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ABSTRACT: OBJECTIVE: The objective of this study was to determine the prevalence of phosphorus-containing food additives in best-selling processed grocery products and to compare the phosphorus content of a subset of top-selling foods with and without phosphorus additives. DESIGN: The labels of 2394 best-selling branded grocery products in northeast Ohio were reviewed for phosphorus additives. The top 5 best-selling products containing phosphorus additives from each food category were matched with similar products without phosphorus additives and analyzed for phosphorus content. Four days of sample meals consisting of foods with and without phosphorus additives were created, and daily phosphorus and pricing differentials were computed. MAIN OUTCOME MEASURES: Presence of phosphorus-containing food additives, phosphorus content. RESULTS: Forty-four percent of the best-selling grocery items contained phosphorus additives. The additives were particularly common in prepared frozen foods (72%), dry food mixes (70%), packaged meat (65%), bread and baked goods (57%), soup (54%), and yogurt (51%) categories. Phosphorus additive-containing foods averaged 67 mg phosphorus/100 g more than matched nonadditive-containing foods (P = .03). Sample meals comprised mostly of phosphorus additive-containing foods had 736 mg more phosphorus per day compared with meals consisting of only additive-free foods. Phosphorus additive-free meals cost an average of $2.00 more per day. CONCLUSION: Phosphorus additives are common in best-selling processed groceries and contribute significantly to their phosphorus content. Moreover, phosphorus additive foods are less costly than phosphorus additive-free foods. As a result, persons with chronic kidney disease may purchase these popular low-cost groceries and unknowingly increase their intake of highly bioavailable phosphorus.
Journal of Renal Nutrition 02/2013; · 1.57 Impact Factor
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ABSTRACT: Because hemodialysis treatment has a limited ability to remove phosphorus, dialysis patients must restrict dietary phosphorus intake and use phosphorus binding medication. Among patients with restricted dietary phosphorus intake (1000 mg/d), phosphorus binders must bind about 250 mg of excess phosphorus per day and among patients with more typical phosphorus intake (1500 mg/d), binders must bind about 750 mg/d. To determine the phosphorus binding capacity of binder prescriptions among American hemodialysis patients, we undertook a cross-sectional study of a random sample of in-center chronic hemodialysis patients. We obtained data for one randomly selected patient from 244 facilities nationwide. About one-third of the patients had hyperphosphatemia (serum phosphorus level > 5.5 mg/dL). Among the 224 patients prescribed binders, the mean phosphorus binding capacity was 256 mg/d [standard deviation (SD) 143]. A total of 59% of prescriptions had insufficient binding capacity for restricted dietary phosphorus intake, and 100% had insufficient binding capacity for typical dietary phosphorus intake. Patients using two binders had a higher binding capacity than patients using one binder (451 vs. 236 mg/d, p < 0.001). A majority of binder prescriptions have insufficient binding capacity to maintain phosphorus balance. Use of two binders results in higher binder capacity. Further work is needed to understand the impact of binder prescriptions on mineral balance and metabolism and to determine the value of substantially increasing binder prescriptions.
Renal Failure 09/2012; 34(10):1258-63. · 0.82 Impact Factor
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Catherine Sullivan,
Janeen B Leon,
Srilekha S Sayre,
Marquisha Marbury,
Michael Ivers,
Julie A Pencak,
Kenneth A Bodziak,
Donald E Hricik,
E Janie Morrison,
Jeffrey M Albert,
Sankar D Navaneethan,
Christina M Delos Reyes, Ashwini R Sehgal
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ABSTRACT: Many patients with ESRD, particularly minorities and women, face barriers in completing the steps required to obtain a transplant. These eight sequential steps are as follows: medical suitability, interest in transplant, referral to a transplant center, first visit to center, transplant workup, successful candidate, waiting list or identify living donor, and receive transplant. This study sought to determine the effect of navigators on completion of steps.
Cluster randomized, controlled trial at 23 Ohio hemodialysis facilities. One hundred sixty-seven patients were recruited between January 2009 and August 2009 and were followed for up to 24 months or until study end in February 2011. Trained kidney transplant recipients met monthly with intervention participants (n=92), determined their step in the transplant process, and provided tailored information and assistance in completing the step. Control participants (n=75) continued to receive usual care. The primary outcome was the number of transplant process steps completed.
