-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Chronic kidney disease (CKD) is associated with worse outcomes among patients with acute coronary syndrome (ACS). Less is known about the impact of CKD on longitudinal outcomes among clopidogrel treated patients following ACS. METHODS: Using a retrospective cohort design, we identified patients hospitalized with ACS between 10/1/2005 and 1/10/10 at Department of Veterans Affairs (VA) facilities and who were discharged on clopidogrel. Using outpatient serum creatinine values, estimated glomerular filtration rate [eGFR (1.73 ml/min/m2)] was calculated using the CKD-EPI equation. The association between eGFR and mortality, hospitalization for acute myocardial infarction (AMI), and major bleeding were examined using Cox proportional hazards models. RESULTS: Among 7413 patients hospitalized with ACS and discharged taking clopidogrel, 34.5% had eGFR 30--60 and 11.6% had eGFR < 30. During 1-year follow-up after hospital discharge, 10% of the cohort died, 18% were hospitalized for AMI, and 4% had a major bleeding event. Compared to those with eGFR > =60, individuals with eGFR 30--60 (HR 1.45; 95% CI: 1.18-1.76) and < 30 (HR 2.48; 95% CI: 1.97-3.13) had a significantly higher risk of death. A progressive increased risk of AMI hospitalization was associated with declining eGFR: HR 1.20; 95% CI: 1.04-1.37 for eGFR 30--60 and HR 1.47; 95% CI: 1.22-1.78 for eGFR < 30. eGFR < 30 was independently associated with over a 2-fold increased risk in major bleeding (HR 2.09; 95% CI: 1.40-3.12) compared with eGFR > = 60. CONCLUSION: Lower levels of kidney function were associated with higher rates of death, AMI hospitalization, and major bleeding among patients taking clopidogrel after hospitalization for ACS.
BMC Nephrology 05/2013; 14(1):107. · 2.18 Impact Factor
-
American Journal of Kidney Diseases 05/2013; 61(5):694-7. · 5.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND AND OBJECTIVE: Among general populations, a healthy lifestyle has been associated with lower risk of death. This study evaluated this association in individuals with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A total of 2288 participants with CKD (estimated GFR < 60 ml/min per 1.73 m(2) or microalbuminuria) in the Third National Health and Nutrition Examination Survey were included. A weighted healthy lifestyle score was calculated (range, -4 to 15, with 15 indicating healthiest lifestyle) on the basis of the multivariable Cox proportional hazards model regression coefficients of the following lifestyle factors: smoking habit, body mass index (BMI), physical activity, and diet. Main outcome was all-cause mortality, ascertained through December 31, 2006. RESULTS: After median follow-up of 13 years, 1319 participants had died. Compared with individuals in the lowest quartile of weighted healthy lifestyle score, adjusted hazard ratios (95% confidence intervals) of all-cause mortality were 0.53 (0.41-0.68), 0.52 (0.42-0.63), and 0.47 (0.38-0.60) for individuals in the second, third, and fourth quartiles, respectively. Mortality increased 30% among individuals with a BMI of 18.5 to <22 kg/m(2) versus 22 to <25 kg/m(2) (P<0.05); decreased mortality was associated with never-smoking versus current smoking (0.54 [0.41-0.70]) and regular versus no physical activity (0.80 [0.65-0.99]). Diet was not significantly associated with mortality. CONCLUSIONS: Compared with nonadherence, adherence to a healthy lifestyle was associated with lower all-cause mortality risk in CKD. Examination of individual components of the healthy lifestyle score, with adjustment for other components, suggested that the greatest reduction in all-cause mortality was related to nonsmoking.
