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Hemodialysis.com Author Interviews from the 2012 ASN Renal Week 11/22/2012 Marie Benz, MD FAAD Read the rest of the interview on Hemodialysis.com.

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Presentation on theme: "Hemodialysis.com Author Interviews from the 2012 ASN Renal Week 11/22/2012 Marie Benz, MD FAAD Read the rest of the interview on Hemodialysis.com."— Presentation transcript:

1 Hemodialysis.com Author Interviews from the 2012 ASN Renal Week 11/22/2012 Marie Benz, MD FAAD Read the rest of the interview on Hemodialysis.com

2 Medical Disclaimer | Terms and Conditions The contents of the Hemodialysis.com Site, such as text, graphics, images, and other material contained on the Hemodialysis.com Site ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on the Hemodialysis.com Site! If you think you may have a medical emergency, call your doctor or 911 immediately. Hemodialysis.com does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by Hemodialysis.com or other Eminent Domains Inc (EDI) websites, EDI employees, others appearing on the Site at the invitation of Hemodialysis.com or EDI, or other visitors to the Site is solely at your own risk. The Site may contain health- or medical-related materials that are sexually explicit. If you find these materials offensive, you may not want to use our Site. The Site and the Content are provided on an "as is" basis. Read more interviews on Hemodialysis.com

3 Treatment effect of frequent hemodialysis on interdialytic weight gain and extracellular volume and their relation to changes in left ventricular mass: Frequent Hemodialysis Network Daily Trial Jochen G. Raimann, MD (Senior Research Fellow) and Nathan W. Levin, MD (Chairman of the Research Board). Renal Research Institute 207 East 94th Street Suite 303 NY, NY USA Hemodialysis.com Editor Marie Benz: What are the main findings of the study? The Frequent Hemodialysis Network (FHN) Daily Trial showed significant treatment effects of increased hemodialysis frequency on the two co-primary outcomes [a composite of mortality and a. left ventricular mass (LVM) and b. physical component score of the SF-36] and in secondary analyses effects on extracellular volume (ECV) and blood pressure (BP). Furthermore BP was determined to be a main determinant of the changes in LVM from baseline of the trial to Month 12. The current analysis confirmed treatment effects on interdialytic weight gain (IDWG) and ECV and showed that this effect was not significantly affected by the presence of urine volume. In a second analysis step changes in ECV from Baseline were found to be significant determinants of change in LVM, independent of change in IDWG and baseline ECV/total body water, age, diabetes status; and IDWG and treatment allocation. Hemodialysis.com: Were any of the findings unexpected? In light of the low urine volumes of subjects in the Daily Trial the lack of significant interaction between urine volumes at baseline and the treatment effect was not surprising. A finding which had been quite surprising was the lack of significance for IDWG (a biomarker of assumed high prognostic significance) as a determinant of change in LVM. The significant relationship between change in ECV from baseline to Month 12 and change in LVM was however expected and corroborated in this analysis, after adjustment for change in IDWG and relevant baseline parameters. Read the rest of the interview on Hemodialysis.com

4 Serum aldosterone concentrations relate to fluid overload and serum potassium levels in hemodialysis patients Hemodialysis.com Author Interview: Jochen G. Raimann, MD (Senior Research Fellow) and Nathan W. Levin, MD (Chairman of the Research Board). Renal Research Institute 207 East 94th Street Suite 303NY, NY USA Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Recently published evidence suggests that the normal inverse relationship between extracellular volume (ECV) and serum aldosterone concentration is right shifted in hemodialysis patients (Bomback, J Renin Angiotensin Aldosterone Syst, 2009). In addition we reported at the ASN Renal Week 2010 in abstract form that the response mechanism of aldosterone secretion to changes in ECV appears to be intact in hemodialysis patients while undergoing successive post hemodialysis weight reduction. We also found in the same analysis that the changes in aldosterone concentration correlated with changes in ECV to total body water (TBW; ECV/TBW) in linear regression analysis (R2=0.57, P<0.01). In addition to ECV, serum potassium also controls aldosterone secretion in healthy subjects. In the current analysis we aimed to analyze the relationship of fluid overload, serum potassium and aldosterone in a longitudinal fashion by means of a linear mixed model. Hemodialysis.com: Were any of the findings unexpected? We knew already that ECV/TBW values inversely relate to serum aldosterone concentrations in our data. In addition, in a cross-sectional study, we found a univariable relation between serum potassium and aldosterone concentrations. We wanted to examine whether this relationship, which we expected to be intact also in dialysis patients, held up over a longer period of time in a longitudinal study. Read the rest of the interview on Hemodialysis.com

