Warfarin in nonvalvular atrial fibrillation-Time for a change?

Warfarin is the most commonly prescribed anticoagulant in hemodialysis (HD) patients with nonvalvular atrial fibrillation (NVAF). Recent trends show that Nephrologists are increasingly prescribing novel oral anticoagulants, despite the fact that no randomized clinical trials have been conducted in dialysis patients. Difficulties maintaining international normalized ratio in the therapeutic range, increased risk of intracranial hemorrhage and concerns regarding warfarin-induced vascular calcification and calciphylaxis may be responsible. Anticoagulation quality is poor in HD patients. A variety of factors contribute to this: increased antibiotic exposure; comorbid illness; decreased adherence and vitamin K deficiency. Attempts to address this with standardized protocols have been uniformly unsuccessful. In nonadherent patients, thrice weekly observed therapy improved quality. Low-dose vitamin K supplementation improves time in the therapeutic range (TTR) in those with normal kidney function and should be studied in HD patients given their high frequency of vitamin K deficiency. Vascular and valvular calcification associated with warfarin could result from reduced carboxylation of matrix Gla protein (MGP), a well-known inhibitor of vascular calcification. Multiple observational studies also link calciphylaxis to warfarin; warfarin-induced hypercoagulability and decreased carboxylation of MGP could explain this. A large observational study, two meta-analyses, and a systematic review in HD patients with NVAF showed reduced bleeding with apixaban compared to warfarin with similar efficacy in reducing stroke and systemic embolism. Given these results, apixaban is a reasonable alternative to warfarin for anticoagulation of HD patients with NVAF, especially in those with low TTR, until data from randomized clinical trials become available.

Clinical Pharmacology of Oral Anticoagulants in Patients with Kidney Disease.

Oral anticoagulants are commonly used drugs in patients with CKD and patients with ESKD to treat atrial fibrillation to reduce stroke and systemic embolism. Some of these drugs are used to treat or prevent deep venous thrombosis and pulmonary embolism in patients with CKD who undergo knee and hip replacement surgeries. Warfarin is the only anticoagulant that is approved for use by the Food and Drug Administration in individuals with mechanical heart valves. Each oral anticoagulant affects the coagulation profile in the laboratory uniquely. Warfarin and apixaban are the only anticoagulants that are Food and Drug Administration approved for use in patients with CKD and patients with ESKD. However, other oral anticoagulants are commonly used off label in this patient population. Given the acquired risk of bleeding from uremia, these drugs are known to cause increased bleeding events, hospitalization, and overall morbidity. Each anticoagulant has unique pharmacologic properties of which nephrologists need to be aware to optimally manage patients. In addition, nephrologists are increasingly asked to aid in the management of adverse bleeding events related to oral anticoagulant use in patients with CKD and patients with ESKD. This article summarizes the clinical pharmacology of these drugs and identifies knowledge gaps in the literature related to their use.

Hungry bone syndrome.

PURPOSE OF REVIEW: In the United States, the number of parathyroidectomies among patients with chronic dialysis has remained stable in the last decade. A fall in serum calcium concentration is common postparathyroidectomy in patients with hyperparathyroidism, which usually resolves in 2-4 days. A severe drop in serum total calcium concentration less than 2.1 mmol/L and/or prolonged hypocalcemia for more than 4 days postparathyroidectomy is called hungry bone syndrome (HBS). Concomitant hypophosphatemia, hypomagnesemia, and hyperkalemia can be seen. Hypocalcemia and hypophosphatemia can persist for months to years. In contemporary clinical practice, HBS may be more commonly seen in patients with secondary compared to primary hyperparathyroidism. Preoperative radiological changes in bone, elevated serum alkaline phosphatase and parathyroid hormone (PTH) levels, and high numbers of osteoclasts on bone biopsy may identify patients at risk. Treatment consists of high-dose oral calcium and calcitriol supplementation. A low-dose pamidronate infusion 1-2 days prior to surgery may prevent HBS. RECENT FINDINGS: Recent in-vitro studies reported net calcium movement into bone because of a sudden fall in serum PTH level after a prolonged period of elevation. This supports a previous hypothesis that a sudden drop in serum PTH level after surgery results in the unopposed action of osteoblasts and influx of calcium into bone. SUMMARY: Incidence of HBS and its association with morbidity and mortality remains unclear in contemporary clinical practice. It is more common to encounter HBS in chronic dialysis patients with secondary hyperparathyroidism than those with primary hyperparathyroidism that undergo parathyroidectomies. Use of bisphosphonates to prevent HBS should be explored in future studies.

