Adherence to antihypertensive agents improves risk reduction of end-stage renal disease

Association between medication adherence and cardiovascular outcomes in patients with both diabetes and hypertension in primary care settings in Canada: A retrospective cohort study

OBJECTIVES

The impact of concurrent adherence to antihypertensives, antidiabetics, and statins on cardiovascular disease (CVD) outcomes and intermediate clinical outcomes in people with hypertension and diabetes remains unclear. This study aimed to evaluate the association between medication adherence and CVD outcomes in such patients.

METHODS

This retrospective cohort study analyzed the electronic medical records of 36,211 adults aged 18 or older diagnosed with hypertension and diabetes between January 2008 and June 2016 in Canada. Patients were prescribed antihypertensives, antidiabetics, and statins, with a minimum 1-year follow-up post-diagnosis. Medication adherence was determined by the proportion of days covered (PDC). For monotherapy, a PDC≥80% and <80% was reflected high and low adherence respectively. In multiple medication scenarios, adherence was considered high when each medication was at PDC≥80%; low when any medication fell below 80%. The primary outcome encompassed cardiac events, including coronary heart disease, stroke, and heart failure. Intermediate clinical outcomes included changes in diastolic blood pressure (DBP), Systolic Blood Pressure (SBP), glycated hemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), and total cholesterol (TC). Cox regression models assessed the association between medication adherence and CVD morbidity, all-cause mortality, and intermediate clinical outcomes.

RESULTS

High adherence to antidiabetic and statin monotherapy was associated with a lower all-cause mortality risk (aHR=0.67, P=0.001; aHR=0.68, P<0.001, respectively). For patients simultaneously prescribed three medications, higher adherence was linked to significant reductions in DBP (6 months: coefficient -0.52, P=0.01; 12 months: coefficient -0.44, P=0.02; 18 months: coefficient -0.55, P=0.004) and LDL-C (6 months: coefficient -0.04, P=0.02; 12 months: coefficient -0.05, P=0.01; 18 months: coefficient -0.04, P=0.02).

CONCLUSIONS

High adherence to antidiabetic and statin monotherapy correlated with lower all-cause mortality risk and improved intermediate clinical outcomes. However, simultaneous adherence to three medications did not significantly affect CVD outcomes, but influenced intermediate outcomes. Therefore, improving adherence to antihypertensives, antidiabetics, and statins among patients with hypertension and diabetes is important in primary care settings.

Prevalence of antihypertensive medication adherence and associated factors in India: A systematic review and meta-analysis

BACKGROUND

Non-adherence to antihypertensive medication is a key factor contributing to uncontrolled blood pressure and the subsequent complications of hypertension. Despite its importance, there is a lack of data regarding the prevalence of and factors associated with non-adherence to medication among individuals with hypertension in India. This review aimed to assess medication adherence rates among hypertensive patients in India and identify the factors influencing non-adherence.

METHODS

A comprehensive search was conducted across PubMed, Scopus, Embase, and Google Scholar. Studies reporting medication adherence/non-adherence to antihypertensive medications in India, using the Morisky Medication Adherence Scale (MMAS), with publication dates up to July 2023, were included.

RESULTS

Twelve studies were included, involving a total of 3164 participants. The pooled rate of medication adherence to antihypertensive medications in India was determined to be 15.8% (95% CI: 4.4; 43.4). The important factors associated with non-adherence included higher age, medication regimen complexity, low socioeconomic status, low education levels, uncontrolled blood pressure, and comorbidities.

CONCLUSIONS

The adherence rate to antihypertensive medication was observed to be quite low. Therefore, it is imperative to enhance the rate of medication adherence among individuals with hypertension in order to attain effective blood pressure control and reduce the burden of non-communicable diseases.

Patient Knowledge, Medication Adherence, and Influencing Factors: A Cross-Sectional Study among Hypertensive Patients in Greece

This study aimed to investigate the knowledge of patients with hypertension about their condition, adherence to antihypertensive medication, and the factors influencing it. A cross-sectional study was conducted in two cardiology outpatient clinics of two tertiary hospitals, in Greece. The study included 188 patients diagnosed with hypertension. The patients' knowledge about their disease and adherence to medication were assessed by using the HK-LS and A-14 scales, respectively. Patients had sufficient knowledge levels about their disease, but significantly low levels of adherence to medication. Patients with higher knowledge levels were more adherent to medications [r(188) = 0.885, p < 0.001]. By using multivariate analysis, higher age (p = 0.018), residence in a more populous area (p = 0.041), more years with the disease (p = 0.012), and a lower number of medications (p = 0.03) were associated with higher levels of knowledge. Conversely, younger age (p = 0.036), lower educational levels (p = 0.048), fewer years with the disease (p = 0.001), and a higher number of medications (p = 0.003) were associated with lower adherence to medication. The Greek patients' hypertension knowledge was sufficient; however, adherence to medication was significantly low. Healthcare managers could utilize our findings to design targeted interventions for improving adherence to medication for these patients.

Understanding reasons and factors for participation and non-participation to a medication adherence program for patients with diabetic kidney disease in Switzerland: a mixed methods study

BACKGROUND

An interprofessional medication adherence intervention led by pharmacists, combining motivational interviews and feedback with electronic monitor (EM) drug assessment, was offered to all consecutive patients with diabetic kidney disease (DKD) (estimated glomerular filtration rate < 60 mL/min/1.73 m²) visiting their nephrologist or endocrinologist. Approximately 73% (202/275) of eligible patients declined to participate, and the factors and reasons for refusal were investigated.

METHODS

Sociodemographic and clinical data of included patients and those who refused were collected retrospectively for those who had previously signed the general consent form. Multivariate logistic regression analysis was performed to identify independent variables associated with non-participation. Patients who refused or accepted the adherence study were invited to participate in semi-structured interviews. Verbatim transcription, thematic analysis, and inductive coding were performed.

RESULTS

Patients who refused to participate were older (n = 123, mean age 67.7 years, SD:10.4) than those who accepted (n = 57, mean age 64.0 years, SD:10.0, p = 0.027) and the proportion of women was higher among them than among patients who accepted it (30.9% vs 12.3%, p = 0.007). The time from diabetes diagnosis was longer in patients who refused than in those who accepted (median 14.2 years IQR 6.9-22.7 vs. 8.6 years, IQR 4.5-15.9, p = 0.003). Factors associated with an increased risk of non-participation were female sex (OR 3.8, 95% CI 1.4-10.0, p = 0.007) and the time from diabetes diagnosis (OR 1.05, 95% CI 1.01-1.09, p = 0.019). The included patients who were interviewed (n = 14) found the interprofessional intervention useful to improve their medication management, support medication literacy, and motivation. Patients who refused to participate and who were interviewed (n = 16) explained no perceived need, did not agree to use EM, and perceived the study as a burden and shared that the study would have been beneficial if introduced earlier in their therapeutic journey. Other barriers emerged as difficult relationships with healthcare providers, lack of awareness of the pharmacist's role, and negative perception of clinical research.

