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Wu Y, Lv K, Hao X, Lv C, Lai W, Xia X, Pang A, Yuan Q, Song T. Waiting-List and early posttransplant prognosis among ethnoracial groups: Data from the organ procurement and transplantation network. Front Surg 2023; 10:1045363. [PMID: 36793312 PMCID: PMC9923172 DOI: 10.3389/fsurg.2023.1045363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/03/2023] [Indexed: 02/03/2023] Open
Abstract
Background Racial/ethnic disparity in waiting-list mortality among candidates listed for kidney transplantation (KT) in the United States remains unclear. We aimed to assess racial/ethnic disparity in waiting-list prognosis among patients listed for KT in the United States in the current era. Methods We compared waiting-list and early posttransplant in-hospital mortality or primary nonfunction (PNF) among adult (age ≥18 years) white, black, Hispanic, and Asian patients listed for only KT in the United States between July 1, 2004 and March 31, 2020. Results Of the 516,451 participants, 45.6%, 29.8%, 17.5%, and 7.1% were white, black, Hispanic, and Asian, respectively. Mortality on the 3-year waiting list (including patients who were removed for deterioration) was 23.2%, 16.6%, 16.2%, and 13.8% in white, black, Hispanic, and Asian patients, respectively. The cumulative incidence of posttransplant in-hospital death or PNF after KT was 3.3%, 2.5%, 2.4%, and 2.2% in black, white, Hispanic, and Asian patients,respectively. White candidates had the highest mortality risk on the waiting list or of becoming too sick for a transplant, while black (adjusted hazard ratio, [95% confidence interval, CI], 0.67 [0.66-0.68]), Hispanic (0.59 [0.58-0.60]), and Asian (0.54 [0.52-0.55]) candidates had a lower risk. Black KT recipients (odds ratio, [95% CI] 1.29 [1.21-1.38]) had a higher risk of PNF or death before discharge than white patients. After controlling confounders, black recipients (0.99 [0.92-1.07]) had a similar higher risk of posttransplant in-hospital mortality or PNF as white patients than Hispanic and Asian counterparts. Conclusions Despite having a better socioeconomic status and being allocated better kidneys, white patients had the worst prognosis during the waiting periods. Black recipients and white recipients have higher posttransplant in-hospital mortality or PNF.
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Affiliation(s)
- Yangyang Wu
- Department of Urology, The Third Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China,Graduate School, Medical School of Chinese People's Liberation Army (PLA), Beijing, China
| | - Kaikai Lv
- Department of Urology, The Third Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China,Graduate School, Medical School of Chinese People's Liberation Army (PLA), Beijing, China
| | - Xiaowei Hao
- Department of Urology, The Third Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China,Graduate School, Medical School of Chinese People's Liberation Army (PLA), Beijing, China
| | - Chao Lv
- Department of Urology, The Third Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China,Graduate School, Medical School of Chinese People's Liberation Army (PLA), Beijing, China
| | - Wenhui Lai
- Graduate School, Hebei North University, Zhangjiakou, China
| | - Xinze Xia
- Graduate School, Shanxi Medical University, Taiyuan, China
| | - Aibo Pang
- Graduate School, Medical School of Chinese People's Liberation Army (PLA), Beijing, China
| | - Qing Yuan
- Department of Urology, The Third Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China,Graduate School, Medical School of Chinese People's Liberation Army (PLA), Beijing, China,Correspondence: Tao Song Qing Yuan
| | - Tao Song
- Department of Urology, The Third Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China,Graduate School, Medical School of Chinese People's Liberation Army (PLA), Beijing, China,Correspondence: Tao Song Qing Yuan
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Awad K, Zaki MM, Mohammed M, Lewek J, Lavie CJ, Banach M. Effect of the Renin-Angiotensin System Inhibitors on Inflammatory Markers: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Mayo Clin Proc 2022; 97:1808-1823. [PMID: 36202494 DOI: 10.1016/j.mayocp.2022.06.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 05/01/2022] [Accepted: 06/30/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To synthesize more conclusive evidence on the anti-inflammatory effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). METHODS PubMed, Scopus, and Embase were searched from inception until March 1, 2021. We included randomized controlled trials (RCTs) that assessed the effect of ACEIs or ARBs, compared with placebo, on any of the following markers: C-reactive protein (CRP), interleukin 6 (IL-6), or tumor necrosis factor α (TNF-α). Mean changes in the levels of these markers were pooled as a weighted mean difference (WMD) with a 95% CI. RESULTS Thirty-two RCTs (n=3489 patients) were included in the final analysis. Overall pooled analysis suggested that ACEIs significantly reduced plasma levels of CRP (WMD, -0.54 [95% CI, -0.88 to -0.21]; P=.002; I2=96%), IL-6 (WMD, -0.84 [95% CI, -1.03 to -0.64]; P<.001; I2=0%), and TNF-α (WMD, -12.75 [95% CI, -17.20 to -8.29]; P<.001; I2=99%). Moreover, ARBs showed a significant reduction only in IL-6 (WMD, -1.34 [95% CI, -2.65 to -0.04]; P=.04; I2=85%) and did not significantly affect CRP (P=.15) or TNF-α (P=.97) levels. The lowering effect of ACEIs on CRP levels remained significant with enalapril (P=.006) and perindopril (P=.01) as well as with a treatment duration of less than 24 weeks (WMD, -0.67 [95% CI, -1.07 to -0.27]; P=.001; I2=94%) and in patients with coronary artery disease (WMD, -0.75 [95% CI, -1.17 to -0.33]; P<.001; I2=96%). CONCLUSION Based on this meta-analysis, ACEIs showed a beneficial lowering effect on CRP, IL-6, and TNF-α, whereas ARBs were effective as a class in reduction of IL-6 only.
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Affiliation(s)
- Kamal Awad
- Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt; Zagazig University Hospitals, Zagazig, El-Sharkia, Egypt.
| | - Mahmoud Mohamed Zaki
- Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt; Zagazig University Hospitals, Zagazig, El-Sharkia, Egypt
| | - Maged Mohammed
- Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt; Zagazig University Hospitals, Zagazig, El-Sharkia, Egypt
| | - Joanna Lewek
- Department of Preventive Cardiology and Lipidology, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland; Department of Cardiology and Adult Congenital Heart Diseases, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland; Department of Cardiology and Adult Congenital Heart Diseases, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland; Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland
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Hassan MO, Balogun RA. The Effects of Race on Acute Kidney Injury. J Clin Med 2022; 11:5822. [PMID: 36233687 PMCID: PMC9573379 DOI: 10.3390/jcm11195822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/16/2022] [Accepted: 09/27/2022] [Indexed: 12/03/2022] Open
Abstract
Racial disparities in incidence and outcomes of acute kidney injury (AKI) are pervasive and are driven in part by social inequities and other factors. It is well-documented that Black patients face higher risk of AKI and seemingly have a survival advantage compared to White counterparts. Various explanations have been advanced and suggested to account for this, including differences in susceptibility to kidney injury, severity of illness, and socioeconomic factors. In this review, we try to understand and further explore the link between race and AKI using the incidence, diagnosis, and management of AKI to illustrate how race is directly related to AKI outcomes, with a focus on Black and White individuals with AKI. In particular, we explore the effect of race-adjusted estimated glomerular filtration rate (eGFR) equation on AKI prediction and discuss racial disparities in the management of AKI and how this might contribute to racial differences in AKI-related mortality among Blacks with AKI. We also identify some opportunities for future research and advocacy.
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Affiliation(s)
- Muzamil Olamide Hassan
- Department of Medicine, Obafemi Awolowo University, Ile-Ife 220005, Nigeria
- Division of Nephrology, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Rasheed Abiodun Balogun
- Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville, VA 22908, USA
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4
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Barrows IR, Devalaraja M, Kakkar R, Chen J, Gupta J, Rosas SE, Saraf S, He J, Go A, Raj DS, Amdur RL. Race, Interleukin-6, TMPRSS6 Genotype, and Cardiovascular Disease in Patients With Chronic Kidney Disease. J Am Heart Assoc 2022; 11:e025627. [PMID: 36102277 PMCID: PMC9683639 DOI: 10.1161/jaha.122.025627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/26/2022] [Indexed: 12/26/2022]
Abstract
Background Differences in death rate and cardiovascular disease (CVD) between Black and White patients with chronic kidney disease is attributed to sociocultural factors, comorbidities, genetics, and inflammation. Methods and Results We examined the interaction of race, plasma IL-6 (interleukin-6), and TMPRSS6 genotype as determinants of CVD and mortality in 3031 Chronic Renal Insufficiency Cohort study participants. The primary outcomes were all-cause mortality and a composite of incident myocardial infarction, peripheral artery disease, stroke, and heart failure. During the median follow-up of 10 years, Black patients with chronic kidney disease experienced a significantly higher mortality (34% versus 26%) and CVD composite (41% versus 28%) compared with White patients. After adjustment, TMPRSS6 genotype did not associate with the outcomes. The adjusted hazard ratio for mortality (4.11 [2.48-6.80], P<0.001) and CVD composite (2.52 [1.96-3.24], P<0.001) were higher for the highest versus lowest IL-6 quintile. The adjusted hazards for death per 1-quintile increase in IL-6 in White and Black individuals were 1.53 (1.42-1.64) versus 1.29 (1.20-1.38) (P<0.001), respectively. For CVD composite they were 1.61 (1.50-1.74) versus 1.30 (1.22-1.39) (P<0.001), respectively. In Cox proportional hazard models that included IL-6, there was no longer a racial disparity for death (1.01 [0.87-1.16], P=0.92), but significant unexplained mediation remained for CVD (1.24 [1.07-1.43]; P=0.004). Path models that included IL-6, diabetes, and urine albumin to creatinine ratio were able to identify variables responsible for racial disparity in mortality and CVD. Conclusions Racial differences in mortality and CVD among patients with chronic kidney disease could be explained by good-fitting path models that include selected mediator variables including diabetes and plasma IL-6.
