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Clinical Care

Clinical Care

Clinical Care

Among 6272 people diagnosed with hyperparathyroidism between 1995 and 2010, there were 56 hip fractures per 1000 people after 10 years among those not treated for hyperparathyroidism. Among those who had parathyroid surgery, there were just 20 fractures per 1000 people. Surprisingly, the hip fracture rate was highest among those taking bisphosphonates, at 86 fractures per 1000 patients. Similar results were seen for bone fractures of all types. People taking medications had a higher fracture risk even though X-rays showed that they had similar gains in bone density as surgery patients, according to the Annals of Internal Medicine study.

A new American Heart Association scientific statement notes that compared with men, women with type 2 diabetes have heart attacks at earlier ages; are more likely to die after a first heart attack; are less likely to undergo procedures to open clogged arteries; are less likely to be on cholesterol lowering drugs, take aspirin, or use blood pressure-lowering medications; are less likely to have their blood sugar or blood pressure under control; and develop type 2 diabetes based on sex-specific differences, such as gestational diabetes and polycystic ovary syndrome. The statement is published in Circulation.

In a retrospective study of the relationship between neutrophils and surgery-related AKI in CKD patients with hypertension, the incidence of AKI increased 1.6-fold for patients with neutrophil counts ≥6.30 × 109/L, and there was a positive linear association between the neutrophil count upon admission and AKI probability. There were no interactions between neutrophil counts and age, sex, eGFR, systolic or diastolic BP, presence of chronic heart failure, or sepsis, but higher neutrophil counts were associated with a heightened risk of AKI in the presence of diabetes. In the Medicine study, 119 of 998 patients experienced surgery-related AKI during hospitalization.

In a recent study of dialysis patients in Japan, warfarin use was not associated with an increased risk of all-cause mortality or a composite outcome of all-cause mortality, stroke, cardiovascular disease, and peripheral arterial disease. Increasing age, however, was associated with an increased risk of these outcomes. The Clinical and Experimental Nephrology study included 365 warfarin users and 692 non-users from 111 hemodialysis centers who were followed for an average of 27.7 months.

Among patients with high-risk IgA nephropathy, adding immunosuppressive therapy to intensive supportive care did not significantly improve outcomes. Also, more patients receiving immunosuppressive therapy had severe infections, impaired glucose tolerance, and weight gain of >5 kg in the first year of treatment. There was no significant difference in the annual decline in eGFR between groups. For the New England Journal of Medicine study, 162 patients who had persistent proteinuria with urinary protein excretion of ≥0.75 g per day were randomized to 3 years of supportive care alone or supportive care plus immunosuppressive therapy.

Research Advances

In a study of patients who underwent coronary artery bypass grafting (CABG) surgery, poor preoperative kidney function was strongly associated with elevated costs related to the surgery. As creatinine clearance decreased from 80 mL/min to 60 mL/min, 40 mL/min, and 20 mL/min, predicted total costs increased by 10%, 20%, and 30%, respectively. Worsening kidney function also was related to a longer length of hospital stay and an increased likelihood of needing dialysis or dying after surgery. The Annals of Thoracic Surgery study included 46,577 isolated CABG operations.

Diabetes may elevate the prevalence of hyperkalemia in patients with CKD stage 3, a new study found. The study included 180 type 2 diabetics and 180 non-diabetic patients with CKD. In patients with CKD stage 3, 28.6% of diabetics experienced hyperkalemia vs. 17.5% of non-diabetics. No difference was noted among patients with CKD stage 2; in CKD stage 4 hyperkalemia was equally high in both groups (35.5% vs. 32.3%). CKD stage 4 and use of ACE inhibitors were associated with 4.5-fold and 2.2-fold increased risks of hyperkalemia, respectively. The findings are published in the American Journal of Nephrology.

In an analysis of all chronic hemodialysis patients of China Medical University Hospital in 2014, the median abdominal aortic calcification score was 9 in patients with loss of residual renal function (RRF) vs. 5 in patients who maintained RRF. Loss of RRF was associated with higher abdominal aortic calcification scores independent of patients' age, diabetes, C-reactive protein, calcium-phosphorus product, and vintage of dialysis. The Therapeutic Apheresis and Dialysis study included 438 chronic hemodialysis patients with an average age of 63 years.

