Statins and Cardiovascular Disease Outcomes in Chronic Kidney Disease: Reaffirmation vs. Repudiation.

Cardiovascular disease (CVD) burden is several-fold higher in patients with chronic kidney disease (CKD). Although statins have been shown to provide significant CVD benefits in both the general population and patients with CKD, this has not translated into survival advantage in patients with advanced CKD or on dialysis. It has been reported that CVD risk continues to escalate as CKD progresses to end-stage kidney disease (ESKD); however, the CVD risk reduction by statins appears to decline as patients' progress from the early to later stages of CKD. Statins have also been associated with a higher incidence of stroke in ESKD patients. Thus, the CVD benefits of statins in ESKD remain questionable.

Iatrogenic hypernatremia in hemodialysis patients: A result of erroneous online conductivity monitor and conductivity meter reading.

Hyponatremia is common in chronic kidney disease and in end stage kidney disease (ESKD) but hypernatremia is infrequent in ESKD. The incidence of hypernatremia is higher in ambulatory peritoneal dialysis (PD) than in hemodialysis (HD) patients. In PD patients it is often a result of excessive ultrafiltration but in HD it is often a result of dialysate composition errors. Dialysate composition errors can inadvertently cause either hyponatremia or hypernatremia. We present two cases of symptomatic hypernatremia which manifested as increased thirst, excessive weight gain and worsening hypertension in HD patients. The hypernatremia was caused by a combination of errors in online conductivity reading and a faulty hand held conductivity meter. Symptoms were relieved in both patients after replacement of the dialysis machine.

Heart surgery in end-stage renal disease: is outcome worse for african american patients?

General results of open heart surgery in end-stage renal disease patients (ESRD) have been well-documented. However, it is unknown if the African American subgroup with known decreased access to advanced healthcare services and a higher prevalence rate of ESRD have a worse long-term survival after heart surgery. Thirty of 150 African American patients who underwent open heart surgery by a single surgeon at an urban community hospital between 1996 and 2010 were identified to have ESRD and were on chronic maintenance hemodialysis prior to surgery. Clinical and outcome data from both groups were retrospectively analyzed. There were no significant differences in the baseline demographic characteristics of the patients, but the ESRD cohort showed a significantly higher prevalence of peripheral vascular and cardiovascular diseases [P < 0.001]. Compared to the non-ESRD subjects, the predicted logistic EuroSCORE was 16.4% vs. 9.4%, [P < 0.001], while the observed 30 days operative mortality was 16.6% vs. 4.2% [P < 0.02], respectively. In isolated coronary artery bypass graft cases, operative mortality was 20.8% and 3.0%, respectively. The 5- and 10-year post-surgery survival was 40% and 25% vs. 72% and 57% [P < 0.01], respectively, in the ESRD and non-ESRD groups. Operative mortality and survival was worse in ESRD patients compared to non-ESRD patients based on their preoperative risk scores. Although the operative mortality of our ESRD patients was high, long-term survival was comparable to reports from both the United States Renal Data System and a Japanese ESRD cohort.

Relationship of missed and shortened hemodialysis treatments to hospitalization and mortality: observations from a US dialysis network.

BACKGROUND: The relationship of missed and shortened hemodialysis (HD) to clinical outcomes has not been well characterized in HD patients in the USA. Here we explored the frequency of missed and shortened treatments and their impact on mortality and hospitalization. METHODS: A retrospective review of data from a cohort of 15 340 HD patients treated in facilities operated by Dialysis Clinics, Inc. We compared the frequency of missed and shortened treatments by gender, race, age and treatment schedules [Mondays, Wednesdays, Fridays (MWF) versus Tuesdays, Thursdays, Saturdays (TTS)]. RESULTS: Of the 15 340 patients, 48% were non-Hispanic whites (NHWs), 41% African Americans (AAs), 6% Hispanics, 2% Native American (NA), 2% Asians and 1% other races. The median number of years on HD was 1.8 years and the median follow-up was 12.4 months. The odds of missing at least one treatment in a month were higher in: patients aged <55 years, odds ratio (OR) 1.33 (P<0.0001); in AAs, OR 1.51 (P < 0.0001); in NAs, OR 1.50 (P = 0.0003); and in Hispanics, OR 1.33 (P = 0.0003) compared with NHWs and in patients who dialyzed on TTS compared with MWF, OR 1.33 (P < 0.0001). Similar findings were observed for treatments shortened by at least 10 min per month. Missed and shortened treatments were most prevalent on Saturdays and were also associated with progressive increases in hospitalization and mortality. CONCLUSION: Missed and shortened HD treatments pose a challenge to providers. Improved adherence to prescribed dialysis may decrease the morbidity and mortality.

