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Wetmore JB, Yan H, Horne L, Peng Y, Gilbertson DT. Risk of hyperkalemia from renin-angiotensin-aldosterone system inhibitors and factors associated with treatment discontinuities in a real-world population. Nephrol Dial Transplant 2021; 36:826-839. [PMID: 31846025 DOI: 10.1093/ndt/gfz263] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Hyperkalemia rates in renin-angiotensin-aldosterone system (RAAS) inhibitor users, and factors associated with treatment interruptions and cessations, have not been explored in a large, population-wide database. METHODS RAAS inhibitor users were identified in the linked UK Clinical Practice Research Datalink-Hospital Episodes Statistics data set, 2009-15. Treatment interruptions (no active prescription followed by reappearance) and cessations were determined. Hyperkalemia (serum K+>5.5 mmol/L) rates were calculated and factors associated with interruptions and cessations modeled using time-varying Cox regression, including hyperkalemia (as a time-dependent variable). RESULTS Among 434 027 RAAS inhibitor users, the hyperkalemia rate was 1.30 (95% confidence interval 1.28-1.32) per 100 patient-years. Of 73.7% of patients who experienced off-treatment periods, 57.6% experienced interruption only, 7.5% cessation only and 8.6% both. Within 1 year of initiating RAAS inhibitor treatment, approximately one-third of the patients experienced interruption or cessation. Hazard ratios for patients with severe hyperkalemia were 1.10 (10.5-1.16) for interruptions and 3.37 (3.25-3.50) for cessation. Compared with no chronic kidney disease (CKD), risk of interruption was 1.20 (1.16-1.25) and 1.57 (1.44-1.72) for Stages 4 and 5, respectively, and of cessation was 2.20 (2.07-2.33) and 2.87 (2.56-3.22). Risk of interruption increased for patients with heart failure or diabetes [1.04 (1.02-1.05); 1.13 (1.12-1.14), respectively] but the risk of cessation decreased [0.85 (0.82-0.87); 0.92 (0.90-0.94)]. CONCLUSIONS Risk of RAAS inhibitor interruption and cessation increased as CKD stage progressed. Efforts targeting reasons for interruptions and, especially, cessations, such as hyperkalemia prevention, could decrease off-treatment periods for patients who would otherwise benefit, such as those with CKD, heart failure or diabetes.
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Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA.,Division of Nephrology, Hennepin Healthcare, University of Minnesota, Minneapolis, MN, USA
| | - Heng Yan
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | | | - Yi Peng
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - David T Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
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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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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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Ducharme NA, Reif DM, Gustafsson JA, Bondesson M. Comparison of toxicity values across zebrafish early life stages and mammalian studies: Implications for chemical testing. Reprod Toxicol 2014; 55:3-10. [PMID: 25261610 DOI: 10.1016/j.reprotox.2014.09.005] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/21/2014] [Accepted: 09/15/2014] [Indexed: 12/12/2022]
Abstract
With the high cost and slow pace of toxicity testing in mammals, the vertebrate zebrafish has become a tractable model organism for high throughput toxicity testing. We present here a meta-analysis of 600 chemicals tested for toxicity in zebrafish embryos and larvae. Nineteen aggregated and 57 individual toxicity endpoints were recorded from published studies yielding 2695 unique data points. These data points were compared to lethality and reproductive toxicology endpoints analyzed in rodents and rabbits and to exposure values for humans. We show that although many zebrafish endpoints did not correlate to rodent or rabbit acute toxicity data, zebrafish could be used to accurately predict relative acute toxicity through the rat inhalation, rabbit dermal, and rat oral exposure routes. Ranking of the chemicals based on toxicity and teratogenicity in zebrafish, as well as human exposure levels, revealed that 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), benzo(a)pyrene, and chlorpyrifos ranked in the top nine of all chemicals for these three categories, and as such should be considered high priority chemicals for testing in higher vertebrates.
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Affiliation(s)
- Nicole A Ducharme
- University of Houston, Department of Biology and Biochemistry, Center for Nuclear Receptors and Cell Signaling, Houston, TX 77204, USA
| | - David M Reif
- North Carolina State University, Department of Biological Sciences, Bioinformatics Research Center, Raleigh, NC 27695-7614, USA
| | - Jan-Ake Gustafsson
- University of Houston, Department of Biology and Biochemistry, Center for Nuclear Receptors and Cell Signaling, Houston, TX 77204, USA; Karolinska Institutet, Department of Biosciences and Nutrition, 14183 Huddinge, Sweden
| | - Maria Bondesson
- University of Houston, Department of Biology and Biochemistry, Center for Nuclear Receptors and Cell Signaling, Houston, TX 77204, USA.
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Fang L, Xie D, Wu X, Cao H, Su W, Yang J. Involvement of endoplasmic reticulum stress in albuminuria induced inflammasome activation in renal proximal tubular cells. PLoS One 2013; 8:e72344. [PMID: 23977286 PMCID: PMC3748031 DOI: 10.1371/journal.pone.0072344] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 07/08/2013] [Indexed: 12/22/2022] Open
Abstract
Albuminuria contributes to the progression of tubulointerstitial fibrosis. Although it has been demonstrated that ongoing albuminuria leads to tubular injury manifested by the overexpression of numerous proinflammatory cytokines, the mechanism remains largely unknown. In this study, we found that the inflammasome activation which has been recognized as one of the cornerstones of intracellular surveillance system was associated with the severity of albuminuria in the renal biopsies specimens. In vitro, bovine serum albumin (BSA) could also induce the activation of NLRP3 inflammasome in the cultured kidney epithelial cells (NRK-52E). Since there was a significant overlap of NLRP3 with the ER marker calreticulin, the ER stress provoked by BSA seemed to play a crucial role in the activation of inflammasome. Here, we demonstrated that the chemical chaperone taurine-conjugated ursodeoxycholic acid (TUDCA) which was proved to be an enhancer for the adaptive capacity of ER could attenuate the inflammasome activation induced by albuminuria not only in vitro but also in diabetic nephropathy. Taken together, these data suggested that ER stress seemed to play an important role in albuminuria-induced inflammasome activation, elimination of ER stress via TUDCA might hold promise as a novel avenue for preventing inflammasome activation ameliorating kidney epithelial cells injury induced by albuminuria.
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Affiliation(s)
- Li Fang
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Da Xie
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xian Wu
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hongdi Cao
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Weifang Su
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Junwei Yang
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
- * E-mail:
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