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Wong MS, Tseng CH, Moy E, Jones KT, Kothari AJ, Washington DL. Relationship between health system quality and racial and ethnic equity in diabetes care. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae073. [PMID: 38989064 PMCID: PMC11235325 DOI: 10.1093/haschl/qxae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/02/2024] [Accepted: 05/16/2024] [Indexed: 07/12/2024]
Abstract
Failing to consider disparities in quality measures, such as by race and ethnicity, may obscure inequities in care, which could exist in facilities with overall high-quality ratings. We examined the relationship between overall quality and racial and ethnic disparities in diabetes care quality by health care facility-level performance on a diabetes-related quality measure within a national dataset of veterans using Veterans Health Administration (VA) ambulatory care between March 1, 2020 and Feburary 28, 2021, and were eligible for diabetes quality assessment. We found racial and ethnic disparities in diabetes care quality existed in top-performing VA medical centers (VAMCs) among American Indian or Alaska Native (AIAN) (predicted probability = 30%), Black (predicted probability = 29%), and Hispanic VA-users (predicted probability = 30%) vs White VA-users (predicted probability = 26%). While disparities among Black and Hispanic VA-users were similar relative to White VA-users across VAMCs at all performance levels, disparities were exacerbated for AIAN and Native Hawaiian or Other Pacific Islander VA-users in bottom-performing VAMCs. Equity remains an issue even in facilities providing overall high-quality care. Integrating equity as a component of quality measures can incentivize greater focus on equity in quality improvement.
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Affiliation(s)
- Michelle S Wong
- HSR Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, United States
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, United States
| | - Ernest Moy
- US Department of Veterans Affairs, Office of Health Equity, Washington, DC 20420, United States
| | - Kenneth T Jones
- US Department of Veterans Affairs, Office of Health Equity, Washington, DC 20420, United States
| | - Amit J Kothari
- Office of the Chief of Staff, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, United States
| | - Donna L Washington
- HSR Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, United States
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, United States
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Duncan CA, Jacobs MA, Gao Y, Mader M, Schmidt S, Davila H, Hadlandsmyth K, Shireman PK, Hausmann LRM, Tessler RA, Strayer A, Vaughan Sarrazin M, Hall DE. Care Fragmentation, Social Determinants of Health, and Postoperative Mortality in Older Veterans. J Surg Res 2024; 300:514-525. [PMID: 38875950 DOI: 10.1016/j.jss.2024.04.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 06/16/2024]
Abstract
INTRODUCTION Veterans Affairs Surgical Quality Improvement Program (VASQIP) benchmarking algorithms helped the Veterans Health Administration (VHA) reduce postoperative mortality. Despite calls to consider social risk factors, these algorithms do not adjust for social determinants of health (SDoH) or account for services fragmented between the VHA and the private sector. This investigation examines how the addition of SDoH change model performance and quantifies associations between SDoH and 30-d postoperative mortality. METHODS VASQIP (2013-2019) cohort study in patients ≥65 y old with 2-30-d inpatient stays. VASQIP was linked to other VHA and Medicare/Medicaid data. 30-d postoperative mortality was examined using multivariable logistic regression models, adjusting first for clinical variables, then adding SDoH. RESULTS In adjusted analyses of 93,644 inpatient cases (97.7% male, 79.7% non-Hispanic White), higher proportions of non-veterans affairs care (adjusted odds ratio [aOR] = 1.02, 95% CI = 1.01-1.04) and living in highly deprived areas (aOR = 1.15, 95% CI = 1.02-1.29) were associated with increased postoperative mortality. Black race (aOR = 0.77, CI = 0.68-0.88) and rurality (aOR = 0.87, CI = 0.79-0.96) were associated with lower postoperative mortality. Adding SDoH to models with only clinical variables did not improve discrimination (c = 0.836 versus c = 0.835). CONCLUSIONS Postoperative mortality is worse among Veterans receiving more health care outside the VA and living in highly deprived neighborhoods. However, adjusting for SDoH is unlikely to improve existing mortality-benchmarking models. Reduction efforts for postoperative mortality could focus on alleviating care fragmentation and designing care pathways that consider area deprivation. The adjusted survival advantage for rural and Black Veterans may be of interest to private sector hospitals as they attempt to alleviate enduring health-care disparities.
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Affiliation(s)
- Carly A Duncan
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Michael A Jacobs
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Yubo Gao
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa; Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa
| | - Michael Mader
- South Texas Veterans Healthcare System, San Antonio, Texas
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Heather Davila
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa; Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa
| | - Katherine Hadlandsmyth
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa; Department of Anesthesia, Carver College of Medicine, The University of Iowa, Iowa City, Iowa
| | - Paula K Shireman
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert A Tessler
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Andrea Strayer
- VA Quality Scholar, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa; College of Nursing, The University of Iowa, Iowa City, Iowa
| | - Mary Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa; Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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3
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Verma A, Minnier J, Wan ES, Huffman JE, Gao L, Joseph J, Ho YL, Wu WC, Cho K, Gorman BR, Rajeevan N, Pyarajan S, Garcon H, Meigs JB, Sun YV, Reaven PD, McGeary JE, Suzuki A, Gelernter J, Lynch JA, Petersen JM, Zekavat SM, Natarajan P, Dalal S, Jhala DN, Arjomandi M, Gatsby E, Lynch KE, Bonomo RA, Freiberg M, Pathak GA, Zhou JJ, Donskey CJ, Madduri RK, Wells QS, Huang RDL, Polimanti R, Chang KM, Liao KP, Tsao PS, Wilson PWF, Hung AM, O’Donnell CJ, Gaziano JM, Hauger RL, Iyengar SK, Luoh SW. A MUC5B Gene Polymorphism, rs35705950-T, Confers Protective Effects Against COVID-19 Hospitalization but Not Severe Disease or Mortality. Am J Respir Crit Care Med 2022; 206:1220-1229. [PMID: 35771531 PMCID: PMC9746845 DOI: 10.1164/rccm.202109-2166oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Rationale: A common MUC5B gene polymorphism, rs35705950-T, is associated with idiopathic pulmonary fibrosis (IPF), but its role in severe acute respiratory syndrome coronavirus 2 infection and disease severity is unclear. Objectives: To assess whether rs35705950-T confers differential risk for clinical outcomes associated with coronavirus disease (COVID-19) infection among participants in the Million Veteran Program (MVP). Methods: The MUC5B rs35705950-T allele was directly genotyped among MVP participants; clinical events and comorbidities were extracted from the electronic health records. Associations between the incidence or severity of COVID-19 and rs35705950-T were analyzed within each ancestry group in the MVP followed by transancestry meta-analysis. Replication and joint meta-analysis were conducted using summary statistics from the COVID-19 Host Genetics Initiative (HGI). Sensitivity analyses with adjustment for additional covariates (body mass index, Charlson comorbidity index, smoking, asbestosis, rheumatoid arthritis with interstitial lung disease, and IPF) and associations with post-COVID-19 pneumonia were performed in MVP subjects. Measurements and Main Results: The rs35705950-T allele was associated with fewer COVID-19 hospitalizations in transancestry meta-analyses within the MVP (Ncases = 4,325; Ncontrols = 507,640; OR = 0.89 [0.82-0.97]; P = 6.86 × 10-3) and joint meta-analyses with the HGI (Ncases = 13,320; Ncontrols = 1,508,841; OR, 0.90 [0.86-0.95]; P = 8.99 × 10-5). The rs35705950-T allele was not associated with reduced COVID-19 positivity in transancestry meta-analysis within the MVP (Ncases = 19,168/Ncontrols = 492,854; OR, 0.98 [0.95-1.01]; P = 0.06) but was nominally significant (P < 0.05) in the joint meta-analysis with the HGI (Ncases = 44,820; Ncontrols = 1,775,827; OR, 0.97 [0.95-1.00]; P = 0.03). Associations were not observed with severe outcomes or mortality. Among individuals of European ancestry in the MVP, rs35705950-T was associated with fewer post-COVID-19 pneumonia events (OR, 0.82 [0.72-0.93]; P = 0.001). Conclusions: The MUC5B variant rs35705950-T may confer protection in COVID-19 hospitalizations.
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Affiliation(s)
- Anurag Verma
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania;,Department of Medicine, Perelman School of Medicine, and
| | - Jessica Minnier
- OHSU-PSU School of Public Health and,Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon;,VA Portland Health Care System, Portland, Oregon
| | - Emily S. Wan
- Department of Medicine, Pulmonary, Critical Care, Sleep, and Allergy Section,,Channing Division of Network Medicine and
| | | | - Lina Gao
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon;,VA Portland Health Care System, Portland, Oregon
| | - Jacob Joseph
- Department of Medicine,,Medicine, Cardiovascular, Brigham & Women’s Hospital, Boston, Massachusetts
| | | | - Wen-Chih Wu
- Department of Medicine, Cardiology, Providence VA Healthcare System, Providence, Rhode Island;,Alpert Medical School & School of Public Health, Brown University, Providence, Rhode Island
| | - Kelly Cho
- MAVERIC,,Medicine, Aging, Brigham & Women’s Hospital and
| | | | - Nallakkandi Rajeevan
- Yale Center for Medical Informatics,,Clinical Epidemiology Research Center (CERC)
| | - Saiju Pyarajan
- MAVERIC,,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | - Yan V. Sun
- Epidemiology, School of Public Health and,Atlanta VA Healthcare System, Decatur, Georgia
| | - Peter D. Reaven
- Department of Medicine, Phoenix VA Healthcare System, Phoenix, Arizona;,College of Medicine, University of Arizona, Phoenix, Arizona
| | - John E. McGeary
- Department of Psychiatry and Human Behavior, Providence VA Medical Center, Providence, Rhode Island;,Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, Rhode Island
| | - Ayako Suzuki
- Department of Medicine, Gastroenterology, Durham VA Medical Center, Durham, North Carolina;,Department of Medicine, Gastroenterology, Duke University, Durham, North Carolina
| | - Joel Gelernter
- Division of Human Genetics, Department of Psychiatry, and,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Julie A. Lynch
- VA Informatics & Computing Infrastructure (VINCI), VA Salt Lake City Healthcare System, Salt Lake City, Utah;,Department of Medicine and
| | - Jeffrey M. Petersen
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania;,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Seyedeh Maryam Zekavat
- Computational Biology & Bioinformatics, Yale University School of Medicine, New Haven, Connecticut;,Program in Medical and Population Genetics, Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
| | - Pradeep Natarajan
- Department of Medicine, Harvard Medical School, Boston, Massachusetts;,Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts;,Program in Medical and Population Genetics, Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts
| | - Sharvari Dalal
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania;,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Darshana N. Jhala
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania;,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mehrdad Arjomandi
- Medicine, Pulmonary and Critical Care, San Francisco VA Healthcare System, University of California, San Francisco, San Francisco, California
| | - Elise Gatsby
- VA Informatics & Computing Infrastructure (VINCI), VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Kristine E. Lynch
- VA Informatics & Computing Infrastructure (VINCI), VA Salt Lake City Healthcare System, Salt Lake City, Utah;,Internal Medicine, Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | | | | | - Gita A. Pathak
- Division of Human Genetics, Department of Psychiatry, and,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Jin J. Zhou
- Department of Medicine, University of California, Los Angeles, Los Angeles, California;,Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona
| | | | - Ravi K. Madduri
- Data Science and Learning, Argonne National Laboratory, Lemont, Illinois
| | - Quinn S. Wells
- Department of Medicine,,Department of Biomedical Informatics, and,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Renato Polimanti
- Division of Human Genetics, Department of Psychiatry, and,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Kyong-Mi Chang
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | - Philip S. Tsao
- Precision Medicine, VA Palo Alto Health Care System, Palo Alto, California
| | - Peter W. F. Wilson
- Emory University, Atlanta, Georgia;,Atlanta VA Healthcare System, Decatur, Georgia
| | - Adriana M. Hung
- Department of Veteran’s Affairs, Tennessee Valley Healthcare System, Vanderbilt University Medical Center, Division of Nephrology & Hypertension, Nashville, Tennessee
| | | | | | - Richard L. Hauger
- Center of Excellence for Stress & Mental Health, VA San Diego Healthcare System, San Diego, California; and,Center for Behavioral Genetics of Aging, University of California, San Diego, La Jolla, California
| | - Sudha K. Iyengar
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio;,Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Shiuh-Wen Luoh
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon;,VA Portland Health Care System, Portland, Oregon
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Chandra R, Meier J, Khoury MK, Weisberg A, Nguyen YT, Peltz M, Jessen ME, Heid CA. Homelessness and Race are Mortality Predictors in US Veterans Undergoing CABG. Semin Thorac Cardiovasc Surg 2022:S1043-0679(22)00230-1. [PMID: 36223817 DOI: 10.1053/j.semtcvs.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
Coronary artery disease requiring surgical revascularization is prevalent in United States Veterans. We aimed to investigate preoperative predictors of 30-day mortality following coronary artery bypass grafting (CABG) in the Veteran population. The Veterans Affairs Surgical Quality Improvement (VASQIP) national database was queried for isolated CABG cases between 2008 and 2018. The primary outcome was 30-day mortality. A multivariable logistic regression was performed to assess for independent predictors of the primary outcome. A P-value of <0.05 was considered statistically significant. A total of 32,711 patients were included. The 30-day mortality rate was 1.37%. Multivariable analysis identified the following predictors of 30-day mortality: African-American race (OR 1.46, 95% CI 1.09-1.96); homelessness (OR 6.49, 95% CI 3.39-12.45); female sex (OR 2.15, 95% CI 1.08-4.30); preoperative myocardial infarction within 7 days (OR 1.49, 95% CI 1.06-2.10) or more than 7 days before CABG (OR 1.34, 95% CI 1.04-1.72); partially/fully dependent functional status (OR 1.44, 95% CI 1.07-1.93); chronic obstructive pulmonary disease (OR 1.54, 95% CI 1.24-1.92); mild (OR 1.48, 95% CI 1.04-2.11) and severe aortic stenosis (OR 2.06, 95% CI 1.37-3.09); moderate (OR 1.88, 95% CI 1.31-2.72), or severe (OR 2.99, 95% CI 1.71-5.22) mitral regurgitation; cardiomegaly (OR 1.73, 95% CI 1.35-2.22); NYHA Class III/IV heart failure (OR 2.05, 95% CI 1.10-3.83); and urgent/emergent operation (OR 1.42, 95% CI 1.08-1.87). The 30-day mortality rate in US Veterans undergoing isolated CABG between 2008 and 2018 was 1.37%. In addition to established clinical factors, African-American race and homelessness were independent demographic predictors of 30-day mortality.
