one another, with black spouses being more likely to indicate that they believe that the patient would be more inclined to continue dialysis under a host of hypothetical conditions than white spouses. Structural equation modeling analyses revealed that differences in spouse substituted judgments between black and white spouses are explained as a direct function of race differences in perception of patient's health, and caregiver burden, and that indirect effects are associated with spouse's fear of death and participation in religious services. We conclude that these variables rather than race per se explain differences in end of life decision making.

Impact of immigration on the clinical expression of systemic lupus erythematosus: a comparative study of Hispanic patients residing in the USA and Mexico

OBJECTIVE

To compare the socio-economic characteristics, clinical features and health-related quality of life in Hispanic SLE patients residing in Mexico and in the Southwest USA (Mexican and Texan, herein).

METHODS

Mexican and Texan SLE patients (fulfilling ACR criteria) participating in separate longitudinal outcome studies were evaluated. Texan patients were randomly chosen to match total disease duration with the Mexican patients. Cross-sectional data for the Mexican patients were obtained by a US-trained investigator who had previously participated in data collection for the cohort to which the Texan patients belonged. Socio-economic and -demographic characteristics, clinical characteristics, disease activity (with SLAM-Revised), damage accrual (with SLICC/ACR Damage Index) and self-reported function (with Short Form-36) were compared between the two groups.

RESULTS

Seventy Mexican patients were matched with either one or two Texan patients (n = 94) for a total of 164 patients. Mexican patients were younger. In age-adjusted analyses, the Mexican patients were more educated, had better health-related quality of life and overall less systemic SLE manifestations. Mexican patients were exposed more frequently to AZA.

CONCLUSIONS

Texan patients had more severe disease than the Mexican patients. In multivariable analyses, Texan Hispanic ethnicity was significantly associated with high disease activity, but significance was not reached for damage. The discrepant findings observed between these two Hispanic groups of SLE patients may reflect socio-economic or biological factors. Given the global phenomenon of immigration, rheumatologists should be aware of the overall course and outcome of immigrant SLE patients if undesirable outcomes are to be prevented.

Global complication rates of type 2 diabetes in Indigenous peoples: A comprehensive review

INTRODUCTION AND OBJECTIVE

The world's Indigenous peoples are experiencing an unprecedented epidemic of type 2 diabetes [T2DM] but little has been published describing the complications burden. The objective of this paper was to conduct a systematic review of T2DM complications in Indigenous populations worldwide.

METHODS

A literature review was conducted using PubMed and EMBASE to examine available complications data. Country, Indigenous population, authors, publication year, total sample size, Indigenous sample size, age, methodology, and prevalence of nephropathy, end-stage renal disease, retinopathy, neuropathy, lower extremity amputations, cardiovascular disease, hospitalizations and mortality due to diabetes were recorded.

RESULTS

One-hundred and eleven studies were selected. Results revealed a disproportionate burden of disease complications among all Indigenous peoples regardless of their geographic location. Complication rates were seen to vary widely across Indigenous groups.

DISCUSSION

Gaps were found in the published literature on complications among Indigenous populations, especially those living in underdeveloped countries. These gaps may be in part due to the challenges caused by varying operational practices, research methodologies, and definitions of the term Indigenous, making documentation of rates among these peoples problematic. Comprehensive surveillance applying standardized definitions and methodologies is needed to design targeted prevention and disease management strategies for Indigenous peoples with T2DM.

Evaluation of genetic association and expression reduction of TRPC1 in the development of diabetic nephropathy

BACKGROUND/AIMS

The TRPC1 gene on chromosome 3q22-24 resides within the linkage region for diabetic nephropathy (DN) in type 1 (T1D) and type 2 diabetes mellitus (T2D). A recent study has demonstrated that TRPC1 expression is reduced in the kidney of diabetic ZDF- and STZ-treated rats. The present study aimed to evaluate the genetic and functional role of TRPC1 in the development of DN.

METHODS

Genetic association study was performed with two independent cohorts, including 1,177 T1D European Americans with or without DN from GoKinD population and 850 African-American subjects with T2D-associated end-stage renal disease (ESRD), or with hypertensive (non-diabetic) ESRD, and nondiabetic controls. Seven tag SNP markers derived from HapMap data (phase II) were genotyped. TRPC1 gene expression was examined using real time RT-PCR.

