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Biomedical subjects

Josef Coresh

Publications and source records attributed to Josef Coresh.

At least 55 records · Page 3Linked to original sources
PubMed2005

Glycemic control, atherosclerosis, and risk factors for cardiovascular disease in individuals with diabetes: the atherosclerosis risk in communities study.

OBJECTIVE: Glycemic control (HbA(1c) [A1C]) is strongly associated with microvascular disease in individuals with diabetes, but its relation to macrovascular disease and atherosclerosis is less clear. This study examines the relationship between A1C, carotid intima-media thickness (IMT), and traditional cardiovascular risk factors in individuals with diabetes. RESEARCH DESIGN AND METHODS: A cross-sectional study of 2,060 people with diagnosed and undiagnosed (unrecognized) diabetes in the Atherosclerosis Risk in Communities study was performed. RESULTS: LDL and HDL cholesterol, plasma triglycerides, and waist-to-hip ratio were significantly associated with A1C after multivariable adjustment. African Americans with undiagnosed and diagnosed diabetes had significantly elevated A1C values compared with whites, even after adjustment for potentially confounding factors. There was a graded association between A1C and carotid IMT. In a fully adjusted model in individuals with undiagnosed diabetes, the odds ratio (OR) of being in the highest quartile of IMT versus the lowest was 2.46 (95% CI 1.16-5.03, comparing the highest quartile of A1C to the lowest). In people with diagnosed diabetes, the comparable OR was 2.62 (1.36-5.06). CONCLUSIONS: This study identified several important associations between A1C and known risk factors for cardiovascular disease and suggested that A1C is independently related to carotid IMT. Chronically elevated glucose levels may contribute to the development of atherosclerosis in people with diabetes, independent of other risk factors.

Aged↗
PubMed2004

Traditional and nontraditional risk factors predict coronary heart disease in chronic kidney disease: results from the atherosclerosis risk in communities study.

Some risk factors for coronary heart disease (CHD) incidence in the general population are not associated with CHD incidence among patients with ESRD but have not been well characterized in chronic kidney disease (CKD). The association of several risk factors with CHD incidence was studied among participants with CKD in the population-based Atherosclerosis Risk in Communities (ARIC) Study. CHD risk factors and estimated GFR using serum creatinine were measured among 807 ARIC participants with CKD (estimated GFR between 15 and 59 ml/min per 1.73 m(2)). The incidence of CHD during 10.5 yr of follow-up was 6.3, 8.5, and 14.4 per 1000 person-years among ARIC participants with an estimated GFR of >/=90, 60 to 89, and 15 to 59 ml/min per 1.73 m(2), respectively. After adjustment for age, race, gender, and ARIC field center, among those with CKD, the relative risk (95% confidence interval) of CHD was 1.65 (1.01 to 2.67) for current smoking, 2.02 (1.27 to 3.22) for hypertension, 3.06 (2.01 to 4.67) for diabetes, and 1.96 (1.14 to 3.36) for anemia. The comparably adjusted relative risks of CHD for each standard deviation higher total and HDL cholesterol were 1.50 (1.25 to 1.71) and 0.79 (0.62 to 1.01), respectively, and 1.38 (1.13 to 1.69), 1.24 (1.06 to 1.46), 0.65 (0.54 to 0.79), and 1.38 (1.19 to 1.59) for waist circumference, leukocyte count, serum albumin, and fibrinogen, respectively. CHD risk factors in the general population remain predictive among patients with CKD. Given the high risk for CHD among patients with CKD, control of these risk factors may have a substantial impact on their excess burden of CHD.

Cohort Studies↗
PubMed2004

Chronic kidney disease awareness, prevalence, and trends among U.S. adults, 1999 to 2000.

