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Murphy DP, Wolfson J, Reule S, Johansen KL, Ishani A, Drawz PE. Kidney Outcomes with Sodium-Glucose Cotransporter-2 Inhibitor Initiation after AKI among Veterans with Diabetic Kidney Disease. Kidney360 2024; 5:335-343. [PMID: 38287468 PMCID: PMC11000713 DOI: 10.34067/kid.0000000000000375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/22/2024] [Indexed: 01/31/2024]
Abstract
Key Points Post-AKI sodium–glucose cotransporter-2 inhibitor use was associated with a reduced risk for progression of CKD and for recurrent AKI among veterans with diabetic kidney disease even after accounting for recovery from the index AKI. A minority of Veterans with diabetic kidney disease received a sodium–glucose cotransporter-2 inhibitor after having had AKI during the study period. Background The effect of sodium–glucose cotransporter-2 inhibitor (SGLT2i) on kidney function after AKI is unknown. Methods The study population was drawn from a retrospective cohort of Veterans with diabetes mellitus type 2 (DM2) and proteinuria. The study exposure was time-varying use of SGLT2i after an index AKI hospitalization. The two study outcomes were time to (1 ) a sustained decrease in eGFR over at least 3 months to <60 ml/min per 1.73 m2 and ≥30% below a post-AKI–updated eGFR and (2 ) recurrent hospitalization with AKI. AKI was defined as a rise in serum creatinine concentration to ≥50% above a moving outpatient creatinine baseline. DM2 was defined by ≥2 billing codes related to DM2 before the index AKI; proteinuria was defined by the most recent albuminuria, proteinuria, or urinalysis test. Veterans were required to have a baseline eGFR and an eGFR 3–12 months after the index AKI hospitalization ≥30 ml/min per 1.73 m2. Results Ten thousand thirty-six Veterans met study inclusion criteria. Two thousand seven hundred and ninety-four (28%) received a SGLT2i. Seven hundred and seventy-five (8%) had CKD progression, and 1816 (18%) had recurrent AKI over a median follow-up of 1.8 and 1.7 years, respectively, which began 1 year after the index AKI hospitalization. SGLT2i use was associated with lower risk for CKD progression (adjusted hazard ratio 0.72 [95% confidence interval, 0.57 to 0.91]) and for recurrent AKI (adjusted hazard ratio 0.75 [95% confidence interval, 0.65 to 0.88]). Conclusions SGLT2i use was associated with a lower risk for CKD progression and for recurrent AKI among those with diabetic kidney disease and recent AKI.
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Affiliation(s)
- Daniel P. Murphy
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Julian Wolfson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Scott Reule
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
- Section of Nephrology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Areef Ishani
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
- Section of Nephrology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Paul E. Drawz
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
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Leatherman SM, Ishani A. Point of Care Clinical Trials in Nephrology. J Am Soc Nephrol 2024:00001751-990000000-00265. [PMID: 38419159 DOI: 10.1681/asn.0000000000000340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/26/2024] [Indexed: 03/02/2024] Open
Affiliation(s)
- Sarah M Leatherman
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Areef Ishani
- Minneapolis VA Healthcare System, Minneapolis, MN
- Department of Medicine, University of Minnesota, Minneapolis, MN
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Hau C, Woods PA, Guski AS, Raju SI, Zhu L, Alba PR, Cushman WC, Glassman PA, Ishani A, Taylor AA, Ferguson RE, Leatherman SM. Strategies for secondary use of real-world clinical and administrative data for outcome ascertainment in pragmatic clinical trials. J Biomed Inform 2024; 150:104587. [PMID: 38244956 DOI: 10.1016/j.jbi.2024.104587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/04/2023] [Accepted: 01/09/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Pragmatic trials are gaining popularity as a cost-effective way to examine treatment effectiveness and generate timely comparative evidence. Incorporating supplementary real-world data is recommended for robust outcome monitoring. However, detailed operational guidelines are needed to inform effective use and integration of heterogeneous databases. OBJECTIVE Lessons learned from the Veterans Affairs (VA) Diuretic Comparison Project (DCP) are reviewed, providing adaptable recommendations to capture clinical outcomes from real-world data. METHODS Non-cancer deaths and major cardiovascular (CV) outcomes were determined using VA, Medicare, and National Death Index (NDI) data. Multiple ascertainment strategies were applied, including claims-based algorithms, natural language processing, and systematic chart review. RESULTS During a mean follow-up of 2.4 (SD = 1.4) years, 907 CV events were identified within the VA healthcare system. Slight delays (∼1 year) were expected in obtaining Medicare data. An additional 298 patients were found having a CV event outside of the VA in 2016 - 2021, increasing the CV event rate from 3.5 % to 5.7 % (770 of 13,523 randomized). NDI data required ∼2 years waiting period. Such inclusion did not increase the number of deaths identified (all 894 deaths were captured by VA data) but enhanced the accuracy in determining cause of death. CONCLUSION Our experience supports the recommendation of integrating multiple data sources to improve clinical outcome ascertainment. While this approach is promising, hierarchical data aggregation is required when facing different acquisition timelines, information availability/completeness, coding practice, and system configurations. It may not be feasible to implement comparable applications and solutions to studies conducted under different constraints and practice. The recommendations provide guidance and possible action plans for researchers who are interested in applying cross-source data to ascertain all study outcomes.
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Affiliation(s)
- Cynthia Hau
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States.
| | - Patricia A Woods
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States
| | - Amanda S Guski
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States
| | - Srihari I Raju
- Minneapolis VA Healthcare System, Minneapolis, MN, United States
| | - Liang Zhu
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States
| | - Patrick R Alba
- VA Informatics and Computing Infrastructure, Salt Lake City VA Healthcare System, Salt Lake City, CT, United States; Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - William C Cushman
- Medical Service, Memphis VA Medical Center, Memphis, TN, United States; Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Peter A Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington DC, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Areef Ishani
- Minneapolis VA Healthcare System, Minneapolis, MN, United States; Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Addison A Taylor
- Michael E. DeBakey VA Medical Center, Houston, TX, United States; Baylor College of Medicine, Department of Medicine, Houston, TX, United States
| | - Ryan E Ferguson
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States; Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Sarah M Leatherman
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States; Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
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Pestka DL, Murphy D, Huynh P, Rechtzigel JA, Kjos S, Ellich LM, Kaplan AN, Taylor BC, Atwood M, Polsfuss BA, Lee JY, Ishani A. Pharmacist-driven outreach initiative to increase prescribing of sodium-glucose cotransporter-2 inhibitors in eligible VHA patients with chronic kidney disease: a study protocol. BMC Nephrol 2024; 25:14. [PMID: 38182983 PMCID: PMC10770983 DOI: 10.1186/s12882-023-03446-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/20/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) are at increased risk for multiple adverse events, several of which have been proven to be less likely with the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i). As a result, guidelines now recommend SGLT2i be given to those with mild to moderate CKD and type 2 diabetes. The objective of this study is to evaluate if a pharmacist-driven SGLT2i prescribing initiative among eligible patients with CKD and diabetes within the VA could more rapidly improve the adoption of SGLT2i via a pragmatic approach aligned with learning health systems. METHODS Eligible patients will be identified through an established VA diabetes dashboard. Veterans with an odd social security number (SSN), which is effectively a random number, will be the intervention group. Those with even SSNs will serve as the control while awaiting a second iteration of the same interventional program. The intervention will be implemented in a rolling fashion across one Veterans Integrated Service Network. Our primary outcome is initiation of an SGLT2i. Secondary outcomes will include medication adherence and safety-related outcomes. DISCUSSION This project tests the impact of a pharmacist-driven medication outreach initiative as a strategy to accelerate initiation of SGLT2i. The results of this work will not only illustrate the effectiveness of this strategy for SGLT2is but may also have implications for increasing other guideline-concordant care. Furthermore, the utilization of SSNs to select Veterans for the first wave of this program has created a pseudo-randomized interventional trial supporting a pragmatic learning health system approach. TRIAL REGISTRATION ISRCTN12374636.
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Affiliation(s)
- Deborah L Pestka
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA.
| | - Daniel Murphy
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Pearl Huynh
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Jessica A Rechtzigel
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Shari Kjos
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Lisa Marie Ellich
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Adam N Kaplan
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Brent C Taylor
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Melissa Atwood
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Beth A Polsfuss
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Joseph Y Lee
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Areef Ishani
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA
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Drawz PE, Lenoir KM, Rai NK, Rastogi A, Chu CD, Rahbari-Oskoui FF, Whelton PK, Thomas G, McWilliams A, Agarwal AK, Suarez MM, Dobre M, Powell J, Rocco MV, Lash JP, Oparil S, Raj DS, Dwyer JP, Rahman M, Soman S, Townsend RR, Pemu P, Horwitz E, Ix JH, Tuot DS, Ishani A, Pajewski NM. Effect of Intensive Blood Pressure Control on Kidney Outcomes: Long-Term Electronic Health Record-Based Post-Trial Follow-Up of SPRINT. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00273. [PMID: 37883184 PMCID: PMC10861101 DOI: 10.2215/cjn.0000000000000335] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 10/19/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Intensive BP lowering in the Systolic Blood Pressure Intervention Trial (SPRINT) produced acute decreases in kidney function and higher risk for AKI. We evaluated the effect of intensive BP lowering on long-term changes in kidney function using trial and outpatient electronic health record (EHR) creatinine values. METHODS SPRINT data were linked with EHR data from 49 (of 102) study sites. The primary outcome was the total slope of decline in eGFR for the intervention phase and the post-trial slope of decline during the observation phase using trial and outpatient EHR values. Secondary outcomes included a ≥30% decline in eGFR to <60 ml/min per 1.73 m 2 and a ≥50% decline in eGFR or kidney failure among participants with baseline eGFR ≥60 and <60 ml/min per 1.73 m 2 , respectively. RESULTS EHR creatinine values were available for a median of 8.3 years for 3041 participants. The total slope of decline in eGFR during the intervention phase was -0.67 ml/min per 1.73 m 2 per year (95% confidence interval [CI], -0.79 to -0.56) in the standard treatment group and -0.96 ml/min per 1.73 m 2 per year (95% CI, -1.08 to -0.85) in the intensive treatment group ( P < 0.001). The slopes were not significantly different during the observation phase: -1.02 ml/min per 1.73 m 2 per year (95% CI, -1.24 to -0.81) in the standard group and -0.85 ml/min per 1.73 m 2 per year (95% CI, -1.07 to -0.64) in the intensive group. Among participants without CKD at baseline, intensive treatment was associated with higher risk of a ≥30% decline in eGFR during the intervention (hazard ratio, 3.27; 95% CI, 2.43 to 4.40), but not during the postintervention observation phase. In those with CKD at baseline, intensive treatment was associated with a higher hazard of eGFR decline only during the intervention phase (hazard ratio, 1.95; 95% CI, 1.03 to 3.70). CONCLUSIONS Intensive BP lowering was associated with a steeper total slope of decline in eGFR and higher risk for kidney events during the intervention phase of the trial, but not during the postintervention observation phase.
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Affiliation(s)
- Paul E. Drawz
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota
| | - Kristin M. Lenoir
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Nayanjot Kaur Rai
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota
| | - Anjay Rastogi
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Chi D. Chu
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | | | - Paul K. Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - George Thomas
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Andrew McWilliams
- Department of Internal Medicine, Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina
| | - Anil K. Agarwal
- Department of Medicine, Veterans Affairs Central California Health Care System, Fresno, California
| | - Maritza Marie Suarez
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Mirela Dobre
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - James Powell
- Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Michael V. Rocco
- Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - James P. Lash
- Division of Nephrology, University of Illinois at Chicago, Chicago, Illinois
| | - Suzanne Oparil
- Division of Cardiovascular Disease, University of Alabama-Birmingham, Birmingham, Alabama
| | - Dominic S. Raj
- Division of Kidney Diseases and Hypertension, George Washington University, Washington, DC
| | - Jamie P. Dwyer
- Division of Nephrology and Hypertension, University of Utah Health, Salt Lake City, Utah
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Sandeep Soman
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan
| | - Raymond R. Townsend
- Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Edward Horwitz
- Division of Nephrology & Hypertension, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Joachim H. Ix
- Division of Nephrology-Hypertension, University of California San Diego, Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Delphine S. Tuot
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Areef Ishani
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota
- Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Nicholas M. Pajewski
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Murphy DP, Wolfson J, Reule S, Johansen KL, Ishani A, Drawz PE. Renin-Angiotensin-Aldosterone System Blockade after AKI with or without Recovery among US Veterans with Diabetic Kidney Disease. J Am Soc Nephrol 2023; 34:1721-1732. [PMID: 37545022 PMCID: PMC10561814 DOI: 10.1681/asn.0000000000000196] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/07/2023] [Indexed: 08/08/2023] Open
Abstract
SIGNIFICANCE STATEMENT Among patients with CKD, optimal use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers after AKI is uncertain. Despite these medications' ability to reduce risk of mortality and other adverse outcomes, there is concern that ACEi/ARB use may delay recovery of kidney function or precipitate recurrent AKI. Prior studies have provided conflicting data regarding the optimal timing of these medications after AKI and have not addressed the role of kidney recovery in determining appropriate timing. This study in US Veterans with diabetes mellitus and proteinuria demonstrated an association between ACEi/ARB use and lower mortality. This association was more pronounced with earlier post-AKI ACEi/ARB use and was not meaningfully affected by initiating ACEis/ARBs before versus after recovery from AKI. BACKGROUND Optimal use of angiotensin-converting enzyme inhibitors (ACEis) or angiotensin II receptor blockers (ARBs) after AKI is uncertain. METHODS Using data derived from electronic medical records, we sought to estimate the association between ACEi/ARB use after AKI and mortality in US military Veterans with indications for such treatment (diabetes and proteinuria) while accounting for AKI recovery. We used ACEi/ARB treatment after hospitalization with AKI (defined as serum creatinine ≥50% above baseline concentration) as a time-varying exposure in Cox models. The outcome was all-cause mortality. Recovery was defined as return to ≤110% of baseline creatinine. A secondary analysis focused on ACEi/ARB use relative to AKI recovery (before versus after). RESULTS Among 54,735 Veterans with AKI, 31,146 deaths occurred over a median follow-up period of 2.3 years. Approximately 57% received an ACEi/ARB <3 months after hospitalization. In multivariate analysis with time-varying recovery, post-AKI ACEi/ARB use was associated with lower risk of mortality (adjusted hazard ratio [aHR], 0.74; 95% confidence interval [CI], 0.72 to 0.77). The association between ACEi/ARB use and mortality varied over time, with lower mortality risk associated with earlier initiation ( P for interaction with time <0.001). In secondary analysis, compared with those with neither recovery nor ACEi/ARB use, risk of mortality was lower in those with recovery without ACEi/ARB use (aHR, 0.90; 95% CI, 0.87 to 0.94), those without recovery with ACEi/ARB use (aHR, 0.69; 95% CI, 0.66 to 0.72), and those with ACEi/ARB use after recovery (aHR, 0.70; 95% CI, 0.67 to 0.73). CONCLUSIONS This study demonstrated lower mortality associated with ACEi/ARB use in Veterans with diabetes, proteinuria, and AKI, regardless of recovery. Results favored earlier ACEi/ARB initiation.
