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Chu CD, Dohan D, Estrella MM, Shlipak MG, Tuot DS. Primary care clinician perspectives on automated nephrology e-consults for diabetic kidney disease: a pre-implementation qualitative study. BMC PRIMARY CARE 2024; 25:197. [PMID: 38834994 PMCID: PMC11149280 DOI: 10.1186/s12875-024-02454-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/30/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Many patients with diabetic kidney disease (DKD) do not receive evidence-based, guideline-recommended treatment shown to reduce DKD progression and complications. Proactive electronic consultations (e-consults) are an emerging intervention strategy that could potentially allow nephrologists to provide timely and evidence-based guidance to primary care providers (PCPs) engaged in early DKD care. METHODS The objective of this study was to explore perspectives about potential barriers and facilitators associated with a proactive e-consult program to improve DKD care delivery. We conducted semi-structured qualitative interviews with PCPs across three different health systems. Interview transcripts were reviewed in a rapid qualitative analysis approach to iteratively identify, refine, and achieve consensus on a final list of themes and subthemes. RESULTS A total of 18 interviews were conducted. PCPs across all sites identified similar challenges to delivering guideline-recommended DKD care. PCPs were supportive of the proactive e-consult concept. Three major themes emerged surrounding (1) perceived potential benefits of proactive e-consults, including educational value and improved specialist access; (2) concerns about the proactive nature of e-consults, including the potential to increase PCP workload and the possibility that e-consults could be seen as documenting substandard care; and (3) leveraging of care teams to facilitate recommended DKD care, such as engaging clinic-based pharmacists to implement specialist recommendations from e-consults. CONCLUSION In this pre-implementation qualitative study, PCPs noted potential benefits and identified concerns and implementation barriers for proactive e-consults for DKD care. Strategies that emerged for promoting successful implementation included involving clinic support staff to enact e-consult recommendations and framing e-consults as a system improvement effort to avoid judgmental associations.
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Affiliation(s)
- Chi D Chu
- Department of Medicine, University of California, San Francisco, San Francisco, CA, 94110, USA.
- Department of Medicine, Division of Nephrology, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Bldg 100, Rm 342, San Francisco, CA, 94110, USA.
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco VA Health Care System, San Francisco, CA, USA.
| | - Daniel Dohan
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Michelle M Estrella
- Department of Medicine, University of California, San Francisco, San Francisco, CA, 94110, USA
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco VA Health Care System, San Francisco, CA, USA
| | - Michael G Shlipak
- Department of Medicine, University of California, San Francisco, San Francisco, CA, 94110, USA
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco VA Health Care System, San Francisco, CA, USA
| | - Delphine S Tuot
- Department of Medicine, University of California, San Francisco, San Francisco, CA, 94110, USA
- Department of Medicine, Division of Nephrology, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Bldg 100, Rm 342, San Francisco, CA, 94110, USA
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Kim K, Crook J, Lu CC, Nyman H, Abdelaziz A, LaFleur J. Epidemiology of Diabetic Kidney Disease among US Veterans. Diabetes Metab Syndr Obes 2024; 17:1585-1596. [PMID: 38616990 PMCID: PMC11011711 DOI: 10.2147/dmso.s450370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/15/2024] [Indexed: 04/16/2024] Open
Abstract
Rationale With a large number of patients and high mortality, diabetic kidney disease (DKD) imposes a significant burden on US health care. Although diabetes is the leading cause of chronic kidney disease and complications, the epidemiology of DKD in the contemporary US veteran population is generally unknown. Objective We aimed to estimate the rate of DKD progression and to measure the general epidemiology of DKD in the United States veteran population. Study Design We performed a retrospective observational research using electronic health-care records and administrative databases. Setting The DKD patient cohort was abstracted from the Veterans Health Administration health-record data from January 2016 to March 2022. Participants We defined DKD patients using the laboratory test data based on Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines. Analytic Approach Summary statistics include the five-year cumulative incidence of progression to an advanced stage from the DKD stage at the cohort entry date and prevalence at a series of single time points. Results A total of 685,288 patients (male [96%], mean age 62 years, Caucasian [64%], non-Hispanic [87%]) met our eligibility criteria. The 5-year cumulative incidence of progression to an advanced DKD stage or all-cause death from DKD stages G1 A2/A3, G2 A2/A3, G3a, and G3b were 52.0%, 47.4%, 50.5%, and 60.9%, respectively. In sum, 594,082 patients were classified as moderate or high risk as per KDIGO guidelines in 2021, and stages G3a and G3b accounted for 51.2% and 25.3%, respectively, of cases. Conclusion More than half of DKD patients underwent a stage progression or death within 5 years. A substantial number of DKD patients at an earlier stage might be left undetermined. The study findings warrant a revision of DKD patient identification and management in US veterans.