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Affiliation(s)
- Raghav Chandra
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Jennie Meier
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Surgery, North Texas Veterans Affairs Health Care System, Dallas, Texas.
| | - Mitri K Khoury
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Asher Weisberg
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Yen T Nguyen
- Department of Surgery, North Texas Veterans Affairs Health Care System, Dallas, Texas; Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Michael E Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Christopher A Heid
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
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Gaffney A, Himmelstein DU, Dickman S, McCormick D, Woolhandler S. Uptake and Equity in Influenza Vaccination Among Veterans with VA Coverage, Veterans Without VA Coverage, and Non-Veterans in the USA, 2019-2020. J Gen Intern Med 2022; 38:1152-1159. [PMID: 36163527 PMCID: PMC9512990 DOI: 10.1007/s11606-022-07797-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Vaccination is a primary method of reducing the burden of influenza, yet uptake is neither optimal nor equitable. Single-tier, primary care-oriented health systems may have an advantage in the efficiency and equity of vaccination. OBJECTIVE To assess the association of Veterans' Health Administration (VA) coverage with influenza vaccine uptake and disparities. DESIGN Cross-sectional. PARTICIPANTS Adult respondents to the 2019-2020 National Health Interview Survey. MAIN MEASURES We examined influenza vaccination rates, and racial/ethnic and income-based vaccination disparities, among veterans with VA coverage, veterans without VA coverage, and adult non-veterans. We performed multivariable logistic regressions adjusted for demographics and self-reported health, with interaction terms to examine differential effects by race/ethnicity and income. KEY RESULTS Our sample included n=2,277 veterans with VA coverage, n=2,821 veterans without VA coverage, and n=46,456 non-veterans. Veterans were more often White and male; among veterans, those with VA coverage had worse health and lower incomes. Veterans with VA coverage had a higher unadjusted vaccination rate (63.0%) than veterans without VA coverage (59.1%) and non-veterans (46.5%) (p<0.05 for each comparison). In our adjusted model, non-veterans were 11.4 percentage points (95% CI -14.3, -8.5) less likely than veterans with VA coverage to be vaccinated, and veterans without VA coverage were 6.7 percentage points (95% CI -10.3, -3.0) less likely to be vaccinated than those with VA coverage. VA coverage, compared with non-veteran status, was also associated with reduced racial/ethnic and income disparities in vaccination. CONCLUSIONS VA coverage is associated with higher and more equitable influenza vaccination rates. A single-tier health system that emphasizes primary care may improve the uptake and equity of vaccination for influenza, and possibly other pathogens, like SARS-CoV2.
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Affiliation(s)
- Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA. .,Harvard Medical School, Boston, MA, USA.
| | - David U Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA.,Hunter College, City University of New York, New York, NY, USA.,Public Citizen Health Research Group, Washington, DC, USA
| | | | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Stephanie Woolhandler
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA.,Hunter College, City University of New York, New York, NY, USA.,Public Citizen Health Research Group, Washington, DC, USA
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Merchant AT. Grand challenges in oral health and nutrition: We are what we eat. FRONTIERS IN ORAL HEALTH 2022; 3:999817. [PMID: 36092139 PMCID: PMC9448949 DOI: 10.3389/froh.2022.999817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/08/2022] [Indexed: 11/17/2022] Open
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Judson GL, Cohen BE, Muniyappa A, Raitt MH, Shen H, Tarasovsky G, Whooley MA, Dhruva SS. Implantable cardioverter-defibrillator placement among patients with left ventricular ejection fraction ≤35 % at least 40 days after acute myocardial infarction. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 19:100186. [PMID: 37886349 PMCID: PMC10601204 DOI: 10.1016/j.ahjo.2022.100186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/16/2022] [Accepted: 07/18/2022] [Indexed: 10/28/2023]
Abstract
Background Implantable cardioverter-defibrillators (ICDs) reduce the risk of sudden cardiac death among patients with persistently reduced (≤35 %) left ventricular ejection fraction (LVEF) at least 40 days following acute myocardial infarction (AMI). Few prior studies have used LVEF measured after the 40-day waiting period to examine primary prevention ICD placement. Methods We sought to determine factors associated with ICD placement among patients who met LVEF criteria post-MI within a large integrated health care system in the U.S by conducting a retrospective cohort study of Veteran patients hospitalized for AMI from 2004 to 2017 who had documented LVEF ≤35 % from echocardiograms performed between 40 and 455 (90 days +1 year) days post-MI. We used multivariable logistic regression to examine factors associated with ICD placement. Results Of 12,893 patients with LVEF ≤35 % at least 40 days post-MI, 2176 (16.9 %) received an ICD between 91- and 455-days post-MI. Younger age, fewer comorbidities, revascularization with PCI, and greater use of GDMT were associated with increased odds of receiving an ICD. However, half of patients treated with a beta-blocker, ACE inhibitor or angiotensin receptor blocker, and mineralocorticoid receptor antagonist prior to LVEF assessment did not receive an ICD. Eligible Black patients were less likely (odds ratio 0.80, 95 % confidence interval 0.69-0.92) to receive an ICD than White patients. Conclusion Many factors affect ICD placement among Veteran patients with a confirmed LVEF ≤35 % at least 40 days post-MI. Greater understanding of factors influencing ICD placement would help clinicians ensure guideline-concordant care.
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Affiliation(s)
- Gregory L. Judson
- Division of Cardiology, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Beth E. Cohen
- Division of General Internal Medicine, University of California, San Francisco, CA, United States of America
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Anoop Muniyappa
- Clinical Informatics, University of California, San Francisco, CA, United States of America
| | - Merritt H. Raitt
- Knight Cardiovascular Institute, Oregon Health and Sciences University, Portland, OR, United States of America
- Portland Veterans Affairs Health Care System, OR, United States of America
| | - Hui Shen
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Gary Tarasovsky
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Mary A. Whooley
- Division of General Internal Medicine, University of California, San Francisco, CA, United States of America
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Sanket S. Dhruva
- Division of Cardiology, Department of Medicine, University of California, San Francisco, CA, United States of America
- San Francisco Veterans Affairs Health Care System, CA, United States of America
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8
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Timmis A, Vardas P, Townsend N, Torbica A, Katus H, De Smedt D, Gale CP, Maggioni AP, Petersen SE, Huculeci R, Kazakiewicz D, de Benito Rubio V, Ignatiuk B, Raisi-Estabragh Z, Pawlak A, Karagiannidis E, Treskes R, Gaita D, Beltrame JF, McConnachie A, Bardinet I, Graham I, Flather M, Elliott P, Mossialos EA, Weidinger F, Achenbach S. European Society of Cardiology: cardiovascular disease statistics 2021. Eur Heart J 2022; 43:716-799. [PMID: 35016208 DOI: 10.1093/eurheartj/ehab892] [Citation(s) in RCA: 325] [Impact Index Per Article: 162.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/07/2021] [Accepted: 12/16/2021] [Indexed: 12/13/2022] Open
Abstract
AIMS This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries. METHODS AND RESULTS Statistics pertaining to 2019, or the latest available year, are presented. Data sources include the World Health Organization, the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards World Health Organization (WHO) 2025 targets for non-communicable diseases. Salient observations in this report: (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high income (81.6 years) compared with middle-income (74.2 years) countries. (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese with similar prevalence in high and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five-member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures. CONCLUSION Risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO NCD targets for 2025 are unlikely to be met across ESC member countries.
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Affiliation(s)
- Adam Timmis
- William Harvey Research Institute, Queen Mary University London, London, UK
| | - Panos Vardas
- Hygeia Hospitals Group, HHG, Athens, Greece
- European Heart Agency, European Society of Cardiology, Brussels, Belgium
| | | | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy
| | - Hugo Katus
- Department of Internal Medicine and Cardiology, University of Heidelberg, Heidelberg, Germany
| | | | - Chris P Gale
- Medical Research Council Bioinformatics Centre, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Aldo P Maggioni
- Research Center of Italian Association of Hospital Cardiologists (ANMCO), Florence, Italy
| | - Steffen E Petersen
- William Harvey Research Institute, Queen Mary University London, London, UK
| | - Radu Huculeci
- European Heart Agency, European Society of Cardiology, Brussels, Belgium
| | | | | | - Barbara Ignatiuk
- Division of Cardiology, Ospedali Riuniti Padova Sud, Monselice, Italy
| | | | - Agnieszka Pawlak
- Mossakowski Medical Research Centre Polish Academy of Sciences, Warsaw, Poland
| | - Efstratios Karagiannidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Roderick Treskes
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dan Gaita
- Universitatea de Medicina si Farmacie Victor Babes, Institutul de Boli Cardiovasculare, Timisoara, Romania
| | - John F Beltrame
- University of Adelaide, Central Adelaide Local Health Network, Basil Hetzel Institute, Adelaide, Australia
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | | | - Ian Graham
- Tallaght University Hospital, Dublin, Ireland
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Perry Elliott
- Institute of Cardiovascular Science, University College London, London, UK
| | | | - Franz Weidinger
- Department of Internal Medicine and Cardiology, Klinik Landstrasse, Vienna, Austria
| | - Stephan Achenbach
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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9
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Rizk JG, Wenziger C, Tran D, Hashemi L, Moradi H, Streja E, Ahluwalia A. Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Use Associated with Reduced Mortality and Other Disease Outcomes in US Veterans with COVID-19. Drugs 2021; 82:43-54. [PMID: 34914085 PMCID: PMC8675115 DOI: 10.1007/s40265-021-01639-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 12/29/2022]
Abstract
Objective To determine the association between angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) use and coronavirus disease 2019 (COVID-19) severity and outcomes in US veterans. Patients and Methods We retrospectively examined 27,556 adult US veterans who tested positive for COVID-19 between March to November 2020. Logistic regression and Cox proportional hazards models using propensity score (PS) for weight, adjustment, and matching were used to examine the odds of an event within 60 days following a COVID-19–positive case date and time to death, respectively, according to ACEI and/or ARB prescription within 6 months prior to the COVID-19–positive case date. Results The overlap PS weighted logistic regression model showed lower odds of an intensive care unit (ICU) admission (odds ratio [OR] 95% CI 0.77, 0.61–0.98) and death within 60 days (0.87, 0.79–0.97) with an ACEI or ARB prescription. Veterans with an ARB-only prescription also had lower odds of an ICU admission (0.64, 0.44–0.92). The overlap PS weighted model similarly showed a lower risk of time to all-cause mortality in veterans with an ACEI or ARB prescription (HR [95% CI]: 0.87, 0.79–0.97) and an ARB only prescription (0.78, 0.67–0.91). Veterans with an ACEI prescription had higher odds of experiencing a septic event within 60 days after the COVID-19–positive case date (1.22, 1.02–1.46). Conclusion In this study of a national cohort of US veterans, we found that the use of an ACEI/ARB in patients with COVID-19 was not associated with increased mortality and other worse outcomes. Future studies should examine underlying pathways and further confirm the relationship of ACEI prescription with sepsis. Supplementary Information The online version contains supplementary material available at 10.1007/s40265-021-01639-2.
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Affiliation(s)
- John G Rizk
- Arizona State University, Edson College, Phoenix, AZ, USA.,Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, MD, USA
| | - Cachet Wenziger
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Diana Tran
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Leila Hashemi
- Greater Los Angeles VA Medical Center, Los Angeles, CA, USA.,UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Hamid Moradi
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Elani Streja
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA. .,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA.
| | - Amrita Ahluwalia
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.
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10
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Silva GC, Jiang L, Gutman R, Wu WC, Mor V, Fine MJ, Kressin NR, Trivedi AN. Racial/Ethnic Differences in 30-Day Mortality for Heart Failure and Pneumonia in the Veterans Health Administration Using Claims-based, Clinical, and Social Risk-adjustment Variables. Med Care 2021; 59:1082-1089. [PMID: 34779794 PMCID: PMC8652730 DOI: 10.1097/mlr.0000000000001650] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Prior studies have identified lower mortality in Black Veterans compared with White Veterans after hospitalization for common medical conditions, but these studies adjusted for comorbid conditions identified in administrative claims. OBJECTIVES The objectives of this study were to compare mortality for non-Hispanic White (hereafter, "White"), non-Hispanic Black (hereafter, "Black"), and Hispanic Veterans hospitalized for heart failure (HF) and pneumonia and determine whether observed mortality differences varied according to whether claims-based comorbid conditions and/or clinical variables were included in risk-adjustment models. RESEARCH DESIGN This was an observational study. SUBJECTS The study cohort included 143,520 admissions for HF and 127,782 admissions for pneumonia for Veterans hospitalized in 132 Veterans Health Administration (VA) Medical Centers between January 2009 and September 2015. MEASURES The primary independent variable was racial/ethnic group (ie, Black, Hispanic, and non-Hispanic White), and the outcome was all-cause mortality 30 days following admission. To compare mortality by race/ethnicity, we used logistic regression models that included different combinations of claims-based, clinical, and sociodemographic variables. For each model, we estimated the average marginal effect (AME) for Black and Hispanic Veterans relative to White Veterans. RESULTS Among the 143,520 (127,782) hospitalizations for HF (pneumonia), the average patient age was 71.6 (70.9) years and 98.4% (97.1%) were male. The unadjusted 30-day mortality rates for HF (pneumonia) were 7.2% (11.0%) for White, 4.1% (10.4%) for Black and 8.4% (16.9%) for Hispanic Veterans. Relative to White Veterans, when only claims-based variables were used for risk adjustment, the AME (95% confidence interval) for the HF [pneumonia] cohort was -2.17 (-2.45, -1.89) [0.08 (-0.41, 0.58)] for Black Veterans and 1.32 (0.49, 2.15) [4.51 (3.65, 5.38)] for Hispanic Veterans. When clinical variables were incorporated in addition to claims-based ones, the AME, relative to White Veterans, for the HF [pneumonia] cohort was -1.57 (-1.88, -1.27) [-0.83 (-1.31, -0.36)] for Black Veterans and 1.50 (0.71, 2.30) [3.30 (2.49, 4.11)] for Hispanic Veterans. CONCLUSIONS Compared with White Veterans, Black Veterans had lower mortality, and Hispanic Veterans had higher mortality for HF and pneumonia. The inclusion of clinical variables into risk-adjustment models impacted the magnitude of racial/ethnic differences in mortality following hospitalization. Future studies examining racial/ethnic disparities should consider including clinical variables for risk adjustment.
