Documentation of acute kidney injury at discharge from the neonatal intensive care unit and role of nephrology consultation

OBJECTIVE

To investigate whether NICU discharge summaries documented neonatal AKI and estimate if nephrology consultation mediated this association.

STUDY DESIGN

Secondary analysis of AWAKEN multicenter retrospective cohort.

EXPOSURES

AKI severity and diagnostic criteria.

OUTCOME

AKI documentation on NICU discharge summaries using multivariable logistic regression to estimate associations and test for causal mediation.

RESULTS

Among 605 neonates with AKI, 13% had documented AKI. Those with documented AKI were more likely to have severe AKI (70.5% vs. 51%, p < 0.001) and SCr-only AKI (76.9% vs. 50.1%, p = 0.04). Nephrology consultation mediated 78.0% (95% CL 46.5-109.4%) of the total effect of AKI severity and 82.8% (95% CL 70.3-95.3%) of the total effect of AKI diagnostic criteria on documentation.

CONCLUSION

We report a low prevalence of AKI documentation at NICU discharge. AKI severity and SCr-only AKI increased odds of AKI documentation. Nephrology consultation mediated the associations of AKI severity and diagnostic criteria with documentation.

Variability in Culture-Negative Peritonitis Rates in Pediatric Peritoneal Dialysis Programs in the United States

BACKGROUND AND OBJECTIVES

International guidelines suggest a target culture-negative peritonitis rate of <15% among patients receiving long-term peritoneal dialysis. Through a pediatric multicenter dialysis collaborative, we identified variable rates of culture-negative peritonitis among participating centers. We sought to evaluate whether specific practices are associated with the variability in culture-negative rates between low- and high-culture-negative rate centers.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Thirty-two pediatric dialysis centers within the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative contributed prospective peritonitis data between October 1, 2011 and March 30, 2017. Clinical practice and patient characteristics were compared between centers with a ≤20% rate of culture-negative peritonitis (low-rate centers) and centers with a rate >20% (high-rate centers). In addition, centers completed a survey focused on center-specific peritoneal dialysis effluent culture techniques.

RESULTS

During the 5.5 years of observation, 1113 patients had 1301 catheters placed, totaling 19,025 patient months. There were 620 episodes of peritonitis in 378 patients with 411 catheters; cultures were negative in 165 (27%) peritonitis episodes from 125 (33%) patients and 128 (31%) catheters. Low-rate centers more frequently placed catheters with a downward-facing exit site and two cuffs (P<0.001), whereas high-rate centers had more patients perform dialysis themselves without the assistance of an adult care provider (P<0.001). The survey demonstrated that peritoneal dialysis effluent culture techniques were highly variable across centers. No consistent practice or technique helped to differentiate low- and high-rate centers.

CONCLUSIONS

Culture-negative peritonitis is a frequent complication of maintenance peritoneal dialysis in children. Despite published recommendations for dialysis effluent collection and culture methods, great variability in culture techniques and procedures exists among individual dialysis programs and respective laboratory processes.

Canadian Association of Paediatric Nephrologists COVID-19 Rapid Response: Home and In-Center Dialysis Guidance

PURPOSE OF THE PROGRAM

This article provides guidance on optimizing the management of pediatric patients with end-stage kidney disease (ESKD) who will be or are being treated with any form of home or in-center dialysis during the COVID-19 pandemic. The goals are to provide the best possible care for pediatric patients with ESKD during the pandemic and ensure the health care team's safety.

SOURCES OF INFORMATION

The core of these rapid guidelines is derived from the Canadian Society of Nephrology (CSN) consensus recommendations for adult patients recently published in the Canadian Journal of Kidney Health and Disease (CJKHD). We also consulted specific documents from other national and international agencies focused on pediatric kidney health. Additional information was obtained by formal review of the published academic literature relevant to pediatric home or in-center hemodialysis.