5 Time-to-Dialysis when Estimated GFR (eGFR) Drops below 15 ml/min/1.73m2: Results from the African American Study of Kidney Disease (AASK) Study Hemodialysis.com Author Interview: Liang Li, PhD Associate Staff of Biostatistics Department of Quantitative Health Sciences Cleveland Clinic 9500 Euclid Ave, JJN3 Cleveland, OH Hemodialysis.com Editor Marie Benz: What are the main findings of the study? This study reports on the natural history of CKD Stage 5 among participants in the African American Study of Kidney Disease and Hypertension, a prospective study of non-diabetic African Americans with hypertensive kidney disease. Among the 175 (21%) participants who reached CKD Stage 5 (eGFR≤15 ml/min/1.73 m2), there was considerable heterogeneity in the time to dialysis initiation. At one year after incident CKD Stage 5, 46% of the participants had started dialysis; at two and three years, 80% and 90% had started dialysis, respectively. Only 7% died prior to dialysis initiation. Age and proteinuria were not associated with time to dialysis; however, those with a slower rate of eGFR decline prior to CKD Stage 5 tended toward longer dialysis-free survival. Hemodialysis.com: Were any of the findings unexpected? The 2006 KDOQI guidelines state that “nephrologists should evaluate the benefits, risks, and disadvantages of beginning kidney replacement therapy” when patients reach eGFR 15 ml/min/ 1.73 m2. In our study, 13% of the study participants were alive and without a dialysis requirement two years after reaching CKD Stage 5. Read the rest of the interview on Hemodialysis.com

6 Differential Risk of ESRD versus Death in Black versus White Veterans is attenuated by Older Age and Lower Levels of Kidney Function Hemodialysis.com Author Interview: Jessica W. Weiss, MD Div. Nephrology, Oregon Health and Science University Portland, OR Hemodialysis.com Editor Marie Benz: What are the main findings of the study? This study was a retrospective cohort analysis of a national sample of United States Veterans examining whether, and if so how, racial differences in the relative risk of end stage renal disease (ESRD) versus death may be modified by age and level of kidney function. We found that racial differences in the relative frequency of ESRD and death do vary as a function of age and estimated glomerular filtration rate (eGFR). In particular, at lower levels of eGFR, the relative risk of progression to ESRD was more common than death among both Black and White patients. Racial disparities in the relative frequency of these two outcomes were more pronounced in older adults and at lower levels of eGFR Hemodialysis.com: Were any of the findings unexpected? Our examination of incident rate ratios of dialysis versus death in Black and White patients found that, in patients of more advanced age (70+) of either race, the relative risk of mortality outweighed that of ESRD. Read the rest of the interview on Hemodialysis.com

7 The Relationship between Blood Pressure and Mortality in Older Adults with Chronic Kidney Disease is Modified by Age and Renal Function Hemodialysis.com Author Interview: Jessica W. Weiss, MD Div. Nephrology, Oregon Health and Science University Portland, OR Hemodialysis.com Editor Marie Benz: What are the main findings of the study? We conducted a retrospective cohort analysis of older adults (age 65+) with moderate to severe pre-dialysis chronic kidney disease (CKD) in order to examine how the relationship between baseline systolic blood pressure (SBP) and mortality might change as a function of age and level of renal function. We found that, lower baseline SBP value values (≤120 mmHg) were associated with an increased mortality risk in all age groups and across all levels of eGFR. However, higher values of SBP (>140 mmHg) were only associated with an increased mortality risk in younger elderly patients. In older members of this cohort, mortality risk did not seem to increase at higher levels of blood pressure. Hemodialysis.com: Were any of the findings unexpected? We had hypothesized that older adults at the younger end of the age spectrum (ages 65-70) might exhibit a different relationship between SBP and mortality as compared to their older counterparts. We found that this was indeed the case as we detected a J-curve effect in this younger subset (with higher mortality at SBP levels both above and below the referent (SBP mmHg) which was not present among older patients. Read the rest of the interview on Hemodialysis.com

