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ABSTRACT: BACKGROUND AND PURPOSE: Evaluation at primary stroke centers (PSCs) has the potential to improve outcomes for patients with stroke. We looked for differences in evaluation at Joint Commission certified PSCs by race, education, income, and geography (urban versus nonurban; Southeastern Stroke Belt versus non-Stroke Belt). METHODS: Community-dwelling, black and white participants from the national Reasons for Geographic And Racial Differences in Stroke (REGARDS) prospective population-based cohort were enrolled between January 2003 and October 2007. Participants were contacted at 6-month intervals for suspected stroke events. For suspected stroke events, it was determined whether the evaluating hospital was a certified PSC. RESULTS: Of 1000 suspected strokes, 204 (20.4%) strokes were evaluated at a PSC. A smaller proportion of women than men (17.8% versus 23.0%; P=0.04), those with a previous stroke (15.1% versus 21.6%; P=0.04), those living in the Stroke Belt (14.7% versus 27.3%; P<0.001), and those in a nonurban area (9.1% versus 23.1%; P<0.001) were evaluated at a PSC. There were no differences by race, education, or income. In multivariable analysis, subjects were less likely to be evaluated at a PSC if they lived in a nonurban area (odds ratio, 0.39; 95% confidence interval, 0.22-0.67) or lived in the Stroke Belt (odds ratio, 0.54; 95% confidence interval, 0.38-0.77) or had a previous stroke (odds ratio, 0.46; 95% confidence interval, 0.27-0.78). CONCLUSIONS: Disparities in evaluation by PSCs are predominately related to geographic factors but not to race, education, or low income. Despite an increased burden of cerebrovascular disease in the Stroke Belt, subjects there were less likely to be evaluated at certified hospitals.
Stroke 05/2013; · 5.73 Impact Factor
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Georgios Tsivgoulis, Suzanne Judd,
Abraham J Letter,
Andrei V Alexandrov,
George Howard,
Fadi Nahab,
Frederick W Unverzagt,
Claudia Moy,
Virginia J Howard,
Brett Kissela,
Virginia G Wadley
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ABSTRACT: OBJECTIVE: We sought to determine the relationship of greater adherence to Mediterranean diet (MeD) and likelihood of incident cognitive impairment (ICI) and evaluate the interaction of race and vascular risk factors. METHODS: A prospective, population-based, cohort of individuals enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study 2003-2007, excluding participants with history of stroke, impaired cognitive status at baseline, and missing data on Food Frequency Questionnaires (FFQ), was evaluated. Adherence to a MeD (scored as 0-9) was computed from FFQ. Cognitive status was evaluated at baseline and annually during a mean follow-up period of 4.0 ± 1.5 years using Six-item-Screener. RESULTS: ICI was identified in 1,248 (7%) out of 17,478 individuals fulfilling the inclusion criteria. Higher adherence to MeD was associated with lower likelihood of ICI before (odds ratio [lsqb]OR[rsqb] 0.89; 95% confidence interval [lsqb]CI[rsqb] 0.79-1.00) and after adjustment for potential confounders (OR 0.87; 95% CI 0.76-1.00) including demographic characteristics, environmental factors, vascular risk factors, depressive symptoms, and self-reported health status. There was no interaction between race (p = 0.2928) and association of adherence to MeD with cognitive status. However, we identified a strong interaction of diabetes mellitus (p = 0.0134) on the relationship of adherence to MeD with ICI; high adherence to MeD was associated with a lower likelihood of ICI in nondiabetic participants (OR 0.81; 95% CI 0.70-0.94; p = 0.0066) but not in diabetic individuals (OR 1.27; 95% CI 0.95-1.71; p = 0.1063). CONCLUSIONS: Higher adherence to MeD was associated with a lower likelihood of ICI independent of potential confounders. This association was moderated by presence of diabetes mellitus.
