Americans' use of dietary supplements that are potentially harmful in CKD

Renally Inappropriate Medications in the Old Population: Prevalence, Risk Factors, Adverse Outcomes, and Potential Interventions

Like most organs, the renal system decreases in function as we age. In the elderly, chronic kidney disease is common. When patients with chronic kidney disease take nephrotoxic medications, they are more likely to suffer adverse drug reactions, be hospitalized, and spend an extended period in the hospital. Calculating the renal clearance of a drug dose based on its glomerular filtration rate, or creatinine clearance, is necessary. Multiple tools are available for identifying renally inappropriate medications (RIMs). RIM prescriptions can be influenced by various factors, which vary according to the study. A higher number of medications means a higher likelihood of using RIMs. Numerous studies have investigated RIMs. The most contraindicated drug in renal insufficiency patients was a non-steroidal anti-inflammatory medication. A variety of interventions have been used to reduce RIM prescriptions to varying degrees of success.

Association between Consumption of Dietary Supplements and Chronic Kidney Disease Prevalence: Results of the Korean Nationwide Population-Based Survey

Despite the enormous global market of dietary supplements, the impact of dietary supplements on kidney disease is still unclear. Based on the National Health and Nutrition Examination Survey from 2015 to 2017, this study evaluated the association between dietary supplement and chronic kidney disease (CKD) in 13,271 Korean adults. Among the dietary supplements, vitamin and mineral intake was the highest at 61.41%, followed by omega-3 fatty acids at 11.85%, and ginseng at 7.99%. The prevalence of CKD was significantly higher in those who consumed amino acids and proteins, ginseng and red ginseng, and herbal medicine (plant extract)-berries than in those who did not. Conversely, patients who consumed probiotic supplements had a significantly lower prevalence of CKD than those who did not. In the population without CKD risk factors or history of CKD, the prevalence of CKD was high in the group consuming ginseng and red ginseng. After adjusting for covariates, the herbal medicine (plant extract)-berry group showed an independent association with CKD incidence. In conclusion, it is suggested that dietary supplements may affect kidney function. Further large-scale cohort studies are required to elucidate the exact effects of each dietary supplement on CKD.

Associations between dietary patterns and stages of chronic kidney disease

BACKGROUND

Studies have revealed that patients with chronic kidney disease (CKD) have dietary patterns different from those of the general population. However, no studies have compared the dietary patterns of between patients with early-stages (stages 1-3a) and late-stages (stages 3b-5) of CKD. Our objective was to investigate the associations between dietary patterns in early and late-stage CKD.

METHODS

We analyzed 4480 participants with CKD at various stages based on the data recorded between 2007 and 2016 from the database of the American National Health and Nutrition Examination Survey.

RESULTS

In total, 3683 and 797 participants had early and late-stage CKD, respectively. Through principal components analysis, the dietary intake dimension was reduced from 63 variables to 3 dietary patterns. We adopted logistic regression for analysis. The three dietary patterns are as follows: (1) saturated fatty acids and mono-unsaturated fatty acids (MUFA); (2) vitamins and minerals; and (3) cholesterols and polyunsaturated fatty acids (PUFA). These 3 patterns explained > 50% of dietary nutrient intake. Results indicated that among participants with dietary patterns 2 (vitamins and minerals) and 3 (cholesterols and PUFA), those with low intakes were more likely to have late-stage CKD. The odds ratios for patterns 2 and 3 were 1.74 (95% CI: 1.21-2.50) and 1.66 (95% CI: 1.13-2.43), respectively.

CONCLUSIONS

This study revealed that intakes of vitamins and minerals and cholesterols and PUFA were associated with the stages of CKD.

Japanese newspaper advertisements for dietary supplements before and after COVID-19: a content analysis

OBJECTIVES

Public health institutions have alerted consumers about advertising for dietary supplements with false claims of preventing or treating COVID-19. We quantitatively and qualitatively examined newspaper advertisements for dietary supplements before and after the COVID-19 spread.

DESIGN

Content analysis.

PARTICIPANTS

We analysed advertisements for dietary supplements in two major Japanese newspapers in February-July 2019 and February-July 2020. Our analysis covered 2167 advertisements.