Clinical Journal of the American Society of Nephrology 03/2013; · 5.23 Impact Factor
-
Rakesh K Mishra,
Yongmei Li,
Christopher Defilippi, Michael J Fischer,
Wei Yang,
Martin Keane,
Jing Chen,
Jiang He,
Radhakrishna Kallem,
Edward J Horwitz,
Mohammad Rafey,
Dominic S Raj,
Alan S Go,
Michael G Shlipak
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Serum cardiac troponin T (cTnT) is associated with increased risk of heart failure and cardiovascular death in several population settings. We evaluated associations of cTnT levels with cardiac structural and functional abnormalities in a cohort of patients with chronic kidney disease (CKD) without heart failure. STUDY DESIGN: Cross-sectional. SETTING & PARTICIPANTS: Chronic Renal Insufficiency Cohort (CRIC; N=3,243) PREDICTOR: The primary predictor was cTnT level. Secondary predictors included demographic and clinical characteristics, hemoglobin level, high-sensitivity C-reactive protein level, and estimated glomerular filtration rate using cystatin C. OUTCOMES: Echocardiography was used to determine left ventricular (LV) mass and LV systolic and diastolic function. MEASUREMENTS: Circulating cTnT was measured in stored sera using the highly sensitive assay. Logistic and linear regression models were used to examine associations of cTnT level with each echocardiographic outcome. RESULTS: cTnT was detectable in 2,735 (84%) persons; median level was 13.3 (IQR, 7.7-23.8) pg/mL. Compared with undetectable cTnT (<3.0 pg/mL), the highest quartile (23.9-738.7 pg/mL) was approximately 2 times as likely to have LV hypertrophy (OR, 2.43; 95% CI, 1.44-4.09) in the fully adjusted model. cTnT level had a more modest association with LV systolic dysfunction; as a log-linear variable, a significant association was present in the fully adjusted model (OR of 1.4 [95% CI, 1.2-1.7] per 1-log unit; P < 0.001). There was no significant independent association between cTnT level and LV diastolic dysfunction. When evaluated as a screening test, cTnT level functioned only modestly for LV hypertrophy and concentric hypertrophy detection (area under the curve, 0.64 for both), with weaker areas under the curve for the other outcomes. LIMITATIONS: The presence of coronary artery disease was not formally assessed using either noninvasive or angiographic techniques in this study. CONCLUSIONS: In this large CKD cohort without heart failure, detectable cTnT had a strong association with LV hypertrophy, a more modest association with LV systolic dysfunction, and no association with diastolic dysfunction. These findings indicate that circulating cTnT levels in patients with CKD are predominantly an indicator of pathologic LV hypertrophy.
American Journal of Kidney Diseases 01/2013; · 5.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In this special feature article, we discuss the development of collaborative care models in chronic disease management and the need for such initiatives in chronic kidney disease (CKD). We identify telemedicine as a potential key element to collaborative care in CKD. Telenephrology-as telemedicine would be referred to as it is applied in CKD-would be comprised of various technology platforms and applications, which are described here. We describe a range of scenarios in which telenephrology would facilitate collaborative care in CKD and how it would be the basis for patient-oriented research to assess improvements in outcomes in the future.
Nephrology Dialysis Transplantation 12/2012; · 3.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Background and Objectives: Chronic kidney disease (CKD) and spinal cord injury and disorders (SCI/D) are common and costly conditions among Veterans. However, little is known about CKD among adults with SCI/D. Methods: We conducted cross-sectional analyses of Veterans with SCI/D across all VA facilities in 2006. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2) and categorized by standard eGFR strata. eGFR was calculated in two ways: (a) the Modification of Diet in Renal Disease (MDRD) equation and (b) the MDRD equation + an empirically derived correction factor for SCI/D (MDRD-SCI/D). Logistic regression models were used to examine the relationship between patient characteristics and CKD. Results: Among 9,333 SCI/D Veterans with an available eGFR, the proportion with CKD was substantially higher based on the MDRD-SCI/D equation (35.2%) than based on the MDRD equation (10.2%). In adjusted analyses, while older age (OR for >65 years = 2.53; 95% CI: 2.21-2.89), female sex (OR 2.18; 95% CI: 1.62-2.92), and a non-traumatic cause for injury (OR 1.39; 95% CI: 1.23-1.57) were associated with an increased odds of CKD, black race (OR 0.64; 95% CI: 0.56-0.72) and a duration of injury of ≥10 years (OR 0.76; 95% CI: 0.67-0.86) were associated with a decreased odds of CKD. Diagnostic codes for CKD and nephrology visits were infrequent for SCI/D Veterans with CKD (27.51 and 6.58%, respectively). Conclusion: Using a recently validated version of the MDRD equation with a correction factor for SCI/D, over 1 in 3 Veterans with SCI/D had CKD, which is more than 3-fold higher than when traditional MDRD estimation is used.