Neurology 04/2013; 80(18):1684-1692. · 8.31 Impact Factor
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ABSTRACT: BACKGROUND: Prior evidence suggests that longer duration of residence in the southeastern United States is associated with higher prevalence of diabetes and hypertension. We postulated that a similar association would exist for chronic kidney disease (CKD). METHODS: In a national population-based cohort study that enrolled 30,239 men and women >= 45 years old (42% black/58% white; 56% residing in the Southeast) between 2003 and 2007, lifetime southeastern residence duration was calculated and categorized [none (0%), less than half (>0-< 50%), half or more (>=50-< 100%), and all (100%)]. Prevalent albuminuria (single spot urinary albumin:creatinine ratio of >=30 mg/g) and reduced kidney function (estimated glomerular filtration rate <60 ml/min/1.73 m2) were defined at enrollment. Incident end-stage renal disease (ESRD) during follow-up was identified through linkage to United States Renal Data System. RESULTS: White and black participants most often reported living their entire lives outside (35.7% and 27.0%, respectively) or inside (27.9% and 33.8%, respectively) the southeastern United States. The prevalence of neither albuminuria nor reduced kidney function was statistically significantly associated with southeastern residence duration, in either race. ESRD incidence was not statistically significantly associated with all vs. none southeastern residence duration (HR = 0.50, 95% CI, 0.22-1.14) among whites, whereas blacks with all vs. none exposure showed increased risk of ESRD (HR = 1.63, 95% CI, 1.02-2.63; PraceXduration = 0.011). CONCLUSIONS: These data suggest that blacks but not whites who lived in the Southeast their entire lives were at increased risk of ESRD, but we found no clear geographic pattern for earlier-stage CKD.
International Journal of Health Geographics 03/2013; 12(1):17. · 2.62 Impact Factor
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ABSTRACT: OBJECTIVE: Sepsis, the syndrome of microbial infection complicated by systemic inflammation, is associated with significant morbidity and mortality. We sought to determine if obesity increases risk of sepsis events. DESIGN AND METHODS: We used data from the 30,239 subject population-based longitudinal cohort study REasons for Geographic and Racial Differences in Stroke (REGARDS). Using measurements at the start of the study, we defined obesity using body mass index (BMI; <18.5 kg/m(2) =underweight, 18.5-24.9 =normal, 25.0-29.9=overweight, 30.0-39.9=obese, ≥40=morbidly obese) and waist circumference (WC; [male≤102 cm or female≤88 cm]= normal, [male>102 cm or female>88 cm]=obese). Over an 8-year observation period, we evaluated the association between obesity and subsequent sepsis events, adjusting for sociodemographic factors, health behaviors, chronic medical conditions, statin use and high-sensitivity C-reactive protein. RESULTS: There were 975 incident sepsis events. Compared to those with a BMI of 18.5-24.9, sepsis risk was higher only for BMI ≥40 (HR 1.57, (1.16-2.14)). Risk of sepsis was associated with increased WC (HR 1.34 (1.14-1.56)). In a model with both BMI and WC, sepsis risk was associated with increased WC (HR 1.47 (1.20-1.79)) but not BMI. CONCLUSIONS: Obesity is independently associated with future sepsis events. WC is a better predictor of future sepsis risk than BMI.
Obesity 03/2013; · 4.28 Impact Factor
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ABSTRACT: PURPOSE: Elevated biomarkers of inflammation and endothelial cell activation have been associated with severity of sepsis. We sought to determine the association between these baseline markers and subsequent episodes of sepsis. MATERIALS AND METHODS: We performed a nested case-control analysis using subjects from the REasons for Geographic and Racial Differences in Stroke cohort. We compared 162 sepsis cases (hospitalized for a serious infection with ≥2 systemic inflammatory response syndrome criteria) with 162 nonsepsis controls (hospitalized for a serious infection but not sepsis) matched by age, sex, and observation time epoch. Using conditional logistic regression, we evaluated the associations between sepsis and baseline levels of interleukin-6 (IL-6), tumor necrosis factor α, E-selectin, intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1), adjusting for smoking status, hypertension, and chronic kidney disease. RESULTS: Compared with controls, individuals with higher baseline IL-6, E-selectin, and ICAM-1 were more likely to develop sepsis (P values for trend = .02, .02, .04). Baseline tumor necrosis factor α and ICAM-1 were not associated with future sepsis (P values for trend = .29, .33). CONCLUSIONS: Individuals with higher baseline IL-6, E-selectin, and ICAM-1 were more likely to develop future sepsis episodes. These biomarkers may play a role in the early identification, mitigation, or prevention of sepsis.