RESULTS

The number of advertisements for dietary supplements that claimed to be effective in infection prevention (p=0.009) and improving joint (p=0.002) and digestive functions (p=0.002) significantly increased after the spread of COVID-19 compared with before. Dietary supplements that claimed to be effective in preventing infection were advertised in combination with recommendations for gargling and handwashing. Such terms as 'defence' and 'prevent' were used to promote the preventive effect.

CONCLUSIONS

False and misleading claims in advertising for dietary supplements may result in consumer harm, such as overdosing and failure to take preventive behaviour. While the pandemic continues, there will be an increasing need for disseminating accessible information about the appropriate use of dietary supplements, consumer education and warnings to manufacturers.

A Content Analysis of Video Advertisements for Dietary Supplements in Japan

Dietary supplements are widely advertised and the market is expanding worldwide. Research suggests that dietary supplement advertising may lead consumers to make inappropriate health-related decisions, to express behaviors such as overdosing, and to neglect healthy lifestyle behaviors. We conducted a content analysis of video advertisements for dietary supplements and described the content of advertisements with high numbers and frequent views. We analyzed 82 video advertisements on YouTube that promoted fat-reduction effects. We extracted 22 themes and classified them into 10 categories. The categories with the highest numbers of advertisements were “Exemption” (i.e., consuming the product frees the audience from refraining from binge eating) (20 ads, 24.4%) and “Health Concerns” (i.e., the product intake solves the health concerns of the audience) (19 ads, 23.2%). These advertisements may stimulate negative audience attitudes toward appropriate health behaviors. The category with the most frequent views was “Lifestyle” (i.e., adding product intake to a healthy lifestyle) (3,035,298 views). “Lifestyle” advertisements portray physical activity in a positive light and may promote appropriate health behaviors in the audience. We discuss the possible effects of the advertisements on audiences and consider issues for future research and practice.

Caffeine consumption and mortality in chronic kidney disease: a nationally representative analysis

BACKGROUND

An inverse relationship between coffee consumption and mortality has been reported in the general population. However, the association between caffeine consumption and mortality in patients with chronic kidney disease (CKD) remains uncertain.

METHODS

We analysed 4863 non-institutionalized USA adults with CKD [defined by an estimated glomerular filtration rate (eGFR) of 15-60 mL/min/1.73 m2 and/or a urinary albumin:creatinine ratio >30 mg/g] in a nationwide study using the National Health and Nutrition Examination Survey (NHANES) 1999-2010. Caffeine consumption was evaluated by 24-h dietary recalls at baseline and all-cause, cardiovascular and cancer mortality were evaluated until 31 December 2011. We also performed an analysis of caffeine consumption according to its source (coffee, tea and soft drinks). Quartiles of caffeine consumption were <28.2 mg/day (Q1), 28.2-103.0 (Q2), 103.01-213.5 (Q3) and >213.5 (Q4).

RESULTS

During a median follow-up of 60 months, 1283 participants died. Comparing with Q1 of caffeine consumption, the adjusted hazard ratio for all-cause mortality was 0.74 [95% confidence interval (CI) 0.60-0.91] for Q2, 0.74 (95% CI 0.62-0.89) for Q3 and 0.78 (95% CI 0.62-0.98) for Q4 (P = 0.02 for trend across quartiles). There were no significant interactions between caffeine consumption quartiles and CKD stages or urinary albumin:creatinine ratio categories regarding all-cause mortality.

CONCLUSIONS

We detected an inverse association between caffeine consumption and all-cause mortality among participants with CKD.

Herbal Nephropathy

This column is supplied by Amita Jain, MD, and Juan Jose Olivero, MD. Dr. Jain completed an internal medicine residency at Houston Methodist Hospital in Houston, Texas, and recently joined a primary care practice in Delaware. She earned a Bachelor of Medicine and Surgery (MBBS) degree, with a distinction in microbiology, from Terna Medical College at the Maharashtra University of Health Sciences in Navi Mumbai, India. Before coming to Houston, Dr. Jain completed residency training in internal medicine and allied subspecialties at the Dr. Babasaheb Ambedkar Memorial Hospital in Byculla, Mumbai. Dr. Olivero is a nephrologist at Houston Methodist Hospital and a member of the hospital's Nephrology Training Program. He obtained his medical degree from the University of San Carlos School of Medicine in Guatemala, Central America, and completed his residency and nephrology fellowship at Baylor College of Medicine in Houston, Texas.