Starting step did not significantly differ between the two groups. By the end of the trial, intervention participants completed more than twice as many steps as control participants (3.5 versus 1.6 steps; difference, 1.9 steps; 95% confidence interval, 1.3-2.5 steps). The effect of the intervention on step completion was similar across race and sex subgroups.
Use of trained transplant recipients as navigators resulted in increased completion of transplant process steps.
Clinical Journal of the American Society of Nephrology 07/2012; 7(10):1639-45. · 5.23 Impact Factor
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ABSTRACT: Observational studies have reported an association between metabolic syndrome (MetS) and microalbuminuria or proteinuria and chronic kidney disease (CKD) with varying risk estimates. We aimed to systematically review the association between MetS, its components, and development of microalbuminuria or proteinuria and CKD. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS AND POPULATION: We searched MEDLINE (1966 to October 2010), SCOPUS, and the Web of Science for prospective cohort confidence interval (CI) studies that reported the development of microalbuminuria or proteinuria and/or CKD in participants with MetS. Risk estimates for eGFR <60 ml/min per 1.73 m(2) were extracted from individual studies and pooled using a random effects model. The results for proteinuria outcomes were not pooled because of the small number of studies.
Eleven studies (n = 30,146) were included. MetS was significantly associated with the development of eGFR <60 ml/min per 1.73 m(2) (odds ratio, 1.55; 95% CI, 1.34, 1.80). The strength of this association seemed to increase as the number of components of MetS increased (trend P value = 0.02). In patients with MetS, the odds ratios (95% CI) for development of eGFR <60 ml/min per 1.73 m(2) for individual components of MetS were: elevated blood pressure 1.61 (1.29, 2.01), elevated triglycerides 1.27 (1.11, 1.46), low HDL cholesterol 1.23 (1.12, 1.36), abdominal obesity 1.19 (1.05, 1.34), and impaired fasting glucose 1.14 (1.03, 1.26). Three studies reported an increased risk for development of microalbuminuria or overt proteinuria with MetS.
MetS and its components are associated with the development of eGFR <60 ml/min per 1.73 m(2) and microalbuminuria or overt proteinuria.
Clinical Journal of the American Society of Nephrology 08/2011; 6(10):2364-73. · 5.23 Impact Factor
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Manjula Kurella Tamura,
Dawei Xie,
Kristine Yaffe,
Debbie L Cohen,
Valerie Teal,
Scott E Kasner,
Steven R Messé, Ashwini R Sehgal,
John Kusek,
Karen B DeSalvo,
Denise Cornish-Zirker,
Janet Cohan,
Stephen L Seliger,
Glenn M Chertow,
Alan S Go
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ABSTRACT: Cognitive impairment is common among persons with chronic kidney disease, but the extent to which nontraditional vascular risk factors mediate this association is unclear.
We conducted cross-sectional analyses of baseline data collected from adults with chronic kidney disease participating in the Chronic Renal Insufficiency Cohort study. Cognitive impairment was defined as a Modified Mini-Mental State Exam score>1 SD below the mean score.
Among 3591 participants, the mean age was 58.2±11.0 years, and the mean estimated GFR (eGFR) was 43.4±13.5 ml/min per 1.73 m2. Cognitive impairment was present in 13%. After adjustment for demographic characteristics, prevalent vascular disease (stroke, coronary artery disease, and peripheral arterial disease) and traditional vascular risk factors (diabetes, hypertension, smoking, and elevated cholesterol), an eGFR<30 ml/min per 1.73 m2 was associated with a 47% increased odds of cognitive impairment (odds ratio 1.47, 95% confidence interval 1.05, 2.05) relative to those with an eGFR 45 to 59 ml/min per 1.73 m2. This association was attenuated and no longer significant after adjustment for hemoglobin concentration. While other nontraditional vascular risk factors including C-reactive protein, homocysteine, serum albumin, and albuminuria were correlated with cognitive impairment in unadjusted analyses, they were not significantly associated with cognitive impairment after adjustment for eGFR and other confounders.
The prevalence of cognitive impairment was higher among those with lower eGFR, independent of traditional vascular risk factors. This association may be explained in part by anemia.
Clinical Journal of the American Society of Nephrology 10/2010; 6(2):248-56. · 5.23 Impact Factor
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Ashwini R Sehgal
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ABSTRACT: U.S. News & World Report's annual rankings of the top 50 American hospitals in 12 specialties are based on a combination of subjective and objective measures of quality. Although the rankings have been criticized for emphasizing the subjective reputation of hospitals too strongly, the role of reputation in determining the relative standings of the top 50 hospitals has not been quantified.
