Prevalence of Chronic Kidney Disease, Thrombotic Cardiovascular Events, and Use of Oral P2Y12 Inhibitors among Veterans

Assessing the Relationship Between Sleep Duration and the Prevalence of Chronic Kidney Disease Among Veterans in the United States: A 2022 Behavior Risk Factor Surveillance System (BRFSS) Cross-Sectional Study

INTRODUCTION

Chronic kidney disease (CKD) is more prevalent among veterans in the United States than in the general population. Similarly, veterans also exhibit higher rates of abnormal sleep duration compared to the general population. The aim of this study was to investigate the association between self-reported length of sleep and the prevalence of CKD among veterans in the United States using responses from the 2022 Behavioral Risk Factor Surveillance System (BRFSS).

METHODS

For this cross-sectional study, a total of 53,211 veterans who responded to the 2022 BRFSS survey were analyzed. Measures include the outcome variable which is self-reported CKD diagnosis and a major independent variable sleep duration. Sleep duration was recategorized into ≤ 5 hours (short sleep duration), 6-10 hours (normal sleep duration), and >10 hours (long sleep duration). Covariates included gender, age, race, residence, insurance, alcohol consumption, diabetes comorbidity, coronary artery disease (CAD) comorbidity, and stroke comorbidity. Descriptive, bivariate, and multivariate logistic regressions were conducted using the SAS software (SAS Institute Inc., Cary, North Carolina, United States).  Results: The prevalence of CKD among veterans in the United States is 3332 (6.29%). Veterans with sleep duration of 6-10 hours had 17.5% lower odds of CKD than veterans who slept for ≤5 hours (adjusted OR (AOR)= 0.825, 95%CI= 0.821-0.830; P=<0.0001). Veterans who slept for more than 10 hours had 68.2% higher odds of having CKD (AOR=1.682, 95%CI= 1.662-1.702; P=<0.0001). Additionally, veterans diagnosed with diabetes, stroke, and coronary artery disease had 2.447-2.103, and 2.838, respectively, higher odds of developing CKD (AOR=2.447, 95%CI= 2.435-2.459; p=<0.0001). Veterans who were 65 years and older had higher odds of developing CKD compared to those aged 35-44 years (AOR= 5.743, 95%CI= 5.669-5.818; P<0.001). The odds of having CKD were also higher among veterans who identified as Black (AOR 1.397, 95%CI =1.388-1.405; P<0.01) or as Hispanic (AOR =1.318, 95%CI = 1.307-1.329; P<0.01) compared to non-Hispanic White veterans. Those who identified as Asian had lower odds of CKD (AOR= 0.87, 95%CI=0.853-0.888; P<0.01). Furthermore, veterans who consumed alcohol had 7.8% lower odds of having CKD as compared to individuals who did not consume alcohol (AOR= 0.922, 95%CI =0.918-0.927; p=<0.0001). Male veterans had 24.7% lower odds of having CKD as compared to female veterans (AOR = 0.753, 95%CI= 0.747-0.758; P<0.001).  Conclusion: This research provides evidence of a greater prevalence of CKD among veterans with short sleep duration (≤ 5 hours) and long sleep duration (> 10 hours). Sleep hygiene education and sleep optimization programs can improve sleep and boost overall kidney health among veterans.

P2Y12 Inhibitors Refill Gap Predicts Death in Medicare Beneficiaries on Chronic Dialysis

Introduction

Oral P2Y12 inhibitors (P2Y12-I) are commonly used antiplatelet drugs in patients with end-stage kidney disease (ESKD) on chronic dialysis. Although gaps in prescription refills are quite common in patients with ESKD, it remains unclear whether P2Y12-I prescription refill patterns are associated with adverse clinical outcomes.

Methods

We used the United States Renal Data System (USRDS) registry for patients with ESKD to capture new P2Y12-I prescriptions from 2011 to 2015. The primary exposure was prescription refill patterns and the primary outcome was all-cause death.

