Implementation of the KDIGO guideline on lipid management requires a substantial increase in statin prescription rates

Use of lipid-lowering therapies in patients with chronic kidney disease and atherosclerotic cardiovascular disease: 2-year results from Getting to an imprOved Understanding of Low-Density lipoprotein cholesterol and dyslipidemia management (GOULD)

BACKGROUND

Chronic kidney disease (CKD) is a known risk factor of atherosclerotic cardiovascular disease (ASCVD). Per the 2018 American Heart Association/American College of Cardiology cholesterol guidelines, high-risk ASCVD patients with CKD and low-density lipoprotein cholesterol (LDL-C) levels  ≥ $\ge $  70 mg/dL should take a high-intensity statin with ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i).

OBJECTIVE/METHODS

We examined the changes in use of lipid lowering therapies (LLT) over two years in 3304 patients with ASCVD and CKD in the Getting to an imprOved Understanding of Low-Density Lipoprotein Cholesterol and Dyslipidemia Management (GOULD) observational cohort study.

RESULTS

Of those with eGFR <60 ml/min/1.73 m² , 21.6% (171/791) had intensification of LLT while 10.4% (82/791) had de-escalation of LLT. Notably, 61.6% (487/791) had no change in LLT regimen over 2 years. Statin use was 83.2% (785/944) at baseline and 80.1% (634/791) at 2 years. Statin/ezetimibe use increased from 2.9% (27/944) to 4.9% (39/791). Statin discontinuation at 2 years was greater with lower eGFR levels across all cohorts.

CONCLUSION

Despite the recommendations of multiscociety guidelines, statin use, while high, is not ubiquitous and rates of high-intensity statin and ezetimibe use remain low in patients with CKD. There remains a significant opportunity to optimize LLT and achieve atheroprotective cholesterol levels in the CKD population.

Statin use before and after the KDIGO Lipids in chronic kidney disease guideline: A population-based interrupted time series analysis

In November 2013, the Kidney Disease: Improving Global Outcomes Clinical Practice Guideline for Lipid Management in Chronic Kidney Disease was published, recommending statins for all individuals 50 years or older with an estimated glomerular filtration rate below 60 ml/min/1.73 m² to lower the risk of major cardiovascular events. We quantified the prevalence of statin use among the target population before and after the guideline publication in a large Danish cohort of individuals with an estimated glomerular filtration rate below 60 ml/min/1.73 m² , to investigate the effect of the guideline, but found no difference in the prevalence of statin use prior to and after the guideline publication.

Cardiovascular Risk Stratification and Appropriate Use of Statins in Patients with Chronic Kidney Disease According to Different Strategies

INTRODUCTION

Different strategies were proposed to stratify cardiovascular risk and assess the appropriate use of statins in patients with chronic kidney disease (CKD).

AIM

(1) To apply two strategies on the management of lipids in patients with CKD, analyzing what proportion of patients received lipid-lowering treatment and how many patients without statin therapy would be candidates for receiving them; (2) to identify how many patients achieve the lipid goals.

METHODS

A cross-sectional study was performed. Patients aged between 18 to 70 years and CKD with an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m² (without hemodialysis) were included. The indications for statin therapy according to 2019 ESC/EAS and 2013 KDIGO guidelines were analyzed as well as the achievement of LDL-C goals.

RESULTS

A total of 300 patients were included. According to ESC/EAS guidelines, 62.3 and 37.7% of the population was classified at high or very high cardiovascular risk. In total, 52% of patients received statins. Applying the 2013 KDIGO and the 2019 ESC/EAS guidelines, 92.4 and 95.8% of the population without lipid-lowering treatment were eligible for statin therapy, respectively. Globally, only 9.1 and 10.6% of the patients with high or very high risk achieved the suggested lipid goals.

CONCLUSION

A large proportion of patients with CKD showed considerable cardiovascular risk and were eligible for statin therapy according to the two strategies evaluated. However, observed statin use was deficient and current lipid goals were not achieved in most cases.

