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Fabre L, Rangel ÉB. Age-related markers and predictors of diabetic kidney disease progression in type 2 diabetes patients: a retrospective cohort study. Ther Adv Endocrinol Metab 2024; 15:20420188241242947. [PMID: 38585445 PMCID: PMC10999127 DOI: 10.1177/20420188241242947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Background Diabetic kidney disease (DKD) is characterized by reduced estimated glomerular filtration rate (eGFR) and albuminuria, which play a pivotal role in both diagnosing and determining the disease's progression. This study aimed to assess the trajectory of these markers concerning age in individuals with DKD and identify predictive factors for the decline in eGFR decline, variation in albuminuria, mortality, and progression to renal replacement therapy (RRT). Design This retrospective cohort encompassed patients with type 2 diabetes (T2D), divided into two age categories: <75 and ⩾75 years old. Methods Over a 3-year span, the study evaluated eGFR (CKD-EPI) and 24-h albuminuria. Univariate and multivariate analyses were employed to pinpoint factors associated with deteriorating renal function and mortality. Significance was set at p < 0.05, and Kaplan-Meier survival curves were constructed to illustrate renal and overall survival. Results The analysis comprised 304 patients. Comparable eGFR declines were evident in both age groups during the transition from the first to the second year and from the second to the third year. Nonetheless, a more pronounced rise in albuminuria was evident in the ⩾75 years group during the first to the second year. Multivariate analysis unveiled that systolic blood pressure (SBP) measurements in the first year positively forecasted eGFR decline. Age was associated with heightened albuminuria and mortality, while hospitalizations linked to cardiovascular causes robustly predicted mortality. Hospitalizations due to sepsis and cardiovascular reasons, coupled with first-year SBP measurements, served as predictive indicators for progression to RRT. Conclusion Both age groups experienced similar declines in eGFR, though the ⩾75 years group displayed a more significant increase in albuminuria during the first to the second year. Age, hospitalizations, and higher blood pressure levels were correlated with exacerbated renal function deterioration and/or elevated mortality in DKD. Timely intervention and tailored management strategies stand as critical components for enhancing outcomes among DKD patients.
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Affiliation(s)
- Larissa Fabre
- Department of Medicine, Nephrology Division, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Hospital Regional Hans Dieter Schmidt, Joinville, SC, Brazil
| | - Érika Bevilaqua Rangel
- Nephrology Division, Department of Medicine, Universidade Federal de São Paulo, Borges Lagoa Street, 591, 6th floor, Vila Clementino, São Paulo, 04038-031, SP, Brazil
- Albert Einstein Research and Education Institute, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Zhang H, Zhu B, Chang L, Ye X, Tian R, He L, Yu D, Chen H, Wang Y. Efficacy and safety of a low-sodium diet and spironolactone in patients with stage 1-3a chronic kidney disease: a pilot study. BMC Nephrol 2022; 23:95. [PMID: 35247964 PMCID: PMC8897863 DOI: 10.1186/s12882-022-02711-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 02/20/2022] [Indexed: 12/03/2022] Open
Abstract
Background Excessive salt intake is associated with the deterioration of chronic kidney disease (CKD). Aldosterone is also known as an independent risk factor for kidney injury. Dietary sodium intake acts as a main stimulator in aldosterone-mediated kidney injury. Hence, this study aimed to further investigate the renal protective effects and safety of a low-sodium diet in combination with spironolactone (SPL) in stage 1-3a CKD. Methods This single-center, SPL-blinded randomized controlled trial recruited patients with stage 1-3a CKD, randomized into three groups, low-sodium (3 g/d salt) + placebo, medium-sodium (5 g/d salt) + SPL, and low-sodium (3 g/d salt) + SPL. Patients received 12 weeks of intervention. The primary and secondary endpoints were 24-h urine protein and estimated glomerular filtration rate (eGFR) at the end of the intervention, respectively. Results A total of 74 patients were analyzed eventually. Significantly decreased 24-h urine protein was found in all three groups, from 0.37 to 0.23 g/d (P = 0.004) in the low-sodium+placebo group, from 0.44 to 0.29 g/d (P = 0.020) in the medium-sodium+SPL group, and from 0.35 to 0.31 g/d (P = 0.013) in the low-sodium +SPL group. There were no significant differences among the three groups in 24-h urine protein amount change after intervention from pre-treatment values (P = 0.760, ITT set). The results of the 24-h urine protein by using PP set analysis was similar to the ITT set. No significant differences in eGFR, nutritional, metabolic, inflammatory, and other biomarkers were observed across all three groups (P > 0.05). No safety signal was observed. Conclusion No additional benefit was observed when SPL was prescribed to patients already on a low-sodium diet (3.0 g/d). Still, small doses of SPL may benefit patients with poor sodium restriction. A combination of short-term low-dose SPL and ARB is safe for patients with stage 1-3a CKD, but blood potassium must be regularly monitored. Trial registration Name of the registry: Chinese clinical trial registry. Trial registration number: ChiCTR1900026991. Date of registration: Retrospectively registered 28 October 2019. URL of trial registry record: http://www.chictr.org.cn/searchproj.aspx?title=&officialname=&subjectid=&secondaryid=&applier=&studyleader=ðicalcommitteesanction=&spo Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02711-z.
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Villain C, Metzger M, Liabeuf S, Hamroun A, Laville S, Mansencal N, Combe C, Fouque D, Frimat L, Jacquelinet C, Laville M, Ayav C, Briançon S, Pecoits-Filho R, Hannedouche T, Stengel B, Massy ZA. Effectiveness and Tolerance of Renin-Angiotensin System Inhibitors With Aging in Chronic Kidney Disease. J Am Med Dir Assoc 2021; 23:998-1004.e7. [PMID: 34856172 DOI: 10.1016/j.jamda.2021.10.019] [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: 03/19/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Renin-angiotensin system inhibitors (RASi) are recommended for slowing chronic kidney disease (CKD) progression to kidney failure. Their effectiveness and tolerance as patients age remain uncertain because older patients have often been excluded from clinical trials. DESIGN CKD-REIN cohort study. SETTING AND PARTICIPANTS We studied 2762 patients with CKD stages 3 and 4 and a clinical indication for RASi enrolled between 2013 and 2016 in 40 nephrology clinics nationally representative in France. METHODS The primary outcome was the occurrence of kidney failure or death. The secondary outcomes were the occurrence of cardiovascular events and hospitalizations with acute kidney injury (AKI) or hyperkalemia. A propensity score analysis was performed. We used Cox models to estimate hazard ratios (HRs) for each outcome associated with RASi prescription and tested interactions with age. RESULTS Patients' mean age was 67 years, including 841 (30%) aged 75 years and older; 2178 (79%) were prescribed RASi's. During a median follow-up of 4.6 years, 33% of patients reached kidney failure or died. RASi prescription was associated with a lower risk of kidney failure or death (HR 0.79, 95% CI 0.66, 0.95), an association not modified by age (P for interaction = .72). It was not significantly associated with cardiovascular events. During the first 3 years of follow-up, 14% of patients were hospitalized with AKI or hyperkalemia, but risk was not higher among those prescribed RASi's (HR 0.75, 95% CI 0.55-1.02) and age did not modify its effect (P for interaction = .28). CONCLUSIONS AND IMPLICATIONS This study shows that aging does not appear to modify either RASi's beneficial effects on major CKD outcomes or their potential adverse effects.
