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Drawz P, Baumann D, Dayton A. Renal denervation: recent developments in clinical and preclinical research. Curr Opin Nephrol Hypertens 2023; 32:404-411. [PMID: 37530084 DOI: 10.1097/mnh.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
PURPOSE OF REVIEW Renal denervation represents a new dimension to hypertension treatment, with multiple device manufacturers seeking premarket FDA approval currently. Interest in the efficacy and safety of the treatment has spurred compelling mechanistic studies into the function of renal nerves and downstream impacts of denervation. RECENT FINDINGS A trial of the ultrasound Paradise Catheter system (RADIANCE II) found a 6.3 mmHg reduction in SBP relative to sham controls. A trial of the Symplicity Spyral system (SPYRAL HTN-ON MED) found an insignificant reduction in SBP relative to sham controls. Individuals were taking antihypertensive medications during the study, and investigators note the sham group experienced a larger medication burden than the denervated group. Recent preclinical studies have evaluated potential risks of renal denervation, how sympathetic activity broadly is affected, as well as identifying possible biomarkers to identify individuals where denervation would be more successful. SUMMARY Studies of renal denervation continue to find a robust antihypertensive effect, especially in studies wherein medications are withdrawn. Further investigation into mechanisms and indicators for usage of the technique will be important in identifying the patient population most likely to benefit from usage of renal denervation.
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Affiliation(s)
- Paul Drawz
- Department of Medicine, Division of Nephrology and Hypertension
| | - Daniel Baumann
- Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Alex Dayton
- Department of Medicine, Division of Nephrology and Hypertension
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2
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McCoy IE, Hsu JY, Zhang X, Diamantidis CJ, Taliercio J, Go AS, Liu KD, Drawz P, Srivastava A, Horwitz EJ, He J, Chen J, Lash JP, Weir MR, Hsu CY. Probing the Association between Acute Kidney Injury and Cardiovascular Outcomes. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00137. [PMID: 37116457 PMCID: PMC10356151 DOI: 10.2215/cjn.0000000000000163] [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: 01/10/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Patients hospitalized with AKI have higher subsequent risks of heart failure, atherosclerotic cardiovascular events, and mortality than their counterparts without AKI, but these higher risks may be due to differences in prehospitalization patient characteristics, including the baseline level of estimated glomerular filtration rate (eGFR), the rate of prior eGFR decline, and the proteinuria level, rather than AKI itself. METHODS Among 2177 adult participants in the Chronic Renal Insufficiency Cohort study who were hospitalized in 2013-2019, we compared subsequent risks of heart failure, atherosclerotic cardiovascular events, and mortality between those with serum creatinine-based AKI (495 patients) and those without AKI (1682 patients). We report both crude associations and associations sequentially adjusted for prehospitalization characteristics including eGFR, eGFR slope, and urine protein-creatinine ratio (UPCR). RESULTS Compared with patients hospitalized without AKI, those with hospitalized AKI had lower eGFR prehospitalization (42 versus 49 ml/min per 1.73 m 2 ), faster chronic loss of eGFR prehospitalization (-0.84 versus -0.51 ml/min per 1.73 m 2 per year), and more proteinuria prehospitalization (UPCR 0.28 versus 0.16 g/g); they also had higher prehospitalization systolic BP (130 versus 127 mm Hg; P < 0.01 for all comparisons). Adjustment for prehospitalization patient characteristics attenuated associations between AKI and all three outcomes, but AKI remained an independent risk factor. Attenuation of risk was similar after adjustment for absolute eGFR, eGFR slope, or proteinuria, individually or in combination. CONCLUSIONS Prehospitalization variables including eGFR, eGFR slope, and proteinuria confounded associations between AKI and adverse cardiovascular outcomes, but these associations remained significant after adjusting for prehospitalization variables.
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Affiliation(s)
- Ian E. McCoy
- Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Jesse Y. Hsu
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xiaoming Zhang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Jonathan Taliercio
- Department of Kidney Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Kathleen D. Liu
- Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Paul Drawz
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota
| | - Anand Srivastava
- Division of Nephrology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Edward J. Horwitz
- Division of Nephrology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jiang He
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | - Jing Chen
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
- Division of Nephrology, Tulane University, New Orleans, Louisiana
| | - James P. Lash
- Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - Matthew R. Weir
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Chi-yuan Hsu
- Division of Nephrology, University of California San Francisco, San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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3
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Bozio CH, Butterfield KA, Briggs Hagen M, Grannis S, Drawz P, Hartmann E, Ong TC, Fireman B, Natarajan K, Dascomb K, Gaglani M, DeSilva MB, Yang DH, Midgley CM, Dixon BE, Naleway AL, Grisel N, Liao IC, Reese SE, Fadel WF, Irving SA, Lewis N, Arndorfer J, Murthy K, Riddles J, Valvi NR, Mamawala M, Embi PJ, Thompson MG, Stenehjem E. Protection from COVID-19 mRNA vaccination and prior SARS-CoV-2 infection against COVID-19-associated encounters in adults during Delta and Omicron predominance. J Infect Dis 2023:7045997. [PMID: 36806690 DOI: 10.1093/infdis/jiad040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 09/21/2022] [Revised: 01/27/2023] [Accepted: 02/10/2023] [Indexed: 02/20/2023] Open
Abstract
BACKGROUND Data assessing protection conferred from COVID-19 mRNA vaccination and/or prior SARS-CoV-2 infection during Delta and Omicron predominance periods in the U.S. are limited. METHODS This cohort study included persons ≥18 years who had ≥1 healthcare encounter across four health systems and had been tested for SARS-CoV-2 before August 26, 2021. COVID-19 mRNA vaccination and prior SARS-CoV-2 infection defined the exposure. Cox regression estimated hazard ratios (HRs) for the Delta and Omicron periods; protection was calculated as (1-HR)x100%. RESULTS Compared to unvaccinated and previously uninfected persons, during Delta predominance, protection against COVID-19-associated hospitalizations was high for those 2- or 3-dose vaccinated and previously infected, 3-dose vaccinated alone, and prior infection alone (range:91%-97%, with overlapping 95% confidence intervals (95%CIs)); during Omicron predominance, estimates were lower (range:77%-90%). Protection against COVID-19-associated emergency department/urgent care (ED/UC) encounters during Delta predominance was high for those exposure groups (range:86%-93%); during Omicron predominance, protection remained high for those 3-dose vaccinated with or without a prior infection (76% (95%CI=67%-83%) and 71% (95%CI=67%-73%), respectively). CONCLUSIONS COVID-19 mRNA vaccination and/or prior SARS-CoV-2 infection provided protection against COVID-19-associated hospitalizations and ED/UC encounters regardless of variant. Staying up-to-date with COVID-19 vaccination still provides protection against severe COVID-19 disease, regardless of prior infection.