Prescription Practices in Patients With Mild to Moderate CKD in India

Introduction

Patients with chronic kidney disease (CKD) require multiple medications. There is no information on prescription patterns or the use of evidence-based therapies for management of CKD from low-middle-income countries. Using baseline data from the Indian CKD (ICKD) cohort, we describe the drug prescription practices in patients with mild to moderate CKD.

Methods

The ICKD study is a prospective, observational cohort study of mild to moderate kidney disease across 11 centers in India. We analyzed all the prescriptions captured at enrollment in the ICKD study. Drugs were categorized into 11 different groups. We provide descriptive data on prescription details and evaluate the appropriateness of medication use.

Results

Complete prescription data were available in 3966 out of 4056 (97.8%) subjects enrolled in the ICKD database. Most patients had stage 3 CKD, 24.9% had diabetic kidney disease, 87% had hypertension, and 25.5% had moderate to severe proteinuria. Renin-angiotensin-aldosterone system blockers were prescribed in less than half (47.9%) and in 58.8% of patients with proteinuric CKD. Metformin was prescribed in 25.7% of diabetic subjects with CKD. Only 40.4% of patients were taking statins; 31.1% and 2.8% subjects with anemia were receiving iron and erythropoiesis-stimulating agents, respectively.

Conclusion

This study highlights the missed opportunities for improving outcomes through appropriate prescriptions of drugs in patients with CKD. There is need for dissemination of evidence-based guidelines and institution of sustainable implementation practices for improving the overall health of patients with CKD.

[Kidney as pacemaker for cardiovascular aging]

Kidney patients age faster and vascular risk factors intensify the process. Lifetime is reduced up to 16 years in patients with diabetes mellitus type 2 and kidney disease. SGLT2 inhibitors play a significant role in maintaining organ function. By inhibiting the SGLT2 transporter in the proximal tubule of the kidneys, energy and water are continuously excreted and metabolic processes that are counter-regulated are set in motion. This hypometabolic adaptation supports organ functions and induces longevity. Kidney protection extends life expectancy of patients with diabetes mellitus type 2.Also patients with heart failure benefit and a 3-stage therapy is newly being discussed. The beta blocker is combined with an SGLT2 inhibitor in the first stage. In the second stage, the angiotensin receptor/neprilysin inhibitor and then a mineralocorticoid receptor antagonist (MRA) is used. These therapies have a complementary effect.

Adverse Drug Reactions in Patients with CKD

BACKGROUND AND OBJECTIVES

Little is known about the burden of adverse drug reactions in CKD. We estimated the incidence of overall and serious adverse drug reactions and assessed the probability of causation, preventability, and factors associated with adverse drug reactions in patients seen by nephrologists.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Chronic Kidney Disease-Renal Epidemiology and Information Network cohort included 3033 outpatients (65% men) with CKD and eGFR<60 ml/min per 1.73 m², with follow-up for 2 years. Adverse drug reactions were identified from hospitalization reports, medical records, and participant interviews and finally assessed for causality, preventability, and immediate therapeutic management by experts in pharmacology.

RESULTS

Median (interquartile range) age was 69 (60-76) years old; 55% had eGFR≥30 ml/min per 1.73 m², and 45% had eGFR<30 ml/min per 1.73 m². Participants were prescribed a median (range) of eight (five to ten) drugs. Over 2 years, 536 patients had 751 adverse drug reactions, 150 (in 125 participants) classified as serious, for rates of 14.4 (95% confidence interval, 12.6 to 16.5) and 2.7 (95% confidence interval, 1.7 to 4.3) per 100 person-years, respectively. Among the serious adverse drug reactions, 32% were considered preventable or potentially preventable; 16 caused death, directly or indirectly. Renin-angiotensin system inhibitors (15%), antithrombotic agents (14%), and diuretics (10%) were the drugs to which the most adverse drug reactions were imputed, but antithrombotic agents caused 34% of serious adverse drug reactions. The drug was discontinued in 71% of cases, at least temporarily. Adjusted hazard ratios for serious adverse drug reaction were significantly higher in patients with eGFR<30 versus ≥30 ml/min per 1.73 m² (1.8; 95% confidence interval, 1.3 to 2.6), in those prescribed more than ten versus less than five medications (2.4; 95% confidence interval, 1.1 to 5.2), or in those with poor versus good adherence (1.6; 95% confidence interval, 1.4 to 2.4).