To quantify the role of reputation in determining the relative standings of the top 50 hospitals in the 2009 edition of U.S. News & World Report's rankings.
Cross-sectional study.
The top 50 hospitals in each of 12 specialties.
Rankings based on the total U.S. News score and on a subjective reputation score.
On average, rankings based on reputation score alone agreed with U.S. News & World Report's overall rankings 100% of the time for the top hospital in each specialty, 97% for the top 5 hospitals, 91% for the top 10 hospitals, and 89% for the top 20 hospitals. Hospital reputation was minimally associated with objective quality measures (mean Spearman rho(2) = 0.03).
The findings apply primarily to interpretations about the relative standings of the 50 top-ranked hospitals in each specialty and not necessarily to the hundreds of unranked hospitals.
The relative standings of the top 50 hospitals largely reflect the subjective reputations of those hospitals. Moreover, little relationship exists between subjective reputation and objective measures of hospital quality among the top 50 hospitals.
None.
Annals of internal medicine 04/2010; 152(8):521-5. · 16.73 Impact Factor
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ABSTRACT: Hepatorenal syndrome (HRS) is a common complication in patients with cirrhosis or fulminant liver failure. We systematically reviewed the benefits and harms of using terlipressin, a novel vasoconstricting agent in patients with HRS.
We searched MEDLINE, SCOPUS, and conference proceedings for relevant trials of terlipressin. Results were summarized using the random-effects model.
Eight trials (320 participants) were included. When compared with placebo, terlipressin-treated patients had higher HRS reversal (odds ratio [OR] 7.47, 95% confidence interval [CI] 3.17-17.59), mean arterial pressure (weighted mean difference [WMD] 11.26 mmHg, 95% CI 1.52-21), and urine output. There was a significant increase in ischemic adverse events with terlipressin when compared to placebo. There was mild-to-moderate heterogeneity in these analyses. There was no significant difference between terlipressin and noradrenaline in HRS reversal (OR 1.23, 95% CI, 0.43-3.54), mean arterial pressure, and urine output. Side-effect profile did not differ between terlipressin and noradrenaline.
Terlipressin improves HRS reversal and other surrogate outcome measures compared with placebo, but no significant differences for these outcomes were noted when comparing terlipressin and noradrenaline. Terlipressin is a potential therapeutic option for HRS, but larger trials comparing terlipressin to other widely used vasoconstrictors are warranted.
International Urology and Nephrology 03/2010; 43(1):175-84. · 1.47 Impact Factor
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Kristine Yaffe,
Lynn Ackerson,
Manjula Kurella Tamura,
Patti Le Blanc,
John W Kusek, Ashwini R Sehgal,
Debbie Cohen,
Cheryl Anderson,
Lawrence Appel,
Karen Desalvo,
Akinlolu Ojo,
Stephen Seliger,
Nancy Robinson,
Gail Makos,
Alan S Go
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ABSTRACT: To investigate cognitive impairment in older, ethnically diverse individuals with a broad range of kidney function, to evaluate a spectrum of cognitive domains, and to determine whether the relationship between chronic kidney disease (CKD) and cognitive function is independent of demographic and clinical factors.
Cross-sectional.
Chronic Renal Insufficiency Cohort Study.
Eight hundred twenty-five adults aged 55 and older with CKD.
Estimated glomerular filtration rate (eGFR, mL/min per 1.73 m(2)) was estimated using the four-variable Modification of Diet in Renal Disease equation. Cognitive scores on six cognitive tests were compared across eGFR strata using linear regression; multivariable logistic regression was used to examine level of CKD and clinically significant cognitive impairment (score < or =1 standard deviations from the mean).
Mean age of the participants was 64.9, 50.4% were male, and 44.5% were black. After multivariable adjustment, participants with lower eGFR had lower cognitive scores on most cognitive domains (P<.05). In addition, participants with advanced CKD (eGFR<30) were more likely to have clinically significant cognitive impairment on global cognition (adjusted odds ratio (AOR) 2.0, 95% CI=1.1-3.9), naming (AOR=1.9, 95% CI=1.0-3.3), attention (AOR=2.4, 95% CI=1.3-4.5), executive function (AOR=2.5, 95% CI=1.9-4.4), and delayed memory (AOR=1.5, 95% CI=0.9-2.6) but not on category fluency (AOR=1.1, 95% CI=0.6-2.0) than those with mild to moderate CKD (eGFR 45-59).
