Determining the association between the type of intervention for ischaemic heart disease and mortality and morbidity in patients with chronic kidney disease.

BACKGROUND: Association between chronic kidney disease (CKD) and ischaemic heart disease (IHD) is well known. Clinically, because of the use of intra-arterial contrast, coronary angiograms are sometimes not performed to avoid further deterioration in kidney function among CKD patients. AIMS: To identify whether intervention for non-ST elevation myocardial infarction (NSTEMI) is associated with increased mortality or further renal deterioration. METHODS: A retrospective observational cohort study involving 144 patients with a diagnosis of IHD in the CKD.QLD registry from May 2011 to August 2017, with a minimum of 2-years follow up, was undertaken. Patients were divided into two groups based on whether they obtained an interventional or medical management for NSTEMI. RESULTS: Fifty-nine patients had medically managed and 85 patients had intervention for IHD. Patients in the medically managed group were observed to be significantly older (median: 78 vs 69 years; P < 0.05) with worse baseline renal function (median: 31 vs 36 mL/min/1.73 m2 ; P <0.05) and higher serum urate level (median: 0.5 vs 0.4 mmol/L; P = 0.2). The interventional group had lower prevalence of diabetes, dyslipidaemia, cerebrovascular disease and peripheral vascular disease. Although this was not significant, Kaplan-Meier analysis revealed a significant decrease in mean survival of medically managed group compared with the interventional group. Furthermore, post adjustment for age and above comorbidities, the medically managed group and higher age were associated with significantly higher mortality. However, the patients in the medically managed and interventional groups had no significant difference in delta estimated glomerular filtration rate. CONCLUSIONS: In this observational study, intervention for IHD was associated with increased survival with no change in renal disease progression in comparison with medically managed patients.

Impact of cardiovascular events on mortality and progression of renal dysfunction in a Queensland CKD cohort.

AIM: Cardiovascular events (CVE) are common co-morbidities amongst patients with chronic kidney disease (CKD). The impact of CVE on the subsequent pattern and rate of deterioration of kidney function is not well described. METHODS: A retrospective cohort study of 1123 Royal Brisbane and Women's Hospital patients enrolled in the CKD.QLD registry from May 2011 to August 2017 was undertaken. Participants CVE data and renal function (eGFR CKD-EPI) were extracted from clinical records. Participants who ultimately started kidney replacement therapy (KRT) were imputed an eGFR of 8 mL/min/1.73 m2 at the date of the first KRT treatment. Annualized percentage delta eGFR was used to explore the association between CVE and rate of renal deterioration. Mortality was ascertained through electronic health records. RESULTS: There were 235 CVE events amongst 222 participants over a period of 6 years. One hundred and forty-four participants experienced ischaemic heart disease (IHD), 51 participants had stroke, 40 participants had peripheral vascular disease (PVD) and 13 participants had more than one event. CVE were associated with significantly shorter time to death in participants who experienced one CVE compared with those without a CVE (1901.2 days vs 2259 days [P < .05]). However, there was no significant change in the absolute mean delta eGFR between participants with CVE and without CVE after adjustment for age (3.8 mL/min/1.73 m2 vs 3.8 mL/min/1.73 m2 [P = .9]). Furthermore, there was no significant difference in the progression to KRT in participants with CVE compared with participants without CVE (1315 days and 1052 days (P = .46). CONCLUSION: Cardiovascular events are associated with increased mortality in the CKD cohort. They were not associated with accelerated deterioration of kidney function.

Adalimumab-induced IgA nephropathy.

Immunoglobulin A nephropathy (IgAN) is the most commonly diagnosed glomerulonephritis worldwide. It is usually idiopathic and may be associated with many other diseases. Recently, biological agents including tumour necrosis factor alpha (TNFα) inhibitors have been identified as a potential cause for IgAN. We report the case of a 39-year-old woman who presented with renal dysfunction and visible haematuria. She had a background of Crohn's disease (CD) and had been on adalimumab for 4 years following a right hemicolectomy. Subsequently, she underwent a renal biopsy that demonstrated IgAN and adalimumab was ceased. Following a flare in her CD, she was commenced on infliximab, which led to remission of the IgAN and CD. This is the first case to demonstrate the occurrence of IgAN as a complication of a TNFα inhibitor (adalimumab) that remained in remission despite the commencement of a second TNFα inhibitor (infliximab).