Results

Among the 31,243 patients with new P2Y12-I prescription, median age was 64 years; 54% were male; and 39% were Caucasian, 37% African American, and 18% Hispanic. We observed 3 P2Y12-I refill patterns as follows: continuous users (45.1%), noncontinuous users (3.6%), and users with ≥30 days refill gap (51.4%). Prescription refill pattern with ≥30 days refill gap (vs. continuous use) was associated with all-cause death (adjusted hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.13-1.23). Age and race were the most important risk factors associated with prescription refill pattern. African Americans (vs. Caucasians) were more likely to demonstrate ≥30 days refill gap, (adjusted odds ratio [OR]: 1.43; 95% CI: 1.36-1.51). In addition, younger patients (vs. older) were more likely to demonstrate ≥30 day refill gap (adjusted OR/decade: 0.9; 95% CI: 0.89-0.92).

Conclusion

Nonadherence to P2Y12-I prescriptions is quite common, and disproportionately affects minorities. Younger individuals with ESKD are independently associated with a higher risk of death. The odds of having a refill gap are decreasing for older patients who are more compliant than younger patients. Future studies should investigate whether phenotyping subgroups of patients with ESKD based on prescription refill patterns can help in improving adverse clinical outcomes.

The Effect of Family-Centered and Peer-Centered Education on the Sleep Quality of Hemodialysis Patients: A Randomized Clinical Trial

Introduction

Sleep disorders in hemodialysis patients are of high prevalence affecting the lives of these patients.

Objective

The present study was conducted to investigate the effect of family-centered and peer-centered education on the sleep quality of hemodialysis patients.

Methods

In this controlled clinical trial, 90 patients were randomly assigned to three groups (control, family-centered, and peer-centered). All three groups completed Pittsburgh Sleep Quality Index before the intervention. The intervention included five training sessions conducted by the researcher according to the patients' needs to improve their sleep quality. Routine ward interventions were performed for the control group. At the end of the study, the Pittsburgh Sleep Quality Index was completed by all three groups once again. Data were collected and analyzed using SPSS version 24 software and statistical tests.

Results

No significant difference was found between the two intervention and control groups regarding demographic variables and variables related to sleep quality before the intervention (p < .05). However, based on the results of the Wilcoxon test, there was a statistically significant difference between the mean rank of sleep quality in the intervention and control groups after the intervention (p-value = .008), indicating that sleep hygiene education was effective in the two intervention groups.

Conclusion

According to the findings, the mean rank of sleep quality in the two intervention groups was significant after the training, indicating the effectiveness of family-centered and peer-centered education. Accordingly, medical healthcare managers, policymakers, and planners, including nurses, are recommended to employ these convenient, safe, and cost-free training methods and provide better sleep quality and more comfort to patients by spending a short period of time for training.

Trends in Illness Severity, Hospitalization, and Mortality for Community-Onset Pneumonia at 118 US Veterans Affairs Medical Centers

BACKGROUND

Deaths from pneumonia were decreasing globally prior to the COVID-19 pandemic, but it is unclear whether this was due to changes in patient populations, illness severity, diagnosis, hospitalization thresholds, or treatment. Using clinical data from the electronic health record among a national cohort of patients initially diagnosed with pneumonia, we examined temporal trends in severity of illness, hospitalization, and short- and long-term deaths.

DESIGN

Retrospective cohort PARTICIPANTS: All patients >18 years presenting to emergency departments (EDs) at 118 VA Medical Centers between 1/1/2006 and 12/31/2016 with an initial clinical diagnosis of pneumonia and confirmed by chest imaging report.

EXPOSURES

Year of encounter.

MAIN MEASURES

Hospitalization and 30-day and 90-day mortality. Illness severity was defined as the probability of each outcome predicted by machine learning predictive models using age, sex, comorbidities, vital signs, and laboratory data from encounters during years 2006-2007, and similar models trained on encounters from years 2015 to 2016. We estimated the changes in hospitalizations and 30-day and 90-day mortality between the first and the last 2 years of the study period accounted for by illness severity using time covariate decompositions with model estimates.

RESULTS

Among 196,899 encounters across the study period, hospitalization decreased from 71 to 63%, 30-day mortality 10 to 7%, 90-day mortality 16 to 12%, and 1-year mortality 29 to 24%. Comorbidity risk increased, but illness severity decreased. Decreases in illness severity accounted for 21-31% of the decrease in hospitalizations, and 45-47%, 32-24%, and 17-19% of the decrease in 30-day, 90-day, and 1-year mortality. Findings were similar among underrepresented patients and those with only hospital discharge diagnosis codes.