New research indicates that people with diabetes who suffer from diabetic foot (a severe but preventable condition characterized by non-healing foot ulcers and necrosis) may have significantly impaired cognitive function. The study found that those with diabetic foot remember less, have decreased concentration, difficulty with learning, decreased inhibition, slower cognitive and psychomotor responses, and decreased verbal fluency compared with diabetics without foot complications. The findings were presented at the American Diabetes Association’s Scientific Sessions.

A study that assessed National Health and Nutrition Examination Survey (NHANES) trends from 1971 to 2012 found that US adults with diabetes lose about twice as many teeth as adults without diabetes. Although overall tooth loss generally declined over the study period, diabetics still were more commonly affected. The authors of the Preventing Chronic Disease study also found that black Americans with diabetes were at a greater risk of tooth loss than white and Mexican Americans with diabetes. The authors suggest this may be due, in part, to poorer oral health–related behaviors and advocate for promotion of better dental self-care.

Bench to Bedside

Among older men who were not taking other antihypertensive agents, α-blocker therapy was associated with an increased risk of ischemic stroke during the early initiation period. Men who were not taking other blood pressure (BP) drugs had a twofold increased risk of ischemic stroke within 21 days after starting treatment than men who initiated α-blocker therapy later. Men already taking other BP medications had no increased risk of stroke. The CMAJ study included 7502 Taiwanese men aged ≥50 years as of 2007 who were incident users of α-blockers and had a diagnosis of ischemic stroke from 2007 to 2009.

Two sleep apnea treatments—continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs)—each reduced both systolic and diastolic BP in a recent review and meta-analysis of randomized clinical trials. Compared with an inactive control, CPAP was associated with a reduction in systolic BP of 2.5 mm Hg and a reduction of 2.0 mm Hg in diastolic BP. MADs were associated with a reduction in systolic BP of 2.1 mm Hg and 1.9 mm Hg in diastolic BP. The JAMA review included 51 studies and 4888 patients.

Researchers have found that urinary levels of epidermal growth factor (EGF), a protein involved in kidney tissue repair, is a marker of CKD progression. The investigators discovered the marker after analyzing the gene expression profiles of kidney biopsies from 261 patients with CKD from across 3 continents. The mRNA levels of EGF in the kidney, mirrored by the amount of EGF secreted in urine, tightly correlated with eGFR. These findings were replicated in about 600 additional patients. The Science Translational Medicine results suggest that EGF may be a useful biomarker of CKD progression that can be tracked without requiring invasive biopsies.

In a review and meta-analysis of studies on the use of statins for the reversion of coronary atherosclerotic plaques, rosuvastatin administration reduced the total atheroma volume and percent atheroma volume to a greater extent than atorvastatin, and it correlated with a greater improvement in lumen volume. There was no difference in the comparative regression of plaques across subgroups. The American Journal of Cardiology analysis included 5 randomized trials, with a total of 1556 participants, of whom 772 received rosuvastatin and 784 received atorvastatin.

In a meta-analysis that included 17 randomized controlled trials, antimicrobial-containing and citrate-alone lock solutions were superior to heparin for preventing catheter-related bacteremia in patients undergoing hemodialysis with central venous catheters. Antimicrobial-containing lock solutions significantly affected clinical sepsis but not exit-site infection, bleeding, or all-cause mortality. Catheter malfunction episodes were less frequent in patients receiving antibiotics + heparin and gentamicin + citrate, while other antimicrobial-containing and citrate-alone lock solutions showed no difference. Only citrate-alone lock solutions significantly decreased bleeding and exit-site infections. The results are published in International Urology and Nephrology.

Policy

The FDA has mandated additional warnings to sodium-glucose cotransporter-2 (SGLT2) inhibitor labeling to include the risks of ketoacidosis and serious urinary tract infections (UTIs). The FDA notes a review of the FDA Adverse Event Reporting System database from March 2013 to May 2015 identified 73 cases of ketoacidosis in patients with diabetes treated with SGLT2 inhibitors. There were also 19 cases of life-threatening blood infections and kidney infections that started as UTIs with the SGLT2 inhibitors reported from March 2013 through October 2014. 

