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Erickson SJ, Yabes JG, Han Z, Roumelioti ME, Rollman BL, Weisbord SD, Steel JL, Unruh ML, Jhamb M. Associations Between Social Support and Patient-Reported Outcomes in Hemodialysis Patients: Results from the TACcare Study. Kidney360 2024:02200512-990000000-00391. [PMID: 38704664 DOI: 10.34067/kid.0000000000000456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND End Stage Kidney Disease (ESKD) patients experience high symptom burden which has been associated with a negative impact on their interpersonal relationships. However, there is limited research exploring associations of social support and patient-reported outcomes among hemodialysis (HD) patients. METHODS The current study is a secondary, cross-sectional analyses of the sociodemographic and clinical correlates of perceived social support (Multidimensional Scale of Perceived Social Support; MSPSS) at baseline. The study examined the extent to which perceived social support is associated with pain, depression, fatigue, anxiety, sleep, and HRQoL (SF-12 Mental Component Score; MCS) and Physical Component Score; PCS)). RESULTS Of the 160 randomized patients: mean (SD) age was 58 ±14 years; years on dialysis was 4.1 + 4.2; 45% were female; 29% Black, 13% American Indian, 18% Hispanic; 88% had at least high school education; and 27% were married. Mean baseline levels of perceived social support were comparable to other chronically ill populations. At least a high school education (p = 0.04) and being married (p = 0.05) were associated with higher total MSPSS scores. Higher MSPSS scores were correlated with lower levels of fatigue (r = 0.21, p =0.008; higher fatigue scores signify lower fatigue), pain (r = -0.17, p = 0.03), depressive symptoms (r = -0.26, p < 0.001), anxiety (r = -0.23, p = 0.004), better sleep quality (r = -0.32, p < 0.001) and SF-12 MCS (r = 0.26, p <0.001). Moderation analyses revealed male sex and non-Hispanic ethnicity resulted in stronger positive associations of perceived social support with SF-12 MCS. CONCLUSIONS The level of perceived social support observed among thrice weekly HD patients in TACcare was similar to those observed in other chronic conditions. Because of the associations between perceived social support and patient-reported outcomes, particularly psychosocial and behavioral health outcomes, targeting social support appears to be warranted among HD patients.
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Affiliation(s)
- Sarah J Erickson
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | - Jonathan G Yabes
- Center for Research on Heath Care Data Center, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Zhuoheng Han
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque, NM, USA
| | - Bruce L Rollman
- Center for Behavioral Health, Media, and Technology, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven D Weisbord
- Renal Section and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jennifer L Steel
- Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark L Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque, NM, USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Hsu CM, Li NC, Lacson EK, Weiner DE, Paine S, Majchrzak K, Argyropoulos C, Roumelioti ME, Pankratz VS, Miskulin D, Manley HJ, Salenger P, Johnson D, Johnson HK, Harford A. Peritoneal Dialysis Technique Survival: A Cohort Study. Am J Kidney Dis 2024:S0272-6386(24)00718-2. [PMID: 38640994 DOI: 10.1053/j.ajkd.2024.03.012] [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: 09/29/2023] [Revised: 02/17/2024] [Accepted: 03/01/2024] [Indexed: 04/21/2024]
Abstract
RATIONALE & OBJECTIVE Reasons for transfer from peritoneal dialysis (PD) to hemodialysis (HD) remain incompletely understood. Among incident and prevalent patients receiving PD, we evaluated the association between prior treatment with HD and PD technique survival. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adults who initiated PD at a Dialysis Clinic, Inc. (DCI) outpatient facility between January 1, 2010 and September 30, 2019. EXPOSURES The primary exposure of interest was timing of PD start, categorized as PD-first, PD-early, or PD-late. Other covariates included demographics, clinical characteristics, and routine laboratory results. OUTCOMES Modality switch from PD to HD sustained for more than 90 days. ANALYTICAL APPROACH Multivariable Fine-Gray models with competing risks and time-varying covariates, stratified at 9 months to account for lack of proportionality. RESULTS Among 5224 patients who initiated PD at a DCI facility, 3174 initiated dialysis with PD ("PD-first"), 942 transitioned from HD to PD within 90 days ("PD-early"), and 1108 transitioned beyond 90 days ("PD-late"); 1472 (28%) subsequently transferred from PD to HD. PD-early and PD-late patients had higher risk of transfer to HD as compared to PD-first patients [adjusted hazard ratio (aHR) 1.51 (95% CI: 1.17-1.96) and 2.41 (1.94-3.00), respectively, in the first 9 months and aHR 1.16 (0.99-1.35) and 1.43 (1.24-1.65), respectively, after 9 months]. More peritonitis episodes, fewer home visits, lower serum albumin, lower residual kidney function, and lower peritoneal clearance calculated with weekly Kt/V were additional risk factors for PD-to-HD transfer. LIMITATIONS Missing data on dialysis adequacy and residual kidney function, confounded by short PD technique survival. CONCLUSIONS Initiating dialysis with PD is associated with greater PD technique survival, though many of those who initiate PD late in their dialysis course still experience substantial time on PD. Peritonitis, lower serum albumin, and lower Kt/V are risk factors for PD-to-HD transfer that may be amenable to intervention.
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Affiliation(s)
| | | | - Eduardo K Lacson
- Tufts Medical Center, Boston, MA; Dialysis Clinic Inc., Nashville, TN
| | | | | | | | | | | | | | | | | | | | | | | | - Antonia Harford
- Dialysis Clinic Inc., Nashville, TN; University of New Mexico, Albuquerque, NM
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Wagner B, Ing TS, Roumelioti ME, Sam R, Argyropoulos CP, Lew SQ, Unruh ML, Dorin RI, Degnan JH, Tzamaloukas AH. Hypernatremia in Hyperglycemia: Clinical Features and Relationship to Fractional Changes in Body Water and Monovalent Cations during Its Development. J Clin Med 2024; 13:1957. [PMID: 38610721 PMCID: PMC11012913 DOI: 10.3390/jcm13071957] [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: 02/10/2024] [Revised: 03/13/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
In hyperglycemia, the serum sodium concentration ([Na]S) receives influences from (a) the fluid exit from the intracellular compartment and thirst, which cause [Na]S decreases; (b) osmotic diuresis with sums of the urinary sodium plus potassium concentration lower than the baseline euglycemic [Na]S, which results in a [Na]S increase; and (c), in some cases, gains or losses of fluid, sodium, and potassium through the gastrointestinal tract, the respiratory tract, and the skin. Hyperglycemic patients with hypernatremia have large deficits of body water and usually hypovolemia and develop severe clinical manifestations and significant mortality. To assist with the correction of both the severe dehydration and the hypovolemia, we developed formulas computing the fractional losses of the body water and monovalent cations in hyperglycemia. The formulas estimate varying losses between patients with the same serum glucose concentration ([Glu]S) and [Na]S but with different sums of monovalent cation concentrations in the lost fluids. Among subjects with the same [Glu]S and [Na]S, those with higher monovalent cation concentrations in the fluids lost have higher fractional losses of body water. The sum of the monovalent cation concentrations in the lost fluids should be considered when computing the volume and composition of the fluid replacement for hyperglycemic syndromes.
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Affiliation(s)
- Brent Wagner
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA; (B.W.); (M.-E.R.); (C.P.A.)
- Kidney Institute of New Mexico, University of New Mexico Health Sciences Center, Albuquerque, NM 87122, USA
- Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, NM 87108, USA
| | - Todd S. Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA; (B.W.); (M.-E.R.); (C.P.A.)
| | - Ramin Sam
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California in San Francisco School of Medicine, San Francisco, CA 94110, USA;
| | - Christos P. Argyropoulos
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA; (B.W.); (M.-E.R.); (C.P.A.)
| | - Susie Q. Lew
- Department of Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA;
| | - Mark L. Unruh
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA;
| | - Richard I. Dorin
- Department of Medicine, Division of Endocrinology, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico, Albuquerque, NM 87108, USA;
| | - James H. Degnan
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, NM 87131, USA;
| | - Antonios H. Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87108, USA
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Mehrotra R, Cukor D, McCurry SM, Rue T, Roumelioti ME, Heagerty PJ, Unruh M. Effectiveness of Existing Insomnia Therapies for Patients Undergoing Hemodialysis : A Randomized Clinical Trial. Ann Intern Med 2024; 177:177-188. [PMID: 38224591 DOI: 10.7326/m23-1794] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Chronic insomnia is common in patients undergoing in-center hemodialysis, yet there is limited evidence on effective treatments for this population. OBJECTIVE To compare the effectiveness of cognitive behavioral therapy for insomnia (CBT-I), trazodone, and placebo for insomnia in patients undergoing long-term hemodialysis. DESIGN Randomized, multicenter, double-blinded, placebo-controlled trial. (ClinicalTrials.gov: NCT03534284). SETTING 26 dialysis units in Albuquerque, New Mexico, and Seattle, Washington. PARTICIPANTS Patients with Insomnia Severity Index (ISI) score of 10 or greater, with sleep disturbances on 3 or more nights per week for 3 or more months. INTERVENTION Participants were randomly assigned to 6 weeks of CBT-I, trazodone, or placebo. MEASUREMENTS The primary outcome was the ISI score at 7 and 25 weeks from randomization. RESULTS A total of 923 patients were prescreened, and of the 411 patients with chronic insomnia, 126 were randomly assigned to CBT-I (n = 43), trazodone (n = 42), or placebo (n = 41). The change in ISI scores from baseline to 7 weeks with CBT-I or trazodone was no different from placebo: CBT-I, -3.7 (95% CI, -5.5 to -1.9); trazodone, -4.2 (CI, -5.9 to -2.4); and placebo, -3.1 (CI, -4.9 to -1.3). There was no meaningful change in ISI scores from baseline to 25 weeks: CBT-I, -4.8 (CI, -7.0 to -2.7); trazodone, -4.0 (CI, -6.0 to -1.9); and placebo, -4.3 (CI, -6.4 to -2.2). Serious adverse events (SAEs), particularly serious cardiovascular events, were more frequent with trazodone (annualized cardiovascular SAE incidence rates: CBT-I, 0.05 [CI, 0.00 to 0.29]; trazodone, 0.64 [CI, 0.34 to 1.10]; and placebo, 0.21 [CI, 0.06 to 0.53]). LIMITATION Modest sample size and most participants had mild or moderate insomnia. CONCLUSION In patients undergoing hemodialysis with mild or moderate chronic insomnia, there was no difference in the effectiveness of 6 weeks of CBT-I or trazodone compared with placebo. The incidence of SAEs was higher with trazodone. PRIMARY FUNDING SOURCE National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Rajnish Mehrotra
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington (R.M.)
