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Brown CO, Pham PC, Shah A, Dukkipati R, Shen J, Elali I, Dai T, Raff EA, Kalantar-Zadeh K. Population health strategies for health equity in chronic kidney disease management. Curr Opin Nephrol Hypertens 2025; 34:41-47. [PMID: 39611278 DOI: 10.1097/01.mnh.0001095808.65804.8c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2024]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is a widespread health issue, affecting one out of every 10 adults. This prevalence is even higher among vulnerable and underserved populations, including low-income individuals, racial and ethnic minorities, and immigrants. Urban areas such as New York City and Los Angeles County offer municipal safety-net healthcare systems for these groups. RECENT FINDINGS Safety-net providers are essential to the healthcare landscape for vulnerable populations with chronic diseases including the Los Angeles County Health Services that exemplifies how effective population health strategies can be utilized to manage CKD and at-risk persons. These approaches focus on risk assessment, integrated practices, patient and care-partner education, cost reduction, and strategic partnerships. Kidney care tailored "Expected Practices" ensure that management strategies are equitable and based on clinical evidence. The eConsult system allows CKD patients' primary care providers to efficiently consult nephrologists, facilitating timely specialty care appointments through "Precision Scheduling." Priority goals include slowing CKD progression, equitable access to home dialysis, and preemptive kidney transplantation. As highlighted by Kalantar-Zadeh et al. in 2025 CJASN, advancing equitable kidney care through population health approaches support comprehensive and efficient CKD management, including diabetic kidney disease, in Los Angeles County's safety-net system. SUMMARY With a large, underserved patient population affected by CKD, urban safety-net healthcare systems like those in Los Angeles County emphasize early detection, multidisciplinary management, shared decision-making, and equitable access to CKD. They prioritize equitable access to home dialysis modality choice and kidney transplantation, aiming to improve outcomes and the quality-of-life for diverse patient groups.
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Brown CO, Pham PC, Shah A, Dukkipati R, Shen J, Dai T, Raff EA, Kalantar-Zadeh K. Population health strategies for health equity in chronic kidney disease management: Retracted. Curr Opin Nephrol Hypertens 2024:00041552-990000000-00202. [PMID: 39575838 DOI: 10.1097/mnh.0000000000001044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2024]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is a widespread health issue, affecting one out of every 10 adults. This prevalence is even higher among vulnerable and underserved populations, including low-income individuals, racial and ethnic minorities, and immigrants. Urban areas such as New York City and Los Angeles County offer municipal safety-net healthcare systems for these groups. RECENT FINDINGS Safety-net providers are essential to the healthcare landscape for vulnerable populations with chronic diseases including the Los Angeles County Health Services that exemplifies how effective population health strategies can be utilized to manage CKD and at-risk persons. These approaches focus on risk assessment, integrated practices, patient and care-partner education, cost reduction, and strategic partnerships. Kidney care tailored "Expected Practices" ensure that management strategies are equitable and based on clinical evidence. The eConsult system allows CKD patients' primary care providers to efficiently consult nephrologists, facilitating timely specialty care appointments through "Precision Scheduling." Priority goals include slowing CKD progression, equitable access to home dialysis, and preemptive kidney transplantation. As highlighted by Kalantar-Zadeh et al. in 2025 CJASN, advancing equitable kidney care through population health approaches support comprehensive and efficient CKD management, including diabetic kidney disease, in Los Angeles County's safety-net system. SUMMARY With a large, underserved patient population affected by CKD, urban safety-net healthcare systems like those in Los Angeles County emphasize early detection, multidisciplinary management, shared decision-making, and equitable access to CKD. They prioritize equitable access to home dialysis modality choice and kidney transplantation, aiming to improve outcomes and the quality-of-life for diverse patient groups.
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Echefu G, Shivangi S, Dukkipati R, Schellack J, Kumbala D. Contemporary review of management techniques for cephalic arch stenosis in hemodialysis. Ren Fail 2023; 45:2176166. [PMID: 36748927 PMCID: PMC9930846 DOI: 10.1080/0886022x.2023.2176166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/29/2023] [Indexed: 02/08/2023] Open
Abstract
The type of hemodialysis access and its preservation impact the quality of life and survival of patients undergoing hemodialysis. Vascular access complications are among the top causes of morbidity, hospitalization, and catheter use, with significant economic burden. Poor maturation and stenosis continue to be key impediments to upper arm arteriovenous fistula feasibility. Cephalic arch is a common location for vascular access dysfunction due to its distinctive anatomy, complex valves, and biochemical alterations attributable to renal failure. Understanding cephalic arch stenosis is critical due to its high prevalence and treatment failure. The appropriate management option is highly debatable and mostly dependent on patient characteristics and interventionist's preference. Current options include, percutaneous transluminal balloon angioplasty, stent grafts, bare metal stents, cutting balloon angioplasty, endovascular banding, and surgical procedures. This article discusses the etiologies of cephalic arch stenosis as well as currents trends in management including endovascular and surgical options.