Factors Related to Disclosure and Nondisclosure of Dietary Supplements in Primary Care, Integrative Medicine, and Naturopathic Medicine

Background:

Patients infrequently disclose use of dietary supplements to providers. Little is known about factors that motivate patients to disclose supplement use. The study aimed to identify reported factors motivating patients’ disclosure and nondisclosure of dietary supplement use and explore differences based on type of supplement and provider practice.

Methods:

Mixed methods study combining qualitative content analysis of semi-structured interviews with statistical analyses to assess differences in identified factors by provider practice type and supplement type. Seventy-eight English-speaking patients who reported taking 466 dietary supplements in the previous 30 days were recruited from primary care and Complementary and Alternative Medicine (CAM), and Integrative Medicine (IM) offices in Southern California.

Results:

We identified nine themes related to disclosure and nine related to nondisclosure of dietary supplement use. Major themes were features of the office visit, circumstances in patient health and medical care, and provider/patient characteristics. The most commonly raised theme promoting disclosure of supplement use was provider inquiry. Patients associate disclosure with having concerns about a supplement but also with annual physical exams and some routine topics of discussion, including self-care, lab results, and new medication prescriptions. Themes related to nondisclosure included lack of provider inquiry, features of the office visit, such as supplements being unrelated to the visit purpose, and patients’ convictions that supplements are safe or not important to discuss. Themes did not vary by supplement type. Primary care patients were more likely than CAM/IM patients to attribute nondisclosure to convictions that supplements were beneficial, not worth mentioning, or equivalent to food (p ≤ 0.001).

Conclusions:

When providers fail to ask directly about dietary supplement use, disclosure is often an impromptu decision that is driven by the content of provider-patient interactions. Ensuring disclosure of dietary supplement use to prevent potential drug-supplement interactions or adverse health outcomes likely requires consistent, proactive provider queries about supplement use.

CKD Awareness in the General Population: Performance of CKD-Specific Questions

Rationale & Objective

Data from patients in one delivery system have suggested that the prevalence of chronic kidney disease (CKD) awareness differs by how the question is asked. We examined the sensitivity and specificity of different CKD awareness questions among diverse community-dwelling adults who were not necessarily engaged in primary care to determine the generalizability of prior results.

Study Design

Cross-sectional study.

Setting & Participants

Participants in the Healthy Aging in Neighborhoods of Diversity Across the Life Span (HANDLS) Study.

Predictor

CKD awareness, ascertained using 5 different questions.

Outcome

Sensitivity and specificity of each awareness question, using laboratory results as the gold standard.

Analytic Approach

Logistic regression was used to compare sensitivities of different awareness questions.

Results

Among 2,046 participants, mean (SD) age was 56.5 (9.1) years, 41.5% were men, and 61.3% were African American. More than 40% were poor, 35% reported not having health insurance, and 16.9% had low health literacy. More than 20% (n = 424) had CKD. Sensitivities of single CKD awareness questions ranged from 2.2% for “kidney damage” to 5.2% for “kidney problem.” Sensitivity of the compound question asking about “weak kidneys, failing kidneys, or kidney disease” was 19.5%. Sensitivity of this compound CKD awareness question was higher among study participants with more advanced CKD and low health literacy, and those who lived below the poverty level.

Limitations

Single measures of estimated glomerular filtration rate and albuminuria; study participants may have been more engaged in their health care than the average US adult, potentially limiting the generalizability of results.

Conclusions

CKD awareness is low among community-dwelling adults with kidney disease, though data using a sensitive compound question ascertaining awareness suggest that we have met the Healthy People 2020 goal related to CKD awareness of 13.4%. Understanding the phrases about kidney disease that are most understandable to patients with and at risk for CKD is important to further increase CKD awareness.