CONCLUSIONS

Adverse drug reactions are common and sometimes serious in patients with CKD. Many serious adverse drug reactions may be preventable. Some specific pharmacologic classes, particularly antithrombotic agents, are at risk of serious adverse drug reactions.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN), NCT03381950.

Lipid management in patients with chronic kidney disease

An increased risk of cardiovascular disease, independent of conventional risk factors, is present even at minor levels of renal impairment and is highest in patients with end-stage renal disease (ESRD) requiring dialysis. Renal dysfunction changes the level, composition and quality of blood lipids in favour of a more atherogenic profile. Patients with advanced chronic kidney disease (CKD) or ESRD have a characteristic lipid pattern of hypertriglyceridaemia and low HDL cholesterol levels but normal LDL cholesterol levels. In the general population, a clear relationship exists between LDL cholesterol and major atherosclerotic events. However, in patients with ESRD, LDL cholesterol shows a negative association with these outcomes at below average LDL cholesterol levels and a flat or weakly positive association with mortality at higher LDL cholesterol levels. Overall, the available data suggest that lowering of LDL cholesterol is beneficial for prevention of major atherosclerotic events in patients with CKD and in kidney transplant recipients but is not beneficial in patients requiring dialysis. The 2013 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Lipid Management in CKD provides simple recommendations for the management of dyslipidaemia in patients with CKD and ESRD. However, emerging data and novel lipid-lowering therapies warrant some reappraisal of these recommendations.

Low statin use in nondialysis-dependent chronic kidney disease in the absence of clinical atherosclerotic cardiovascular disease or diabetes

Background

Both reduced glomerular filtration rate and increased urine albumin excretion, markers of chronic kidney disease (CKD), are associated with increased risk of atherosclerotic cardiovascular disease (ASCVD). However, CKD is not recognized as an ASCVD risk equivalent by most lipid guidelines. Statin medications, especially when combined with ezetimibe, significantly reduce ASCVD risk in patients with nondialysis-dependent CKD. Unless physicians recognize the heightened ASCVD risk in this population, statins may not be prescribed in the absence of clinical cardiovascular disease or diabetes, a recognized ASCVD risk equivalent. We examined statin use in adults with nondialysis-dependent CKD and examined whether the use differed in the presence of clinical ASCVD and diabetes.

Methods

This study ascertained statin use from pharmacy dispensing records during fiscal years 2012 and 2013 from the US Department of Veterans Affairs Healthcare System. The study included 581 344 veterans aged ≥50 years with nondialysis-dependent CKD Stages 3-5 with no history of kidney transplantation or dialysis. The 10-year predicted ASCVD risk was calculated with the pooled risk equation.

Results

Of veterans with CKD, 62.1% used statins in 2012 and 55.4% used statins continuously over 2 years (2012-13). Statin use in 2012 was 76.2 and 75.5% among veterans with CKD and ASCVD or diabetes, respectively, but in the absence of ASCVD, diabetes or a diagnosis of hyperlipidemia, statin use was 21.8% (P < 0.001). The 10-year predicted ASCVD risk was ≥7.5% in 95.1% of veterans with CKD, regardless of diabetes status.

Conclusions

Statin use is low in veterans with nondialysis-dependent CKD in the absence of ASCVD or diabetes despite high-predicted ASCVD risk. Future studies should examine other populations.