METHODS

The Leadership of the Canadian Association of Paediatric Nephrologists (CAPN), which is affiliated with the CSN, solicited a team of clinicians and researchers with expertise in pediatric home and in-center dialysis. The goal was to adapt the guidelines recently adopted for Canadian adult dialysis patients for pediatric-specific settings. These included specific COVID-19-related themes that apply to dialysis in a Canadian environment, as determined by a group of senior renal leaders. Expert clinicians and nurses with deep expertise in pediatric home and in-center dialysis reviewed the revised pediatric guidelines.

KEY FINDINGS

We identified 7 broad areas of home dialysis practice management that may be affected by the COVID-19 pandemic: (1) peritoneal dialysis catheter placement, (2) home dialysis training, (3) home dialysis management, (4) personal protective equipment, (5) product delivery, (6) minimizing direct health care providers and patient contact, and (7) caregivers support in the community. In addition, we identified 8 broad areas of in-center dialysis practice management that may be affected by the COVID-19 pandemic: (1) identification of patients with COVID-19, (2) hemodialysis of patients with confirmed COVID-19, (3) hemodialysis of patients not yet known to have COVID-19, (4) management of visitors to the dialysis unit, (5) handling COVID-19 testing of patients and staff, (6) safe practices during resuscitation procedures in a pandemic, (7) routine hemodialysis care, and (8) hemodialysis care under fixed dialysis resources. We make specific suggestions and recommendations for each of these areas.

LIMITATIONS

At the time when we started this work, we knew that evidence on the topic of pediatric dialysis and COVID-19 would be severely limited, and our resources were also limited. We did not, therefore, do formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. Thus, this article's advice and recommendations are primarily expert opinions and subject to the biases associated with this level of evidence. To expedite the publication of this work, we created a parallel review process that may not be as robust as standard arms' length peer-review processes.

IMPLICATIONS

We intend these recommendations to help provide the best care possible for pediatric patients prescribed in-center or home dialysis during the COVID-19 pandemic, a time of altered priorities and reduced resources.

Continuous Renal Replacement Therapy for Two Neonates With Hyperammonemia

Objectives: This study aims to assess the feasibility of using hemofiltration for ammonia clearance in low body weight infants with an inborn error of metabolism. Design: A study of two cases. Setting: Quaternary pediatric hospital (Saint Louis Children's Hospital) NICU and PICU. Patients: Infants <6 months of age with an ICD-9 diagnosis of 270.6 (hyperammonemia). Interventions: Continuous renal replacement therapy (CRRT). Measurements and Main Results: We measure serum ammonia levels over time and the rate of ammonia clearance over time. Continuous renal replacement therapy was more effective than scavenger therapy alone (Ammonul™) for rapid removal of ammonia in low weight infants (as low as 2.5 kg). Conclusions: Continuous renal replacement therapy is technically feasible in low weight infants with severe hyperammonemia secondary to an inborn error of metabolism.

Longitudinal Changes in Health-Related Quality of Life in Primary Glomerular Disease: Results From the CureGN Study

Introduction

Prior cross-sectional studies suggest that health-related quality of life (HRQOL) worsens with more severe glomerular disease. This longitudinal analysis was conducted to assess changes in HRQOL with changing disease status.

Methods

Cure Glomerulonephropathy (CureGN) is a cohort of patients with minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, IgA vasculitis, or IgA nephropathy. HRQOL was assessed at enrollment and follow-up visits 1 to 3 times annually for up to 5 years with the Patient-Reported Outcomes Measurement Information System (PROMIS). Global health, anxiety, and fatigue domains were measured in all; mobility was measured in children; and sleep-related impairment was measured in adults. Linear mixed effects models were used to evaluate HRQOL responsiveness to changes in disease status.

Results

A total of 469 children and 1146 adults with PROMIS scores were included in the analysis. HRQOL improved over time in nearly all domains, though group-level changes were modest. Edema was most consistently associated with worse HRQOL across domains among children and adults. A greater number of symptoms also predicted worse HRQOL in all domains. Sex, age, obesity, and serum albumin were associated with some HRQOL domains. The estimated glomerular filtration rate (eGFR) was only associated with fatigue and adult physical health; proteinuria was not associated with any HRQOL domain in adjusted models.