Dietary Habits and Risk of Kidney Function Decline in an Urban Population

OBJECTIVE

Explore the association between following a Dietary Approaches to Stop Hypertension (DASH)-accordant diet and kidney end points among urban adults.

DESIGN

Prospective cohort study.

SETTING

Healthy Aging in Neighborhoods of Diversity across the Life Span study.

SUBJECTS

A total of 1,534 urban dwelling participants of the Healthy Aging in Neighborhoods of Diversity across the Life Span study with a baseline estimated glomerular filtration rate (eGFR) ≥60 mL/minute/1.73 m².

INTERVENTION

DASH diet accordance determined via a score based on nine target nutrients.

MAIN OUTCOME MEASURE

Rapid kidney function decline (eGFR decline >3 mL/minute/1.73 m² per year), incident chronic kidney disease (CKD) (follow-up eGFR <60 mL/minute/1.73 m²), and eGFR decline >25%.

RESULTS

Participants' mean age was 48 years, and 59% were African-American. Median DASH score was 1.5 (range, 0-8). Over a median of 5 years, 13.4% experienced rapid eGFR decline, including 15.2% among participants not following a DASH-accordant diet (score ≤1) and 12.0% with higher accordance (score >1) (P = .08). Outcomes varied by hypertension status. In multinomial logistic regression models, following adjustment for sociodemographic and clinical factors, including total energy intake, low DASH diet accordance was associated with rapid eGFR decline among participants with hypertension (risk ratio, 1.68; 95% confidence interval: 1.17-2.42) but not among those without hypertension (risk ratio, 0.83; 95% confidence interval: 0.56-1.24; P interaction .001). There was no statistically significant association between DASH diet accordance and incident CKD or eGFR decline >25%. Results were similar when DASH diet accordance was analyzed in tertiles.

CONCLUSIONS

Among urban adults, low accordance to a DASH-type diet was not associated with incident CKD, but was associated with higher risk of rapid eGFR decline among those with hypertension, yet not among those without hypertension. Further study of dietary patterns as a potential target for improving kidney outcomes among high-risk populations is warranted.

Risk of interactions between complementary and alternative medicine and medication for comorbidities in patients with melanoma

Complementary and alternative medicine (CAM) is used widely among cancer patients. Beside the risk of interaction with cancer therapies, interactions with treatment for comorbidities are an underestimated problem. The aim of this study was to assess prevalence of interactions between CAM and drugs for comorbidities from a large CAM usage survey on melanoma patients and to classify herb-drug interactions with regard to their potential to harm. Consecutive melanoma outpatients of seven skin cancer centers were asked to complete a standardized CAM questionnaire including questions to their CAM use and their taken medication for comorbidities and cancer. Each combination of conventional drugs and complementary substances was evaluated for their potential of interaction. 1089 questionnaires were eligible for evaluation. From these, 61.6% of patients reported taking drugs regularly from which 34.4% used biological-based CAM methods. Risk evaluation for interaction was possible for 180 CAM users who listed the names or substances they took for comorbidities. From those patients, we found 37.2% at risk of interaction of their co-consumption of conventional and complementary drugs. Almost all patients using Chinese herbs were at risk (88.6%). With a high rate of CAM usage at risk of interactions between CAM drugs and drugs taken for comorbidities, implementation of a regular assessment of CAM usage and drugs for comorbidities is mandatory in cancer care.

Association of herbal and dietary supplements with progression and complications of chronic kidney disease: A prospective cohort study

AIM

To determine associations between herbal and dietary supplement (HDS) use and the progression of chronic kidney disease (CKD), and associations of HDS with uncontrolled hyperphosphataemia in patients with CKD.

METHOD

The cohort study recruited 406 Thai outpatients with stage 3-5 CKD from two kidney clinics of which 357 were followed up over 12 months. Patients receiving renal replacement therapy prior to recruitment were excluded. Participants were interviewed regarding their HDS use, dietary intake and conventional medication adherence using a questionnaire. The primary outcome was a composite of a decline of at least 5 mL/min per 1.73 m² per year of estimated glomerular filtration rate and end stage renal disease. Serum creatinine, serum levels of potassium and phosphate were extracted from their medical notes over the 12 months. χ² tests and multiple logistic regression analyses were performed to ascertain any associations.