The incidence of kidney failure treatment in the United States increased 57% from 1991 to 2000. Chronic kidney disease (CKD) prevalence was 11% among U.S. adults surveyed in 1988 to 1994. The objective of this study was to estimate awareness of CKD in the U.S. population during 1999 to 2000 and to determine whether the prevalence of CKD in the United States increased compared with 1988 to 1994. Analysis was conducted of nationally representative samples of noninstitutionalized adults, aged 20 yr and older, in two National Health and Nutrition Examination Surveys conducted in 1988 to 1994 (n = 15,488) and 1999 to 2000 (n = 4101) for prevalence +/- SE. Awareness of CKD is self-reported. Kidney function (GFR), kidney damage (microalbuminuria or greater), and stages of CKD (GFR and albuminuria) were estimated from calibrated serum creatinine, spot urine albumin to creatinine ratio (ACR), age, gender, and race. GFR was estimated using the simplified Modification of Diet in Renal Disease Study equation. Self-reported awareness of weak or failing kidneys in 1999 to 2000 was strongly associated with decreased kidney function and albuminuria but was low even in the presence of both conditions. Only 24.3 +/- 6.4% of patients at GFR 15 to 59 ml/min per 1.73 m(2) and albuminuria were aware of CKD compared with 1.1 +/- 0.3% at GFR of 90 ml/min per 1.73 m(2) or greater and no microalbuminuria. At moderately decreased kidney function (GFR 30 to 59 ml/min per 1.73 m(2)), awareness was much lower among women than men (2.9 +/- 1.6 versus 17.9 +/- 5.9%; P = 0.008). The prevalence of moderately or severely decreased kidney function (GFR 15 to 59 ml/min per 1.73 m(2)) remained stable over the past decade (4.4 +/- 0.3% in 1988 to 1994 and 3.8 +/- 0.4% in 1999 to 2000; P = 0.23). At the same time, the prevalence of albuminuria (ACR >/= 30 mg/g) in single spot urine increased from 8.2 +/- 0.4% to 10.1 +/- 0.7% (P = 0.01). Overall CKD prevalence was similar in both surveys (9% using ACR > 30 mg/g for persistent microalbuminuria; 11% in 1988 to 1994 and 12% in 1999 to 2000 using gender-specific ACR cutoffs). Despite a high prevalence, CKD awareness in the U.S. population is low. In contrast to the dramatic increase in treated kidney failure, overall CKD prevalence in the U.S. population has been relatively stable.

Adult↗
PubMed2004

Clinical practice guidelines for chronic kidney disease in adults: Part II. Glomerular filtration rate, proteinuria, and other markers.

The Kidney Disease Outcome Quality Initiative of the National Kidney Foundation published clinical practice guidelines on chronic kidney disease in February 2002. Of the 15 guidelines, the first six are of greatest relevance to family physicians. Part II of this two-part review covers guidelines 4, 5, and 6. Glomerular filtration rate is the best overall indicator of kidney function. It is superior to the serum creatinine level, which varies with age, sex, and race and often does not reflect kidney function accurately. The glomerular filtration rate can be estimated using prediction equations that take into account the serum creatinine level and some or all of specific variables (age, sex, race, body size). In many patients, estimates of the glomerular filtration rate can replace 24-hour urine collections for creatinine clearance measurements. Urine dipsticks generally are acceptable for detecting proteinuria. To quantify proteinuria, the ratio of protein or albumin to creatinine in an untimed (spot) urine sample is an accurate alternative to measurement of protein excretion in a 24-hour urine collection. Patients with persistent proteinuria have chronic kidney disease. Other techniques for evaluating patients with chronic kidney disease include examination of urinary sediment, urine dipstick testing for red and white blood cells, and imaging studies of the kidneys (especially ultrasonography). These techniques also can help determine the underlying cause of chronic kidney disease. Family physicians should weigh the value of the National Kidney Foundation guidelines for their clinical practice based on the strength of evidence and perceived cost-effectiveness until additional evidence becomes available on the usefulness of the recommended quality indicators.

Adult↗
PubMed2004

The prevalence of reduced glomerular filtration rate in older hypertensive patients and its association with cardiovascular disease: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.