Conclusion

HRQOL measures were responsive to changes in disease activity, as indicated by edema. HRQOL over time was not predicted by laboratory-based markers of disease. Patient-reported edema and number of symptoms were the strongest predictors of HRQOL, highlighting the importance of the patient experience in glomerular disease. HRQOL outcomes inform understanding of the patient experience for children and adults with glomerular diseases.

Correction to: Recurrence of nephrotic syndrome following kidney transplantation is associated with initial native kidney biopsy findings : A Midwest Pediatric Nephrology Consortium (MWPNC) study

The original version of this article unfortunately contained a mistake. The subtitle "A Midwest Pediatric Nephrology Consortium (MWPNC) study" was missing. The correct title including subtitle is given above.

Optimizing the AKI definition during first postnatal week using Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) cohort

BACKGROUND

Neonates with serum creatinine (SCr) rise ≥0.3 mg/dL and/or ≥50% SCr rise are more likely to die, even when controlling for confounders. These thresholds have not been tested in newborns. We hypothesized that different gestational age (GA) groups require different SCr thresholds.

METHODS

Neonates in Assessment of Worldwide Acute Kidney Epidemiology in Neonates (AWAKEN) with ≥1 SCr on postnatal days 1-2 and ≥1 SCr on postnatal days 3-8 were assessed. We compared the mortality predictability of SCr absolute (≥0.3 mg/dL) vs percent (≥50%) rise. Next, we determine usefulness of combining absolute with percent rise. Finally, we determined the optimal absolute, percent, and maximum SCr thresholds that provide the highest mortality area under curve (AUC) and specificity for different GA groups.

RESULTS

The ≥0.3 mg/dL rise outperformed ≥50% SCr rise. Addition of percent rise did not improve mortality predictability. The optimal SCr thresholds to predict AUC and specificity were ≥0.3 and ≥0.6 mg/dL for ≤29 weeks GA, and ≥0.1 and ≥0.3 mg/dL for >29 week GA. The maximum SCr value provides great specificity.

CONCLUSION

Unique SCr rise cutoffs for different GA improves outcome prediction. Percent SCr rise does not add value to the neonatal AKI definition.

Recurrence of nephrotic syndrome following kidney transplantation is associated with initial native kidney biopsy findings

BACKGROUND AND OBJECTIVES

Steroid-resistant nephrotic syndrome (SRNS) due to focal segmental glomerulosclerosis (FSGS) and minimal change disease (MCD) is a leading cause of end-stage kidney disease in children. Recurrence of primary disease following transplantation is a major cause of allograft loss. The clinical determinants of disease recurrence are not completely known. Our objectives were to determine risk factors for recurrence of FSGS/MCD following kidney transplantation and factors that predict response to immunosuppression following recurrence.

METHODS

Multicenter study of pediatric patients with kidney transplants performed for ESKD due to SRNS between 1/2006 and 12/2015. Demographics, clinical course, and biopsy data were collected. Patients with primary-SRNS (PSRNS) were defined as those initially resistant to corticosteroid therapy at diagnosis, and patients with late-SRNS (LSRNS) as those initially responsive to steroids who subsequently developed steroid resistance. We performed logistic regression to determine risk factors associated with nephrotic syndrome (NS) recurrence.

RESULTS

We analyzed 158 patients; 64 (41%) had recurrence of NS in their renal allograft. Disease recurrence occurred in 78% of patients with LSRNS compared to 39% of those with PSRNS. Patients with MCD on initial native kidney biopsy had a 76% recurrence rate compared with a 40% recurrence rate in those with FSGS. Multivariable analysis showed that MCD histology (OR; 95% CI 5.6; 1.3-23.7) compared to FSGS predicted disease recurrence.

