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Chay J, Jafar TH, Su RJ, Shirore RM, Tan NC, Finkelstein EA. Cost-Effectiveness of a Multicomponent Primary Care Intervention for Hypertension. J Am Heart Assoc 2024; 13:e033631. [PMID: 38606776 DOI: 10.1161/jaha.123.033631] [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] [Received: 11/20/2023] [Accepted: 03/11/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND The SingHypertension primary care clinic intervention, which consisted of clinician training in hypertension management, subsidized single-pill combination medications, nurse-delivered motivational conversations and telephone follow-ups, improved blood pressure control and cardiovascular disease (CVD) risk scores relative to usual care among patients with uncontrolled hypertension in Singapore. This study quantified the incremental cost-effectiveness, in terms of incremental cost per unit reduction disability-adjusted life years, of SingHypertension relative to usual care for patients with hypertension from the health system perspective. METHODS AND RESULTS We developed a Markov model to simulate CVD events and associated outcomes for a hypothetical cohort of patients over a 10-year period. Costs were measured in US dollars, and effectiveness was measured in disability-adjusted life years averted. We present base-case results and conducted deterministic and probabilistic sensitivity analyses. Based on a willingness-to-pay threshold of US $55 500 per DALY averted, SingHypertension was cost-effective for patients with hypertension (incremental cost-effectiveness ratio: US $24 765 per disability-adjusted life year averted) relative to usual care. This result held even if risk reduction was assumed to decline linearly to 0 over 10 years but not sooner than 7 years. Incremental cost-effectiveness ratios were most sensitive to the magnitude of the reduction in CVD risk; at least a 0.13% to 0.16% point reduction in 10-year CVD risk is required for cost-effectiveness. Probabilistic sensitivity analysis indicates that SingHypertension has a 78% chance of being cost-effective at the willingness-to-pay threshold. CONCLUSIONS SingHypertension represents good value for the money for reducing CVD incidence, morbidity, and mortality and should be considered for wide-scale implementation in Singapore and possibly other countries. REGISTRATION INFORMATION REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02972619.
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Affiliation(s)
- Junxing Chay
- Program in Health Services & Systems Research Duke-NUS Medical School Singapore
| | - Tazeen H Jafar
- Program in Health Services & Systems Research Duke-NUS Medical School Singapore
- Department of Renal Medicine Singapore General Hospital Singapore
- Duke Global Health Institute Durham NC USA
| | - Rebecca J Su
- Program in Health Services & Systems Research Duke-NUS Medical School Singapore
| | - Rupesh M Shirore
- Program in Health Services & Systems Research Duke-NUS Medical School Singapore
| | | | - Eric A Finkelstein
- Program in Health Services & Systems Research Duke-NUS Medical School Singapore
- Duke Global Health Institute Durham NC USA
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Chaturvedi A, Zhu A, Gadela NV, Prabhakaran D, Jafar TH. Social Determinants of Health and Disparities in Hypertension and Cardiovascular Diseases. Hypertension 2024; 81:387-399. [PMID: 38152897 PMCID: PMC10863660 DOI: 10.1161/hypertensionaha.123.21354] [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] [Indexed: 12/29/2023]
Abstract
High blood pressure causes over 10 million preventable deaths annually globally. Populations in low- and middle-income countries suffer the most, experiencing increased uncontrolled blood pressure and cardiovascular disease (CVD) deaths. Despite improvements in high-income countries, disparities persist, notably in the United States, where Black individuals face up to 4× higher CVD mortality than White individuals. Social determinants of health encompass complex, multidimensional factors linked to an individual's birthplace, upbringing, activities, residence, workplaces, socioeconomic and environmental structures, and significantly affect health outcomes, including hypertension and CVD. This review explored how social determinants of health drive disparities in hypertension and related CVD morbidity from a socioecological and life course perspective. We present evidence-based strategies, emphasizing interventions tailored to specific community needs and cross-sector collaboration to address health inequalities rooted in social factors, which are key elements toward achieving the United Nations' Sustainable Development Goal 3.4 for reducing premature CVD mortality by 30% by 2030.
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Affiliation(s)
- Abhishek Chaturvedi
- Georgetown University, MedStar Washington Hospital Center, Washington, DC (A.C.)
| | - Anqi Zhu
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore (A.Z., T.H.J.)
| | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India (D.P.)
- Public Health Foundation of India, Gurugram, India (D.P.)
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore (A.Z., T.H.J.)
- Aga Khan University, Karachi, Pakistan (T.H.J.)
- Duke Global Health Institute, Durham, NC (T.H.J.)
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Jafar TH, Seng LL, Wang Y, Lim CW, Chan CM, Kwek JL, Coffman TM, Ping Y, Bee YM, Allen JC. Heterogeneity by age and gender in the association of kidney function with mortality among patients with diabetes - analysis of diabetes registry in Singapore. BMC Nephrol 2024; 25:23. [PMID: 38233790 PMCID: PMC10795380 DOI: 10.1186/s12882-024-03463-8] [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: 03/07/2023] [Accepted: 01/08/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND We aimed to explore the three-way interaction among age, gender, and kidney function on the risk of all-cause mortality and cardiovascular mortality among patients with type 2 diabetes (T2D). METHODS In a retrospective cohort study, patients aged > 40 years with T2D with serum creatinine and urine albumin measured from 2013 to 2019 were included from a multi-institutional diabetes registry. The exposure was estimated glomerular filtration rate (eGFR), outcomes were all-cause mortality (primary outcome) and cardiovascular disease (CVD) mortality (secondary outcome). We applied multivariable cox proportional hazards regression analysis to compute the association between eGFR and mortality. RESULTS A total of 36,556 patients were followed for up to 6 years during which 2492 (6.82%) died from all causes, and 690 (1.9%) died from CVD. We observed a significant three-way interaction (p = 0.021) among age (younger, < 65; older, ≥65 years), gender and eGFR for the risk of all-cause mortality. Using age- and gender-specific eGFR of 90 ml/min/1.73m2 as the reference point, the adjusted hazard rate (HR) (95% CI) for all-cause mortality at eGFR of 40 ml/min/1.73m2 was 3.70 (2.29 to 5.99) in younger women and 1.86 (1.08 to 3.19) in younger men. The corresponding adjusted HRs in older women and older men were 2.38 (2.02 to 2.82) and 2.18 (1.85 to 2.57), respectively. Similar results were observed for CVD deaths, although the three-way interaction was not statistically significant. Sensitivity analysis yielded similar results. CONCLUSIONS In this T2D population, younger women with reduced kidney function might be more susceptible to higher risks of all-cause mortality and CVD mortality than younger men.
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Affiliation(s)
- Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Loraine Liping Seng
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Yeli Wang
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Nutrition Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ching Wee Lim
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Center for Quantitative Medicine, Office of Clinical Sciences, Duke-NUS Medical School, Singapore, Singapore
| | - Choong Meng Chan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Jia Liang Kwek
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Thomas M Coffman
- Cardiovascular & Metabolic Disorders Programme, Duke-NUS Medical School, Singapore, Singapore
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Yongjing Ping
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Yong Mong Bee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - John C Allen
- Center for Quantitative Medicine, Office of Clinical Sciences, Duke-NUS Medical School, Singapore, Singapore
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4
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Feng L, Bee YM, Fu X, Kwek JL, Chan CM, Jafar TH. Kidney function trajectories, associated factors, and outcomes in multiethnic Asian patients with type 2 diabetes. J Diabetes 2024. [PMID: 38169157 DOI: 10.1111/1753-0407.13523] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 11/02/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND We examined the trajectory of estimated glomerular filtrate rate (eGFR), associated risk factors, and its relationship with end-stage kidney disease (ESKD) among a multiethnic patient population with type 2 diabetes in Singapore. METHODS A follow-up study included 62 080 individuals with type 2 diabetes aged ≥18 years in a multi-institutional SingHealth Diabetes Registry between 2013 and 2019. eGFR trajectories were analyzed using latent class linear mixed models. Factors associated with eGFR trajectories were evaluated using multinomial logistic regression. The association of eGFR trajectories with ESKD was assessed via competing risk models. RESULTS Trajectory of kidney function, determined by eGFR, was nonlinear. The trajectory pattern was classified as stable initially then gradual decline (75%), progressive decline (21.9%), and rapid decline (3.1%). Younger age, female sex, Malay ethnicity, lower-income housing type, current smoking, higher glycated hemoglobin, lower low-density lipoprotein, higher triglyceride, uncontrolled blood pressure, albuminuria, cardiovascular disease, hypertension, and higher eGFR levels each were associated with progressive or rapid decline. Compared with the trajectory of stable initially then gradual eGFR decline, progressive decline increased the hazard of ESKD by 6.14-fold (95% confidence interval [CI]: 4.96-7.61)) and rapid decline by 82.55 folds (95% CI: 55.90-121.89). CONCLUSIONS Three nonlinear trajectory classes of kidney function were identified among multiethnic individuals with type 2 diabetes in Singapore. About one in four individuals had a progressive or rapid decline in eGFR. Our results suggest that eGFR trajectories are correlated with multiple social and modifiable risk factors and inform the risk of ESKD.
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Affiliation(s)
- Liang Feng
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Yong Mong Bee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Xiuju Fu
- Institute of High Performance Computing, A*STAR, Singapore, Singapore
| | - Jia Liang Kwek
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Choong Meng Chan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Tazeen H Jafar
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Duke Global Health Institute, Durham, North Carolina, USA
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Charchar FJ, Prestes PR, Mills C, Ching SM, Neupane D, Marques FZ, Sharman JE, Vogt L, Burrell LM, Korostovtseva L, Zec M, Patil M, Schultz MG, Wallen MP, Renna NF, Islam SMS, Hiremath S, Gyeltshen T, Chia YC, Gupta A, Schutte AE, Klein B, Borghi C, Browning CJ, Czesnikiewicz-Guzik M, Lee HY, Itoh H, Miura K, Brunström M, Campbell NR, Akinnibossun OA, Veerabhadrappa P, Wainford RD, Kruger R, Thomas SA, Komori T, Ralapanawa U, Cornelissen VA, Kapil V, Li Y, Zhang Y, Jafar TH, Khan N, Williams B, Stergiou G, Tomaszewski M. Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension. J Hypertens 2024; 42:23-49. [PMID: 37712135 PMCID: PMC10713007 DOI: 10.1097/hjh.0000000000003563] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/12/2023] [Accepted: 08/22/2023] [Indexed: 09/16/2023]
Abstract
Hypertension, defined as persistently elevated systolic blood pressure (SBP) >140 mmHg and/or diastolic blood pressure (DBP) at least 90 mmHg (International Society of Hypertension guidelines), affects over 1.5 billion people worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (e.g. coronary heart disease, heart failure and stroke) and death. An international panel of experts convened by the International Society of Hypertension College of Experts compiled lifestyle management recommendations as first-line strategy to prevent and control hypertension in adulthood. We also recommend that lifestyle changes be continued even when blood pressure-lowering medications are prescribed. Specific recommendations based on literature evidence are summarized with advice to start these measures early in life, including maintaining a healthy body weight, increased levels of different types of physical activity, healthy eating and drinking, avoidance and cessation of smoking and alcohol use, management of stress and sleep levels. We also discuss the relevance of specific approaches including consumption of sodium, potassium, sugar, fibre, coffee, tea, intermittent fasting as well as integrated strategies to implement these recommendations using, for example, behaviour change-related technologies and digital tools.
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Affiliation(s)
- Fadi J. Charchar
- Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia
- Department of Physiology, University of Melbourne, Melbourne, Australia
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Priscilla R. Prestes
- Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia
| | - Charlotte Mills
- Department of Food and Nutritional Sciences, University of Reading, Reading, UK
| | - Siew Mooi Ching
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang
- Department of Medical Sciences, School of Medical and Live Sciences, Sunway University, Bandar Sunway, Selangor, Malaysia
| | - Dinesh Neupane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Francine Z. Marques
- Hypertension Research Laboratory, School of Biological Sciences, Monash University
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne
| | - James E. Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Liffert Vogt
- Department of Internal Medicine, Section Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, The Netherlands
| | - Louise M. Burrell
- Department of Medicine, University of Melbourne, Austin Health, Melbourne, Australia
| | - Lyudmila Korostovtseva
- Department of Hypertension, Almazov National Medical Research Centre, St Petersburg, Russia
| | - Manja Zec
- School of Nutritional Sciences and Wellness, University of Arizona, Tucson, USA
- Colorado Program for Musculoskeletal Research, Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Mansi Patil
- Department of Nutrition and Dietetics, Asha Kiran JHC Hospital, Chinchwad
- Hypertension and Nutrition, Core Group of IAPEN India, India
| | - Martin G. Schultz
- Department of Internal Medicine, Section Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, The Netherlands
| | | | - Nicolás F. Renna
- Unit of Hypertension, Hospital Español de Mendoza, School of Medicine, National University of Cuyo, IMBECU-CONICET, Mendoza, Argentina
| | | | - Swapnil Hiremath
- Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Canada
| | - Tshewang Gyeltshen
- Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
| | - Yook-Chin Chia
- Department of Medical Sciences, School of Medical and Life Sciences, Sunway University, Selangor
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Abhinav Gupta
- Department of Medicine, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, India
| | - Aletta E. Schutte
- School of Population Health, University of New South Wales, The George Institute for Global Health, Sydney, New South Wales, Australia
- Hypertension in Africa Research Team, SAMRC Unit for Hypertension and Cardiovascular Disease, North-West University
- SAMRC Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Britt Klein
- Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, Faculty of Medicine, University of Bologna, Bologna, Italy
| | - Colette J. Browning
- Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia
| | - Marta Czesnikiewicz-Guzik
- School of Medicine, Dentistry and Nursing-Dental School, University of Glasgow, UK
- Department of Periodontology, Prophylaxis and Oral Medicine; Jagiellonian University, Krakow, Poland
| | - Hae-Young Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hiroshi Itoh
- Department of Internal Medicine (Nephrology, Endocrinology and Metabolism), Keio University, Tokyo
| | - Katsuyuki Miura
- NCD Epidemiology Research Center, Shiga University of Medical Science, Otsu, Japan
| | - Mattias Brunström
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Norm R.C. Campbell
- Libin Cardiovascular Institute, Department of Medicine, University of Calgary, Calgary, Canada
| | | | - Praveen Veerabhadrappa
- Kinesiology, Division of Science, The Pennsylvania State University, Reading, Pennsylvania
| | - Richard D. Wainford
- Department of Pharmacology and Experimental Therapeutics, The Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston
- Division of Cardiology, Emory University, Atlanta, USA
| | - Ruan Kruger
- Hypertension in Africa Research Team (HART), North-West University, Potchefstroom
- MRC Research Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa
| | - Shane A. Thomas
- Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia
| | - Takahiro Komori
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Udaya Ralapanawa
- Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | | | - Vikas Kapil
- William Harvey Research Institute, Centre for Cardiovascular Medicine and Devices, NIHR Barts Biomedical Research Centre, BRC, Faculty of Medicine and Dentistry, Queen Mary University London
- Barts BP Centre of Excellence, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Yan Li
- Department of Cardiovascular Medicine, Shanghai Institute of Hypertension, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
| | - Yuqing Zhang
- Department of Cardiology, Fu Wai Hospital, Chinese Academy of Medical Sciences, Chinese Hypertension League, Beijing, China
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Nadia Khan
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Bryan Williams
- University College London (UCL), Institute of Cardiovascular Science, National Institute for Health Research (NIHR), UCL Hospitals Biomedical Research Centre, London, UK
| | - George Stergiou
- Hypertension Centre STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester
- Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
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Seng LL, Hai Kiat TP, Bee YM, Jafar TH. Real-World Systolic and Diastolic Blood Pressure Levels and Cardiovascular Mortality in Patients With Type 2 Diabetes-Results From a Large Registry Cohort in Asia. J Am Heart Assoc 2023; 12:e030772. [PMID: 37930066 PMCID: PMC10727329 DOI: 10.1161/jaha.123.030772] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Elevated blood pressure (BP) is associated with increased risk of cardiovascular mortality. However, there is ongoing debate whether intensive BP lowering may paradoxically increase the risk of cardiovascular disease (CVD), especially in patients with type 2 diabetes (T2D). We investigated the association of BP with risk of CVD mortality in patients with T2D. METHODS AND RESULTS We used data on 83 721 patients with T2D from a multi-institutional diabetes registry in Singapore from 2013 to 2019. BP was analyzed as categories and restricted cubic splines using Cox multivariable regression analysis stratified by preexisting CVD and age (<65 years versus ≥65 years). The primary outcome was CVD mortality, determined via linkage with the national registry. Among 83 721 patients with T2D (mean age 65.3 years, 50.6% women, 78.9% taking antihypertensive medications), 7.6 per 1000 person-years experienced the primary outcome. Systolic BP had a graded relationship with a significant increase in CVD mortality at levels >120 to 129 mm Hg. Diastolic BP levels >90 mm Hg were significantly associated with CVD mortality in those aged ≥65 years. In addition, diastolic BP <70 mm Hg was associated with a significantly higher risk of CVD mortality in all patients. CONCLUSIONS In patients with T2D, clinic systolic BP levels ≥130 mm Hg or diastolic BP levels ≥90 mm Hg are associated with higher risk of CVD mortality. Diastolic BP <70 mm Hg is also associated with the risk of adverse CVD outcomes, although reverse causality cannot be ruled out.