Journal of critical care 02/2013; · 2.13 Impact Factor
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C Barrett Bowling,
Paul Muntner,
Brian D Bradbury,
Ryan D Kilpatrick,
John J Isitt,
Amy H Warriner,
Jeffrey R Curtis, Suzanne Judd,
Cynthia J Brown,
Richard M Allman,
David G Warnock,
William McClellan
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ABSTRACT: BACKGROUND:: There are few data available on low hemoglobin and incident falls in the general U.S. population. METHODS:: Of 30,239 black and white U.S. adults ≥45 years in the population-based REasons for Geographic And Racial Differences in Stroke study, 16,782 had hemoglobin measured at baseline and follow-up data on falls. Hemoglobin was categorized by 1.0 g/dL increments relative to the World Health Organization anemia threshold (<13.0 g/dL for men, <12.0 g/dL for women). Recurrent falls (≥2 falls in the 6 months after baseline) were assessed during a telephone interview. RESULTS:: Recurrent falls occurred in 3.9% of men and 4.8% of women. Compared with those with a hemoglobin level 1 to 2 g/dL above the anemia cut-off, multivariable adjusted odds ratios (95% confidence intervals) for recurrent falls associated with hemoglobin levels ≥3, 2 to <3 and 0 to 1 g/dL above the cut-off point, and 0 to <1 and ≥1 g/dL below the cut-off point were 0.73 (0.45-1.19), 0.84 (0.57-1.24), 1.29 (0.88-1.90), 1.32 (0.0.80-1.2.18) and 2.12 (1.23-3.63), respectively, among men (linear trend P < 0.001), and 1.59 (1.10-2.3), 1.24 (0.95-1.62), 1.42(1.11-1.81), 1.28 (0.91-1.80) and 1.76 (1.13-2.74), respectively, among women (linear trend P = 0.45; quadratic trend P = 0.016). CONCLUSIONS:: Among men, lower hemoglobin levels were associated with an increased risk for recurrent falls. Although our findings suggest an increased risk for recurrent falls at both lower and higher hemoglobin levels among women, these findings should be confirmed in subsequent studies.
The American Journal of the Medical Sciences 01/2013; · 1.39 Impact Factor
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ABSTRACT: BACKGROUND: It is not known whether geographic differences in the prevalence of chronic kidney disease exist and are associated with end-stage renal disease (ESRD) incidence rates across the United States. STUDY DESIGN: Cross-sectional and ecologic. SETTING & PARTICIPANTS: White (n = 16,410) and black (n = 11,109) participants from across the continental United States in the population-based Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. PREDICTOR: Geographic region, defined by the 18 networks of the US ESRD Network Program. OUTCOMES & MEASUREMENTS: Albuminuria, defined as albumin-creatinine ratio ≥30 mg/g, and decreased estimated glomerular filtration rate (eGFR), defined as <60 mL/min/1.73 m(2), were measured in the REGARDS Study. ESRD incidence rates were obtained from the US Renal Data System. RESULTS: For whites, the network-specific prevalence of albuminuria ranged from 8.4% (95% CI, 3.3%-13.5%) in Network 15 to 14.8% (95% CI, 8.0%-21.6%) in Network 3, and decreased eGFR ranged from 4.3% (95% CI, 2.0%-6.6%) in Network 4 to 16.7% (95% CI, 12.7%-20.7%) in Network 7. For blacks, the prevalence of albuminuria ranged from 12.1% (95% CI, 8.7%-15.5%) in Network 5 to 26.5% (95% CI, 16.7%-36.3%) in Network 4, and decreased eGFR ranged from 6.7% (95% CI, 5.0%-8.4%) in Network 17/18 to 13.4% (95% CI, 7.8%-19.1%) in Network 12. Spearman correlation coefficients for the prevalence of albuminuria and decreased eGFR with network-specific ESRD incidence rates were 0.49 and 0.24, respectively, for whites and 0.29 and 0.25, respectively, for blacks. LIMITATIONS: There were few cases of albuminuria and decreased eGFR in some geographic regions. CONCLUSIONS: In the United States, substantial geographic variations in the prevalence of albuminuria and decreased eGFR exist, but were correlated only modestly with ESRD incidence, suggesting the chronic kidney disease burden may not explain the geographic variation in ESRD incidence.
American Journal of Kidney Diseases 12/2012; · 5.43 Impact Factor
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ABSTRACT: Albuminuria is an important risk factor for progressive chronic kidney disease (CKD) and is more prevalent in black than white adults. We sought to determine the association between low income and albuminuria and whether this association differs for blacks and whites.
Cross-sectional study.
9,144 black and 13,684 white US adults 45 years and older in the population-based Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.
Self-reported annual household income category (≥$75,000, $35,000-$74,999, $20,000-$34,999, and <$20,000); black and white race.
Albuminuria defined as high (30-300 mg/g) or very high (>300 mg/g) urinary albumin-creatinine ratio (ACR). Multinomial logistic regression used to examine the race-stratified association between categories of income and albuminuria (normal, high, or very high ACR).