CONCLUSIONS

Investigating the factors and reasons for participation and non-participation in a study helps tailor intervention designs to the needs of polypharmacy patients. Patients who refused the adherence intervention may not be aware of the benefits of medication management and medication literacy. There is an urgent need to advocate for interprofessional outpatient collaborations to support medication adherence in patients with DKD. Trial registration Clinicaltrials.gov NCT04190251_PANDIA IRIS.

The IL-18/IL-18R1 signalling axis: Diagnostic and therapeutic potential in hypertension and chronic kidney disease

Chronic kidney disease (CKD) is inherently an inflammatory condition, which ultimately results in the development of end stage renal disease or cardiovascular events. Low-grade inflammatory diseases such as hypertension and diabetes are leading causes of CKD. Declines in renal function correlate with elevated circulating pro-inflammatory cytokines in patients with these conditions. The inflammasome is an important inflammatory signalling platform that has been associated with low-grade chronic inflammatory diseases. Notably, activation and assembly of the inflammasome causes the auto cleavage of pro-caspase-1 into its active form, which then processes the pro-inflammatory cytokines pro-interleukin (IL)-1β and pro-IL-18 into their active forms. Currently, the nod-like receptor protein 3 (NLRP3) inflammasome has been implicated in the development of CKD in pre-clinical and clinical settings, and the ablation or inhibition of inflammasome components have been shown to be reno-protective in models of CKD. While clinical trials have demonstrated that neutralisation of IL-1β signalling by the drug anakinra lowers inflammation markers in haemodialysis patients, ongoing preclinical studies are showing that this ability to attenuate disease is limited in progressive models of kidney disease. These results suggest a potential predominant role for IL-18 in the development of CKD. This review will discuss the role of the inflammasome and its pro-inflammatory product IL-18 in the development of renal fibrosis and inflammation that contribute to the pathophysiology of CKD. Furthermore, we will examine the potential of the IL-18 signalling axis as an anti-inflammatory target in CKD and its usefulness as diagnostic biomarker to predict acute kidney injury.

A Non-Invasive Method for Detection of Antihypertensive Drugs in Biological Fluids: The Salivary Therapeutic Drug Monitoring

Objectives: Arterial hypertension is still the most frequent cause of cardiovascular and cerebrovascular morbidity and mortality. Antihypertensive treatment has proved effective in reduction of cardiovascular risk. Nevertheless, lifestyle interventions and pharmacological therapy in some cases are ineffective in reaching blood pressure target values, despite full dose and poly-pharmacological treatment. Poor adherence to medications is an important cause of treatment failure. Different methods to assess therapeutic adherence are currently available: Therapeutic drug monitoring in biological fluids has previously demonstrated its efficacy and reliability. Plasma and urine have been already used for this purpose, but they may be affected by some practical limitations. Saliva may represent a feasible alternative.

Methods: Fourteen antihypertensive drugs and two metabolites were simultaneously tested in plasma, urine, and saliva. Tested molecules included: atenolol, nebivolol, clonidine, ramipril, olmesartan, telmisartan, valsartan, amlodipine, nifedipine, doxazosin, chlorthalidone, hydrochlorothiazide, indapamide, sacubitril, ramiprilat, and sacubitrilat. Therapeutic drug monitoring was performed using ultra-high performance liquid chromatography, coupled to tandem mass spectrometry (UHPLC-MS/MS). The method has been preliminarily evaluated in a cohort of hypertensive patients.

Results: The method has been validated according to US Food and Drug Administration (FDA) and European Medicines Agency (EMA) guidelines. The application on a cohort of 32 hypertensive patients has demonstrated sensibility and specificity of 98% and 98.1%, respectively, with a good feasibility in real-life clinical practice.

Conclusion: Saliva may represent a feasible biological sample for therapeutic drug monitoring by non-invasive collection, prompt availability, and potential accessibility also in out-of-clinic settings.

Association between Multimorbidity and Kidney Function among Patients with Non-Dialysis-Dependent CKD

Aim: Individuals with chronic kidney disease (CKD) have a high prevalence of comorbidities, including cardiovascular disease (CVD) and its risk factors. However, epidemiological results to assess the association between multimorbidity and kidney function among the CKD population remains limited.

Methods: We performed a cross-sectional analysis of the association between 23 comorbid conditions and reduced kidney function in 4,476 patients with non-dialysis-dependent CKD enrolled in a multicenter cohort in Japan. Reduced kidney function was defined as an estimated glomerular filtration rate of ≤ 60 mL/min/1.73 m².

Results: The mean age of patients was 67 years (male, 56.0%). The prevalence of hypertension, diabetes mellitus, dyslipidemia, prior CVD, cancer, and bone fracture, which are the major comorbidities, was 83.3%, 28.7%, 45.9%, 23.3%, 12.7%, and 6.3%, respectively. Multivariable-adjusted analyses revealed that age, male sex, hypertension, dyslipidemia, prior CVD, body mass index, urinary protein excretion, and underlying kidney disease were independent factors associated with reduced kidney function. Importantly, the odds ratios (ORs) for reduced kidney function increased linearly as the number of major comorbid conditions increased (OR for 1–2 conditions: 2.22, 95% confidence interval [CI]: 1.65–2.97; OR for 3–4 conditions: 3.04, 95% CI: 2.12–4.37; OR for ≥ 5 conditions: 4.37, 95% CI: 1.75–10.9). The upward trend in OR was more pronounced with cardiovascular comorbidities but not significant with non-cardiovascular comorbidities.

Conclusions: In conclusion, we observed an independent association between cardiovascular comorbidity and its risk factors and reduced kidney function. The results of this study highlight the importance of managing multimorbidity among patients with CKD.

Impact of a motivational interviewing intervention targeting statins on adherence to concurrent hypertension or diabetes medications

OBJECTIVE

This study explored if a motivational interviewing intervention customized for statins impacted adherence to concomitantly used antidiabetic/antihypertensive medications.

METHODS

The intervention was conducted among patients with a history of suboptimal adherence to statins and included 152 patients in intervention and 304 controls. This retrospective study design identified patients with claims for statins and either antidiabetic/antihypertensive medications. The outcome variable was adherence, measured as proportion of days covered ≥ 0.80, to antidiabetic/antihypertensive medications. Multivariable linear and logistic regression evaluated the effect of intervention on adherence to antidiabetic/antihypertensive medications during the 6 months post-intervention.

RESULTS

The antidiabetic group had 53 intervention patients and 102 controls. The antihypertensive group had 80 intervention patients and 159 controls. There was no significant improvement in adherence for antidiabetic/antihypertensive medications following the intervention. Adherence at baseline was a significant predictor of adherence post-intervention in the antidiabetic (OR = 6.5;P < 0.0001) and antihypertensive (OR = 4.1; P = 0.0001 & β = 0.09; P = 0.008) users. Physician specialty (OR = 3.902; P = 0.01& β = 0.09; P = 0.015) among antidiabetic users and age >70 years (OR = 2.148; P = 0.025) among antihypertensive users were predictors of adherence.

CONCLUSION

The intervention targeting statin did not significantly improve antihypertensive/antidiabetic adherence.