8 Predicting Mortality in Dialysis Patients: Does a Simple Chest X-Ray Have Prognostic Value? Hemodialysis.com Author Interview: Ethan Bohn, Claudio Rigatto, MD. University of Manitoba, Winnipeg, Canada. Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Given that previous studies had confirmed the relationship between increasing heart size, degree of vascular calcification, and mortality both in the general and dialysis populations, it was hypothesized that these measures would represent useful prognostic tools. This hypothesis was rejected in our prevalent cohort of patients. Hemodialysis.com: What should clinicians and patients take away from your report? Read the rest of the interview on Hemodialysis.com

9 Tumor Necrosis Factor-α Modifies the Relationship between Obestatin and All-Cause and Cardiovascular Mortality in Maintenance Hemodialysis Patients Hemodialysis.com Author Interview: Dr.Ilia Beberashvili Dr.Ilia Beberashvili Nephrology Division, Assaf Harofeh Medical Center Zerifin 70300, Israel. Hemodialysis.com Editor Marie Benz: What are the main findings of the study? This study reports an increased mortality risk for hemodialysis patients with low obestatin values. In addition, it shows novel interactions between obestatin and TNF-α associated with mortality risk, especially because of cardiovascular causes. The joint occurrence of high obestatin and high TNF-α seems to be associated with lower all- cause and cardiovascular mortality risk, while co-existence of high TNF-a levels with low obestatin, in contrast, predicts the worst outcome. Hemodialysis.com: Were any of the findings unexpected? Soon after its discovery, obestatin became a very controversial peptide. It was claimed to be a physiological opponent of acylated ghrelin, another peptide which originates from the same pre-prohormone as obestatin and has a number of beneficial nutritional and cardiotropic effects. We hypothesized, therefore, that high obestatin levels in hemodialysis patients may link to worse clinical outcomes. Surprisingly, patients with low obestatin levels had a worse all-cause mortality and cardiovascular mortality in our study. Read the rest of the interview on Hemodialysis.com

10 Predictors of Red Cell Transfusion in Hemodialysis Patients Hemodialysis.com Author Interview: Scott Sibbel, PhD, MPH, DaVita Clinical Research Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Dr. Sibbel: In our comparison of maintenance hemodialysis patients needing transfusion (n = 2,252) and maintenance hemodialysis patients not needing transfusion (n = 6,646), over the study period (2 January 2011–31 May 2011), my coauthors and I studied the patient and treatment factors associated with red cell transfusion. After adjusting for covariates and creating regression models, we found that 3-month cumulative doses of intravenous iron sucrose > 1,500 mg and high serum ferritin concentrations (> 1,200 ng/mL) were independently associated with risk of transfusion. As might be expected, patients who did not receive any iron and patients with hemoglobin < 10 mg/mL were at greatest risk of transfusion. Hemodialysis.com: Were any of the findings unexpected? Dr. Sibbel: High 3-month cumulative doses of iron sucrose, used to treat iron-deficiency anemia in hemodialysis patients, were associated with significant risk of transfusion. We continue to study this result to determine why. Read the rest of the interview on Hemodialysis.com

