Worsening Kidney Function Associated With Significantly Higher Medical Costs

MedicalResearch.com Interview with:

Shaum Kabadi</strong> HEOR Director at AstraZeneca

Shaum Kabadi

Shaum Kabadi
HEOR Director at AstraZeneca

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: More than 20 million adults – roughly 1 in 10 adults – in the US are estimated to have chronic kidney disease (CKD), and this population is expected to grow as the US population ages. Patients with CKD are at high risk for progression to end-stage renal disease (ESRD), a condition requiring dialysis or kidney transplantation to maintain patients’ long-term survival. The cost of treating ESRD patients was over $40 billion in public and private funds in 2009. Prior research shows per-person annual Medicare expenses attributable to CKD were $1,700 for Stage 2, $3,500 for Stage 3, and $12,700 for Stage 4. Additional research is required to understand the economic burden of CKD by stage in a contemporary cohort of commercially insured patients with non-dialysis-dependent (NDD)-CKD.

This retrospective cohort study utilized data from the HealthCore Integrated Research Environment, which contained medical and pharmacy administrative claims integrated with laboratory result values from 14 regionally dispersed Anthem health plans in the US.

Of 16,030 patients identified with CKD, the mean (SD) estimated glomerular filtration rate (eGFR) (all in mL/min/1.73 m2) in 2014 was 44.3 (±18.7), and the breakdown by eGFR levels was: Stage 1 (≥90) 3%, Stage 2 (60–89) 13%, Stage 3a (45–59) 27%, Stage 3b (30–44) 35%, Stage 4 (15–29) 19%, and Stage 5 (<15) 3%. Mean age across all stages was 67.4 years, and 47% were women. Hospitalization rate (%) and number of outpatient encounters (visits per patient per year) by stage were: Stage 1 (11.6%, 19.8), Stage 2 (14.9%, 22.5), Stage 3a (16.2%, 23.6), Stage 3b (23.7%, 29.5), Stage 4 (30.7%, 36.3), and Stage 5 (30.8%, 61.7) (p-trend).

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Chronic Kidney Disease Still Highly Prevalent in Hypertensive Patients

MedicalResearch.com Interview with:
Tanushree Banerjee, M.S., M.Phil., Ph.D.
Research Specialist,
Department of General Internal Medicine,
San Francisco General Hospital,
University of California, San Francisco,

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Prevalence of chronic kidney disease (CKD) has increased among adults with diagnosed hypertension (HTN), undiagnosed HTN and pre-hypertension as compared to normotension. However, whether CKD prevalence has changed across each of these groups is unknown.

The prevalence of CKD decreased over time among persons with diagnosed, undiagnosed, and pre-hypertension while there was not any change in normotensives.

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How Do Patients With Compromised Kidney Function Do After TAVR?

MedicalResearch.com Interview with:

Nirat Beohar, MD Vice-Chief of Cardiology Director Cardiac Catheterization Laboratory Director Structural Heart Disease Program Director Interventional Cardiology Fellowship program Cardiac Catheterization Laboratory Columbia University Division of Cardiology, Mount Sinai Medical Center Miami Beach, Miami, FL 33140

Dr. Beohar

Nirat Beohar, MD
Vice-Chief of Cardiology
Director Cardiac Catheterization Laboratory
Director Structural Heart Disease Program
Director Interventional Cardiology Fellowship program
Cardiac Catheterization Laboratory
Columbia University Division of Cardiology,
Mount Sinai Medical Center
Miami Beach, Miami, FL 33140

MedicalResearch.com: What is the background for this study?

Response: Nirat Beohar MD, Director of the Cardiovascular Catheterization Laboratory and Vice-Chief of Cardiology at the Columbia University Division of Cardiology at the Mount Sinai Medical Center and co-authors report the effect of trans-catheter aortic valve replacement (TAVR) on subsequent renal function and outcomes in high-risk and inoperable patients presenting with baseline renal dysfunction (eGFR < 60 ml/min/1.73 m2). This was a sub-study of patients undergoing TAVR in the PARTNER 1 trial and continued access registry that was conducted in 25 centers in the United States and Canada.

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Support Required To Encourage Patients With End Stage Kidney Disease To Return to Work

MedicalResearch.com Interview with:

Wendy Tan Senior Medical Social Worker Medical Social Work The National Kidney Foundation

Wendy Tan

Wendy Tan
Senior Medical Social Worker
Medical Social Work
The National Kidney Foundation

MedicalResearch.com: What is the background for this study?