American Journal of Nephrology 12/2012; 36(6):542-548. · 2.54 Impact Factor
-
Claudia M Lora,
Ana C Ricardo,
Carolyn S Brecklin, Michael J Fischer,
Robert T Rosman,
Eunice Carmona,
Amada Lopez,
Manjunath Balaram,
Lisa Nessel,
Kaixiang Kelvin Tao,
Dawei Xie,
John W Kusek,
Alan S Go,
James P Lash
[show abstract]
[hide abstract]
ABSTRACT: Despite the large burden of chronic kidney disease (CKD) in Hispanics, this population has been underrepresented in research studies. We describe the recruitment strategies employed by the Hispanic Chronic Renal Insufficiency Cohort Study, which led to the successful enrollment of a large population of Hispanic adults with CKD into a prospective observational cohort study. Recruitment efforts by bilingual staff focused on community clinics with Hispanic providers in high-density Hispanic neighborhoods in Chicago, academic medical centers, and private nephrology practices. Methods of publicizing the study included church meetings, local Hispanic print media, Spanish television and radio stations, and local health fairs. From October 2005 to July 2008, we recruited 327 Hispanics aged 21-74years with mild-to-moderate CKD as determined by age-specific estimated glomerular filtration rate (eGFR). Of 716 individuals completing a screening visit, 49% did not meet eGFR inclusion criteria and 46% completed a baseline visit. The mean age at enrollment was 57.1 and 67.1% of participants were male. Approximately 75% of enrolled individuals were Mexican American, 15% Puerto Rican, and 10% had other Latin American ancestry. Eighty two percent of participants were Spanish-speakers. Community-based and academic primary care clinics yielded the highest percentage of participants screened (45.9% and 22.4%) and enrolled (38.2% and 24.5%). However, academic and community-based specialty clinics achieved the highest enrollment yield from individuals screened (61.9% to 71.4%). A strategy focused on primary care and nephrology clinics and the use of bilingual recruiters allowed us to overcome barriers to the recruitment of Hispanics with CKD.
Contemporary clinical trials 07/2012; 33(6):1238-44. · 1.51 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Illicit drug use has been associated with chronic kidney disease (CKD) in select populations, but it is unknown whether the same association exists in the general population. By using data from the National Health and Nutrition Examination Survey 2005-2008, we conducted a cross-sectional analysis of 5861 adults who were questioned about illicit drug use, including cocaine, methamphetamines, and heroin, during their lifetime. The primary outcome was CKD as defined by an estimated glomerular filtration rate ≤60 mL/min/1.73 m(2) using the Chronic Kidney Disease Epidemiology Collaboration equation or by microalbuminuria. We also examined the association between illicit drug use and blood pressure (BP) ≥120/80, ≥130/85, and ≥140/90 mm Hg. Logistic regression was used to examine the association between illicit drug use and CKD and BP. Mean estimated glomerular filtration rate was similar between illicit drug users and nonusers (100.7 vs 101.4 mL/min/1.73 m(2), P = 0.4), as was albuminuria (5.7 vs 6.0 mg/g creatinine, P = 0.5). Accordingly, illicit drug use was not significantly associated with CKD in logistic regression models (odds ratio [OR], 0.98; confidence interval [CI], 0.75-1.27) after adjusting for other important factors. However, illicit drug users had higher systolic (120 vs 118 mm Hg, P = 0.04) and diastolic BP (73 vs 71 mm Hg, P = 0.0003) compared with nonusers. Cocaine use was independently associated with BP ≥130/85 mm Hg (OR, 1.24; CI, 1.00-1.54), especially when used more during a lifetime (6-49 times; OR, 1.42; CI, 1.06-1.91). In a representative sample of the US population, illicit drug use was not associated with CKD, but cocaine users were more likely to have elevated BP.
