Renal Association Clinical Practice Guideline on cardiovascular disease in CKD

The association between long-term glycemic control and all-cause mortality is different among older versus younger patients with diabetes mellitus and maintenance hemodialysis treatment

AIMS

Knowledge about association between glycated hemoglobin (HbA1c) and risk of all-cause mortality in patients with diabetes mellitus on maintenance hemodialysis (HD)-treatment is sparse. The study aims to investigate association between HbA1c and all-cause mortality in patients with diabetes and maintenance HD-treatment, separately for two age groups- above and below 75 years.

METHODS

2487 patients (mean age 66 years, 66 % men) were separated in two age groups: ≤75 years (n = 1810) and > 75 years (n = 677) and followed up between 2008 and 2018. Hazard ratios (HR) and 95 % confidence intervals (CI) for associations between HbA1c and all-cause mortality were calculated using Cox-regression-models.

RESULTS

1295 (52 %) patients died and 473 (70 %) among the patients above 75 years old. In the multivariate analysis, HbA1c5-6 % was used as reference. In patients ≤ 75 years old, only increased HbA1c > 9.7 %, HR2.03(CI1.43-2.89) was associated with increased risk of all-cause mortality. In patients > 75 years, HbA1c ≤ 5 %, HR1.67(CI1.16-2.40); HbA1c6.9-7.8 %, HR1.41(CI1.03-1.93) and HbA1c8.7-9.7 %, HR1.79 (CI1.08-2.96) were associated with increased risk of all-cause mortality.

CONCLUSIONS

We found a J-shaped association between HbA1c and mortality only in diabetic HD-patients > 75 years. This probably indicates that in an old population of diabetic HD-patients, both intensive glucose control and hyperglycemia could be harmful and associated with higher risk of death.

The Challenges of Using UK Renal Registry Data to Audit the Care of Patients with Diabetes on Renal Replacement Therapy

INTRODUCTION

Diabetes is a major cause of CKD and of mortality in patients on renal replacement therapy (RRT). Auditing the care of patients with diabetes on RRT against published guidelines relies on robust data collection.

OBJECTIVE

This article assesses the completeness of data items collected by the UK Renal Registry (UKRR) that are required to audit the care of patients with diabetes on RRT.

METHODS

The UKRR receives data on all patients receiving RRT in the UK. Patients with diabetes, diabetes type, and method of renal diagnosis were identified from primary renal disease (PRD) codes and comorbidity data for patients commencing RRT at one of the 57 renal centres in England and Wales between 2010 and 2016. The completeness of demographic and clinical data (blood pressure, cholesterol, glycated haemoglobin [HbA1c], and smoking status) was assessed for the first year of RRT.

RESULTS

Ninety-three per cent of all patients on RRT irrespective of diagnosis had a PRD code, but only 28/57 renal centres had comorbidity data completeness ≥70%; 34.9% of patients with diabetic nephropathy (DN) had type 1 diabetes, but this varied between centres (9.2-100%). Overall, 4.2% of DN diagnoses were by biopsy. Data completeness in the first year of RRT for cardiovascular risk factors ranged between 50.0 and 80.0%, with HbA1c data completeness being 63.0%. Of 57 centres, 20 had HbA1c data for ≥70% of patients in the first year of RRT.

CONCLUSIONS

There is persistent variation between renal centres in the completeness of data collected on patients with diabetes on RRT, impacting on the ability to undertake robust audit. Data linkages and expanded data permissions could see registry data play a key role in ongoing audit and research into patients with diabetes and CKD, provided adequate data can be collected.

International Study of Comparative Health Effectiveness with Medical and Invasive Approaches-Chronic Kidney Disease (ISCHEMIA-CKD): Rationale and design

BACKGROUND

Patients with chronic kidney disease (CKD) and stable ischemic heart disease are at markedly increased risk of cardiovascular events. Prior trials comparing a strategy of optimal medical therapy (OMT) with or without revascularization have largely excluded patients with advanced CKD. Whether a routine invasive approach when compared with a conservative strategy is beneficial in such patients is unknown.

METHODS

ISCHEMIA-CKD is a National Heart, Lung, and Blood Institute-funded randomized trial designed to determine the comparative effectiveness of an initial invasive strategy (cardiac catheterization and optimal revascularization [percutaneous coronary intervention or coronary artery bypass graft surgery, if suitable] plus OMT) versus a conservative strategy (OMT alone, with cardiac catheterization and revascularization [percutaneous coronary intervention or coronary artery bypass graft surgery, if suitable] reserved for failure of OMT) on long-term clinical outcomes in 777 patients with advanced CKD (defined as those with estimated glomerular filtration rate <30 mL/min/1.73m2 or on dialysis) and moderate or severe ischemia on stress testing. Participants were randomized in a 1:1 fashion to the invasive or a conservative strategy. The primary end point is a composite of death or nonfatal myocardial infarction. Major secondary endpoints are a composite of death, nonfatal myocardial infarction, hospitalization for unstable angina, hospitalization for heart failure, or resuscitated cardiac arrest; angina control; and disease-specific quality of life. Safety outcomes such as initiation of maintenance dialysis and a composite of initiation of maintenance dialysis or death will be reported. The trial is projected to have 80% power to detect a 22% to 24% reduction in the primary composite end point with the invasive strategy when compared with the conservative strategy.

CONCLUSIONS

ISCHEMIA-CKD will determine whether an initial invasive management strategy improves clinical outcomes when added to OMT in patients with advanced CKD and stable ischemic heart disease.