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Affiliation(s)
| | - Lan Jiang
- Providence VA Medical Center, Brown University School of Public Health, Providence, RI
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health
| | - Wen-Chih Wu
- Providence VA Medical Center, Brown University School of Public Health, Providence, RI
| | - Vincent Mor
- Providence VA Medical Center, Brown University School of Public Health, Providence, RI
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nancy R. Kressin
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System
- School of Medicine, Boston University, Boston, MA
| | - Amal N. Trivedi
- Providence VA Medical Center, Brown University School of Public Health, Providence, RI
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
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11
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Gaffey AE, Haskell SG, Brandt CA, Bastian LA, Meadows JL, Burg MM. Post-9/11 veterans' heart disease knowledge, self-perceived risk, and prevention beliefs and behaviors. Health Psychol 2021; 40:737-746. [PMID: 34780203 PMCID: PMC10691753 DOI: 10.1037/hea0001110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Veterans, including the growing number of women veterans, have a greater risk of heart disease than nonveterans, and the incidence of heart disease is increasing among the most recent veterans who participated in post-9/11 military conflicts. Investigating heart disease-related knowledge, self-perceived risk, and prevention beliefs and behavior among these veterans, and identifying potential differences in knowledge, risk, beliefs and behavior between men and women, may guide prevention strategies. METHOD Cross-sectional data from a nationwide survey of 1,141 (53% women) post-9/11 veterans were used to examine heart disease awareness and information-seeking, perceived risk and importance of heart disease risk factors, beliefs about traditional (e.g., weight, blood pressure) and nontraditional (e.g., stress, sleep) factors, and engagement in prevention behaviors. Differences between men and women were also tested, using t-tests, chi-square, and Fisher's exact tests. RESULTS Only one-third reported they felt very informed or sought information about heart disease, or that their providers had discussed heart disease with them. Although veterans generally believe that addressing traditional and nontraditional factors can reduce their risk of heart disease, far fewer endorsed the value of mental health treatment in prevention. Overall, women were slightly more knowledgeable about heart disease risk, and of behaviors that can lower this risk, but for both men and women, this knowledge did not translate to engaging in equivalent prevention behaviors. CONCLUSIONS Post-9/11 veterans, and potentially their providers, may each benefit from improved education regarding their risk of heart disease. Veterans may also require better, more personalized approaches to prevention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Allison E. Gaffey
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | - Sally G. Haskell
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Internal Medicine (General), Yale School of Medicine
| | - Cynthia A. Brandt
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Emergency Medicine, Yale School of Medicine
| | - Lori A. Bastian
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Internal Medicine (General), Yale School of Medicine
| | - Judith L. Meadows
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | - Matthew M. Burg
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
- Department of Anesthesiology, Yale School of Medicine
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12
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Dashputre AA, Gatwood J, Sumida K, Thomas F, Akbilgic O, Potukuchi PK, Obi Y, Molnar MZ, Streja E, Kalantar-Zadeh K, Kovesdy CP. Association of dyskalemias with short-term health care utilization in patients with advanced CKD. J Manag Care Spec Pharm 2021; 27:1403-1415. [PMID: 34595956 PMCID: PMC10119640 DOI: 10.18553/jmcp.2021.27.10.1403] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Patients with advanced chronic kidney disease (CKD) are at high risk for dyskalemias, which may induce arrhythmias that require immediate emergent or hospital care. The association of dyskalemias with short-term hospital/emergency room (ER) visits in advanced CKD is understudied. OBJECTIVE: To assess the association of dyskalemias with short-term hospital/ER visits in an advanced CKD population. METHODS: From among 102,477 US veterans transitioning to dialysis from 2007 to 2015, we identified 21,366 patients with 2 predialysis outpatient eGFR < 30 ml/min/1.73m2 90-365 days apart (with the second eGFR serving as the index date) and at least 1 potassium (K) in the baseline period (1 year before index) and 1 outpatient K (oK) in the follow-up (1 year after the index but before dialysis initiation). We examined the association of time-varying hypokalemia (K < 3.5 mEq/L) and hyperkalemia (K > 5.5 mEq/L) vs referent (3.5-5.5 mEq/L) with separate hospital and ER visits within 2 calendar days following each oK value over the 1-year follow-up period from the index. We used generalized estimating equations with binary distribution and logit link to model the exposure-outcome relationship adjusted for various confounders. We conducted various subgroup and sensitivity analyses to test the robustness of our results. RESULTS: Over the 1-year follow-up, 125,266 oK measurements were observed, of which 6.8% and 3.7% were classified as hyper- and hypokalemia, respectively. In the multivariable-adjusted model, hyperkalemia (adjusted odds ratio [aOR] = 2.04; 95% CI = 1.88-2.21) and hypokalemia (aOR = 1.66; 95% CI = 1.48-1.86) were associated with significantly higher odds of hospital visits. Similarly, hyperkalemia (aOR = 1.83; 95% CI = 1.65-2.03) and hypokalemia (aOR = 1.24; 95% CI = 1.07-1.44) were associated with significantly higher odds of ER visits. Results were robust to subgroups and sensitivity analyses. CONCLUSIONS: In patients with advanced CKD, dyskalemias are associated with higher risk of hospital/ER visits. Interventions targeted at lowering the risk of dyskalemias might help in reducing the health care utilization and associated economic burden among patients with advanced CKD experiencing dyskalemias. DISCLOSURES: This study was supported by grant 5U01DK102163 from the National Institute of Health (NIH) to Kamyar Kalantar-Zadeh and Csaba P. Kovesdy and by resources from the US Department of Veterans Affairs. The data reported here have been supplied in part by the United States Renal Data System (USRDS). Support for VA/CMS data were provided by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (project numbers SDR 02-237 and 98-004). Opinions expressed in this article are those of the authors and do not necessarily represent the opinion of the Department of Veterans Affairs or the funding institution. Kovesdy has received honoraria from Akebia, Ardelyx, Astra Zeneca, Bayer, Boehringer-Ingelheim, Cara Therapeutics, Reata, and Tricida unrelated to this study. Kalantar-Zadeh has received honoraria and/or support from Abbott, Abbvie, ACI Clinical (Cara Therapeutics), Akebia, Alexion, Amgen, American Society of Nephrology, Astra-Zeneca, Aveo, BBraun, Chugai, Cytokinetics, Daiichi, DaVita, Fresenius, Genentech, Haymarket Media, Hofstra Medical School, International Federation of Kidney Foundations, International Society of Hemodialysis, International Society of Renal Nutrition & Metabolism, Japanese Society of Dialysis Therapy, Hospira, Kabi, Keryx, Kissei, Novartis, OPKO, National Institutes of Health, National Kidney Foundations, Pfizer, Regulus, Relypsa, Resverlogix, Dr Schaer, Sandoz, Sanofi, Shire, Veterans Affairs, Vifor, UpToDate, and ZS-Pharma, unrelated to this study. Gatwood has received research support from AstraZeneca, Merck & Co., and GlaxoSmithKline unrelated to this study. Obi has received research support from Relypsa/Vifor Pharma Inc. The remaining authors declare that they have no relevant financial interests.
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Affiliation(s)
- Ankur A Dashputre
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis
| | - Justin Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis
| | - Oguz Akbilgic
- Department of Health Informatics and Data Science, Parkinson School of Health Sciences and Public Health, Loyola University, Chicago, IL
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Miklos Z Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of CaliforniaIrvine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of CaliforniaIrvine, Orange, CA
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13
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Kalantar-Zadeh K, Jafar TH, Nitsch D, Neuen BL, Perkovic V. Chronic kidney disease. Lancet 2021; 398:786-802. [PMID: 34175022 DOI: 10.1016/s0140-6736(21)00519-5] [Citation(s) in RCA: 428] [Impact Index Per Article: 142.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/11/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA, USA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA.
| | - Tazeen H Jafar
- Duke-NUS Graduate Medical School, Singapore; Department of Renal Medicine, Singapore General Hospital, Singapore; Duke Global Health Institute, Durham, NC, USA
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; United Kingdom Renal Registry, Bristol, UK; Department of Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Vlado Perkovic
- Faculty of Medicine, University of New South Wales Sydney, Sydney, NSW, Australia
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14
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Gosmanov AR, Gemoets DE, Kaminsky LS, Kovesdy CP, Gosmanova EO. Efficacy of metformin monotherapy in US veterans with type 2 diabetes and preexisting chronic kidney disease stage 3. Diabetes Obes Metab 2021; 23:1879-1885. [PMID: 33908689 DOI: 10.1111/dom.14414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/15/2021] [Accepted: 04/26/2021] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the glycaemic efficacy of metformin in people with type 2 diabetes (T2D) and stage 3 chronic kidney disease (CKD3). PARTICIPANTS AND METHODS This was a retrospective study including 145980 US veterans with T2D and an estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2 who initiated metformin monotherapy between November 1999 and July 2017. Propensity-score-matched cohorts were generated based on baseline variables associated with CKD3 (eGFR 30-59 mL/min/1.73 m2 ) to evaluate the independent association between CKD3 and metformin discontinuation, the addition of a second hypoglycaemic agent, and changes in glycated haemoglobin (HbA1c) from baseline in those with and without CKD3. Associations were examined using the Kaplan-Meier method and multivariable regression models, adjusted for baseline and 12-month average metformin dose. RESULTS The mean age of the entire cohort was 60.7 years, and 95% of the cohort were men, 21% were African American and 9% had CKD3. In the adjusted analyses, patients with CKD3 had a higher risk of metformin discontinuation or addition of a second hypoglycaemic agent, as compared with patients without CKD (hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.19-1.26, and HR 1.26, 95% CI 1.13-1.40, respectively). Among metformin monotherapy users, there were no differences in the average HbA1c reduction from baseline to 12 or 24 months between patients with and without CKD3. CONCLUSIONS Individuals with CKD3 and T2D were at increased risk of metformin monotherapy failure. However, the HbA1c-lowering efficacy of metformin was similar in patients with and without CKD3, highlighting that metformin is a valuable treatment option for newly treated individuals with T2D and CKD3.
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Affiliation(s)
- Aidar R Gosmanov
- Department of Medicine, Stratton VA Medical Centre, Albany, New York, USA
- Division of Endocrinology, Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Darren E Gemoets
- Department of Research and Development, Stratton VA Medical Centre, Albany, New York, USA
| | - Laurence S Kaminsky
- Department of Research and Development, Stratton VA Medical Centre, Albany, New York, USA
| | - Csaba P Kovesdy
- Department of Medicine, Memphis VA Medical Centre, Memphis, Tennessee, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Centre, Memphis, Tennessee, USA
| | - Elvira O Gosmanova
- Department of Medicine, Stratton VA Medical Centre, Albany, New York, USA
- Division of Nephrology, Department of Medicine, Albany Medical College, Albany, New York, USA
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15
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Dashputre AA, Sumida K, Thomas F, Gatwood J, Akbilgic O, Potukuchi PK, Obi Y, Molnar MZ, Streja E, Kalantar Zadeh K, Kovesdy CP. Association of Dyskalemias with Ischemic Stroke in Advanced Chronic Kidney Disease Patients Transitioning to Dialysis. Am J Nephrol 2021; 52:539-547. [PMID: 34289468 DOI: 10.1159/000516902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/26/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hypo- and hyperkalemia are associated with a higher risk of ischemic stroke. However, this association has not been examined in an advanced chronic kidney disease (CKD) population. METHODS From among 102,477 US veterans transitioning to dialysis between 2007 and 2015, 21,357 patients with 2 pre-dialysis outpatient estimated glomerular filtration rates <30 mL/min/1.73 m2 90-365 days apart and at least 1 potassium (K) each in the baseline and follow-up period were identified. We separately examined the association of both baseline time-averaged K (chronic exposure) and time-updated K (acute exposure) treated as categorized (hypokalemia [K <3.5 mEq/L] and hyperkalemia [K >5.5 mEq/L] vs. referent [3.5-5.5 mEq/L]) and continuous exposure with time to the first ischemic stroke event prior to dialysis initiation using multivariable-adjusted Cox regression models. RESULTS A total of 2,638 (12.4%) ischemic stroke events (crude event rate 41.9 per 1,000 patient years; 95% confidence interval [CI] 40.4-43.6) over a median (Q1-Q3) follow-up time of 2.56 (1.59-3.89) years were observed. The baseline time-averaged K category of hypokalemia (adjusted hazard ratio [aHR], 95% CI: 1.35, 1.01-1.81) was marginally associated with a significantly higher risk of ischemic stroke. However, time-updated hyperkalemia was associated with a significantly lower risk of ischemic stroke (aHR, 95% CI: 0.82, 0.68-0.98). The exposure-outcome relationship remained consistent when using continuous K levels for both the exposures. DISCUSSION/CONCLUSION In patients with advanced CKD, hypokalemia (chronic exposure) was associated with a higher risk of ischemic stroke, whereas hyperkalemia (acute exposure) was associated with a lower risk of ischemic stroke. Further studies in this population are needed to explore the mechanisms underlying these associations.
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Affiliation(s)
- Ankur A Dashputre
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Justin Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, Tennessee, USA
| | - Oguz Akbilgic
- Department of Health Informatics and Data Science, Parkinson School of Health Sciences and Public Health, Loyola University, Chicago, Illinois, USA
| | - Praveen K Potukuchi
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Kamyar Kalantar Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
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16
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Iyer HS, Gomez SL, Chen JT, Trinh QD, Rebbeck TR. Trends in mortality among Black and White men with prostate cancer in Massachusetts and Pennsylvania: Race and neighborhood socioeconomic position. Cancer 2021; 127:2525-2534. [PMID: 33798264 PMCID: PMC8249310 DOI: 10.1002/cncr.33506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/18/2021] [Accepted: 02/04/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Reducing disparities in men with prostate cancer (PCa) that may be caused by racial and socioeconomic differences is a major public health priority. Few reports have studied whether these disparities have changed over time. METHODS Men diagnosed with PCa from January 1, 2000 to December 31, 2015 were identified from the Massachusetts and Pennsylvania cancer registries. All-cause mortality and PCa and cardiovascular cause-specific mortality were assessed. To estimate neighborhood socioeconomic position (nSEP), a summary score was generated using census tract-level measures of income, wealth, educational attainment, and racial and income segregation. Participants were grouped by diagnosis year (2000-2003, 2004-2007, 2008-2011, or 2012-2015), and changing trends in the mortality rate ratio by race and nSEP were estimated using covariate-adjusted Cox models with follow-up for up to 10 years, until death, or until censoring on January 1, 2018. RESULTS There were 193,883 patients with PCa and 43,661 deaths over 1,404,131 person-years of follow-up. The Black-White adjusted hazard ratio (aHR) from 2000 to 2003 through 2012 to 2015 was stable for all-cause mortality (aHR, 1.14 to 0.97; P for heterogeneity = .42), decreased for PCa-specific mortality (aHR, 1.38 to 0.93; P for heterogeneity = .005), and increased for cardiovascular mortality (aHR, 1.09 to 1.28; P for heterogeneity = .034). The aHR comparing those in the lowest versus the highest nSEP quintile increased significantly for all-cause mortality (aHR, 1.54 to 1.79; P for heterogeneity = .008), but not for PCa-specific mortality (aHR, 1.60 to 1.72; P for heterogeneity = .40) or cardiovascular mortality (aHR, 1.72 to 1.89; P for heterogeneity = .085). CONCLUSIONS Although Black-White disparities in prostate mortality declined in Massachusetts and Pennsylvania over the study period, nSEP mortality disparity trends were stagnant or increased, warranting further attention. LAY SUMMARY Few reports have examined whether racial and socioeconomic disparities in prostate cancer mortality have widened or narrowed in recent years. Using data from 2 state registries (Massachusetts and Pennsylvania) with differing intensities of government-mandated health insurance, trends in racial and neighborhood socioeconomic disparities were studied among Black and White men diagnosed from 2000 to 2015. Overall, trends in racial disparities were stagnant for all-cause mortality, shrank for prostate mortality, and widened for cardiovascular mortality. Disparities associated with neighborhood socioeconomic status either were stagnant or widened across all mortality end points. In general, disparities were more pronounced in Pennsylvania than in Massachusetts.
