Effect of Vitamin D and Omega-3 Fatty Acid Supplementation on Kidney Function in Patients With Type 2 Diabetes: A Randomized Clinical Trial.

Importance: Chronic kidney disease (CKD) is a common complication of type 2 diabetes that can lead to end-stage kidney disease and is associated with high cardiovascular risk. Few treatments are available to prevent CKD in type 2 diabetes. Objective: To test whether supplementation with vitamin D3 or omega-3 fatty acids prevents development or progression of CKD in type 2 diabetes. Design, Setting, and Participants: Randomized clinical trial with a 2 × 2 factorial design conducted among 1312 adults with type 2 diabetes recruited between November 2011 and March 2014 from all 50 US states as an ancillary study to the Vitamin D and Omega-3 Trial (VITAL), coordinated by a single center in Massachusetts. Follow-up was completed in December 2017. Interventions: Participants were randomized to receive vitamin D3 (2000 IU/d) and omega-3 fatty acids (eicosapentaenoic acid and docosahexaenoic acid; 1 g/d) (n = 370), vitamin D3 and placebo (n = 333), placebo and omega-3 fatty acids (n = 289), or 2 placebos (n = 320) for 5 years. Main Outcomes and Measures: The primary outcome was change in glomerular filtration rate estimated from serum creatinine and cystatin C (eGFR) from baseline to year 5. Results: Among 1312 participants randomized (mean age, 67.6 years; 46% women; 31% of racial or ethnic minority), 934 (71%) completed the study. Baseline mean eGFR was 85.8 (SD, 22.1) mL/min/1.73 m2. Mean change in eGFR from baseline to year 5 was -12.3 (95% CI, -13.4 to -11.2) mL/min/1.73 m2 with vitamin D3 vs -13.1 (95% CI, -14.2 to -11.9) mL/min/1.73 m2 with placebo (difference, 0.9 [95% CI, -0.7 to 2.5] mL/min/1.73 m2). Mean change in eGFR was -12.2 (95% CI, -13.3 to -11.1) mL/min/1.73 m2 with omega-3 fatty acids vs -13.1 (95% CI, -14.2 to -12.0) mL/min/1.73 m2 with placebo (difference, 0.9 [95% CI, -0.7 to 2.6] mL/min/1.73 m2). There was no significant interaction between the 2 interventions. Kidney stones occurred among 58 participants (n = 32 receiving vitamin D3 and n = 26 receiving placebo) and gastrointestinal bleeding among 45 (n = 28 receiving omega-3 fatty acids and n = 17 receiving placebo). Conclusions and Relevance: Among adults with type 2 diabetes, supplementation with vitamin D3 or omega-3 fatty acids, compared with placebo, resulted in no significant difference in change in eGFR at 5 years. The findings do not support the use of vitamin D or omega-3 fatty acid supplementation for preserving kidney function in patients with type 2 diabetes. Trial Registration: ClinicalTrials.gov Identifier: NCT01684722.

A Enfermagem no processo de reconhecimento da autonomia do usuário renal crônico: a importância da avaliação da qualidade de vida para uma bioética do cuidado / Nursing in the process of recognizing the autonomy of chronic renal users: the importance of assessing quality of life for a bioethics of care