PRACTICE IMPLICATIONS

Targeted interventions tailored to patient past adherence and specific medications should be explored.

Non-adherence to antidiabetic and cardiovascular drugs in type 2 diabetes mellitus and its association with renal and cardiovascular outcomes: A narrative review

Cardiovascular and renal complications are a major burden for individuals with type 2 diabetes mellitus (T2DM). Besides lifestyle interventions, current guidelines recommend combination drug therapy to prevent or delay the incidence and progression of comorbidities. However, non-adherence to pharmacotherapy is common in chronic conditions such as T2DM and a barrier to successful disease management. Numerous studies have associated medication non-adherence with worse outcome as well as higher health care costs. This narrative review provides (i) an overview on adherence measures used within and outside research settings, (ii) an estimate on the prevalence of non-adherence to antidiabetic and cardiovascular drugs in T2DM, and (iii) specifically focuses on the association of non-adherence to these drugs with renal and cardiovascular outcomes.

Medication non-adherence in chronic kidney disease: a mixed-methods review and synthesis using the theoretical domains framework and the behavioural change wheel

OBJECTIVE

Medication non-adherence is a well-recognised issue in chronic diseases but data in patients with chronic kidney disease (CKD) not receiving kidney replacement therapy (KRT) remains limited. This review summarised the prevalence of medication non-adherence and assessed determinants and outcomes associated with it in adults with CKD, not on KRT.

METHOD

We searched PubMed, Embase, PsychInfo, Web of Science, and Cochrane (CENTRAL) for studies published until January 2020. Pooled prevalence of medication non-adherence was reported. Determinants of adherence-identified from quantitative and qualitative studies-were mapped into the theoretical domains framework and interventions proposed using the behavioural change wheel.

RESULTS

Twenty-seven studies (22 quantitative and 5 qualitative) were included. The pooled prevalence of medication non-adherence was 39% (95% CI 30-48%). Nine studies reported association between non-adherence and outcomes, including blood pressure, disease progression, adverse events, and mortality. Modifiable determinants of non-adherence were mapped into 11 of the 14 Theoretical Domains Framework-of which, six appeared most relevant. Non-adherence decisions were usually due to lack of knowledge on CKD, comorbidities, and medications; polypharmacy and occurrence of medication side effects; changes in established routines such as frequent medication changes; higher medication cost, poor accessibility to medications, services and facilities; inadequate patient-healthcare professional communication; and forgetfulness. Using the behavioural change wheel, we identified several areas where interventions can be directed to improve medication adherence.

CONCLUSION

Medication non-adherence is common in adults with CKD, not on KRT and may lead to poor outcomes. Evidence synthesis using mixed study designs was crucial in identifying determinants of non-adherence, drawing on a parsimonious approach from behaviour science.

PROSPERO REGISTRATION

CRD42020149983.

Erectile dysfunction and adherence to antihypertensive therapy: Focus on β-blockers

The management of arterial hypertension is very challenging in everyday clinical practice. Blood pressure control rates remain disappointingly low, despite intense efforts. Poor adherence to antihypertensive treatment is among the main causes of inadequate blood pressure control. Among the various parameters leading to poor adherence, medication adverse events seem to be the prevailing cause of treatment discontinuation. Β-blockers are a class of drugs commonly used in the management of hypertension. However, β-blockers use has been associated with various adverse events, among which, erectile dysfunction is a prevalent one. Accumulating evidence supports the detrimental role of β-blockers on erectile function. Older studies have shown contradictory findings, which however may be attributed to methodological errors related with the assessment of erectile function. More recent studies, however, unveiled the negative impact of this drug category on erectile function. Nevertheless, β-blockers represent a class of drugs with substantial within class heterogeneity. Nebivolol presents a unique mode of action through enhanced nitric oxide bioavailability that may be associated with benefits on erectile function. Indeed, studies of nebivolol have shown improvement in erectile function, suggesting that nebivolol represents the only exception in this class of drugs in terms of erectile function.

Agreement Between Administrative Database and Medical Chart Review for the Prediction of Chronic Kidney Disease G category

Background

Chronic kidney disease (CKD) is a major health issue and cardiovascular risk factor. Validity assessment of administrative data for the detection of CKD in research for drug benefit and risk using real-world data is important. Existing algorithms have limitations and we need to develop new algorithms using administrative data, giving the importance of drug benefit/risk ratio in real world.

Objective

The aim of this study was to validate a predictive algorithm for CKD GFR category 4-5 (eGFR < 30 mL/min/1.73 m² but not receiving dialysis or CKD G4-5ND) using the administrative databases of the province of Quebec relative to estimated glomerular filtration rate (eGFR) as a reference standard.

Design

This is a retrospective cohort study using chart collection and administrative databases.

Setting

The study was conducted in a community outpatient medical clinic and pre-dialysis outpatient clinic in downtown Montreal and rural area.

Patients

Patient medical files with at least 2 serum creatinine measures (up to 1 year apart) between September 1, 2013, and June 30, 2015, were reviewed consecutively (going back in time from the day we started the study). We excluded patients with end-stage renal disease on dialysis. The study was started in September 2013.

Measurement

Glomerular filtration rate was estimated using the CKD Epidemiological Collaboration (CKD-EPI) from each patient's file. Several algorithms were developed using 3 administrative databases with different combinations of physician claims (diagnostics and number of visits) and hospital discharge data in the 5 years prior to the cohort entry, as well as specific drug use and medical intervention in preparation for dialysis in the 2 years prior to the cohort entry.

Methods

Chart data were used to assess eGFR. The validity of various algorithms for detection of CKD groups was assessed with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Results

A total of 434 medical files were reviewed; mean age of patients was 74.2 ± 10.6 years, and 83% were older than 65 years. Sensitivity of algorithm #3 (diagnosis within 2-5 years and/or specific drug use within 2 years and nephrologist visit ≥4 within 2-5 years) in identification of CKD G4-5ND ranged from 82.5% to 89.0%, specificity from 97.1% to 98.9% with PPV and NPV ranging from 94.5% to 97.7% and 91.1% to 94.2%, respectively. The subsequent subgroup analysis (diabetes, hypertension, and <65 and ≥65 years) and also the comparisons of predicted prevalence in a cohort of older adults relative to published data emphasized the accuracy of our algorithm for patients with severe CKD (CKD G4-5ND).

Limitations

Our cohort comprised mostly older adults, and results may not be generalizable to all adults. Participants with CKD without 2 serum creatinine measurements up to 1 year apart were excluded.

Conclusions

The case definition of severe CKD G4-5ND derived from an algorithm using diagnosis code, drug use, and nephrologist visits from administrative databases is a valid algorithm compared with medical chart reviews in older adults.

Acute kidney injury in critically ill children and 5-year hypertension

BACKGROUND

To develop a pediatric-specific hypertension algorithm using administrative data and use it to evaluate the association between acute kidney injury (AKI) in the intensive care unit (ICU) and hypertension diagnosis 5 years post-discharge.