RESULTS

Despite no association between HDS and the progression of CKD over a one-year period (adjusted odds ratio (OR) 1.16, 95% confidence interval (CI) 0.66-2.03), two patients had acute kidney injury, which may be related to an unknown Chinese herbal medicine, or river spiderwort combined with diclofenac reported in the medical notes. The use of HDS was associated with uncontrolled hyperphosphataemia (adjusted OR 3.53, 95%CI 1.20-10.43).

CONCLUSIONS

The findings suggest that HDS are likely to be related to acute kidney injury rather than the progression of CKD in Thai patients with CKD. The products were associated with uncontrolled hyperphosphataemia. Patients who have CKD and use HDS should be closely monitored regarding their kidney function and electrolytes.

CKD as a Model for Improving Chronic Disease Care through Electronic Health Records

Electronic health records have the potential to improve the care of patients with chronic medical conditions. CKD provides a unique opportunity to show this potential: the disease is common in the United States, there is significant room to improve CKD detection and management, CKD and its related conditions are defined primarily by objective laboratory data, CKD care requires collaboration by a diverse team of health care professionals, and improved access to CKD-related data would enable identification of a group of patients at high risk for multiple adverse outcomes. However, to realize the potential for improvement in CKD-related care, electronic health records will need to provide optimal functionality for providers and patients and interoperability across multiple health care settings. The goal of the National Kidney Disease Education Program Health Information Technology Working Group is to enable and support the widespread interoperability of data related to kidney health among health care software applications to optimize CKD detection and management. Over the course of the last 2 years, group members met to identify general strategies for using electronic health records to improve care for patients with CKD. This paper discusses these strategies and provides general goals for appropriate incorporation of CKD-related data into electronic health records and corresponding design features that may facilitate (1) optimal care of individual patients with CKD through improved access to clinical information and decision support, (2) clinical quality improvement through enhanced population management capabilities, (3) CKD surveillance to improve public health through wider availability of population-level CKD data, and (4) research to improve CKD management practices through efficiencies in study recruitment and data collection. Although these strategies may be most effectively applied in the setting of CKD, because it is primarily defined by laboratory abnormalities and therefore, an ideal computable electronic health record phenotype, they may also apply to other chronic diseases.

Too little, too late: ineffective regulation of dietary supplements in the United States

Millions of people in the United States consume dietary supplements hoping to maintain or improve their health; however, extensive research has failed to demonstrate the efficacy of numerous supplements in disease prevention. In addition, concerns about the safety of routine and high-dose supplementation have been raised. The Food and Drug Administration regulates dietary supplement quality, safety, and labeling, and the Federal Trade Commission monitors advertisements and marketing; still, vast enforcement challenges remain, and optimal governmental oversight has not been achieved. If the composition and quality of ingredients cannot be reliably ensured, the validity of research on dietary supplements is questionable. Moreover, the health of the US public is put at risk.

Survey of dietary and medication practices of owners of cats with chronic kidney disease

The objective of this study was to describe the dietary and medication patterns of cats with chronic kidney disease (CKD). In this prospective, cross-sectional descriptive study, owners of cats with CKD were asked to complete a web-based survey. The study was advertised on CKD-, pet-, veterinary- and breed-associated websites and list serves. Owners of 1089 cats with CKD participated in the study. The mean reported age of the cats with CKD was 13.7 ± 4.2 years. Forty percent (430/1089) of cats had concurrent diseases, with hyperthyroidism, heart disease and inflammatory bowel disease being the most common. Veterinarian recommendation was the most common reason reported (684/1032; 66%) for diet selection, and 51% (556/1089) of owners fed a veterinary therapeutic diet formulated for kidney disease as some component of the diet. Many owners (466/1079; 43%) reported that their cats had an abnormal appetite; of these owners, 52% responded that their cats had a poor appetite or required coaxing to eat 5–7 days per week. Forty-seven percent and 51% of cats were receiving subcutaneous fluids and oral medications, respectively; however, most cats (811/1036; 78%) were not receiving phosphorus-binding medications. Fifty-six percent and 38% of cats received commercial cat treats and dietary supplements, respectively. Anorexia or hyporexia is a common problem in cats with CKD and may lead to cats being fed suboptimal diets for their disease. This information may be useful for treating or designing nutritional studies for cats with CKD.