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Affiliation(s)
- Daniel P. Murphy
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Julian Wolfson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Scott Reule
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
- Section of Nephrology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Kirsten L. Johansen
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Areef Ishani
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
- Section of Nephrology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Paul E. Drawz
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
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Hau C, Efird JT, Leatherman SM, Soloviev OV, Glassman PA, Woods PA, Ishani A, Cushman WC, Ferguson RE. A Centralized EHR-Based Model for the Recruitment of Rural and Lower Socioeconomic Participants in Pragmatic Trials: A Secondary Analysis of the Diuretic Comparison Project. JAMA Netw Open 2023; 6:e2332049. [PMID: 37656456 PMCID: PMC10474559 DOI: 10.1001/jamanetworkopen.2023.32049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/18/2023] [Indexed: 09/02/2023] Open
Abstract
Importance Participant diversity is important for reducing study bias and increasing generalizability of comparative effectiveness research. Objective Demonstrate the operational efficiency of a centralized electronic health record (EHR)-based model for recruiting difficult-to-reach participants in a pragmatic trial. Design, Setting, and Participants This comparative effectiveness study was a secondary analysis of Diuretic Comparison Project, a randomized clinical trial conducted between 2016 and 2022 (mean [SD] follow-up, 2.4 [1.4] years) comparing 2 commonly prescribed antihypertensives, which used an EHR-based recruitment model. Electronic study workflows, in tandem with routine clinical practice, were adapted by 72 Veteran Affairs (VA) primary care networks. Data were analyzed from August to December 2022. Main Outcomes and Measures Measures reflecting recruitment capacity (monthly rate), operational efficiency (median time for completion of electronic procedures), and geographic reach (percentage of patients recruited from rural areas) were examined. Results A total of 13 523 patients with hypertension (mean [SD] age, 72 [5.4] years; 13 092 male [96.8%]) were recruited from 537 outpatient clinics. Approximately 205 patients were randomized per month and a median of 35 days (Q1-Q3, 23-80 days) was needed to complete electronic recruitment. The annual income was below the national median for 69% of the cohort. Patients from all 50 states, Puerto Rico, and the District of Columbia were included and 45% resided in rural areas. Conclusions and Relevance In this secondary analysis of a multicenter pragmatic trial, a centralized EHR-based recruitment model was associated with improved participation from underrepresented groups. These participants often are difficult to reach, with their exclusion potentially biasing trial results; eliminating in-person study visits and local site involvement can minimize barriers for the recruitment of patients from rural and lower socioeconomic areas. Trial Registration The Diuretic Comparison Project (DCP) was registered on ClinicalTrials.gov Identifier: NCT02185417.
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Affiliation(s)
- Cynthia Hau
- VA Cooperative Studies Program Coordinating Center, Boston, Massachusetts
| | - Jimmy T. Efird
- VA Cooperative Studies Program Coordinating Center, Boston, Massachusetts
- Department of Radiation Oncology, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Sarah M. Leatherman
- VA Cooperative Studies Program Coordinating Center, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Oleg V. Soloviev
- VA Cooperative Studies Program Coordinating Center, Boston, Massachusetts
| | - Peter A. Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington DC
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Patricia A. Woods
- VA Cooperative Studies Program Coordinating Center, Boston, Massachusetts
| | - Areef Ishani
- Minneapolis VA Healthcare System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis
| | - William C. Cushman
- Medical Service, Memphis VA Medical Center, Memphis, Tennessee
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
| | - Ryan E. Ferguson
- VA Cooperative Studies Program Coordinating Center, Boston, Massachusetts
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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8
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Ferguson RE, Leatherman SM, Woods P, Hau C, Lew R, Cushman WC, Brophy MT, Fiore L, Ishani A. Practical issues in pragmatic trials: the implementation of the Diuretic Comparison Project. Clin Trials 2023; 20:276-283. [PMID: 36992530 DOI: 10.1177/17407745231160553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
BACKGROUND/AIMS The US Department of Veterans Affairs Point of Care Clinical Trial Program conducts studies that utilize informatics infrastructure to integrate clinical trial protocols into routine care delivery. The Diuretic Comparison Project compared hydrochlorothiazide to chlorthalidone in reduction of major cardiovascular events in subjects with hypertension. Here we describe the cultural, technical, regulatory, and logistical challenges and solutions that enabled successful implementation of this large pragmatic comparative effectiveness Point of Care clinical trial. METHODS Patients were recruited from 72 Veterans Affairs Healthcare Systems using centralized processes for subject identification, obtaining informed consent, data collection, safety monitoring, site communication, and endpoint identification with minimal perturbation of the local clinical care ecosystem. Patients continued to be managed exclusively by their clinical care providers without protocol specified study visits, treatment recommendations, or data collection extraneous to routine care. Centralized study processes were operationalized through the application layer of the electronic health record via a data coordinating center staffed by clinical nurses, data scientists, and statisticians without site-based research coordinators. Study data was collected from the Veterans Affairs electronic health record supplemented by Medicare and National Death Index data. RESULTS The study exceeded its enrolled goal (13,523 subjects) and followed subjects for the 5-year study duration. The key determinant of program success was collaboration between researchers, regulators, clinicians, and administrative staff at the site level to customize study procedures to align with local clinical practice. This flexibility was enabled by designation of the study as minimal risk and determination that clinical care providers were not engaged in research by the Veterans Affairs Central Institutional Review Board. Cultural, regulatory, technical, and logistical problems were identified and solved through iterative collaboration between clinical and research entities. Paramount among these problems was customization of the Veterans Affairs electronic health record and data systems to accommodate study procedures. CONCLUSIONS Leveraging clinical care for large-scale clinical trials is feasible but requires a rethinking of traditional clinical trial design (and regulation) to better meet requirements of clinical care ecosystems. Study designs must accommodate site-specific practice variation to reduce the impact on clinical care. A tradeoff thus exists between designing trial processes tailored to expedite local study implementation versus those to produce a more refined response to the research question. The availability of a uniform and flexible electronic health record in the Department of Veterans Affairs played a major role in the success of the trial. Conducting Point of Care research in other healthcare systems without such research-friendly infrastructure presents a more formidable challenge.
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Affiliation(s)
- Ryan E Ferguson
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sarah M Leatherman
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Patricia Woods
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
| | - Cynthia Hau
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
| | - Robert Lew
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - William C Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mary T Brophy
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Louis Fiore
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
| | - Areef Ishani
- Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Klint A, Leatherman SM, Taylor O, Glassman PA, Ferguson RE, Cushman WC, Ishani A. Telephone informed consent in a pragmatic point-of-care clinical trial embedded in primary care. Contemp Clin Trials 2023:107239. [PMID: 37244366 DOI: 10.1016/j.cct.2023.107239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND One benefit of pragmatic clinical trials is reduction of the burden on patients and clinical staff while facilitating a learning healthcare system. One way to decrease the work of clinical staff is through decentralized telephone consent. METHODS The Diuretic Comparison Project (DCP) was a nationwide Point of Care pragmatic clinical trial conducted by the VA Cooperative Studies Program. The purpose of the trial was to compare the clinical effectiveness on major CV outcomes of two commonly used diuretics, hydrochlorothiazide and chlorthalidone, in an elderly patient population. Telephone consent was allowed for this study because of its minimal risk designation. Telephone consent was more difficult than initially anticipated and the study team constantly adjusted methods to find timely solutions. RESULTS The major challenges can be categorized as call center-related, telecommunications, operational, and study population based. In particular, the possible technical and operational pitfalls are rarely discussed. By presenting hurdles here, future studies may avoid these challenges and start studies with a more effective system in place. CONCLUSIONS DCP is a novel study designed to answer an important clinical question. The lessons learned from implementing a centralized call center for the Diuretic Comparison Project helped the study reach enrollment goals and develop a centralized telephone consent system that can be utilized for future pragmatic and explanatory clinical trials. CLINICAL TRIAL REGISTRATION The study is registered on ClinicalTrials.gov; NCT02185417 [https://clinicaltrials.gov/ct2/show/NCT02185417]. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.
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Affiliation(s)
- Alison Klint
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America.
| | - Sarah M Leatherman
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America; Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States of America
| | - Olivia Taylor
- Minneapolis VA Healthcare System, Minneapolis, MN, United States of America
| | - Peter A Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington, DC, United States of America; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Ryan E Ferguson
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America; Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
| | - William C Cushman
- Medical Service, Memphis VA Medical Center, Memphis, TN, United States of America; Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, United States of America
| | - Areef Ishani
- Minneapolis VA Healthcare System, Minneapolis, MN, United States of America; Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
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Raju S, Hau C, Woods P, Flynn M, Sadatis C, McPherson J, Tella A, Ishani A, Ferguson RE, Leatherman SM. Ascertainment of stroke from administrative data to support a pragmatic embedded clinical trial. Contemp Clin Trials 2023; 130:107214. [PMID: 37137378 DOI: 10.1016/j.cct.2023.107214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/19/2023] [Accepted: 04/29/2023] [Indexed: 05/05/2023]
Abstract
The goal of this observational study was to identify stroke hospitalizations using International Classification of Disease (ICD)-10 codes and use these codes to develop an ascertainment algorithm for use in pragmatic clinical trials, reducing or eliminating the need for manual chart adjudication in future. Using VA (Veterans Affairs) electronic medical records, 9959 patient charts with ICD-10 codes indicating stroke were screened and a sample of 304 were adjudicated by three clinical reviewers. Hospitalizations were categorized as stroke or non-stroke and positive predictive value (PPV) was calculated for each ICD-10 code that was sampled. The adjudicated codes were categorized for use in a decision tool for identifying stroke in a clinical trial. Of the 304 hospitalizations adjudicated, 192 met the definition of stroke. Of the ICD-10 codes evaluated, I61 yielded the highest PPV (100%) while I63.x yielded the 2nd highest PPV (90%) with a false discovery rate of 10%. A relatively high PPV of ≥80% was associated with codes I60.1-0.7, I61, I62.9 and I63, which accounted for nearly half of all cases reviewed. Hospitalizations associated with these codes were categorized at positive stroke cases. The incorporation of large administrative datasets, and elimination of trial specific data collection, increases efficiencies, while reducing costs. Accurate algorithms must be developed to allow for identification of clinical endpoints from administrative databases to offer a reliable alternative to study-specific case report form completion. This study demonstrates an example of how to apply medical record data to a decision tool for clinical trial outcomes. CSP597 or clinicaltrials.gov NCT02185417.
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Affiliation(s)
- Srihari Raju
- Minneapolis VA Healthcare System, Minneapolis, MN, United States of America.
| | - Cynthia Hau
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Patricia Woods
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Maura Flynn
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Christal Sadatis
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Jacob McPherson
- Minneapolis VA Healthcare System, Minneapolis, MN, United States of America
| | - Abhinav Tella
- Minneapolis VA Healthcare System, Minneapolis, MN, United States of America
| | - Areef Ishani
- Minneapolis VA Healthcare System, Minneapolis, MN, United States of America; Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Ryan E Ferguson
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America; Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
| | - Sarah M Leatherman
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America; Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States of America
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Chu CD, Lenoir KM, Rai NK, Soman S, Dwyer JP, Rocco MV, Agarwal AK, Beddhu S, Powell JR, Suarez MM, Lash JP, McWilliams A, Whelton PK, Drawz PE, Pajewski NM, Ishani A, Tuot DS. Concordance between clinical outcomes in the Systolic Blood Pressure Intervention Trial and in the electronic health record. Contemp Clin Trials 2023; 128:107172. [PMID: 37004812 PMCID: PMC10547257 DOI: 10.1016/j.cct.2023.107172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Randomized trials are the gold standard for generating clinical practice evidence, but follow-up and outcome ascertainment are resource-intensive. Electronic health record (EHR) data from routine care can be a cost-effective means of follow-up, but concordance with trial-ascertained outcomes is less well-studied. METHODS We linked EHR and trial data for participants of the Systolic Blood Pressure Intervention Trial (SPRINT), a randomized trial comparing intensive and standard blood pressure targets. Among participants with available EHR data concurrent to trial-ascertained outcomes, we calculated sensitivity, specificity, positive predictive value, and negative predictive value for EHR-recorded cardiovascular disease (CVD) events, using the gold standard of SPRINT-adjudicated outcomes (myocardial infarction (MI)/acute coronary syndrome (ACS), heart failure, stroke, and composite CVD events). We additionally compared the incidence of non-CVD adverse events (hyponatremia, hypernatremia, hypokalemia, hyperkalemia, bradycardia, and hypotension) in trial versus EHR data. RESULTS 2468 SPRINT participants were included (mean age 68 (SD 9) years; 26% female). EHR data demonstrated ≥80% sensitivity and specificity, and ≥ 99% negative predictive value for MI/ACS, heart failure, stroke, and composite CVD events. Positive predictive value ranged from 26% (95% CI; 16%, 38%) for heart failure to 52% (95% CI; 37%, 67%) for MI/ACS. EHR data uniformly identified more non-CVD adverse events and higher incidence rates compared with trial ascertainment. CONCLUSIONS These results support a role for EHR data collection in clinical trials, particularly for capturing laboratory-based adverse events. EHR data may be an efficient source for CVD outcome ascertainment, though there is clear benefit from adjudication to avoid false positives.