CONCLUSIONS

Pediatric patients with MCD and LSRNS are at higher risk of disease recurrence following kidney transplantation. These findings may be useful for designing studies to test strategies for preventing recurrence.

Posaconazole-induced hypertension and hypokalemia due to inhibition of the 11β-hydroxylase enzyme

Posaconazole is an antifungal therapy reported to cause incident hypertension. Hypokalemia is also a known side effect. The combination of hypertension and hypokalemia suggests mineralocorticoid excess. We present the case of a 15-year-old adolescent male with hypertensive urgency while on prophylactic posaconazole therapy for a combined immunodeficiency. We identify the mechanism of posaconazole-induced hypertension to be inhibition of the 11β-hydroxylase enzyme, resulting in elevated levels of the mineralocorticoid receptor activator deoxycorticosterone. Loss of function of the 11β-hydroxylase enzyme is responsible for a rare form of congenital adrenal hyperplasia and can be associated with life-threatening adrenal crisis.

In tandem extracorporeal therapies during hemodialysis in pediatric patients

We describe the successful treatment of a pediatric transplant patient with simultaneous intermittent hemodialysis and therapeutic plasma exchange (TPE). The patient presented with kidney graft failure. He had life threatening electrolyte disturbances and fluid overload due to antibody-mediated rejection. Therefore, he was in need of both emergent kidney replacement therapy and TPE. Both extracorporeal circuits were set up, established, and maintained safely and effectively without difficulty or alarms. Running intermittent hemodialysis and TPE simultaneously significantly reduced therapy time, allowed both needed therapies priority, and provided a superior pediatric patient experience in an acute situation.

Pneumococcal hemolytic uremic syndrome and steroid resistant nephrotic syndrome

Pneumococcal-associated hemolytic uremic syndrome (pHUS) is a rare but severe complication of invasive Streptococcus pneumoniae infection. We report the case of a 12-year-old female with steroid-resistant nephrotic syndrome treated with adrenocorticotrophic hormone (H.P. Acthar(®) Gel), who developed pneumococcal pneumonia and subsequent pHUS. While nephrotic syndrome is a well-known risk factor for invasive pneumococcal disease, this is the first reported case of pHUS in an adolescent patient with nephrotic syndrome, and reveals novel challenges in the diagnosis, treatment and potential prevention of this complication.

To bud or not to bud: the RET perspective in CAKUT

Congenital anomalies of the kidneys or lower urinary tract (CAKUT) encompass a spectrum of anomalies that result from aberrations in spatio-temporal regulation of genetic, epigenetic, environmental, and molecular signals at key stages of urinary tract development. The Rearranged in Transfection (RET) tyrosine kinase signaling system is a major pathway required for normal development of the kidneys, ureters, peripheral and enteric nervous systems. In the kidneys, RET is activated by interaction with the ligand glial cell line-derived neurotrophic factor (GDNF) and coreceptor GFRα1. This activated complex regulates a number of downstream signaling cascades (PLCγ, MAPK, and PI3K) that control proliferation, migration, renewal, and apoptosis. Disruption of these events is thought to underlie diseases arising from aberrant RET signaling. RET mutations are found in 5-30 % of CAKUT patients and a number of Ret mouse mutants show a spectrum of kidney and lower urinary tract defects reminiscent of CAKUT in humans. The remarkable similarities between mouse and human kidney development and in defects due to RET mutations has led to using RET signaling as a paradigm for determining the fundamental principles in patterning of the upper and lower urinary tract and for understanding CAKUT pathogenesis. In this review, we provide an overview of studies in vivo that delineate expression and the functional importance of RET signaling complex during different stages of development of the upper and lower urinary tracts. We discuss how RET signaling balances activating and inhibitory signals emanating from its docking tyrosines and its interaction with upstream and downstream regulators to precisely modulate different aspects of Wolffian duct patterning and branching morphogenesis. We outline the diversity of cellular mechanisms regulated by RET, disruption of which causes malformations ranging from renal agenesis to multicystic dysplastic kidneys in the upper tract and vesicoureteral reflux or ureteropelvic junction obstruction in the lower tract.