BACKGROUND: The prevalence of reduced glomerular filtration rate (GFR) in older hypertensive patients and the relationship between level of GFR and cardiovascular disease (CVD) and its risk factors are not well known. METHODS: We evaluated baseline renal function in 40 514 hypertensive patients 55 years or older who were enrolled in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). We used the simplified Modification of Diet in Renal Disease study equation to estimate GFR and examined the prevalence of CVD in patients with different levels of GFR. RESULTS: Fifty-seven percent of patients had mild (60-89 mL/min per 1.73 m(2)), 17.2% had moderate (30-59 mL/min per 1.73 m(2)), and 0.6% had severe (<or=29 mL/min per 1.73 m(2)) reductions in GFR. Compared with patients with normal or mildly reduced GFR, patients with moderate or severe reductions in GFR were more likely to have had a prior myocardial infarction or stroke (19.2% and 23.4% vs 28.7% and 26.9%, respectively), have ischemic changes on electrocardiography (ECG) (16.0% and 18.9% vs 24.6% and 34.1%, respectively), and have left ventricular hypertrophy on ECG (ECG-LVH) (3.9% and 4.2% vs 6.0% and 11.2%, respectively). A decrease in GFR of 10 mL/min per 1.73 m(2) was independently associated with a 6% higher risk for CVD and 14% higher risk for ECG-LVH. The increase in risk was marked at a GFR of approximately 60 to 70 mL/min per 1.73 m(2). CONCLUSIONS: The prevalence of reduced GFR is high in older hypertensive patients. Patients with moderate or severe reduction in GFR are more likely to have a history of CVD and ECG-LVH. Even modest reductions in GFR are independently associated with a higher prevalence of CVD and ECG-LVH.

Cardiovascular Diseases↗
PubMed2004

Lipoprotein-associated phospholipase A2, high-sensitivity C-reactive protein, and risk for incident coronary heart disease in middle-aged men and women in the Atherosclerosis Risk in Communities (ARIC) study.

BACKGROUND: Measuring C-reactive protein (CRP) has been recommended to identify patients at high risk for coronary heart disease (CHD) with low LDL cholesterol (LDL-C). Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a proinflammatory enzyme associated primarily with LDL. METHODS AND RESULTS: In a prospective, case cohort study in 12 819 apparently healthy middle-aged men and women in the Atherosclerosis Risk in Communities study, the relation between Lp-PLA2, CRP, traditional risk factors, and risk for CHD events over a period of approximately 6 years was examined in a proportional hazards model, stratified by LDL-C. Lp-PLA2 and CRP levels were higher in the 608 cases than the 740 noncases. Both Lp-PLA2 and CRP were associated with incident CHD after adjustment for age, sex, and race with a hazard ratio of 1.78 for the highest tertile of Lp-PLA2 and 2.53 for the highest category of CRP versus the lowest categories. Lp-PLA2 correlated positively with LDL-C (r=0.36) and negatively with HDL-C (r=-0.33) but not with CRP (r=-0.05). In a model adjusted for traditional risk factors including LDL-C, the association of Lp-PLA2 with CHD was attenuated and not statistically significant. For individuals with LDL-C below the median (130 mg/dL), Lp-PLA2 and CRP were both significantly and independently associated with CHD in fully adjusted models. For individuals with LDL-C <130 mg/dL, those with both Lp-PLA2 and CRP levels in the highest tertile were at the greatest risk for a CHD event. CONCLUSIONS: Lp-PLA2 and CRP may be complementary in identifying individuals at high CHD risk who have low LDL-C.

1-Alkyl-2-acetylglycerophosphocholine Esterase↗
PubMed2004

Association between cholesterol level and mortality in dialysis patients: role of inflammation and malnutrition.