We Use Too Much Vitamin D in Hemodialysis Patients.

Current Kidney Disease Improving Global Outcomes guidelines for chronic kidney disease-mineral and bone disorder recommend maintaining the PTH level between 2 and 9 times the upper limit of normal. PTH levels function as a surrogate for bone turnover to differentiate forms of renal osteodystrophy. Vitamin D receptor agonists are primarily used to treat osteitis fibrosa in hemodialysis patients. However, there is concern that overtreatment may put HD patients at risk for adynamic bone disease, which has been associated with fracture and vascular calcification. This raises the issue as to whether "we use too much vitamin D in hemodialysis patients."

Oral P2Y12 Receptor Inhibitors in Hemodialysis Patients Undergoing Percutaneous Coronary Interventions: Current Knowledge and Future Directions.

Oral P2Y12 receptor inhibitors are commonly used drugs in patients on hemodialysis (HD) to treat acute coronary syndrome with or without percutaneous coronary intervention (PCI), and patients with stable coronary artery disease after PCI. Clopidogrel is the most commonly prescribed P2Y12 receptor inhibitor because it is effective in the general population and is not as costly as newer FDA-approved agents (prasugrel, ticagrelor). However, increasing evidence is accumulating that clopidogrel may not be as effective in reducing mortality and preventing future ischemic events in patients with kidney disease. In this review, we will explore some of the studies that form the basis for this statement and discuss potential pharmacokinetic and pharmacodynamic reasons why clopidogrel might be less effective in HD patients, as well as explore potential risks and benefits of alternatives to clopidogrel therapy.

Medical and surgical care during the American Civil War, 1861-1865.

This review describes medical and surgical care during the American Civil War. This era is often referred to in a negative way as the Middle Ages of medicine in the United States. Many misconceptions exist regarding the quality of care during the war. It is commonly believed that surgery was often done without anesthesia, that many unnecessary amputations were done, and that care was not state of the art for the times. None of these assertions is true. Physicians were practicing in an era before the germ theory of disease was established, before sterile technique and antisepsis were known, with very few effective medications, and often operating 48 to 72 hours with no sleep. Each side was woefully unprepared, in all aspects, for the extent of the war and misjudged the degree to which each would fight for their cause. Despite this, many medical advances and discoveries occurred as a result of the work of dedicated physicians on both sides of the conflict.

BP and Renal Outcomes in Diabetic Kidney Disease: The Veterans Affairs Nephropathy in Diabetes Trial.

