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INTRODUCTION: Adults residing in deprived neighborhoods face various socioeconomic stressors, hindering their likelihood of receiving live-donor kidney transplantation (LDKT) and preemptive kidney transplantation (KT). We quantified the association between residential neighborhood deprivation index (NDI) and the likelihood of LDKT/preemptive KT, testing for a differential impact by race and ethnicity. METHODS: We studied 403 937 adults (age ≥ 18) KT candidates (national transplant registry; 2006-2021). NDI and its 10 components were averaged at the ZIP-code level. Cause-specific hazards models were used to quantify the adjusted hazard ratio (aHR) of LDKT and preemptive KT across tertiles of NDI and its 10 components. RESULTS: Candidates residing in high-deprivation neighborhoods were more likely to be female (40.1% vs. 36.2%) and Black (41.9% vs. 17.7%), and were less likely to receive both LDKT (aHR = 0.66, 95% confidence interval [CI]: 0.64-0.67) and preemptive KT (aHR = 0.60, 95% CI: 0.59-0.62) than those in low-deprivation neighborhoods. These associations differedby race and ethnicity (Black: aHRLDKT = 0.58, 95% CI: 0.55-0.62; aHRpreemptive KT = 0.68, 95% CI: 0.63-0.73; Pinteractions: LDKT < 0.001; Preemptive KT = 0.002). All deprivation components were associated with the likelihood of both LDKT and preemptive KT (except median home value): for example, higher median household income (LDKT: aHR = 1.08, 95% CI: 1.07-1.09; Preemptive KT: aHR = 1.10, 95% CI: 1.08-1.11) and educational attainments (≥high school [LDKT: aHR = 1.17, 95% CI: 1.15-1.18; Preemptive KT: aHR = 1.23, 95% CI: 1.21-1.25]). CONCLUSION: Residence in socioeconomically deprived neighborhoods is associated with a lower likelihood of LDKT and preemptive KT, differentially impacting minority candidates. Identifying and understanding which neighborhood-level socioeconomic status contributes to these racial disparities can be instrumental in tailoring interventions to achieve health equity in LDKT and preemptive KT.
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Transplante de Rim , Doadores Vivos , Características da Vizinhança , Humanos , Feminino , Masculino , Doadores Vivos/provisão & distribuição , Pessoa de Meia-Idade , Adulto , Seguimentos , Prognóstico , Características de Residência , Falência Renal Crônica/cirurgia , Fatores Socioeconômicos , Sistema de Registros/estatística & dados numéricos , Fatores de Risco , Adulto Jovem , AdolescenteRESUMO
BACKGROUND: Medical distrust may hinder kidney transplantation (KT) access. Among KT candidates evaluated for waitlisting, we identified factors associated with high distrust levels and quantified their association with waitlisting. METHODS: Among 812 candidates (2018-2023), we assessed distrust using the Revised Health Care System Distrust Scale across composite, competence, and values subscales. We used linear regression to quantify the associations between candidate and neighborhood-level factors and distrust scores. We used Cox models to quantify the associations between distrust scores and waitlisting. RESULTS: At KT evaluation, candidates who were aged 35-49 years (difference = 1.97, 95% CI: 0.78-3.16), female (difference = 1.10, 95% CI: 0.23-1.97), and Black (difference = 1.47, 95% CI: 0.47-2.47) were more likely to report higher composite distrust score. For subscales, candidates aged 35-49 were more likely to have higher competence distrust score (difference = 1.14, 95% CI: 0.59-1.68) and values distrust score (difference = 0.83, 95% CI: 0.05-1.61). Race/ethnicity (Black, difference = 1.42, 95% CI: 0.76-2.07; Hispanic, difference = 1.52, 95% CI: 0.35-2.69) was only associated with higher values distrust scores. Female candidates reporting higher rescaled values distrust scores (each one point) had a lower chance of waitlisting (aHR = 0.78, 95% CI: 0.63-0.98), whereas this association was not observed among males. Similarly, among non-White candidates, each 1-point increase in both rescaled composite (aHR = 0.87, 95% CI: 0.77-0.99) and values (aHR = 0.82, 95% CI: 0.68-0.99) distrust scores was associated with a lower chance of waitlisting, while there was no association among White candidates. CONCLUSION: Female, younger, and non-White candidates reported higher distrust scores. Values distrust may contribute to the long-standing racial/ethnic and gender disparities in access to KT. Implementing tailored strategies to reduce distrust in transplant care may improve KT access for groups that experience persistent disparities.