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Affiliation(s)
- Ian R. Barrows
- Division of CardiologyGeorge Washington University School of MedicineWashingtonDC
| | | | - Rahul Kakkar
- Research & DevelopmentCorvidia TherapeuticsWalthamMA
| | - Jing Chen
- Section of Nephrology and Hypertension, Department of MedicineTulane University School of MedicineNew OrleansLA
| | - Jayanta Gupta
- Department of Health Sciences, Marieb College of Health & Human ServicesFlorida Gulf Coast UniversityFort MyersFL
| | - Sylvia E. Rosas
- Department of MedicineJoslin Diabetes Center, Harvard Medical SchoolBostonMA
| | - Santosh Saraf
- Division of Hematology/Oncology, Department of MedicineUniversity of Illinois at ChicagoIL
| | - Jiang He
- Department of EpidemiologyTulane University School of Public Health and Tropical MedicineNew OrleansLA
| | - Alan Go
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCA
| | - Dominic S. Raj
- Division of Kidney Diseases and Hypertension, Department of MedicineThe George Washington University School of Medicine and Health SciencesWashingtonDC
| | - Richard L. Amdur
- Department of SurgeryThe George Washington University School of Medicine and Health SciencesWashingtonDC
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5
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Nicholas SB, Norris KC. Race, Biomarkers, and Cardiovascular Disease in Patients With Chronic Kidney Disease. J Am Heart Assoc 2022; 11:e026998. [PMID: 36102224 PMCID: PMC9683640 DOI: 10.1161/jaha.122.026998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Keith C. Norris
- Department of MedicineUniversity of California, Los AngelesLos AngelesCA
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6
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Blum MF, Feng Y, Anderson GB, Segev DL, McAdams-DeMarco M, Grams ME. Hurricanes and Mortality among Patients Receiving Dialysis. J Am Soc Nephrol 2022; 33:1757-1766. [PMID: 35835459 PMCID: PMC9529177 DOI: 10.1681/asn.2021111520] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 05/15/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Hurricanes are severe weather events that can disrupt power, water, and transportation systems. These disruptions may be deadly for patients requiring maintenance dialysis. We hypothesized that the mortality risk among patients requiring maintenance dialysis would be increased in the 30 days after a hurricane. METHODS Patients registered as requiring maintenance dialysis in the United States Renal Data System who initiated treatment between January 1, 1997 and December 31, 2017 in one of 108 hurricane-afflicted counties were followed from dialysis initiation until transplantation, dialysis discontinuation, a move to a nonafflicted county, or death. Hurricane exposure was determined as a tropical cyclone event with peak local wind speeds ≥64 knots in the county of a patient's residence. The risk of death after the hurricane was estimated using time-varying Cox proportional hazards models. RESULTS The median age of the 187,388 patients was 65 years (IQR, 53-75) and 43.7% were female. There were 27 hurricanes and 105,398 deaths in 529,339 person-years of follow-up on dialysis. In total, 29,849 patients were exposed to at least one hurricane. Hurricane exposure was associated with a significantly higher mortality after adjusting for demographic and socioeconomic covariates (hazard ratio, 1.13; 95% confidence interval, 1.05 to 1.22). The association persisted when adjusting for seasonality. CONCLUSIONS Patients requiring maintenance dialysis have a higher mortality risk in the 30 days after a hurricane.
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Affiliation(s)
- Matthew F. Blum
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yijing Feng
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - G. Brooke Anderson
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado
| | - Dorry L. Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
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7
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Mosterd CM, Hayfron-Benjamin CF, van den Born BJH, Maitland-van der Zee AH, Agyemang C, van Raalte DH. Ethnic disparities in the association between low-grade inflammation biomarkers and chronic kidney disease: The HELIUS Cohort Study. J Diabetes Complications 2022; 36:108238. [PMID: 35791984 DOI: 10.1016/j.jdiacomp.2022.108238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 05/30/2022] [Accepted: 06/19/2022] [Indexed: 11/30/2022]
Abstract
AIMS Ethnic differences exist in the prevalence and progression of chronic kidney disease (CKD). However, underlying mechanisms remain unclear. It has been proposed that chronic low-grade inflammation plays an important role in CKD pathogenesis. In the current analysis, we study the association between systemic inflammatory biomarkers and CKD prevalence in different ethnic groups. METHODS We examined cross-sectional associations between biomarkers of low-grade inflammation, including serum high-sensitive (hs)-CRP, fibrinogen, and D-dimer, and CKD prevalence in different ethnic groups residing in Amsterdam, the Netherlands. We included 5740 participants (similar-sized Dutch, African Surinamese, South-Asian Surinamese, Ghanaian, Turkish and Moroccan populations) aged 18 to 70 years of the Healthy Life in an Urban Setting study (HELIUS) cohort. RESULTS In the fully adjusted models, adjusted for ethnicity-specific cut-off values, elevated fibrinogen [odds ratio 2.50 (95 % confidence interval 1.10-5.78)] and D-dimer [2.99 (1.28-7.00)] were significantly associated with CKD in Dutch. In South-Asian Surinamese, a significant association with elevated D-dimer [2.66 (1.32-5.37)] was found. CONCLUSIONS Our study shows that there are both differences in biomarker levels and the association with CKD across ethnic groups. Future research to identify potential drivers of the differential associations and susceptibility of CKD among ethnic groups to reduce the CKD burden is necessary.
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Affiliation(s)
- Charlotte M Mosterd
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, Location VUMC, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands; Department of Vascular Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Internal Medicine, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Charles F Hayfron-Benjamin
- Department of Vascular Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Departments of Physiology and Anesthesiology/Critical Care, University of Ghana Medical School, Ghana; Department of Internal Medicine, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Bert-Jan H van den Born
- Department of Vascular Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Internal Medicine, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | | | - Charles Agyemang
- Department of Public Health, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Internal Medicine, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, Location VUMC, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands; Department of Vascular Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Internal Medicine, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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Hladek MD, Zhu J, Crews DC, McAdams-DeMarco MA, Buta B, Varadhan R, Shafi T, Walston JD, Bandeen-Roche K. Physical Resilience Phenotype Trajectories in Incident Hemodialysis: Characterization and Mortality Risk Assessment. Kidney Int Rep 2022; 7:2006-2015. [PMID: 36090502 PMCID: PMC9459128 DOI: 10.1016/j.ekir.2022.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/13/2022] [Indexed: 12/19/2022] Open
Abstract
Introduction Methods Results Conclusion
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Salerno S, Messana JM, Gremel GW, Dahlerus C, Hirth RA, Han P, Segal JH, Xu T, Shaffer D, Jiao A, Simon J, Tong L, Wisniewski K, Nahra T, Padilla R, Sleeman K, Shearon T, Callard S, Yaldo A, Borowicz L, Agbenyikey W, Horton GM, Roach J, Li Y. COVID-19 Risk Factors and Mortality Outcomes Among Medicare Patients Receiving Long-term Dialysis. JAMA Netw Open 2021; 4:e2135379. [PMID: 34787655 PMCID: PMC8600389 DOI: 10.1001/jamanetworkopen.2021.35379] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/20/2021] [Indexed: 12/18/2022] Open
Abstract
Importance There is a need for studies to evaluate the risk factors for COVID-19 and mortality among the entire Medicare long-term dialysis population using Medicare claims data. Objective To identify risk factors associated with COVID-19 and mortality in Medicare patients undergoing long-term dialysis. Design, Setting, and Participants This retrospective, claims-based cohort study compared mortality trends of patients receiving long-term dialysis in 2020 with previous years (2013-2019) and fit Cox regression models to identify risk factors for contracting COVID-19 and postdiagnosis mortality. The cohort included the national population of Medicare patients receiving long-term dialysis in 2020, derived from clinical and administrative databases. COVID-19 was identified through Medicare claims sources. Data were analyzed on May 17, 2021. Main Outcomes and Measures The 2 main outcomes were COVID-19 and all-cause mortality. Associations of claims-based risk factors with COVID-19 and mortality were investigated prediagnosis and postdiagnosis. Results Among a total of 498 169 Medicare patients undergoing dialysis (median [IQR] age, 66 [56-74] years; 215 935 [43.1%] women and 283 227 [56.9%] men), 60 090 (12.1%) had COVID-19, among whom 15 612 patients (26.0%) died. COVID-19 rates were significantly higher among Black (21 787 of 165 830 patients [13.1%]) and Hispanic (13 530 of 86 871 patients [15.6%]) patients compared with non-Black patients (38 303 of 332 339 [11.5%]), as well as patients with short (ie, 1-89 days; 7738 of 55 184 patients [14.0%]) and extended (ie, ≥90 days; 10 737 of 30 196 patients [35.6%]) nursing home stays in the prior year. Adjusting for all other risk factors, residing in a nursing home 1 to 89 days in the prior year was associated with a higher hazard for COVID-19 (hazard ratio [HR] vs 0 days, 1.60; 95% CI 1.56-1.65) and for postdiagnosis mortality (HR, 1.31; 95% CI, 1.25-1.37), as was residing in a nursing home for an extended stay (COVID-19: HR, 4.48; 95% CI, 4.37-4.59; mortality: HR, 1.12; 95% CI, 1.07-1.16). Black race (HR vs non-Black: HR, 1.25; 95% CI, 1.23-1.28) and Hispanic ethnicity (HR vs non-Hispanic: HR, 1.68; 95% CI, 1.64-1.72) were associated with significantly higher hazards of COVID-19. Although home dialysis was associated with lower COVID-19 rates (HR, 0.77; 95% CI, 0.75-0.80), it was associated with higher mortality (HR, 1.18; 95% CI, 1.11-1.25). Conclusions and Relevance These results shed light on COVID-19 risk factors and outcomes among Medicare patients receiving long-term chronic dialysis and could inform policy decisions to mitigate the significant extra burden of COVID-19 and death in this population.
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Affiliation(s)
- Stephen Salerno
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Joseph M. Messana
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
- Division of Nephrology, University of Michigan Health System, Ann Arbor
- Department of Health Policy and Management, University of Michigan, Ann Arbor
| | - Garrett W. Gremel
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Claudia Dahlerus
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
- Division of Nephrology, University of Michigan Health System, Ann Arbor
| | - Richard A. Hirth
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
- Department of Health Policy and Management, University of Michigan, Ann Arbor
| | - Peisong Han
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Jonathan H. Segal
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
- Division of Nephrology, University of Michigan Health System, Ann Arbor
| | - Tao Xu
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Dan Shaffer
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Amy Jiao
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Jeremiah Simon
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Lan Tong
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Karen Wisniewski
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Tammie Nahra
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Robin Padilla
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Kathryn Sleeman
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Tempie Shearon
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Sandra Callard
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Alexander Yaldo
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | - Lisa Borowicz
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
| | | | | | - Jesse Roach
- Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Yi Li
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor
- Department of Biostatistics, University of Michigan, Ann Arbor
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Abstract
Kidney pathophysiology is influenced by gender. Evidence suggests that kidney damage is more severe in males than in females and that sexual hormones contribute to this. Elevated prolactin concentration is common in renal impairment patients and is associated with an unfavorable prognosis. However, PRL is involved in the osmoregulatory process and promotes endothelial proliferation, dilatation, and permeability in blood vessels. Several proteinases cleavage its structure, forming vasoinhibins. These fragments have antagonistic PRL effects on endothelium and might be associated with renal endothelial dysfunction, but its role in the kidneys has not been enough investigated. Therefore, the purpose of this review is to describe the influence of sexual dimorphism and gonadal hormones on kidney damage, emphasizing the role of the hormone prolactin and its cleavage products, the vasoinhibins.