BACKGROUND AND OBJECTIVES: Proteinuric diabetic kidney disease frequently progresses to ESRD. Control of BP delays progression, but the optimal BP to improve outcomes remains unclear. The objective of this analysis was to evaluate the relationship between BP and renal outcomes in proteinuric diabetic kidney disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: BP data from all 1448 randomized participants in the Veterans Affairs Nephropathy in Diabetes Trial were included in a post hoc analysis. The associations of mean on-treatment BP with the primary end point (decline in eGFR, ESRD, or death), renal end point (decline in eGFR or ESRD), rate of eGFR decline, and mortality were measured. RESULTS: The median (25th, 75th percentile) follow-up time was 2.2 (1.2, 3.0) years. There were 284 primary end points. In univariate analyses, both mean systolic and mean diastolic BPs were strongly associated (P<0.001) with the primary end point. After multivariate adjustment, the hazard of developing the primary end point became progressively higher as mean systolic BP rose from <120 to ≥ 150 mmHg (P=0.02), with a significantly higher hazard ratio for 140-149 versus 120-129 mmHg (1.51 [1.06, 2.15]; P=0.02). There was also a significant association of mean diastolic BP with the hazard of developing the primary end point (P<0.01), with a significantly higher hazard ratio when mean diastolic BP was 80-89 versus 70-79 mmHg (1.54 [1.05, 2.25]; P=0.03); there was also a strong trend when mean diastolic BP was <60 mmHg. Associations between BP and both renal end point and rate of eGFR decline were similar to those with the primary end point. No association of BP with mortality was observed, possibly because of the limited number of mortality events. CONCLUSIONS: In patients with proteinuric diabetic kidney disease, mean systolic BP ≥ 140 mmHg and mean diastolic BP ≥ 80 mmHg were associated with worse renal outcomes.

Hypokalemia Associated with Colonic Pseudo-Obstruction (Ogilvie's Syndrome).

We report a case of hypokalemia resulting from colonic pseudo-obstruction or Ogilvie's syndrome. Colonic pseudo-obstruction is characterized by profuse watery diarrhea that has a low sodium and high potassium concentration. It is seen in a variety of medical and surgical conditions, but its exact cause remains unknown. It is thought to result from an imbalance of sympathetic and parasympathetic input in the distal colon. The diarrhea is secretory and driven by potassium secretion rather than the inhibition of sodium reabsorption or chloride secretion, which are the most common pathophysiologic mechanisms of secretory diarrhea. Affected patients often lose >100 mmol of potassium daily. Colonic pseudo-obstruction is associated with a dramatic upregulation of the maxiK or BK potassium channel. This channel plays a prominent role in flow-mediated potassium secretion in the connecting tubule and collecting duct and is also upregulated in the distal colon in patients with advanced chronic kidney disease and end-stage renal disease. In vitro studies show that the channel is regulated by catecholamine binding to the ß receptor and cyclic AMP upregulation, somatostatin and aldosterone, insights that can be used to help guide pharmacologic therapy. Nephrologists should be aware of colonic pseudo-obstruction as a cause of extrarenal potassium loss.

Effects of dietary interventions on incidence and progression of CKD.

Traditional strategies for management of patients with chronic kidney disease (CKD) have not resulted in any change in the growing prevalence of CKD worldwide. A historic belief that eating healthily might ameliorate kidney disease still holds credibility in the 21(st) century. Dietary sodium restriction to <2.3 g daily, a diet rich in fruits and vegetables and increased water consumption corresponding to a urine output of 3-4 l daily might slow the progression of early CKD, polycystic kidney disease or recurrent kidney stones. Current evidence suggests that a reduction in dietary net acid load could be beneficial in patients with CKD, but the supremacy of any particular diet has yet to be established. More trials of dietary interventions are needed, especially in diabetic nephropathy, before evidence-based recommendations can be made. In the meantime, nephrologists should discuss healthy dietary habits with their patients and provide individualized care aimed at maximizing the potential benefits of dietary intervention, reducing the incidence of CKD and delaying its progression to end-stage renal disease. Keeping in mind the lack of data on hard outcomes, dietary recommendations should take into account barriers to adherence and be tailored to different cultures, ethnicities and geographical locations.

Attending rounds: A patient with intradialytic hypotension.