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Affiliation(s)
- Loraine Liping Seng
- Program in Health Services and Systems ResearchDuke‐NUS Medical SchoolSingapore
| | | | - Yong Mong Bee
- Department of EndocrinologySingapore General HospitalSingapore
| | - Tazeen H. Jafar
- Program in Health Services and Systems ResearchDuke‐NUS Medical SchoolSingapore
- Department of Renal MedicineSingapore General HospitalSingapore
- Duke Global Health Institute, Duke UniversityDurhamNCUSA
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7
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Khan SD, Jafar TH, Siddiqi K, Ahmad T, Khan AA, Samad Z. Data on non-communicable diseases: A missed opportunity in Pakistan. J Glob Health 2023; 13:03045. [PMID: 37651641 PMCID: PMC10471149 DOI: 10.7189/jogh.13.03045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Affiliation(s)
- Sarim D Khan
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
- CITRIC Health Data Science Center, The Aga Khan University, Karachi, Pakistan
| | | | - Kamran Siddiqi
- Department of Health Sciences, University of York, UK
- Hull New York Medical School, University of York, UK
| | - Taimoor Ahmad
- Akhter Hameed Khan Foundation (AHKF), Islamabad, Pakistan
| | - Adnan A Khan
- Research and Development Solutions, Islamabad, Pakistan
| | - Zainab Samad
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
- CITRIC Health Data Science Center, The Aga Khan University, Karachi, Pakistan
- Institute for Global Health and Development, The Aga Khan University, Pakistan, Kenya, United Kingdom
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8
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Inker LA, Collier W, Greene T, Miao S, Chaudhari J, Appel GB, Badve SV, Caravaca-Fontán F, Del Vecchio L, Floege J, Goicoechea M, Haaland B, Herrington WG, Imai E, Jafar TH, Lewis JB, Li PKT, Maes BD, Neuen BL, Perrone RD, Remuzzi G, Schena FP, Wanner C, Wetzels JFM, Woodward M, Heerspink HJL. A meta-analysis of GFR slope as a surrogate endpoint for kidney failure. Nat Med 2023; 29:1867-1876. [PMID: 37330614 DOI: 10.1038/s41591-023-02418-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [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] [Received: 10/31/2022] [Accepted: 05/24/2023] [Indexed: 06/19/2023]
Abstract
Glomerular filtration rate (GFR) decline is causally associated with kidney failure and is a candidate surrogate endpoint for clinical trials of chronic kidney disease (CKD) progression. Analyses across a diverse spectrum of interventions and populations is required for acceptance of GFR decline as an endpoint. In an analysis of individual participant data, for each of 66 studies (total of 186,312 participants), we estimated treatment effects on the total GFR slope, computed from baseline to 3 years, and chronic slope, starting at 3 months after randomization, and on the clinical endpoint (doubling of serum creatinine, GFR < 15 ml min-1 per 1.73 m2 or kidney failure with replacement therapy). We used a Bayesian mixed-effects meta-regression model to relate treatment effects on GFR slope with those on the clinical endpoint across all studies and by disease groups (diabetes, glomerular diseases, CKD or cardiovascular diseases). Treatment effects on the clinical endpoint were strongly associated with treatment effects on total slope (median coefficient of determination (R2) = 0.97 (95% Bayesian credible interval (BCI) 0.82-1.00)) and moderately associated with those on chronic slope (R2 = 0.55 (95% BCI 0.25-0.77)). There was no evidence of heterogeneity across disease. Our results support the use of total slope as a primary endpoint for clinical trials of CKD progression.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA.
| | - Willem Collier
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tom Greene
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
| | - Juhi Chaudhari
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
| | - Gerald B Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, NY, USA
| | - Sunil V Badve
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Benjamin Haaland
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Julia B Lewis
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Philip K T Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - Bart D Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Brendon L Neuen
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco P Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Renal Research Unit, Comprehensive Heart Failure Center, Department of Clinical Research and Epidemiology, University of Würzburg, Würzburg, Germany
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Mark Woodward
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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9
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Yoon S, Hoe PS, Chan A, Malhotra R, Visaria A, Matchar D, Goh H, Seng B, Ramakrishnan C, Koh MS, Yee TP, Nadarajan GD, Bee YM, Graves N, Jafar TH, Ong ME. Impact of COVID-19 on perceived wellbeing, self-management and views of novel modalities of care among medically vulnerable patients in Singapore. Chronic Illn 2023; 19:314-326. [PMID: 34964364 PMCID: PMC9996168 DOI: 10.1177/17423953211067458] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study aims to examine the impact of COVID-19 measures on wellbeing and self-management in medically vulnerable non-COVID patients and their views of novel modalities of care in Singapore. METHODS Patients with cardiovascular disease (CVD), respiratory disease, chronic kidney disease, diabetes and cancer were recruited from the SingHealth cluster and national cohort of older adults. Data on demographics, chronic conditions and perceived wellbeing were collected using questionnaire. We performed multivariable regression to examine factors associated with perceived wellbeing. Qualitative interviews were conducted to elicit patient's experience and thematically analyzed. RESULTS A total of 91 patients participated. Male patients compared with female patients perceived a lower impact of the pandemic on subjective wellbeing. Patients with CVD compared to those having conditions other than CVD perceived a lower impact. Impacts of the pandemic were primarily described in relation to emotional distress and interference in maintaining self-care. Hampering of physical activity featured prominently, but most did not seek alternative ways to maintain activity. Despite general willingness to try novel care modalities, lack of physical interaction and communication difficulties were perceived as main barriers. DISCUSSION Findings underline the need to alleviate emotional distress and develop adaptive strategies to empower patients to maintain wellbeing and self-care.
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Affiliation(s)
- Sungwon Yoon
- Health Services and Systems Research, 121579Duke-NUS Medical School, Singapore
| | - Pei Shan Hoe
- Centre for Ageing Research and Education (CARE), 121579Duke-NUS Medical School, Singapore
| | - Angelique Chan
- Health Services and Systems Research, 121579Duke-NUS Medical School, Singapore.,Centre for Ageing Research and Education (CARE), 121579Duke-NUS Medical School, Singapore
| | - Rahul Malhotra
- Health Services and Systems Research, 121579Duke-NUS Medical School, Singapore.,Centre for Ageing Research and Education (CARE), 121579Duke-NUS Medical School, Singapore
| | - Abhijit Visaria
- Centre for Ageing Research and Education (CARE), 121579Duke-NUS Medical School, Singapore
| | - David Matchar
- Health Services and Systems Research, 121579Duke-NUS Medical School, Singapore.,Department of Medicine (General Internal Medicine), 22957Duke University Medical Center, Durham, North Carolina, USA
| | - Hendra Goh
- Health Services and Systems Research, 121579Duke-NUS Medical School, Singapore
| | - Bridget Seng
- Centre for Ageing Research and Education (CARE), 121579Duke-NUS Medical School, Singapore
| | | | - Mariko S Koh
- 121579Duke-NUS Medical School, Singapore.,Department of Respiratory and Critical Care Medicine, 37581Singapore General Hospital, Singapore
| | - Tiew Pei Yee
- 121579Duke-NUS Medical School, Singapore.,Department of Respiratory and Critical Care Medicine, 37581Singapore General Hospital, Singapore
| | | | - Yong Mong Bee
- Department of Endocrinology, 37581Singapore General Hospital, Singapore
| | - Nicholas Graves
- Health Services and Systems Research, 121579Duke-NUS Medical School, Singapore
| | - Tazeen H Jafar
- Health Services and Systems Research, 121579Duke-NUS Medical School, Singapore.,Department of Medicine, 9615Aga Khan University, Karachi, Pakistan.,Duke Global Health Institute, 3065Duke University, Durham, North Carolina, USA
| | - Marcus Eh Ong
- Health Services and Systems Research, 121579Duke-NUS Medical School, Singapore.,Department of Emergency Medicine, 37581Singapore General Hospital, Singapore
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10
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Jafar TH, Shirore RM. Team-Based Care With Nonphysician Titration of Antihypertensive Medications in Collaboration With Physicians: A Cost-Effective Way to Control Blood Pressure? Hypertension 2023; 80:1209-1212. [PMID: 37196100 DOI: 10.1161/hypertensionaha.123.21100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore (T.H.J., R.M.S.)
- Duke Global Health Institute, Duke University, Durham, NC (T.H.J.)
| | - Rupesh M Shirore
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore (T.H.J., R.M.S.)
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11
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Heerspink HJ, Inker LA, Tighiouart H, Collier WH, Haaland B, Luo J, Appel GB, Chan TM, Estacio RO, Fervenza F, Floege J, Imai E, Jafar TH, Lewis JB, Kam-Tao Li P, Locatelli F, Maes BD, Perna A, Perrone RD, Praga M, Schena FP, Wanner C, Xie D, Greene T. Change in Albuminuria and GFR Slope as Joint Surrogate End Points for Kidney Failure: Implications for Phase 2 Clinical Trials in CKD. J Am Soc Nephrol 2023; 34:955-968. [PMID: 36918388 PMCID: PMC10278784 DOI: 10.1681/asn.0000000000000117] [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: 10/11/2022] [Accepted: 01/19/2023] [Indexed: 03/16/2023] Open
Abstract
SIGNIFICANCE STATEMENT Changes in albuminuria and GFR slope are individually used as surrogate end points in clinical trials of CKD progression, and studies have demonstrated that each is associated with treatment effects on clinical end points. In this study, the authors sought to develop a conceptual framework that combines both surrogate end points to better predict treatment effects on clinical end points in Phase 2 trials. The results demonstrate that information from the combined treatment effects on albuminuria and GFR slope improves the prediction of treatment effects on the clinical end point for Phase 2 trials with sample sizes between 100 and 200 patients and duration of follow-up ranging from 1 to 2 years. These findings may help inform design of clinical trials for interventions aimed at slowing CKD progression. BACKGROUND Changes in log urinary albumin-to-creatinine ratio (UACR) and GFR slope are individually used as surrogate end points in clinical trials of CKD progression. Whether combining these surrogate end points might strengthen inferences about clinical benefit is unknown. METHODS Using Bayesian meta-regressions across 41 randomized trials of CKD progression, we characterized the combined relationship between the treatment effects on the clinical end point (sustained doubling of serum creatinine, GFR <15 ml/min per 1.73 m 2 , or kidney failure) and treatment effects on UACR change and chronic GFR slope after 3 months. We applied the results to the design of Phase 2 trials on the basis of UACR change and chronic GFR slope in combination. RESULTS Treatment effects on the clinical end point were strongly associated with the combination of treatment effects on UACR change and chronic slope. The posterior median meta-regression coefficients for treatment effects were -0.41 (95% Bayesian Credible Interval, -0.64 to -0.17) per 1 ml/min per 1.73 m 2 per year for the treatment effect on GFR slope and -0.06 (95% Bayesian Credible Interval, -0.90 to 0.77) for the treatment effect on UACR change. The predicted probability of clinical benefit when considering both surrogates was determined primarily by estimated treatment effects on UACR when sample size was small (approximately 60 patients per treatment arm) and follow-up brief (approximately 1 year), with the importance of GFR slope increasing for larger sample sizes and longer follow-up. CONCLUSIONS In Phase 2 trials of CKD with sample sizes of 100-200 patients per arm and follow-up between 1 and 2 years, combining information from treatment effects on UACR change and GFR slope improved the prediction of treatment effects on clinical end points.
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Affiliation(s)
- Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Willem H. Collier
- Division of Biostatistics, Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah
| | - Benjamin Haaland
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah
| | - Jiyu Luo
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, California
| | - Gerald B. Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, New York
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | | | - Fernando Fervenza
- Division of Nephrology and Hypertension and Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Julia B. Lewis
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Francesco Locatelli
- Department of Nephrology, Alessandro Manzoni Hospital (past Director), ASST Lecco, Italy
| | - Bart D. Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | | | - Manuel Praga
- Nephrology Department, Hospital Universitario 12 de Octubre, Department of Medicine, Complutense University, Madrid, Spain
| | - Francesco P. Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Di Xie
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tom Greene
- Division of Biostatistics, Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah
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12
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Campbell NR, Whelton PK, Orias M, Cobb LL, Jones ES, Garg R, Willliams B, Khan N, Chia YC, Jafar TH, Ide N. It is strongly recommended to not conduct, fund, or publish research studies that use spot urine samples with estimating equations to assess individuals' sodium (salt) intake in association with health outcomes: a policy statement of the World Hypertension League, International Society of Hypertension and Resolve to Save Lives. J Hypertens 2023; 41:683-686. [PMID: 36723484 PMCID: PMC10090307 DOI: 10.1097/hjh.0000000000003385] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 01/06/2023] [Accepted: 01/07/2023] [Indexed: 02/02/2023]
Abstract
Spot urine samples with estimating equations have been used to assess individuals' sodium (salt) intake in association with health outcomes. There is large random and systematic error in estimating sodium intake using this method and spurious health outcome associations. Substantial controversy has resulted from false claims the method is valid. Hence, the World Hypertension League, International Society of Hypertension and Resolve to Save Lives, supported by 21 other health organizations, have issued this policy statement that strongly recommends that research using spot urine samples with estimating equations to assess individuals' sodium (salt) intake in association with health outcomes should not be conducted, funded or published. Literature reviews on the health impacts of reducing dietary sodium that include studies that have used spot and short duration timed urine samples with estimating equations need to explicitly acknowledge that the method is not recommended to be used and is associated with spurious health outcome associations.
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Affiliation(s)
| | - Paul K. Whelton
- Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | | | | | - Erika S.W. Jones
- Division of Nephrology and Hypertension, Department of Medicine, Groote Schuur Hospital, University of Cape Town, South Africa
| | - Renu Garg
- Resolve to Save Lives, New York, New York, USA
| | - Bryan Willliams
- University College London, NIHR University College London, Hospitals Biomedical Research Centre, London, UK
| | - Nadia Khan
- Center for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada
| | - Yook-Chin Chia
- Department of Medical Sciences, School of Medical and Live Sciences, Sunway University, Bandar Sunway, Selangor, Malaysia
| | - Tazeen H. Jafar
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Nicole Ide
- Resolve to Save Lives, New York, New York, USA
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13
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Feng L, Khan AH, Jehan I, Samad Z, Jafar TH. Sex disparity in left ventricular hypertrophy in South Asians with hypertension: influence of central obesity and high blood pressure. J Hum Hypertens 2023; 37:327-329. [PMID: 36806826 DOI: 10.1038/s41371-023-00814-0] [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] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 02/20/2023]
Abstract
Women have been reported to be at greater risk of left ventricular hypertrophy (LVH) than men in South Asia, but whether the sex disparity is affected by central obesity and blood pressure has not been well studied. We examined prospectively the interaction of sex with waist circumference and systolic blood pressure at baseline on LVH measured after a median of 8-year follow-up among 539 individuals with hypertension in Karachi, Pakistan, and found that the risk of LVH for women vs men increased with higher baseline waist circumference and systolic blood pressure. Our results underscore the urgency for public health programs to prevent obesity and control hypertension in women in South Asia.