Response: End Stage Renal Disease (ESRD) patients experience significant changes to their daily routine and lifestyle. Their time and attention were often centred solely on their sickness whilst receiving treatment accentuating the employment isolation.

This study determined the need for extra support to assist patients adjust (e.g. learning about their psychological wellbeing, change of role and mindset, suitable work conditions and employment support) in returning to work. It also sheds light on how individuals perceive the particular situations they are facing, how they are making sense of their health conditions and the society at large in relations to seeking continued employment.

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Elevated Kidney Biomarker Creatinine Predicts Worse Outcome in STEMI Heart Attack

MedicalResearch.com Interview with:

MedicalResearch.com Interview with: Mohamed Khayata, MD Internal Medicine Resident PGY-3 Cleveland Clinic Akron General, Akron, Ohio MedicalResearch.com: What is the background for this study? What are the main findings? Response: Previous studies showed that patients with ST-elevation myocardial infarction (STEMI) who had elevated creatinine and/or impaired creatinine clearance on presentation had higher short- and long-term mortality independent of other cardiovascular risk factors. We used the National Cardiovascular Database Registry to investigate the impact of creatinine levels at the time of presentation on the cardiovascular outcomes in patients who presented with STEMI. Our study showed that elevated creatinine levels correlated with higher incidence of atrial fibrillation, bleeding, heart failure, and cardiogenic shock during hospital stay after the percutaneous intervention. MedicalResearch.com: What should readers take away from your report? Response: Creatinine level is being checked in almost all patients who present with STEMI within few hours of presentation. Based on previous reports and our results, creatinine is a critical marker that correlate not only with mortality, but is also with morbidity during hospital stay. This marker should be used as a predictor of worse outcomes; thus, patients with higher creatinine levels should be provided higher attention. MedicalResearch.com: What recommendations do you have for future research as a result of this study? Response: Based on our study limitations, I would encourage performing similar outcomes analysis in larger group, multi-center registries. I would also suggest extending outcomes to post-discharge status including quality of life besides cardiovascular compilcations. MedicalResearch.com: Is there anything else you would like to add? Response: MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community. Citation: Abstract presented at the 2017 National Kidney Foundation Spring Clinical Meeting https://www.kidney.org/spring-clinical The Impact of Admission Serum Creatinine on Major Adverse Clinical Events in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions. More Medical Research Interviews on MedicalResearch.com

Dr. Khayata

Mohamed Khayata, MD
Internal Medicine Resident PGY-3
Cleveland Clinic Akron General
Akron, Ohio

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Previous studies showed that patients with ST-elevation myocardial infarction (STEMI) who had elevated creatinine and/or impaired creatinine clearance on presentation had higher short- and long-term mortality independent of other cardiovascular risk factors.

We used the National Cardiovascular Database Registry to investigate the impact of creatinine levels at the time of presentation on the cardiovascular outcomes in patients who presented with STEMI.

Our study showed that elevated creatinine levels correlated with higher incidence of atrial fibrillation, bleeding, heart failure, and cardiogenic shock during hospital stay after the percutaneous intervention.

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Spark Study: Does Low Dose Lasix Provide Kidney Protection in AKI?

MedicalResearch.com Interview with:
Sean Bagshaw MD MSc
Director for Research for the Division of Critical Care Medicine
School of Public Health
University of Alberta, Canada

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The rationale for SPARK stemmed from two general observations.

First, experimental and pre-clinical data have suggested the timely utilization of loop diuretics in early AKI could provide “kidney protection” largely mediated through reduction in medullary oxygen demand. Yet, this is in apparent paradox with clinical data (largely derived from older observational studies at some risk of bias) suggesting use of loop diuretics in AKI may be associated with increased risk for death and/or non-recovery of kidney function.

Second, in AKI, loop diuretics are used exceedingly often. Surveys of healthcare practitioners and observational data suggest more than two-thirds to three-quarters of patients are exposed to diuretics at some point during their course. This represents a significant misalignment between evidence and clinical practice. This would suggest there is need to generate new evidence and knowledge that would ideally help inform best practice in the management of AKI.