Internet claims on dietary and herbal supplements in advanced nephropathy: truth or myth

BACKGROUND

The use of complementary/alternative medicine has garnered rising interest in recent years. Natural products including herbs, vitamins, and minerals are the most popularly consumed. The Internet is a ubiquitous source of information/market for these supplements.

AIM

To systematically evaluate the dietary and herbal supplement recommended for patients with CKD and ESRD on the Internet, and try to distinguish between the claim of the manufacturer and proven scientific data.

METHODS

A questionnaire assessing each website was formulated. Each product ingredient was recorded in the questionnaire by two independent reviewers and statistically analyzed.

RESULTS

Of the 184 websites, 28% claimed to decrease CKD progression, 60% did not advise to consult a doctor before taking the supplement, and >90% did not mention any potential drug interaction, disease interaction, or caution in use during pregnancy or in children. The ten common plant ingredients claiming to be beneficial in kidney diseases were uva ursi, dandelion, parsley, corn silk, juniper, celery, buchu, horsetail, marshmallow, and stinging nettle. In contrast to their claims, these substances were not adequately studied in humans. The available animal studies showed detrimental effects and potential drug interactions with commonly used medications in the CKD/ESRD population.

CONCLUSIONS

Nephrologists need to be cognizant of the lack of substantiated proven benefits of these substances and of the potential adverse effects in the animal models that can translate to the patients. Most importantly, the policy needs to change regarding the regulation of these products to prevent patient harm and misinformation.

Dietary habits, poverty, and chronic kidney disease in an urban population

BACKGROUND

Poverty is associated with chronic kidney disease (CKD) in the United States and worldwide. Poor dietary habits may contribute to this disparity.

STUDY DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

A total of 2,058 community-dwelling adults aged 30 to 64 years residing in Baltimore City, Maryland.

PREDICTORS

Adherence to the Dietary Approaches to Stop Hypertension (DASH) diet. DASH scoring based on 9 target nutrients (total fat, saturated fat, protein, fiber, cholesterol, calcium, magnesium, sodium, and potassium); adherence defined as score ≥4.5 of maximum possible score of 9. Poverty (self-reported household income <125% of 2004 Department of Health and Human Services guideline) and nonpoverty (≥125% of guideline).

OUTCOMES AND MEASUREMENTS

CKD defined as estimated glomerular filtration rate <60 mL/minute/1.73 m(2) (CKD epidemiology collaboration equation). Multivariable logistic regression was used to calculate adjusted odds ratios (AORs) for relation of DASH score tertile and CKD, stratified by poverty status.

RESULTS

Among 2,058 participants (mean age 48 years; 57% black; 44% male; 42% with poverty), median DASH score was low, 1.5 (interquartile range, 1-2.5). Only 5.4% were adherent. Poverty, male sex, black race, and smoking were more prevalent among the lower DASH score tertiles, whereas higher education and regular health care were more prevalent among the highest DASH score tertile (P < .05 for all). Fiber, calcium, magnesium, and potassium intake were lower, and cholesterol higher, among the poverty compared with nonpoverty group (P < .05 for all), with no difference in sodium intake. A total of 5.6% of the poverty and 3.8% of the nonpoverty group had CKD (P = .05). The lowest DASH tertile (compared with the highest) was associated with more CKD among the poverty (AOR 3.15, 95% confidence interval 1.51-6.56), but not among the nonpoverty group (AOR 0.73, 95% confidence interval 0.37-1.43; P interaction = .001).

CONCLUSIONS

Poor dietary habits are strongly associated with CKD among the urban poor and may represent a target for interventions aimed at reducing disparities in CKD.