Overall, geometric mean ACR was 10.2 mg/g and was higher for blacks (11.8 mg/g) than whites (9.3 mg/g), P < 0.001. Lower income was associated with a higher prevalence of albuminuria for both whites and blacks in unadjusted analyses. After adjustment for demographics, lifestyle factors, comorbid illnesses, and estimated glomerular filtration rate, there was a trend toward a stronger association between lower income levels and high ACR in blacks (ORs of 1.38 [95% CI, 1.07-1.77], 1.36 [95% CI, 1.05-1.75], and 1.58 [95% CI, 1.21-2.05] for income levels of $35,000-$74,999, $20,000-$34,999, and <$20,000, respectively; reference group is those with income ≥$75,000) compared with whites (ORs of 0.95 [95% CI, 0.81-1.12], 0.95 [95% CI, 0.79-1.14], and 1.26 [95% CI, 1.02-1.55], respectively); P interaction = 0.08 between race and income. Results were similar for very high ACR and subgroups of participants with diabetes or hypertension.
Cross-sectional design; not all REGARDS participants provided their annual income.
Lower income may be associated more strongly with albuminuria in blacks than whites and may be a determinant of racial disparities in albuminuria.
American Journal of Kidney Diseases 06/2012; 60(5):779-86. · 5.43 Impact Factor
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ABSTRACT: Few studies have compared different blood pressure (BP) indexes for end-stage renal disease (ESRD) risk among individuals with chronic kidney disease.
We examined the relationship between systolic BP (SBP), diastolic BP (DBP), pulse pressure (PP) and mean arterial pressure (MAP) and ESRD risk among 2,772 participants with an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2) calculated using the Chronic Kidney Disease Epidemiology Collaboration equation in the REasons for the Geographic And Racial Differences in Stroke (REGARDS) study. BP was measured during a baseline study visit between January 2003 and October 2007 with ESRD incidence through August 2009 ascertained via linkage with the United States Renal Data System (n = 138 ESRD cases).
The mean age was 72.1(standard deviation: 8.7) years. After multivariable adjustment for socio-demographic and clinical risk factors including antihypertensive medication use, the hazard ratio (HR) for ESRD associated with one standard deviation higher SBP (18 mm Hg) was 1.67, (95% confidence intervals (CI) 1.43-1.96), DBP (11 mm Hg) was 1.38, (95% CI 1.16-1.63), PP (15 mm Hg) was 1.50, (95% CI 1.27-1.78) and MAP (11 mm Hg) was 1.54, (95% CI 1.32-1.79). Higher levels of SBP remained associated with an increased HR for ESRD after additional adjustment for DBP (1.65, 95% CI: 1.35-2.01), PP (1.73, 95% CI: 1.32-2.26), and MAP (1.61, 95% CI: 1.16-2.23). After adjustment for SBP, the other BP indexes were not significantly associated with incident ESRD.
These data suggest that of several blood pressure indexes including DBP, PP and MAP, SBP may have the strongest association with ESRD incidence among individuals with reduced eGFR.
American Journal of Hypertension 05/2012; 25(7):789-96. · 3.18 Impact Factor
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ABSTRACT: The purpose of this study was to examine the association between prolongation of QT interval corrected for heart rate (QTc) with incident stroke.
Unlike cardiovascular morbidity and mortality, little is known about the relationship between QTc and risk of stroke.
A total of 27,411 participants age 45 years and older without previous stroke from the REGARDS (REasons for Geographic and Racial Differences in Stroke) study were included in this analysis. QTc was calculated using Framingham formula (QTc(Fram)). Stroke cases were identified and adjudicated during up to 8.2 years of follow-up (median, 5.1 years).
The risk of incident stroke in study participants with prolonged QTc(Fram) was almost 3 times the risk in those with normal QTc(Fram) (hazard ratio [HR] [95% confidence interval (CI)]: 2.88 [2.12 to 3.92], p < 0.0001). After adjustment for demographics (age, race, and sex), traditional stroke risk factors (antihypertensive medication use, systolic blood pressure, current smoking, diabetes, left ventricular hypertrophy, atrial fibrillation, and previous cardiovascular disease), warfarin use, aspirin use, QRS duration and use of QTc-prolonging drugs, the risk of stroke remained significantly high (HR [95% CI]: 1.67 [1.16 to 2.41], p = 0.0061) and was consistent across several subgroups of REGARDS study participants. Similar results were obtained when the risk of stroke was estimated per 1-SD increase in QTc(Fram), (HR [95% CI]: 1.12 [1.03 to 1.21], p = 0.0053 in multivariable-adjusted model) and when other QTc correction formulas including those of Hodge, Bazett, and Fridericia were used.
QTc prolongation is associated with a significantly increased risk of incident stroke independent of traditional stroke risk factors. Examining the risk of stroke associated with QTc-prolonging drugs may be warranted.