SPARK was designed as a pilot trial largely aimed at evaluating the feasibility of the approach to use of loop diuretics in early AKI. While SPARK did not find significant differences in risk of worsening AKI, utilization of RRT or mortality, we recognize the trial was underpowered to meaningfully inform about these and other patient-centered outcomes. We did see differences in secondary endpoints (i.e., fluid balance); however, use of loop diuretics in this setting was also associated with greater incidence of electrolyte abnormalities.

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Prevalence of Chronic Kidney Disease In US Tops 30 Million

MedicalResearch.com Interview with:

Jennifer L. Bragg-Gresham, MS, PhD Assistant Research Scientist Kidney Epidemiology and Cost Center Department of Internal Medicine - Nephrology University of Michigan Ann Arbor, MI 48109

Dr. Bragg-Gresham

Jennifer L. Bragg-Gresham, MS, PhD
Assistant Research Scientist
Kidney Epidemiology and Cost Center
Department of Internal Medicine – Nephrology
University of Michigan Ann Arbor, MI 48109 

MedicalResearch.com: What is the background for this study?

Response: While a trend toward stabilization in CKD prevalence had been detected over the past decade, the most recent data from NHANES (2013-2014) suggests this trend may be ending.

MedicalResearch.com: What are the main findings?

Response: Data from 2013-2014 shows that 15.5% of the US population has reduced kidney function, up from 14.1% (2011-2012) and 12.0% (1988-1994). Over the same time period we have witnessed an increase in risk factors for CKD (age and diabetes, in particular). Adjusting for this fact accounted for much, but not all, of the increase in CKD prevalence.

MedicalResearch.com: What should readers take away from your report?

Response: Despite this finding, we should not become complacent in our fight against kidney disease, as the absolute number of individuals with CKD has increased from approximately 19.2 million (1988-2004) to 33.6 million (2013-2014) in our latest estimates. We must continue to improve awareness and detection of early stages of CKD, as well as improve treatment for CKD risk factors.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: We must continue to improve awareness and detection of early stages of CKD, as well as improve treatment for CKD risk factors.

MedicalResearch.com: Is there anything else you would like to add?

Response: Health surveillance is paramount to the success of all public health initiatives to understand current data and varied aspects of disease, which supports correct allocation of resources.

Disclosures: This poster was supported by the Supporting, Maintaining and Improving the Surveillance System for Chronic Kidney Disease in the U.S., Cooperative Agreement Number, U58 DP006254, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Department of Health and Human Services.
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MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Abstract presented at the Spring 2017 National Kidney Foundation Meeting
RISING CKD PREVALENCE IN THE UNITED STATES (1988-2014)

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Food Costs Can Lead To Less Protein and Phosphorous in Indigent Kidney Transplant Patients

MedicalResearch.com Interview with:

Ms. Shifra Mincer Medical Student in the class of 2019 SUNY Downstate Medical School

Shifra Mincer

Ms. Shifra Mincer
Medical Student in the class of 2019
SUNY Downstate Medical School

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Hypophosphatemia is commonly encountered in the post-transplant setting. Early post-transplant hypophosphatemia has been ascribed to excess FGF23 and hyperphosphaturia.

Many patients remain hypohosphatemic months or even years after their transplant and the mechanism was assumed to be the same, however, our group recently reported that patients with late post-transplant hypophosphatemia had very little phosphorous in their urine (Wu S, Brar A, Markell, MS. Am J Kidney Dis. 2016,67(5): A18). We hypothesized that they were not eating enough phosphorous to compensate for the acute phosphorous losses they experienced immediately post-transplant.

In this study, using both 3-day diet journals and 24-hour diet recall questionnaires, we found that mean intake of phosphorous and protein was barely at the Recommended Daily Allowance, and that despite 70% of the patients using EBT, 30% of those patients still reported concerns regarding food security. Patients who reported that the cost of food influenced their dietary choices ate 43% less protein (average 48,5 gms vs. 85.8 gms) and 29% less phosphorous (average 887 mg vs 1257 mg). When ability to rise from a chair over a 30 second period was evaluated, only patients who expressed food cost concerns were unable to complete the test.

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Trial To Test Effect of Aspirin on Progression of Kidney Disease in Diabetes

MedicalResearch.com Interview with:
Francesco Violi MD
Department of Internal Medicine and Medical Specialties e Sapienza University
Rome, Italy

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The paper reports on the protocol of a trial where we will test the effect of aspirin on renal disease progression in diabetic patients. The study will start shortly and will be terminate next year.

