Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 84
Filtrar
Mais filtros

Base de dados
País/Região como assunto
Tipo de documento
País de afiliação
Intervalo de ano de publicação
1.
Kidney Int ; 106(1): 126-135, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38685561

RESUMO

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce the risk for several adverse outcomes among patients with diabetic kidney disease. Yet, optimal timing for SGLT2i after acute kidney injury (AKI) is uncertain, as are the providers responsible for post-AKI SGLT2i initiation. Using a retrospective cohort of United States Veterans with diabetes mellitus type 2 and proteinuria, we examined encounters by provider specialty before SGLT2i initiation and subsequent all-cause mortality after hospitalization with AKI, defined by a 50% or more rise in serum creatinine. Covariates included recovery, defined by return to a 110% or less of baseline creatinine, and time since AKI hospitalization. Among 21,330 eligible Veterans, 7,798 died (37%) and 6,562 received a SGLT2i (31%) over median follow-up of 2.1 years. Post-AKI SGLT2i use was associated with lower mortality risk [adjusted hazard ratio 0.63 (95% confidence interval 0.58-0.68)]. Compared with neither SGLT2i use nor recovery, mortality risk was similar with recovery without SGLT2i use [0.97 (0.91-1.02)] but was lower without recovery prior to SGLT2i use [0.62 (0.55-0.71)] and with SGLT2i use after recovery [0.60 (0.54-0.67)]. Finally, the effect of SGLT2i was stable over time (P for time-interaction 0.19). Thus, we observed reduced mortality with SGLT2i use after AKI among Veterans with diabetic kidney disease whether started earlier or later or before or after observed recovery. Hence, patients with diabetic kidney disease who receive a SGLT2i earlier after AKI experience no significant harm impacting mortality and experience a lower mortality risk than those who do not.


Assuntos
Injúria Renal Aguda , Diabetes Mellitus Tipo 2 , Nefropatias Diabéticas , Inibidores do Transportador 2 de Sódio-Glicose , Veteranos , Humanos , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/induzido quimicamente , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Nefropatias Diabéticas/mortalidade , Nefropatias Diabéticas/tratamento farmacológico , Nefropatias Diabéticas/complicações , Nefropatias Diabéticas/etiologia , Veteranos/estatística & dados numéricos , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/mortalidade , Diabetes Mellitus Tipo 2/sangue , Estados Unidos/epidemiologia , Fatores de Tempo , Creatinina/sangue , Proteinúria/mortalidade , Proteinúria/tratamento farmacológico , Fatores de Risco , Hospitalização/estatística & dados numéricos
2.
J Community Health ; 49(3): 448-457, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38066221

RESUMO

COVID-19 disproportionately affects people experiencing homelessness or incarceration. While homelessness or incarceration alone may not impact vaccine effectiveness, medical comorbidities along with social conditions associated with homelessness or incarceration may impact estimated vaccine effectiveness. COVID-19 vaccines reduce rates of hospitalization and death; vaccine effectiveness (VE) against severe outcomes in people experiencing homelessness or incarceration is unknown. We conducted a retrospective, observational cohort study evaluating COVID-19 vaccine VE against SARS-CoV-2 related hospitalization (positive SARS-CoV-2 molecular test same week or within 3 weeks prior to hospital admission) among patients who had experienced homelessness or incarceration. We utilized data from 8 health systems in the Minnesota Electronic Health Record Consortium linked to data from Minnesota's immunization information system, Homeless Management Information System, and Department of Corrections. We included patients 18 years and older with a history of experiencing homelessness or incarceration. VE and 95% Confidence Intervals (CI) against SARS-CoV-2 hospitalization were estimated for primary series and one booster dose from Cox proportional hazard models as 100*(1-Hazard Ratio) during August 26, 2021, through October 8, 2022 adjusting for patient age, sex, comorbid medical conditions, and race/ethnicity. We included 80,051 individuals who had experienced homelessness or incarceration. Adjusted VE was 52% (95% CI, 41-60%) among those 22 weeks or more since their primary series, 66% (95% CI, 53-75%) among those less than 22 weeks since their primary series, and 69% (95% CI: 60-76%) among those with one booster. VE estimates were consistently lower during the Omicron predominance period compared with the combined Omicron and Delta periods. Despite higher exposure risk, COVID-19 vaccines provided good effectiveness against SARS-CoV-2 related hospitalizations in persons who have experienced homelessness or incarceration.