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Affiliation(s)
- Catherine H Bozio
- Centers for Disease Control and Prevention COVID-19 Emergency Response Team, Atlanta, Georgia, USA
| | | | - Melissa Briggs Hagen
- Centers for Disease Control and Prevention COVID-19 Emergency Response Team, Atlanta, Georgia, USA
| | - Shaun Grannis
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA.,Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Paul Drawz
- Division of Nephrology & Hypertension, University of Minnesota, Minneapolis, Minnesota, USA
| | - Emily Hartmann
- Paso Del Norte Health Information Exchange, El Paso, Texas, USA
| | - Toan C Ong
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Bruce Fireman
- Kaiser Permanente Vaccine Study Center, Kaiser Permanente Northern California Division of Research, Oakland, California, USA
| | - Karthik Natarajan
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA.,New York Presbyterian Hospital, New York, New York, USA
| | - Kristin Dascomb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Manjusha Gaglani
- Baylor Scott & White Health, Texas A&M University College of Medicine, Temple, Texas, USA.,Texas A&M University College of Medicine, Temple, Texas
| | | | | | - Claire M Midgley
- Centers for Disease Control and Prevention COVID-19 Emergency Response Team, Atlanta, Georgia, USA
| | - Brian E Dixon
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Allison L Naleway
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Nancy Grisel
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - I-Chia Liao
- Baylor Scott & White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | | | - William F Fadel
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Stephanie A Irving
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Ned Lewis
- Kaiser Permanente Vaccine Study Center, Kaiser Permanente Northern California Division of Research, Oakland, California, USA
| | - Julie Arndorfer
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Kempapura Murthy
- Baylor Scott & White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | | | - Nimish R Valvi
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Mufaddal Mamawala
- Baylor Scott & White Health, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Peter J Embi
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA.,Regenstrief Institute, Indianapolis, Indiana, USA
| | - Mark G Thompson
- Centers for Disease Control and Prevention COVID-19 Emergency Response Team, Atlanta, Georgia, USA
| | - Edward Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
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Whelton PK, Picone DS, Padwal R, Campbell NRC, Drawz P, Rakotz MK, Parati G, Zhang XH, Sharman JE. Global proliferation and clinical consequences of non-validated automated BP devices. J Hum Hypertens 2023; 37:115-119. [PMID: 35279699 DOI: 10.1038/s41371-022-00667-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 02/06/2022] [Accepted: 02/23/2022] [Indexed: 01/13/2023]
Abstract
Professional societies, guideline writing committees, and other interested parties emphasize the importance of accurate measurement of blood pressure for clinical and public health decisions related to prevention, treatment, and follow-up of high blood pressure. Use of a clinically validated instrument to measure blood pressure is a central component of measurement accuracy and precision. Despite this, most regulatory authorities do not specify validation requirements that manufacturers must meet to sell their blood pressure measurement devices. Likewise, device validity is not a major area of focus for most consumers and healthcare providers, perhaps because they assume it is a pre-requisite for market approval. This has led to a global proliferation of non-validated blood pressure measurement devices, with only a small minority of blood pressure measurement devices having passed internationally accepted validation protocols. The clinical consequences are likely to be significant because non-validated devices are more likely to provide inaccurate estimates of blood pressure compared with validated devices. Even small inaccuracies in blood pressure measurement can result in substantial misdiagnosis and mistreatment of hypertension. There is an urgent need for clinical validation of blood pressure measurement devices prior to marketing them to consumers. There is also need for simplification of the process for consumers and healthcare providers to determine whether a blood pressure measurement device has successfully met an internationally accepted test of validity.
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Affiliation(s)
- Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
| | - Dean S Picone
- Menzies institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Raj Padwal
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Paul Drawz
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, and Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Xin-Hua Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - James E Sharman
- Menzies institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
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Murray AM, Slinin Y, Tupper DE, Pederson SL, Davey C, Gilbertson DT, Drawz P, Mello R, Hart A, Johansen KL, Reule S, Rossom R, Knopman DS. Kidney-Metabolic Factors Associated with Cognitive Impairment in Chronic Kidney Disease: A Pilot Study. Am J Nephrol 2022; 53:435-445. [PMID: 35483332 PMCID: PMC9361741 DOI: 10.1159/000524166] [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: 12/17/2021] [Accepted: 03/11/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The associations of kidney-metabolic biomarkers with cognitive impairment (CI) beyond the estimated glomerular filtration rate (eGFR, in mL/min/1.73 m2) and albuminuria levels are not well understood. In exploratory analysis, our objective was to determine the extent that three kidney-metabolic factors, previously proposed as mechanisms of CI and commonly abnormal in chronic kidney disease (CKD), were associated with prevalent CI in CKD participants, adjusted for kidney function measures. METHODS The study cohort included community-dwelling individuals aged ≥45 years with CKD (eGFR <60), not requiring dialysis, recruited from four health systems. We examined the serum biomarkers bicarbonate (CO2), TNFαR1, and cholesterol as primary exposures. A structured neuropsychological battery conducted by trained staff measured global and domain-specific cognitive performance. Logistic regression analyses estimated the cross-sectional associations between kidney-metabolic measures and global and cognitive domain-specific moderate/severe (Mod/Sev) CI, adjusted for the eGFR, urinary albumin-creatinine ratio (UACR, mg/g), demographics, comorbid conditions, and other kidney-metabolic biomarkers commonly abnormal in CKD. RESULTS Among 436 CKD participants with mean age 70 years, 16% were Black, the mean eGFR was 34, and the median [IQR] UACR was 49 [0.0, 378] mg/g. In adjusted models, increased TNFαR1 was associated with global Mod/Sev CI (odds ratio [95% confidence interval] = 1.40 [1.02, 1.93]; p = 0.04); low bicarbonate (CO2 <20 mEq/L) with Mod/Sev memory impairment (3.04 [1.09, 8.47]; p = 0.03), and each 10-mg/dL lower cholesterol was associated with Mod/Sev executive function/processing speed impairment (1.12 [1.02, 1.23]; p = 0.02). However, after adjustment for multiple comparisons, these associations were no longer significant nor were any other kidney-metabolic factors significant for any CI classification. CONCLUSION In exploratory analyses in a CKD population, three kidney-metabolic factors were associated with CI, but after adjustment for multiple comparisons, were no longer significant. Future studies in larger CKD populations are needed to assess these potential risk factors for CI.
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Affiliation(s)
- Anne M Murray
- The Berman Center for Outcomes and Clinical Research, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Division of Geriatrics, Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Yelena Slinin
- Kaiser Permanente Fremont Medical Center, Fremont, California, USA
| | - David E Tupper
- Department of Psychology and Neuropsychology, Hennepin Healthcare Minneapolis, Minneapolis, Minnesota, USA.,Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Cynthia Davey
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | - David T Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Paul Drawz
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ryan Mello
- Division of Nephrology, Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Allyson Hart
- Division of Nephrology, Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Kirsten L Johansen
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Division of Nephrology, Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Scott Reule
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Nephrology Division, Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | | | - David S Knopman
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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6
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Sakhuja S, Jaeger BC, Akinyelure OP, Bress AP, Shimbo D, Schwartz JE, Hardy ST, Howard G, Drawz P, Muntner P. Potential impact of systematic and random errors in blood pressure measurement on the prevalence of high office blood pressure in the United States. J Clin Hypertens (Greenwich) 2022; 24:263-270. [PMID: 35137521 PMCID: PMC8925005 DOI: 10.1111/jch.14418] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 09/29/2021] [Revised: 11/22/2021] [Accepted: 12/08/2021] [Indexed: 11/29/2022]
Abstract
The authors examined the proportion of US adults that would have their high blood pressure (BP) status changed if systolic BP (SBP) and diastolic BP (DBP) were measured with systematic bias and/or random error versus following a standardized protocol. Data from the 2017-2018 National Health and Nutrition Examination Survey (NHANES; n = 5176) were analyzed. BP was measured up to three times using a mercury sphygmomanometer by a trained physician following a standardized protocol and averaged. High BP was defined as SBP ≥130 mm Hg or DBP ≥80 mm Hg. Among US adults not taking antihypertensive medication, 32.0% (95%CI: 29.6%,34.4%) had high BP. If SBP and DBP were measured with systematic bias, 5 mm Hg for SBP and 3.5 mm Hg for DBP higher and lower than in NHANES, the proportion with high BP was estimated to be 44.4% (95%CI: 42.6%,46.2%) and 21.9% (95%CI 19.5%,24.4%). Among US adults taking antihypertensive medication, 60.6% (95%CI: 57.2%,63.9%) had high BP. If SBP and DBP were measured 5 and 3.5 mm Hg higher and lower than in NHANES, the proportion with high BP was estimated to be 71.8% (95%CI: 68.3%,75.0%) and 48.4% (95%CI: 44.6%,52.2%), respectively. If BP was measured with random error, with standard deviations of 15 mm Hg for SBP and 7 mm Hg for DBP, 21.4% (95%CI: 19.8%,23.0%) of US adults not taking antihypertensive medication and 20.5% (95%CI: 17.7%,23.3%) taking antihypertensive medication had their high BP status re-categorized. In conclusions, measuring BP with systematic or random errors may result in the misclassification of high BP for a substantial proportion of US adults.