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Donor Sex and Size Important to Kidney Transplant Success

MedicalResearch.com Interview with:
Amanda Miller, MD, FRCPC

Dalhousie University
Transplant Nephrology

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Earlier studies have shown that there may be a higher risk of kidney transplant failure if a kidney donor is smaller than their recipient. This may be due to increased strain on the relatively smaller transplanted kidney. Very few studies have investigated outcomes associated with donor and recipient weight mismatch measured directly by differences in body weight however. There is also a suggestion that sex mismatch between kidney donor and recipient may lead to worse outcomes post-transplant, however results from earlier studies have been controversial and conflicting. The combined effect of weight and sex matching/mismatching between kidney donor and recipient (two very important and physiologically relevant factors) has not been rigorously studied previously.

Thus, the aim of this study was to determine if receiving a kidney transplant from a smaller donor of the opposite sex would impact transplant outcomes. Accounting for other transplant variables, we demonstrated that if a kidney transplant recipient is more than 30 kg (66 pounds) heavier than the donor there is a 28% increased risk of the transplant failing compared to equally weighted donors and recipients. If the kidney is from a smaller donor of the opposite sex, the risk of transplant failure is further increased to 35% for a male receiving a kidney from a female donor, and 50% for a female receiving a kidney from a male donor. This risk is high and is similar to that when a recipient receives a kidney transplant from a donor who has diabetes; a known risk factor for kidney failure in the non-transplant population.

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Acute Kidney Injury Is A Frequent Complication of Pediatric Diabetic Ketoacidosis

MedicalResearch.com Interview with:

Constadina Panagiotopoulos, MD, FRCPC Department of Pediatrics, Endocrinology & Diabetes Unit British Columbia Children’s Hospital Vancouver, British Columbia, Canada

Dr. Panagiotopoulos

Constadina Panagiotopoulos, MD, FRCPC
Department of Pediatrics, Endocrinology & Diabetes Unit
British Columbia Children’s Hospital
Vancouver, British Columbia, Canada

MedicalResearch.com: What is the background for this study?

Response: I decided to conduct this study after observing a few cases of severe acute kidney injury (AKI) in children hospitalized with diabetic ketoacidosis (DKA) (with two patients requiring dialysis) while on call in the 18 months prior to initiating the study. While caring for these patients, I scanned the literature and realized that aside from 2 published case reports, there had been no large-scale systematic studies assessing AKI in children with DKA. It immediately became apparent to me that managing patients with AKI and DKA was more challenging. On presentation to hospital, many of these children with DKA present quite volume depleted but fluid management is conservative because of the risk for cerebral edema.

One of the most important management strategies for acute kidney injury in patients with DKA is early detection and correcting volume depletion in a timely manner to prevent further injury. I discussed my observations and these clinical cases with pediatric nephrologist and co-investigator Dr. Cherry Mammen, a pediatric AKI expert, and he confirmed my initial literature review findings. Thus, we decided to conduct this study to better understand the scope of the problem and any associated risk factors.

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Association of Intensive Blood Pressure Control and Kidney Disease Progression in Nondiabetic Patients With CKD

MedicalResearch.com Interview with:
Hon-Yen Wu, MD, PhD, on behalf of all authors

Attending Physician and Assistant Professor, Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
Assistant Professor, Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan.
Assistant Professor, National Taiwan University Hospital and College of Medicine,
National Taiwan University, Taipei, Taiwan.
Assistant Professor, School of Medicine, National Yang-Ming University, Taipei, Taiwan. 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The effect of intensive blood pressure (BP) control in nondiabetic patients with chronic kidney disease (CKD) has long been a topic of debate. We summarized the published information comparing intensive BP control (< 130/80 mmHg) with standard BP control (< 140/90 mmHg) on major renal outcomes in CKD patients without diabetes. We pooled data from 9 randomized clinical trials with more than 8000 patients and over 800 events of kidney disease progression. We found that targeting blood pressure below the current standard did not provide additional benefit for renal outcomes compared with standard BP control, but may benefit nonblack patients or those with heavy proteinuria.

MedicalResearch.com: What should readers take away from your report?

Response: For the optimal blood pressure target in CKD patients without diabetes, an individually tailored treatment rather than a general rule to control hypertension is suggested.

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