| | - Daniel Cukor
- The Rogosin Institute, New York, New York (D.C.)
| | - Susan M McCurry
- School of Nursing, University of Washington, Seattle, Washington (S.M.M.)
| | - Tessa Rue
- Center for Biomedical Statistics, University of Washington School of Public Health, Seattle, Washington (T.R., P.J.H.)
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico, Albuquerque, New Mexico (M.-E.R., M.U.)
| | - Patrick J Heagerty
- Center for Biomedical Statistics, University of Washington School of Public Health, Seattle, Washington (T.R., P.J.H.)
| | - Mark Unruh
- Division of Nephrology, Department of Medicine, University of New Mexico, Albuquerque, New Mexico (M.-E.R., M.U.)
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Ravender R, Roumelioti ME, Schmidt DW, Unruh ML, Argyropoulos C. Chronic Kidney Disease in the Older Adult Patient with Diabetes. J Clin Med 2024; 13:348. [PMID: 38256482 PMCID: PMC10816477 DOI: 10.3390/jcm13020348] [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: 10/06/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
Diabetes mellitus (DM) and chronic kidney disease (CKD) are common in middle aged and older adult individuals. DM may accelerate the aging process, and the age-related declines in the estimated glomerular filtration rate (eGFR) can pose a challenge to diagnosing diabetic kidney disease (DKD) using standard diagnostic criteria especially with the absence of severe albuminuria among older adults. In the presence of CKD and DM, older adult patients may need multidisciplinary care due to susceptibility to various health issues, e.g., cognitive decline, auditory or visual impairment, various comorbidities, complex medical regimens, and increased sensitivity to medication adverse effects. As a result, it can be challenging to apply recent therapeutic advancements for the general population to older adults. We review the evidence that the benefits from these newer therapies apply equally to older and younger patients with CKD and diabetes type 2 and propose a comprehensive management. This framework will address nonpharmacological measures and pharmacological management with renin angiotensin system inhibitors (RASi), sodium glucose co-transporter 2 inhibitors (SGLT2i), non-steroidal mineralocorticoids receptor antagonists (MRAs), and glucagon like peptide 1 receptor agonists (GLP1-RAs).
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Affiliation(s)
| | | | | | | | - Christos Argyropoulos
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, MSC 04-2785, Albuquerque, NM 87131, USA; (R.R.); (M.-E.R.); (D.W.S.); (M.L.U.)
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Arzhan S, Roumelioti ME, Litvinovich I, Bologa CG, Unruh ML. Outcomes of Hospital-Acquired Hypernatremia. Clin J Am Soc Nephrol 2023; 18:1396-1407. [PMID: 37722368 PMCID: PMC10637455 DOI: 10.2215/cjn.0000000000000250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Hospital-acquired hypernatremia is highly prevalent, overlooked, and associated with unfavorable consequences. There are limited studies examining the outcomes and discharge dispositions of various levels of hospital-acquired hypernatremia in patients with or without CKD. METHODS We conducted an observational retrospective cohort study, and we analyzed the data of 1,728,141 patients extracted from the Cerner Health Facts database (January 1, 2000, to June 30, 2018). In this report, we investigated the association between hospital-acquired hypernatremia (serum sodium [Na] levels >145 mEq/L) and in-hospital mortality or discharge dispositions with kidney function status at admission using adjusted multinomial regression models. RESULTS Of all hospitalized patients, 6% developed hypernatremia after hospital admission. The incidence of in-hospital mortality was 12% and 1% in patients with hypernatremia and normonatremia, respectively. The risk of all outcomes was significantly greater for serum Na >145 mEq/L compared with the reference interval (serum Na, 135-145 mEq/L). In patients with hypernatremia, odds ratios (95% confidence interval) for in-hospital mortality, discharge to hospice, and discharge to nursing facilities were 14.04 (13.71 to 14.38), 4.35 (4.14 to 4.57), and 3.88 (3.82 to 3.94), respectively ( P < 0.001, for all). Patients with eGFR (Chronic Kidney Disease Epidemiology Collaboration) 60-89 ml/min per 1.73 m 2 and normonatremia had the lowest odds ratio for in-hospital mortality (1.60 [1.52 to 1.70]). CONCLUSIONS Hospital-acquired hypernatremia is associated with in-hospital mortality and discharge to hospice or to nursing facilities in all stages of CKD.
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Affiliation(s)
- Soraya Arzhan
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Department of Neurology and Rehabilitation, University of Illinois Chicago, Chicago, Illinois
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Igor Litvinovich
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Cristian G. Bologa
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Mark L. Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Medicine Service, Division of Nephrology, Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico
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Devaraj SM, Roumelioti ME, Yabes JG, Schopp M, Erickson S, Steel JL, Rollman BL, Weisbord SD, Unruh M, Jhamb M. Correlates of Rates and Treatment Readiness for Depressive Symptoms, Pain, and Fatigue in Hemodialysis Patients: Results from the TĀCcare Study. Kidney360 2023; 4:e1265-e1275. [PMID: 37461138 PMCID: PMC10547226 DOI: 10.34067/kid.0000000000000213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/23/2023] [Accepted: 07/10/2023] [Indexed: 09/29/2023]
Abstract
Key Points Lower neighborhood walkability was associated with higher depressive symptoms and fatigue and younger age with depressive symptoms. Depressive symptoms, pain, and fatigue were frequently reported, often occurred together, and were often not all already treated. Patients with a higher symptom burden and men may be more likely to be ready to seek treatment for depressive symptoms, pain, or fatigue. Background Patients on hemodialysis (HD) often experience clinically significant levels of pain, fatigue, and depressive symptoms. We explored potential sociodemographic differences in symptom burden, current treatment, and readiness to seek treatment for these symptoms in patients screened for the TĀCcare trial. Methods In-center HD patients from Pennsylvania and New Mexico were screened for fatigue (≥5 on 0–10-point Likert scale), pain (Likert scale ≥4), depressive symptoms (≥10 Patient Health Questionnaire-9), and readiness to seek treatment (5–item Stages of Behavior Change questionnaire). Symptom burden and treatment status by sociodemographic factors were evaluated using chi square, Fisher exact tests, and logistic regression models. Results From March 2018 to December 2021, 506 of 896 (57%) patients screened met eligibility criteria and completed the symptom screening (mean age 60±13.9 years, 44% female, 17% Black, 25% American Indian, and 25% Hispanics). Of them, 77% screened positive for ≥1 symptom and 35% of those were receiving treatment for ≥1 of these symptoms. Pain, fatigue, and depressive symptom rates were 52%, 64%, and 24%, respectively. Age younger than 65 years was associated with a higher burden of depressive symptoms, pain, and reporting ≥1 symptom (P <0.05). The percentage of patients ready to seek treatment increased with symptom burden. More men reported readiness to seek treatment (85% versus 68% of women, P <0.001). Among those with symptoms and treatment readiness, income was inversely associated with pain (>$60,000/yr: odds ratio [OR]=0.16, confidence interval [CI]=0.03 to 0.76) and living in less walkable neighborhoods with more depressive symptoms (OR= 5.34, CI=1.19 to 24.05) and fatigue (OR= 5.29, CI=1.38 to 20.33). Conclusions Pain, fatigue, and depressive symptoms often occurred together, and younger age, less neighborhood walkability, and lower income were associated with a higher burden of symptoms in HD patients. Male patients were less likely to be receiving treatment for symptoms. These findings could inform priority HD patient symptom identification and treatment targets.