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Affiliation(s)
- Swati Sakhuja
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Byron C Jaeger
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Adam P Bress
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Daichi Shimbo
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Joseph E Schwartz
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.,Department of Psychiatry and Behavioral Health, Renaissance School of Medicine, Stony Brook, New York, USA
| | - Shakia T Hardy
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Paul Drawz
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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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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8
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Ghazi L, Cohen J, Townsend RR, Drawz P, Rahman M, Pradhan N, Cohen DL, Weir MR, Rincon-choles H, Juraschek SP. Abstract P112: Orthostatic Hypotension, Orthostatic Hypertension And Ambulatory Blood Pressure In Patients With Chronic Kidney Disease: Findings From The Chronic Renal Insufficiency Cohort Study. Hypertension 2021. [DOI: 10.1161/hyp.78.suppl_1.p112] [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
Background:
We recently demonstrated how orthostatic hypotension might be used to identify out-of-office blood pressure phenotypes, including white coat effects and nocturnal non-dipping patterns. However, these findings have not been replicated in a population with chronic kidney disease (CKD).
Objective:
To examine the association between orthostatic hypotension (OH) or hypertension (OHTN) with ambulatory BP in adults with CKD.
Methods:
CRIC is a prospective multicenter observation cohort study of participants with CKD. Standing BP at 1 minute and ABPM were obtained on 1467 participants. OH was defined as a 20mmHg drop in systolic BP (SBP) or 10 mmHg drop in diastolic BP (DBP) when changing from seated to standing positions. OHTN was defined as a 20 mmHg or 10mmHg rise in SBP or DBP respectively when changing from seated to standing position. White coat effects, based on ABPM, was defined as the difference between seated clinic and ambulatory BP. Systolic and diastolic night to day ratio was also calculated.
Results:
Of the 1467 participants (age: 58 ± 10 yrs, 44% female, 39% black) 73 had OH and 165 had OHTN). OH was positively associated with systolic and diastolic white coat effect (β=5.9 [0.9, 10.9] and 4.2 [1.3, 7.1]). OHTN was negatively associated with diastolic white coat effect (-4.9 [-6.9, -3]). OH was positively associated with systolic and diastolic night-to-day ratio (0.03 [0.01, 0.05] and 0.03 [0.01, 0.06] respectively).
Conclusions:
Clinic-based assessments of OH and OHTN may be useful for identifying BP phenotypes often missed with seated office BP measurements in CKD patients.
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Lakshminarayan K, Murray TA, Westberg SM, Connett J, Overton V, Nyman JA, Culhane-Pera KA, Pergament SL, Drawz P, Vollbrecht E, Xiong T, Everson-Rose SA. Mobile Health Intervention to Close the Guidelines-To-Practice Gap in Hypertension Treatment: Protocol for the mGlide Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e25424. [PMID: 33492231 PMCID: PMC7870345 DOI: 10.2196/25424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 11/29/2020] [Accepted: 12/18/2020] [Indexed: 12/29/2022] Open
Abstract
Background Suboptimal treatment of hypertension remains a widespread problem, particularly among minorities and socioeconomically disadvantaged groups. We present a health system–based intervention with diverse patient populations using readily available smartphone technology. This intervention is designed to empower patients and create partnerships between patients and their provider team to promote hypertension control. Objective The mGlide randomized controlled trial is a National Institutes of Health–funded study, evaluating whether a mobile health (mHealth)-based intervention that is an active partnership between interprofessional health care teams and patients results in better hypertension control rates than a state-of-clinical care comparison. Methods We are recruiting 450 participants including stroke survivors and primary care patients with elevated cardiovascular disease risk from diverse health systems. These systems include an acute stroke service (n=100), an academic medical center (n=150), and community medical centers including Federally Qualified Health Centers serving low-income and minority (Latino, Hmong, African American, Somali) patients (n=200). The primary aim tests the clinical effectiveness of the 6-month mHealth intervention versus standard of care. Secondary aims evaluate sustained hypertension control rates at 12 months; describe provider experiences of system usability and satisfaction; examine patient experiences, including medication adherence and medication use self-efficacy, self-rated health and quality of life, and adverse event rates; and complete a cost-effectiveness analysis. Results To date, we have randomized 107 participants (54 intervention, 53 control). Conclusions This study will provide evidence for whether a readily available mHealth care model is better than state-of-clinical care for bridging the guideline-to-practice gap in hypertension treatment in health systems serving diverse patient populations. Trial Registration Clinicaltrials.gov NCT03612271; https://clinicaltrials.gov/ct2/show/NCT03612271 International Registered Report Identifier (IRRID) DERR1-10.2196/25424
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Affiliation(s)
- Kamakshi Lakshminarayan
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Sarah M Westberg
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Val Overton
- Fairview Health Services, Minneapolis, MN, United States
| | - John A Nyman
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Kathleen A Culhane-Pera
- SoLaHmo Partnership for Health and Wellness, Minneapolis, MN, United States.,Minnesota Community Care, Saint Paul, MN, United States
| | | | - Paul Drawz
- Division of Renal Disease and Hypertension, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Emily Vollbrecht
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Txia Xiong
- SoLaHmo Partnership for Health and Wellness, Minneapolis, MN, United States
| | - Susan A Everson-Rose
- Department of Medicine and Program in Health Disparities Research, Medical School, University of Minnesota, Minneapolis, MN, United States
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10
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Ghazi L, Drawz P, Pajewski N, Juraschek SP. Abstract P172: Orthostatic Hypotension And 24-hr Ambulatory Blood Pressure Monitoring In The Sprint Trial. Hypertension 2020. [DOI: 10.1161/hyp.76.suppl_1.p172] [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
Background:
Clinic blood pressure (BP) is measured in the seated position, which can miss important home BP phenotypes such as low ambulatory BP (white coat effects) or high supine BP (nocturnal non-dippers). Orthostatic hypotension (OH) is determined based on BP measurements in both seated (or supine) and standing positions, and thus could theoretically identify these important phenotypes in clinic.
Objective:
To determine the association of OH with white coat effects or night-to-daytime systolic BP (SBP)
Methods:
SPRINT was a randomized trial testing the effects of intensive (<120 mmHg) or standard (<140 mmHg) SBP treatment strategies in adults at higher risk of cardiovascular disease. OH was assessed at 6, 12, or 24-mths and defined as a decrease in standing and mean seated SBP ≥20 or DBP ≥10 mmHg after 1 min of standing. White coat effects, based on 24-hr ambulatory BP monitoring performed at the 27-mth visit (every 30-minutes), were defined as the difference between 27-mth seated clinic and ambulatory BP ≥ 20/≥10 mmHg. SBP dipping ratio was defined as the ratio of night-to-daytime SBP >0.9.
Results:
Of 897 adults (mean age 71.5 [SD, 9.5] yrs, 28.7% female, 28.0% black), 128 had OH at least once. Among those with OH, 14.8% had white coat effects versus 7.2% among those without OH. Moreover, 68.8% of those with OH demonstrated non-dipping patterns versus only 52.0% of those without OH. OH was positively associated with both white coat effects (OR=2.24; 95% CI: 1.28, 4.27) and higher night-to-daytime SBP (β=0.04; 95% CI: 0.02, 0.06) (
Table
).
Conclusions:
Clinic-based assessments of OH may be a useful tool for identifying BP phenotypes often missed with traditional seated BP assessments.