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Affiliation(s)
- Liang Feng
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Aamir Hameed Khan
- Section of Cardiology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Imtiaz Jehan
- Department of Community Health Science, Aga Khan University, Karachi, Pakistan
| | - Zainab Samad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Tazeen H Jafar
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore.
- Duke Global Health Institute, Duke University, Durham, NC, USA.
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14
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Schutte AE, Jafar TH, Poulter NR, Damasceno A, Khan NA, Nilsson PM, Alsaid J, Neupane D, Kario K, Beheiry H, Brouwers S, Burger D, Charchar FJ, Cho MC, Guzik TJ, Haji Al-Saedi GF, Ishaq M, Itoh H, Jones ESW, Khan T, Kokubo Y, Kotruchin P, Muxfeldt E, Odili A, Patil M, Ralapanawa U, Romero CA, Schlaich MP, Shehab A, Mooi CS, Steckelings UM, Stergiou G, Touyz RM, Unger T, Wainford RD, Wang JG, Williams B, Wynne BM, Tomaszewski M. Addressing global disparities in blood pressure control: perspectives of the International Society of Hypertension. Cardiovasc Res 2023; 119:381-409. [PMID: 36219457 PMCID: PMC9619669 DOI: 10.1093/cvr/cvac130] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/13/2022] [Accepted: 05/31/2022] [Indexed: 11/14/2022] Open
Abstract
ABSTRACT Raised blood pressure (BP) is the leading cause of preventable death in the world. Yet, its global prevalence is increasing, and it remains poorly detected, treated, and controlled in both high- and low-resource settings. From the perspective of members of the International Society of Hypertension based in all regions, we reflect on the past, present, and future of hypertension care, highlighting key challenges and opportunities, which are often region-specific. We report that most countries failed to show sufficient improvements in BP control rates over the past three decades, with greater improvements mainly seen in some high-income countries, also reflected in substantial reductions in the burden of cardiovascular disease and deaths. Globally, there are significant inequities and disparities based on resources, sociodemographic environment, and race with subsequent disproportionate hypertension-related outcomes. Additional unique challenges in specific regions include conflict, wars, migration, unemployment, rapid urbanization, extremely limited funding, pollution, COVID-19-related restrictions and inequalities, obesity, and excessive salt and alcohol intake. Immediate action is needed to address suboptimal hypertension care and related disparities on a global scale. We propose a Global Hypertension Care Taskforce including multiple stakeholders and societies to identify and implement actions in reducing inequities, addressing social, commercial, and environmental determinants, and strengthening health systems implement a well-designed customized quality-of-care improvement framework.
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Affiliation(s)
- Aletta E Schutte
- School of Population Health, University of New South Wales, Kensington Campus, High Street, Sydney 2052 NSW, Australia; The George Institute for Global Health, King Street, Newton, Sydney NSW 2052, Australia
- Hypertension in Africa Research Team, SAMRC Unit for Hypertension and Cardiovascular Disease; North-West University, Hoffman Street, Potchefstroom 2520, South Africa
- SAMRC Development Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, 1 Jan Smuts Ave, Braamfontein, Johannesburg, 2000, South Africa
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Department of Renal Medicine, 8 College Rd., Singapore 169857, Singapore
- Duke Global Health Institute, Duke University, 310 Trent Dr, Durham, NC 27710, USA
| | - Neil R Poulter
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London W12 7RH, UK
| | - Albertino Damasceno
- Faculty of Medicine, Eduardo Mondlane University, 3453 Avenida Julius Nyerere, Maputo, Mozambique
| | - Nadia A Khan
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Center for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
| | - Peter M Nilsson
- Department of Clinical Sciences, Skane University Hospital, Lund University, Malmö, Sweden
| | - Jafar Alsaid
- Ochsner Health System, New Orleans, Louisiana, USA
- Queensland University, Brisbane, Queensland, Australia
| | - Dinesh Neupane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Hind Beheiry
- International University of Africa, Khartoum, Sudan
| | - Sofie Brouwers
- Department of Cardiology, Cardiovascular Center Aalst, OLV Clinic Aalst, Aalst, Belgium
- Department of Experimental Pharmacology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Dylan Burger
- Kidney Research Centre, Ottawa Hospital Research Institute, Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Fadi J Charchar
- Health Innovation and Transformation Centre, Federation University, Ballarat, Victoria, Australia
- Department of Physiology and Anatomy, University of Melbourne, Melbourne, Victoria, Australia
| | - Myeong-Chan Cho
- Department of Internal Medicine, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8585, Japan
| | - Erika S W Jones
- Division of Nephrology and Hypertension, Groote Schuur Hospital and Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Taskeen Khan
- Department of Public Health Medicine, University of Pretoria, Pretoria, South Africa
| | - Yoshihiro Kokubo
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Praew Kotruchin
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Elizabeth Muxfeldt
- University Hospital Clementino Fraga Filho, Hypertension Program, Universidade Federal do Rio de Janeiro, Brazil
| | - Augustine Odili
- Circulatory Health Research Laboratory, College of Health Sciences, University of Abuja, Abuja, Nigeria
| | - Mansi Patil
- Department of Nutrition and Dietetics, Asha Kiran JHC Hospital, Chinchwad, India
| | - Udaya Ralapanawa
- Faculty of Medicine, University of Peradeniya, Kandy, Central Province, Sri Lanka
| | - Cesar A Romero
- Renal Division, Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit and RPH Research Foundation, The University of Western Australia, Perth, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Perth, Western Australia, Australia
| | - Abdulla Shehab
- College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Ching Siew Mooi
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
| | - U Muscha Steckelings
- Department of Cardiovascular & Renal Research, Institute of Molecular Medicine. University of Southern Denmark, Odense, Denmark
| | - George Stergiou
- Hypertension Centre STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Rhian M Touyz
- Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Thomas Unger
- CARIM - Cardiovascular Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Richard D Wainford
- Department of Pharmacology & Experimental Therapeutics and the Whitaker, Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - Ji-Guang Wang
- Department of Hypertension, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Shanghai Key Laboratory of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bryan Williams
- Institute of Cardiovascular Science, University College London (UCL), National Institute for Health Research (NIHR), UCL Hospitals Biomedical Research Centre, London, UK
| | - Brandi M Wynne
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah, Salt Lake City, UT, USA
| | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
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15
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Collier W, Inker LA, Haaland B, Appel GB, Badve SV, Caravaca-Fontán F, Chalmers J, Floege J, Goicoechea M, Imai E, Jafar TH, Lewis JB, Li PK, Locatelli F, Maes BD, Neuen BL, Perrone RD, Remuzzi G, Schena FP, Wanner C, Heerspink HJ, Greene T. Evaluation of Variation in the Performance of GFR Slope as a Surrogate End Point for Kidney Failure in Clinical Trials that Differ by Severity of CKD. Clin J Am Soc Nephrol 2023; 18:183-192. [PMID: 36754007 PMCID: PMC10103374 DOI: 10.2215/cjn.0000000000000050] [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: 08/12/2022] [Accepted: 12/02/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The GFR slope has been evaluated as a surrogate end point for kidney failure in meta-analyses on a broad collection of randomized controlled trials (RCTs) in CKD. These analyses evaluate how accurately a treatment effect on GFR slope predicts a treatment effect on kidney failure. We sought to determine whether severity of CKD in the patient population modifies the performance of GFR slope. METHODS We performed Bayesian meta-regression analyses on 66 CKD RCTs to evaluate associations between effects on GFR slope (the chronic slope and the total slope over 3 years, expressed as mean differences in ml/min per 1.73 m2/yr) and those of the clinical end point (doubling of serum creatinine, GFR <15 ml/min per 1.73 m2, or kidney failure, expressed as a log-hazard ratio), where models allow interaction with variables defining disease severity. We evaluated three measures (baseline GFR in 10 ml/min per 1.73 m2, baseline urine albumin-to-creatinine ratio [UACR] per doubling in mg/g, and CKD progression rate defined as the control arm chronic slope, in ml/min per 1.73 m2/yr) and defined strong evidence for modification when 95% posterior credible intervals for interaction terms excluded zero. RESULTS There was no evidence for modification by disease severity when evaluating 3-year total slope (95% credible intervals for the interaction slope: baseline GFR [-0.05 to 0.03]; baseline UACR [-0.02 to 0.04]; CKD progression rate [-0.07 to 0.02]). There was strong evidence for modification in evaluations of chronic slope (95% credible intervals: baseline GFR [0.02 to 0.11]; baseline UACR [-0.11 to -0.02]; CKD progression rate [0.01 to 0.15]). CONCLUSIONS These analyses indicate consistency of the performance of total slope over 3 years, which provides further evidence for its validity as a surrogate end point in RCTs representing varied CKD populations.
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Affiliation(s)
- Willem Collier
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin Haaland
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Gerald B. Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, New York
| | - Sunil V. Badve
- Renal and Metabolic Division, the George Institute for Global Health, Newtown, New South Wales, Australia
| | | | - John Chalmers
- Renal and Metabolic Division, the George Institute for Global Health, Newtown, New South Wales, Australia
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Julia B. Lewis
- Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Philip K.T. Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Francesco Locatelli
- Department of Nephrology, Alessandro Manzoni Hospital (past Director), ASST Lecco, Italy
| | - Bart D. Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Brendon L. Neuen
- Renal and Metabolic Division, the George Institute for Global Health, Newtown, New South Wales, Australia
| | | | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco P. Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tom Greene
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
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Tee C, Xu H, Fu X, Cui D, Jafar TH, Bee YM. Longitudinal HbA1c trajectory modelling reveals the association of HbA1c and risk of hospitalization for heart failure for patients with type 2 diabetes mellitus. PLoS One 2023; 18:e0275610. [PMID: 36662791 PMCID: PMC9858041 DOI: 10.1371/journal.pone.0275610] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 09/20/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Inconsistent conclusions in past studies on the association between poor glycaemic control and the risk of hospitalization for heart failure (HHF) have been reported largely due to the analysis of non-trajectory-based HbA1c values. Trajectory analysis can incorporate the effects of HbA1c variability across time, which may better elucidate its association with macrovascular complications. Furthermore, studies analysing the relationship between HbA1c trajectories from diabetes diagnosis and the occurrence of HHF are scarce. METHODS This is a prospective cohort study of the SingHealth Diabetes Registry (SDR). 17,389 patients diagnosed with type 2 diabetes mellitus (T2DM) from 2013 to 2016 with clinical records extending to the end of 2019 were included in the latent class growth analysis to extract longitudinal HbA1c trajectories. Association between HbA1c trajectories and risk of first known HHF is quantified with the Cox Proportional Hazards (PH) model. RESULTS 5 distinct HbA1c trajectories were identified as 1. low stable (36.1%), 2. elevated stable (40.4%), 3. high decreasing (3.5%), 4. high with a sharp decline (10.8%), and 5. moderate decreasing (9.2%) over the study period of 7 years. Poorly controlled HbA1c trajectories (Classes 3, 4, and 5) are associated with a higher risk of HHF. Using the diabetes diagnosis time instead of a commonly used pre-defined study start time or time from recruitment has an impact on HbA1c clustering results. CONCLUSIONS Findings suggest that tracking the evolution of HbA1c with time has its importance in assessing the HHF risk of T2DM patients, and T2DM diagnosis time as a baseline is strongly recommended in HbA1c trajectory modelling. To the authors' knowledge, this is the first study to identify an association between HbA1c trajectories and HHF occurrence from diabetes diagnosis time.
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Affiliation(s)
- Clarence Tee
- Systems Science Department, Institute of High-Performance Computing, Singapore, Singapore
| | - Haiyan Xu
- Systems Science Department, Institute of High-Performance Computing, Singapore, Singapore
| | - Xiuju Fu
- Systems Science Department, Institute of High-Performance Computing, Singapore, Singapore
| | - Di Cui
- Systems Science Department, Institute of High-Performance Computing, Singapore, Singapore
- Department of Advanced Design and Systmes Engineering, City University of Hong Kong, Kowloon Tong, Hong Kong
| | - Tazeen H. Jafar
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Yong Mong Bee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
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17
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Jafar TH, Tavajoh S, de Silva HA, Naheed A, Jehan I, Kanatiwela de Silva C, Chakma N, Huda M, Legido-Quigley H. Post-intervention acceptability of multicomponent intervention for management of hypertension in rural Bangladesh, Pakistan, and Sri Lanka- a qualitative study. PLoS One 2023; 18:e0280455. [PMID: 36656903 PMCID: PMC9851540 DOI: 10.1371/journal.pone.0280455] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 01/03/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND COBRA-BPS (Control of Blood Pressure and Risk Attenuation-Bangladesh, Pakistan, Sri Lanka), a multicomponent, community health-worker (CHW)-led hypertension management program, has been shown to be effective in rural communities in South Asia. This paper presents the acceptability of COBRA-BPS multicomponent intervention among the key stakeholders. METHODS We conducted post-implementation interviews of 87 stakeholder including 23 community health workers (CHWs), 19 physicians and 45 patients in 15 rural communities randomized to COBRA-BPS multicomponent intervention in in Bangladesh, Pakistan, and Sri Lanka. We used Theoretical Framework for Acceptability framework (TFA) with a focus on affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness and self-efficacy. RESULTS COBRA-BPS multicomponent intervention was acceptable to most stakeholders. Despite some concerns about workload, most CHWs were enthusiastic and felt empowered. Physicians appreciated the training sessions and felt trusted by their patients. Patients were grateful to receive the intervention and valued it. However, patients in Pakistan and Bangladesh expressed the need for supplies of free medicines from the primary health facilities, while those in Sri Lanka were concerned about supplies' irregularities. All stakeholders favoured scaling-up COBRA-BPS at a national level. CONCLUSIONS COBRA-BPS multicomponent intervention is acceptable to the key stakeholders in Bangladesh, Pakistan and Sri Lanka. Community engagement for national scale-up of COBRA-BPS is likely to be successful in all three countries.