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Transplante de Rim , Confiança , Listas de Espera , Humanos , Feminino , Masculino , Transplante de Rim/psicologia , Pessoa de Meia-Idade , Adulto , Prognóstico , Seguimentos , Falência Renal Crônica/cirurgia , Falência Renal Crônica/psicologiaRESUMO
Repeat kidney transplantation (re-KT) is the preferred treatment for patients with graft failure. Changing allocation policies, widening the risk profile of recipients, and improving dialysis care may have altered the survival benefit of a re-KT. We characterized trends in re-KT survival benefit over 3 decades and tested whether it differed by age, race/ethnicity, sex, and panel reactive assay (PRA). By using the Scientific Registry of Transplant Recipient data, we identified 25 419 patients who underwent a re-KT from 1990 to 2019 and 25 419 waitlisted counterfactuals from the same year with the same waitlisted time following graft failure. In the adjusted analysis, a re-KT was associated with a lower risk of death (adjusted hazard ratio [aHR] = 0.63; 95% confidence interval [CI], 0.61-0.65). By using the 1990-1994 era as a reference (aHR = 0.77; 95% CI, 0.69-0.85), incremental improvements in the survival benefit were noted (1995-1999: aHR = 0.72; 95% CI, 0.67-0.78: 2000-2004: aHR = 0.59; 95% CI, 0.55-0.63: 2005-2009: aHR = 0.59; 95% CI, 0.56-0.63: 2010-2014: aHR = 0.57; 95% CI, 0.53-0.62: 2015-2019: aHR = 0.64; 95% CI, 0.57-0.73). The survival benefit of a re-KT was noted in both younger (age = 18-64 years: aHR = 0.63; 95% CI, 0.61-0.65) and older patients (age ≥65 years: aHR = 0.66; 95% CI, 0.58-0.74; Pinteraction = .45). Patients of all races/ethnicities demonstrated similar benefits with a re-KT. However, it varied by the sex of the recipient (female patients: aHR = 0.60; 95% CI, 0.56-0.63: male patients: aHR = 0.66; 95% CI, 0.63-0.68; Pinteraction = .004) and PRA (0-20: aHR = 0.69; 95% CI, 0.65-0.74: 21-80: aHR = 0.61; 95% CI, 0.57-0.66; Pinteraction = .02; >80: aHR = 0.57; 95% CI, 0.53-0.61; Pinteraction< .001). Our findings support the continued practice of a re-KT and efforts to overcome the medical, immunologic, and surgical challenges of a re-KT.
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Falência Renal Crônica , Transplante de Rim , Humanos , Masculino , Feminino , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Risco , Sistema de Registros , Sobrevivência de Enxerto , Falência Renal Crônica/complicações , Fatores de RiscoRESUMO
PURPOSE: The purpose of this study was to determine whether a combined music pharmacological intervention was an effective multimodal approach to reduce adult pain in the postanesthesia care unit (PACU). DESIGN: A prospective, randomized control trial study. METHODS: Participants were recruited in the preoperative holding area on the day of surgery by the principal investigators. Music was selected by the patient following the informed consent process. Participants were randomized either to the intervention group or the control group. Patients in the intervention group received music in addition to standard pharmacological protocol while the control group received only the standard pharmacological protocol. Measured outcomes were change in visual analog pain scores and length of stay. FINDINGS: In this cohort (N = 134), 68 participants (50.7%) received the intervention, and 66 participants (49.3%) were in the control group. Paired t tests showed that pain scores for the control group worsened by an average of 1.45-points (95% CI: 0.75, 2.15; P < .001) compared to 0.34-points in the intervention group and was not significant (P = .314) as scores went from 1 out of 10 to 1.4 out of 10. Both control and intervention groups experienced pain, with the control group's overall pain scores worsening over time. This finding was statistically significant (P = .023). No statistically significant difference was noted in the average PACU length of stay (LOS). CONCLUSIONS: The addition of music to the standard postoperative pain protocol demonstrated a lower average pain score on discharge from the PACU. The absence of a difference in LOS may be due to the confounding variables (eg, general versus spinal anesthesia or a difference in voiding time).