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Affiliation(s)
- Chi D Chu
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America.
| | - Kristin M Lenoir
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States of America
| | - Nayanjot Kaur Rai
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, United States of America
| | - Sandeep Soman
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, United States of America
| | - Jamie P Dwyer
- Division of Nephrology & Hypertension, University of Utah Health, Salt Lake City, UT, United States of America
| | - Michael V Rocco
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Anil K Agarwal
- Department of Medicine, Veterans Affairs Central California Health Care System, Fresno, CA, United States of America
| | - Srinivasan Beddhu
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - James R Powell
- Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, United States of America
| | - Maritza M Suarez
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - James P Lash
- Division of Nephrology, University of Illinois at Chicago, Chicago, IL, United States of America
| | - Andrew McWilliams
- Department of Internal Medicine, Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, United States of America
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, United States of America
| | - Paul E Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, United States of America
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States of America
| | - Areef Ishani
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, United States of America
| | - Delphine S Tuot
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
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12
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Leatherman SM, Hau C, Klint A, Glassman PA, Taylor AA, Ferguson RE, Cushman WC, Ishani A. The impact of COVID-19 on a large pragmatic clinical trial embedded in primary care. Contemp Clin Trials 2023; 129:107179. [PMID: 37031794 PMCID: PMC10080857 DOI: 10.1016/j.cct.2023.107179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/28/2023] [Accepted: 04/06/2023] [Indexed: 04/11/2023]
Abstract
INTRODUCTION The COVID-19 pandemic had significant impact on clinical care and clinical trial operations, but the impact on decentralized pragmatic trials is unclear. The Diuretic Comparison Project (DCP) is a Point-of Care (POC) pragmatic trial testing whether chlorthalidone is superior to hydrochlorothiazide in preventing major cardiovascular (CV) events and non-cancer death. DCP utilized telephone consent, data collection from the electronic health record and Medicare, forwent study visits, and limited provider commitment beyond usual care. We assessed the impact of COVID-19 on recruitment, follow-up, data collection, and outcome ascertainment in DCP. METHODS We compared data from two 8-month periods: Pre-Pandemic (July 2019-February 2020) and Mid-Pandemic (July 2020-February 2021). Consent and randomization rates, diuretic adherence, blood pressure (BP) and electrolyte follow-up rates, records of CV events, hospitalization, and death rates were compared. RESULTS Providers participated at a lower rate mid-pandemic (65%) than pre-pandemic (71%), but more patients were contacted (7622 vs. 5363) and consented (3718 vs. 3048) mid-pandemic than pre-pandemic. Patients refilled medications and remained on their randomized diuretic equally (90%) in both periods. Overall, rates of BP, electrolyte measurements, and hospitalizations decreased mid-pandemic while deaths increased. CONCLUSIONS While recruitment, enrollment, and adherence did not suffer during the pandemic, documented blood pressure checks and laboratory evaluations decreased, likely due to fewer in-person visits. VA hospitalizations decreased, despite a considerable number of COVID-related hospitalizations. This suggests changes in clinical care during the pandemic, but the limited impact on DCP's operations during a global pandemic is an important strength of POC trials. CLINICAL TRIAL REGISTRATION NCT02185417.
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Affiliation(s)
- Sarah M Leatherman
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America; Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States of America.
| | - Cynthia Hau
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Alison Klint
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Peter A Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington DC, United States of America; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Addison A Taylor
- Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Baylor College of Medicine, Department of Medicine, Houston, TX, United States of America
| | - Ryan E Ferguson
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America; Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
| | - William C Cushman
- Medical Service, Memphis VA Medical Center, Memphis, TN, United States of America; Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, United States of America
| | - Areef Ishani
- Minneapolis VA Healthcare System, Minneapolis, MN, United States of America; Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
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Johansen KL, Chertow GM, Gilbertson DT, Ishani A, Israni A, Ku E, Li S, Li S, Liu J, Obrador GT, Schulman I, Chan K, Abbott KC, O'Hare AM, Powe NR, Roetker NS, Scherer JS, St Peter W, Snyder J, Winkelmayer WC, Wong SPY, Wetmore JB. US Renal Data System 2022 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2023; 81:A8-A11. [PMID: 36822739 PMCID: PMC10807034 DOI: 10.1053/j.ajkd.2022.12.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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14
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Ishani A, Cushman WC, Leatherman SM, Lew RA, Woods P, Glassman PA, Taylor AA, Hau C, Klint A, Huang GD, Brophy MT, Fiore LD, Ferguson RE. Chlorthalidone vs. Hydrochlorothiazide for Hypertension-Cardiovascular Events. N Engl J Med 2022; 387:2401-2410. [PMID: 36516076 DOI: 10.1056/nejmoa2212270] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Whether chlorthalidone is superior to hydrochlorothiazide for preventing major adverse cardiovascular events in patients with hypertension is unclear. METHODS In a pragmatic trial, we randomly assigned adults 65 years of age or older who were patients in the Department of Veterans Affairs health system and had been receiving hydrochlorothiazide at a daily dose of 25 or 50 mg to continue therapy with hydrochlorothiazide or to switch to chlorthalidone at a daily dose of 12.5 or 25 mg. The primary outcome was a composite of nonfatal myocardial infarction, stroke, heart failure resulting in hospitalization, urgent coronary revascularization for unstable angina, and non-cancer-related death. Safety was also assessed. RESULTS A total of 13,523 patients underwent randomization. The mean age was 72 years. At baseline, hydrochlorothiazide at a dose of 25 mg per day had been prescribed in 12,781 patients (94.5%). The mean baseline systolic blood pressure in each group was 139 mm Hg. At a median follow-up of 2.4 years, there was little difference in the occurrence of primary-outcome events between the chlorthalidone group (702 patients [10.4%]) and the hydrochlorothiazide group (675 patients [10.0%]) (hazard ratio, 1.04; 95% confidence interval, 0.94 to 1.16; P = 0.45). There were no between-group differences in the occurrence of any of the components of the primary outcome. The incidence of hypokalemia was higher in the chlorthalidone group than in the hydrochlorothiazide group (6.0% vs. 4.4%, P<0.001). CONCLUSIONS In this large pragmatic trial of thiazide diuretics at doses commonly used in clinical practice, patients who received chlorthalidone did not have a lower occurrence of major cardiovascular outcome events or non-cancer-related deaths than patients who received hydrochlorothiazide. (Funded by the Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT02185417.).
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Affiliation(s)
- Areef Ishani
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - William C Cushman
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Sarah M Leatherman
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Robert A Lew
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Patricia Woods
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Peter A Glassman
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Addison A Taylor
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Cynthia Hau
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Alison Klint
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Grant D Huang
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Mary T Brophy
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Louis D Fiore
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
| | - Ryan E Ferguson
- From Minneapolis Veterans Affairs (VA) Health Care System, and the Department of Medicine, University of Minnesota - both in Minneapolis (A.I.); Medical Service, Memphis VA Medical Center, and the Department of Preventive Medicine, University of Tennessee Health Science Center - both in Memphis (W.C.C.); the Cooperative Studies Program Coordinating Center, VA Boston Healthcare System (S.M.L., R.A.L., P.W., C.H., A.K., M.T.B., L.D.F., R.E.F.), the Department of Biostatistics, Boston University School of Public Health (S.M.L., R.A.L.), and the Department of Medicine, Boston University School of Medicine (M.T.B., R.E.F.) - all in Boston; Pharmacy Benefits Management Services (P.A.G.) and the Office of Research and Development (G.D.H.), Department of Veterans Affairs, Washington, DC; VA Greater Los Angeles Healthcare System, and the David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (P.A.G.); and Michael E. DeBakey VA Medical Center, and the Department of Medicine, Baylor College of Medicine - both in Houston (A.A.T.)
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15
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Drawz PE, Rai NK, Lenoir KM, Suarez M, Powell JR, Raj DS, Beddhu S, Agarwal AK, Soman S, Whelton PK, Lash J, Rahbari-Oskoui FF, Dobre M, Parkulo MA, Rocco MV, McWilliams A, Dwyer JP, Thomas G, Rahman M, Oparil S, Horwitz E, Pajewski NM, Ishani A. Effect of Intensive versus Standard BP Control on AKI and Subsequent Cardiovascular Outcomes and Mortality: Findings from the SPRINT EHR Study. Kidney360 2022; 3:1253-1262. [PMID: 35919535 PMCID: PMC9337898 DOI: 10.34067/kid.0001572022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/18/2022] [Indexed: 01/11/2023]
Abstract
Background Adjudication of inpatient AKI in the Systolic Blood Pressure Intervention Trial (SPRINT) was based on billing codes and admission and discharge notes. The purpose of this study was to evaluate the effect of intensive versus standard BP control on creatinine-based inpatient and outpatient AKI, and whether AKI was associated with cardiovascular disease (CVD) and mortality. Methods We linked electronic health record (EHR) data from 47 clinic sites with trial data to enable creatinine-based adjudication of AKI. Cox regression was used to evaluate the effect of intensive BP control on the incidence of AKI, and the relationship between incident AKI and CVD and all-cause mortality. Results A total of 3644 participants had linked EHR data. A greater number of inpatient AKI events were identified using EHR data (187 on intensive versus 155 on standard treatment) as compared with serious adverse event (SAE) adjudication in the trial (95 on intensive versus 61 on standard treatment). Intensive treatment increased risk for SPRINT-adjudicated inpatient AKI (HR, 1.51; 95% CI, 1.09 to 2.08) and for creatinine-based outpatient AKI (HR, 1.40; 95% CI, 1.15 to 1.70), but not for creatinine-based inpatient AKI (HR, 1.20; 95% CI, 0.97 to 1.48). Irrespective of the definition (SAE or creatinine based), AKI was associated with increased risk for all-cause mortality, but only creatinine-based inpatient AKI was associated with increased risk for CVD. Conclusions Creatinine-based ascertainment of AKI, enabled by EHR data, may be more sensitive and less biased than traditional SAE adjudication. Identifying ways to prevent AKI may reduce mortality further in the setting of intensive BP control.
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Affiliation(s)
- Paul E. Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Nayanjot Kaur Rai
- Division of Renal Diseases and Hypertension, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Kristin Macfarlane Lenoir
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Maritza Suarez
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - James R. Powell
- Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Dominic S. Raj
- Division of Kidney Diseases and Hypertension, George Washington University, Washington, DC
| | - Srinivasan Beddhu
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah Health, Salt Lake City, Utah
| | - Anil K. Agarwal
- Department of Medicine, Veterans Affairs Central California Health Care System, Fresno, California
| | - Sandeep Soman
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan
| | - Paul K. Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - James Lash
- Division of Nephrology, University of Illinois at Chicago, Chicago, Illinois
| | | | - Mirela Dobre
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Mark A. Parkulo
- Department of Medicine, Division of Community Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Michael V. Rocco
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Andrew McWilliams
- Department of Internal Medicine and Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina
| | - Jamie P. Dwyer
- Division of Nephrology & Hypertension, University of Utah Health, Salt Lake City, Utah
| | - George Thomas
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mahboob Rahman
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
| | - Suzanne Oparil
- Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Edward Horwitz
- Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio
| | - Nicholas M. Pajewski
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Areef Ishani
- Division of Renal Diseases and Hypertension, University of Minnesota Medical School, Minneapolis, Minnesota,Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
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16
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Ishani A, Leatherman SM, Woods P, Hau C, Klint A, Lew RA, Taylor AA, Glassman PA, Brophy MT, Fiore LD, Ferguson RE, Cushman WC. Design of a pragmatic clinical trial embedded in the Electronic Health Record: The VA's Diuretic Comparison Project. Contemp Clin Trials 2022; 116:106754. [PMID: 35390512 DOI: 10.1016/j.cct.2022.106754] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Recent US guidelines recommend chlorthalidone over other thiazide-type diuretics for the treatment of hypertension based on its long half-life and proven ability to reduce CVD events. Despite recommendations most clinicians prescribe hydrochlorothiazide (HCTZ) over chlorthalidone (CTD). No randomized controlled data exist comparing these two diuretics on cardiovascular outcomes. METHODS The Diuretic Comparison Project (DCP) is a multicenter, two-arm, parallel, Prospective Randomized Open, Blinded End-point (PROBE) trial testing the primary hypothesis that CTD is superior to HCTZ in the prevention of non-fatal CVD events and non-cancer death. Patients with hypertension taking HCTZ 25 or 50 mg were randomly assigned to either continue their current HCTZ or switch to an equipotent dose of CTD. The primary outcome is time to the first occurrence of a composite outcome consisting of a non-fatal CVD event (stroke, myocardial infarction, urgent coronary revascularization because of unstable angina, or hospitalization for acute heart failure) or non-cancer death. The trial randomized 13,523 patients at 72 VA medical centers. The study is conducted by a centralized research team with site procedures embedded in the electronic health record and all data collected through administrative claims data, with no study related visits for participants. The trial will have 90% power to detect an absolute reduction in the composite event rate of 2.4%. RESULTS Enrollment ended in November 2021. There are 4128 participting primary care providers and 16,595 patients individually consented to participate, 13,523 of whom were randomized. CONCLUSIONS DCP should provide much needed evidence as to whether CTD is superior to HCTZ in preventing cardiovascular events in hypertensive patients. CLINICAL TRIAL REGISTRATION NCT02185417 [https://clinicaltrials.gov/ct2/show/NCT02185417].
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Affiliation(s)
- Areef Ishani
- Minneapolis VA Health Care System, Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Sarah M Leatherman
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America.
| | - Patricia Woods
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Cynthia Hau
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Alison Klint
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Robert A Lew
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston University School of Public Health, Boston, MA, United States of America
| | - Addison A Taylor
- Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX, United States of America
| | - Peter A Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Mary T Brophy
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, United States of America
| | - Louis D Fiore
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, United States of America
| | - Ryan E Ferguson
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, United States of America
| | - William C Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center, United States of America
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17
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Tella A, Vang W, Ikeri E, Taylor O, Zhang A, Mazanec M, Raju S, Ishani A. β-Blocker Use and Cardiovascular Outcomes in Hemodialysis: A Systematic Review. Kidney Med 2022; 4:100460. [PMID: 35539430 PMCID: PMC9079357 DOI: 10.1016/j.xkme.2022.100460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Rationale & Objective There is conflicting evidence regarding the type of β-blockers to use in dialysis patients. This systematic review seeks to determine whether highly dialyzable β-blockers are associated with higher rates of cardiovascular events and mortality in hemodialysis patients than poorly dialyzable β-blockers. Study Design A systematic review of the existing literature was conducted. A meta-analysis was performed using data from the selected studies. Setting & Study Populations Participants were from the United States, Canada, and Taiwan. The mean ages of participants ranged from 55.9-75.7 years. Selection Criteria for Studies We searched the Ovid MEDLINE database from 1990 to September 2020. Studies without adult hemodialysis participants and without comparisons of at least 2 β-blockers of different dialyzability were excluded. Data Extraction Baseline and adjusted outcome data were extracted from each study. Analytical Approach Random-effects models were used to calculate pooled risk ratios using fully adjusted models from individual studies. Results Four cohort studies were included. Pooling fully adjusted models, highly dialyzable β-blockers did not influence mortality (HR, 0.94; 95% CI, 0.81-1.08; I2 = 0.84) compared with poorly dialyzable β-blockers but were associated with a reduction in cardiovascular events (HR, 0.88; 95% CI, 0.83-0.93). There was significant heterogeneity between studies (I2 = 0.35). Only 1 study reported on adverse events. Intradialytic hypotension was more common in those on carvedilol (a poorly dialyzable β-blocker) compared with those on metoprolol (a highly dialyzable β-blocker; adjusted incidence rate ratio, 1.10; 95% CI, 1.09-1.11). Limitations No randomized controlled trials were identified. Each study used different analytic methods and different definitions for outcomes. Classifications of β-blockers varied. Only 1 study reported on adverse events. Conclusions Pooled data suggest highly dialyzable β-blockers are associated with similar mortality events and fewer cardiovascular events compared with poorly dialyzable β-blockers.