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Affiliation(s)
- Tazeen H. Jafar
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
| | - Saeideh Tavajoh
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - H. Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Aliya Naheed
- Initiative for Noncommunicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Imtiaz Jehan
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Chamini Kanatiwela de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Nantu Chakma
- Initiative for Noncommunicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Maryam Huda
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Helena Legido-Quigley
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
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18
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Matsushita K, Kaptoge S, Hageman SHJ, Sang Y, Ballew SH, Grams ME, Surapaneni A, Sun L, Arnlov J, Bozic M, Brenner H, Brunskill NJ, Chang AR, Chinnadurai R, Cirillo M, Correa A, Ebert N, Eckardt KU, Gansevoort RT, Gutierrez O, Hadaegh F, He J, Hwang SJ, Jafar TH, Jassal SK, Kayama T, Kovesdy CP, Landman GW, Levey AS, Lloyd-Jones DM, Major RW, Miura K, Muntner P, Nadkarni GN, Nowak C, Ohkubo T, Pena MJ, Polkinghorne KR, Sairenchi T, Schaeffner E, Schneider MP, Shalev V, Shlipak MG, Solbu MD, Stempniewicz N, Tollitt J, Valdivielso JM, van der Leeuw J, Wang AYM, Wen CP, Woodward M, Yamagishi K, Yatsuya H, Zhang L, Dorresteijn JAN, Di Angelantonio E, Visseren FLJ, Pennells L, Coresh J. Including measures of chronic kidney disease to improve cardiovascular risk prediction by SCORE2 and SCORE2-OP. Eur J Prev Cardiol 2023; 30:8-16. [PMID: 35972749 PMCID: PMC9839538 DOI: 10.1093/eurjpc/zwac176] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 01/17/2023]
Abstract
AIMS The 2021 European Society of Cardiology (ESC) guideline on cardiovascular disease (CVD) prevention categorizes moderate and severe chronic kidney disease (CKD) as high and very-high CVD risk status regardless of other factors like age and does not include estimated glomerular filtration rate (eGFR) and albuminuria in its algorithms, systemic coronary risk estimation 2 (SCORE2) and systemic coronary risk estimation 2 in older persons (SCORE2-OP), to predict CVD risk. We developed and validated an 'Add-on' to incorporate CKD measures into these algorithms, using a validated approach. METHODS In 3,054 840 participants from 34 datasets, we developed three Add-ons [eGFR only, eGFR + urinary albumin-to-creatinine ratio (ACR) (the primary Add-on), and eGFR + dipstick proteinuria] for SCORE2 and SCORE2-OP. We validated C-statistics and net reclassification improvement (NRI), accounting for competing risk of non-CVD death, in 5,997 719 participants from 34 different datasets. RESULTS In the target population of SCORE2 and SCORE2-OP without diabetes, the CKD Add-on (eGFR only) and CKD Add-on (eGFR + ACR) improved C-statistic by 0.006 (95%CI 0.004-0.008) and 0.016 (0.010-0.023), respectively, for SCORE2 and 0.012 (0.009-0.015) and 0.024 (0.014-0.035), respectively, for SCORE2-OP. Similar results were seen when we included individuals with diabetes and tested the CKD Add-on (eGFR + dipstick). In 57 485 European participants with CKD, SCORE2 or SCORE2-OP with a CKD Add-on showed a significant NRI [e.g. 0.100 (0.062-0.138) for SCORE2] compared to the qualitative approach in the ESC guideline. CONCLUSION Our Add-ons with CKD measures improved CVD risk prediction beyond SCORE2 and SCORE2-OP. This approach will help clinicians and patients with CKD refine risk prediction and further personalize preventive therapies for CVD.
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Affiliation(s)
- Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Stephen Kaptoge
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Steven HJ Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Aditya Surapaneni
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Luanluan Sun
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Johan Arnlov
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Milica Bozic
- Vascular & Renal Translational Research Group, IRBLleida, Spain and Spanish Research Network for Renal Diseases (RedInRen. ISCIII) , Lleida , Spain
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ) and Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Nigel J Brunskill
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom, Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Alex R Chang
- Department of Nephrology and Kidney Health Research Institute, Geisinger Medical Center, Danville, Pennsylvania
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Massimo Cirillo
- Department of Public Health, University of Naples “Federico II”, Italy
| | | | - Natalie Ebert
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany; Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Orlando Gutierrez
- Departments of Epidemiology and Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Farzad Hadaegh
- Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Shih-Jen Hwang
- National Heart, Lung, and Blood Institute, Framingham, Massachusetts
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-National University of Singapore Medical School, Singapore, Department of Medicine, Aga Khan University, Karachi, Pakistan, and Duke Global Health Institute, Durham, Duke University, North Carolina
| | - Simerjot K Jassal
- Division of General Internal Medicine, University of California, San Diego and VA San Diego Healthcare, San Diego, California
| | - Takamasa Kayama
- Global Center of Excellence, Yamagata University Faculty of Medicine, Yamagata, Japan; Department of Public Health Medicine, Faculty of Medicine, and Health Services Research and Development Center, University of Tsukuba, Japan
| | - Csaba P Kovesdy
- Medicine-Nephrology, Memphis Veterans Affairs Medical Center and University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | | | - Rupert W Major
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom, Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Katsuyuki Miura
- NCD Epidemiology Research Center, Shiga University of Medical Science, Shiga, Japan
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Girish N Nadkarni
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christoph Nowak
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Takayoshi Ohkubo
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
| | - Michelle J Pena
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Toshimi Sairenchi
- Medical Science of Nursing, Dokkyo Medical University School of Nursing, Mibu, Japan
| | - Elke Schaeffner
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Markus P Schneider
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Varda Shalev
- Institute for Health and Research and Innovation, Maccabi Healthcare Services and Tel Aviv University, Tel Aviv, Israel
| | - Michael G Shlipak
- Kidney Health Research Collaborative, University of California, San Francisco, and San Francisco VA Healthcare System, San Francisco
| | - Marit D Solbu
- Section of Nephrology, University Hospital of North Norway, Tromsø, Norway and UiT The Arctic University of Norway, Tromsø, Norway
| | - Nikita Stempniewicz
- AMGA (American Medical Group Association), Alexandria, Virginia and OptumLabs Visiting Fellow
| | - James Tollitt
- Department of Renal Medicine, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Salford, UK; Renal Department, University of Manchester, Oxford Road, Manchester, United Kingdom
| | - José M Valdivielso
- Vascular & Renal Translational Research Group, IRBLleida, Spain and Spanish Research Network for Renal Diseases (RedInRen. ISCIII) , Lleida , Spain
| | - Joep van der Leeuw
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Chi-Pang Wen
- China Medical University Hospital, Taichung, Taiwan
| | - Mark Woodward
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kazumasa Yamagishi
- George Institute for Global Health, Australia, and George Institute for Global Health, Imperial College, London, United Kingdom
| | - Hiroshi Yatsuya
- Department of Public Health, Fujita Health University School of Medicine, Aichi, Japan and Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Luxia Zhang
- Peking University First Hospital and Peking University, Beijing, China
| | - Jannick AN Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Emanuele Di Angelantonio
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom; Health Data Science Centre, Human Technopole, Milan, Italy
| | - Frank LJ Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisa Pennells
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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19
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Wilson GJ, Van K, O'Lone E, Tong A, Craig JC, Sautenet B, Budde K, Forfang D, Gill J, Herrington WG, Jafar TH, Johnson DW, Krane V, Levin A, Malyszko J, Rossignol P, Sawinski D, Scholes-Robertons N, Strippoli G, Wang A, Winkelmayer WC, Hawley CM, Viecelli AK. Range and Consistency of Cardiovascular Outcomes Reported by Clinical Trials in Kidney Transplant Recipients: A Systematic Review. Transplant Direct 2023; 9:e1398. [PMID: 36518792 PMCID: PMC9742089 DOI: 10.1097/txd.0000000000001398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/28/2022] [Accepted: 09/13/2022] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular disease is a major cause of morbidity and mortality in kidney transplant recipients. Trial evidence to improve cardiovascular outcomes is limited by inconsistent reporting of outcomes, which may also lack patient-relevance. This study aimed to assess the range and consistency of cardiovascular outcomes reported by contemporary trials in kidney transplant recipients. Methods A systematic review of all randomized controlled trials involving adult kidney transplant recipients that reported at least 1 cardiovascular outcome from January 2012 to December 2019 was performed, including Embase, MEDLINE, Cochrane, and ClinicalTrials.gov electronic databases. Trial characteristics were extracted and all levels of specification of the cardiovascular outcome measures reported were analyzed (the measure definition, metric' and method of aggregation). Measures assessing a similar aspect of cardiovascular disease were categorized into outcomes. Results From 93 eligible trials involving 27 609 participants, 490 outcome measures were identified. The outcome measures were grouped into 38 outcomes. A cardiovascular composite was the most common outcome reported (40 trials, 43%) followed by cardiovascular mortality (42%) and acute coronary syndrome (31%). Cardiovascular composite was also the most heterogeneous outcome with 77 measures reported followed by cardiovascular mortality (n = 58) and inflammatory biomarkers (n = 51). The most common cardiovascular composite outcome components reported were major cardiovascular events (18 trials), stroke unspecified (11 trials), and myocardial infarction unspecified (10 trials). Conclusions There is substantial heterogeneity in cardiovascular outcome reporting in kidney transplant trials.
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Affiliation(s)
- Gregory J Wilson
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Nephrology, Mater Health Services, Brisbane, QLD, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Kim Van
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Emma O'Lone
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Benedicte Sautenet
- Service de Nephrologie-Hypertension, Dialyses, Transplantation Rénale, Hopital Bretonneau, Université de Tours, Université de Nantes, INSERM SPHERE U 1246, Tours, France
| | | | | | - John Gill
- University of British Columbia, Vancouver, BC, Canada
| | - William G Herrington
- Nuffield Department of Population Health, Medical Research Council Population Health Research Unit at the University of Oxford, Oxford, United Kingdom
| | | | - David W Johnson
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Vera Krane
- University of Würzburg, Würzburg, Germany
| | - Adeera Levin
- University of British Columbia, Vancouver, BC, Canada
| | - Jolanta Malyszko
- Department of Medicine, Division of Nephrology, University of Wurzburg, Wurzburg, Germany
| | - Patrick Rossignol
- Université de Lorraine & FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) Network, Nancy, France
| | | | | | | | - Angela Wang
- The University of Hong Kong, Pok Fu Lam, Hong Kong
| | | | - Carmel M Hawley
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Andrea K Viecelli
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
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20
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Carrero JJ, Fu EL, Vestergaard SV, Jensen SK, Gasparini A, Mahalingasivam V, Bell S, Birn H, Heide-Jørgensen U, Clase CM, Cleary F, Coresh J, Dekker FW, Gansevoort RT, Hemmelgarn BR, Jager KJ, Jafar TH, Kovesdy CP, Sood MM, Stengel B, Christiansen CF, Iwagami M, Nitsch D. Defining measures of kidney function in observational studies using routine health care data: methodological and reporting considerations. Kidney Int 2023; 103:53-69. [PMID: 36280224 DOI: 10.1016/j.kint.2022.09.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [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: 11/10/2021] [Revised: 08/31/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022]
Abstract
The availability of electronic health records and access to a large number of routine measurements of serum creatinine and urinary albumin enhance the possibilities for epidemiologic research in kidney disease. However, the frequency of health care use and laboratory testing is determined by health status and indication, imposing certain challenges when identifying patients with kidney injury or disease, when using markers of kidney function as covariates, or when evaluating kidney outcomes. Depending on the specific research question, this may influence the interpretation, generalizability, and/or validity of study results. This review illustrates the heterogeneity of working definitions of kidney disease in the scientific literature and discusses advantages and limitations of the most commonly used approaches using 3 examples. We summarize ways to identify and overcome possible biases and conclude by proposing a framework for reporting definitions of exposures and outcomes in studies of kidney disease using routinely collected health care data.
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Affiliation(s)
- Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden.
| | - Edouard L Fu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Søren V Vestergaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Simon Kok Jensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Alessandro Gasparini
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Viyaasan Mahalingasivam
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Samira Bell
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
| | - Henrik Birn
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Biomedicine, Aarhus University, Aarhus, Denmark; Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Uffe Heide-Jørgensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Catherine M Clase
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research and Methodology, McMaster University, Hamilton, Ontario, Canada
| | - Faye Cleary
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Kitty J Jager
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Meibergdreef, Amsterdam, Netherlands; Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Manish M Sood
- Department of Medicine, the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Bénédicte Stengel
- CESP (Center for Research in Epidemiology and Population Health), Clinical Epidemiology Team, University Paris-Saclay, University Versailles-Saint Quentin, Inserm U1018, Villejuif, France
| | - Christian F Christiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Masao Iwagami
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK; Department of Health Services Research, University of Tsukuba, Ibaraki, Japan
| | - Dorothea Nitsch
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK; Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; UK Renal Registry, UK Kidney Association, Bristol, UK.
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21
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Jafar TH. ISH-PP-7: SCALING-UP HYPERTENSION CARE IN RESOURCE-CHALLENGED SETTINGS GLOBALLY. J Hypertens 2023. [DOI: 10.1097/01.hjh.0000914168.68327.29] [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: 01/14/2023]
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22
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Almas A, Awan S, Bloomfield G, Nisar MI, Siddiqi S, Ahmed A, Ali A, Shafqat SH, Bhutta ZA, Mark DB, Douglas P, Bartlett J, Jafar TH, Samad Z. Opportunities and challenges to non-communicable disease (NCD) research and training in Pakistan: a qualitative study from Pakistan. BMJ Open 2022; 12:e066460. [PMID: 36535721 PMCID: PMC9764671 DOI: 10.1136/bmjopen-2022-066460] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Most of the global non-communicable disease (NCD)-related death burden is borne by low and middle-income countries (LMICs). In LMICs like Pakistan, however, a major gap in responding to NCDs is a lack of high-quality research leading to policy development and implementation of NCDs. To assess institutional opportunities and constraints to NCD research and training we conducted a situational analysis for NCD research and training at Aga Khan University Pakistan. METHODS We conducted a descriptive exploratory study using grounded theory as a qualitative approach: semistructured interviews of 16 NCD stakeholders (three excluded) and two focus group discussions with postgraduate and undergraduate trainees were conducted. A simple thematic analysis was done where themes were identified, and then recurring ideas were critically placed in their specific themes and refined based on the consensus of the investigators. RESULTS The major themes derived were priority research areas in NCDs; methods to improve NCD research integration; barriers to NCD research in LMICs like Pakistan; design of NCD research programme and career paths; and NCD prevention at mass level, policy and link to the government. In general, participants opined that while there was an appetite for NCD research and training, but few high-quality research training programmes in NCDs existed, such programmes needed to be established. The ideal NCD research and training programmes would have in-built protected time, career guidance and dedicated mentorship. Most participants identified cardiovascular diseases as a priority thematic area and health information technology and data science as key methodological approaches to be introduced into research training. CONCLUSION We conclude from this qualitative study on NCD research and training that high-quality research training programmes for NCDs are rare. Such programmes need to be established with in-built protected time, career guidance and mentorship for the trainees to improve their research capacity in Pakistan.
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Affiliation(s)
- Aysha Almas
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Safia Awan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Gerald Bloomfield
- Department of Medicine, Duke University, Durham, North Carolina, USA
- Global health, Duke university, Durhum, North Carolina, USA
| | - Muhammad Imran Nisar
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sameen Siddiqi
- Community Health Sciences Department, Aga Khan University Medical College, Karachi, Pakistan
| | - Asma Ahmed
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Asad Ali
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Zulfiqar Ahmed Bhutta
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
- Global Child Health, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Daniel Benjamin Mark
- Department of Medicine, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Pamela Douglas
- Department of Medicine, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - John Bartlett
- Department of Medicine and Global Health, Duke University, Durham, North Carolina, USA
| | - Tazeen H Jafar
- Health Services & Systems Research Programme, Duke-NUS Medical School, Singapore
- Department of Global Health, Duke University, Durhum, North Carolina, USA
| | - Zainab Samad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
- Department of Medicine, Duke University, Durham, North Carolina, USA
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23
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Yeung KF, Lee YQ, Chong MFF, Gandhi M, Lam AYR, Julianty S, Tan GCS, Ho ETL, Goh SY, Tan GSW, Shum EJW, Finkelstein EA, Jafar TH, van Dam RM, Teoh YL, Thumboo J, Bee YM. Baseline characteristics of participants in the Pre-Diabetes Interventions and Continued Tracking to Ease-out Diabetes (Pre-DICTED) Program. BMJ Open Diabetes Res Care 2022; 10:10/5/e002966. [PMID: 36220198 PMCID: PMC9558793 DOI: 10.1136/bmjdrc-2022-002966] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/25/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The Pre-Diabetes Interventions and Continued Tracking to Ease-out Diabetes (Pre-DICTED) Program is a diabetes prevention trial comparing the diabetes conversion rate at 3 years between the intervention group, which receives the incentivized lifestyle intervention program with stepwise addition of metformin, and the control group, which receives the standard of care. We describe the baseline characteristics and compare Pre-DICTED participants with other diabetes prevention trials cohort. RESEARCH DESIGN AND METHODS Participants were aged between 21 and 64 years, overweight (body mass index (BMI) ≥23.0 kg/m2), and had pre-diabetes (impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT)). RESULTS A total of 751 participants (53.1% women) were randomized. At baseline, mean (SD) age was 52.5 (8.5) years and mean BMI (SD) was 29.0 (4.6) kg/m2. Twenty-three per cent had both IFG and IGT, 63.9% had isolated IGT, and 13.3% had isolated IFG. Ethnic Asian Indian participants were more likely to report a family history of diabetes and had a higher waist circumference, compared with Chinese and Malay participants. Women were less likely than men to meet the physical activity recommendations (≥150 min of moderate-intensity physical activity per week), and dietary intake varied with both sex and ethnicity. Compared with other Asian diabetes prevention studies, the Pre-DICTED cohort had a higher mean age and BMI. CONCLUSION The Pre-DICTED cohort represents subjects at high risk of diabetes conversion. The study will evaluate the effectiveness of a community-based incentivized lifestyle intervention program in an urban Asian context.