Translational research : the journal of laboratory and clinical medicine. 06/2012;
-
Michael J Fischer,
Dawei Xie,
Neil Jordan,
Willem J Kop,
Marie Krousel-Wood,
Manjula Kurella Tamura,
John W Kusek,
Virginia Ford,
Leigh K Rosen,
Louise Strauss,
Valerie L Teal,
Kristine Yaffe,
Neil R Powe,
James P Lash
[show abstract]
[hide abstract]
ABSTRACT: Depressive symptoms are correlated with poor health outcomes in adults with chronic kidney disease (CKD). The prevalence, severity, and treatment of depressive symptoms and potential risk factors, including level of kidney function, in diverse populations with CKD have not been well studied.
Cross-sectional analysis.
Participants at enrollment into the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC (H-CRIC) Studies. CRIC enrolled Hispanics and non-Hispanics at 7 centers in 2003-2007, and H-CRIC enrolled Hispanics at the University of Illinois in 2005-2008.
Depressive symptoms measured by Beck Depression Inventory (BDI).
Demographic and clinical factors.
Elevated depressive symptoms (BDI score ≥11) and antidepressant medication use.
Of 3,853 participants, 27.4% had evidence of elevated depressive symptoms and 18.2% were using antidepressant medications; 31.0% of persons with elevated depressive symptoms were using antidepressants. The prevalence of elevated depressive symptoms varied by level of kidney function: 23.6% for participants with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m(2) and 33.8% of those with eGFR <30 mL/min/1.73 m(2). Lower eGFR (OR per 10-mL/min/1.73 m(2) decrease, 1.10; 95% CI, 1.04-1.17), and non-Hispanic black race (OR, 1.42; 95% CI, 1.16-1.74) were each associated with increased odds of elevated depressive symptoms after controlling for other factors. In regression analyses incorporating BDI score, whereas female sex was associated with greater odds of antidepressant use, Hispanic ethnicity, non-Hispanic black race, and higher urine albumin levels were associated with decreased odds of antidepressant use (P < 0.05 for each).
Absence of clinical diagnosis of depression and use of nonpharmacologic treatments.
Although elevated depressive symptoms were common in individuals with CKD, use of antidepressant medications is low. Individuals of racial and ethnic minority background and with more advanced CKD had a greater burden of elevated depressive symptoms and lower use of antidepressant medications.
American Journal of Kidney Diseases 04/2012; 60(1):27-38. · 5.43 Impact Factor
-
Anna Porter, Michael J Fischer,
Deborah Brooks,
Marino Bruce,
Jeanne Charleston,
William H Cleveland,
Donna Dowie,
Marquetta Faulkner,
Jennifer Gassman,
Tom Greene,
Leena Hiremath,
Cindy Kendrick,
John W Kusek,
Denyse Thornley-Brown,
Xuelei Wang,
Keith Norris,
Mark Unruh,
James Lash
[show abstract]
[hide abstract]
ABSTRACT: Health-related quality of life (HRQOL) is poorly understood in patients with chronic kidney disease (CKD) prior to end-stage renal disease. The association between psychosocial measures and HRQOL has not been fully explored in CKD, especially in African Americans. We performed a cross-sectional analysis of HRQOL and its association with sociodemographic and psychosocial factors in African Americans with hypertensive CKD. There were 639 participants in the African American Study of Kidney Disease and Hypertension Cohort Study. The Short Form-36 was used to measure HRQOL. The Diener Satisfaction with Life Scale measured life satisfaction, the Beck Depression Inventory-II assessed depression, the Coping Skills Inventory-Short Form measured coping, and the Interpersonal Support Evaluation List-16 was used to measure social support. The mean participant age was 60 years at enrollment, and men comprised 61% of participants. Forty-two percent reported a household income less than $15,000/year. Higher levels of social support, coping skills, and life satisfaction were associated with higher HRQOL, whereas unemployment and depression were associated with lower HRQOL (P < 0.05). A significant positive association between higher estimated glomerular filtration rate (eGFR) was observed with the Physical Health Composite (PHC) score (P = 0.004) but not in the Mental Health Composite (MHC) score (P = 0.24). Unemployment was associated with lower HRQOL, and lower eGFR was associated with lower PHC. African Americans with hypertensive CKD with better social support and coping skills had higher HRQOL. This study demonstrates an association between CKD and low HRQOL, and it highlights the need for longitudinal studies to examine this association in the future.