Achievement of Low-Density Lipoprotein Cholesterol Targets in CKD

Introduction

We describe the characteristics of patients with moderate/advanced chronic kidney disease (CKD) according to receipt of lipid-lowering therapy (LLT), and whether they achieved low-density lipoprotein cholesterol (LDL-C) targets for high- and very high-risk patients.

Methods

CKD-REIN (NCT03381950), a prospective cohort study conducted in 40 nephrology clinics in France, enrolled 3033 patients with moderate (stage G3) or advanced (stage G4/G5) CKD (2013-2016) who had not been on chronic dialysis or undergone kidney transplantation. Data were collected from patients' interviews and medical records. Patients were followed up at 1 year.

Results

Among 2542 patients (mean [SD] age 67 [13] years, 34% women) with LDL-C measurements at baseline (mean [SD] LDL-C 2.7 [1.1] mmol/l; cholesterol 4.8 [1.3] mmol/l), 63% were on LLT; 24% were at high (CKD stage G3, no cardiovascular disease [CVD] or diabetes) and 74% at very high (CKD stage G3 with diabetes or CVD, or CKD stage G4/5) cardiovascular risk. Among high-risk patients, 45% of those on statin and/or ezetimibe achieved the LDL-C treatment target (<2.6 mmol/l). Among very high-risk patients, the percentage at goal (<1.8 mmol/l) was 38% for CKD stage G3 and 29% for stage G4/5. There was a trend toward higher achievement of LDL-C targets with increasing LLT intensity (adjusted odds ratios for moderate vs. low intensity 1.20; 95% confidence interval 0.92-1.56; high vs. low intensity 1.46; 1.02-2.09; P _trend = 0.036).

Conclusion

Many patients with CKD stage G3-G5 who are eligible for LLT are not treated, and those on LLT rarely achieve LDL-C targets.

Patterns of medication use and the burden of polypharmacy in patients with chronic kidney disease: the German Chronic Kidney Disease study

Background

Patients with chronic kidney disease (CKD) bear a substantial burden of comorbidities leading to the prescription of multiple drugs and a risk of polypharmacy. However, data on medication use in this population are scarce.

Methods

A total of 5217 adults with an estimated glomerular filtration rate (eGFR) between 30 and 60 mL/min/1.73 m² or an eGFR ≥60 mL/min/1.73m² and overt proteinuria (>500 mg/day) were studied. Self-reported data on current medication use were assessed at baseline (2010-12) and after 4 years of follow-up (FU). Prevalence and risk factors associated with polypharmacy (defined as the regular use of five or more drugs per day) as well as initiation or termination of polypharmacy were evaluated using multivariable logistic regression.

Results

The prevalence of polypharmacy at baseline and FU was almost 80%, ranging from 62% in patients with CKD Stage G1 to 86% in those with CKD Stage G3b. The median number of different medications taken per day was eight (range 0-27). β-blockers, angiotensin-converting enzyme inhibitors and statins were most frequently used. Increasing CKD G stage, age and body mass index, diabetes mellitus, cardiovascular disease and a history of smoking were significantly associated with both the prevalence of polypharmacy and its maintenance during FU. Diabetes mellitus was also significantly associated with the initiation of polypharmacy [odds ratio (OR) 2.46, (95% confidence interval 1.36-4.45); P = 0.003].

Conclusion

Medication burden in CKD patients is high. Further research appears warranted to address the implications of polypharmacy, risks of drug interactions and strategies for risk reduction in this vulnerable patient population.

Impact of the application of the JNC 8 and KDIGO-2013 guidelines on hypertension and lipid control in a Nephrology outpatient clinic

OBJECTIVE

Observational retrospective study with consecutive patients with CKD to assess the degree of accomplishment of the therapeutic objectives in hypertension and dyslipidaemia recommended by JNC 8 and KDIGO-2013 CKD guidelines the impact of their implementation compared with previous guidelines.