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Affiliation(s)
- Susan M. Devaraj
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Jonathan G. Yabes
- Center for Research on Heath Care Data Center, Division of General Internal Medicine; Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary Schopp
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sarah Erickson
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Jennifer L. Steel
- Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bruce L. Rollman
- Center for Behavioral Health, Media, and Technology, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Steven D. Weisbord
- Renal Section and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Jhamb M, Steel JL, Yabes JG, Roumelioti ME, Erickson S, Devaraj SM, Vowles KE, Vodovotz Y, Beach S, Weisbord SD, Rollman BL, Unruh M. Effects of Technology Assisted Stepped Collaborative Care Intervention to Improve Symptoms in Patients Undergoing Hemodialysis: The TĀCcare Randomized Clinical Trial. JAMA Intern Med 2023; 183:795-805. [PMID: 37338898 PMCID: PMC10282960 DOI: 10.1001/jamainternmed.2023.2215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/15/2023] [Indexed: 06/21/2023]
Abstract
Importance Patients with end-stage kidney disease (ESKD) undergoing long-term hemodialysis often experience a high burden of debilitating symptoms for which effective treatment options are limited. Objective To compare the effectiveness of a stepped collaborative care intervention vs attention control for reducing fatigue, pain, and depression among patients with ESKD undergoing long-term hemodialysis. Design, Setting, and Participants Technology Assisted Stepped Collaborative Care (TĀCcare) was a parallel-group, single-blinded, randomized clinical trial of adult (≥18 years) patients undergoing long-term hemodialysis and experiencing clinically significant levels of fatigue, pain, and/or depression for which they were considering treatment. The trial took place in 2 US states (New Mexico and Pennsylvania) from March 1, 2018, to June 31, 2022. Data analyses were performed from July 1, 2022, to April 10, 2023. Interventions The intervention group received 12 weekly sessions of cognitive behavioral therapy delivered via telehealth in the hemodialysis unit or patient home, and/or pharmacotherapy using a stepped approach in collaboration with dialysis and primary care teams. The attention control group received 6 telehealth sessions of health education. Main Outcomes and Measures The coprimary outcomes were changes in fatigue (measured using the Functional Assessment of Chronic Illness Therapy Fatigue), average pain severity (Brief Pain Inventory), and/or depression (Beck Depression Inventory-II) scores at 3 months. Patients were followed up for 12 months to assess maintenance of intervention effects. Results There were 160 participants (mean [SD] age, 58 [14] years; 72 [45%] women and 88 [55%] men; 21 [13%] American Indian, 45 [28%] Black, 28 [18%] Hispanic, and 83 [52%] White individuals) randomized, 83 to the intervention and 77 to the control group. In the intention-to-treat analyses, when compared with controls, patients in the intervention group experienced statistically and clinically significant reductions in fatigue (mean difference [md], 2.81; 95% CI, 0.86 to 4.75; P = .01) and pain severity (md, -0.96; 95% CI, -1.70 to -0.23; P = .02) at 3 months. These effects were sustained at 6 months (md, 3.73; 95% CI, 0.87 to 6.60; P = .03; and BPI, -1.49; 95% CI, -2.58 to -0.40; P = .02). Improvement in depression at 3 months was statistically significant but small (md -1.73; 95% CI, -3.18 to -0.28; P = .02). Adverse events were similar in both groups. Conclusions and Relevance This randomized clinical trial found that a technology assisted stepped collaborative care intervention delivered during hemodialysis led to modest but clinically meaningful improvements in fatigue and pain at 3 months vs the control group, with effects sustained until 6 months. Trial Registration ClinicalTrials.gov Identifier: NCT03440853.
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Affiliation(s)
- Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer L. Steel
- Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Center for Research on Heath Care Data Center, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque
| | - Sarah Erickson
- Department of Psychology, University of New Mexico, Albuquerque
| | - Susan M. Devaraj
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kevin E. Vowles
- School of Psychology, Queen’s University, Belfast, Northern Ireland, United Kingdom
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott Beach
- Department of Psychology, University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Steven D. Weisbord
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Renal Section and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Bruce L. Rollman
- Center for Behavioral Health, Media, and Technology, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque
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Aziz F, Sam R, Lew SQ, Massie L, Misra M, Roumelioti ME, Argyropoulos CP, Ing TS, Tzamaloukas AH. Pseudohyponatremia: Mechanism, Diagnosis, Clinical Associations and Management. J Clin Med 2023; 12:4076. [PMID: 37373769 DOI: 10.3390/jcm12124076] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/08/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Pseudohyponatremia remains a problem for clinical laboratories. In this study, we analyzed the mechanisms, diagnosis, clinical consequences, and conditions associated with pseudohyponatremia, and future developments for its elimination. The two methods involved assess the serum sodium concentration ([Na]S) using sodium ion-specific electrodes: (a) a direct ion-specific electrode (ISE), and (b) an indirect ISE. A direct ISE does not require dilution of a sample prior to its measurement, whereas an indirect ISE needs pre-measurement sample dilution. [Na]S measurements using an indirect ISE are influenced by abnormal concentrations of serum proteins or lipids. Pseudohyponatremia occurs when the [Na]S is measured with an indirect ISE and the serum solid content concentrations are elevated, resulting in reciprocal depressions in serum water and [Na]S values. Pseudonormonatremia or pseudohypernatremia are encountered in hypoproteinemic patients who have a decreased plasma solids content. Three mechanisms are responsible for pseudohyponatremia: (a) a reduction in the [Na]S due to lower serum water and sodium concentrations, the electrolyte exclusion effect; (b) an increase in the measured sample's water concentration post-dilution to a greater extent when compared to normal serum, lowering the [Na] in this sample; (c) when serum hyperviscosity reduces serum delivery to the device that apportions serum and diluent. Patients with pseudohyponatremia and a normal [Na]S do not develop water movement across cell membranes and clinical manifestations of hypotonic hyponatremia. Pseudohyponatremia does not require treatment to address the [Na]S, making any inadvertent correction treatment potentially detrimental.
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Affiliation(s)
- Fahad Aziz
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
| | - Ramin Sam
- Department of Medicine, Zuckerberg San Francisco General Hospital, School of Medicine, University of California in San Francisco, San Francisco, CA 94110, USA
| | - Susie Q Lew
- Department of Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20052, USA
| | - Larry Massie
- Department of Pathology, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87108, USA
| | - Madhukar Misra
- Department of Medicine, Division of Nephrology, University of Missouri, Columbia, MO 65211, USA
| | - Maria-Eleni Roumelioti
- Department of Medicine, Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Christos P Argyropoulos
- Department of Medicine, Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Todd S Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA
| | - Antonios H Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87108, USA
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10
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Arzhan S, Roumelioti ME, Litvinovich I, Bologa CG, Myers OB, Unruh ML. Hypernatremia in Hospitalized Patients: A Large Population-Based Study. Kidney360 2022; 3:1144-1157. [PMID: 35919520 PMCID: PMC9337903 DOI: 10.34067/kid.0000702022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/18/2022] [Indexed: 01/11/2023]
Abstract
Background Hypernatremia is a frequently encountered electrolyte disorder in hospitalized patients. Controversies still exist over the relationship between hypernatremia and its outcomes in hospitalized patients. This study examines the relationship of hypernatremia to outcomes among hospitalized patients and the extent to which this relationship varies by kidney function and age. Methods We conducted an observational study to investigate the association between hypernatremia, eGFR, and age at hospital admission and in-hospital mortality, and discharge dispositions. We analyzed the data of 1.9 million patients extracted from the Cerner Health Facts databases (2000-2018). Adjusted multinomial regression models were used to estimate the relationship of hypernatremia to outcomes of hospitalized patients. Results Of all hospitalized patients, 3% had serum sodium (Na) >145 mEq/L at hospital admission. Incidence of in-hospital mortality was 12% and 2% in hyper- and normonatremic patients, respectively. The risk of all outcomes increased significantly for Na >155 mEq/L compared with the reference interval of Na=135-145 mEq/L. Odds ratios (95% confidence intervals) for in-hospital mortality and discharge to a hospice or nursing facility were 34.41 (30.59-38.71), 21.14 (17.53-25.5), and 12.21 (10.95-13.61), respectively (all P<0.001). In adjusted models, we found that the association between Na and disposition was modified by eGFR (P<0.001) and by age (P<0.001). Sensitivity analyses were performed using the eGFR equation without race as a covariate, and the inferences did not substantially change. In all hypernatremic groups, patients aged 76-89 and ≥90 had higher odds of in-hospital mortality compared with younger patients (all P<0.001). Conclusions Hypernatremia was significantly associated with in-hospital mortality and discharge to a hospice or nursing facility. The risk of in-hospital mortality and other outcomes was highest among those with Na >155 mEq/L. This work demonstrates that hypernatremia is an important factor related to discharge disposition and supports the need to study whether protocolized treatment of hypernatremia improves outcomes.