11 A Comparative Analysis of Transfusion Trends Between Types of Providers o f Dialysis Services Using Medicare Claims Data Mahesh Krishnan, MD, MPH, MBA, FASN Allen Nissenson, MD, FACP Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Given the recent changes that occurred to the erythropoiesis-stimulating agent (ESA) label in June 2011, there has been an increased focus on the number of transfusions that have taken place in patients with end-stage renal disease (ESRD). As a result of the label change, hemoglobin (Hb) concentrations in dialysis patients have fallen, and patients with risk factors such as gastrointestinal bleeding, myelodysplasia, and other chronic conditions may be at a higher risk for transfusions. While transfusions are not routinely administered in the outpatient setting, anemia management in the outpatient setting may have an effect on inpatient transfusion rates. Little is known, however, about the rates of transfusions among different provider types prior to the label change. Results from the study indicate that in 2009 and 2010, nonprofit facilities and for-profit facilities had similar percentages of ESRD patients (26% in 2009 and 25% in 2010) who received 1 or more inpatient blood product administrations. Hospital-based units reported the highest percentages of patients with blood product administrations: prevalent ESRD patients who received 1 or more inpatient blood product administrations; outpatient transfusion codes and outpatient blood product administrations; and transfusion codes on a dialysis claim and administrations of a dialysis claim. Read the rest of the interview on Hemodialysis.com

12 A Comparative Analysis of Vascular Access and Immunization Betwee n For-Profit and Nonprofit Dialysis Facilities Using Medicare Claims Data Hemodialysis.com Authors' Interview: A Comparative Analysis of Vascular Access and Immunization Betwee n For-Profit and Nonprofit Dialysis Facilities Using Medicare Claims Data Hemodialysis.com Authors' Interview: Mahesh Krishnan, MD, MPH, MBA, FASN Mahesh Krishnan, MD, MPH, MBA, FASN and Allen Nissenson, MD, FACP Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Results from the study suggest that for-profit providers had superior vascular access and vaccination outcomes compared with nonprofit providers. For example, for-profit dialysis facilities reported better outcomes in percent of vaccination rates for influenza than nonprofit facilities (54.8% for- profit versus 52.3% nonprofit). These trends continued for Pneumococcal pneumonia immunization at 26.1% for-profit versus 21.3% nonprofit and Hepatitis B immunization at 25.2% for-profit versus 21.1% nonprofit. In addition, for-profit dialysis facilities showed better outcomes for vascular access than nonprofit dialysis facilities, as measured by the difference in percent of catheter use at 17.5% and 20.1%, respectively. Hemodialysis.com: Were any of the findings unexpected? The hypothesis of the study was that for-profit organizations would perform better on outcomes that require intense focus on processes within facilities, since more resources would be available to drive such programs. In that sense, the findings from this study were not surprising. Of note is the fact that the absolute numbers for immunizations reported were taken from United States Renal Data System and were neither up- to-date nor complete. At DaVita, for the 2012–2013 flu season, 91% of patients have had influenza vaccinations and 92% of patients have had Pneumococcal pneumonia vaccinations. Hemodialysis.com: What should clinicians and patients take away from your report? Intense focus on care processes such as vaccination and vascular access can significantly augment population-based and patient-based goals, improving population health and constraining healthcare costs. However, sufficient infrastructure support and scaling capabilities are needed as well as high prioritization, as seen in for-profit dialysis facilities. Read the rest of the interview on Hemodialysis.com

13 Patient ‑ Reported Pruritus Rates and Indicators of Infection Co ‑ vary Directly Among Patients Receiving Dialysis. Patient ‑ Reported Pruritus Rates and Indicators of Infection Co ‑ vary Directly Among Patients Receiving Dialysis. Hemodialysis.com Author Interview: T. Christopher Bond, PhD Senior Manager, Epidemiology at DaVita Clinical Research Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Increased patient ‑ reported itching was hypothesized to be associated with intravenous (IV) antibiotic use, and infection ‑ related inflammation was hypothesized to be associated with increased epoetin alfa (EPO) use. Results from this study demonstrated that patient ‑ reported itchiness was highly correlated with the validated physical and mental component scores of the Kidney Disease Quality of Life ‑ 36 survey, which is administered annually to all dialysis patients treated by a large dialysis organization. Additionally, increased itchiness varied directly with IV antibiotic use and EPO dose. Taken together, these results suggest that increasing pruritus may be directly correlated with increased rates of infection and healthcare resource utilization. Hemodialysis.com: Were any of the findings unexpected? Sixty percent of dialysis patients in the study population reported some level of itchiness, using a 5 ‑ point ordinal scale from “Not bothered at all” to “Extremely bothered.” Patients reporting high degrees of itchiness were slightly younger, female, and more likely to have diabetes, cardiovascular disease, chronic obstructive pulmonary disease, or liver disease. Read the rest of the interview on Hemodialysis.com