Journal of the American College of Cardiology 04/2012; 59(16):1460-7. · 14.16 Impact Factor
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ABSTRACT: Few studies have examined the effects of race and region on dietary intakes and the evidence on racial and regional disparities among women is limited. We aimed to examine whether race and region were associated with nutrient intakes among black and white women living in the Stroke Belt, Stroke Buckle, and Other regions in the United States. We hypothesized that significant differences would be observed among population sub-groups and that the effects of race on dietary intakes would vary across regions.
This study included dietary data from 12,105 women from the Reasons for Geographic and Racial Differences in Stroke study (United States). Dietary data were collected using the Block 98 food frequency questionnaire.
Blacks consumed 1.05% lower energy from saturated fat (95% CI: -0.95, -1.16), and intakes were also lower in the Buckle (β = -0.20; 95% CI: -0.08, -0.32) and Belt (β = -0.35; 95% CI: -0.24, -0.46) compared to the Other regions. Within each region, sodium, potassium, and magnesium intakes were all lower among black women compared to white women (P <0.05 for all); intakes were significantly lower among blacks living in the Belt and Buckle compared to those in the Other regions. Significant interactions between race and region were detected for trans fat, calcium, and cholesterol (P <0.05 for all), where black women in the Other regions consumed the lowest dietary cholesterol and calcium while black women in the Belt consumed the lowest trans fat.
Race and region were significantly associated with nutrient intakes in a large study of black and non-Hispanic white women in the United States. Intakes of trans fat, calcium, and cholesterol among black and white women differed across regions. Race and region thus interact to impact dietary intakes, and their effects may be mediated by such factors as the broader food environment and food availability as well as food customs and culture. Race, region, and their correlates should therefore be considered together when examining diet and disease associations and planning dietary advice for population sub-groups.
Nutrition Journal 04/2012; 11:25. · 2.48 Impact Factor
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ABSTRACT: We sought to determine the associations between baseline chronic medical conditions and future risk of sepsis.
Longitudinal cohort study using the 30,239 community-dwelling participants of the REGARDS cohort. We determined associations between baseline chronic medical conditions and incident sepsis episodes, defined as hospitalization for an infection with the presence of infection plus two or more systemic inflammatory response syndrome criteria.
Over the mean observation time of 4.6 years (February 5, 2003 through October 14, 2011), there were 975 incident cases of sepsis. Incident sepsis episodes were associated with older age (p<0.001), white race (HR 1.39; 95% CI: 1.22-1.59), lower education (p<0.001) and income (p<0.001), tobacco use (p<0.001), and alcohol use (p = 0.02). Incident sepsis episodes were associated with baseline chronic lung disease (adjusted HR 2.43; 95% CI: 2.05-2.86), peripheral artery disease (2.16; 1.58-2.95), chronic kidney disease (1.99; 1.73-2.29), myocardial infarction 1.79 (1.49-2.15), diabetes 1.78 (1.53-2.07), stroke 1.67 (1.34-2.07), deep vein thrombosis 1.63 (1.29-2.06), coronary artery disease 1.61 (1.38-1.87), hypertension 1.49 (1.29-1.74), atrial fibrillation 1.48 (1.21-1.81) and dyslipidemia 1.16 (1.01-1.34). Sepsis risk increased with the number of chronic medical conditions (p<0.001).
Individuals with chronic medical conditions are at increased risk of future sepsis events.
PLoS ONE 01/2012; 7(10):e48307. · 4.09 Impact Factor
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ABSTRACT: The contribution of albuminuria to the increased risk of incident end-stage renal disease (ESRD) in individuals with a family history of ESRD has not been well studied.
Prospective cohort study. STUDY SETTING & PARTICIPANTS: We analyzed data for family history of ESRD collected from 19,409 participants of the Renal REGARDS (Reasons for Geographic and Racial Differences in Stroke) cohort study.
Family history of ESRD was ascertained by asking "Has anyone in your immediate family ever been told that he or she had kidney failure? This would be someone who is on or had been on dialysis or someone who had a kidney transplant."
Incidence rate for ESRD.
Morning urine albumin-creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR). Incident cases of ESRD were identified through the US Renal Data System.