RESULTS

618 patients were included, mean age 67±15 years, 61.33% male. Mean eGFR was 45.99±18.94ml/min, with median albumin/creatinine 26 (0-151)mg/g. A total of 87.6% received antihypertensive treatment and 50.2% received statins. According to KDIGO guidelines, 520 patients (84.14%) should receive statins, but only 304 (58.46%) were receiving them. Patients on statin treatment had more diabetes and hypertension, and a greater cardiovascular history and lower levels of total and LDL-cholesterol. A total of 97.7% of patients were under 60 years of age or had eGFR<60ml/min/1.73m² or were diabetic, so according to the JNC 8 report, they should have a target blood pressure<140/90mmHg. A total of 289 patients did (47.85%). According to the JNC 7 report, this group had a tighter target blood pressure<130/90mmHg, reducing the number of patients who fulfilled the target: 136 (22.52%). Patients reclassified were older, had a greater cardiovascular history and less DM.

CONCLUSION

The new KDIGO guidelines for dyslipidaemia treatment increase the indication of statin therapy, especially in patients at high cardiovascular risk. The JNC 8 guidelines improve the percentage of patients with controlled blood pressure, especially the elderly and patients with increased cardiovascular risk, in whom the target blood pressure is currently controversial.

Attainment of guideline targets in EURODOPPS haemodialysis patients: are differences related to a country's healthcare expenditure and nephrologist workforce?

Background

In the field of chronic kidney disease, global clinical practice guidelines have been developed and implemented with a view to improving patient care and outcomes. The attainment of international and European guideline targets for haemodialysis patients in European countries has not been audited recently. Hence, we sought to establish whether the attainment of the targets set out in guidelines and inappropriate care are similar across European countries and whether inter-country differences are related to disparities in national healthcare expenditures (as a percentage of gross domestic product) and/or the nephrologist workforce per capita.

Methods

EURODOPPS is the European part of an international, prospective study of a cohort of adult, in-centre, haemodialysed patients. For the current project, 6317 patients from seven European countries were included between 2009 and 2011. Data on laboratory test results and medication prescriptions were extracted from patient records, in order to determine the overall percentage of patients treated according to the international guidelines on anaemia, dyslipidaemia, metabolic acidosis and mineral bone disease. Data related to macroeconomic indices were collected from World Health Organization database and World Bank stats.

Results

Attainment of the targets set in international guidelines was far from complete; only 34.1% of patients attained their target blood pressure and 31.2% attained their target haemoglobin level. Overall, only 5% of the patients attained all of the studied guideline targets. We observed marked inter-country differences in levels of guideline uptake/application and the use of pharmacological agents. The levels of national healthcare expenditures and nephrologist workforce were not correlated with the percentage of patients on-target for ≥50% of the studied variables or with inappropriate care (except for anaemia).

Conclusions

Our analysis of EURODOPPS data highlighted a low overall level of guideline target attainment in Europe and substantial differences between European countries. These inter-country differences did not appear to be linked to macroeconomic determinants.

The effects of short sleep duration on proteinuria and chronic kidney disease: a systematic review and meta-analysis

Background

The risks of proteinuria and chronic kidney disease (CKD) in adults who regularly have short sleep duration (short sleepers) are controversial. The aim of this meta-analysis was to assess the effects of short sleep duration on proteinuria and CKD.

Methods

A literature search was conducted using MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews from the inception of the databases through November 2015. Studies that reported relative risks, odd ratios or hazard ratios comparing the risks of proteinuria and CKD in short sleepers were included. Pooled risk ratios (RR) and 95% confidence intervals (CI) were computed utilizing a random-effect, generic inverse variance method.

Results

Six observational studies with 252 075 individuals and three observational studies with 37 197 individuals were included in the analyses to assess the risks of CKD and proteinuria in short sleepers, respectively. The pooled RR of CKD in short sleepers was 1.51 (95% CI, 0.99-2.55). When meta-analysis was restricted only to studies with adjusted analysis for confounders assessing the risk of CKD in short sleepers, the pooled RR of CKD was 1.54 (95% CI, 0.80-2.95). The pooled RR of proteinuria in short sleepers was 1.47 (95% CI, 1.26-1.72).