METHODS

Two-center retrospective cohort study of children (≤ 18 years old) admitted to the pediatric ICU in Montreal, Canada, between 2003 and 2005 and followed until 2010. Patients with a valid healthcare number and without end-stage renal disease were included. Patients who could not be merged with the provincial database, did not survive admission, underwent cardiac surgery, had pre-existing renal disease associated with hypertension or a prior diagnosis of hypertension were excluded. AKI defined using the Kidney Disease: Improving Global Outcomes (KDIGO) definition. Using diagnostic codes and medications from administrative data, novel pediatric-specific hypertension definitions were designed. Both the evaluation of the prevalence of hypertension diagnosis and the association between AKI and hypertension occurred.

RESULTS

Nineteen hundred and seventy eight patients were included (median age at admission [interquartile range] 4.3 years [1.1-11.8], 44% female, 325 (16.4%) developed AKI). Of these patients, 130 (7%) had a hypertension diagnosis 5 years after discharge. Patients with AKI had a higher prevalence of hypertension diagnosis [non-AKI: 84/1653 (5.1%) vs. AKI: 46/325 (14.2%), p < .001]. Children with AKI had a higher adjusted risk of hypertension diagnosis (hazard ratio [95% confidence interval] 2.19 [1.47-3.26]).

CONCLUSIONS

Children admitted to the ICU have a high prevalence of hypertension post-discharge and children with AKI have over two times higher risk of hypertension compared to those with no AKI.

Adherence in Hypertension

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Acute Kidney Injury in Critically Ill Children and Subsequent Chronic Kidney Disease

BACKGROUND

The progression from acute kidney injury (AKI) to chronic kidney disease (CKD) is not well understood in children.

OBJECTIVES

We aimed to develop a pediatric CKD definition using administrative data and use it to evaluate the association between AKI in critically ill children and CKD 5 years after hospital discharge.

DESIGN

Retrospective cohort study using chart collection and administrative data.

SETTING

Two-center study in Montreal, Canada.

PATIENTS

Children (≤18 years old) admitted to two pediatric intensive care units (ICUs) between 2003 and 2005. We a priori excluded patients with end-stage renal disease or no health care number. Only the first admission during the study period was included. We excluded patients who could not be linked to administrative data, did not survive hospitalization, or had preexisting renal disease.

MEASUREMENTS

Acute kidney injury was defined using Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Patients were defined as having CKD 5 years post-discharge if they had ≥1 CKD diagnostic code or ≥1 CKD-specific medication prescription.

METHODS

Chart data used to define the exposure (AKI) were merged with provincial administrative data used to define the outcome (CKD). Cox regression was used to evaluate the AKI-CKD association.

RESULTS

A total of 2235 (56% male) patients were included, and the median admission age was 3.7 years. A total of 464 (21%) patients developed AKI during pediatric ICU admission. At 5 years post-discharge, 43 (2%) patients had a CKD diagnosis. Patients with both stage 1 and stage 2-3 AKI had increased risk of a CKD diagnosis, with the adjusted hazard ratios (95% confidence intervals) of 2.2 (1.1-4.5) and 2.5 (1.1-5.7), respectively (P < .001).

LIMITATIONS

Results may not be generalizable to non-ICU patients. We were not able to control for post-discharge variables; future research should try to explore these additional potential risk factors further.

CONCLUSIONS

Acute kidney injury is associated with 5-year post-discharge CKD diagnosis defined by administrative health care data.

The Impact of Treatment Adherence for Patients With Diabetes and Hypertension on Cardiovascular Disease Risk: Protocol for a Retrospective Cohort Study, 2008-2018

Background

Cardiovascular disease (CVD) is the leading cause of death globally and in Canada. Diabetes and hypertension are major risk factors for CVD events. Despite the increasing availability of effective treatments, the majority of diabetic and hypertensive patients do not have adequate blood pressure and glycemic control. One of the major contributors is poor treatment adherence.

Objective

This study aims to evaluate the impact of treatment adherence for patients with both diabetes and hypertension on acute severe CVD events and intermediate clinical outcomes in Canadian primary care settings.

Methods

We will conduct a population-based retrospective cohort study of patients living with both diabetes and hypertension in Ontario, Canada, between January 1, 2008, and March 31, 2018. The Social Cognitive Theory will be used as a conceptual framework by which to frame the reciprocal relationship between treatment adherence, personal factors, and environmental determinants and how this interplay impacts CVD events and clinical outcomes. Data will be derived from the Diabetes Action Canada National Data Repository. A time-varying Cox proportional hazards model will be used to estimate the impacts of treatment adherence on CVD morbidity and mortality. Multivariable linear regression models and hierarchical regression models will be used to estimate the associations between treatment adherence of different medication categories and intermediate clinical outcomes. Our primary outcome is the association between treatment adherence and the risk of acute severe CVD events, including CVD mortality. The secondary outcome is the association between treatment adherence and intermediate clinical outcomes including diastolic and systolic blood pressures, glycated hemoglobin, low-density lipoprotein cholesterol, and total cholesterol. Owing to data limitation, we use medication prescriptions as a proxy to estimate treatment adherence. We assume that a patient adhered to medications if she or he had any prescription record in the 4 preceding quarters and 1 quarter after each quarter of interest. Acute severe CVD events are defined based on the World Health Organization’s Monitoring Trends and Determinants in Cardiovascular Disease Project, including acute coronary heart disease, stroke, and heart failure. As causes of death are not available, the number of CVD deaths will be computed using the most recent systolic blood pressure distributions and the population attributable risks related to systolic blood pressure level.

Results

The project was funded by Diabetes Action Canada (reference number: 503854) and approved by the University of Toronto Research Ethics Board (reference number: 36065). The project started in June 2018 and is expected to be finished by September 2019.

Conclusions

The findings will be helpful in identifying the challenges of treatment adherence for diabetic and hypertensive patients in primary care settings. This will also help to develop intervention strategies to promote treatment adherence for patients with multi-morbidities.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13571

Management Practice, and Adherence and Its Contributing Factors among Patients with Chronic Kidney Disease at Tikur Anbessa Specialized Hospital: A Hospital Based Cross-Sectional Study

The objective of this study was to assess the management practice, medication adherence, and factors affecting medication adherence in CKD patients at Tikur Anbessa Specialized Hospital (TASH). Methods. A cross-sectional study was conducted at the nephrology clinic of TASH. A total of 256 CKD (stages 1 and 2=50, stage 3=88, stage 4=55, and stage 5=63) patients were recruited through systematic random sampling. Data were collected from medical records and interviewing patients. The rate of adherence was determined using 8-item Morisky medication adherence scale. The data were analyzed using SPSS version 20.0 statistical software. Univariate and multivariate binary logistic regression were used to investigate the potential predictors of medication nonadherence. Results. About 57.3% of diabetes mellitus with hypertension were treated with combination of insulin and ACEI based regimens. Other cardiovascular comorbidities were predominantly treated with Acetyl Salicylic Acid in combination with β-blocker. Only 61.3% (stages 1 and 2=70%, stage 3=73.9%, stage 4=54.5%, and stage 5=43%) of the study population were adherent to their treatment regimens. Forgetfulness (79.8%) was the major reason for medication nonadherence. Patients who had an average and high monthly income were 4.14 (AOR=4.14, 95% CI: 1.45-11.84, p=0.008) and 6.17 times (AOR=6.17, 95% CI: 1.02-37.46, p=0.048) more likely to adhere as compared to those who had very low income. Patients who were prescribed with ≥5 drugs were 0.46 times (AOR= 0.54, 95% CI: 0.27-1.10, p=0.049) less likely to adhere compared to their counterpart. Patients who were students, drivers, or teachers working in private school were about 7.46 times (AOR=7.46, 95% CI: 1.49-37.26, p=0.014) more likely to adhere compared with patients who were farmers. Conclusion. Insulin and ACEIs based regimens were the most frequently used regimens in the treatment of diabetes mellitus and hypertension comorbidities. Very low income, increased number of prescribed medications, and being a farmer were the predictors of medication nonadherence.