Assuntos
COVID-19 , Pessoas Mal Alojadas , Humanos , SARS-CoV-2 , Vacinas contra COVID-19/uso terapêutico , Encarceramento , Minnesota/epidemiologia , Estudos Retrospectivos , Eficácia de Vacinas , COVID-19/epidemiologia , COVID-19/prevenção & controle , Hospitalização
3.
Ann Intern Med ; 176(7): 961-968, 2023 07.
Artigo em Inglês | MEDLINE | ID: mdl-37429030

RESUMO

BACKGROUND: Prior studies associating acute kidney injury (AKI) with more rapid subsequent loss of kidney function had methodological limitations, including inadequate control for differences between patients who had AKI and those who did not. OBJECTIVE: To determine whether AKI is independently associated with subsequent kidney function trajectory among patients with chronic kidney disease (CKD). DESIGN: Multicenter prospective cohort study. SETTING: United States. PARTICIPANTS: Patients with CKD (n = 3150). MEASUREMENTS: Hospitalized AKI was defined by a 50% or greater increase in inpatient serum creatinine (SCr) level from nadir to peak. Kidney function trajectory was assessed using estimated glomerular filtration rate (eGFR) based on SCr level (eGFRcr) or cystatin C level (eGFRcys) measured at annual study visits. RESULTS: During a median follow-up of 3.9 years, 433 participants had at least 1 AKI episode. Most episodes (92%) had stage 1 or 2 severity. There were decreases in eGFRcr (-2.30 [95% CI, -3.70 to -0.86] mL/min/1.73 m2) and eGFRcys (-3.61 [CI, -6.39 to -0.82] mL/min/1.73 m2) after AKI. However, in fully adjusted models, the decreases were attenuated to -0.38 (CI, -1.35 to 0.59) mL/min/1.73 m2 for eGFRcr and -0.15 (CI, -2.16 to 1.86) mL/min/1.73 m2 for eGFRcys, and the CI bounds included the possibility of no effect. Estimates of changes in eGFR slope after AKI determined by either SCr level (0.04 [CI, -0.30 to 0.38] mL/min/1.73 m2 per year) or cystatin C level (-0.56 [CI, -1.28 to 0.17] mL/min/1.73 m2 per year) also had CI bounds that included the possibility of no effect. LIMITATIONS: Few cases of severe AKI, no adjudication of AKI cause, and lack of information about nephrotoxic exposures after hospital discharge. CONCLUSION: After pre-AKI eGFR, proteinuria, and other covariables were accounted for, the association between mild to moderate AKI and worsening subsequent kidney function in patients with CKD was small. PRIMARY FUNDING SOURCE: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.


Assuntos
Injúria Renal Aguda , Insuficiência Renal Crônica , Humanos , Estados Unidos/epidemiologia , Estudos de Coortes , Cistatina C , Estudos Prospectivos , Insuficiência Renal Crônica/complicações , Injúria Renal Aguda/etiologia , Taxa de Filtração Glomerular , Creatinina , Fatores de Risco
4.
J Am Soc Nephrol ; 34(10): 1721-1732, 2023 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-37545022

RESUMO

SIGNIFICANCE STATEMENT: Among patients with CKD, optimal use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers after AKI is uncertain. Despite these medications' ability to reduce risk of mortality and other adverse outcomes, there is concern that ACEi/ARB use may delay recovery of kidney function or precipitate recurrent AKI. Prior studies have provided conflicting data regarding the optimal timing of these medications after AKI and have not addressed the role of kidney recovery in determining appropriate timing. This study in US Veterans with diabetes mellitus and proteinuria demonstrated an association between ACEi/ARB use and lower mortality. This association was more pronounced with earlier post-AKI ACEi/ARB use and was not meaningfully affected by initiating ACEis/ARBs before versus after recovery from AKI. BACKGROUND: Optimal use of angiotensin-converting enzyme inhibitors (ACEis) or angiotensin II receptor blockers (ARBs) after AKI is uncertain. METHODS: Using data derived from electronic medical records, we sought to estimate the association between ACEi/ARB use after AKI and mortality in US military Veterans with indications for such treatment (diabetes and proteinuria) while accounting for AKI recovery. We used ACEi/ARB treatment after hospitalization with AKI (defined as serum creatinine ≥50% above baseline concentration) as a time-varying exposure in Cox models. The outcome was all-cause mortality. Recovery was defined as return to ≤110% of baseline creatinine. A secondary analysis focused on ACEi/ARB use relative to AKI recovery (before versus after). RESULTS: Among 54,735 Veterans with AKI, 31,146 deaths occurred over a median follow-up period of 2.3 years. Approximately 57% received an ACEi/ARB <3 months after hospitalization. In multivariate analysis with time-varying recovery, post-AKI ACEi/ARB use was associated with lower risk of mortality (adjusted hazard ratio [aHR], 0.74; 95% confidence interval [CI], 0.72 to 0.77). The association between ACEi/ARB use and mortality varied over time, with lower mortality risk associated with earlier initiation ( P for interaction with time <0.001). In secondary analysis, compared with those with neither recovery nor ACEi/ARB use, risk of mortality was lower in those with recovery without ACEi/ARB use (aHR, 0.90; 95% CI, 0.87 to 0.94), those without recovery with ACEi/ARB use (aHR, 0.69; 95% CI, 0.66 to 0.72), and those with ACEi/ARB use after recovery (aHR, 0.70; 95% CI, 0.67 to 0.73). CONCLUSIONS: This study demonstrated lower mortality associated with ACEi/ARB use in Veterans with diabetes, proteinuria, and AKI, regardless of recovery. Results favored earlier ACEi/ARB initiation.