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Affiliation(s)
- Kibum Kim
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago, Chicago, IL, USA
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jacob Crook
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Chao-Chin Lu
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Heather Nyman
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Abdullah Abdelaziz
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago, Chicago, IL, USA
| | - Joanne LaFleur
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 124] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Schwartz AL, Zhao X, Sileanu FE, Lovelace EZ, Rose L, Radomski TR, Thorpe CT. Variation in Low-Value Service Use Across Veterans Affairs Facilities. J Gen Intern Med 2023; 38:2245-2253. [PMID: 36964425 PMCID: PMC10406760 DOI: 10.1007/s11606-023-08157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/10/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND It is unclear whether extensive variation in the use of low-value services exists even within a national integrated delivery system like the Veterans Health Administration (VA). OBJECTIVE To quantify variation in the use of low-value services across VA facilities and examine associations between facility characteristics and low-value service use. DESIGN In this retrospective cross-sectional study of VA administrative data, we constructed facility-level rates of low-value service use as the mean count of 29 low-value services per 100 Veterans per year. Adjusted rates were calculated via ordinary least squares regression including covariates for Veteran sociodemographic and clinical characteristics. We quantified the association between adjusted facility-level rates and facility geographic/operational characteristics. PARTICIPANTS 5,242,301 patients across 139 VA facilities. MAIN MEASURES Use of 29 low-value services within six domains: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and surgery. KEY RESULTS The mean rate of low-value service use was 20.0 services per 100 patients per year (S.D. 6.1). Rates ranged from 13.9 at the 10th percentile to 27.6 at the 90th percentile (90th/10th percentile ratio 2.0, 95% CI 1.8‒2.3). With adjustment for patient covariates, variation across facilities narrowed (S.D. 5.2, 90th/10th percentile ratio 1.8, 95% CI 1.6‒1.9). Only one facility characteristic was positively associated with low-value service use percent of patients seeing non-VA clinicians via VA Community Care, p < 0.05); none was associated with total low-value service use after adjustment for other facility characteristics. There was extensive variation in low-value service use within categories of facility operational characteristics. CONCLUSIONS Despite extensive variation in the use of low-value services across VA facilities, we observed substantial use of these services across facility operational characteristics and at facilities with lower rates of low-value service use. Thus, system-wide interventions to address low-value services may be more effective than interventions targeted to specific facilities or facility types.
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Affiliation(s)
- Aaron L Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, USA.
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Elijah Z Lovelace
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford University, Stanford, CA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Charlotte, NC, USA
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Chu CD, Xia F, Du Y, Singh R, Tuot DS, Lamprea-Montealegre JA, Gualtieri R, Liao N, Kong SX, Williamson T, Shlipak MG, Estrella MM. Estimated Prevalence and Testing for Albuminuria in US Adults at Risk for Chronic Kidney Disease. JAMA Netw Open 2023; 6:e2326230. [PMID: 37498594 PMCID: PMC10375308 DOI: 10.1001/jamanetworkopen.2023.26230] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/16/2023] [Indexed: 07/28/2023] Open
Abstract
Importance Albuminuria testing is crucial for guiding evidence-based treatments to mitigate chronic kidney disease (CKD) progression and cardiovascular morbidity, but it is widely underutilized among persons with or at risk for CKD. Objective To estimate the extent of albuminuria underdetection from lack of testing and evaluate its association with CKD treatment in a large US cohort of patients with hypertension or diabetes. Design, Setting, and Participants This cohort study examined adults with hypertension or diabetes, using data from the 2007 to 2018 National Health and Nutrition Examination Surveys (NHANES) and the Optum deidentified electronic health record (EHR) data set of diverse US health care organizations. Analyses were conducted from October 31, 2022, to May 19, 2023. Main Outcomes and Measures Using NHANES as a nationally representative sample, a logistic regression model was developed to estimate albuminuria (urine albumin-creatinine ratio ≥30 mg/g). This model was then applied to active outpatients in the EHR from January 1, 2017, to December 31, 2018. The prevalence of albuminuria among those with and without albuminuria testing during this period was estimated. A multivariable logistic regression was used to examine associations between having albuminuria testing and CKD therapies within the subsequent year (prescription for angiotensin-converting enzyme inhibitor [ACEi] or angiotensin II receptor blocker [ARB], prescription for sodium-glucose cotransporter 2 inhibitor [SGLT2i], and blood pressure control to less than 130/80 mm Hg or less than 140/90 mm Hg on the latest outpatient measure). Results The total EHR study population included 192 108 patients (mean [SD] age, 60.3 [15.1] years; 185 589 [96.6%] with hypertension; 50 507 [26.2%] with diabetes; mean [SD] eGFR, 84 [21] mL/min/1.73 m2). There were 33 629 patients (17.5%) who had albuminuria testing; of whom 11 525 (34.3%) had albuminuria. Among 158 479 patients who were untested, the estimated albuminuria prevalence rate was 13.4% (n = 21 231). Thus, only 35.2% (11 525 of 32 756) of the projected population with albuminuria had been tested. Albuminuria testing was associated with higher adjusted odds of receiving ACEi or ARB treatment (OR, 2.39 [95% CI, 2.32-2.46]), SGLT2i treatment (OR, 8.22 [95% CI, 7.56-8.94]), and having blood pressure controlled to less than 140/90 mm Hg (OR, 1.20 [95% CI, 1.16-1.23]). Conclusions and Relevance In this cohort study of patients with hypertension or diabetes, it was estimated that approximately two-thirds of patients with albuminuria were undetected due to lack of testing. These results suggest that improving detection of CKD with albuminuria testing represents a substantial opportunity to optimize care delivery for reducing CKD progression and cardiovascular complications.