Translational research : the journal of laboratory and clinical medicine. 01/2012; 159(1):4-11.
-
[show abstract]
[hide abstract]
ABSTRACT: Healthcare for end-stage renal disease (ESRD) is intensive, expensive, and provided in both the public and private sector. Using a societal perspective, we examined healthcare costs and health outcomes for Department of Veterans Affairs (VA) ESRD patients comparing those who received hemodialysis care at VA versus private sector facilities.
Dialysis patients were recruited from 8 VA medical centers from 2001 through 2003 and followed for 12 months in a prospective cohort study. Patient demographics, clinical characteristics, quality of life, healthcare use, and cost data were collected. Healthcare data included utilization (VA), claims (Medicare), and patient self-report. Costs included VA calculated costs, Medicare dialysis facility reports and reimbursement rates, and patient self-report. Multivariable regression was used to compare costs between patients receiving dialysis at VA versus private sector facilities.
The cohort comprised 334 patients: 170 patients in the VA dialysis group and 164 patients in the private sector group. The VA dialysis group had more comorbidities at baseline, outpatient and emergency visits, prescriptions, and longer hospital stays; they also had more conservative anemia management and lower baseline urea reduction ratio (67% vs. 72%; P<0.001), although levels were consistent with guidelines (Kt/V≥1.2). In adjusted analysis, the VA dialysis group had $36,431 higher costs than those in the private sector dialysis group (P<0.001).
Continued research addressing costs and effectiveness of care across public and private sector settings is critical in informing health policy options for patients with complex chronic illnesses such as ESRD.
Medical care 09/2011; 50(2):161-70. · 3.24 Impact Factor
-
Ana C Ricardo,
James P Lash, Michael J Fischer,
Claudia M Lora,
Matthew Budoff,
Martin G Keane,
John W Kusek,
Monica Martinez,
Lisa Nessel,
Thomas Stamos,
Akinlolu Ojo,
Mahboob Rahman,
Elsayed Z Soliman,
Wei Yang,
Harold I Feldman,
Alan S Go
[show abstract]
[hide abstract]
ABSTRACT: Hispanics are the largest minority group in the United States. The leading cause of death in patients with chronic kidney disease (CKD) is cardiovascular disease (CVD), yet little is known about its prevalence among Hispanics with CKD.
We conducted cross-sectional analyses of prevalent self-reported clinical and subclinical measures of CVD among 497 Hispanics, 1638 non-Hispanic Caucasians, and 1650 non-Hispanic African Americans, aged 21 to 74 years, with mild-to-moderate CKD at enrollment in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic CRIC (HCRIC) studies. Measures of subclinical CVD included left ventricular hypertrophy (LVH), coronary artery calcification (CAC), and ankle-brachial index.
Self-reported coronary heart disease (CHD) was lower in Hispanics compared with non-Hispanic Caucasians (18% versus 23%, P = 0.02). Compared with non-Hispanic Caucasians, Hispanics had a lower prevalence of CAC >100 (41% versus 34%, P = 0.03) and CAC >400 (26% versus 19%, P = 0.02). However, after adjusting for sociodemographic factors, these differences were no longer significant. In adjusted analyses, Hispanics had a higher odds of LVH compared with non-Hispanic Caucasians (odds ratio 1.97, 95% confidence interval, 1.22 to 3.17, P = 0.005), and a higher odds of CAC >400 compared with non-Hispanic African Americans (odds ratio, 2.49, 95% confidence interval, 1.11 to 5.58, P = 0.03). Hispanic ethnicity was not independently associated with any other CVD measures.
Prevalent LVH was more common among Hispanics than non-Hispanic Caucasians, and elevated CAC score was more common among Hispanics than non-Hispanic African Americans. Understanding reasons for these racial/ethnic differences and their association with long-term clinical outcomes is needed.