Assuntos
Injúria Renal Aguda , Diabetes Mellitus , Nefropatias Diabéticas , Veteranos , Humanos , Sistema Renina-Angiotensina , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Antagonistas de Receptores de Angiotensina/efeitos adversos , Nefropatias Diabéticas/complicações , Nefropatias Diabéticas/tratamento farmacológico , Nefropatias Diabéticas/induzido quimicamente , Injúria Renal Aguda/etiologia , Proteinúria/tratamento farmacológico , Proteinúria/induzido quimicamente , Estudos Retrospectivos , Diabetes Mellitus/tratamento farmacológico
6.
Am J Kidney Dis ; 79(3): 311-327, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-35063302

RESUMO

The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the 2021 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for the management of blood pressure in chronic kidney disease (CKD). This commentary is the product of that work group and presents the recommendations and practice points from the KDIGO guideline in the context of US clinical practice. A critical addition to the KDIGO guideline is the recommendation for accurate assessment of blood pressure using standardized office blood pressure measurement. In the general adult population with CKD, KDIGO recommends a goal systolic blood pressure less than 120 mm Hg on the basis of results from the Systolic Blood Pressure Intervention Trial (SPRINT) and secondary analyses of the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial. The KDOQI work group agreed with most of the recommendations while highlighting the weak evidence base especially for patients with diabetes and advanced CKD.


Assuntos
Insuficiência Renal Crônica , Adulto , Pressão Sanguínea , Determinação da Pressão Arterial , Humanos , Rim , Insuficiência Renal Crônica/complicações
7.
Am J Kidney Dis ; 78(1): 57-65.e1, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33359151

RESUMO

RATIONALE & OBJECTIVE: Screening for chronic kidney disease (CKD) is recommended for patients with diabetes and hypertension as stated by the respective professional societies. However, CKD, a silent disease usually detected at later stages, is associated with low socioeconomic status (SES). We assessed whether adding census tract SES status to the standard screening approach improves our ability to identify patients with CKD. STUDY DESIGN: Screening test analysis. SETTINGS & PARTICIPANTS: Electronic health records (EHR) of 256,162 patients seen at a health care system in the 7-county Minneapolis/St. Paul area and linked census tract data. EXPOSURE: The first quartile of census tract SES (median value of owner-occupied housing units <$165,200; average household income <$35,935; percentage of residents >25 years of age with a bachelor's degree or higher <20.4%), hypertension, and diabetes. OUTCOMES: CKD (eGFR <60 mL/min/1.73 m2, or urinary albumin-creatinine ratio >30mg/g, or urinary protein-creatinine ratio >150mg/g, or urinary analysis [albuminuria] >30 mg/d). ANALYTICAL APPROACH: Sensitivity, specificity, and number needed to screen (NNS) to detect CKD if we screened patients who had hypertension and/or diabetes and/or who lived in low-SES tracts (belonging to the first quartile of any of the 3 measures of tract SES) versus the standard approach. RESULTS: CKD was prevalent in 13% of our cohort. Sensitivity, specificity, and NNS of detecting CKD after adding tract SES to the screening approach were 67% (95% CI, 66.2%-67.2%), 61% (95% CI, 61.1%-61.5%), and 5, respectively. With the standard approach, sensitivity of detecting CKD was 60% (95% CI, 59.4%-60.4%), specificity was 73% (95% CI, 72.4%-72.7%), and NNS was 4. LIMITATIONS: One health care system and selection bias. CONCLUSIONS: Leveraging patients' addresses from the EHR and adding tract-level SES to the standard screening approach modestly increases the sensitivity of detecting patients with CKD at a cost of decreased specificity. Identifying further factors that improve CKD detection at an early stage are needed to slow the progression of CKD and prevent cardiovascular complications.