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Affiliation(s)
- Cédric Villain
- Université Paris-Saclay, UVSQ, Inserm, Clinical Epidemiology Team, CESP (Centre de recherche en Epidémiologie et Santé des Populations), Villejuif, France; Service de Gériatrie, CHU de Caen, Normandie Université UNICAEN, Caen, France.
| | - Marie Metzger
- Université Paris-Saclay, UVSQ, Inserm, Clinical Epidemiology Team, CESP (Centre de recherche en Epidémiologie et Santé des Populations), Villejuif, France
| | - Sophie Liabeuf
- Université Paris-Saclay, UVSQ, Inserm, Clinical Epidemiology Team, CESP (Centre de recherche en Epidémiologie et Santé des Populations), Villejuif, France; Service de Pharmacologie Clinique, Département de Recherche Clinique, CHU d'Amiens, Université de Picardie Jules Verne, INSERM U-1088, Amiens, France
| | - Aghilès Hamroun
- Université Paris-Saclay, UVSQ, Inserm, Clinical Epidemiology Team, CESP (Centre de recherche en Epidémiologie et Santé des Populations), Villejuif, France
| | - Solene Laville
- Université Paris-Saclay, UVSQ, Inserm, Clinical Epidemiology Team, CESP (Centre de recherche en Epidémiologie et Santé des Populations), Villejuif, France
| | - Nicolas Mansencal
- Université Paris-Saclay, UVSQ, Inserm, Clinical Epidemiology Team, CESP (Centre de recherche en Epidémiologie et Santé des Populations), Villejuif, France; Service de Cardiologie, CHU Ambroise Paré, APHP, Boulogne-Billancourt, Université de Versailles-Saint Quentin (UVSQ), France
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse Aphérèses, CHU de Bordeaux, Bordeaux, France; INSERM Unité 1026, Université de Bordeaux, Bordeaux, France
| | - Denis Fouque
- Université de Lyon, Service de Néphrologie, CarMeN INSERM 1060, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Luc Frimat
- Service de Néphrologie, Université de Lorraine, APEMAC, CHRU de Nancy-Hôpitaux de Brabois, Nancy, France
| | - Christian Jacquelinet
- Université Paris-Saclay, UVSQ, Inserm, Clinical Epidemiology Team, CESP (Centre de recherche en Epidémiologie et Santé des Populations), Villejuif, France; Agence de Biomédecine, La Plaine Saint-Denis, France
| | - Maurice Laville
- Université de Lyon, Service de Néphrologie, CarMeN INSERM 1060, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Carole Ayav
- CIC 1433 Epidémiologie Clinique, INSERM, CHRU, Université de Lorraine, CHRU de Nancy-Hôpitaux de Brabois, Nancy, France
| | - Serge Briançon
- CIC 1433 Epidémiologie Clinique, INSERM, CHRU, Université de Lorraine, CHRU de Nancy-Hôpitaux de Brabois, Nancy, France
| | | | - Thierry Hannedouche
- Service de Néphrologie-Hémodialyse, Hôpitaux Universitaires de Strasbourg, Faculté de Médecine de Strasbourg, Strasbourg, France
| | - Bénédicte Stengel
- Université Paris-Saclay, UVSQ, Inserm, Clinical Epidemiology Team, CESP (Centre de recherche en Epidémiologie et Santé des Populations), Villejuif, France
| | - Ziad A Massy
- Université Paris-Saclay, UVSQ, Inserm, Clinical Epidemiology Team, CESP (Centre de recherche en Epidémiologie et Santé des Populations), Villejuif, France; Service de Néphrologie-Dialyse, CHU Ambroise Paré, APHP, Boulogne-Billancourt, France
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García-Prieto AM, Verdalles Ú, Goicoechea M. Use of renin-angiotensin-aldosterone system blockade in controversial chronic kidney disease populations. Med Clin (Barc) 2021; 156:561-567. [PMID: 33757646 DOI: 10.1016/j.medcli.2020.12.025] [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: 09/28/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023]
Abstract
Renin-angiotensin-aldosterone system blockers have shown to be effective in controlling blood pressure and proteinuria, slowing the progression to end stage renal disease and reducing cardiovascular risk, so they are the mainstream treatment of hypertension in chronic kidney disease. Their beneficial effects have been proven in multiple randomized clinical trials on different study populations, but there has recently been some controversial data on its use in some subgroups of patients, especially those with advanced chronic kidney disease. In some other populations such as patients with non-proteinuric nephropathies or the elderly, who can be more susceptible to its adverse events, their benefits have also been questioned. The aim of the present review is to collect available published data on the effect of renin-angiotensin-aldosterone system blockers in some controversial populations and provide perspective on future research areas in this field.
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Affiliation(s)
| | - Úrsula Verdalles
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marian Goicoechea
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Red de Investigación Renal (REDinREN), Spain
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Kitamura M, Arai H, Abe S, Ota Y, Muta K, Furusu A, Mukae H, Kohno S, Nishino T. Renal outcomes of treatment with telmisartan in patients with stage 3-4 chronic kidney disease: A prospective, randomized, controlled trial (JINNAGA). SAGE Open Med 2020; 8:2050312120973502. [PMID: 33282300 PMCID: PMC7686635 DOI: 10.1177/2050312120973502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 10/26/2020] [Indexed: 11/27/2022] Open
Abstract
Objectives: Although angiotensin II receptor blockers are effective for patients with
chronic kidney disease, dose-dependent renoprotective effects of angiotensin
II receptor blockers in patients with moderate to severe chronic kidney
disease with non-nephrotic proteinuria are not known. Our aim was to
elucidate the dose-dependent renoprotective effects of angiotensin II
receptor blockers on such patients. Methods: A multicenter, prospective, randomized trial was conducted from 2009 to 2014.
Patients with non-nephrotic stage 3–4 chronic kidney disease were randomized
for treatment with either 40 or 80 mg telmisartan and were observed for up
to 104 weeks. Overall, 32 and 29 patients were allocated to the 40 and 80 mg
telmisartan groups, respectively. The composite primary outcome was renal
death, doubling of serum creatinine level, transition to stage 5 chronic
kidney disease, and death from any cause. Secondary outcomes included the
level of urinary proteins and changes in the estimated glomerular filtration
rate. Results: There was no difference in the primary outcome (p = 0.78) and eGFR (p = 0.53)
between the two groups; however, after 24 weeks, urinary protein level was
significantly lower in the 80 mg group than in the 40 mg group
(p < 0.05). No severe adverse events occurred in either group, and the
occurrence of adverse events did not significantly differ between them
(p = 0.56). Conclusion: Our findings do not demonstrate a direct dose-dependent renoprotective effect
of telmisartan. The higher telmisartan dose resulted in a decrease in the
amount of urinary protein. Even though high-dose angiotensin II receptor
blockers may be preferable for patients with stage 3–4 chronic kidney
disease, the clinical importance of the study results may be limited. The
study was registered in the UMIN-CTR (https://www.umin.ac.jp/ctr) with the registration number
UMIN000040875.
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Affiliation(s)
- Mineaki Kitamura
- Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan
| | - Hideyuki Arai
- Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan.,Department of Nephrology, JCHO Isahaya General Hospital, Isahaya, Nagasaki, Japan
| | - Shinichi Abe
- Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan
| | - Yuki Ota
- Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan
| | - Kumiko Muta
- Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan
| | - Akira Furusu
- Department of Nephrology, Wajinkai Hospital, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Unit of Basic Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shigeru Kohno
- Department of Respiratory Medicine, Unit of Basic Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan
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Forsat ND, Palmowski A, Palmowski Y, Boers M, Buttgereit F. Recruitment and Retention of Older People in Clinical Research: A Systematic Literature Review. J Am Geriatr Soc 2020; 68:2955-2963. [DOI: 10.1111/jgs.16875] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Noah D. Forsat
- Department of Rheumatology and Clinical Immunology Charité–University Medicine Berlin Berlin Germany
| | - Andriko Palmowski
- Department of Rheumatology and Clinical Immunology Charité–University Medicine Berlin Berlin Germany
| | - Yannick Palmowski
- Center for Musculoskeletal Surgery Charité–University Medicine Berlin Berlin Germany
| | - Maarten Boers
- Department of Epidemiology and Biostatistics, and Amsterdam Rheumatology and Immunology Center Amsterdam UMC, Vrije Universiteit Amsterdam Amsterdam the Netherlands
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology Charité–University Medicine Berlin Berlin Germany
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García-Prieto AM, Verdalles Ú, de José AP, Verde E, Arroyo D, Aragoncillo I, Linares T, Barbieri D, Goicoechea M. The effect of renin-angiotensin-aldosterone system blockers on the progression of chronic kidney disease in hypertensive elderly patients without proteinuria: PROERCAN study. Rationale and design. HIPERTENSION Y RIESGO VASCULAR 2020; 37:101-107. [PMID: 32156479 DOI: 10.1016/j.hipert.2020.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Blood pressure (BP) control is fundamental to the care of patients with chronic kidney disease (CKD), and is relevant at all stages of CKD. Renin-angiotensin-aldosterone system (RAAS) blockers have shown to be effective, not only in BP control but also in reducing proteinuria and slowing CKD progression. However, there is a lack of evidence for recommending RAAS blockers in elderly patients with CKD without proteinuria. The primary outcome of the present study is to evaluate the impact of RAAS blockers on CKD progression in elderly patients without proteinuria. MATERIALS AND METHODS The PROERCAN trial (trial registration, NCT03195023) is a multicentre open-label, randomized controlled clinical trial with 110 participants over 65 years-old with hypertension and CKD stages 3-4 without proteinuria. Patients will be randomized in a 1:1 ratio to either receive RAAS blockers or other antihypertensive drugs, and will be followed up for three years. Primary outcome is the estimated glomerular filtration rate (eGFR) decline at 3 years. Secondary outcomes include BP control, renal and cardiovascular events, and mortality. RESULTS AND CONCLUSIONS The design of this trial is presented here. The results will show if antihypertensive treatment with RAAS blockers has an impact on CKD progression in elderly patients without proteinuria. Any differences in BP control, cardiovascular events, and mortality with each antihypertensive treatment will be also clarified.