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11
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Chang AR, Kramer H, Wei G, Boucher R, Grams ME, Berlowitz D, Bhatt U, Cohen DL, Drawz P, Punzi H, Freedman BI, Haley W, Hawfield A, Horwitz E, McLouth C, Morisky D, Papademetriou V, Rocco MV, Wall B, Weiner DE, Zias A, Beddhu S. Effects of Intensive Blood Pressure Control in Patients with and without Albuminuria: Post Hoc Analyses from SPRINT. Clin J Am Soc Nephrol 2020; 15:1121-1128. [PMID: 32669306 PMCID: PMC7409741 DOI: 10.2215/cjn.12371019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 10/11/2019] [Accepted: 06/12/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES It is unclear whether the presence of albuminuria modifies the effects of intensive systolic BP control on risk of eGFR decline, cardiovascular events, or mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Systolic Blood Pressure Intervention Trial randomized nondiabetic adults ≥50 years of age at high cardiovascular risk to a systolic BP target of <120 or <140 mm Hg, measured by automated office BP. We compared the absolute risk differences and hazard ratios of ≥40% eGFR decline, the Systolic Blood Pressure Intervention Trial primary cardiovascular composite outcome, and all-cause death in those with or without baseline albuminuria (urine albumin-creatinine ratio ≥30 mg/g). RESULTS Over a median follow-up of 3.1 years, 69 of 1723 (4%) participants with baseline albuminuria developed ≥40% eGFR decline compared with 61 of 7162 (1%) participants without albuminuria. Incidence rates of ≥40% eGFR decline were higher in participants with albuminuria (intensive, 1.74 per 100 person-years; standard, 1.17 per 100 person-years) than in participants without albuminuria (intensive, 0.48 per 100 person-years; standard, 0.11 per 100 person-years). Although effects of intensive BP lowering on ≥40% eGFR decline varied by albuminuria on the relative scale (hazard ratio, 1.48; 95% confidence interval, 0.91 to 2.39 for albumin-creatinine ratio ≥30 mg/g; hazard ratio, 4.55; 95% confidence interval, 2.37 to 8.75 for albumin-creatinine ratio <30 mg/g; P value for interaction <0.001), the absolute increase in ≥40% eGFR decline did not differ by baseline albuminuria (incidence difference, 0.38 events per 100 person-years for albumin-creatinine ratio ≥30 mg/g; incidence difference, 0.58 events per 100 person-years for albumin-creatinine ratio <30 mg/g; P value for interaction =0.60). Albuminuria did not significantly modify the beneficial effects of intensive systolic BP lowering on cardiovascular events or mortality evaluated on relative or absolute scales. CONCLUSIONS Albuminuria did not modify the absolute benefits and risks of intensive systolic BP lowering.
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Affiliation(s)
- Alex R Chang
- Kidney Health Research Institute, Department of Population Health Sciences, Geisinger Health System, Danville, Pennsylvania
| | - Holly Kramer
- Division of Nephrology, Loyola University Medical Center, Maywood, Illinois
| | - Guo Wei
- Division of Nephrology & Hypertension, University of Utah School of Medicine, Salt Lake City, Utah
| | - Robert Boucher
- Division of Nephrology & Hypertension, University of Utah School of Medicine, Salt Lake City, Utah
| | - Morgan E Grams
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dan Berlowitz
- Department of Public Health, University of Massachusetts-Lowell, Lowell, Massachusetts
| | - Udayan Bhatt
- Division of Nephrology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Debbie L Cohen
- Renal Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, Minnesota
| | - Henry Punzi
- Punzi Medical Center, Trinity Hypertension and Metabolic Research Institute, Carollton, Texas
| | - Barry I Freedman
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - William Haley
- Division of Nephrology, Mayo Clinic, Jacksonville, Florida
| | - Amret Hawfield
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Edward Horwitz
- Division of Nephrology, MetroHealth Medical Center, Cleveland, Ohio
| | - Christopher McLouth
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Don Morisky
- Department of Community Health Sciences, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Vasilios Papademetriou
- Department of Cardiology, Veterans Affairs Medical Center, Georgetown University, Washington, DC
| | - Michael V Rocco
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Barry Wall
- Division of Nephrology, Veterans Affairs Medical Center, Memphis, Tennessee
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Athena Zias
- Stony Brook University School of Medicine, Stony Brook, New York
| | - Srinivasan Beddhu
- Division of Nephrology & Hypertension, University of Utah School of Medicine, Salt Lake City, Utah.,Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
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12
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Norton JM, Ali K, Jurkovitz CT, Kiryluk K, Park M, Kawamoto K, Shang N, Navaneethan SD, Narva AS, Drawz P. Development and Validation of a Pragmatic Electronic Phenotype for CKD. Clin J Am Soc Nephrol 2019; 14:1306-1314. [PMID: 31405830 PMCID: PMC6730512 DOI: 10.2215/cjn.00360119] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [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: 01/08/2019] [Accepted: 06/25/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Poor identification of individuals with CKD is a major barrier to research and appropriate clinical management of the disease. We aimed to develop and validate a pragmatic electronic (e-) phenotype to identify patients likely to have CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The e-phenotype was developed by an expert working group and implemented among adults receiving in- or outpatient care at five healthcare organizations. To determine urine albumin (UA) dipstick cutoffs for CKD to enable use in the e-phenotype when lacking urine albumin-to-creatinine ratio (UACR), we compared same day UACR and UA results at four sites. A sample of patients, spanning no CKD to ESKD, was randomly selected at four sites for validation via blinded chart review. RESULTS The CKD e-phenotype was defined as most recent eGFR <60 ml/min per 1.73 m2 with at least one value <60 ml/min per 1.73 m2 >90 days prior and/or a UACR of ≥30 mg/g in the most recent test with at least one positive value >90 days prior. Dialysis and transplant were identified using diagnosis codes. In absence of UACR, a sensitive CKD definition would consider negative UA results as normal to mildly increased (KDIGO A1), trace to 1+ as moderately increased (KDIGO A2), and ≥2+ as severely increased (KDIGO A3). Sensitivity, specificity, and diagnostic accuracy of the CKD e-phenotype were 99%, 99%, and 98%, respectively. For dialysis sensitivity was 94% and specificity was 89%. For transplant, sensitivity was 97% and specificity was 91%. CONCLUSIONS The CKD e-phenotype provides a pragmatic and accurate method for EHR-based identification of patients likely to have CKD.
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Affiliation(s)
- Jenna M. Norton
- National Kidney Disease Education Program, Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Kaltun Ali
- National Kidney Disease Education Program, Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | | | | | - Meyeon Park
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Ning Shang
- Department of Bioinformatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Sankar D. Navaneethan
- Section of Nephrology, Department of Medicine, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; and
| | - Andrew S. Narva
- National Kidney Disease Education Program, Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul Drawz
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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13
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Hall D, Shaughnessy D, Drawz P, Akkina S, Esten A, Foley RN, Reule S. Time to thrombectomy is associated with increased risk for dialysis catheter placement. J Ren Care 2019; 45:232-238. [PMID: 31448871 DOI: 10.1111/jorc.12295] [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] [Indexed: 11/29/2022]
Abstract
BACKGROUND Arteriovenous dialysis access, fistulae (AVF) or grafts (AVG), are associated with significant rates of thrombosis. Timely thrombectomy may have a significant impact on immediate and long-term access survival. However, switching to a catheter is associated with higher rates of morbidity and mortality compared with those who have an AVF or AVG. OBJECTIVES The goal of this study was to evaluate whether time to thrombectomy increases the risk for loss of dialysis access and subsequent placement of a dialysis catheter at hospital discharge, at 6 months, 12 months, and data at any time after discharge. METHODS Using retrospective data, 444 patients were identified as having undergone thrombectomy for dialysis access dysfunction between January 2008 and April 2015, with 122 hospital admissions primarily for thrombectomy. RESULTS The mean age was 60.4 years, 65% were male, and 44.3% had an arteriovenous fistula as their dialysis access. The mean time to thrombectomy was 10.8 hours, and 14 patients utilised a catheter for haemodialysis as primary access upon discharge. After adjustment for prior access intervention, access type, and time to thrombectomy, the adjusted odds ratios (AOR) of a one-day delay in thrombectomy was associated with a twofold increase in requirement for catheter at discharge and at 6 months. This association remained present at any time after discharge. CONCLUSION In this study of patients cared for within an academic health system, a single day delay in thrombectomy nearly doubled the risk of needing a dialysis catheter at hospital discharge, 6 months, or any time after discharge.