Conclusions

Despite the lack of significant association between short sleep duration and CKD, our meta-analysis suggests a potential association between short sleep duration and proteinuria, a surrogate marker for kidney disease progression. Future study is required to investigate if reversal of short sleep helps reduce proteinuria.

A Population-Based Analysis of Quality Indicators in CKD

BACKGROUND AND OBJECTIVES

Awareness of CKD remains low in comparison with other chronic diseases, such as diabetes, leading to low use of preventive medications and appropriate testing. The objective of this study was to evaluate the quality of care provided to people with and at risk of CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a population-based analysis of all Albertans with eGFR=15-59 ml/min per 1.73 m2 between April 1, 2011 and March 31, 2012 as well as patients with diabetes (as of March 31, 2012). We assessed multiple quality indicators in people with eGFR=15-59 ml/min per 1.73 m2, including appropriate risk stratification with albuminuria testing and preventive medication use and screened people with diabetes using urine albumin-to-creatinine ratio and serum creatinine measurements.

RESULTS

Among 96,480 adults with eGFR=15-59 ml/min per 1.73 m2, we found that 17.0% of those without diabetes were appropriately risk stratified with a measure of albuminuria compared with 64.2% of those with diabetes (P<0.001). Of those with eGFR=15-59 ml/min per 1.73 m2 and moderate or severe albuminuria, 63.2% of those without diabetes received an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker compared with 82.1% in those with diabetes (P<0.001). Statin use was also significantly lower in patients with eGFR=15-59 ml/min per 1.73 m2 without diabetes (39.2%) compared with those with diabetes (64.6%; P<0.001). Among 235,649 adults with diabetes, only 41.8% received a urine albumin-to-creatinine ratio and 73.2% received a serum creatinine measurement over 1 year.

CONCLUSIONS

We identified large gaps in care, especially in those with CKD but no diabetes. The largest gap was in the prescription of guideline-concordant medication in those with CKD as well as appropriate screening for albuminuria in those with diabetes. Our work illustrates the importance of measuring health system performance as the first step in a quality improvement process to improve care and outcomes in CKD.

Lost in Menopausal Transition: the Timing of Atherosclerosis Prevention in Women

Advanced atherosclerotic changes can often resist even to very aggressive treatment. Although basic mechanisms of its origin and development are known, some important steps in this process are still waiting for more detailed explanation. Therefore, in addition to already proved aggressive lowering of LDL cholesterol, appropriate timing of atherosclerosis treatment is of the essence. Revealing different stages of atherosclerotic process, less or more sensitive to treatment is of primary importance; however, its detection is complicated by several facts including not exactly identifiable periods of quiescence and progression of atherosclerotic process. One of populations, study of which could add valuable information regarding this problem, are women in menopausal transition. Previously unsuccessful therapy with hormone replacement therapy is restudied with focus on the time of/after menopause. Now, it is supposed to be favorable in women soon, approximately less than 8 years, after menopause. In addition, the same principle – optimal timing of the intervention of traditional cardiovascular risk factors, especially lipids, could be also of importance. Therefore, menopausal transition could be optimal period for the intervention in women at risk. However, this approach is to be proved by evidence from controlled prospective studies focused on lifestyle and/or pharmacological intervention.

Using pharmacists to improve risk stratification and management of stage 3A chronic kidney disease: a feasibility study

BACKGROUND

Measurement of albuminuria to stratify risk in chronic kidney disease (CKD) is not done universally in the primary care setting despite recommendation in KDIGO (Kidney Disease Improving Global Outcomes) guidelines. Pharmacist medication therapy management (MTM) may be helpful in improving CKD risk stratification and management.