CONTEXT: Total cholesterol level is inversely associated with mortality in dialysis patients, a group at high risk of cardiovascular disease (CVD). This paradox may be explained by systemic inflammation and/or malnutrition, which are associated with lower cholesterol levels and higher mortality. OBJECTIVE: To determine the relationship between cholesterol level and outcome in patients undergoing dialysis, accounting for inflammation and malnutrition. DESIGN, SETTING, AND PARTICIPANTS: Prospective study of 823 patients enrolled from October 1995 to June 1998 who recently initiated dialysis, from 79 clinics, classified by absence or presence of inflammation and/or malnutrition (defined as serum albumin levels <3.6 mg/dL, C-reactive protein > or =10 mg/L, or interleukin 6 > or =3.09 pg/mL). MAIN OUTCOME MEASURES: All-cause and cardiovascular disease mortality. RESULTS: During a median follow-up of 2.4 years, 324 deaths (159 CVD deaths), 153 renal transplantations, and 10 losses to follow-up occurred. Average serum cholesterol level was lower in the presence of inflammation/malnutrition than in its absence. In a Cox model adjusted for age, race, and sex, a 40-mg/dL (1.0-mmol/L) increment in baseline total serum cholesterol level was associated with a decreased risk of all-cause mortality overall (relative hazard [RH], 0.92; 95% confidence interval [CI], 0.87-0.98) and in the presence of inflammation/malnutrition (RH, 0.89; CI, 0.84-0.95). In contrast, serum cholesterol level was associated with an increased risk in the absence of inflammation/malnutrition (RH, 1.32; 95% CI, 1.07-1.63). For CVD mortality, an inverse trend was not statistically significant in the presence of inflammation/malnutrition, and a positive association was evident in the absence of inflammation/malnutrition (RH, 1.41; 95% CI, 1.04-1.89). Further adjustment for traditional CVD risk factors, dialysis modality, comorbidity, and inflammatory markers attenuated the inverse association but strengthened the positive association. CONCLUSIONS: The inverse association of total cholesterol level with mortality in dialysis patients is likely due to the cholesterol-lowering effect of systemic inflammation and malnutrition, not to a protective effect of high cholesterol concentrations. These findings support treatment of hypercholesterolemia in this population.

Adult↗
PubMed2004

Association of kidney function and hemoglobin with left ventricular morphology among African Americans: the Atherosclerosis Risk in Communities (ARIC) study.

BACKGROUND: Left ventricular (LV) hypertrophy (LVH) is present in more than 70% of patients with kidney failure. Hypertension and anemia, 2 strong risk factors for LVH, are common in patients with moderate kidney dysfunction. It is unknown whether kidney function and lower hemoglobin levels are associated with LV morphological characteristics among African Americans with moderate kidney dysfunction, independent of blood pressure. METHODS: As part of the Atherosclerosis Risk in Communities Study, 1,968 African Americans aged 50 to 75 years underwent an echocardiogram after 6 to 9 years of follow-up. LV mass was indexed (LVMI) to body surface area. Glomerular filtration rate (GFR) was estimated from calibrated serum creatinine levels measured at baseline and after 3 years (<30 mL/min/1.73 m2 excluded). Hemoglobin was measured at baseline and after 3 years. Blood pressure was measured every 3 years. RESULTS: A mean GFR of 30 to 59 mL/min/1.73 m2 was associated with a 15.3 g/m2 greater LVMI, 0.9 mm greater posterior wall thickness, and 1.0 mm greater interventricular septal thickness compared with a GFR of 90 mL/min/1.73 m2 or greater. These associations remained after adjustment for age, sex, hemoglobin level, blood pressure, and other covariates. Wall thickness and LVMI increased with lower GFR less than 75 mL/min/1.73 m2 (5.5 g/m2 greater LVMI [95% confidence interval (CI), 0.9 to 10.1] per 10 mL/min/1.73 m2 lower GFR). A lower hemoglobin level was associated with greater LV diameter (0.5 mm [95% CI, 0.2 to 0.7] per 1 g/dL [10 g/L]), but not wall thickness, after adjustment. CONCLUSION: These results in a general population sample of middle-aged African Americans suggest that moderately decreased kidney function independently predicts greater LV wall thickness, and lower hemoglobin level independently predicts greater LV diameter. These findings may explain, in part, the high risk for cardiovascular disease observed among individuals with kidney disease.

Black or African American↗
PubMed2004

Ankle brachial index independently predicts early kidney disease.

INTRODUCTION: Chronic kidney disease (CKD) and atherosclerotic cardiovascular disease (CVD) are often both present in selected populations. The independent association of early renal disease and atherosclerosis has not been studied in the general population. We hypothesized that the presence of low ankle brachial index (ABI), a surrogate measure of atherosclerotic cardiovascular disease, is associated with a low estimated glomerular filtration rate (GFR). METHODS: The study population consisted of 14,917 middle-aged black and white men and women from the Atherosclerosis Risk in Communities (ARIC) Study. An ABI<0.90 was defined as the exposure, and an estimated GFR<90 mL/min/1.73 m2 was defined as the outcome. Logistic regression analysis was performed cross-sectionally using an ABI of 1.00-1.19 as the reference, and was adjusted for the usual cardiovascular risk factors. RESULTS: The presence of an ABI<0.90 was associated with an increased odds of having an estimated GFR<90 (OR: 1.80; 95% C.I.: 1.40-2.32) compared to the reference group. After adjustment, an ABI<0.90 remained significant, and increased the odds of having an estimated GFR<90 (OR: 1.54; 95% C.I.: 1.17-2.04) compared to the reference group. The odds ratio for GFR<90 was higher among African Americans than Whites, 1.88 versus 1.36 respectively. DISCUSSION: This study gives support to the independent association of early CKD and atherosclerotic CVD. The relationship appears to be stronger among African Americans than among Whites. It will be necessary to investigate this observation more fully with prospective studies given the rising incidence of CKD.