Intradialytic hypotension is the most common adverse event that occurs during the hemodialysis procedure. Despite advances in machine technology, it remains a difficult management issue. The pathophysiology of intradialytic hypotension and measures to reduce its frequency are discussed. An accurate assessment of dry weight is crucial in all patients on dialysis and especially those patients prone to intradialytic hypotension. The presence of edema and hypertension has recently been shown to be a poor predictor of volume overload. Noninvasive methods to assess volume status, such as whole body and segmental bioimpedance, hold promise to more accurately assess fluid status. Reducing salt intake is key to limiting interdialytic weight gain. A common problem is that patients are often told to restrict fluid but not salt intake. Lowering the dialysate temperature, prohibiting food ingestion during hemodialysis, and midodrine administration are beneficial. Sodium modeling in the absence of ultrafiltration modeling should be abandoned. There is not enough data on the efficacy of l-carnitine to warrant its routine use.

Combined angiotensin inhibition for the treatment of diabetic nephropathy.

BACKGROUND: Combination therapy with angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) decreases proteinuria; however, its safety and effect on the progression of kidney disease are uncertain. Methods We provided losartan (at a dose of 100 mg per day) to patients with type 2 diabetes, a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 300, and an estimated glomerular filtration rate (GFR) of 30.0 to 89.9 ml per minute per 1.73 m(2) of body-surface area and then randomly assigned them to receive lisinopril (at a dose of 10 to 40 mg per day) or placebo. The primary end point was the first occurrence of a change in the estimated GFR (a decline of ≥ 30 ml per minute per 1.73 m(2) if the initial estimated GFR was ≥ 60 ml per minute per 1.73 m(2) or a decline of ≥ 50% if the initial estimated GFR was <60 ml per minute per 1.73 m(2)), end-stage renal disease (ESRD), or death. The secondary renal end point was the first occurrence of a decline in the estimated GFR or ESRD. Safety outcomes included mortality, hyperkalemia, and acute kidney injury. Results The study was stopped early owing to safety concerns. Among 1448 randomly assigned patients with a median follow-up of 2.2 years, there were 152 primary end-point events in the monotherapy group and 132 in the combination-therapy group (hazard ratio with combination therapy, 0.88; 95% confidence interval [CI], 0.70 to 1.12; P=0.30). A trend toward a benefit from combination therapy with respect to the secondary end point (hazard ratio, 0.78; 95% CI, 0.58 to 1.05; P=0.10) decreased with time (P=0.02 for nonproportionality). There was no benefit with respect to mortality (hazard ratio for death, 1.04; 95% CI, 0.73 to 1.49; P=0.75) or cardiovascular events. Combination therapy increased the risk of hyperkalemia (6.3 events per 100 person-years, vs. 2.6 events per 100 person-years with monotherapy; P<0.001) and acute kidney injury (12.2 vs. 6.7 events per 100 person-years, P<0.001). Conclusions Combination therapy with an ACE inhibitor and an ARB was associated with an increased risk of adverse events among patients with diabetic nephropathy. (Funded by the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development; VA NEPHRON-D ClinicalTrials.gov number, NCT00555217.).

Antiplatelet therapy in the management of cardiovascular disease in patients with CKD: what is the evidence?

Antiplatelet agents (APAs) are proven to reduce risk of major cardiovascular events in patients with cardiovascular disease and normal kidney function. With recent post hoc analyses of large trials questioning the safety and efficacy of APAs in CKD, major gaps exist in our understanding of platelet aggregability and the effects of APAs on thrombosis and bleeding in CKD. Clinical practice guidelines are ambiguous about use of such agents in CKD patients, because patients with moderate to advanced CKD were systematically excluded from clinical trials of APAs. CKD patients experience excessive rates of cardiovascular thrombotic events, yet paradoxically are at higher risk for major bleeding while receiving APAs. Furthermore, observational studies suggest that CKD patients may exhibit poor response to APAs. High residual platelet aggregability, as determined by inhibition of platelet aggregation, is associated with increased risk for cardiovascular events. In addition, metabolism of certain APAs may be altered in CKD patients. It is, therefore, imperative to explore the mechanisms responsible for poor response to APAs in CKD patients in order to use these drugs more safely and effectively. This review identifies the knowledge gaps and future trials needed to address those issues with the use of APAs in CKD patients.