METHODS

We conducted a pragmatic, cluster-randomized trial using seven primary care clinic sites in the Geisinger Health System to evaluate the feasibility of pharmacist MTM in patients with estimated glomerular filtration rate (eGFR) 45-59 ml/min/1.73 m² and uncontrolled blood pressure (≥150/85 mmHg). In the three pharmacist MTM sites, pharmacists were instructed to follow a protocol aimed to improve adherence to KDIGO guidelines on testing for proteinuria and lipids, and statin and blood pressure medical therapy. In the four control clinics, patients received usual care. The primary outcome was proteinuria screening over a follow-up of 1 year. A telephone survey was administered to physicians, pharmacists, and patients in the pharmacist MTM arm at the end of the trial.

RESULTS

Baseline characteristics were similar between pharmacist MTM (n = 24) and control (n = 23) patients, although pharmacist MTM patients tended to be younger (64 vs. 71 y; p = 0.06) and less likely to have diabetes (17 % vs. 35 %; p = 0.2) or baseline proteinuria screening (41.7 % vs. 60.9 %, p = 0.2). Mean eGFR was 54 ml/min/1.73 m² in both groups. The pharmacist MTM intervention did not significantly improve total proteinuria screening at the population level (OR 2.6, 95 % CI: 0.5-14.0; p = 0.3). However, it tended to increase screening of previously unscreened patients (78.6 % in the pharmacist MTM group compared to 33.3 % in the control group; OR 7.3, 95 % CI: 0.96-56.3; p = 0.05). In general, the intervention was well-received by patients, pharmacists, and providers, who agreed that pharmacists could play an important role in CKD management. A few patients contacted the research team to express anxiety about having a CKD diagnosis without prior knowledge.

CONCLUSIONS

Pharmacist MTM may be useful in improving risk stratification and management of CKD in the primary care setting, although implementation requires ongoing education and multidisciplinary collaboration and careful communication regarding CKD diagnosis. Future studies are needed to establish the effectiveness of pharmacist MTM on slowing CKD progression and improvement in cardiovascular outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02208674 Registered August 1, 2014, first patient enrolled September 30, 2014.

Arterial and Cellular Inflammation in Patients with CKD

CKD associates with a 1.5- to 3.5-fold increased risk for cardiovascular disease. Both diseases are characterized by increased inflammation, and in patients with CKD, elevated C-reactive protein level predicts cardiovascular risk. In addition to systemic inflammation, local arterial inflammation, driven by monocyte-derived macrophages, predicts future cardiovascular events in the general population. We hypothesized that subjects with CKD have increased arterial and cellular inflammation, reflected by ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography computed tomography (PET/CT) of the arterial wall and a migratory phenotype of monocytes. We assessed ¹⁸F-FDG uptake in the arterial wall in 14 patients with CKD (mean±SD age: 59±5 years, mean±SD eGFR: 37±12 ml/min per 1.73 m²) but without cardiovascular diseases, diabetes, or inflammatory conditions and in 14 control subjects (mean age: 60±11 years, mean eGFR: 86±16 ml/min per 1.73 m²). Compared with controls, patients with CKD showed increased arterial inflammation, quantified as target-to-background ratio (TBR) in the aorta (TBR_max: CKD, 3.14±0.70 versus control, 2.12±0.27; P=0.001) and the carotid arteries (TBR_max: CKD, 2.45±0.65 versus control, 1.66±0.27; P<0.001). Characterization of circulating monocytes using flow cytometry revealed increased chemokine receptor expression and enhanced transendothelial migration capacity in patients with CKD compared with controls. In conclusion, this increased arterial wall inflammation, observed in patients with CKD but without overt atherosclerotic disease and with few traditional risk factors, may contribute to the increased cardiovascular risk associated with CKD. The concomitant elevation of monocyte activity may provide novel therapeutic targets for attenuating this inflammation and thereby preventing CKD-associated cardiovascular disease.