Chronic kidney disease, prevalence of premature cardiovascular disease, and relationship to short-term mortality.

BACKGROUND: Chronic kidney disease (CKD) is recognized as an independent cardiovascular disease (CVD) risk state, particularly in the elderly, and has been defined by levels of estimated glomerular filtration rate (eGFR) and markers of kidney damage. The relationship between CKD and CVD in younger and middle-aged adults has not been fully explored. METHODS: Community volunteers completed surveys regarding past medical events and underwent blood pressure and laboratory testing. Chronic kidney disease was defined as an eGFR <60 mL x min(-1) x 1.73 m(-2) or urine albumin-creatinine ratio (ACR) > or =30 mg/g. Premature CVD was defined as self-reported myocardial infarction or stroke at <55 years of age in men and <65 years of age in women. Mortality was ascertained by linkage to national data systems. RESULTS: Of 31 417 participants, the mean age was 45.1 +/- 11.2 years, 75.5% were female, 36.8% African American, and 21.6% had diabetes. A total of 20.6% were found to have CKD, with the ACR and eGFR being the dominant positive screening tests in the younger and older age deciles, respectively. The prevalences of premature myocardial infarction (MI), stroke, or death, and the composite were 5.3%, 4.7%, 0.8%, 9.2%, and 2.5%, 2.2%, 0.2%, 4.2% for those with and without CKD, respectively (P < .0001 for composite). Multivariable analysis found CKD (OR 1.44, 95% CI 1.27-1.63), age (OR 1.05 [per year], 95% CI 1.04-1.06), hypertension (OR 1.61, 95% CI 1.40-1.84), diabetes (OR 2.03, 95% CI 1.79-2.29), smoking (OR 1.91, 95% CI 1.66-2.21), and less than high school education (OR 1.59, 95% CI 1.37-1.85) as the most significantly associated factors for premature CVD or death (all P < .0001). Survival analysis found those with premature MI or stroke and CKD had the poorest short-term survival over the next 3 years after screening. CONCLUSIONS: Chronic kidney disease is an independent predictor of MI, stroke, and death among men and women younger than age 55 and 65 years, respectively. These data suggest the biologic changes that occur with kidney failure promote CVD at an accelerated rate that cannot be fully explained by conventional risk factors or older age. Screening for CKD by using both the ACR and eGFR can identify younger and middle-aged individuals at high risk for premature CVD and near-term death.

Dialysis "no-shows" on saturdays: implications of the weekly hemodialysis schedules on nonadherence and outcomes.

BACKGROUND: The prevalence of skipped hemodialysis or no-show is higher among African Americans, younger Sages, smokers and illicit drug users. The effect of the weekly hemodialysis treatment schedules (Mondays, Wednesdays, Fridays (MWF); or Tuesdays, Thursdays, Saturdays (TTS)] on adherence is unknown. METHODS: Our hemodialysis patients were prospectively monitored for compliance over a 12-month duration. Regression analyses were employed for associations between variables and outcomes. RESULTS: A total of 114 African-American patients-mean age 55 +/- 14 and 53% male--were surveyed. Compared to the MWF, the TTS patients had higher rates of no show (2.4% vs. 1.7%, p = NS); shortened hemodialysis time (30% vs. 26%, p = NS); cocaine use (18% vs. 8%, p = 0.09); higher interdialytic weight gain 14.3 +/- 1.8 kg vs. 3.4 +/-1.3 kg, p = 0.005); prolonged length of hospital stay (9 +/- 12 days vs. 4 +/- 5 days, p = 0.02); and higher mortality (16% vs. 8%, p = NS). Compared to other days of the week, the Saturday no-show rate was significantly higher: 31% vs. 13%, 15%, 16%, 17%, 8%, Monday through Friday, respectively. Length of hospital stay correlated with no show (R2 = 0.4, p < 0.0001), while early termination was associated with smoking, cocaine use, female gender, TTS schedule, low serum albumin, hematocrit and adequacy of dialysis (Kt/V) (R2 = 0.6, p = 0.009). CONCLUSIONS: The TTS-scheduled hemodialysis patients are less adherent, and have higher morbidity than the MWF Spatients and a predilection for skipping on Saturdays.

CKD and cardiovascular disease in screened high-risk volunteer and general populations: the Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES) 1999-2004.