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18
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Johansen KL, Chertow GM, Gilbertson DT, Herzog CA, Ishani A, Israni AK, Ku E, Li S, Li S, Liu J, Obrador GT, O'Hare AM, Peng Y, Powe NR, Roetker NS, St Peter WL, Saeed F, Snyder J, Solid C, Weinhandl ED, Winkelmayer WC, Wetmore JB. US Renal Data System 2021 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2022; 79:A8-A12. [PMID: 35331382 PMCID: PMC8935019 DOI: 10.1053/j.ajkd.2022.02.001] [Citation(s) in RCA: 112] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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19
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Abstract
BACKGROUND The primary objective of this analysis is to assess if greater exposure to any major antihypertensive drug class was associated with reduced primary composite outcome events in SPRINT (Systolic Blood Pressure Intervention Trial). METHODS This is a secondary analysis of the SPRINT trial evaluating whether longitudinal, time varying exposure to any major antihypertensive drug class had any impact on primary outcome events, after adjusting for effects of randomization arm, time varying achieved systolic blood pressure, other drug class exposure, and baseline characteristics. RESULTS Nine thousand two hundred fifty-two participants were included. After adjustments, exposure of one year or greater to thiazide-type diuretics or renin-angiotensin system blockers was associated with significantly fewer primary events than exposure of less than one year (hazard ratio, 0.78 [95% CI, 0.64-0.94]). There was no significant difference with longer versus shorter exposure to calcium channel blockers. Greater exposure to beta-blockers was associated with an increase in primary events compared with exposure of <1 year (hazard ratio, 1.35 [95% CI, 1.13-1.62]). Furthermore, thiazide-type diuretics were associated with a reduction in heart failure events and renin-angiotensin system blockers with reduced myocardial infarction. Both were associated with less cardiovascular deaths. CONCLUSIONS The SPRINT trial demonstrated a lower target blood pressure led to reductions in adverse cardiovascular events. This analysis suggests greater exposure to thiazide-type diuretics and renin-angiotensin system blockers also contributed to reduced adverse cardiovascular events. Greater exposure to beta-blockers was associated with increased cardiovascular events.
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Affiliation(s)
| | - Amy Gravely
- Research Service, Minneapolis VA Health Care System, MN (A.G., C.M.O.)
| | - Christine M Olney
- Research Service, Minneapolis VA Health Care System, MN (A.G., C.M.O.)
| | - Areef Ishani
- Minneapolis VA Health Care System and University of Minnesota (A.F.)
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20
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Reule S, Foley R, Shaughnessy D, Drawz P, Ishani A, Rosenberg M. Does experience matter? The relationship between nephrologist characteristics and end stage kidney disease patient outcomes. Hemodial Int 2022; 26:114-123. [PMID: 34227221 PMCID: PMC8724381 DOI: 10.1111/hdi.12961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Nephrology offers the unique opportunity to directly link patients to providers, allowing the study of patient outcomes at the provider level. The purpose of this analysis was to determine whether nephrologist experience, defined as years in nephrology practice, was associated with clinical outcomes. DESIGN Physician data contained within the American Medical Association (AMA) Physician Masterfile was combined with patient and Medicare claims data from the United States Renal Data System (USRDS) for the calendar year 2012, with follow up extending through June 30, 2014. Associations with important healthcare outcomes including mortality in patients receiving maintenance renal replacement therapy (RRT), waitlisting for kidney transplantation, and receipt of a kidney transplant were determined with broad adjustment for both patient and provider level variables, with attention on tertile of provider time in practice. RESULTS We identified 256,324 patients on maintenance RRT cared for by 6193 nephrologists. Nephrologists with the least experience were more likely to be female, reside in a region with ≥1,000,000 people, have a Doctor of Osteopathic Medicine degree, and have a listed maintenance of certification status as "yes." Overall, 30.2% of the cohort died at a mean follow up of 1.99 years. Compared to those with the 0-10 years of experience, receipt of care from nephrologists with more experience was associated with lower mortality (AHR 0.97 CI 0.94-0.99 for nephrologists with 11-20 years) and increased listing for kidney transplantation (AHR 1.10; CI 1.01-1.21 for nephrologists with >21 years experience). Experience level did not result in a difference in kidney transplantation rates. CONCLUSIONS Receipt of maintenance RRT from nephrologists with greater experience was associated with decreased mortality and increased listing for kidney transplantation, an effect that remained significant after multiple adjustments for important patient and nephrologist variables.
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Affiliation(s)
- Scott Reule
- Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Robert Foley
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Shaughnessy
- School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Paul Drawz
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Areef Ishani
- Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Mark Rosenberg
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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21
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Sperl-Hillen JM, Crain AL, Chumba L, Ekstrom HL, Appana D, Kopski KM, Wetmore JB, Wheeler J, Ishani A, O'Connor PJ. Pragmatic clinic randomized trial to improve chronic kidney disease care: Design and adaptation due to COVID disruptions. Contemp Clin Trials 2021; 109:106501. [PMID: 34271175 PMCID: PMC8276567 DOI: 10.1016/j.cct.2021.106501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/24/2021] [Accepted: 06/30/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND We describe a clinic-randomized trial to improve chronic kidney disease (CKD) care through a CKD-clinical decision support (CKD-CDS) intervention in primary care clinics and the challenges we encountered due to COVID-19 care disruption. METHODS/DESIGN Primary care clinics (N = 32) were randomized to usual care (UC) or to CKD-CDS. Between April 17, 2019 and March 14, 2020, more than 7000 patients had accrued for analysis by meeting study-eligibility criteria at an index office visit: age 18-75, laboratory criteria for stage 3 or 4 CKD (eGFR 15-59 mL/min/1.73 m2), and one or more opportunities algorithmically identified to improve CKD care such as blood pressure (BP) or glucose control, angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) use, discontinuance of a nonsteroidal anti-inflammatory drug (NSAID), or nephrology referral. At CKD-CDS clinics, CDS provided individualized treatment suggestions that were printed for patients and clinicians at the start of office encounters and were viewable within the electronic health record. By initial design, the impact of the CKD-CDS intervention on care gaps was to be assessed 12 months after the index date, but COVID-19 caused major disruptions to care delivery during the intervention period. In response to disruptions, the intervention was temporarily suspended while we expanded CDS use for telehealth encounters and programmed new criteria for displaying the CKD-CDS to intervention patients due to clinic closures and scheduling changes. DISCUSSION We describe a NIH-funded pragmatic trial of web-based EHR-integrated CKD-CDS and modifications necessary mid-study to complete the study as intended in the face of COVID-19 pandemic challenges.
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Affiliation(s)
| | - A Lauren Crain
- HealthPartners Institute, Minneapolis, MN, United States of America
| | - Lilian Chumba
- HealthPartners Institute, Minneapolis, MN, United States of America
| | - Heidi L Ekstrom
- HealthPartners Institute, Minneapolis, MN, United States of America
| | - Deepika Appana
- HealthPartners Institute, Minneapolis, MN, United States of America
| | - Kristen M Kopski
- Park Nicollet Medical Group, Minneapolis, MN, United States of America
| | - James B Wetmore
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN, United States of America
| | - James Wheeler
- Park Nicollet Medical Group, Minneapolis, MN, United States of America
| | - Areef Ishani
- Minneapolis Veterans Affairs Health Care System and the University of Minnesota, Minneapolis, MN, United States of America
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22
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Hau C, Leatherman S, Klint A, Glassman P, Taylor A, CUSHMAN WILLIAM, Ishani A. Abstract P268: The Impact Of Covid-19 On A Large Pragmatic Clinical Trial Embedded In Primary Care. Hypertension 2021. [DOI: 10.1161/hyp.78.suppl_1.p268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
The COVID-19 pandemic has had a significant impact on traditional clinical trial operations, but it is unclear whether the impact persists in pragmatic trials with a centralized study design. The Diuretic Comparison Project (DCP) is a Point-of Care pragmatic trial that operates through a usual care system to compare chlorthalidone and hydrochlorothiazide at preventing major cardiovascular (CV) events and non-cancer death. We assessed the impact of the COVID-19 pandemic on the centralized recruitment, patient follow-up, data collection, and outcome ascertainment performed in the DCP.
Methods:
We assessed operations in two 8-month periods: Pre-COVID-19 (Jul 2019 - Feb 2020) and Mid-COVID-19 (Jul 2020 - Feb 2021). Enrollment, study medication adherence, blood pressure (BP) and electrolyte follow-up rates, VA records of CV events, all-cause hospitalization, and death rates were compared.
Results:
Providers agreed to participate at a lower rate, but more patients were contacted and randomized during mid-COVID-19. While BP evaluations decreased, the rates of electrolyte, major CV, and medication prescription records were comparable to the pre-COVID-19 period (
Table 1
).
Conclusions:
The DCP was able to recruit and maintain critical data collection at the pre-COVID-19 levels. There were some decreases in BP evaluations, likely due to fewer in-person visits. All-cause VA hospitalizations also decreased, despite rises in COVID-related hospitalizations and death. While the impact on outcome and safety rates awaits complete data from Medicare, the DCP has demonstrated a promising centralized design that can support pragmatic trial operations during a pandemic.
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Affiliation(s)
- Cynthia Hau
- Boston Cooperative Studies Program Coordinating Cntr, Boston VA Healthcare System, Boston, MA
| | - Sarah Leatherman
- Boston Cooperative Studies Program Coordinating Cntr, Boston VA Healthcare System, Boston, MA
| | - Alison Klint
- Boston Cooperative Studies Program Coordinating Cntr, Boston VA Healthcare System, Boston, MA
| | - Peter Glassman
- Pharmacy Benefits Management Services, Dept of Veteran Affairs, Washington DC; VA Greater Los Angeles Healthcare System; David Geffen Sch of Medicine at UCLA, Los Angeles, CA
| | | | | | - Areef Ishani
- Minneapolis VA Healthcare System, Minneapolis, MN
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23
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Majkut Klint A, McPherson J, Tella A, Vang W, Raju S, Windschitl R, Ishani A. Impacts of Research Staff Burnout for a National Large Scale Pragmatic Clinical Trial. OAJCT 2021. [DOI: 10.2147/oajct.s312365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Johansen KL, Chertow GM, Foley RN, Gilbertson DT, Herzog CA, Ishani A, Israni AK, Ku E, Kurella Tamura M, Li S, Li S, Liu J, Obrador GT, O'Hare AM, Peng Y, Powe NR, Roetker NS, St Peter WL, Abbott KC, Chan KE, Schulman IH, Snyder J, Solid C, Weinhandl ED, Winkelmayer WC, Wetmore JB. US Renal Data System 2020 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2021; 77:A7-A8. [PMID: 33752804 DOI: 10.1053/j.ajkd.2021.01.002] [Citation(s) in RCA: 292] [Impact Index Per Article: 97.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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25
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Malhotra R, Katz R, Jotwani V, Agarwal A, Cohen DL, Cushman WC, Ishani A, Killeen AA, Kitzman DW, Oparil S, Papademetriou V, Parikh CR, Raphael KL, Rocco MV, Tamariz LJ, Whelton PK, Wright JT, Shlipak MG, Ix JH. Estimated GFR Variability and Risk of Cardiovascular Events and Mortality in SPRINT (Systolic Blood Pressure Intervention Trial). Am J Kidney Dis 2020; 78:48-56. [PMID: 33333147 DOI: 10.1053/j.ajkd.2020.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/16/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE Although low estimated glomerular filtration rate (eGFR) is associated with cardiovascular disease (CVD) events and mortality, the clinical significance of variability in eGFR over time is uncertain. This study aimed to evaluate the associations between variability in eGFR and the risk of CVD events and all-cause mortality. STUDY DESIGN Longitudinal analysis of clinical trial participants. SETTINGS AND PARTICIPANTS 7,520 Systolic Blood Pressure Intervention Trial (SPRINT) participants ≥50 year of age with 1 or more CVD risk factors. PREDICTORS eGFR variability, estimated by the coefficient of variation of eGFR assessments at the 6th, 12th, and 18-month study visits. OUTCOMES The SPRINT primary CVD composite outcome (myocardial infarction, acute coronary syndrome, stroke, heart failure, or CVD death) and all-cause mortality from month 18 to the end of follow-up. ANALYTICAL APPROACH Cox models were used to evaluate associations between eGFR variability and CVD outcomes and all-cause mortality. Models were adjusted for demographics, randomization arm, CVD risk factors, albuminuria, and eGFR at month 18. RESULTS Mean age was 68 ± 9 years; 65% were men; and 58% were White. The mean eGFR was 73 ± 21 (SD) mL/min/1.73 m2 at 6 months. There were 370 CVD events and 154 deaths during a median follow-up of 2.4 years. Greater eGFR variability was associated with higher risk for all-cause mortality (hazard ratio [HR] per 1 SD greater variability, 1.29; 95% CI, 1.14-1.45) but not CVD events (HR, 1.05; 95% CI, 0.95-1.16) after adjusting for albuminuria, eGFR, and other CVD risk factors. Associations were similar when stratified by treatment arm and by baseline CKD status, when accounting for concurrent systolic blood pressure changes, use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and diuretic medications during follow up. LIMITATIONS Persons with diabetes and proteinuria > 1 g/d were excluded. CONCLUSIONS In trial participants at high risk for CVD, greater eGFR variability was independently associated with all-cause mortality but not CVD events.
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Affiliation(s)
- Rakesh Malhotra
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, CA
| | - Ronit Katz
- Kidney Research Institute, University of Washington, Seattle, WA
| | - Vasantha Jotwani
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, CA
| | - Adhish Agarwal
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah Health, Salt Lake City, UT
| | - Debbie L Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William C Cushman
- Medical Service, Veteran Affairs Medical Center and Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Areef Ishani
- Division of Nephrology, Department of Medicine, University of Minnesota and Veteran Affairs Medical Center, Minneapolis, MN
| | - Anthony A Killeen
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Dalane W Kitzman
- Division of Cardiovascular Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Vasilios Papademetriou
- Division of Cardiology, Department of Medicine, Georgetown University and Veteran Affairs Medical Center, Washington, DC
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, John Hopkins University, Baltimore, MD
| | - Kalani L Raphael
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah Health, Salt Lake City, UT
| | - Michael V Rocco
- Division of Nephrology, Department of Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Leonardo J Tamariz
- Department of Medicine, Miller School of Medicine at the University of Miami, Miami, FL
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Jackson T Wright
- Division of Nephrology and Hypertension, University Hospital Cleveland Medical Center, Cleveland, OH
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, CA; Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Joachim H Ix
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA; Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, CA.