Assuntos
Registros Eletrônicos de Saúde , Insuficiência Renal Crônica/diagnóstico , Características de Residência , Classe Social , Adulto , Idoso , Feminino , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Minnesota/epidemiologia , Insuficiência Renal Crônica/epidemiologia
8.
Clin Transplant ; 35(4): e14234, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33511679

RESUMO

Variants in apolipoprotein L1 (APOL1) gene are associated with nondiabetic kidney diseases in black subjects and reduced kidney transplant graft survival. Living and deceased black kidney donors (n = 107) were genotyped for APOL1 variants. To determine whether allografts from high-risk APOL1 donors have reduced podocyte densities contributing to allograft failure, we morphometrically estimated podocyte number, glomerular volume, and podocyte density. We compared allograft loss and eGFR trajectories stratified by APOL1 high-risk and low-risk genotypes. Demographic characteristics were similar in high-risk (n = 16) and low-risk (n = 91) donors. Podocyte density was significantly lower in high-risk than low-risk donors (108 ± 26 vs 127 ± 40 podocytes/106 um3 , P = .03). Kaplan-Meier graft survival (high-risk 61% vs. low-risk 91%, p-value = 0.049) and multivariable Cox models (hazard ratio = 2.6; 95% CI, 0.9-7.8) revealed higher graft loss in recipients of APOL1 high-risk allografts over 48 months. More rapid eGFR decline was seen in recipients of high-risk APOL1 allografts (P < .001). At 60 months, eGFR was 27 vs. 51 mL/min/1.73 min2 in recipients of APOL1 high-risk vs low-risk kidney allografts, respectively. Kidneys from high-risk APOL1 donors had worse outcomes versus low-risk APOL1 genotypes. Lower podocyte density in kidneys from high-risk APOL1 donors may increase susceptibility to CKD from subsequent stresses in both the recipients and donors.


Assuntos
Apolipoproteína L1 , Transplante de Rim , Podócitos , Aloenxertos , Apolipoproteína L1/genética , Genótipo , Sobrevivência de Enxerto , Humanos , Rim
9.
J Am Soc Nephrol ; 31(11): 2609-2621, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32973085

RESUMO

BACKGROUND: Whether ambulatory BP monitoring is of value in evaluating risk for outcomes in patients with CKD is not clear. METHODS: We followed 1502 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study for a mean of 6.72 years. We evaluated, as exposures, ambulatory BP monitoring profiles (masked uncontrolled hypertension, white-coat effect, sustained hypertension, and controlled BP), mean ambulatory BP monitoring and clinic BPs, and diurnal variation in BP-reverse dipper (higher at nighttime), nondipper, and dipper (lower at nighttime). Outcomes included cardiovascular disease (a composite of myocardial infarction, cerebrovascular accident, heart failure, and peripheral arterial disease), kidney disease (a composite of ESKD or halving of the eGFR), and mortality. RESULTS: Compared with having controlled BP, the presence of masked uncontrolled hypertension independently associated with higher risk of the cardiovascular outcome and the kidney outcome, but not with all-cause mortality. Higher mean 24-hour systolic BP associated with higher risk of cardiovascular outcome, kidney outcome, and mortality, independent of clinic BP. Participants with the reverse-dipper profile of diurnal BP variation were at higher risk of the kidney outcome. CONCLUSIONS: In this cohort of participants with CKD, BP metrics derived from ambulatory BP monitoring are associated with cardiovascular outcomes, kidney outcomes, and mortality, independent of clinic BP. Masked uncontrolled hypertension and mean 24-hour BP associated with high risk of cardiovascular disease and progression of kidney disease. Alterations of diurnal variation in BP are associated with high risk of progression of kidney disease, stroke, and peripheral arterial disease. These data support the wider use of ambulatory BP monitoring in the evaluation of hypertension in patients with CKD. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2020_09_24_JASN2020030236.mp3.


Assuntos
Monitorização Ambulatorial da Pressão Arterial , Pressão Sanguínea , Doenças Cardiovasculares/epidemiologia , Insuficiência Renal Crônica/fisiopatologia , Idoso , Ritmo Circadiano , Progressão da Doença , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Masculino , Hipertensão Mascarada/epidemiologia , Hipertensão Mascarada/fisiopatologia , Pessoa de Meia-Idade , Mortalidade , Prognóstico , Estudos Prospectivos , Sístole , Hipertensão do Jaleco Branco/epidemiologia , Hipertensão do Jaleco Branco/fisiopatologia
10.
Am J Kidney Dis ; 75(3): 426-434, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31864820

RESUMO

The majority of patients with chronic kidney disease (CKD) have elevated blood pressure (BP). In patients with CKD, hypertension is associated with increased risk for cardiovascular disease, progression of CKD, and all-cause mortality. New guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommend new thresholds and targets for the diagnosis and treatment of hypertension in patients with and without CKD. A new aspect of the guidelines is the recommendation for measurement of out-of-office BP to confirm the diagnosis of hypertension and guide therapy. In this KDOQI (Kidney Disease Outcomes Quality Initiative) perspective, we review the recommendations for accurate BP measurement in the office, at home, and with ambulatory BP monitoring. Regardless of location, validated devices and appropriate cuff sizes should be used. In the clinic and at home, proper patient preparation and positioning are critical. Patients should receive information about the importance of BP measurement techniques and be encouraged to advocate for adherence to guideline recommendations. Implementing appropriate BP measurement in routine practice is feasible and should be incorporated in system-wide efforts to improve the care of patients with hypertension. Hypertension is the number 1 chronic disease risk factor in the world; BP measurements in the office, at home, and with ambulatory BP monitoring should adhere to recommendations from the AHA.


