[Show abstract][Hide abstract] ABSTRACT: Medication safety in patients with chronic kidney disease (CKD) is a growing concern. This is particularly relevant in older adults due to underlying CKD. Metformin use is contraindicated in patients with abnormal kidney function; however, many patients are potentially prescribed metformin inappropriately. We evaluated the prevalence of CKD among older adults prescribed metformin for type 2 diabetes mellitus using available equations to estimate kidney function and examined demographic characteristics of patients who were potentially inappropriately prescribed metformin.
[Show abstract][Hide abstract] ABSTRACT: Comorbid major depression is associated with adverse health outcomes in patients with diabetes, but little is known regarding its associations with long-term renal outcomes in this population. Furthermore, the impact of minor depression on renal outcomes is not known. This study evaluated associations between depressive symptoms and risk of incident ESRD in a diabetic cohort.
In this prospective, observational cohort study, 3886 ambulatory adults with diabetes were recruited from primary care clinics of a large health maintenance organization in the state of Washington. Demographics, laboratory data, depressive symptoms (based on the Patient Health Questionnaire-9), and patterns of diabetes self-care were collected. Participants were considered depressed if they had the required number of depressive symptoms (≥5 for major or 2-4 for minor depressive symptoms), including depressed mood or anhedonia, >50% of the time for ≥2 weeks and a Patient Health Questionnaire-9 score≥10 for major and ≥5 for minor depressive symptoms. Risk of incident ESRD was estimated using Cox proportional hazards regression, with predialysis death as a competing risk.
During a median follow-up of 8.8 years, 87 patients (2.2%) developed ESRD. Major depressive symptoms were associated with a higher risk of incident ESRD (hazard ratio, 1.85; 95% confidence interval, 1.02 to 3.33) after adjusting for age, sex, race/ethnicity, marital status, education, smoking, body mass index, diabetes duration, hemoglobin A1c, baseline kidney function, microalbuminuria, hypertension, renin-angiotensin system blockers, and adherence to diabetes self-care. Minor depressive symptoms were not significantly associated with incident ESRD (hazard ratio, 1.08; 95% confidence interval, 0.52 to 2.25).
Major depressive symptoms, but not minor depressive symptoms, were associated with a higher risk of incident ESRD over 10 years. Additional studies are needed to determine whether treatment for depression can improve renal outcomes in patients with diabetes.
Clinical Journal of the American Society of Nephrology 03/2014; · 5.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the association between health-related quality of life (HRQOL) and oral health in older U.S. adults with diabetes mellitus (DM).
Data from the U.S. Behavioral Risk Factor Surveillance System 2006, 2008, and 2010.
Nationally representative sample of 70,363 adults aged 65 and older with DM.
Older adults with DM were more likely to report permanent tooth loss due to caries or periodontal disease than those without (82.3% vs 74.3%, P < .001) and less likely to receive dental care in the past year (59.0% vs 70.9%, P < .001). Loss of permanent teeth from caries or periodontal disease was associated with 1.25 times greater odds of worse self-rated general health (95% confidence interval (CI) = 1.13-1.37). Lack of dental care in the preceding 12 months was associated with 1.34 times greater odds of worse self-rated general health (95% CI = 1.25-1.44) than receiving dental care in the preceding 12 months. Poor dentition and longer time since last dental visit were associated with more physically unhealthy days.
Poor dentition and lack of dental care were associated with worse HRQOL in older adults with DM. Further research is needed to determine whether better oral health improves HRQOL in this population.