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Canales MT, Bozorgmehri S, Ishani A, Weiner ID, Berry R, Beyth R. Prevalence and correlates of sleep apnea among US Veterans with chronic kidney disease. J Sleep Res 2020; 29:e12981. [PMID: 31912641 DOI: 10.1111/jsr.12981] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/30/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022]
Abstract
The prevalence and correlates of sleep apnea (SA) among Veterans with chronic kidney disease (CKD), a population at high risk of both SA and CKD, are unknown. We performed a cross-sectional analysis of 248 Veterans (18-89 years) selected only for presence of moderate to severe CKD. All participants underwent full, unattended polysomnography, measurement of renal function and a sleepiness questionnaire. Logistic regression with backward selection was used to identify predictors of prevalent SA (apnea-hypopnea index [AHI, ≥15 events/hr] and prevalent nocturnal hypoxia [NH, % of total sleep time spent at <90% oxygen saturation]). The mean age of our cohort was 73.2 ± 9.6 years, 95% were male, 78% were Caucasian and the mean body mass index (BMI) was 30.3 ± 4.8 kg/m2 . The prevalence of SA was 39%. There was no difference in daytime sleepiness among those with and without SA. In the final model, older age, higher BMI and diabetes mellitus (DM) were associated with higher odds of SA, after controlling for age, BMI, race and sex. Higher BMI, DM, unemployed/retired status, current smoking and higher serum bicarbonate level were associated with prevalent NH. To sum, SA was common among Veterans with moderate to severe CKD. Although some traditional risk factors for SA were associated with SA in this population, sleepiness did not correlate with SA. Further study is needed to validate our findings and understand how best to address the high burden of SA among Veterans with CKD.
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Affiliation(s)
- Muna T Canales
- Division of Nephrology, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Shahab Bozorgmehri
- Division of Nephrology, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Areef Ishani
- Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - I David Weiner
- Division of Nephrology, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Richard Berry
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Rebecca Beyth
- Division of General Medicine, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
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Leither MD, Murphy DP, Bicknese L, Reule S, Vock DM, Ishani A, Foley RN, Drawz PE. The impact of outpatient acute kidney injury on mortality and chronic kidney disease: a retrospective cohort study. Nephrol Dial Transplant 2019; 34:493-501. [PMID: 29579290 DOI: 10.1093/ndt/gfy036] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/29/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) has been extensively studied in hospital settings. Limited data exist regarding outcomes for patients with outpatient AKI who are not subsequently admitted. We investigated whether outpatient AKI, defined by a 50% increase in creatinine (Cr), is associated with increased mortality and renal events. METHODS In this retrospective study, outpatient serum Cr values from adults receiving primary care at a health system during an 18-month exposure period were used to categorize patients into one of five groups (no outpatient AKI, outpatient AKI with recovery, outpatient AKI without recovery, outpatient AKI without repeat Cr and no Cr). Principal outcomes of all-cause mortality and renal events (50% decline in estimated glomerular filtration rate to <30 mL/min/1.73 m2) were examined using Cox proportional hazards models. RESULTS Among 384 869 eligible patients, 51% had at least one Cr measured during the exposure period. Outpatient AKI occurred in 1.4% of patients while hospital AKI occurred in only 0.3% of patients. The average follow-up was 5.3 years. Outpatient AKI was associated with an increased risk of all-cause mortality {adjusted hazard ratio [aHR] 1.90 [95% confidence interval (CI) 1.76-2.06]} and results were consistent across all AKI groups. Outpatient AKI was also associated with an increased risk of renal events [aHR 1.33 (95% CI 1.11-1.59)], even among those who recovered. CONCLUSIONS Outpatient AKI is more prevalent than inpatient AKI and is a risk factor for all-cause mortality and renal events, even among those who recover kidney function. Further research is necessary to determine risk factors and identify strategies for preventing outpatient AKI.
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Affiliation(s)
- Maxwell D Leither
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN, USA
| | - Daniel P Murphy
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN, USA
| | - Luke Bicknese
- Academic Health Center-Information Systems, University of Minnesota, Minneapolis, MN, USA
| | - Scott Reule
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN, USA.,Section of Nephrology, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - David M Vock
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Areef Ishani
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN, USA.,Section of Nephrology, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Robert N Foley
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN, USA
| | - Paul E Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN, USA
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Bullen AL, Katz R, Lee AK, Anderson CAM, Cheung AK, Garimella PS, Jotwani V, Haley WE, Ishani A, Lash JP, Neyra JA, Punzi H, Rastogi A, Riessen E, Malhotra R, Parikh CR, Rocco MV, Wall BM, Bhatt UY, Shlipak MG, Ix JH, Estrella MM. The SPRINT trial suggests that markers of tubule cell function in the urine associate with risk of subsequent acute kidney injury while injury markers elevate after the injury. Kidney Int 2019; 96:470-479. [PMID: 31262489 PMCID: PMC6650383 DOI: 10.1016/j.kint.2019.03.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 03/26/2019] [Accepted: 03/28/2019] [Indexed: 01/19/2023]
Abstract
Urine markers can quantify tubular function including reabsorption (α-1 microglobulin [α1m]) and β-2-microglobulin [β2m]) and protein synthesis (uromodulin). Individuals with tubular dysfunction may be less able to compensate to insults than those without, despite similar estimated glomerular filtration rate (eGFR) and albuminuria. Among Systolic Blood Pressure Intervention Trial (SPRINT) participants with an eGFR under 60 ml/min/1.73m2, we measured urine markers of tubular function and injury (neutrophil gelatinase-associated lipocalin [NGAL], kidney injury molecule-1 [KIM-1], interleukin-18 [IL-18], monocyte chemoattractant protein-1, and chitinase-3-like protein [YKL-40]) at baseline. Cox models evaluated associations with subsequent acute kidney injury (AKI) risk, adjusting for clinical risk factors, baseline eGFR and albuminuria, and the tubular function and injury markers. In a random subset, we remeasured biomarkers after four years, and compared changes in biomarkers in those with and without intervening AKI. Among 2351 participants, 184 experienced AKI during 3.8 years mean follow-up. Lower uromodulin (hazard ratio per two-fold higher (0.68, 95% confidence interval [0.56, 0.83]) and higher α1m (1.20; [1.01, 1.44]) were associated with subsequent AKI, independent of eGFR and albuminuria. None of the five injury markers were associated with eventual AKI. In the random subset of 947 patients with repeated measurements, the 59 patients with intervening AKI versus without had longitudinal increases in urine NGAL, IL-19, and YKL-40 and only 1 marker of tubule function (α1m). Thus, joint evaluation of tubule function and injury provided novel insights to factors predisposing to AKI, and responses to kidney injury.
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Affiliation(s)
- Alexander L Bullen
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Ronit Katz
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Alexandra K Lee
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California, USA
| | - Cheryl A M Anderson
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA; Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California-San Diego, San Diego, California, USA
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA; Medical Service, Veterans Affairs, Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Pranav S Garimella
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Vasantha Jotwani
- Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - William E Haley
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida, USA
| | - Areef Ishani
- Division of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - James P Lash
- Division of Nephrology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky Medical Center, Lexington, Kentucky, USA; Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern, Dallas, Texas, USA
| | - Henry Punzi
- UT Southwestern Medical Center, Carrollton, Texas, USA
| | - Anjay Rastogi
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, California, USA
| | - Erik Riessen
- Medical Service, Veterans Affairs, Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Rakesh Malhotra
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Chirag R Parikh
- Department of Medicine, Section of Nephrology, Yale University, New Haven, Connecticut, USA
| | - Michael V Rocco
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Barry M Wall
- Division of Nephrology, Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Udayan Y Bhatt
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California, USA; Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA
| | - Joachim H Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA; Nephrology Section, Veterans Affairs, San Diego Healthcare System, La Jolla, California, USA
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California, USA; Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA.
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Coresh J, Heerspink HJL, Sang Y, Matsushita K, Arnlov J, Astor BC, Black C, Brunskill NJ, Carrero JJ, Feldman HI, Fox CS, Inker LA, Ishani A, Ito S, Jassal S, Konta T, Polkinghorne K, Romundstad S, Solbu MD, Stempniewicz N, Stengel B, Tonelli M, Umesawa M, Waikar SS, Wen CP, Wetzels JFM, Woodward M, Grams ME, Kovesdy CP, Levey AS, Gansevoort RT. Change in albuminuria and subsequent risk of end-stage kidney disease: an individual participant-level consortium meta-analysis of observational studies. Lancet Diabetes Endocrinol 2019; 7:115-127. [PMID: 30635225 PMCID: PMC6379893 DOI: 10.1016/s2213-8587(18)30313-9] [Citation(s) in RCA: 182] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/21/2018] [Accepted: 10/23/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Change in albuminuria as a surrogate endpoint for progression of chronic kidney disease is strongly supported by biological plausibility, but empirical evidence to support its validity in epidemiological studies is lacking. We aimed to assess the consistency of the association between change in albuminuria and risk of end-stage kidney disease in a large individual participant-level meta-analysis of observational studies. METHODS In this meta-analysis, we collected individual-level data from eligible cohorts in the Chronic Kidney Disease Prognosis Consortium (CKD-PC) with data on serum creatinine and change in albuminuria and more than 50 events on outcomes of interest. Cohort data were eligible if participants were aged 18 years or older, they had a repeated measure of albuminuria during an elapsed period of 8 months to 4 years, subsequent end-stage kidney disease or mortality follow-up data, and the cohort was active during this consortium phase. We extracted participant-level data and quantified percentage change in albuminuria, measured as change in urine albumin-to-creatinine ratio (ACR) or urine protein-to-creatinine ratio (PCR), during baseline periods of 1, 2, and 3 years. Our primary outcome of interest was development of end-stage kidney disease after a baseline period of 2 years. We defined an end-stage kidney disease event as initiation of kidney replacement therapy. We quantified associations of percentage change in albuminuria with subsequent end-stage kidney disease using Cox regression in each cohort, followed by random-effects meta-analysis. We further adjusted for regression dilution to account for imprecision in the estimation of albuminuria at the participant level. We did multiple subgroup analyses, and also repeated our analyses using participant-level data from 14 clinical trials, including nine clinical trials not in CKD-PC. FINDINGS Between July, 2015, and June, 2018, we transferred and analysed data from 28 cohorts in the CKD-PC, which included 693 816 individuals (557 583 [80%] with diabetes). Data for 675 904 individuals and 7461 end-stage kidney disease events were available for our primary outcome analysis. Change in ACR was consistently associated with subsequent risk of end-stage kidney disease. The adjusted hazard ratio (HR) for end-stage kidney disease after a 30% decrease in ACR during a baseline period of 2 years was 0·83 (95% CI 0·74-0·94), decreasing to 0·78 (0·66-0·92) after further adjustment for regression dilution. Adjusted HRs were fairly consistent across cohorts and subgroups (ie, estimated glomerular filtration rate, diabetes, and sex), but the association was somewhat stronger among participants with higher baseline ACR than among those with lower baseline ACR (pinteraction<0·0001). In individuals with baseline ACR of 300 mg/g or higher, a 30% decrease in ACR over 2 years was estimated to confer a more than 1% absolute reduction in 10-year risk of end-stage kidney disease, even at early stages of chronic kidney disease. Results were generally similar when we used change in PCR and when study populations from clinical trials were assessed. INTERPRETATION Change in albuminuria was consistently associated with subsequent risk of end-stage kidney disease across a range of cohorts, lending support to the use of change in albuminuria as a surrogate endpoint for end-stage kidney disease in clinical trials of progression of chronic kidney disease in the setting of increased albuminuria. FUNDING US National Kidney Foundation and US National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Johan Arnlov
- School of Health and Social Studies, Dalarna University, Falun, Sweden; Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Huddinge, Sweden
| | - Brad C Astor
- Department of Medicine and Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Corri Black
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; Public Health, NHS Grampian, Summerfield House, Aberdeen, UK
| | - Nigel J Brunskill
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK; John Walls Renal Unit, University Hospitals of Leicester, Leicester, UK
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Huddinge, Sweden
| | - Harold I Feldman
- Department of Biostatistics, Epidemiology and Informatics and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline S Fox
- National Heart, Lung, and Blood Institute's Framingham Heart Study, Center for Population Studies, Framingham, MA, USA; Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
| | - Areef Ishani
- Veterans Administration Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Simerjot Jassal
- Division of General Internal Medicine, Department of Medicine, VA San Diego Healthcare System, University of California San Diego, San Diego, CA, USA
| | - Tsuneo Konta
- Department of Public Health and Hygiene, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Kevan Polkinghorne
- Department of Nephrology, Monash Medical Centre, Melbourne, VIC, Australia; Department of Medicine and School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Solfrid Romundstad
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Department of Internal Medicine, Levanger Hospital, Health Trust Nord-Trøndelag, Levanger, Norway
| | - Marit D Solbu
- Section of Nephrology, Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway; Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | | | - Benedicte Stengel
- Inserm UMR1018, Center for Research in Epidemiology and Population Health, Villejuif, Paris, France; Versailles Saint-Quentin-en-Yvelines University, Versailles, France; Paris-Sud University, Orsay, France
| | - Marcello Tonelli
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mitsumasa Umesawa
- Department of Public Health, Dokkyo Medical University, Tochigi, Japan; Ibaraki Health Plaza, Ibaraki Health Service Association, Mito, Japan
| | - Sushrut S Waikar
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Chi-Pang Wen
- China Medical University Hospital, Taichung, Taiwan; Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
| | - Jack F M Wetzels
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Mark Woodward
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; The George Institute for Global Health, University of Oxford, Oxford, UK; The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Csaba P Kovesdy
- University of Tennessee Health Science Center, Memphis, TN, USA; Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
| | - Ron T Gansevoort
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Canales MT, Holzworth M, Bozorgmehri S, Ishani A, Weiner ID, Berry RB, Beyth RJ, Gumz M. Clock gene expression is altered in veterans with sleep apnea. Physiol Genomics 2019; 51:77-82. [PMID: 30657733 DOI: 10.1152/physiolgenomics.00091.2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Clock gene dysregulation has been shown to underlie various sleep disorders and may lead to negative cardio-metabolic outcomes. However, the association between sleep apnea (SA) and core clock gene expression is unclear. We performed a cross-sectional analysis of 49 Veterans enrolled in a study of SA outcomes in veterans with chronic kidney disease, not selected for SA or sleep complaints. All participants underwent full polysomnography and next morning whole blood collection for clock gene expression. We defined SA as an apnea-hypopnea index ≥15 events/h; nocturnal hypoxemia(NH) was defined as ≥10% of total sleep time spent at <90% oxygen saturation. We used quantitative real-time PCR to compare the relative gene expression of clock genes between those with and without SA or NH. Clock genes studied were Bmal1, Ck1δ, Ck1ε, Clock, Cry1, Cry2, NPAS2, Per1, Per2, Per3, Rev-Erb-α, RORα, and Timeless. Our cohort was 90% male, mean age was 71 yr (SD 11), mean body mass index was 30 kg/m2 (SD 5); 41% had SA, and 27% had NH. Compared with those without SA, Per3 expression was reduced by 35% in SA ( P = 0.027). Compared with those without NH, NPAS2, Per1, and Rev-Erb-α expression was reduced in NH (50.4%, P = 0.027; 28.7%, P = 0.014; 31%, P = 0.040, respectively). There was no statistical difference in expression of the remaining clock genes by SA or NH status. Our findings suggest that SA or related NH and clock gene expression may be interrelated. Future study of 24 h clock gene expression in SA is needed to establish the role of clock gene regulation on the pathway between SA and cardio-metabolic outcomes.