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Dukkipati R, Richler A, Shah A, de Virgilio C. Median Nerve and Ulnar Nerve Entrapment with Cubital Tunnel Syndrome in a Hemodialysis Patient Following Creation of an Arteriovenous Fistula. Case Rep Nephrol Dial 2021; 11:275-280. [PMID: 34703827 PMCID: PMC8460880 DOI: 10.1159/000518001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/19/2021] [Indexed: 11/19/2022] Open
Abstract
Neurological and vascular complications associated with creation of arteriovenous access need to be recognized promptly to deliver appropriate interventions for relief of symptoms and avoid loss of function of the involved extremity. We present here a 55-year-old female with end-stage renal disease on hemodialysis secondary to diabetic nephropathy who had a surgical creation of first stage of the brachial artery-basilic vein fistula in the left arm. She subsequently developed pain and weakness of the left arm which was diagnosed as median and ulnar nerve entrapment. She was treated with surgical nerve release and neurolysis and her symptoms improved.
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Miyata KN, Nast CC, Dai T, Dukkipati R, LaPage JA, Troost JP, Schurgers LJ, Kretzler M, Adler SG. Renal matrix Gla protein expression increases progressively with CKD and predicts renal outcome. Exp Mol Pathol 2018; 105:120-129. [PMID: 29981754 PMCID: PMC6167754 DOI: 10.1016/j.yexmp.2018.07.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 06/23/2018] [Accepted: 07/04/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Matrix Gla Protein (MGP) is a potent inhibitor of ectopic calcification and modulates bone morphogenesis. Little is known about MGP expression or function in kidney. METHODS We investigated renal MGP expression in Sprague-Dawley rats after 5/6 nephrectomy (5/6 Nx) and in human kidney biopsies in the Nephrotic Syndrome Study Network (NEPTUNE) cohort. We analyzed associations between glomerular (n = 182) and tubulointerstitial (TI) (n = 219) MGP mRNA levels and the disease activity/histologic features in NEPTUNE patients. Additionally, uncarboxylated and carboxylated MGP (ucMGP and cMGP, respectively) were localized by immunohistochemistry and quantitated in kidney tissues of patients at different stages of CKD (n = 18). RESULTS Renal MGP expression was increased in rats after 5/6 Nx. In NEPTUNE data, baseline estimated glomerular filtration rate (eGFR) negatively correlated with glomerular and TI MGP expression (p <0.001). TI MGP expression strongly correlated with interstitial fibrosis, tubular atrophy, acute tubular injury, and interstitial inflammation, independent of eGFR. Kaplan-Meier analysis and multivariable Cox regression showed that higher levels of TI MGP expression were associated with an increased risk for the composite of 40% decline in eGFR and end-stage renal disease (ESRD) (HR, 3.31; 95% CI, 1.31 to 6.32; p =0.02). Glomerular and tubulointerstitial cells demonstrated nuclear and cytoplasmic cMGP and ucMGP staining, and eGFR inversely correlated with quantified glomerular cMGP staining (p <0.05). CONCLUSIONS Our data demonstrate that renal MGP expression is increased in human and experimental CKD, and is associated with renal outcome. Additional studies are needed to determine its mechanism of action.
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Kim JJ, Gifford E, Nguyen V, Kaji AH, Chisum P, Zeng A, Dukkipati R, de Virgilio C. Increased use of brachiocephalic arteriovenous fistulas improves functional primary patency. J Vasc Surg 2015; 62:442-7. [PMID: 25935277 DOI: 10.1016/j.jvs.2015.03.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/01/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE As vascular surgeons strive to meet the Fistula First Initiative, some authors have observed a decrease in arteriovenous fistula (AVF) maturation rates in association with an increase in AVF creation. In May 2012, we adopted a practice change in an attempt to maintain the same high level of AVF creation while leading to a decrease in fistula failures. METHODS A retrospective study was conducted of all dialysis access procedures performed by a single vascular surgeon before (period 1; before May 1, 2012) and after (period 2; after May 1, 2012) the change in practice pattern. The adopted change included favoring the brachiocephalic location unless the patient was an ideal anatomic candidate for a radiocephalic AVF, creating a larger and standardized arteriotomy, and using a large venous footplate whenever possible. The main outcome measure was primary functional patency at 1 year. Secondary outcome measures included primary patency at 1 year, time to maturation, type of fistula created, steal syndrome, and tunneled hemodialysis catheter infections. RESULTS Of 213 vascular access procedures performed, 191 (90%) were AVFs. There was no difference in use of AVFs between period 1 (93% AVFs) and period 2 (88% AVFs; P = .2). Use of brachiocephalic AVFs increased from 38% in period 1 to 56% in period 2 (P = .01), with a corresponding trend toward a decrease in radiocephalic AVFs in period 2 (36% in period 1 to 27% in period 2; P = .2). Primary functional patency at 1 year was 47% in period 1 and 63% in period 2 (P = .03). Primary patency at 1 year was 51% in period 1 and 70% in period 2 (P = .001). Time to reach functional maturation was decreased in period 2 (median, 76 vs 82.5 days; P = .046). There was no difference in steal syndrome (P = 1.0), and the incidence of hemodialysis catheter infections was lower in period 2 (0 vs 7 [7%]; P = .006). CONCLUSIONS Increasing brachiocephalic AVF creation and reducing our reliance on radiocephalic AVFs resulted in a significant increase in primary functional patency at 1 year. This was achieved while maintaining the same high percentage of fistulas, a lower rate of central catheter infections, and the same low incidence of steal syndrome.