Prevalence of comorbidities and management of gout in a tropical city in Australia.

To examine the management of gout in general practice in Townsville, Australia, and to explore comorbid conditions in patients with gout. Study will also explore how closely guidelines are being followed in managing gout. Retrospective chart review was conducted from May to November 2014 in three general practices in Townsville. Registers for patients were established by searching "gout" and "gouty arthritis". Three hundred and twenty-one patients were included in the study after excluding inactive patients, patients below age of 18 and patients with cancer. Main outcome measures were prevalence of comorbidities in gout patients, gout medications and adequate serum urate control (≤0.36 mmol/l). Multivariate logistic regression was used to study the relationship between serum urate level, comorbid conditions and lifestyle factors. Hypertension was the most common comorbid condition with 60.8 % of patients followed by obesity and dyslipidaemia. In terms of medication, 46.7 % of patients were on allopurinol, 12.8 % on indomethacin and 13.4 % on diuretics. Eighty-six percentage of patients had serum urate level (sUA) recorded in the previous year. Of these, 32.2 % had a serum urate level below or equal to 0.36 mmol/l. Moreover, 17.4 % of patients had lifestyle advice documented in chart. Male gender was the most influential factor in having poor uric acid control (p < 0.01), followed by not being on allopurinol (p < 0.01) and patients older than 50 years (p = 0.02). Management of gout in this study sample was not entirely concordant with guidelines. The study also suggests a need for possible tighter monitoring and allopurinol dosing regime in older, male patients.

General practitioners' perspectives on the management of gout: a qualitative study.

BACKGROUND: Many quantitative studies globally have identified suboptimal management of gout. PURPOSE: To explore management of gout from the perspective of general practitioners (GPs), while identifying the barriers and possible strategies for improvement. STUDY DESIGN: This descriptive qualitative study used semistructured interviews with 14 purposely selected GPs from four separate general practices in Townsville. The questions focused on management strategies, practicalities in managing gout, barriers and possible strategies to improve management. RESULTS: Indomethacin was commonly reported to be used in acute gout with progression to allopurinol after the acute stage had subsided. There were differences with the initial allopurinol dose and follow-up periods. GPs reported lack of patient adherence to allopurinol and lifestyle modifications, mainly due to lack of education. Most suggested the need for allied health input and improved patient education. CONCLUSIONS: Tailor-made plan in terms of education and lifestyle advice could help adherence to gout management.

Management of gout in general practice--a systematic review.

This systematic review aims to summarise published evidence that assessed the management of gout in regard to the following: prescription of urate lowering therapy (ULT), monitoring of serum urate levels (sUA) and allopurinol dosing in patients with renal impairment, lifestyle advice and acute management of gout. Studies investigating the management of gout in general practice (GP) were identified by searching PubMed and Scopus databases. To be eligible for inclusion, studies had to be focused on the GP setting alone. Studies were also excluded if they examined diagnosis without exploring management of gout. Editorials and reviews were excluded. A total of nine studies were identified. Eight studies explored the proportion of gout patients currently on ULT. Six out of the eight studies revealed that ULT was prescribed in less than 50 % of gout patients. Four studies considered the monitoring of sUA levels in gout patients. The results were generally similar throughout studies indicating sub-optimal management. Only two studies examined the monitoring of sUA levels specifically in patients who were prescribed ULT. The two studies showed 28 and 38 % of patients on ULT had their sUA levels monitored. Two studies examined the dosing of allopurinol in renally impaired patients and revealed that 74-78 % of renally impaired patients had an appropriate allopurinol dose of less than 300 mg. This systematic review suggests that gout is sub-optimally managed in general practice. However, more studies with a larger sample size focusing on active patients are required to provide more definitive evidence.