Journal of the American Geriatrics Society 09/2013; · 3.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Although chronic kidney disease (CKD) is a highly prevalent condition among older adults with diabetes, the associations between health-related quality of life (HRQoL) and severity of CKD in this population are not well understood. The objective of this study was to assess HRQoL and depressive symptoms across estimated glomerular filtration rate (eGFR) stages. STUDY DESIGN: Cross-sectional. SETTING & PARTICIPANTS: 5,805 members of Kaiser Permanente Northern California, 60 years or older with diabetes, from the 2005-2006 Diabetes Study of Northern California (DISTANCE) survey. PREDICTOR: eGFR categories were defined as ≥90 (referent category), 75-89, 60-74, 45-59, 30-44, or ≤29 mL/min/1.73 m(2). OUTCOMES: HRQoL was measured using the modified Short Form-8 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Depressive symptoms were measured using the Patient Health Questionnaire-8. RESULTS: In unadjusted linear regression analyses, physical (PCS) and mental (MCS) HRQoL scores were significantly lower with worsening eGFR level. However, after adjustment for sociodemographics, diabetes duration, obesity, and cardiovascular comorbid conditions and taking into account interactions with proteinuria, none of the eGFR categories was significantly or substantively associated with PCS or MCS score. In both unadjusted and adjusted analyses, higher risk of depressive symptoms was observed in respondents with eGFR ≤29 mL/min/1.73 m(2) (relative risk, 2.02; 95% CI, 1.10-3.71; P < 0.05) compared with the referent group. However, this eGFR-depression relationship was no longer significant after adjusting for hemoglobin level. LIMITATIONS: Participants are part of a single health care delivery system. CONCLUSIONS: Our findings suggest the need for greater attention to and potential interventions for depression in patients with reduced eGFR.
American Journal of Kidney Diseases 06/2013; · 5.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to examine whether patients who received a multicondition collaborative care intervention for chronic illnesses and depression had greater improvement in self-care knowledge and efficacy, and whether greater knowledge and self-efficacy was positively associated with improved target outcomes. A randomized controlled trial with 214 patients with comorbid depression and poorly controlled diabetes and/or coronary heart disease tested a 12-month team-based intervention that combined self-management support and collaborative care management. At 6 and 12 month outcomes the intervention group showed significant improvements over the usual care group in confidence in ability to follow through with medical regimens important to managing their conditions and to maintain lifestyle changes even during times of stress. Improvements in self care-efficacy were significantly related to improvements in depression, and early improvements in confidence to maintain lifestyle changes even during times of stress explained part of the observed subsequent improvements in depression.
Behavioral Medicine 01/2013; 39(1):1-6. · 1.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients with chronic diabetic complications experience high morbidity and mortality. Sex disparities in modifiable factors such as processes of care or self-care activities have not been explored in detail, particularly in these high-risk patients. Sex differences in processes of care and self-care activities were assessed in a cross-sectional analysis of the Pathways Study, an observational cohort of primary care diabetic patients from a managed care organization (N = 4,839). Compared to men, women had decreased odds of dyslipidemia screening (adjusted odds ratio (AOR) 0.73, 95% CI 0.62-0.85), reaching low-density lipoprotein goal (AOR 0.70, 95% CI 0.58-0.86), and statin use (AOR 0.69, 95% CI 0.58-0.81); women had 19% greater odds of reaching hemoglobin A1c <7% (95% CI 1.02-1.41). There were no sex differences in hemoglobin A1c testing, microalbuminuria screening, or angiotensin-converting enzyme inhibitor use. Women were less likely to report regular exercise but had better adherence to healthy diet, glucose monitoring, and self-foot examination compared to men. Patterns of sex differences were consistent in subjects with diabetic complications. Significant sex disparities exist in diabetes process of care measures and self-care, even amongst patients known to have chronic diabetic complications.
Journal of Diabetes Research 01/2013; 2013:575814. · 3.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Home hemodialysis (HD) is an underused dialysis modality in the United States, even though it provides an efficient and probably cost-effective way to provide more frequent or longer dialysis. With the advent of newer home HD systems that are easier for patients to learn, use, and maintain, patient and provider interest in home HD is increasing. Although barriers for providers are similar to those for peritoneal dialysis, home HD requires more extensive patient training, nursing education, and infrastructure support in order to maintain a successful program. In addition, because many physicians and patients do not have experience with home HD, reluctance to start home HD programs is widespread. This in-depth review describes barriers to home HD, focusing on patients, individual physicians and practices, and dialysis facilities, and offers suggestions for how to overcome these barriers and establish a successful home HD program.