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Affiliation(s)
- Damian Hall
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Daniel Shaughnessy
- University of Minnesota School of Public Health (SPH), University of Minnesota, Minneapolis, Minnesota, USA
| | - Paul Drawz
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sunil Akkina
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew Esten
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert N Foley
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Scott Reule
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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14
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Jotwani VK, Lee AK, Estrella MM, Katz R, Garimella PS, Malhotra R, Rifkin DE, Ambrosius W, Freedman BI, Cheung AK, Raphael KL, Drawz P, Neyra JA, Oparil S, Punzi H, Shlipak MG, Ix JH. Urinary Biomarkers of Tubular Damage Are Associated with Mortality but Not Cardiovascular Risk among Systolic Blood Pressure Intervention Trial Participants with Chronic Kidney Disease. Am J Nephrol 2019; 49:346-355. [PMID: 30939472 DOI: 10.1159/000499531] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 12/03/2018] [Accepted: 02/11/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Kidney tubulointerstitial fibrosis on biopsy is a strong predictor of chronic kidney disease (CKD) progression, and CKD is associated with elevated risk of cardiovascular disease (CVD). Tubular health is poorly quantified by traditional kidney function measures, including estimated glomerular filtration rate (eGFR) and albuminuria. We hypothesized that urinary biomarkers of tubular injury, inflammation, and repair would be associated with higher risk of CVD and mortality in persons with CKD. METHODS We measured urinary concentrations of interleukin-18 (IL-18), kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, monocyte chemoattractant protein-1, and chitinase-3-like protein-1 (YKL-40) at baseline among 2,377 participants of the Systolic Blood Pressure Intervention Trial who had an eGFR < 60 mL/min/1.73 m2. We used Cox proportional hazards models to evaluate biomarker associations with CVD events and all-cause mortality. RESULTS At baseline, the mean age of participants was 72 ± 9 years, and eGFR was 48 ± 11 mL/min/1.73 m2. Over a median follow-up of 3.8 years, 305 CVD events (3.6% per year) and 233 all-cause deaths (2.6% per year) occurred. After multivariable adjustment including eGFR, albuminuria, and urinary creatinine, none of the biomarkers showed statistically significant associations with CVD risk. Urinary IL-18 (hazard ratio [HR] per 2-fold higher value, 1.14; 95% CI 1.01-1.29) and YKL-40 (HR per 2-fold higher value, 1.08; 95% CI 1.02-1.14) concentrations were each incrementally associated with higher mortality risk. Associations were similar when stratified by randomized blood pressure arm. CONCLUSIONS Among hypertensive trial participants with CKD, higher urinary IL-18 and YKL-40 were associated with higher risk of mortality, but not CVD.
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Affiliation(s)
- Vasantha K Jotwani
- Department of Medicine, San Francisco VA Medical Health Care System, San Francisco, California, USA,
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, California, USA,
| | - Alexandra K Lee
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, California, USA
| | - Michelle M Estrella
- Department of Medicine, San Francisco VA Medical Health Care System, San Francisco, California, USA
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, California, USA
| | - Ronit Katz
- Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Pranav S Garimella
- Department of Medicine, University of California, San Diego, California, USA
| | - Rakesh Malhotra
- Department of Medicine, University of California, San Diego, California, USA
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Dena E Rifkin
- Department of Medicine, University of California, San Diego, California, USA
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Walter Ambrosius
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Barry I Freedman
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alfred K Cheung
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kalani L Raphael
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Paul Drawz
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Javier A Neyra
- Department of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Suzanne Oparil
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Henry Punzi
- Punzi Medical Center, Trinity Hypertension Research Institute, Carollton, Texas, USA
| | - Michael G Shlipak
- Department of Medicine, San Francisco VA Medical Health Care System, San Francisco, California, USA
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, California, USA
| | - Joachim H Ix
- Department of Medicine, University of California, San Diego, California, USA
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
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15
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Zhang WR, Craven TE, Malhotra R, Cheung AK, Chonchol M, Drawz P, Sarnak MJ, Parikh CR, Shlipak MG, Ix JH. Kidney Damage Biomarkers and Incident Chronic Kidney Disease During Blood Pressure Reduction: A Case-Control Study. Ann Intern Med 2018; 169:610-618. [PMID: 30357395 PMCID: PMC6953744 DOI: 10.7326/m18-1037] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Whether the increased incidence of chronic kidney disease (CKD) during intensive systolic blood pressure (SBP) lowering is accompanied by intrinsic kidney injury is unknown. OBJECTIVE To compare changes in kidney damage biomarkers between incident CKD case participants and matched control participants as well as between case participants in the intensive (<120 mm Hg) versus the standard (<140 mm Hg) SBP management groups of SPRINT (Systolic Blood Pressure Intervention Trial). DESIGN Nested case-control study within SPRINT. SETTING Adults with hypertension without baseline kidney disease. PARTICIPANTS Case participants (n = 162), who developed incident CKD during trial follow-up (128 in the intensive and 34 in the standard group), and control participants (n = 162) without incident CKD, who were matched on age, sex, race, baseline estimated glomerular filtration rate, and randomization group. MEASUREMENTS 9 urinary biomarkers of kidney damage were measured at baseline and at 1 year. Linear mixed-effects models were used to estimate 1-year biomarker changes. RESULTS Higher concentrations of urinary albumin, kidney injury molecule-1, and monocyte chemoattractant protein-1 at baseline were significantly associated with greater odds of incident CKD (adjusted odds ratio per doubling: 1.50 [95% CI, 1.14 to 1.98], 1.51 [CI, 1.05 to 2.17], and 1.70 [CI, 1.13 to 2.56], respectively). After 1 year of blood pressure intervention, incident CKD case participants in the intensive group had significantly greater decreases in albumin-creatinine ratio (ACR), interleukin-18, anti-chitinase-3-like protein 1 (YKL-40), and uromodulin than the matched control participants. Compared with case participants in the standard group, those in the intensive group had significantly greater decreases in ACR, β2-microglobulin, α1-microglobulin, YKL-40, and uromodulin. LIMITATION Biomarker measurements were available only at baseline and 1 year. CONCLUSION Incident CKD in the setting of intensive SBP lowering was accompanied by decreases, rather than elevations, in levels of kidney damage biomarkers and thus may reflect benign changes in renal blood flow rather than intrinsic injury. PRIMARY FUNDING SOURCE National Institute for Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- William R Zhang
- San Francisco Veterans Affairs Medical Center and University of California, San Francisco, San Francisco, California (W.R.Z., M.G.S.)
| | - Timothy E Craven
- Wake Forest School of Medicine, Winston-Salem, North Carolina (T.E.C.)
| | - Rakesh Malhotra
- University of California, San Diego, La Jolla, and Imperial Valley Family Care Medical Group, El Centro, California (R.M.)
| | | | | | - Paul Drawz
- University of Minnesota, Minneapolis, Minnesota (P.D.)
| | - Mark J Sarnak
- Tufts Medical Center, Boston, Massachusetts (M.J.S.)
| | - Chirag R Parikh
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.R.P.)
| | - Michael G Shlipak
- San Francisco Veterans Affairs Medical Center and University of California, San Francisco, San Francisco, California (W.R.Z., M.G.S.)
| | - Joachim H Ix
- University of California, San Diego, La Jolla, and Veterans Affairs San Diego Healthcare System, San Diego, California (J.H.I.)
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16
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Supiano MA, Lovato L, Ambrosius WT, Bates J, Beddhu S, Drawz P, Dwyer JP, Hamburg NM, Kitzman D, Lash J, Lustigova E, Miracle CM, Oparil S, Raj DS, Weiner DE, Taylor A, Vita JA, Yunis R, Chertow GM, Chonchol M. Pulse wave velocity and central aortic pressure in systolic blood pressure intervention trial participants. PLoS One 2018; 13:e0203305. [PMID: 30256784 PMCID: PMC6157848 DOI: 10.1371/journal.pone.0203305] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 08/16/2018] [Indexed: 12/14/2022] Open
Abstract
Arterial stiffness, typically assessed as the aortic pulse wave velocity (PWV), and central blood pressure levels may be indicators of cardiovascular disease (CVD) risk. This ancillary study to the Systolic Blood Pressure Intervention Trial (SPRINT) obtained baseline assessments (at randomization) of PWV and central systolic blood pressure (C-SBP) to: 1) characterize these vascular measurements in the SPRINT cohort, and 2) test the hypotheses that PWV and C-SBP are associated with glucose homeostasis and markers of chronic kidney disease (CKD). The SphygmoCor® CPV device was used to assess carotid-femoral PWV and its pulse wave analysis study protocol was used to obtain C-SBP. Valid results were obtained from 652 participants. Mean (±SD) PWV and C-SBP for the SPRINT cohort were 10.7 ± 2.7 m/s and 132.0 ± 17.9 mm Hg respectively. Linear regression analyses for PWV and C-SBP results adjusted for age, sex, and race/ethnicity in relation to several markers of glucose homeostasis and CKD did not identify any significant associations with the exception of a marginally statistically significant and modest association between PWV and urine albumin-to-creatinine ratio (linear regression estimate ± SE, 0.001 ± 0.0006; P-value 0.046). In a subset of SPRINT participants, PWV was significantly higher than in prior studies of normotensive persons, as expected. For older age groups in the SPRINT cohort (age > 60 years), PWV was compared with a reference population of hypertensive individuals. There were no compelling associations noted between PWV or C-SBP and markers of glucose homeostasis or CKD. Clinical Trial Registration: NCT01206062.