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Affiliation(s)
- Chi D. Chu
- Department of Medicine, University of California, San Francisco
- Kidney Health Research Collaborative, University of California, San Francisco
| | - Fang Xia
- Gilead Sciences Inc, Foster City, California
| | | | | | | | - Julio A. Lamprea-Montealegre
- Department of Medicine, University of California, San Francisco
- Kidney Health Research Collaborative, University of California, San Francisco
| | | | | | | | | | - Michael G. Shlipak
- Department of Medicine, University of California, San Francisco
- Kidney Health Research Collaborative, University of California, San Francisco
- San Francisco VA Health Care System, San Francisco, California
| | - Michelle M. Estrella
- Department of Medicine, University of California, San Francisco
- Kidney Health Research Collaborative, University of California, San Francisco
- San Francisco VA Health Care System, San Francisco, California
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Gregg LP, Richardson PA, Herrera MA, Akeroyd JM, Jafry SA, Gobbel GT, Wydermyer S, Arney J, Hung A, Matheny ME, Virani SS, Navaneethan SD. Documented Adverse Drug Reactions and Discontinuation of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Chronic Kidney Disease. Am J Nephrol 2023; 54:126-135. [PMID: 37231800 PMCID: PMC10424561 DOI: 10.1159/000530988] [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: 02/21/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) are frequently discontinued in patients with chronic kidney disease (CKD). Documented adverse drug reactions (ADRs) in medical records may provide insight into the reasons for treatment discontinuation. METHODS In this retrospective cohort of US veterans from 2005 to 2019, we identified individuals with CKD and a current prescription for an ACEi or ARB (current user group) or a discontinued prescription within the preceding 5 years (discontinued group). Documented ADRs in structured datasets associated with an ACEi or ARB were categorized into 17 pre-specified groups. Logistic regression assessed associations of documented ADRs with treatment discontinuation. RESULTS There were 882,441 (73.0%) individuals in the current user group and 326,794 (27.0%) in the discontinued group. There were 26,434 documented ADRs, with at least one documented ADR in 7,520 (0.9%) current users and 9,569 (2.9%) of the discontinued group. ADR presence was associated with treatment discontinuation, aOR 4.16 (95% CI: 4.03, 4.29). The most common documented ADRs were cough (37.3%), angioedema (14.2%), and allergic reaction (10.4%). ADRs related to angioedema (aOR 3.81, 95% CI: 3.47, 4.17), hyperkalemia (aOR 2.03, 95% CI: 1.84, 2.24), peripheral edema (aOR 1.53, 95% CI: 1.33, 1.77), or acute kidney injury (aOR 1.32, 95% CI: 1.15, 1.51) were associated with treatment discontinuation. CONCLUSION ADRs leading to drug discontinuation were infrequently documented. ADR types were differentially associated with treatment discontinuation. An understanding of which ADRs lead to treatment discontinuation provides an opportunity to address them at a healthcare system level.
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Affiliation(s)
- L. Parker Gregg
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX
- Research Service Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Peter A. Richardson
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Michael A. Herrera
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Julia M. Akeroyd
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Shehrezade A. Jafry
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
| | - Glenn T Gobbel
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Sheena Wydermyer
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Jennifer Arney
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Department of Sociology, University of Houston-Clear Lake, Houston, TX
| | - Adriana Hung
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Center for Kidney Disease, Nashville, TN
- Division of Nephrology, Veterans Affairs Tennessee Valley Health Care System, Nashville, TN
| | - Michael E. Matheny
- Geriatrics Research Education and clinical Care Service, Tennessee Valley Healthcare System VA, Nashville, TN
- Departments of Biomedical Informatics, Biostatistics, and Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Salim S. Virani
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sankar D. Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX
- Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX
- Renal Section, Medical Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
- Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, TX
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Higgins MCSS, Seren A, Foster MV, Sturgeon DJ, Bart N, Hederstedt K, Friefeld A, Lamkin RP, Sullivan BA, Branch-Elliman W, Mull HJ. Arteriovenous Graft Failure in the Veterans Health Administration: Outcome Disparities Associated with Race. Radiology 2023; 307:e220619. [PMID: 36809217 PMCID: PMC11262058 DOI: 10.1148/radiol.220619] [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] [Indexed: 02/23/2023]
Abstract
Background Vascular access for ongoing hemodialysis often fails, frequently requiring repeated procedures to maintain vascular patency. While research has shown racial discrepancies in multiple aspects of renal failure treatment, there is poor understanding of how these factors might relate to vascular access maintenance procedures after arteriovenous graft (AVG) placement. Purpose To evaluate racial disparities associated with premature vascular access failure after percutaneous access maintenance procedures following AVG placement using a retrospective national cohort from the Veterans Health Administration (VHA). Materials and Methods All hemodialysis vascular maintenance procedures performed at VHA hospitals between October 2016 and March 2020 were identified. To ensure the sample represented patients who consistently used the VHA, patients without AVG placement within 5 years of their first maintenance procedure were excluded. Access failure was defined as a repeat access maintenance procedure or as hemodialysis catheter placement occurring 1-30 days after the index procedure. Multivariable logistic regression analyses were performed to calculate prevalence ratios (PRs) measuring the association between hemodialysis maintenance failure and African American race compared with all other races. Models controlled for vascular access history, patient socioeconomic status, and procedure and facility characteristics. Results In total, 1950 access maintenance procedures in 995 patients (mean age, 69 years ± 9 [SD], 1870 men) with an AVG created in one of 61 VHA facilities were identified. Most procedures involved African American patients (1169 of 1950, 60%) and patients residing in the South (1002 of 1950, 51%). Premature access failure occurred in 215 of 1950 (11%) procedures. When compared with all other races, African American race was associated with premature access site failure (PR, 1.4; 95% CI: 1.07, 1.43; P = .02). Among the 1057 procedures in 30 facilities with interventional radiology resident training programs, there was no evidence of racial disparity in the outcome (PR, 1.1; P = .63). Conclusion African American race was associated with higher risk-adjusted rates of premature arteriovenous graft failure after dialysis maintenance. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Forman and Davis in this issue.
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Affiliation(s)
- Mikhail C S S Higgins
- From the Departments of Radiology (M.C.S.S.H.), Medical School (A.S., A.F.), Medicine (M.V.F.), and Surgery (H.J.M.), Boston University Chobanian & Avedisian School of Medicine, Boston, Mass; Department of Radiology, Boston Medical Center, Boston, Mass (M.C.S.S.H.); Center for Healthcare Organization and Implementation Research (M.F., D.J.S., K.H., R.P.L., W.B.E., H.J.M.), Department of Quality Management (M.V.F.), and Department of Medicine, Section of Infectious Diseases (W.B.E.), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130; Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Chan Medical School, Boston, Mass (N.B.); Department of Gastroenterology, Duke University School of Medicine, Durham, NC (B.A.S.); Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC (B.A.S.); and Harvard Medical School, Boston, Mass (W.B.E.)