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Rhee CM, Nguyen DV, Moradi H, Brunelli SM, Dukkipati R, Jing J, Nakata T, Kovesdy CP, Brent GA, Kalantar-Zadeh K. Association of Adiponectin With Body Composition and Mortality in Hemodialysis Patients. Am J Kidney Dis 2015; 66:313-21. [PMID: 25824125 DOI: 10.1053/j.ajkd.2015.02.325] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/12/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND In the general population, circulating adiponectin is associated with a favorable cardiovascular risk profile (eg, lower triglycerides and body fat) and decreased mortality. Hemodialysis (HD) patients have comparatively higher adiponectin concentrations, but prior studies examining the adiponectin-mortality association in this population have not accounted for body composition or shown a consistent relationship. STUDY DESIGN Prospective cohort study. SETTINGS & PARTICIPANTS We examined baseline serum adiponectin concentrations in 501 HD patients across 13 dialysis centers from the prospective MADRAD (Malnutrition, Diet, and Racial Disparities in Chronic Kidney Disease) cohort (entry period, October 2011 to February 2013; follow-up through August 2013). PREDICTOR Serum adiponectin concentration in tertiles (tertiles 1, 2, and 3 defined as ≤16.1, >16.1-<30.1, and ≥30.1-100.0 μg/mL, respectively). Adjustment variables included case-mix and laboratory test results (age, sex, race, ethnicity, vintage, diabetes, serum albumin, total iron-binding capacity, serum creatinine, white blood cell count, phosphate, hemoglobin, and normalized protein catabolic rate), body composition surrogates (subcutaneous, visceral, and total-body fat and lean body mass), and serum lipid levels (cholesterol, high-density lipoprotein cholesterol, and triglycerides). OUTCOMES All-cause mortality using survival (Cox) models incrementally adjusted for case-mix and laboratory test results. RESULTS Among 501 HD patients, 50 deaths were observed during 631.1 person-years of follow-up. In case-mix- and laboratory-adjusted Cox analyses, the highest adiponectin tertile was associated with increased mortality versus the lowest tertile (HR, 3.35; 95% CI, 1.50-7.47). These associations were robust in analyses that additionally accounted for body composition (HR, 3.18; 95% CI, 1.61-8.24) and lipid levels (HR, 3.64; 95% CI, 1.34-7.58). LIMITATIONS Residual confounding cannot be excluded. CONCLUSIONS Higher adiponectin level is associated with a 3-fold higher death risk in HD patients independent of body composition and lipid levels. Future studies are needed to elucidate underlying mechanisms and determine therapeutic targets associated with improved outcomes in HD patients.