BACKGROUND: Chronic kidney disease (CKD) is recognized as an independent cardiovascular disease risk state. The relationship between CKD and cardiovascular disease in volunteer and general populations has not been explored. METHODS: The National Kidney Foundation Kidney Early Evaluation Program (KEEP) is a community-based health-screening program to raise kidney disease awareness and detect CKD for early disease intervention in individuals 18 years or older with diabetes, hypertension, or family history of kidney disease, diabetes, or hypertension. KEEP volunteers completed surveys and underwent blood pressure and laboratory testing. Estimated glomerular filtration rate (eGFR) was computed, and urine albumin-creatinine ratio (ACR) was measured. In KEEP, CKD was defined as eGFR less than 60 mL/min/1.73 m(2) or ACR of 30 mg/g or greater. Cardiovascular disease was defined as self-reported myocardial infarction or stroke. Data were compared with National Health and Nutrition Examination Survey (NHANES) 1999-2004 data for prevalence of cardiovascular disease risk factors and cardiovascular outcomes. RESULTS: Of 69,244 KEEP participants, mean age was 53.4 +/- 15.7 years, 68.3% were women, 33.0% were African American, and 27.6% had diabetes. Of 17,061 NHANES participants, mean age was 45.1 +/- 0.27 years, 52% were women, 11.2% were African American, and 6.7% had diabetes. In KEEP, 26.8% had CKD, and in NHANES, 15.3%. ACR was the dominant positive screening test for younger age groups, and eGFR, for older age groups, for both populations. Prevalences of myocardial infarction or stroke were 16.5% in KEEP and 15.1% in NHANES (P < 0.001) and 7.8% in KEEP and 3.7% in NHANES (P < 0.001) for individuals with and without CKD, respectively. In adjusted analysis of both KEEP and NHANES data, CKD was associated with a significantly increased risk of prevalent myocardial infarction or stroke (odds ratio, 1.34; 95% confidence interval, 1.25 to 1.43; odds ratio, 1.37; 95% confidence interval, 1.10 to 1.70, respectively). In KEEP, short-term mortality was greater in individuals with CKD (1.52 versus 0.33 events/1,000 patient-years). CONCLUSIONS: CKD is independently associated with myocardial infarction or stroke in participants in a voluntary screening program and a randomly selected survey population. Heightened concerns regarding risks in volunteers yielded greater cardiovascular disease prevalence in KEEP, which was associated with increased short-term mortality.

Cardiorenal consideration as a risk factor for heart failure.

Cardiovascular disease-related factors are responsible for about 50% of the mortality in patients with both chronic kidney disease and end-stage renal disease. Therefore, it is not surprising that 30%-50% of patients with congestive heart failure also have an impaired glomerular filtration rate. This signifies a co-dependence between the kidneys and the heart. The role of anemia, microalbuminuria, calcium, and phosphorus imbalance in this cardiorenal interdependence is discussed in this article.

Ultralate referral and presentation for renal replacement therapy: socioeconomic implications.

BACKGROUND: Clinical and metabolic complications of late referral (LR) for dialysis therapy have been well documented, but there is a paucity of data on its socioeconomic implications. This study examines the role of lifestyle and socioeconomic status on referral pattern. METHODS: During a 4-year period (1999 to 2002), we retrospectively reviewed records of all patients who initiated dialysis therapy at an urban tertiary-care center. Patients were classified into 3 categories according to the interval between first contact with a nephrologist and initiation of dialysis therapy: contact time of 3 months or longer indicates early referral (ER); 1 to less than 3 months, LR; and less than 1 month, ultralate referral (ULR). RESULTS: Of 460 patients (97% African Americans, 3% Hispanics), 212 patients (46%) were ULR, 168 patients (37%) were LR, and 80 patients (17%) were ER. Compared with ER and LR patients, those with ULR had significantly (P < 0.0001) lower hematocrits (23% versus 29% and 27%), serum albumin levels (3.1 versus 3.3 and 3.2 g/dL [31 versus 33 and 32 g/L]), and glomerular filtration rates (5 versus 8 and 7 mL/min/1.73 m2 [0.08 versus 0.13 and 0.12 mL/s/1.73 m2]), but greater rates of temporary dialysis catheter use (92% versus 39% and 70%) and mortality (40% versus 15% and 26%, respectively). Logistic regression analysis showed an association between mortality and homelessness (odds ratio, 3.8; P < 0.0001), polysubstance abuse (odds ratio, 2.3; P = 0.013), and alcoholism (odds ratio, 2.2; P = 0.009). Alcoholics (odds ratio, 2.5; P = 0.03), substance abusers (odds ratio, 5.5; P = 0.001), and the homeless/unemployed (odds ratio, 6.0; P = 0.004) were more likely to present as ULR cases. Patient-provided explanations for LR and ULR were denial (45%), unawareness of the presence of chronic kidney disease (30%), and economic difficulties (25%). Denial was more prevalent in LR (52%; P = 0.003) and ULR cases (39%; P = 0.003). CONCLUSION: Poor socioeconomic status is a major contributor to delayed referral. More efforts need to be directed at patient and physician chronic kidney disease educational awareness and improved health care access for inner-city and minority populations.