Clinical Journal of the American Society of Nephrology 10/2012; · 5.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background/Aims: Women with diabetes experience a disproportionately greater burden of diabetic kidney disease (DKD) risk factors compared to men; however, sex-specific differences in DKD are not well defined. The effect of age on sex differences in DKD is unknown. Methods: We performed a cross-sectional analysis of the prevalence of DKD (eGFR <60 ml/min/1.73 m(2) or microalbuminuria), advanced DKD (eGFR <30 ml/min/1.73 m(2)), and common DKD risk factors in the Pathways Study (n = 4,839), a prospective cohort study of diabetic patients from a managed care setting. Subjects were stratified by age <60 and ≥60 years to examine for differences by age. Logistic regression models examined the association between sex and prevalence of DKD and risk factors. Results: Women of all ages had 28% decreased odds of DKD (OR 0.72, 95% CI 0.62-0.83); however, they had a greater prevalence of advanced DKD (OR 1.67, 95% CI 1.05-2.64), dyslipidemia (OR 1.42, 95% CI 1.16-1.74), and obesity (OR 1.87, 95% CI 1.60-2.20) compared to men. Women had similar odds of hypertension and poor glycemic control as men. Women ≥60 years had increased odds of advanced DKD, hypertension, dyslipidemia, and obesity compared to similarly aged men. Women <60 years had increased odds of obesity compared to their male counterparts. Conclusion: Women with diabetes had an increased prevalence of advanced DKD and common DKD risk factors compared to men and these disparities were most prominent amongst the elderly.
American Journal of Nephrology 09/2012; 36(3):245-251. · 2.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chronic kidney disease is characterized, in part, as a state of decreased production of 1,25-dihydroxyvitamin D (1,25(OH)(2)D); however, this paradigm overlooks the role of vitamin D catabolism. We developed a mass spectrometric assay to quantify serum concentration of 24,25-dihydroxyvitamin D (24,25(OH)(2)D), the first metabolic product of 25-hydroxyvitamin D (25(OH)D) by CYP24A1, and determined its clinical correlates and associated outcomes among 278 participants with chronic kidney disease in the Seattle Kidney Study. For eGFRs of 60 or more, 45-59, 30-44, 15-29, and under 15 ml/min per 1.73 m(2), the mean serum 24,25(OH)(2)D concentrations significantly trended lower from 3.6, 3.2, 2.6, 2.6, to 1.7 ng/ml, respectively. Non-Hispanic black race, diabetes, albuminuria, and lower serum bicarbonate were also independently and significantly associated with lower 24,25(OH)(2)D concentrations. The 24,25(OH)(2)D concentration was more strongly correlated with that of parathyroid hormone than was 25(OH)D or 1,25(OH)(2)D. A 24,25(OH)(2)D concentration below the median was associated with increased risk of mortality in unadjusted analysis, but this was attenuated with adjustment for potential confounding variables. Thus, chronic kidney disease is a state of stagnant vitamin D metabolism characterized by decreases in both 1,25(OH)(2)D production and vitamin D catabolism.Kidney International advance online publication, 30 May 2012; doi:10.1038/ki.2012.193.
Kidney International 05/2012; · 8.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients with depression and poorly controlled diabetes mellitus, coronary heart disease (CHD), or both have higher medical complication rates and higher health care costs, suggesting that more effective care management of psychiatric and medical disease control might also reduce medical service use and enhance quality of life.
To evaluate the cost-effectiveness of a multicondition collaborative treatment program (TEAMcare) compared with usual primary care (UC) in outpatients with depression and poorly controlled diabetes or CHD.
Randomized controlled trial of a systematic care management program aimed at improving depression scores and hemoglobin A(1c) (HbA(1c)), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels.
Fourteen primary care clinics of an integrated health care system.
Population-based screening identified 214 adults with depressive disorder and poorly controlled diabetes or CHD.
Physician-supervised nurses collaborated with primary care physicians to provide treatment of multiple disease risk factors.
Blinded assessments evaluated depressive symptoms, SBP, and HbA(1c) at baseline and at 6, 12, 18, and 24 months. Fasting LDL-C concentration was assessed at baseline and at 12 and 24 months. Health plan accounting records were used to assess medical service costs. Quality-adjusted life-years (QALYs) were assessed using a previously developed regression model based on intervention vs UC differences in HbA(1c), LDL-C, and SBP levels over 24 months.