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Dukkipati R, Lee L, Atray N, Kajani R, Nassar G, Kalantar-Zadeh K. Outcomes of Cephalic Arch Stenosis With and Without Stent Placement after Percutaneous Balloon Angioplasty in Hemodialysis Patients. Semin Dial 2014; 28:E7-E10. [DOI: 10.1111/sdi.12310] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gifford ED, Nguyen V, Kaji AH, Chisum P, Kim J, Zeng A, Dukkipati R, deVirgilio C. Migration Towards Proximal Location Improves Maturation Rate of Arteriovenous Fistula. J Vasc Surg 2014. [DOI: 10.1016/j.jvs.2014.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rattanasompattikul M, Molnar MZ, Lee ML, Dukkipati R, Bross R, Jing J, Kim Y, Voss AC, Benner D, Feroze U, Macdougall IC, Tayek JA, Norris KC, Kopple JD, Unruh M, Kovesdy CP, Kalantar-Zadeh K. Anti-Inflammatory and Anti-Oxidative Nutrition in Hypoalbuminemic Dialysis Patients (AIONID) study: results of the pilot-feasibility, double-blind, randomized, placebo-controlled trial. J Cachexia Sarcopenia Muscle 2013; 4:247-57. [PMID: 24052226 PMCID: PMC3830006 DOI: 10.1007/s13539-013-0115-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 07/19/2013] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Low serum albumin is common and associated with protein-energy wasting, inflammation, and poor outcomes in maintenance hemodialysis (MHD) patients. We hypothesized that in-center (in dialysis clinic) provision of high-protein oral nutrition supplements (ONS) tailored for MHD patients combined with anti-oxidants and anti-inflammatory ingredients with or without an anti-inflammatory appetite stimulator (pentoxifylline, PTX) is well tolerated and can improve serum albumin concentration. METHODS Between January 2008 and June 2010, 84 adult hypoalbuminemic (albumin <4.0 g/dL) MHD outpatients were double-blindly randomized to receive 16 weeks of interventions including ONS, PTX, ONS with PTX, or placebos. Nutritional and inflammatory markers were compared between the four groups. RESULTS Out of 84 subjects (mean ± SD; age, 59 ± 12 years; vintage, 34 ± 34 months), 32 % were Blacks, 54 % females, and 68 % diabetics. ONS, PTX, ONS plus PTX, and placebo were associated with an average change in serum albumin of +0.21 (P = 0.004), +0.14 (P = 0.008), +0.18 (P = 0.001), and +0.03 g/dL (P = 0.59), respectively. No related serious adverse events were observed. In a predetermined intention-to-treat regression analysis modeling post-trial serum albumin as a function of pre-trial albumin and the three different interventions (ref = placebo), only ONS without PTX was associated with a significant albumin rise (+0.17 ± 0.07 g/dL, P = 0.018). CONCLUSIONS In this pilot-feasibility, 2 × 2 factorial, placebo-controlled trial, daily intake of a CKD-specific high-protein ONS with anti-inflammatory and anti-oxidative ingredients for up to 16 weeks was well tolerated and associated with slight but significant increase in serum albumin levels. Larger long-term controlled trials to examine hard outcomes are indicated.
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Dukkipati R, Molnar MZ, Park J, Jing J, Kovesdy CP, Kajani R, Kalantar-Zadeh K. Association of vascular access type with inflammatory marker levels in maintenance hemodialysis patients. Semin Dial 2013; 27:415-23. [PMID: 24118625 DOI: 10.1111/sdi.12146] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Aggressive NIH is a common histopathological lesion found at the sites of venous stenosis in arteriovenous fistula (AVF) and arteriovenous grafts (AVG). Inflammatory mediators have been proposed to play a pathogenic role in NIH, but there is paucity of data evaluating this hypothesis in clinical studies or in animal models. Serum levels of inflammatory mediators can potentially identify patients at high risk of AVF and AVG dysfunction. In a cross-sectional cohort study of 754 HD patients who were part of the NIED study cohort, we examined the associations between inflammatory markers including serum interleukin (IL) 1β, IL-6, C-reactive protein (CRP), and tumor necrosis factor-α (TNF-α) and type of vascular access. Unadjusted and multivariate-adjusted linear regression models were used. In addition, time-dependent regression model was used to assess the association between inflammatory markers and mortality. We observed that in the multivariate-adjusted model, inflammatory mediators interleukin-6 (IL-6), interleukin-1L-ß (IL-1ß), and C-reactive protein (CRP), the predicted value in hemodialysis patients, are lowest in patients with AVF and highest in central venous catheter (CVC) and AVG even in case-mix and malnutrition-inflammation complex syndrome (MICS)-adjusted models. IL-6 and CRP levels fall consistently in the same patients when AVG or CVC is changed to AVF and increase if the same patient changes access from AVF to AVG or CVC. Obesity is a risk factor for fistula failure and fistulas are associated with the lowest mortality compared with CVC and AVG. We did not find any statistically significant association between tumor necrosis factor-α (TNF- α) and vascular access outcomes. Higher levels of inflammatory mediators seen in CVC and AVG compared with AVF could potentially explain the higher mortality seen in patients with CVC and AVG compared with AVF.