Management practice, and adherence and its contributing factors among patients with chronic kidney disease at Tikur Anbessa Specialized Hospital: A hospital-based cross-sectional study

INTRODUCTION

Chronic kidney disease (CKD) has a complicated interrelationship with other diseases and major risk factor for cardiovascular disease. Therapeutic management for CKD patients is complicated due to co-morbidities and dominant risk factors of CKD. Non-adherence to treatment is an increasing problem for patients with CKD and it has not been extensively studied in patients with CKD. Hence, the present study was carried out to assess the management practice, medication adherence and factors affecting medication adherence in CKD patients at Tikur Anbessa Specialized Hospital (TASH).

METHODS

A hospital-based cross-sectional study was conducted at the nephrology clinic of TASH. A total of 256 patients were recruited through systematic random sampling. Data were collected from medical records and interviewing patients. The degree of adherence was determined using eight-item Morisky Medication Adherence Scale. The data were entered into Epi Info 7.2.2.2 and analyzed using SPSS version 20.0 statistical software. Descriptive statistics such as frequency, percent, mean and standard deviation were used to summarize patients' baseline characteristics. Univariable and multivariable binary logistic regression were used to investigate the potential predictors of medication non-adherence.

RESULTS

About 55% patients with hypertension only were treated with non-angiotensin converting enzyme inhibition based regimens; 57.3% of diabetes mellitus with hypertension treated with combination of insulin and ACEI based regimens. About three-fourth of patients with anemia and osteodystrophy complications were treated with iron preparations and calcium based phosphate binder. Only 61.3% of the study population were adherent to their treatment regimens. Forgetfulness (79.8%) was the major reason for medication non-adherence. Patients who had an average and high monthly income were 4.14 (AOR = 4.14, 95% CI: 1.45-11.84, p = 0.008) and 6.17 times (AOR = 6.17, 95% CI: 1.02-37.46, p = 0.048) more likely to adhere as compared to those who had very low income. Patients who were prescribed with ≥5 drugs were 0.46 times (AOR = 0.54, 95% CI: 0.27-1.10, p = 0.049) less likely to adhere compared to their counterpart. Patients who were students, drivers, teachers working in private school were about 7.46 times (AOR = 7.46, 95% CI: 1.49-37.26, p = 0.014) more likely to adhere compared with patients who were farmers.

CONCLUSION

Insulin and ACEIs based regimens were the most frequently used regimens in the treatment of diabetes mellitus and hypertension co-morbidities. Very low income, increased number of prescribed medications and being a farmer were the predictors of medication non-adherence.

Opinions on the use of technology to improve tablet taking in >65-year-old patients on cardiovascular medications

Objective

This study was performed to evaluate the perceptions of the use of technology to improve cardiovascular medicine taking among patients aged >65 years.

Methods

This qualitative study used focus groups with people aged >65 years taking cardiovascular medications from two East London community centres. Thematic analysis was informed by the Perceptions and Practicalities Approach framework.

Results

Participants welcomed technologies they considered familiar, accessible, and easy to use. They valued the opportunity to receive alerts to help with forgetting and monitoring their treatment. More advanced technologies such as ingestible sensor systems were considered helpful for elderly people with significant cognitive impairments still living in the community because of improved monitoring by caregivers and clinicians and prolonging independence. Although generally adapting to the increase in technology in everyday life, participants raised a number of concerns that included potential reduction in face-to-face communication, data security, becoming dependent on technology, and worrying about the consequences of technological failure.

Conclusions

Participants raised a number of concerns and practical barriers that would need to be addressed for technologies to be accepted and adopted in this patient group.

Continuity of care with physicians and risk of subsequent hospitalization and end-stage renal disease in newly diagnosed type 2 diabetes mellitus patients

Purpose

Effective management for type 2 diabetes mellitus (DM) can slow the progression of kidney outcomes and reduce hospital admissions. Better continuity of care (COC) was found to improve patients’ adherence and self-management. This study examined the associations between COC, hospitalization, and end-stage renal disease (ESRD) in DM patients.

Patients and methods

In the cohort study, data from 1996 to 2012 were retrieved from the Longitudinal Health Insurance Database, using inverse probability weighted analysis. A total of 26,063 patients with newly diagnosed type 2 DM who had been treated with antihyperglycemic agents were included. COC is to assess the extent to which a DM patient visited the same physician during the study period. This study categorized COC into 3 groups – low, intermediate, and high, – according to the distribution of scores in our sample.

Results

The number of ESRD patients in the high, intermediate, and low COC groups were 92 (22.33%), 130 (31.55%), and 190 (46.12%), respectively, and the mean follow-up periods for the 3 groups were 7.13, 7.12, and 7.27 years, respectively. After using inverse probability weighting, the intermediate and low COC groups were significantly associated with an increased risk of ESRD compared with the high COC group (adjusted hazard ratio (aHR) 1.36 [95% CI, 1.03–1.80] and aHR 1.76 [95% CI, 1.35–2.30], respectively). The intermediate and low COC groups were also significantly associated with the subsequent hospitalization compared with the high COC group (aHR 1.15 [95% CI, 0.99–1.33] and aHR 1.72 [95% CI, 1.50–1.97], respectively).

Conclusion

COC is related to ESRD onset and subsequent hospitalization among patients with DM. This study suggested that when DM patients keep visiting the same physician for managing their diseases, the progression of renal disease can be prevented.

Self-reported Medication Adherence and CKD Progression

Introduction

In the general population, medication nonadherence contributes to poorer outcomes. However, little is known about medication adherence among adults with chronic kidney disease (CKD). We evaluated the association of self-reported medication adherence with CKD progression and all-cause death in patients with CKD.

Methods

In this prospective observational study of 3305 adults with mild-to-moderate CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study, the baseline self-reported medication adherence was assessed by responses to 3 questions and categorized as high, medium, and low. CKD progression (50% decline in eGFR or incident end-stage renal disease) and all-cause death were measured using multivariable Cox proportional hazards.

Results

Of the patients, 68% were categorized as high adherence, 17% medium adherence, and 15% low adherence. Over a median follow-up of 6 years, there were 969 CKD progression events and 675 deaths. Compared with the high-adherence group, the low-adherence group experienced increased risk for CKD progression (hazard ratio = 1.27, 95% confidence interval = 1.05, 1.54) after adjustment for sociodemographic and clinical factors, cardiovascular medications, number of medication types, and depressive symptoms. A similar association existed between low adherence and all-cause death, but did not reach standard statistical significance (hazard ratio = 1.14 95% confidence interval = 0.88, 1.47).