Over 24 months, compared with UC controls, intervention patients had a mean of 114 (95% CI, 79 to 149) additional depression-free days and an estimated 0.335 (95% CI, -0.18 to 0.85) additional QALYs. Intervention patients also had lower mean outpatient health costs of $594 per patient (95% CI, -$3241 to $2053) relative to UC patients.
For adults with depression and poorly controlled diabetes, CHD, or both, a systematic intervention program aimed at improving depression scores and HbA(1c), SBP, and LDL-C levels seemed to be a high-value program that for no or modest additional cost markedly improved QALYs.
clinicaltrials.gov Identifier: NCT00468676
Archives of general psychiatry 05/2012; 69(5):506-14. · 12.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Medication nonadherence, inconsistent patient self-monitoring, and inadequate treatment adjustment exacerbate poor disease control. In a collaborative, team-based, care management program for complex patients (TEAMcare), we assessed patient and physician behaviors (medication adherence, self-monitoring, and treatment adjustment) in achieving better outcomes for diabetes, coronary heart disease, and depression.
A randomized controlled trial was conducted (2007-2009) in 14 primary care clinics among 214 patients with poorly controlled diabetes (glycated hemoglobin [HbA(1c)] ≥8.5%) or coronary heart disease (blood pressure >140/90 mm Hg or low-density lipoprotein cholesterol >130 mg/dL) with coexisting depression (Patient Health Questionnaire-9 score ≥10). In the TEAMcare program, a nurse care manager collaborated closely with primary care physicians, patients, and consultants to deliver a treat-to-target approach across multiple conditions. Measures included medication initiation, adjustment, adherence, and disease self-monitoring.
Pharmacotherapy initiation and adjustment rates were sixfold higher for antidepressants (relative rate [RR] = 6.20; P <.001), threefold higher for insulin (RR = 2.97; P <.001), and nearly twofold higher for antihypertensive medications (RR = 1.86, P <.001) among TEAMcare relative to usual care patients. Medication adherence did not differ between the 2 groups in any of the 5 therapeutic classes examined at 12 months. TEAMcare patients monitored blood pressure (RR = 3.20; P <.001) and glucose more frequently (RR = 1.28; P = .006).
Frequent and timely treatment adjustment by primary care physicians, along with increased patient self-monitoring, improved control of diabetes, depression, and heart disease, with no change in medication adherence rates. High baseline adherence rates may have exerted a ceiling effect on potential improvements in medication adherence.
The Annals of Family Medicine 01/2012; 10(1):6-14. · 4.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine whether ethnic differences in the incidence of albuminuria are present in patients with diabetes, and to identify social, behavioral, and provider factors that explain ethnic differences.
Survey follow-up design with a race-stratified baseline survey (2005-2006) in diabetic patients from a nonprofit, fully integrated healthcare system in Northern California. We followed the 10,596 respondents (30% whites, 20% blacks, 23% Hispanics, 14% Asians, and 13% Filipinos) without evidence of prevalent albuminuria at baseline.
Incident albuminuria was defined by positive dipstick urinalysis (>1) or urine albumin to creatinine level (>30 mg/g), and confirmed with repeat testing at least 3 months later.
The 27,292 person-years of observation yielded 981 incident albuminuria events. Agestandardized rates of albuminuria (per 1000 person-years) ranged from 13.6 (95% confidence interval [CI] 10.5-17.0) in whites to 27.8 (CI 18.2- 38.3) in blacks. In fully adjusted Cox models, the hazard ratio for blacks (1.22, 95% CI 1.09-1.38), Asians (1.35, 95% CI 1.13-1.61), and Filipinos (1.93, 95% CI 1.61-2.32), but not Hispanics, was significantly greater than it was for whites. In some cases, point estimates changed markedly from the base model when fully adjusted for potential confounders. Moreover, adjustment for an array of potentially mediating factors explained only a small proportion of the observed ethnic disparities.
Despite uniform medical care coverage, Filipinos, blacks, and Asians with diabetes developed albuminuria at higher rates than white and Hispanic adults.