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Affiliation(s)
- A M García-Prieto
- Servicio Nefrología Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain.
| | - Ú Verdalles
- Servicio Nefrología Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain
| | - A P de José
- Servicio Nefrología Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain
| | - E Verde
- Servicio Nefrología Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain
| | - D Arroyo
- Servicio Nefrología Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain
| | - I Aragoncillo
- Servicio Nefrología Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain
| | - T Linares
- Servicio Nefrología Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain
| | - D Barbieri
- Servicio Nefrología Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain
| | - M Goicoechea
- Servicio Nefrología Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain; Spanish Research Network (REDINREN), Madrid, Spain
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Palmowski A, Nielsen SM, Buttgereit T, Palmowski Y, Boers M, Christensen R, Buttgereit F. Glucocorticoid-trials in rheumatoid arthritis mostly study representative real-world patients: A systematic review and meta-analysis. Semin Arthritis Rheum 2020; 50:1400-1405. [PMID: 32222381 DOI: 10.1016/j.semarthrit.2020.02.016] [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: 12/18/2019] [Revised: 02/15/2020] [Accepted: 02/25/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Randomized controlled trials (RCTs) are considered the gold standard in clinical research due to credible causality. Their results, however, may not be generalizable to real-world populations. While glucocorticoids (GCs) remain a mainstay of rheumatoid arthritis (RA) treatment, it is unclear whether the results of GC-RCTs are generalizable to current real-world RA patients. METHODS MEDLINE was searched for RCTs and, as comparators, cohort studies (CSs) in RA evaluating systemic GCs. Random-effects meta-analyses were performed for descriptive baseline characteristics (including general demographics, comorbidities, and disease activity) that have been shown to be able to modify the benefit-risk-ratio of various RA therapeutics. These meta-analyses were stratified by study type (RCT and CS). Stratified estimates were subsequently compared. Further sensitivity analyses were performed stratifying by disease duration. RESULTS 56 RCTs (7053 participants) and 10 CSs (14,688 participants) were included. 12 characteristics were reported frequently enough to allow for comparative analysis. In 10/12 characteristics (83%), RCT estimates did not appear to differ from CS estimates. However, RCT participants were younger (-4.7 years [95% CI -7.2 to -2.1]; p < 0.001) and had higher erythrocyte sedimentation rates (11.8 mm/h [5.7 to 17.8]; p < 0.001) than CS participants. Comorbidities could not be assessed due to insufficient reporting. CONCLUSION Our findings suggest that evidence from GC trials in RA is of acceptable generalizability to current real-world patients - especially compared to findings from biologic agents in RA. However, RCT participants were younger than real-world patients, potentially limiting the generalizability of trial results to elderly patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO (CRD42019134675).
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Affiliation(s)
- Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany.
| | - Sabrina M Nielsen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, 2000 Frederiksberg, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, 5000 Odense, Denmark
| | - Thomas Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Dermatology, Venerology, and Allergology, Charité - University Medicine Berlin, 10117 Berlin, Germany
| | - Yannick Palmowski
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, 10117 Berlin, Germany
| | - Maarten Boers
- Department of Epidemiology and Biostatistics, and Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit Amsterdam, 1007 MB Amsterdam, the Netherlands
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, 2000 Frederiksberg, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, 5000 Odense, Denmark
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Loutradis C, Sarafidis P. Pharmacotherapy of hypertension in patients with pre-dialysis chronic kidney disease. Expert Opin Pharmacother 2020; 21:1201-1217. [PMID: 32073319 DOI: 10.1080/14656566.2020.1726318] [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] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hypertension is the most common co-morbidity in patients with chronic kidney disease (CKD), with prevalence gradually increasing across CKD Stages to the extent that about 90% of end-stage renal disease (ESRD) patients are hypertensives. Several factors contribute to blood pressure (BP) elevation and guide the therapeutic interventions that should be employed in these patients. AREAS COVERED This review summarizes the existing data for the management of hypertension, regarding optimal BP targets and the use of major antihypertensive classes in patients with CKD. EXPERT OPINION Management of hypertension in CKD requires both lowering BP levels and reducing proteinuria to minimize the risk of both CKD progression and cardiovascular disease. In this respect, aggressive control of office BP to levels <130/80 mmHg has long been proposed for patients with proteinuric nephropathies. Following evidence from recent studies that confirmed significant reductions in renal and cardiovascular outcomes with strict BP control, most, but not all, of international guidelines, suggest such BP goals for all hypertensive patients, including those with CKD. Use of renin-angiotensin system (RAS) blockers is the treatment of choice for patients with proteinuric nephropathies, while, in most patients with CKD, combination treatment with two, three, or more antihypertensive agents is often required to control BP.
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Affiliation(s)
- Charalampos Loutradis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki , Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki , Thessaloniki, Greece
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Hamroun A, Frimat M, Beuscart JB, Buob D, Lionet A, Lebas C, Daroux M, Provôt F, Hazzan M, Boulanger É, Glowacki F. [Kidney disease care for the elderly]. Nephrol Ther 2019; 15:533-552. [PMID: 31711751 DOI: 10.1016/j.nephro.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In our aging population, kidney disease management needs to take into account the frailty of the elderly. Standardized geriatric assessments can be proposed to help clinicians apprehend this dimension in their daily practice. These tools allow to better identify frail patients and offer them more personalized and harmless treatments. This article aims to focus on the kidney diseases commonly observed in elderly patients and analyze their specific nephrogeriatric care modalities. It should be noticed that all known kidney diseases can be also observed in the elderly, most often with a quite similar clinical presentation. This review is thus focused on the diseases most frequently and most specifically observed in elderly patients (except for monoclonal gammopathy associated nephropathies, out of the scope of this work), as well as the peculiarities of old age nephrological care.
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Affiliation(s)
- Aghilès Hamroun
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marie Frimat
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | | | - David Buob
- Service d'anatomopathologie, Centre de biologie-pathologie, CHRU de Lille, 59037 Lille, France
| | - Arnaud Lionet
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Céline Lebas
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Maïté Daroux
- Service de néphrologie, hôpital Duchenne, allée Jacques Monod, 62200 Boulogne-sur-Mer, France
| | - François Provôt
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marc Hazzan
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Éric Boulanger
- Service de gériatrie, CHRU de Lille, 59037 Lille, France
| | - François Glowacki
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France.
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11
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Palmowski A, Buttgereit T, Palmowski Y, Nielsen SM, Boers M, Christensen R, Buttgereit F. Applicability of trials in rheumatoid arthritis and osteoarthritis: A systematic review and meta-analysis of trial populations showing adequate proportion of women, but underrepresentation of elderly people. Semin Arthritis Rheum 2019; 48:983-989. [DOI: 10.1016/j.semarthrit.2018.10.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/05/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023]
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12
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Bowling CB, Whitson HE, Johnson TM. The 5Ts: Preliminary Development of a Framework to Support Inclusion of Older Adults in Research. J Am Geriatr Soc 2019; 67:342-346. [PMID: 30693952 DOI: 10.1111/jgs.15785] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/14/2018] [Accepted: 11/30/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES To address the underrepresentation of older adults in clinical research, the National Institutes of Health will require investigators to include individuals across the lifespan. As investigators from other fields endeavor to recruit participants who are more representative of the patient population, geriatricians may have the opportunity to influence a broad range of research studies in older adults. Our aims were to elicit challenges to inclusion of older adults in clinical research and to develop a preliminary framework for communicating these challenges to non-geriatrics-trained researchers. DESIGN Communication framework development. SETTING Academic hospital and Veterans Affairs Medical Center. PARTICIPANTS Nongeriatrician researchers and staff, aging research experts. MEASUREMENTS Interviews were used to elicit challenges nongeriatrician investigators and research staff experience when conducting research that includes older adults and then solicit experienced aging researchers' responses to these challenges. RESULTS Challenges described by nongeriatrician investigators included lack of knowledge, rigid study structures, and a disease-focused approach. Responses from our geriatrics experts included communicating practical advice for avoiding common pitfalls. Our resulting framework is the 5Ts: Target Population, Team, Tools, Time, and Tips to Accommodate. This tool complements the 5Ms (Mind, Mobility, Medications, Multicomplexity, and Matters Most to Me) model for geriatric care and emphasizes representation of the Target Population, building research Teams that include aging expertise, incorporating appropriate Tools for function and patient-reported outcomes, anticipating Time for longer study visits, and accommodating common needs with practical Tips. Limitations include convenience sampling and lack of formal qualitative thematic analysis. CONCLUSION Communicating with nongeriatrician researchers using the 5Ts may offer a practical approach to avoiding barriers to inclusion of older adults in research and complements an existing framework for communicating the value of geriatric medicine. Next steps in developing the 5Ts will be to include additional stakeholders (eg, national samples of nongeriatrician investigators, older adults and their families) and evaluating the impact of its implementation. J Am Geriatr Soc 67:342-346, 2019.
