1
|
Sumida K, Shrestha P, Mallisetty Y, Surbhi S, Thomas F, Streja E, Kalantar-Zadeh K, Kovesdy CP. Incident Diuretic Use and Subsequent Risk of Bone Fractures: A Large Nationwide Observational Study of US Veterans. Mayo Clin Proc 2024:S0025-6196(23)00466-4. [PMID: 38573302 DOI: 10.1016/j.mayocp.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 04/05/2024]
Abstract
OBJECTIVE To investigate the association of incident use of diuretics with subsequent risk of incident bone fractures. PATIENTS AND METHODS In a nationwide cohort of 863,339 US veterans receiving care from the VA health care system between October 1, 2004, and September 30, 2006, with follow-up through June 30, 2018, we examined the association of incident diuretic use (overall, and separately by thiazide, loop, and potassium-sparing diuretics) with subsequent risk of incident bone fractures using multivariable Cox regression models while minimizing confounding by indication using a target trial emulation approach. RESULTS Patients were 63.3±12.9 years old; 93.5% (n=807,180) were male; and 27.1% (n=233,996) were diabetic. Their baseline estimated glomerular filtration rate was 84.4±16.5 mL/min per 1.73 m2. Among 863,339 patients, 424,386 (49.2%) newly initiated diuretics, of which 77.4% (n=328,524), 22.5% (n=95,457), and 0.1% (n=405) were thiazide, loop, and potassium-sparing diuretic users, respectively. After multivariable adjustments, incident diuretic use (vs non-use) was significantly associated with higher risk of incident fracture (adjusted HR [aHR], 1.14; 95% CI, 1.11 to 1.16). The association was most pronounced for loop diuretics (aHR, 1.39; 95% CI, 1.35 to 1.44) but less evident for thiazide diuretics (aHR, 1.08; 95% CI, 1.06 to 1.10) and was not significant for potassium-sparing diuretics (aHR, 0.97; 95% CI, 0.62 to 1.52). The diuretic-fracture association was more evident in younger (vs older) patients, those with (vs without) corticosteroid use, and those with lower (vs higher) serum sodium levels. CONCLUSION Incident use of diuretics, particularly loop diuretics, was independently associated with higher risk of incident bone fractures. Our findings suggest distinct pathophysiologic contributions of diuretics to bone metabolism and the need for careful attention to skeletal outcomes when initiating diuretics.
Collapse
Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Prabin Shrestha
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yamini Mallisetty
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Satya Surbhi
- Center for Health System Improvement, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Elani Streja
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange, CA, USA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange, CA, USA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA; Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA.
| |
Collapse
|
2
|
Sumida K, Shrestha P, Mallisetty Y, Thomas F, Gyamlani G, Streja E, Kalantar-Zadeh K, Kovesdy CP. Anti-Tumor Necrosis Factor Therapy and Risk of Kidney Function Decline and Mortality in Inflammatory Bowel Disease. JAMA Netw Open 2024; 7:e246822. [PMID: 38625700 PMCID: PMC11022116 DOI: 10.1001/jamanetworkopen.2024.6822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/16/2024] [Indexed: 04/17/2024] Open
Abstract
Importance Inflammatory bowel disease (IBD) is associated with adverse clinical outcomes, including chronic kidney disease and mortality, due in part to chronic inflammation. Little is known about the effects of anti-tumor necrosis factor (TNF) therapy on kidney disease progression and mortality among patients with new-onset IBD. Objective To examine the association of incident use of TNF inhibitors with subsequent decline in kidney function and risk of all-cause mortality. Design, Setting, and Participants This retrospective cohort study used data from the US Department of Veterans Affairs health care system. Participants were US veterans with new-onset IBD enrolled from October 1, 2004, through September 30, 2019. Data were analyzed from December 2022 to February 2024. Exposures Incident use of TNF inhibitors. Main Outcomes and Measures The main outcomes were at least 30% decline in estimated glomerular filtration rate (eGFR) and all-cause mortality. Results Among 10 689 patients (mean [SD] age, 67.4 [12.3] years; 9999 [93.5%] male) with incident IBD, 3353 (31.4%) had diabetes, the mean (SD) baseline eGFR was 77.2 (19.2) mL/min/1.73 m2, and 1515 (14.2%) were newly initiated on anti-TNF therapy. During a median (IQR) follow-up of 4.1 (1.9-7.0) years, 3367 patients experienced at least 30% decline in eGFR, and over a median (IQR) follow-up of 5.0 (2.5-8.0) years, 2502 patients died. After multivariable adjustments, incident use (vs nonuse) of TNF inhibitors was significantly associated with higher risk of decline in eGFR (adjusted hazard ratio [HR], 1.34 [95% CI, 1.18-1.52]) but was not associated with risk of all-cause mortality (adjusted HR, 1.02 [95% CI, 0.86-1.21]). Similar results were observed in sensitivity analyses. Conclusions and Relevance In this cohort study of US veterans with incident IBD, incident use (vs nonuse) of TNF inhibitors was independently associated with higher risk of progressive eGFR decline but was not associated with risk of all-cause mortality. Further studies are needed to elucidate potentially distinct pathophysiologic contributions of TNF inhibitor use to kidney and nonkidney outcomes in patients with IBD.
Collapse
Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Prabin Shrestha
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Yamini Mallisetty
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis
| | - Geeta Gyamlani
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee
| | - Elani Streja
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee
| |
Collapse
|
3
|
Gulanski BI, Goulet JL, Radhakrishnan K, Ko J, Li Y, Rajeevan N, Lee KM, Heberer K, Lynch JA, Streja E, Mutalik P, Cheung KH, Concato J, Shih MC, Lee JS, Aslan M. Metformin prescription for U.S. veterans with prediabetes, 2010-2019. J Investig Med 2024; 72:139-150. [PMID: 37668313 DOI: 10.1177/10815589231201141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
Affecting an estimated 88 million Americans, prediabetes increases the risk for developing type 2 diabetes mellitus (T2DM), and independently, cardiovascular disease, retinopathy, nephropathy, and neuropathy. Nevertheless, little is known about the use of metformin for diabetes prevention among patients in the Veterans Health Administration, the largest integrated healthcare system in the U.S. This is a retrospective observational cohort study of the proportion of Veterans with incident prediabetes who were prescribed metformin at the Veterans Health Administration from October 2010 to September 2019. Among 1,059,605 Veterans with incident prediabetes, 12,009 (1.1%) were prescribed metformin during an average 3.4 years of observation after diagnosis. Metformin prescribing was marginally higher (1.6%) among those with body mass index (BMI) ≥35 kg/m2, age <60 years, HbA1c≥6.0%, or those with a history of gestational diabetes, all subgroups at a higher risk for progression to T2DM. In a multivariable model, metformin was more likely to be prescribed for those with BMI ≥35 kg/m2 incidence rate ratio [IRR] 2.6 [95% confidence intervals (CI): 2.1-3.3], female sex IRR, 2.4 [95% CI: 1.8-3.3], HbA1c≥6% IRR, 1.93 [95% CI: 1.5-2.4], age <60 years IRR, 1.7 [95% CI: 1.3-2.3], hypertriglyceridemia IRR, 1.5 [95% CI: 1.2-1.9], hypertension IRR, 1.5 [95% CI: 1.1-2.1], Major Depressive Disorder IRR, 1.5 [95% CI: 1.1-2.0], or schizophrenia IRR, 2.1 [95% CI: 1.2-3.8]. Over 20% of Veterans with prediabetes attended a comprehensive structured lifestyle modification clinic or program. Among Veterans with prediabetes, metformin was prescribed to 1.1% overall, a proportion that marginally increased to 1.6% in the subset of individuals at highest risk for progression to T2DM.
Collapse
Affiliation(s)
- Barbara I Gulanski
- Department of Medicine, Endocrinology, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Joseph L Goulet
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
- Pain, Research, Informatics, Multi-morbidities and Education Center (PRIME), West Haven, CT, USA
| | - Krishnan Radhakrishnan
- National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services Administration, Rockville, MD, USA
| | - John Ko
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
| | - Yuli Li
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
| | - Nallakkandi Rajeevan
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
| | - Kyung Min Lee
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Kent Heberer
- VA Palo Alto Cooperative Studies Program Coordinating Center, VA Palo Alto Heath Care System, CA, USA
- Division of Endocrinology, Gerontology, and Metabolism, Department of Medicine, Endocrinology, Stanford University School of Medicine, Stanford, CA, USA
| | - Julie A Lynch
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elani Streja
- Department of Medicine, Nephrology, Hypertension and Transplant, University of California-Irvine School of Medicine, Long Beach, CA, USA
| | - Pradeep Mutalik
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
| | - Kei-Hoi Cheung
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - John Concato
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Mei-Chiung Shih
- VA Palo Alto Cooperative Studies Program Coordinating Center, VA Palo Alto Heath Care System, CA, USA
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer S Lee
- VA Palo Alto Cooperative Studies Program Coordinating Center, VA Palo Alto Heath Care System, CA, USA
- Division of Endocrinology, Gerontology, and Metabolism, Department of Medicine, Endocrinology, Stanford University School of Medicine, Stanford, CA, USA
| | - Mihaela Aslan
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
4
|
Lu JL, Shrestha P, Streja E, Kalantar-Zadeh K, Kovesdy CP. Association of long-term aspirin use with kidney disease progression. Front Med (Lausanne) 2023; 10:1283385. [PMID: 38111701 PMCID: PMC10726126 DOI: 10.3389/fmed.2023.1283385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/08/2023] [Indexed: 12/20/2023] Open
Abstract
Background Chronic microinflammation contributes to the progression of chronic kidney disease (CKD). Aspirin (ASA) has been used to treat inflammation for centuries. The effects of long-term low-dose ASA on CKD progression are unclear. Methods We examined the association of long-term use of newly initiated low-dose ASA (50-200 mg/day) with all-cause mortality using Cox proportional hazard models; with cardiovascular/cerebrovascular (CV) mortality and with end stage kidney disease (ESKD) using Fine and Gray competing risk regression models; with progression of CKD defined as patients' eGFR slopes steeper than -5 mL/min/1.73m2/year using logistic regression models in a nationwide cohort of US Veterans with incident CKD. Among 831,963 patients, we identified 385,457 who either initiated ASA (N = 21,228) within 1 year of CKD diagnosis or never received ASA (N = 364,229). We used propensity score matching to account for differences in key characteristics, yielding 29,480 patients (14,740 in each group). Results In the matched cohort, over a 4.9-year median follow-up period, 11,846 (40.2%) patients (6,017 vs. 5,829 ASA users vs. non-users) died with 25.8% CV deaths, and 934 (3.2%) patients (476 vs. 458) reached ESKD. ASA users had a higher risk of faster decline of kidney functions, i.e., steeper slopes (OR 1.30 [95%CI: 1.18, 1.44], p < 0.01), but did not have apparent benefits on mortality (HR 0.97 [95%CI: 0.94, 1.01], p = 0.17), CV mortality (Sub-Hazard Ratio [SHR]1.06 [95%CI: 0.99-1.14], p = 0.11), or ESKD (SHR1.00 [95%CI: 0.88, 1.13], p = 0.95). Conclusion Chronic low-dose ASA use was associated with faster kidney function deterioration, and no association was observed with mortality or risk of ESKD.
Collapse
Affiliation(s)
- Jun Ling Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Prabin Shrestha
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Elani Streja
- VA Connecticut Healthcare System, West Haven VA Medical Center, West Haven, CT, United States
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Transplantation, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, United States
- Division of Nephrology, Memphis VA Medical Center, Memphis, TN, United States
| |
Collapse
|
5
|
Shrestha P, Paul S, Sumida K, Thomas F, Surbhi S, Naser AM, Streja E, Rhee CM, Kalantar-Zadeh K, Kovesdy CP. Association of iron therapy with incidence of chronic kidney disease. Eur J Haematol 2023; 111:872-880. [PMID: 37668586 DOI: 10.1111/ejh.14091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE We investigated the association of oral iron replacement with the incidence of chronic kidney disease (CKD) in a population with normal kidney function to study the effects of iron replacement on the development of new onset CKD. METHODS In a national cohort of US Veterans with no pre-existing CKD, we identified 33 894 incident new users of oral iron replacement and a comparable group of 112 780 patients who did not receive any iron replacement during 2004-2018. We examined the association of oral iron replacement versus no iron replacement with the incidence of eGFR <60 mL/min/1.73 m2 and the incidence of urine albumin creatinine ratio (UACR) ≥30 mg/g in competing risk regressions and in Cox models. We used propensity score weighing to account for differences in key baseline characteristics associated with the use of oral iron replacement. RESULTS In the cohort of 146 674 patients, a total of 18 547 (13%) patients experienced incident eGFR <60 mL/min/1.73 m2 , and 16 117 patients (11%) experienced new onset UACR ≥30 mg/g. Oral iron replacement was associated with significantly higher risk of incident eGFR <60 mL/min/1.73 m2 (subhazard ratio, 95% confidence interval [CI]: 1.3 [1.22-1.38], p < .001) and incident albuminuria (subhazard ratio, 95% CI: 1.14 [1.07-1.22], p < .001). CONCLUSION Oral iron replacement is associated with higher risk of new onset CKD. The long-term kidney safety of oral iron replacement should be tested in clinical trials.
Collapse
Affiliation(s)
- Prabin Shrestha
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Shejuti Paul
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Satya Surbhi
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Abu Mohd Naser
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Connie M Rhee
- Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
- Long Beach VA Medical Center, Long Beach, California, USA
| | - Kamyar Kalantar-Zadeh
- Long Beach VA Medical Center, Long Beach, California, USA
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, Habor-UCLA Medical Center and the Lundquist Institute, Torrance, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
| |
Collapse
|
6
|
Kang DH, Streja E, You AS, Lee Y, Narasaki Y, Torres S, Novoa-Vargas A, Kovesdy CP, Kalantar-Zadeh K, Rhee CM. Hypoglycemia and Mortality Risk in Incident Hemodialysis Patients. J Ren Nutr 2023:S1051-2276(23)00151-6. [PMID: 37918644 DOI: 10.1053/j.jrn.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/14/2023] [Accepted: 09/10/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVE Hypoglycemia is a frequent occurrence in chronic kidney disease patients due to alterations in glucose and insulin metabolism. However, there are sparse data examining the predictors and clinical implications of hypoglycemia including mortality risk among incident hemodialysis patients. DESIGN AND METHODS Among 58,304 incident hemodialysis patients receiving care from a large national dialysis organization over 2007-2011, we examined clinical characteristics associated with risk of hypoglycemia, defined as a blood glucose concentration <70 mg/dL, in the first year of dialysis using expanded case-mix + laboratory logistic regression models. We then examined the association between hypoglycemia during the first year of dialysis with all-cause mortality using expanded case-mix + laboratory Cox models. RESULTS In the first year of dialysis, hypoglycemia was observed among 16.8% of diabetic and 6.9% of nondiabetic incident hemodialysis patients. In adjusted logistic regression models, clinical characteristics associated with hypoglycemia included younger age, female sex, African-American race, presence of a central venous catheter, lower residual renal function, and longer dialysis session length. In the overall cohort, patients who experienced hypoglycemia had a higher risk of all-cause mortality risk (reference: absence of hypoglycemia): adjusted hazard ratio (95% confidence interval) 1.08 (1.04, 1.13). In stratified analyses, hypoglycemia was also associated with higher mortality risk in the diabetic and nondiabetic subgroups: adjusted hazard ratios (95% confidence interval's) 1.08 (1.04-1.13), and 1.17 (0.94-1.45), respectively. CONCLUSIONS Hypoglycemia was a frequent occurrence among both diabetic and nondiabetic hemodialysis patients and was associated with a higher mortality risk. Further studies are needed to identify approaches that reduce hypoglycemia risk in the hemodialysis population.