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Affiliation(s)
- Hari S. Iyer
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, United States of America
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, United States of America
| | - Scarlett Lin Gomez
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, United States of America
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, United States of America
| | - Jarvis T. Chen
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, United States of America
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, United States of America
| | - Timothy R. Rebbeck
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, United States of America
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, United States of America
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17
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Harvey PD, Bigdeli TB, Fanous AH, Li Y, Rajeevan N, Sayward F, Radhakrishnan K, Huang G, Aslan M. Cooperative Studies Program (CSP) #572: A Study of Serious Mental Illness in Veterans as a Pathway to personalized medicine in Schizophrenia and Bipolar Illness. PERSONALIZED MEDICINE IN PSYCHIATRY 2021; 27-28:10.1016/j.pmip.2021.100078. [PMID: 34222732 PMCID: PMC8247126 DOI: 10.1016/j.pmip.2021.100078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Personalization of psychiatric treatment includes treatment of symptoms, cognition and functional deficits, suicide, and medical co-morbidities. VA Collaborative Study 572 examined a large sample of male and female veterans with schizophrenia (n=3,942) and with bipolar disorder (n=5,414) with phenotyping and genomic analyses. We present the results to date and future directions. METHODS All veterans received a structured diagnostic interview and assessments of suicidal ideation and behavior, PTSD, and health. Veterans with schizophrenia were assessed for negative symptoms and lifetime depression. All were assessed with a cognitive and functional capacity assessment. Data for genome wide association studies were collected. Controls came from the VA Million Veteran Program. RESULTS Suicidal ideation or behavior was present in 66%. Cognitive and functional deficits were consistent with previous studies. 40% of the veterans with schizophrenia had a lifetime major depressive episode and PTSD was present in over 30%. Polygenic risk score (PRS) analyses indicated that cognitive and functional deficits overlapped with PRS for cognition, education, and intelligence in the general population and PRS for suicidal ideation and behavior correlated with previous PRS for depression and suicidal ideation and behavior, as did the PRS for PTSD. DISCUSSION Results to date provide directions for personalization of treatment in SMI, veterans with SMI, and veterans in general. The results of the genomic analyses suggest that cognitive deficits in SMI may be associated with general population features. Upcoming genomic analyses will reexamine the issues above, as well as genomic factors associated with smoking, substance abuse, negative symptoms, and treatment response.
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Affiliation(s)
- Philip D. Harvey
- Bruce W. Carter Miami Veterans Affairs (VA) Medical Center, Miami, FL
- University of Miami School of Medicine, Miami, FL
| | - Tim B. Bigdeli
- VA New York Harbor Healthcare System, Brooklyn, NY
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Medical Center, Brooklyn, NY
| | - Ayman H. Fanous
- VA New York Harbor Healthcare System, Brooklyn, NY
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Medical Center, Brooklyn, NY
| | - Yuli Li
- Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, New Haven, CT
| | - Nallakkandi Rajeevan
- Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, New Haven, CT
| | - Frederick Sayward
- Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, New Haven, CT
| | - Krishnan Radhakrishnan
- Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT
- Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration
- University of Kentucky School of Medicine, Lexington, KY
| | - Grant Huang
- Office of Research and Development, Veterans Health Administration, Washington, DC
| | - Mihaela Aslan
- VA New York Harbor Healthcare System, Brooklyn, NY
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Medical Center, Brooklyn, NY
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18
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Tantisattamo E, Murray V, Obi Y, Park C, Catabay CJ, Lee Y, Wenziger C, Hsiung JT, Soohoo M, Kleine CE, Rhee CM, Kraut J, Kovesdy CP, Kalantar-Zadeh K, Streja E. Association of Pre-ESRD Serum Bicarbonate with Post-ESRD Mortality in Patients with Incident ESRD. Am J Nephrol 2021; 52:304-317. [PMID: 33895727 DOI: 10.1159/000513855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Serum bicarbonate or total carbon dioxide (CO2) concentrations decline as chronic kidney disease (CKD) progresses and rise after dialysis initiation. While metabolic acidosis accelerates the progression of CKD and is associated with higher mortality among patients with end stage renal disease (ESRD), there are scarce data on the association of CO2 concentrations before ESRD transition with post-ESRD mortality. METHODS A historical cohort from the Transition of Care in CKD (TC-CKD) study includes 85,505 veterans who transitioned to ESRD from October 1, 2007, through March 31, 2014. After 1,958 patients without follow-up data, 3 patients with missing date of birth, and 50,889 patients without CO2 6 months prior to ESRD transition were excluded, the study population includes 32,655 patients. Associations between CO2 concentrations averaged over the last 6 months and its rate of decline during the 12 months prior to ESRD transition and post-ESRD all-cause, cardiovascular (CV), and non-CV mortality were examined by using hierarchical adjustment with Cox regression models. RESULTS The cohort was on average 68 ± 11 years old and included 29% Black veterans. Baseline concentrations of CO2 were 23 ± 4 mEq/L, and median (interquartile range) change in CO2 were -1.8 [-3.4, -0.2] mEq/L/year. High (≥28 mEq/L) and low (<18 mEq/L) CO2 concentrations showed higher adjusted mortality risk while there was no clear trend in the middle range. Consistent associations were observed irrespective of sodium bicarbonate use. There was also a U-shaped association between the change in CO2 and all-cause, CV, and non-CV mortality with the lowest risk approximately at -2.0 and 0.0 mEq/L/year among sodium bicarbonate nonusers and users, respectively, and the highest mortality was among patients with decline in CO2 >4 mEq/L/year. CONCLUSION Both high and low pre-ESRD CO2 levels (≥28 and <18 mEq/L) during 6 months prior to dialysis transition and rate of CO2 decline >4 mEq/L/year during 1 year before dialysis initiation were associated with greater post-ESRD all-cause, CV, and non-CV mortality. Further studies are needed to determine the optimal management of CO2 in patients with advanced CKD stages transitioning to ESRD.
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Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Victoria Murray
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Christina J Catabay
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Yuji Lee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Jeffrey Kraut
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
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19
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Sumida K, Dashputre AA, Potukuchi PK, Thomas F, Obi Y, Molnar MZ, Gatwood JD, Streja E, Kalantar-Zadeh K, Kovesdy CP. Laxative Use and Risk of Dyskalemia in Patients with Advanced CKD Transitioning to Dialysis. J Am Soc Nephrol 2021; 32:950-959. [PMID: 33547216 PMCID: PMC8017552 DOI: 10.1681/asn.2020081120] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/20/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients with advanced CKD experience increased intestinal potassium excretion. This compensatory mechanism may be enhanced by laxative use; however, little is known about the association of laxative use with risk of dyskalemia in advanced CKD. METHODS Our study population encompassed 36,116 United States veterans transitioning to ESKD from 2007 to 2015 with greater than or equal to one plasma potassium measurement during the last 1-year period before ESKD transition. Using generalized estimating equations with adjustment for potential confounders, we examined the association of time-varying laxative use with risk of dyskalemia (i.e., hypokalemia [potassium <3.5 mEq/L] or hyperkalemia [>5.5 mEq/L]) versus normokalemia (3.5-5.5 mEq/L) over the 1-year pre-ESKD period. To avoid potential overestimation of dyskalemia risk, potassium measurements within 7 days following a dyskalemia event were disregarded in the analyses. RESULTS Over the last 1-year pre-ESKD period, there were 319,219 repeated potassium measurements in the cohort. Of these, 12,787 (4.0%) represented hypokalemia, and 15,842 (5.0%) represented hyperkalemia; the time-averaged potassium measurement was 4.5 mEq/L. After multivariable adjustment, time-varying laxative use (compared with nonuse) was significantly associated with lower risk of hyperkalemia (adjusted odds ratio [aOR], 0.79; 95% confidence interval [95% CI], 0.76 to 0.84) but was not associated with risk of hypokalemia (aOR, 1.01; 95% CI, 0.95 to 1.07). The results were robust to several sensitivity analyses. CONCLUSIONS Laxative use was independently associated with lower risk of hyperkalemia during the last 1-year pre-ESKD period. Our findings support a putative role of constipation in potassium disarrays and also support (with a careful consideration for the risk-benefit profiles) the therapeutic potential of laxatives in hyperkalemia management in advanced CKD.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ankur A. Dashputre
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee,Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Praveen K. Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Miklos Z. Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Justin D. Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, Tennessee
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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20
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McMaster KJ, Peeples AD, Schaffner RM, Hack SM. Mental Healthcare Provider Perceptions of Race and Racial Disparity in the Care of Black and White Clients. J Behav Health Serv Res 2021; 48:501-516. [PMID: 33751397 DOI: 10.1007/s11414-019-09682-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Black-white disparities in mental healthcare persist, despite efforts to eliminate them via culturally competent care. To gain insight into how providers implement culturally competent care practices, interviews were conducted with mental healthcare providers' about their self-reported behaviors with black and white clients and their perceptions of how race affects the treatment they provide. Thematic analysis was used to analyze 12 semi-structured interviews with providers from a Veterans Affairs healthcare system. Three sets of themes emerged: providers' general beliefs and behaviors (discomfort discussing race; belief that socioeconomic differences explained disparities; and use of coded language for race groups), providers' clinical beliefs and behaviors (race-matching enhances care and recognition of intersecting cultural identities), and providers' professional beliefs and behaviors (participation in passive racism facilitated by provider-provider alliance). Mental healthcare providers showed good awareness of intersectionality and subtle racism but held limiting beliefs that led to avoidance of discussions of race.
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Affiliation(s)
| | - Amanda D Peeples
- U.S. Department of Veterans Affairs, Baltimore, MD, USA.,University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rebecca M Schaffner
- U.S. Department of Veterans Affairs, Baltimore, MD, USA.,University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samantha M Hack
- U.S. Department of Veterans Affairs, Baltimore, MD, USA. .,University of Maryland School of Medicine, Baltimore, MD, USA. .,VISN 5 MIRECC, 10 North Green Street, Baltimore, MD, 21201, USA.
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21
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Dashputre AA, Sumida K, Potukuchi PK, Kar S, Obi Y, Thomas F, Molnar MZ, Streja E, Kalantar-Zadeh K, Kovesdy CP. Potassium Trajectories prior to Dialysis and Mortality following Dialysis Initiation in Patients with Advanced CKD. Nephron Clin Pract 2021; 145:265-274. [PMID: 33752200 DOI: 10.1159/000514294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/04/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Patients with advanced non-dialysis-dependent CKD (NDD-CKD) have a reduced ability for maintaining plasma potassium (K) in normal range. Deviation from normal plasma K ranges is associated with increased mortality; however, the average trajectory of plasma K over time in patients with advanced NDD-CKD and the outcomes associated with plasma K trajectory are unknown. METHODS We identified 34,167 US veterans with advanced NDD-CKD transitioning to dialysis between October 2007 and March 2015 with at least 1 K measurement each year over a 3-year period prior to dialysis transition (3-year prelude). The K trajectory defined as the change in K (slope) per year over the entire 3-year prelude was estimated using linear mixed-effects models. The association between unadjusted (crude) K slope (categorized as stable [-0.09 to 0.09 mEq/L/year], decreasing [≤-0.10 mEq/L/year], and increasing [≥0.10 mEq/L/year]) and time to all-cause and cardiovascular mortality during the 6 months following dialysis initiation was assessed using multivariable-adjusted survival models. RESULTS The crude and multivariable-adjusted K slopes (mean, 95% CI) over the 3-year prelude were 0.008 (0.0059, 0.0110) and -0.15 mEq/L/year (-0.19, -0.11), respectively. Decreasing K slope was associated with higher multivariable-adjusted risk of all-cause mortality (adjusted hazard ratio [95% CI] vs. stable K slope: 1.08 [1.00-1.17]). No association was observed between K slope and cardiovascular mortality. DISCUSSION/CONCLUSION The average intraindividual plasma K trajectory is remarkably stable in patients with advanced NDD-CKD. A decreasing K slope is associated with higher all-cause mortality risk.
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Affiliation(s)
- Ankur A Dashputre
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Praveen K Potukuchi
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Suryatapa Kar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA, .,Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA,
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22
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Hassan MO, Owoyemi I, Abdel-Rahman EM, Ma JZ, Balogun RA. Association of Race with In-Hospital and Post-Hospitalization Mortality in Patients with Acute Kidney Injury. Nephron Clin Pract 2021; 145:214-224. [PMID: 33657572 DOI: 10.1159/000511405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 09/05/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is known to be associated with increased mortality, and racial differences in hospital mortality exist in patients with AKI. However, it remains to be seen whether racial differences exist in post-hospitalization mortality among AKI patients. METHODS We analyzed data of adult AKI patients admitted to the University of Virginia Medical Center between January 1, 2001, and December 31, 2015, to compare in-hospital and post-hospitalization mortality among hospitalized black and white patients with AKI. Multivariable logistic regression analysis was used to analyze the association between race and in-hospital mortality, and 90-day post-hospitalization mortality among AKI patients that were discharged. Kaplan-Meier survival curve was used to evaluate long-term survival between black and white patients. RESULTS Black patients had lower in-hospital mortality than white patients after adjusting for age, sex, estimated glomerular filtration rate, hospital length of stay, severity of AKI, comorbidities, and the need for dialysis and mechanical ventilation (odds ratio: 0.82; 95% confidence interval, 0.70-0.96, p = 0.0015). Similarly, at 90-day post-hospitalization, black patients had significantly lower adjusted odds of death than white patients (odds ratio: 0.64; 95% confidence interval, 0.46-0.93; p = 0.008). The median length of follow-up was 11.9 months (0.6-46.7 months). Kaplan-Meier survival curve showed that long-term survival was significantly better in black patients compared to white patients (median duration of survival; 39.7 vs. 24.8 months; p ≤ 0.001). CONCLUSIONS Black patients with AKI had lower in-hospital mortality, 90-day post-hospitalization mortality, and better long-term survival rates compared to white patients with AKI.
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Affiliation(s)
- Muzamil O Hassan
- Department of Medicine, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Itunu Owoyemi
- Jared Grantham Kidney Institute, Kansas University Medical Center, Kansas City, Kansas, USA
| | | | - Jennie Z Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA,
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23
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Dashputre AA, Potukuchi PK, Sumida K, Kar S, Obi Y, Thomas F, Molnar MZ, Streja E, Kalantar-Zadeh K, Kovesdy CP. Predialysis Potassium Variability and Postdialysis Mortality in Patients With Advanced CKD. Kidney Int Rep 2021; 6:366-380. [PMID: 33615062 PMCID: PMC7879127 DOI: 10.1016/j.ekir.2020.11.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Patients with advanced non–dialysis-dependent chronic kidney disease (NDD-CKD) are prone to potassium (K) imbalances due to reduced kidney function. Both hypo- and hyperkalemia are associated with increased mortality; however, it is unclear if K variability before dialysis initiation is associated with outcomes after dialysis initiation. Methods We identified 34,167 US veterans with advanced NDD-CKD transitioning to dialysis between October 1, 2007, through March 31, 2015, who had at least 1 K measurement each year over a 3-year period before transition (3-year prelude). For each patient, a linear mixed-effects model was used to regress K over time (in years) over the 3-year prelude to derive K variability (square root of the average squared distance between the observed and estimated K). The main outcomes of interest were 6-month all-cause and cardiovascular mortality after dialysis initiation. Multivariable Cox and Fine-Gray competing risk regression adjusted for 3-year prelude K intercept, K slope (per year), demographics, smoking status, comorbidities, length of hospitalizations, body mass index, vascular access type, medications, average estimated glomerular filtration rate, and number of K measurements over the 3-year prelude were used to assess the association of K variability (expressed as quartiles) with all-cause and cardiovascular mortality, respectively. Results Higher prelude K variability was associated with higher multivariable-adjusted risk of all-cause mortality but not cardiovascular mortality (adjusted hazard/subhazard ratios [95% confidence interval] for highest quartile [vs. lowest] of K variability, 1.14 [1.03–1.25] and 0.99 [0.85–1.16] for all-cause and cardiovascular mortality, respectively). Conclusion Higher K variability is associated with higher all-cause mortality after dialysis initiation.