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Affiliation(s)
- Mark A. Supiano
- Geriatrics Division University of Utah School of Medicine and VA Salt Lake City Geriatric Research, Education and Clinical Center, Salt Lake City, Utah, United States of America
- * E-mail:
| | - Laura Lovato
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Walter T. Ambrosius
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Jeffrey Bates
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, United States of America
| | - Srinivasan Beddhu
- Nephrology Division University of Utah and Salt Lake City VA Medical Center, Salt Lake City, Utah, United States of America
| | - Paul Drawz
- Division of Renal Diseases & Hypertension, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Jamie P. Dwyer
- Division of Nephrology/Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Naomi M. Hamburg
- Section of Vascular Biology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Dalane Kitzman
- Sections on Cardiovascular Medicine and Geriatrics, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - James Lash
- Section of Nephrology, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Eva Lustigova
- Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
| | - Cynthia M. Miracle
- Division of Nephrology and Hypertension, University of California San Diego and VA San Diego Healthcare System, San Diego, California, United States of America
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Dominic S. Raj
- Division of Kidney Diseases and Hypertension, George Washington University, Washington, DC, United States of America
| | - Daniel E. Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - Addison Taylor
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, United States of America
| | - Joseph A. Vita
- Section of Vascular Biology, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Reem Yunis
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Denver, Colorado, United States of America
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17
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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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Stephens-Shields AJ, Spieker AJ, Anderson A, Drawz P, Fischer M, Sozio SM, Feldman H, Joffe M, Yang W, Greene T. Blood pressure and the risk of chronic kidney disease progression using multistate marginal structural models in the CRIC Study. Stat Med 2017; 36:4167-4181. [PMID: 28791722 PMCID: PMC5730991 DOI: 10.1002/sim.7425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 06/10/2016] [Revised: 06/23/2017] [Accepted: 06/28/2017] [Indexed: 01/13/2023]
Abstract
In patients with chronic kidney disease (CKD), clinical interest often centers on determining treatments and exposures that are causally related to renal progression. Analyses of longitudinal clinical data in this population are often complicated by clinical competing events, such as end-stage renal disease (ESRD) and death, and time-dependent confounding, where patient factors that are predictive of later exposures and outcomes are affected by past exposures. We developed multistate marginal structural models (MS-MSMs) to assess the effect of time-varying systolic blood pressure on disease progression in subjects with CKD. The multistate nature of the model allows us to jointly model disease progression characterized by changes in the estimated glomerular filtration rate (eGFR), the onset of ESRD, and death, and thereby avoid unnatural assumptions of death and ESRD as noninformative censoring events for subsequent changes in eGFR. We model the causal effect of systolic blood pressure on the probability of transitioning into 1 of 6 disease states given the current state. We use inverse probability weights with stabilization to account for potential time-varying confounders, including past eGFR, total protein, serum creatinine, and hemoglobin. We apply the model to data from the Chronic Renal Insufficiency Cohort Study, a multisite observational study of patients with CKD.
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Affiliation(s)
- Alisa J Stephens-Shields
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, U.S.A
| | - Andrew J Spieker
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, U.S.A
| | - Amanda Anderson
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, U.S.A
| | - Paul Drawz
- Department of Medicine, University of Minnesota, Minneapolis, U.S.A
| | - Michael Fischer
- Department of Medicine, University of Illinois College of Medicine, Chicago, U.S.A
| | - Stephen M Sozio
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, U.S.A
| | - Harold Feldman
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, U.S.A
| | - Marshall Joffe
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, U.S.A
| | - Wei Yang
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, U.S.A
| | - Tom Greene
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, U.S.A
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Ghazi L, Drawz P. Advances in understanding the renin-angiotensin-aldosterone system (RAAS) in blood pressure control and recent pivotal trials of RAAS blockade in heart failure and diabetic nephropathy. F1000Res 2017; 6. [PMID: 28413612 PMCID: PMC5365219 DOI: 10.12688/f1000research.9692.1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 12/11/2022] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) plays a fundamental role in the physiology of blood pressure control and the pathophysiology of hypertension (HTN) with effects on vascular tone, sodium retention, oxidative stress, fibrosis, sympathetic tone, and inflammation. Fortunately, RAAS blocking agents have been available to treat HTN since the 1970s and newer medications are being developed. In this review, we will (1) examine new anti-hypertensive medications affecting the RAAS, (2) evaluate recent studies that help provide a better understanding of which patients may be more likely to benefit from RAAS blockade, and (3) review three recent pivotal randomized trials that involve newer RAAS blocking agents and inform clinical practice.
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Affiliation(s)
- Lama Ghazi
- Division of Renal Disease and Hypertension, Department of Medicine, University of Minnesota, Minnesota, MN, USA
| | - Paul Drawz
- Division of Renal Disease and Hypertension, Department of Medicine, University of Minnesota, Minnesota, MN, USA
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Dobre M, Roy J, Tao K, Anderson AH, Bansal N, Chen J, Deo R, Drawz P, Feldman HI, Hamm LL, Hostetter T, Kusek JW, Lora C, Ojo AO, Shrama K, Rahman M. Serum Bicarbonate and Structural and Functional Cardiac Abnormalities in Chronic Kidney Disease - A Report from the Chronic Renal Insufficiency Cohort Study. Am J Nephrol 2016; 43:411-20. [PMID: 27241893 DOI: 10.1159/000446860] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/01/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Heart failure (HF) is a frequent occurrence in chronic kidney disease (CKD) patients and predicts poor survival. Serum bicarbonate is associated with increased rates of HF in CKD; however, the mechanisms leading to this association are incompletely understood. This study aims to assess whether serum bicarbonate is independently associated with structural and functional cardiac abnormalities in CKD. METHODS The association between serum bicarbonate and left ventricular (LV) hypertrophy (LVH), LV mass indexed to height2.7, LV geometry, ejection fraction (EF) and diastolic dysfunction was assessed in 3,483 participants without NYHA class III/IV HF, enrolled in the Chronic Renal Insufficiency Cohort study. RESULTS The mean estimated glomerular filtration rate was 42.5 ± 17 ml/min/1.73 m2. The overall prevalence of LVH was 51.2%, with 57.8, 50.9 and 47.7% for bicarbonate categories <22, 22-26 and >26 mmol/l, respectively. Participants with low bicarbonate were more likely to have LVH and abnormal LV geometry (OR 1.32; 95% CI 1.07-1.64, and OR 1.57; 95% CI 1.14-2.16, respectively). However, the association was not statistically significant after adjustment for demographics, traditional cardiovascular risk factors, medications and kidney function (OR 1.07; 95% CI 0.66-1.72, and OR 1.27; 95% CI 0.64-2.51, respectively). No association was found between bicarbonate and systolic or diastolic dysfunction. During follow-up, no significant changes in LV mass or EF were observed in any bicarbonate strata. CONCLUSIONS In a large CKD study, serum bicarbonate was associated with LV mass and concentric LVH; however, this association was attenuated after adjustment for clinical factors suggesting that the observed cardiac effects are mediated through yet unknown mechanisms.