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Hassan MO, Owoyemi I, Abdel-Rahman EM, Ma JZ, Balogun RA. Association of Race with In-Hospital and Post-Hospitalization Mortality in Patients with Acute Kidney Injury. Nephron Clin Pract 2021; 145:214-224. [PMID: 33657572 DOI: 10.1159/000511405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 09/05/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is known to be associated with increased mortality, and racial differences in hospital mortality exist in patients with AKI. However, it remains to be seen whether racial differences exist in post-hospitalization mortality among AKI patients. METHODS We analyzed data of adult AKI patients admitted to the University of Virginia Medical Center between January 1, 2001, and December 31, 2015, to compare in-hospital and post-hospitalization mortality among hospitalized black and white patients with AKI. Multivariable logistic regression analysis was used to analyze the association between race and in-hospital mortality, and 90-day post-hospitalization mortality among AKI patients that were discharged. Kaplan-Meier survival curve was used to evaluate long-term survival between black and white patients. RESULTS Black patients had lower in-hospital mortality than white patients after adjusting for age, sex, estimated glomerular filtration rate, hospital length of stay, severity of AKI, comorbidities, and the need for dialysis and mechanical ventilation (odds ratio: 0.82; 95% confidence interval, 0.70-0.96, p = 0.0015). Similarly, at 90-day post-hospitalization, black patients had significantly lower adjusted odds of death than white patients (odds ratio: 0.64; 95% confidence interval, 0.46-0.93; p = 0.008). The median length of follow-up was 11.9 months (0.6-46.7 months). Kaplan-Meier survival curve showed that long-term survival was significantly better in black patients compared to white patients (median duration of survival; 39.7 vs. 24.8 months; p ≤ 0.001). CONCLUSIONS Black patients with AKI had lower in-hospital mortality, 90-day post-hospitalization mortality, and better long-term survival rates compared to white patients with AKI.
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Affiliation(s)
- Muzamil O Hassan
- Department of Medicine, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Itunu Owoyemi
- Jared Grantham Kidney Institute, Kansas University Medical Center, Kansas City, Kansas, USA
| | | | - Jennie Z Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA,
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12
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Crews DC, Novick TK. Achieving equity in dialysis care and outcomes: The role of policies. Semin Dial 2020; 33:43-51. [PMID: 31899828 DOI: 10.1111/sdi.12847] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Socially disadvantaged persons, including racial and ethnic minorities, individuals with low incomes, homeless persons, and non-US citizens bear a disproportionate burden of end-stage kidney disease (ESKD). Inequities in nephrology referral, vascular access, use of home dialysis modalities, kidney transplantation, and mortality are prominent. Public policies, including the Patient Protection and Affordable Care Act, end-stage renal disease Quality Incentive Program, and the Prospective Payment System, were enacted to improve healthcare access and dialysis care. Here, we highlight inequities in dialysis care and outcomes, how current ESKD and other public policies may influence or exacerbate these inequities, and gaps in the literature needed to inform future policies toward achieving equity in ESKD. We give special attention to the 2019 Advancing American Kidney Health Executive Order, which has high potential to radically transform dialysis care.
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Affiliation(s)
- Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Tessa K Novick
- Division of Nephrology, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
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13
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Abstract
BACKGROUND Symptom burden associated with chronic kidney disease can be debilitating, with a negative effect on patient health-related quality of life. Latent class clustering analysis is an innovative tool for classifying patient symptom experience. OBJECTIVES The aim of the study was to identify subgroups of patients at greatest risk for high symptom burden, which may facilitate development of patient-centered symptom management interventions. METHODS In this cross-sectional analysis, baseline data were analyzed from 3,921 adults enrolled in the Chronic Renal Insufficiency Cohort Study from 2003 to 2008. Latent class cluster modeling using 11 items on the Kidney Disease Quality of Life symptom profile was employed to identify patient subgroups based on similar observed physical symptom response patterns. Multinomial logistic regression models were estimated with demographic variables, lifestyle and clinical variables, and self-reported measures (Kidney Disease Quality of Life physical and mental component summaries and the Beck Depression Inventory). RESULTS Three symptom-based subgroups were identified, differing in severity (low symptom, moderate symptom, and high symptom). After adjusting for other variables in multinomial logistic regression, membership in the high-symptom subgroup was less likely for non-Hispanic Blacks and men. Other factors associated with membership in the high-symptom subgroup included lower estimated glomerular filtration rate, history of cardiac/cardiovascular disease, higher Beck Depression Inventory scores, and lower Kidney Disease Quality of Life physical and mental component summaries. DISCUSSION Three symptom subgroups of patients were identified among patients with mild-to-moderate chronic kidney disease. Several demographic and clinical variables predicted membership in subgroups. Further research is needed to determine if symptom subgroups are stable over time and can be used to predict healthcare utilization and clinical outcomes.
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14
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Thomas A, Silver SA, Perl J, Freeman M, Slater JJ, Nash DM, Vinegar M, McArthur E, Garg AX, Harel Z, Chanchlani R, Zappitelli M, Iliescu E, Kitchlu A, Blum D, Beaubien-Souligny W, Wald R. The Frequency of Routine Blood Sampling and Patient Outcomes Among Maintenance Hemodialysis Recipients. Am J Kidney Dis 2019; 75:471-479. [PMID: 31732233 DOI: 10.1053/j.ajkd.2019.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/20/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Surveillance blood work is routinely performed in maintenance hemodialysis (HD) recipients. Although more frequent blood testing may confer better outcomes, there is little evidence to support any particular monitoring interval. STUDY DESIGN Retrospective population-based cohort study. SETTING & PARTICIPANTS All prevalent HD recipients in Ontario, Canada, as of April 1, 2011, and a cohort of incident patients commencing maintenance HD in Ontario, Canada, between April 1, 2011, and March 31, 2016. EXPOSURE Frequency of surveillance blood work, monthly versus every 6 weeks. OUTCOMES The primary outcome was all-cause mortality. Secondary outcomes were major adverse cardiovascular events, all-cause hospitalization, and episodes of hyperkalemia. ANALYTICAL APPROACH Cox proportional hazards with adjustment for demographic and clinical characteristics was used to evaluate the association between blood testing frequency and all-cause mortality. Secondary outcomes were evaluated using the Andersen-Gill extension of the Cox model to allow for potential recurrent events. RESULTS 7,454 prevalent patients received care at 17 HD programs with monthly blood sampling protocols (n=5,335 patients) and at 8 programs with blood sampling every 6 weeks (n=2,119 patients). More frequent monitoring was not associated with a lower risk for all-cause mortality compared to blood sampling every 6 weeks (adjusted HR, 1.16; 95% CI, 0.99-1.38). Monthly monitoring was not associated with a lower risk for any of the secondary outcomes. Results were consistent among incident HD recipients. LIMITATIONS Unmeasured confounding; limited data for center practices unrelated to blood sampling frequency; no information on frequency of unscheduled blood work performed outside the prescribed sampling interval. CONCLUSIONS Monthly routine blood testing in HD recipients was not associated with a lower risk for death, cardiovascular events, or hospitalizations as compared with testing every 6 weeks. Given the health resource implications, the frequency of routine blood sampling in HD recipients deserves careful reassessment.
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Affiliation(s)
- Alison Thomas
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada; ICES, London, Ontario, Canada
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Megan Freeman
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | | | | | | | - Amit X Garg
- ICES, London, Ontario, Canada; Division of Nephrology, Western University, London, Ontario, Canada
| | - Ziv Harel
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; ICES, London, Ontario, Canada
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Michael Zappitelli
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eduard Iliescu
- Division of Nephrology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Daniel Blum
- Division of Nephrology, Sir Mortimer B Davis Jewish General Hospital, Quebec, Canada
| | | | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; ICES, London, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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15
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Ku E, Yang W, McCulloch CE, Feldman HI, Go AS, Lash J, Bansal N, He J, Horwitz E, Ricardo AC, Shafi T, Sondheimer J, Townsend RR, Waikar SS, Hsu CY. Race and Mortality in CKD and Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2019; 75:394-403. [PMID: 31732235 DOI: 10.1053/j.ajkd.2019.08.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/02/2019] [Indexed: 01/13/2023]
Abstract
RATIONALE & OBJECTIVES Few studies have investigated racial disparities in survival among dialysis patients in a manner that considers risk factors and mortality during the phase of kidney disease before maintenance dialysis. Our objective was to explore racial variations in survival among dialysis patients and relate them to racial differences in comorbid conditions and rates of death in the setting of kidney disease not yet requiring dialysis therapy. STUDY DESIGN Retrospective cohort study. SETTINGS & PARTICIPANTS 3,288 black and white participants in the Chronic Renal Insufficiency Cohort (CRIC), none of whom were receiving dialysis at enrollment. EXPOSURE Race. OUTCOME Mortality. ANALYTIC APPROACH Cox proportional hazards regression was used to examine the association between race and mortality starting at: (1) time of dialysis initiation and (2) entry into the CRIC. RESULTS During 7.1 years of median follow-up, 678 CRIC participants started dialysis. Starting from the time of dialysis initiation, blacks had lower risk for death (unadjusted HR, 0.67; 95% CI, 0.51-0.87) compared with whites. Starting from baseline CRIC enrollment, the strength of the association between some risk factors and dialysis was notably stronger for whites than blacks. For example, the HR for dialysis onset in the presence (vs absence) of heart failure at CRIC enrollment was 1.30 (95% CI, 1.01-1.68) for blacks versus 2.78 (95% CI, 1.90-4.50) for whites, suggesting differential severity of these risk factors by race. When we included deaths occurring both before and after dialysis, risk for death was higher among blacks (vs whites) starting from CRIC enrollment (HR, 1.41; 95% CI, 1.22-1.64), but this finding was attenuated in adjusted models (HR, 1.08; 95% CI, 0.91-1.28). LIMITATIONS Residual confounding. CONCLUSIONS The apparent survival advantage among blacks over whites treated with dialysis may be attributed to selected transition of a subset of whites with more severe comorbid conditions onto dialysis.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA; Division of Pediatric Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, CA.