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Affiliation(s)
- Ankur A. Dashputre
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Praveen K. Potukuchi
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Suryatapa Kar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miklos Z. Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
- Correspondence: Csaba P.Kovesdy, Nephrology Section, Memphis VA Medical Center, 1030 Jefferson Avenue, Memphis, Tennessee 38104, United States.
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24
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Streja E, Norris KC, Budoff MJ, Hashemi L, Akbilgic O, Kalantar-Zadeh K. The quest for cardiovascular disease risk prediction models in patients with nondialysis chronic kidney disease. Curr Opin Nephrol Hypertens 2021; 30:38-46. [PMID: 33186224 DOI: 10.1097/mnh.0000000000000672] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) is the leading cause of death in patients with chronic kidney disease (CKD). However, traditional CVD risk prediction equations do not work well in patients with CKD, and inclusion of kidney disease metrics such as albuminuria and estimated glomerular filtration rate have a modest to no benefit in improving prediction. RECENT FINDINGS As CKD progresses, the strength of traditional CVD risk factors in predicting clinical outcomes weakens. A pooled cohort equation used for CVD risk prediction is a useful tool for guiding clinicians on management of patients with CVD risk, but these equations do not calibrate well in patients with CKD, although a number of studies have developed modifications of the traditional equations to improve risk prediction. The reason for the poor calibration may be related to the fact that as CKD progresses, associations of traditional risk factors such as BMI, lipids and blood pressure with CVD outcomes are attenuated or reverse, and other risk factors may become more important. SUMMARY Large national cohorts such as the US Veteran cohort with many patients with evolving CKD may be useful resources for the developing CVD prediction models; however, additional considerations are needed for the unique composition of patients receiving care in these healthcare systems, including those with multiple comorbidities, as well as mental health issues, homelessness, posttraumatic stress disorders, frailty, malnutrition and polypharmacy. Machine learning over conventional risk prediction models may be better suited to handle the complexity needed for these CVD prediction models.
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Affiliation(s)
- Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange
- Veterans Affairs Tibor Rubin Long Beach Healthcare System, Long Beach
| | - Keith C Norris
- David Geffen School of Medicine, UCLA, Los Angeles, California
| | | | - Leila Hashemi
- Veterans Affairs Greater Los Angeles Medical Center, Los Angeles, California
| | - Oguz Akbilgic
- Department of Health Informatics and Data Science, Loyola University Chicago, Maywood, Illinois, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange
- Veterans Affairs Tibor Rubin Long Beach Healthcare System, Long Beach
- University of Tennessee at Memphis Health Sciences Center, Memphis, Tennessee
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25
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Sumida K, Dashputre AA, Potukuchi PK, Thomas F, Obi Y, Molnar MZ, Gatwood JD, Streja E, Kalantar-Zadeh K, Kovesdy CP. Laxative use in patients with advanced chronic kidney disease transitioning to dialysis. Nephrol Dial Transplant 2020; 36:2018-2026. [PMID: 33035325 DOI: 10.1093/ndt/gfaa205] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Constipation is highly prevalent in patients with chronic kidney disease (CKD), particularly among those with end-stage renal disease (ESRD), partly due to their dietary restrictions, comorbidities and medications. Laxatives are typically used for constipation management; however, little is known about laxative use and its associated factors in patients with advanced CKD transitioning to ESRD. METHODS In a retrospective cohort of 102 477 US veterans transitioning to dialysis between October 2007 and March 2015, we examined the proportion of patients who filled a prescription for any type of laxative within each 6-month period over 36 months pre- and post-transition to ESRD. Factors associated with laxative use during the last 1-year pre-ESRD period were identified by multivariable logistic regression. RESULTS The proportion of patients prescribed laxatives increased as patients progressed to ESRD, peaking at 37.1% in the 6 months immediately following ESRD transition, then remaining fairly stable throughout the post-ESRD transition period. Among laxative users, stool softeners were the most commonly prescribed (∼30%), followed by hyperosmotics (∼20%), stimulants (∼10%), bulk formers (∼3%), chloride channel activator (<1%) and several combinations of these. The use of anticoagulants, oral iron supplements, non-opioid analgesics, antihistamines and opioid analgesics were among the factors independently associated with pre-ESRD laxative use. CONCLUSION The use of laxatives increased considerably as patients neared transition to ESRD, likely mirroring the increasing burden of drug-induced constipation during the ESRD transition period. Findings may provide novel insight into better management strategies to alleviate constipation symptoms and reduce medication requirements in patients with advanced CKD.
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Affiliation(s)
- Keiichi Sumida
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ankur A Dashputre
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,College of Graduate Health Sciences, Institute for Health Outcomes and Policy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Praveen K Potukuchi
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,College of Graduate Health Sciences, Institute for Health Outcomes and Policy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Department of Preventive Medicine, Division of Biostatistics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yoshitsugu Obi
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miklos Z Molnar
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, Division of Transplant, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Justin D Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, TN, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, CA, USA
| | - Csaba P Kovesdy
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
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26
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Egan BM, Li J, Sutherland SE, Jones DW, Ferdinand KC, Hong Y, Sanchez E. Sociodemographic Determinants of Life's Simple 7: Implications for Achieving Cardiovascular Health and Health Equity Goals. Ethn Dis 2020; 30:637-650. [PMID: 32989364 DOI: 10.18865/ed.30.4.637] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Life's Simple 7 (LS7; nutrition, physical activity, cigarette use, body mass index, blood pressure, cholesterol, glucose) predicts cardiovascular health. The principal objective of our study was to define demographic and socioeconomic factors associated with LS7 to better inform programs addressing cardiovascular health and health equity. Methods National Health and Nutrition Examination Surveys 1999-2016 data were analyzed on non-Hispanic White [NHW], NH Black [NHB], and Hispanic adults aged ≥20 years without cardiovascular disease. Each LS7 variable was assigned 0, 1, or 2 points for poor, intermediate, and ideal levels, respectively. Composite LS7 scores were grouped as poor (0-4 points), intermediate (5-9), and ideal (10-14). Results 32,803 adults were included. Mean composite LS7 scores were below ideal across race/ethnicity groups. After adjusting for confounders, NHBs were less likely to have optimal LS7 scores than NHW (multivariable odds ratios (OR .44; 95% CI .37-.53), whereas Hispanics tended to have better scores (1.18; .96-1.44). Hispanics had more ideal LS7 scores than NHBs, although Hispanics had lower incomes and less education, which were independently associated with fewer ideal LS7 scores. Adults aged ≥45 years were less likely to have ideal LS7 scores (.11; .09-.12) than adults aged <45 years. Conclusions NHBs were the least likely to have optimal scores, despite higher incomes and more education than Hispanics, consistent with structural racism and Hispanic paradox. Programs to optimize lifestyle should begin in childhood to mitigate precipitous age-related declines in LS7 scores, especially in at-risk groups. Promoting higher education and reducing poverty are also important.
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Affiliation(s)
- Brent M Egan
- American Medical Association, Improving Health Outcomes, Greenville, SC.,University of South Carolina School of Medicine-Greenville, SC
| | - Jiexiang Li
- College of Charleston, Department of Mathematics, Charleston, SC
| | - Susan E Sutherland
- American Medical Association, Improving Health Outcomes, Greenville, SC.,University of South Carolina School of Medicine-Greenville, SC
| | - Daniel W Jones
- University of Mississippi Medical Center, Center for Obesity Research, Jackson, MS
| | - Keith C Ferdinand
- Tulane University School of Medicine, Tulane Heart and Vascular Institute, New Orleans, LA
| | - Yuling Hong
- Centers for Disease Control, Division of Heart Disease and Stroke Prevention, Atlanta, GA
| | - Eduardo Sanchez
- American Heart Association, Center for Health Metrics and Evaluation, Dallas, TX
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27
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Sumida K, Dashputre AA, Potukuchi PK, Thomas F, Obi Y, Molnar MZ, Gatwood JD, Streja E, Kalantar-Zadeh K, Kovesdy CP. Laxative Use and Change in Estimated Glomerular Filtration Rate in Patients With Advanced Chronic Kidney Disease. J Ren Nutr 2020; 31:361-369. [PMID: 32952006 DOI: 10.1053/j.jrn.2020.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/30/2020] [Accepted: 08/09/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Constipation is highly prevalent in advanced chronic kidney disease (CKD), due in part to dietary (e.g., fiber) restrictions, and is often managed by laxatives; however, the effect of laxative use on kidney function in advanced CKD remains unclear. We aimed to examine the association of laxative use with longitudinal change in estimated glomerular filtration rate (eGFR) in patients with advanced CKD. DESIGN AND METHODS In a retrospective cohort of 43,622 US veterans transitioning to end-stage renal disease (ESRD) from 2007 to 2015, we estimated changes in eGFR (slope) by linear mixed-effects models using ≥2 available outpatient eGFR measurements during the 2-year period before transition to ESRD. The association of laxative use with change in eGFR was examined by testing the interaction of time-varying laxative use with time for eGFR slope in the mixed-effects models with adjustment for fixed and time-varying confounders. RESULTS Laxatives were prescribed in 49.8% of patients during the last 2-year pre-ESRD period. In the crude model, time-varying laxative use was modestly associated with more progressive eGFR decline compared with non-use of laxatives (median [interquartile interval] -7.1 [-11.9, -4.3] vs. -6.8 [-11.6, -4.0] mL/min/1.73 m2/year, P < .001). After multivariable adjustment, a faster eGFR decline associated with laxative use (vs. non-use of laxatives) remained statistically significant, although the between-group difference in eGFR slope was minimal (median [interquartile interval] -8.8 [-12.9, -5.9] vs. -8.6 [-12.6, -5.6] mL/min/1.73 m2/year, P < .001). The significant association was no longer evident across different types of laxatives (i.e., stool softeners, stimulants, or hyperosmotics). CONCLUSIONS There was a clinically negligible association of laxative use with change in eGFR during the last 2-year pre-ESRD period, suggesting the renal safety profile of laxatives in advanced CKD patients.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ankur A Dashputre
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee; Division of Transplant, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Justin D Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, Tennessee
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, Orange, California
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee.
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28
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Soohoo M, Moradi H, Obi Y, Rhee CM, Gosmanova EO, Molnar MZ, Kashyap ML, Gillen DL, Kovesdy CP, Kalantar-Zadeh K, Streja E. Statin Therapy Before Transition to End-Stage Renal Disease With Posttransition Outcomes. J Am Heart Assoc 2020; 8:e011869. [PMID: 30885048 PMCID: PMC6475049 DOI: 10.1161/jaha.118.011869] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Although studies have shown that statin therapy in patients with non-dialysis-dependent chronic kidney disease was associated with a lower risk of death, this was not observed in dialysis patients newly initiated on statins. It is unclear if statin therapy benefits administered during the predialysis period persist after transitioning to end-stage renal disease. Methods and Results In 47 720 veterans who transitioned to end-stage renal disease during 2007 to 2014, we examined the association of statin therapy use 1 year before transition with posttransition all-cause and cardiovascular mortality and hospitalization incidence rates over the first 12 months of follow-up. Associations were examined using multivariable adjusted Cox proportional hazard models and negative binomial regressions. Sensitivity analyses included propensity score and subgroup analyses. The cohort's mean± SD age was 71±11 years, and the cohort included 4% women, 23% blacks, and 66% diabetics. Over 12 months of follow-up, there were 13 411 deaths, with an incidence rate of 35.3 (95% CI , 34.7-35.8) deaths per 100 person-years. In adjusted models, statin therapy compared with no statin therapy was associated with lower risks of 12-month all-cause (hazard ratio [95% CI], 0.79 [0.76-0.82]) and cardiovascular (hazard ratio [95% CI ], 0.83 [0.78-0.88]) mortality, as well as with a lower rate of hospitalizations (incidence rate ratio [95% CI ], 0.89 [0.87-0.92]) after initiating dialysis. These lower outcome risks persisted across strata of clinical characteristics, and in propensity score analyses. Conclusions Among veterans with non-dialysis-dependent chronic kidney disease, treatment with statin therapy within the 1 year before transitioning to end-stage renal disease is associated with favorable early end-stage renal disease outcomes.
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Affiliation(s)
- Melissa Soohoo
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA.,2 Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
| | - Hamid Moradi
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA.,2 Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
| | - Yoshitsugu Obi
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA
| | - Connie M Rhee
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA
| | - Elvira O Gosmanova
- 3 Nephrology Section Stratton Veterans Affairs Medical Center Albany NY.,4 Division of Nephrology Department of Medicine Albany Medical College Albany NY
| | - Miklos Z Molnar
- 5 Division of Transplant Surgery Methodist University Hospital Transplant Institute Memphis TN.,6 Department of Surgery University of Tennessee Health Science Center Memphis TN.,7 Department of Medicine University of Tennessee Health Science Center Memphis TN.,8 Department of Transplantation and Surgery Semmelweis University Budapest Hungary
| | - Moti L Kashyap
- 9 Atherosclerosis Research Center Gerontology Section, Geriatric, Rehabilitation Medicine and Extended Care Health Care Group Veterans Affairs Medical Center Long Beach CA
| | - Daniel L Gillen
- 10 Department of Medicine University of California Irvine CA
| | - Csaba P Kovesdy
- 11 Nephrology Section Memphis Veterans Affairs Medical Center Memphis TN.,12 Division of Nephrology University of Tennessee Health Science Center Memphis TN
| | - Kamyar Kalantar-Zadeh
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA.,2 Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
| | - Elani Streja
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA.,2 Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
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29
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Mujamammi AH, Alluhaymid YM, Alshibani MG, Alotaibi FY, Alzahrani KM, Alotaibi AB, Almasabi AA, Sabi EM. Awareness of cardiovascular disease associated risk factors among Saudis in Riyadh City. J Family Med Prim Care 2020; 9:3100-3105. [PMID: 32984180 PMCID: PMC7491763 DOI: 10.4103/jfmpc.jfmpc_458_20] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/25/2020] [Accepted: 05/11/2020] [Indexed: 11/19/2022] Open
Abstract
Objective: The aim of this study was to estimate the awareness of Saudi population in Riyadh regarding cardiovascular diseases (CVDs) and their risk factors. Methods: This was a cross-sectional study that used self-administered questionnaires conducted in universities, primary care centers, and electronic copies distributed in social media websites. Results: Overall, 47.1% of the respondents had a good awareness of CVD and associated risk factors. However, awareness of the symptoms of stroke and heart attack was low. Pulmonary embolism and deep vein thrombosis were the most commonly identified types of CVD, with 39.2% aware of these conditions. The most well-known symptom of heart attack was shortness of breath (known by 54.4% of the respondents). In relation to stroke, the most commonly recognized symptom was “sudden dizziness, trouble walking, or loss of balance” (45.4%). Respondents’ awareness of CVD risk factors was moderate. The most common factors—identified by over two-thirds of participants—were unhealthy diet, smoking, dyslipidemia, and physical inactivity. Independent predictors of good CVD awareness were age 35–44 years, living in the north of Riyadh and following a healthy diet. Conclusions: The awareness of CVD and associated risk factors is insufficient among Saudis in Riyadh City. This study emphasizes the necessity for effective education to increase the awareness about CVD in Saudi Arabia. High awareness may lead to early recognition of the risk factors and lead to early implementation of primary prevention which the cornerstone of family medicine practice.