Pilot trial of cryoplasty or conventional balloon post-dilation of nitinol stents for revascularization of peripheral arterial segments: the COBRA trial.

OBJECTIVES: The purpose of this study is to compare post-dilation strategies of nitinol self-expanding stents implanted in the superficial femoral artery of diabetic patients with peripheral arterial disease. BACKGROUND: Endovascular treatment of superficial femoral artery disease with nitinol self-expanding stents is associated with high rates of in-stent restenosis in patients with diabetes mellitus. METHODS: We conducted a prospective, multicenter, randomized, controlled clinical trial of diabetic patients to investigate whether post-dilation of superficial femoral artery nitinol self-expanding stents using a cryoplasty balloon reduces restenosis compared to a conventional balloon. Inclusion criteria included diabetes mellitus, symptomatic peripheral arterial disease, and superficial femoral artery lesions requiring implantation of stents>5 mm in diameter and >60 mm in length. Primary endpoint was binary restenosis at 12 months, defined as ≥2.5-fold increase in peak systolic velocity by duplex ultrasonography. RESULTS: Seventy-four patients, with 90 stented superficial femoral artery lesions, were randomly assigned to post-dilation using cryoplasty (n=45 lesions) or conventional balloons (n=45 lesions). Mean lesion length was 148±98 mm, mean stented length was 190±116 mm, mean stent diameter was 6.1±0.4 mm, and 50% of the lesions were total occlusions. Post-dilation balloon diameters were 5.23±0.51 mm versus 5.51±0.72 mm in the cryoplasty and conventional balloon angioplasty groups, respectively (p=0.02). At 12 months, binary restenosis was significantly lower in the cryoplasty group (29.3% vs. 55.8%, p=0.01; odds ratio: 0.36, 95% confidence interval: 0.15 to 0.89). CONCLUSIONS: Among diabetic patients undergoing implantation of nitinol self-expanding stents in the superficial femoral artery, post-dilation with cryoplasty balloon reduced binary restenosis compared to conventional balloon angioplasty. (Study Comparing Two Methods of Expanding Stents Placed in Legs of Diabetics With Peripheral Vascular Disease [COBRA]; NCT00827853).

Predictors of hyperkalemia and death in patients with cardiac and renal disease.

Predictors of hyperkalemia in patients with cardiovascular disease (CVD; defined as patients with hypertension and heart failure) and associated chronic kidney disease (CKD) are not well established. The aim of this study was to ascertain risk factors of hyperkalemia (defined as serum potassium concentration >5.0 mEq/L) and associated all-cause mortality in patients with CVD treated with antihypertensive drugs that impair potassium homeostasis. In a retrospective analysis using a logistic regression model, risk factors for hyperkalemia and all-cause mortality were analyzed in 15,803 patients with CVD treated with antihypertensive drugs. The mean estimated glomerular filtration rate and mean serum potassium concentration were 55.55 ml/min/1.73 m(2) and 4.06 mEq/L, respectively. Hyperkalemia was observed in 24.5% of study patients and 1.7% of total hospital admissions. Compared to patients with normokalemia, those with hyperkalemia had a higher percentage of death (6.25% vs 2.92%, p = 0.0001) and admissions (7.80% vs 5.04%, p = 0.0001). Predictors of hyperkalemia were CKD stage (odds ratio [OR] 2.14, 95% confidence interval [CI] 2.02 to 2.28), diabetes mellitus (OR 1.59, 95% CI 1.47 to 1.72), coronary artery disease (OR 1.32, 95% CI 1.21 to 1.43), and peripheral vascular disease (OR 1.55, 95% CI 1.36 to 1.77). Predictors of all-cause mortality were CKD stage (OR 1.26, 95% CI 1.12 to 1.43), hyperkalemic event (OR 1.56, 95% CI 1.30 to 1.88), age (OR 1.04, 95% CI 1.03 to 1.05), and hospitalization (OR 1.04, 95% CI 1.04 to 1.05). In conclusion, hyperkalemia is encountered frequently in patients with established CVD who are taking antihypertensive drugs and is associated with increases in all-cause mortality and hospitalizations. Advanced CKD, diabetes mellitus, coronary artery disease, and peripheral vascular disease are independent predictors of hyperkalemia.