Conclusion

Baseline self-reported low medication adherence was associated with an increased risk for CKD progression. Future work is needed to better understand the mechanisms underlying this association and to develop interventions to improve adherence.

Any link of gout disease control among hypertensive patients and onset of end-stage renal disease? Results from a population-based study

AIM

To determine the impact of allopurinol non-adherence as a proxy for uncontrolled disease on primary prevention of end-stage renal disease (ESRD).

METHODS

A cohort of 2752 patients with gout diagnosis was reconstructed using the Québec Régie de l’assurance maladie du Québec and MedEcho administrative databases. Eligible patients were new users of allopurinol, aged 45-85, with a diagnosis of hypertension, and treated with an antihypertensive drug between 1997 and 2007.

RESULTS

Major risk factor for ESRD onset was chronic kidney disease at stages 1 to 3 [rate ratio (RR) = 8.00; 95% confidence interval (CI): 3.16-22.3 and the severity of hypertension (≥ 3 vs < 3 antihypertensives)] was a trending risk factor as a crude estimate (RR = 1.94; 95%CI: 0.68-5.51). Of 341 patients, cases (n = 22) and controls (n = 319), high adherence level (≥ 80%) to allopurinol therapy, compared with lower adherence level (< 80%), was associated with a lower rate of ESRD onset (RR = 0.35; 95%CI: 0.13-0.91).

CONCLUSION

Gout control seem to be associated with a significant decreased risk of ESRD onset in hypertensive populations, further research should be conducted confirming this potential associated risk.

The effectiveness and safety of angiotensin-converting enzyme inhibition or receptor blockade in vascular diseases in patients with hemodialysis

Patients with end-stage renal disease (ESRD) who are on hemodialysis have high risk of vascular diseases. Our study sought to examine whether angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin type 1 receptor blockers (ARBs) could reduce the frequencies of cardiovascular and cerebrovascular events in patients receiving hemodialysis using the medication possession ratio (MPR) method of analysis.This retrospective cohort study identified cases of ESRD with dialysis from the National Health Insurance Research Database between 1999 and 2006, and used Cox-regression methods to evaluate risk of poor outcomes. Primary outcomes, including death from any cause, and secondary outcomes, including admission for stroke, myocardial infarction, and heart failure, were examined.Compared to the nonuser group, the adjusted HRs for mortality of the nonadherence group and the adherence group were 0.81 (95% CI: 0.76-0.86) and 0.98 (95% CI: 0.86-1.13), respectively. Cardiovascular events were more frequent in patients with ESRD receiving ACEIs /ARBs than in nonusers. Compared with nonusers, the hazard of secondary outcome significantly increased in the nonadherence group or adherence group in 10 years follow-up.Compared with patients with diabetes or chronic kidney disease, patients on hemodialysis may not experience the same cardiovascular and cerebrovascular benefits from ACEIs/ARBs use.

Simultaneous control of glycemic, blood pressure, and lipid significantly reduce the risk of renal progression in diabetes patients

BACKGROUND AND AIM

Hyperglycemic, hypertension, and lipid abnormalities are risk factors for diabetic kidney disease However, no study has discussed the association of the simultaneous control of glycemic, blood pressure, and lipids with renal function among diabetes patients. Thus, this study examined the interactive effects of the intensive control of all 3 conditions on the progression of renal function.

MATERIALS AND METHODS

The study population was derived from eight hospitals in Taiwan from October 2008 to April 2015. Demographic characteristics were collected using structured questionnaires. Clinical variables were obtained from medical chart review. The renal progression was defined as a decline in the eGFR by more than 25% according to the baseline eGFR.

RESULTS

Total of 1602 diabetes patients were included in the study analysis, the mean age was 63.03±10.98years, 55.56% were men. Compared to the simultaneous control of glycemic, blood pressure and lipid group, the poor control of all three diseases had the highest risk of renal progression, with an adjusted OR of 2.21 (95% CI, 1.26-3.86). Even if the patients with an intensive control of lipid, the result showed that the poor control of both glycemic and hypertension was associated with the increased risk of renal progression than the reference group.

CONCLUSION

This study demonstrated that the simultaneous poor control of glycemic, blood pressure, and lipid had the highest risk of renal progression. Thus, patients with type 2 diabetes should not only control glycemic but also manage their blood pressure and lipid.

Predialysis Cardiovascular Disease Medication Adherence and Mortality After Transition to Dialysis

BACKGROUND

Medication nonadherence is a known risk factor for adverse outcomes in the general population. However, little is known about the association of predialysis medication adherence among patients with advanced chronic kidney disease and mortality following their transition to dialysis.

STUDY DESIGN

Observational study.

SETTING & PARTICIPANTS

32,348 US veterans who transitioned to dialysis during 2007 to 2011.

PREDICTORS

Adherence to treatment with cardiovascular drugs, ascertained from pharmacy database records using proportion of days covered (PDC) and persistence during the predialysis year.

OUTCOMES

Post-dialysis therapy initiation all-cause and cardiovascular mortality, using Cox models with adjustment for confounders.

RESULTS

Mean age of the cohort was 72±11 (SD) years; 96% were men, 74% were white, 23% were African American, and 69% had diabetes. During a median follow-up of 23 (IQR, 9-36) months, 18,608 patients died. Among patients with PDC>80%, there were 14,006 deaths (mortality rate, 283 [95% CI, 278-288]/1,000 patient-years]); among patients with PDC>60% to 80%, there were 3,882 deaths (mortality rate, 294 [95% CI, 285-304]/1,000 patient-years); among patients with PDC≤60%, there were 720 deaths (mortality rate, 291 [95% CI, 271-313]/1,000 patient-years). Compared with patients with PDC>80%, the adjusted HR for post-dialysis therapy initiation all-cause mortality for patients with PDC>60% to 80% was 1.12 (95% CI, 1.08-1.16), and for patients with PDC≤60% was 1.21 (95% CI, 1.11-1.30). In addition, compared with patients showing medication persistence, adjusted HR risk for post-dialysis therapy initiation all-cause mortality for patients with nonpersistence was 1.11 (95% CI, 1.05-1.16). A similar trend was detected for cardiovascular mortality and in subgroup analyses.

LIMITATIONS

Large number of missing values; results may not be generalizable to women or the general US population.

CONCLUSIONS

Predialysis cardiovascular medication nonadherence is an independent risk factor for postdialysis mortality in patients with advanced chronic kidney disease transitioning to dialysis therapy. Further studies are needed to assess whether interventions targeting adherence improve survival after dialysis therapy initiation.