Ability of troponin T to predict angiographic coronary artery disease in patients with chronic kidney disease.

Association between angiographic coronary artery disease and cardiac troponin T levels has been observed in patients with normal kidney function; however, this association remains unsettled in patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD). Over a 12-month period we retrospectively reviewed coronary angiograms (CAs) performed in 194 hospitalized patients with presumed acute myocardial injury. About 50% of the ESRD and 30% of the CKD patients had normal CAs. Troponin T levels significantly correlated with CAs in patients with normal kidney function (r = 0.4, p = 0.005) but not in ESRD and CKD patients (r = 0.2, p = NS, respectively).

Adequacy and survival of autogenous arteriovenous fistula in African American hemodialysis patients.

In African American hemodialysis patients, the prevalence of autogenous arteriovenous fistula (AVF) use is lower yet AVF complications are higher. However, the adequacy and survival rates of AVF in African American patients have not been clarified. These rates were evaluated in this study. A prospective surveillance of AVF was conducted at the Morehouse School of Medicine affiliated dialysis units. A database was generated to adequately document the dates of AVF creation, cannulation, and failure; anatomic fistula sites; and demographic and pertinent clinical information. A total of 167 AVF were created in 140 African American patients between 1997 and 2001. The mean age of the patients was 56 +/- 14 (21-83) years, and the mean duration of follow-up was 40 +/- 3 (1-200) weeks. Only 92 of 167 (55%) AVF were adequate for cannulation; 12% (20 of 167) failed to mature and 33% (55 of 167) developed early failure. Unassisted primary patency rates at 6 and 12 months were 85% and 61%, respectively. Both fistula adequacy and survival were greater in younger (aged < 65 years), male patients and in nondiabetic patients, but the differences were not significant. Logistic regression analysis showed that advanced age (> or = 65 years), female gender, and diabetic state did not significantly alter AVF adequacy. However, the presence of peripheral vascular disease adversely affected AVF adequacy [Odds Ratio 0.4 (confidence interval 0.2-1.0), p = 0.048]. The adequacy and survival rates of AVF in African Americans are comparable with those reported in other populations. Fistula adequacy and survival appear to be independent of ethnicity but dependent on individual comorbid conditions and the integrity of the vasculature. Discriminant AVF site selection and adequate preoperative assessment of the vasculature remain crucial to AVF survival.

Maintaining patency of tunneled hemodialysis catheters--efficacy of aspirin compared to warfarin.

OBJECTIVE: Tunneled hemodialysis catheters (caths) often fail as a result of luminal obstructive thrombus or formation of a fibrin sheath at the tip. Anecdotal and non-randomized studies have indicated that aspirin (A) and/or warfarin (W) can prolong cath patency. We examined the effect of chronic usage of either A or W on primary cath patency. MATERIAL AND METHODS: A prospective cross-sectional monitoring of cath patency was conducted over a 3-year period. Patients were grouped according to their long-term usage of either A (325 mg daily) or W. Patients on neither medication served as a control (C). The end point of the study occurred at cannulation of the patients' arteriovenous fistulae, when there was development of cath-related bacteremia or when there was inability to maintain a blood flow of 250 ml/min. RESULTS: Sixty-three patients with a mean age of 57 +/- 15 years completed the study. There were 21 patients in the A group, 11 in the W group and 31 in the C group. Cath survival was 91%, 73% and 29% at 120 days for the A, W and C groups, respectively (A vs C, p < 0.0001; W vs C, p < 0.0001; A vs W, p = NS). The mean durations of cath patency were 114 +/- 18, 111 +/- 17 and 68 +/- 37 days for the A, W and C groups, respectively (A vs C, p < 0.0001; W vs C, p < 0.0001; A vs W, p = NS). Gastrointestinal (GI) bleeding complication rates were 24%, 18% and 0% for the A, W and C groups, respectively (A vs C, p = 0.02; W vs C, p = 0.02; A vs W, p = NS). The relative risk of GI bleeding associated with aspirin was 0.71 [95% confidence interval (CI) 0.11-4.4, p = 0.7] but among elderly aspirin users it was 1.14 (CI 1.0-1.3, p = 0.008). CONCLUSION: Both aspirin and warfarin are equally effective at prolonging cath patency but their routine use for failing caths cannot be unequivocally recommended because of the increased risk of GI bleeding. Further prospective and randomized studies are called for.