Aggressive blood pressure control for chronic kidney disease unmasks moyamoya!

Hypertensive crises in children or adolescents are rare, but chronic kidney disease (CKD) is a major risk factor for occurrence. Vesicoureteral reflux nephropathy is a common cause of pediatric renal failure and is associated with hypertension. Aggressive blood pressure (BP) control has been shown to delay progression of CKD and treatment is targeted for the 50th percentile for height when compared with a target below the 90th percentile for the general pediatric hypertensive patient. We present a case of an adolescent presenting with seizures and renal failure due to a hypertensive crisis. Hypertension was thought to be secondary to CKD as she had scarred echogenic kidneys due to known reflux nephropathy. However, aggressive BP treatment improved kidney function which is inconsistent with CKD from reflux nephropathy. Secondly, aggressive BP control caused transient neurological symptoms. Further imaging identified moyamoya disease. We present this case to highlight the consideration of moyamoya as a diagnosis in the setting of renal failure and hypertensive crisis.

Treatment of Shiga toxin-producing Escherichia coli infections

The management of Shiga toxin-producing Escherichia coli (STEC) infections is reviewed. Certain management practices optimize the likelihood of good outcomes, such as avoidance of antibiotics during the pre-hemolytic uremic syndrome phase, admission to hospital, and vigorous intravenous volume expansion using isotonic fluids. The successful management of STEC infections is based on recognition that a patient might have an STEC infection, and appropriate use of the microbiology laboratory. The timeliness of STEC identification cannot be overemphasized, because it avoids therapies prompted by inappropriate additional testing and directs the clinician to focus on effective management strategies. The opportunities during STEC infections to avert the worst outcomes are brief, and this article emphasizes practical matters relevant to making a diagnosis, anticipating the trajectory of illness, and optimizing care.

Stage specific requirement of Gfrα1 in the ureteric epithelium during kidney development

Glial cell line-derived neurotrophic factor (GDNF) binds a coreceptor GDNF family receptor α1 (GFRα1) and forms a signaling complex with the receptor tyrosine kinase RET. GDNF-GFRα1-RET signaling activates cellular pathways that are required for normal induction of the ureteric bud (UB) from the Wolffian duct (WD). Failure of UB formation results in bilateral renal agenesis and perinatal lethality. Gfrα1 is expressed in both the epithelial and mesenchymal compartments of the developing kidney while Ret expression is specific to the epithelium. The biological importance of Gfrα1's wider tissue expression and its role in later kidney development are unclear. We discovered that conditional loss of Gfrα1 in the WD epithelium prior to UB branching is sufficient to cause renal agenesis. This finding indicates that Gfrα1 expressed in the nonepithelial structures cannot compensate for this loss. To determine Gfrα1's role in branching morphogenesis after UB induction we used an inducible Gfrα1-specific Cre-deletor strain and deleted Gfrα1 from the majority of UB tip cells post UB induction in vivo and in explant kidney cultures. We report that Gfrα1 excision from the epithelia compartment after UB induction caused a modest reduction in branching morphogenesis. The loss of Gfrα1 from UB-tip cells resulted in reduced cell proliferation and decreased activated ERK (pERK). Further, cells without Gfrα1 expression are able to populate the branching UB tips. These findings delineate previously unclear biological roles of Gfrα1 in the urinary tract and demonstrate its cell-type and stage-specific requirements in kidney development.