Impact of a Basal-Bolus Insulin Regimen on Metabolic Control and Risk of Hypoglycemia in Patients With Diabetes Undergoing Peritoneal Dialysis

INTRODUCTION

Clinical interventional studies in diabetes mellitus usually exclude patients undergoing peritoneal dialysis (PD). This study evaluates the impact of an educational program and a basal-bolus insulin regimen on the blood glucose level control and risk of hypoglycemia in this population.

METHODS

A before-and-after study was conducted in type 1 and type 2 DM patients undergoing PD at the Renal Therapy Services (RTS) clinic network, Bogota, Colombia. An intervention was instituted consisting of a three-month educational program and a basal-bolus detemir (Levemir, NovoNordisk) and aspart (Novorapid, NovoNordisk) insulin regimen. Prior to the intervention and at the end of treatment were conducted measures of HbA1c levels and continuous glucose monitoring (CGM).

RESULTS

Forty-seven patients were recruited. Mean HbA1c level decreased from 8.41% ± 0.83 to 7.68% ± 1.32 (mean difference -0.739, 95% CI -0.419, -1.059; P < .0001). Of subjects, 52% achieved HbA1c levels <7.5% at the end of study. Mean blood glucose level reduced from 194.0 ± 42.5 to 172.9 ± 31.8 mg/dl ( P = .0015) measured by CGM. Significant differences were not observed in incidence of overall ( P = .7739), diurnal ( P = .3701), or nocturnal ( P = .5724) hypoglycemia episodes nor in area under the curve (AUC) <54 mg/dl ( P = .9528), but a reduction in AUC >180 ( P < .01) and AUC >250 ( P = .01) was evidenced for total, diurnal, and nocturnal episodes.

CONCLUSIONS

An intervention consisting of an educational program and a basal-bolus insulin regimen in type 1 and type 2 diabetes mellitus patients undergoing PD caused a decrease in HbA1c levels, and mean blood glucose levels as measured from CGM with no significant increases in hypoglycemia episodes.

Tailoring of alerts substantially reduces the alert burden in computerized clinical decision support for drugs that should be avoided in patients with renal disease

OBJECTIVE

Electronic alerts are often ignored by physicians, which is partly due to the large number of unspecific alerts generated by decision support systems. The aim of the present study was to analyze critical drug prescriptions in a university-based nephrology clinic and to evaluate the effect of different alerting strategies on the alert burden.

METHODS

In a prospective observational study, two advanced strategies to automatically generate alerts were applied when medication regimens were entered for discharge letters, outpatient clinic letters, and written prescriptions and compared to two basic reference strategies. Strategy A generated alerts whenever drug-specific information was available, whereas strategy B generated alerts only when the estimated glomerular filtration rate of a patient was below a drug-specific value. Strategies C and D included further patient characteristics and drug-specific information to generate even more specific alerts.

RESULTS

Overall, 1012 medication regimens were entered during the observation period. The average number of alerts per drug preparation in medication regimens entered for letters was 0.28, 0.080, 0.019, and 0.011, when using strategy A, B, C, or D (P<0.001, for comparison between the strategies), leading to at least one alert in 87.5%, 39.3%, 13.5%, or 7.81 % of the regimens. Similar average numbers of alerts were observed for medication regimens entered for written prescriptions.

CONCLUSIONS

The prescription of potentially hazardous drugs is common in patients with renal impairment. Alerting strategies including patient and drug-specific information to generate more specific alerts have the potential to reduce the alert burden by more than 90 %.

Exercise counselling practices for patients with chronic kidney disease in the UK: a renal multidisciplinary team perspective

BACKGROUND

Patients with chronic kidney disease (CKD) have elevated cardiovascular disease (CVD) risk. Physical activity (PA) is a strong and independent CVD risk factor, and despite the fact that current clinical practice guidelines recommend simultaneous treatment of multiple risk factors for optimum management of CKD, PA is rarely addressed by renal care teams. The aim of this observational cross-sectional survey was to document current exercise/PA practices across renal units in the UK, and capture views and experiences regarding the provision of PA/exercise options for patients with CKD.

METHODS

An 18-item online survey questionnaire regarding exercise counselling practice patterns was administered to 565 multidisciplinary renal care professionals.

RESULTS

142 individuals (25% response rate) completed the questionnaire. Overall, 42% of respondents discussed and encouraged PA, but only 18 and 11% facilitated implementation of PA for their patients. Nephrologists (p < 0.003) were more likely to prescribe or recommend PA compared to professionals with a nursing background and believed that specific renal rehabilitation services, including an active PA/exercise component, should be available to all patients (p < 0.01). The most commonly reported barriers for the development and implementation of PA/exercise options included lack of funding, time, and knowledgeable personnel, such as physiotherapists or other exercise professionals.

CONCLUSION

Beliefs and attitudes towards PA amongst members of the renal multidisciplinary team are encouraging. However there is a big gap between believing in the benefits of PA and promoting/implementing PA for patient benefit. This gap needs to be minimised by at least trying to address some of the reported barriers.

Challenges in blood pressure measurement in patients treated with maintenance hemodialysis

The association between blood pressure and cardiovascular outcomes in patients undergoing hemodialysis remains controversial. This may relate in part to the technique and device used and the timing of the blood pressure measurement in relation to the hemodialysis procedure. Emerging evidence indicates that standardized hemodialysis unit blood pressure measurements or measurements obtained at home, either by the patient or using an ambulatory blood pressure monitor, may offer advantages over routine hemodialysis unit blood pressure measurements for determining cardiovascular risk and treatment. This review discusses the available evidence and implications for clinicians and clinical trials.