Novel Omega-3 Fatty Acid Epoxygenase Metabolite Reduces Kidney Fibrosis

Cytochrome P450 (CYP) monooxygenases epoxidize the omega-3 polyunsaturated fatty acid (PUFA) docosahexaenoic acid into novel epoxydocosapentaenoic acids (EDPs) that have multiple biological actions. The present study determined the ability of the most abundant EDP regioisomer, 19,20-EDP to reduce kidney injury in an experimental unilateral ureteral obstruction (UUO) renal fibrosis mouse model. Mice with UUO developed kidney tubular injury and interstitial fibrosis. UUO mice had elevated kidney hydroxyproline content and five-times greater collagen positive fibrotic area than sham control mice. 19,20-EDP treatment to UUO mice for 10 days reduced renal fibrosis with a 40%-50% reduction in collagen positive area and hydroxyproline content. There was a six-fold increase in kidney α-smooth muscle actin (α-SMA) positive area in UUO mice compared to sham control mice, and 19,20-EDP treatment to UUO mice decreased α-SMA immunopositive area by 60%. UUO mice demonstrated renal epithelial-to-mesenchymal transition (EMT) with reduced expression of the epithelial marker E-cadherin and elevated expression of multiple mesenchymal markers (FSP-1, α-SMA, and desmin). Interestingly, 19,20-EDP treatment reduced renal EMT in UUO by decreasing mesenchymal and increasing epithelial marker expression. Overall, we demonstrate that a novel omega-3 fatty acid metabolite 19,20-EDP, prevents UUO-induced renal fibrosis in mice by reducing renal EMT.

Kidney Function Decline and Apparent Treatment-Resistant Hypertension in the Elderly

BACKGROUND

Cross-sectional studies show a strong association between chronic kidney disease and apparent treatment-resistant hypertension, but the longitudinal association of the rate of kidney function decline with the risk of resistant hypertension is unknown.

METHODS

The population-based Three-City included 8,695 participants older than 65 years, 4265 of them treated for hypertension. We estimated the odds ratios (OR) of new-onset apparent treatment-resistant hypertension, defined as blood pressure ≥ 140/90 mmHg despite use of 3 antihypertensive drug classes or ≥ 4 classes regardless of blood pressure, associated with the mean estimated glomerular filtration rate (eGFR) level and its rate of decline over 4 years, compared with both controlled hypertension and uncontrolled nonresistant hypertension with ≤ 2 drugs. GFR was estimated with three different equations.

RESULTS

Baseline prevalence of apparent treatment-resistant hypertension and of controlled and uncontrolled nonresistant hypertension, were 6.5%, 62.3% and 31.2%, respectively. During follow-up, 162 participants developed apparent treatment-resistant hypertension. Mean eGFR decline with the MDRD equation was 1.5±2.9 mL/min/1.73 m² per year: 27.7% of the participants had an eGFR ≥3 and 10.1% ≥ 5 mL/min/1.73 m² per year. After adjusting for age, sex, obesity, diabetes, and cardiovascular history, the ORs for new-onset apparent treatment-resistant hypertension associated with a mean eGFR level, per 15 mL/min/1.73 m² drop, were 1.23 [95% confidence interval 0.91-1.64] compared to controlled hypertension and 1.10 [0.83-1.45] compared to uncontrolled nonresistant hypertension; ORs associated with a decline rate ≥ 3 mL/min/1.73 m² per year were 1.89 [1.09-3.29] and 1.99 [1.19-3.35], respectively. Similar results were obtained when we estimated GFR with the CKDEPI and the BIS1 equations. ORs tended to be higher for an eGFR decline rate ≥ 5 mL/min/1.73 m² per year.

CONCLUSION

The speed of kidney function decline is associated more strongly than kidney function itself with the risk of apparent treatment-resistant hypertension in the elderly.

Persistence and compliance with newly initiated antihypertensive drug treatment in patients with chronic kidney disease

BACKGROUND

Patients with chronic kidney disease initiating an antihypertensive drug (AH) treatment must persist and comply with it to slow disease progression and benefit from the reduction of cardiovascular morbidity and mortality.

OBJECTIVES

This study evaluates the persistence and compliance with AH treatment and identifies the associated factors among chronic kidney disease patients who initiated AH treatment.

METHODS

A population-based cohort study using Quebec administrative data was conducted. Patients who still take any AH 1 year after initiation were considered persistent. Of these patients, those who had ≥80% of days covered with an AH in the year after initiation were considered compliant. Factors associated with persistence and compliance were identified using a modified Poisson regression.

RESULTS

Of the 7,119 eligible patients, 78.8% were persistent, 87.7% of whom were compliant with their AH treatment. Compared with patients on diuretic monotherapy, those who initially used angiotensin-converting enzyme inhibitor monotherapy, angiotensin II receptor blocker monotherapy, calcium channel blocker monotherapy, β-blocker monotherapy, or multidrug therapy were more likely to be persistent. In contrast, individuals who visited their physicians ≥17 times were less likely to be persistent than those who visited between 0 and 8 times. The patients who were more likely to be compliant had initially used an angiotensin-converting enzyme inhibitor, β-blocker, calcium channel blocker, or multitherapy as opposed to a diuretic.

CONCLUSION

A year after initiating AH treatment, nearly a third of chronic kidney disease patients were either not taking an AH or had not been compliant. Factors associated with persistence and compliance could help identify patients who need help in managing their AH treatment.

Nonadherence of Oral Antihyperglycemic Medication Will Increase Risk of End-Stage Renal Disease

Poor glycemic control is related to an increased risk of end-stage renal disease (ESRD). This study investigated the association between medication adherence and the risk of ESRD in patients with newly diagnosed diabetes mellitus.In this population-based cohort study, we used the Taiwan National Health Insurance Research Database (NHIRD) to identify 559,864 patients with newly diagnosed or treated diabetes mellitus who were ages from 20 to 85 years between 2001 and 2008. We identified 1695 patients with ESRD during the study period. The mean follow-up time of the patients with ESRD was 5.7 years. Time-dependent Cox proportional hazards regression was performed to estimate the hazard ratios for ESRD among the patients with newly diagnosed diabetes mellitus.After adjustment for various covariates, nonadherence to oral antihyperglycemic medication (OAM) was associated with a higher risk of ESRD compared with adherence to OAM (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.01-1.23). The effects of nonadherence to OAM on the risk of ESRD were significant for patients without hypertension, without gout, without chronic kidney disease, undergoing OAM polytherapy, and undergoing metformin polytherapy (HR [95% CIs], 1.18 [1.00-1.39], 1.13 [1.02-1.26], 1.17 [1.03-1.33], 1.22 [1.08-1.38], and 1.13 [1.02-1.25], respectively).In conclusion, nonadherence to OAM therapy is associated with ESRD. Adherence to medication therapy can prevent the progressive loss of renal function and ESRD for patients with diabetes.

Impact of Non-Adherence on Renal and Cardiovascular Outcomes in US Veterans

BACKGROUND

Adherence is paramount in treating hypertension; however, no gold standard method is available for non-adherence screening, delineating high-risk patients. An International Classification of Diseases 9th Edition non-adherence diagnostic code (V15.81) has been available for decades; but, its utility is poorly studied. We examined the association between the V15.81 code assigned prior to the initiation of anti-hypertensive drugs (AHDs) and renal and cardiovascular outcomes.