In older adults with CKD, lower level of kidney function was associated with lower cognitive function on most domains. These results suggest that older patients with advanced CKD should be screened for cognitive impairment.
Journal of the American Geriatrics Society 02/2010; 58(2):338-45. · 3.74 Impact Factor
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Seminars in Nephrology 01/2010; 30(1):1-2. · 2.12 Impact Factor
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ABSTRACT: Self-care for kidney transplantation is recommended to maintain kidney function. Little is known about levels of self-care practices and demographic, psychosocial, and health-related correlates.
To investigate patients' self-reported exercise and fluid intake, demographic and psychosocial factors associated with these self-care practices, and health-related quality of life.
Eighty-eight of 158 kidney recipients from two academic medical centers completed a semi-structured interview and surveys 2 months post-transplant.
Most patients were sedentary (76%) with a quarter exercising either regularly (11%) or not at current recommendations (13%). One-third (35%) reported drinking the recommended 3 L of fluid daily. Multivariate analyses indicated that private insurance, high self-efficacy, and better physical functioning were significantly associated with engaging in physical activity (p < 0.05); while male gender, private insurance, high self-efficacy, and not attributing oneself responsible for transplant success were significant predictors of adherence to fluid intake (p < 0.05). Despite the significance of these predictors, models for physical activity and fluid intake explained 10-15% of the overall variance in these behaviors. Multivariate analyses indicated that younger age, high value of exercise, and higher social functioning significantly (p < 0.05) predicted high self-efficacy for physical activity, while being married significantly (p < 0.05) predicted high self-efficacy for fluid intake.
Identifying patients at risk of inadequate self-care practice is essential for educating patients about the importance of self-care.
Clinical Transplantation 11/2009; 24(3):E69-81. · 1.67 Impact Factor
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ABSTRACT: Self-care is recommended to kidney transplant recipients as a vital component to maintain long-term graft function. However, little is known about the effects of physical activity, fluid intake, and smoking history on graft function. This longitudinal study examined the relationship between self-care practices on graft function among 88 new kidney transplant recipients in Chicago, IL and Albany, NY between 2005 and 2008. Participants were interviewed, completed surveys, and medical charts were abstracted. Physical activity, fluid intake, and smoking history at baseline were compared with changes in estimated glomerular filtration rate (eGFR) (every 6 months up to 1 year) using bivariate and multivariate regression analysis, while controlling for sociodemographic and clinical transplant variables. Multivariate analyses revealed that greater physical activity was significantly (P < 0.05) associated with improvement in GFR at 6 months; while greater physical activity, absence of smoking history, and nonwhite ethnicity were significant (P < 0.05) predictors of improvement in GFR at 12 months. These results suggest that increasing physical activity levels in kidney recipients may be an effective behavioral measure to help ensure graft functioning. Our findings suggest the need for a randomized controlled trial of exercise, fluid intake, and smoking history on GFR beyond 12 months.
Transplant International 08/2009; 22(10):990-8. · 2.92 Impact Factor
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ABSTRACT: Waiting times to deceased-donor transplantation (DDTx) have significantly increased in the past decade. This trend particularly affects older candidates given a high mortality rate on dialysis.
We conducted a retrospective analysis from the national Scientific Registry of Transplant Recipients database that included 54,669 candidates who were older than 60 yr and listed in the United States for a solitary kidney transplant from 1995 through 2007. Using survival models, we estimated time to DDTx and mortality after candidate listing with and without patients initially listed as temporarily inactive (status 7).
Almost half (46%) of candidates who were older than 60 yr and listed in 2006 through 2007 are projected to die before receiving a DDTx. This proportion varied by individual characteristics: Diabetes (61%), age > or =70 yr (52%), black (62%), blood types O (60%) and B (71%), highly sensitized (68%), and on dialysis at listing (53%). Marked variation also existed by United Network for Organ Sharing region (6 to 81%). The overall projected proportion was reduced to 35% excluding patients who initially were listed as status 7.