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Affiliation(s)
- Muna T Canales
- Malcom Randall VA Medical Center , Gainesville, Florida.,Department of Medicine, Division of Nephrology, University of Florida , Gainesville, Florida
| | - Meaghan Holzworth
- Department of Medicine, Division of Nephrology, University of Florida , Gainesville, Florida
| | - Shahab Bozorgmehri
- Department of Medicine, Division of Nephrology, University of Florida , Gainesville, Florida
| | - Areef Ishani
- Minneapolis VA Medical Center and Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - I David Weiner
- Malcom Randall VA Medical Center , Gainesville, Florida.,Department of Medicine, Division of Nephrology, University of Florida , Gainesville, Florida
| | - Richard B Berry
- Malcom Randall VA Medical Center , Gainesville, Florida.,Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida , Gainesville, Florida
| | - Rebecca J Beyth
- Malcom Randall VA Medical Center , Gainesville, Florida.,Department of Medicine, Division of General Internal Medicine, University of Florida , Gainesville, Florida
| | - Michelle Gumz
- Department of Medicine, Division of Nephrology, University of Florida , Gainesville, Florida
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Kaboli PJ, Howren MB, Ishani A, Carter B, Christensen AJ, Vander Weg MW. Efficacy of Patient Activation Interventions With or Without Financial Incentives to Promote Prescribing of Thiazides and Hypertension Control: A Randomized Clinical Trial. JAMA Netw Open 2018; 1:e185017. [PMID: 30646291 PMCID: PMC6324341 DOI: 10.1001/jamanetworkopen.2018.5017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Evidence-based guidelines recommend thiazide diuretics as a first-line therapy for uncomplicated hypertension; however, thiazides are underused, and hypertension remains inadequately managed. OBJECTIVE To test the efficacy of a patient activation intervention with financial incentives to promote thiazide prescribing. DESIGN, SETTING, AND PARTICIPANTS The Veterans Affairs Project to Implement Diuretics, a randomized clinical trial, was conducted at 13 Veterans Affairs primary care clinics from August 1, 2006, to July 31, 2008, with 12 months of follow-up. A total of 61 019 patients were screened to identify 2853 eligible patients who were not taking a thiazide and not at their blood pressure (BP) goal; 598 consented to participate. Statistical analysis was conducted from December 1, 2017, to September 12, 2018. INTERVENTIONS Patients were randomized to a control group (n = 196) or 1 of 3 intervention groups designed to activate patients to talk with their primary care clinicians about thiazides and hypertension: group A (n = 143) received an activation letter, group B (n = 128) received a letter plus a financial incentive, and group C (n = 131) received a letter, financial incentive, and a telephone call encouraging patients to speak with their primary care clinicians. MAIN OUTCOMES AND MEASURES Primary outcomes were thiazide prescribing and BP control. A secondary process measure was discussion between patient and primary care clinician about thiazides. RESULTS Among 598 participants (588 men and 10 women), the mean (SD) age for the combined intervention groups (n = 402) was 62.9 (8.8) years, and the mean baseline BP was 148.1/83.8 mm Hg; the mean (SD) age for the control group (n = 196) was 64.1 (9.2) years, and the mean baseline BP was 151.0/83.4 mm Hg. At index visits, the unadjusted rate of thiazide prescribing was 9.7% for the control group (19 of 196) and 24.5% (35 of 143) for group A, 25.8% (33 of 128) for group B, and 32.8% (43 of 131) for group C (P < .001). Adjusted analyses demonstrated an intervention effect on thiazide prescribing at the index visit and 6-month visit, which diminished at the 12-month visit. For BP control, there was a significant intervention effect at the 12-month follow-up for group C (adjusted odds ratio, 1.73; 95% CI, 1.06-2.83; P = .04). Intervention groups exhibited improved thiazide discussion rates in a dose-response fashion: group A, 44.1% (63 of 143); group B, 56.3% (72 of 128); and group C, 68.7% (90 of 131) (P = .004). CONCLUSIONS AND RELEVANCE This patient activation intervention about thiazides for hypertension resulted in two-thirds of patients having discussions and nearly one-third initiating a prescription of thiazide. Adding a financial incentive and telephone call to the letter resulted in incremental improvements in both outcomes. By 12 months, improved BP control was also evident. This low-cost, low-intensity intervention resulted in high rates of discussions between patients and clinicians and subsequent thiazide treatment and may be used to promote evidence-based guidelines and overcome clinical inertia. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00265538.
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Affiliation(s)
- Peter J. Kaboli
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City
| | - M. Bryant Howren
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Psychological and Brain Sciences, The University of Iowa College of Liberal Arts and Sciences, Iowa City
| | - Areef Ishani
- Center for Epidemiology and Clinical Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
- Section of Nephrology, Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis
| | - Barry Carter
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Pharmacy Practice and Science, The University of Iowa College of Pharmacy, Iowa City
- Department of Family Medicine, The University of Iowa Carver College of Medicine, Iowa City
| | - Alan J. Christensen
- Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City
- Department of Psychological and Brain Sciences, The University of Iowa College of Liberal Arts and Sciences, Iowa City
| | - Mark W. Vander Weg
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City
- Department of Psychological and Brain Sciences, The University of Iowa College of Liberal Arts and Sciences, Iowa City
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Foley RN, Sexton DJ, Drawz P, Ishani A, Reule S. Race, Ethnicity, and End-of-Life Care in Dialysis Patients in the United States. J Am Soc Nephrol 2018; 29:2387-2399. [PMID: 30093455 DOI: 10.1681/asn.2017121297] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 06/26/2018] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND End-of-life care is a prominent consideration in patients on maintenance dialysis, especially when death appears imminent and quality of life is poor. To date, examination of race- and ethnicity-associated disparities in end-of-life care for patients with ESRD has largely been restricted to comparisons of white and black patients. METHODS We performed a retrospective national study using United States Renal Data System files to determine whether end-of-life care in United States patients on dialysis is subject to racial or ethnic disparity. The primary outcome was a composite of discontinuation of dialysis and death in a nonhospital or hospice setting. RESULTS Among 1,098,384 patients on dialysis dying between 2000 and 2014, the primary outcome was less likely in patients from any minority group compared with the non-Hispanic white population (10.9% versus 22.6%, P<0.001, respectively). We also observed similar significant disparities between any minority group and non-Hispanic whites for dialysis discontinuation (16.7% versus 31.2%), as well as hospice (10.3% versus 18.1%) and nonhospital death (34.4% versus 46.4%). After extensive covariate adjustment, the primary outcome was less likely in the combined minority group than in the non-Hispanic white population (adjusted odds ratio, 0.55; 95% confidence interval, 0.55 to 0.56; P<0.001). Individual minority groups (non-Hispanic Asian, non-Hispanic black, non-Hispanic Native American, and Hispanic) were significantly less likely than non-Hispanic whites to experience the primary outcome. This disparity was especially pronounced for non-Hispanic Native American and Hispanic subgroups. CONCLUSIONS There appear to be substantial race- and ethnicity-based disparities in end-of-life care practices for United States patients receiving dialysis.
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Affiliation(s)
- Robert N Foley
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota;
| | - Donal J Sexton
- Division of Medicine, National University of Ireland, University College Galway, Galway, Ireland; and
| | - Paul Drawz
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Areef Ishani
- Division of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Scott Reule
- Division of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
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Abstract
BACKGROUND Ultrafiltration rate (UFR) has attracted attention as a modifiable aspect of volume management. OBJECTIVE The objective of this review is to summarize the evidence that links UFR to patient outcomes and discuss UFR cut-offs proposed, and discuss possible consequences of adapting UFR as a quality metric. RESULTS Higher UFRs has been associated with younger age, longer dialysis vintage, greater prevalence of comorbidities, higher Kt/V, lower weight, greater interdialytic weight gain, lower residual renal function, and shorter treatment times. Many of the characteristics associated with high UFRs have also been independently associated with poor patient outcomes. Four observational studies have assessed the association between UFR and patient mortality. All of them reported an association between higher UFR and greater patient mortality, though the studies differed in their definition of UFR, follow-up, and adjustment for confounding. Evidence for the association between higher UFR and potential mediations of the mortality association, such as interdialytic hypotension, cardiac remodeling, and cardiovascular events was less consistent. There was a graded association between higher UFRs and all-cause mortality; no definitive cut-off for acceptable UFR can be established based on the current evidence. Targeting UFR in isolation might result in volume expansion and worsening patient outcomes. Residual confounding likely contributed to the findings of the observational studies. No randomized controlled trials addressed the questions. CONCLUSION Evidence supporting UFR limits is weak and confounded. Randomized controlled trials are needed before UFR can be used as a quality of care indicator.
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Affiliation(s)
- Yelena Slinin
- Veterans Administration Health Care System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Megha Babu
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Areef Ishani
- Veterans Administration Health Care System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Johnson LA, Bozogmehri S, Ishani A, Weiner D, Berry R, Beyth R, Canales M. 0876 Sleep Apnea and Change in Quality of Life Among Veterans with Kidney Disease: A Prospective Cohort Study. Sleep 2018. [DOI: 10.1093/sleep/zsy061.875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- L A Johnson
- Malcom Randall VA Medical Center, Gainesville, FL
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, FL
| | - S Bozogmehri
- Malcom Randall VA Medical Center, Gainesville, FL
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, FL
| | - A Ishani
- Minneapolis VA Medical Center, Minneapolis, MN
- University of Minnesota, Minneapolis, MN
| | - D Weiner
- Malcom Randall VA Medical Center, Gainesville, FL
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, FL
| | - R Berry
- Malcom Randall VA Medical Center, Gainesville, FL
| | - R Beyth
- Malcom Randall VA Medical Center, Gainesville, FL
| | - M Canales
- Malcom Randall VA Medical Center, Gainesville, FL
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, FL
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Nguyen JT, Vakil K, Adabag S, Westanmo A, Madlon-Kay R, Ishani A, Garcia S, McFalls EO. Hospital Readmission Rates Following AMI: Potential Interventions to Improve Efficiency. South Med J 2018; 111:93-97. [PMID: 29394425 DOI: 10.14423/smj.0000000000000768] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Quality of care utilization measures for patients admitted to the hospital with an acute myocardial infarction (AMI) include length of stay (LOS) and 30-day readmission rates. Our aim was to test whether efforts resulting in reduced LOS in patients diagnosed as having AMI would result in a higher risk of readmission within 30 days of hospital discharge and whether specific interventions could be targeted to reduce readmissions. METHODS Using data supplied by the Veterans Affairs Inpatient Evaluation Center, we analyzed both the readmissions within 30 days of an AMI and LOS and determined the timing of readmissions and associated diagnoses. RESULTS During 2013-2015, 35 (13.3%) of 263 patients with AMI were readmitted within 30 days of discharge compared with 19 (13.4%) of 142 patients during 2016 (not significant). During the same time, LOS was <3 days in most patients. From 2013 to 2015, the initial hospital time was 6 ± 6 days, whereas time out of the hospital before readmission was 11 ± 8 days; these times did not differ from 2016. Initial therapeutic decisions were based on coronary anatomy in >90% of patients with a decision to proceed with revascularization in most patients. Diagnoses during readmission to the hospital were also similar during early and later time periods and most frequently were a result of either coronary artery bypass grafting-related complications from the initial hospitalization or elective coronary artery bypass grafting. Acute coronary syndrome-related diagnoses and recurrent noncardiac causes of chest pain also were common diagnoses during both time periods and did not involve extensive workup during the readmission. CONCLUSIONS Readmissions for patients with AMI were stable during a 4-year period, at a time that efforts to reduce LOS were emphasized. Because a significant proportion of readmissions involved noncardiac sources of chest pain, improved communication between the emergency department and in-patient cardiology services at the time of triage may be a feasible way to improve efficiency of utilization.