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Affiliation(s)
- C Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Division of Geriatric Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Heather E Whitson
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Division of Geriatric Medicine, Department of Medicine, Duke University, Durham, North Carolina.,Duke Center for the Study of Aging and Human Development, Duke University, Durham, NC
| | - Theodore M Johnson
- Department of Veterans Affairs Medical Center, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Decatur, Georgia.,Department of Medicine, Emory University, Atlanta, Georgia
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13
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Practical management of concomitant acute heart failure and worsening renal function in the emergency department. Eur J Emerg Med 2018; 25:229-236. [PMID: 28984663 DOI: 10.1097/mej.0000000000000505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Worsening renal function (i.e. any increase in creatinine or decrease in the estimated glomerular filtration rate) is common in patients admitted for acute heart failure in the emergency department. Although worsening renal function (WRF) has been associated with the occurrence of dismal outcomes, this only appears to be the case when associated with clinical deterioration. However, if the clinical status of the patient is improving, a certain increase in serum creatinine may be acceptable. This WRF, which is not associated with clinical deterioration or adverse outcomes (e.g. during treatment up-titration), has been referred to as 'pseudo-WRF' and should not detract clinicians from targeting 'guideline-recommended' therapies. This is an important message for emergency physicians to pursue diuretics as long as signs of pulmonary congestion persist to improve the clinical status of the patient. In the present review, we aim to provide clinicians in acute settings with an integrative and comprehensive approach to cardiorenal interactions in acute heart failure.
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14
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Park KJ, Johnson ES, Smith N, Mosen DM, Thorp ML. Association of Proteinuria with Central Venous Catheter Use at Initial Hemodialysis. Perm J 2018; 22:16-194. [PMID: 29236655 PMCID: PMC5737917 DOI: 10.7812/tpp/16-194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Central venous catheter (CVC) use is associated with increased mortality and complications in hemodialysis recipients. Although prevalent CVC use has decreased, incident use remains high. OBJECTIVE To examine characteristics associated with CVC use at initial dialysis, specifically looking at proteinuria as a predictor of interest. DESIGN Retrospective cohort of 918 hemodialysis recipients from Kaiser Permanente Northwest who started hemodialysis from January 1, 2004, to January 1, 2014. MAIN OUTCOME MEASURES Multivariable logistic regression was used to examine an association of proteinuria with the primary outcome of CVC use. RESULTS More than one-third (36%) of patients in our cohort started hemodialysis with an arteriovenous fistula, and 64% started with a CVC. Proteinuria was associated with starting hemodialysis with a CVC (likelihood ratio test, p < 0.001) after adjustment for age, peripheral vascular disease, congestive heart failure, diabetes, sex, race, and length of predialysis care. However, on pairwise comparison, only patients with midgrade proteinuria (0.5-3.5 g) had lower odds of starting hemodialysis with a CVC (odds ratio = 0.39, 95% confidence interval = 0.24-0.65). CONCLUSION Proteinuria was associated with use of CVC at initial hemodialysis. However, a graded association did not exist, and only patients with midgrade proteinuria had significantly lower odds of CVC use. Our findings suggest that proteinuria is an explanatory finding for CVC use but may not have pragmatic value for decision making. Patients with lower levels of proteinuria may have a higher risk of starting dialysis with a CVC.
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Affiliation(s)
- Ken J Park
- Nephrologist at the Salem Medical Center in OR.
| | - Eric S Johnson
- Research Investigator at the Center for Health Research in Portland, OR.
| | - Ning Smith
- Research Investigator at the Center for Health Research in Portland, OR. E-mapil:
| | - David M Mosen
- Affiliate Investigator at the Center for Health Research in Portland, OR.
| | - Micah L Thorp
- Chief of Nephrology for Kaiser Permanente Northwest in Portland, OR.
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15
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Chong K, Unruh M. Why does quality of life remain an under-investigated issue in chronic kidney disease and why is it rarely set as an outcome measure in trials in this population? Nephrol Dial Transplant 2017; 32:ii47-ii52. [PMID: 28206614 DOI: 10.1093/ndt/gfw399] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 10/10/2016] [Indexed: 12/14/2022] Open
Abstract
The growing importance of quality of life (QoL) measures in health care is reflected by the increased volume and rigor of published research on this topic. The ability to measure and assess patients' experience of symptoms and functions has transformed the development of disease treatments and interventions. However, QoL remains an under-investigated issue in chronic kidney disease (CKD) and is seldom set as an outcome measure in trials in this population. In this article, we present various challenges in using patient-reported outcome (PRO) end points in CKD trials. We outline the need for additional research to examine more closely patient experiences with specific kidney disease symptoms and conditions, as well as caregiver perspectives of patients' symptom burden and end-of-life experiences. These efforts will better guide the development or enhancement of PRO instruments that can be used in clinical trials to more effectively assess treatment benefit, and improve therapy and care. Better understanding of health-related QoL issues would enable providers to deliver more patient-centered care and improve the overall well-being of patients. Even small improvements in QoL could have a large impact on the population's overall health and disease burden.
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Affiliation(s)
- Kelly Chong
- Renal Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Mark Unruh
- Renal Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.,Renal Section, New Mexico VA Health System, Albuquerque, NM, USA
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16
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Sarafidis PA, Alexandrou ME, Ruilope LM. A review of chemical therapies for treating diabetic hypertension. Expert Opin Pharmacother 2017; 18:909-923. [DOI: 10.1080/14656566.2017.1328054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Pantelis A. Sarafidis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
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17
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Bourgeois FT, Orenstein L, Ballakur S, Mandl KD, Ioannidis JPA. Exclusion of Elderly People from Randomized Clinical Trials of Drugs for Ischemic Heart Disease. J Am Geriatr Soc 2017; 65:2354-2361. [PMID: 28306144 DOI: 10.1111/jgs.14833] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To measure exclusion of elderly adults from randomized trials studying drug interventions for ischemic heart disease (IHD) and describe the characteristics of these trials. DESIGN Cross-sectional analysis. SETTING Interventional clinical trials studying a drug intervention for IHD that started in 2006 and after were identified in ClinicalTrials.gov. Data were extracted on study features, including age-based inclusion criteria. Data on participants and their age distribution were collected from trial publications, investigator inquiry, and result data in ClinicalTrials.gov. PARTICIPANTS Individuals aged 65 and older. MEASUREMENTS Proportion of trials excluding individuals based on age, mean age of trial participants, and proportion of enrolled participants aged 65 and older and 75 and older. RESULTS Of 839 identified trials, 446 (53%) explicitly excluded elderly adults. The most-frequent upper age limits were 80 (n = 164) and 75 (n = 114), with a median upper age limit of 80 (interquartile range 75-80). Trials with upper age limit exclusions tended to be smaller (median number of participants 100 vs 201, P < .001) and were more likely to be funded primarily by nonindustry sources (78.3% vs 70.0%, P = .006). The overall mean age of trial participants was 62.7 (mean maximum age 74). The estimated proportion of participants aged 65 and older was 42.5% and the estimated proportion aged 75 and older was 12.3%. CONCLUSION Despite the high burden of IHD in elderly adults, the majority of drug trials do not enroll participants reflective of age-related prevalence of the disease.