CONCLUSIONS

Outcomes for community-onset pneumonia have improved across the VA healthcare system after accounting for illness severity, despite an increase in cases and comorbidity burden.

Total coumarin derivates from Hydrangea paniculata attenuate renal injuries in cationized-BSA induced membranous nephropathy by inhibiting complement activation and interleukin 10-mediated interstitial fibrosis

BACKGROUND

Total coumarins extracted from Hydrangea. Paniculata, Sieb (HP) have showed renal protective effect in several experimental acute and chronic kidney diseases.

PURPOSE

The aim of current study is to evaluate renal protective effect of HP against cationized-BSA (c-BSA) induced experimental membranous nephritis (MN), and further investigate its underlying mechanisms.

METHODS

Rat MN model was established by intravenous injection of 5 mg c-BSA for consecutive 14 days, and after albuminuria confirmed, HP was orally administrated with 7.5, 15, 30 mg/kg for nine weeks. The renal function was measured and histopathological injuries were observed. RNA sequencing was used to analyze the altered signaling pathways in kidneys. Pharmacokinetics was performed to investigate the pharmacodynamics of major ingredients in HP and possible metabolites. Discover X platform helped to clarify the possible molecular mechanisms of major compound in HP.

RESULTS

HP administration could significantly improve the renal function, and ameliorate the dyslipidemia and histopathological injuries. mRNA sequencing demonstrated that HP had anti-inflammation and anti-fibrosis effects possible through down-regulating the complement activation and PI3K-AKT pathways. Pharmacokinetics demonstrated that skimmin and 7-hydoxycoumarin (7-HC) were major compound or metabolite in plasma after oral administration. Based on Discover X platform, we confirmed that skimmin and 7-HC inhibited the   IL10 production by inflammatory macrophages through blocking PI3K-AKT and NFκB signaling pathways. Finally, we demonstrated that HP protected tubulointerstitium from complement attack by reducing the C3 self-production and auto-cleavage in tubular cells.

CONCLUSIONS

HP has a renal protective effect, and its drug development may provide one alternative strategy to treat immune-mediated nephropathy.

Accurate Medication Adherence Measurement Using Administrative Data for Frequently Hospitalized Patients

Background: Pharmacy administrative claims data remain an accessible and efficient source to measure medication adherence for frequently hospitalized patient populations that are systematically excluded from the landmark drug trials. Published pharmacotherapy studies use medication possession ratio (MPR) and proportion of days covered (PDC) to calculate medication adherence and usually fail to incorporate hospitalization and prescription overlap/gap from claims data. To make the cacophony of adherence measures clearer, this study created a refined hospital-adjusted algorithm to capture pharmacotherapy adherence among patients with end-stage renal disease (ESRD). Methods: The United States Renal Data System (USRDS) registry of ESRD was used to determine prescription-filling patterns of those receiving new prescriptions for oral P2Y12 inhibitors (P2Y12-I) between 2011 and 2015. P2Y12-I-naïve patients were followed until death, kidney transplantation, discontinuing medications, or loss to follow-up. After flagging/censoring key variables, the algorithm adjusted for hospital length of stay (LOS) and medication overlap. Hospital-adjusted medication adherence (HA-PDC) was calculated and compared with traditional MPR and PDC methods. Analyses were performed with SAS software. Results: Hospitalization occurred for 78% of the cohort (N = 46 514). The median LOS was 12 (interquartile range [IQR] = 2-34) days. MPR and PDC were 61% (IQR = 29%-94%) and 59% (IQR = 31%-93%), respectively. After applying adjustments for overlapping coverage days and hospital stays independently, HA-PDC adherence values changed in 41% and 52.7% of the cohort, respectively. When adjustments for overlap and hospital stay were made concurrently, HA-PDC adherence values changed in 68% of the cohort by 5.8% (HA-PDC median = 0.68, IQR = 0.31-0.93). HA-PDC declined over time (3M-6M-9M-12M). Nearly 48% of the cohort had a ≥30 days refill gap in the first 3 months, and this increased over time (P < .0001). Conclusions: Refill gaps should be investigated carefully to capture accurate pharmacotherapy adherence. HA-PDC measures increased adherence substantially when adjustments for hospital stay and medication refill overlaps are made. Furthermore, if hospitalizations were ignored for medications that are included in Medicare quality measures, such as Medicare STAR program, the apparent reduction in adherence might be associated with lower quality and health plan reimbursement.