Assuntos
Algoritmos , Determinação da Pressão Arterial/métodos , Pressão Sanguínea/fisiologia , Hipertensão/etiologia , Cooperação do Paciente , Insuficiência Renal Crônica/complicações , Humanos , Hipertensão/fisiopatologia , Guias de Prática Clínica como Assunto , Insuficiência Renal Crônica/fisiopatologia , Fatores de Risco
11.
Am J Nephrol ; 51(10): 797-805, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32906135

RESUMO

BACKGROUND: Kidney tubular atrophy on biopsy is a strong predictor of chronic kidney disease (CKD) progression, but tubular health is poorly quantified by traditional measures including estimated glomerular filtration rate (eGFR) and albuminuria. We hypothesized that urinary biomarkers of impaired tubule function would be associated with faster eGFR declines in persons with CKD. METHODS: We measured baseline urine concentrations of uromodulin, ß2-microglobulin (ß2m), and α1-microglobulin (α1m) among 2,428 participants of the Systolic Blood Pressure Intervention Trial with an eGFR <60 mL/min/1.73 m2. We used linear mixed models to evaluate biomarker associations with annualized relative change in eGFR, stratified by randomization arm. RESULTS: At baseline, the mean age was 73 ± 9 years and eGFR was 46 ± 11 mL/min/1.73 m2. In the standard blood pressure treatment arm, each 2-fold higher urinary uromodulin was associated with slower % annual eGFR decline (0.34 [95% CI: 0.08, 0.60]), whereas higher urinary ß2m was associated with faster % annual eGFR decline (-0.10 [95% CI: -0.18, -0.02]) in multivariable-adjusted models including baseline eGFR and albuminuria. Associations were weaker and did not reach statistical significance in the intensive blood pressure treatment arm for either uromodulin (0.11 [-0.13, 0.35], p value for interaction by treatment arm = 0.045) or ß2m (-0.01 [-0.08, 0.08], p value for interaction = 0.001). Urinary α1m was not independently associated with eGFR decline in the standard (0.01 [-0.22, 0.23]) or intensive (0.03 [-0.20, 0.25]) arm. CONCLUSIONS: Among trial participants with hypertension and CKD, baseline measures of tubular function were associated with subsequent declines in kidney function, although these associations were diminished by intensive blood pressure control.


Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Túbulos Renais/fisiopatologia , Insuficiência Renal Crônica/diagnóstico , Idoso , Idoso de 80 Anos ou mais , alfa-Globulinas/urina , Biomarcadores/urina , Determinação da Pressão Arterial , Progressão da Doença , Feminino , Taxa de Filtração Glomerular/fisiologia , Humanos , Hipertensão/diagnóstico , Hipertensão/etiologia , Hipertensão/urina , Masculino , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/tratamento farmacológico , Insuficiência Renal Crônica/urina , Fatores de Risco , Uromodulina/urina , Microglobulina beta-2/urina
12.
J Am Soc Nephrol ; 30(7): 1314-1321, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31167823

RESUMO

BACKGROUND: Although hypertension is common in CKD and evidence-based treatment of hypertension has changed considerably, contemporary and nationally representative information about use of angiotensin-converting enzyme (ACEs) inhibitors or angiotensin II receptor blockers (ARBs) in CKD is lacking. METHODS: We examined ACE/ARB trends from 1999 to 2014 among 38,885 adult National Health and Nutrition Examination Survey participants with creatinine-based eGFR<60 ml/min per 1.73 m2 or urinary albumin-to-creatinine ratio ≥30 mg/g. RESULTS: Of 7085 participants with CKD, 34.9% used an ACE/ARB. Across four eras studied, rates of use rose significantly (rates were 25.5% in 1999-2002, 33.3% in 2003-2006, 39.0% in 2007-2010, and 40.1% in 2011-2014) but appeared to plateau after 2003. Among those with CKD, use was significantly greater among non-Hispanic white and black individuals (36.1% and 38.2%, respectively) and lower among Hispanic individuals (26.7%) and other races/ethnicities (29.3%). In age-, sex-, and race/ethnicity-adjusted models, ACE/ARB use was significantly associated with era (adjusted odds ratios [aOR], 1.41; 95% confidence interval [95% CI], 1.14 to 1.74 for 2003-2006, 1.84; 95% CI, 1.48 to 2.28 for 2007-2010, and 2.02; 95% CI, 1.61 to 2.53 for 2011-2014 versus 1999-2002); it also was significantly associated with non-Hispanic black versus non-Hispanic white race/ethnicity (aOR, 1.40; 95% CI, 1.19 to 1.66). Other multivariate associations included older age, men, elevated BMI, diabetes mellitus, treated hypertension, cardiac failure, myocardial infarction, health insurance, and receiving medical care within the prior year. CONCLUSIONS: Rates of ACE/ARB use increased in the early 2000s among United States adults with CKD, but for unclear reasons, use appeared to plateau in the ensuing decade. Research examining barriers to care and other factors is needed.