METHODS

This was a historical prospective cohort study involving 312,489 newly treated hypertensive individuals (mean age 53.8 years, 90.9% males, 20.3% black, median follow-up 8.0 years). We used crude and Cox models adjusted for baseline socio-demographic characteristics, estimated glomerular filtration rate (eGFR), body mass index, blood pressure, comorbidities, and prospective AHD adherence (measured as proportion of days covered, PDC).

RESULTS

In the unadjusted analysis, the V15.81 code was associated with higher risks for faster eGFR decline (hazard ratio, HR 1.22, 95% CI 1.11-1.33), incident CKD (HR 1.17, 95% CI 1.09-1.27), end-stage renal disease (ESRD) (HR 2.53, 95% CI 1.72-3.72), incident coronary artery disease (CAD) (HR 1.26, 95% CI 1.15-1.38), and stroke (HR 1.55, 95% CI 1.38-1.73). In the adjusted model, the V15.81 code remained predictive of increased risk of CKD (HR 1.33, 95% CI 1.22-1.45), ESRD (HR 1.81, 95% CI 1.18-2.78), incident CAD (HR 1.26, 95% CI 1.14-1.40), and stroke (HR 1.46, 95% CI 1.29-1.65). Additional adjustment for PDC did not alter adverse associations between V15.81 code and studied outcomes.

CONCLUSIONS

Assignment of V15.81 code prior to AHD therapy was associated with higher risks of renal and cardiovascular outcomes in incident hypertensive US veterans. Previous history of non-adherence is a poor prognostic marker in hypertensive individuals; therefore, patients with V15.81 code may require close monitoring. The observational nature of this study limits our ability to make firm recommendations for clinical practice.

[Factors associated with medication non-adherence in uncontrolled hypertensive males and females: ODACE study]

OBJECTIVES

The aim of this study was (1) to measure adherence in males and females with uncontrolled hypertension, and (2) to identify factors associated with non-adherence to antihypertensive medication.

PATIENTS AND METHODS

Each general practitioner (GP) should include the first two male and the first two female patients with uncontrolled treated hypertension. Adherence to antihypertensive treatment was estimated by the GP and using the French League Against High blood pressure (FLAH) self-administered questionnaire. A stepwise logistic regression analysis was used to identify factors associated with non-adherence on the FLAH scale, independently in males and in females.

RESULTS

A total of 1630 males and 1612 females were included in the analysis. Adherence to treatment was significantly better in females or when estimated by the GP. Lack of motivation was the first factor associated with poor adherence in both sexes. Considering hypertension as a simple anomaly and not a disease that can lead to cardiac or cerebral disorders was the second common parameter in both sexes. Other common factors were: having monthly periods of financial difficulties in facing his/her needs and absence of regular screening for colon cancer.

CONCLUSION

Adherence to treatment is better in uncontrolled hypertensive females. Poor adherence is mainly associated with non-clinical factors. The lack of motivation is the most important element.

Combination therapy of mesenchymal stem cells and serelaxin effectively attenuates renal fibrosis in obstructive nephropathy

Chronic kidney disease (CKD) results from the development of fibrosis, ultimately leading to end-stage renal disease (ESRD). Although human bone marrow-derived mesenchymal stem cells (MSCs) can accelerate renal repair following acute injury, the establishment of fibrosis during CKD may affect their potential to influence regeneration capacity. Here we tested the novel combination of MSCs with the antifibrotic serelaxin to repair and protect the kidney 7 d post-unilateral ureteral obstruction (UUO), when fibrosis is established. Male C57BL6 mice were sham-operated or UUO-inured (n = 4-6) and received vehicle, MSCs (1 × 10(6)), serelaxin (0.5 mg/kg per d), or the combination of both. In vivo tracing studies with luciferin/enhanced green fluorescent protein (eGFP)-tagged MSCs showed specific localization in the obstructed kidney where they remained for 36 h. Combination therapy conferred significant protection from UUO-induced fibrosis, as indicated by hydroxyproline analysis (P < 0.001 vs. vehicle, P < 0.05 vs. MSC or serelaxin alone). This was accompanied by preserved structural architecture, decreased tubular epithelial injury (P < 0.01 vs. MSCs alone), macrophage infiltration, and myofibroblast localization in the kidney (both P < 0.01 vs. vehicle). Combination therapy also stimulated matrix metalloproteinase (MMP)-2 activity over either treatment alone (P < 0.05 vs. either treatment alone). These results suggest that the presence of an antifibrotic in conjunction with MSCs ameliorates established kidney fibrosis and augments tissue repair to a greater extent than either treatment alone.

Adherence to antihypertensive medications: is prescribing the right pill enough?

Significant progress has been made in the management of hypertension (HTN) in the last 60 years. A large number of antihypertensive drugs (AHD) is available for effective control of elevated blood pressure (BP) that were also shown to be beneficial in improving all-cause mortality and cardiovascular morbidity in hypertensive individuals. Despite these successes, rates of BP control and outcomes in hypertensive patients remain suboptimal. Therefore, the availability of effective drug therapy itself appears to be insufficient to guarantee desirable results. Adherence to antihypertensive medications is a crucial mediator of favorable outcomes in treating HTN, and non-adherence, in turn, halts BP control. In this review, we will summarize the available evidence on health-related impacts of adherence to AHD, methods for the evaluation of adherence and potential interventions aimed to improve adherence in hypertensive individuals.

Understanding antihypertensive medication use after living kidney donation through linked national registry and pharmacy claims data

BACKGROUND

Use of antihypertensive medications (AHM) after living kidney donation is not well described.

METHODS

We examined a database wherein national transplant registry data for 4,650 living kidney donors in 1987-2007 were linked to pharmacy claims from a US private health insurer (2000-2007 claims) to identify post-donation AHM fills. Cox regression with left- and right-censoring was used to estimate the frequencies and relative likelihood (adjusted hazards ratios, aHR) of post-donation AHM fills according to donor demographic traits. Medication possession ratio (MPRs), defined as (days of AHM dispensed)/(days observed), were also compared among donors and non-donor general beneficiaries.

RESULTS

Overall, 17.8% of the sample filled at least one AHM by 5 years post-donation. As compared with White living donors, African-Americans had 37% higher relative likelihood of any AHM use after donation (aHR 1.37, p < 0.0007), including significantly higher likelihoods of filling diuretics (aHR 2.25, p < 0.0001), ACEi/ARBs (aHR 1.46, p < 0.01), calcium channel blockers (aHR 1.56, p = 0.03), and vasodilators/other agents (aHR 2.17, p = 0.03). MPRs for any AHM and subcategories were lower among donors compared with age- and sex-matched non-donors. However, AHM MPRs rose in donors with multiple hypertension diagnoses, and prescription fill exposure for all AHM classes except diuretics was similar among donors and general non-donors with ≥ 3 hypertension diagnoses.

CONCLUSIONS

While AHM requirements are lower after kidney donation than among unscreened general persons, racial variation in AHM use occurs in privately insured donors. Demonstration of pharmaceutical care needs of insured donors supports the need for long-term follow-up and healthcare access for all donors.