14 Changing Hemoglobin Targets: Effects on Epoetin Alfa, Intravenous Iron, and Iron Storage Measures from 2009–2012 Hemodialysis.com Author Interview: T. Christopher Bond, PhD Senior Manager, Epidemiology at DaVita Clinical Research Hemodialysis.com Editor Marie Benz: What are the main findings of the study? In order to assess trends in hemoglobin and dosing of anemia medications, we reviewed electronic medical records from a large dialysis organization for incident and prevalent in-center hemodialysis patients between 1 January 2009 and 30 April Over the 3-year study period, patients’ mean hemoglobin fell from 11.6 to 10.8 g/dL. In addition, the proportion of patients receiving any intravenous (IV) iron each month increased from approximately 65% to 75% at the end of the study. Corresponding to the introduction of more patients to low- dose IV iron, the mean IV iron dose was reduced over the study from 291 to 241 mg/month. Mean monthly doses of epoetin alfa fell from approximately 73,000 units to 46,000 units, and the proportion of patients receiving epoetin alfa each month fell from 93% to 86%. These changes in dosing of anemia medications coincided with increases in monthly means for serum ferritin (606 and 769 ng/mL in April 2009 and April 2012, respectively) and saturated transferrin (29.9% and 30.9% in April 2009 and April 2012, respectively). Hemodialysis.com: Were any of the findings unexpected? The trends observed in hemoglobin and epoetin alfa dosing were expected given the revisions to the Epogen® (epoetin alfa) package insert on June 24, 2011, warning of hemoglobin levels > 11 g/dL. The most dramatic reduction in erythropoiesis-stimulating agent dose temporally corresponded to this change. The increase in the proportion of patients receiving IV iron, which occurred in concert with decreases in the proportion of patients receiving epoetin alfa, was not necessarily anticipated. Read the rest of the interview on Hemodialysis.com

15 The Effect of Oral Ferric Citrate on Intravenous Iron Dose and Serum Iron Markers Hemodialysis.com Author Interview: T. Christopher Bond, PhD Senior Manager, Epidemiology at DaVita Clinical Research Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Dr. Bond: Ferric citrate is a phosphate binder in Phase 3 clinical development to treat hyperphosphatemia in patients with end-stage renal disease. A 28-day, Phase 2, multicenter open-label study was executed to assess the safety and tolerability of ferric citrate in dialysis patients. In a post-hoc analysis we found that 5 subjects (17%) who received intravenous iron prior to the study were able to discontinue its use while receiving ferric citrate. No subjects who did not receive intravenous iron at baseline needed to add intravenous iron while taking ferric citrate. Hemodialysis.com: Were any of the findings unexpected? Dr. Bond: It was not known if patients taking this iron-containing binder would be able to stop taking intravenous iron during the study. Read the rest of the interview on Hemodialysis.com

