The effects of changing vitamin D levels on anemia in chronic kidney disease patients: a retrospective cohort review.

BACKGROUND: Investigate whether changes in vitamin D levels affected erythropoiesis stimulating agent (ESA) requirements in chronic kidney disease (CKD) patients with anemia. METHODS: A retrospective cohort study of nondialysis-dependent patients with CKD of all stages. Patients were anemic and on ESA with at least 2 documented 25-hydroxylated vitamin D (D25) levels drawn 4 months apart. Patients were grouped based on the change in their D25 levels. The primary end point evaluated was absolute change in the ESA doses needed to maintain target hemoglobin levels between 11 and 12 g/dl. RESULTS: A total of 153 patients met the inclusion criteria for analysis. With the exception of the normal-to-low D25 group, patients showed a trend toward lower ESA doses with time. The low-to-normal vitamin D group showed a significant reduction in dose of 24% (1,415 units, p = 0.025). The normal-to-low group, however, showed a 22% increase in dose of 1,270 units (NS). Levels of Ca, PTH, and iron indexes were similar across all groups. CONCLUSION: Our retrospective cohort study demonstrates an ESA sparing effect in patients with vitamin D deficiency after repletion to normal levels. Conversely, there was a trend toward increased ESA requirements in patients who became vitamin D deficient from a previously normal state.

Benefits of a multidisciplinary predialysis program in maintaining employment among patients on home dialysis.

We evaluated the benefits of a multidisciplinary predialysis intervention to help home dialysis patients maintain employment. This program was shown to be successful with in-center hemodialysis patients in a case-controlled study published in the American Journal of Kidney Disease in September, 1993. We looked at 30 patients on home dialysis (28 on continuous ambulatory peritoneal dialysis and 2 on home hemodialysis) as of March, 1995. The age of the patients ranged from 28 to 63 years, with a mean of 46.8 years. Forty-three percent of the patients were diabetic. The patients went through a multidisciplinary predialysis program which consisted of: (1) psychosocial assessment, (2) education about dialysis and choice of modalities, (3) orientation to dialysis unit, and (4) counseling sessions with patient, significant family members, and others. During this time, patients were referred to the program approximately six months before beginning dialysis. There was continued collaboration among members of the multidisciplinary team. Of the 30 patients, 11 were already disabled when beginning dialysis. Of the 19 who were working once dialysis began, 14 maintained employment (3 diabetic), with 1 retiring and 4 becoming disabled. Therefore, 74% of patients maintained employment. In conclusion, employment was maintained by this predialysis multidisciplinary program.

Increased risk of renal cell cancer among women using diuretics in the United States.

Use of prescription diuretics and incidence of renal cell cancer have increased in the United States in the past 25 years. Recent interview-based epidemiologic studies have reported an association between diuretic use and renal cell cancer risk. Our study evaluated this hypothesis using, for the first time, medical records as the source of the information on prescription diuretic use. Using medical records of women from a prepaid health plan, we identified 191 cases and 191 controls matched on age, membership duration, and membership at diagnosis. Diuretics use and history of potential confounding factors were ascertained by a standardized review of the medical records of each subject, without reference to case or control status. There was a strong and statistically significant association between renal cell cancer and prescription diuretics (odds ratio [OR] adjusted for hypertension, smoking, and obesity = 2.9, 95 percent confidence interval [CI] = 1.7-4.7). Risk tended to increase with dose, measured by number of prescriptions. Since renal cancer can induce hypertension, which is treated by diuretics, and thereby confound the association with diuretics, we examined diuretic use 10 or more years prior to diagnosis when secondary hypertension would be unlikely. The OR for prescriptions 10 or more years before diagnosis was 3.5 (CI = 1.7-7.4). Our results support earlier reports of an excess risk of renal cell cancer among users of prescription diuretics and indicate need for further study to evaluate this relationship, especially due to the extensive use of diuretics and the increasing incidence of this cancer.