These data highlight the prominent and growing challenge facing the field of kidney transplantation. Older candidates are now at significant risk for not surviving the interval in which a deceased-donor transplant would become available. Importantly, this risk is variable within this population, and specific information should be disseminated to patients and caregivers to facilitate informed decision-making and potential incentives to seek living donors.
Clinical Journal of the American Society of Nephrology 06/2009; 4(7):1239-45. · 5.23 Impact Factor
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ABSTRACT: Addition of aldosterone antagonists (AA) might provide renal benefits to proteinuric chronic kidney disease (CKD) patients over and above the inhibition of renin-angiotensin system blockers (RAS). We evaluated the benefits and harms of adding selective and nonselective AA in CKD patients already on RAS.
MEDLINE, EMBASE, and Renal Health Library were searched for relevant randomized clinical trials in adult CKD patients. Results were summarized using the random-effects model.
Eleven trials (991 patients) were included. In comparison to angiotensin- converting enzyme inhibitors (ACEi) and/or angiotensin receptor blockers (ARB) plus placebo, nonselective AA along with ACEi and/or ARB significantly reduced 24 h proteinuria (seven trials, 372 patients, weighted mean difference [WMD] -0.80 g, 95% CI -1.27, -0.33) and BP. This did not translate into an improvement in GFR (WMD -0.70 ml/min/1.73m(2), 95% CI -4.73, 3.34). There was a significant increase in the risk of hyperkalemia with the addition of nonselective AA to ACEi and/or ARB (relative risk 3.06, 95% CI 1.26, 7.41). In two trials, addition of selective AA to ACEi resulted in an additional reduction in 24 h proteinuria, without any impact on BP and renal function. Data on cardiovascular outcomes, long-term renal outcomes and mortality were not available in any of the trials.
Aldosterone antagonists reduce proteinuria in CKD patients already on ACEis and ARBs but increase the risk of hyperkalemia. Long-term effects of these agents on renal outcomes, mortality, and safety need to be established.
Clinical Journal of the American Society of Nephrology 03/2009; 4(3):542-51. · 5.23 Impact Factor
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ABSTRACT: High dietary phosphorus intake has deleterious consequences for renal patients and is possibly harmful for the general public as well. To prevent hyperphosphatemia, patients with end-stage renal disease limit their intake of foods that are naturally high in phosphorus. However, phosphorus-containing additives are increasingly being added to processed and fast foods. The effect of such additives on serum phosphorus levels is unclear.
To determine the effect of limiting the intake of phosphorus-containing food additives on serum phosphorus levels among patients with end-stage renal disease.
Cluster randomized controlled trial at 14 long-term hemodialysis facilities in northeast Ohio. Two hundred seventy-nine patients with elevated baseline serum phosphorus levels (>5.5 mg/dL) were recruited between May and October 2007. Two shifts at each of 12 large facilities and 1 shift at each of 2 small facilities were randomly assigned to an intervention or control group.
Intervention participants (n=145) received education on avoiding foods with phosphorus additives when purchasing groceries or visiting fast food restaurants. Control participants (n=134) continued to receive usual care.
Change in serum phosphorus level after 3 months.
At baseline, there was no significant difference in serum phosphorus levels between the 2 groups. After 3 months, the decline in serum phosphorus levels was 0.6 mg/dL larger among intervention vs control participants (95% confidence interval, -1.0 to -0.1 mg/dL). Intervention participants also had statistically significant increases in reading ingredient lists (P<.001) and nutrition facts labels (P = .04) but no significant increase in food knowledge scores (P = .13).
Educating end-stage renal disease patients to avoid phosphorus-containing food additives resulted in modest improvements in hyperphosphatemia.
clinicaltrials.gov Identifier: NCT00583570.
JAMA The Journal of the American Medical Association 02/2009; 301(6):629-35. · 30.03 Impact Factor
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ABSTRACT: Treatment with angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) is increasingly used to reduce proteinuria and retard the progression of chronic kidney disease (CKD). But some patients do not attain complete resolution of proteinuria and might have higher aldosterone levels within few months of treatment. The addition of aldosterone antagonists may be beneficial to these patients for reduction of progression of renal damage.
We evaluated the benefits and harms of adding aldosterone antagonists in patients with CKD currently treated with ACEi and/or ARB.
We searched MEDLINE, EMBASE, CENTRAL, and hand-searched reference lists of textbooks, articles and scientific proceedings for relevant articles.