RESULTS

No significant association of TRPC1 DNA polymorphisms with DN or ERSD was found in GoKinD and African-American populations. TRPC1 gene mRNA expression in kidney was found to be trendily reduced in 12-week and significantly in 26-week-old db/db mice.

CONCLUSIONS

TRPC1 genetic polymorphism may not fundamentally contribute to the development of DN, while reduction of the gene expression in kidney may be a late phenomenon of DN as seen in diabetic animal models.

HCV in patients with end-stage renal disease

Chronic hepatitis C virus (HCV) infection remains an important cause of liver disease in patients with end-stage renal disease (ESRD) and conversely, renal failure has a significant impact on morbidity and mortality throughout the natural history of chronic HCV and its treatment. With improved awareness within dialysis units of the potential for spread and the institution of preventative measures, the prevalence of HCV infection in the hemodialysis-dependent population has continued to decline since 1995. Use of HCV (+) donor kidneys is associated with an increase in the prevalence of liver disease, but when compared with continued hemodialysis, transplantation using these kidneys is associated with improved survival. Overall, survival in patients with chronic HCV infection appears to be better after renal transplantation when compared with maintenance hemodialysis, and transplant should be considered for these patients. Data support the use of interferon and the improved efficacy of pegylated interferon formulations for treatment of chronic HCV infection in ESRD patients, although tolerability continues to be troublesome. The newest and most promising data regarding the treatment of HCV in ESRD involve the combination of reduced dose ribavirin with interferon or pegylated interferon suggesting similar enhancements in sustained virologic response (SVR) as seen in non-ESRD patients, but caution is advised, as all studies to date used ribavirin plasma concentration monitoring in patient with ESRD. Finally, with regard to postrenal transplant treatment of HCV infection, there is no evidence to support treatment with interferon-based therapy and pretransplant treatment remains the best option whenever possible.

Levels of GFR and protein-induced hyperfiltration in kidney donors: a single-center experience in India

BACKGROUND

Some studies have shown that the normal range of glomerular filtration rate (GFR) was lower in an Indian population than in western populations. To verify these findings and determine whether it is physiological or an expression of subclinical disease, we measured GFR in a cohort of healthy Indian adults by using more stringent criteria to define "healthy" than used in previous studies.

STUDY DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

109 healthy adults being evaluated for kidney donation with normal blood pressure, body mass index, urinalysis results, and protein excretion and symmetrical function on radionuclide renogram. Subjects followed a vegetarian diet with 1 g/kg of protein intake for 10 days before the study.

PREDICTORS

Age, sex, relation to recipient (relative versus spouse), body surface area, body mass index, kidney size, serum creatinine level, and urinary protein-creatinine ratio. OUTCOME AND MEASUREMENTS: GFR measured as plasma clearance of technetium 99m diethyl-triamine-penta-acetic acid before and after amino-acid infusion (protein-induced hyperfiltration). Measurements were performed after a 12-hour fast.

RESULTS

Mean baseline GFR was 82.4 +/-12.7 mL/min/1.73 m(2) (95% confidence interval, 80.0 to 84.8). Mean stimulated GFR was 104.7 +/- 16.1 mL/min/1.73 m(2) (95% confidence interval, 101.6 to 107.8). Measured mean protein-induced hyperfiltration was 27.3% +/- 10.04% (range, 6.7% to 56%). In multivariable linear regression analysis, younger age, spousal donor, and larger average kidney size were associated with significantly greater baseline GFR, and only greater baseline GFR was associated significantly with stimulated GFR.

LIMITATIONS

Dietary protein intake was not measured; a habitual low-protein diet cannot be excluded as a cause of low GFR.

CONCLUSIONS

Basal GFR is significantly lower than the normal value of 120 to 130 mL/min/1.73 m(2) in western populations. The conventional cutoff value of 60 mL/min/1.73 m(2) for defining chronic kidney disease might not be appropriate in India.