Black or African American↗
PubMed2004

Predicting 1 year mortality in an outpatient haemodialysis population: a comparison of comorbidity instruments.

BACKGROUND: A valid and practical measure of comorbid illness burden in dialysis populations is greatly needed to enable unbiased comparisons of clinical outcomes. We compare the discriminatory accuracy of 1 year mortality predictions derived from four comorbidity instruments in a large representative US dialysis population. METHODS: Comorbidity information was collected using the Index of Coexistent Diseases (ICED) in 1779 haemodialysis patients of a national dialysis provider between 1997 and 2000. Comorbidity was also scored according to the Charlson Comorbidity Index (CCI), Wright-Khan and Davies indices. Relationships of instrument scores with 1 year mortality were assessed in separate logistic regression analyses. Discriminatory ability was compared using the area under the receiver-operating characteristics curve (AUC), based on predictions of each regression model. RESULTS: When mortality was predicted using comorbidity and age, the ICED better discriminated between survivors and those who died (AUC 0.72) as compared with the CCI (0.67), Wright-Khan (0.68) and Davies (0.68) indices. Upon addition of race and serum albumin, predictive accuracy of each model improved further (AUCs of the ICED, 0.77; CCI, 0.75; Wright-Khan Index, 0.75; Davies Index, 0.74). CONCLUSIONS: The ICED had greater discriminatory ability than the CCI, Davies and Wright-Khan indices, when age and a comorbidity index were used alone to predict 1 year mortality; however, the differences among instruments diminished once serum albumin, race and the cause of ESRD were accounted for. None of the currently available comorbidity instruments tested in this study discriminated mortality outcomes particularly well. Assessing comorbidity using the ICED takes significantly more time. Identifying the key prognostic comorbid conditions and weighting these according to outcomes in a dialysis population should increase accuracy and, with restriction to a finite number of items, provide a practical means for widespread comorbidity assessment.

Cause of Death↗
PubMed2004

Prospective association between hypotension and idiopathic chronic fatigue.

OBJECTIVE: To determine whether there is an association between hypotension and incident cases of idiopathic chronic fatigue. DESIGN: A prospective study. SETTING: Johns Hopkins Precursors Study. PARTICIPANTS: Medical students (n = 876) in graduating classes from 1948 to 1964. MAIN OUTCOME MEASURE: 'Easy fatigability' reported by participants at 5- or 10-year follow-up after graduation. RESULTS: The unadjusted risk in women was 5.0 (95% exact confidence interval = 1.4 to 17.4) and in men was 1.7 (95% exact confidence interval = 0.8, to 3.5). CONCLUSION: These preliminary findings suggest that hypotension may be a risk factor for the development of idiopathic chronic fatigue in women.

Adult↗
PubMed2004

Evidence for increased cardiovascular disease risk in patients with chronic kidney disease.