Randomised controlled trials (RCTs) and quasi-RCTs comparing aldosterone antagonists in addition to ACEi and/or ARB versus ACEi and/or ARB alone were included.
Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and heterogeneity was tested formally using the Cochran Q and I(2) statistic. Results were expressed as mean difference (MD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes with 95% confidence intervals (CI).
Ten studies (845 patients) were included. Compared to ACEi and/or ARB plus placebo, non-selective aldosterone antagonists along with ACEi and/or ARB significantly reduced 24 hour proteinuria (7 studies, 372 patients; MD -0.80 g, 95% CI -1.23 to -0.38). There was a significant reduction in both systolic and diastolic blood pressure at the end of treatment with the addition of non-selective aldosterone antagonists to ACEi and/or ARB. This did not translate into an improvement in glomerular filtration rate (5 studies, 306 patients; MD -0.70 mL/min/1.73 m(2), 95% CI -4.73 to 3.34). There was a significant increase in the risk of hyperkalaemia with the addition of non-selective aldosterone antagonists to ACEi and/or ARB (8 studies, 436 patients; RR 3.06, 95% CI 1.26 to 7.41). In two studies, the addition of selective aldosterone antagonists to ACEi resulted in an additional reduction in 24 hour proteinuria but without any impact on BP and renal function. Data on cardiovascular outcomes, long-term renal outcomes and mortality were not available.
Aldosterone antagonists contribute to reduction of proteinuria in patients with CKD who are already on ACEi and ARB but increase the risk of hyperkalaemia. Available studies are small and have short follow-up. Long-term effects on renal outcomes, mortality and safety are unknown.
Cochrane database of systematic reviews (Online) 02/2009; · 5.72 Impact Factor
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ABSTRACT: Medication adherence is essential for the survival of kidney grafts, however, the complexity of the medication-taking regimen makes adherence difficult. Little is known about barriers to medication-taking and strategies to foster medication-taking. This cross-sectional study involved semi-structured interviews with 82 kidney transplant recipients approximately 2 months post-transplant on medication-related adherence, barriers to medication-taking, and strategies to foster medication-taking. Although self-reported adherence was high (88%), qualitative analysis revealed that half of the patients (49%) reported experiencing at least one barrier to medication-taking. The most common barriers were: not remembering to refill prescriptions (13%), changes to medication prescriptions or dosages (13%), being busy (10%), forgetting to bring medicines with them (10%), and being away from home (10%). The most common strategies to foster medication-taking were: maintaining a schedule of medication-taking (60%), organizing pills using pillboxes, baggies, cups (42%), bringing medicines with them (34%), organizing pills according to routine times (32%), and relying on other people to remind them (26%). Understanding the range of barriers to adherence and strategies kidney recipients devised to promote medication-taking may help transplant clinicians to better educate transplant recipients about appropriate medication-taking, mitigate the risk of medication nonadherence-related rejection, and may help inform patient-centered interventions to improve medication adherence.
Transplant International 02/2009; 22(5):534-45. · 2.92 Impact Factor
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ABSTRACT: Optimal hydration measures to prevent contrast-induced nephropathy are controversial.
We conducted a systematic review and meta-analysis using the MEDLINE database (1966 to January 2008), EMBASE (January 2008), and abstracts from conference proceedings.
Adult patients undergoing contrast procedures.
Randomized controlled trials comparing intravenous hydration with sodium bicarbonate with hydration with intravenous normal saline for prevention of contrast-induced nephropathy.
Hydration with intravenous sodium bicarbonate with or without N-acetylcysteine versus hydration with normal saline with or without N-acetylcysteine.
Contrast-induced nephropathy, need for renal replacement therapy, and worsening of heart failure.
Twelve trials (1,854 participants) were included. Sodium bicarbonate significantly decreased the risk of contrast-induced nephropathy (12 trials, 1,652 patients; odds ratio [OR], 0.46; 95% confidence interval [CI], 0.26 to 0.82; I2 = 55.9%) without a significant difference in need for renal replacement therapy (9 trials, 1,215 patients; OR, 0.50; 95% CI, 0.16 to 1.53; I2 = 0%), in-hospital mortality (11 trials, 1,640 patients; OR, 0.51; 95% CI, 0.15 to 1.69), or congestive heart failure compared with controls. Similar results were seen for the risk of contrast-induced nephropathy when sodium bicarbonate was compared with normal saline alone (OR, 0.39; 95% CI, 0.20 to 0.77), but not when sodium bicarbonate/N-acetylcysteine combination was compared with N-acetylcysteine/normal saline combination (OR, 0.68; 95% CI, 0.34 to 1.37). A subgroup analysis limited to published trials showed similar results (OR, 0.26; 95% CI, 0.10 to 0.64; I2 = 63.3%), whereas unpublished studies showed a nonsignificant decrease (OR, 0.85; 95% CI, 0.46 to 1.57; I2 = 25.9%) in risk of contrast-induced nephropathy.