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Affiliation(s)
- Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
| | - Liat Orenstein
- Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
| | - Sarita Ballakur
- Faculty of Arts and Sciences, Brown University, Providence, Rhode Island
| | - Kenneth D Mandl
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, California.,Department of Health Research and Policy, School of Medicine, Stanford University, Stanford, California
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18
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Chen CH, Wu HY, Wang CL, Yang FJ, Wu PC, Hung SC, Kan WC, Yang CW, Chiang CK, Huang JW, Hung KY. Proteinuria as a Therapeutic Target in Advanced Chronic Kidney Disease: a Retrospective Multicenter Cohort Study. Sci Rep 2016; 6:26539. [PMID: 27198863 PMCID: PMC4873744 DOI: 10.1038/srep26539] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 05/04/2016] [Indexed: 01/10/2023] Open
Abstract
Current evidence of proteinuria reduction as a surrogate target in advanced chronic kidney disease (CKD) is incomplete due to lack of patient-pooled database. We retrospectively studied a multicenter cohort of 1891 patients who were enrolled in the nationwide multidisciplinary pre-end stage renal disease care program with a baseline glomerular filtration rate (GFR) <45 mL/min/1.73 m(2) and followed longitudinally to investigate the effect of the change in proteinuria on renal death (defined as composite of dialysis and death occurring before initiation of dialysis). The group with a change in proteinuria ≤0.30 g/g (n = 1261) had lower cumulative probabilities of renal death (p < 0.001). In a linear regression model, a higher baseline proteinuria and a greater increase in proteinuria were associated with faster annual GFR decline. Cox's analysis showed that every 1 unit increase in natural log(baseline proteinuria, 10 g/g) and every 0.1 g/g increase in the change in proteinuria resulted in 67% (HR = 1.67, 95% CI: 1.46-1.91) and 1% (HR = 1.01, 95% CI: 1.01-1.01) greater risk of renal death respectively after adjusting for the effects of the other covariates. Our study provided a patient-based evidence to support proteinuria as a therapeutic target in advanced CKD.
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Affiliation(s)
- Chang-Hsu Chen
- Division of Nephrology, Tungs’ Taichung MetroHarbor Hospital, Taichung City, Taiwan
| | - Hon-Yen Wu
- Division of Nephrology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chieh-Li Wang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei City, Taiwan
| | - Feng-Jung Yang
- Division of Nephrology, National Taiwan University Hospital Yun-Lin Branch, Yunlin County, Taiwan
| | - Pei-Chen Wu
- Division of Nephrology, Da Chien General Hospital, Miaoli County, Taiwan
| | - Szu-Chun Hung
- Division of Nephrology, Buddhist Tzu Chi Hospital Taipei Branch, New Taipei City, Taiwan
| | - Wei-Chih Kan
- Department of Nephrology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chung-Wei Yang
- Division of Nephrology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Chih-Kang Chiang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei City, Taiwan
| | - Jenq-Wen Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei City, Taiwan
| | - Kuan-Yu Hung
- Division of Nephrology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei City, Taiwan
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19
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Prevalence and Characteristics of Interventional Trials Conducted Exclusively in Elderly Persons: A Cross-Sectional Analysis of Registered Clinical Trials. PLoS One 2016; 11:e0155948. [PMID: 27196289 PMCID: PMC4873036 DOI: 10.1371/journal.pone.0155948] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 04/15/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Elderly patients represent the greatest consumers of healthcare per capita but have historically been underrepresented in clinical trials. It is unknown how many trials are designed to focus exclusively on elderly patients. OBJECTIVE To define the prevalence of interventional trials that study exclusively elderly persons and describe the characteristics of these trials, including their distribution across conditions most prevalent in the elderly. DESIGN All interventional clinical trials enrolling exclusively elderly patients (≥65 years), conducted primarily in high-income countries, and initiated between 2006 and 2014, identified through ClincialTrials.gov. MAIN MEASURES Trials were identified and characterized according to design features and disease categories studied. Across disease categories we examined the burden of disease in the elderly in high-income countries (measured in disability-adjusted life years [DALYs]) and compared to the number of trials conducted exclusively in the elderly. RESULTS Among 80,965 interventional trials, 1,112 (1.4%) focused on elderly patients. Diverse types of interventions were studied in these trials (medications 33%, behavioral interventions 18%, and dietary supplements 10%) and the majority was funded by non-profit organizations (81%). Studies tended to be small (median sample size 122 participants [IQR 58, 305]), single-center studies (67%). Only 43% of 126 disease categories affecting elderly persons were studied in trials focused on the elderly. Among these disease categories, there was a 5162-fold range in the ratio of DALYs per trial. Across 5 conditions where over 80% of DALYs are in the elderly, there were a total of only 117 trials done exclusively in the elderly. CONCLUSIONS Very few and mostly small studies are conducted exclusively in elderly persons, even for conditions that affect almost exclusively the elderly.
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20
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Conservative management of chronic kidney disease stage 5: role of angiotensin converting enzyme inhibitors. J Nephrol 2016; 29:809-815. [DOI: 10.1007/s40620-016-0290-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/13/2016] [Indexed: 01/13/2023]
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21
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Priority topics for European multidisciplinary guidelines on the management of chronic kidney disease in older adults. Int Urol Nephrol 2016; 48:859-69. [DOI: 10.1007/s11255-016-1257-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/26/2016] [Indexed: 12/16/2022]
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22
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O'Hare AM, Rodriguez RA, Bowling CB. Caring for patients with kidney disease: shifting the paradigm from evidence-based medicine to patient-centered care. Nephrol Dial Transplant 2016; 31:368-75. [PMID: 25637639 PMCID: PMC4762396 DOI: 10.1093/ndt/gfv003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 12/18/2014] [Indexed: 02/07/2023] Open
Abstract
The last several decades have witnessed the emergence of evidence-based medicine as the dominant paradigm for medical teaching, research and practice. Under an evidence-based approach, populations rather than individuals become the primary focus of investigation. Treatment priorities are largely shaped by the availability, relevance and quality of evidence and study outcomes and results are assumed to have more or less universal significance based on their implications at the population level. However, population-level treatment goals do not always align with what matters the most to individual patients-who may weigh the risks, benefits and harms of recommended treatments quite differently. In this article we describe the rise of evidence-based medicine in historical context. We discuss limitations of this approach for supporting real-world treatment decisions-especially in older adults with confluent comorbidity, functional impairment and/or limited life expectancy-and we describe the emergence of more patient-centered paradigms to address these limitations. We explain how the principles of evidence-based medicine have helped to shape contemporary approaches to defining, classifying and managing patients with chronic kidney disease. We discuss the limitations of this approach and the potential value of a more patient-centered paradigm, with a particular focus on the care of older adults with this condition. We conclude by outlining ways in which the evidence-base might be reconfigured to better support real-world treatment decisions in individual patients and summarize relevant ongoing initiatives.
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Affiliation(s)
- Ann M. O'Hare
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, WA, USA
- Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Rudolph A. Rodriguez
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher Barrett Bowling
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta VA Medical Center, Decatur, GA, USA
- Department of Medicine, Emory University, Atlanta, GA, USA
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23
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Hishida M, Tamai H, Morinaga T, Maekawa M, Aoki T, Tomida H, Komatsu S, Kamiya T, Maruyama S, Matsuo S, Inaguma D. Aichi cohort study of the prognosis in patients newly initiated into dialysis (AICOPP): baseline characteristics and trends observed in diabetic nephropathy. Clin Exp Nephrol 2016; 20:795-807. [PMID: 26905064 DOI: 10.1007/s10157-015-1206-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 11/19/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Over 300,000 patients receive maintenance dialysis in Japan; managing these patients is extremely important. This study aimed to report on prior management of chronic kidney diseases and prognostication after dialysis initiation. PATIENTS AND METHODS Seventeen institutions participated in the Aichi cohort study of prognosis in patients newly initiated into dialysis and recruited patients over a period of 2 years. Exclusion criteria were (1) patients under 20 years; (2) patients who died before hospital discharge; and (3) patients who could not provide consent. RESULT Here, we showed data on dialysis initiation time. Of 1524 patients with mean age of 67.5 ± 13.0 years, 659 patients were put on dialysis following diabetic nephropathy diagnosis. At dialysis initiation time, creatinine and estimated glomerular filtration rate levels were 8.97 ± 3.21 mg/dl and 5.45 ± 2.22 ml/min/1.73 m2, respectively. Medications taken were angiotensin II receptor blockers in 866; angiotensin-converting enzyme inhibitors in 135; calcium antagonist in 1202; and diuretics, alone or in combination, in 1059. Among patients with diabetic nephropathy, many had increased body weight and systolic blood pressure and were taking loop and thiazide diuretics at dialysis initiation time. Many patients with diabetic nephropathy had coronary artery disease and percutaneous coronary intervention. CONCLUSION Many patients with diabetic nephropathy who registered for this study had coronary artery disease and problems with excess body fluid. Further analyses may clarify how underlying conditions and disease management before and after dialysis initiation affect prognosis.