| | - Alex Seren
- From the Departments of Radiology (M.C.S.S.H.), Medical School (A.S., A.F.), Medicine (M.V.F.), and Surgery (H.J.M.), Boston University Chobanian & Avedisian School of Medicine, Boston, Mass; Department of Radiology, Boston Medical Center, Boston, Mass (M.C.S.S.H.); Center for Healthcare Organization and Implementation Research (M.F., D.J.S., K.H., R.P.L., W.B.E., H.J.M.), Department of Quality Management (M.V.F.), and Department of Medicine, Section of Infectious Diseases (W.B.E.), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130; Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Chan Medical School, Boston, Mass (N.B.); Department of Gastroenterology, Duke University School of Medicine, Durham, NC (B.A.S.); Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC (B.A.S.); and Harvard Medical School, Boston, Mass (W.B.E.)
| | - Marva V Foster
- From the Departments of Radiology (M.C.S.S.H.), Medical School (A.S., A.F.), Medicine (M.V.F.), and Surgery (H.J.M.), Boston University Chobanian & Avedisian School of Medicine, Boston, Mass; Department of Radiology, Boston Medical Center, Boston, Mass (M.C.S.S.H.); Center for Healthcare Organization and Implementation Research (M.F., D.J.S., K.H., R.P.L., W.B.E., H.J.M.), Department of Quality Management (M.V.F.), and Department of Medicine, Section of Infectious Diseases (W.B.E.), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130; Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Chan Medical School, Boston, Mass (N.B.); Department of Gastroenterology, Duke University School of Medicine, Durham, NC (B.A.S.); Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC (B.A.S.); and Harvard Medical School, Boston, Mass (W.B.E.)
| | - Daniel J Sturgeon
- From the Departments of Radiology (M.C.S.S.H.), Medical School (A.S., A.F.), Medicine (M.V.F.), and Surgery (H.J.M.), Boston University Chobanian & Avedisian School of Medicine, Boston, Mass; Department of Radiology, Boston Medical Center, Boston, Mass (M.C.S.S.H.); Center for Healthcare Organization and Implementation Research (M.F., D.J.S., K.H., R.P.L., W.B.E., H.J.M.), Department of Quality Management (M.V.F.), and Department of Medicine, Section of Infectious Diseases (W.B.E.), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130; Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Chan Medical School, Boston, Mass (N.B.); Department of Gastroenterology, Duke University School of Medicine, Durham, NC (B.A.S.); Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC (B.A.S.); and Harvard Medical School, Boston, Mass (W.B.E.)
| | - Nina Bart
- From the Departments of Radiology (M.C.S.S.H.), Medical School (A.S., A.F.), Medicine (M.V.F.), and Surgery (H.J.M.), Boston University Chobanian & Avedisian School of Medicine, Boston, Mass; Department of Radiology, Boston Medical Center, Boston, Mass (M.C.S.S.H.); Center for Healthcare Organization and Implementation Research (M.F., D.J.S., K.H., R.P.L., W.B.E., H.J.M.), Department of Quality Management (M.V.F.), and Department of Medicine, Section of Infectious Diseases (W.B.E.), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130; Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Chan Medical School, Boston, Mass (N.B.); Department of Gastroenterology, Duke University School of Medicine, Durham, NC (B.A.S.); Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC (B.A.S.); and Harvard Medical School, Boston, Mass (W.B.E.)
| | - Kierstin Hederstedt
- From the Departments of Radiology (M.C.S.S.H.), Medical School (A.S., A.F.), Medicine (M.V.F.), and Surgery (H.J.M.), Boston University Chobanian & Avedisian School of Medicine, Boston, Mass; Department of Radiology, Boston Medical Center, Boston, Mass (M.C.S.S.H.); Center for Healthcare Organization and Implementation Research (M.F., D.J.S., K.H., R.P.L., W.B.E., H.J.M.), Department of Quality Management (M.V.F.), and Department of Medicine, Section of Infectious Diseases (W.B.E.), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130; Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Chan Medical School, Boston, Mass (N.B.); Department of Gastroenterology, Duke University School of Medicine, Durham, NC (B.A.S.); Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC (B.A.S.); and Harvard Medical School, Boston, Mass (W.B.E.)
| | - Alex Friefeld
- From the Departments of Radiology (M.C.S.S.H.), Medical School (A.S., A.F.), Medicine (M.V.F.), and Surgery (H.J.M.), Boston University Chobanian & Avedisian School of Medicine, Boston, Mass; Department of Radiology, Boston Medical Center, Boston, Mass (M.C.S.S.H.); Center for Healthcare Organization and Implementation Research (M.F., D.J.S., K.H., R.P.L., W.B.E., H.J.M.), Department of Quality Management (M.V.F.), and Department of Medicine, Section of Infectious Diseases (W.B.E.), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130; Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Chan Medical School, Boston, Mass (N.B.); Department of Gastroenterology, Duke University School of Medicine, Durham, NC (B.A.S.); Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC (B.A.S.); and Harvard Medical School, Boston, Mass (W.B.E.)
| | - Rebecca P Lamkin
- From the Departments of Radiology (M.C.S.S.H.), Medical School (A.S., A.F.), Medicine (M.V.F.), and Surgery (H.J.M.), Boston University Chobanian & Avedisian School of Medicine, Boston, Mass; Department of Radiology, Boston Medical Center, Boston, Mass (M.C.S.S.H.); Center for Healthcare Organization and Implementation Research (M.F., D.J.S., K.H., R.P.L., W.B.E., H.J.M.), Department of Quality Management (M.V.F.), and Department of Medicine, Section of Infectious Diseases (W.B.E.), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130; Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Chan Medical School, Boston, Mass (N.B.); Department of Gastroenterology, Duke University School of Medicine, Durham, NC (B.A.S.); Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC (B.A.S.); and Harvard Medical School, Boston, Mass (W.B.E.)