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Harold I Feldman
- Division of Nephrology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alan S Go
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, San Francisco, CA
| | - James Lash
- Division of Nephrology, Department of Medicine, University of Illinois, Chicago, IL
| | - Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Ed Horwitz
- Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland OH
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois, Chicago, IL
| | - Tariq Shafi
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | | | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sushrut S Waikar
- Division of Nephrology, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA
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16
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Kleine CE, Moradi H, Streja E, Kalantar-Zadeh K. Racial and Ethnic Disparities in the Obesity Paradox. Am J Kidney Dis 2019; 72:S26-S32. [PMID: 30343719 DOI: 10.1053/j.ajkd.2018.06.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 06/25/2018] [Indexed: 11/11/2022]
Abstract
Obesity is a major risk factor for cardiovascular disease and worse survival in the general population. However, in patients with end-stage renal disease (ESRD), higher body mass index and indexes of body fat and muscle are associated with better survival. Furthermore, these associations, which some have described as the obesity paradox, are more consistent in African American patients being treated with hemodialysis when compared with other racial-ethnic groups. This is in view of data indicating that although the rate of progression to ESRD is faster in African American patients, they have a survival advantage after transition to ESRD when compared with their white counterparts. These observations indicate that there may be significant interaction between race/ethnicity and association of body mass index with outcomes in patients with ESRD. In addition, it is possible that mechanisms underlying improved survival in African American hemodialysis patients are partly related to the association of body mass index with outcomes observed in this patient population. Some of these potential mechanisms may include comparatively reduced risk for protein-energy wasting and malnutrition, possible salutary effects of factors that play a role in energy preservation, resistance to deleterious effects of inflammation, and enhanced muscle mass and body composition. Given that ESRD is associated with significantly increased risk for morbidity and mortality, understanding the pathophysiologic mechanisms responsible for the obesity paradox across race-ethnic populations might help identify potential therapeutic targets that can be used to improve survival in this patient population.
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Affiliation(s)
- Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA; Department of Medicine, Long Beach Veteran Affairs Health System, Long Beach, CA
| | - Hamid Moradi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA; Department of Medicine, Long Beach Veteran Affairs Health System, Long Beach, CA.
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA; Department of Medicine, Long Beach Veteran Affairs Health System, Long Beach, CA; Program for Public Health, University of California Irvine, Irvine, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA; Department of Medicine, Long Beach Veteran Affairs Health System, Long Beach, CA; Program for Public Health, University of California Irvine, Irvine, CA; Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA.
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17
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Shrestha P, Haugen CE, Chu NM, Shaffer A, Garonzik-Wang J, Norman SP, Walston JD, Segev DL, McAdams-DeMarco MA. Racial differences in inflammation and outcomes of aging among kidney transplant candidates. BMC Nephrol 2019; 20:176. [PMID: 31101015 PMCID: PMC6524264 DOI: 10.1186/s12882-019-1360-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 04/29/2019] [Indexed: 01/12/2023] Open
Abstract
Background Inflammation is more common among African Americans (AAs), and it is associated with frailty, poor physical performance, and mortality in community-dwelling older adults. Given the elevated inflammation levels among end-stage renal disease (ESRD) patients, inflammation may be associated with adverse health outcomes such as frailty, physical impairment, and poor health-related quality of life (HRQOL), and these associations may differ between AA and non-AA ESRD patients. Methods One thousand three ESRD participants were recruited at kidney transplant evaluation (4/2014–5/2017), and inflammatory markers (interleukin-6 [IL-6], tumor necrosis factor-a receptor-1 [TNFR1], C-reactive protein [CRP]) were measured. We quantified the association with frailty (Fried phenotype), physical impairment (Short Physical Performance Battery [SPPB]), and fair/poor HRQOL at evaluation using adjusted modified Poisson regression and tested whether these associations differed by race (AA vs. non-AA). Results Non-AAs had lower levels of TNFR1 (9.7 ng/ml vs 14.0 ng/ml, p < 0.001) and inflammatory index (6.7 vs 6.8, p < 0.001) compared to AAs, but similar levels of IL-6 (4.5 pg/ml vs 4.3 pg/ml, p > 0.9) and CRP (4.7 μg/ml vs 4.9 μg/ml, p = 0.4). Non-AAs had an increased risk of frailty with elevated IL-6 (RR = 1.58, 95% CI:1.27–1.96, p < 0.001), TNFR1 (RR = 1.60, 95% CI:1.25–2.05, p < 0.001), CRP (RR = 1.41, 95% CI:1.10–1.82, p < 0.01), and inflammatory index (RR = 1.82, 95% CI:1.44–2.31, p < 0.001). The associations between elevated inflammatory markers and frailty were not present among AAs. Similar results were seen with SPPB impairment and poor/fair HRQOL. Conclusions Non-AAs with elevated inflammatory markers may need closer follow-up and may benefit from prehabilitation to improve physical function, reduce frailty burden, and improve quality of life prior to transplant.
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Affiliation(s)
- Prakriti Shrestha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine E Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA
| | - Ashton Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Silas P Norman
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Jeremy D Walston
- Department of Medicine, Division of Geriatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Epidemiology, Johns Hopkins School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA.
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18
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Lertdumrongluk P, Streja E, Rhee CM, Moradi H, Chang Y, Reddy U, Tantisattamo E, Kalantar-Zadeh K, Kopp JB. Survival Advantage of African American Dialysis Patients with End-Stage Renal Disease Causes Related to APOL1. Cardiorenal Med 2019; 9:212-221. [PMID: 30995638 DOI: 10.1159/000496472] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/22/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Observational studies show that African American (AA) dialysis patients have longer survival than European Americans. We hypothesized that apolipoprotein L1 (APOL1) genetic variation, associated with nephropathy in AAs, contributes to the survival advantage in AA dialysis patients. METHODS We examined the association between race and mortality among 37,097 adult dialysis patients, including 54% AAs and 46% European Americans from a large dialysis organization (entry period from July 2001 to June 2006, follow-up through June 2007), within each cause of end-stage renal disease (ESRD) category associated with APOL1 renal risk variants using Cox proportional hazard models. RESULTS AA dialysis patients had numerically lower mortality than their European American counterparts for all causes of ESRD. The mortality reduction among AAs compared to European Americans was statistically significant in patients with ESRD attributed to diabetes mellitus, hypertension, and APOL1-enriched glomerulonephritis (GN) (HR [95% CI]: 0.69 [0.66-0.72], 0.73 [0.68-0.79], and 0.89 [0.79-0.99], respectively); these are conditions in which APOL1 variants promote kidney disease. By contrast, the significant survival advantage of AA dialysis patients was not observed in patients with ESRD attributed to other kidney disease (including polycystic kidney disease, interstitial nephritis, and pyelonephritis) and other GN, which are not associated with APOL1 variants. CONCLUSIONS These data suggest the hypothesis that the relative survival advantage of AA dialysis patients may be related to APOL1 variation. Further large population-based genetic studies are required to test this hypothesis.
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Affiliation(s)
- Paungpaga Lertdumrongluk
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Orange, California, USA.,Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Nonthaburi, Thailand
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Orange, California, USA.,University of California Irvine School of Medicine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Orange, California, USA.,University of California Irvine School of Medicine, Orange, California, USA
| | - Hamid Moradi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Orange, California, USA
| | - Yongen Chang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Orange, California, USA
| | - Uttam Reddy
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Orange, California, USA
| | - Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Orange, California, USA.,University of California Irvine School of Medicine, Orange, California, USA
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19
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Carnethon MR, Pu J, Howard G, Albert MA, Anderson CAM, Bertoni AG, Mujahid MS, Palaniappan L, Taylor HA, Willis M, Yancy CW. Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e393-e423. [PMID: 29061565 DOI: 10.1161/cir.0000000000000534] [Citation(s) in RCA: 691] [Impact Index Per Article: 98.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Population-wide reductions in cardiovascular disease incidence and mortality have not been shared equally by African Americans. The burden of cardiovascular disease in the African American community remains high and is a primary cause of disparities in life expectancy between African Americans and whites. The objectives of the present scientific statement are to describe cardiovascular health in African Americans and to highlight unique considerations for disease prevention and management. METHOD The primary sources of information were identified with PubMed/Medline and online sources from the Centers for Disease Control and Prevention. RESULTS The higher prevalence of traditional cardiovascular risk factors (eg, hypertension, diabetes mellitus, obesity, and atherosclerotic cardiovascular risk) underlies the relatively earlier age of onset of cardiovascular diseases among African Americans. Hypertension in particular is highly prevalent among African Americans and contributes directly to the notable disparities in stroke, heart failure, and peripheral artery disease among African Americans. Despite the availability of effective pharmacotherapies and indications for some tailored pharmacotherapies for African Americans (eg, heart failure medications), disease management is less effective among African Americans, yielding higher mortality. Explanations for these persistent disparities in cardiovascular disease are multifactorial and span from the individual level to the social environment. CONCLUSIONS The strategies needed to promote equity in the cardiovascular health of African Americans require input from a broad set of stakeholders, including clinicians and researchers from across multiple disciplines.
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20
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Lorenz G, Schmalenberg M, Kemmner S, Haller B, Steubl D, Pham D, Schreiegg A, Bachmann Q, Schmidt A, Haderer S, Huber M, Angermann S, Günthner R, Braunisch M, Hauser C, Reichelt AL, Matschkal J, Suttmann Y, Moog P, Stock K, Küchle C, Thürmel K, Renders L, Bauer A, Baumann M, Heemann U, Luppa PB, Schmaderer C. Mortality prediction in stable hemodialysis patients is refined by YKL-40, a 40-kDa glycoprotein associated with inflammation. Kidney Int 2017; 93:221-230. [PMID: 28941940 DOI: 10.1016/j.kint.2017.07.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/01/2017] [Accepted: 07/13/2017] [Indexed: 12/21/2022]
Abstract
Chronic inflammation contributes to increased mortality in hemodialysis (HD) patients. YKL-40 is a novel marker of inflammation, tissue remodeling, and highly expressed in macrophages inside vascular lesions. Elevated levels of YKL-40 have been reported for HD patients but how it integrates into the proinflammatory mediator network as a predictor of mortality remains elusive. We studied serum YKL-40, Interleukin-6 (IL-6), high-sensitivity C-reactive protein, monocyte chemotactic protein-1 (MCP-1), and interferon-gamma induced protein-10 (IP-10) in 475 chronic hemodialysis patients. Patients were followed for mortality for a median of 37 [interquartile range: 25-49] months and checked for interrelation of the measured mediators. To plot cumulative incidence functions, patients were stratified into terciles per YKL-40, IL-6, MCP-1, and IP-10 levels. Multivariable Cox regression models were built to examine associations of YKL-40, IP-10, and MCP-1 with all-cause and cause-specific mortality. Net reclassification improvement was calculated for the final models containing YKL-40 and IL-6. Increased YKL-40 was independently associated with age, IP-10, and IL-6 serum levels. After adjustment for demographic and laboratory parameters, comorbidities, and IL-6, only YKL-40 significantly improved risk prediction for all-cause (hazard ratio 1.4; 95% confidence interval 1.1-1.8) and cardiovascular mortality (hazard ratio 1.5; 95% confidence interval 1.03-2.2). Thus, in contrast to other biomarkers of aberrant macrophage activation, YKL-40 reflects inflammatory activity, which is not covered by IL-6. Mechanistic and prospective studies are needed to test for causal involvement of YKL-40 and whether it might qualify as a therapeutic target.