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Park J, Jin DC, Molnar MZ, Dukkipati R, Kim Y, Jing J, Levin NW, Nissenson AR, Lee JS, Kalantar–Zadeh K. Mortality predictability of body size and muscle mass surrogates in Asian vs white and African American hemodialysis patients. Mayo Clin Proc 2013; 88:479-86. [PMID: 23562348 PMCID: PMC3909735 DOI: 10.1016/j.mayocp.2013.01.025] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 01/08/2013] [Accepted: 01/15/2013] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To determine whether the association of body size and muscle mass with survival among patients undergoing long-term hemodialysis (HD) is consistent across race, especially in East Asian vs white and African American patients. PATIENTS AND METHODS Using data from 20,818 patients from South Korea who underwent HD from February 1, 2001, to June 30, 2009, and 20,000 matched patients from the United States (10,000 whites and 10,000 African Americans) who underwent HD from July 1, 2001, to June 30, 2006, we compared mortality associations of baseline body mass index (BMI) and serum creatinine level as likely surrogates of obesity and muscle mass across the 3 races. RESULTS In Korean HD patients, higher BMI together with higher serum creatinine levels were associated with greater survival, as previously reported from US and European studies. In the matched cohort (10,000 patients from each of the 3 races), mortality risks were lower across higher BMI and serum creatinine levels, and these associations were similar in all 3 races (reference groups: patients with BMI >25.0 kg/m(2) or serum creatinine >12 mg/dL in each race). White, African American, and Korean patients with BMI levels of 18.5 kg/m(2) or less (underweight) had 78%, 79%, and 57% higher mortality risk, respectively, and white, African American, and Korean patients with serum creatinine levels of 6.0 mg/dL or less had 108%, 87%, and 78% higher mortality, respectively. CONCLUSION This study shows that race does not modify the association of higher body size and muscle mass with greater survival in HD patients. Given the consistency of the obesity paradox, which may be related to a mitigated effect of protein-energy wasting on mortality irrespective of racial disparities, nutritional support to improve survival should be tested in HD patients of all races.
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Dukkipati R, Peck M, Dhamija R, Hentschel DM, Reynolds T, Tammewar G, McAllister T. Biological grafts for hemodialysis access: historical lessons, state-of-the-art and future directions. Semin Dial 2012; 26:233-9. [PMID: 22909001 DOI: 10.1111/j.1525-139x.2012.01106.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The vast majority of arteriovenous grafts (AVG) have been constructed using expanded polytetrafluoroethylene (ePTFE). While ePTFE grafts have the advantage of being relatively inexpensive and easy to manufacture, distribute, ship, and store, their primary patency rates are disappointing when compared with the native AVF. Though use of arteriovenous fistulas (AVF) in the United States has increased substantially, approximately 25% of hemodialysis patients continue to use AVG as their vascular access. We present here a comprehensive review of biological grafts and their use in hemodialysis vascular access. In this review, we discuss the use of synthetics and then explore the evolution of biological grafts over the past 20 years, their clinical impact, and future challenges in widespread clinical use in hemodialysis patients. Provided are in depth descriptions of currently used nonbiological arteriovenous grafts and the recent approaches in increasing the patency of synthetic grafts. Recent technological advances using tissue-engineered AVGs have shown promise for patients receiving hemodialysis and their potential to provide an attractive, viable option for vascular access have been discussed.
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Kalantar Zadeh K, Dukkipati R, Moore E, Van Bolt G. Practice Patterns Of Clinicians: Assessment Of Malnutrition In Ckd Dialysis And Interventions. Kidney Res Clin Pract 2012. [DOI: 10.1016/j.krcp.2012.04.489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Glassock R, Dukkipati R. What Are the Best Biomarkers and Definitions for Chronic Kidney Disease and How Well Do They Relate to Cardiovascular Risk? CURRENT CARDIOVASCULAR RISK REPORTS 2012. [DOI: 10.1007/s12170-012-0223-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Rattanasompattikul M, Feroze U, Molnar MZ, Dukkipati R, Kovesdy CP, Nissenson AR, Norris KC, Kopple JD, Kalantar-Zadeh K. Charlson comorbidity score is a strong predictor of mortality in hemodialysis patients. Int Urol Nephrol 2011; 44:1813-23. [PMID: 22134841 DOI: 10.1007/s11255-011-0085-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 11/02/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE The Charlson comorbidity index (CCI) is a commonly used scale for assessing morbidity, but its role in assessing mortality in hemodialysis patients is not clear. Age, a component of CCI, is a strong risk factor for morbidity and mortality in chronic diseases and correlates with comorbidities. We hypothesized that the Charlson comorbidity index without age is a strong predictor of mortality in hemodialysis patients. METHODS A 6-year cohort of 893 hemodialysis patients was examined for an association between a modified CCI (without age and kidney disease) (mCCI) and mortality. RESULTS Patients were 53±15 years old (mean±SD), had a median mCCI score of 2, and included 47% women, 31% African Americans and 55% diabetics. After adjusting for case-mix and nutritional and inflammatory markers including C-reactive protein and interleukin-6, 2nd (mCCI: 1-2), 3rd (mCCI=3), and 4th (mCCI: 4-9) quartiles compared to 1st (mCCI=0) quartiles showed death hazard ratios (95% confidence intervals) of 1.43 (0.92-2.23), 1.70 (1.06-2.72), and 2.33 (1.43-3.78), respectively. The mCCI-death association was robust in non-African Americans. The CCI-death association linearity was verified in cubic splines. Each 1 unit higher mCCI score was associated with a death hazard ratio of 1.16 (1.07-1.27). CONCLUSIONS CCI independent of age is a robust and linear predictor of mortality in hemodialysis patients, in particular in non-African Americans.