| | - Brian A Sullivan
- From the Departments of Radiology (M.C.S.S.H.), Medical School (A.S., A.F.), Medicine (M.V.F.), and Surgery (H.J.M.), Boston University Chobanian & Avedisian School of Medicine, Boston, Mass; Department of Radiology, Boston Medical Center, Boston, Mass (M.C.S.S.H.); Center for Healthcare Organization and Implementation Research (M.F., D.J.S., K.H., R.P.L., W.B.E., H.J.M.), Department of Quality Management (M.V.F.), and Department of Medicine, Section of Infectious Diseases (W.B.E.), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130; Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Chan Medical School, Boston, Mass (N.B.); Department of Gastroenterology, Duke University School of Medicine, Durham, NC (B.A.S.); Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC (B.A.S.); and Harvard Medical School, Boston, Mass (W.B.E.)
| | - Westyn Branch-Elliman
- From the Departments of Radiology (M.C.S.S.H.), Medical School (A.S., A.F.), Medicine (M.V.F.), and Surgery (H.J.M.), Boston University Chobanian & Avedisian School of Medicine, Boston, Mass; Department of Radiology, Boston Medical Center, Boston, Mass (M.C.S.S.H.); Center for Healthcare Organization and Implementation Research (M.F., D.J.S., K.H., R.P.L., W.B.E., H.J.M.), Department of Quality Management (M.V.F.), and Department of Medicine, Section of Infectious Diseases (W.B.E.), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130; Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Chan Medical School, Boston, Mass (N.B.); Department of Gastroenterology, Duke University School of Medicine, Durham, NC (B.A.S.); Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC (B.A.S.); and Harvard Medical School, Boston, Mass (W.B.E.)
| | - Hillary J Mull
- From the Departments of Radiology (M.C.S.S.H.), Medical School (A.S., A.F.), Medicine (M.V.F.), and Surgery (H.J.M.), Boston University Chobanian & Avedisian School of Medicine, Boston, Mass; Department of Radiology, Boston Medical Center, Boston, Mass (M.C.S.S.H.); Center for Healthcare Organization and Implementation Research (M.F., D.J.S., K.H., R.P.L., W.B.E., H.J.M.), Department of Quality Management (M.V.F.), and Department of Medicine, Section of Infectious Diseases (W.B.E.), VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130; Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Chan Medical School, Boston, Mass (N.B.); Department of Gastroenterology, Duke University School of Medicine, Durham, NC (B.A.S.); Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, NC (B.A.S.); and Harvard Medical School, Boston, Mass (W.B.E.)
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8
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Nakayama T, Mitsuno R, Azegami T, Sato Y, Hayashi K, Itoh H. A systematic review and meta-analysis of the clinical impact of stopping renin-angiotensin system inhibitor in patients with chronic kidney disease. Hypertens Res 2023:10.1038/s41440-023-01260-8. [PMID: 36977900 DOI: 10.1038/s41440-023-01260-8] [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: 01/24/2023] [Revised: 02/24/2023] [Accepted: 03/05/2023] [Indexed: 03/30/2023]
Abstract
Although renin-angiotensin system (RAS) inhibitors reduce the risk of cardiovascular diseases and end-stage kidney disease (ESKD) in chronic kidney disease (CKD) patients, they are often discontinued in clinical practice due to drug-related adverse events. However, limited evidence is available about the clinical impact of RAS inhibitor discontinuation in CKD patients. A comprehensive search of publications investigating the effect of discontinuing RAS inhibitors on clinical outcomes in CKD patients in PubMed, the Cochrane Library, and Web of Science was conducted (inception to November 7, 2022), and potentially relevant studies were searched by hand (through November 30, 2022). Two reviewers independently extracted data according to the PRISMA and MOOSE guidelines and assessed the quality of each study with risk-of-bias tools, RoB2 and ROBINS-I. The pooled hazard ratio (HR) for each outcome was integrated with a random-effect model. A total of 1 randomized clinical trial and 6 observational studies involving 248,963 patients were included in the systematic review. The meta-analysis of observational studies showed that discontinuation of RAS inhibitors was associated with a higher risk of all-cause mortality (HR, 1.41 [95% CI, 1.23-1.62]; I2 = 97%), ESKD (1.32 [95% CI, 1.10-1.57]; I2 = 94%) and MACE (1.20 [95% CI 1.15-1.25]; I2 = 38%), but not with hyperkalemia (0.79 [95% CI 0.55-1.15]; I2 = 90%). Overall risk of bias was moderate-to-serious, and quality of evidence (GRADE system) was low-to-very low. The present study suggests that CKD patients would benefit from continuing RAS inhibitors.
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Affiliation(s)
- Takashin Nakayama
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Ryunosuke Mitsuno
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Tatsuhiko Azegami
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
- Keio University Health Center, 4-1-1 Hiyoshi, Kohoku-ku, Yokohama-shi, Kanagawa, 223-8521, Japan.
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kaori Hayashi
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hiroshi Itoh
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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9
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1288] [Impact Index Per Article: 1288.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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10
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Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2489] [Impact Index Per Article: 1244.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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11
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Research Priorities for Kidney-Related Research-An Agenda to Advance Kidney Care: A Position Statement From the National Kidney Foundation. Am J Kidney Dis 2022; 79:141-152. [PMID: 34627932 DOI: 10.1053/j.ajkd.2021.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 02/01/2023]
Abstract
Despite the high prevalence and economic burden of chronic kidney disease (CKD) in the United States, federal funding for kidney-related research, prevention, and education activities under the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) remains substantially lower compared to other chronic diseases. More federal support is needed to promote critical research that will expand knowledge of kidney health and disease, develop new and effective therapies, and reduce health disparities. In 2021, the National Kidney Foundation (NKF) convened 2 Research Roundtables (preclinical and clinical research), comprising nephrology leaders from prominent US academic institutions and the pharmaceutical industry, key bodies with expertise in research, and including individuals with CKD and their caregivers and kidney donors. The goal of these roundtables was to identify priorities for preclinical and clinical kidney-related research. The research priorities identified by the Research Roundtables and presented in this position statement outline attainable opportunities for groundbreaking and critically needed innovations that will benefit patients with kidney disease in the next 5-10 years. Research priorities fall within 4 preclinical science themes (expand data science capability, define kidney disease mechanisms and utilize genetic tools to identify new therapeutic targets, develop better models of human disease, and test cell-specific drug delivery systems and utilize gene editing) and 3 clinical science themes (expand number and inclusivity of clinical trials, develop and test interventions to reduce health disparities, and support implementation science). These priorities in kidney-related research, if supported by additional funding by federal agencies, will increase our understanding of the development and progression of kidney disease among diverse populations, attract additional industry investment, and lead to new and more personalized treatments.