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Affiliation(s)
- Georg Lorenz
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
| | - Michael Schmalenberg
- Department of Clinical Chemistry, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Stephan Kemmner
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Bernhard Haller
- Department of Medical Statistics and Epidemiology, Technical University Munich, Munich, Germany
| | - Dominik Steubl
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Dang Pham
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Anita Schreiegg
- Department of Clinical Chemistry, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Quirin Bachmann
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Alina Schmidt
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Sandra Haderer
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Monika Huber
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Susanne Angermann
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Roman Günthner
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Matthias Braunisch
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Christine Hauser
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Anna-Lena Reichelt
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Julia Matschkal
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Yana Suttmann
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Philipp Moog
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Konrad Stock
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Claudius Küchle
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Klaus Thürmel
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Axel Bauer
- Department of Cardiology, Ludwig-Maximilian University, Munich, Germany
| | - Marcus Baumann
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Peter B Luppa
- Department of Clinical Chemistry, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
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21
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High Serum Alkaline Phosphatase, Hypercalcaemia, Race, and Mortality in South African Maintenance Haemodialysis Patients. Int J Nephrol 2017; 2017:2795432. [PMID: 28168054 PMCID: PMC5266852 DOI: 10.1155/2017/2795432] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 11/12/2016] [Accepted: 12/14/2016] [Indexed: 12/30/2022] Open
Abstract
Objective. To determine the association between serum total alkaline phosphatase (TAP) and mortality in African maintenance haemodialysis patients (MHD). Patients and Methods. The study enrolled a total of 213 patients on MHD from two dialysis centers in Johannesburg between January 2009 and March 2016. Patients were categorized into a low TAP group (≤112 U/L) versus a high TAP group (>112 U/L) based on a median TAP of 112 U/L. Results. During the follow-up period of 7 years, there were 55 (25.8%) deaths. After adjusting for cofounders such as age, other markers of bone disorder, and comorbidity (diabetes mellitus), patients in the high TAP group had significantly higher risk of death compared to patients in the low TAP group (hazard ratio, 2.50; 95% CI 1.24-5.01, P = 0.01). Similarly, serum calcium >2.75 mmol/L was associated with increased risk of death compared to patients within levels of 2.10-2.37 mmol/L (HR 6.34, 95% CI 1.40-28.76; P = 0.02). The HR for death in white patients compared to black patients was 6.88; 95% CI 1.82-25.88; P = 0.004. Conclusion. High levels of serum alkaline phosphatase, hypercalcaemia, and white race are associated with increased risk of death in MHD patients.
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22
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Thakur N, White MJ, Burchard EG. Race and Ethnicity. Respir Med 2017. [DOI: 10.1007/978-3-319-43447-6_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Norton JM, Moxey-Mims MM, Eggers PW, Narva AS, Star RA, Kimmel PL, Rodgers GP. Social Determinants of Racial Disparities in CKD. J Am Soc Nephrol 2016; 27:2576-95. [PMID: 27178804 PMCID: PMC5004663 DOI: 10.1681/asn.2016010027] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture. Social determinants of health have an important role as environmental components, especially for black populations, who are disproportionately disadvantaged. Understanding the social determinants of health and appreciating the underlying differences associated with meaningful clinical outcomes may help nephrologists treat all their patients with CKD in an optimal manner. Altering the social determinants of health, although difficult, may embody important policy and research efforts, with the ultimate goal of improving outcomes for patients with kidney diseases, and minimizing the disparities between groups.
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Affiliation(s)
- Jenna M Norton
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Marva M Moxey-Mims
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul W Eggers
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Andrew S Narva
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Robert A Star
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul L Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Griffin P Rodgers
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland Office of the Director and
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24
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Nutrition, vitamin D, and health outcomes in hemodialysis: time for a feeding frenzy? Curr Opin Nephrol Hypertens 2016; 24:546-56. [PMID: 26418058 DOI: 10.1097/mnh.0000000000000173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW The role of nutrition and nutritional supplementation in dialysis recently has been reinvigorated, with small clinical trials exploring surrogate outcomes and larger epidemiologic studies generating treatment hypotheses requiring further study. The present review focuses on major aspects of nutrition and outcomes in hemodialysis patients: protein and calorie intake and nutritional vitamin D supplementation. RECENT FINDINGS Building on data from small studies, two large, quasi-experimental cohort studies showed significant mortality benefits associated with oral nutritional supplements provided during dialysis, suggesting potential options for ameliorating the protein-energy wasting that is common in dialysis patients and associated with poor outcomes. Multiple cohort studies suggest, both in the general population and in dialysis, that higher 25(OH) vitamin D levels are associated with improved outcomes; however, no major mortality trials exist in dialysis, and the smaller, surrogate studies conducted to date have been disappointing, showing no consistent benefits in surrogate outcomes including inflammation and anemia, despite appropriate responses of vitamin D levels to repletion. SUMMARY Nutritional interventions are attractive options for improving outcomes in dialysis patients. Nutritional protein supplements have considerable promise, but require further study, preferably in a large, generalizable pragmatic trial. Small nutritional vitamin D supplementation trials in dialysis have had disappointing results. In the absence of new data, there appears to be no role for routine assessment or repletion of 25(OH) vitamin D deficiency or insufficiency in dialysis.
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25
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Shafi T, Powe NR, Meyer TW, Hwang S, Hai X, Melamed ML, Banerjee T, Coresh J, Hostetter TH. Trimethylamine N-Oxide and Cardiovascular Events in Hemodialysis Patients. J Am Soc Nephrol 2016; 28:321-331. [PMID: 27436853 DOI: 10.1681/asn.2016030374] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/22/2016] [Indexed: 12/18/2022] Open
Abstract
Cardiovascular disease causes over 50% of the deaths in dialysis patients, and the risk of death is higher in white than in black patients. The underlying mechanisms for these findings are unknown. We determined the association of the proatherogenic metabolite trimethylamine N-oxide (TMAO) with cardiovascular outcomes in hemodialysis patients and assessed whether this association differs by race. We measured TMAO in stored serum samples obtained 3-6 months after randomization from a total of 1232 white and black patients of the Hemodialysis Study, and analyzed the association of TMAO with cardiovascular outcomes using Cox models adjusted for potential confounders (demographics, clinical characteristics, comorbidities, albumin, and residual kidney function). Mean age of the patients was 58 years; 35% of patients were white. TMAO concentration did not differ between whites and blacks. In whites, 2-fold higher TMAO associated with higher risk (hazard ratio [95% confidence interval]) of cardiac death (1.45 [1.24 to 1.69]), sudden cardiac death [1.70 (1.34 to 2.15)], first cardiovascular event (1.15 [1.01 to 1.32]), and any-cause death (1.22 [1.09 to 1.36]). In blacks, the association was nonlinear and significant only for cardiac death among patients with TMAO concentrations below the median (1.58 [1.03 to 2.44]). Compared with blacks in the same quintile, whites in the highest quintile for TMAO (≥135 μM) had a 4-fold higher risk of cardiac or sudden cardiac death and a 2-fold higher risk of any-cause death. We conclude that TMAO concentration associates with cardiovascular events in hemodialysis patients but the effects differ by race.
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Affiliation(s)
- Tariq Shafi
- Department of Medicine and .,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Neil R Powe
- Department of Medicine, University of California, San Francisco, California
| | - Timothy W Meyer
- Department of Medicine, Palo Alto Veterans Affairs Health Care System and Stanford University, Palo Alto, California
| | | | - Xin Hai
- Department of Medicine, Case Western University School of Medicine, Cleveland, Ohio
| | - Michal L Melamed
- Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York; and
| | - Tanushree Banerjee
- Department of Medicine, University of California, San Francisco, California
| | - Josef Coresh
- Department of Medicine and.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland.,Departments of Epidemiology and Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Thomas H Hostetter
- Department of Medicine, Case Western University School of Medicine, Cleveland, Ohio
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26
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Kato S, Lindholm B, Yuzawa Y, Tsuruta Y, Nakauchi K, Yasuda K, Sugiura S, Morozumi K, Tsuboi N, Maruyama S. High Ferritin Level and Malnutrition Predict High Risk of Infection-Related Hospitalization in Incident Dialysis Patients: A Japanese Prospective Cohort Study. Blood Purif 2016; 42:56-63. [PMID: 27093060 DOI: 10.1159/000445424] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 03/11/2016] [Indexed: 11/19/2022]
Abstract
AIMS The aim of the study was to clarify the relationship between serum ferritin and infectious risks. METHODS We evaluated all hospital admissions due to infections, clinical biomarkers and nutrition status in 129 incident Japanese dialysis patients during a median follow-up of 38 months. RESULTS Kaplan-Meier analysis revealed that the period without infections requiring hospitalization was significantly shorter in ferritin > median (82.0 ng/ml) group than in the ferritin < median group (log-rank test 4.44, p = 0.035). High ferritin was associated with significantly increased relative risk of hospitalization for infection (Cox hazard model 1.52, 95% CI 1.06-2.17). The number of hospitalization days was gradually longer in patients with high ferritin levels and malnutrition. CONCLUSION Although serum ferritin levels were low, and doses of iron administered to dialysis patients in Japan are generally lower than in Western countries, an elevated ferritin level was associated with increased risk of infection, particularly in patients with poor nutritional status.
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Affiliation(s)
- Sawako Kato
- Division of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
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27
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Scialla JJ, Parekh RS, Eustace JA, Astor BC, Plantinga L, Jaar BG, Shafi T, Coresh J, Powe NR, Melamed ML. Race, Mineral Homeostasis and Mortality in Patients with End-Stage Renal Disease on Dialysis. Am J Nephrol 2015; 42:25-34. [PMID: 26287973 DOI: 10.1159/000438999] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 06/08/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Abnormalities in mineral homeostasis are ubiquitous in patients on dialysis, and influenced by race. In this study, we determine the race-specific relationship between mineral parameters and mortality in patients initiating hemodialysis. METHODS We measured the levels of fibroblast growth factor 23 (FGF23) and 25-hydroxyvitamin D (25 D) in 184 African American and 327 non-African American hemodialysis patients who enrolled between 1995 and 1998 in the Choices for Healthy Outcomes in Caring for ESRD Study. Serum calcium, phosphorus, parathyroid hormone (PTH) and total alkaline phosphatase levels were averaged from clinical measurements during the first 4.5 months of dialysis. We evaluated the associated prospective risk of mortality using multivariable Cox proportional hazards models stratified by race. RESULTS PTH and total alkaline phosphatase levels were higher, whereas calcium, phosphorus, FGF23 and 25 D levels were lower in African Americans compared to those of non-African Americans. Higher serum phosphorus and FGF23 levels were associated with greater mortality risk overall; however, phosphorus was only associated with risk among African Americans (HR 5.38, 95% CI 2.14-13.55 for quartile 4 vs. 1), but not among non-African Americans (p-interaction = 0.04). FGF23 was associated with mortality in both groups, but more strongly in African Americans (HR 3.91, 95% CI 1.74-8.82 for quartiles 4 vs. 1; p-interaction = 0.09). Serum calcium, PTH, and 25 D levels were not consistently associated with mortality. The lowest and highest quartiles of total alkaline phosphatase were associated with higher mortality risk, but this did not differ by race (p-interaction = 0.97). CONCLUSIONS Aberrant phosphorus homeostasis, reflected by higher phosphorus and FGF23, may be a risk factor for mortality in patients initiating hemodialysis, particularly among African Americans.