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Affiliation(s)
- Soraya Arzhan
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Igor Litvinovich
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Cristian G. Bologa
- Division of Translational Informatics, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Orrin B. Myers
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Mark L. Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico,Medicine Service, Division of Nephrology, Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico
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11
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Arzhan S, Argyropoulos C, Roumelioti ME. Electronic Health Record Portals and Patient-Centered Outcomes in CKD. Kidney Med 2021; 3:167-170. [PMID: 33851111 PMCID: PMC8039424 DOI: 10.1016/j.xkme.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Soraya Arzhan
- Renal and Electrolyte Division, University of New Mexico, Albuquerque, NM
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12
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Lee J, Steel J, Roumelioti ME, Erickson S, Myaskovsky L, Yabes JG, Rollman BL, Weisbord S, Unruh M, Jhamb M. Psychosocial Impact of COVID-19 Pandemic on Patients with End-Stage Kidney Disease on Hemodialysis. ACTA ACUST UNITED AC 2020; 1:1390-1397. [DOI: 10.34067/kid.0004662020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/12/2020] [Indexed: 11/27/2022]
Abstract
BackgroundThe coronavirus disease 2019 (COVID-19) may have a negative effect on the mental and social health of patients with ESKD on chronic in-center hemodialysis (HD), who have a high burden of psychologic symptoms at baseline and unavoidable treatment-related COVID exposures. The goal of our study was to assess the effect of the COVID-19 pandemic on the psychosocial health of patients on chronic in-center HD.MethodsParticipants enrolled in the ongoing Technology Assisted Collaborative Care (TĀCcare) trial in Western Pennsylvania and New Mexico were approached for participation in a phone survey in May 2020. Data on the pandemic’s effects on participants’ physical and mental health, symptoms (such as anxiety, mood, loneliness, sleep, and stress), and food and housing security were collected.ResultsSurveys were completed by 49 participants (mean age 56 years; 53% men, 18% Black, 20% American Indian, and 22% Hispanic). Almost 80% of participants reported being moderately to extremely worried about the pandemic’s effects on their mental/emotional health and interpersonal relationships. More than 85% of the participants were worried about obtaining their dialysis treatments due to infection risk from close contact in the dialysis facility or during transportation. Despite this, 82% of participants reported being not at all/slightly interested in trying home dialysis as an alternative option. Overall, 27% of the participants had clinical levels of depressive symptoms but only 12% had anxiety meeting clinical criteria. About 33% of participants reported poor sleep quality over the last month. Perceived stress was high in about 30% of participants and 85% felt overwhelmed by difficulties with COVID-19, although 41% felt that things were fairly/very often going their way.ConclusionsOur study provides preliminary insights into the psychosocial distress caused by the COVID-19 pandemic among a diverse cohort of patients receiving chronic HD who are participating in an ongoing clinical trial.
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13
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Unruh M, Cukor D, Rue T, Abad K, Roumelioti ME, McCurry SM, Heagerty P, Mehrotra R. Sleep-HD trial: short and long-term effectiveness of existing insomnia therapies for patients undergoing hemodialysis. BMC Nephrol 2020; 21:443. [PMID: 33081705 PMCID: PMC7574396 DOI: 10.1186/s12882-020-02107-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/14/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) experience many distressing symptoms. One frequently reported symptom is insomnia. There are unique issues about HD treatments and schedules that disrupt regular sleep/wake routines and possibly contribute to the high severity of insomnia. Despite evidence for broad-ranging health effects of insomnia, very few clinical trials have tested the efficacy of treatments for HD patients. Cognitive-behavioral therapy for insomnia (CBT-I) is a recommended first-line therapy but largely inaccessible to HD patients in the United States, partly because they commit considerable amounts of time to thrice-weekly dialysis treatments. Another important reason could be the logistical and reimbursement challenges associated with providing behavioral health care at the dialysis center. CBT-I delivered by telehealth can overcome barriers to access, but its efficacy has never been rigorously tested for these patients. Pharmacotherapy is the most widely used treatment for insomnia; however, some drugs presently used are unsafe as they are associated with a higher risk for death for HD patients (benzodiazepines and zolpidem-like drugs). The efficacy and safety of other medications (trazodone) for the treatment of insomnia has never been tested for patients treated with HD. METHODS This trial tests the short- and long-term comparative effectiveness of 6-week treatment with telehealth CBT-I, trazodone, or medication placebo. This will be accomplished with a randomized controlled trial (RCT) in which 126 participants treated with HD in community-based dialysis facilities with chronic insomnia will be assigned 1:1:1 to telehealth CBT-I, trazodone, or medication placebo, respectively; short-term effectiveness of each treatment arm will be determined at the end of 6-weeks of treatment and long-term effectiveness at 25-weeks. The primary and secondary patient-reported outcomes will be assessed with computer-based telephone interviewing by research scientists blinded to treatment assignment; additional secondary outcomes will be assessed by participant interview and actigraphy. DISCUSSION This clinical RCT will provide the first evidence for the comparative effectiveness of two distinct approaches for treating chronic insomnia and other patient-reported outcomes for patients receiving maintenance HD. TRIAL REGISTRATION NCT03534284 May 23, 2018. SLEEP-HD Protocol Version: 1.3.4 (7/22/2020).
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Affiliation(s)
- Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA.
- Nephrology Section, New Mexico Veterans Hospital, Albuquerque, NM, USA.
| | | | - Tessa Rue
- Center for Biomedical Statistics, University of Washington, Seattle, WA, USA
| | - Kashif Abad
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Susan M McCurry
- Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Patrick Heagerty
- Center for Biomedical Statistics, University of Washington, Seattle, WA, USA
| | - Rajnish Mehrotra
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA, USA
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14
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Roumelioti ME, Sun Y, Ganta K, Gibb J, Tzamaloukas AH. Management of extracellular volume in patients with end-stage kidney disease and severe hyperglycemia. J Diabetes Complications 2020; 34:107615. [PMID: 32402841 DOI: 10.1016/j.jdiacomp.2020.107615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 11/19/2022]
Abstract
This commentary addresses volume replacement in hyperglycemic crises in patients with end-stage kidney disease (ESKD). The management of volume issues in this group of patients should not be based on guidelines for management of hyperglycemic crises, but should be individualized and based on directed patient medical history, physical examination, and imaging of the heart and lungs. A scheme for combining information from these three sources is provided.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, MSC 04-2785, University of New Mexico, Albuquerque, NM 87131, USA.
| | - Yijuan Sun
- Renal Section, Raymond G. Murphy VA Medical Center and University of New Mexico School of Medicine, 1501 San Pedro, SE, Albuquerque, NM 87108, USA.
| | - Kavitha Ganta
- Renal Section, Raymond G. Murphy VA Medical Center and University of New Mexico School of Medicine, 1501 San Pedro, SE, Albuquerque, NM 87108, USA.
| | - James Gibb
- Division of Nephrology, Department of Medicine, MSC 04-2785, University of New Mexico, Albuquerque, NM 87131, USA.
| | - Antonios H Tzamaloukas
- Research Service, Raymond G. Murphy VA Medical Center and University of New Mexico School of Medicine, 1501 San Pedro, SE, Albuquerque, NM 87108, USA.
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15
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Hill DA, Argyropoulos C, Roumelioti ME, Unruh M. Abstract P5-07-14: Chronic kidney disease in breast cancer treatment and survival. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p5-07-14] [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
Abstract
Background: Presence of chronic kidney disease (CKD Stages 3-5) prior to breast cancer diagnosis may increase the risk of mortality among women with invasive breast cancer. However, the evidence base is limited, and the magnitude of this mortality risk is unknown. Breast cancer therapy may also be altered by presence of CKD. We sought to understand the role of CKD in breast cancer survival, with particular attention to receipt of recommended treatment.
Methods: All women diagnosed with invasive breast cancer from 1992-2016 in 18 SEER-Medicare sites (age 66 or older; n= 168701) were evaluated for breast cancer-specific mortality (BCSM) using multivariate Cox models, with estimation of hazard ratios (HR) and 95% confidence intervals (CI). All analyses were adjusted for age, race/ethnicity, diagnosis year, tumor characteristics, and socioeconomic factors, and also for diabetes, myocardial infarction, and congestive heart failure prior to diagnosis. Separate analyses were run according to receipt vs non-receipt of standard of care for breast cancer treatment (defined according to National Comprehensive Cancer Network (NCCN) guidelines.
Results: Median follow-up was 63 months (26 months with CKD). Women with CKD were at increased risk of BCSM (CKD Stage 3: HR 1.2; 95% CI 1.0-1.5; CKD Stage 4 HR 1.7; 95% CI 1.3-2.2; CKD Stage 5/End Stage Renal Disease HR 1.5; 95% CI 1.1-2.1), compared to women without CKD. In analyses of any CKD, restricted to women who met NCCN guideline therapy recommendations, women had an elevated risk of BCSM regardless of whether they did (HR 1.6; 95% CI 1.1-2.1) or did not (HR 1.4; 95% CI 1.0-1.8) receive recommended chemotherapy, and whether they did (HR 1.6; 95% CI 1.1-2.3) or did not (HR 1.3; 95% CI 0.9-2.0) receive recommended radiotherapy.
Discussion: Women with CKD have an increased risk of breast cancer mortality regardless of receipt of guideline-based treatment. CKD is underascertained in Medicare claims data, thus the reported results (likely underestimates) will be presented with sensitivity analyses. CKD may influence breast cancer outcomes due to associated systemic inflammation and comorbid conditions, as well as release of soluble mediators such as cytokines, chemokines, growth factors, and factors involved in remodeling of the extracellular matrix and epithelial-mesenchymal transition. As such factors involved in CKD progression also influence cancer, increased understanding may provide clues to ameliorate adverse outcomes in both disease entities.
Citation Format: Deirdre A Hill, Christos Argyropoulos, Maria-Eleni Roumelioti, Mark Unruh. Chronic kidney disease in breast cancer treatment and survival [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-07-14.