Clinical Journal of the American Society of Nephrology 09/2011; 6(9):2121-31. · 5.23 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Hispanics are the fastest growing minority group in the United States, and compared with non-Hispanic whites, they have a higher incidence of end-stage renal disease. Examining novel factors that may explain this disparity in progression of chronic kidney disease (CKD) in Hispanics is urgently needed. Interpersonal and patient-centered characteristics, including health literacy, acculturation, and social support, have been shown to affect health outcomes in patients with other chronic diseases. However, these characteristics have not been well studied in the context of CKD, particularly in relation to disease knowledge, attitudes, and behaviors. In this report, we examine the potential roles of these factors for CKD progression in Hispanics and propose targeted therapeutic interventions.
American Journal of Kidney Diseases 08/2011; 58(2):282-90. · 5.43 Impact Factor
-
Michael J Fischer,
Alan S Go,
Claudia M Lora,
Lynn Ackerson,
Janet Cohan,
John W Kusek,
Alejandro Mercado,
Akinlolu Ojo,
Ana C Ricardo,
Leigh K Rosen,
Kaixiang Tao,
Dawei Xie,
Harold I Feldman,
James P Lash
[show abstract]
[hide abstract]
ABSTRACT: Little is known regarding chronic kidney disease (CKD) in Hispanics. We compared baseline characteristics of Hispanic participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC (H-CRIC) Studies with non-Hispanic CRIC participants.
Cross-sectional analysis.
Participants were aged 21-74 years with CKD using age-based estimated glomerular filtration rate (eGFR) at enrollment into the CRIC/H-CRIC Studies. H-CRIC included Hispanics recruited at the University of Illinois in 2005-2008, whereas CRIC included Hispanics and non-Hispanics recruited at 7 clinical centers in 2003-2007.
Race/ethnicity.
Blood pressure, angiotensin-converting enzyme (ACE)-inhibitor/angiotensin receptor blocker (ARB) use, and CKD-associated complications.
Demographic characteristics, laboratory data, blood pressure, and medications were assessed using standard techniques and protocols.
Of H-CRIC/CRIC participants, 497 were Hispanic, 1,650 were non-Hispanic black, and 1,638 were non-Hispanic white. Low income and educational attainment were nearly twice as prevalent in Hispanics compared with non-Hispanics (P < 0.01). Hispanics had self-reported diabetes (67%) more frequently than non-Hispanic blacks (51%) and whites (40%; P < 0.01). Blood pressure >130/80 mm Hg was more common in Hispanics (62%) than blacks (57%) and whites (35%; P < 0.05), and abnormalities in hematologic, metabolic, and bone metabolism parameters were more prevalent in Hispanics (P < 0.05), even after stratifying by entry eGFR. Hispanics had the lowest use of ACE inhibitors/ARBs among the high-risk subgroups, including participants with diabetes, proteinuria, and blood pressure >130/80 mm Hg. Mean eGFR was lower in Hispanics (39.6 mL/min/1.73 m(2)) than in blacks (43.7 mL/min/1.73 m(2)) and whites (46.2 mL/min/1.73 m(2)), whereas median proteinuria was higher in Hispanics (protein excretion, 0.72 g/d) than in blacks (0.24 g/d) and whites (0.12 g/d; P < 0.01).
Generalizability; observed associations limited by residual bias and confounding.
Hispanics with CKD in the CRIC/H-CRIC Studies are disproportionately burdened with lower socioeconomic status, more frequent diabetes mellitus, less ACE-inhibitor/ARB use, worse blood pressure control, and more severe CKD and associated complications than their non-Hispanic counterparts.