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Affiliation(s)
- Manabu Hishida
- Department of Nephrology, Anjo Kosei Hospital, Aichi, 28 Higashihirokute, Anjo-cho, Anjo, 446-8602, Japan
| | - Hirofumi Tamai
- Department of Nephrology, Anjo Kosei Hospital, Aichi, 28 Higashihirokute, Anjo-cho, Anjo, 446-8602, Japan.
| | - Takatoshi Morinaga
- Department of Nephrology, Anjo Kosei Hospital, Aichi, 28 Higashihirokute, Anjo-cho, Anjo, 446-8602, Japan
| | - Michitaka Maekawa
- Department of Nephrology, Anjo Kosei Hospital, Aichi, 28 Higashihirokute, Anjo-cho, Anjo, 446-8602, Japan
| | - Takafumi Aoki
- Department of Nephrology, Anjo Kosei Hospital, Aichi, 28 Higashihirokute, Anjo-cho, Anjo, 446-8602, Japan
| | - Hidetaka Tomida
- Department of Nephrology, Anjo Kosei Hospital, Aichi, 28 Higashihirokute, Anjo-cho, Anjo, 446-8602, Japan
| | - Shintaro Komatsu
- Department of Nephrology, Anjo Kosei Hospital, Aichi, 28 Higashihirokute, Anjo-cho, Anjo, 446-8602, Japan
| | - Tomoaki Kamiya
- Department of Nephrology, Anjo Kosei Hospital, Aichi, 28 Higashihirokute, Anjo-cho, Anjo, 446-8602, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Seiichi Matsuo
- Department of Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Daijo Inaguma
- Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
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Butler CR, O'Hare AM. Considerations in Applying the Results of Randomized Controlled Clinical Trials to the Care of Older Adults With Kidney Disease in the Clinical Setting: The SHARP Trial. Adv Chronic Kidney Dis 2016; 23:29-35. [PMID: 26709060 DOI: 10.1053/j.ackd.2015.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The Study of Heart and Renal Protection (SHARP) found that treatment with ezetemibe and low-dose simvastatin reduced the incidence of major atherosclerotic events in patients with kidney disease. Due to the paucity of evidence-based interventions that lower cardiovascular morbidity in this high-risk population, the SHARP trial will likely have a large impact on clinical practice. However, applying the results of clinical trials conducted in select populations to the care of individual patients in real-world settings can be fraught with difficulty. This is especially true when caring for older adults with complex comorbidity and limited life expectancy. These patients are often excluded from clinical trials, frequently have competing health priorities, and may be less likely to benefit and more likely to be harmed by medications. We discuss key considerations in applying the results of the SHARP trial to the care of older adults with CKD in real-world clinical settings using guiding principles set forth by the American Geriatrics Society's Expert Panel on the Care of Older Adults with Multimorbidity. Using this schema, we emphasize the importance of evaluating trial results in the unique context of each patient's goals, values, priorities, and circumstances.
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25
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Fung E, Kurella Tamura M. Epidemiology and Public Health Concerns of CKD in Older Adults. Adv Chronic Kidney Dis 2016; 23:8-11. [PMID: 26709057 PMCID: PMC4693627 DOI: 10.1053/j.ackd.2015.10.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 10/13/2015] [Accepted: 10/14/2015] [Indexed: 01/29/2023]
Abstract
CKD is increasingly common in older adults. Estimating the glomerular filtration rate can be challenging in this population, with sarcopenia affecting the accuracy of various formulae. Competing risks of death influence the risk of progression to end-stage kidney disease. In managing CKD in this population, one must take into consideration other comorbidities including assessment of geriatric syndromes. More research is still needed to guide medical management in this heterogeneous population.
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Affiliation(s)
- Enrica Fung
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; and VA Palo Alto Geriatric Research and Education Clinical Center, Palo Alto, CA
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; and VA Palo Alto Geriatric Research and Education Clinical Center, Palo Alto, CA.
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26
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Arora P, Golzy M, Patel N, Quigg R, Carter RL, Lohr JW. Renin-Angiotensin-Aldosterone System Blockers in Elderly Adults with Chronic Kidney Disease without Diabetes Mellitus or Proteinuria. J Am Geriatr Soc 2015; 63:2478-2484. [DOI: 10.1111/jgs.13842] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Pradeep Arora
- Department of Medicine; University at Buffalo; Buffalo New York
- Department of Biostatistics; University at Buffalo; Buffalo New York
| | - Mojgan Golzy
- Division of Nephrology; Veterans Affairs Medical Center; Buffalo New York
| | - Nilang Patel
- Department of Medicine; Virginia Commonwealth University; Richmond Virginia
- Division of Nephrology; Veterans Affairs Medical Center; Richmond Virginia
| | - Richard Quigg
- Department of Medicine; University at Buffalo; Buffalo New York
| | - Randolph L. Carter
- Division of Nephrology; Veterans Affairs Medical Center; Buffalo New York
| | - James W. Lohr
- Department of Medicine; University at Buffalo; Buffalo New York
- Department of Biostatistics; University at Buffalo; Buffalo New York
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Arora P, Elkin PL, Eberle J, Bono JJ, Argauer L, Murray BM, Ram R, Venuto RC. An observational study of the quality of care for chronic kidney disease: a Buffalo and Albany, New York metropolitan area study. BMC Nephrol 2015; 16:199. [PMID: 26634443 PMCID: PMC4669622 DOI: 10.1186/s12882-015-0194-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/24/2015] [Indexed: 11/30/2022] Open
Abstract
Background The database of a major regional health insurer was employed to identify the number and frequency of covered patients with chronic kidney disease (CKD). We then examined the characteristics of their care as defined, in part, by the frequency of physician visits and specialty referral, the characteristics of laboratory testing and total costs as indices of the quality of care of the subject population. Methods This retrospective, cross-sectional study analyzed insurance claims, laboratory results and medication prescription data. Patients with two estimated glomerular filtration rate readings below 60 ml/min/1.73 m2 (n = 20,388) were identified and classified by CKD stage. Results The prevalence of CKD stages 3a and above was 12 %. Vascular comorbidities were common with prevalence increasing steadily from stage 3a through stage 5. Only 55.6 % of stage 4 CKD patients had claims for nephrology visits within one year of their index date. Fifty-nine percent of patients had claims for renin-angiotensin system (RAS) blockers. Twenty-five percent of patients in stage 3a CKD filled a prescription for non-steroidal anti-inflammatory drugs. Fifty-two percent of patients who developed end-stage renal disease received their first dialysis treatment as inpatients. Conclusions The pattern of medical practice observed highlights apparent deficiencies in the care of CKD patients including inappropriate medication use, delayed nephrology referral, and a lack of preparation for dialysis. This study shows the potential value of using large patient databases available through insurers to assess and likely improve regional CKD care.
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Affiliation(s)
- Pradeep Arora
- State University of New York at Buffalo, School of Medicine and Biosciences, Buffalo, NY, 14215, USA.
| | - Peter L Elkin
- State University of New York at Buffalo, School of Medicine and Biosciences, Buffalo, NY, 14215, USA.
| | - Joseph Eberle
- Computer Task Group, Inc, 800 Delaware Avenue, Buffalo, NY, 14209, USA.
| | - J James Bono
- Computer Task Group, Inc, 800 Delaware Avenue, Buffalo, NY, 14209, USA.
| | - Laura Argauer
- Computer Task Group, Inc, 800 Delaware Avenue, Buffalo, NY, 14209, USA.
| | - Brian M Murray
- State University of New York at Buffalo, School of Medicine and Biosciences, Buffalo, NY, 14215, USA.
| | - Raghu Ram
- HealthNow New York, 257 West Genesee Street, Buffalo, NY, 14202, USA.
| | - Rocco C Venuto
- State University of New York at Buffalo, School of Medicine and Biosciences, Buffalo, NY, 14215, USA. .,Nephrology Department, 462 Grider Street, Buffalo, NY, 14215, USA.