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Affiliation(s)
| | | | | | - Mark Unruh
- University of New Mexico, Albuquerque, NM
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16
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Jhamb M, Roumelioti ME. Socioeconomic Determinants of Quality of Life in Patients with Kidney Diseases. Clin J Am Soc Nephrol 2020; 15:162-164. [PMID: 37095653 PMCID: PMC7015099 DOI: 10.2215/cjn.14941219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico, Albuquerque, New Mexico
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17
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Jhamb M, Ran X, Abdalla H, Roumelioti ME, Hou S, Davis H, Patel SR, Yabes J, Unruh M. Association of Sleep Apnea with Mortality in Patients with Advanced Kidney Disease. Clin J Am Soc Nephrol 2020; 15:182-190. [PMID: 31969341 PMCID: PMC7015094 DOI: 10.2215/cjn.07880719] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 07/09/2019] [Accepted: 12/18/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES In the general population, sleep disorders are associated with mortality. However, such evidence in patients with CKD and ESKD is limited and shows conflicting results. Our aim was to examine the association of sleep apnea with mortality among patients with CKD and ESKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this prospective cohort study, 180 patients (88 with CKD stage 4 or 5, 92 with ESKD) underwent in-home polysomnography, and sleep apnea measures such as apnea hypopnea index (AHI) and nocturnal hypoxemia were obtained. Mortality data were obtained from the National Death Index. Cox proportional hazard models were used for survival analysis. RESULTS Among the 180 patients (mean age 54 years, 37% women, 39% with diabetes, 49% CKD with mean eGFR 18±7 ml/min per 1.73 m2), 71% had sleep apnea (AHI>5) and 23% had severe sleep apnea (AHI>30). Median AHI was 13 (range, 4-29) and was not significantly different in patients with advanced CKD or ESKD. Over a median follow-up of 9 years, there were 84 (47%) deaths. AHI was not significantly associated with mortality after adjusting for age, sex, race, diabetes, body mass index, CKD/ESKD status, and kidney transplant status (AHI>30: hazard ratio [HR], 1.5; 95% confidence interval [95% CI], 0.6 to 4.0; AHI >15 to 30: HR, 2.3; 95% CI, 0.9 to 5.9; AHI >5 to 15: HR, 2.1; 95% CI, 0.8 to 5.4, compared with AHI≤5). Higher proportion of sleep time with oxygen saturation <90% and lower mean oxygen saturation were significantly associated with higher mortality in adjusted analysis (HR, 1.4; 95% CI, 1.1 to 1.7; P=0.007 for every 15% higher proportion, and HR, 1.6; 95% CI, 1.2 to 2.1; P=0.003 for every 2% lower saturation, respectively). Sleep duration, sleep efficiency, or periodic limb movement index were not associated with mortality. CONCLUSIONS Hypoxemia-based measures of sleep apnea are significantly associated with increased risk of death among advanced CKD and ESKD.
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Affiliation(s)
| | | | | | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; and
| | | | - Herbert Davis
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; and
| | - Sanjay R Patel
- Division of Pulmonary, Allergy and Critical Care Medicine, and
| | - Jonathan Yabes
- Department of Biostatistics.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; and.,Section of Nephrology, New Mexico Veterans Affairs Hospital, Albuquerque, New Mexico
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18
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Arzhan S, Roumelioti ME, Unruh M. Itch and Ache on Dialysis: New Approaches to Manage Uremic Pruritus and Restless Legs. Blood Purif 2019; 49:222-227. [DOI: 10.1159/000504081] [Citation(s) in RCA: 11] [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] [Received: 09/30/2019] [Accepted: 10/10/2019] [Indexed: 11/19/2022]
Abstract
Background: Uremic pruritus (UP) and restless legs syndrome (RLS) are highly prevalent complaints among patients with end-stage renal disease (ESRD) undergoing chronic dialysis. These chronic troublesome symptoms lead to a significant decrease in quality of life (QOL) and increase in mortality rate. Despite their distressing characteristics, these symptoms usually remain under-recognized by healthcare providers. Therefore, careful history intake, and stepwise treatment are essential. Numerous pharmacological and non-pharmacological treatments have been demonstrated to help in controlling these 2 conditions. Summary: In this review, we discuss the latest findings regarding UP and RLS among ESRD patients on maintenance dialysis. We also examine different treatment options in this group of patients. The majority of these patients do not have the opportunity to receive a kidney transplant and need other treatments for these burdensome symptoms in order to improve their QOL and prognosis. Key Messages: UP and RLS are common but underdiagnosed conditions in ESRD patients on maintenance dialysis that are related to a decline in patients’ QOL and poor prognosis. The pathophysiology of these conditions remains not well understood. Therefore, controversies still exist on treatment options. Treating these conditions provides an opportunity to improve the health-related QOL and outcomes of dialysis patients.
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19
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Tzamaloukas AH, Khitan ZJ, Glew RH, Roumelioti ME, Rondon-Berrios H, Elisaf MS, Raj DS, Owen J, Sun Y, Siamopoulos KC, Rohrscheib M, Ing TS, Murata GH, Shapiro JI, Malhotra D. Serum Sodium Concentration and Tonicity in Hyperglycemic Crises: Major Influences and Treatment Implications. J Am Heart Assoc 2019; 8:e011786. [PMID: 31549572 PMCID: PMC6806024 DOI: 10.1161/jaha.118.011786] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Antonios H Tzamaloukas
- Raymond G. Murphy Veterans Affairs Medical Center Albuquerque NM.,University of New Mexico School of Medicine Albuquerque NM
| | - Zeid J Khitan
- Joan C. Edwards School of Medicine Marshall University Huntington WV
| | - Robert H Glew
- University of New Mexico School of Medicine Albuquerque NM
| | | | | | - Moses S Elisaf
- University of Ioannina School of Medicine Ioannina Greece
| | - Dominic S Raj
- George Washington University School of Medicine Washington DC
| | - Jonathan Owen
- University of New Mexico School of Medicine Albuquerque NM
| | - Yijuan Sun
- Raymond G. Murphy Veterans Affairs Medical Center Albuquerque NM.,University of New Mexico School of Medicine Albuquerque NM
| | | | | | - Todd S Ing
- Stritch School of Medicine Loyola University Chicago Maywood IL
| | - Glen H Murata
- Raymond G. Murphy Veterans Affairs Medical Center Albuquerque NM
| | - Joseph I Shapiro
- Joan C. Edwards School of Medicine Marshall University Huntington WV
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20
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Roumelioti ME, Tzamaloukas AH. Management of plasma hypertonicity resulting from osmotic diuresis. Int Urol Nephrol 2019; 51:1079-1080. [PMID: 31098817 DOI: 10.1007/s11255-019-02137-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/26/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Antonios H Tzamaloukas
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA. .,Research Service, Raymond G. Murphy Veterans Affairs Medical Center (111C), 1501 San Pedro, SE, Albuquerque, NM, 87108, USA.
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21
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Roumelioti ME, Steel JL, Yabes J, Vowles KE, Vodovotz Y, Beach S, Rollman B, Weisbord SD, Unruh ML, Jhamb M. Rationale and design of technology assisted stepped collaborative care intervention to improve patient-centered outcomes in hemodialysis patients (TĀCcare trial). Contemp Clin Trials 2018; 73:81-91. [PMID: 30208343 PMCID: PMC6168366 DOI: 10.1016/j.cct.2018.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/17/2018] [Accepted: 09/07/2018] [Indexed: 01/08/2023]
Abstract
Most hemodialysis (HD) patients experience symptoms of depression, pain and fatigue that impair their health-related quality of life (HRQOL) significantly. These symptoms are associated with increased hospitalization and mortality, mediated by behavioral factors (e.g. non-adherence to medication and dialysis) and biological factors (e.g. inflammatory cytokines). Prior interventions to alleviate symptoms and improve HRQOL showed limited effectiveness in HD patients and their effect on bio-behavioral mediators is lacking evidence. It is imperative to improve patient-centered dialysis care and to address call from Kidney Disease Improving Global Outcomes (KDIGO) guidelines for integration of symptom assessment and management in routine HD-care. Technology-Assisted stepped Collaborative Care (TĀCcare) is a multi-center randomized controlled trial (RCT) of 150 diverse HD patients from Pennsylvania and New Mexico, designed to compare the effectiveness of a 12-week stepped collaborative care intervention (cognitive behavioral therapy, CBT) with an attention control arm of technology-delivered health education. Collaborative care provides an integrated multi-disciplinary structured management plan. Furthermore, a stepped approach to pharmacotherapy and/or CBT allows for individualization of treatment according to patients' clinical status, preferences and treatment response. To simplify the delivery of CBT and to minimize patient and provider burden, we will use live video-conferencing with patients in dialysis units. We will examine the effect of these interventions on patient symptoms, HRQOL, treatment adherence and inflammatory biomarkers. This RCT tests a readily implementable intervention that can be integrated in routine HD-care and will generate novel and meaningful insights on strategies to alleviate common symptoms and improve HRQOL in HD.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque, NM, United States
| | - Jennifer L Steel
- Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jonathan Yabes
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kevin E Vowles
- Department of Psychology, University of New Mexico & Division of Physical Medicine and Rehabilitation, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Yoram Vodovotz
- Department of Immunology and Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Scott Beach
- Department of Psychology, University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Bruce Rollman
- Department of Medicine, Psychiatry, Biomedical Informatics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, United States
| | - Steven D Weisbord
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Mark L Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine Albuquerque, NM, United States
| | - Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
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Al Mawed S, Pankratz VS, Chong K, Sandoval M, Roumelioti ME, Unruh M. Low serum sodium levels at hospital admission: Outcomes among 2.3 million hospitalized patients. PLoS One 2018; 13:e0194379. [PMID: 29566068 PMCID: PMC5864034 DOI: 10.1371/journal.pone.0194379] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 02/20/2018] [Indexed: 12/30/2022] Open
Abstract
Background Hyponatremia is the most common electrolyte disorder among hospitalized patients. Controversies still exist over the relationship between hyponatremia and outcomes of hospitalized patients. Methods To analyze the association of low serum sodium levels at hospital admission with in-hospital mortality and patient disposition and to compare the distribution of the risk of death associated with hyponatremia across the lifespan of hospitalized patients, we conducted an observational study of 2.3 million patients using data extracted from the Cerner Health Facts database between 2000 and 2014. Logistic regression models were used in the analyses. Results At hospital admission 14.4% of hospitalized patients had serum sodium levels [Na] <135 mEq/L. In adjusted multinomial logistic regression analysis, we found that the risk of in-hospital mortality significantly increases for [Na] levels < 135 or ≥143 to ≤145 mEq/L compared to the reference interval of 140 to <143 mEq/L (p<0.001). We observed similar trends for the relationship between [Na] levels and discharge to hospice or to a nursing facility. We demonstrated that younger age groups (18 to <45, 45 to <65) had a higher risk of in-hospital mortality compared to older age groups (65 to <75, ≥75) for [Na] levels <130 mEq/L or 143 to ≤145 mEq/L (p<0.001). Conclusions Hyponatremia is common among hospitalized patients and is significantly associated with in-hospital mortality, discharge to hospice or to a nursing facility. The risk of death and other outcomes was more evident for [Na] <135 mEq/L. The mortality associated with low [Na] was significantly higher in younger versus older patients.