American Journal of Kidney Diseases 06/2011; 58(2):214-27. · 5.43 Impact Factor
-
Michael J Fischer,
Paul L Kimmel,
Tom Greene,
Jennifer J Gassman,
Xuelei Wang,
Deborah H Brooks,
Jeanne Charleston,
Donna Dowie,
Denyse Thornley-Brown,
Lisa A Cooper,
Marino A Bruce,
John W Kusek,
Keith C Norris,
James P Lash
[show abstract]
[hide abstract]
ABSTRACT: This study was designed to examine the impact of elevated depressive affect on health outcomes among participants with hypertensive chronic kidney disease in the African-American Study of Kidney Disease and Hypertension (AASK) Cohort Study. Elevated depressive affect was defined by Beck Depression Inventory II (BDI-II) thresholds of 11 or more, above 14, and by 5-Unit increments in the score. Cox regression analyses were used to relate cardiovascular death/hospitalization, doubling of serum creatinine/end-stage renal disease, overall hospitalization, and all-cause death to depressive affect evaluated at baseline, the most recent annual visit (time-varying), or average from baseline to the most recent visit (cumulative). Among 628 participants at baseline, 42% had BDI-II scores of 11 or more and 26% had a score above 14. During a 5-year follow-up, the cumulative incidence of cardiovascular death/hospitalization was significantly greater for participants with baseline BDI-II scores of 11 or more compared with those with scores <11. The baseline, time-varying, and cumulative elevated depressive affect were each associated with a significant higher risk of cardiovascular death/hospitalization, especially with a time-varying BDI-II score over 14 (adjusted HR 1.63) but not with the other outcomes. Thus, elevated depressive affect is associated with unfavorable cardiovascular outcomes in African Americans with hypertensive chronic kidney disease.
Kidney International 06/2011; 80(6):670-8. · 6.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Access to nephrology care before initiation of chronic dialysis is associated with improved outcomes after initiation. Less is known about the effect of predialysis nephrology care on healthcare costs and utilization.
We conducted retrospective analyses of elderly patients who initiated dialysis between January 1, 2000 and December 31, 2001 and were eligible for services covered by the Department of Veterans Affairs. We used multivariable generalized linear models to compare healthcare costs for patients who received no predialysis nephrology care during the year before dialysis initiation with those who received low- (1-3 nephrology visits), moderate- (4-6 visits), and high-intensity (>6 visits) nephrology care during this time period.
There were 8022 patients meeting inclusion criteria: 37% received no predialysis nephrology care, while 24% received low, 16% moderate, and 23% high-intensity predialysis nephrology care. During the year after dialysis initiation, patients in these groups spent an average of 52, 40, 31, and 27 days in the hospital (P < 0.001), respectively, and accounted for an average of $103,772, $96,390, $93,336, and $89,961 in total healthcare costs (P < 0.001), respectively. Greater intensity of predialysis nephrology care was associated with lower costs even among patients whose first predialysis nephrology visit was ≤ 3 months before dialysis initiation. Patients with greater predialysis nephrology care also had lower mortality rates during the year after dialysis initiation (43%, 38%, 28%, and 25%, respectively, P < 0.001).
Greater intensity of predialysis nephrology care was associated with fewer hospital days and lower total healthcare costs during the year after dialysis initiation, even though patients survived longer.
Medical care 03/2011; 49(3):248-56. · 3.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Despite the adverse health outcomes with late nephrology referral for patients with chronic kidney disease (CKD), little is known about the underlying mechanisms and reasons for late referral patterns.
We conducted a Medline search for peer-reviewed articles focused on nephrology referral among adults with CKD. We critically reviewed this literature in regard to late nephrology referral, highlighted its shortcomings, and provided a theoretically based framework for future research.
Late referral has been attributed to three key types of factors: primary care provider (PCP), patient, and healthcare system factors. Limited empirical research has pointed to knowledge deficits, perceptions, and preferences by PCPs as well as to knowledge deficits, psychological concerns, and economic concerns by patients. The existing literature is severely limited by retrospective designs, closed-ended surveys, and the absence of a theoretically driven conceptual framework to fully evaluate root causes of this ongoing problem. Social Cognitive Theory may be a particularly well-suited conceptual model for late nephrology referral because important PCP and patient factors correspond to key constructs of this theory.
Future research is needed to delineate pathways underlying reasons for PCPs' late referral patterns and CKD patients' referral nonadherence. Interventions are urgently needed to reduce late referrals and improve the health of patients with CKD.