PURPOSE OF REVIEW: Chronic kidney disease is becoming recognized as an important risk factor for cardiovascular disease. Recent publications on cardiovascular disease risk in chronic kidney disease, cardiovascular disease risk factors in chronic kidney disease and clinical trials for cardiovascular disease risk reduction in chronic kidney disease are summarized. RECENT FINDINGS: An American Heart Association statement published in 2003 recommended that patients with chronic kidney disease be considered as members of the 'highest risk group' for subsequent cardiovascular disease events. In the past year, several large prospective studies have reported that cardiovascular disease risk is independently associated with chronic kidney disease markers, e.g. elevated serum creatinine, low estimated glomerular filtration rate and microalbuminuria. The populations studied have included community samples of middle-aged and older adults, subjects with myocardial infarction, those undergoing coronary angiography, and transplant patients. There is a very strong crude association between a low glomerular filtration rate and cardiovascular disease and mortality. Much of the association is explained by traditional cardiovascular disease risk factors, but an independent risk remains. Studies have documented a disturbing underutilization of preventive treatments for cardiovascular disease among patients with chronic kidney disease. Studies of non-traditional cardiovascular disease risk factors are reviewed. The utility of targeting these for cardiovascular disease risk reduction needs to be proved. A summary of large ongoing clinical trials intended to reduce cardiovascular disease risk in chronic kidney disease is presented. SUMMARY: Increasing data support the importance of chronic kidney disease as a predictor of cardiovascular disease risk. However, treatments designed to lower cardiovascular disease risk are used less often in patients with chronic kidney disease than in patients without chronic kidney disease. There is a need for increased application and testing of cardiovascular disease prevention treatments in chronic kidney disease.

Aging↗
PubMed2004

Frequency of patient-physician contact and patient outcomes in hemodialysis care.

There is little evidence supporting the widespread belief that regular patient-physician contact in chronic disease management leads to better patient outcomes. The objective of this study was to examine the relationship of the frequency of patient-physician contact with several patient outcomes in a prospective cohort study begun in 1995 of incident hemodialysis patients treated at 75 US dialysis clinics. Average frequency of patient-physician contact at each clinic was determined by clinic survey (low, monthly or less frequent; intermediate, between monthly and weekly; high, more than weekly). The authors used logistic, Poisson, and Cox proportional hazards regression analyses to assess the relationship between contact and satisfaction, quality of life, patient adherence, hospitalizations, and mortality. Of 735 hemodialysis patients, 14.3% were treated at clinics with high frequency of contact, 65.2% intermediate, and 20.5% low. Patients treated at clinics reporting less frequent physician contact had lower odds of rating the frequency at which they saw a nephrologist excellent (low: adjusted OR = 0.39, 95% CI, 0.23-0.67; intermediate: adjusted OR = 0.57, 95% CI, 0.37-0.87; reference, high) and greater odds of nonadherence (low: adjusted OR = 2.89, 95% CI, 1.01-8.29; intermediate: adjusted OR = 1.58, 95% CI, 0.78-3.19). However, patient survival did not vary by frequency of physician contact (low: adjusted RH = 0.87, 95% CI, 0.53-1.44; intermediate: adjusted RH = 1.33, 95% CI, 0.82-2.13), nor did patients' overall ratings of care, hospitalization rates, or quality of life measures. Although less frequent patient-physician contact was associated with lower patient satisfaction with that contact and patient nonadherence, it was not associated with several other outcomes of care. Future studies are needed to assess the individual frequency and nature of physician contact over time, including total time spent with the patient and quality of the interaction, to guide the provision of patient-centered and cost-effective care.

Cohort Studies↗
PubMed2004

Retinal microvascular abnormalities and renal dysfunction: the atherosclerosis risk in communities study.

Microvascular disease has been linked with renal dysfunction in patients with diabetes. The aim of this study was to examine the association of retinal microvascular abnormalities to renal dysfunction among participants of the Atherosclerosis Risk in Communities Study, a population-based investigation in four U.S. communities. At the third examination (1993 to 1995), retinal photography was performed and the presence of retinal microvascular abnormalities was documented using a standard grading protocol. Renal dysfunction was defined as an increase in serum creatinine of at least 0.4 mg/dl or a death or hospitalization as a result of chronic kidney disease between the second (1990 to 1992) and fourth (1996 to 1998) examinations. Among 10,056 people who were included in the study, 270 (2.7%) developed renal dysfunction. After controlling for age, gender, race, diabetes, BP, and other risk factors, individuals with retinopathy (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.4 to 2.8), microaneurysms (OR, 2.0; 95% CI, 1.3 to 3.1), retinal hemorrhages (OR, 2.6; 95% CI, 1.6 to 4.0), soft exudates (OR, 2.7; 95% CI, 1.6 to 4.8), and arteriovenous nicking (OR, 1.4; 95% CI, 1.0 to 1.9) were more likely to develop renal dysfunction than individuals without these abnormalities. Retinal microvascular abnormalities are associated with renal dysfunction, suggesting that common systemic microvascular processes may underlie the development of microvascular damage in the eye and kidneys.