Nephrotic proteinuria as a result of essential hypertension.

BACKGROUND: The presence of nephrotic-range proteinuria in a nondiabetic hypertensive patient is generally indicative of an underlying glomerular disease. A few published reports have noted nephrotic proteinuria in some patients with hypertensive nephrosclerosis. The frequency of this association is unknown. METHODS: We retrospectively reviewed renal biopsy reports on all cases of nephrotic syndrome over an 8-year period (1993-2000). We excluded all cases of diabetes mellitus, lupus, hepatitis, human immunodeficiency virus, and chronic use of nonsteroidal anti-inflammatory drugs. Biopsy specimens showing glomerular eosinophilic hyalinosis lesions, positive immunofluorescence staining, or dense deposits on electron microscopy were also excluded. Thirteen of the remaining 237 (5.5%) biopsy specimens satisfied the standard histological criteria for hypertensive nephrosclerosis. RESULTS: All patients were African-Americans with a mean age of 47.5 +/- 13 years and an average mean arterial blood pressure of 122 +/- 19 mm Hg. The mean values for urinary protein excretion, serum creatinine, albumin, and cholesterol were 8.9 g/day, 3.3 mg/dl, 3.1 g/dl, and 245 mg/dl, respectively. Optimal blood pressure control required at least three antihypertensive agents. Progression to end-stage renal disease occurred over a mean duration of 8.3 +/- 6.5 months. Multivariate regression showed a strong but nonsignificant association between the level of proteinuria at the time of biopsy, duration of hypertension, and number of blood pressure medications (R(2) = 0.56, p = 0.38). CONCLUSIONS: Nephrotic syndrome may be more common in poorly controlled essential hypertension than previously realized. In African-American patients, the differential diagnosis of nephrotic syndrome should include hypertensive nephrosclerosis, but abrogation of renal biopsy is not implied.

Kidney disease in elderly minorities.

As a result of altered kidney physiology, the aging kidney is at increased risk for both acute and chronic kidney injury. When coupled with the higher prevalence of such comorbid conditions as hypertension, diabetes and cardiovascular disease, it is not surprising that both the incidence and prevalence of chronic kidney disease, including end-stage renal disease (ESRD), increases with age. Although the increase in ESRD with age is observed for all races, it is disproportionately high among ethnic minority populations. The reasons for this are varied and numerous, and a complex interplay of environmental, socioeconomic, cultural, and possibly genetic factors, may be involved. It is clear, therefore, that kidney disease in the elderly ethnic minority population is a cause for specific concern and that targeted strategies are needed to improve disease management and treatment outcomes in this high-risk group of patients.

Acute renal failure mortality in hospitalized African Americans: age and gender considerations.

The aging kidney is at risk for both toxic and hemodynamic-induced acute damage, resulting in a high incidence of acute renal failure (ARF) in elderly patients. The effect of age and or gender in ARF mortality in African Americans (AA) was studied in a 3-year, computer assisted retrospective review. In an inner city medical center, 100 patients classified as ARF at discharge or expiration were included in the study. Patients were classified into 3 age categories: <40, 40-64, and >64 years. The incidence of ARF was 35%, 28% and 37%, respectively. Patients >64 years of age were less likely to be dialyzed. Both pre- and postrenal causes of ARF were more common in patients >64 years of age than in younger patients. Hospital length of stay increased progressively with age. Mortality was lower in patients >64 years of age than in younger patients. The incidence of ARF was higher in male than female patients and the incidence of sepsis was higher in female than male patients. Dialytic need was greater in male patients, but mortality was higher in female than male patients. Multivariate logistic regression showed that in the presence of sepsis, oliguria and mechanical ventilatory support, the relative risk of mortality associated with advanced age was 16.5, the relative risk of mortality associated with female gender was 0.2. In summary, hospitalized elderly African-American patients have a high incidence of ARF, and patients less than 40 years of age are equally at risk. Although mortality was higher in female patients, gender and advanced age did not independently contribute to high mortality. Neither age nor gender considerations should supplant sound clinical judgment in the management of and decision making in elderly African-American patients with ARF.