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Affiliation(s)
- Kar-Fu Yeung
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Yu Qi Lee
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Mary Foong Fong Chong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Singapore Institute for Clinical Sciences, Brenner Centre for Molecular Medicine, Agency for Science, Technology, and Research (A*STAR), Singapore
| | - Mihir Gandhi
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
- Biostatistics, Singapore Clinical Research Institute, Singapore
- The Center for Child Health Research, Tampere University, Tampere, Finland
| | - Amanda Yun Rui Lam
- Department of Endocrinology, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Diabetes Centre, Singapore
| | - Selly Julianty
- SingHealth Duke-NUS Diabetes Centre, Singapore
- Regional Health System Office, SingHealth, Singapore
| | | | - Emily Tse Lin Ho
- Department of Endocrinology, Singapore General Hospital, Singapore
- Regional Health System Office, SingHealth, Singapore
| | - Su-Yen Goh
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Gavin Siew Wei Tan
- SingHealth Duke-NUS Diabetes Centre, Singapore
- Surgical Retinal Department, Singapore National Eye Centre, Singapore
| | | | - Eric A Finkelstein
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Tazeen H Jafar
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Rob M van Dam
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Department of Nutrition and Exercise Sciences and Epidemiology, Milken Institute School of Public Health, George Washington University, Washington DC, Washington DC, USA
| | - Yee Leong Teoh
- Ministry of Health Office of Healthcare Transformation, Government of Singapore, Singapore
| | - Julian Thumboo
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
| | - Yong Mong Bee
- Department of Endocrinology, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Diabetes Centre, Singapore
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24
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Poulter NR, Borghi C, Damasceno A, Jafar TH, Khan NA, Kokubo Y, Nilsson PM, Prabhakaran D, Schlaich MP, Schutte AE, Stergiou GS, Unger T, Wang W, Beaney T. May Measurement Month: results of 12 national blood pressure screening programmes between 2017 and 2019 . Eur Heart J Suppl 2022; 24:F1-F5. [PMID: 36381519 PMCID: PMC9647150 DOI: 10.1093/eurheartjsupp/suac045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Neil R Poulter
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, 68 Wood Lane, London W12 7RH, UK
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, Bologna, Italy
| | | | - Tazeen H Jafar
- Health Services and Systems Research, DUKE-NUS Medical School, Singapore, Singapore.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Nadia A Khan
- Department of Medicine, Center for Health Evaluation and Outcomes Sciences, University of British Colombia, Vancouver, BC, Canada
| | - Yoshihiro Kokubo
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Peter M Nilsson
- Department of Clinical Sciences, Lund University, Skane University Hospital, Malmo, Sweden
| | | | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Level 3, MRF Building, 50 Rear Street, Perth, WA 6000, Australia
| | - Aletta E Schutte
- School of Population Health, University of New South Wales, The George Institute for Global Health, Sydney, NSW 2052, Australia
| | - George S Stergiou
- Hypertension Center STRIDE-7, Third Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Hospital, 152 Mesogion Avenue, Athens 11527, Greece
| | - Thomas Unger
- CARIM School for Cardiovascular Diseases, Maastricht University, P.O. Box 616,6200, Maastricht, The Netherlands
| | - Wei Wang
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, 68 Wood Lane, London W12 7RH, UK
| | - Thomas Beaney
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, 68 Wood Lane, London W12 7RH, UK.,Department of Primary Care and Public Health, Imperial College London, St Dunstan's Road, London W6 8RP, UK
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25
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Bhattarai P, Shrestha A, Xiong S, Peoples N, Ramakrishnan C, Shrestha S, Yin R, Karmacharya B, Yan LL, Jafar TH. Strengthening urban primary healthcare service delivery using electronic health technologies: A qualitative study in urban Nepal. Digit Health 2022; 8:20552076221114182. [PMID: 35898291 PMCID: PMC9309786 DOI: 10.1177/20552076221114182] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022] Open
Abstract
Background Nepal is a South Asian country with a high burden of non-communicable diseases. Electronic health technologies are a promising strategy to mitigate the rising burden of non-communicable diseases by strengthening primary healthcare center service delivery. However, electronic health implementation in Nepal is limited. Furthermore, electronic health use at the primary healthcare center level is chronically understudied. This qualitative study seeks to understand the perceived awareness, benefits, and determinants of electronic health uptake in Nepal, focusing on primary healthcare center-level non-communicable disease management. Methods We conducted in-depth interviews with 27 participants including policymakers, health experts, facility administrators, providers, and non-communicable diseases patients in 2019. We selected six urban primary healthcare center facilities via cluster convenience sampling for recruiting facility administrators, providers, and patients, and used convenience sampling to recruit policymakers and experts. We conducted thematic data analysis inductively and deductively using the electronic health readiness assessment framework to understand perceived barriers and facilitators of electronic health implementation. Results While there was general awareness and acceptance of electronic health, multiple barriers impede readiness for implementation. These include policy making gaps, language barriers, low user technical literacy, concerns of overreliance on technology, and inadequate training for administrators and providers. Stakeholder suggestions include creating electronic health interfaces that meet the needs of end users (providers and patients), providing training to enable end users to effectively use electronic health technologies, and strong policy support at the national level. Conclusion We identify several determinants for effectively promoting the use of electronic health for non-communicable diseases service delivery at the primary healthcare center level in Nepal.
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Affiliation(s)
- Prayog Bhattarai
- Yale-NUS College, Singapore,Biraj Karmacharya, Department of Community
Programs, Kathmandu University School of Medical Sciences (KUSMS), Nepal.
Lijing L. Yan, Global Health Research
Center, Duke Kunshan University, China.
| | - Abha Shrestha
- Kathmandu University School of Medical
Sciences (KUSMS), Nepal
| | - Shangzhi Xiong
- Duke Kunshan University, ChinaThe George Institute for Global Health, University
of New South Wales, Australia
| | | | | | | | - Ruoyu Yin
- Department of Family Medicine and Primary Care, Nanyang Technological
University, Singapore
| | - Biraj Karmacharya
- Department of Community Programs, Kathmandu University School of
Medical Sciences (KUSMS), Nepal
| | - Lijing L. Yan
- Global Health Research Center, Duke Kunshan University, China
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26
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Affiliation(s)
- Tazeen H Jafar
- Programme in Health Services & Systems Research, Duke-NUS Medical School, Singapore 169857; Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Samer Jabbour
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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27
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Ramakrishnan C, Tan NC, Yoon S, Hwang SJ, Foo MWY, Paulpandi M, Gun SY, Lee JY, Chang ZY, Jafar TH. Healthcare professionals' perspectives on facilitators of and barriers to CKD management in primary care: a qualitative study in Singapore clinics. BMC Health Serv Res 2022; 22:560. [PMID: 35473928 PMCID: PMC9044787 DOI: 10.1186/s12913-022-07949-9] [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] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 04/11/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION The burden of chronic kidney disease (CKD) is rising globally including in Singapore. Primary care is the first point of contact for most patients with early stages of CKD. However, several barriers to optimal CKD management exist. Knowing healthcare professionals' (HCPs) perspectives is important to understand how best to strengthen CKD services in the primary care setting. Integrating a theory-based framework, we explored HCPs' perspectives on the facilitators of and barriers to CKD management in primary care clinics in Singapore. METHODS In-depth interviews were conducted on a purposive sample of 20 HCPs including 13 physicians, 2 nurses and 1 pharmacist from three public primary care polyclinics, and 4 nephrologists from one referral hospital. Interviews were audio recorded, transcribed verbatim and thematically analyzed underpinned by the Theoretical Domains Framework (TDF) version 2. RESULTS Numerous facilitators of and barriers to CKD management identified. HCPs perceived insufficient attention is given to CKD in primary care and highlighted several barriers including knowledge and practice gaps, ineffective CKD diagnosis disclosure, limitations in decision-making for nephrology referrals, consultation time, suboptimal care coordination, and lack of CKD awareness and self-management skills among patients. Nevertheless, intensive CKD training of primary care physicians, structured CKD-care pathways, multidisciplinary team-based care, and prioritizing nephrology referrals with risk-based assessment were key facilitators. Participants underscored the importance of improving awareness and self-management skills among patients. Primary care providers expressed willingness to manage early-stage CKD as a collaborative care model with nephrologists. Our findings provide valuable insights to design targeted interventions to enhance CKD management in primary care in Singapore that may be relevant to other countries. CONCLUSIONS The are several roadblocks to improving CKD management in primary care settings warranting urgent attention. Foremost, CKD deserves greater priority from HCPs and health planners. Multipronged approaches should urgently address gaps in care coordination, patient-physician communication, and knowledge. Strategies could focus on intensive CKD-oriented training for primary care physicians and building novel team-based care models integrating structured CKD management, risk-based nephrology referrals coupled with education and motivational counseling for patients. Such concerted efforts are likely to improve outcomes of patients with CKD and reduce the ESKD burden.
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Affiliation(s)
- Chandrika Ramakrishnan
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Program in Health Services & Systems Research, 8 College Road Singapore 169857, Singapore, Singapore
| | - Ngiap Chuan Tan
- grid.490507.f0000 0004 0620 9761Department of Research, SingHealth Polyclinics, Singapore, Singapore ,grid.490507.f0000 0004 0620 9761General Practice, SingHealth Polyclinics, Singapore, Singapore
| | - Sungwon Yoon
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Program in Health Services & Systems Research, 8 College Road Singapore 169857, Singapore, Singapore
| | - Sun Joon Hwang
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Program in Health Services & Systems Research, 8 College Road Singapore 169857, Singapore, Singapore
| | - Marjorie Wai Yin Foo
- grid.490507.f0000 0004 0620 9761Department of Research, SingHealth Polyclinics, Singapore, Singapore ,grid.163555.10000 0000 9486 5048Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Muthulakshmi Paulpandi
- grid.490507.f0000 0004 0620 9761Department of Research, SingHealth Polyclinics, Singapore, Singapore
| | - Shi Ying Gun
- grid.490507.f0000 0004 0620 9761General Practice, SingHealth Polyclinics, Singapore, Singapore
| | - Jia Ying Lee
- grid.490507.f0000 0004 0620 9761General Practice, SingHealth Polyclinics, Singapore, Singapore
| | - Zi Ying Chang
- grid.490507.f0000 0004 0620 9761General Practice, SingHealth Polyclinics, Singapore, Singapore
| | - Tazeen H. Jafar
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Program in Health Services & Systems Research, 8 College Road Singapore 169857, Singapore, Singapore ,grid.163555.10000 0000 9486 5048Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
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28
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Wang Y, Levey AS, Inker LA, Jessani S, Bux R, Samad Z, Yaqub S, Karger AB, Allen JC, Jafar TH. Performance of Serum β2-Microglobulin- and β-Trace Protein-Based Panel Markers and 2021 Creatinine- and Cystatin-Based GFR Estimating Equations in Pakistan. Kidney Med 2022; 4:100444. [PMID: 35402891 PMCID: PMC8988004 DOI: 10.1016/j.xkme.2022.100444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Yeli Wang
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Andrew S Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Lesley A Inker
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Saleem Jessani
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Rasool Bux
- Department of Paediatrics (Division of Women & Child Health), Aga Khan University, Karachi, Pakistan
| | - Zainab Samad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Sonia Yaqub
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, MN
| | - John C Allen
- Center for Quantitative Medicine, Office of Clinical Sciences, Duke-NUS Medical School, Singapore
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Department of Medicine, Aga Khan University, Karachi, Pakistan.,Department of Renal Medicine, Singapore General Hospital, Singapore.,Duke Global Health Institute, Duke University, Durham, NC
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29
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Geng TT, Jafar TH. Hypertension Pharmacogenomics in CKD: The Clinical Relevance and Public Health Implications. Kidney360 2022; 3:204-207. [PMID: 35373121 PMCID: PMC8967644 DOI: 10.34067/kid.0007792021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/19/2022] [Indexed: 04/11/2023]
Affiliation(s)
- Ting-Ting Geng
- Department of Epidemiology and Biostatistics, Huazhong University of Science and Technology, Wuhan, China
| | - Tazeen H. Jafar
- Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
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30
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Neuen BL, Tighiouart H, Heerspink HJ, Vonesh EF, Chaudhari J, Miao S, Chan TM, Fervenza FC, Floege J, Goicoechea M, Herrington WG, Imai E, Jafar TH, Lewis JB, Li PKT, Locatelli F, Maes BD, Perrone RD, Praga M, Perna A, Schena FP, Wanner C, Wetzels JF, Woodward M, Xie D, Greene T, Inker LA. Acute Treatment Effects on GFR in Randomized Clinical Trials of Kidney Disease Progression. J Am Soc Nephrol 2022; 33:291-303. [PMID: 34862238 PMCID: PMC8819983 DOI: 10.1681/asn.2021070948] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 07/14/2021] [Accepted: 10/28/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Acute changes in GFR can occur after initiation of interventions targeting progression of CKD. These acute changes complicate the interpretation of long-term treatment effects. METHODS To assess the magnitude and consistency of acute effects in randomized clinical trials and explore factors that might affect them, we performed a meta-analysis of 53 randomized clinical trials for CKD progression, enrolling 56,413 participants with at least one estimated GFR measurement by 6 months after randomization. We defined acute treatment effects as the mean difference in GFR slope from baseline to 3 months between randomized groups. We performed univariable and multivariable metaregression to assess the effect of intervention type, disease state, baseline GFR, and albuminuria on the magnitude of acute effects. RESULTS The mean acute effect across all studies was -0.21 ml/min per 1.73 m2 (95% confidence interval, -0.63 to 0.22) over 3 months, with substantial heterogeneity across interventions (95% coverage interval across studies, -2.50 to +2.08 ml/min per 1.73 m2). We observed negative average acute effects in renin angiotensin system blockade, BP lowering, and sodium-glucose cotransporter 2 inhibitor trials, and positive acute effects in trials of immunosuppressive agents. Larger negative acute effects were observed in trials with a higher mean baseline GFR. CONCLUSION The magnitude and consistency of acute GFR effects vary across different interventions, and are larger at higher baseline GFR. Understanding the nature and magnitude of acute effects can help inform the optimal design of randomized clinical trials evaluating disease progression in CKD.