The American journal of managed care 11/2011; 17(11):737-45. · 2.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We examined provider-level factors and reported discrimination in the healthcare setting.
With data from the Diabetes Study of Northern California (DISTANCE) - a race-stratified survey of diabetes patients in Kaiser Permanente Northern California - we analyzed patient-reported racial/ethnic discrimination from providers. Primary exposures were characteristics of the primary care provider (PCP, who coordinates care in this system), including specialty/type, and patient-provider relationship variables, including racial concordance.
Subjects (n=12,151) included 20% black, 20% Latino, 23% Asian, 30% white, and 6% other patients, with 2-8% reporting discrimination by racial/ethnic group. Patients seeing nurse practitioners as their PCP (OR=0.09; 95% CI: 0.01-0.67) and those rating their provider higher on communication (OR=0.70; 95% CI: 0.66-0.74) were less likely to report discrimination, while those with more visits (OR=1.10; 95% CI: 1.03-1.18) were more likely to report discrimination. Racial concordance was not significant once adjusting for patient race/ethnicity.
Among diverse diabetes patients in managed care, provider type and communication were significantly related to patient-reported discrimination.
Given potential negative impacts on patient satisfaction and treatment decisions, future studies should investigate which interpersonal aspects of the provider-patient relationship reduce patient perceptions of unfair treatment.
Patient Education and Counseling 05/2011; 85(3):e216-24. · 2.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Racial/ethnic minority patients are more likely to report experiences with discrimination in the healthcare setting, potentially leading to reduced access to appropriate care; however, few studies evaluate reports of discrimination with objectively measured quality of care indicators.
To evaluate whether patient-reported racial/ethnic discrimination by healthcare providers was associated with evidence of poorer quality care measured by medication intensification. RESEARCH DESIGN AND PARTICIPANTS: Baseline data from the Diabetes Study of Northern California (DISTANCE), a random, race-stratified sample from the Kaiser Permanente Diabetes Registry from 2005-2006, including both survey and medical record data.
Self-reported healthcare provider discrimination (from survey data) and medication intensification (from electronic prescription records) for poorly controlled diabetes patients (A1c ≥9.0%; systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg; low-density lipoprotein (LDL) ≥130 mg/dl).
Of 10,409 eligible patients, 21% had hyperglycemia, 14% had hyperlipidemia, and 32% had hypertension. Of those with hyperglycemia, 59% had their medications intensified, along with 40% with hyperlipidemia, 33% with hypertension, and 47% in poor control of any risk factor. In adjusted log-binomial GEE models, discrimination was not associated with medication intensification [RR = 0.96 (95% CI: 0.74, 1.24) for hyperglycemia, RR = 1.23 (95% CI: 0.93, 1.63) for hyperlipidemia, RR = 1.06 (95% CI: 0.69, 1.61) for hypertension, and RR = 1.08 (95% CI: 0.88, 1.33) for the composite cohort].
We found no evidence that patient-reported healthcare discrimination was associated with less medication intensification. While not associated with this technical aspect of care, discrimination could still be associated with other aspects of care (e.g., patient-centeredness, communication).
Journal of General Internal Medicine 05/2011; 26(10):1138-44. · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To examine whether intensive care unit (ICU) admission is independently associated with increased risk of major depression in patients with diabetes.
This prospective cohort study included 3596 patients with diabetes enrolled in the Pathways Epidemiologic Follow-Up Study, of whom 193 had at least one ICU admission over a 3-year period. We controlled for baseline depressive symptoms, demographics, and clinical characteristics. We examined associations between ICU admission and subsequent major depression using logistic regression.
There were 2624 eligible patients who survived to complete follow-up; 98 had at least one ICU admission. Follow-up assessments occurred at a mean of 16.4 months post-ICU for those who had an ICU admission. At baseline, patients who had an ICU admission tended to be depressed, older, had greater medical comorbidity, and had more diabetic complications. At follow-up, the point prevalence of probable major depression among patients who had an ICU admission was 14% versus 6% among patients without an ICU admission. After multivariate adjustment, ICU admission was independently associated with subsequent probable major depression (Odds Ratio 2.07, 95% confidence interval (1.06-4.06)). Additionally, baseline probable major depression was significantly associated with post-ICU probable major depression.