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Affiliation(s)
- Ahmed H Mujamammi
- Department of Pathology, Clinical Biochemistry Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | | | | | | | | | | | - Essa M Sabi
- Department of Pathology, Clinical Biochemistry Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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30
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Chisholm-Burns MA, Spivey CA, Potukuchi PK, Streja E, Kalantar-Zadeh K, Kovesdy CP, Molnar MZ. Association between Posttransplant Opioid Use and Immunosuppressant Therapy Adherence among Renal Transplant Recipients. Nephron Clin Pract 2020; 144:321-330. [PMID: 32434210 DOI: 10.1159/000507257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 03/14/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Little is known about the effect of posttransplant opioid use on adherence to immunosuppressant therapy (IST) among adult renal transplant recipients (RTRs). OBJECTIVE The aim of this study was to examine the relationship between opioid use and IST adherence among adult RTRs during the first year posttransplant. METHODS Longitudinal data were analyzed from a retrospective cohort study examining US veterans undergoing renal transplant from October 1, 2007, through March 31, 2015. Data were collected from the US Renal Data System, Centers for Medicare and Medicaid Services Data (Medicare Part D), and Veterans Affairs pharmacy records. Dose of opioid prescriptions was collected and divided based on annual morphine milligram equivalent within a year of transplant. Proportion of days covered of greater than or equal to 80% indicated adherence to tacrolimus. Unadjusted and multivariable-adjusted logistic regression analyses were performed. RESULTS A study population of 1,229 RTRs included 258 with no opioid use, while 971 opioid users were identified within the first year after transplantation. Compared to RTRs without opioid usage, RTRs with opioid usage had a lower probability of being adherent to tacrolimus in unadjusted logistic regression (odds ratio [OR] (95% confidence interval [CI]): 0.22 [0.07-0.72]) and adjusted logistic regression (OR [95% CI]: 0.11 [0.03-0.44]). These patterns generally remained consistent in unadjusted and adjusted main and sensitivity analyses. CONCLUSIONS Findings indicate RTRs who use prescription opioids during the first year posttransplant, regardless of the dosage/amount, are less likely to be adherent to tacrolimus. Future studies are needed to better understand underlying causes of the association between opioid use and tacrolimus nonadherence.
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Affiliation(s)
- Marie A Chisholm-Burns
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA,
| | - Christina A Spivey
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Elani Streja
- Division of Nephrology, University of California, Irvine, California, USA
| | | | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Methodist University Hospital Transplant Institute, Memphis, Tennessee, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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31
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Aslan M, Radhakrishnan K, Rajeevan N, Sueiro M, Goulet JL, Li Y, Depp C, Concato J, Harvey PD. Suicidal ideation, behavior, and mortality in male and female US veterans with severe mental illness. J Affect Disord 2020; 267:144-152. [PMID: 32063566 DOI: 10.1016/j.jad.2020.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 12/20/2019] [Accepted: 02/06/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND We compared male and female American veterans with schizophrenia or bipolar disorder regarding clinical characteristics associated with lifetime suicidal ideation and behavior. Subsequent mortality, including death by suicide, was also assessed. METHODS Data from questionnaires and face-to-face evaluations were collected during 2011-2014 from 8,049 male and 1,290 female veterans with schizophrenia or bipolar disorder. In addition to comparing male-female characteristics, Cox regression models-adjusted for demographic information, medical-psychiatric comorbidities, and self-reported suicidal ideation and behavior-were used to examine gender differences in associations of putative risk factors with suicide-specific and all-cause mortality during up to six years of follow-up. RESULTS Women overall were younger, more likely to report a history of suicidal behavior, less likely to be substance abusers, and had lower overall mortality during follow-up. Among women only, psychiatric comorbidity was paradoxically associated with lower all-cause mortality (hazard ratio [HR]=0.53, 95% CI, 0.29-0.96, p = 0.037 for 1 disorder vs. none; HR=0.44, 95% CI, 0.25-0.77, p = 0.004 for ≥2 disorders vs. none). Suicide-specific mortality involved relatively few events, but crude rates were an order of magnitude higher than in the U.S. general and overall veteran populations. LIMITATIONS Incomplete cause-of-death information and low statistical power for male-female comparisons regarding mortality. CONCLUSIONS Female veterans with SMI differed from females in the general population by having a higher risk of suicide attempts. They also had more lifetime suicide attempts than male veterans with same diagnoses. These differences should inform public policy and clinical planning.
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Affiliation(s)
- Mihaela Aslan
- VA Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT, United States; Department of Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Krishnan Radhakrishnan
- VA Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT, United States; College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Nallakkandi Rajeevan
- VA Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT, United States; Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, United States
| | - Melyssa Sueiro
- Research Service, Bruce W. Carter Veterans Affairs (VA) Medical Center, Miami, FL, United States
| | - Joseph L Goulet
- Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, United States; Pain, Research, Informatics, Multimorbidities, & Education Center, West Haven, CT, United States
| | - Yuli Li
- VA Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT, United States; Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, United States
| | - Colin Depp
- VA San Diego Healthcare System, San Diego, CA, United States; Department of Psychiatry, UC San Diego, La Jolla, CA, United States
| | - John Concato
- VA Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT, United States; Department of Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Philip D Harvey
- Research Service, Bruce W. Carter Veterans Affairs (VA) Medical Center, Miami, FL, United States; Department of Psychiatry, University of Miami Miller School of Medicine, Miami, FL, United States.
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Gaipov A, Molnar MZ, Potukuchi PK, Sumida K, Szabo Z, Akbilgic O, Streja E, Rhee CM, Koshy SKG, Canada RB, Kalantar-Zadeh K, Kovesdy CP. Acute kidney injury following coronary revascularization procedures in patients with advanced CKD. Nephrol Dial Transplant 2020; 34:1894-1901. [PMID: 29986054 DOI: 10.1093/ndt/gfy178] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/12/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Previous studies reported that compared with percutaneous coronary interventions (PCIs), coronary artery bypass grafting (CABG) is associated with a reduced risk of mortality and repeat revascularization in patients with mild to moderate chronic kidney disease (CKD) and end-stage renal disease (ESRD). Information about outcomes associated with CABG versus PCI in patients with advanced stages of CKD is limited. We evaluated the incidence and relative risk of acute kidney injury (AKI) associated with CABG versus PCI in patients with advanced CKD. METHODS We examined 730 US veterans with incident ESRD who underwent a first CABG or PCI up to 5 years prior to dialysis initiation. The association of CABG versus PCI with AKI was examined in multivariable adjusted logistic regression analyses. RESULTS A total of 466 patients underwent CABG and 264 patients underwent PCI. The mean age was 64 ± 8 years, 99% were male, 20% were African American and 84% were diabetic. The incidence of AKI in the CABG versus PCI group was 67% versus 31%, respectively (P < 0.001). The incidence of all stages of AKI were higher after CABG compared with PCI. CABG was associated with a 4.5-fold higher crude risk of AKI {odds ratio [OR] 4.53 [95% confidence interval (CI) 3.28-6.27]; P < 0.001}, which remained significant after multivariable adjustments [OR 3.50 (95% CI 2.03-6.02); P < 0.001]. CONCLUSION CABG was associated with a 4.5-fold higher risk of AKI compared with PCI in patients with advanced CKD. Despite other benefits of CABG over PCI, the extremely high risk of AKI associated with CABG should be considered in this vulnerable population when deciding on the optimal revascularization strategy.
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Affiliation(s)
- Abduzhappar Gaipov
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Extracorporeal Hemocorrection, National Scientific Medical Research Center, Astana, Kazakhstan
| | - Miklos Z Molnar
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN, USA.,Department of Surgery and Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Zoltan Szabo
- Department of Cardiothoracic Surgery and Anesthesia, Linköping University Hospital, Linköping, Sweden.,Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Oguz Akbilgic
- Center for Biomedical Informatics, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, CA, USA
| | - Santhosh K G Koshy
- Division of Cardiology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Robert B Canada
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
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Racial and Regional Disparities in Outcomes Among Veterans Initially Adherent to Oral Antidiabetic Therapies: an Observational Cohort Study. J Gen Intern Med 2020; 35:1211-1218. [PMID: 31916211 PMCID: PMC7174452 DOI: 10.1007/s11606-019-05373-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Adherence to prescribed medications is connected with, but is not a guarantee of, improved disease management and health outcomes. It remains unclear whether underlying health disparities exist among patients adherent to therapy and whether differences in outcomes vary by race and residential areas of the country. OBJECTIVE To determine the extent of racial and regional variation in outcomes within 5 years of oral antidiabetic drug initiation among veterans adherent to therapy. DESIGN Retrospective cohort study of 83,265 US Veterans Health Administration data, 2002-2014 PATIENTS: US veterans with uncomplicated diabetes and taking oral antidiabetic agents MAIN MEASURES: Veterans initially adherent to oral antidiabetic therapy were followed for up to 5 years, and comparisons focused on differences between non-Hispanic White and non-Hispanic Black veterans across geographic region and residential type (urban or rural). Outcomes included composite cardiovascular events, composite cerebrovascular events, or all-cause mortality using Poisson and adjusted Cox proportional hazards models. KEY RESULTS Cardiovascular event and all-cause mortality rates differed by race and region, while urban/rural differences were evident for cerebrovascular events and all-cause mortality. For non-Hispanic Blacks, the mortality rate was half that compared to non-Hispanic Whites (6.5 [95% CI 5.8-7.2] versus 13.3 [95% CI 12.9-13.8], p < 0.0001). Compared to the Northeast, all other regions had higher adjusted hazards for cardiovascular or cerebrovascular events (with a single exception), but no regional differences in all-cause mortality were observed. Models with interactions demonstrated that racial differences in cardiovascular events and all-cause mortality were isolated to the Midwest (HR 1.99 [95% CI 1.301-3.06; HR 1.64 [95% CI 1.210-2.215]) and South (HR 1.69 [85% CI 1.347-2.131]; HR 1.27 [95% CI 1.095-1.470]). CONCLUSIONS Despite adherence to therapy, differences in outcomes are likely among veterans with diabetes based on race and geography. Localized analyses may uncover specific social determinants contributing to differences in outcomes.
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Dyskalemia, its patterns, and prognosis among patients with incident heart failure: A nationwide study of US veterans. PLoS One 2019; 14:e0219899. [PMID: 31393910 PMCID: PMC6687136 DOI: 10.1371/journal.pone.0219899] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 07/04/2019] [Indexed: 12/01/2022] Open
Abstract
Background Although hypokalemia has been viewed as a significant concern among patients with heart failure (HF), recent advances in HF management tend to increase the risk of hyperkalemia. Objective To characterize contemporary data regarding correlates and prognostic values of dyskalemia in patients with HF. Design, setting, and participants In cross-sectional and longitudinal analyses, we studied 142,087 patients with newly diagnosed HF in US nationwide Veterans Administration database from 2005 through 2013. Exposures Demographic characteristics, laboratory variables, comorbidities, and medication use for the analysis of correlates of dyskalemia as well as potassium level in the analysis of mortality. Main Outcomes and Measures Dyskalemia and mortality. Results Hypokalemia (<3.5 mmol/L) at baseline was observed in 3.0% of the population, whereas hyperkalemia (≥5.5 mmol/L) was seen in 0.9%. An additional 20.4% and 5.7% had mild hypokalemia (3.5–3.9 mmol/L) and mild hyperkalemia (5.0–5.4 mmol/L). Key correlates were black race, higher blood pressure, and use of potassium-wasting diuretics for hypokalemia, and lower kidney function for hyperkalemia. Baseline potassium levels showed a U-shaped association with mortality, with the lowest risk between 4.0–4.5 mmol/L. With respect to potassium levels over a year after HF diagnosis, persistent (>50% of measurements), intermittent (>1 occurrence but ≤50%), and transient (1 occurrence) hypo- and hyperkalemia were also related to increased mortality in a graded fashion regardless of the aforementioned thresholds for dyskalemia. These dyskalemic patterns were also related to other clinical actions and demands such as emergency room visit. Conclusions Potassium levels below 4 mmol/L and above 5 mmol/L at and after HF diagnosis were associated with poor prognosis and the clinical actions. HF patients (particularly with risk factors for dyskalemia like black race and kidney dysfunction) may require special attention for both hypo- and hyperkalemia.