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Affiliation(s)
- Julia J Scialla
- University of Miami Miller School of Medicine, Miami, Fla., USA
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28
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Costello-White R, Ryff CD, Coe CL. Aging and low-grade inflammation reduce renal function in middle-aged and older adults in Japan and the USA. AGE (DORDRECHT, NETHERLANDS) 2015; 37:9808. [PMID: 26187318 PMCID: PMC4506280 DOI: 10.1007/s11357-015-9808-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/21/2015] [Indexed: 06/04/2023]
Abstract
The objective of this study was to investigate the effects of low-grade inflammation on age-related changes in glomerular filtration rate (GFR) in middle-aged and older white Americans, African-Americans, and Japanese adults. Serum creatinine, C-reactive protein (CRP), and interleukin-6 (IL-6) levels were determined for 1570 adult participants in two surveys of aging in the USA and Japan (N = 1188 and 382, respectively). Kidney function declined with age in both countries and was associated with IL-6 and CRP. IL-6 and CRP also influenced the extent of the arithmetic bias when calculating the GFR using the chronic kidney disease epidemiology (CKD-EPI) formula with just serum creatinine. Younger African-Americans initially had the highest GFR but showed a steep age-related decrement that was associated with elevated inflammation. Japanese adults had the lowest average GFR but evinced a large effect of increased inflammatory activity when over 70 years of age. Importantly, our results also indicate that low-grade inflammation is important to consider when evaluating kidney function solely from serum creatinine.
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29
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Kalbfleisch J, Wolfe R, Bell S, Sun R, Messana J, Shearon T, Ashby V, Padilla R, Zhang M, Turenne M, Pearson J, Dahlerus C, Li Y. Risk Adjustment and the Assessment of Disparities in Dialysis Mortality Outcomes. J Am Soc Nephrol 2015; 26:2641-5. [PMID: 25882829 DOI: 10.1681/asn.2014050512] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 03/14/2015] [Indexed: 12/28/2022] Open
Abstract
Standardized mortality ratios (SMRs) reported by Medicare compare mortality at individual dialysis facilities with the national average, and are currently adjusted for race. However, whether the adjustment for race obscures or clarifies disparities in quality of care for minority groups is unknown. Cox model-based SMRs were computed with and without adjustment for patient race for 5920 facilities in the United States during 2010. The study population included virtually all patients treated with dialysis during this period. Without race adjustment, facilities with higher proportions of black patients had better survival outcomes; facilities with the highest percentage of black patients (top 10%) had overall mortality rates approximately 7% lower than expected. After adjusting for within-facility racial differences, facilities with higher proportions of black patients had poorer survival outcomes among black and non-black patients; facilities with the highest percentage of black patients (top 10%) had mortality rates approximately 6% worse than expected. In conclusion, accounting for within-facility racial differences in the computation of SMR helps to clarify disparities in quality of health care among patients with ESRD. The adjustment that accommodates within-facility comparisons is key, because it could also clarify relationships between patient characteristics and health care provider outcomes in other settings.
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Affiliation(s)
- John Kalbfleisch
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | | | - Sarah Bell
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Rena Sun
- Kidney Epidemiology and Cost Center
| | - Joseph Messana
- Kidney Epidemiology and Cost Center, Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; and
| | - Tempie Shearon
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Valarie Ashby
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Robin Padilla
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Min Zhang
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Marc Turenne
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Jeffrey Pearson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Claudia Dahlerus
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
| | - Yi Li
- Kidney Epidemiology and Cost Center, Department of Biostatistics, and
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30
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Akchurin OM, Kaskel F. Update on inflammation in chronic kidney disease. Blood Purif 2015; 39:84-92. [PMID: 25662331 DOI: 10.1159/000368940] [Citation(s) in RCA: 377] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite recent advances in chronic kidney disease (CKD) and end-stage renal disease (ESRD) management, morbidity and mortality in this population remain exceptionally high. Persistent, low-grade inflammation has been recognized as an important component of CKD, playing a unique role in its pathophysiology and being accountable in part for cardiovascular and all-cause mortality, as well as contributing to the development of protein-energy wasting. SUMMARY The variety of factors contribute to chronic inflammatory status in CKD, including increased production and decreased clearance of pro-inflammatory cytokines, oxidative stress and acidosis, chronic and recurrent infections, including those related to dialysis access, altered metabolism of adipose tissue, and intestinal dysbiosis. Inflammation directly correlates with the glomerular filtration rate (GFR) in CKD and culminates in dialysis patients, where extracorporeal factors, such as impurities in dialysis water, microbiological quality of the dialysate, and bioincompatible factors in the dialysis circuit play an additional role. Genetic and epigenetic influences contributing to inflammatory activation in CKD are currently being intensively investigated. A number of interventions have been proposed to target inflammation in CKD, including lifestyle modifications, pharmacological agents, and optimization of dialysis. Importantly, some of these therapies have been recently tested in randomized controlled trials. KEY MESSAGES Chronic inflammation should be regarded as a common comorbid condition in CKD and especially in dialysis patients. A number of interventions have been proven to be safe and effective in well-designed clinical studies. This includes such inexpensive approaches as modification of physical activity and dietary supplementation. Further investigations are needed to evaluate the effects of these interventions on hard outcomes, as well as to better understand the role of inflammation in selected CKD populations (e.g., in children).
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Affiliation(s)
- Oleh M Akchurin
- Weill Cornell College of Medicine, Department of Pediatrics, New York, N.Y., USA
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31
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Morton RL, Schlackow I, Mihaylova B, Staplin ND, Gray A, Cass A. The impact of social disadvantage in moderate-to-severe chronic kidney disease: an equity-focused systematic review*. Nephrol Dial Transplant 2015; 31:46-56. [DOI: 10.1093/ndt/gfu394] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/28/2014] [Indexed: 11/12/2022] Open
Abstract
Abstract
It is unclear whether a social gradient in health outcomes exists for people with moderate-to-severe chronic kidney disease (CKD). We critically review the literature for evidence of social gradients in health and investigate the ‘suitability’ of statistical analyses in the primary studies. In this equity-focused systematic review among adults with moderate-to-severe CKD, factors of disadvantage included gender, race/ethnicity, religion, education, socio-economic status or social capital, occupation and place of residence. Outcomes included access to healthcare, kidney disease progression, cardiovascular events, all-cause mortality and suitability of analyses. Twenty-four studies in the pre-dialysis population and 34 in the dialysis population representing 8.9 million people from 10 countries were included. In methodologically suitable studies among pre-dialysis patients, a significant social gradient was observed in access to healthcare for those with no health insurance and no home ownership. Low income and no home ownership were associated with higher cardiovascular event rates and higher mortality [HR 1.94, 95% confidence interval (CI) 1.27–2.98; HR 1.28, 95% CI 1.04–1.58], respectively. In methodologically suitable studies among dialysis patients, females, ethnic minorities, those with low education, no health insurance, low occupational level or no home ownership were significantly less likely to access cardiovascular healthcare than their more advantaged dialysis counterparts. Low education level and geographic remoteness were associated with higher cardiovascular event rates and higher mortality (HR 1.54, 95% CI 1.01–2.35; HR 1.21, 95% CI 1.08–1.37), respectively. Socially disadvantaged pre-dialysis and dialysis patients experience poorer access to specialist cardiovascular health services, and higher rates of cardiovascular events and mortality than their more advantaged counterparts.
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Affiliation(s)
- Rachael Lisa Morton
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Iryna Schlackow
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Natalie Dawn Staplin
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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Johns TS, Estrella MM, Crews DC, Appel LJ, Anderson CAM, Ephraim PL, Cook C, Boulware LE. Neighborhood socioeconomic status, race, and mortality in young adult dialysis patients. J Am Soc Nephrol 2014; 25:2649-57. [PMID: 24925723 PMCID: PMC4214533 DOI: 10.1681/asn.2013111207] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 03/14/2014] [Indexed: 12/28/2022] Open
Abstract
Young blacks receiving dialysis have an increased risk of death compared with whites in the United States. Factors influencing this disparity among the young adult dialysis population have not been well explored. Our study examined the relation of neighborhood socioeconomic status (SES) and racial differences in mortality in United States young adults receiving dialysis. We merged US Renal Data System patient-level data from 11,027 black and white patients ages 18-30 years old initiating dialysis between 2006 and 2009 with US Census data to obtain neighborhood poverty information for each patient. We defined low SES neighborhoods as those neighborhoods in U.S. Census zip codes with ≥20% of residents living below the federal poverty level and quantified race differences in mortality risk by level of neighborhood SES. Among patients residing in low SES neighborhoods, blacks had greater mortality than whites after adjusting for baseline demographics, clinical characteristics, rurality, and access to care factors. This difference in mortality between blacks and whites was significantly attenuated in higher SES neighborhoods. In the United States, survival between young adult blacks and whites receiving dialysis differs by neighborhood SES. Additional studies are needed to identify modifiable factors contributing to the greater mortality among young adult black dialysis patients residing in low SES neighborhoods.