Collapse
Affiliation(s)
- Duk-Hee Kang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California; Division of Nephrology, Department of Internal Medicine, Ewha Womans University School of Medicine, Ewha Medical Research Center, Seoul, South Korea
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Amy S You
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California
| | - Yongkyu Lee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California; Nephrology Division, Department of Internal Medicine, NHIS Ilsan Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Yoko Narasaki
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California
| | - Silvina Torres
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California
| | - Alejandra Novoa-Vargas
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California.
| |
Collapse
|
7
|
Paul S, Shrestha P, Sumida K, Thomas F, Surbhi S, Naser AM, Streja E, Rhee CM, Kalantar-Zadeh K, Kovesdy CP. Association of oral iron replacement therapy with kidney failure and mortality in CKD patients. Clin Kidney J 2023; 16:2082-2090. [PMID: 37915900 PMCID: PMC10616436 DOI: 10.1093/ckj/sfad190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Indexed: 11/03/2023] Open
Abstract
Background Oral iron is the predominant route of iron replacement (IRT) but its benefits and safety are unclear in patients with chronic kidney disease (CKD). Methods We examined the association of oral IRT vs no IRT with end-stage kidney disease (ESKD) and mortality in a national cohort of US Veterans. We identified 17 413 incident new users of oral IRT with estimated glomerular filtration rates <60 mL/min/1.73 m2 and 32 530 controls who did not receive any IRT during 2004-18. We used propensity score-overlap weighting to account for differences in key baseline characteristics associated with the use of oral IRT. We examined associations using competing risk regression and Cox models. Results In the cohort of 49 943 patients, 1616 (3.2%) patients experienced ESKD and 28 711 (57%) patients died during a median follow-up of 1.9 years. Oral IRT was not associated with ESKD [subhazard ratio (HR) (95% confidence interval, CI) 1.00 (0.84-1.19), P = .9] and was associated with higher risk of all-cause mortality [HR (95% CI) 1.06 (1.01-1.11), P = .01]. There was significant heterogeneity of treatment effect for mortality, with oral IRT associated with higher mortality in the subgroups of patients without congestive heart failure (CHF), anemia or iron deficiency. In patient with blood hemoglobin <10 g/dL oral IRT was associated with significantly lower mortality. Conclusion Oral IRT was associated with lower mortality only in patients with anemia. In patients without anemia, iron deficiency or CHF, the risk-benefit ratio of oral IRT should be further examined.
Collapse
Affiliation(s)
- Shejuti Paul
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Prabin Shrestha
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Satya Surbhi
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Abu Mohd Naser
- Division of Epidemiology, Biostatistics, and Environmental Health, University of Memphis, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California-Irvine, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California-Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California-Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
| |
Collapse
|
8
|
Attai DJ, Katz MS, Streja E, Hsiung JT, Marroquin MV, Zavaleta BA, Nekhlyudov L. Patient preferences and comfort for cancer survivorship models of care: results of an online survey. J Cancer Surviv 2023; 17:1327-1337. [PMID: 35113306 DOI: 10.1007/s11764-022-01177-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Workforce shortages will impact oncologists' ability to provide both active and survivorship care. While primary care provider (PCP) or survivorship clinic transition has been emphasized, there is little evidence regarding patient comfort. METHODS We developed an online survey in partnership with patient advocates to assess survivors' comfort with PCP or survivorship clinic care and distributed the survey to online, cancer-specific patient communities from June to August 2020. Descriptive and logistic regression analyses were conducted. RESULTS A total of 975 surveys were complete. Most respondents were women (91%) and had private insurance (65%). Thirty-six cancer types were reported. Ninety-three percent had a PCP. Twenty-four percent were comfortable seeing a PCP for survivorship care. Higher odds of comfort were seen among respondents who were Black or had stage 0 cancer; female sex was associated with lower odds. Fifty-five percent were comfortable with a survivorship clinic. Higher odds of comfort were seen with lymphoma or ovarian cancer, > 15 years from diagnosis, and non-US government insurance. Lower odds were seen with melanoma, advanced stage, Medicaid insurance, and one late effect. Preference for PCP care was 87% for general health, 32% for recurrence monitoring, and 37% for late effect management. CONCLUSIONS One quarter of cancer survivors were comfortable with PCP-led survivorship care and about half with a survivorship clinic. Most preferred oncologist care for recurrence monitoring and late-effect management. IMPLICATIONS FOR CANCER SURVIVORS Patient preference and comfort should be considered when developing survivorship care models. Future efforts should focus on facilitating patient-centered transitions to non-oncologist care.
Collapse
Affiliation(s)
- Deanna J Attai
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- UCLA Health Burbank Breast Care, 191 S. Buena Vista #415, Burbank, CA, 91505, USA.
| | - Matthew S Katz
- Department of Radiation Medicine, Lowell General Hospital, Lowell, MA, USA
| | - Elani Streja
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Jui-Ting Hsiung
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
| | | | - Beverly A Zavaleta
- Department of Medicine, Valley Baptist Medical Center - Brownsville, Brownsville, TX, USA
| | - Larissa Nekhlyudov
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
9
|
Hamiduzzaman A, Wu R, Murray V, Kalantar-Zadeh K, Streja E, Sy J. Comparing the Fried frailty phenotype versus the Veterans Affairs frailty index among dialysis dependent patients. Hemodial Int 2023; 27:444-453. [PMID: 37318050 DOI: 10.1111/hdi.13101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Frailty in dialysis patients is a modifiable disease state which can increase mortality if left untreated but remains underdiagnosed as frailty evaluations can be arduous or time consuming. We evaluate the agreement between a clinical frailty construct (Fried frailty phenotype, FFP) against and an electronic health record-based Veterans Affairs Frailty Index (VAFI) and their association with mortality. METHODS A retrospective cohort analysis of 764 participants from the ACTIVE/ADIPOSE study was performed. Frailty as measured by VAFI and FFP was obtained and Kappa statistic estimating concordance between the two scores were calculated. Differences in mortality risk were analyzed according to presence or absence of frailty. FINDINGS When assessing agreement between the VAFI and FFP, the kappa statistic was 0.09 (95% confidence interval [CI] 0.02-0.16) suggesting a low level of agreement. Frailty was independently associated with higher mortality risk (hazards ratio [HR] 1.40-1.42 in fully adjusted models depending upon frailty construct). Discordantly frail patients by construct had a higher risk of mortality though this was not statistically significant after adjustment. However, concordantly frail patients had much higher mortality risk compared to concordantly nonfrail (adjusted HR 2.08, 95% CI 1.44-3.01). DISCUSSION Poor agreement between constructs is likely reflective of the multifactorial definition of frailty. While further longitudinal studies are needed to determine if the VAFI would be beneficial in the reassessment of frailty, it may be beneficial as a cue for further frailty testing (e.g., with FFP) with the combination of multiple frail constructs providing improved prognostic information.
Collapse
Affiliation(s)
- Anum Hamiduzzaman
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
- Veterans Affairs Long Beach Healthcare System, Division of Nephrology, Long Beach, California, USA
| | - Ruoxue Wu
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Victoria Murray
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
- Veterans Affairs Long Beach Healthcare System, Division of Nephrology, Long Beach, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
- Veterans Affairs Long Beach Healthcare System, Division of Nephrology, Long Beach, California, USA
| | - John Sy
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
- Veterans Affairs Long Beach Healthcare System, Division of Nephrology, Long Beach, California, USA
| |
Collapse
|
10
|
Yan L, Streja E, Li Y, Rajeevan N, Rowneki M, Berry K, Hynes DM, Cunningham F, Huang GD, Aslan M, Ioannou GN, Bajema KL. Anti-SARS-CoV-2 Pharmacotherapies Among Nonhospitalized US Veterans, January 2022 to January 2023. JAMA Netw Open 2023; 6:e2331249. [PMID: 37651140 PMCID: PMC10472184 DOI: 10.1001/jamanetworkopen.2023.31249] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/11/2023] [Indexed: 09/01/2023] Open
Abstract
Importance Several pharmacotherapies have been authorized to treat nonhospitalized persons with symptomatic COVID-19. Longitudinal information on the use of these therapies is needed. Objective To analyze trends and factors associated with prescription of outpatient COVID-19 pharmacotherapies within the Veterans Health Administration (VHA). Design, Setting, and Participants This cohort study evaluated nonhospitalized veterans in VHA care who tested positive for SARS-CoV-2 from January 2022 through January 2023 using VHA and linked Community Care and Medicare databases. Exposures Demographic characteristics, underlying medical conditions, COVID-19 vaccination, and regional and local systems of care, including Veterans Integrated Services Networks (VISNs). Main Outcomes and Measures Monthly receipt of any COVID-19 pharmacotherapy (nirmatrelvir-ritonavir, molnupiravir, sotrovimab, or bebtelovimab) was described. Multivariable logistic regression was used to identify factors independently associated with receipt of any vs no COVID-19 pharmacotherapy. Results Among 285 710 veterans (median [IQR] age, 63.1 [49.9-73.7] years; 247 358 males [86.6%]; 28 444 Hispanic [10.0%]; 61 269 Black [21.4%] and 198 863 White [69.6%]) who tested positive for SARS-CoV-2 between January 2022 and January 2023, the proportion receiving any pharmacotherapy increased from 3285 of 102 343 veterans (3.2%) in January 2022 to 5180 of 21 688 veterans (23.9%) in August 2022. The proportion declined to 2194 of 10 551 veterans (20.8%) by January 2023. Across VISNs, the range in proportion of patients who tested positive who received nirmatrelvir-ritonavir or molnupiravir during January 2023 was 41 of 692 veterans (5.9%) to 106 of 494 veterans (21.4%) and 2.1% to 120 of 1074 veterans (11.1%), respectively. Veterans receiving any treatment were more likely to be older (adjusted odds ratio [aOR] for ages 65-74 vs 50-64 years, 1.18; 95% CI, 1.14-1.22; aOR for ages ≥75 vs 50-64 years, 1.19; 95% CI, 1.15-1.23) and have a higher Charlson Comorbidity Index score (aOR for CCI ≥6 vs 0, 1.52; 95% CI, 1.44-1.59). Compared with White veterans, Black veterans (aOR, 1.06; 95% CI, 1.02-1.09) were more likely to receive treatment, and compared with non-Hispanic veterans, Hispanic veterans (aOR 1.06; 95% CI, 1.01-1.11) were more likely to receive treatment. Conclusions And Relevance This study found that prescription of outpatient COVID-19 pharmacotherapies in the VHA peaked in August 2022 and declined thereafter. There were large regional differences in patterns of nirmatrelvir-ritonavir and molnupiravir use.
Collapse
Affiliation(s)
- Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Elani Streja
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Yuli Li
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Nallakkandi Rajeevan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences; Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis
| | - Francesca Cunningham
- Pharmacy Benefit Management Services, Veterans Affairs Center for Medication Safety, Hines, Illinois
| | - Grant D. Huang
- Office of Research and Development, Veterans Health Administration, Washington, District of Columbia
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - George N. Ioannou
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Kristina L. Bajema
- Veterans Affairs Portland Health Care System, Portland, Oregon
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Sciences University, Portland
| |
Collapse
|
11
|
Ahdoot RS, Hsiung JT, Agiro A, Brahmbhatt YG, Cooper K, Fawaz S, Westfall L, Kalantar-Zadeh K, Streja E. Liver Disease Is a Risk Factor for Recurrent Hyperkalemia: A Retrospective Cohort Study. J Clin Med 2023; 12:4562. [PMID: 37510679 PMCID: PMC10380673 DOI: 10.3390/jcm12144562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/21/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
Liver disease is often associated with dysfunctional potassium homeostasis but is not a well-established risk factor for hyperkalemia. This retrospective cohort study examined the potential relationship between liver disease and recurrent hyperkalemia. Patients with ≥1 serum potassium measurement between January 2004 and December 2018 who experienced hyperkalemia (serum potassium >5.0 mmol/L) were identified from the United States Veterans Affairs database. A competing risk regression model was used to analyze the relationship between patient characteristics and recurrent hyperkalemia. Of 1,493,539 patients with incident hyperkalemia, 71,790 (4.8%) had liver disease (one inpatient or two outpatient records) within 1 year before the index hyperkalemia event. Recurrent hyperkalemia within 1 year after the index event occurred in 234,807 patients (15.7%) overall, 19,518 (27.2%) with liver disease, and 215,289 (15.1%) without liver disease. The risk of recurrent hyperkalemia was significantly increased in patients with liver disease versus those without (subhazard ratio, 1.34; 95% confidence interval, 1.32-1.37; p < 0.0001). Aside from vasodilator therapy, the risk of recurrent hyperkalemia was not increased with concomitant medication. In this cohort study, liver disease was an independent risk factor strongly associated with recurrent hyperkalemia within 1 year, independent of concomitant renin-angiotensin-aldosterone system inhibitor or potassium-sparing diuretic use.
Collapse
Affiliation(s)
- Rebecca S Ahdoot
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Irvine, CA 92868, USA
| | - Jui-Ting Hsiung
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Irvine, CA 92868, USA
- Veterans Affairs Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA 90822, USA
| | - Abiy Agiro
- AstraZeneca, US Evidence, US Medical Affairs, Wilmington, DE 19803, USA
| | | | - Kerry Cooper
- AstraZeneca, US Renal, US Medical Affairs, Wilmington, DE 19803, USA
| | - Souhiela Fawaz
- AstraZeneca, US Renal, US Medical Affairs, Wilmington, DE 19803, USA
| | - Laura Westfall
- AstraZeneca, US Renal, US Medical Affairs, Wilmington, DE 19803, USA
| | - Kamyar Kalantar-Zadeh
- Veterans Affairs Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA 90822, USA
- Harbor UCLA Medical Center, Nephrology, University of California Los Angeles, Los Angeles, CA 90502, USA
| | - Elani Streja
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Irvine, CA 92868, USA
- Veterans Affairs Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA 90822, USA
| |
Collapse
|
12
|
Bajema KL, Berry K, Streja E, Rajeevan N, Li Y, Mutalik P, Yan L, Cunningham F, Hynes DM, Rowneki M, Bohnert A, Boyko EJ, Iwashyna TJ, Maciejewski ML, Osborne TF, Viglianti EM, Aslan M, Huang GD, Ioannou GN. Effectiveness of COVID-19 Treatment With Nirmatrelvir-Ritonavir or Molnupiravir Among U.S. Veterans: Target Trial Emulation Studies With One-Month and Six-Month Outcomes. Ann Intern Med 2023; 176:807-816. [PMID: 37276589 PMCID: PMC10243488 DOI: 10.7326/m22-3565] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Information about the effectiveness of oral antivirals in preventing short- and long-term COVID-19-related outcomes in the setting of Omicron variant transmission and COVID-19 vaccination is limited. OBJECTIVE To measure the effectiveness of nirmatrelvir-ritonavir and molnupiravir for outpatient treatment of COVID-19. DESIGN Three retrospective target trial emulation studies comparing matched cohorts of nirmatrelvir-ritonavir versus no treatment, molnupiravir versus no treatment, and nirmatrelvir-ritonavir versus molnupiravir. SETTING Veterans Health Administration (VHA). PARTICIPANTS Nonhospitalized veterans in VHA care who were at risk for severe COVID-19 and tested positive for SARS-CoV-2 during January through July 2022. INTERVENTION Nirmatrelvir-ritonavir or molnupiravir pharmacotherapy. MEASUREMENTS Incidence of any hospitalization or all-cause mortality at 30 days and from 31 to 180 days. RESULTS Eighty-seven percent of participants were male; the median age was 66 years, and 18% were unvaccinated. Compared with matched untreated control participants, those treated with nirmatrelvir-ritonavir (n = 9607) had lower 30-day risk for hospitalization (22.07 vs. 30.32 per 1000 participants; risk difference [RD], -8.25 [95% CI, -12.27 to -4.23] per 1000 participants) and death (1.25 vs. 5.47 per 1000 participants; RD, -4.22 [CI, -5.45 to -3.00] per 1000 participants). Among persons alive at day 31, reductions were seen in 31- to 180-day incidence of death (hazard ratio, 0.66 [CI, 0.49 to 0.89]) but not hospitalization (subhazard ratio, 0.90 [CI, 0.79 to 1.02]). Molnupiravir-treated participants (n = 3504) had lower 30-day and 31- to 180-day risks for death (3.14 vs. 13.56 per 1000 participants at 30 days; RD, -10.42 [CI, -13.49 to -7.35] per 1000 participants; hazard ratio at 31 to 180 days, 0.67 [CI, 0.48 to 0.95]) but not hospitalization. A difference in 30-day or 31- to 180-day risk for hospitalization or death was not observed between matched nirmatrelvir- or molnupiravir-treated participants. LIMITATION The date of COVID-19 symptom onset for most veterans was unknown. CONCLUSION Nirmatrelvir-ritonavir was effective in reducing 30-day hospitalization and death. Molnupiravir was associated with a benefit for 30-day mortality but not hospitalization. Further reductions in mortality from 31 to 180 days were observed with both antivirals. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
Collapse
Affiliation(s)
- Kristina L Bajema
- Veterans Affairs Portland Health Care System, and Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon (K.L.B.)