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12
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Walther CP, Winkelmayer WC, Richardson PA, Virani SS, Navaneethan SD. Renin-angiotensin system blocker discontinuation and adverse outcomes in chronic kidney disease. Nephrol Dial Transplant 2021; 36:1893-1899. [PMID: 33367872 PMCID: PMC8633426 DOI: 10.1093/ndt/gfaa300] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Treatment with renin-angiotensin system inhibitors (RASIs), angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) is the standard of care for those with chronic kidney disease (CKD) and albuminuria. However, ACEI/ARB treatment is often discontinued for various reasons. We investigated the association of ACEI/ARB discontinuation with outcomes among US veterans with non-dialysis-dependent CKD. METHODS We performed a retrospective cohort study of patients in the Veterans Affairs healthcare system with non-dialysis-dependent CKD who subsequently were started on ACEI/ARB therapy (new user design). Discontinuation events were defined as a gap in ACEI/ARB therapy of ≥14 days and were classified further based on duration (14-30, 31-60, 61-90, 91-180 and >180 days). This was treated as a time-varying risk factor in adjusted Cox proportional hazards models for the outcomes of death and incident end-stage kidney disease (ESKD), which also adjusted for relevant confounders. RESULTS We identified 141 252 people with CKD and incident ACEI/ARB use who met the inclusion criteria; these were followed for a mean 4.87 years. There were 135 356 discontinuation events, 68 699 deaths and 6152 incident ESKD events. Discontinuation of ACEI/ARB was associated with a higher risk of death [hazard ratio (HR) 2.3, 2.0, 1.99, 1.92 and 1.74 for those discontinued for 14-30, 31-60, 61-90, 91-180 and >180 days, respectively]. Similar associations were noted between ACEI and ARB discontinuation and ESKD (HR 1.64, 1.47, 1.54, 1.65 and 1.59 for those discontinued for 14-30, 31-60, 61-90, 91-180 and >180 days, respectively). CONCLUSIONS In a cohort of predominantly male veterans with CKD Stages 3 and 4, ACEI/ARB discontinuation was independently associated with an increased risk of subsequent death and ESKD. This may be due to the severity of illness factors that drive the decision to discontinue therapy. Further investigations to determine the causes of discontinuations and to provide an evidence base for discontinuation decisions are needed.
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Affiliation(s)
- Carl P Walther
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Selzman Institute for Kidney Health, Houston, TX, USA
| | - Wolfgang C Winkelmayer
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Selzman Institute for Kidney Health, Houston, TX, USA
| | - Peter A Richardson
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, TX, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, TX, USA
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Department of Medicine, Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA
| | - Sankar D Navaneethan
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Selzman Institute for Kidney Health, Houston, TX, USA
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
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Stempniewicz N, Vassalotti JA, Cuddeback JK, Ciemins E, Storfer-Isser A, Sang Y, Matsushita K, Ballew SH, Chang AR, Levey AS, Bailey RA, Fishman J, Coresh J. Chronic Kidney Disease Testing Among Primary Care Patients With Type 2 Diabetes Across 24 U.S. Health Care Organizations. Diabetes Care 2021; 44:2000-2009. [PMID: 34233925 PMCID: PMC8740923 DOI: 10.2337/dc20-2715] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 05/24/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Clinical guidelines for people with diabetes recommend chronic kidney disease (CKD) testing at least annually using estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (uACR). We aimed to understand CKD testing among people with type 2 diabetes in the U.S. RESEARCH DESIGN AND METHODS Electronic health record data were analyzed from 513,165 adults with type 2 diabetes receiving primary care from 24 health care organizations and 1,164 clinical practice sites. We assessed the percentage of patients with both one or more eGFRs and one or more uACRs and each test individually in the 1, 2, and 3 years ending September 2019 by health care organization and clinical practice site. Elevated albuminuria was defined as uACR ≥30 mg/g. RESULTS The 1-year median testing rate across organizations was 51.6% for both uACR and eGFR, 89.5% for eGFR, and 52.9% for uACR. uACR testing varied (10th-90th percentile) from 44.7 to 63.3% across organizations and from 13.3 to 75.4% across sites. Over 3 years, the median testing rate for uACR across organizations was 73.7%. Overall, the prevalence of detected elevated albuminuria was 15%. The average prevalence of detected elevated albuminuria increased linearly with uACR testing rates at sites, with estimated prevalence of 6%, 15%, and 30% at uACR testing rates of 20%, 50%, and 100%, respectively. CONCLUSIONS While eGFR testing rates are uniformly high among people with type 2 diabetes, testing rates for uACR are suboptimal and highly variable across and within the organizations examined. Guideline-recommended uACR testing should increase detection of CKD.