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Affiliation(s)
- Saleem Al Mawed
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - V. Shane Pankratz
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Kelly Chong
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Matthew Sandoval
- University of New Mexico Clinical and Translational Science Center (CTSC), Albuquerque, New Mexico, United States of America
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
- * E-mail:
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23
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Roumelioti ME, Ing TS, Rondon-Berrios H, Glew RH, Khitan ZJ, Sun Y, Malhotra D, Raj DS, Agaba EI, Murata GH, Shapiro JI, Tzamaloukas AH. Principles of quantitative water and electrolyte replacement of losses from osmotic diuresis. Int Urol Nephrol 2018; 50:1263-1270. [PMID: 29511980 DOI: 10.1007/s11255-018-1822-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/04/2018] [Indexed: 02/08/2023]
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24
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Roumelioti ME, Trietley G, Nolin TD, Ng YH, Xu Z, Alaini A, Figueroa R, Unruh ML, Argyropoulos CP. Beta-2 microglobulin clearance in high-flux dialysis and convective dialysis modalities: a meta-analysis of published studies. Nephrol Dial Transplant 2018; 33:542. [DOI: 10.1093/ndt/gfx373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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25
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Jaros A, Sroya HA, Wolfe VK, Ghai V, Roumelioti ME, Shaffi K, Wang K, Pankratz VS, Unruh ML, Argyropoulos C. Study protocol: rationale and design of the community-based prospective cohort study of kidney function and diabetes in rural New Mexico, the COMPASS study. BMC Nephrol 2018; 19:47. [PMID: 29486722 PMCID: PMC5830321 DOI: 10.1186/s12882-018-0842-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 10/26/2017] [Accepted: 02/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rural areas in the state of New Mexico have been the "ground-zero" for the epidemic of diabetic Chronic Kidney Disease (CKD) in the United States. However, there is limited research about risk factors of diabetic CKD in this area and scarce data regarding the performance of emerging markers of renal filtration and epigenetic biomarkers of renal function and diabetes in this area with its unique ethnic/racial population. We designed the COMPASS study as a community-based program in rural New Mexico aiming to screen for CKD and to discover CKD-related translational biomarkers. METHODS/DESIGN The study involves a prospective, longitudinal cohort design involving individuals living in rural New Mexico. Participants undergo a screening for kidney disease using markers of abnormal renal filtration (impaired glomerular filtration rate) or damage (albuminuria). Those found to have CKD on the basis of these tests or those at risk for CKD are enrolled in a prospective longitudinal cohort. We measure markers of renal function, insulin resistance and epigenetics (microRNAs) on patients. Individuals are invited to participate in interviews and focus groups in order to characterize their attitudes towards research and barriers or facilitators to participation in future research studies about kidney disease. DISCUSSION This study will provide important data about the local epidemiology of kidney disease in a high-risk rural setting and the utility of emerging renal filtration markers (Beta 2 Microglobulin and Cystatin C), while generating data and methods for the analyses of microRNA biomarkers. The qualitative research subproject will identify factors associated with increased willingness to participate in future translational research projects. With its geographical focus, this study will address a critical disparity in kidney disease research, while generating novel epigenetic data that are relevant for future studies in the general population.
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Affiliation(s)
- Antonin Jaros
- Department of Internal Medicine, Division of Nephrology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Hafiz A Sroya
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Venita K Wolfe
- Community Engagement and Research Core, Clinical and Translational Science Center, University of New Mexico, Albuquerque, NM, USA
| | - Vikas Ghai
- Institute for Systems Biology, Seattle, WA, USA
| | - Maria-Eleni Roumelioti
- Department of Internal Medicine, Division of Nephrology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Kamran Shaffi
- Department of Internal Medicine, Division of Nephrology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Kai Wang
- Institute for Systems Biology, Seattle, WA, USA
| | - Vernon Shane Pankratz
- Department of Internal Medicine, Division of Nephrology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Mark L Unruh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.,Section of Nephrology, New Mexico Veterans Hospital, Alburquerque, NM, USA
| | - Christos Argyropoulos
- Department of Internal Medicine, Division of Nephrology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
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Roumelioti ME, Glew RH, Khitan ZJ, Rondon-Berrios H, Argyropoulos CP, Malhotra D, Raj DS, Agaba EI, Rohrscheib M, Murata GH, Shapiro JI, Tzamaloukas AH. Fluid balance concepts in medicine: Principles and practice. World J Nephrol 2018; 7:1-28. [PMID: 29359117 PMCID: PMC5760509 DOI: 10.5527/wjn.v7.i1.1] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/16/2017] [Accepted: 11/27/2017] [Indexed: 02/06/2023] Open
Abstract
The regulation of body fluid balance is a key concern in health and disease and comprises three concepts. The first concept pertains to the relationship between total body water (TBW) and total effective solute and is expressed in terms of the tonicity of the body fluids. Disturbances in tonicity are the main factor responsible for changes in cell volume, which can critically affect brain cell function and survival. Solutes distributed almost exclusively in the extracellular compartment (mainly sodium salts) and in the intracellular compartment (mainly potassium salts) contribute to tonicity, while solutes distributed in TBW have no effect on tonicity. The second body fluid balance concept relates to the regulation and measurement of abnormalities of sodium salt balance and extracellular volume. Estimation of extracellular volume is more complex and error prone than measurement of TBW. A key function of extracellular volume, which is defined as the effective arterial blood volume (EABV), is to ensure adequate perfusion of cells and organs. Other factors, including cardiac output, total and regional capacity of both arteries and veins, Starling forces in the capillaries, and gravity also affect the EABV. Collectively, these factors interact closely with extracellular volume and some of them undergo substantial changes in certain acute and chronic severe illnesses. Their changes result not only in extracellular volume expansion, but in the need for a larger extracellular volume compared with that of healthy individuals. Assessing extracellular volume in severe illness is challenging because the estimates of this volume by commonly used methods are prone to large errors in many illnesses. In addition, the optimal extracellular volume may vary from illness to illness, is only partially based on volume measurements by traditional methods, and has not been determined for each illness. Further research is needed to determine optimal extracellular volume levels in several illnesses. For these reasons, extracellular volume in severe illness merits a separate third concept of body fluid balance.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Robert H Glew
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Zeid J Khitan
- Division of Nephrology, Department of Medicine, Joan Edwards School of Medicine, Marshall University, Huntington, WV 25701, United States
| | - Helbert Rondon-Berrios
- Division of Renal and Electrolyte, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, United States
| | - Christos P Argyropoulos
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Deepak Malhotra
- Division of Nephrology, Department of Medicine, University of Toledo School of Medicine, Toledo, OH 43614-5809, United States
| | - Dominic S Raj
- Division of Renal Disease and Hypertension, Department of Medicine, George Washington University, Washington, DC 20037, United States
| | - Emmanuel I Agaba
- Division of Nephology, Department of Medicine, Jos University Medical Center, Jos, Plateau State 930001, Nigeria
| | - Mark Rohrscheib
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Glen H Murata
- Research Service, Raymond G Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
| | | | - Antonios H Tzamaloukas
- Research Service, Raymond G Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
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Roumelioti ME, Trietley G, Nolin TD, Ng YH, Xu Z, Alaini A, Figueroa R, Unruh ML, Argyropoulos CP. Beta-2 microglobulin clearance in high-flux dialysis and convective dialysis modalities: a meta-analysis of published studies. Nephrol Dial Transplant 2017; 33:1025-1039. [DOI: 10.1093/ndt/gfx311] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 10/04/2017] [Indexed: 01/01/2023] Open
Affiliation(s)
- Maria-Eleni Roumelioti
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Gregory Trietley
- Department of Pharmacy and Therapeutics, Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
| | - Yue-Harn Ng
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Zhi Xu
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Ahmed Alaini
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Rocio Figueroa
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Mark L Unruh
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
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Argyropoulos CP, Chen SS, Ng YH, Roumelioti ME, Shaffi K, Singh PP, Tzamaloukas AH. Rediscovering Beta-2 Microglobulin As a Biomarker across the Spectrum of Kidney Diseases. Front Med (Lausanne) 2017; 4:73. [PMID: 28664159 PMCID: PMC5471312 DOI: 10.3389/fmed.2017.00073] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [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: 04/12/2017] [Accepted: 05/26/2017] [Indexed: 12/28/2022] Open
Abstract
There is currently an unmet need for better biomarkers across the spectrum of renal diseases. In this paper, we revisit the role of beta-2 microglobulin (β2M) as a biomarker in patients with chronic kidney disease and end-stage renal disease. Prior to reviewing the numerous clinical studies in the area, we describe the basic biology of β2M, focusing in particular on its role in maintaining the serum albumin levels and reclaiming the albumin in tubular fluid through the actions of the neonatal Fc receptor. Disorders of abnormal β2M function arise as a result of altered binding of β2M to its protein cofactors and the clinical manifestations are exemplified by rare human genetic conditions and mice knockouts. We highlight the utility of β2M as a predictor of renal function and clinical outcomes in recent large database studies against predictions made by recently developed whole body population kinetic models. Furthermore, we discuss recent animal data suggesting that contrary to textbook dogma urinary β2M may be a marker for glomerular rather than tubular pathology. We review the existing literature about β2M as a biomarker in patients receiving renal replacement therapy, with particular emphasis on large outcome trials. We note emerging proteomic data suggesting that β2M is a promising marker of chronic allograft nephropathy. Finally, we present data about the role of β2M as a biomarker in a number of non-renal diseases. The goal of this comprehensive review is to direct attention to the multifaceted role of β2M as a biomarker, and its exciting biology in order to propose the next steps required to bring this recently rediscovered biomarker into the twenty-first century.