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Musicoterapia , Música , Adulto , Humanos , Analgésicos , Dor Pós-Operatória/tratamento farmacológico , Estudos Prospectivos , Manejo da DorRESUMO
BACKGROUND: The National Institutes of Health supports professional development of diverse researchers through diversity supplements. Limited awareness and understanding of the application process have hindered utilization of this funding mechanism. PURPOSE: We describe perspectives and recommendations of mentee and mentor recipients of diversity supplements. METHODS: Our working group, comprised of faculty from an Historically Black College and University and an R1 research university, conducted stakeholder interviews with three mentees and four mentors from various institutions. We used content analysis to derive categories of experiences and recommendations. DISCUSSION: Interviewees reported on advantages of diversity supplements, ensuring institutional support, identifying a good mentee-mentor match, developing grantsmanship specific to diversity supplements, and increasing numbers of these applications. CONCLUSION: We identify opportunities for stakeholders to increase awareness of diversity supplements. Our data support greater understanding of this mechanism, establishing strong mentoring relationships, and submitting robust applications. Findings can enhance diversity among the scientific community.
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Tutoria , Mentores , Estados Unidos , Humanos , Avaliação de Programas e Projetos de Saúde , Pesquisadores , National Institutes of Health (U.S.)RESUMO
BACKGROUND: The NIH Diversity Administrative Supplement is a funding mechanism that provides support for diverse early-stage researchers. There is limited guidance on how to apply for these awards. PURPOSE: We describe perspectives of NIH program/diversity officers and university research administrators offering recommendations for diversity supplement submission. METHODS: This article is the product of a working group exploring diversity in research. Nursing faculty from an R2 Historically Black College and University and an R1 research intensive university conducted stakeholder interviews with NIH program/diversity officers and university research administrators. We used content analysis to categorize respondents' recommendations. FINDINGS: Recommendations centered on harmonizing the applicant with the program announcement, communication with program/diversity officers, mentor/mentee relationship, scientific plan, and systematic institutional approaches to the diversity supplement. DISCUSSION: Successful strategies in submitting diversity supplements will facilitate inclusion of diverse researchers in NIH-sponsored programs. Systematic approaches are needed to support development of diverse voices to enhance the scientific community.
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Distinções e Prêmios , Pesquisa Biomédica , Estados Unidos , Humanos , National Institutes of Health (U.S.) , Pesquisadores , MentoresRESUMO
Chronic kidney disease (CKD) is more prevalent in individuals with obesity, diabetes mellitus, or hypertension. Individuals with CKD are prone to kidney failure, with symptom experiences that rival those of patients with cancer. We explored symptom burden in individuals with CKD via a systematic review of 30 quantitative and qualitative articles. The most common CKD symptoms were fatigue, weakness, pain, sleep disturbances and itchy skin. Instruments used to assess symptoms were the Kidney Disease Quality of Life (KDQOL)-36, the Palliative Outcome Symptom-Scale renal (POS-r)-13, and the Dialysis Symptom Index (DSI)-10. The included qualitative studies expand and expound on the quantitative data presented. This article describes the prevalence of symptom burden in individuals with CKD in relation to psychosocial and demographic factors and discuss the importance of symptom management.