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Singh S, Bajorek B. Pharmacotherapy in the ageing patient: The impact of age per se (A review). Ageing Res Rev 2015; 24:99-110. [PMID: 26226330 DOI: 10.1016/j.arr.2015.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/17/2015] [Indexed: 12/23/2022]
Abstract
A literature search was carried out to review the influence of 'ageing' on pharmacotherapeutic decision-making, specifically how 'age' is defined and considered in the utilisation of medication. Embase, Medline, International Pharmaceutical Abstracts, and Google scholar were canvassed in a three-tiered search according to pre-established inclusion criteria. In tier 1, a total of 22 studies were identified highlighting the underutilisation of medication in elderly patients, with a particular focus on warfarin. Four studies highlighted an age-bias in medication-prescribing for elderly patients, specifically in relation to medicines for rheumatoid arthritis, angina, and hypertension. Tier 2 identified diverse definitions for 'elderly', including biological age, chronological age, physiological age, as well as various descriptions of 'elderly' in clinical trials and guidelines. Finally, medication optimisation tools were identified through the third tier, emphasising the use of chronological age to describe the 'elderly'. Old age influences pharmacotherapeutic decision-making at various levels, however, what complicates the situation is the absence of a comprehensive definition of 'elderly'. Clinical recommendations need to be based more on objective factors known to affect medication effectiveness and safety.
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Montero RM, Covic A, Gnudi L, Goldsmith D. Diabetic nephropathy: What does the future hold? Int Urol Nephrol 2015; 48:99-113. [PMID: 26438328 PMCID: PMC4705119 DOI: 10.1007/s11255-015-1121-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 09/19/2015] [Indexed: 12/24/2022]
Abstract
The consensus management of diabetic nephropathy (DN) in 2015 involves good control of glycaemia, dyslipidaemia and blood pressure (BP). Blockade of the renin-angiotensin-aldosterone system using angiotensin-converting enzyme inhibitors, angiotensin-2 receptor blockers or mineralocorticoid inhibitors are key therapeutic approaches, shown to be beneficial once overt nephropathy is manifest, as either, or both, of albuminuria and loss of glomerular filtration rate. Some significant additional clinical benefits in slowing the progression of DN was reported from the Remission clinic experience, where simultaneous intensive control of BP, tight glycaemic control, weight loss, exercise and smoking cessation were prioritised in the management of DN. This has not proved possible to translate to more conventional clinical settings. This review briefly looks over the history and limitations of current therapy from landmark papers and expert reviews, and following an extensive PubMed search identifies the most promising clinical biomarkers (both established and proposed). Many challenges need to be addressed urgently as in order to obtain novel therapies in the clinic; we also need to examine what we mean by remission, stability and progression of DN in the modern era.
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Affiliation(s)
- R M Montero
- Renal, Dialysis and Transplantation Unit, Guy's and St Thomas' Hospital, London, UK.
| | - A Covic
- Hospital "C.I.Parhon" and University of Medicine "Grigore T Popa", Iasi, Romania
| | - L Gnudi
- Cardiovascular Division, Department of Diabetes and Endocrinology, Guy's and St Thomas' Hospital, School of Medicine and Life Science, King's College London, London, UK
| | - D Goldsmith
- Renal, Dialysis and Transplantation Unit, Guy's and St Thomas' Hospital, London, UK
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Weiss JW, Peters D, Yang X, Petrik A, Smith DH, Johnson ES, Thorp ML, Morris C, O'Hare AM. Systolic BP and Mortality in Older Adults with CKD. Clin J Am Soc Nephrol 2015; 10:1553-9. [PMID: 26276142 DOI: 10.2215/cjn.11391114] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 05/22/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Optimal BP targets for older adults with CKD are unclear. This study sought to determine whether a nonlinear relationship between BP and mortality-as described for the broader CKD population and for older adults in the general population-is present for older adults with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A cohort of 21,015 adults age 65-105 years with a moderate or severe reduction in eGFR (<60 ml/min per 1.73 m(2)) were identified within the Kaiser Permanente Northwest Health Maintenance Organization population. The relationship between baseline systolic BP (SBP; ≤120, 121-130, 131-140, 141-150, >150 mmHg; referent, 131-140 mmHg) and all-cause mortality across age groups (65-70, 71-80, and >80 years) was examined; patients were followed for up to 11 years after cohort entry. RESULTS The median times at risk were 3.15 years, 3.53 years, and 2.76 years for adults age 65-70, 71-80, and >80 years, respectively. Mortality during follow-up was 19.6% for those age 65-70 years, 33.4% for those age 71-80 years, and 55.7% for those age >80 years. The relationship between SBP and mortality varied as a function of age. The risk of death was highest for patients with the lowest SBP in all age groups. Only among adults age 65-70 years was an SBP>140 mmHg associated with a higher risk of death compared with the referent category. Patterns of age modification of the relationship between SBP and mortality were consistent in all sensitivity analyses. CONCLUSIONS In a cohort of older adults, the relationship between SBP and mortality varied systematically with age. A relationship between higher SBP and mortality was present only for younger members of this cohort and not for those older than 70. These results raise the question of whether the relative benefits and harms of lowering BP to recommended targets for older adults with CKD may vary as a function of age.
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Affiliation(s)
| | | | - Xiuhai Yang
- Science Program Department, Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon; and
| | - Amanda Petrik
- Science Program Department, Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon; and
| | - David H Smith
- Science Program Department, Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon; and
| | - Eric S Johnson
- Science Program Department, Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon; and
| | - Micah L Thorp
- Science Program Department, Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon; and
| | - Cynthia Morris
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
| | - Ann M O'Hare
- Division of Nephrology, University of Washington, Veterans Affairs Puget Sound Healthcare, Seattle, Washington
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Bedford M, Farmer CK, Irving J, Stevens PE. Acute kidney injury: an acceptable risk of treatment with renin-angiotensin system blockade in primary care? Can J Kidney Health Dis 2015; 2:14. [PMID: 25926996 PMCID: PMC4414427 DOI: 10.1186/s40697-015-0044-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 02/17/2015] [Indexed: 02/07/2023] Open
Abstract
Background Use of renin-angiotensin system (RAS) blockade has become increasingly widespread driven by evidence-based guidance. There is concern about the role of these agents in the genesis of avoidable acute kidney injury (AKI). Objectives To investigate the association between AKI and use of RAS blockade. Design Multilevel hierarchical analysis of a large cohort of patients registered with UK general practitioners. Setting Primary care practices in East and West Kent, United Kingdom. Patients 244,715 patients from 27 practices. Measurements Demographic, clinical, biochemical and prescription data. Methods Analyses of data acquired between 02/3/2004 and 17/04/2012 using multilevel logistic regression to determine the relationship between AKI and use of RAS blockade; further analysed by indication for treatment with RAS blockade. Results Sufficient serum creatinine data were available to define AKI in 63,735 patients with 208,275 blood test instances. In 95,569 instances the patient was prescribed a RAS antagonist of which 5.4% fulfilled criteria for AKI. The unadjusted odds ratio (OR) for AKI in those prescribed RAS blockade was 1.93 (1.81-2.06, 95%CI) falling to 1.11 (1.02-1.20, 95%CI) when adjusted for age, gender, co-morbidity, GFR category, proteinuria, systolic blood pressure and diuretic therapy. In patients with an evidence-based indication there was no difference in absolute risk of AKI. However, prescription of RAS blockade in the absence of indication appeared to be associated with greater risk of AKI. When analysis was repeated with AKIN2/AKIN3 as the outcome, although risk of AKI remained significant when unadjusted (OR 1.73, 95%CI 1.42-2.11, p<0.001), after full adjustment there was no increased risk (OR 0.83, 95%CI 0.63-1.09) in those taking RAS antagonists. However, when analysed by indication AKIN2/AKIN3 was significantly more likely in those prescribed RAS antagonists without indication (OR 2.04, 95%CI 1.41-2.94, p<0.001). Limitations Observational database study. No information concerning hospitalisation. Prescribing assumptions and potential inaccurate coding. Potential survival bias; patients surviving longer will contribute more data. Conclusions Use of RAS antagonists increased the risk of AKI, independent of common confounding variables. After correction for confounders the risk fell away and became non-significant for moderate and severe AKI. However, where there was no evidence-based indication for RAS antagonists the risk of AKI, whether mild, moderate or severe, remained greater.