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Affiliation(s)
- Christos P Argyropoulos
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Shan Shan Chen
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Yue-Harn Ng
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Maria-Eleni Roumelioti
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Kamran Shaffi
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Pooja P Singh
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Antonios H Tzamaloukas
- Nephrology Division, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States.,Raymond G. Murphy VA Medical Center Albuquerque, Albuquerque, NM, United States
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Roumelioti ME, Argyropoulos C, Pankratz VS, Jhamb M, Bender FH, Buysse DJ, Strollo P, Unruh ML. Objective and subjective sleep disorders in automated peritoneal dialysis. Can J Kidney Health Dis 2016; 3:6. [PMID: 26889382 PMCID: PMC4756443 DOI: 10.1186/s40697-016-0093-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 05/15/2015] [Accepted: 12/28/2015] [Indexed: 11/25/2022] Open
Abstract
Background Automated peritoneal dialysis (APD) is one of the fastest growing dialysis modalities. It is unknown whether sleep and mood are disturbed while performing repeated overnight exchanges. Objectives In this report, we aim to describe and compare the prevalence of sleep-disordered breathing (SDB), periodic limb movements (PLMS), poor sleep quality (SQ), and depression among APD patients compared with stages 3b–5 (estimated glomerular filtration rate ≤44 ml/min/1.73 m2) chronic kidney disease (CKD) and hemodialysis (HD) patients. Design This is a cross-sectional, descriptive study. Setting Study participants were recruited from outpatient nephrology clinics, local dialysis centers, and the Thomas E. Starzl Transplant Institute in Western Pennsylvania between April 2004 and July 2009. Patients There were 186 participants in this study including 22 APD patients, 89 CKD patients, and 75 HD patients. Measurements In-home polysomnography was performed and two questionnaires were completed, the Pittsburgh Sleep Quality Index (PSQI) and the Patient Health Questionnaire-9 (PHQ-9). Methods SDB and PLMS were quantified by in-home unattended polysomnography; poor SQ was defined by a score >5 on the PSQI, and the presence of moderate to severe depression was defined by a score >5 on the PHQ-9. Results The APD patients had a median age of 37.5 years, were predominantly female (72.7 %), and had a median body mass index (BMI) of 23.8 kg/m2. In univariate analyses, APD patients had significantly lower apnea-hypopnea index compared to HD patients by 12.2 points (likelihood ratio test p = 0.008) and revealed the least percent of TST with nocturnal hypoxemia compared to CKD patients by 2.7 points, respectively (likelihood ratio test p = 0.01). The APD group had also significantly greater stages 3 to 4 sleep compared to the CKD patients by 8.6 points (likelihood ratio test p = 0.009). In multivariate analyses and after adjustment for age, gender, race, and BMI, both APD and HD patients had higher average PSQI scores than CKD patients by 2.54 and 2.22 points, respectively (likelihood ratio test p = 0.005). No other comparisons of sleep parameters among groups reached statistical significance. Limitations The limitations of this study are the small sample size of the APD population and the demographic and clinical differences among the three study groups. Conclusions Despite differences in univariate analyses, after multivariate adjustment, APD patients had similar sleep parameters and sleep architecture and as poor SQ and symptoms of depression as HD patients. Future studies with larger APD cohorts are needed.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Nephrology Division, Department of Medicine, University of New Mexico, 901 University Blvd. SE, Suite 150, MSC 04-2785, Albuquerque, NM 87106 USA
| | - Christos Argyropoulos
- Nephrology Division, Department of Medicine, University of New Mexico, 901 University Blvd. SE, Suite 150, MSC 04-2785, Albuquerque, NM 87106 USA
| | - Vernon Shane Pankratz
- Nephrology Division, Department of Medicine, University of New Mexico, 901 University Blvd. SE, Suite 150, MSC 04-2785, Albuquerque, NM 87106 USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Filitsa H Bender
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Daniel J Buysse
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA USA
| | - Patrick Strollo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Mark L Unruh
- Nephrology Division, Department of Medicine, University of New Mexico, 901 University Blvd. SE, Suite 150, MSC 04-2785, Albuquerque, NM 87106 USA
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Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Mark L Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
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Argyropoulos C, Roumelioti ME, Sattar A, Kellum JA, Weissfeld L, Unruh ML. Dialyzer Reuse and Outcomes of High Flux Dialysis. PLoS One 2015; 10:e0129575. [PMID: 26057383 PMCID: PMC4461247 DOI: 10.1371/journal.pone.0129575] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 05/11/2015] [Indexed: 11/23/2022] Open
Abstract
Background The bulk of randomized trial evidence for the expanding use of High Flux (HF) hemodialysis worldwide comes from two randomized controlled trials, one of which (HEMODIALYSIS, HEMO) allowed, while the other (Membrane Outcomes Permeability, MPO) excluded, the reuse of membranes. It is not known whether dialyzer reuse has a differential impact on outcomes with HF vs low flyx (LF) dialyzers. Methods Proportional Hazards Models and Joint Models for longitudinal measures and survival outcomes were used in HEMO to analyze the relationship between β2-microglobulin (β2M) concentration, flux, and reuse. Meta-analysis and regression techniques were used to synthesize the evidence for HF dialysis from HEMO and MPO. Findings In HEMO, minimally reused (< 6 times) HF dialyzers were associated with a hazard ratio (HR) of 0.67 (95% confidence interval, 95%CI: 0.48–0.92, p = 0.015), 0.64 (95%CI: 0.44 – 0.95, p = 0.03), 0.61 (95%CI: 0.41 – 0.90, p = 0.012), 0.53 (95%CI: 0.28 – 1.02, p = 0.057) relative to minimally reused LF ones for all cause, cardiovascular, cardiac and infectious mortality respectively. These relationships reversed for extensively reused membranes (p for interaction between reuse and flux < 0.001, p = 0.005) for death from all cause and cardiovascular causes, while similar trends were noted for cardiac and infectious mortality (p of interaction between reuse and flux of 0.10 and 0.08 respectively). Reduction of β2M explained only 1/3 of the effect of minimally reused HF dialyzers on all cause mortality, while non-β2M related factors explained the apparent attenuation of the benefit with more extensively reused dialyzers. Meta-regression of HEMO and MPO estimated an adjusted HR of 0.63 (95% CI: 0.51–0.78) for non-reused HF dialyzers compared with non-reused LF membranes. Conclusions This secondary analysis and synthesis of two large hemodialysis trials supports the widespread use of HF dialyzers in clinical hemodialysis over the last decade. A mechanistic understanding of the effects of HF dialysis and the reuse process on dialyzers may suggest novel biomarkers for uremic toxicity and may accelerate membrane technology innovations that will improve patient outcomes.