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Falência Renal Crônica , Insuficiência Renal Crônica , Fadiga/etiologia , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/terapia , Cuidados Paliativos , Qualidade de Vida/psicologia , Diálise Renal , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/terapiaRESUMO
PURPOSE OF REVIEW: The purpose of this review was to assess the prevalence of United States chronic kidney disease (CKD) health disparities, focusing on racial/ethnic groups, immigrants and refugees, sex or gender, and older adults. RECENT FINDINGS: There are major racial/ethnic disparities in CKD, with possible contributions from the social determinants of health, socioeconomics, and racial discrimination. Racial/ethnic minority patients experience faster progression to end-stage kidney disease (ESKD) and higher mortality predialysis, however, once on dialysis, appear to live longer. Similarly, men are quicker to progress to ESKD than women, with potential biological, behavioral, and measurement error factors. There is a lack of substantial evidence for intersex, nonbinary, or transgender patients. There are also strikingly few studies about US immigrants or older adults with CKD despite the fact that they are at high risk for CKD due to a variety of factors. SUMMARY: As providers and scientists, we must combat both conscious and unconscious biases, advocate for minority patient populations, and be inclusive and diverse in our treatment regimens and provision of care. We need to acknowledge that sufficient evidence exists to change treatment guidelines, and that more is required to support the diversity of our patient population.
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Disparidades em Assistência à Saúde , Insuficiência Renal Crônica , Idoso , Etnicidade , Feminino , Humanos , Falência Renal Crônica , Masculino , Grupos Minoritários , Diálise Renal , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/terapia , Estados Unidos/epidemiologiaRESUMO
Patients living with end stage renal disease (ESRD) who are undergoing hemodialysis experience frequent hospitalizations associated with complications of care and exacerbations of illness. Efforts to reduce hospitalizations have had limited success. The purpose of this study was to explore why hospitalizations occur from the perspectives of patients undergoing hemodialysis treatment, their caregivers, and health care providers. Semi-structured interviews and focus groups were conducted with 21 patients living with ESRD, 10 caregivers, and three focus groups with health care professionals. Findings are discussed under four main themes: Graft site/Catheter/Access issues, "My resistance is low," "I could not breathe,"" and "The perfect storm." Results highlight the complexity of care and vulnerability of patients with ESRD. Further interprofessional research is needed to improve transitional care and care delivery for patient populations receiving hemodialysis.
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Hospitalização/estatística & dados numéricos , Falência Renal Crônica/terapia , Diálise Renal , Cuidadores/psicologia , Grupos Focais , Humanos , Fatores de Risco , Participação dos InteressadosAssuntos
Demência , Transplante de Rim , Segregação Social , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aloenxertos , Demência/etiologia , Demência/etnologia , Etnicidade , Rejeição de Enxerto/etnologia , Sobrevivência de Enxerto , Falência Renal Crônica/cirurgia , Falência Renal Crônica/mortalidade , Transplante de Rim/efeitos adversos , Transplante de Rim/mortalidade , Racismo , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Cardiovascular disease accounts for more than half of all deaths in the hemodialysis (HD) population. Although much of this mortality is associated with fluid overload (FO), FO is difficult to measure, and many HD patients have significant pulmonary congestion despite the absence of clinical presentation. Cohort studies have observed that FO, as measured by bioimpedance spectroscopy (BIS), correlates with mortality. Other studies have observed that lower sodium intake is associated with less fluid-related weight gain, improved hypertension, and survival. Whether sodium intake influences FO in HD patients as measured by BIS is not known. OBJECTIVE: The aims of the study were to determine the feasibility of assessing the impact of sodium restriction on body fluid composition as measured by BIS among patients with three levels of sodium intake and to determine if there are statistical and/or clinical differences in BIS measures across sodium intake groups. METHODS: We used a double-blinded randomized controlled trial design with three levels of sodium restriction, 2,400 mg per day, 1,500 mg per day, and unrestricted (control group), to test our aims. Forty-two HD patients from a tertiary acute care academic institution associated with three urban DaVita dialysis centers were enrolled. Participants remained in the inpatient center for 5 days and 4 nights and were randomly assigned to sodium intake groups. Body fluid composition was measured with BIS. RESULTS: Recruitment, enrollment, and retention statistics supported the feasibility of the study design. Regression analyses showed that there were no statistically significant differences among sodium intake groups on any of the outcomes. DISCUSSION: Our data suggest the need for additional research into the effects of sodium restriction on body fluid composition.