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35
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Sumida K, Molnar MZ, Potukuchi PK, Thomas F, Lu JL, Obi Y, Rhee CM, Streja E, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Prognostic significance of pre-end-stage renal disease serum alkaline phosphatase for post-end-stage renal disease mortality in late-stage chronic kidney disease patients transitioning to dialysis. Nephrol Dial Transplant 2019; 33:264-273. [PMID: 28064159 DOI: 10.1093/ndt/gfw412] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 10/25/2016] [Indexed: 12/20/2022] Open
Abstract
Background Higher serum alkaline phosphatase (ALP) levels have been associated with excess mortality in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) and end-stage renal disease (ESRD). However, little is known about the impact of late-stage NDD-CKD ALP levels on outcomes after dialysis initiation. Methods Among 17 732 US veterans who transitioned to dialysis between October 2007 and September 2011, we examined the association of serum ALP levels averaged over the last 6 months of the pre-ESRD transition period ('prelude period') with all-cause, cardiovascular and infection-related mortality following dialysis initiation, using Cox (for all-cause mortality) and competing risk (for cause-specific mortality) regressions adjusted for demographics, comorbidities, medications, estimated glomerular filtration rate and serum albumin levels over the 6-month prelude period, and vascular access type at dialysis initiation. Results During a median follow-up of 2.0 (interquartile range, 1.1-3.2) years following dialysis initiation, a total of 9196 all-cause deaths occurred. Higher ALP levels were incrementally associated with higher all-cause, cardiovascular and infection-related mortality. Compared with patients in the lowest ALP quartile (<66.0 U/L), those in the highest quartile (≥111.1 U/L) had multivariable-adjusted hazard/subhazard ratios (95% confidence interval) of 1.42 (1.34-1.51), 1.43 (1.09-1.88) and 1.39 (1.09-1.78) for all-cause, cardiovascular and infection-related mortality, respectively. The associations remained consistent in various subgroups and after further adjustment for liver enzymes, serum phosphorus and intact parathyroid hormone levels. Conclusions Higher pre-ESRD serum ALP levels are independently associated with higher post-ESRD mortality risk. Further studies are warranted to determine if interventions that lower pre-ESRD ALP levels reduce mortality in incident dialysis patients.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan.,Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z Molnar
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
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36
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Siwakoti A, Potukuchi PK, Thomas F, Gaipov A, Talwar M, Balaraman V, Cseprekal O, Yazawa M, Streja E, Eason JD, Kalantar-Zadeh K, Kovesdy CP, Molnar MZ. History of posttraumatic stress disorder and outcomes after kidney transplantation. Am J Transplant 2019; 19:2294-2305. [PMID: 30672107 PMCID: PMC6650381 DOI: 10.1111/ajt.15268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 01/25/2023]
Abstract
A history of posttraumatic stress disorder (PTSD), if uncontrolled, represents a contraindication for kidney transplantation. However, no previous large study has assessed the association between pretransplant history of PTSD and posttransplantation outcomes. We examined 4479 US veterans who had undergone transplantation. The diagnosis of history of PTSD was based on a validated algorithm. Measured covariates were used to create a matched cohort (n = 560). Associations between pretransplant PTSD and death with functioning graft, all-cause death, and graft loss were examined in survival models. Posttransplant medication nonadherence was assessed using proportion of days covered (PDC). From among 4479 veterans, 282 (6.3%) had a history of PTSD. The mean age ± standard deviation (SD) of the cohort at baseline was 61 ± 11 years, 91% were male, and 66% and 28% of patients were white and African American, respectively. Compared to patients without a history of PTSD, patients with a history of PTSD had a similar risk of death with a functioning graft (subhazard ratio [SHR] 0.97, 95% confidence interval [CI] 0.61-1.54), all-cause death (1.05, 0.69-1.58), and graft loss (1.09, 0.53-2.26). Moreover, there was no difference in immunosuppressive drug PDC in patients with and without a history of PTSD (PDC: 98 ± 4% vs 99 ± 3%, P = .733 for tacrolimus; PDC: 99 ± 4% vs 98 ± 7%, P = .369 for mycophenolic acid). A history of PTSD in US veterans with end-stage renal disease should not on its own preclude a veteran from being considered for transplantation.
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Affiliation(s)
- Ashmita Siwakoti
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Praveen K. Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee,IHOP, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Abduzhappar Gaipov
- Department of Medicine, Nazarbayev University School of Medicine, Astana, Kazakhstan
| | - Manish Talwar
- Methodist University Hospital Transplant Institute, Memphis, Tennessee,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Vasanthi Balaraman
- Methodist University Hospital Transplant Institute, Memphis, Tennessee,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Orsolya Cseprekal
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Masahiko Yazawa
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Elani Streja
- Division of Nephrology, University of California, Irvine, California
| | - James D. Eason
- Methodist University Hospital Transplant Institute, Memphis, Tennessee,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Miklos Z. Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee,Methodist University Hospital Transplant Institute, Memphis, Tennessee,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
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Are racial differences in hospital mortality after coronary artery bypass graft surgery real? A risk-adjusted meta-analysis. J Thorac Cardiovasc Surg 2019; 157:2216-2225.e4. [DOI: 10.1016/j.jtcvs.2018.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/12/2018] [Accepted: 12/02/2018] [Indexed: 01/13/2023]
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Wong MS, Hoggatt KJ, Steers WN, Frayne SM, Huynh AK, Yano EM, Saechao FS, Ziaeian B, Washington DL. Racial/Ethnic Disparities in Mortality Across the Veterans Health Administration. Health Equity 2019; 3:99-108. [PMID: 31289768 PMCID: PMC6608703 DOI: 10.1089/heq.2018.0086] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Purpose: Equal-access health care systems such as the Veterans Health Administration (VHA) reduce financial and nonfinancial barriers to care. It is unknown if such systems mitigate racial/ethnic mortality disparities, such as those well documented in the broader U.S. population. We examined racial/ethnic mortality disparities among VHA health care users, and compared racial/ethnic disparities in VHA and U.S. general populations. Methods: Linking VHA records for an October 2008 to September 2009 national VHA user cohort, and National Death Index records, we assessed all-cause, cancer, and cardiovascular-related mortality through December 2011. We calculated age-, sex-, and comorbidity-adjusted mortality hazard ratios. We computed sex-stratified, age-standardized mortality risk ratios for VHA and U.S. populations, then compared racial/ethnic disparities between the populations. Results: Among VHA users, American Indian/Alaskan Natives (AI/ANs) had higher adjusted all-cause mortality, whereas non-Hispanic Blacks had higher cause-specific mortality versus non-Hispanic Whites. Asians, Hispanics, and Native Hawaiian/Other Pacific Islanders had similar, or lower all-cause and cause-specific mortality versus non-Hispanic Whites. Mortality disparities were evident in non-Hispanic-Black men compared with non-Hispanic White men in both VHA and U.S. populations for all-cause, cardiovascular, and cancer (cause-specific) mortality, but disparities were smaller in VHA. VHA non-Hispanic Black women did not experience the all-cause and cause-specific mortality disparity present for U.S. non-Hispanic Black women. Disparities in all-cause and cancer mortality existed in VHA but not in U.S. population AI/AN men. Conclusion: Patterns in racial/ethnic disparities differed between VHA and U.S. populations, with fewer disparities within VHAs equal-access system. Equal-access health care may partially address racial/ethnic mortality disparities, but other nonhealth care factors should also be explored.
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Affiliation(s)
- Michelle S. Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Katherine J. Hoggatt
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California
| | - Susan M. Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Alexis K. Huynh
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Elizabeth M. Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Fay S. Saechao
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California
| | - Boback Ziaeian
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of Cardiology, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California
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Gaipov A, Molnar MZ, Potukuchi PK, Sumida K, Canada RB, Akbilgic O, Kabulbayev K, Szabo Z, Koshy SKG, Kalantar-Zadeh K, Kovesdy CP. Predialysis coronary revascularization and postdialysis mortality. J Thorac Cardiovasc Surg 2019; 157:976-983.e7. [PMID: 31431793 PMCID: PMC6701475 DOI: 10.1016/j.jtcvs.2018.08.107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objectives Coronary artery bypass grafting (CABG) is associated with better survival than percutaneous coronary intervention (PCI) in patients with mild-to-moderate chronic kidney disease (CKD) and End-Stage Renal Disease (ESRD). However, the optimal strategy for coronary artery revascularization in advanced CKD patients who transition to ESRD is unclear. Methods We examined a contemporary national cohort of 971 US veterans with incident ESRD, who underwent first CABG or PCI up to 5 years prior to dialysis initiation. We examined the association of a history of CABG versus PCI with all-cause mortality following transition to dialysis, using Cox proportional hazards models adjusted for time between procedure and dialysis initiation, socio-demographics, comorbidities and medications. Results 582 patients underwent CABG and 389 patients underwent PCI. The mean age was 66±8 years, 99% of patients were male, 79% were white, 19% were African Americans, and 84% were diabetics. The all-cause post-dialysis mortality rates after CABG and PCI were 229/1000 patient-years (PY) [95% CI: 205-256] and 311/1000PY [95% CI: 272-356], respectively. Compared to PCI, patients who underwent CABG had 34% lower risk of death [multivariable adjusted Hazard Ratio (95% CI) 0.66 (0.51-0.86), p=0.002] after initiation of dialysis. Results were similar in all subgroups of patients stratified by age, race, type of intervention, presence/absence of myocardial infarction, congestive heart failure and diabetes. Conclusion CABG in advanced CKD patients was associated lower risk of death after initiation of dialysis compared to PCI.
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Affiliation(s)
- Abduzhappar Gaipov
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
- Department of Extracorporeal Hemocorrection, National Scientific Medical Research Center, Astana, Kazakhstan
| | - Miklos Z Molnar
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN, USA
- Department of Surgery and Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Robert B Canada
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Oguz Akbilgic
- Center for Biomedical Informatics, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Kairat Kabulbayev
- Department of Nephrology, Kazakh National Medical University, Almaty, Kazakhstan
| | - Zoltan Szabo
- Department of Cardiothoracic Surgery and Anesthesia, Linköping University Hospital, Linkoping, Sweden
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Santhosh K G Koshy
- Division of Cardiology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, United States
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
- Nephrology Section, Memphis VA Medical Center, Memphis, TN, United States
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Gyamlani G, Potukuchi PK, Thomas F, Akbilgic O, Soohoo M, Streja E, Naseer A, Sumida K, Molnar MZ, Kalantar-Zadeh K, Kovesdy CP. Vancomycin-Associated Acute Kidney Injury in a Large Veteran Population. Am J Nephrol 2019; 49:133-142. [PMID: 30677750 DOI: 10.1159/000496484] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/21/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND To determine the association of vancomycin with acute kidney injury (AKI) in relation to its serum concentration value and to examine the risk of AKI in patients treated with vancomycin when compared with a matched cohort of patients receiving non-glycopeptide antibiotics (linezolid/daptomycin). METHODS From a cohort of > 3 million US veterans with baseline estimated glomerular filtration rate ≥60 mL/min/1.73 m2, we identified 33,527 patients who received either intravenous vancomycin (n = 22,057) or non-glycopeptide antibiotics (linezolid/daptomycin, n = 11,470). We examined the association of the serum trough vancomycin level recorded within the first 48 h of administration with subsequent AKI in all patients treated with vancomycin and association of vancomycin vs. non-glycopeptide antibiotics use with the risk of incident AKI. RESULTS The overall multivariable adjusted ORs of AKI stages 1, 2, and 3 in patients on vancomycin vs. non-glycopeptides were 1.1 (1.1-1.2), 1.2 (1-1.4), and 1.4 (1.1-1.7), respectively. When examined in strata divided by vancomycin trough level, the odds of AKI were similar or lower in patients receiving vancomycin compared to non-glycopeptide antibiotics as long as serum vancomycin levels were ≤20 mg/L. However, in patients with serum vancomycin levels > 20 mg/L, the ORs of AKI stages 1, 2, and 3 in patients on vancomycin vs. non-glycopeptide antibiotics were 1.5 (1.4-1.7), 1.9 (1.5-2.3), and 2.7 (2-3.5), respectively. CONCLUSIONS Vancomycin use is associated with a higher risk of AKI when serum levels exceed > 20 mg/L.
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Affiliation(s)
- Geeta Gyamlani
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Praveen K Potukuchi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- IHOP, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Oguz Akbilgic
- Center for Biomedical Informatics, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Melissa Soohoo
- Division of Nephrology, University of California, Irvine, California, USA
| | - Elani Streja
- Division of Nephrology, University of California, Irvine, California, USA
| | - Adnan Naseer
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, Tennessee, USA
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA,
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA,
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Constipation and risk of death and cardiovascular events. Atherosclerosis 2018; 281:114-120. [PMID: 30658186 DOI: 10.1016/j.atherosclerosis.2018.12.021] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 11/17/2018] [Accepted: 12/05/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Constipation is one of the most frequent symptoms encountered in daily clinical practice and is implicated in the development of atherosclerosis, potentially through altered gut microbiota. However, little is known about its association with incident cardiovascular events. METHODS In a nationally representative cohort of 3,359,653 US veterans with an estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 between October 1, 2004 and September 30, 2006 (baseline period), with follow-up through 2013, we examined the association of constipation status (absence or presence; defined using diagnostic codes and laxative use) and laxative use (none, one, or ≥2 types of laxatives) with all-cause mortality, incident coronary heart disease (CHD), and incident ischemic stroke. RESULTS Among 3,359,653 patients, 237,855 (7.1%) were identified as having constipation. After multivariable adjustments for demographics, prevalent comorbidities, medications, and socioeconomic status, patients with (versus without) constipation had 12% higher all-cause mortality (hazard ratio [HR], 1.12; 95% CI, 1.11-1.13), 11% higher incidence of CHD (HR, 1.11; 95% CI, 1.08-1.14), and 19% higher incidence of ischemic stroke (HR, 1.19; 95% CI, 1.15-1.22). Patients with one and ≥2 (versus none) types of laxatives experienced a similarly higher risk of all-cause mortality (HRs [95% CI], 1.15 [1.13-1.16] and 1.14 [1.12-1.15], respectively), incident CHD (HRs [95% CI], 1.11 [1.07-1.15] and 1.10 [1.05-1.15], respectively) and incident ischemic stroke (HRs [95% CI], 1.19 [1.14-1.23] and 1.21 [1.16-1.26], respectively). CONCLUSIONS Constipation status and laxative use are independently associated with higher risk of all-cause mortality and incident CHD and ischemic stroke.
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Vontela N, Kovesdy C, Latif Z, Lane R, Weir A. Prevalence and Incidence of Immune Thrombocytopenia in Patients With Prostate Cancer. Am J Med Sci 2018; 356:499-500. [DOI: 10.1016/j.amjms.2018.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 04/30/2018] [Accepted: 05/03/2018] [Indexed: 11/26/2022]
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Kovesdy CP. CKD in African Americans as a Complex Intertwining of Biology and Socioeconomics: An Introduction. Am J Kidney Dis 2018; 72:S1-S2. [DOI: 10.1053/j.ajkd.2018.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 06/25/2018] [Indexed: 11/11/2022]
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Lu JL, Freire AX, Molnar MZ, Kalantar-Zadeh K, Kovesdy CP. Association of Chronic Insomnia With Mortality and Adverse Renal Outcomes. Mayo Clin Proc 2018; 93:1563-1570. [PMID: 30392541 DOI: 10.1016/j.mayocp.2018.05.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/30/2018] [Accepted: 05/15/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine whether chronic insomnia is associated with an increased risk of adverse renal outcomes and all-cause mortality. PATIENTS AND METHODS We examined associations of chronic insomnia (defined as the presence of both International Classification of Diseases, Ninth Revision codes 307.42, 307.49, and 780.52 and long-term use of insomnia medications) with adverse renal outcomes (end-stage renal disease, incidence of estimated glomerular filtration rate [eGFR] ≤45 mL/min per 1.73 m2, and eGFR slopes <-3.0 mL/min per 1.73 m2 per year) and all-cause mortality in a national cohort of 1,639,090 US veterans by using Cox proportional hazards and logistic regression models with multivariable adjustments. RESULTS A total of 36,741 patients (2.24%) had chronic insomnia; 32,985 (89.8%) were male and 28,090 (76.5%) were white, with a mean baseline eGFR of 84.1±16.4 mL/min per 1.73 m2. Chronic insomnia was associated with a significantly higher risk of eGFR 45 mL/min per 1.73 m2 or less (multivariable-adjusted hazard ratio [HR], 1.39; 95% CI, 1.34-1.44; P<.001), and rapid loss of kidney function (odds ratio, 1.07; 95% CI, 1.03-1.12; P=.002), but not end-stage renal disease (HR, 1.25; 95% CI, 0.81-1.93; P=.32). Chronic insomnia was not associated with a higher risk of all-cause mortality (HR, 1.00; 95% CI, 0.97-1.03; P=.99). CONCLUSION Chronic insomnia is associated with a higher risk of development and progression of chronic kidney disease, but not ESRD. Further studies are needed to establish the underlying mechanisms of action and to determine whether treatment of insomnia could be beneficial to prevent deteriorating kidney function.