Assuntos
Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Hipertensão/tratamento farmacológico , Insuficiência Renal Crônica/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade
14.
Nephrol Dial Transplant ; 34(3): 493-501, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-29579290

RESUMO

BACKGROUND: Acute kidney injury (AKI) has been extensively studied in hospital settings. Limited data exist regarding outcomes for patients with outpatient AKI who are not subsequently admitted. We investigated whether outpatient AKI, defined by a 50% increase in creatinine (Cr), is associated with increased mortality and renal events. METHODS: In this retrospective study, outpatient serum Cr values from adults receiving primary care at a health system during an 18-month exposure period were used to categorize patients into one of five groups (no outpatient AKI, outpatient AKI with recovery, outpatient AKI without recovery, outpatient AKI without repeat Cr and no Cr). Principal outcomes of all-cause mortality and renal events (50% decline in estimated glomerular filtration rate to <30 mL/min/1.73 m2) were examined using Cox proportional hazards models. RESULTS: Among 384 869 eligible patients, 51% had at least one Cr measured during the exposure period. Outpatient AKI occurred in 1.4% of patients while hospital AKI occurred in only 0.3% of patients. The average follow-up was 5.3 years. Outpatient AKI was associated with an increased risk of all-cause mortality {adjusted hazard ratio [aHR] 1.90 [95% confidence interval (CI) 1.76-2.06]} and results were consistent across all AKI groups. Outpatient AKI was also associated with an increased risk of renal events [aHR 1.33 (95% CI 1.11-1.59)], even among those who recovered. CONCLUSIONS: Outpatient AKI is more prevalent than inpatient AKI and is a risk factor for all-cause mortality and renal events, even among those who recover kidney function. Further research is necessary to determine risk factors and identify strategies for preventing outpatient AKI.


Assuntos
Injúria Renal Aguda/complicações , Hospitalização/estatística & dados numéricos , Pacientes Ambulatoriais/estatística & dados numéricos , Insuficiência Renal Crônica/etiologia , Insuficiência Renal Crônica/mortalidade , Adulto , Creatinina/sangue , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
15.
J Am Soc Nephrol ; 29(2): 383-388, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29051347

RESUMO

Hypertension is the leading chronic disease risk factor in the world and is especially important in patients with CKD, nearly 90% of whom have hypertension. Recently, in the Systolic BP Intervention Trial (SPRINT), intensive lowering of clinic systolic BP to a target <120 mm Hg, compared with a standard BP target of <140 mm Hg, reduced risk for cardiovascular disease and all-cause mortality. However, because BP was measured unobserved using an automated device, some investigators have questioned the ability to translate SPRINT results into routine clinical practice, in which measurement of BP is typically less standardized. In this review, we discuss the BP measurement techniques used in major observational studies and clinical trials that form the evidence base for our current approach to treating hypertension, evaluate the effect of measurement technique on BP readings, and explore how ambulatory BP data from the SPRINT trial may inform this discussion. We conclude by arguing for implementation of guideline-recommended BP measurement techniques in routine clinical practice.


Assuntos
Determinação da Pressão Arterial/normas , Pressão Sanguínea , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Ensaios Clínicos como Assunto , Humanos , Hipertensão/complicações , Estudos Observacionais como Assunto , Guias de Prática Clínica como Assunto , Insuficiência Renal Crônica/etiologia , Sístole
16.
Am J Kidney Dis ; 71(3): 352-361, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29162340

RESUMO

BACKGROUND: Treating to a lower blood pressure (BP) may increase acute kidney injury (AKI) events. STUDY DESIGN: Data for AKI resulting in or during hospitalization or emergency department visits were collected as part of the serious adverse events reporting process of the Systolic Blood Pressure Intervention Trial (SPRINT). SETTING & PARTICIPANTS: 9,361 participants 50 years or older with 1 or more risk factors for cardiovascular disease. INTERVENTIONS: Participants were randomly assigned to a systolic BP target of <120 (intensive arm) or <140mmHg (standard arm). OUTCOMES & MEASUREMENTS: Primary outcome was the number of adjudicated AKI events. Secondary outcomes included severity of AKI and degree of recovery of kidney function after an AKI event. Baseline creatinine concentration was defined as the most recent SPRINT outpatient creatinine value before the date of the AKI event. RESULTS: There were 179 participants with AKI events in the intensive arm and 109 in the standard arm (3.8% vs 2.3%; HR, 1.64; 95% CI, 1.30-2.10; P<0.001). Of 288 participants with an AKI event, 248 (86.1%) had a single AKI event during the trial. Based on modified KDIGO (Kidney Disease: Improving Global Outcomes) criteria for severity of AKI, the number of AKI events in the intensive versus standard arm by KDIGO stage was 128 (58.5%) versus 81 (62.8%) for AKI stage 1, 42 (19.2%) versus 18 (14.0%) for AKI stage 2, and 42 (19.2%) versus 25 (19.4%) for AKI stage 3 (P=0.5). For participants with sufficient data, complete or partial resolution of AKI was seen for 169 (90.4%) and 9 (4.8%) of 187 AKI events in the intensive arm and 86 (86.9%) and 4 (4.0%) of 99 AKI events in the standard arm, respectively. LIMITATIONS: Trial results are not generalizable to patients with diabetes mellitus or without risk factors for cardiovascular disease. CONCLUSIONS: More intensive BP lowering resulted in more frequent episodes of AKI. Most cases were mild and most participants had complete recovery of kidney function. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT01206062.