Introdução: A pesquisa apresenta uma perspectiva original sobre as implicações bioéticas inerentes ao cuidado de Enfermagem e, com ela, uma nova consciência acerca da conduta profissional no diálogo com a diversidade dos sujeitos autônomos. A partir deste novo recorte, se insere o reconhecimento como componente elementar de análise da integralidade da assistência que, no caso do usuário renal crônico, se concretiza na qualidade de vida atribuída à sua condição clínica, mensurável quantitativamente através do Kidney Disease and Quality of Life ­ Short Form (KDQOL-SFTM1.3). Esta pesquisa apresenta a seguinte hipótese teórica: a avaliação da qualidade de vida do usuário renal crônico, como parte inerente do cuidado de Enfermagem, possibilita o reconhecimento da sua autonomia como ponto articulador de uma bioética do cuidado. Questão norteadora: Como a qualidade de vida resultante da avaliação dos usuários renais crônicos possibilita ao enfermeiro reconhecer o sentido da autonomia como fundamento bioético na relação do cuidado? Objeto: O reconhecimento da autonomia dos usuários renais crônicos, considerando sua percepção de qualidade de vida, como elemento fundamental para um cuidado bioético de Enfermagem. Objetivos: Avaliar a qualidade de vida dos usuários renais crônicos, de forma quantificada através do instrumento Kidney Disease and Quality of Life ­ Short Form (KDQOL-SFTM1.3), como parte integrante da compreensão do processo de reconhecimento da sua autonomia; Analisar os resultados obtidos através de uma perspectiva bioética fundada em uma concepção holística do cuidado de Enfermagem; Discutir, etnograficamente, como os elementos sócio-antropológicos, presentes na concepção de reconhecimento, integram o cuidado bioético de Enfermagem; Propor uma bioética do cuidado, capaz de auxiliar a Enfermagem na construção de uma assistência que associe competência profissional (beneficência/não-maleficência), respeito pela integridade moral do usuário (autonomia) e responsabilidade social na aplicação dos recursos de saúde (justiça). Metodologia: Trata-se de uma pesquisa transversal de investigação quantitativa, na modalidade etnometodologia. Os dados oriundos da aplicação do questionário autoaplicável KDQOL- SFTM1.3, em que o escore final varia de 0 a 100, considerando que valores próximos ao 0 correspondem a uma qualidade de vida menos favorável e os valores próximos a 100 a uma melhor qualidade de vida, sofreram análise descritiva-analítica com auxílio do software Statistical Package for the Social Sciences (SPSS) versão 21.0, com geração de média, mediana e desvio padrão além de considerar o nível de significância de 5%. Resultados e discussão: A pesquisa demonstra, através da aplicação do questionário KDQOL-SFTM1.3, a transição da quantificação dos dados para a qualificação dos procedimentos terapêuticos e serviços de saúde prestados aos usuários. Em todas e cada uma das dimensões abordadas pelo questionário,equipe de enfermagem tem relevância ímpar no processo de enfrentamento do usuário. O reconhecimento de sua autonomia permite vislumbrar a corresponsabilidade envolvida no plano terapêutico estabelecido entre usuário e profissional de saúde. Conclusão: A bioética do cuidado, entendida como forma privilegiada da condição epistemológica e pragmática da Enfermagem permite a construção de pontes entre conhecimento e entre pessoas, com o objetivo de promover bem-estar e qualidade de vida. Os três axiomas: inseparabilidade das habilidades, unidade bidimensional e aggiornamento do mundo circundante demonstram que o valor bioético do cuidado deve estar em sintonia com os imperativos instituídos pelos usuários, autônomos, inseridos em um contexto sócio-antropológico. Assim, se pode dizer que a bioética do cuidado é uma Bioética do cuidado real de uma Enfermagem real.

Introduction: The research presents an original perspective on the bioethical implications inherent to nursing care and, with it, a new awareness about professional conduct in dialogue with the diversity of autonomous subjects. Based on this new approach, recognition is inserted as an elementary component of the analysis of the comprehensiveness of care that, in the case of chronic renal users, is reflected in the quality of life attributed to their clinical condition, measurable quantitatively through the instrument Kidney Disease and Quality of Life ­ Short Form (KDQOL-SFTM1.3). This research presents the following theoretical hypothesis: the assessment of the quality of life of chronic renal users, as an inherent part of nursing care, enables the recognition of their autonomy as an articulating point of a bioethics of care. Guiding question: How does the quality of life resulting from the assessment of chronic renal users enable nurses to recognize the sense of autonomy as a bioethical foundation in the relationship of care? Object: The recognition of the autonomy of chronic renal users, considering their perception of quality of life, as a fundamental element for a bioethical nursing care. Objectives: To evaluate the quality of life of chronic renal users, quantified through the instrument Kidney Disease and Quality of Life ­ Short Form (KDQOL-SFTM1.3). as an integral part of understanding the process of recognizing their autonomy; To analyze the results obtained through a bioethical perspective based on a holistic conception of nursing care; Discuss, ethnographically, how the socio-anthropological elements, present in the conception of recognition, integrate the bioethical nursing care; Propose a bioethics of care, capable of assisting nursing in the construction of care that associates professional competence (beneficence / nonmaleficence), respect for the moral integrity of the user (autonomy) and social responsibility in the application of health resources (justice). Methodology: This is a cross-sectional research of quantitative research, in the ethnomethodology modality. Data from the self-administered KDQOL-SFTM1.3 questionnaire, in which the final score ranges from 0 to 100, considering that values close to 0 correspond to a less favorable quality of life and values close to 100 to a better quality of life. suffered descriptive-analytical analysis with the aid of the software Statistical Package for the Social Sciences (SPSS) version 21.0, with generation of mean, median and standard deviation and considering the significance level of 5%. Results and discussion: The research demonstrates, through the application of the KDQOL-SFTM1.3 questionnaire, the transition from data quantification to the qualification of therapeutic procedures and health services provided to users. In each and every one of the dimensions addressed by the questionnaire, the nursing team has unique relevance in the user's coping process. The recognition of their autonomy allows us to glimpse the co-responsibility involved in the therapeutic plan established between users and health professionals. Conclusion: The bioethics of care, understood as a privileged form of the epistemological and pragmatic condition of nursing, allows the construction of bridges between knowledge and between people, with the objective of promoting well-being and quality of life. The three axioms: inseparability of skills, two-dimensional unity and aggiornamento of the surrounding world demonstrate that the bioethical value of care must be in line with the imperatives instituted by autonomous users, inserted in a socio-anthropological context. Thus, it can be said that the bioethics of care is a real care bioethics of a real nursing.

Blood Fatty Acid Status and Clinical Outcomes in Dialysis Patients: A Systematic Review.

Blood fatty acids (FAs) are derived from endogenous and dietary routes. Metabolic abnormalities from kidney dysfunction, as well as cross-cultural dietary habits, may alter the FA profile of dialysis patients (DP), leading to detrimental clinical outcomes. Therefore, we aimed to (i) summarize FA status of DP from different countries, (ii) compare blood FA composition between healthy controls and DP, and (iii) evaluate FA profile and clinical endpoints in DP. Fifty-three articles from 1980 onwards, reporting FA profile in hemodialysis and peritoneal DP, were identified from PubMed, Embase, and the Cochrane library. Studies on pediatric, predialysis chronic kidney disease, acute kidney injury, and transplant patients were excluded. Moderate to high levels of n-3 polyunsaturated fatty acids (PUFA) were reported in Japan, Korea, Denmark, and Sweden. Compared to healthy adults, DP had lower proportions of n-3 and n-6 PUFA, but higher proportion of monounsaturated fatty acids. Two studies reported inverse associations between n-3 PUFAs and risks of sudden cardiac death, while one reported eicosapentaenoic acid + docosahexaenoic acid)/arachidonic acid ratio was inversely associated with cardiovascular events. The relationship between all-cause mortality and blood FA composition in DP remained inconclusive. The current evidence highlights a critical role for essential FA in nutritional management of DP.

Food Patterns are Associated with Likelihood of CKD in US Adults.

We investigated the association between dietary patterns and prevalent chronic kidney diseases (CKD), in participants of the 2005-2012 US National Health and Nutrition Examination Survey (NHANES) conducted between 2005 and 2012, who had measured data on dietary intake and kidney function. Analyse of covariance (ANCOVA) and logistic regression models were employed to account for the survey design and sample weights. A total of 21,649 eligible participants (634 with and 20,015 without prevalent CKD) were included in the final analysis. Three food patterns together explained 50.8% of the variance of the dietary nutrients consumption. The first food pattern was representative of a diet containing high levels of saturated and mono-unsaturated fatty acids; the second food pattern comprised vitamins and trace elements; and the third food pattern was mainly representative of polyunsaturated fatty acids. The odd of prevalent CKD decreased across increasing quarters of vitamins and trace elements, so that the top quarter was associated with a 53% (95%CI: 42-62%) lower odds of CKD in age, sex and race adjusted logistic regression models. These results suggest that vitamins and trace elements intake are associated with lower risk of prevalent CKD.

Vitamin K Dependent Protection of Renal Function in Multi-ethnic Population Studies.

BACKGROUND: Following activation by vitamin K (VK), matrix Gla protein (MGP) inhibits arterial calcification, but its role in preserving renal function remains unknown. METHODS: In 1166 white Flemish (mean age, 38.2 years) and 714 South Africans (49.2% black; 40.6 years), we correlated estimated glomerular filtration (eGFR [CKD-EPI formula]) and stage of chronic kidney disease (CKD [KDOQI stages 2-3]) with inactive desphospho-uncarboxylated MGP (dp-ucMGP), using multivariable linear and logistic regression. RESULTS: Among Flemish and white and black Africans, between-group differences in eGFR (90, 100 and 122 mL/min/1.73 m(2)), dp-ucMGP (3.7, 6.5 and 3.2 µg/L), and CKD prevalence (53.5, 28.7 and 10.5%) were significant, but associations of eGFR with dp-ucMGP did not differ among ethnicities (P ≥ 0.075). For a doubling of dp-ucMGP, eGFR decreased by 1.5 (P = 0.023), 1.0 (P = 0.56), 2.8 (P = 0.0012) and 2.1 (P < 0.0001) mL/min/1.73 m(2) in Flemish, white Africans, black Africans and all participants combined; the odds ratios for moving up one CKD stage were 1.17 (P = 0.033), 1.03 (P = 0.87), 1.29 (P = 0.12) and 1.17 (P = 0.011), respectively. INTERPRETATION: In the general population, eGFR decreases and CKD risk increases with higher dp-ucMGP, a marker of VK deficiency. These findings highlight the possibility that VK supplementation might promote renal health.

Genetic African Ancestry and Markers of Mineral Metabolism in CKD.

BACKGROUND AND OBJECTIVES: Disorders of mineral metabolism are more common in African Americans with CKD than in European Americans with CKD. Previous studies have focused on the differences in mineral metabolism by self-reported race, making it difficult to delineate the importance of environmental compared with biologic factors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In a cross-sectional analysis of 3013 participants of the Chronic Renal Insufficiency Cohort study with complete data, we compared markers of mineral metabolism (phosphorus, calcium, alkaline phosphatase, parathyroid hormone, fibroblast growth factor 23, and urine calcium and phosphorus excretion) in European Americans versus African Americans and separately, across quartiles of genetic African ancestry in African Americans (n=1490). RESULTS: Compared with European Americans, African Americans had higher blood concentrations of phosphorus, alkaline phosphatase, fibroblast growth factor 23, and parathyroid hormone, lower 24-hour urinary excretion of calcium and phosphorus, and lower urinary fractional excretion of calcium and phosphorus at baseline (P<0.001 for all). Among African Americans, a higher percentage of African ancestry was associated with lower 24-hour urinary excretion of phosphorus (Ptrend<0.01) in unadjusted analyses. In linear regression models adjusted for socio-demographic characteristics, kidney function, serum phosphorus, and dietary phosphorus intake, higher percentage of African ancestry was significantly associated with lower 24-hour urinary phosphorus excretion (each 10% higher African ancestry was associated with 39.6 mg lower 24-hour urinary phosphorus, P<0.001) and fractional excretion of phosphorus (each 10% higher African ancestry was associated with an absolute 1.1% lower fractional excretion of phosphorus, P=0.01). CONCLUSIONS: A higher percentage of African ancestry was independently associated with lower 24-hour urinary phosphorus excretion and lower fractional excretion of phosphorus among African Americans with CKD. These findings suggest that genetic variability might contribute to racial differences in urinary phosphorus excretion in CKD.

Mindfulness meditation lowers muscle sympathetic nerve activity and blood pressure in African-American males with chronic kidney disease.

Mindfulness meditation (MM) is a stress-reduction technique that may have real biological effects on hemodynamics but has never previously been tested in chronic kidney disease (CKD) patients. In addition, the mechanisms underlying the potential blood pressure (BP)-lowering effects of MM are unknown. We sought to determine whether MM acutely lowers BP in CKD patients, and whether these hemodynamic changes are mediated by a reduction in sympathetic nerve activity. In 15 hypertensive African-American (AA) males with CKD, we conducted a randomized, crossover study in which participants underwent 14 min of MM or 14 min of BP education (control intervention) during two separate random-order study visits. Muscle sympathetic nerve activity (MSNA), beat-to-beat arterial BP, heart rate (HR), and respiratory rate (RR) were continuously measured at baseline and during each intervention. A subset had a third study visit to undergo controlled breathing (CB) to determine whether a reduction in RR alone was sufficient in exacting hemodynamic changes. We observed a significantly greater reduction in systolic BP, diastolic BP, mean arterial pressure, and HR, as well as a significantly greater reduction in MSNA, during MM compared with the control intervention. Participants had a significantly lower RR during MM; however, in contrast to MM, CB alone did not reduce BP, HR, or MSNA. MM acutely lowers BP and HR in AA males with hypertensive CKD, and these hemodynamic effects may be mediated by a reduction in sympathetic nerve activity. RR is significantly lower during MM, but CB alone without concomitant meditation does not acutely alter hemodynamics or sympathetic activity in CKD.

Analgesic use, parents' clan, and coffee intake are three independent risk factors of chronic kidney disease in middle and elderly-aged population: a community-based study.

Chronic kidney disease (CKD) is a world-wide public health problem. The purpose of this study was to identify the role of some controversial potential risk factors in development of CKD. "Community Complex Health Screening" is a large-scale, free, health program for individuals ≥40 years of age that has been available since January 2002 in Chiayi County, Taiwan. A questionnaire was administered to study participants, collecting information on ethnicity, use of analgesics, and life habits. Age, sex, and blood biochemical analyses were considered as potential confounders. A high prevalence and low awareness of CKD were noted in this population. Females with CKD had a lower awareness of their illness than males. Analgesic users had a significantly lower estimated glomerular filtration rate (eGFR). Age (OR = 1.095), females (OR = 0.348), fasting plasma glucose (OR = 1.005), level of uric acid (UA) (OR = 1.517), and analgesic usage (OR = 1.512) remained independent predictors of CKD. Multivariate linear regression found that use of analgesics, father' clan from Fujian, mother' clan from Fujian, and coffee intake were independent determinants of renal outcome with coefficient of regression (ß) of -0.102, -0.192, 0.210 and 0.88, respectively. The prevalence of CKD decreased with advanced education. Further, there was no significant difference between education background and analgesics use. In conclusion, analgesic use, parents' clan, and coffee intake were independent risk factors for CKD in middle-aged and elderly Taiwanese. Thus, an effective educational program that increases the awareness of such individuals residing in rural counties is warranted.

Ethnic differences in 25-hydroxyvitamin D levels and response to treatment in CKD.