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Affiliation(s)
- Tanya S Johns
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York;
| | - Michelle M Estrella
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Lawrence J Appel
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Cheryl A M Anderson
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland; Division of Preventive Medicine, Department of Family and Preventive Medicine, University of California San Diego School of Medicine, San Diego, California; and
| | - Patti L Ephraim
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Courtney Cook
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland; Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - L Ebony Boulware
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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33
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Neutrophil/lymphocyte ratio as a predictor of cardiovascular events in incident dialysis patients: a Japanese prospective cohort study. Clin Exp Nephrol 2014; 19:718-24. [DOI: 10.1007/s10157-014-1046-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 10/17/2014] [Indexed: 12/24/2022]
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34
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Fedewa SA, McClellan WM, Judd S, Gutiérrez OM, Crews DC. The association between race and income on risk of mortality in patients with moderate chronic kidney disease. BMC Nephrol 2014; 15:136. [PMID: 25150057 PMCID: PMC4144698 DOI: 10.1186/1471-2369-15-136] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 08/13/2014] [Indexed: 02/02/2023] Open
Abstract
Background Socioeconomic status (SES) is independently associated with chronic kidney disease (CKD) progression; however, its association with other CKD outcomes is unclear. In particular, the potential differential effect of SES on mortality among blacks and whites is understudied in CKD. We aimed to examine survival among individuals with prevalent CKD by income and race in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Methods We examined 2,761 participants with prevalent CKD stage 3 or 4 between 2003 and 2007 in the REGARDS cohort. Participants were followed through March 2013. Mortality from any cause was assessed by income and race (black or white). Low income was defined as an annual household income < $20,000, and was compared to higher incomes (≥$20,000). Cox proportional hazards models adjusted for age, gender, education, insurance, CKD stage, comorbidity and county-level poverty were used to estimate hazard ratios (HR) and 95% confidence intervals (CI). Results A total of 750 deaths (27.5%) occurred during the follow-up period. Average follow-up time was 6.6 years among those alive and 3.7 years among those who died. Low income participants had an elevated adjusted hazard of mortality (HR = 1.58, 95% CI 1.24-2.00) compared to higher income participants. Low income was associated with all-cause mortality regardless of race (HR 1.53; 95% CI 1.18-1.99 among blacks and HR 1.38; 95% CI 1.10-1.74 among whites), with no significant statistical interaction between household income and race (p-value = 0.634). However, black participants had a higher adjusted hazard of mortality (HR = 1.30, 95% CI 1.02-1.65) compared to whites, which was independent of income. Conclusion Income was associated with increased mortality for both blacks and whites with CKD. Blacks with CKD had higher mortality than whites even after adjusting for important socio-demographic and clinical factors.
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Affiliation(s)
- Stacey A Fedewa
- Department of Epidemiology, Emory University, Claudia Nance Rollins Building, 3rd Floor, 1518 Clifton Road, NE, Atlanta, GA 30322, USA.
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Abstract
Chronic kidney disease (CKD) is a national public health problem. Although the prevalence of early stages of CKD is similar across different racial/ethnic and socioeconomic groups, the prevalence of end-stage renal disease is greater for minorities than their non-Hispanic white peers. Paradoxically, once on dialysis, minorities experience survival rates that exceed their non-Hispanic white peers. Advancing our understanding of the unique interplay of biological, genetic, environmental, sociocultural, and health care system level factors may prompt reorientation of our approach to health promotion and disease prevention. The potential of this new approach is to create previously unimagined gains to improve patient outcomes and reduce health inequities for patients with CKD.
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Affiliation(s)
- Susanne B Nicholas
- Department of Medicine, Division of Nephrology and Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine at University of California, Los Angeles, CA; Charles R. Drew University of Medicine and Science, Los Angeles, CA.
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Sinha SK, Shaheen M, Rajavashisth TB, Pan D, Norris KC, Nicholas SB. Association of race/ethnicity, inflammation, and albuminuria in patients with diabetes and early chronic kidney disease. Diabetes Care 2014; 37:1060-8. [PMID: 24550221 PMCID: PMC4069363 DOI: 10.2337/dc13-0013] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE African Americans (AAs) and Hispanics have higher diabetes and end-stage renal disease but similar or lower early chronic kidney disease (CKD) compared with whites. Inflammation plays a critical role in the pathogenesis of diabetes-related CKD. We postulated that in contrast to the general population, AAs and Hispanics have a higher prevalence of early diabetic CKD and systemic inflammatory markers compared with whites. RESEARCH DESIGN AND METHODS We analyzed the National Health and Nutrition Examination Survey 1999-2008 of 2,310 diabetic patients aged ≥20 years with fasting plasma glucose (FPG) ≥126 mg/dL. We performed multiple linear regression among patients with early CKD (urinary albumin excretion [UAE] ≥30 μg/mL and estimated glomerular filtration rate ≥60 mL/min/1.73 m(2)) to test the relationship between UAE and C-reactive protein (CRP) by race/ethnicity, adjusting for demographics, diabetes duration, FPG, hemoglobin A1c, uric acid, white blood cell count, medication use, cardiovascular disease, and related parameters. RESULTS In patients with diabetes, the prevalence of early CKD was greater among Hispanics and AAs than whites (P < 0.0001). AAs had higher adjusted odds ratio (AOR) for CRP ≥0.2 mg/dL (AOR 1.81 [95% CI 1.19-2.78]), and Hispanics had higher AOR for UAE ≥30 μg/mL (AOR 1.65 [1.07-2.54]). In a regression model adjusted for confounding variables, there was a significant association between UAE and CRP in the mid-CRP tertile (CRP 0.20-0.56 mg/dL, P = 0.001) and highest CRP tertile (CRP ≥0.57 mg/dL, P = 0.01) for Hispanics, but only in the mid-CRP tertile (P = 0.04) for AAs, compared with whites. CONCLUSIONS AAs and Hispanics with diabetes have a higher prevalence of early CKD compared with whites, which is significantly associated with UAE and/or CRP.
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Siracuse JJ, Gill HL, Epelboym I, Wollstein A, Kotsurovskyy Y, Catz D, Kim IK, Morrissey NJ. Effect of race and insurance status on outcomes after vascular access placement for hemodialysis. Ann Vasc Surg 2013; 28:964-9. [PMID: 24370501 DOI: 10.1016/j.avsg.2013.10.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 10/27/2013] [Accepted: 10/31/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Race and insurance status are seen as potential barriers to health care access and maintenance. Our goal was to see how these, as well as other patient and procedural characteristics, affected our populations' upper extremity vascular access outcomes. METHODS We retrospectively reviewed 601 vascular access patients from 2004 through 2012 in our urban university hospital. We recorded patient demographics, insurance status, comorbidities, and complications. Primary outcomes were reintervention, long-term mortality, and transplantation. RESULTS Median age was 62 ± 15.8 years, and 58% were male. Most operations were arteriovenous fistulas (66%). The majority of patients identified themselves as Hispanic (50%), followed by white (22%), and black (19%). Most patients had Medicare only (42%), 31% had private insurance, and 27% had Medicaid as their insurance. Black/African American patients were more likely to receive an arteriovenous graft (AVG) compared with white and Hispanic patients (44% vs. 28% and 33%, P < 0.05). White patients were significantly older (68) than Hispanics (61) or blacks (58). Freedom from reintervention at 5 years was 55% with previous tunneled catheter use predictive. Mortality at 5 years was 35% and predicted by age, AVG placement, white race, and not receiving a kidney transplant. Predictors of not receiving a transplant included older age, lower albumin, AVG placement, and coronary artery disease. CONCLUSIONS There were no disparities with insurance status in long-term outcomes in our population. Race was not a factor for reintervention or transplantation; however, black/African American patients were more likely have an AVG placed, and white patients had a lower long-term survival after access placement.
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Affiliation(s)
- Jeffrey J Siracuse
- New York-Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York, NY.
| | - Heather L Gill
- New York-Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Irene Epelboym
- New York-Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Adi Wollstein
- New York-Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Yuriy Kotsurovskyy
- New York-Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Diana Catz
- New York-Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York, NY
| | - In-Kyong Kim
- New York-Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Nicholas J Morrissey
- New York-Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York, NY
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Jesky M, Lambert A, Burden ACF, Cockwell P. The impact of chronic kidney disease and cardiovascular comorbidity on mortality in a multiethnic population: a retrospective cohort study. BMJ Open 2013; 3:e003458. [PMID: 24302500 PMCID: PMC3855607 DOI: 10.1136/bmjopen-2013-003458] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To assess the impact of chronic kidney disease (CKD) and cardiovascular comorbidity on mortality in a multiethnic primary care population. DESIGN Retrospective cohort study. SETTING Inner-city primary care trust in West Midlands, UK. PARTICIPANTS Individuals aged 40 years and older, of South Asian, black or white ethnicity, registered with a general practice and with their kidney function checked within the last 12 months (n=31 254). OUTCOME MEASURE All-cause mortality. RESULTS Reduced estimated glomerular filtration rate, higher albuminuria, older age, white ethnicity (vs South Asian or black ethnicity) and increasing cardiovascular comorbidities were independent determinants of a higher mortality risk. In the multivariate model including comorbidities and kidney function, the HR for mortality for South Asians was 0.697 (95% CI 0.56 to 0.868, p=0.001) and for blacks it was 0.533 (95% CI 0.403 to 0.704, p<0.001) compared to whites. CONCLUSIONS The HR for death is lower for South Asian and black individuals compared to white individuals. This is, in part, independent of age, gender, socioeconomic status, kidney function and comorbidities. Risk of death is higher in individuals with CKD and with a higher cumulative cardiovascular comorbidity.
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Affiliation(s)
- Mark Jesky
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Division of Infection and Immunity, University of Birmingham, Birmingham, UK
| | - Amanda Lambert
- Public Health Intelligence, Birmingham City Council, Birmingham, UK
| | - A C Felix Burden
- Sandwell and West Birmingham Clinical Commissioning Group, Birmingham, UK
| | - Paul Cockwell
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Division of Infection and Immunity, University of Birmingham, Birmingham, UK
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Crews DC, Scialla JJ, Liu J, Guo H, Bandeen-Roche K, Ephraim PL, Jaar BG, Sozio SM, Miskulin DC, Tangri N, Shafi T, Meyer KB, Wu AW, Powe NR, Boulware LE. Predialysis health, dialysis timing, and outcomes among older United States adults. J Am Soc Nephrol 2013; 25:370-9. [PMID: 24158988 DOI: 10.1681/asn.2013050567] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Studies of dialysis initiation timing have not accounted for predialysis clinical factors that could impact postdialysis outcomes. We examined the association of predialysis health with timing of dialysis initiation in older adult patients in the United States and contrasted morbidity and mortality outcomes among patients with early [estimated GFR (eGFR)≥10 ml/min per 1.73 m(2)] versus later (eGFR<10 ml/min per 1.73 m(2)) initiation. We included all patients from the US Renal Data System who initiated dialysis between 2006 and 2008, were ≥67 years old, and had ≥2 years of prior Medicare coverage (n=84,654). We calculated patients' propensity to initiate dialysis early and matched patients by propensity scores. Cox models were used to compare risks of mortality and hospitalization among initiation groups. The majority (58%) of patients initiated dialysis early. Early initiators were more likely to have had AKI, multiple congestive heart failure admissions, and other hospitalizations preceding initiation. Among propensity-matched patients (n=61,930), early initiation associated with greater all-cause (hazard ratio [HR], 1.11; 95% confidence interval [95% CI], 1.08 to 1.14), cardiovascular (CV; HR, 1.13; 95% CI, 1.09 to 1.17), and infectious (HR, 1.13; 95% CI, 1.06 to 1.22) mortality and greater all-cause (HR, 1.03; 95% CI, 1.01 to 1.05) and infectious (HR, 1.10; 95% CI, 1.07 to 1.13) hospitalizations. There was no difference in CV hospitalizations. Among these older adults, early dialysis initiation associates with greater mortality and hospitalizations, even after accounting for predialysis clinical factors. These findings do not support the common practice of early dialysis initiation in the United States.