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Affiliation(s)
- Christos Argyropoulos
- Department of Internal Medicine, Division of Nephrology, University of New Mexico, Albuqurque, New Mexico, United States of America
- * E-mail:
| | - Maria-Eleni Roumelioti
- Department of Internal Medicine, Division of Nephrology, University of New Mexico, Albuqurque, New Mexico, United States of America
| | - Abdus Sattar
- Department of Epidemiology and Biostatistics School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - John A. Kellum
- Department of Critical Care Medicine, CRISMA Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Lisa Weissfeld
- Department of Critical Care Medicine, CRISMA Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Biostatistics University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Mark L. Unruh
- Department of Internal Medicine, Division of Nephrology, University of New Mexico, Albuqurque, New Mexico, United States of America
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Abstract
Obstructive sleep apnea (OSA) is common, underdiagnosed, and undertreated among patients with end-stage renal disease (ESRD). As in all cases, pathogenesis of OSA is related to repeated upper airway (UA) occlusion or narrowing, but in ESRD, additional contributory factors likely include uremic destabilization of central respiratory control and anatomic changes in the UA related to fluid status. Pulmonary congestion is common in acute and chronic kidney failure and is a consequence of cardiomyopathy and fluid overload, two potentially reversible risk factors. Emerging evidence suggests that volume overload also reduces the UA caliber. The diminution in UA area as well as destabilization of ventilatory control in ESRD have been postulated as causes of increased OSA prevalence and severity in these patients, and creates a vicious cycle wherein OSA exacerbates fluid overload disorders such as in congestive heart failure (CHF) and ESRD, which then further worsen OSA. Dialysis modalities may differ in their effects on volume status, the accumulation of uremic toxins, and acid-base status, and as a consequence, on the emergence and severity of OSA. Given the contribution of excess fluid to both the severity of nocturnal hypoxia and UA narrowing, establishing and maintaining dry weight is of particular importance when managing OSA in ESRD. Clinical trials to determine the extent to which more aggressive fluid removal in ESRD patients may alleviate OSA are needed.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Lee K Brown
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, and the Program in Sleep Medicine, University of New Mexico Health Sciences Centre, Albuquerque, New Mexico
| | - Mark L Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
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Roumelioti ME, Unruh M. Update in nephrology: evidence published in 2013. Ann Intern Med 2014; 161:54-7. [PMID: 24723262 DOI: 10.7326/m14-0263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Roumelioti ME, Buysse DJ, Sanders MH, Strollo P, Newman AB, Unruh ML. Sleep-disordered breathing and excessive daytime sleepiness in chronic kidney disease and hemodialysis. Clin J Am Soc Nephrol 2011; 6:986-94. [PMID: 21441128 PMCID: PMC3087794 DOI: 10.2215/cjn.05720710] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [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: 07/02/2010] [Accepted: 12/30/2010] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Sleep-disordered breathing (SDB) and excessive daytime sleepiness (EDS) are highly prevalent among hemodialysis (HD) patients. It is unclear to what extent SDB is associated with advanced chronic kidney disease (CKD; stages 4 to 5). This paper describes and compares the prevalence, severity, and patterns of SDB and EDS among patients with advanced CKD, HD-dependent patients, and community individuals without known renal disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Eighty-nine CKD and 75 HD patients were compared with 224 participants from the Sleep-Strategies Concentrating on Risk Evaluation Sleep-SCORE study of sleep and cardiovascular risk. Participants had in-home unattended polysomnography for quantifying SDB. EDS was defined by a score ≥10 on the Epworth Sleepiness Scale. RESULTS The sample had a median age 58.1 years, was predominantly male (57.4%) and white (62.5%), and had a median body mass index of 28.1 kg/m(2). Controls and Sleep-SCORE Study CKD patients had significantly higher median total sleep time and sleep efficiency compared with HD patients. The adjusted odds of severe SDB were higher for CKD and HD groups compared with the controls. Nocturnal hypoxemia was significantly elevated in the HD group compared with the CKD group. There were similar proportions of participants with EDS between the controls (33%), the CKD patients (29.3%), and the HD patients (40.6%). CONCLUSIONS Severe SDB (predominantly obstructive) and EDS are common among advanced CKD and HD patients. EDS correlated modestly with severe SDB and its obstructive and mixed patterns in the HD group.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, 200 Lothrop Street, PUH C-1111, Pittsburgh, PA 15213, USA.
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Roumelioti ME, Ranpuria R, Hall M, Hotchkiss JR, Chan CT, Unruh ML, Argyropoulos C. Abnormal nocturnal heart rate variability response among chronic kidney disease and dialysis patients during wakefulness and sleep. Nephrol Dial Transplant 2010; 25:3733-41. [PMID: 20466675 DOI: 10.1093/ndt/gfq234] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Dialysis patients and patients with chronic kidney disease (CKD) experience a substantial risk for abnormal autonomic function and abnormal heart rate variability (HRV). It remains unknown whether HRV changes across sleep stages in patients with different severity of CKD or dialysis dependency. We hypothesized that high-frequency (HF) HRV (vagal tone) will be attenuated from wakefulness to non-rapid eye movement (NREM) and then to rapid eye movement (REM) sleep in dialysis patients as compared to patients with CKD. METHODS In-home polysomnography was performed in 95 patients with stages 4-5 CKD or end-stage renal disease (ESRD) on haemodialysis (HD) or peritoneal dialysis (PD). HRV was measured using fast Fourier transform of interbeat intervals during wakefulness and sleep. Low-frequency (LF) and HF intervals were generated. Natural logarithm HF (LNHF) and the logarithm LF/HF ratio (sympathovagal tone) were analysed by multivariable quantile regression and generalized estimating equations. RESULTS Of the 95 patients, 63.2% (n = 60) was male, 35.8% (n = 34) was African American and 20.4% (n = 19) was diabetic. Average age was 51.6 ± 15.1 (range 19-82). HRV variables were significantly associated with diabetic status, higher periodic limb movement indices and lower bicarbonate levels. Patients with advanced CKD did not differ from dialysis patients in their inability to increase vagal tone during sleep. During wakefulness, female gender (P = 0.05) was associated with the increases in the vagal tone. CONCLUSIONS Patients with CKD/ESRD exhibit dysregulation of the autonomic nervous system tone manifesting as a failure to increase HRV during wakefulness and sleep. Different patient characteristics are associated with changes in HRV at different sleep stages.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, A909 Scaife Hall, Pittsburgh, PA 15261, USA.
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Roumelioti ME, Argyropoulos C, Buysse DJ, Nayar H, Weisbord SD, Unruh ML. Sleep quality, mood, alertness and their variability in CKD and ESRD. Nephron Clin Pract 2010; 114:c277-87. [PMID: 20090370 DOI: 10.1159/000276580] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Accepted: 09/22/2009] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND/AIMS Little is known about the association of chronic kidney disease (CKD) with sleep quality, mood, and alertness. In this report, we assessed these symptoms among patients with advanced CKD (stages 4-5) and those with end-stage renal disease (ESRD) and compared them to healthy controls without known kidney disease. METHODS Patients were recruited from local dialysis units, outpatient nephrology clinics and the Thomas E. Starzl Transplant Institute. Healthy control subjects matched for age, gender and race were drawn from an archival database. Daily symptoms of sleep quality, mood, and alertness were assessed by visual analogue scales of the Pittsburgh Sleep Diary. Health-related quality of life was assessed by the Short Form-36 instrument. RESULTS Sixty-nine dialysis patients and 23patients with advanced CKD demonstrated worse scores in sleep quality, mood, and alertness (p < 0.001) than controls. In adjusted analyses, European-American race, dialysis dependency, younger age, and physical performance SF-36 components were significantly associated with poor sleep quality, mood and alertness (p < 0.05). The dialysis population demonstrated higher day-to-day variability in scores than either the advanced CKD patients or the controls. CONCLUSION Advanced CKD and dialysis dependency are associated with impaired and highly variable sleep quality, mood, and alertness.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, Pa. 15213, USA
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Roumelioti ME, Wentz A, Schneider MF, Gerson AC, Hooper S, Benfield M, Warady BA, Furth SL, Unruh ML. Sleep and fatigue symptoms in children and adolescents with CKD: a cross-sectional analysis from the chronic kidney disease in children (CKiD) study. Am J Kidney Dis 2010; 55:269-80. [PMID: 20034719 DOI: 10.1053/j.ajkd.2009.09.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 09/14/2009] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although symptoms of sleepiness and fatigue are common in adults with chronic kidney disease (CKD), little is known about the prevalence of these symptoms in children with CKD. STUDY DESIGN Cross-sectional analysis within a cohort study. SETTING & PARTICIPANTS We describe the frequency and severity of sleep problems and fatigue and assess the extent of their association with measured glomerular filtration rate (mGFR) and health-related quality of life (HRQOL) in 301 participants of the Chronic Kidney Disease in Children cohort. OUTCOMES & MEASUREMENTS Sleep and fatigue-related items from the Pediatric Quality of Life Inventory 4.0 Generic Scales and the CKD-related Symptoms List were used. RESULTS Median mGFR was 42.0 mL/min/1.73 m(2) (25th-75th percentiles, 31.2-53.2), and median age was 13.9 years (25th-75th percentiles, 10.8-16.2). Children with mGFR of 40-<50, 30-<40, or <30 mL/min/1.73 m(2) had 2.07 (95% CI, 1.05-4.09), 2.35 (95% CI, 1.17-4.72), and 2.59 (95% CI, 1.15-5.85) higher odds of having more severe parent reports of low energy than children with mGFR > or = 50 mL/min/1.73 m(2). Compared with participants with mGFR > or = 50 mL/min/1.73 m(2), those with mGFR < 30 mL/min/1.73 m(2) had 3.92 (95% CI, 1.37-11.17) higher odds of reporting more severe weakness, and those with mGFR of 40-<50 mL/min/1.73 m(2) had 2.95 (95% CI, 1.26-6.88) higher odds of falling asleep during the day. Low energy, trouble sleeping, and weakness were associated with lower HRQOL scores. LIMITATIONS Symptoms of sleep and fatigue represent the child's or parent's perception of symptom severity, whereas individual items can lead to imprecise measurements of sleep and fatigue. CONCLUSIONS Lower mGFR was associated with increased weakness, low energy, and daytime sleepiness. Furthermore, a strong association between trouble sleeping, low energy, and weakness with decreases in overall HRQOL was observed. Detection and treatment of poor sleep and fatigue may improve the development and HRQOL of children and adolescents with CKD.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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