Publication bias and heterogeneity.
Hydration with sodium bicarbonate decreases the incidence of contrast-induced nephropathy in comparison to hydration with normal saline without a significant difference in need for renal replacement therapy and in-hospital mortality. Larger studies analyzing patient-centered outcomes are needed.
American Journal of Kidney Diseases 12/2008; 53(4):617-27. · 5.43 Impact Factor
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ABSTRACT: Fast food is commonly consumed by hemodialysis patients, but many menu items are not compatible with renal diets because of their sodium, potassium, or phosphorus content. Moreover, the phosphorus content of fast foods is difficult for patients to estimate, because phosphorus-containing additives are commonly added to many fast foods. We sought to determine how many fast-food entrees and side dishes are compatible with renal diets.
We examined nutrition-facts labels and ingredient lists provided by 15 fast-food chains. Each entree and side dish was first assessed according to traditional criteria (limited sodium, potassium, and naturally occurring phosphorus content), and then according to the presence of a phosphorus -containing additive.
Of 804 total entrees across all restaurants, 415 (52%) were acceptable according to traditional criteria, but only 128 (16%) were also free of phosphorus-containing additives. Of 163 total side dishes, 37 (23%) were acceptable according to traditional criteria, and 27 (17%) were also free of phosphorus-containing additives. There were no acceptable entrees at 3 chains, and no acceptable side dishes at 5 chains.
Only a small proportion of fast-food entrees and side dishes are compatible with renal diets. The widespread use of phosphorus-containing additives is a major impediment to the availability of acceptable fast-food choices for hemodialysis patients. We recommend limiting the use of phosphorus-containing additives, and including phosphorus content in nutrition-facts labels.
Journal of Renal Nutrition 10/2008; 18(5):466-70. · 1.57 Impact Factor
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ABSTRACT: This study aimed to examine kidney transplant recipients' ability to afford transplant-related out-of-pocket expenses and the financial impact of these expenses on their lives.
This cross-sectional study involved 77 kidney recipients. Variables analyzed were: ability to afford daily necessities; impact of immunosuppressant expenses on patients' lives; awareness of Medicare support terminating three yr post-transplant; and strategies used to pay for out-of-pocket transplant expenses. The Economic Strain Scale measured financial strain.
Twenty-nine percent of kidney recipients experienced financial strain. Poor, less educated, and younger patients were more likely to report financial strain. Out-of-pocket expenses relating to kidney transplantation adversely affected patients' ability to afford leisure activities (35%), a house (27%), and a car (26%). Thirty-one percent reported that immunosuppressant expenses have had somewhat to great (adverse) impact on their lives. Of those on Medicare and not disabled (n = 41), 51% were unaware Medicare coverage will terminate and 71% did not know how long coverage lasts.
Financial strain presents a considerable risk to kidney recipients' ability to purchase immunosuppression. Socioeconomic disparities in recipients' financial strain may be a source of disparities in graft survival. Transplant professionals should better inform transplant candidates about financial consequences of transplantation.
Clinical Transplantation 08/2008; 22(6):738-48. · 1.67 Impact Factor
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ABSTRACT: Elevated serum phosphorus levels are a major source of morbidity and mortality for the 350,000 Americans receiving chronic dialysis treatment. Despite the widespread application of medical and behavioral interventions, the prevalence of hyperphosphatemia remains exceedingly high. At first glance, a public health perspective may seem inappropriate for addressing a disorder of mineral metabolism among patients receiving a life-sustaining treatment. However, we analyzed this topic from a public health perspective and identified many opportunities to improve the management of hyperphosphatemia, including (1) media and cultural messages about food, (2) the availability of appropriate foods and medications, (3) physical structures such as the location of products in grocery stores, and (4) social structures such as food-labeling laws.
Journal of Renal Nutrition 06/2008; 18(3):256-61. · 1.57 Impact Factor