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Affiliation(s)
| | - Joseph A Vassalotti
- National Kidney Foundation, New York, NY.,Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | - Yingying Sang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | | | | | | | | | - Josef Coresh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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14
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Rodriguez F, Lee DJ, Gad SS, Santos MP, Beetel RJ, Vasey J, Bailey RA, Patel A, Blais J, Weir MR, Dash R. Real-World Diagnosis and Treatment of Diabetic Kidney Disease. Adv Ther 2021; 38:4425-4441. [PMID: 34254257 DOI: 10.1007/s12325-021-01777-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/06/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION People with type 2 diabetes mellitus (T2DM) and diabetic kidney disease (DKD) have increased morbidity and mortality risk. Angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB) are recommended to slow kidney function decline in DKD. This representative, real-world data analysis of patients with T2DM was performed to detect onset of DKD and determine methods and timing of DKD diagnosis and time to initiation of ACEi/ARB therapy. METHODS Patients diagnosed with T2DM before January 1, 2016 who developed DKD between January 1, 2017 and June 30, 2019 were identified from a longitudinal ambulatory electronic health record (EHR) dataset (Veradigm Inc). Each record was analyzed using the CLinical INTelligence engine (CLINT™, HealthPals, Inc.) to identify delays and gaps in diagnosing DKD. DKD was diagnosed through two reduced estimated glomerular filtration rate (eGFR; < 60 mL/min/1.73 m2) measurements at least 90 days apart, a single elevated urine albumin-to-creatinine ratio (UACR; > 30 mg/g) measurement, or ICD-9/10 diagnosis codes for DKD and/or albuminuria. Time to diagnose (TTD), time to treat (TTT), and diagnosis to treatment time were assessed. RESULTS Of 6,499,409 patients with T2DM before January 2016, 245,978 developed DKD between January 1, 2017 and June 30, 2019. In this DKD cohort, ca. 50% were first identified through EHR diagnosis and ca. 50% by UACR or eGFR lab-based diagnosis. In patients who had UACR/eGFR assessed, more than 90% exhibited DKD-level results on the first diagnostic test. Average TTD after eGFR labs was 2 years; average TTT with ACEi/ARB was 6-9 months after DKD lab evidence. The majority of patients who developed DKD received ACEi/ARB therapy 6-7 months after diagnosis. CONCLUSION In a contemporary, large national cohort of patients with T2DM, progression to DKD was common but likely underrepresented. The low rate of DKD-screening labs, along with sizable delays in diagnosis of DKD and initiation of ACEi/ARB therapy, indicates that many patients who progress to DKD are not being properly treated.
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Affiliation(s)
- Fatima Rodriguez
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University School of Medicine, 300 Pasteur Drive, H2157, Stanford, CA, 94305-5233, USA
| | | | | | | | | | | | | | - Aarti Patel
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | - Jaime Blais
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | - Matthew R Weir
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rajesh Dash
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford University School of Medicine, 300 Pasteur Drive, H2157, Stanford, CA, 94305-5233, USA.
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15
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Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation 2021; 143:e254-e743. [PMID: 33501848 DOI: 10.1161/cir.0000000000000950] [Citation(s) in RCA: 3098] [Impact Index Per Article: 1032.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Bradshaw C, Thomas IC, Montez-Rath ME, Lorenz KA, Asch SM, Leppert JT, Wang V, O’Hare AM, Kurella Tamura M. Facility-Level Variation in Dialysis Use and Mortality Among Older Veterans With Incident Kidney Failure. JAMA Netw Open 2021; 4:e2034084. [PMID: 33449098 PMCID: PMC7811178 DOI: 10.1001/jamanetworkopen.2020.34084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE Current guidelines lack consensus regarding the treatment of patients who may not benefit from dialysis; this lack of consensus may be associated with the substantial variation in dialysis use and outcomes across health care facilities. OBJECTIVE To assess the degree to which variation in dialysis use and mortality was associated with patient rather than facility characteristics and to distinguish which features identified the US Department of Veterans Affairs (VA) facilities with high rates of dialysis use. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed data of veterans with stage 3 or 4 chronic kidney disease that progressed to kidney failure between January 1, 2011, and December 31, 2014. These patients received care from VA facilities across the US. Data sources included laboratory and administrative records from the VA, Medicare, and United States Renal Data System. Data analysis was conducted from August 1, 2019, to September 1, 2020. EXPOSURES The primary exposure was the VA facility in which patients received most of their care before the onset of incident kidney failure defined as the first occurrence of either a sustained estimated glomerular filtration rate of less than 15 mL/min/1.73 m2 or the initiation of maintenance dialysis. MAIN OUTCOMES AND MEASURES The primary outcomes were dialysis use and mortality within 2 years of incident kidney failure. Median rate ratio was used to quantify facility-level variation, and variance partition coefficient was used to quantify the sources of unexplained variation. RESULTS The cohort included 8695 older veterans with a mean (SD) age of 78.8 (7.5) years who were predominantly male (8573 [99%]) and White (6102 [70%]) individuals treated at 108 VA facilities. The observed frequency of dialysis use across facilities ranged from 25.0% to 81.4%, with a median (interquartile range [IQR]) rate of 51.7% (48.4%-60.0%). The observed frequency of mortality across facilities ranged from 27.2% to 60.0%, with a median (IQR) rate of 45.2% (41.2%-48.6%). The median rate ratio (adjusted for multiple patient and facility characteristics) was 1.40 for dialysis use and 1.08 for mortality. The unexplained variation in both outcomes mainly derived from patient characteristics rather than facility characteristics. No correlation was found between dialysis use and mortality at the facility level (correlation coefficient = 0.03). CONCLUSIONS AND RELEVANCE This study found sizable variation in dialysis use for older adults that was poorly correlated with facility-level mortality rates and was not accounted for by differences in measured patient and facility characteristics. These findings suggest opportunities to improve the degree to which dialysis use practices align with the values, goals, and preferences of older adults with kidney failure.