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Flythe JE, Brunelli SM. Racial Disparities in Survival on Peritoneal Dialysis. Am J Kidney Dis 2013; 62:10-1. [DOI: 10.1053/j.ajkd.2013.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 04/09/2013] [Indexed: 11/11/2022]
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Yan G, Norris KC, Yu AJ, Ma JZ, Greene T, Yu W, Cheung AK. The relationship of age, race, and ethnicity with survival in dialysis patients. Clin J Am Soc Nephrol 2013; 8:953-61. [PMID: 23539227 PMCID: PMC3675850 DOI: 10.2215/cjn.09180912] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 01/26/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Reports on the racial and ethnic differences in dialysis patient survival rates have been inconsistent. The literature suggests that these survival differences may be modified by age as well as categorizing white race as inclusive of Hispanic ethnicity. The goal of this study was to better understand these associations by examining survival among US dialysis patients by age, ethnicity, and race. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Between 1995 and 2009, 1,282,201 incident dialysis patients ages 18 years or older were identified in the United States Renal Data System. Dialysis survival was compared among non-Hispanic blacks, non-Hispanic whites, and Hispanics overall and stratified by seven age groups. RESULTS The median duration of follow-up was 22.3 months. Compared with non-Hispanic whites, a lower mortality risk was seen in Hispanics in all age groups. Consequently, when Hispanic patients were excluded from the white race, the mortality rates in white race all increased. Using non-Hispanic whites as the reference, a significantly lower mortality risk for non-Hispanic blacks was consistently observed in all age groups above 30 years (unadjusted hazard ratios ranged from 0.70 to 0.87; all P<0.001). In the 18- to 30-years age group, there remained an increased mortality risk in blacks versus non-Hispanic whites after adjustment for case mix (adjusted hazard ratio=1.19, 95% confidence interval=1.13-1.25). CONCLUSIONS The mortality risk was lowest in Hispanics, intermediate in non-Hispanic blacks, and highest in non-Hispanic whites. This pattern generally holds in all age groups except for the 18- to 30-years group, where the adjusted mortality rate for non-Hispanic blacks exceeds the adjusted mortality rate of non-Hispanic whites.
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Affiliation(s)
- Guofen Yan
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia 22908-0717, USA.
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Lertdumrongluk P, Kovesdy CP, Norris KC, Kalantar-Zadeh K. Nutritional and inflammatory axis of racial survival disparities. Semin Dial 2012; 26:36-9. [PMID: 23230959 DOI: 10.1111/sdi.12025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Paungpaga Lertdumrongluk
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA
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Ameling JM, Auguste P, Ephraim PL, Lewis-Boyer L, DePasquale N, Greer RC, Crews DC, Powe NR, Rabb H, Boulware LE. Development of a decision aid to inform patients' and families' renal replacement therapy selection decisions. BMC Med Inform Decis Mak 2012. [PMID: 23198793 PMCID: PMC3560257 DOI: 10.1186/1472-6947-12-140] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few educational resources have been developed to inform patients' renal replacement therapy (RRT) selection decisions. Patients progressing toward end stage renal disease (ESRD) must decide among multiple treatment options with varying characteristics. Complex information about treatments must be adequately conveyed to patients with different educational backgrounds and informational needs. Decisions about treatment options also require family input, as families often participate in patients' treatment and support patients' decisions. We describe the development, design, and preliminary evaluation of an informational, evidence-based, and patient-and family-centered decision aid for patients with ESRD and varying levels of health literacy, health numeracy, and cognitive function. METHODS We designed a decision aid comprising a complementary video and informational handbook. We based our development process on data previously obtained from qualitative focus groups and systematic literature reviews. We simultaneously developed the video and handbook in "stages." For the video, stages included (1) directed interviews with culturally appropriate patients and families and preliminary script development, (2) video production, and (3) screening the video with patients and their families. For the handbook, stages comprised (1) preliminary content design, (2) a mixed-methods pilot study among diverse patients to assess comprehension of handbook material, and (3) screening the handbook with patients and their families. RESULTS The video and handbook both addressed potential benefits and trade-offs of treatment selections. The 50-minute video consisted of demographically diverse patients and their families describing their positive and negative experiences with selecting a treatment option. The video also incorporated health professionals' testimonials regarding various considerations that might influence patients' and families' treatment selections. The handbook was comprised of written words, pictures of patients and health care providers, and diagrams describing the findings and quality of scientific studies comparing treatments. The handbook text was written at a 4th to 6th grade reading level. Pilot study results demonstrated that a majority of patients could understand information presented in the handbook. Patient and families screening the nearly completed video and handbook reviewed the materials favorably. CONCLUSIONS This rigorously designed decision aid may help patients and families make informed decisions about their treatment options for RRT that are well aligned with their values.
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Affiliation(s)
- Jessica M Ameling
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Ephraim PL, Powe NR, Rabb H, Ameling J, Auguste P, Lewis-Boyer L, Greer RC, Crews DC, Purnell TS, Jaar BG, DePasquale N, Boulware LE. The providing resources to enhance African American patients' readiness to make decisions about kidney disease (PREPARED) study: protocol of a randomized controlled trial. BMC Nephrol 2012; 13:135. [PMID: 23057616 PMCID: PMC3489555 DOI: 10.1186/1471-2369-13-135] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 10/08/2012] [Indexed: 01/28/2023] Open
Abstract
Background Living related kidney transplantation (LRT) is underutilized, particularly among African Americans. The effectiveness of informational and financial interventions to enhance informed decision-making among African Americans with end stage renal disease (ESRD) and improve rates of LRT is unknown. Methods/design We report the protocol of the Providing Resources to Enhance African American Patients’ Readiness to Make Decisions about Kidney Disease (PREPARED) Study, a two-phase study utilizing qualitative and quantitative research methods to design and test the effectiveness of informational (focused on shared decision-making) and financial interventions to overcome barriers to pursuit of LRT among African American patients and their families. Study Phase I involved the evidence-based development of informational materials as well as a financial intervention to enhance African American patients’ and families’ proficiency in shared decision-making regarding LRT. In Study Phase 2, we are currently conducting a randomized controlled trial in which patients with new-onset ESRD receive 1) usual dialysis care by their nephrologists, 2) the informational intervention (educational video and handbook), or 3) the informational intervention in addition to the option of participating in a live kidney donor financial assistance program. The primary outcome of the randomized controlled trial will include patients’ self-reported rates of consideration of LRT (including family discussions of LRT, patient-physician discussions of LRT, and identification of a LRT donor). Discussion Results from the PREPARED study will provide needed evidence on ways to enhance the decision to pursue LRT among African American patients with ESRD. Trial registration ClinicalTrials.gov NCT01439516
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Affiliation(s)
- Patti L Ephraim
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 E. Monument Street, Suite 2-600, Baltimore, MD 21205, USA
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Golden SH, Brown A, Cauley JA, Chin MH, Gary-Webb TL, Kim C, Sosa JA, Sumner AE, Anton B. Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement. J Clin Endocrinol Metab 2012; 97:E1579-639. [PMID: 22730516 PMCID: PMC3431576 DOI: 10.1210/jc.2012-2043] [Citation(s) in RCA: 271] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Society's Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement. EVIDENCE The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society. CONCLUSIONS Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.
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Affiliation(s)
- Sherita Hill Golden
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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Kato S, Lindholm B, Stenvinkel P, Ekström TJ, Luttropp K, Yuzawa Y, Yasuda Y, Tsuruta Y, Maruyama S. DNA hypermethylation and inflammatory markers in incident Japanese dialysis patients. NEPHRON EXTRA 2012; 2:159-68. [PMID: 22811689 PMCID: PMC3398825 DOI: 10.1159/000339437] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background/Aims Inflammation is an established mortality risk factor in chronic kidney disease (CKD) patients. Although a previous report showed that uremic Caucasian patients with inflammation had signs of global DNA hypermethylation, it is still unknown whether DNA hypermethylation is linked to inflammatory markers including a marker of bacterial infections in Japanese CKD patients. Methods In 44 consecutive incident dialysis patients (26 males, mean age 59 ± 12 years) without clinical signs of infection, global DNA methylation was evaluated in peripheral blood DNA using the HpaII/MspI ratio by the luminometric methylation assay method. A lower ratio of HpaII/MspI indicates global DNA hypermethylation. Procalcitonin (PCT), a marker of inflammation due to bacterial infections, was measured using an immunochromatographic assay. Results The patients were divided into hyper- and hypomethylation groups based on the median value of the HpaII/MspI ratio 0.31 (range 0.29–0.37). Whereas patients in the hypermethylation group had higher ferritin levels [133.0 (51.5–247.3) vs. 59.5 (40.0–119.0) ng/ml; p = 0.046], there were no significant differences in age, gender, diabetes, smoking, anemia or serum albumin levels. However, the HpaII/MspI ratio showed significant negative correlations with PCT (ρ = −0.32, p = 0.035) and ferritin (ρ = −0.33, p = 0.027) in Spearman's rank test. In a multiple linear regression analysis, PCT and ferritin were associated with a lower HpaII/MspI ratio (R2 = 0.24, p = 0.013). Conclusion In this study, global DNA hypermethylation was associated with ferritin and, most likely, PCT, suggesting that inflammation induced by subclinical bacterial infection promoted DNA methylation.
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Affiliation(s)
- Sawako Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Sherman RA. Briefly Noted. Semin Dial 2012. [DOI: 10.1111/j.1525-139x.2012.01086.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kalantar-Zadeh K, Kovesdy CP, Norris KC. Racial survival paradox of dialysis patients: robust and resilient. Am J Kidney Dis 2012; 60:182-5. [PMID: 22495468 DOI: 10.1053/j.ajkd.2012.02.321] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 02/22/2012] [Indexed: 12/15/2022]
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Zaritsky JJ, Kalantar-Zadeh K. The crossroad of RAAS modulation, inflammation, and oxidative stress in dialysis patients: light at the end of the tunnel? J Am Soc Nephrol 2012; 23:189-91. [PMID: 22241894 DOI: 10.1681/asn.2011121208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Explaining racial disparities in survival on dialysis. Nat Rev Nephrol 2011. [DOI: 10.1038/nrneph.2011.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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