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Affiliation(s)
- Jun Ling Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis
| | - Amado X Freire
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Tennessee Health Science Center, Memphis; Pulmonary Section, Memphis VA Medical Center, Memphis, TN
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis; Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine Medical Center, Orange
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis; Nephrology Section, Memphis VA Medical Center, Memphis, TN.
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Mulia N, Ye Y, Karriker-Jaffe KJ, Zemore SE, Jones-Webb R. Protective Factors as an Explanation for the "Paradox" of Black-White Differences in Heavy Drinking. Subst Use Misuse 2018; 53:2003-2016. [PMID: 29608112 PMCID: PMC6173315 DOI: 10.1080/10826084.2018.1451892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND African Americans are generally known to have lower heavy drinking prevalence than Whites despite often greater individual and community risk factors. While it is supposed that their protective resources explain this "paradox," studies have not explicitly examined this. OBJECTIVE Assess the contribution of protective resources to Black-White differences in heavy drinking, and (secondarily) whether protective resources operate by reducing heavy drinking and/or increasing abstinence. METHODS Using data from the 2009-2010 U.S. National Alcohol Survey (N = 3,133 Whites and 1,040 Blacks ages 18+), we applied propensity score (PS) weighting to estimate racial differences in heavy drinking and abstinence under hypothetical conditions in which Whites are similar to Blacks in: (1) age and marital status; (2) socioeconomic position and unfair treatment; (3) neighborhood socioeconomic conditions and alcohol outlet density; and (4) protective resources (proscriptive religiosity, area-level religiosity, "drier" network drinking norms and patterns, and family social support). RESULTS The Black-White gap in male and female drinkers' baseline heavy drinking increased after weighting adjustments for demographics. In women, this gap was reduced after weighting on disadvantage and eliminated after adjusting for protective resources. In men, adjustment for disadvantage increased the racial gap, and protective resources reduced it. Protective resources had a stronger effect on Black-White differences in men's abstinence than heavy drinking, but similar effects on these outcomes in women. CONCLUSION Protective resources help explain Black-White differences in men's and particularly women's heavy drinking. Future research is needed to elucidate mechanisms of action and additional factors underlying racial differences in men's heavy drinking.
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Affiliation(s)
- Nina Mulia
- a Alcohol Research Group , Public Health Institute , Emeryville , California , USA
| | - Yu Ye
- a Alcohol Research Group , Public Health Institute , Emeryville , California , USA
| | | | - Sarah E Zemore
- a Alcohol Research Group , Public Health Institute , Emeryville , California , USA
| | - Rhonda Jones-Webb
- b University of Minnesota School of Public Health , Division of Epidemiology , Minnesota , Minneapolis , USA
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Norris KC, Edwina Barnett M, Meng YX, Martins D, Nicholas SB, Gibbons GH, Lee JE. Rationale and design of a placebo controlled randomized trial to assess short term, high-dose oral cholecalciferol on select laboratory and genomic responses in African Americans with hypovitaminosis D. Contemp Clin Trials 2018; 72:20-25. [PMID: 30012355 PMCID: PMC6133748 DOI: 10.1016/j.cct.2018.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 06/28/2018] [Accepted: 07/12/2018] [Indexed: 12/25/2022]
Abstract
Cardiovascular Disease (CVD) and related disorders remain a leading cause of health disparities and premature death for African Americans. Hypovitaminosis D is disproportionately prevalent in African Americans and has been linked to CVD and CVD risk factors including hypertension, diabetes and obesity. Thus, hypovitaminosis D may represent a common pathway influencing CV risk factors in a select subgroup of persons. The purpose of this paper is to report the study design of a prospective eight week prospective double-blind randomized, placebo-controlled trial (n = 330 allocated 2:1 to intervention vs. control) to assess the effect of placebo vs. high-dose oral cholecalciferol (100,000 IU vitamin D3 at baseline and week 2) on 6-week change of select biologic cardiometabolic risk factors (including parathyroid hormone to assess biologic activity, pro-inflammatory/pro-thrombotic/fibrotic markers, insulin sensitivity and vitamin D metabolites) and their relationship to vitamin D administration and modification by vitamin D receptor polymorphisms in overweight, hypertensive African Americans with hypovitaminosis D. Findings from this trial will present insights into potential causal links between vitamin D repletion and mechanistic pathways of CV disease, including established and novel genomic markers.
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Affiliation(s)
- Keith C Norris
- University of California Los Angeles, Los Angeles, CA, USA.
| | | | | | - David Martins
- Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | | | - Gary H Gibbons
- National Heart, Lung, and Blood Institute, Bethesda, MD. USA
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Suarez J, Cohen JB, Potluri V, Yang W, Kaplan DE, Serper M, Shah SP, Reese PP. Racial Disparities in Nephrology Consultation and Disease Progression among Veterans with CKD: An Observational Cohort Study. J Am Soc Nephrol 2018; 29:2563-2573. [PMID: 30120108 DOI: 10.1681/asn.2018040344] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 07/20/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Incident rates of ESRD are much higher among black and Hispanic patients than white patients. Access to nephrology care before progression to ESRD is associated with better clinical outcomes among patients with CKD. However, it is unknown whether black or Hispanic patients with CKD experience lower pre-ESRD nephrology consultation rates compared with their white counterparts, or whether such a disparity contributes to worse outcomes among minorities. METHODS We assembled a retrospective cohort of patients with CKD who received care through the Veterans Health Administration from 2003 to 2015, focusing on individuals with incident CKD stage 4 who had an initial eGFR≥60 ml/min per 1.73 m2 followed by two consecutive eGFRs<30 ml/min per 1.73 m2. We repeated analyses among individuals with incident CKD stage 3. Outcomes included nephrology provider referral, nephrology provider visit, progression to CKD stage 5, and mortality. RESULTS We identified 56,767 veterans with CKD stage 4 and 640,704 with CKD stage 3. In both cohorts, rates of nephrology referral and visits were significantly higher among black and Hispanic veterans than among non-Hispanic white veterans. Despite this, both black and Hispanic patients experienced faster progression to CKD stage 5 compared with white patients. Black patients with CKD stage 4 experienced slightly lower mortality than white patients, whereas black patients with CKD stage 3 had a small increased risk of death. CONCLUSIONS Black or Hispanic veterans with CKD are more likely than white patients to see a nephrologist, yet are also more likely to suffer disease progression. Biologic and environmental factors may play a bigger role than nephrology consultation in driving racial disparities in CKD progression.
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Affiliation(s)
- Jonathan Suarez
- Renal-Electrolyte and Hypertension Division, Department of Medicine, and
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, and.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vishnu Potluri
- Renal-Electrolyte and Hypertension Division, Department of Medicine, and
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David E Kaplan
- Gastroenterology Section, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania; and.,Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marina Serper
- Gastroenterology Section, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania; and.,Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Siddharth P Shah
- Renal-Electrolyte and Hypertension Division, Department of Medicine, and
| | - Peter Philip Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, and .,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Gastroenterology Section, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania; and
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Gaffney AW, Woolhander S, Himmelstein D, McCormick D. Disparities in pulmonary fibrosis care in the United States: an analysis from the Nationwide Inpatient Sample. BMC Health Serv Res 2018; 18:618. [PMID: 30089521 PMCID: PMC6083621 DOI: 10.1186/s12913-018-3407-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/22/2018] [Indexed: 11/11/2022] Open
Abstract
Background Idiopathic pulmonary fibrosis is a disease with high morbidity and mortality. Care for these patients, including lung transplantation, may provide significant benefits, but is resource-intensive and expensive. Disadvantaged patients with IPF may hence be at risk for receiving inferior care. Methods We analyzed data from the Nationwide Inpatient Sample, a database consisting of all hospitalizations from a 20% sample of US hospitals. We identified adults hospitalized with IPF between 1998 and 2011 using ICD-9 codes. We assessed the effect of insurance coverage and socioeconomic status (SES) on lung transplantation, a treatment that may improve survival. We also examined the effect of coverage and SES on mortality, as well as discharge to inpatient rehabilitation and receipt of a lung biopsy, two markers of the intensity of care delivered. We used multiple logistic regression to adjust for patient and hospital characteristics. Results We identified 148,877 hospitalizations that met our definition of pulmonary fibrosis. In the main adjusted analyses, hospitalizations of patients with Medicaid (OR 0.30, 95% CI 0.16–0.57) or no insurance (OR 0.22, 95% CI 0.07–0.72) were less likely to result in a lung transplantation compared to hospitalizations of those with non-Medicaid insurance. Those of lower SES were also less likely to undergo transplantation, while hospitalized patients with Medicaid and the uninsured were less likely to be discharged to inpatient rehabilitation or to receive a lung biopsy. Conclusions Among hospitalized patients with IPF, those with lower SES, Medicaid coverage and without insurance were less likely to receive several clinical interventions. Electronic supplementary material The online version of this article (10.1186/s12913-018-3407-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adam W Gaffney
- Division of Pulmonary and Critical Care Medicine, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA, 02138, USA. .,Harvard Medical School, Boston, MA, USA.
| | | | | | - Danny McCormick
- Harvard Medical School, Boston, MA, USA.,Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA
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Gerber C, Cai X, Lee J, Craven T, Scialla J, Souma N, Srivastava A, Mehta R, Paluch A, Hodakowski A, Frazier R, Carnethon MR, Wolf MS, Isakova T. Incidence and Progression of Chronic Kidney Disease in Black and White Individuals with Type 2 Diabetes. Clin J Am Soc Nephrol 2018; 13:884-892. [PMID: 29798889 PMCID: PMC5989671 DOI: 10.2215/cjn.11871017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 03/01/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Type 2 diabetes and associated CKD disproportionately affect blacks. It is uncertain if racial disparities in type 2 diabetes-associated CKD are driven by biologic factors that influence propensity to CKD or by differences in type 2 diabetes care. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a post hoc analysis of 1937 black and 6372 white participants of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial to examine associations of black race with change in eGFR and risks of developing microalbuminuria, macroalbuminuria, incident CKD (eGFR<60 ml/min per 1.73m2, ≥25% decrease from baseline eGFR, and eGFR slope <-1.6 ml/min per 1.73 m2 per year), and kidney failure or serum creatinine >3.3 mg/dl. RESULTS During a median follow-up that ranged between 4.4 and 4.7 years, 278 black participants (58 per 1000 person-years) and 981 white participants (55 per 1000 person-years) developed microalbuminuria, 122 black participants (16 per 1000 person-years) and 374 white participants (14 per 1000 person-years) developed macroalbuminuria, 111 black participants (21 per 1000 person-years) and 499 white participants (28 per 1000 person-years) developed incident CKD, and 59 black participants (seven per 1000 person-years) and 178 white participants (six per 1000 person-years) developed kidney failure or serum creatinine >3.3 mg/dl. Compared with white participants, black participants had lower risks of incident CKD (hazard ratio, 0.73; 95% confidence intervals, 0.57 to 0.92). There were no significant differences by race in eGFR decline or in risks of microalbuminuria, macroalbuminuria, and kidney failure or of serum creatinine >3.3 mg/dl. CONCLUSIONS Black participants enrolled in a randomized controlled trial had lower rates of incident CKD compared with white participants. Rates of eGFR decline, microalbuminuria, macroalbuminuria, and kidney failure did not vary by race.
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Affiliation(s)
- Claire Gerber
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Xuan Cai
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
| | - Jungwha Lee
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
| | - Timothy Craven
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - Julia Scialla
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Duke University, Durham, North Carolina
| | - Nao Souma
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Rupal Mehta
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Amanda Paluch
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alexander Hodakowski
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
| | - Rebecca Frazier
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Mercedes R. Carnethon
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Myles Selig Wolf
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Duke University, Durham, North Carolina
| | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
- Division of Nephrology and Hypertension, Department of Medicine, and
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50
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Rhee CM, Kalantar-Zadeh K, Ravel V, Streja E, You AS, Brunelli SM, Nguyen DV, Brent GA, Kovesdy CP. Thyroid Status and Death Risk in US Veterans With Chronic Kidney Disease. Mayo Clin Proc 2018; 93:573-585. [PMID: 29728200 PMCID: PMC6049829 DOI: 10.1016/j.mayocp.2018.01.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/25/2018] [Accepted: 01/30/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Given that patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) have a disproportionately higher prevalence of hypothyroidism compared with their non-CKD counterparts, we sought to determine the association between thyroid status, defined by serum thyrotropin (TSH) levels, and mortality among a national cohort of patients with NDD-CKD. PATIENTS AND METHODS Among 227,422 US veterans with stage 3 NDD-CKD with 1 or more TSH measurements during the period October 1, 2004, to September 30, 2012, we first examined the association of thyroid status, defined by TSH categories of less than 0.5, 0.5 to 5.0 (euthyroidism), and more than 5.0 mIU/L, with all-cause mortality. We then evaluated 6 granular TSH categories: less than 0.1, 0.1 to less than 0.5, 0.5 to less than 3.0, 3.0 to 5.0, more than 5.0 to 10.0, and more than 10.0 mIU/L. We concurrently examined thyroid status, thyroid-modulating therapy, and mortality in sensitivity analyses. RESULTS In expanded case-mix adjusted Cox analyses, compared with euthyroidism, baseline and time-dependent TSH levels of more than 5.0 mIU/L were associated with higher mortality (adjusted hazard ratios [aHRs] [95% CI], 1.19 [1.15-1.24] and 1.23 [1.19-1.28], respectively), as were baseline and time-dependent TSH levels of less than 0.5 mIU/L (aHRs [95% CI], 1.18 [1.15-1.22] and 1.41 [1.37-1.45], respectively). Granular examination of thyroid status showed that incrementally higher TSH levels of 3.0 mIU/L or more were associated with increasingly higher mortality in baseline and time-dependent analyses, and TSH categories of less than 0.5 mIU/L were associated with higher mortality (reference, 0.5-<3.0 mIU/L) in baseline analyses. In time-dependent analyses, untreated and undertreated hypothyroidism and untreated hyperthyroidism were associated with higher mortality (reference, spontaneous euthyroidism), whereas hypothyroidism treated-to-target showed lower mortality. CONCLUSION Among US veterans with NDD-CKD, high-normal TSH (≥3.0 mIU/L) and lower TSH (<0.5 mIU/L) levels were associated with higher death risk. Interventional studies identifying the target TSH range associated with the greatest survival in patients with NDD-CKD are warranted.
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Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Vanessa Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Amy S You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | | | - Danh V Nguyen
- Division of General Internal Medicine, University of California Irvine School of Medicine, Orange, CA
| | - Gregory A Brent
- Division of Endocrinology, Diabetes and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN; Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN.
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