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Affiliation(s)
- Jennifer T Nguyen
- From Cardiology, Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Kairav Vakil
- From Cardiology, Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Selcuk Adabag
- From Cardiology, Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Anders Westanmo
- From Cardiology, Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Richard Madlon-Kay
- From Cardiology, Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Areef Ishani
- From Cardiology, Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Santiago Garcia
- From Cardiology, Veterans Affairs Medical Center, Minneapolis, Minnesota
| | - Edward O McFalls
- From Cardiology, Veterans Affairs Medical Center, Minneapolis, Minnesota
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Fink HA, Vo TN, Langsetmo L, Barzilay JI, Cauley JA, Schousboe JT, Orwoll ES, Canales MT, Ishani A, Lane NE, Ensrud KE. Association of Increased Urinary Albumin With Risk of Incident Clinical Fracture and Rate of Hip Bone Loss: the Osteoporotic Fractures in Men Study. J Bone Miner Res 2017; 32:1090-1099. [PMID: 28012217 PMCID: PMC5413394 DOI: 10.1002/jbmr.3065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 12/06/2016] [Accepted: 12/15/2016] [Indexed: 12/29/2022]
Abstract
Prior studies suggest that increased urine albumin is associated with a heightened fracture risk in women, but results in men are unclear. We used data from Osteoporotic Fractures in Men (MrOS), a prospective cohort study of community-dwelling men aged ≥65 years, to evaluate the association of increased urine albumin with subsequent fractures and annualized rate of hip bone loss. We calculated albumin/creatinine ratio (ACR) from urine collected at the 2003-2005 visit. Subsequent clinical fractures were ascertained from triannual questionnaires and centrally adjudicated by review of radiographic reports. Total hip BMD was measured by DXA at the 2003-2005 visit and again an average of 3.5 years later. We estimated risk of incident clinical fracture using Cox proportional hazards models, and annualized BMD change using ANCOVA. Of 2982 men with calculable ACR, 9.4% had ACR ≥30 mg/g (albuminuria) and 1.0% had ACR ≥300 mg/g (macroalbuminuria). During a mean of 8.7 years of follow-up, 20.0% of men had an incident clinical fracture. In multivariate-adjusted models, neither higher ACR quintile (p for trend 0.75) nor albuminuria (HR versus no albuminuria, 0.89; 95% CI, 0.65 to 1.20) was associated with increased risk of incident clinical fracture. Increased urine albumin had a borderline significant, multivariate-adjusted, positive association with rate of total hip bone loss when modeled in ACR quintiles (p = 0.06), but not when modeled as albuminuria versus no albuminuria. Macroalbuminuria was associated with a higher rate of annualized hip bone loss compared to no albuminuria (-1.8% more annualized loss than in men with ACR <30 mg/g; p < 0.001), but the limited prevalence of macroalbuminuria precluded reliable estimates of its fracture associations. In these community-dwelling older men, we found no association between urine albumin levels and risk of incident clinical fracture, but found a borderline significant, positive association with rate of hip bone loss. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Howard A Fink
- Geriatric Research Education & Clinical Center, Veterans Affairs Health Care System, Minneapolis, MN, USA.,Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Tien N Vo
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Lisa Langsetmo
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Joshua I Barzilay
- Division of Endocrinology, Kaiser Permanente of Georgia, Atlanta, GA, USA.,Division of Endocrinology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jane A Cauley
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - John T Schousboe
- Park Nicollet Institute, Minneapolis, MN, USA.,Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - Eric S Orwoll
- Bone and Mineral Unit, Oregon Health & Science University, Portland, OR, USA
| | - Muna T Canales
- Department of Medicine (Nephrology), College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL, USA
| | - Areef Ishani
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nancy E Lane
- Division of Rheumatology, Allergy and Clinical Immunology, Department of Medicine, University of California, Davis, Davis, CA, USA
| | - Kristine E Ensrud
- Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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37
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Canales MT, Blackwell T, Ishani A, Taylor BC, Hart A, Beyth RJ, Ensrud KE. Renal Function and Death in Older Women: Which eGFR Formula Should We Use? Int J Nephrol 2017; 2017:8216878. [PMID: 28465840 PMCID: PMC5390547 DOI: 10.1155/2017/8216878] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 02/16/2017] [Accepted: 03/01/2017] [Indexed: 11/17/2022] Open
Abstract
Background. The Berlin Initiative Study (BIS) eGFR equations were developed specifically for aged populations, but their predictive validity compared to standard formulae is unknown in older women. Methods. In a prospective study of 1289 community-dwelling older women (mean age 79.5 years), we compared the performance of the BIS1 SCr-based equation to the CKD-EPIcr and the BIS2 SCr- and Scysc-based equation to the CKD-EPIcr,cysc to predict cardiovascular and all-cause mortality. Results. Prevalence of specific eGFR category (i.e., ≥75, 60-74, 45-59, and <45) according to eGFR equation was 12.3%, 38.4%, 37.3%, and 12.0% for BIS1; 48.3%, 27.8%, 16.2%, and 7.8% for CKD-EPIcr; 14.1%, 38.6%, 37.6%, and 9.6% for BIS2; and 33.5%, 33.4%, 22.0%, and 11.1% for CKD-EPIcr,cysc, respectively. Over 9 ± 4 years, 667 (51.8%) women died. For each equation, women with eGFR <45 were at increased risk of mortality compared to eGFR ≥75 [adjusted HR (95% CI): BIS1, 1.5 (1.1-2.0); CKD-EPIcr, 1.7 (1.3-2.2); BIS2, 2.0 (1.4-2.8); CKD-EPIcr,cysc, 1.8 (1.4-2.3); p-trend <0.01]. Net reclassification analyses found no material difference in discriminant ability between the BIS and CKD-EPI equations. Results were similar for cardiovascular death. Conclusions. Compared to CKD-EPI, BIS equations identified a greater proportion of older women as having CKD but performed similarly to predict mortality risk. Thus, the BIS equations should not replace CKD-EPI equations to predict risk of death in older women.
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Affiliation(s)
- Muna T. Canales
- Malcom-Randall VAMC, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Terri Blackwell
- Research Institute, California Pacific Medical Center, San Francisco, CA, USA
| | - Areef Ishani
- Department of Medicine, University of Minnesota, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Brent C. Taylor
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Allyson Hart
- Hennepin County Medical Center, Minneapolis, MN, USA
| | - Rebecca J. Beyth
- Malcom-Randall VAMC GRECC, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Kristine E. Ensrud
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Wetmore JB, Liu J, Dluzniewski PJ, Ishani A, Block GA, Collins AJ. Geographic variation of parathyroidectomy in patients receiving hemodialysis: a retrospective cohort analysis. BMC Surg 2016; 16:77. [PMID: 27899108 PMCID: PMC5129232 DOI: 10.1186/s12893-016-0193-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 11/24/2016] [Indexed: 11/24/2022] Open
Abstract
Background Secondary hyperparathyroidism (SHPT) is associated with adverse outcomes in patients receiving maintenance dialysis. Parathyroidectomy is a treatment for SHPT; whether parathyroidectomy utilization varies geographically in the US is unknown. Methods A retrospective cohort analysis was undertaken to identify all patients aged 18 years or older who were receiving in-center hemodialysis between 2007 and 2009, were covered by Medicare Parts A and B, and had been receiving hemodialysis for at least 1 year. Parathyroidectomy was identified from inpatient claims using relevant International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Patient characteristics and End-Stage Renal Disease Network (a proxy for geography) were ascertained. Adjusted odds ratios for parathyroidectomy were estimated from a logistic model. Results A total of 286,569 patients satisfied inclusion criteria, of whom 4435 (1.5%) underwent PTX. After adjustment for a variety of patient characteristics, there was a 2-fold difference in adjusted odds of parathyroidectomy between the most- and least-frequently performing regions. Adjusted odds ratios were more than 20% higher than average in four networks, and more than 20% lower in four networks. Conclusions Parathyroidectomy use varies substantially by geography in the US; the factors responsible should be further investigated.
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Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South 8th Street, Suite S4.100, Minneapolis, MN, 55404, USA. .,Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN, USA. .,Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South 8th Street, Suite S4.100, Minneapolis, MN, 55404, USA
| | | | - Areef Ishani
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South 8th Street, Suite S4.100, Minneapolis, MN, 55404, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Section of Renal Diseases and Hypertension, Minneapolis Veterans Administration Health Care System, Minneapolis, MN, USA
| | | | - Allan J Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South 8th Street, Suite S4.100, Minneapolis, MN, 55404, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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DeCarolis DD, Kim GM, Rector TS, Ishani A. Comparative dose response using the intravenous versus enteral route of administration for potassium replenishment. Intensive Crit Care Nurs 2016; 36:17-23. [DOI: 10.1016/j.iccn.2015.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/19/2015] [Accepted: 08/20/2015] [Indexed: 12/12/2022]
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40
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Naimark DMJ, Grams ME, Matsushita K, Black C, Drion I, Fox CS, Inker LA, Ishani A, Jee SH, Kitamura A, Lea JP, Nally J, Peralta CA, Rothenbacher D, Ryu S, Tonelli M, Yatsuya H, Coresh J, Gansevoort RT, Warnock DG, Woodward M, de Jong PE. Past Decline Versus Current eGFR and Subsequent Mortality Risk. J Am Soc Nephrol 2016; 27:2456-66. [PMID: 26657865 PMCID: PMC4978054 DOI: 10.1681/asn.2015060688] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/27/2015] [Indexed: 11/03/2022] Open
Abstract
A single determination of eGFR associates with subsequent mortality risk. Prior decline in eGFR indicates loss of kidney function, but the relationship to mortality risk is uncertain. We conducted an individual-level meta-analysis of the risk of mortality associated with antecedent eGFR slope, adjusting for established risk factors, including last eGFR, among 1.2 million subjects from 12 CKD and 22 other cohorts within the CKD Prognosis Consortium. Over a 3-year antecedent period, 12% of participants in the CKD cohorts and 11% in the other cohorts had an eGFR slope <-5 ml/min per 1.73 m(2) per year, whereas 7% and 4% had a slope >5 ml/min per 1.73 m(2) per year, respectively. Compared with a slope of 0 ml/min per 1.73 m(2) per year, a slope of -6 ml/min per 1.73 m(2) per year associated with adjusted hazard ratios for all-cause mortality of 1.25 (95% confidence interval [95% CI], 1.09 to 1.44) among CKD cohorts and 1.15 (95% CI, 1.01 to 1.31) among other cohorts during a follow-up of 3.2 years. A slope of +6 ml/min per 1.73 m(2) per year also associated with higher all-cause mortality risk, with adjusted hazard ratios of 1.58 (95% CI, 1.29 to 1.95) among CKD cohorts and 1.43 (95% CI, 1.11 to 1.84) among other cohorts. Results were similar for cardiovascular and noncardiovascular causes of death and stronger for longer antecedent periods (3 versus <3 years). We conclude that prior decline or rise in eGFR associates with an increased risk of mortality, independent of current eGFR.
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Affiliation(s)
- David M J Naimark
- Division of Nephrology, Sunnybrook Health Sciences Centre and Institute of Health Policy Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Corri Black
- Institute of Applied Health Science, University of Aberdeen, Aberdeen, United Kingdom
| | - Iefke Drion
- Diabetes Centre, Isala Clinics, Zwolle, The Netherlands
| | - Caroline S Fox
- National Heart, Lung, and Blood Institute's Framingham Heart Study, Center for Population Studies, Framingham, Massachusetts; Division of Endocrinology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Areef Ishani
- Section of Nephrology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Sun Ha Jee
- Department of Epidemiology and Health Promotion, Institute for Health Promotion, Graduate School of Public Health, Yonsei University, Seoul, Korea
| | - Akihiko Kitamura
- Osaka Center for Cancer and Cardiovascular Disease Prevention, Osaka, Japan
| | - Janice P Lea
- Renal Division, Emory University School of Medicine, Atlanta, Georgia
| | - Joseph Nally
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland, Ohio
| | - Carmen Alicia Peralta
- Department of Medicine, University of California and San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Dietrich Rothenbacher
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Seungho Ryu
- Kangbuk Samsung Hospital, Sunkgyunkwan University School of Medicine, Seoul, Korea
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hiroshi Yatsuya
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - David G Warnock
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark Woodward
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; The George Institute for Global Health, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; and The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Paul E de Jong
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Canales MT, Blackwell T, Ishani A, Taylor BC, Hart A, Barrett-Connor E, Lewis C, Beyth RJ, Stone K, Ensrud KE. Estimated GFR and Mortality in Older Men: Are All eGFR Formulae Equal. Am J Nephrol 2016; 43:325-33. [PMID: 27166079 PMCID: PMC4881738 DOI: 10.1159/000445757] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/18/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Recently, the first estimated glomerular filtration rate (eGFR) formula specifically developed for community-dwelling older adults, the Berlin Initiative Study Equation 2 (BIS2), was reported. To date, however, no study has examined the performance of the BIS2 to predict death in older adults as compared to equations used clinically and in research. METHODS We prospectively followed 2,994 community-dwelling men (age 76.4 ± 5.6) enrolled in the MrOS Sleep Study. We calculated baseline eGFR from serum creatinine and cystatin-C using the BIS2, Chronic Kidney Disease Epidemiology (CKD-EPIcr,cysc), CKD-EPIcysc and CKD-EPIcr equations. Analyses included Cox-proportional hazards regression and net reclassification improvement (NRI) for the outcomes of all-cause and cardiovascular death. RESULTS Follow-up time was 7.3 ± 1.9 years. By BIS2, 42 and 11% had eGFR <60 and <45, respectively, compared to CKD-EPIcr (23 and 6%), CKD-EPIcysc (36 and 13%) and CKD-EPIcr,cysc (28 and 8%). BIS2 eGFR <45 was associated with twofold higher rate of all-cause mortality when compared to eGFR ≥75 after multivariate adjustment (HR 2.1, 95% CI 1.5-2.8). Results were similar for CKD-EPIcr,cysc <45 (HR 2.1, 95% CI 1.6-2.7) and CKD-EPIcysc <45 (HR 2.1, 95% CI 1.7-2.7) and weaker for CKD-EPIcr <45 (HR 1.5, 95% CI 1.2-2.0). In NRI analyses, when compared to CKD-EPIcr,cysc, both BIS2 and CKD-EPIcr equations more often misclassified participants with respect to mortality. We found similar results for cardiovascular death. CONCLUSION The BIS2 did not outperform and the CKD-EPIcr was inferior to the cystatin C-based CKD-EPI equations to predict death in this cohort of older men. Thus, the cystatin C-based CKD-EPI equations are the formulae of choice to predict death in community-dwelling older men.
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Affiliation(s)
- Muna T Canales
- Department of Medicine, Malcom-Randall VAMC, University of Florida, Gainesville, Fl., USA
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Ishani A, Christopher J, Palmer D, Otterness S, Clothier B, Nugent S, Nelson D, Rosenberg ME. Telehealth by an Interprofessional Team in Patients With CKD: A Randomized Controlled Trial. Am J Kidney Dis 2016; 68:41-9. [PMID: 26947216 DOI: 10.1053/j.ajkd.2016.01.018] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/14/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Telehealth and interprofessional case management are newer strategies of care within chronic disease management. We investigated whether an interprofessional team using telehealth was a feasible care delivery strategy and whether this strategy could affect health outcomes in patients with chronic kidney disease (CKD). STUDY DESIGN Randomized clinical trial. SETTING & PARTICIPANTS Minneapolis Veterans Affairs Health Care System (VAHCS), St. Cloud VAHCS, and affiliated clinics March 2012 to November 2013 in patients with CKD (estimated glomerular filtration rate < 60mL/min/1.73m(2)). INTERVENTIONS Patients were randomly assigned to receive an intervention (n=451) consisting of care by an interprofessional team (nephrologist, nurse practitioner, nurses, clinical pharmacy specialist, psychologist, social worker, and dietician) using a telehealth device (touch screen computer with peripherals) or to usual care (n=150). OUTCOMES The primary end point was a composite of death, hospitalization, emergency department visits, or admission to skilled nursing facilities, compared to usual care. RESULTS Baseline characteristics of the overall study group: mean age, 75.1±8.1 (SD) years; men, 98.5%; white, 97.3%; and mean estimated glomerular filtration rate, 37±9mL/min/1.73m(2). Telehealth and interprofessional care were successfully implemented with meaningful engagement with the care system. One year after randomization, 208 (46.2%) patients in the intervention group versus 70 (46.7%) in the usual-care group had the primary composite outcome (HR, 0.98; 95% CI, 0.75-1.29; P=0.9). There was no difference between groups for any component of the primary outcome: all-cause mortality (HR, 1.46; 95% CI, 0.42-5.11), hospitalization (HR, 1.15; 95% CI, 0.80-1.63), emergency department visits (HR, 0.92; 95% CI, 0.68-1.24), or nursing home admission (HR, 3.07; 95% CI, 0.71-13.24). LIMITATIONS Older population, mostly men, potentially underpowered/wide CIs. CONCLUSIONS Telehealth by an interprofessional team is a feasible care delivery strategy in patients with CKD. There was no statistically significant evidence of superiority of this intervention on health outcomes compared to usual care.