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Composição Corporal/fisiologia , Líquidos Corporais/fisiologia , Falência Renal Crônica/metabolismo , Sódio/metabolismo , Equilíbrio Hidroeletrolítico/fisiologia , Dieta Hipossódica/métodos , Estudos de Viabilidade , Feminino , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Diálise Renal , Sódio na Dieta/administração & dosagemRESUMO
OBJECTIVE: To identify characteristics of hemodialysis patients most likely to experience difficulty adhering to sodium restrictions associated with their dietary regimen. DESIGN: Secondary analysis using baseline data from an ongoing randomized clinical trial examining the effects of a technology-supported behavioral intervention on dietary sodium intake in hemodialysis patients. SETTING: Thirteen dialysis centers in southwestern Pennsylvania. SUBJECTS: We included 122 participants (61% women; 48% African American) aged 61 ± 14 years undergoing maintenance, intermittent hemodialysis for end-stage renal disease. MAIN OUTCOME MEASURES: Normalized dietary sodium intake, adjusted interdialytic weight gain, perceived problems, and self-efficacy for restricting dietary sodium. RESULTS: Younger participants were more likely to report problems managing their hemodialysis diet and low self-efficacy for restricting sodium intake. Consistent with these findings, younger participants had a higher median sodium intake and higher average adjusted interdialytic weight gain. Females reported more problems managing their diet. Race, time on dialysis, and perceived income adequacy did not seem to influence outcome measures. CONCLUSION: Our findings suggest that patients who are younger and female encounter more difficulty adhering to the hemodialysis regimen. Hence, there may be a need to individualize counseling and interventions for these individuals. Further investigation is needed to understand the independent effects of age and gender on adherence to hemodialysis dietary recommendations and perceived self-efficacy.
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Cooperação do Paciente , Recomendações Nutricionais , Diálise Renal , Sódio na Dieta/administração & dosagem , Negro ou Afro-Americano , Idoso , Dieta , Feminino , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Pennsylvania , Autoeficácia , Fatores Socioeconômicos , Inquéritos e Questionários , Aumento de Peso , População BrancaRESUMO
BACKGROUND: Recent data suggest patients with graft failure had better access to repeat kidney transplantation (re-KT) than transplant-naive dialysis accessing first KT. This was postulated to be because of better familiarity with the transplant process and healthcare system; whether this advantage is equitably distributed is not known. We compared the magnitude of racial/ethnic disparities in access to re-KT versus first KT. METHODS: Using United States Renal Data System, we identified 104 454 White, Black, and Hispanic patients with a history of graft failure from 1995 to 2018, and 2 357 753 transplant-naive dialysis patients. We used adjusted Cox regression to estimate disparities in access to first and re-KT and whether the magnitude of these disparities differed between first and re-KT using a Wald test. RESULTS: Black patients had inferior access to both waitlisting and receiving first KT and re-KT. However, the racial/ethnic disparities in waitlisting for (adjusted hazard ratio [aHR]â =â 0.77; 95% confidence interval [CI], 0.74-0.80) and receiving re-KT (aHRâ =â 0.61; 95% CI, 0.58-0.64) was greater than the racial/ethnic disparities in first KT (waitlisting: aHRâ =â 0.91; 95% CI, 0.90-0.93; Pinteraction = 0.001; KT: aHRâ =â 0.68; 95% CI, 0.64-0.72; Pinteraction < 0.001). For Hispanic patients, ethnic disparities in waitlisting for re-KT (aHRâ =â 0.83; 95% CI, 0.79-0.88) were greater than for first KT (aHRâ =â 1.14; 95% CI, 1.11-1.16; Pinteractionâ <â 0.001). However, the disparity in receiving re-KT (aHRâ =â 0.76; 95% CI, 0.72-0.80) was similar to that for first KT (aHRâ =â 0.73; 95% CI, 0.68-0.79; Pinteractionâ =â 0.55). Inferences were similar when restricting the cohorts to the Kidney Allocation System era. CONCLUSIONS: Unlike White patients, Black and Hispanic patients with graft failure do not experience improved access to re-KT. This suggests that structural and systemic barriers likely persist for racialized patients accessing re-KT, and systemic changes are needed to achieve transplant equity.