Assuntos
Injúria Renal Aguda/prevenção & controle , Anti-Hipertensivos/administração & dosagem , Pressão Sanguínea/efeitos dos fármacos , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Injúria Renal Aguda/etiologia , Idoso , Determinação da Pressão Arterial , Cuidados Críticos/métodos , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Padrões de Referência , Medição de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
17.
Clin Exp Hypertens ; 40(6): 569-573, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29211509

RESUMO

Evening dosing of antihypertensive medications lowers nighttime blood pressure, and in one large randomized trial, it reduced the risk for cardiovascular outcomes. However, the feasibility of nighttime dosing in routine clinical practice is unknown. The purpose of this pilot study was to evaluate the effect of a brief pharmacist intervention to assign patients to take antihypertensive medications at specific times of the day. In this pilot, randomized controlled trial, 79 patients with moderate to severe chronic kidney disease (CKD) taking one or more antihypertensive medications once daily were randomized to take one once-daily antihypertensive either in the morning or in the evening. A total of 79 patients were randomized (39 to morning dosing, 40 to evening dosing). Average (SD) age was 56.5 (14) years, 68% were male, and average (SD) estimated glomerular filtration rate (eGFR) was 36.6 (8.9) mL/min/1.73m2. Adherence, defined as taking the once-daily medication at the time indicated six or seven times in the last 7 days and not taking it at any other time during the day, was 91% in the morning arm and 95% in the evening arm (p = 0.57). This pilot demonstrates the feasibility and efficacy of a pharmacist-physician collaborative to assign once-daily antihypertensive medications to either morning or evening dosing.


Assuntos
Anti-Hipertensivos/administração & dosagem , Cronofarmacoterapia , Hipertensão/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Serviço de Farmácia Hospitalar/métodos , Insuficiência Renal Crônica/complicações , Adulto , Idoso , Pressão Sanguínea/efeitos dos fármacos , Estudos de Viabilidade , Feminino , Taxa de Filtração Glomerular , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Farmacêuticos , Projetos Piloto
18.
J Am Soc Nephrol ; 27(12): 3600-3610, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27026370

RESUMO

APOL1 risk variants are associated with kidney disease in blacks, but the mechanisms of renal injury associated with APOL1 risk variants are unknown. Because APOL1 is unique to humans and some primates, we created transgenic (Tg) mice using the promoter of nephrin-encoding Nphs1 to express the APOL1 reference sequence (G0) or the G2 risk variant in podocytes, establishing Tg lines with a spectrum of APOL1 expression levels. Podocytes from Tg-G0 and Tg-G2 mice did not undergo necrosis, apoptosis, or autophagic cell death in vivo, even in lines with highly expressed transgenes. Further, Tg-G0 and Tg-G2 mice did not develop kidney pathology, proteinuria, or azotemia as of 300 days of age. However, by 200 days of age, Tg-G2 mice had significantly lower podocyte density than age-matched WT and Tg-G0 mice had, a difference that was not evident at weaning. Notably, a pregnancy-associated phenotype that encompassed eclampsia, preeclampsia, fetal/neonatal deaths, and small litter sizes occurred in some Tg-G0 mice and more severely in Tg-G2 mice. Similar to human placenta, placentas of Tg mice expressed APOL1. Overall, these results suggest podocyte depletion could predispose individuals with APOL1 risk genotypes to kidney disease in response to a second stressor, and add to other published evidence associating APOL1 expression with preeclampsia.