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Affiliation(s)
- Mirela Dobre
- Division of Nephrology and Hypertension, University Hospital Case Medical Center, Case Western Reserve University, Cleveland, Ohio., USA
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Drawz P, Rahman M. Effect of intensive versus standard clinic-based blood pressure management on ambulatory blood pressure - results from the sprint abpm study. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.jash.2016.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Thomas G, Xie D, Chen HY, Anderson AH, Appel LJ, Bodana S, Brecklin CS, Drawz P, Flack JM, Miller ER, Steigerwalt SP, Townsend RR, Weir MR, Wright JT, Rahman M. Prevalence and Prognostic Significance of Apparent Treatment Resistant Hypertension in Chronic Kidney Disease: Report From the Chronic Renal Insufficiency Cohort Study. Hypertension 2015; 67:387-96. [PMID: 26711738 DOI: 10.1161/hypertensionaha.115.06487] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [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: 09/11/2015] [Accepted: 11/03/2015] [Indexed: 11/16/2022]
Abstract
The association between apparent treatment resistant hypertension (ATRH) and clinical outcomes is not well studied in chronic kidney disease. We analyzed data on 3367 hypertensive participants in the Chronic Renal Insufficiency Cohort (CRIC) to determine prevalence, associations, and clinical outcomes of ATRH in nondialysis chronic kidney disease patients. ATRH was defined as blood pressure ≥140/90 mm Hg on ≥3 antihypertensives, or use of ≥4 antihypertensives with blood pressure at goal at baseline visit. Prevalence of ATRH was 40.4%. Older age, male sex, black race, diabetes mellitus, and higher body mass index were independently associated with higher odds of having ATRH. Participants with ATRH had a higher risk of clinical events than participants without ATRH-composite of myocardial infarction, stroke, peripheral arterial disease, congestive heart failure (CHF), and all-cause mortality (hazard ratio [95% confidence interval], 1.38 [1.22-1.56]); renal events (1.28 [1.11-1.46]); CHF (1.66 [1.38-2.00]); and all-cause mortality (1.24 [1.06-1.45]). The subset of participants with ATRH and blood pressure at goal on ≥4 medications also had higher risk for composite of myocardial infarction, stroke, peripheral arterial disease, CHF, and all-cause mortality (hazard ratio [95% confidence interval], (1.30 [1.12-1.51]) and CHF (1.59 [1.28-1.99]) than those without ATRH. ATRH was associated with significantly higher risk for CHF and renal events only among those with estimated glomerular filtration rate ≥30 mL/min per 1.73 m(2). Our findings show that ATRH is common and associated with high risk of adverse outcomes in a cohort of patients with chronic kidney disease. This underscores the need for early identification and management of patients with ATRH and chronic kidney disease.
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Affiliation(s)
- George Thomas
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Dawei Xie
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Hsiang-Yu Chen
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Amanda H Anderson
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Lawrence J Appel
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Shirisha Bodana
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Carolyn S Brecklin
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Paul Drawz
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - John M Flack
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Edgar R Miller
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Susan P Steigerwalt
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Raymond R Townsend
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Matthew R Weir
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Jackson T Wright
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
| | - Mahboob Rahman
- From the Department of Nephrology and Hypertension, Cleveland Clinic, OH (G.T.); Departments of Medicine (R.R.T.) and Biostatistics and Epidemiology (A.H.A., D.X., H.-Y.C.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Medicine (L.J.A., E.R.M.) and Epidemiology (L.J.A.), Johns Hopkins University, Baltimore, MD; Department of Nephrology, Ochsner Medical Center, New Orleans, LA (S.B.); Department of Medicine, University of Illinois at Chicago (C.B.); Department of Medicine, University of Minnesota, Minneapolis (P.D.); Hypertension Section, Division of General Medicine, Department of Medicine, Southern Illinois University, Springfield (J.M.F.); Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.P.S.); Department of Medicine, University of Maryland School of Medicine, Baltimore (M.R.W.); Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland VA Medical Center Cleveland, OH (J.T.W., M.R.)
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Drawz P, Ayyappan S, Nouraie M, Saraf S, Gordeuk V, Hostetter T, Gladwin MT, Little J. Kidney Disease among Patients with Sickle Cell Disease, Hemoglobin SS and SC. Clin J Am Soc Nephrol 2015; 11:207-15. [PMID: 26672090 DOI: 10.2215/cjn.03940415] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [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: 04/09/2015] [Accepted: 10/30/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Sickle cell disease (SCD) is an inherited anemia that afflicts millions worldwide. Kidney disease is a major contributor to its morbidity and mortality. We examined contemporary and historical SCD populations to understand how renal disease behaved in hemoglobin SS (HbSS) compared with HbSC. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Kidney function was examined in the multicentered Treatment of Pulmonary Hypertension and Sickle Cell Disease with Sildenafil Therapy (Walk-PHaSST) Trial (HbSS=463; HbSC=127; years 2007-2009) and historical comparator populations from the Cooperative Study of Sickle Cell Disease (CSSCD; HbSS=708) and the Multicenter Study of Hydroxyurea in Sickle Cell Disease (MSH; HbSS=299). RESULTS In adults with SCD, eGFR was lower among older individuals: -1.78 ml/min per 1.73 m(2) per year of age (95% confidence interval [95% CI], -2.06 to -1.50; Walk-PHaSST Trial), -1.75 ml/min per 1.73 m(2) per year of age (95% CI, -2.05 to -1.44; MSH), and -1.69 ml/min per 1.73 m(2) per year of age (95% CI, -2.00 to -1.38; CSSCD) in HbSS compared with -1.09 ml/min per 1.73 m(2) per year of age (95% CI, -1.39 to -0.75) in HbSC (Walk-PHaSST Trial). Macroalbuminuria was seen in 20% of participants with SCD (HbSS or HbSC; P=0.45; Walk-PHaSST Trial), but microalbuminuria was more prevalent in HbSS (44% versus 23% in HbSC; P<0.002). In the Walk-PHaSST Trial, albuminuria was associated with hemolysis (higher lactate dehydrogenase, P<0.001; higher absolute reticulocyte count, P<0.02; and lower Hb, P=0.07) and elevated systolic BP (P<0.001) in HbSS. One half of all participants with HbSS (20 of 39) versus one fifth without (41 of 228) elevated tricuspid regurgitant jet velocity (≥3 m/s; adverse prognostic indicator in SCD) had macroalbuminuria (P<0.001). In the CSSCD, overt proteinuria, detected (less sensitively) by urine dipstick, associated with higher 3-year mortality (odds ratio, 2.48; 95% CI, 1.07 to 5.77). Serum bicarbonate was lower in HbSS (23.8 versus 24.8 mEq/dl in HbSC; P<0.05) and associated with reticulocytopenic anemia and decreased renal function. CONCLUSIONS In SCD, albuminuria or proteinuria was highly prevalent, in HbSS more than in HbSC. Proteinuria associated with mortality in HbSS. Older individuals had a lower than expected eGFR, and this was more prominent in HbSS. Current management does not routinely address renal complications in SCD, which could plausibly reduce morbidity and mortality.
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Affiliation(s)
- Paul Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, Minnesota
| | | | - Mehdi Nouraie
- Center for Sickle Cell Disease, Howard University, Washington, DC
| | - Santosh Saraf
- Division of Hematology/Oncology, University of Illinois, Chicago, Illinois; and
| | | | - Thomas Hostetter
- Nephrology and Hypertension,University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Mark T Gladwin
- Vascular Medicine Institute and Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Watts B, Lawrence RH, Drawz P, Carter C, Shumaker AH, Kern EF. Development and Implementation of Team-Based Panel Management Tools: Filling the Gap between Patient and Population Information Systems. Popul Health Manag 2015; 19:232-9. [PMID: 26440062 DOI: 10.1089/pop.2015.0093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Effective team-based models of care, such as the Patient-Centered Medical Home, require electronic tools to support proactive population management strategies that emphasize care coordination and quality improvement. Despite the spread of electronic health records (EHRs) and vendors marketing population health tools, clinical practices still may lack the ability to have: (1) local control over types of data collected/reports generated, (2) timely data (eg, up-to-date data, not several months old), and accordingly (3) the ability to efficiently monitor and improve patient outcomes. This article describes a quality improvement project at the hospital system level to develop and implement a flexible panel management (PM) tool to improve care of subpopulations of patients (eg, panels of patients with diabetes) by clinical teams. An in-depth case analysis approach is used to explore barriers and facilitators in building a PM registry tool for team-based management needs using standard data elements (eg, laboratory values, pharmacy records) found in EHRs. Also described are factors that may contribute to sustainability; to date the tool has been adapted to 6 disease-focused subpopulations encompassing more than 200,000 patients. Two key lessons emerged from this initiative: (1) though challenging, team-based clinical end users and information technology needed to work together consistently to refine the product, and (2) locally developed population management tools can provide efficient data tracking for frontline clinical teams and leadership. The preliminary work identified critical gaps that were successfully addressed by building local PM registry tools from EHR-derived data and offers lessons learned for others engaged in similar work. (Population Health Management 2016;19:232-239).