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Affiliation(s)
- Michael Bedford
- Kent Kidney Research Group, East Kent Hospitals University NHS Foundation Trust, Kent and Canterbury Hospital, Ethelbert Road, CT1 3NG Canterbury, Kent
| | - Christopher Kt Farmer
- Kent Kidney Research Group, East Kent Hospitals University NHS Foundation Trust, Kent and Canterbury Hospital, Ethelbert Road, CT1 3NG Canterbury, Kent
| | - Jean Irving
- Kent Kidney Research Group, East Kent Hospitals University NHS Foundation Trust, Kent and Canterbury Hospital, Ethelbert Road, CT1 3NG Canterbury, Kent
| | - Paul E Stevens
- Kent Kidney Research Group, East Kent Hospitals University NHS Foundation Trust, Kent and Canterbury Hospital, Ethelbert Road, CT1 3NG Canterbury, Kent
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Tonelli M, Riella M. Chronic kidney disease and the ageing population. Intern Med J 2014; 44:213-7. [PMID: 24621282 DOI: 10.1111/imj.12367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 01/07/2014] [Indexed: 11/30/2022]
Affiliation(s)
- M Tonelli
- University of Alberta, Alberta, Canada
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Tonelli M, Riella M. Chronic kidney disease and the aging population. Nephrol Dial Transplant 2014; 29:221-4. [PMID: 24493860 DOI: 10.1093/ndt/gft519] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Tonelli M, Riella MC. World Kidney Day 2014: CKD and the aging population. Am J Kidney Dis 2014; 63:349-53. [PMID: 24560153 DOI: 10.1053/j.ajkd.2014.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 01/08/2014] [Indexed: 01/22/2023]
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Affiliation(s)
- M Tonelli
- University of Alberta, Alberta, Canada
| | - M Riella
- Catholic University of Parana, Curitiba, Brazil
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Tonelli M, Riella M. Chronic kidney disease and the aging population. Int J Organ Transplant Med 2014. [DOI: 10.1016/j.hkjn.2014.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Tonelli M, Riella M. Chronic kidney disease and the aging population. Nephrol Ther 2014; 10:74-7. [PMID: 24662271 DOI: 10.1016/j.nephro.2013.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 12/26/2013] [Indexed: 10/25/2022]
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Abstract
Chronic kidney disease (CKD) is increasingly being recognized as a disease of elderly individuals. In recent years the definition and categorization of kidney disease has been standardized. There are concerns that this standardization has led to an increase in the number of older individuals labeled as having CKD. This article addresses the definitions of CKD, recently published revised CKD stages with risk stratifications, and limitations of using formulas to assess renal function in the elderly. Also discussed are management of common risk factors of progression CKD, nonrenal-related outcomes, prognosis of CKD in older individuals, and criteria for referral to nephrology.
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Affiliation(s)
- Thin Thin Maw
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
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43
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Tonelli M, Riella M. Editorial: chronic kidney disease and the ageing population. Int J Older People Nurs 2014; 9:3-7. [PMID: 24588903 DOI: 10.1111/opn.12046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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O'Hare AM, Hotchkiss JR, Kurella Tamura M, Larson EB, Hemmelgarn BR, Batten A, Do TP, Covinsky KE. Interpreting treatment effects from clinical trials in the context of real-world risk information: end-stage renal disease prevention in older adults. JAMA Intern Med 2014; 174:391-7. [PMID: 24424348 PMCID: PMC4119007 DOI: 10.1001/jamainternmed.2013.13328] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Older adults are often excluded from clinical trials. The benefit of preventive interventions tested in younger trial populations may be reduced when applied to older adults in the clinical setting if they are less likely to survive long enough to experience those outcomes targeted by the intervention. OBJECTIVE To extrapolate a treatment effect similar to those reported in major randomized clinical trials of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for prevention of end-stage renal disease (ESRD) to a real-world population of older patients with chronic kidney disease. DESIGN, SETTING, AND PARTICIPANTS Simulation study in a retrospective cohort conducted in Department of Veterans Affairs medical centers. We included 371 470 patients 70 years or older with chronic kidney disease. EXPOSURE Level of estimated glomerular filtration rate (eGFR) and proteinuria. MAIN OUTCOMES AND MEASURES Among members of this cohort, we evaluated the expected effect of a 30% reduction in relative risk on the number needed to treat (NNT) to prevent 1 case of ESRD over a 3-year period. These limits were selected to mimic the treatment effect achieved in major trials of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for prevention of ESRD. These trials have reported relative risk reductions of 23% to 56% during observation periods of 2.6 to 3.4 years, yielding NNTs to prevent 1 case of ESRD of 9 to 25. RESULTS The NNT to prevent 1 case of ESRD among members of this cohort ranged from 16 in patients with the highest baseline risk (eGFR of 15-29 mL/min/1.73 m(2) with a dipstick proteinuria measurement of ≥ 2+) to 2500 for those with the lowest baseline risk (eGFR of 45-59 mL/min/1.73 m(2) with negative or trace proteinuria and eGFR of ≥ 60 mL/min/1.73 m2 with dipstick proteinuria measurement of 1+). Most patients belonged to groups with an NNT of more than 100, even when the exposure time was extended over 10 years and in all sensitivity analyses. CONCLUSIONS AND RELEVANCE Differences in baseline risk and life expectancy between trial subjects and real-world populations of older adults with CKD may reduce the marginal benefit to individual patients of interventions to prevent ESRD.
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Affiliation(s)
- Ann M O'Hare
- Department of Medicine, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington2Department of Medicine, University of Washington, Seattle3Group Health Research Institute, Seattle, Washington
| | - John R Hotchkiss
- Veterans Engineering Resource Center, Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennyslvania5Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Manjula Kurella Tamura
- Department of Medicine, Department of Veterans Affairs Palo Alto Healthcare System, Palo Alto, California7Department of Medicine, Stanford University Medical Center, Palo Alto, California
| | - Eric B Larson
- Department of Medicine, University of Washington, Seattle3Group Health Research Institute, Seattle, Washington
| | | | - Adam Batten
- Department of Medicine, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| | - Thy P Do
- Department of Medicine, Department of Veterans Affairs Puget Sound Healthcare System, Seattle, Washington9currently with Amgen, Thousand Oaks, California
| | - Kenneth E Covinsky
- Department of Medicine, Department of Veterans Affairs Medical Center, San Francisco, San Francisco, California11Department of Medicine, University of California, San Francisco
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Tonelli M, Riella M. Chronic Kidney Disease and the Aging Population. J Clin Hypertens (Greenwich) 2014. [DOI: 10.1111/jch.12292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tonelli M, Riella M. Chronic kidney disease and the aging population. Am J Physiol Renal Physiol 2014; 306:F469-72. [PMID: 24500692 DOI: 10.1152/ajprenal.00063.2014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Tonelli M, Riella M. Chronic kidney disease and the aging population. Nephrology (Carlton) 2014; 19:65-8. [PMID: 24428214 DOI: 10.1111/nep.12185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Renin–angiotensin–aldosterone system blockade in hypertensive patients with chronic kidney disease. Blood Press 2013. [DOI: 10.3109/08037051.2013.852376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Aggressive blood pressure reduction and renin-angiotensin system blockade in chronic kidney disease: time for re-evaluation? Kidney Int 2013; 85:536-46. [PMID: 24048382 DOI: 10.1038/ki.2013.355] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 05/26/2013] [Accepted: 06/05/2013] [Indexed: 12/19/2022]
Abstract
Over the past decades, aggressive control of blood pressure (BP) and blockade of the renin-angiotensin-aldosterone system (RAAS) were considered the cornerstones of treatment against progression of chronic kidney disease (CKD), following important background and clinical evidence on the associations of hypertension and RAAS activation with renal injury. To this end, previous recommendations included a BP target of <130/80 mm Hg for all individuals with CKD (and possibly <125/75 mm Hg for those with proteinuria >1 g/day), as well as use of angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers as first-line therapy for hypertension in all CKD patients. However, long-term extensions of relevant clinical trials support a low-BP goal only for patients with proteinuria, whereas recent cardiovascular trials questioned the benefits of low systolic BP for diabetic patients, leading to more individualized recommendations. Furthermore, our previous knowledge of the specific renoprotective properties of RAAS blockers in patients with proteinuric CKD is now extended with data on the use of these agents in patients with less advanced nephropathy and/or absence of proteinuria, deriving mostly from subanalyses of cardiovascular trials. This review discusses previous and recent clinical evidence on the issues of BP reduction and RAAS blockade by type and stage of renal damage, aiming to aid clinicians in their treatment decisions for patients with CKD.
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