A family history of ESRD was reported by 11.1% of participants. Mean eGFRs for those with and without a family history of ESRD were 87.5 ± 22.2 (SD) and 86.5 ± 19.3 mL/min/1.73 m(2), respectively (P = 0.05) and the respective geometric mean ACRs were 12.2 and 9.7 mg/g (P < 0.001). ESRD incidence rates for those with and without a family history of ESRD were 244.3 and 106.1/100,000 person-years, respectively. After adjusting for age, sex, and race, the ESRD HR for those with versus those without a family history of ESRD was 2.13 (95% CI, 1.18-3.83). Adjustment for comorbid conditions and socioeconomic status attenuated this association (HR, 1.82; 95% CI, 1.00-3.28), and further adjustment for baseline eGFR and ACR completely attenuated the association between family history of ESRD and incident ESRD (HR, 1.12; 95% CI, 0.69-1.80).
The report of a family history of ESRD was not validated.
Family history of ESRD is common in older Americans and the increased risk of ESRD associated with a family history reflects lower GFR, higher albuminuria, and comorbid conditions.
American Journal of Kidney Diseases 11/2011; 59(1):25-31. · 5.43 Impact Factor
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ABSTRACT: Previously in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort, we found 18% of the stroke/transient ischemic attack-free study population reported ≥1 stroke symptom at baseline. We sought to evaluate the additional impact of these stroke symptoms on risk for subsequent stroke.
REGARDS recruited 30,239 US blacks and whites, aged 45+ years in 2003 to 2007 who are being followed every 6 months for events. All stroke events are physician-verified; those with prior diagnosed stroke or transient ischemic attack are excluded from this analysis. At baseline, participants were asked 6 questions regarding stroke symptoms. Measured stroke risk factors were components of the Framingham Stroke Risk Score.
After excluding those with prior stroke or missing data, there were 24,412 participants in this analysis with a median follow-up of 4.4 years. Participants were 39% black, 55% female, and had median age of 64 years. There were 381 physician-verified stroke events. The Framingham Stroke Risk Score explained 72.0% of stroke risk; individual components explained between 0.2% (left ventricular hypertrophy) and 5.7% (age+race) of stroke risk. After adjustment for Framingham Stroke Risk Score factors, stroke symptoms were significantly related to stroke risk: for each stroke symptom reported, the risk of stroke increased by 21% per symptom.
Among participants without self-reported stroke or transient ischemic attack, prior stroke symptoms are highly predictive of future stroke events. Compared with Framingham Stroke Risk Score factors, the impact of stroke symptom on the prediction of future stroke was almost as large as the impact of smoking and hypertension and larger than the impact of diabetes and heart disease.
Stroke 09/2011; 42(11):3122-6. · 5.73 Impact Factor
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ABSTRACT: The causes of the increased risk for ESRD among African Americans are not completely understood. Here, we examined whether higher levels of urinary albumin excretion among African Americans contributes to this disparity. We analyzed data from 27,911 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who had urinary albumin-to-creatinine ratio (ACR) and estimated GFR (eGFR) measured at baseline. We identified incident cases of ESRD through linkage with the United States Renal Data System. At baseline, African Americans were less likely to have an eGFR <60 ml/min per 1.73 m(2) but more likely to have an ACR ≥ 30 mg/g. The incidence rates of ESRD among African Americans and whites were 204 and 58.6 cases per 100,000 person-years, respectively. After adjustment for age and gender, African Americans had a fourfold greater risk for developing ESRD (HR 4.0; 95% CI 2.8 to 5.9) compared with whites. Additional adjustment for either eGFR or ACR reduced the risk associated with African-American race to 2.3-fold (95% CI 1.5 to 3.3) or 1.8-fold (95% CI 1.2 to 2.7), respectively. Adjustment for both ACR and eGFR reduced the race-associated risk to 1.6-fold (95% CI 1.1 to 2.4). Finally, in a model that further adjusted for both eGFR and ACR, hypertension, diabetes, family income, and educational status, African-American race associated with a nonsignificant 1.4-fold (95% CI 0.9 to 2.3) higher risk for ESRD. In conclusion, the increased prevalence of albuminuria may be an important contributor to the higher risk for ESRD experienced by African Americans.
Journal of the American Society of Nephrology 08/2011; 22(9):1721-8. · 9.66 Impact Factor
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ABSTRACT: We compared the associations of self-reported atrial fibrillation (AF) and ECG-detected AF with incident stroke in the Risk of Stroke in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.
In this analysis, 27 109 participants aged 45 years or older without previous stroke were included. Stroke cases were identified and adjudicated during an average of 4.4 years of follow-up. Cox proportional hazards analysis was used to calculate hazard ratios (HR) of self-reported AF, ECG-detected AF, and AF detected by either method with incident stroke. We also examined the predictive ability of the Framingham Stroke Risk Score (FSRS) when the component AF was defined by different methods.