Cardiovascular risk in chronic kidney disease (CKD): the CKD-mineral bone disorder (CKD-MBD)

Recent advances in our understanding of the excess mortality of chronic kidney disease (CKD) due to cardiovascular complications, obtained through observational studies, demonstrate that vascular calcification and hyperphosphatemia are major cardiovascular risk factors. Mechanistic studies demonstrate that these two risk factors are related and that hyperphosphatemia directly stimulates vascular calcification. The role of hyperphosphatemia in stimulating vascular calcification in CKD is associated with a block to the skeletal reservoir function in phosphate balance due to excess bone resorption. This has led to the realization that renal osteodystrophy is linked to vascular calcification by disordered mineral homeostasis (phosphate) and that a multiorgan system fails in CKD, leading to cardiovascular mortality. In children with renal disease, the multiorgan system fails, just as in adults, but the outcomes have been less well studied, and perceptions of differences from adults are possibly incorrect. Vascular calcification and cardiovascular mortality are less prevalent among pediatric patients, but they are present. However, CKD-induced vascular disease causes stiffness of the arterial tree causing, in turn, systolic hypertension and left ventricular hypertrophy as early manifestations of the same pathology in the adult. Because of the role of the skeleton in these outcomes, renal osteodystrophy has been renamed as the CKD mineral bone disorder (CKD-MBD). This review, which focuses on the pediatric patient population, describes our current state of knowledge with regards to the pathophysiology of the CKD-MBD, including the new discoveries related to early stages of CKD. As a new necessity, cardiovascular function issues are incorporated into the CKD-MBD, and new advances in our knowledge of this critical component of the disorder will lead to improved outcomes in CKD.

Inter-stimulus interval in audiometry for neonates

The usual paradigm employed for both clinical and experimental evaluation of auditory responsiveness of newborns dictates that signal presentations be separated by a minimum of 15 s. Furthermore, this paradigm requires that there be 8 presentations of the signal and that two responses among the 8 trials should be taken as normal responsiveness. Many have been concerned about accepting 25% as normal, and would prefer a paradigm that could lead to increased responsiveness. A procedure with inter-stimulus intervals longer than 15 s might be that paradigm. Therefore, the following experiment employed inter-stimulus intervals of 15, 30 and 60 s to examine responsiveness of infants young enough to be in a newborn nursery. Each infant received 24 signal presentations (8 with each of the 3 inter-stimulus intervals), and these were counter-balanced across babies. Although there is evidence of response habituation across time, there is also evidence that longer inter-stimulus intervals do lead to increased responsiveness.

Antihypertensive drug therapy withdrawal in a general population

To determine the fraction of all hypertensives who can be successfully withdrawn from antihypertensive medication, a study was conducted of a patient group originally drawn from a screened population of union members. Of 157 patients, 88 (56.1%) met preestablished blood pressure criteria for drug interruption, and 66 (75%) actually had medication withdrawn. Of these 66 patients, 69.8% and 54.5% followed up for one and two years, respectively, remained normotensive. Patients requiring reintroduction of antihypertensive therapy were distinguished from those remaining drug free by increased systolic blood pressure (141.4 +/- 13.2 vs 131.6 +/- 8.6 mm Hg) after one month. Extrapolation of the finding that 28% of the study population remained normotensive one year after drug therapy withdrawal suggests the possibility that as many as 5 million Americans currently taking antihypertensive drugs could have therapy interrupted for at least one year and thus avoid both the hazards and costs of drug therapy.