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Affiliation(s)
- Christina Bradshaw
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - I-Chun Thomas
- Geriatric Research and Education Clinical Center, Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, California
| | - Maria E. Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Karl A. Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
- Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California
| | - Steven M. Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
- Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California
| | - John T. Leppert
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
- Division of Urology, VA Palo Alto Health Care System, Palo Alto, California
- Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Virginia Wang
- Center of Innovation for Health Services Research, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ann M. O’Hare
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington
- Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
- Geriatric Research and Education Clinical Center, Veterans Affairs (VA) Palo Alto Health Care System, Palo Alto, California
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Runesson B, Xu Y, Qureshi AR, Lindholm B, Barany P, Elinder CG, Carrero JJ. Association between reduced kidney function and incident hypoglycaemia in people with diabetes: The Stockholm Creatinine Measurements (SCREAM) project. Diabetes Obes Metab 2020; 22:1425-1435. [PMID: 32250539 DOI: 10.1111/dom.14051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022]
Abstract
AIM To evaluate possible associations between estimated glomerular filtration rate (eGFR) and hypoglycaemia in adults with diabetes. METHODS We conducted an observational study in adults with diabetes from the Stockholm Creatinine Measurement (SCREAM) project, a Swedish healthcare utilization cohort during 2007 to 2011. We evaluated diagnoses and outpatient glucose tests for incidence rate ratios (IRRs) of hypoglycaemia (overall and by severity) in outpatient care by eGFR strata using zero-inflated negative binomial regression. We identified clinical predictors through ordinal logistic regression and assessed 7-day and 30-day mortality from hypoglycaemia in relation to eGFR with Cox proportional hazard models. RESULTS We identified 29 434 people with diabetes (13% with type 1 diabetes). Their mean age was 66 years, 43% were women and the median eGFR was 80 mL/min/1.73 m2 . During 2 years of follow-up, 1812 patients (6.2%) had hypoglycaemia registered at least once. The risk of hypoglycaemia increased linearly with lower eGFR, with an IRR of 1.2 (95% confidence interval [CI] 1.0-1.4) for eGFR 60-89 mL/min/1.73 m2 and 5.8 (95% CI 3.8-9.0) for eGFR <15 mL/min/1.73 m2 compared to eGFR 90 to 104 mL/min/1.73 m2 . This trend was observed for both mild and severe hypoglycaemia. Both 7-day and 30-day post-hypoglycaemia mortality increased with lower eGFR, peaking in those with eGFR <15 mL/min/1.73 m2 (hazard ratio 21.2, 95% CI 5.1-87.9) as compared to those with eGFR 90 to 104 mL/min/1.73 m2 . Lower eGFR categories, type 1 diabetes, previous hypoglycaemia, liver disease, presence of diabetic complications and use of insulin and sulphonylureas increased the odds of hypoglycaemia. CONCLUSION In this large, observational study, low eGFR was strongly associated with the occurrence, severity and fatality of hypoglycaemia in people with diabetes.
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Affiliation(s)
| | - Yang Xu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Abdul R Qureshi
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Peter Barany
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Carl G Elinder
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
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Kramer H, Markossian T. Eliminating Missed Opportunities for CKD Care. Kidney Med 2019; 1:229-231. [PMID: 32734938 PMCID: PMC7380418 DOI: 10.1016/j.xkme.2019.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Holly Kramer
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Chicago, IL
- Division of Nephrology and Hypertension, Department of Medicine, Loyola University Chicago, Chicago, IL
| | - Talar Markossian
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Chicago, IL
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Tummalapalli SL, Powe NR, Keyhani S. Trends in Quality of Care for Patients with CKD in the United States. Clin J Am Soc Nephrol 2019; 14:1142-1150. [PMID: 31296503 PMCID: PMC6682807 DOI: 10.2215/cjn.00060119] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 05/04/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Improving the quality of CKD care has important public health implications to delay disease progression and prevent ESKD. National trends of the quality of CKD care are not well established. Furthermore, it is unknown whether gaps in quality of care are due to lack of physician awareness of CKD status of patients or other factors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a national, serial, cross-sectional study of visits to office-based ambulatory care practices for adults with diagnosed CKD from the years 2006 to 2014. We assessed the following quality indicators: (1) BP measurement, (2) uncontrolled hypertension, (3) uncontrolled diabetes, (4) angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use among patients with hypertension, (5) statin use if age ≥50 years old, and (6) nonsteroidal anti-inflammatory drug use. Using multivariable linear regression and chi-squared analysis, we examined the change in quality performance over time. RESULTS Between 2006 and 2014, there were 7099 unweighted visits for patients with CKD representing 186,961,565 weighted visits. There was no difference in the prevalence of uncontrolled hypertension (>130/80 mm Hg) over time (46% in 2006-2008 versus 48% in 2012-2014; P=0.50). There was a high prevalence of uncontrolled diabetes in 2012-2014 (40% for hemoglobin A1c >7%). The prevalence of ACEi/ARB use decreased from 45% in 2006-2008 to 36% in 2012-2014, which did not reach statistical significance (P=0.07). Statin use in patients with CKD who were 50 years or older was low and remained unchanged from 29% in 2006-2008 to 31% in 2012-2014 (P=0.92). CONCLUSIONS In a nationally representative dataset, we found that patients with CKD had a high prevalence of uncontrolled hypertension and diabetes and a low use of statins that did not improve over time and was not concordant with guidelines.
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Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Nephrology and
- Department of Medicine, University of California, San Francisco, California
| | - Neil R. Powe
- Department of Medicine, University of California, San Francisco, California
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, California; and
| | - Salomeh Keyhani
- Department of Medicine, University of California, San Francisco, California
- Division of General Internal Medicine, San Francisco Veterans Affairs Hospital, San Francisco, California
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Woodell TB, Rifkin DE. Still Asking "Which Rate Is Right?" Years Later. Clin J Am Soc Nephrol 2018; 13:1783-1784. [PMID: 30498001 PMCID: PMC6302325 DOI: 10.2215/cjn.12371018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Tyler B. Woodell
- Division of Nephrology, Department of Medicine, University of California, San Diego, California; and
| | - Dena E. Rifkin
- Division of Nephrology, Department of Medicine, University of California, San Diego, California; and
- Veterans’ Administration Healthcare System, San Diego, California
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