An international matched cohort study of the contribution of metabolic impairments to subclinical atherosclerosis in United Kingdom and Jamaican African-Caribbeans

BACKGROUND

A gradient of increased vascular risk exists across the African diaspora. We hypothesised that increased insulin resistance with environmental transition contributes to this risk.

METHODS

The study was undertaken in 73 healthy African-Caribbeans in the UK and 151 age and sex matched African-Caribbeans in Jamaica. Body mass index (BMI), fasting insulin, insulin resistance, carotid intima media thickness (CIMT) and endothelium dependent vasodilatation (EDV) were compared. CIMT was measured ultrasonographically in the distal 1cm of both common carotid arteries. EDV was measured the absolute change from baseline in the Reflection index (RI) of the digital volume pulse during intravenous infusion of albuterol (DeltaRI(ALB)).

RESULTS

UK African-Caribbeans had greater CIMT (mean difference 0.124 [95% C.I. 0.075-0.173] mm, p<0.0001) and decreased EDV (mean difference in DeltaRI(ALB) 5.1 [95% C.I. 2.5-7.6] percentage points, p<0.0001). This was associated with higher insulin concentrations (mean difference 1.6 [95% C.I. 1.3-4.1] microU/mL, p=0.038) and greater HOMA score (2.8 versus 2.0; p=0.035) despite no significant differences in BMI (28.8 versus 27.6; p=0.168) or the waist to hip ratio (0.86 versus 0.85; p=0.188). HOMA scores correlated positively with CIMT (r=0.35, p=0.01) and negatively with DeltaRI(ALB) (r=-0.17; p=0.02) in UK, but not in Jamaican, African-Caribbeans. A significant interaction was seen between HOMA and UK domicile for CIMT (p<0.0001) and between fasting insulin and UK domicile for DeltaRI(ALB) (p<0.0001).

CONCLUSIONS

Increased insulin resistance, associated with living in a nutritionally enriched environment, may contribute to early subclinical atherosclerosis in UK African-Caribbeans.

Epidemiologic and clinical factors associated with chronic kidney disease among Asian Americans and Native Hawaiians

OBJECTIVE

To examine the association between key susceptibility factors and measures of chronic kidney disease in Asian American and Native Hawaiian participants enrolled in the Hawai'i site of the national Kidney Early Evaluation Program (KEEP-2) study community screening program.

DESIGN

In 2001-2003, 793 participants from five ethnic groups (Japanese, Native Hawaii an, Chinese, Filipino and Caucasian) were enrolled in the Hawai'i KEEP-2 program. Odds ratios were used as the measure of association and were computed using unconditional logistic regression. Renal susceptibility factors for chronic kidney disease were included in a multivariable model if found to be statistically significant in univariate analysis. The proportion of Hawai'i KEEP-2 study participants manifesting various clinical characteristics were compared by ethnicity with Japanese as the referent group.

RESULTS

Significant ethnic differences in the occurrence of chronic kidney disease were found, with Japanese having the lowest occurrence of chronic kidney disease (18%) and Native Hawaiians the highest (40%). Within each ethnic group, the occurrence of chronic kidney disease was associated with a different ethnic-specific clustering of susceptibility factors. Hypertension was associated with chronic kidney disease among four of the five ethnic groups: Japanese, Caucasian, Native Hawaiian and Filipino. Overweight was associated with a decreased occurrence of chronic kidney disease among Caucasians, while diabetes and lower educational attainment were associated with increased occurrence of chronic kidney disease among Native Hawaiians. For Filipinos, diabetes and age 65 years and older were both associated with an increased occurrence for chronic kidney disease while lower educational attainment was associated with a reduced occurrence of chronic kidney disease. Among Chinese, no factors were significantly associated with chronic kidney disease, although trends for all factors paralleled those of the overall study group.

CONCLUSIONS

The occurrence of chronic kidney disease in the Hawai'i KEEP-2 study was nearly fourfold greater compared with the general US population. The clustering of susceptibility factors for chronic kidney disease occurrence was found to differ for all five ethnic groups.