Assuntos
Apolipoproteínas/genética , Nefropatias/genética , Lipoproteínas HDL/genética , Pré-Eclâmpsia/genética , Animais , Apolipoproteína L1 , Modelos Animais de Doenças , Feminino , Camundongos , Camundongos Transgênicos , Podócitos/fisiologia , Gravidez
19.
Am J Kidney Dis ; 67(4): 593-600, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26744128

RESUMO

BACKGROUND: The Brain in Kidney Disease (BRINK) Study aims to identify mechanisms that contribute to increased risk for cognitive impairment in patients with chronic kidney disease (CKD). We describe the rationale, design, and methods of the study and report baseline recruitment and cognitive function results. STUDY DESIGN: Longitudinal observational cohort study of the epidemiology of cognitive impairment in CKD. The primary aim is to characterize the association between (1) baseline and incident stroke, white matter disease, estimated glomerular filtration rate (eGFR), inflammation, microalbuminuria, and dialysis initiation and (2) cognitive decline over 3 years in a CKD cohort with a mean eGFR<45 mL/min/1.73 m(2). SETTING & PARTICIPANTS: Community-dwelling participants 45 years or older recruited from 4 health systems into 2 groups: reduced eGFR, defined as eGFR<60 mL/min/1.73 m(2) (non-dialysis dependent), and control, defined as eGFR≥60 mL/min/1.73 m(2). PREDICTOR: eGFR group. OUTCOMES: Performance on cognitive function tests and structural brain magnetic resonance imaging. MEASUREMENTS: Sequential cognitive and physical function testing, serum and urine biomarker measurement, and brain magnetic resonance images over 3 years. RESULTS: Of 554 participants, mean age was 69.3 years; 333, 88, and 133 had eGFRs<45 (non-dialysis dependent, nontransplantation), 45 to <60, and ≥60 (controls) mL/min/1.73 m(2), respectively. Mean eGFR in reduced-eGFR participants was 34.3 mL/min/1.73 m(2). Baseline cognitive performance was significantly associated with eGFR in all domains except language. Participants with eGFRs<30 mL/min/1.73 m(2) performed significantly worse than those with eGFRs≥30 mL/min/1.73 m(2) on tests of memory, processing speed, and executive function. Participants with reduced eGFRs overall scored worst on the Immediate Brief Visual-Spatial Memory Test-Revised. LIMITATIONS: Healthy cohort bias, competing risk for death versus cognitive decline. CONCLUSIONS: Cognitive function was significantly worse in participants with eGFRs<30 mL/min/1.73 m(2). Future BRINK analyses will measure risk factors for cognitive decline using the longitudinal data.


Assuntos
Transtornos Cognitivos/etiologia , Insuficiência Renal Crônica/complicações , Idoso , Cognição , Transtornos Cognitivos/epidemiologia , Estudos de Coortes , Feminino , Taxa de Filtração Glomerular , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos , Insuficiência Renal Crônica/fisiopatologia , Insuficiência Renal Crônica/psicologia , Projetos de Pesquisa
20.
J Gen Intern Med ; 31(1): 22-9, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26138006

RESUMO

BACKGROUND: Predialysis nephrology care for adults with late stage chronic kidney disease (CKD) is associated with improved outcomes. Less is known about the effects of nephrology care in earlier stages of CKD. OBJECTIVE: We aimed to evaluate the effect of nephrology care on management of CKD risk factors and complications, CKD progression, incident cardiovascular disease (CVD), and death. DESIGN: This was a prospective cohort study. PARTICIPANTS: Participants included 3855 men and women aged 21 to 74 years enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study with a mean (SD) estimated glomerular filtration rate (eGFR) at entry of 45 (17) ml/min/1.73 m(2), followed for a median of 6.6 years. MAIN MEASURES: The main predictor was self-reported prior contact with a nephrologist at study enrollment. Outcomes evaluated included CKD progression (≥ 50 % eGFR loss or end-stage renal disease), incident CVD, and death. RESULTS: Two-thirds (67 %) of the participants reported prior contact with a nephrologist at study enrollment. They were younger, more likely to be male, non-Hispanic white, and had lower eGFR and higher urine protein (p < 0.05). A subgroup with eGFR 30- < 60 ml/min/1.73 m(2) and prior contact with a nephrologist were more likely to receive pharmacologic treatment for CKD-related complications and to report angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use. After propensity score matching (for reporting prior contact with a nephrologist vs. not) and adjusting for demographic and clinical variables, prior contact with a nephrologist was not significantly associated with CKD progression, incident CVD or death (p > 0.05). CONCLUSIONS: One-third of CRIC participants had not seen a nephrologist before enrollment, and this prior contact was subject to age, sex, and ethnic-related disparities. While prior nephrology care was associated with more frequent treatment of CKD complications and use of ACEi/ARB medications, there was neither an association between this care and achievement of guideline-recommended intermediate measures, nor long-term adverse outcomes.


Assuntos
Competência Clínica , Gerenciamento Clínico , Nefrologia/métodos , Avaliação de Resultados em Cuidados de Saúde/métodos , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/terapia , Adulto , Idoso , Progressão da Doença , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Encaminhamento e Consulta , Fatores de Risco , Fatores de Tempo , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA