Heart Failure Hospitalization Risk associated with Iron Status in Veterans with CKD.

BACKGROUND AND OBJECTIVES: CKD is an independent risk factor for heart failure. Iron dysmetabolism potentially contributes to heart failure, but this relationship has not been well characterized in CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We performed a historical cohort study using data from the Veterans Affairs Corporate Data Warehouse to evaluate the relationship between iron status and heart failure hospitalization. We identified a CKD cohort with at least one set of iron indices between 2006 and 2015. The first available date of serum iron indices was identified as the study index date. The cohort was divided into four iron groups on the basis of the joint quartiles of serum transferrin saturation (shown in percent) and ferritin (shown in nanograms per milliliter): reference (16%-28%, 55-205 ng/ml), low iron (0.4%-16%, 0.9-55 ng/ml), high iron (28%-99.5%, 205-4941 ng/ml), and function iron deficiency (0.8%-16%, 109-2783 ng/ml). We compared 1-year heart failure hospitalization risk between the iron groups using matching weights derived from multinomial propensity score models and Poisson rate-based regression. RESULTS: A total of 78,551 veterans met the eligibility criteria. The covariates were well balanced among the iron groups after applying the propensity score weights (n=31,819). One-year adjusted relative rate for heart failure hospitalization in the iron deficiency groups were higher compared with the reference group (low iron: 1.29 [95% confidence interval, 1.19 to 1.41]; functional iron deficiency: 1.25 [95% confidence interval, 1.13 to 1.37]). The high-iron group was associated with lower 1-year relative rate of heart failure hospitalization (0.82; 95% confidence interval, 0.72 to 0.92). Furthermore, the association between iron deficiency and heart failure hospitalization risk remained consistent regardless of the diabetes status or heart failure history at baseline. CONCLUSIONS: Iron deficiency, regardless of cause, was associated with higher heart failure hospitalization risk in CKD. Higher iron status was associated with lower heart failure hospitalization risks.

Peri-implantation intercourse does not lower fecundability.

STUDY QUESTION: Does sexual intercourse in the implantation time window (5-9 days after ovulation) reduce fecundability? SUMMARY ANSWER: After adjustment for intercourse in the fecund window and clustering by couple, there was no association between intercourse in the implantation time window and fecundity. WHAT IS KNOWN ALREADY: Previous research has suggested an association between intercourse in the peri-implantation time window (5-9 days after estimated ovulation) and reduced fecundability. STUDY DESIGN, SIZE, DURATION: We used data from the FERTILI study, a prospective observational study conducted in five European countries, with data collected from 1992 to 1996. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women who were experienced in fertility awareness tracking kept a daily diary of cervical mucus observations, basal body temperature measurements, coitus and clinically identified pregnancy. We estimated the day of ovulation as cycle length minus 13 days. From 661 women, 2606 cycles had intercourse during the fecund window (from 5 days before to 3 days after the estimated day of ovulation), resulting in 418 pregnancies (conception cycles). An established Bayesian fecundability model was used to estimate the fecundability ratio (FR) of peri-implantation intercourse on fecundability, while adjusting for each partner's age, prior pregnancy, the couple's probability of conception and intercourse pattern(s). We conducted sensitivity analyses estimating ovulation as cycle length minus 12 days, or alternatively, as the peak day of estrogenic cervical mucus. MAIN RESULTS AND THE ROLE OF CHANCE: There was no effect of peri-implantation intercourse on fecundability: adjusted FR for three or more acts of peri-implantation intercourse versus none: 1.00, 95% credible interval: 0.76-1.13. Results were essentially the same with sensitivity analyses. There was an inverse relationship between frequency of intercourse in the fecund window and intercourse in the peri-implantation window. LIMITATIONS, REASONS FOR CAUTION: Women with known subfertility were excluded from this study. Many couples in the study were avoiding pregnancy during much of the study, so 61% of otherwise eligible cycles in the database were not at meaningful risk of pregnancy and did not contribute to the analysis. Some couples may not have recorded all intercourse. WIDER IMPLICATIONS OF THE FINDINGS: We believe the current balance of evidence does not support a recommendation for avoiding intercourse in the peri-implantation period among couples trying to conceive. STUDY FUNDING/COMPETING INTEREST(S): No external funding. The authors have no potential competing interests. TRIAL REGISTRATION NUMBER: N/A.

Real-world management of hyperkalemia with patiromer among United States Veterans.

Objective: Patiromer is a sodium-free, non-absorbed, potassium (K+) binder approved for the treatment of hyperkalemia (HK). Among US Veterans with HK, this retrospective, observational cohort study evaluated patiromer utilization, RAASi continuation, and K+ concentration change following patiromer initiation.Methods: Using data from the Veterans Affairs Corporate Data Warehouse, Veterans with HK (K+ ≥5.1 mmol/L) were included upon patiromer initiation (index date) during the study period (1/2016-8/2018). All patients had heart failure (HF), diabetes, or chronic kidney disease (CKD). Patients with end-stage renal disease were excluded. The following outcomes were assessed within 6-months post-patiromer initiation: patiromer utilization (using proportion of days covered); K+ concentration change (pre- vs post-initiation); and RAASi continuation.Results: 288 Veterans with HK were included. Baseline characteristics were: median age 70 years, African-American race 24%, diabetes 83%, HF 32%, CKD 95%, and median K+ concentration 5.7 mmol/L. At 1, 3, and 6 months post-index, the median patiromer PDC was 100%, 66%, and 44%, respectively. K+ concentration reductions post-patiromer initiation were, on average, - 1.0 mmol/L (P < 0.001). At 3-6 months, 71% of patiromer initiators had K+ <5.1 mmol/L and 95% had K+ <5.5 mmol/L. RAASi therapy was continued in >80%-90% of patiromer-treated patients.Conclusions: The real-world utilization results suggest patiromer is used for the chronic management of HK. Clinically relevant K+ concentration reductions were observed at all study time points. The successful management of HK may have contributed to the observed high rate of RAASi therapy continuation. Further research is warranted to corroborate and extend these findings.

Validation of Algorithms Used to Identify Red Blood Cell Transfusion Related Admissions in Veteran Patients with End Stage Renal Disease.

BACKGROUND: The goal of this study was to compare the performance of several database algorithms designed to identify red blood cell (RBC) Transfusion Related hospital Admissions (TRAs) in Veterans with end stage renal disease (ESRD). METHODS: Hospitalizations in Veterans with ESRD and evidence of dialysis between 01/01/2008 and 12/31/2013 were screened for TRAs using a clinical algorithm (CA) and four variations of claims-based algorithms (CBA 1-4). Criteria were implemented to exclude patients with non-ESRD-related anemia (e.g., injury, surgery, bleeding, medications known to produce anemia). Diagnostic performance of each algorithm was delineated based on two clinical representations of a TRA: RBC transfusion required to treat ESRD-related anemia on admission regardless of the reason for admission (labeled as TRA) and hospitalization for the primary purpose of treating ESRD-related anemia (labeled TRA-Primary). The performance of all algorithms was determined by comparing each to a reference standard established by medical records review. Population-level estimates of classification agreement statistics were calculated for each algorithm using inverse probability weights and bootstrapping procedures. Due to the low prevalence of TRAs, the geometric mean was considered the primary measure of algorithm performance. RESULTS: After application of exclusion criteria, the study consisted of 12,388 Veterans with 26,672 admissions. The CA had a geometric mean of 90.8% (95% Confidence Interval: 81.8, 95.6) and 94.7% (95% CI: 80.5, 98.7) for TRA and TRA-Primary, respectively. The geometric mean for the CBAs ranged from 60.3% (95% CI: 53.2, 66.9) to 91.8% (95% CI: 86.9, 95) for TRA, and from 80.7% (95% CI: 72.9, 86.7) to 96.7% (95% CI: 94.1, 98.2) for TRA-Primary. The adjusted proportions of admissions classified as TRAs was 3.2% (95% CI: 2.8, 3.8) and TRA-Primary was 1.3% (95% CI: 1.1, 1.7). CONCLUSIONS: The CA and select CBAs were able to identify TRAs and TRA-primary with high levels of accuracy and can be used to examine anemia management practices in ESRD patients.

An increased mortality risk is associated with abnormal iron status in diabetic and non-diabetic Veterans with predialysis chronic kidney disease.

Iron parameters have not been well characterized in pre-dialysis patients with chronic kidney disease (CKD), and it remains unclear if abnormal iron balance is associated with increased mortality. Therefore, we performed a historical cohort study using data from the Veterans Affairs Corporate Data Warehouse to evaluate the relationship between iron status and mortality. We identified a pre-dialysis CKD cohort with at least one set of iron indices between 2006-2015. The cohort was divided into four iron groups based on the joint quartiles of serum transferrin saturation (percent) and ferritin concentration (ng/ml): reference (16-28%, 55-205 ng/ml), low iron (0.4-16%, 0.4-55 ng/ml), high iron (28-99.6%, 205-4941 ng/ml), and function iron deficiency (0.8-16%, 109-2783 ng/ml). We compared mortality risk between the iron groups using matching weights based on multinomial propensity score models and Poisson rate-based regression. We also evaluated if the association between iron groups and mortality differs between the diabetic and non-diabetic subgroups. Of the 80,067 eligible veterans, 32,489 were successfully matched. During the mean follow-up period of 4.0 years, adjusted relative rate (95% confidence interval) for all-cause mortality in three abnormal iron groups were increased compared to the reference: functional iron deficiency [1.21 (1.17, 1.25)], low iron [1.10 (1.07, 1.14)], and high iron [1.09 (1.06, 1.13)]. The mortality risk was similar between diabetic and non-diabetic subgroups for each iron group. Thus, an abnormal iron balance, particularly functional iron deficiency, is associated with increased mortality in CKD.

Using Attitudes, Age and Gender to Estimate an Adolescent's Substance Use Risk.

PURPOSE: The purpose of this paper is to present a strategy for estimating an individual's risk of alcohol, cigarette and cannabis use that relies on an assessment of an adolescent's age, gender and attitude. METHODOLOGY: The authors assembled surveys from 35,987 11 through 17 year-olds assembled from 36 databases were analysed to examine the relationship between attitude and behaviour. FINDINGS: Attitudes were strongly correlated with concurrent use of alcohol, drunkenness, smoking, and cannabis, with point biserial correlations of -0.555, -0.517, -0.552 and -0.476, respectively. Logistic regression provided a means for using age, gender and attitudes to estimate an individual's risk of engaging in substance use behaviour. Developmental changes in attitudes were estimated by analysing changes in scores associated with percentile rankings for each age and gender group. Projected year-to-year changes in attitude were used as a heuristic for estimating future risk. RESEARCH LIMITATIONS: Analyses relied on cross-sectional panel data. Analyses would benefit from longitudinal data in which age-related changes in attitudes could be more precisely modelled. PRACTICAL IMPLICATIONS: Information about estimated current and future risk may use useful for motivating the adoption and implementation of effective prevention approaches by parents and care providers. ORIGINALITY: The authors present a novel method for estimating an individual's risk of substance use knowing attitude, age and gender.