Trends for and Clinical Factors Associated with Choice of Oral P2Y12 Inhibitors for Patients on Chronic Dialysis

Background

Trends and clinical factors associated with prescribing choices for oral P2Y12 inhibitors (P2Y12-I) remain unknown for patients on chronic dialysis, i.e., with end-stage renal disease (ESRD).

Methods

From 2011–2014 U.S. Renal Data System registry, we identified 36,542 ESRD patients who received new prescriptions for P2Y12-I (median age 64.0 years and 54% males). Of the cohort, 93% were receiving hemodialysis and 7% on peritoneal dialysis. We analyzed trends and investigated clinical factors associated with specific P2Y12-I prescribed.

Results

Clopidogrel was prescribed for 95%, prasugrel for 3%, and ticagrelor for 2%. Clopidogrel was favored for those ≥75 years (18% of cohort). Compared to Caucasians, African Americans (36% of cohort) and Hispanics (19% of cohort) were less likely to receive prasugrel and ticagrelor (P<0.05). Patients receiving hemodialysis versus peritoneal dialysis were less likely to receive prasugrel over clopidogrel, adjusted odds ratio (aOR) 0.67 (0.55-0.82). Each additional year of dialysis decreased the odds of receiving prasugrel over clopidogrel, aOR 0.91 (0.85-0.98). History of atrial fibrillation reduced the odds of receiving ticagrelor or prasugrel over clopidogrel, aOR 0.69 (0.54-0.89) and 0.73 (0.60-0.89), respectively. Concomitant oral anticoagulant use was not associated with choice of P2Y12-I. Occurrence of non-ST segment elevation myocardial infarction or percutaneous coronary intervention within the 6-month period prior to the index date favored ticagrelor over prasugrel, aOR 1.31 (1.06-1.62) and 1.29 (1.01-1.66), respectively. However, prescribing trends favoring ticagrelor over prasugrel were not observed for deployment of drug-eluting, or multiple coronary stents.

Conclusion

Between 2011 and 2014, clopidogrel remained the most common P2Y12-I whereas ticagrelor and prasugrel remained underutilized in ESRD patients. Prescribing practices for these drugs were based upon clinically approved indication for their use in the general population as well as perceived complexity of an ESRD patient including demographics, dialysis-related factors and comorbidities. Comparative effectiveness studies involving ESRD patients are needed to prove that ticagrelor and prasugrel are just as safe and effective as clopidogrel before clinicians can make informed decisions for choice of P2Y12-I in this patient population.

Electronic supplementary material

The online version of this article (10.1007/s10557-019-06913-w) contains supplementary material, which is available to authorized users.

Home run-results of a chronic kidney disease Telemedicine Patient Education Study

Background

Chronic kidney disease (CKD) incidence is increasing and associated mortality and morbidity are high. Educating patients is effective in delaying progression and establishing optimal renal replacement therapy (RRT). Tele-education/telemedicine (TM) can be an effective tool to provide such education, but there are no available data quantifying its effectiveness. We attempted to establish such evidence correlating the effect of education in patient choices and with the start of actual RRT. We present results from a 3-year pilot study evaluating the effectiveness of comprehensive predialysis education (CPE) through TM for CKD patients compared with a standard care group [face to face (FTF)]. The patient’s ability to choose RRT was the primary endpoint.

Methods

This was a randomized controlled study providing CPE over three classes at nine sites (one FTF and eight TM). Three assessment tools were utilized to compare groups: CKD knowledge, literacy and quality of life.

Results

A total of 47.1% of FTF and 52.2% of TM patients reported not having enough information to choose a modality. This decreased by the third visit (FTF 7.4%, TM 13.2%). Home modality choices more than doubled in both groups (FTF 25.8–67.7%, TM 22.2–50.1%). In patients that completed one visit and needed to start RRT, 47% started on a home modality or received a pre-emptive transplant (home hemodialysis 6%, peritoneal dialysis 38%, transplant 3%).

Conclusions

Results show almost 90% (TM 87%, FTF 95%) of the attendees could choose a modality after education. Home modality choices doubled. Patients were able to make an informed choice regardless of the modality of education.