Initial antihypertensive therapy. Comparison of prazosin and hydrochlorothiazide

Increasing awareness of the hazards of diuretic therapy has cast doubt on the appropriateness of its uniform use as initial treatment for hypertension. To establish the relative efficacy and acceptability of alternative forms of initial therapy, prazosin and hydrochlorothiazide were prospectively compared. In a one-year study, 62 patients with a diastolic blood pressure greater than or equal to 100 mm Hg were randomly allocated to receive one of the two agents. Twenty of 32 (63 percent) patients receiving prazosin and 17 of 30 (57 percent) receiving hydrochlorothiazide satisfied the year-long study requirements. For the most part, the dropout rate was not drug related. The percentages of subjects completing the study with the initial drug, without addition of a second drug, were identical in both groups (prazosin: 10 of 32 [31 percent] and hydrochlorothiazide: nine of 30 [30 percent]). In both treatment groups, blood pressure declined similarly and significantly (p less than 0.001) by the end of the study. The blood pressure of subjects receiving prazosin decreased from 150.3/105.8 mm Hg to 135.3/90.3 mm Hg, whereas the blood pressure of subjects receiving hydrochlorothiazide declined from 147.3/103.8 to 130.0/89.1 mm Hg. A reduction in diastolic blood pressure to less than 95 mm Hg was achieved in 80.0 percent of patients started with prazosin and in 78.6 percent of those started with hydrochlorothiazide. A further reduction to less than 90 mm Hg was achieved in 45.0 and 64.3 percent, respectively (not significant). Patients who completed the study with single-drug therapy in both treatment groups showed nonsignificant decreases in mean potassium levels from initial to final readings when compared with baseline readings (prazosin: 0.21 meq; hydrochlorothiazide: 0.41 meq). However, patients receiving prazosin had 11.5 percent of their readings less than or equal to 4.0 meq, whereas those receiving hydrochlorothiazide had 38.1 percent of their readings similarly distributed (p less than 0.05). Furthermore, four patients receiving hydrochlorothiazide had potassium levels less than or equal to 3.5 meq; none of those receiving prazosin had levels in that range. At baseline, no patient in the study had potassium levels of less than 4.0 meq. Prazosin-treated patients whose initial fasting blood glucose was less than 110 mg/dl had 3.7 percent (one of 27) of subsequent measurements greater than or equal to 110 mg/dl. These abnormal levels were found 18.2 percent (six of 33) (not significant) of the time in similar hydrochlorothiazide-treated subjects. Symptomatic side effects were primarily mild and transient in those receiving either drug alone.(ABSTRACT TRUNCATED AT 400 WORDS)

Step-down therapy for hypertension. Results in a community-based program

The study reported here involved a systematic attempt to withdraw medication from participants in a community-based hypertension treatment program. Sixty-six of 88 patients with well-controlled mild or moderate disease had medication withdrawn after at least six months of treatment; nonpharmacologic intervention was not employed. After one year, 44 (66.6%) remained normotensive and drug free; after two years, 33 (50.0%). Of the 29 patients still available for three-year follow-up, 15 (51.7%) were still normotensive and drug free. Withdrawal of medication was associated with correction of hypokalemia and reversal of impaired glucose tolerance. Thus, nearly one fourth of these patients, who were believed to be reasonably representative of those with mild or moderate hypertension, could discontinue drug therapy and remain normotensive for at least one year. Substantial medical and economic benefits are to be realized from wide replication of this experience.

Blood pressure control programs on and off the worksite

In order to assess the importance of physical accessibility in the efficacy of a union-sponsored, worksite-based hypertension detection and treatment program, the experience of patients offered identical systematic treatment in worksite and non-worksite settings was compared. Although attrition was greater in the offsite clinic in the first year, the difference disappeared by the second year. Successful blood pressure control was maintained over three years in both treatment sites. These results suggest that physical accessibility was not the sole or even the most important factor producing favorable results in this program. Other factors such as protocol-directed treatment by non-physicians, the categorical nature of the program, lack of cost, and a socially cohesive work community may singly or together be factors responsible for successful therapy.

Systolic hypertension: occurrence and treatment in a defined community

Systolic hypertension, a disorder occurring predominantly in the elderly, is associated with an increased incidence of stroke and coronary artery disease. Based on the supposition that it is a risk factor, many authorities have urged that it be treated. This report concerns an experience in treating systolic hypertension in a defined ambulatory population of 898 hypertensive subjects in a work-site program. The systolic hypertension group (N = 39) was compared with a matched diastolic hypertension group and with a matched systolic/diastolic hypertension group (N = 39 each). The patients with systolic hypertension responded to standard treatment (chiefly with diuretics), but less satisfactorily than did the patients with diastolic hypertension. Side effects or toxicity were uncommon and did not interfere with the therapeutic regimen. However, the ultimate value of such therapy in the prevention of vascular complications remains to be determined.