American Journal of Nephrology 01/2011; 33(1):60-9. · 2.54 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Depression is common in individuals with end-stage renal disease. However, its relationship with earlier stages of chronic kidney disease (CKD) is less well known. In this study, we examined the association between depressive symptoms and CKD.
Cross-sectional analysis of the prevalence and correlates of depressive symptoms were measured by the Patient Health Questionnaire (PHQ-9) among adult participants with CKD in the National Health and Nutrition Examination Survey 2005-2006. CKD was defined according to estimated glomerular filtration rate by Modification of Diet in Renal Disease Study equation of <60 ml/min/1.73 m(2) or the presence of microalbuminuria (≥ 30 mg/g creatinine), using the Kidney Disease Outcomes Quality Initiative classification. A PHQ-9 score ≥ 10 was considered to be indicative of depressive symptoms.
Among 3653 subjects in our study sample, 683 (15.2%) met laboratory criteria for CKD. The prevalence of depressive symptoms was 7% (95% confidence interval [CI] 3.2-10.8%) in subjects with CKD and 6% (95% CI 4.6-7.4%) in subjects without CKD (P = 0.6). In regression analysis, the presence of CKD was not significantly associated with depressive symptoms (adjusted odds ratio = 0.96 [95% CI 0.51, 1.78], P = 0.9).
We found no difference in the prevalence of depressive symptoms among individuals with or without CKD.
International Urology and Nephrology 12/2010; 42(4):1063-8. · 1.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: As the population of the United States ages, the prevalence of age-related chronic conditions such as hypertension and chronic kidney disease (CKD) will also increase. Available studies in nationally representative samples and select outpatient populations indicate that hypertension is very common in older adults with CKD, and despite the use of medication it is often poorly controlled. Generally, less than one-third of the elderly patients with CKD achieve a level of blood pressure control consistent with that of the current guideline recommendations. However, limited evidence is available from observational studies and clinical trials to inform management of hypertension in the elderly population with CKD. The available published data suggest that the relationship between clinical outcomes and the treatment of hypertension among older adults with CKD is complex and distinct from that of their younger counterparts. Larger and more robust analyses are needed for a better understanding of the association between hypertension, its treatment, and clinical events in elderly patients with CKD.
Advances in chronic kidney disease 07/2010; 17(4):329-40. · 2.42 Impact Factor
-
Michael J Fischer,
Paul L Kimmel,
Tom Greene,
Jennifer J Gassman,
Xuelei Wang,
Deborah H Brooks,
Jeanne Charleston,
Donna Dowie,
Denyse Thornley-Brown,
Lisa A Cooper,
Marino A Bruce,
John W Kusek,
Keith C Norris,
James P Lash
[show abstract]
[hide abstract]
ABSTRACT: Depression is common in end-stage renal disease and is associated with poor quality of life and higher mortality; however, little is known about depressive affect in earlier stages of chronic kidney disease. To measure this in a risk group burdened with hypertension and kidney disease, we conducted a cross-sectional analysis of individuals at enrollment in the African American Study of Kidney Disease and Hypertension Cohort Study. Depressive affect was assessed by the Beck Depression Inventory II and quality of life by the Medical Outcomes Study-Short Form and the Satisfaction with Life Scale. Beck Depression scores over 14 were deemed consistent with an increased depressive affect and linear regression analysis was used to identify factors associated with these scores. Among 628 subjects, 166 had scores over 14 but only 34 were prescribed antidepressants. The mean Beck Depression score of 11.0 varied with the estimated glomerular filtration rate (eGFR) from 10.7 (eGFR 50-60) to 16.0 (eGFR stage 5); however, there was no significant independent association between these. Unemployment, low income, and lower quality and satisfaction with life scale scores were independently and significantly associated with a higher Beck Depression score. Thus, our study shows that an increased depressive affect is highly prevalent in African Americans with chronic kidney disease, is infrequently treated with antidepressants, and is associated with poorer quality of life. Sociodemographic factors have especially strong associations with this increased depressive affect. Because this study was conducted in an African-American cohort, its findings may not be generalized to other ethnic groups.
Kidney International 03/2010; 77(11):1010-9. · 6.61 Impact Factor