After adjustment for components of the FSRS, self-reported AF, ECG-detected AF, and AF by either method were predictive of incident stroke (HR, 1.41; 95% CI, 1.05-1.88; HR, 1.90; 95% CI, 1.10-3.27; HR, 1.53; 95% CI, 1.16-2.01, respectively). When self-report, ECG, or either method, separately, were considered as the method of AF ascertainment in the FSRS, the HR per 1% increase in the FSRS were identical across AF ascertainment methods (HR, 1.04; 95% CI, 1.03-1.04; HR, 1.04; 95% CI, 1.04-1.05; HR, 1.04; 95% CI, 1.03-1.04; respectively).
Self-reported AF is a strong predictor of stroke that can be used interchangeably or in combination with ECG-detected AF in stroke risk prediction models.
Stroke 08/2011; 42(10):2950-3. · 5.73 Impact Factor
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ABSTRACT: It has been suggested that reduced estimated GFR (eGFR) among older adults does not necessarily reflect a pathologic phenomenon.
We examined the association between eGFR and albumin-to-creatinine ratio (ACR) and all-cause mortality stratified by age (45 to 59.9, 60 to 69.9, 70 to 79.9, and ≥80 years) among 24,350 U.S. adults in the population-based REasons for Geographic and Racial Differences in Stroke (REGARDS) study. A spot urine sample was used to calculate ACR, and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation was used to calculate eGFR. All-cause mortality was assessed over a median follow-up of 4.5 years.
Among participants ≥80 years of age (n = 1669), the age, race, gender, and geographic region of residence adjusted hazard ratios (95% confidence intervals) for mortality associated with eGFR levels of 45 to 59.9 and <45 ml/min per 1.73 m(2), versus ≥60 ml/min per 1.73 m(2), were 1.6 (1.3 - 2.1) and 2.2 (1.7 - 2.9), respectively. Also, among participants ≥80 years of age, the hazard ratios for mortality associated with ACR levels of 10 to 29.9, 30 to 299.9, and ≥300 mg/g, versus <10 mg/g, were 1.7 (1.3 - 2.1), 2.5 (1.9 - 3.3), and 5.1 (3.6 - 7.4), respectively. These associations were present after further multivariable adjustment and within the younger age groupings studied.
These data suggest that reduced eGFR and albuminuria confer an increased risk for mortality in all age groups, including adults ≥80 years of age.
Clinical Journal of the American Society of Nephrology 07/2011; 6(9):2200-7. · 5.23 Impact Factor
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ABSTRACT: Obesity management requires understanding the mortality risks associated with different adiposity measures.
Prospective cohort.
5,805 adults with body mass index (BMI) ≥18.5 kg/m(2) and stages 1-4 chronic kidney disease, defined as a spot urine albumin-creatinine ratio ≥30 mg/g and/or estimated glomerular filtration rate <60 mL/min/1.73 m(2), enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.
BMI categorized as 18.5-24.9, 25.0-29.9, 30.0-34.9, 35.0-39.9, and ≥40 kg/m(2) and waist circumference categorized as <80, 80-87.9, 88-97.9, 98-107.9, and ≥108 cm in women and <94, 94-101.9, 102-111.9, 112-121.9, and ≥122 cm in men.
All-cause mortality.
BMI and waist circumference were measured using a standardized protocol during the home visit.
686 (11.8%) deaths occurred during a median follow-up of 4 years. Compared with the referent BMI category of 25-29.9 kg/m(2), HRs for mortality were 1.27 (95% CI, 0.96-1.69) for BMI <25 kg/m(2) and 0.84 (95% CI, 0.62-1.13), 0.81 (95% CI, 0.52-1.26), and 0.95 (95% CI, 0.54-1.65) for BMI categories 30-34.9, 35-39.9, and ≥40 kg/m(2) after adjustment for covariates including waist circumference, respectively. In contrast, after adjustment for covariates including BMI, higher mortality rates were noted for all waist circumference categories compared with the referent (<80 cm in women and <94 cm in men), with HRs of 1.04 (95% CI, 0.77-1.41) for waist circumference of 80-87.9 cm in women and 94-101.9 cm in men, 1.29 (95% CI, 0.92-1.81) for waist circumference of 88-97.9 cm in women and 102-111.9 cm in men, 1.72 (95% CI, 1.12-2.62) for waist circumference of 98-107.9 cm in women and 112-121.9 cm in men, and 2.09 (95% CI, 1.26-3.46) for waist circumference ≥108 cm in women and ≥122 cm in men.
BMI and waist circumference measured at baseline only.