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Vachharajani TJ, Moossavi S, Salman L, Wu S, Dwyer AC, Ross J, Dukkipati R, Maya ID, Yevzlin AS, Agarwal A, Abreo KD, Work J, Asif A. Dialysis Vascular Access Management by Interventional Nephrology Programs at University Medical Centers in the United States. Semin Dial 2011; 24:564-9. [DOI: 10.1111/j.1525-139x.2011.00985.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Noori N, Dukkipati R, Kovesdy CP, Sim JJ, Feroze U, Murali SB, Bross R, Benner D, Kopple JD, Kalantar-Zadeh K. Dietary omega-3 fatty acid, ratio of omega-6 to omega-3 intake, inflammation, and survival in long-term hemodialysis patients. Am J Kidney Dis 2011; 58:248-56. [PMID: 21658827 DOI: 10.1053/j.ajkd.2011.03.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 03/04/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Mortality in long-term hemodialysis patients is high, mostly attributed to cardiovascular events, and may be related to chronic inflammation. We hypothesized that the anti-inflammatory benefits of higher dietary intake of omega-3 compared with omega-6 polyunsaturated fatty acids may modulate the inflammatory processes and decrease death risk. STUDY DESIGN Prospective cohort study using linear and Cox proportional regressions. SETTING & PARTICIPANTS 145 hemodialysis patients from 8 DaVita dialysis clinics in Southern California in 2001-2007. PREDICTORS Intake of dietary omega-3 and ratio of omega-6 to omega-3 using 3-day food record supplemented by dietary interview. OUTCOMES 1-year change in serum C-reactive protein (CRP) level and 6-year survival. RESULTS Patients were aged 53 ± 14 years (mean ± SD) and included 43% women and 42% African Americans. Median dietary omega-3 intake, ratio of omega-6 to omega-3 intake, baseline serum CRP level, and change in CRP level over 1 year were 1.1 (25th-75th percentile, 0.8-1.6) g/d, 9.3 (25th-75th percentile, 7.6-11.3), 3.1 (25th-75th percentile, 0.8-6.8) mg/L, and +0.2 (25th-75th percentile, -0.4 to +0.8) mg/L, respectively. In regression models adjusted for case-mix, dietary calorie and fat intake, body mass index, and history of hypertension, each 1-unit higher ratio of omega-6 to omega-3 intake was associated with a 0.55-mg/L increase in serum CRP level (P = 0.03). In the fully adjusted model, death HRs for the first (1.7-<7.6), second (7.6-<9.3), third (9.3-<11.3), and fourth (11.3-17.4) quartiles of dietary omega-6 to omega-3 ratio were 0.39 (95% CI, 0.14-1.18), 0.30 (95% CI, 0.09-0.99), 0.67 (95% CI, 0.25-1.79), and 1.00 (reference), respectively (P for trend = 0.06). LIMITATIONS 3-day food record may underestimate actual dietary fat intake at an individual level. CONCLUSIONS Higher dietary omega-6 to omega-3 ratio appears to be associated with both worsening inflammation over time and a trend toward higher death risk in hemodialysis patients. Additional studies including interventional trials are needed to examine the association of dietary fatty acids with clinical outcomes in these patients.
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Dukkipati R, de Virgilio C, Reynolds T, Dhamija R. Outcomes of Brachial Artery-Basilic Vein Fistula. Semin Dial 2011; 24:220-30. [DOI: 10.1111/j.1525-139x.2011.00860.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Noori N, Kovesdy CP, Dukkipati R, Feroze U, Molnar MZ, Bross R, Nissenson AR, Kopple JD, Norris KC, Kalantar-Zadeh K. Racial and ethnic differences in mortality of hemodialysis patients: role of dietary and nutritional status and inflammation. Am J Nephrol 2011; 33:157-67. [PMID: 21293117 DOI: 10.1159/000323972] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 12/30/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Racial/ethnic disparities prevail among hemodialysis patients. We hypothesized that significant differences exist between Black and non-Hispanic and Hispanic White hemodialysis patients in nutritional status, dietary intake and inflammation, and that they account for racial survival disparities. METHODS In a 6-year (2001-2007) cohort of 799 hemodialysis patients, we compared diet and surrogates of nutritional-inflammatory status and their mortality-predictabilities between 279 Blacks and 520 Whites using matched and regression analyses and Cox with cubic splines. RESULTS In age-, gender- and diabetes-matched analyses, Blacks had higher lean body mass and serum prealbumin, creatinine and homocysteine levels than Whites. In case-mix-adjusted analyses, dietary intakes in Blacks versus Whites were higher in energy (+293 ± 119 cal/day) and fat (+18 ± 5 g/day), but lower in fiber (-2.9 ± 1.3 g/day) than Whites. In both races, higher serum albumin, prealbumin and creatinine were associated with greater survival, whereas CRP and IL-6, but not TNF-α, were associated with increased mortality. The highest (vs. lowest) quartile of IL-6 was associated with a 2.4-fold (95% CI: 1.3-3.8) and 4.1-fold (2.2-7.2) higher death risk in Blacks and Whites, respectively. CONCLUSIONS Significant racial disparities exist in dietary, nutritional and inflammatory measures, which may contribute to hemodialysis outcome disparities. Testing race-specific dietary and/or anti-inflammatory interventions is indicated.