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Importance: Identifying the mechanisms of structural racism, such as racial and ethnic segregation, is a crucial first step in addressing the persistent disparities in access to live donor kidney transplantation (LDKT). Objective: To assess whether segregation at the candidate's residential neighborhood and transplant center neighborhood is associated with access to LDKT. Design, Setting, and Participants: In this cohort study spanning January 1995 to December 2021, participants included non-Hispanic Black or White adult candidates for first-time LDKT reported in the US national transplant registry. The median (IQR) follow-up time for each participant was 1.9 (0.6-3.0) years. Main Outcome and Measures: Segregation, measured using the Theil H method to calculate segregation tertiles in zip code tabulation areas based on the American Community Survey 5-year estimates, reflects the heterogeneity in neighborhood racial and ethnic composition. To quantify the likelihood of LDKT by neighborhood segregation, cause-specific hazard models were adjusted for individual-level and neighborhood-level factors and included an interaction between segregation tertiles and race. Results: Among 162â¯587 candidates for kidney transplant, the mean (SD) age was 51.6 (13.2) years, 65â¯141 (40.1%) were female, 80â¯023 (49.2%) were Black, and 82â¯564 (50.8%) were White. Among Black candidates, living in a high-segregation neighborhood was associated with 10% (adjusted hazard ratio [AHR], 0.90 [95% CI, 0.84-0.97]) lower access to LDKT relative to residence in low-segregation neighborhoods; no such association was observed among White candidates (P for interaction = .01). Both Black candidates (AHR, 0.94 [95% CI, 0.89-1.00]) and White candidates (AHR, 0.92 [95% CI, 0.88-0.97]) listed at transplant centers in high-segregation neighborhoods had lower access to LDKT relative to their counterparts listed at centers in low-segregation neighborhoods (P for interaction = .64). Within high-segregation transplant center neighborhoods, candidates listed at predominantly minority neighborhoods had 17% lower access to LDKT relative to candidates listed at predominantly White neighborhoods (AHR, 0.83 [95% CI, 0.75-0.92]). Black candidates residing in or listed at transplant centers in predominantly minority neighborhoods had significantly lower likelihood of LDKT relative to White candidates residing in or listed at transplant centers located in predominantly White neighborhoods (65% and 64%, respectively). Conclusions: Segregated residential and transplant center neighborhoods likely serve as a mechanism of structural racism, contributing to persistent racial disparities in access to LDKT. To promote equitable access, studies should assess targeted interventions (eg, community outreach clinics) to improve support for potential candidates and donors and ultimately mitigate the effects of segregation.