In New York City, any menu item at chain restaurants containing ≥2300 mg sodium (the daily limit many nutritionists recommend and which equals about 1 tsp salt) must now display the emblem of a salt shaker in a black triangle. The measure that was approved by the New York City Board of Health applies to restaurants with at least 15 establishments across the US. Food service establishments that are part of a chain and must follow the new rule include restaurants, cafeterias, mobile food vendors, and temporary food vendors.

Wales is now the first UK country to introduce a presumed consent “opt-out” system of organ donation. Starting today, individuals who have not registered a decision to opt-in or opt-out of organ donation will be treated as having no objection to being organ donors. This change, called deemed consent, is part of the Human Transplantation (Wales) Act 2013.

A US Government Accountability Office report notes that 11% of dialysis patients received home dialysis in 2012. The report states that Medicare's payment policy likely gives facilities financial incentives to provide home dialysis, but facilities also have incentives in the short term to increase provision of hemodialysis in facilities. (For example, facilities may be able to add in-center patients without paying for additional dialysis machines.) Also, Medicare payment policies may constrain physicians' prescribing of home dialysis, and while Medicare pays for predialysis education—the Kidney Disease Education benefit—<2% of eligible patients received the benefit in 2010 and 2011.

In its finalized 2016 payment rules, Medicare has announced that it will pay doctors for consultations with patients on how they would like to be cared for when they are near death. Starting on January 1st, Medicare will pay $86 for the first 30 minutes of advance care planning in a doctor’s office and $80 for the service in a hospital. It will pay up to $75 for 30 additional minutes of consultation. Discussions can take place before patients become ill, after they receive a diagnosis of cancer or other serious illness, or while they are receiving hospice or palliative care.

Other

Raymond C. Harris, MD, FASN, will become the next ASN President at the conclusion of ASN Kidney Week 2015 in San Diego, CA. Dr. Harris is a Professor and Chief of the Division of Nephrology and Hypertension at Vanderbilt University School of Medicine. “2016 will be a pivotal year for ASN and nephrology as the society celebrates its 50th anniversary,” said Dr. Harris.

The ASN Foundation for Kidney Research has announced that the Ben J. Lipps Research Fellowship Program has been fully endowed. The Program funds 10 new and 10 continuing fellowships annually, and recipients receive $100,000 over two years to conduct original, meritorious research projects. With the most recent contribution from the Polycystic Kidney Disease (PKD) Foundation, the Program can guarantee research funding for nephrology fellows in perpetuity.

A new Canadian guideline recommends anticoagulants for all patients with iliofemoral deep vein thrombosis (DVT), but the recommended type and length of treatment vary.

An international panel has published guidelines on the use of peripherally inserted central catheters (PICCs) across patient populations. PICC use was rated as inappropriate for peripherally compatible infusions when the proposed duration was ≤5 days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days in the guidelines, which are published in the Annals of Internal Medicine.

Investigators supported by the American College of Rheumatology and the European League against Rheumatism recently developed new classification criteria for gout. The researchers conducted a systematic literature review regarding advanced imaging for gout, conducted a study in which the gold standard to identify gout was presence of monosodium urate crystals, and used a decision analysis approach to generate criteria encompassing multiple domains of clinical, laboratory, and imaging parameters to guide classification of gout.

Archive

Eating a 28 g serving of yogurt every day was associated with an 18% lower risk of developing type 2 diabetes in a meta-analysis of 14 prospective cohorts with 459,790 participants and 35,863 incident type 2 diabetes cases. Other dairy foods and consumption of total dairy were not appreciably associated with diabetes incidence.

Implementing interventions to optimize patients’ readiness for surgery was associated with reduced risk of mortality and morbidity, shorter intubation times, and shorter hospital stays for urgent patients after coronary artery bypass graft surgery.

The development of midlife diabetes was linked with a 19% greater cognitive decline over 20 years compared to no diabetes in an analysis of the community-based ARIC (Atherosclerosis Risk in Communities) study. Study participants with poorly controlled diabetes experienced cognitive decline approximately 5 years sooner than healthy individuals of the same age. Also, longer-duration diabetes was associated with greater late-life cognitive decline.