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Affiliation(s)
- Areef Ishani
- Section of Renal Diseases and Hypertension, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN; Division of Renal Diseases and Hypertension, University of Minnesota Medical School, Minneapolis, MN.
| | - Juleen Christopher
- Section of Renal Diseases and Hypertension, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Deirdre Palmer
- Section of Renal Diseases and Hypertension, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Sara Otterness
- Section of Renal Diseases and Hypertension, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Barbara Clothier
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - David Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Mark E Rosenberg
- Division of Renal Diseases and Hypertension, University of Minnesota Medical School, Minneapolis, MN
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Slinin Y, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, Wilt TJ. Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: a systematic review for a KDOQI clinical practice guideline. Am J Kidney Dis 2016; 66:823-36. [PMID: 26498415 DOI: 10.1053/j.ajkd.2014.11.031] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/03/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND In 2006, NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) published clinical practice guidelines for hemodialysis adequacy. Recent studies evaluating hemodialysis adequacy as determined by initiation timing, frequency, duration, and membrane type and prompted an update to the guideline. STUDY DESIGN Systematic review and evidence synthesis. SETTING & POPULATION Patients with advanced chronic kidney disease receiving hemodialysis. SELECTION CRITERIA FOR STUDIES We screened publications from 2000 to March 2014, systematic reviews, and references and consulted the NKF-KDOQI Hemodialysis Adequacy Work Group members. We included randomized or controlled clinical trials in patients undergoing long-term hemodialysis if they reported outcomes of interest. INTERVENTIONS Early versus late dialysis therapy initiation; more frequent (>3 times a week) or longer duration (>4.5 hours) compared to conventional hemodialysis; low- versus high-flux dialyzer membranes. OUTCOMES All-cause and cardiovascular mortality, myocardial infarction, stroke, hospitalizations, quality of life, depression or cognitive function scores, blood pressure, number of antihypertensive medications, left ventricular mass, interdialytic weight gain, and harms or complications related to vascular access or the process of dialysis. RESULTS We included 32 articles reporting on 19 trials. Moderate-quality evidence indicated that earlier dialysis therapy initiation (at estimated creatinine clearance [eClcr] of 10-14mL/min) did not reduce mortality compared to later initiation (eClcr of 5-7mL/min). More than thrice-weekly hemodialysis and extended-length hemodialysis during a short follow-up did not improve clinical outcomes compared to conventional hemodialysis and resulted in a greater number of vascular access procedures (very low-quality evidence). Hemodialysis using high-flux membranes did not reduce all-cause mortality, but reduced cardiovascular mortality compared to hemodialysis using low-flux membranes (moderate-quality evidence). LIMITATIONS Few studies were adequately powered to evaluate mortality. Heterogeneity of study designs and interventions precluded pooling data for most outcomes. CONCLUSIONS Limited data indicate that earlier dialysis therapy initiation and more frequent and longer hemodialysis did not improve clinical outcomes compared to conventional hemodialysis.
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Affiliation(s)
- Yelena Slinin
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN; Department of Medicine, University of Minnesota, Minneapolis, MN.
| | - Nancy Greer
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN
| | - Areef Ishani
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN; Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | - Carin Olson
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Indulis Rutks
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN
| | - Timothy J Wilt
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN; Department of Medicine, University of Minnesota, Minneapolis, MN
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Katkish L, Rector T, Ishani A, Gupta P. Incidence and severity of pseudohyperkalemia in chronic lymphocytic leukemia: a longitudinal analysis. Leuk Lymphoma 2016; 57:1952-5. [DOI: 10.3109/10428194.2015.1117608] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Daugirdas JT, Depner TA, Inrig J, Mehrotra R, Rocco MV, Suri RS, Weiner DE, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, Slinin Y, Wilt TJ, Rocco M, Kramer H, Choi MJ, Samaniego-Picota M, Scheel PJ, Willis K, Joseph J, Brereton L. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am J Kidney Dis 2015; 66:884-930. [DOI: 10.1053/j.ajkd.2015.07.015] [Citation(s) in RCA: 603] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 07/31/2015] [Indexed: 12/13/2022]
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Grubbs V, Vittinghoff E, Taylor G, Kritz-Silverstein D, Powe N, Bibbins-Domingo K, Ishani A, Cummings SR. The association of periodontal disease with kidney function decline: a longitudinal retrospective analysis of the MrOS dental study. Nephrol Dial Transplant 2015; 31:466-72. [PMID: 26320037 DOI: 10.1093/ndt/gfv312] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 07/06/2015] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Identifying modifiable risk factors for chronic kidney disease (CKD) is essential for reducing its burden. Periodontal disease is common, modifiable and has been implicated as a novel potential CKD risk factor, but evidence of its association with kidney function decline over time is limited. METHODS In a longitudinal retrospective cohort of 761 elderly men with preserved kidney function [estimated glomerular filtration rate > 60 mL/min/1.73 m(2) using a calibrated creatinine and cystatin C (eGFRcr-cys) equation] at baseline, we performed multivariable Poisson's regression to examine the association of severe periodontal disease with incident CKD, defined as incident eGFRcr-cys <60 mL/min/1.73 m(2) and rapid (>5% annualized) eGFRcr-cys decline. Severe periodontal disease was defined in two ways: (i) ≥5 mm proximal attachment loss in 30% of teeth examined (European Workshop in Periodontology Group C, European Workshop); and (ii) 2+ interproximal sites with attachment loss ≥6 mm and 1+ interproximal sites with probing depth ≥5 mm (Centers for Disease Control/American Academy of Periodontology, CDC/AAP). RESULTS At baseline, the mean age was 73.4 (SD 4.8) years, the median eGFRcr-cys was 82.4 mL/min/1.73 m(2), and 35.5 and 25.4% of participants had severe periodontal disease by European Workshop and CDC/AAP criteria, respectively. After a mean follow-up of 4.9 years (SD 0.3), 56 (7.4%) participants had incident CKD. Severe periodontal disease was associated with a 2-fold greater rate of incident CKD [incidence rate ratio (IRR) 2.01 (1.21-3.44), P = 0.007] after adjusting for confounders compared with not severe periodontal disease by European Workshop criteria but did not reach statistical significance by CDC/AAP criteria [IRR 1.10 (0.63-1.91), P = 0.9]. CONCLUSIONS Severe periodontal disease may be associated with incident clinically significant kidney function decline among a cohort of elderly men.
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Affiliation(s)
- Vanessa Grubbs
- Division of Nephrology, University of California, San Francisco/San Francisco General Hospital, San Francisco, CA, USA
| | - Eric Vittinghoff
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - George Taylor
- Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco,San Francisco, CA, USA
| | - Donna Kritz-Silverstein
- Department of Family Medicine & Public Health, University of California, San Diego, San Diego, CA, USA
| | - Neil Powe
- Department of Medicine, University of California, San Francisco/San Francisco General Hospital, San Francisco, CA, USA
| | | | - Areef Ishani
- Division of Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - Steven R Cummings
- San Francisco Coordinating Center, California Pacific Medical Center Research Institute, San Francisco, CA, USA
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Wetmore JB, Liu J, Do TP, Lowe KA, Ishani A, Bradbury BD, Block GA, Collins AJ. Changes in secondary hyperparathyroidism-related biochemical parameters and medication use following parathyroidectomy. Nephrol Dial Transplant 2015; 31:103-11. [PMID: 26292694 DOI: 10.1093/ndt/gfv291] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 07/03/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Little is known about changes in parathyroid hormone (PTH), calcium and phosphorous levels after parathyroidectomy in hemodialysis patients. We studied the effects of parathyroidectomy on these biochemical values in a large cohort of patients receiving maintenance hemodialysis. METHODS This retrospective cohort study included patients identified in both the United States Renal Data System and the database of a large dialysis organization who underwent parathyroidectomy in 2007-09, were aged ≥ 18 years, had Medicare Parts A and B as primary payer and had received hemodialysis for ≥ 1 year pre-parathyroidectomy. Descriptive statistics were calculated for continuous variables; categorical variables were used to characterize the population and evaluate monthly laboratory and medication use; median values were calculated for laboratory measures. RESULTS Among 1402 parathyroidectomy patients, mean age was 48.9 years, 52.4% were males, 58.8% were African American and mean dialysis duration was 7.5 years. Median PTH levels increased over the year before parathyroidectomy from 1039 to 1661 pg/mL and decreased afterward to 98 pg/mL at 1 month; levels remained ≥ 897 pg/mL for 10% of patients. Median calcium levels fell from 9.6 mg/dL before to 7.9 mg/dL 1 month after parathyroidectomy; levels were ≤ 7.1 mg/dL for 25% and remained ≤ 7.2 mg/dL for the lowest 25% at 3 months. Median phosphorous level was 6.8 mg/dL immediately before parathyroidectomy, decreased to 3.8 mg/dL immediately after and reached 5.8 mg/dL at 1 year. CONCLUSIONS While PTH levels dropped after parathyroidectomy for most patients, surgery was sometimes ineffective in reducing levels and sometimes led to over-suppression. Hypocalcemia could be profound and long lasting, suggesting the need for prolonged vigilance.
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Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - Thy P Do
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Kimberly A Lowe
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Areef Ishani
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA Section of Renal Diseases and Hypertension, Minneapolis Veterans Administration Health Care System, Minneapolis, MN, USA Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Brian D Bradbury
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | | | - Allan J Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Katkish L, Rector T, Ishani A, Gupta P. Pseudohyperkalemia in Chronic Lymphocytic Leukemia. Longitudinal Analysis and Review of the Literature. Minn Med 2015; 98:45-46. [PMID: 26267922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Ishani A, Liu J, Wetmore JB, Lowe KA, Do T, Bradbury BD, Block GA, Collins AJ. Clinical outcomes after parathyroidectomy in a nationwide cohort of patients on hemodialysis. Clin J Am Soc Nephrol 2014; 10:90-7. [PMID: 25516915 DOI: 10.2215/cjn.03520414] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients receiving dialysis undergo parathyroidectomy to improve laboratory parameters in resistant hyperparathyroidism with the assumption that clinical outcomes will also improve. However, no randomized clinical trial data demonstrate the benefits of parathyroidectomy. This study aimed to evaluate clinical outcomes up to 1 year after parathyroidectomy in a nationwide sample of patients receiving hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using data from the US Renal Data System, this study identified prevalent hemodialysis patients aged ≥18 years with Medicare as primary payers who underwent parathyroidectomy from 2007 to 2009. Baseline characteristics and comorbid conditions were assessed in the year preceding parathyroidectomy; clinical events were identified in the year preceding and the year after parathyroidectomy. After parathyroidectomy, patients were censored at death, loss of Medicare coverage, kidney transplant, change in dialysis modality, or 365 days. This study estimated cause-specific event rates for both periods and rate ratios comparing event rates in the postparathyroidectomy versus preparathyroidectomy periods. RESULTS Of 4435 patients who underwent parathyroidectomy, 2.0% died during the parathyroidectomy hospitalization and the 30 days after discharge. During the 30 days after discharge, 23.8% of patients were rehospitalized; 29.3% of these patients required intensive care. In the year after parathyroidectomy, hospitalizations were higher by 39%, hospital days by 58%, intensive care unit admissions by 69%, and emergency room/observation visits requiring hypocalcemia treatment by 20-fold compared with the preceding year. Cause-specific hospitalizations were higher for acute myocardial infarction (rate ratio, 1.98; 95% confidence interval, 1.60 to 2.46) and dysrhythmia (rate ratio 1.4; 95% confidence interval1.16 to 1.78); fracture rates did not differ (rate ratio 0.82; 95% confidence interval 0.6 to 1.1). CONCLUSIONS Parathyroidectomy is associated with significant morbidity in the 30 days after hospital discharge and in the year after the procedure. Awareness of clinical events will assist in developing evidence-based risk/benefit determinations for the indication for parathyroidectomy.
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Affiliation(s)
- Areef Ishani
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota;
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - James B Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Kimberly A Lowe
- Center for Observational Research, Amgen Inc, Thousand Oaks, California; and
| | - Thy Do
- Center for Observational Research, Amgen Inc, Thousand Oaks, California; and
| | - Brian D Bradbury
- Center for Observational Research, Amgen Inc, Thousand Oaks, California; and
| | | | - Allan J Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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Slinin Y, Peters KW, Ishani A, Yaffe K, Fink HA, Stone KL, Steffes M, Ensrud KE. Cystatin C and cognitive impairment 10 years later in older women. J Gerontol A Biol Sci Med Sci 2014; 70:771-8. [PMID: 25362662 DOI: 10.1093/gerona/glu189] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 09/08/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Results of prospective studies examining the association between cystatin C and incident cognitive impairment have been inconsistent. We tested the hypothesis that there is a U-shaped association in older women between cystatin C and risk of incident cognitive impairment 10 years later. METHODS We conducted a longitudinal analysis of a prospective cohort of 1,332 community-dwelling elderly women without dementia at baseline who had baseline cystatin C and serum creatinine measurements and completed an extended cognitive battery of neuropsychological tests with determination of cognitive status 10 years later. Incident cognitive impairment was defined as either new onset of adjudicated diagnosis of mild cognitive impairment or dementia. RESULTS Incident mild cognitive impairment or dementia was identified among 140 (26.0%) women in quartile 1 (Q1), 122 (22.6%) in Q2, 121 (22.5%) in Q3, and 156 (28.9%) in Q4 of cystatin C. In the fully adjusted model, compared to women in Q2-Q3 of cystatin C, adjusted odds ratios (95% CI) for incident cognitive impairment were 1.31 (0.98-1.75) for Q1, and 1.25 (0.94-1.66) for Q4 Compared to women in Q2-Q3 of estimated glomerular filtration rate (eGFRCysC), adjusted odds ratios (95% CI) for incident cognitive impairment after 10 years of follow-up were 1.18 (0.88-1.58) for Q4 (eGFRCysC 76.1-109.4mL/min/1.73 m(2)) and 1.26 (0.94-1.67) for Q1 (eGFRCysC 21.8-55.5mL/min/1.73 m(2)). CONCLUSIONS These results support a U-shaped association between cystatin C concentration and risk of cognitive impairment or dementia 10 years later, but the association is not independent of potential confounding factors.
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Affiliation(s)
- Yelena Slinin
- Department of Medicine, University of Minnesota, Minneapolis. Department of Medicine, Minneapolis VA Health Care System, Minnesota.
| | | | - Areef Ishani
- Department of Medicine, University of Minnesota, Minneapolis. Department of Medicine, Minneapolis VA Health Care System, Minnesota
| | - Kristine Yaffe
- Department of Psychiatry, Neurology, and Epidemiology & Biostatistics, University of California, San Francisco
| | - Howard A Fink
- Department of Medicine, University of Minnesota, Minneapolis. Department of Medicine, Minneapolis VA Health Care System, Minnesota. Division of Epidemiology & Community Health and
| | - Katie L Stone
- California Pacific Medical Center Research Institute, San Francisco
| | - Michael Steffes
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | - Kristine E Ensrud
- Department of Medicine, University of Minnesota, Minneapolis. Department of Medicine, Minneapolis VA Health Care System, Minnesota. Division of Epidemiology & Community Health and
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