Association of race, heart failure and chronic kidney disease

Heart failure and kidney disease are two important emerging epidemics. The importance of pre-end stage kidney disease was introduced in the 2002 publication of the National Kidney Foundation's Chronic Kidney Disease Guidelines. One in nine US adults has some degree of kidney disease, many of whom also have heart failure. Among all patients with heart failure, approximately half have significant kidney disease. The distribution of etiologies of these conditions varies among races; blacks tend to have heart and kidney disease predominantly due to hypertension, while whites tend to be affected by ischemic heart disease and Hispanics by diabetic kidney disease. The burden of disease is disproportionately borne by minorities, the cause of which remains to be fully elucidated. The bulk of knowledge of these diseases is based on studies involving predominantly white subjects. Recent studies have suggested that there are racial differences in patients' responsiveness to various classes of drugs. Designs of future studies should take into account these differences.

Peer mentoring: a culturally sensitive approach to end-of-life planning for long-term dialysis patients

BACKGROUND

This study is designed to explore the impact of peer mentoring on end-of-life decision making.

METHODS

A controlled randomized intervention study with 203 patients from 21 dialysis centers across Michigan explored the impact of peer mentors, dialysis patients trained to help other patients, on end-of-life planning.

RESULTS

Communicating information on advance directives (ADs) through peer mentoring significantly influenced the completion of ADs overall compared with distributing standard printed material or no specific designed intervention. However, the influence was most prominent among African Americans, not only increasing actual completion of ADs (P < 0.001) and comfort discussing ADs (P < 0.01), but also improving subjective well-being (P < 0.05) and anxiety (P < 0.05) during the study period. These effects of peer mentoring did not appear among white patients, although printed material on ADs decreased reported suicidal ideation (P < 0.05).

CONCLUSION

These results suggest the importance of addressing specific cultural factors in the process of AD education. Common practice assumes that printed materials are effective in educating patients about health care and decision making. However, peer mentoring, a relationship-centered person-to-person approach, may be more effective in some cultural groups because it partakes of oral, rather than written, traditions. Acknowledging cultural differences and tailoring our approach could be powerful in enhancing trust and participation and decreasing potential disparities in health care outcomes.

Ethnic Differences in Arterial Responses and Inflammatory Markers in Afro-Caribbean and Caucasian Subjects

OBJECTIVE

Small vessel disease is more common in Afro-Caribbeans than Caucasians. We investigated underlying differences in metabolic, inflammatory, and vascular responses that may predispose Afro-Caribbeans to small vessel pathology.

METHODS AND RESULTS

Seventy-eight Afro-Caribbeans aged 35-75 years, with no vascular disease or medications, were compared with 82 matched Caucasians for metabolic variables, fasting insulin, interleukin 6, tumor necrosis factor (TNF) alpha, and cytoplasmic repressor protein levels. Carotid intima media thickness (CIMT) was measured ultrasonographically. Small vessel function was assessed by measuring the absolute change from baseline in the reflectance index (RI) of the digital volume pulse during IV infusion of albuterol (5 microg/min, DeltaRIALB) and glyceryl tri nitrate (5 microg/min, DeltaRIGTN). Large artery elasticity was measured as the stiffness index (SI) and derived from the time to pulse wave reflection adjusted for subject height. Afro-Caribbeans had significantly higher diastolic blood pressure (80.3 versus 77.6 mm Hg; P=0.033), fasting insulin (14.0 versus 10.6 microU/mL; P=0.026), TNF-alpha (6.7 versus 4.3; pg/mL; P=0.001), and interleukin 6 (2.3 versus 1.5 pg/mL; P=0.036) levels compared with Caucasians. CIMT was greater (0.81+/-0.20 versus 0.75+/-0.18 mm; P=0.02) and small vessel reactivity attenuated (mean DeltaRIALB 6.8+/-8.0% versus 12.3+/-8.%; P<0.0001) in Afro-Caribbeans, but their large artery elasticity (mean index of large artery stiffness 9.9 versus 9.7 m/s; P=0.48) was comparable with Caucasians. CIMT was independently associated with an index of large artery stiffness (beta=0.03; P=0.002) in Caucasians but not in Afro-Caribbeans. There were independent relationships among Afro-Caribbean ethnicity, TNF-alpha, and insulin levels.

CONCLUSIONS

Selective impairment of small artery function may contribute to excess small vessel disease in Afro-Caribbeans.