Arteriosclerosis↗
PubMed2004

Frequency of sit-down patient care rounds, attainment of clinical performance targets, hospitalization, and mortality in hemodialysis patients.

Sit-down patient rounding in hemodialysis units allows providers to focus collectively on each patient's needs and may affect patient outcomes positively. The objective was to examine whether sit-down rounding practices improve patient outcomes in a cohort of 644 adult hemodialysis patients from 75 outpatient dialysis clinics in 17 states throughout the United States who survived at least 6 mo after enrollment (average follow-up, 3.2 yr). Achievement of well-accepted 6-mo clinical performance targets of albumin (> or =3.5 g/dl), hemoglobin (> or =11 g/dl), calcium-phosphate product (<60 mg(2)/dl(2)), dose (Kt/V > or =1.2), and vascular access type (fistula); hospitalization rates; and all-cause mortality served as outcomes. Monthly or more frequent sit-down rounds were conducted in 36 (48%) of 75 clinics, representing 287 (45%) of 644 patients. More frequent sit-down rounds were positively associated with an increased chance of achieving the 6-mo clinical performance target for albumin compared with less frequent rounds (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.12 to 3.15); patients who were treated at clinics with more frequent rounds also had nearly twice the odds of achieving more of the five performance targets (OR, 1.95; 95% CI, 1.11 to 3.42). After adjustment for potential confounders, patients who were treated at clinics with more frequent sit-down rounds were 32% less likely to be hospitalized (incidence rate ratio, 0.68; 95% CI, 0.51 to 0.91), had fewer hospital days per year (rate ratio, 0.50; 95% CI, 0.26 to 0.98), and were 29% less likely to die (relative hazard, 0.71; 95% CI, 0.53 to 0.95). Adjustment for some clinical performance targets attenuated the statistical significance of the association with hospitalization. More frequent sit-down rounds in hemodialysis units are associated with better patient outcomes, including an increased chance of meeting the albumin clinical performance target, decreased hospitalization, and decreased risk of mortality. This association may be due to the positive effect of collaborative discussion by the patient care team of short- and long-term care goals for individual patients.

Adult↗
PubMed2004

Prevalence of acidosis and inflammation and their association with low serum albumin in chronic kidney disease.

BACKGROUND: Low serum albumin is a strong risk factor for mortality, but its association with low serum bicarbonate and inflammation in the setting of mild to moderately decreased kidney function is uncertain. METHODS: We analyzed data from 15594 subjects over the age of 20 who participated in the Third National Health and Nutrition Examination Survey (NHANES III). Glomerular filtration rate (GFR) in mL/min/1.73 m2 was estimated by the abbreviated Modification of Diet in Renal Disease (MDRD) equation using appropriately calibrated serum creatinine. RESULTS: The age-adjusted prevalence of hypoalbuminemia (serum albumin <3.8 g/dL) at a GFR of 90, 60, 30, and 15 mL/min/1.73 m2 was 19%, 21%, 38%, and 59%, respectively, while the age-adjusted prevalence of C-reactive protein (CRP) >or= 0.22 mg/dL was 36%, 44%, 69%, and 81%, respectively, both P trend <0.001. Age, female gender, non-Hispanic black compared with non-Hispanic white race, diabetes, hypertension, hepatitis C, urine albumin: creatinine ratio >1 g/g, dietary protein intake, dietary caloric intake, serum bicarbonate, CRP, and GFR category were all significant predictors of hypoalbuminemia on univariate analysis. On simultaneously adjusting for the above variables, hypertension, diabetes, GFR, and dietary protein and caloric intake were no longer significant independent predictors of hypoalbuminemia. The adjusted odds ratio (OR) of serum bicarbonate (by quartile) for hypoalbuminemia was 1.0 for serum bicarbonate >28 mEq/L (reference), 1.25 for 26-28 mEq/L, 1.51 for 23-25 mEq/L, and 1.54 for 1.0 mg/dL. CONCLUSION: Elevated CRP and low serum bicarbonate are independently associated with hypoalbuminemia, explaining much of the high prevalence of hypoalbuminemia in chronic kidney disease.

Acidosis↗