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Transplante de Rim , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Negro ou Afro-Americano , Estudos de Coortes , Doadores Vivos , Grupos Minoritários , Brancos , Estados UnidosRESUMO
BACKGROUND: Illness perceptions are the unique perspective individuals have on their illness, based on their context and experiences, and are associated with patient outcomes including coping and adherence. The purpose of this study was to explore characteristics that may be driving membership in illness perceptions cluster groups for adults with chronic kidney disease (CKD). METHODS: This study was conducted within the multicenter longitudinal Chronic Renal Insufficiency Cohort (CRIC) Study. Cross-sectional data were collected and combined with CRIC data. Illness perceptions were measured using the Revised Illness Perception Questionnaire. Clustering analysis was conducted in R, and bivariate analysis including linear regression was performed in STATA 16. RESULTS: The sample (n = 197) had a mean age of 68, was 52% women, 53% non-White, and mean estimated glomerular filtration rate (eGFR) 56 ml/min/1.73 m2. Three cluster groups were identified, labeled as "Disengaged" (n = 20), "Well-Resourced" (n = 108), and "Distressed" (n = 69). The "Disengaged" group was characterized by low CKD knowledge, many recent hospitalization days, and the lowest perceived CKD burden. The "Well-Resourced" group was characterized by the highest levels of education, CKD knowledge, optimism, and medication adherence. The "Distressed" group was characterized by the highest levels of depression scores, comorbidity burden, CKD burden, CKD symptoms, and lowest optimism. Group membership significantly predicted the number of hospitalization days in adjusted analyses. CONCLUSIONS: Illness perceptions groups are associated with number of hospitalization days but are independent of many patient characteristics. Illness perceptions data could be used to tailor care for specific patients at risk for poor health outcomes.
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Conhecimentos, Atitudes e Prática em Saúde , Insuficiência Renal Crônica , Humanos , Feminino , Masculino , Insuficiência Renal Crônica/psicologia , Insuficiência Renal Crônica/fisiopatologia , Insuficiência Renal Crônica/epidemiologia , Idoso , Pessoa de Meia-Idade , Estudos Transversais , Estudos Longitudinais , Inquéritos e Questionários , Efeitos Psicossociais da Doença , Percepção , Taxa de Filtração Glomerular , Análise por ConglomeradosRESUMO
High blood pressure, also known as hypertension, is a major risk factor for cardiovascular disease. Salt intake has been shown to have a significant impact on BP, but the mechanisms by which it influences the blood pressure dipping pattern, and 24-h blood pressure remains controversial. This literature review aims to both summarize the current evidence on high salt diet induced hypertension and discuss the epidemiological aspects including socioeconomic issues in the United States and abroad. Our review indicates that a high salt diet is associated with a blunted nocturnal blood pressure dipping pattern, which is characterized by a reduced decrease in blood pressure during the nighttime hours. The mechanisms by which high salt intake affects blood pressure dipping patterns are not fully understood, but it is suggested that it may be related to changes in the sympathetic nervous system. Further, we looked at the association between major blood pressure and circadian rhythm regulatory centers in the brain, including the paraventricular nucleus (PVN), suprachiasmatic nucleus (SCN) and nucleus tractus solitarius (nTS). We also discuss the underlying social and economic issues in the United States and around the world. In conclusion, the evidence suggests that a high salt diet is associated with a blunted, non-dipping, or reverse dipping blood pressure pattern, which has been shown to increase the risk of cardiovascular disease. Further research is needed to better understand the underlying mechanisms by which high salt intake influences changes within the central nervous system.