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Affiliation(s)
- Brendon L. Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands
| | - Edward F. Vonesh
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Juhi Chaudhari
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Fernando C. Fervenza
- Division of Nephrology and Hypertension and Department of Medicine, Mayo Clinic Rochester, Minnesota
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - William G. Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Julia B. Lewis
- Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Philip Kam-Tao Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Bart D. Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | | | - Manuel Praga
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco P. Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Jack F.M. Wetzels
- Department of Nephrology, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, Imperial College London, United Kingdom
| | - Di Xie
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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31
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Ozdemir S, Choong LHL, Gan SWS, Lim LW, Malhotra C, Jafar TH, Yee ACP, Vishwanath P, Tan SNG, Finkelstein EA. Patient Decision Aid Development for Older Adults With End-Stage Kidney Disease in Singapore. Kidney Int Rep 2021; 6:2885-2896. [PMID: 34805639 PMCID: PMC8589693 DOI: 10.1016/j.ekir.2021.08.027] [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] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 10/25/2022] Open
Abstract
Introduction In managing end-stage kidney disease (ESKD), older adults face a decision regarding whether to undergo dialysis or manage symptoms through kidney supportive care (KSC). This article describes the development of a patient decision aid (PDA) that is designed specifically for older adults with ESKD. Methods The decision context of the PDA was to choose a treatment between hemodialysis, peritoneal dialysis, and KSC. The development process used insights obtained from qualitative interviews with patients, informal caregivers, and health care providers. The PDA was then developed in English and Mandarin and was pilot-tested with patients, caregivers, and health care providers. We finalized the PDA based on feedback from pilot testing and performed a preliminary evaluation based on the International Patient Decision Aid Standards (IPDASi v4.0) criteria. Results The final PDA consists of 2 booklets and a video. During pilot testing, patients and caregivers reported high levels of ease of understanding and usefulness with ≥92.5% providing agree/strongly agree responses for the "Content"-related criteria, and ≥75% providing agree/strongly agree responses for the "Development Process and Effectiveness"-related criteria. The final PDA met 10 of 12 IPDASi v4.0 criteria. Conclusions This PDA was found useful during pilot-testing. It will be used during renal counseling in Singapore to help older adults with ESKD and their caregivers make informed decisions on which treatment option is best for the patients.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | | | - Lydia Wei Lim
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Tazeen H Jafar
- Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | | | | | | | - Eric Andrew Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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Lian Q, Jafar TH, Allen JC, Ma S, Malhotra R. Association of Systolic and Diastolic Blood Pressure With All-Cause Mortality Among Community-Dwelling Older Adults: A Prospective Observational Study. J Aging Health 2021; 34:674-683. [PMID: 34814767 DOI: 10.1177/08982643211055245] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess the association of systolic blood pressure (SBP) and diastolic blood pressure (DBP) with mortality among older adults in Singapore. METHODS Association of SBP and DBP measured in 2009 for 4443 older adults (69.5±7.4 years; 60-97 years) participating in a nationally representative study with mortality risk through end-December 2015 was assessed using Cox regression. RESULTS Higher mortality risk was observed at the lower and upper extremes of SBP and DBP. With SBP of 100-119 mmHg as the reference, multivariable mortality hazard ratios [HRs (95% confidence interval)] were SBP <100 mmHg: 2.41 (1.23-4.72); SBP 160-179 mmHg: 1.51 (1.02-2.22); and SBP ≥180 mmHg: 1.78 (1.12-2.81). With DBP of 70-79 mmHg as the reference, HRs were DBP <50 mmHg: 2.41 (1.28-4.54) and DBP ≥110 mmHg: 2.16 (1.09-4.31). DISCUSSION Management of high blood pressure among older adults will likely reduce their mortality risk. However, the association of excessively low SBP and DBP values with mortality risk needs further evaluation.
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Affiliation(s)
- Qian Lian
- 37581Singapore General Hospital, Singapore
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, 121579Duke-NUS Medical School, Singapore.,199688Duke Global Health Institute, Duke University, Durham, NC, USA
| | - John C Allen
- Centre for Quantitative Medicine, 121579Duke-NUS Medical School, Singapore
| | - Stefan Ma
- Epidemiology & Disease Control Division, 50107Ministry of Health, Singapore
| | - Rahul Malhotra
- Program in Health Services and Systems Research, 121579Duke-NUS Medical School, Singapore.,Centre for Ageing Research and Education, 121579Duke-NUS Medical School, Singapore
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Feng L, Lam A, Carmody D, Lim CW, Tan G, Goh SY, Bee YM, Jafar TH. Trends in cardiovascular risk factors and treatment goals in patients with diabetes in Singapore-analysis of the SingHealth Diabetes Registry. PLoS One 2021; 16:e0259157. [PMID: 34748574 PMCID: PMC8575178 DOI: 10.1371/journal.pone.0259157] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/13/2021] [Indexed: 01/04/2023] Open
Abstract
Background Asian populations are at high risk of diabetes and related vascular complications. We examined risk factor control, preventive care, and disparities in these trends among adults with diabetes in Singapore. Methods The sample included 209,930 adults with diabetes aged≥18 years from a multi-institutional SingHealth Diabetes Registry between 2013 and 2019 in Singapore. We performed logistic generalized estimating equations (GEEs) regression analysis and used linear mixed effect modeling to evaluate the temporal trends. Results Between 2013 and 2019, the unadjusted control rates of glycated hemoglobin (4.8%, 95%CI (4.4 to 5.1) and low-density lipoprotein cholesterol (LDL-C) (11.5%, 95%CI (11.1 to 11.8)) improved, but blood pressure (BP) control worsened (systolic BP (SBP)/diastolic BP (DBP) <140/90 mmHg: -6.6%, 95%CI (-7.0 to -6.2)). These trends persisted after accounting for the demographics including age, gender, ethnicity, and housing type. The 10-year adjusted risk for coronary heart disease (CHD) (3.4%, 95% (3.3 to 3.5)) and stroke (10.4%, 95% CI (10.3 to 10.5)) increased. In 2019, the control rates of glycated hemoglobin, BP (SBP/DBP<140/90 mmHg), LDL-C, each, and all three risk factors together, accounted for 51.5%, 67.7%, 72.2%, and 24.4%, respectively. Conclusions Trends in risk factor control improved for glycated hemoglobin and LDL-C, but worsened for BP among diabetic adults in Singapore from 2013 to 2019. Control rates for all risk factors remain inadequate.
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Affiliation(s)
- Liang Feng
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Amanda Lam
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - David Carmody
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Ching Wee Lim
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Gilbert Tan
- SingHealth Polyclinics, Singapore, Singapore
| | - Su-Yen Goh
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Yong Mong Bee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Tazeen H. Jafar
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Duke Global Health Institute, Durham, NC, United States of America
- * E-mail:
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Feng L, Jehan I, de Silva HA, Naheed A, Khan AH, Kasturiratne A, Clemens JD, Lim CW, Hughes AD, Chaturvedi N, Jafar TH. Effect of a Multicomponent Intervention on Antihypertensive Medication Intensification in Rural South Asia: Post Hoc Analysis of a Cluster RCT. Am J Hypertens 2021; 34:981-988. [PMID: 34013966 DOI: 10.1093/ajh/hpab072] [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: 03/01/2021] [Revised: 04/06/2021] [Accepted: 05/05/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Inadequate treatment of hypertension is a widespread problem, especially in South Asian countries where cardiovascular disease mortality rates are high. We aimed to explore the effect of a multicomponent intervention (MCI) on antihypertensive medication intensification among rural South Asians with hypertension. METHODS A post hoc analysis of a 2-year cluster-randomized controlled trial including 2,645 hypertensives aged ≥40 years from 30 rural communities, 10 each, in Bangladesh, Pakistan, and Sri Lanka. Independent assessors collected information on participants' self-reports and physical inspection of medications. The main outcomes were the changes from baseline to 24 months in the following: (i) the therapeutic intensity score (TIS) for all (and class-specific) antihypertensive medications; (ii) the number of antihypertensive medications in all trial participants. RESULTS At 24 months, the mean increase in the TIS score of all antihypertensive medications was 0.11 in the MCI group and 0.03 in the control group, with a between-group difference in the increase of 0.08 (95% confidence interval (CI, 0.03, 0.12); P = 0.002). In MCI compared with controls, a greater increase in the TIS of renin-angiotensin-aldosterone system blockers (0.05; 95% CI (0.02, 0.07); P < 0.001) and calcium channel blockers (0.03; 95% CI (0.00, 0.05); P = 0.031), and in the number of antihypertensive medications (0.11, 95% CI (0.02, 0.19); P = 0.016) was observed. CONCLUSIONS In rural communities in Bangladesh, Pakistan, and Sri Lanka, MCI led to a greater increase in antihypertensive medication intensification compared with the usual care among adults with hypertension. CLINICAL TRIALS REGISTRATION Trial Number NCT02657746.
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Affiliation(s)
- Liang Feng
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | - Imtiaz Jehan
- Department of Community Health Science, Aga Khan University, Karachi, Pakistan
| | - H Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Aliya Naheed
- The International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Aamir H Khan
- Section of Cardiology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Anuradhani Kasturiratne
- Department of Public Health, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - John D Clemens
- The International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Ching Wee Lim
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | - Alun D Hughes
- MRC Unit for Lifelong Health and Ageing, Institute of Cardiovascular Science, University College London, London, UK
| | - Nish Chaturvedi
- MRC Unit for Lifelong Health and Ageing, Institute of Cardiovascular Science, University College London, London, UK
| | - Tazeen H Jafar
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
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Abstract
Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA, USA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA.
| | - Tazeen H Jafar
- Duke-NUS Graduate Medical School, Singapore; Department of Renal Medicine, Singapore General Hospital, Singapore; Duke Global Health Institute, Durham, NC, USA
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; United Kingdom Renal Registry, Bristol, UK; Department of Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Vlado Perkovic
- Faculty of Medicine, University of New South Wales Sydney, Sydney, NSW, Australia
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Yeung KF, Gandhi M, Lam AYR, Julianty S, Chia AYM, Tan GCS, Goh SY, Ho ETL, Koh AFY, Tan GSW, Shum EJW, Finkelstein EA, Jafar TH, Teoh YL, van Dam RM, Whitton C, Thumboo J, Bee YM. The Pre-Diabetes Interventions and Continued Tracking to Ease-out Diabetes (Pre-DICTED) program: study protocol for a randomized controlled trial. Trials 2021; 22:522. [PMID: 34362409 PMCID: PMC8349028 DOI: 10.1186/s13063-021-05500-5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community-based diabetes prevention programs varied widely in effectiveness, and the intervention strategy consisting of lifestyle interventions, stepwise addition of metformin, and financial incentives has not been studied in real-world clinical practice settings. The Pre-Diabetes Interventions and Continued Tracking to Ease-out Diabetes (Pre-DICTED) trial is a pragmatic trial that aims to compare the effectiveness of a community-based stepwise diabetes prevention program with added financial incentives (intervention) versus the standard of care (control) in reducing the risk of type 2 diabetes over 3 years among overweight or obese individuals with pre-diabetes. METHODS This is an open-label, 1:1 randomized controlled trial which aims to recruit 846 adult individuals with isolated impaired fasting glucose (IFG), isolated impaired glucose tolerance (IGT), or both IFG and IGT from Singapore. Intervention arm participants attend 12 group-based sessions (2 nutrition workshops, 9 exercise sessions, and a goal-setting workshop) delivered at community sites (weeks 1 to 6), receive weekly physical activity and nutrition recommendations delivered by printed worksheets (weeks 7 to 12), and receive monthly health tips delivered by text messages (months 4 to 36). From month 6 onwards, intervention arm participants who remain at the highest risk of conversion to diabetes are prescribed metformin. Intervention arm participants are also eligible for a payment/rewards program with incentives tied to attendance at the group sessions and achievement of the weight loss target (5% of baseline weight). All participants are assessed at baseline, month 3, month 6, and every 6 months subsequently till month 36. The primary endpoint is the proportion of participants with diabetes at 3 years. Secondary endpoints include the mean change from baseline at 3 years in fasting plasma glucose, 2-hour plasma glucose, HbA1c, body weight, body mass index, physical activity, and dietary intake. DISCUSSION The Pre-DICTED trial will provide evidence of the effectiveness and feasibility of a community-based stepwise diabetes prevention program with added financial incentives for individuals with pre-diabetes in Singapore. The study will provide data for a future cost-effectiveness analysis, which will be used to inform policymakers of the value of a nationwide implementation of the diabetes prevention program. TRIAL REGISTRATION ClinicalTrials.gov NCT03503942 . Retrospectively registered on April 20, 2018. Protocol version: 5.0 Date: 1 March 2019.
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Affiliation(s)
- Kar-Fu Yeung
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Mihir Gandhi
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore.,Biostatistics, Singapore Clinical Research Institute, Singapore, Singapore.,The Center for Child Health Research, Tampere University, Tampere, Finland
| | - Amanda Yun Rui Lam
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore.,SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore
| | - Selly Julianty
- SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore.,Regional Health System Office, SingHealth, Singapore, Singapore
| | | | - Gilbert Choon Seng Tan
- SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore.,SingHealth Polyclinics, Singapore, Singapore
| | - Su-Yen Goh
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore.,SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore
| | - Emily Tse Lin Ho
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore.,Regional Health System Office, SingHealth, Singapore, Singapore
| | - Angela Fang Yung Koh
- SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore.,Department of Internal Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Gavin Siew Wei Tan
- SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore.,Surgical Retinal Department, Singapore National Eye Centre, Singapore, Singapore
| | | | - Eric A Finkelstein
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Tazeen H Jafar
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Yee Leong Teoh
- Biostatistics, Singapore Clinical Research Institute, Singapore, Singapore
| | - Rob M van Dam
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Clare Whitton
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Julian Thumboo
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
| | - Yong Mong Bee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore. .,SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore.
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Affiliation(s)
- Tazeen H Jafar
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 169857 Singapore; Department of Renal Medicine, Singapore General Hospital, Singapore; Duke Global Health Institute, Duke University, Durham, NC, USA.
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Porhcisaliyan VD, Wang Y, Tan NC, Jafar TH. Socioeconomic status and ethnic variation associated with type 2 diabetes mellitus in patients with uncontrolled hypertension in Singapore. BMJ Open Diabetes Res Care 2021; 9:e002064. [PMID: 34301679 PMCID: PMC8728350 DOI: 10.1136/bmjdrc-2020-002064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 06/30/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The burden of type 2 diabetes mellitus (T2DM) and related vascular complications is particularly high in Asians and ethnic minorities living in the West. However, the association of T2DM with socioeconomic status (SES) and ethnicity has not been widely studied in populations living in Asia. Therefore, we investigated these associations among the multiethnic population with uncontrolled hypertension in Singapore. RESEARCH DESIGN AND METHODS In a cross-sectional study using baseline data of a 2-year randomized trial in Singapore, we obtained demographic, SES, lifestyle and clinical factors from 915 patients aged ≥40 years with uncontrolled hypertension. T2DM was defined as having either: (i) self-reported 'physician-diagnosed diabetes confirmed through medical records' or taking antidiabetes medications, (ii) fasting blood glucose levels ≥7.0 mmol/dL or (iii) hemoglobin A1c ≥6.5%. The SES proxies included education, employment status, housing ownership and housing type, and the ethnicities were Chinese, Malays and Indians. Logistic regression analyses were used to evaluate the association of T2DM with SES and ethnicity. RESULTS Higher proportion of T2DM was observed in Malays (40.0%) and Indians (56.0%) than Chinese (26.8%) (p<0.001), and in patients with lower SES (ranging from 25.7% to 66.2% using different proxies) than those with higher SES (19.4% to 32.0%). In a multivariate model comprising age, gender, ethnicity and SES, Malay ethnicity (OR 1.59; 95% CI 1.04 to 2.44, p=0.031) or Indian ethnicity (OR 3.65; 95% CI 2.25 to 5.91, p<0.001) versus Chinese and housing type (residing in one to three rooms (OR 2.00; 95% CI 1.16 to 3.43, p=0.012) or four to five rooms public housing (OR 1.86; 95% CI 1.13 to 3.04, p=0.013) vs private housing) were associated with higher T2DM odds. The associations of Indians and one to three rooms public housing with T2DM met the significance after accounting for multiple testing (p≤0.0125). CONCLUSION Our study suggests that housing type and ethnic variation are independently associated with higher T2DM risk in patients with uncontrolled hypertension in Singapore. Further studies are needed to validate our results. TRIAL REGISTRATION NUMBER NCT02972619.
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Affiliation(s)
| | - Yeli Wang
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Ngiap Chuan Tan
- SingHealth Polyclinics, Singapore
- SingHealth-Duke NUS Family Academic Clinical Program, Singapore
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
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Poulter NR, Borghi C, Damasceno A, Jafar TH, Khan N, Kokubo Y, Nilsson PM, Prabhakaran D, Schlaich MP, Schutte AE, Stergiou GS, Unger T, Beaney T. May Measurement Month 2019: results of blood pressure screening from 47 countries. Eur Heart J Suppl 2021; 23:B1-B5. [PMID: 34054360 PMCID: PMC8141949 DOI: 10.1093/eurheartj/suab014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Neil R Poulter
- Imperial Clinical Trials Unit, Imperial College London, 68 Wood Lane, London W12 7RH, UK
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, Bologna, Italy
| | | | - Tazeen H Jafar
- Health Services and Systems Research, DUKE-NUS Medical School, Singapore, Singapore.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Nadia Khan
- Department of Medicine, Center for Health Evaluation and Outcomes Sciences, University of British Colombia, Vancouver, Canada
| | - Yoshihiro Kokubo
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Peter M Nilsson
- Department of Clinical Sciences, Lund University, Skane University Hospital, Malmo, Sweden
| | | | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Level 3, MRF Building, 50 Rear Street, Perth WA 6000, Australia
| | - Aletta E Schutte
- School of Population Health, University of New South Wales; The George Institute for Global Health, Sydney, NSW 2052, Australia
| | - George S Stergiou
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, 152 Mesogion Avenue, Athens 11527, Greece
| | - Thomas Unger
- CARIM School for Cardiovascular Diseases, Maastricht University P.O. Box 616,6200 Maastricht, The Netherlands
| | - Thomas Beaney
- Imperial Clinical Trials Unit, Imperial College London, 68 Wood Lane, London W12 7RH, UK.,Department of Primary Care and Public Health, St Dunstan's Road, Imperial College London, London, W6 8RP, UK
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Jafar TH, Kyobutungi C. A Good Start to Lowering BP and CVD Risk in Sub-Saharan Africa. J Am Coll Cardiol 2021; 77:2019-2021. [PMID: 33888252 DOI: 10.1016/j.jacc.2021.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.
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Wang Y, Levey AS, Inker LA, Jessani S, Bux R, Samad Z, Khan AR, Karger AB, Allen JC, Jafar TH. Performance and Determinants of Serum Creatinine and Cystatin C-Based GFR Estimating Equations in South Asians. Kidney Int Rep 2021; 6:962-975. [PMID: 33912746 PMCID: PMC8071622 DOI: 10.1016/j.ekir.2021.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION The creatinine-based Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimated glomerular filtration rate (eGFR) equation was calibrated for the general Pakistan population (eGFRcr-PK) to eliminate bias and improve accuracy. Cystatin C-based CKD-EPI equations (eGFRcys and eGFRcr-cys) have not been assessed in this population, and non-GFR determinants of cystatin C are unknown. METHODS We assessed eGFRcys, eGFRcr-cys, and non-GFR determinants of cystatin C in a cross-sectional study of 557 participants (≥40 years of age) from Pakistan. We compared bias (median difference in measured GFR [mGFR] and eGFR), precision (interquartile range [IQR] of differences), accuracy (percentage of eGFR within 30% of mGFR), root mean square error (RMSE), and classification of mGFR <60 ml/min/1.73 m2 (area under the receiver operating characteristic curve [AUC] and net reclassification index [NRI]) among eGFR equations. RESULTS We found that eGFRcys underestimated mGFR (bias, 12.7 ml/min/1.73 m2 [95% confidence interval {CI} 10.7-15.2]). eGFRcr-cys did not improve performance over eGFRcr-PK in precision (P = 0.52), accuracy (P = 0.58), or RMSE (P = 0.49). Results were consistent among subgroups by age, sex, smoking, body mass index (BMI), and eGFR. NRI was 7.31% (95% CI 1.52%-13.1%; P < 0.001) for eGFRcr-cys versus eGFRcr-PK, but AUC was not improved (0.92 [95% CI 0.87-0.96] vs. 0.90 [95% CI 0.86-0.95]; P = 0.056). Non-GFR determinants of higher cystatin C included male sex, smoking, higher BMI and total body fat, and lower lean body mass. CONCLUSION eGFRcys underestimated mGFR in South Asians and eGFRcr-cys did not offer substantial advantage compared with eGFRcr-PK. Future studies are warranted to better understand the large bias in eGFRcys and non-GFR determinants of cystatin C in South Asians.
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Affiliation(s)
- Yeli Wang
- Program in Health Services and Systems Research, Duke–NUS Medical School, Singapore
| | - Andrew S. Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Lesley A. Inker
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Saleem Jessani
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Rasool Bux
- Department of Pediatrics (Division of Women and Child Health), Aga Khan University, Karachi, Pakistan
| | - Zainab Samad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Ali Raza Khan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Amy B. Karger
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - John C. Allen
- Center for Quantitative Medicine, Office of Clinical Sciences, Duke–NUS Medical School, Singapore
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke–NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
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Finkelstein EA, Krishnan A, Naheed A, Jehan I, de Silva HA, Gandhi M, Lim CW, Chakma N, Ediriweera DS, Khan J, Kasturiratne A, Hirani S, Solayman AKM, Jafar TH. Budget impact and cost-effectiveness analyses of the COBRA-BPS multicomponent hypertension management programme in rural communities in Bangladesh, Pakistan, and Sri Lanka. Lancet Glob Health 2021; 9:e660-e667. [PMID: 33751956 PMCID: PMC8050199 DOI: 10.1016/s2214-109x(21)00033-4] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 12/18/2020] [Accepted: 01/22/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND COBRA-BPS (Control of Blood Pressure and Risk Attenuation-Bangladesh, Pakistan, Sri Lanka), a multi-component hypertension management programme that is led by community health workers, has been shown to be efficacious at reducing systolic blood pressure in rural communities in Bangladesh, Pakistan, and Sri Lanka. In this study, we aimed to assess the budget required to scale up the programme and the incremental cost-effectiveness ratios. METHODS In a cluster-randomised trial of COBRA-BPS, individuals aged 40 years or older with hypertension who lived in 30 rural communities in Bangladesh, Pakistan, and Sri Lanka were deemed eligible for inclusion. Costs were quantified prospectively at baseline and during 2 years of the trial. All costs, including labour, rental, materials and supplies, and contracted services were recorded, stratified by programme activity. Incremental costs of scaling up COBRA-BPS to all eligible adults in areas covered by community health workers were estimated from the health ministry (public payer) perspective. FINDINGS Between April 1, 2016, and Feb 28, 2017, 11 510 individuals were screened and 2645 were enrolled and included in the study. Participants were examined between May 8, 2016, and March 31, 2019. The first-year per-participant costs for COBRA-BPS were US$10·65 for Bangladesh, $10·25 for Pakistan, and $6·42 for Sri Lanka. Per-capita costs were $0·63 for Bangladesh, $0·29 for Pakistan, and $1·03 for Sri Lanka. Incremental cost-effectiveness ratios were $3430 for Bangladesh, $2270 for Pakistan, and $4080 for Sri Lanka, per cardiovascular disability-adjusted life year averted, which showed COBRA-BPS to be cost-effective in all three countries relative to the WHO-CHOICE threshold of three times gross domestic product per capita in each country. Using this threshold, the cost-effectiveness acceptability curves predicted that the probability of COBRA-BPS being cost-effective is 79·3% in Bangladesh, 85·2% in Pakistan, and 99·8% in Sri Lanka. INTERPRETATION The low cost of scale-up and the cost-effectiveness of COBRA-BPS suggest that this programme is a viable strategy for responding to the growing cardiovascular disease epidemic in rural communities in low-income and middle-income countries where community health workers are present, and that it should qualify as a priority intervention across rural settings in south Asia and in other countries with similar demographics and health systems to those examined in this study. FUNDING The UK Department of Health and Social Care, the UK Department for International Development, the Global Challenges Research Fund, the UK Medical Research Council, Wellcome Trust.
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Affiliation(s)
- Eric A Finkelstein
- Programme in Health Services & Systems Research, Duke-NUS Medical School, Singapore; Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Anirudh Krishnan
- Programme in Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | - Aliya Naheed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Imtiaz Jehan
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - H Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, University of Kelaniya, Kelaniya, Sri Lanka
| | - Mihir Gandhi
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore; Biostatistics, Singapore Clinical Research Institute, Singapore
| | - Ching Wee Lim
- Programme in Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | - Nantu Chakma
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Dileepa S Ediriweera
- Centre for Health Informatics, Biostatistics and Epidemiology, University of Kelaniya, Kelaniya, Sri Lanka
| | - Jehanzeb Khan
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Anuradhani Kasturiratne
- Department of Public Health, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Samina Hirani
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - A K M Solayman
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Tazeen H Jafar
- Programme in Health Services & Systems Research, Duke-NUS Medical School, Singapore; Duke Global Health Institute, Duke University, Durham, NC, USA; Department of Renal Medicine, Singapore General Hospital, Singapore.
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Allen JC, Halaand B, Shirore RM, Jafar TH. Correction to: Statistical analysis plan for management of hypertension and multiple risk factors to enhance cardiovascular health in Singapore: the SingHypertension pragmatic cluster randomized controlled trial. Trials 2021; 22:122. [PMID: 33557875 PMCID: PMC7869191 DOI: 10.1186/s13063-021-05097-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- John C Allen
- Centre for Quantitative Medicine, Duke-NUS Medical School, Level 6, Academia, 20 College Road, Singapore, Singapore.
| | - Benjamin Halaand
- Centre for Quantitative Medicine, Duke-NUS Medical School, Level 6, Academia, 20 College Road, Singapore, Singapore.,Division of Biostatistics, Population Health Sciences, University of Utah, Salt Lake City, USA
| | - Rupesh M Shirore
- Program in Health Services & Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, Singapore
| | - Tazeen H Jafar
- Program in Health Services & Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, Singapore.
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Allen JC, Halaand B, Shirore RM, Jafar TH. Statistical analysis plan for management of hypertension and multiple risk factors to enhance cardiovascular health in Singapore: the SingHypertension pragmatic cluster randomized controlled trial. Trials 2021; 22:66. [PMID: 33468225 PMCID: PMC7814171 DOI: 10.1186/s13063-020-05016-4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 12/31/2020] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Cardiovascular disease (O'Lone E, Viecelli AK, Craig JC, Tong A, Sautenet B, Herrington WG, et al., Am J Kidney Dis 76(1):109-20, 2020) remains the leading cause of death in Singapore. Uncontrolled hypertension confers the highest attributable risk of CVD and remains a significant public health issue with sub-optimal blood pressure (BP) control rates. The aim of the trial is to evaluate the effectiveness and cost-effectiveness of a multicomponent intervention (MCI) versus usual care on lowering BP among adults with uncontrolled hypertension visiting primary care clinics in Singapore. This article describes the statistical analysis plan for the primary and secondary objectives related to intervention effectiveness. METHODS The study is a cluster randomized trial enrolling 1000 participants with uncontrolled hypertension aged ≥ 40 years from eight primary care clinics in Singapore. The unit of randomization is the clinic, with eight clusters (clinics) randomized in a 1:1 ratio to either MCI or usual care. All participants will be assessed at baseline, 12 months, and 24 months with measurements of systolic and diastolic BP, antihypertensive and statin medication use, medication adherence, physical activity level, anthropometric parameters, smoking status, and dietary habits. The primary objective of this study is to assess the effectiveness of MCI versus usual care on mean SBP at the 2-year follow-up. The primary outcome is SBP at 24 months. SBP at baseline, 12, and 24 months will be modeled at the subject level using a likelihood-based, linear mixed-effects model repeated measures (MMRM) analysis with treatment group and follow-up as fixed effects, random cluster (clinic) effects, Gaussian error distribution, and adjustment to degrees of freedom using the Satterthwaite approximation. Secondary outcomes will be analyzed using a similar modeling approach incorporating generalized techniques appropriate for the type of outcome. DISCUSSION The trial will allow us to determine whether the MCI has an impact on BP and cardiovascular risk factors over a 2-year follow-up period and inform recommendations for health planners in scaling up these strategies for the benefit of society at large. A pre-specified and pre-published statistical analysis plan mitigates reporting bias and data driven approaches. TRIAL REGISTRATION ClinicalTrials.gov NCT02972619 . Registered on 23 November 2016.
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Affiliation(s)
- John C Allen
- Centre for Quantitative Medicine, Duke-NUS Medical School, Level 6, Academia, 20 College Road, Singapore, Singapore.
| | - Benjamin Halaand
- Centre for Quantitative Medicine, Duke-NUS Medical School, Level 6, Academia, 20 College Road, Singapore, Singapore.,Division of Biostatistics, Population Health Sciences, University of Utah, Salt Lake City, USA
| | - Rupesh M Shirore
- Program in Health Services & Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, Singapore
| | - Tazeen H Jafar
- Program in Health Services & Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, Singapore.
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O'Lone E, Howell M, Viecelli AK, Craig JC, Tong A, Sautenet B, Herrington WG, Herzog CA, Jafar TH, Jardine M, Krane V, Levin A, Malyszko J, Rocco MV, Strippoli G, Tonelli M, Wang AYM, Wanner C, Zannad F, Winkelmayer WC, Wheeler DC. Identifying critically important cardiovascular outcomes for trials in hemodialysis: an international survey with patients, caregivers and health professionals. Nephrol Dial Transplant 2021; 35:1761-1769. [PMID: 32040154 DOI: 10.1093/ndt/gfaa008] [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: 10/22/2019] [Accepted: 12/17/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is a major contributor to morbidity and mortality in people on hemodialysis (HD). Cardiovascular outcomes are reported infrequently and inconsistently across trials in HD. This study aimed to identify the priorities of patients/caregivers and health professionals (HPs) for CVD outcomes to be incorporated into a core outcome set reported in all HD trials. METHODS In an international online survey, participants rated the absolute importance of 10 cardiovascular outcomes (derived from a systematic review) on a 9-point Likert scale, with 7-9 being critically important. The relative importance was determined using a best-worst scale. Likert means, medians and proportions and best-worst preference scores were calculated for each outcome. Comments were thematically analyzed. RESULTS Participants included 127 (19%) patients/caregivers and 549 (81%) HPs from 53 countries, of whom 530 (78%) completed the survey in English and 146 (22%) in Chinese. All but one cardiovascular outcome ('valve replacement') was rated as critically important (Likert 7-9) by all participants; 'sudden cardiac death', 'heart attack', 'stroke' and 'heart failure' were all rated at the top by patients/caregivers (median Likert score 9). Patients/caregivers ranked the same four outcomes as the most important outcomes with mean preference scores of 6.2 (95% confidence interval 4.8-7.5), 5.9 (4.6-7.2), 5.3 (4.0-6.6) and 4.9 (3.6-6.3), respectively. The same four outcomes were ranked most highly by HPs. We identified five themes underpinning the prioritization of outcomes: 'clinical equipoise and potential for intervention', 'specific or attributable to HD', 'severity or impact on the quality of life', 'strengthen knowledge and education', and 'inextricably linked burden and risk'. CONCLUSIONS Patients and HPs believe that all cardiovascular outcomes are of critical importance but consistently identify sudden cardiac death, myocardial infarction, stroke and heart failure as the most important outcomes to be measured in all HD trials.
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Affiliation(s)
- Emma O'Lone
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Martin Howell
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, QLD, Australia
| | - Jonathan C Craig
- College of Medicine and Health, Flinders University, Adelaide, SA, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Benedicte Sautenet
- Department of Nephrology and Clinical Immunology, Tours University, Tours, France.,Department of Nephrology-Hypertension, Dialysis, Renal Transplantation, Tours Hospital, Tours, France.,INSERM U1246, Tours, France
| | - William G Herrington
- Nuffield Department of Population Health, University of Oxford, Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford, UK
| | - Charles A Herzog
- Department of Medicine, Division of Cardiology, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore.,Department of Renal Medicine, Singapore General Hospital, Singapore.,Department of Medicine, Section of Nephrology, Aga Khan University, Karachi, Pakistan
| | - Meg Jardine
- George Institute for Global Health, Sydney, NSW, Australia.,Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Vera Krane
- Department of Medicine I, Division of Nephrology, University Hospital, Würzburg, Germany
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine Warsaw Medical University, Warsaw, Poland
| | - Michael V Rocco
- Wake Forest School of Medicine, Section on Nephrology, Winston-Salem, NC, USA
| | - Giovanni Strippoli
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, NSW, Australia.,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.,Medical Scientific Office, Diaverum Sweden AB, Lund, Sweden.,Diaverum Academy, Bari, Italy
| | - Marcello Tonelli
- Department of Medicine, Division of Nephrology, University of Calgary, Calgary, AB, Canada
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, PR China
| | - Christoph Wanner
- Department of Medicine I, Division of Nephrology, University Hospital, Würzburg, Germany
| | - Faiez Zannad
- Université de Lorraine, Inserm CIC 1433 and INI-CRCT, CHU, Nancy, France
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
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Geng TT, Jafar TH, Neelakantan N, Yuan JM, van Dam RM, Koh WP. Healthful dietary patterns and risk of end-stage kidney disease: the Singapore Chinese Health Study. Am J Clin Nutr 2020; 113:675-683. [PMID: 33381807 PMCID: PMC7948892 DOI: 10.1093/ajcn/nqaa348] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/22/2020] [Accepted: 10/27/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Although adherence to healthful dietary patterns has been associated with a lower risk of kidney function decline in Western populations, evidence in Asian populations remains scanty. OBJECTIVES We examined predefined dietary patterns, namely, the Alternate Healthy Eating Index-2010 (AHEI-2010), the Dietary Approaches to Stop Hypertension (DASH), and the alternate Mediterranean diet (aMED), in relation to risk of end-stage kidney disease (ESKD). METHODS We included 56,985 Chinese adults (aged 45-74 y) in the Singapore Chinese Health Study who were free of cancer, stroke, coronary artery disease, and ESKD at recruitment (1993-1998). Dietary pattern scores were calculated based on a validated 165-item FFQ. AHEI-2010 and aMED scores were modified by excluding the alcohol intake component because daily drinking has been associated with a higher risk of ESKD in our study population. We identified 1026 ESKD cases over a median follow-up of 17.5 y via linkage with the nationwide Singapore Renal Registry. Multivariable Cox regression models were used to compute HRs and their 95% CIs. RESULTS Higher scores of all 3 dietary patterns were associated with lower ESKD risk in a dose-dependent manner. Compared with the lowest quintiles, the multivariable-adjusted HRs (95% CIs) of ESKD were 0.75 (0.61, 0.92) for the highest quintile of AHEI-2010, 0.67 (0.54, 0.84) for DASH, and 0.73 (0.59, 0.91) for aMED (all P-trend ≤ 0.004). These inverse associations were stronger with increasing BMI (in kg/m2), and the HRs for the diet-ESKD association were lowest in the obese (BMI ≥ 27.5), followed by the overweight (BMI = 25 to <27.5) participants, compared with those in lower BMI categories; the P-interaction values between BMI and diet scores were 0.03 for AHEI-2010, 0.004 for aMED, and 0.06 for DASH. CONCLUSIONS Adherence to healthful dietary patterns was associated with a lower ESKD risk in an Asian population, especially in overweight or obese individuals.
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Affiliation(s)
- Ting-Ting Geng
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Tazeen H Jafar
- Health Services and Systems Research, Duke-NUS Medical School, Singapore,Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Nithya Neelakantan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Jian-Min Yuan
- Division of Cancer Control and Population Sciences, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rob M van Dam
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore,Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
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Wang Y, Kala MP, Jafar TH. Factors associated with psychological distress during the coronavirus disease 2019 (COVID-19) pandemic on the predominantly general population: A systematic review and meta-analysis. PLoS One 2020; 15:e0244630. [PMID: 33370404 PMCID: PMC7769562 DOI: 10.1371/journal.pone.0244630] [Citation(s) in RCA: 186] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/14/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The Coronavirus Disease 2019 (COVID-19) outbreak has escalated the burden of psychological distress. We aimed to evaluate factors associated with psychological distress among the predominantly general population during the COVID-19 pandemic. METHODS We searched PubMed, EMBASE, Scopus, Cochrane Library, PsycINFO, and World Health Organization COVID-19 databases (Dec 2019-15 July 2020). We included cross-sectional studies that reported factors associated with psychological distress during the COVID-19 pandemic. Primary outcomes were self-reported symptoms of anxiety and depression. Random-effects models were used to pool odds ratios (OR) and 95% confidence intervals (CI). The protocol was registered in PROSPERO (#CRD42020186735). FINDINGS We included 68 studies comprising 288,830 participants from 19 countries. The prevalence of anxiety and depression was 33% (95% CI: 28%-39%) and 30% (26%-36%). Women versus men (OR: 1.48 [95% CI: 1.29-1.71; I2 = 90.8%]), younger versus older (< versus ≥35 years) adults (1.20 [1.13-1.26]; I2 = 91.7%), living in rural versus urban areas (1.13 [1.00-1.29]; I2 = 82.9%), lower versus higher socioeconomic status (e.g. lower versus higher income: 1.45 [1.24-1.69; I2 = 82.3%]) were associated with higher anxiety odds. These factors (except for residential area) were also associated with higher depression odds. Furthermore, higher COVID-19 infection risk (suspected/confirmed cases, living in hard-hit areas, having pre-existing physical or mental conditions) and longer media exposure were associated with higher odds of anxiety and depression. INTERPRETATION One in three adults in the predominantly general population have COVID-19 related psychological distress. Concerted efforts are urgently needed for interventions in high-risk populations to reduce urban-rural, socioeconomic and gender disparities in COVID-19 related psychological distress.
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Affiliation(s)
- Yeli Wang
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | | | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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Arshad V, Samad Z, Das J, Almas A, Rashid N, Virani SS, Bloomfield GS, Jafar TH, Ahmed B. Prescribing Patterns of Antihypertensive Medications in Low- and Middle-Income Countries: A Systematic Review. Asia Pac J Public Health 2020; 33:14-22. [PMID: 33084371 DOI: 10.1177/1010539520965280] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hypertension is highly prevalent, but its pharmacological management has not been well evaluated in low- and middle-income countries (LMICs). This review examined the prescribing patterns of antihypertensives in LMICs. Data were extracted from a total of 26 studies spanning the time period 2000 to 2018. In 10 studies, calcium channel blockers (CCBs) were the most frequently prescribed medication for managing hypertension (range = 33% to 72%); in six studies, renin angiotensin system (RAS) blockers (range = 25% to 83%); in five studies, diuretics (range = 39% to 99%); and in five studies, β-blockers (BBs; range = 26% to 49%) were the most commonly prescribed antihypertensive medications. Prescribing sedatives and sublingual administration of captopril for controlling hypertension was also reported in 3 studies. Only 10 studies presented their findings in light of national or international guidelines. This review calls for further antihypertensive utilization and dispensation studies and a better understanding of clinician's perception and practice of hypertension management guidelines in LMICs.
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Affiliation(s)
| | | | - Jai Das
- The Aga Khan University, Karachi, Pakistan
| | | | | | - Salim S Virani
- Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
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Hwang SJ, Tan NC, Yoon S, Ramakrishnan C, Paulpandi M, Gun S, Lee JY, Chang ZY, Jafar TH. Perceived barriers and facilitators to chronic kidney disease care among patients in Singapore: a qualitative study. BMJ Open 2020; 10:e041788. [PMID: 33067304 PMCID: PMC7569996 DOI: 10.1136/bmjopen-2020-041788] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To outline the facilitators and barriers to patients' self-management of predialysis chronic kidney disease (CKD). DESIGN Qualitative. SETTING Three polyclinics in a public primary care institution in Singapore. PARTICIPANTS 20 patients entered and completed the study. Inclusion criteria were: (1) English speaking, (2) aged 40 years and above, (3) identified by clinical coding as 'DM (diabetes mellitus) nephropathy-overt' and 'DM nephropathy-incipient', by their physicians in the polyclinic, with an estimated glomerular filtration rate of less than 60 mL/min/1.73 m2 (based on electronic health records) and (4) aware of their CKD illness. Exclusion criteria were: (1) receiving dialysis or had received a kidney transplant, (2) suffered from any visual, auditory or cognitive impairment which could hinder their ability to participate in the study or (3) pregnant. RESULTS We found that the major barriers to CKD management were a lack of knowledge and awareness of CKD, a passive attitude toward self-management and insufficient patient-physician communication. Major facilitators included patient trust and satisfaction with the physician and family support. Many patients reported that there was an overload of information and too little guidance on how to manage their condition, especially regarding dietary recommendations. CONCLUSION We identified several barriers and facilitators to the management of predialysis CKD among patients. A multi-pronged approach for raising CKD awareness is required: improving patient-physician communication, implementing CKD workshops and home-visits and disseminating accurate online information about CKD. Strategies should also focus on increasing patient engagement and optimising family support by involving family members in patients' care. Furthermore, clear dietary recommendations and patient-specific advice are needed to empower patients to manage their own condition.
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Affiliation(s)
- Sun Joon Hwang
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | - Ngiap Chuan Tan
- Department of Research, SingHealth Polyclinics, Singapore
- General Practice, SingHealth Polyclinics, Singapore
| | - Sungwon Yoon
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | | | | | - Shihying Gun
- General Practice, SingHealth Polyclinics, Singapore
| | - Jia Ying Lee
- General Practice, SingHealth Polyclinics, Singapore
| | | | - Tazeen H Jafar
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
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50
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Matsushita K, Jassal SK, Sang Y, Ballew SH, Grams ME, Surapaneni A, Arnlov J, Bansal N, Bozic M, Brenner H, Brunskill NJ, Chang AR, Chinnadurai R, Cirillo M, Correa A, Ebert N, Eckardt KU, Gansevoort RT, Gutierrez O, Hadaegh F, He J, Hwang SJ, Jafar TH, Kayama T, Kovesdy CP, Landman GW, Levey AS, Lloyd-Jones DM, Major RW, Miura K, Muntner P, Nadkarni GN, Naimark DMJ, Nowak C, Ohkubo T, Pena MJ, Polkinghorne KR, Sabanayagam C, Sairenchi T, Schneider MP, Shalev V, Shlipak M, Solbu MD, Stempniewicz N, Tollitt J, Valdivielso JM, van der Leeuw J, Wang AYM, Wen CP, Woodward M, Yamagishi K, Yatsuya H, Zhang L, Schaeffner E, Coresh J. Incorporating kidney disease measures into cardiovascular risk prediction: Development and validation in 9 million adults from 72 datasets. EClinicalMedicine 2020; 27:100552. [PMID: 33150324 PMCID: PMC7599294 DOI: 10.1016/j.eclinm.2020.100552] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/01/2020] [Accepted: 09/04/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) measures (estimated glomerular filtration rate [eGFR] and albuminuria) are frequently assessed in clinical practice and improve the prediction of incident cardiovascular disease (CVD), yet most major clinical guidelines do not have a standardized approach for incorporating these measures into CVD risk prediction. "CKD Patch" is a validated method to calibrate and improve the predicted risk from established equations according to CKD measures. METHODS Utilizing data from 4,143,535 adults from 35 datasets, we developed several "CKD Patches" incorporating eGFR and albuminuria, to enhance prediction of risk of atherosclerotic CVD (ASCVD) by the Pooled Cohort Equation (PCE) and CVD mortality by Systematic COronary Risk Evaluation (SCORE). The risk enhancement by CKD Patch was determined by the deviation between individual CKD measures and the values expected from their traditional CVD risk factors and the hazard ratios for eGFR and albuminuria. We then validated this approach among 4,932,824 adults from 37 independent datasets, comparing the original PCE and SCORE equations (recalibrated in each dataset) to those with addition of CKD Patch. FINDINGS We confirmed the prediction improvement with the CKD Patch for CVD mortality beyond SCORE and ASCVD beyond PCE in validation datasets (Δc-statistic 0.027 [95% CI 0.018-0.036] and 0.010 [0.007-0.013] and categorical net reclassification improvement 0.080 [0.032-0.127] and 0.056 [0.044-0.067], respectively). The median (IQI) of the ratio of predicted risk for CVD mortality with CKD Patch vs. the original prediction with SCORE was 2.64 (1.89-3.40) in very high-risk CKD (e.g., eGFR 30-44 ml/min/1.73m2 with albuminuria ≥30 mg/g), 1.86 (1.48-2.44) in high-risk CKD (e.g., eGFR 45-59 ml/min/1.73m2 with albuminuria 30-299 mg/g), and 1.37 (1.14-1.69) in moderate risk CKD (e.g., eGFR 60-89 ml/min/1.73m2 with albuminuria 30-299 mg/g), indicating considerable risk underestimation in CKD with SCORE. The corresponding estimates for ASCVD with PCE were 1.55 (1.37-1.81), 1.24 (1.10-1.54), and 1.21 (0.98-1.46). INTERPRETATION The "CKD Patch" can be used to quantitatively enhance ASCVD and CVD mortality risk prediction equations recommended in major US and European guidelines according to CKD measures, when available. FUNDING US National Kidney Foundation and the NIDDK.
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Affiliation(s)
- Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Simerjot K Jassal
- Division of General Internal Medicine, University of California, San Diego and VA San Diego Healthcare, San Diego, California
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Corresponding author.
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Aditya Surapaneni
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Johan Arnlov
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Milica Bozic
- Vascular & Renal Translational Research Group, IRBLleida, Spain and Spanish Research Network for Renal Diseases (RedInRen. ISCIII), Lleida, Spain
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ) and Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Nigel J Brunskill
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Alex R Chang
- Department of Nephrology and Kidney Health Research Institute, Geisinger Medical Center, Danville, Pennsylvania
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Massimo Cirillo
- Department of Public Health, University of Naples “Federico II”, Italy
| | - Adolfo Correa
- University of Mississippi Medical Center, Jackson, United States
| | - Natalie Ebert
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Orlando Gutierrez
- Departments of Epidemiology and Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Farzad Hadaegh
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, United States
| | - Shih-Jen Hwang
- National Heart, Lung, and Blood Institute, Framingham, MA, United States
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-National University of Singapore Medical School, Singapore
- Duke Global Health Institute, Durham, Duke University, NC, United States
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Takamasa Kayama
- Global Center of Excellence, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Csaba P Kovesdy
- Medicine-Nephrology, Memphis Veterans Affairs Medical Center and University of Tennessee Health Science Center, Memphis, TN, United States
| | | | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA, United States
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois, United States
| | - Rupert W. Major
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Katsuyuki Miura
- Department of Public Health, Center for Epidemiologic Research in Asia (CERA) Shiga University of Medical Science (SUMS) Seta-Tsukinowa-cho, Shiga, Japan
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Girish N Nadkarni
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Christoph Nowak
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Takayoshi Ohkubo
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
| | - Michelle J Pena
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Monashhealth, Melbourne, Australia and Department of Medicine, and Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Toshimi Sairenchi
- Department of Public Health, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Markus P Schneider
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Varda Shalev
- Institute for Health and Research and Innovation, Maccabi Healthcare Services and Tel Aviv University, Tel Aviv, Israel
| | - Michael Shlipak
- Department of Epidemiology and Biostatistics, University of California, San Francisco, and San Francisco VA Medical Center, San Francisco, United States
| | - Marit D Solbu
- Section of Nephrology, University Hospital of North Norway, Tromsø, Norway and UiT The Arctic University of Norway, Tromsø, Norway
| | - Nikita Stempniewicz
- AMGA (American Medical Group Association), Alexandria, Virginia and OptumLabs Visiting Fellow, United States
| | - James Tollitt
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
| | - José M Valdivielso
- Vascular & Renal Translational Research Group, IRBLleida, Spain and Spanish Research Network for Renal Diseases (RedInRen. ISCIII), Lleida, Spain
| | - Joep van der Leeuw
- Department of Vascular Medicine and Department of Nephrology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Chi-Pang Wen
- China Medical University Hospital, Taichung, Taiwan
| | - Mark Woodward
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- George Institute for Global Health, Australia, and George Institute for Global Health, Imperial College, London, United Kingdom
| | - Kazumasa Yamagishi
- Department of Public Health Medicine, Faculty of Medicine, and Health Services Research and Development Center, University of Tsukuba, Japan
| | - Hiroshi Yatsuya
- Department of Public Health, Fujita Health University School of Medicine, Aichi, Japan
- Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Luxia Zhang
- Peking University First Hospital and Peking University, Beijing, China
| | - Elke Schaeffner
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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