Waist circumference should be considered in conjunction with BMI when assessing mortality risk associated with obesity in adults with chronic kidney disease.
American Journal of Kidney Diseases 05/2011; 58(2):177-85. · 5.43 Impact Factor
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ABSTRACT: A triple-marker approach for chronic kidney disease (CKD) evaluation has not been well studied.
To evaluate whether combining creatinine, cystatin C, and urine albumin-to-creatinine ratio (ACR) would improve identification of risks associated with CKD compared with creatinine alone.
Prospective cohort study involving 26,643 US adults enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study from January 2003 to June 2010. Participants were categorized into 8 groups defined by estimated glomerular filtration rate (GFR) determined by creatinine and by cystatin C of either <60 or ≥60 mL/min/1.73 m(2) and ACR of either <30 or ≥30 mg/g.
All-cause mortality and incident end-stage renal disease with median follow-up of 4.6 years.
Participants had a mean age of 65 years, 40% were black, and 54% were women. Of 26,643 participants, 1940 died and 177 developed end-stage renal disease. Among participants without CKD defined by creatinine, 24% did not have CKD by either ACR or cystatin C. Compared with those with CKD defined by creatinine alone, the hazard ratio for death in multivariable-adjusted models was 3.3 (95% confidence interval [CI], 2.0-5.6) for participants with CKD defined by creatinine and ACR; 3.2 (95% CI, 2.2-4.7) for those with CKD defined by creatinine and cystatin C, and 5.6 (95% CI, 3.9-8.2) for those with CKD defined by all biomarkers. Among participants without CKD defined by creatinine, 3863 (16%) had CKD detected by ACR or cystatin C. Compared with participants who did not have CKD by any measure, the HRs for mortality were 1.7 (95% CI, 1.4-1.9) for participants with CKD defined by ACR alone, 2.2 (95% CI, 1.9-2.7) for participants with CKD defined by cystatin C alone, and 3.0 (95% CI, 2.4-3.7) for participants with CKD defined by both measures. Risk of incident end-stage renal disease was higher among those with CKD defined by all markers (34.1 per 1000 person-years; 95% CI, 28.7-40.5 vs 0.33 per 1000 person-years; 95% CI, 0.05-2.3) for those with CKD defined by creatinine alone. The second highest end-stage renal disease rate was among persons missed by the creatinine measure but detected by both ACR and cystatin C (rate per 1000 person-years, 6.4; 95% CI, 3.6-11.3). Net reclassification improvement for death was 13.3% (P < .001) and for end-stage renal disease was 6.4% (P < .001) after adding estimated GFR cystatin C in fully adjusted models with estimated GFR creatinine and ACR.
Adding cystatin C to the combination of creatinine and ACR measures improved the predictive accuracy for all-cause mortality and end-stage renal disease.
JAMA The Journal of the American Medical Association 04/2011; 305(15):1545-52. · 30.03 Impact Factor
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ABSTRACT: Medication adherence may be a proxy for healthy behaviors and other factors that affect outcomes. Prior studies of the association between placebo adherence and health outcomes have been limited primarily to men enrolled in clinical trials and cardiovascular disease outcomes. We examined associations between adherence to placebo and the risk of fracture, coronary heart disease, cancer, and all-cause mortality in the 2 Women's Health Initiative hormone therapy randomized trials.
Postmenopausal women randomized to placebo with adherence measured at least once were eligible for analysis. Time-varying adherence was assessed by dispensing history and pill counts. Outcome adjudication was based on physician review of medical records. Cox proportional hazards models evaluated the relation between high adherence (≥80%) to placebo and various outcomes, referent to low adherence (<80%).
A total of 13,444 postmenopausal women were under observation for 106,066 person-years. High placebo adherence was inversely associated with most outcomes including hip fracture [hazard ratio (HR), 0.50; 95% confidence interval (CI), 0.33-0.78], myocardial infarction (HR, 0.69; 95% CI, 0.50-0.95), cancer death (HR, 0.60; 95% CI, 0.43-0.82), and all-cause mortality (HR, 0.64; 95% CI, 0.51-0.80) after adjustment for potential confounders. Women with low adherence to placebo were 20% more likely to have low adherence to statins and osteoporosis medications.
In the Women's Health Initiative clinical trials, high adherence to placebo was associated with favorable clinical outcomes and mortality. Until the healthy behaviors and/or other factors for which high adherence is a proxy can be better elucidated, caution is warranted when interpreting the magnitude of benefit of medication adherence.
Medical care 03/2011; 49(5):427-35. · 3.24 Impact Factor