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Feroze U, Molnar MZ, Dukkipati R, Kovesdy CP, Kalantar-Zadeh K. Insights into nutritional and inflammatory aspects of low parathyroid hormone in dialysis patients. J Ren Nutr 2011; 21:100-4. [PMID: 21195929 PMCID: PMC3032422 DOI: 10.1053/j.jrn.2010.10.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In individuals with advanced chronic kidney disease, secondary hyperparathyroidism is known to be associated with high turnover bone disease. Low serum parathyroid hormone (PTH) levels may not necessarily be because of hypodynamic bone, but could be another facet of the malnutrition-inflammation-cachexia syndrome (MICS). A recent 5-year cohort study in 748 stable hemodialysis outpatients showed that after the confounding effect by the MICS was removed, the moderately low levels of PTH in the 100 to 150 pg/mL range was associated with the greatest survival rate. Data from Japanese dialysis patients show similar survival advantages of having a lower PTH range. Low levels of serum PTH seem to be associated with markers of protein-energy wasting and inflammation, and this association may confound the relationship between serum PTH and alkaline phosphatase. PTH stimulates lipogenesis through influx of calcium into the adipocytes. PTH secretion is suppressed by interleukin-1 beta and interleukin-6, which are proinflammatory cytokines that are associated with poor outcome in dialysis patients. These cytokines inhibits PTH secretion in cultured parathyroid tissue slices. In this article, we review the association of a low serum PTH level with the MICS in patients with chronic kidney disease and suggest avoiding over-interpretation of low serum PTH level as an indicator of low turnover bone disease.
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Dukkipati R, Tammewar G, Kalantar-Zadeh K, Dhamija R. Radiation exposure in dialysis access-related procedures decreases with increase in number of procedures performed by the interventional nephrologist. Semin Dial 2010; 23:630-3. [PMID: 21175836 DOI: 10.1111/j.1525-139x.2010.00798.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
An appreciation of the inherent risks with radiation exposure to patients and to the physician performing the procedure and the staff is urgently needed. The objective of this study is to assess radiation exposure to both patients and interventional nephrologists performing procedures and see any trends in the procedure and fluoroscopy times over a 2-year period. A total of 400 procedures performed at our vascular access center by a new to practice interventional nephrologist were recorded and retrospectively analyzed. Fluoroscopic time and procedure time for various procedures over the course of 2 years were recorded. This data were subsequently separated into eight groups (four quarters per year) based on the date of the procedure. Our study demonstrates a decrease in mean and median fluoroscopy times and procedure times for newly trained interventional with gain in number of procedures. The mean fluoroscopy time for the first two quarters was 5 minutes and 4 seconds, and the median was 3 minutes and 37 seconds. The mean procedure time for the first two quarters was 38 minutes, and the median was 32 minutes. The mean fluoroscopy time for the last two quarters was 1 minute and 54 seconds, and the median was 1 minute and 26 seconds. The mean procedure time for the last two quarters was 27 minutes, and the median was 21 minutes. In conclusion, gain of experience by the practicing Interventional Nephrologist from performing an increasing number of procedures leads to decreased procedure times and fluoroscopy times, which lowers the risk of radiation.