Association of urinary sodium/potassium ratio with blood pressure: sex and racial differences.

BACKGROUND AND OBJECTIVES: Previous studies reporting an association between high BP and high sodium and low potassium intake or urinary sodium/potassium ratio (U[Na(+)]/[K(+)]) primarily included white men and did not control for cardiovascular risk factors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This cross-sectional study investigated the association of U[Na(+)]/[K(+)] with BP in 3303 participants using robust linear regression. RESULTS: Mean age was 43±10 years, 56% of participants were women, and 52% were African American. BP was higher in African Americans than in non-African Americans, 131/81±20/11 versus 120/76±16/9 mmHg (P<0.001). Mean U[Na(+)]/[K(+)] was 4.4±3.0 in African Americans and 4.1±2.5 in non-African Americans (P=0.002), with medians (interquartile ranges) of 3.7 (3.2) and 3.6 (2.8). Systolic BP increased by 1.6 mmHg (95% confidence interval, 1.0, 2.2) and diastolic BP by 1.0 mmHg (95% confidence interval, 0.6, 1.4) for each 3-unit increase in U[Na(+)]/[K(+)] (P<0.001 for both). This association remained significant after adjusting for diabetes mellitus, smoking, body mass index, total cholesterol, GFR, and urine albumin/creatinine ratio. There was no interaction between African-American race and U[Na(+)]/[K(+)], but for any given value of U[Na(+)]/[K(+)], both systolic BP and diastolic BP were higher in African Americans than in non-African Americans. The diastolic BP increase was higher in men than in women per 3-unit increase in U[Na(+)]/[K(+)] (1.6 versus 0.9 mmHg, interaction P=0.03). CONCLUSIONS: Dietary Na(+) excess and K(+) deficiency may play an important role in the pathogenesis of hypertension independent of cardiovascular risk factors. This association may be more pronounced in men than in women.

Cost approach of health care entity intangible asset valuation.

In the valuation synthesis and conclusion process, the analyst should consider the following question: Does the selected valuation approach(es) and method(s) accomplish the analyst's assignment? Also, does the selected valuation approach and method actually quantify the desired objective of the intangible asset analysis? The analyst should also consider if the selected valuation approach and method analyzes the appropriate bundle of legal rights. The analyst should consider if there were sufficient empirical data available to perform the selected valuation approach and method. The valuation synthesis should consider if there were sufficient data available to make the analyst comfortable with the value conclusion. The valuation analyst should consider if the selected approach and method will be understandable to the intended audience. In the valuation synthesis and conclusion, the analyst should also consider which approaches and methods deserve the greatest consideration with respect to the intangible asset's RUL. The intangible asset RUL is a consideration of each valuation approach. In the income approach, the RUL may affect the projection period for the intangible asset income subject to either yield capitalization or direct capitalization. In the cost approach, the RUL may affect the total amount of obsolescence, if any, from the estimate cost measure (that is, the intangible reproduction cost new or replacement cost new). In the market approach, the RUL may effect the selection, rejection, and/or adjustment of the comparable or guideline intangible asset sale and license transactional data. The experienced valuation analyst will use professional judgment to weight the various value indications to conclude a final intangible asset value, based on: The analyst's confidence in the quantity and quality of available data; The analyst's level of due diligence performed on that data; The relevance of the valuation method to the intangible asset life cycle stage and degree of marketability; and The degree of variation in the range of value indications. Valuation analysts value health care intangible assets for a number of reasons. In addition to regulatory compliance reasons, these reasons include various transaction, taxation, financing, litigation, accounting, bankruptcy, and planning purposes. The valuation analyst should consider all generally accepted intangible asset valuation approaches, methods, and procedures. Many valuation analysts are more familiar with market approach and income approach valuation methods. However, there are numerous instances when cost approach valuation methods are also applicable to the health care intangible asset valuation. This discussion summarized the analyst's procedures and considerations with regard to the cost approach. The cost approach is often applicable to the valuation of intangible assets in the health care industry. However, the cost approach is only applicable if the valuation analyst (1) appropriately considers all of the cost components and (2) appropriately identifies and quantifies all obsolescence allowances. Regardless of the health care intangible asset or the reason for the valuation, the analyst should be familiar with all generally accepted valuation approaches and methods. And, the valuation analyst should have a clear, convincing, and cogent rationale for (1) accepting each approach and method applied and (2) rejecting each approach and method not applied. That way, the valuation analyst will best achieve the purpose and objective of the health care intangible asset valuation.