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Affiliation(s)
- Brook Watts
- 1 Department of Medicine, Louis Stokes Cleveland Department of Veterans Affairs Medical Center , Cleveland, Ohio.,2 Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Renée H Lawrence
- 1 Department of Medicine, Louis Stokes Cleveland Department of Veterans Affairs Medical Center , Cleveland, Ohio
| | - Paul Drawz
- 3 Department of Medicine, University of Minnesota , Minneapolis, Minnesota
| | - Cameron Carter
- 1 Department of Medicine, Louis Stokes Cleveland Department of Veterans Affairs Medical Center , Cleveland, Ohio
| | - Amy Hirsch Shumaker
- 1 Department of Medicine, Louis Stokes Cleveland Department of Veterans Affairs Medical Center , Cleveland, Ohio
| | - Elizabeth F Kern
- 1 Department of Medicine, Louis Stokes Cleveland Department of Veterans Affairs Medical Center , Cleveland, Ohio.,4 National Jewish Health , Denver, Colorado
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Abstract
This issue provides a clinical overview of chronic kidney disease, focusing on prevention, diagnosis, treatment, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.
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Dumford D, Suwantarat N, Bhasker V, Kundrapu S, Zabarsky TF, Drawz P, Zhu H, Donskey CJ. Outbreak of Fluoroquinolone-Resistant Escherichia coli Infections after Transrectal Ultrasound—Guided Biopsy of the Prostate. Infect Control Hosp Epidemiol 2015; 34:269-73. [DOI: 10.1086/669512] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Design.We conducted an investigation after identifying a cluster of 4 serious infections following transrectal ultrasound–guided biopsy of the prostate (TRUBP) during a 2-month period.Setting.veterans Affairs medical center.Patients.Patients with urinary tract infection (UTI) after TRUBP and time-matched controls with no evidence of infection.Methods.The incidence of UTI within 30 days after TRUBP was calculated from 2002 through 2010. We evaluated the correlation between infection with fluoroquinolone-resistant gram-negative bacilli (GNB) and fluoroquinolone resistance in outpatient Escherichia coli urinary isolates and performed a case-control study to determine risk factors for infection with fluoroquinolone-resistant GNB. Processes for TRUBP prophylaxis, procedures, and equipment sterilization were reviewed.Results.An outbreak of UTI due to fluoroquinolone-resistant E. coli after TRUBP began 2 years before the cluster was identified and was correlated with increasing fluoroquinolone resistance in outpatient E. coli. No deficiencies were identified in equipment processing or biopsy procedures. Fluoroquinolone-resistant E. coli UTI after TRUBP was independently associated with prior infection with fluoroquinolone-resistant GNB (adjusted odds ratio, 20.8; P = .005). A prediction rule including prior UTI, hospitalization in the past year, and previous infection with fluoroquinolone-resistant GNB identified only 17 (49%) of 35 cases.Conclusions.The outbreak of fluoroquinolone-resistant E. coli infections after TRUBP closely paralleled rising rates of fluoroquinolone resistance among outpatient E. coli isolates. The delayed detection of the outbreak and the absence of sensitive predictors of infection suggest that active surveillance for infection after TRUBP is necessary in the context of increasing fluoroquinolone resistance in the United States.
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Cuschieri JR, Drawz P, Falck-Ytter Y, Wong RCK. Risk factors for acute gastrointestinal bleeding following myocardial infarction in veteran patients who are prescribed clopidogrel. J Dig Dis 2014; 15:195-201. [PMID: 24373542 DOI: 10.1111/1751-2980.12123] [Citation(s) in RCA: 10] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Our aim was to identify risk factors for acute gastrointestinal (GI) bleeding in patients with myocardial infarction (MI) who were prescribed clopidogrel following hospital discharge. METHODS Data were collected retrospectively from patients treated in Veteran Affairs hospitals in Ohio, USA, from 2001 to 2008 with a primary diagnosis of MI (International Classification of Diseases, 9th Revision) and a prescription for clopidogrel filled within 48 h of discharge. Primary outcome was acute GI bleeding after discharge. RESULTS Acute GI bleeding occurred in 107 of 3218 patients. Bleeding occurred in those who were elder (66.2 vs. 62.4 years, P = 0.0002), had lower glomerular filtration rate (74 vs. 81 mL/min, P = 0.024), had filled prescription for warfarin (15.9% vs. 6.9%, P = 0.0004), diagnosed as atrial fibrillation (20.6% vs. 11.1%, P = 0.003), chronic liver (5.6% vs. 2.2%, P = 0.018) or kidney disease (29.0% vs. 19.4%, P = 0.016). A risk model and GI bleed risk score were developed and showed that patients with age >65 years, use of warfarin, the presence of chronic liver or kidney disease were at increased risk for GI bleeding. CONCLUSIONS Veterans patients of advanced age, using warfarin and with chronic liver and kidney disease may be at increased risk of GI bleeding when prescribed clopidogrel following MI. A scoring system may help to identify patients at high risk for GI bleeding.
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Dobre M, Yang W, Chen J, Drawz P, Hamm LL, Horwitz E, Hostetter T, Jaar B, Lora CM, Nessel L, Ojo A, Scialla J, Steigerwalt S, Teal V, Wolf M, Rahman M. Association of serum bicarbonate with risk of renal and cardiovascular outcomes in CKD: a report from the Chronic Renal Insufficiency Cohort (CRIC) study. Am J Kidney Dis 2013; 62:670-8. [PMID: 23489677 DOI: 10.1053/j.ajkd.2013.01.017] [Citation(s) in RCA: 164] [Impact Index Per Article: 14.9] [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: 08/02/2012] [Accepted: 01/15/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND The purpose of this study is to evaluate serum bicarbonate level as a risk factor for renal outcomes, cardiovascular events, and mortality in patients with chronic kidney disease (CKD). STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 3,939 participants with CKD stages 2-4 who enrolled in the Chronic Renal Insufficiency Cohort (CRIC) between June 2003 and December 2008. PREDICTOR Serum bicarbonate level. OUTCOMES Renal outcomes, defined as end-stage renal disease (either initiation of dialysis therapy or kidney transplantation) or 50% reduction in estimated glomerular filtration rate (eGFR); atherosclerotic events (myocardial infarction, stroke, or peripheral arterial disease); congestive heart failure events; and death. MEASUREMENTS Time to event. RESULTS Mean eGFR was 44.8 ± 16.8 (SD) mL/min/1.73 m(2), and median serum bicarbonate level was 24 (IQR, 22-26) mEq/L. During a median follow-up of 3.9 years, 374 participants died, 767 had a renal outcome, 332 experienced an atherosclerotic event, and 391 had a congestive heart failure event. In adjusted analyses, the risk of developing a renal end point was 3% lower per 1-mEq/L increase in serum bicarbonate level (HR, 0.97; 95% CI, 0.94-0.99; P = 0.01). The association was stronger for participants with eGFR >45 mL/min/1.73 m(2) (HR, 0.91; 95% CI, 0.85-0.97; P = 0.004). The risk of heart failure increased by 14% (HR, 1.14; 95% CI, 1.03-1.26; P = 0.02) per 1-mEq/L increase in serum bicarbonate level over 24 mEq/L. Serum bicarbonate level was not associated independently with atherosclerotic events (HR, 0.99; 95% CI, 0.95-1.03; P = 0.6) and all-cause mortality (HR, 0.98; 95% CI, 0.95-1.02; P = 0.3). LIMITATIONS Single measurement of sodium bicarbonate. CONCLUSIONS In a cohort of participants with CKD, low serum bicarbonate level was an independent risk factor for kidney disease progression, particularly for participants with preserved kidney function. The risk of heart failure was higher at the upper extreme of serum bicarbonate levels. There was no association between serum bicarbonate level and all-cause mortality or atherosclerotic events.
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Affiliation(s)
- Mirela Dobre
- Case Western Reserve University, Cleveland, OH; Division of Nephrology and Hypertension, University Hospital Case Medical Center, Cleveland, OH; Louis Stokes Cleveland VA Medical Center, Cleveland, OH.
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