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Dukkipati R, Noori N, Feroze U, Kopple JD. Dietary protein intake in patients with advanced chronic kidney disease and on dialysis. Semin Dial 2010; 23:365-72. [PMID: 20701715 DOI: 10.1111/j.1525-139x.2010.00753.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Many patients with chronic kidney disease (CKD), particularly those with stage 5 CKD, have protein wasting. The degree to which increased morbidity and mortality seen in these patients is due to protein depletion rather than to the often accompanying comorbidity is not clear. High protein diets lead to the accumulation of metabolites of protein that are potentially toxic. The MDRD Study, which investigated the effects of three levels of dietary protein and phosphorus intakes and two blood pressure goals on the progression of CKD, has several limitations. Several meta-analyses have examined the effects of low protein diets (LPD) on the progression of CKD. It is possible that the lower SUN levels or lesser degree of uremic symptoms may have contributed to the positive findings of LPD in the meta-analyses of Fouque and Pedrini et al., when compared with the study of Kasiske et al. A number of published reports indicate that LPD provide adequate protein for almost all clinically stable CKD patients and do not adversely affect body composition. In general, there are no large differences in the protein intake recommended by different expert groups for a given stage of CKD.
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Noori N, Kovesdy CP, Dukkipati R, Kim Y, Duong U, Bross R, Oreopoulos A, Luna A, Benner D, Kopple JD, Kalantar-Zadeh K. Survival predictability of lean and fat mass in men and women undergoing maintenance hemodialysis. Am J Clin Nutr 2010; 92:1060-70. [PMID: 20844076 PMCID: PMC2954443 DOI: 10.3945/ajcn.2010.29188] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Larger body size is associated with greater survival in maintenance hemodialysis (MHD) patients. It is not clear how lean body mass (LBM) and fat mass (FM) compare in their associations with survival across sex in these patients. OBJECTIVE We examined the hypothesis that higher FM and LBM are associated with greater survival in MHD patents irrespective of sex. DESIGN In 742 MHD patients, including 31% African Americans with a mean (± SD) age of 54 ± 15 y, we categorized men (n = 391) and women (n = 351) separately into 4 quartiles of near-infrared interactance-measured LBM and FM. Cox proportional hazards models estimated death hazard ratios (HRs) (and 95% CIs), and cubic spline models were used to examine associations with mortality over 5 y (2001-2006). RESULTS After adjustment for case-mix and inflammatory markers, the highest quartiles of FM and LBM were associated with greater survival in women: HRs of 0.38 (95% CI: 0.20, 0.71) and 0.34 (95% CI: 0.17, 0.67), respectively (reference: first quartile). In men, the highest quartiles of FM and percentage FM (FM%) but not of LBM were associated with greater survival: HRs of 0.51 (95% CI: 0.27, 0.96), 0.45 (95% CI: 0.23, 0.88), and 1.17 (95% CI: 0.60, 2.27), respectively. Cubic spline analyses showed greater survival with higher FM% and higher "FM minus LBM percentiles" in both sexes, whereas a higher LBM was protective in women. CONCLUSIONS In MHD patients, higher FM in both sexes and higher LBM in women appear to be protective. The survival advantage of FM appears to be superior to that of LBM. Clinical trials to examine the outcomes of interventions that modify body composition in MHD patients are indicated.
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Kalantar-Zadeh K, Shah A, Duong U, Hechter RC, Dukkipati R, Kovesdy CP. Kidney bone disease and mortality in CKD: revisiting the role of vitamin D, calcimimetics, alkaline phosphatase, and minerals. KIDNEY INTERNATIONAL. SUPPLEMENT 2010; 78:S10-21. [PMID: 20671739 PMCID: PMC5494176 DOI: 10.1038/ki.2010.189] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recent evidence suggests that the traditional syndromes known as renal osteodystrophy, secondary hyperparathyroidism, and vitamin D deficiency are related to mortality in persons with moderate to advanced chronic kidney disease (CKD). The so-called 'kidney bone disease', also known as 'mineral and bone disorders', is defined to include bone disorders, mineral disarrays, and vascular calcification. We have identified 14 common and clinically relevant conditions of contemporary nature that are related to the kidney bone disease, including calcitriol (active vitamin D) deficiency, 25(OH)-vitamin D deficiency, biochemical hyperparathyroidism, relatively low parathyroid hormone (PTH) level, increased serum alkaline phosphatase (hyperphosphatasemia), elevated fibroblast growth factor (FGF)-23, high turnover bone disease, adynamic bone disease, uremic osteoporosis, vascular calcification, hyper- and hypophosphatemia, and hyper- and hypocalcemia. We present a critical review of these 14 conditions with emphasis on patient survival and other pertinent clinical outcomes. We also review unresolved controversies surrounding the management of these conditions by administration of nutritional vitamin D (ergocalciferol and cholecalciferol), vitamin D receptor activators (calcitriol, alphacalcidiol, doxercalciferol), D-mimetics (paricalcitol, maxacalcitol), calcimimetics (cinacalcet), recombinant PTH (teriparatide), and receptor activator of nuclear factor-kappaB ligand modulators (denosumab); compare mortality predictability of PTH and alkaline phosphatase; and examine potential risks of bone disorders and mineral disarrays in CKD patients.
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