Reasons to value the health care intangible asset valuation.

There are numerous individual reasons to conduct a health care intangible asset valuation. This discussion summarized many of these reasons and considered the common categories of these individual reasons. Understanding the reason for the intangible asset analysis is an important prerequisite to conducting the valuation, both for the analyst and the health care owner/operator. This is because an intangible asset valuation may not be the type of analysis that the owner/operator really needs. Rather, the owner/operator may really need an economic damages measurement, a license royalty rate analysis, an intercompany transfer price study, a commercialization potential evaluation, or some other type of intangible asset analysis. In addition, a clear definition of the reason for the valuation will allow the analyst to understand if (1) any specific analytical guidelines, procedures, or regulations apply and (2) any specific reporting requirement applies. For example, intangible asset valuations prepared for fair value accounting purposes should meet specific ASC 820 fair value accounting guidance. Intangible asset valuations performed for intercompany transfer price tax purposes should comply with the guidance provided in the Section 482 regulations. Likewise, intangible asset valuations prepared for Section 170 charitable contribution purposes should comply with specific reporting requirements. The individual reasons for the health care intangible asset valuation may influence the standard of value applied, the valuation date selected, the valuation approaches and methods applied, the form and format of valuation report prepared, and even the type of professional employed to perform the valuation.

Considering the health care entity C corporation conversion to tax pass-through entity status.

The double taxation of C corporation income from operations and from the ultimate sale of its assets makes the C corporation an inefficient tax status for many health care entities. At the time of this writing, the changes in the federal tax law that are scheduled to take effect in 2013 will increase this level of double-taxation inefficiency. The owners of a C corporation practice can avoid the C corporation status tax inefficiency by converting the practice to either (1) S corporation status or (2) LLC status. The conversion of the health care C corporation to an S corporation may be accomplished without a current tax cost. However, the conversion of a health care C corporation to an LLC status can result in a current tax at both the corporation level and the shareholder level. Nonetheless, the current conversion tax cost may be less than the future tax cost (1) of operating the practice as a C corporation and incurring double taxation at what may be higher tax rates or (2) of incurring the higher tax cost (or reduced price) on the ultimate disposition of the practice assets and the attendant double taxation of the appreciation in the value of the practice assets. Since individual income tax rates on qualifying dividends from C corporations and on capital gains are currently at very low rates, this may be a good time for C corporation practice owners to consider the costs and benefits of a conversion to either S corporation status or LLC status. The practice owners should consult with their accounting, legal, and valuation advisors in order to consider all of the costs and benefits of a possible corporate tax status conversion. An estimation of both the costs and benefits of the corporate tax status conversion depends on the concluded fair market values of the medical practice, dental practice, or other health care entity assets. And, that practice asset appraisal should encompass all of the practice assets, both tangible assets and intangible assets.