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Importance: Hypertension self-management is recommended for optimal blood pressure (BP) control, but self-identified residential contextual factors that hinder hypertension self-care are understudied. Objective: To quantify perceived neighborhood health and hypertension self-care and assess interactions with the area deprivation index (ADI) and healthy food availability at home. Design, Setting, and Participants: A cross-sectional study was conducted in Baltimore, Maryland, including primary care adults enrolled in the Achieving Blood Pressure Control Together trial between September 1, 2013, and June 30, 2014. Participants were Black and had at least 2 BP readings greater than or equal to 140/90 mm Hg in the 6 months before enrollment. Analyses were conducted from August 5, 2021, to January 28, 2022. Exposures: Participants' perceived neighborhood health, defined as the mean standardized score across 4 subdomains of aesthetic quality, walkability, safety, and violence, with a higher score signifying better neighborhood health. Main Outcomes and Measures: Hypertension self-care behavior and self-efficacy. Multivariable generalized linear models were fit regressing each outcome on perceived neighborhood health (higher scores on each domain signify better perceived neighborhood health), adjusted for confounders, and interaction terms between neighborhood health and potential modifiers (ADI [higher percentiles correspond to more deprivation] and healthy food availability [higher scores indicate greater availability]) of the primary association were included. Results: Among 159 participants (median [IQR] age, 57 [49-64] years; mean [SD] age, 57 (11) years; 117 women [74%]), median (IQR) hypertension self-care behavior was 50 (45-56) and self-efficacy was 64 (57-72). Better perceived neighborhood health was associated with greater hypertension self-care behavior (ß, 2.48; 95% CI, 0.63-4.33) and self-efficacy (ß, 4.42; 95% CI, 2.25-6.59); these associations persisted for all neighborhood health subdomains except aesthetic quality. There were no statistically significant interactions between perceived neighborhood health or its subdomains with ADI on self-care behavior (P = .74 for interaction) or self-efficacy (P = .85 for interaction). However, better perceived neighborhood aesthetic quality had associations with greater self-care behavior specifically at higher healthy food availability at home scores: ß at -1 SD, -0.29; 95% CI, -2.89 to 2.30 vs ß at 1 SD, 2.97; 95% CI, 0.46-5.47; P = .09 for interaction). Likewise, associations of perceived worse neighborhood violence with lower self-care behavior were attenuated at higher healthy food availability at home scores (ß for -1 SD, 3.69; 95% CI, 1.31-6.08 vs ß for 1 SD, 0.01; 95% CI, -2.53 to 2.54; P = .04 for interaction). Conclusions and Relevance: In this cross-sectional study, better perceived neighborhood health was associated with greater hypertension self-care among Black individuals with hypertension, particularly among those with greater in-home food availability. Thus, optimizing hypertension self-management may require multifaceted interventions targeting both the patients' perceived contextual neighborhood barriers to self-care and availability of healthy food resources in the home.
Assuntos
Hipertensão , Autocuidado , Adulto , Humanos , Feminino , Pessoa de Meia-Idade , Estudos Transversais , Hipertensão/epidemiologia , Hipertensão/terapia , Pressão Sanguínea , ViolênciaRESUMO
Background: Advancements in medical technology, healthcare delivery, and organ allocation resulted in improved patient/graft survival for older (age ≥65) kidney transplant (KT) recipients. However, the recent trends in these post-KT outcomes are uncertain in light of the mounting burden of cardiovascular disease, changing kidney allocation policies, heterogeneity in candidates' risk profile, and the coronavirus disease 2019 pandemic. Thus, we examined secular trends in post-KT outcomes among older and younger KT recipients over the last 3 decades. Methods: We identified 73 078 older and 378 800 younger adult (aged 18-64) recipients using Scientific Registry of Transplant Recipients (1990-2022). KTs were grouped into 6 prepandemic eras and 1 postpandemic-onset era. Kaplan-Meier and Cox proportional hazards models were used to examine temporal trends in post-KT mortality and death-censored graft failure. Results: From 1990 to 2022, a 19-fold increase in the proportion of older KT recipients was observed compared to a 2-fold increase in younger adults despite a slight decline in the absolute number of older recipients in 2020. The mortality risk for older recipients between 2015 and March 14, 2020, was 39% (adjusted hazard ratio [aHR] = 0.61, 95% confidence interval [CI], 0.50-0.75) lower compared to 1990-1994, whereas that for younger adults was 47% lower (aHR = 0.53, 95% CI, 0.48-0.59). However, mortality risk during the pandemic was 25% lower (aHR = 0.75, 95% CI, 0.61-0.93) in older adults and 37% lower in younger adults (aHR = 0.63, 95% CI, 0.56-0.70) relative to 1990-1994. For both populations, the risk of graft failure declined over time and was unaffected during the pandemic relative to the preceding period. Conclusions: The steady improvements in 5-y mortality and graft survival were disrupted during the pandemic, particularly among older adults. Specifically, mortality among older adults reflected rates seen 20 y prior.