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (K.B.)
| | - Elani Streja
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut (E.S., Y.L.)
| | - Nallakkandi Rajeevan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut (N.R., P.M.)
| | - Yuli Li
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut (E.S., Y.L.)
| | - Pradeep Mutalik
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut (N.R., P.M.)
| | - Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut (L.Y.)
| | - Francesca Cunningham
- Veterans Affairs Center for Medication Safety - Pharmacy Benefit Management (PBM) Services, Hines, Illinois (F.C.)
| | - Denise M Hynes
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon, and Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, and Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon (D.M.H.)
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon (M.R.)
| | - Amy Bohnert
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan (A.B.)
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (E.J.B.)
| | - Theodore J Iwashyna
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, and Schools of Medicine and Public Health, Johns Hopkins University, Baltimore, Maryland (T.J.I.)
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center; Department of Population Health Sciences, Duke University School of Medicine; and Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina (M.L.M.)
| | - Thomas F Osborne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, and Department of Radiology, Stanford University School of Medicine, Stanford, California (T.F.O.)
| | - Elizabeth M Viglianti
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, and Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (E.M.V.)
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Department of Medicine, Yale School of Medicine, New Haven, Connecticut (M.A.)
| | - Grant D Huang
- Office of Research and Development, Veterans Health Administration, Washington, DC (G.D.H.)
| | - George N Ioannou
- Research and Development and Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, and Division of Gastroenterology, University of Washington, Seattle, Washington (G.N.I.)
| |
Collapse
|
13
|
Rucker L, Rucker G, Nguyen A, Noel M, Marroquin M, Streja E, Hennrikus E. Medical Faculty and Medical Student Opinions on the Utility of Questions to Teach and Evaluate in the Clinical Environment. Med Sci Educ 2023; 33:669-678. [PMID: 37501806 PMCID: PMC10368585 DOI: 10.1007/s40670-023-01780-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/23/2023] [Indexed: 07/29/2023]
Abstract
Objectives We sought to report medical student and faculty perceptions of the purpose and utility of questions on clinical rounds. Methods We developed and administered a survey to third and fourth-year medical students and teaching physicians. The survey elicited attitudes about using questions to teach on rounds in both benign and malignant learning environments. Results Ninety-seven percent of faculty and 85% of students predicted they will use questions to teach. Nine percent of students described learning-impairing stress during benign bedside teaching. Fifty-nine percent of faculty felt questions were mostly for teaching; 74% of students felt questions were mostly for evaluation. Forty-six percent of students felt questions underestimated their knowledge. Students felt questions were more effective for classroom teaching than bedside teaching. Faculty and students agreed that a malignant environment detrimentally affected learning and performance. Conclusions Students and faculty supported the use of questions to teach and evaluate, especially in benign teaching environments. Many students described stress severe enough to affect their learning and performance, even when questioned in benign teaching environments. Faculty underestimated the degree to which students experience stress-related learning impairment and the degree to which students see questions as evaluation rather than teaching. Nearly half of students felt that questions underestimated their own knowledge. Students feel more stress and less learning when questioned with a patient present. Faculty must realize that even in the best learning environment some students experience stress-impaired learning and performance, perhaps because of the conflict between learning and evaluation.
Collapse
Affiliation(s)
- Lloyd Rucker
- Department of Medicine, Irvine School of Medicine, University of California, 101 the City Drive Orange, Irvine, CA 92868 USA
- Tibor Rubin Long Beach Veterans Administration Hospital, Long Beach, CA USA
| | - Garrett Rucker
- Department of Medicine, MedStar Washington Hospital Center – Georgetown University, Washington, DC USA
| | - Angelica Nguyen
- Tibor Rubin Long Beach Veterans Administration Hospital, Long Beach, CA USA
- Irvine School of Medicine, University of California, Irvine, CA USA
| | - Maria Noel
- Department of Emergency Medicine, Christiana Care, Newark, DE USA
| | | | - Elani Streja
- Division of Nephrology, Department of Medicine, University of California, Irvine School of Medicine, Irvine, CA USA
| | | |
Collapse
|
14
|
Rizk JG, Hsiung JT, Arif Y, Hashemi L, Sumida K, Kovesdy CP, Kalantar-Zadeh K, Streja E. Triglycerides and Renal Outcomes According to Albuminuria and in Consideration of Other Metabolic Syndrome Components in Diabetic US Veterans. Am J Nephrol 2023; 54:14-24. [PMID: 36889289 PMCID: PMC10500632 DOI: 10.1159/000529414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/19/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION Hypertriglyceridemia, a component of the metabolic syndrome, is a known independent predictor of albuminuria and chronic kidney disease (CKD) in the general population. Previous studies have shown that the relationship of triglycerides (TGs) with outcomes changes across stages of CKD. Our objective was to examine the association of TG independent of other metabolic syndrome components with renal outcomes in diabetic patients with or without CKD. METHODS This retrospective cohort study included diabetic US veteran patients with valid data on TGs, estimated glomerular filtration rate (eGFR), and albuminuria (urinary albumin/creatinine ratio) between fiscal years 2004 and 2006. Using Cox models adjusted for clinical characteristics and laboratory markers, we evaluated the relationship of TG with incident albuminuria (stratified by eGFR category) and based on eGFR (stratified by baseline albuminuria categories). To evaluate the relationship of TG with time to end-stage renal disease (ESRD), we stratified models by baseline CKD stage (eGFR category) and baseline albuminuria stage ascertained at time of TG measurement. RESULTS In a cohort of 138,675 diabetic veterans, the mean ± SD age was 65 ± 11 years old and included 3% females and 14% African Americans. The cohort also included 28% of patients with non-dialysis-dependent CKD (eGFR <60 mL/min/1.73 m2), as well as 28% of patients with albuminuria (≥30 mg/g). The median (IQR) of serum TG was 148 (100, 222) mg/dL. We observed a slight positive linear association between TG and incident CKD after adjustment for Case-Mix and Laboratory variables among non-albuminuric and microalbuminuric patients. The relationship of high TG trended towards a higher risk of ESRD in CKD 3A non-albuminuric patients and in CKD 3A and 4/5 patients with microalbuminuria. CONCLUSION In a large cohort, we have shown that elevated TGs are associated with all kidney outcomes tested independently of other metabolic syndrome components in diabetic patients with normal eGFR and normal albumin excretion rate, but the association is weaker in some groups of diabetic patients with preexisting renal complications.
Collapse
Affiliation(s)
- John G. Rizk
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Yousif Arif
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA
| | - Leila Hashemi
- Greater Los Angeles Healthcare System, Department of General Internal Medicine, Los Angeles, CA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Keiichi Sumida
- University of Tennessee Health Science Center, Memphis, TN
| | - Csaba P. Kovesdy
- University of Tennessee Health Science Center, Memphis, TN
- VA Memphis Medical Center, Memphis, TN
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| |
Collapse
|
15
|
Tio M, Zhu X, Yen T, Hall M, Streja E, Kalantar-Zadeh K, Dossabhoy N, Shafi T. Quantification of risk of chronic kidney disease progression in the US population. Am J Med Sci 2023. [DOI: 10.1016/s0002-9629(23)00740-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
16
|
Potukuchi PK, Moradi H, Park F, Kaplan C, Thomas F, Dashputre AA, Sumida K, Molnar MZ, Gaipov A, Gatwood JD, Rhee C, Streja E, Kalantar-Zadeh K, Kovesdy CP. Cannabis Use and Risk of Acute Kidney Injury in Patients with Advanced Chronic Kidney Disease Transitioning to Dialysis. Cannabis Cannabinoid Res 2023; 8:138-147. [PMID: 34597156 PMCID: PMC9940810 DOI: 10.1089/can.2021.0044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: The current social and legal landscape is likely to foster the medicinal and recreational use of cannabis. Synthetic cannabinoid use is associated with acute kidney injury (AKI) in case reports; however, the association between natural cannabis use and AKI risk in patients with advanced chronic kidney disease (CKD) is unknown. Materials and Methods: From a nationally representative cohort of 102,477 U.S. veterans transitioning to dialysis between 2007 and 2015, we identified 2215 patients with advanced CKD who had undergone urine toxicology (UTOX) tests within a year before dialysis initiation and had inpatient serial serum creatinine levels measured within 7 days after their UTOX test. The exposure of interest was cannabis use compared with no use as ascertained by the UTOX test. We examined the association of this exposure with AKI using logistic regression and inverse probability of treatment weighting with extensive adjustment for potential confounders. Results: The mean age of the overall cohort was 61 years; 97% were males, 51% were African Americans, 97% had hypertension, 76% had hyperlipidemia, and 75% were diabetic. AKI occurred in 56% of the cohort, and in multivariable-adjusted analysis, cannabis use (when compared with no substance use) was not associated with significantly higher odds of AKI (odds ratio 0.85, 95% confidence interval 0.38-1.87; p=0.7). These results were robust to various sensitivity analyses. Conclusions: In this observational study examining patients with advanced CKD, cannabis use was not associated with AKI risk. Additional studies are needed to characterize the impact of cannabis use on risk of kidney disease and injury.
Collapse
Affiliation(s)
- Praveen K. Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Hamid Moradi
- Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
- Nephrology Section, Long Beach VA Medical Center, Long Beach, California, USA
| | - Frank Park
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Cameron Kaplan
- USC Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Ankur A. Dashputre
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z. Molnar
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Abduzhappar Gaipov
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
| | - Justin D. Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, Tennessee, USA
| | - Connie Rhee
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, California, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California-Irvine, Orange, California, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
| |
Collapse
|
17
|
Rizk JG, Streja E, Wenziger C, Shlipak MG, Norris KC, Crowley ST, Kalantar-Zadeh K. Serum Creatinine-to-Cystatin-C Ratio as a Potential Muscle Mass Surrogate and Racial Differences in Mortality. J Ren Nutr 2023; 33:69-77. [PMID: 34923112 DOI: 10.1053/j.jrn.2021.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/02/2021] [Accepted: 11/22/2021] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Serum creatinine-based estimated glomerular filtration rate equations and muscle mass are powerful markers of health and mortality risk. However, the serum creatinine-to-cystatin-C ratio may be a better indicator of health status. The objective of this study was to describe the relationship between creatinine-to-cystatin-C ratio and all-cause mortality when stratifying patients as per race and as per chronic kidney disease status. METHODS This was a retrospective cohort study examining black and nonblack US veterans between October 2004 and September 2019, with baseline cystatin C and creatinine data from those not on dialysis during the study period. Veterans were divided into four creatinine-to-cystatin-C ratio groups: <0.75, 0.75-<1.00, 1.0-<1.25, and ≥1.25. The primary outcome of interest was all-cause mortality subsequent to the cystatin C laboratory measure. RESULTS Among 22,316 US veterans, the mean (± standard deviation) age of the cohort was 67 ± 14 years, 5% were female, 82% were nonblack, and 18% were black. The proportion of black veterans increased across creatinine-to-cystatin-C ratio groups. In the fully adjusted model, compared with the reference (creatinine-to-cystatin-C ratio: 1.00-<1.25), a creatinine-to-cystatin-C ratio <0.75 had the highest mortality risk among both black and nonblack veterans (nonblack: hazard ratio [HR] [95% confidence interval {CI}]: 3.01 [2.78-3.26] and black: 4.17 [3.31-5.24]). A creatinine-to-cystatin-ratio ≥1.25 was associated with lower death risk than the referent in both groups (nonblack: HR [95% CI]: 0.89 [0.80-0.99] and black: HR [95% CI]: 0.55 [0.45-0.69]). However, there was a significant difference in the effect by race (Wald's P-value: <0.01). CONCLUSIONS Higher creatinine-to-cystatin-C ratios indicate better health status and are strongly associated with lower mortality risk regardless of the kidney function level, and the relation was similar for both black and nonblack veterans, but with different strengths of effect across racial groups. Thereby, use of a fixed race coefficient in estimating kidney function may be biased.
Collapse
Affiliation(s)
- John G Rizk
- Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, MD
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Division of Nephrology, Tibor Rubin VA Medical Center, Long Beach, CA.
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Division of Nephrology, Tibor Rubin VA Medical Center, Long Beach, CA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, University of California San Francisco and San Francisco VA Medical Center, San Francisco, CA
| | | | | | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Division of Nephrology, Tibor Rubin VA Medical Center, Long Beach, CA
| |
Collapse
|
18
|
Duong LM, Nono Djotsa ABS, Vahey J, Steele L, Quaden R, Harrington KM, Ahmed ST, Polimanti R, Streja E, Gaziano JM, Concato J, Zhao H, Radhakrishnan K, Hauser ER, Helmer DA, Aslan M, Gifford EJ. Association of Gulf War Illness with Characteristics in Deployed vs. Non-Deployed Gulf War Era Veterans in the Cooperative Studies Program 2006/Million Veteran Program 029 Cohort: A Cross-Sectional Analysis. Int J Environ Res Public Health 2022; 20:258. [PMID: 36612580 PMCID: PMC9819371 DOI: 10.3390/ijerph20010258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 06/17/2023]
Abstract
Gulf War Illness (GWI), a chronic multisymptom illness with a complex and uncertain etiology and pathophysiology, is highly prevalent among veterans deployed to the 1990-1991 GW. We examined how GWI phenotypes varied by demographic and military characteristics among GW-era veterans. Data were from the VA's Cooperative Studies Program 2006/Million Veteran Program (MVP) 029 cohort, Genomics of GWI. From June 2018 to March 2019, 109,976 MVP enrollees (out of a total of over 676,000) were contacted to participate in the 1990-1991 GW-era Survey. Of 109,976 eligible participants, 45,169 (41.1%) responded to the 2018-2019 survey, 35,902 respondents met study inclusion criteria, 13,107 deployed to the GW theater. GWI phenotypes were derived from Kansas (KS) and Centers for Disease Control and Prevention (CDC) GWI definitions: (a) KS Symptoms (KS Sym+), (b) KS GWI (met symptom criteria and without exclusionary health conditions) [KS GWI: Sym+/Dx-], (c) CDC GWI and (d) CDC GWI Severe. The prevalence of each phenotype was 67.1% KS Sym+, 21.5% KS Sym+/Dx-, 81.1% CDC GWI, and 18.6% CDC GWI severe. These findings affirm the persistent presence of GWI among GW veterans providing a foundation for further exploration of biological and environmental underpinnings of this condition.
Collapse
Affiliation(s)
- Linh M. Duong
- Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System 151B, West Haven, CT 06516, USA
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT 06511, USA
| | - Alice B. S. Nono Djotsa
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jacqueline Vahey
- VA Cooperative Studies Program Epidemiology Center—Durham, Department of Veterans Affairs, Durham, NC 27705, USA
- Computational Biology and Bioinformatics Program, Duke University, Durham, NC 27705, USA
| | - Lea Steele
- Veterans Health Research Program, Yudofsky Division of Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX 77030, USA
| | - Rachel Quaden
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA 02130, USA
| | - Kelly M. Harrington
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA 02118, USA
| | - Sarah T. Ahmed
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Renato Polimanti
- Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System 151B, West Haven, CT 06516, USA
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT 06511, USA
| | - Elani Streja
- Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System 151B, West Haven, CT 06516, USA
| | - John Michael Gaziano
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - John Concato
- Yale School of Medicine, Yale University, New Haven, CT 06511, USA
- Food and Drug Administration, Silver Spring, MD 20993, USA
| | - Hongyu Zhao
- Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System 151B, West Haven, CT 06516, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT 06520, USA
| | - Krishnan Radhakrishnan
- National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
| | - Elizabeth R. Hauser
- VA Cooperative Studies Program Epidemiology Center—Durham, Department of Veterans Affairs, Durham, NC 27705, USA
- Department of Biostatistics and Bioinformatics, Duke Molecular Physiology Institute, Duke University, Durham, NC 27705, USA
| | - Drew A. Helmer
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Mihaela Aslan
- Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System 151B, West Haven, CT 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT 06511, USA
| | - Elizabeth J. Gifford
- VA Cooperative Studies Program Epidemiology Center—Durham, Department of Veterans Affairs, Durham, NC 27705, USA
- Center for Child and Family Policy, Duke Margolis Center for Health Policy, Duke University Sanford School of Public Policy, Durham, NC 27708, USA
| |
Collapse
|
19
|
Bajema KL, Berry K, Streja E, Rajeevan N, Li Y, Yan L, Cunningham F, Hynes DM, Rowneki M, Bohnert A, Boyko EJ, Iwashyna TJ, Maciejewski ML, Osborne TF, Viglianti EM, Aslan M, Huang GD, Ioannou GN. Effectiveness of COVID-19 treatment with nirmatrelvir-ritonavir or molnupiravir among U.S. Veterans: target trial emulation studies with one-month and six-month outcomes. medRxiv 2022:2022.12.05.22283134. [PMID: 36561190 PMCID: PMC9774229 DOI: 10.1101/2022.12.05.22283134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Information about the effectiveness of oral antivirals in preventing short- and long-term COVID-19-related outcomes during the Omicron surge is limited. We sought to determine the effectiveness of nirmatrelvir-ritonavir and molnupiravir for the outpatient treatment of COVID-19. Methods We conducted three retrospective target trial emulation studies comparing matched patient cohorts who received nirmatrelvir-ritonavir versus no treatment, molnupiravir versus no treatment, and nirmatrelvir-ritonavir versus molnupiravir in the Veterans Health Administration (VHA). Participants were Veterans in VHA care at risk for severe COVID-19 who tested positive for SARS-CoV-2 in the outpatient setting during January and February 2022. Primary outcomes included all-cause 30-day hospitalization or death and 31-180-day incidence of acute or long-term care admission, death, or post-COVID-19 conditions. For 30-day outcomes, we calculated unadjusted risk rates, risk differences, and risk ratios. For 31-180-day outcomes, we used unadjusted time-to-event analyses. Results Participants were 90% male with median age 67 years and 26% unvaccinated. Compared to matched untreated controls, nirmatrelvir-ritonavir-treated participants (N=1,587) had a lower 30-day risk of hospitalization (27.10/1000 versus 41.06/1000, risk difference [RD] - 13.97, 95% CI -23.85 to -4.09) and death (3.15/1000 versus 14.86/1000, RD -11.71, 95% CI - 16.07 to -7.35). Among persons who were alive at day 31, further significant reductions in 31-180-day incidence of hospitalization (sub-hazard ratio 1.07, 95% CI 0.83 to 1.37) or death (hazard ratio 0.61, 95% CI 0.35 to 1.08) were not observed. Molnupiravir-treated participants aged ≥65 years (n=543) had a lower combined 30-day risk of hospitalization or death (55.25/1000 versus 82.35/1000, RD -27.10, 95% CI -50.63 to -3.58). A statistically significant difference in 30-day or 31-180-day risk of hospitalization or death was not observed between matched nirmatrelvir- or molnupiravir-treated participants. Incidence of most post-COVID conditions was similar across comparison groups. Conclusions Nirmatrelvir-ritonavir was highly effective in preventing 30-day hospitalization and death. Short-term benefit from molnupiravir was observed in older groups. Significant reductions in adverse outcomes from 31-180 days were not observed with either antiviral.
Collapse
Affiliation(s)
- Kristina L. Bajema
- Veterans Affairs Portland Health Care System, Portland, OR,Division of Infectious Diseases, Department of Medicine, Oregon Health and Sciences University, Portland, OR
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Elani Streja
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Nallakkandi Rajeevan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT,Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT
| | - Yuli Li
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT,Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Francesca Cunningham
- Veterans Affairs Center for Medication Safety - Pharmacy Benefit Management (PBM) Services, Hines, IL
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), VA Portland Healthcare System, Portland, OR,Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences; Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), VA Portland Healthcare System, Portland, OR
| | - Amy Bohnert
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI,Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Edward J. Boyko
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Theodore J. Iwashyna
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI,Schools of Medicine and Public Health, Johns Hopkins, Baltimore, MD
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC,Duke-Margolis Center for Health Policy, Duke University, Durham, NC
| | - Thomas F. Osborne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA,Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Elizabeth M. Viglianti
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI,Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT,Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Grant D. Huang
- Office of Research and Development, Veterans Health Administration, Washington, DC
| | - George N. Ioannou
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA,Divisions of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
| |
Collapse
|
20
|
Bajema KL, Wang XQ, Hynes DM, Rowneki M, Hickok A, Cunningham F, Bohnert A, Boyko EJ, Iwashyna TJ, Maciejewski ML, Viglianti EM, Streja E, Yan L, Aslan M, Huang GD, Ioannou GN. Early Adoption of Anti-SARS-CoV-2 Pharmacotherapies Among US Veterans With Mild to Moderate COVID-19, January and February 2022. JAMA Netw Open 2022; 5:e2241434. [PMID: 36367727 PMCID: PMC9652752 DOI: 10.1001/jamanetworkopen.2022.41434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
IMPORTANCE Older adults and individuals with medical comorbidities are at increased risk for severe COVID-19. Several pharmacotherapies demonstrated to reduce the risk of COVID-19-related hospitalization and death have been authorized for use. OBJECTIVE To describe factors associated with receipt of outpatient COVID-19 pharmacotherapies in the Veterans Affairs (VA) health care system. DESIGN, SETTINGS, AND PARTICIPANTS This cohort study assessed outpatient veterans with risk factors for severe COVID-19 who tested positive for SARS-CoV-2 during January and February 2022. The setting was the VA health care system, the largest integrated health care system in the US. EXPOSURES Demographic characteristics, place of residence, underlying medical conditions, and COVID-19 vaccination. MAIN OUTCOMES AND MEASURES The odds of receipt of any COVID-19 pharmacotherapy, including sotrovimab, nirmatrelvir boosted with ritonavir, molnupiravir, or remdesivir were estimated using multivariable logistic regression. RESULTS Among 111 717 veterans included in this study (median [IQR] age, 60 [46-72] years; 96 482 [86.4%] male, 23 362 [20.9%] Black, 10 740 [9.6%] Hispanic, 75 973 [68.0%] White) who tested positive for SARS-CoV-2 during January to February 2022, 4233 (3.8%) received any COVID-19 pharmacotherapy, including 2870 of 92 396 (3.1%) in January and 1363 of 19 321 (7.1%) in February. Among a subset of 56 285 veterans with documented COVID-19-related symptoms in the 30 days preceding a positive SARS-CoV-2 test, 3079 (5.5%) received any COVID-19 pharmacotherapy. Untreated veterans had a median (IQR) age of 60 (46-71) years and a median (IQR) of 3 (2-5) underlying medical conditions. Veterans receiving any treatment were more likely to be older (aged 65 to 74 years vs 50 to 64 years: adjusted odds ratio [aOR], 1.66 [95% CI, 1.52-1.80]; aged at least 75 years vs 50 to 64 years: aOR, 1.67 [95% CI, 1.53-1.84]) and have a higher number of underlying conditions (at least 5 conditions vs 1 to 2 conditions: aOR, 2.17 [95% CI, 1.98-2.39]). Compared with White veterans, Black veterans (aOR, 0.65 [95% CI, 0.60-0.72]) were less likely to receive treatment; and compared with non-Hispanic veterans, Hispanic veterans (aOR, 0.88 [95% CI, 0.77-0.99]) were less likely to receive treatment. There were 16 546 courses of sotrovimab, nirmatrelvir, and molnupiravir allocated across the VA during this period. CONCLUSIONS AND RELEVANCE In this cohort study of veterans who tested positive for SARS-CoV-2 during January and February when supply of outpatient COVID-19 pharmacotherapies was limited, prescription of these pharmacotherapies was underused, and many veterans with risk factors for severe COVID-19 did not receive treatment. Veterans from minority racial and ethnic groups were less likely to receive any pharmacotherapy.
Collapse
Affiliation(s)
- Kristina L. Bajema
- Veterans Affairs Portland Health Care System, Portland, Oregon
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Sciences University, Portland
| | - Xiao Qing Wang
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis
- Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Alex Hickok
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Francesca Cunningham
- Veterans Affairs Center for Medication Safety - Pharmacy Benefit Management (PBM) Services, Hines, Illinois
| | - Amy Bohnert
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - Edward J. Boyko
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Theodore J. Iwashyna
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Elizabeth M. Viglianti
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Elani Streja
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Health Care System, West Haven
| | - Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Health Care System, West Haven
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Health Care System, West Haven
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Grant D. Huang
- Office of Research and Development, Veterans Health Administration, Washington, DC
| | - George N. Ioannou
- Divisions of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| |
Collapse
|
21
|
Lo RH, Kalantar-Zadeh K, You AS, Ayus JC, Streja E, Park C, Sohn P, Nakata T, Narasaki Y, Brunelli SM, Kovesdy CP, Nguyen DV, Rhee CM. Dysnatremia and risk of bloodstream infection in dialysis patients. Clin Kidney J 2022; 15:2322-2330. [PMID: 36381361 PMCID: PMC9664572 DOI: 10.1093/ckj/sfac197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Indexed: 12/02/2022] Open
Abstract
Background Emerging data suggest that sodium disarrays including hyponatremia are potential risk factors for infection ensuing from impairments in host immunity, which may be exacerbated by coexisting conditions (i.e. mucosal membrane and cellular edema leading to breakdown of microbial barrier function). While dysnatremia and infection-related mortality are common in dialysis patients, little is known about the association between serum sodium levels and the risk of bloodstream infection in this population. Methods Among 823 dialysis patients from the national Biospecimen Registry Grant Program who underwent serum sodium testing over the period January 2008–December 2014, we examined the relationship between baseline serum sodium levels and subsequent rate of bloodstream infection. Bloodstream infection events were directly ascertained using laboratory blood culture data. Associations between serum sodium level and the incidence of bloodstream infection were estimated using expanded case mix–adjusted Poisson regression models. Results In the overall cohort, ∼10% of all patients experienced one or more bloodstream infection events during the follow-up period. Patients with both lower sodium levels <134 mEq/l and higher sodium levels ≥140 mEq/l had higher incident rate ratios (IRRs) of bloodstream infection in expanded case mix analyses (reference 136–<138 mEq/l), with adjusted IRRs of 2.30 [95% confidence interval (CI) 1.19–4.44], 0.77 (95% CI 0.32–1.84), 1.39 (95% CI 0.78–2.47), 1.88 (95% CI 1.08–3.28) and 1.96 (95% CI 1.08–3.55) for sodium levels <134, 134–<136, 138–<140, 140–<142 and ≥142 Eq/l, respectively. Conclusions Both lower and higher baseline serum sodium levels were associated with a higher rate of subsequent bloodstream infections in dialysis patients. Further studies are needed to determine whether correction of dysnatremia ameliorates infection risk in this population.
Collapse
Affiliation(s)
- Robin H Lo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
- Tibor Rubin Long Beach Veterans Affairs Medical Center , Long Beach, CA , USA
| | - Amy S You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
| | - Juan Carlos Ayus
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
- Renal Consultants , Houston, TX , USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
- Tibor Rubin Long Beach Veterans Affairs Medical Center , Long Beach, CA , USA
| | - Christina Park
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
- University of Washington School of Public Health , Seattle, WA , USA
| | - Peter Sohn
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
| | - Tracy Nakata
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
| | - Yoko Narasaki
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
| | | | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center , Memphis, TN , USA
- Nephrology Section, Memphis Veterans Affairs Medical Center , Memphis, TN , USA
| | - Danh V Nguyen
- Division of General Internal Medicine, University of California Irvine , Orange, CA , USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
| |
Collapse
|
22
|
Soohoo M, Streja E, Hsiung JT, Kovesdy CP, Kalantar-Zadeh K, Arah OA. Cohort Study and Bias Analysis of the Obesity Paradox Across Stages of Chronic Kidney Disease. J Ren Nutr 2022; 32:529-536. [PMID: 34861399 PMCID: PMC10032545 DOI: 10.1053/j.jrn.2021.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/06/2021] [Accepted: 10/17/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE In advanced chronic kidney disease (CKD), patients with obesity often have better outcomes than patients without obesity, often called the 'obesity paradox'. Yet, in CKD, the prevalence of inflammation increases as CKD progresses. Although a potential confounder, inflammation may be left unaccounted in obesity-mortality studies. We examined the associations of body mass index (BMI) with all-cause and cause-specific mortality across CKD stages, with consideration for uncontrolled confounding due to unmeasured inflammation. METHODS We investigated 2,703,512 patients with BMI data between 2004 and 2006. We used Cox models to examine the associations of BMI with all-cause, cardiovascular, and cancer mortality, (ref: BMI 25-<30 kg/m2), adjusted for clinical characteristics and stratified by CKD stages. To address uncontrolled confounding, we performed bias analysis using a weighted probabilistic model of inflammation given the observed data applied to weighted Cox models. RESULTS The cohort included 5% females and 14% African Americans. In adjusted analyses, the associations of the BMI with all-cause and cardiovascular mortality showed a reverse J-shape, where a higher BMI (>40 kg/m2) was associated with a higher risk. Conversely, a lower mortality risk was observed with a BMI 30-<35 kg/m2 across all CKD stages and for BMI >40 kg/m2 in CKD stage 4/5. Cancer mortality analyses showed an inverse relationship. Bias analysis for uncontrolled confounding suggested that independent of inflammation, the obesity paradox was present. CONCLUSION We observed the presence of the obesity paradox in this study. This association was consistent in advanced CKD and in our bias analysis, suggesting that inflammation may not fully explain the observed BMI-mortality associations including in patients with CKD.
Collapse
Affiliation(s)
- Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California; Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California; Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California.
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California; Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California
| | - Onyebuchi A Arah
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California; Department of Statistics, College of Letters and Science, University of California, Los Angeles (UCLA), Los Angeles, California; Section for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark.
| |
Collapse
|
23
|
Hassan W, Shrestha P, Sumida K, Thomas F, Sweeney PL, Potukuchi PK, Rhee CM, Streja E, Kalantar-Zadeh K, Kovesdy CP. Association of Uric Acid-Lowering Therapy With Incident Chronic Kidney Disease. JAMA Netw Open 2022; 5:e2215878. [PMID: 35657621 PMCID: PMC9166229 DOI: 10.1001/jamanetworkopen.2022.15878] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
IMPORTANCE Uric acid is a waste metabolite produced from the breakdown of purines, and elevated serum uric acid levels are associated with higher risk of hypertension, cardiovascular disease, and mortality and progression of chronic kidney disease (CKD). Treatment of hyperuricemia in patients with preexisting CKD has not been shown to improve kidney outcomes, but the associations of uric acid-lowering therapies with the development of new-onset kidney disease in patients with estimated glomerular filtration rate (eGFR) within reference range and no albuminuria is unclear. OBJECTIVE To examine the association of initiating uric acid-lowering therapy with the incidence of CKD. DESIGN, SETTING, AND PARTICIPANTS This cohort study included patients with eGFR of 60 mL/min/1.73 m2 or greater and no albuminuria treated at US Department of Veterans Affairs health care facilities from 2004 to 2019. Clinical trial emulation methods, including propensity score weighting, were used to minimize confounding. Data were analyzed from 2020 to 2022. EXPOSURE Newly started uric acid-lowering therapy. MAIN OUTCOMES AND MEASURES The main outcomes were incidences of eGFR less than 60 mL/min/1.73 m2, new-onset albuminuria, and end-stage kidney disease. RESULTS A total of 269 651 patients were assessed (mean [SD] age, 57.4 [12.5] years; 252 171 [94%] men). Among these, 29 501 patients (10.9%) started uric acid-lowering therapy, and 240 150 patients (89.1%) did not. Baseline characteristics, including serum uric acid level, were similar among treated and untreated patients after propensity score weighting. In the overall cohort, uric acid-lowering therapy was associated with higher risk of both incident eGFR less than 60 mL/min/1.73 m2 (weighted subhazard ratio [SHR], 1.15 [95% CI, 1.10-1.20; P < .001) and incident albuminuria (SHR, 1.05 [95% CI, 1.01-1.09; P < .001) but was not associated with the risk of end-stage kidney disease (SHR, 0.96 [95% CI, 0.62-1.50]; P = .87). In subgroup analyses, the association of uric acid-lowering therapy with worse kidney outcomes was limited to patients with baseline serum uric acid levels of 8 mg/dL or less. CONCLUSIONS AND RELEVANCE These findings suggest that in patients with kidney function within reference range, uric acid-lowering therapy was not associated with beneficial kidney outcomes and may be associated with potential harm in patients with less severely elevated serum uric acid levels.
Collapse
Affiliation(s)
- Waleed Hassan
- Department of Medicine, North Mississippi Medical Center, Tupelo
- Division of Nephrology, University of Tennessee Health Science Center, Memphis
| | - Prabin Shrestha
- Division of Nephrology, University of Tennessee Health Science Center, Memphis
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
| | - Patrick L. Sweeney
- John W. Demming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Connie M. Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California–Irvine, Orange
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California–Irvine, Orange
- Long Beach VA Medical Center, Long Beach, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California–Irvine, Orange
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee
| |
Collapse
|
24
|
Ma H, Ricks-Oddie J, Streja E, Eapen A, Gupta P. Factors associated with death from lymphoma in a single center study. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e19566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e19566 Background: It is well known that age, stage, and performance status are important prognostic factors in predicting survival of patients diagnosed with lymphoid malignancies. At the VA Healthcare System, many patients have comorbidities and poor performance status. We evaluated the association of clinical outcomes with lymphoma stage, subtype and performance status in US Veterans. Methods: This retrospective study included patients diagnosed with a lymphoid malignancy including diffuse large B-cell lymphoma (DLBCL), chronic lymphocytic leukemia (CLL), follicular lymphoma (FL), marginal zone lymphoma (MZL), mantle cell lymphoma (MCL), and peripheral T-cell lymphoma (PTCL) from January 2008 - December 2021 at the VA Long Beach Healthcare System (n = 221). Endpoints included clinically relevant hematological and non-hematological adverse events (AE), and death from lymphoma (with death from other causes as competing events). Variables of interest included aggressive lymphomas (DLBCL and PTCL, n = 85) vs indolent lymphomas (CLL, FL, MZL and MCL, n = 149), stage (early [0-2] vs advanced [3-4]), age at diagnosis (continuous variable), and performance status (Eastern Cooperative Oncology Group [ECOG] scale: good [0-2] vs poor [3-4]). Logistic regression and Cox models with Fine and Gray competing risk were performed. Results: In patients receiving first line therapy, performance status, disease type, stage, and age at diagnosis did not predict development of clinically relevant AEs with an odds ratio [OR] of 4.1 (p = 0.12, 95% CI 0.70-24), 0.36 (p = 0.06, 95% CI 0.12-1.0), 1.5 (p = 0.39, 95% CI 0.58-4.0), and 1.0 (p = 0.12, 95% 0.99-1.1), respectively. Patients with worse performance status (ECOG 3-4) and advancing age did not have a statistically higher risk of dying from lymphoma vs other causes: performance status: HR 1.7, p = 0.26, 95% CI 0.67-4.3 and age: HR 1.02, p = 0.11, 95% CI 1.0-1.1. In a multivariate analysis, patients with more advanced stage and aggressive subtype were more likely to die from lymphoma vs other causes (hazard ratio [HR] 4.1; p < 0.001, 95% CI 2.2-7.8 and 3.1; p = < 0.0001, 95% CI 1.7-5.5), respectively. Conclusions: The fact that performance status may not predict the development of AEs with first line therapy for lymphoid malignancies is relevant to clinical decision making. However, our findings need confirmation in larger prospective studies.
Collapse
Affiliation(s)
- Helen Ma
- University of California-Irvine, Orange, CA
| | | | | | - Ann Eapen
- University of California-Irvine, Orange, CA
| | | |
Collapse
|
25
|
Arif Y, Wenziger C, Hsiung JT, Edward A, Lau WL, Hanna RM, Lee Y, Obi Y, Kovesdy CP, Kalantar-Zadeh K, Streja E. Association of serum potassium with decline in residual kidney function in incident hemodialysis patients. Nephrol Dial Transplant 2022; 37:2234-2240. [PMID: 35561740 PMCID: PMC9585465 DOI: 10.1093/ndt/gfac181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hyperkalemia is associated with kidney function decline in patients with non-dialysis dependent chronic kidney disease, but this relationship is unclear for residual kidney function among hemodialysis (HD) patients. METHODS We conducted a retrospective cohort study of 6655 patients who started HD from January 2007 to December 2011 and who had data on renal urea clearance (KRU). Serum potassium levels were stratified into four groups (i.e. ≤4.0, >4.0 to ≤ 4.5, >4.5 to ≤ 5.0, >5.0 mEq/L) and 1-year KRU slope for each group was estimated by a linear mixed-effects model. RESULTS Higher serum potassium was associated with greater decline in KRU, and the greatest decrease in KRU (-0.20, 95% CI -0.50, -0.06) was observed for baseline potassium > 5.0 mEq/L in the fully adjusted model. Mediation analysis showed that KRU slope mediated 1.78% of the association between serum potassium and mortality. CONCLUSIONS In conclusion, hyperkalemia is associated with decline in residual kidney function amongst incident HD patients. These findings may have important clinical implications in the management of hyperkalemia in advanced CKD if confirmed in additional studies including clinical trials.
Collapse
Affiliation(s)
- Yousif Arif
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Jui Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Amanda Edward
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Wei Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Ramy M Hanna
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Yuji Lee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Kam Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, VA Long Beach Healthcare System, Long Beach, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, VA Long Beach Healthcare System, Long Beach, CA
| |
Collapse
|
26
|
Hashemi L, Hsiung JT, Arif Y, Soohoo M, Jackson N, Gosmanova EO, Budoff M, Kovesdy CP, Kalantar-Zadeh K, Streja E. Serum Low-Density Lipoprotein Cholesterol and Cardiovascular Disease Risk Across Chronic Kidney Disease Stages (Data from 1.9 Million United States Veterans). Am J Cardiol 2022; 170:47-55. [PMID: 35300833 DOI: 10.1016/j.amjcard.2022.01.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 12/30/2022]
Abstract
In the general population, elevated low-density lipoprotein (LDL) cholesterol levels are an important risk factor for cardiovascular disease (CVD) and mortality; however, the association of LDL with mortality risk and cardiovascular events are less clear in chronic kidney disease (CKD). We sought to examine the relationship of LDL with mortality and rates of atherosclerotic cardiovascular disease (ASCVD) and non-atherosclerotic cardiovascular-related (non-ASCVD) hospitalizations across CKD stages. Our analytical cohort consisted of 1,972,851 United States veterans with serum LDL data between 2004 and 2006. Associations of LDL with all-cause and cardiovascular mortality across CKD stages were evaluated using Cox proportional hazard models with adjustment for demographics, comorbid conditions, smoking status, prescription of statins and non-statin lipid-lowering drugs, body mass index, albumin, high-density lipoprotein, and triglycerides. Associations between LDL and ASCVD and non-ASCVD hospitalizations were estimated using negative binomial regression models across CKD stages. The cohort consisted of 5% female, 14% Black, 29% diabetic, 33% statin-users, and 44% current smokers, with a mean patient age of 64 ± 14 years. Patients with high LDL (≥160 mg/dL) had a higher risk of all-cause and cardiovascular mortality as well as ASCVD and non-ASCVD hospitalization rates across all CKD stages compared with the reference (LDL 70 to <100 mg/dL). The associations with all-cause and cardiovascular mortality and ASCVD hospitalization rate were attenuated at higher CKD stages. These trends were reversed with amplification of the association of high LDL with non-ASCVD hospitalization at higher CKD stages. In conclusion, associations of LDL with mortality and both ASCVD and non-ASCVD hospitalizations are modified according to kidney disease stage.
Collapse
|
27
|
Soohoo M, Hashemi L, Hsiung JT, Moradi H, Budoff MJ, Kovesdy CP, Kalantar-Zadeh K, Streja E. Association of Serum Triglycerides and Renal Outcomes among 1.6 Million US Veterans. Nephron Clin Pract 2022; 146:457-468. [PMID: 35354153 PMCID: PMC9533458 DOI: 10.1159/000522388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/23/2022] [Indexed: 11/19/2022] Open
Abstract
Background Previous studies have suggested that metabolic syndrome (MetS) components are associated with renal outcomes, defined as a decline in kidney function or reaching end-stage renal disease (ESRD). Elevated triglycerides (TGs) are a component of MetS that have been reported to be associated with renal outcomes. However, the association of TGs with renal outcomes in chronic kidney disease (CKD) patients independent of the other components of the MetS remains understudied. Methods We examined 1,657,387 patients with data on TGs and other components of MetS in 2004–2006 and followed up until 2014. Patients with ESRD on renal replacement therapy were excluded. We examined time to ESRD, estimated glomerular filtration rate (eGFR) slope (renal function decline), and time to incident CKD (eGFR <60 mL/min/1.73 m<sup>2</sup>) among baseline normal kidney function (non-CKD) patients, using Cox or logistic regression, adjusted for clinical characteristics and MetS components. We also stratified analyses by the number of MetS components. Results The cohort was on average 64 years old and comprised 5% females, 15% African Americans, and 24% with nondialysis-dependent CKD. Among non-CKD patients, the adjusted relationship of TGs with time to incident CKD was strong and linear. Compared to TGs 120–<160 mg/dL, higher TGs were associated with a faster renal function decline across all CKD stages. Elevated TGs ≥240 mg/dL were associated with a faster time to ESRD among non-CKD and CKD stages 3A–3B, while the risk gradually declined to null or lower in CKD stages 4–5. Models were robust after MetS component adjustment and stratification. Conclusion Independent of MetS components, high TGs levels were associated with a higher incidence of CKD and a faster renal function decline, yet showed no or inverse associations with time to ESRD in CKD stages 4–5. Examining the effects of TGs-lowering interventions on incident CKD and kidney preserving therapy warrants further studies including clinical trials.
Collapse
Affiliation(s)
- Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Leila Hashemi
- Assistant Professor of Medicine, Department of General Internal Medicine, University of California Los Angeles, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Hamid Moradi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Matthew J Budoff
- Division of Cardiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA.,Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| |
Collapse
|
28
|
Soohoo M, Obi Y, Rivara MB, Adams SV, Lau WL, Rhee CM, Kovesdy CP, Kalantar-Zadeh K, Arah OA, Mehrotra R, Streja E. Comparative Effectiveness of Dialysis Modality on Laboratory Parameters of Mineral Metabolism. Am J Nephrol 2022; 53:157-168. [PMID: 35226895 PMCID: PMC9116596 DOI: 10.1159/000521508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/07/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Chronic kidney disease-mineral and bone disorders (CKD-MBD) are prevalent in patients undergoing maintenance dialysis. Yet, there are limited and mixed evidence on the effects of different dialysis modalities involving longer treatment times or higher frequencies on CKD-MBD markers. METHODS This cohort study used data from 132,523 incident dialysis patients treated with any of the following modalities: conventional thrice-weekly in-center hemodialysis, nocturnal in-center hemodialysis (NICHD), home hemodialysis (HHD), or peritoneal dialysis (PD) from 2007 to 2011. We used marginal structural models fitted with inverse probability weights to adjust for fixed and time-varying confounding and informative censoring. We estimated the average effects of treatments with different dialysis modalities on time-varying serum concentrations of CKD-MBD markers: albumin-corrected calcium, phosphate, parathyroid hormone (PTH), and alkaline phosphatase (ALP) using pooled linear regression. RESULTS Most of the cohort were exclusively treated with conventional in-center hemodialysis, while few were ever treated with NICHD or HHD. At the baseline, PD patients had the lowest mean and median values of PTH, while NICHD patients had the highest median values. During follow-up, compared to hemodialysis patients, patients treated with NICHD had lower mean serum PTH (19.8 pg/mL [95% confidence interval: 2.8, 36.8] lower), whereas PD and HHD patients had higher mean PTH (39.7 pg/mL [31.6, 47.8] and 51.2 pg/mL [33.0, 69.3] higher, respectively). Compared to hemodialysis patients, phosphate levels were lower for patients treated with NICHD (0.44 mg/dL [0.37, 0.52] lower), PD (0.15 mg/dL [0.12, 0.19] lower), or HHD (0.33 mg/dL [0.27, 0.40] lower). There were no clinically meaningful associations between dialysis modalities and concentrations of calcium or ALP. CONCLUSION In incident dialysis patients, compared to treatment with conventional in-center hemodialysis, treatments with other dialysis modalities with longer treatment times or higher frequency were associated with different patterns of serum phosphate and PTH. Given the recent growth in the use of dialysis modalities other than hemodialysis, the associations between the treatment and the CKD-MBD markers warrant additional study.
Collapse
Affiliation(s)
- Melissa Soohoo
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Matthew B. Rivara
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Scott V. Adams
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Wei Ling Lau
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA
| | - Connie M. Rhee
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA
| | - Csaba P. Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Onyebuchi A. Arah
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
- Department of Statistics, College of Letters and Science, University of California, Los Angeles (UCLA), Los Angeles, California, USA
- Section for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Rajnish Mehrotra
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| |
Collapse
|
29
|
Sy J, Wenziger C, Marroquin M, Kalantar-Zadeh K, Kovesdy C, Streja E. Warfarin Use, Stroke, and Bleeding Risk among Pre-Existing Atrial Fibrillation US Veterans Transitioning to Dialysis. Nephron Clin Pract 2022; 146:360-368. [PMID: 35124673 PMCID: PMC9262829 DOI: 10.1159/000521494] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/08/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Anticoagulation is commonly used for stroke prevention among patients with atrial fibrillation (AF); however, end-stage renal disease (ESRD) patients on hemodialysis are at higher risk of bleeding and stroke, even without anticoagulation. It is unclear if patients should be continued on anticoagulation at the time of transition to ESRD. In this study, we validated risk scores for stroke and bleeding in this population and assessed risk of stroke and bleeding among warfarin users compared to nonusers. METHODS We utilized a cohort of 28,620 pre-dialysis US veterans transitioning to hemodialysis between October 2007 and March 2015. Incident rates for the risks of stroke and bleeding were ascertained based upon CHA2DS2-VASc or HAS-BLED scores, respectively. A propensity score-based competing risk analysis was used to assess risk of stroke and bleeding. FINDINGS The mean age of our cohort was 77 ± 9 years, and the median CHA2DS2-VASc and HAS-BLED scores were 7 (5, 8) and 3 (3, 4), respectively. Increasing CHA2DS2-VASc and HAS-BLED scores were predictive of increasing stroke and bleeding rates, respectively. However, warfarin use did not appear to affect the risk of stroke and bleeding (p-interaction = 0.84 for stroke and 0.24 for bleeding). Warfarin use was associated with a higher risk of stroke (adjusted SHR 1.44, 95% CI: 1.23-1.69) and a higher risk of bleeding (adjusted SHR 1.38, 95% CI: 1.25-1.52) when accounting for the competing risk of death. DISCUSSION There was no difference in incidence rates of stroke or bleeding among warfarin users versus nonusers. Warfarin was associated with a higher risk of stroke and bleeding after considering mortality risk.
Collapse
Affiliation(s)
- John Sy
- Division of Nephrology, Tibor Rubin VA Medical Center, Long Beach, CA, USA,Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Disease, University of California Irvine School of Medicine, Orange, CA, USA
| | - Cachet Wenziger
- Division of Nephrology, Tibor Rubin VA Medical Center, Long Beach, CA, USA,Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Disease, University of California Irvine School of Medicine, Orange, CA, USA
| | - Maria Marroquin
- Division of Nephrology, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Tibor Rubin VA Medical Center, Long Beach, CA, USA,Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Disease, University of California Irvine School of Medicine, Orange, CA, USA
| | - Csaba Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
| | - Elani Streja
- Division of Nephrology, Tibor Rubin VA Medical Center, Long Beach, CA, USA,Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Disease, University of California Irvine School of Medicine, Orange, CA, USA
| |
Collapse
|
30
|
Fischer MJ, Streja E, Hsiung JT, Crowley ST, Kovesdy CP, Kalantar-Zadeh K, Kourany WM. Depression screening and clinical outcomes among adults initiating maintenance hemodialysis. Clin Kidney J 2021; 14:2548-2555. [PMID: 34950466 DOI: 10.1093/ckj/sfab097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Indexed: 11/14/2022] Open
Abstract
Background Transitioning to maintenance hemodialysis (HD) is a vulnerable period for persons with end-stage renal disease (ESRD), punctuated by high rates of depression, hospitalizations and death. Screening for depression during this time may help to improve patient outcomes but formal inquiry has yet to be conducted. Among a national Veteran cohort, we examined whether depression screening in the year prior to HD initiation led to improved outcomes in the year thereafter. Methods Associations between pre-ESRD depression screening and post-ESRD outcomes were examined with Cox proportional hazards models (mortality) and Poisson regression models (hospitalization). Hierarchal adjustment models accounted for sociodemographic, clinical, pre-ESRD care and dialysis characteristics. Results The final analytic cohort of the study was 30 013 Veterans of whom 64% underwent pre-ESRD depression screening. During the 12 months post-transition, the crude all-cause mortality rate was 0.32 person-year for those screened and 0.35 person-year for those not screened, while the median (interquartile range) hospitalizations were 2 (2, 2) per year for both groups. In fully adjusted models, pre-ESRD depression screening was associated with a lower risk of mortality [hazard ratio (95% confidence interval): 0.94 (0.90-0.99)] and hospitalization [incidence rate ratio (95% confidence interval): 0.97 (0.9-0.99)]. Conclusion Depression screening among adults prior to maintenance HD transition may be associated with better outcomes during the following year.
Collapse
Affiliation(s)
- Michael J Fischer
- Center of Innovation for Complex Chronic Healthcare, Research Service, Edward Hines Jr VA Hospital, Hines, IL, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, CA, USA
| | | | | | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, School of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, CA, USA
| | | |
Collapse
|
31
|
Rizk JG, Wenziger C, Tran D, Hashemi L, Moradi H, Streja E, Ahluwalia A. Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Use Associated with Reduced Mortality and Other Disease Outcomes in US Veterans with COVID-19. Drugs 2021; 82:43-54. [PMID: 34914085 PMCID: PMC8675115 DOI: 10.1007/s40265-021-01639-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 12/29/2022]
Abstract
Objective To determine the association between angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) use and coronavirus disease 2019 (COVID-19) severity and outcomes in US veterans. Patients and Methods We retrospectively examined 27,556 adult US veterans who tested positive for COVID-19 between March to November 2020. Logistic regression and Cox proportional hazards models using propensity score (PS) for weight, adjustment, and matching were used to examine the odds of an event within 60 days following a COVID-19–positive case date and time to death, respectively, according to ACEI and/or ARB prescription within 6 months prior to the COVID-19–positive case date. Results The overlap PS weighted logistic regression model showed lower odds of an intensive care unit (ICU) admission (odds ratio [OR] 95% CI 0.77, 0.61–0.98) and death within 60 days (0.87, 0.79–0.97) with an ACEI or ARB prescription. Veterans with an ARB-only prescription also had lower odds of an ICU admission (0.64, 0.44–0.92). The overlap PS weighted model similarly showed a lower risk of time to all-cause mortality in veterans with an ACEI or ARB prescription (HR [95% CI]: 0.87, 0.79–0.97) and an ARB only prescription (0.78, 0.67–0.91). Veterans with an ACEI prescription had higher odds of experiencing a septic event within 60 days after the COVID-19–positive case date (1.22, 1.02–1.46). Conclusion In this study of a national cohort of US veterans, we found that the use of an ACEI/ARB in patients with COVID-19 was not associated with increased mortality and other worse outcomes. Future studies should examine underlying pathways and further confirm the relationship of ACEI prescription with sepsis. Supplementary Information The online version contains supplementary material available at 10.1007/s40265-021-01639-2.
Collapse
Affiliation(s)
- John G Rizk
- Arizona State University, Edson College, Phoenix, AZ, USA.,Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, MD, USA
| | - Cachet Wenziger
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Diana Tran
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Leila Hashemi
- Greater Los Angeles VA Medical Center, Los Angeles, CA, USA.,UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Hamid Moradi
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Elani Streja
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA. .,Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, CA, USA.
| | - Amrita Ahluwalia
- Research, Tibor Rubin VA Medical Center, VA Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA, 90822, USA.
| |
Collapse
|
32
|
Rizk JG, Lazo JG, Quan D, Gabardi S, Rizk Y, Streja E, Kovesdy CP, Kalantar-Zadeh K. Mechanisms and management of drug-induced hyperkalemia in kidney transplant patients. Rev Endocr Metab Disord 2021; 22:1157-1170. [PMID: 34292479 DOI: 10.1007/s11154-021-09677-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
Hyperkalemia is a common and potentially life-threatening complication following kidney transplantation that can be caused by a composite of factors such as medications, delayed graft function, and possibly potassium intake. Managing hyperkalemia after kidney transplantation is associated with increased morbidity and healthcare costs, and can be a cause of multiple hospital admissions and barriers to patient discharge. Medications used routinely after kidney transplantation are considered the most frequent culprit for post-transplant hyperkalemia in recipients with a well-functioning graft. These include calcineurin inhibitors (CNIs), pneumocystis pneumonia (PCP) prophylactic agents, and antihypertensives (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers). CNIs can cause hyperkalemic renal tubular acidosis. When hyperkalemia develops following transplantation, the potential offending medication may be discontinued, switched to another agent, or dose-reduced. Belatacept and mTOR inhibitors offer an alternative to calcineurin inhibitors in the event of hyperkalemia, however should be prescribed in the appropriate patient. While trimethoprim/sulfamethoxazole (TMP/SMX) remains the gold standard for prevention of PCP, alternative agents (e.g. dapsone, atovaquone) have been studied and can be recommend in place of TMP/SMX. Antihypertensives that act on the Renin-Angiotensin-Aldosterone System are generally avoided early after transplant but may be indicated later in the transplant course for patients with comorbidities. In cases of mild to moderate hyperkalemia, medical management can be used to normalize serum potassium levels and allow the transplant team additional time to evaluate the function of the graft. In the immediate post-operative setting following kidney transplantation, a rapidly rising potassium refractory to medical therapy can be an indication for dialysis. Patiromer and sodium zirconium cyclosilicate (ZS-9) may play an important role in the management of chronic hyperkalemia in kidney transplant patients, although additional long-term studies are necessary to confirm these effects.
Collapse
Affiliation(s)
- John G Rizk
- Arizona State University, Edson College, Phoenix, AZ, USA.
| | - Jose G Lazo
- UCSF Medical Center, University of California San Francisco, San Francisco, CA, USA
| | - David Quan
- UCSF Medical Center, University of California San Francisco, San Francisco, CA, USA
| | - Steven Gabardi
- Department of Transplant Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Youssef Rizk
- Department of Internal Medicine, Division of Family Medicine, Lebanese American University Medical Center - St. John's Hospital, Beirut, Lebanon
| | - Elani Streja
- Department of Medicine, Division of Nephrology, Hypertension and Kidney Transplantation, School of Medicine, University of California, CA, Irvine, Orange, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Department of Medicine, Division of Nephrology, Hypertension and Kidney Transplantation, School of Medicine, University of California, CA, Irvine, Orange, USA
- Department of Epidemiology, University of California, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| |
Collapse
|
33
|
Soohoo M, Hashemi L, Hsiung JT, Moradi H, Budoff MJ, Kovesdy CP, Kalantar-Zadeh K, Streja E. Risk of Atherosclerotic Cardiovascular Disease and Nonatherosclerotic Cardiovascular Disease Hospitalizations for Triglycerides Across Chronic Kidney Disease Stages Among 2.9 Million US Veterans. J Am Heart Assoc 2021; 10:e022988. [PMID: 34729994 PMCID: PMC9075381 DOI: 10.1161/jaha.121.022988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background High triglycerides are associated with atherosclerotic cardiovascular disease (ASCVD) risks. Among patients with advanced chronic kidney disease (CKD), the association of elevated triglycerides with mortality is diminished and, thus, we investigated the relationship of triglycerides with ASCVD and non‐ASCVD hospitalizations across CKD stages. Methods and Results The cohort comprised 2 963 176 veterans who received care in 2004 to 2006 (baseline) and were followed up to 2014. Using Cox models, we evaluated baseline and time‐varying triglycerides with time to ASCVD or non‐ASCVD hospitalizations, stratified by baseline CKD stage, and adjusted for demographics and baseline or time‐updated clinical characteristics. The cohort mean±SD age was 63±14 years, with a baseline median (interquartile range) triglycerides level of 127 (87–189) mg/dL, and a quarter had prevalent CKD. There was a linear association between baseline triglycerides and ASCVD risk; however, the risk with high triglycerides ≥240 mg/dL attenuated with worsening CKD stages (reference: triglycerides 120 to <160 mg/dL). Baseline triglycerides were associated with a U‐shaped relationship for non‐ASCVD events in patients with CKD 3A to 3B. Patients with late‐stage CKD had lower to null relationships between baseline triglycerides and non‐ASCVD events. Time‐varying triglycerides associations with ASCVD were similar to baseline analyses. Yet, the time‐varying triglycerides relationship with non‐ASCVD events was inverse and linear, where elevated triglycerides were associated with lower risks. Conclusions Associations of higher triglycerides with ASCVD and non‐ASCVD events declined across advancing CKD stages, where a lower to null risk was observed in patients with advanced CKD. Studies are needed to examine the impact of advanced CKD on triglycerides metabolism and its association with outcomes in this high‐risk population.
Collapse
Affiliation(s)
- Melissa Soohoo
- Division of Nephrology and Hypertension Harold Simmons Center for Kidney Disease Research and Epidemiology University of California Irvine Medical Center Orange CA.,Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
| | - Leila Hashemi
- Department of General Internal Medicine Greater Los Angeles Healthcare System Los Angeles CA.,David Geffen School of Medicine University of California Los Angeles Los Angeles CA
| | - Jui-Ting Hsiung
- Division of Nephrology and Hypertension Harold Simmons Center for Kidney Disease Research and Epidemiology University of California Irvine Medical Center Orange CA.,Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
| | - Hamid Moradi
- Division of Nephrology and Hypertension Harold Simmons Center for Kidney Disease Research and Epidemiology University of California Irvine Medical Center Orange CA.,Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
| | - Matthew J Budoff
- Division of Cardiology The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center Torrance CA
| | - Csaba P Kovesdy
- Nephrology Section Memphis Veterans Affairs Medical Center Memphis TN.,Division of Nephrology University of Tennessee Health Science Center Memphis TN
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension Harold Simmons Center for Kidney Disease Research and Epidemiology University of California Irvine Medical Center Orange CA.,Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
| | - Elani Streja
- Division of Nephrology and Hypertension Harold Simmons Center for Kidney Disease Research and Epidemiology University of California Irvine Medical Center Orange CA.,Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
| |
Collapse
|
34
|
Bielopolski D, Wenziger C, Steinmetz T, Rozen Zvi B, Kalantar-Zadeh K, Streja E. Novel Protein to Phosphorous Ratio Score Predicts Mortality in Hemodialysis Patients. J Ren Nutr 2021; 32:450-457. [PMID: 34740537 DOI: 10.1053/j.jrn.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 07/19/2021] [Accepted: 08/10/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Lowering serum phosphorus in people on hemodialysis may improve their survival. However, prior studies have shown that restricting dietary protein intake, a major source of phosphorus, is associated with higher mortality. We hypothesized that a novel metric that incorporates both these values commensurately can improve survival prediction. METHODS We used serum phosphorous and normalized protein catabolic rate (nPCR), a surrogate of dietary protein intake, to form a new metric R that was used to examine the associations with mortality in 63,016 people on hemodialysis (HD) of one year after treatment initiation. Survival models were adjusted for case-mix, malnutrition-inflammation cachexia syndrome (MICS), and residual kidney function (RKF). RESULTS Individuals treated with hemodialysis were divided into five groups in accordance with R value. Group 1 included sick individuals with high phosphorous and low nPCR. Group 5 included individuals with low phosphorous and high nPCR. After 1-year follow-up, survival difference between the groups reflected R value, where an increase in R was associated with improved survival. The association of R with mortality was strengthened by adjustment in demographic variables and attenuated after adjustment to MICS. Mortality associations in accordance with R were not influenced by residual kidney function (RKF). CONCLUSION The novel protein to phosphorus ratio score R predicts mortality in people on dialysis, probably reflecting both nutrition and inflammation state independent of RKF. The metric enables better phosphorus monitoring, although adequate dietary protein intake is ensured and may improve the prediction of outcomes in the clinical setting.
Collapse
Affiliation(s)
- Dana Bielopolski
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, Irvine, CA; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Nephrology Institute, Rabin Medical Center, Petah Tiqva, Israel.
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, Irvine, CA
| | - Tali Steinmetz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Nephrology Institute, Rabin Medical Center, Petah Tiqva, Israel
| | - Benaya Rozen Zvi
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Nephrology Institute, Rabin Medical Center, Petah Tiqva, Israel
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, Irvine, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, Irvine, CA
| |
Collapse
|
35
|
Pai AY, Sy J, Kim J, Kleine CE, Edward J, Hsiung JT, Kovesdy CP, Kalantar-Zadeh K, Streja E. Association of serum globulin with all-cause mortality in incident hemodialysis patients. Nephrol Dial Transplant 2021; 37:1993-2003. [PMID: 34617572 DOI: 10.1093/ndt/gfab292] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Serum globulin is a major component of total protein and can be elevated in inflammatory disease states. While inflammation is common in hemodialysis patients and associated with mortality and morbidity, the association between serum globulin and mortality have never been examined in hemodialysis patients. METHODS In a retrospective cohort of 104,164 incident hemodialysis patients treated by a large dialysis organization from 2007 to 2011, we explored the association between baseline serum globulin, A/G ratio and serum protein levels and all-cause, cardiovascular and infection-related mortality with adjustments for demographic variables and laboratory markers of malnutrition and inflammation using Cox proportional hazard models. RESULTS Patients with globulin concentration >3.8 g/dL had higher all-cause and infection-related mortality risk (Hazard Ratio [HR] 1.11, 95% Confidence Interval [95%CI]: 1.06, 1.16 and HR 1.28, 95%CI: 1.09, 1.51; respectively) in the fully adjusted model when compared to the reference group of 3.0-<3.2 g/dL. In addition, patients with A/G ratio <0.75 had a 45% higher all-cause mortality hazard (HR 1.45, 95%CI: 1.38, 1.52) and patients with total serum protein <5.5 g/dL had a 34% higher risk of death (HR: 1.34, 95%CI: 1.27, 1.42) when compared to the reference (A/G ratio 1.05-<1.15 and total serum protein 6.5-<7 g/dL, respectively). CONCLUSIONS Among incident hemodialysis patients, higher globulin level was associated with higher mortality risk independent of other markers of malnutrition and inflammation, including albumin. Lower A/G ratio and serum protein was also associated with higher mortality hazard. The mechanisms that contribute to elevated serum globulin should be further explored.
Collapse
Affiliation(s)
- Alex Y Pai
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - John Sy
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Joseph Kim
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Jessica Edward
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| |
Collapse
|
36
|
Yamarik RL, Wenziger C, Streja E, Pham ANT, Wei KS, Bedi B, Asch S. Changing Institutional Culture Around Hospice Using LEAN Tools to Improve Hospice Utilization in a Veteran Population. J Pain Symptom Manage 2021; 62:836-842. [PMID: 33831462 DOI: 10.1016/j.jpainsymman.2021.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Longer hospice length of stay improves the palliation of symptoms, quality of life, and the dying process for patients and their caregivers. We used a Lean designed Rapid Improvement Event (RIE) to facilitate earlier entry into hospice. MEASURES Our primary outcome was hospice length of stay. Secondary outcomes were avoiding unwanted inpatient utilization and hospice location. INTERVENTIONS We conducted a five-day RIE utilizing Lean tools targeting the inpatient medicine wards. OUTCOMES Hospice length of stay increased from a median (interquartile range [IQR]) of 11 (7,27) days prior to 37 (7,73) days following the RIE. Home hospice and outside Skilled Nursing Home (SNF) hospice use increased while use of the onsite VA hospice decreased. CONCLUSIONS/LESSONS LEARNED LEAN tools can be used successfully to improve end of life outcomes in an inpatient VA setting. The 90-day sustainment period following the RIE uncovers barriers to implementation and allows for adjustments to implementation.
Collapse
Affiliation(s)
| | - Cachet Wenziger
- Long Beach Veterans Affairs, Long Beach, California USA; Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, California, USA
| | - Elani Streja
- Long Beach Veterans Affairs, Long Beach, California USA; Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California Irvine Medical Center, Orange, California, USA
| | | | - Kevin S Wei
- University of California, Irvine School of Medicine, Irvine, California USA
| | - Bishen Bedi
- University of California San Diego School of Medicine, San Diego, California USA
| | - Steven Asch
- Department of Medicine, Stanford University, Stanford, California USA; Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California USA
| |
Collapse
|
37
|
Dashputre AA, Gatwood J, Sumida K, Thomas F, Akbilgic O, Potukuchi PK, Obi Y, Molnar MZ, Streja E, Kalantar-Zadeh K, Kovesdy CP. Association of dyskalemias with short-term health care utilization in patients with advanced CKD. J Manag Care Spec Pharm 2021; 27:1403-1415. [PMID: 34595956 PMCID: PMC10119640 DOI: 10.18553/jmcp.2021.27.10.1403] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Patients with advanced chronic kidney disease (CKD) are at high risk for dyskalemias, which may induce arrhythmias that require immediate emergent or hospital care. The association of dyskalemias with short-term hospital/emergency room (ER) visits in advanced CKD is understudied. OBJECTIVE: To assess the association of dyskalemias with short-term hospital/ER visits in an advanced CKD population. METHODS: From among 102,477 US veterans transitioning to dialysis from 2007 to 2015, we identified 21,366 patients with 2 predialysis outpatient eGFR < 30 ml/min/1.73m2 90-365 days apart (with the second eGFR serving as the index date) and at least 1 potassium (K) in the baseline period (1 year before index) and 1 outpatient K (oK) in the follow-up (1 year after the index but before dialysis initiation). We examined the association of time-varying hypokalemia (K < 3.5 mEq/L) and hyperkalemia (K > 5.5 mEq/L) vs referent (3.5-5.5 mEq/L) with separate hospital and ER visits within 2 calendar days following each oK value over the 1-year follow-up period from the index. We used generalized estimating equations with binary distribution and logit link to model the exposure-outcome relationship adjusted for various confounders. We conducted various subgroup and sensitivity analyses to test the robustness of our results. RESULTS: Over the 1-year follow-up, 125,266 oK measurements were observed, of which 6.8% and 3.7% were classified as hyper- and hypokalemia, respectively. In the multivariable-adjusted model, hyperkalemia (adjusted odds ratio [aOR] = 2.04; 95% CI = 1.88-2.21) and hypokalemia (aOR = 1.66; 95% CI = 1.48-1.86) were associated with significantly higher odds of hospital visits. Similarly, hyperkalemia (aOR = 1.83; 95% CI = 1.65-2.03) and hypokalemia (aOR = 1.24; 95% CI = 1.07-1.44) were associated with significantly higher odds of ER visits. Results were robust to subgroups and sensitivity analyses. CONCLUSIONS: In patients with advanced CKD, dyskalemias are associated with higher risk of hospital/ER visits. Interventions targeted at lowering the risk of dyskalemias might help in reducing the health care utilization and associated economic burden among patients with advanced CKD experiencing dyskalemias. DISCLOSURES: This study was supported by grant 5U01DK102163 from the National Institute of Health (NIH) to Kamyar Kalantar-Zadeh and Csaba P. Kovesdy and by resources from the US Department of Veterans Affairs. The data reported here have been supplied in part by the United States Renal Data System (USRDS). Support for VA/CMS data were provided by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (project numbers SDR 02-237 and 98-004). Opinions expressed in this article are those of the authors and do not necessarily represent the opinion of the Department of Veterans Affairs or the funding institution. Kovesdy has received honoraria from Akebia, Ardelyx, Astra Zeneca, Bayer, Boehringer-Ingelheim, Cara Therapeutics, Reata, and Tricida unrelated to this study. Kalantar-Zadeh has received honoraria and/or support from Abbott, Abbvie, ACI Clinical (Cara Therapeutics), Akebia, Alexion, Amgen, American Society of Nephrology, Astra-Zeneca, Aveo, BBraun, Chugai, Cytokinetics, Daiichi, DaVita, Fresenius, Genentech, Haymarket Media, Hofstra Medical School, International Federation of Kidney Foundations, International Society of Hemodialysis, International Society of Renal Nutrition & Metabolism, Japanese Society of Dialysis Therapy, Hospira, Kabi, Keryx, Kissei, Novartis, OPKO, National Institutes of Health, National Kidney Foundations, Pfizer, Regulus, Relypsa, Resverlogix, Dr Schaer, Sandoz, Sanofi, Shire, Veterans Affairs, Vifor, UpToDate, and ZS-Pharma, unrelated to this study. Gatwood has received research support from AstraZeneca, Merck & Co., and GlaxoSmithKline unrelated to this study. Obi has received research support from Relypsa/Vifor Pharma Inc. The remaining authors declare that they have no relevant financial interests.
Collapse
Affiliation(s)
- Ankur A Dashputre
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis
| | - Justin Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis
| | - Oguz Akbilgic
- Department of Health Informatics and Data Science, Parkinson School of Health Sciences and Public Health, Loyola University, Chicago, IL
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
| | - Miklos Z Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of CaliforniaIrvine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of CaliforniaIrvine, Orange, CA
| | | |
Collapse
|
38
|
Soohoo M, Hsiung JT, Marroquin M, Kovesdy C, Kalantar-Zadeh K, Streja E. Odds of Steep eGFR Decline Associated with Serum Triglycerides, Independent of CKD and Metabolic Syndrome. J Clin Lipidol 2021. [DOI: 10.1016/j.jacl.2021.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
39
|
Soohoo M, Hsiung JT, Marroquin M, Kovesdy C, Kalantar-Zadeh K, Streja E. Association of Serum Triglycerides with UACR Slope Across CKD Risk and Metabolic Syndrome Strata. J Clin Lipidol 2021. [DOI: 10.1016/j.jacl.2021.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
40
|
Soohoo M, Norris K, Budoff M, Kovesdy C, Kalantar-Zadeh K, Streja E. Racial Differences in the Association of Triglycerides with ASCVD and non-ASCVD Outcomes According to CKD Status. J Clin Lipidol 2021. [DOI: 10.1016/j.jacl.2021.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
41
|
Hsiung JT, Soohoo M, Marroquin M, Norris K, Kovesdy C, Kalantar-Zadeh K, Streja E. Cardiovascular Mortality and Hospitalization Risk with LDL by CKD Stage in African-American and White US Veterans. J Clin Lipidol 2021. [DOI: 10.1016/j.jacl.2021.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
42
|
Marroquin MV, Sy J, Kleine CE, Oveyssi J, Hsiung JT, Park C, Soohoo M, Kovesdy CP, Rhee CM, Streja E, Kalantar-Zadeh K, Tantisattamo E. Association of Pre-ESKD Hyponatremia with Post-ESKD Outcomes among Incident ESKD Patients. Nephrol Dial Transplant 2021; 37:358-365. [PMID: 34390572 DOI: 10.1093/ndt/gfab203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hyponatremia is one of the most common electrolyte disturbances in advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) patients and has been shown to be associated with higher mortality risk. However, the relationship between hyponatremia during late-stage CKD and the risk of poor outcomes after ESKD transition is unknown. METHODS We conducted a retrospective cohort study including 32,257 US veterans transitioning to ESKD from October 1, 2007 to March 30, 2015. We evaluated adjusted associations between the 3-month averaged pre-transition to ESKD serum sodium and all-cause mortality. Secondary outcomes included cardiovascular (CV) mortality, infection-related mortalities, and hospitalization rate. RESULTS Cohort mean±SD serum sodium was 139 ± 3 mEq/L, mean age was 67 ± 11 years, 98% were male, and 32% were African American. Over a median follow-up of 702 days (296, 1301) there were 17,162 deaths. Compared to the reference of 135-<144 mEq/L, the lowest serum sodium group (<130 mEq/L) had a 54% higher all-cause mortality risk (hazard ratio [HR]: 1.54, 95% confidence interval [CI]: 1.34, 1.76) in the fully adjusted model. Associations were similar for CV and infection-related mortality, and hospitalization outcomes. CONCLUSIONS Hyponatremia prior to ESKD transition is associated with higher risk of all-cause, CV, and infection-related mortalities and hospitalization rates after ESKD transition. Future studies evaluating management of pre-ESKD hyponatremia may be indicated to improve patient outcomes for those transitioning to ESKD.
Collapse
Affiliation(s)
- Maria V Marroquin
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA.,Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - John Sy
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA.,Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Justin Oveyssi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA.,Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA.,Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA.,Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA.,Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA.,Tibor Rubin VA Medical Center, Long Beach, CA, USA.,Fielding School of Public Health at UCLA, Los Angeles, CA, USA
| | - Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
| |
Collapse
|
43
|
Dashputre AA, Sumida K, Thomas F, Gatwood J, Akbilgic O, Potukuchi PK, Obi Y, Molnar MZ, Streja E, Kalantar Zadeh K, Kovesdy CP. Association of Dyskalemias with Ischemic Stroke in Advanced Chronic Kidney Disease Patients Transitioning to Dialysis. Am J Nephrol 2021; 52:539-547. [PMID: 34289468 DOI: 10.1159/000516902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/26/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hypo- and hyperkalemia are associated with a higher risk of ischemic stroke. However, this association has not been examined in an advanced chronic kidney disease (CKD) population. METHODS From among 102,477 US veterans transitioning to dialysis between 2007 and 2015, 21,357 patients with 2 pre-dialysis outpatient estimated glomerular filtration rates <30 mL/min/1.73 m2 90-365 days apart and at least 1 potassium (K) each in the baseline and follow-up period were identified. We separately examined the association of both baseline time-averaged K (chronic exposure) and time-updated K (acute exposure) treated as categorized (hypokalemia [K <3.5 mEq/L] and hyperkalemia [K >5.5 mEq/L] vs. referent [3.5-5.5 mEq/L]) and continuous exposure with time to the first ischemic stroke event prior to dialysis initiation using multivariable-adjusted Cox regression models. RESULTS A total of 2,638 (12.4%) ischemic stroke events (crude event rate 41.9 per 1,000 patient years; 95% confidence interval [CI] 40.4-43.6) over a median (Q1-Q3) follow-up time of 2.56 (1.59-3.89) years were observed. The baseline time-averaged K category of hypokalemia (adjusted hazard ratio [aHR], 95% CI: 1.35, 1.01-1.81) was marginally associated with a significantly higher risk of ischemic stroke. However, time-updated hyperkalemia was associated with a significantly lower risk of ischemic stroke (aHR, 95% CI: 0.82, 0.68-0.98). The exposure-outcome relationship remained consistent when using continuous K levels for both the exposures. DISCUSSION/CONCLUSION In patients with advanced CKD, hypokalemia (chronic exposure) was associated with a higher risk of ischemic stroke, whereas hyperkalemia (acute exposure) was associated with a lower risk of ischemic stroke. Further studies in this population are needed to explore the mechanisms underlying these associations.
Collapse
Affiliation(s)
- Ankur A Dashputre
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Justin Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, Tennessee, USA
| | - Oguz Akbilgic
- Department of Health Informatics and Data Science, Parkinson School of Health Sciences and Public Health, Loyola University, Chicago, Illinois, USA
| | - Praveen K Potukuchi
- Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Kamyar Kalantar Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
| |
Collapse
|
44
|
Narasaki Y, Okuda Y, Kalantar SS, You AS, Novoa A, Nguyen T, Streja E, Nakata T, Colman S, Kalantar-Zadeh K, Nguyen DV, Rhee CM. Dietary Potassium Intake and Mortality in a Prospective Hemodialysis Cohort. J Ren Nutr 2021; 31:411-420. [PMID: 33121888 PMCID: PMC8614638 DOI: 10.1053/j.jrn.2020.05.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 04/11/2020] [Accepted: 05/03/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Among hemodialysis patients, clinical practice guidelines recommend dietary potassium restriction given concerns about potential hyperkalemia leading to malignant arrhythmias and mortality. However, there are sparse data informing recommendations for dietary potassium intake in this population. We thus sought to examine the relationship between dietary potassium intake and death risk in a prospective cohort of hemodialysis patients. DESIGN AND METHODS Among 415 hemodialysis patients from the prospective "Malnutrition, Diet, and Racial Disparities in Chronic Kidney Disease" cohort recruited across 16 outpatient dialysis clinics, information regarding dietary potassium intake was obtained using Food Frequency Questionnaires administered over October 2011 to March 2015. We first examined associations of baseline dietary potassium intake categorized as tertiles with mortality risk using Cox regression. We then examined clinical characteristics associated with low dietary potassium intake (defined as the lowest tertile) using logistic regression. RESULTS In expanded case-mix Cox analyses, patients whose dietary potassium intake was in the lowest tertile had higher mortality (ref: highest tertile) (adjusted hazard ratio 1.74, 95% confidence interval 1.14-2.66). These associations had even greater magnitude of risk following adjustment for laboratory and nutritional covariates (adjusted hazard ratio 2.65, 95% confidence interval 1.40-5.04). In expanded case-mix restricted cubic spline analyses, there was a monotonic increase in mortality risk with incrementally lower dietary potassium intake. In expanded case-mix logistic regression models, female sex; higher serum bicarbonate; and lower dietary energy, protein, and fiber intake were associated with low dietary potassium intake. CONCLUSIONS In a prospective cohort of hemodialysis patients, lower dietary potassium intake was associated with higher mortality risk. These findings suggest that excessive dietary potassium restriction may be deleterious in hemodialysis patients, and further studies are needed to determine the optimal dietary potassium intake in this population.
Collapse
Affiliation(s)
- Yoko Narasaki
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California; Department of Clinical Nutrition and Food Management, Tokushima University Graduate School of Nutrition and Biosciences, Tokushima, Japan; Japan Society for the Promotion of Science, Tokyo, Japan; Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yusuke Okuda
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California
| | - Sara S Kalantar
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California; University of California, Berkeley, Berkeley, California
| | - Amy S You
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California
| | - Alejandra Novoa
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California
| | - Theresa Nguyen
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California; Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Tracy Nakata
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California
| | | | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California; Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Danh V Nguyen
- Division of General Internal Medicine, University of California, Irvine, Orange, California
| | - Connie M Rhee
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California.
| |
Collapse
|
45
|
Kimura H, Kalantar-Zadeh K, Rhee CM, Streja E, Sy J. Polypharmacy and Frailty among Hemodialysis Patients. Nephron Clin Pract 2021; 145:624-632. [PMID: 34139698 DOI: 10.1159/000516532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/07/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Both polypharmacy and frailty are highly prevalent among the patients on hemodialysis and associated with adverse outcomes; however, little is known about the association between them. METHODS We examined 337 patients enrolled in the ACTIVE/ADIPOSE dialysis cohort study between 2009 and 2011. The number of prescribed medications and frailty were assessed at baseline, 12, and 24 months. Frailty was defined based upon the Fried's frailty phenotype. We used logistic regression with generalized estimating equations to model the association of the number of medications and frailty at baseline and over time. A competing-risk regression analysis was also used to assess the association between the number of medications and incidence of frailty. RESULTS The mean number of medications was 10 ± 5, and 94 patients (28%) were frail at baseline. Patients taking >11 medications showed higher odds for frailty than the patients taking fewer than 8 medications (OR 1.54, 95% CI 1.05-2.26). During the 2-year of follow-up, 87 patients developed frailty among those who were nonfrail at baseline. Compared with the patients taking fewer than 8 medications, the incidence of frailty was approximately 2-fold in those taking >11 medications (sub-distribution hazard ratio 2.15, 95% CI 1.32-3.48). CONCLUSIONS Using a higher number of medications was associated with frailty and the incidence of frailty among hemodialysis patients. Minimizing polypharmacy may reduce the incidence and prevalence of frailty among dialysis patients.
Collapse
Affiliation(s)
- Hiroshi Kimura
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California, USA,
| | - Connie M Rhee
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California, USA
| | - John Sy
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California, USA.,Division of Nephrology, Veterans Affairs Long Beach Healthcare System, Long Beach, California, USA
| |
Collapse
|
46
|
Attai DJ, Katz MS, Streja E, Hsiung JT, Zavaleta BA, Nekhlyudov L. Patient preferences for cancer survivorship care: Results of an online survey. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.12064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12064 Background: Nearly 17 million cancer survivors live in the United States. Workforce shortages are projected to diminish the number of available medical oncologists (MOs) to care for newly diagnosed patients with cancer and for the growing number of cancer survivors. Models of survivorship care include oncologist-led, primary care-led, and shared care approaches. Recent proposals recommend a risk-stratified approach to care, guided by individual and cancer-specific factors, but there is little evidence regarding patient preferences for non-oncologist survivorship care. Methods: We developed a survey in partnership with patient advocates. The primary endpoints were patient-reported comfort with survivorship care by a primary care provider (PCP) or in a dedicated survivorship clinic. We distributed the survey to online, cancer-specific patient communities from June to August 2020. Logistic regression analyses were adjusted for patient age, race and ethnicity, insurance, and cancer type and stage. Results: Of 1166 responses, 975 surveys were complete and available for analysis. Respondents were primarily women (91%), white (92%), and US residents (73%); 78% had a college or graduate degree. Two-thirds had private insurance. Thirty-six different cancer types were reported; 61% of respondents had breast cancer, and 25% were treated for more than one type of cancer. Most respondents (83%) had nonmetastatic disease, 74% reported experiencing late effects of cancer therapy, and almost all (93%) had a PCP. Only 21% of respondents were comfortable seeing a PCP (versus MO) for survivorship care, including cancer follow-up, side effect management, and monitoring for recurrence or progression. About half (55%) were comfortable with follow-up in a survivorship clinic instead of with their MO. Multivariable analyses showed no significant associations between age, race or ethnicity, insurance, cancer type, or stage at diagnosis and comfort with follow-up care from a PCP or in a survivorship clinic. In analyses restricted to the 439 respondents with a history of early-stage breast cancer, the 239 (54%) who were within 1 to 5 years of diagnosis were less comfortable with PCP versus MO follow-up, compared with the 52 (12%) who were > 15 years from diagnosis (OR 0.40; 95% CI 0.20–0.75; p= 0.004). In this sub-analysis, time from diagnosis was not associated with comfort being seen in a survivorship clinic. Conclusions: In our study, most patients with a history of cancer were not comfortable receiving follow-up care from their PCP. It is often recommended that survivors of early-stage breast cancer transition to primary care for follow-up and surveillance, but our study revealed comfort with this approach only many years after diagnosis. While both PCP survivorship training and patient confidence in PCP follow up is needed, preferences of cancer survivors should be considered in designing new models of survivorship care.
Collapse
Affiliation(s)
| | | | | | | | | | - Larissa Nekhlyudov
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| |
Collapse
|
47
|
Baker JL, Dizon DS, Wenziger CM, Streja E, Thompson CK, Lee MK, DiNome ML, Attai DJ. ASO Visual Abstract: "Going Flat" After Mastectomy: Patient-Reported Outcomes by Online Survey. Ann Surg Oncol 2021. [PMID: 33704608 DOI: 10.1245/s10434-021-09769-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The "Going Flat" movement aims to increase awareness and acceptance of mastectomy alone as a viable option for patients. Little is known about the motivation for and satisfaction with surgical outcomes in this population. Among 931 women surveyed in online "Going Flat" communities, 74% were satisfied with their surgical outcome after mastectomy without reconstruction ( http://doi.org/10.1245/s10434-020-09448-9 ). However, 22% of women experienced a low level of surgeon support for going flat, and this "flat denial" strongly predicted dissatisfaction. Most patients undergoing mastectomy alone are satisfied with their surgical outcome. Surgeons may optimize patient experience by recognizing and supporting a patient's decision to go flat.
Collapse
Affiliation(s)
- Jennifer L Baker
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Don S Dizon
- Brown University and the Lifespan Cancer Institute, Providence, RI, USA
| | - Cachet M Wenziger
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Elani Streja
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Carlie K Thompson
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Minna K Lee
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Maggie L DiNome
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Deanna J Attai
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA. .,UCLA Health Burbank Breast Care, 191 S. Buena Vista #415, Burbank, CA, 91505, USA.
| |
Collapse
|
48
|
Baker JL, Dizon DS, Wenziger CM, Streja E, Thompson CK, Lee MK, DiNome ML, Attai DJ. "Going Flat" After Mastectomy: Patient-Reported Outcomes by Online Survey. Ann Surg Oncol 2021; 28:2493-2505. [PMID: 33393025 DOI: 10.1245/s10434-020-09448-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/17/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Going Flat movement aims to increase awareness and acceptance of mastectomy alone as a viable option for patients. Little is known about motivations and satisfaction with surgical outcomes in this population. METHODS An online survey was administered to 931 women who had a history of uni- or bilateral mastectomy for treatment of breast cancer or elevated breast cancer risk without current breast mound reconstruction. Satisfaction with outcome and surgeon support for the patient experience were characterized using 5-level scaled scores. RESULTS Mastectomy alone was the first choice for 73.7% of the respondents. The top two reasons for going flat were desire for a faster recovery and avoidance of a foreign body placement. Overall, the mean scaled satisfaction score was 3.72 ± 1.17 out of 5. In the multivariable analysis, low level of surgeon support for the decision to go flat was the strongest predictor of a satisfaction score lower than 3 (odds ratio [OR], 3.85; 95% confidence interval [CI], 2.59-5.72; p < 0.001). Dissatisfaction also was more likely among respondents reporting a body mass index (BMI) of 30 kg/m2 or higher (OR, 2.74; 95% CI, 1.76-4.27; p < 0.001) and those undergoing a unilateral procedure (OR, 1.99; 95% CI, 1.29-3.09; p = 0.002). Greater satisfaction was associated with receiving adequate information about surgical options (OR, 0.48; 95% CI, 0.32-0.69; p < 0.0001) and having a surgeon with a specialized breast surgery practice (OR, 0.56; 95% CI, 0.38-0.81; p = 0.002). CONCLUSIONS Most patients undergoing mastectomy alone are satisfied with their surgical outcome. Surgeons may optimize patient experience by recognizing and supporting a patient's decision to go flat.
Collapse
Affiliation(s)
- Jennifer L Baker
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Don S Dizon
- Brown University and the Lifespan Cancer Institute, Providence, RI, USA
| | - Cachet M Wenziger
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Elani Streja
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Carlie K Thompson
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Minna K Lee
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Maggie L DiNome
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Deanna J Attai
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA.
- UCLA Health Burbank Breast Care, Burbank, CA, USA.
| |
Collapse
|
49
|
Tantisattamo E, Murray V, Obi Y, Park C, Catabay CJ, Lee Y, Wenziger C, Hsiung JT, Soohoo M, Kleine CE, Rhee CM, Kraut J, Kovesdy CP, Kalantar-Zadeh K, Streja E. Association of Pre-ESRD Serum Bicarbonate with Post-ESRD Mortality in Patients with Incident ESRD. Am J Nephrol 2021; 52:304-317. [PMID: 33895727 DOI: 10.1159/000513855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Serum bicarbonate or total carbon dioxide (CO2) concentrations decline as chronic kidney disease (CKD) progresses and rise after dialysis initiation. While metabolic acidosis accelerates the progression of CKD and is associated with higher mortality among patients with end stage renal disease (ESRD), there are scarce data on the association of CO2 concentrations before ESRD transition with post-ESRD mortality. METHODS A historical cohort from the Transition of Care in CKD (TC-CKD) study includes 85,505 veterans who transitioned to ESRD from October 1, 2007, through March 31, 2014. After 1,958 patients without follow-up data, 3 patients with missing date of birth, and 50,889 patients without CO2 6 months prior to ESRD transition were excluded, the study population includes 32,655 patients. Associations between CO2 concentrations averaged over the last 6 months and its rate of decline during the 12 months prior to ESRD transition and post-ESRD all-cause, cardiovascular (CV), and non-CV mortality were examined by using hierarchical adjustment with Cox regression models. RESULTS The cohort was on average 68 ± 11 years old and included 29% Black veterans. Baseline concentrations of CO2 were 23 ± 4 mEq/L, and median (interquartile range) change in CO2 were -1.8 [-3.4, -0.2] mEq/L/year. High (≥28 mEq/L) and low (<18 mEq/L) CO2 concentrations showed higher adjusted mortality risk while there was no clear trend in the middle range. Consistent associations were observed irrespective of sodium bicarbonate use. There was also a U-shaped association between the change in CO2 and all-cause, CV, and non-CV mortality with the lowest risk approximately at -2.0 and 0.0 mEq/L/year among sodium bicarbonate nonusers and users, respectively, and the highest mortality was among patients with decline in CO2 >4 mEq/L/year. CONCLUSION Both high and low pre-ESRD CO2 levels (≥28 and <18 mEq/L) during 6 months prior to dialysis transition and rate of CO2 decline >4 mEq/L/year during 1 year before dialysis initiation were associated with greater post-ESRD all-cause, CV, and non-CV mortality. Further studies are needed to determine the optimal management of CO2 in patients with advanced CKD stages transitioning to ESRD.
Collapse
Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Victoria Murray
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Christina J Catabay
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Yuji Lee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Jeffrey Kraut
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| |
Collapse
|
50
|
Sumida K, Dashputre AA, Potukuchi PK, Thomas F, Obi Y, Molnar MZ, Gatwood JD, Streja E, Kalantar-Zadeh K, Kovesdy CP. Laxative Use and Risk of Dyskalemia in Patients with Advanced CKD Transitioning to Dialysis. J Am Soc Nephrol 2021; 32:950-959. [PMID: 33547216 PMCID: PMC8017552 DOI: 10.1681/asn.2020081120] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/20/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients with advanced CKD experience increased intestinal potassium excretion. This compensatory mechanism may be enhanced by laxative use; however, little is known about the association of laxative use with risk of dyskalemia in advanced CKD. METHODS Our study population encompassed 36,116 United States veterans transitioning to ESKD from 2007 to 2015 with greater than or equal to one plasma potassium measurement during the last 1-year period before ESKD transition. Using generalized estimating equations with adjustment for potential confounders, we examined the association of time-varying laxative use with risk of dyskalemia (i.e., hypokalemia [potassium <3.5 mEq/L] or hyperkalemia [>5.5 mEq/L]) versus normokalemia (3.5-5.5 mEq/L) over the 1-year pre-ESKD period. To avoid potential overestimation of dyskalemia risk, potassium measurements within 7 days following a dyskalemia event were disregarded in the analyses. RESULTS Over the last 1-year pre-ESKD period, there were 319,219 repeated potassium measurements in the cohort. Of these, 12,787 (4.0%) represented hypokalemia, and 15,842 (5.0%) represented hyperkalemia; the time-averaged potassium measurement was 4.5 mEq/L. After multivariable adjustment, time-varying laxative use (compared with nonuse) was significantly associated with lower risk of hyperkalemia (adjusted odds ratio [aOR], 0.79; 95% confidence interval [95% CI], 0.76 to 0.84) but was not associated with risk of hypokalemia (aOR, 1.01; 95% CI, 0.95 to 1.07). The results were robust to several sensitivity analyses. CONCLUSIONS Laxative use was independently associated with lower risk of hyperkalemia during the last 1-year pre-ESKD period. Our findings support a putative role of constipation in potassium disarrays and also support (with a careful consideration for the risk-benefit profiles) the therapeutic potential of laxatives in hyperkalemia management in advanced CKD.
Collapse
Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ankur A. Dashputre
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee,Institute for Health Outcomes and Policy, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Praveen K. Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Miklos Z. Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Justin D. Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, Tennessee
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| |
Collapse
|