ICU admission in patients with diabetes is independently associated with subsequent probable major depression. Additional research is needed to identify at-risk patients and potentially modifiable ICU exposures in order to inform future interventional studies with the goal of decreasing the burden of comorbid depression in older patients with diabetes who survive critical illnesses.
International Journal of Geriatric Psychiatry 02/2011; 27(1):22-30. · 2.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We examined possible determinants of self-reported health care discrimination.
We examined survey data from the Diabetes Study of Northern California (DISTANCE), a race-stratified sample of Kaiser diabetes patients. Respondents reported perceived discrimination, and regression models examined socioeconomic, acculturative, and psychosocial correlates.
Subjects (n=17,795) included 20% Blacks, 23% Latinos, 13% East Asians, 11% Filipinos, and 27% Whites. Three percent and 20% reported health care and general discrimination. Health care discrimination was more frequently reported by minorities (ORs ranging from 2.0 to 2.9 compared with Whites) and those with poorer health literacy (OR=1.10, 95% CI: 1.04-1.16), limited English proficiency (OR=1.91, 95% CI: 1.32-2.78), and depression (OR=1.53, 95% CI: 1.10-2.13).
In addition to race/ethnicity, health literacy and English proficiency may be bases of discrimination. Evaluation is needed to determine whether patients are treated differently or more apt to perceive discrimination, and whether depression fosters and/or follows perceived discrimination.
Journal of Health Care for the Poor and Underserved 02/2011; 22(1):211-25. · 1.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the effectiveness of integrated care for chronic physical diseases and depression in reducing disability and improving quality of life.
A randomised controlled trial of multi-condition collaborative care for depression and poorly controlled diabetes and/or risk factors for coronary heart disease compared with usual care among middle aged and elderly people
Fourteen primary care clinics in Seattle, Washington.
Patients with diabetes or coronary heart disease, or both, and blood pressure above 140/90 mm Hg, low density lipoprotein concentration >3.37 mmol/L, or glycated haemoglobin 8.5% or higher, and PHQ-9 depression scores of ≥ 10.
A 12 month intervention to improve depression, glycaemic control, blood pressure, and lipid control by integrating a "treat to target" programme for diabetes and risk factors for coronary heart disease with collaborative care for depression. The intervention combined self management support, monitoring of disease control, and pharmacotherapy to control depression, hyperglycaemia, hypertension, and hyperlipidaemia.
Social role disability (Sheehan disability scale), global quality of life rating, and World Health Organization disability assessment schedule (WHODAS-2) scales to measure disabilities in activities of daily living (mobility, self care, household maintenance).
Of 214 patients enrolled (106 intervention and 108 usual care), disability and quality of life measures were obtained for 97 intervention patients at six months (92%) and 92 at 12 months (87%), and for 96 usual care patients at six months (89%) and 92 at 12 months (85%). Improvements from baseline on the Sheehan disability scale (-0.9, 95% confidence interval -1.5 to -0.2; P = 0.006) and global quality of life rating (0.7, 0.2 to 1.2; P = 0.005) were significantly greater at six and 12 months in patients in the intervention group. There was a trend toward greater improvement in disabilities in activities of daily living (-1.5, -3.3 to 0.4; P = 0.10).
Integrated care that covers chronic physical disease and comorbid depression can reduce social role disability and enhance global quality of life. Trial registration Clinical Trials NCT00468676.
[Show abstract][Hide abstract] ABSTRACT: Sudden cardiac arrest (SCA) is a leading cause of cardiac-associated mortality in dialysis patients. Risk factors unique to hemodialysis patients include abnormal electrolytes, large-volume ultrafiltration, and prior history of cardiac disease. Few randomized controlled trials of standard cardiac interventions have been completed in dialysis patients. Observational studies suggest that modification of the dialysis prescription may be one place to intervene. Prospective research is needed to determine mechanisms of SCA in hemodialysis patients.
Kidney International 01/2011; 79(2):147-9. · 8.52 Impact Factor