AIM: Nutritional vitamin D [25(OH)D] deficiency is common in patients with chronic kidney disease (CKD). No studies have specifically examined the differences between ethnic groups in response to ergocalciferol ("D2") therapy. METHODS: A retrospective analysis was performed to evaluate the effectiveness of D2 therapy as recommended by the KDOQI guidelines in 184 Hispanic and Caucasian nondialysis CKD patients. RESULTS: Low 25(OH)D levels (<75 nmol/L) were found in 89.4 % of Hispanics versus 61.4 % of Caucasians, despite similar degrees of CKD. Treatment per KDOQI guidelines resulted in 85.5 % of treated Hispanics and 66.7 % of treated Caucasians remaining vitamin D-deficient. Although both Hispanics and Caucasians had significant (P < 0.0001) changes in 25(OH)D levels, absolute changes were modest (12.5 ± 2.0 nmol/mL in Hispanics, 20.0 ± 3.5 nmol/L in Caucasians). The increase seen in Caucasians was significantly greater than in Hispanics (P < 0.0001). In multiple logistic regression modeling, Hispanic ethnicity remained independently associated with poorer response to therapy (P = 0.0055), even after adjustment for other factors. CONCLUSIONS: While both Hispanics and Caucasians demonstrated suboptimal response to the KDOQI-guided vitamin D repletion strategy, Hispanic ethnicity was significantly associated with poorer response. Our findings may have implications for other darker-skinned populations, even in solar-rich environments.

Contribution of calcium, phosphorus and 25-hydroxyvitamin D to the excessive severity of secondary hyperparathyroidism in African-Americans with CKD.

BACKGROUND: Parathyroid hormone (PTH) levels in African-American (AA) chronic kidney disease (CKD) patients exceed those in patients of other races; mechanisms are unknown. METHODS: We performed a cross-sectional analysis of initial laboratory data collected on 2028 CKD patients (505 AA) from US practices using a laboratory CKD service. Serum calcium (Ca), phosphorus (P), 25-hydroxyvitamin D (25-D) and plasma PTH levels were compared between the two groups. RESULTS: Mean PTH for AA exceeded PTH for non-AA in Stages 2-5 (P<0.001, all four stages). 25-D levels were higher for non-AA in Stages 1-3 (P<0.001). Serum Ca and P did not differ between groups at any stage. Full adjustment for these variables using multivariable generalized linear modeling did not remove the effect of AA race: AA PTH values exceeded non-AA values in CKD Stages 2-5 (P<0.02, all four stages). Serum Ca, P and 25-D were all inversely correlated with PTH levels irrespective of race, but all factors combined accounted for ∼42% of the variance in PTH. CONCLUSIONS: PTH rises with progressive CKD stage far more in AA than in non-AA patients, and only a moderate component of the rise in PTH is explained by changes in serum Ca, P and 25-D in either group. These findings concur with those from other large CKD cohorts and support the need for further study to determine other factors responsible for this racial difference.

A varying patient safety profile between black and nonblack adults with decreased estimated GFR.

BACKGROUND: Chronic kidney disease is a high-risk condition for a variety of adverse safety events, yet little is known about differential rates of safety events across racial groups with decreased kidney function. We sought to examine the incidence of an array of disease-specific adverse safety events in black versus nonblack patients with decreased estimated glomerular filtration rate (eGFR). STUDY DESIGN: Retrospective observational study of a national US Veterans Affairs cohort. SETTINGS & PARTICIPANTS: Veterans with eGFR <60 mL/min/1.73 m(2) and one or more hospitalization during federal fiscal year 2005 (n = 70,154). PREDICTOR: Self-reported race/ethnicity dichotomized as black or nonblack. OUTCOMES: Hospital discharge coding for Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs), laboratory records for detection of hyperkalemia and hypoglycemia, and pharmacy records to determine dosing of 4 selected medications. MEASUREMENTS: Relationship between race and disease-specific patient safety events. RESULTS: Black veterans were more likely than nonblack veterans to experience one type of safety event (33% vs 32%, respectively) and multiple types of safety events (32% vs 23%, respectively; both P < 0.001). After adjustment, black veterans were 11% and 36% more likely to have at least one episode of hyperkalemia and hypoglycemia, respectively, than nonblack veterans, but were 14% less likely to experience a medication error (all P < 0.001). There was no association between the occurrence of AHRQ PSIs and race after adjustment. LIMITATIONS: Use of administrative data has a risk of imprecision in coding; Veterans Affairs cohort may limit generalizability. CONCLUSIONS: Black veterans with decreased eGFR are more likely to experience a broad array of safety events than nonblacks with decreased eGFR, with a preponderance of metabolic disturbances rather than medication errors or AHRQ PSIs. The differential safety phenotype in blacks versus nonblacks may have implications for preventive strategies to improve patient safety in an integrated health care system.

Management of aboriginal and nonaboriginal people with chronic kidney disease in Quebec: quality-of-care indicators.

OBJECTIVE: To compare quality-of-care indicators for management of patients with chronic kidney disease (CKD) and type 2 diabetes among the James Bay Cree of Northern Quebec with those among residents of Montreal, Que. DESIGN: A cross-sectional survey using medical records from patients seen between 2002 and 2008. SETTING: Predialysis clinics of the McGill University Health Centre in Montreal. PARTICIPANTS: Thirty Cree and 51 nonaboriginal patients older than 18 years of age with type 2 diabetes mellitus and estimated glomerular filtration rates of less than 60 mL/min/1.73 m2. MAIN OUTCOME MEASURES: Rates of anemia, iron deficiency, obesity, and renoprotective medication use among aboriginal and nonaboriginal patients. RESULTS: Overall, the Cree patients were younger (59 vs 68 years of age, P < .0035) and weighed more (101 vs 77 kg,P < .001). The 2 groups were prescribed medication to control blood pressure, lipids, and phosphate levels at similar rates, but the Cree patients were more likely to receive renoprotective agents (87% vs 65%, P = .04). Despite similar rates of erythropoietin supplementation, the Cree patients were at greater risk of anemia, with an adjusted risk ratio of 2.80 (95% CI 1.01 to 7.87). CONCLUSION: Cree patients with CKD were younger, weighed more, and were more likely to receive renoprotective agents. With the exception of the management of anemia, quality of CKD care was similar between the 2 groups.Anemia education for family physicians and continuous monitoring of quality indicators must be implemented in northern Quebec.

Serum alkaline phosphatase and mortality in African Americans with chronic kidney disease.

BACKGROUND AND OBJECTIVES: Serum alkaline phosphatase has been associated with increased mortality in hemodialysis patients but its associations with mortality in chronic kidney disease (CKD) stages III and IV are unknown. Design, settings, participants & measurements: In 1094 participants in the African-American Study of Kidney Disease and Hypertension (AASK) database, the associations of serum alkaline phosphatase with mortality and cardiovascular events were examined in Cox models. RESULTS: The mean (+/-SD) age was 54 +/- 11 yr, and 61% were men. The median alkaline phosphatase was 80 IU/L, and interquartile range was 66 to 97 IU/L. The mean follow-up was 4.6 yr. There were 105 (9.6%) all-cause deaths and 149 (13.6%) cardiovascular events. Each doubling of serum alkaline phosphatase was significantly associated with increased hazard [hazard ratio (HR) 1.60, 95% confidence interval (CI) 1.08 -2.36] of all-cause mortality adjusted for demographics, drug and blood pressure groups, and comorbidity. With further adjustment for liver function tests as well as serum calcium and phosphorus, each doubling of serum alkaline phosphatase remained significantly associated with increased mortality (HR 1.55, 95% CI 1.03 to 2.33). Serum alkaline phosphatase was not significantly associated with increased risk of cardiovascular events. CONCLUSIONS: Independent of liver function tests and serum calcium and phosphorus, higher levels of serum alkaline phosphatase are associated with increased mortality in the CKD population. Further studies are warranted to identify the potential mechanisms for this association.