16 Palliative Care Experience of US Internal Medicine Subspecialty and US Adult Nephrology Fellows Hemodialysis.com Author Interview: Kenar D Jhaveri MD, FASN,FACP,FNKF Assistant Prof of Medicine, Hofstra University with North Shore/ Long Island Jewish H Great Neck, NY Hemodialysis.com Editor Marie Benz: What are the main findings of the study? The series of two studies looked at the palliative care experience of US adult nephrology fellows and compared it with experiences of cardiology, GI, critical care and Heme-oncology fellows. Of all the fellows surveyed in nephrology, 87% of the respondent's programs did not offer formal clinical training or rotation in palliative care medicine during the fellowship training. While over 90% of fellows felt most comfortable with either writing dialysis orders or seeing an ICU consult, only 35% felt most comfortable not offering dialysis to a patient in the ICU with multi organ failure. 67% of the respondents thought a formal palliative care rotation during the course of their fellowship would be very helpful. Compared to hematology-oncology and critical care, nephrology fellows had the lesser palliative care training. Nephrology fellows had the least amount of end of life encounters patient discussions during their training compared to cardiology, GI, critical care and hematology/oncology. Majority of the responding nephrology fellows felt the need of having a formal palliative care rotation during their fellowship as compared to other internal medicine fellows. Hemodialysis.com: Were any of the findings unexpected? The fact that nephrology fellows have lesser palliative care experience was expected. When compared to other fields in medicine, we didn't expect such drastic difference in the experience. It was interesting to note that despite having a palliative care division at their institution, only 50% got even a didactic session on this topic. Read the rest of the interview on Hemodialysis.com

17 Hypercholesterolemia and Hypertriglyceridemia Are Associated with Better Survival in Hemodialysis Patients Hemodialysis.com Author Interview: Hamid Moradi MD FASN Assistant Clinical Professor Medical Director, UCI Renal Dialysis Center University of California, Irvine Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Building on our previous work, we noted a paradoxic association between higher serum total cholesterol and triglycerides levels and reduced mortality even after adjusting for markers of inflammation and malnutrition. Furthermore, in contrast to the general population, higher serum HDL cholesterol concentrations were not associated with improved survival. In addition, increasing serum LDL cholesterol concentrations were not associated with increased mortality except in patient of Asian background. Hemodialysis.com: Were any of the findings unexpected? The majority of these findings are paradoxic to what we would find in the general population. Based on these results, only patients of Asian background would benefit from aggressive reduction of LDL cholesterol. Read the rest of the interview on Hemodialysis.com

18 Impact of ß-Blocker Therapy on All-Cause Mortality and Initiation of Chronic Dialysis in Patients with Chronic Kidney Disease Not Yet on Dialysis: A Propensity Score Analysis Hemodialysis.com Author Interview: Anna Jeanette Jovanovich, MD Anna Jeanette Jovanovich, MD Hemodialysis.com Editor Marie Benz: What are the main findings of the study? In a cohort of Veteran’s Administration patients with severe chronic kidney disease (CKD) defined as stage IV CKD with mean eGFR of 18 or ESRD, beta blocker use was not associated with decreased mortality. In a subset of the cohort with stage IV CKD, beta blocker use was not associated with decreased progression to chronic dialysis. Hemodialysis.com: Were any of the findings unexpected? These findings were somewhat unexpected. Subjects with severe CKD have high sympathetic tone and often die from arrhythmias and other cardiovascular causes. Furthermore, beta blockade has been associated with decreased renin. Beta blockade could theoretically attenuate some of these adverse outcomes associated with progression of and mortality in CKD. However, we do not see this association in this cohort. Read the rest of the interview on Hemodialysis.com

19 Association of the Metabolic Syndrome with Death, Cardiovascular Events or Progression to Dialysis Initiation in Non-Diabetic Chronic Kidney Hemodialysis.com Author Interview: Jessica Kendrick, MD, Assistant Professor Division of Renal Diseases and Hypertension University of Colorado School of Medicine Denver Health Medical Center 660 Bannock, Mail Code 4000 Denver, CO Hemodialysis.com Editor Marie Benz: What are the main findings of the study? We performed an analysis on 495 non-diabetic patients with severe kidney disease, not yet on dialysis, who participated in the Homocysteine in Kidney and End Stage Renal Disease study. A total of 292 (59%) patients in the cohort met criteria for the metabolic syndrome. Over a mean follow-up of 3 years, there were 169 (34%) deaths, 70 (14%) cardiovascular events and 246 patients (50%) initiated chronic dialysis. After adjustment for demographics, smoking status, alcohol use, body mass index, history of cardiovascular disease and hypertension, systolic blood pressure, eGFR, albumin, and 25- hydroxyvitamin D level, presence of the metabolic syndrome was not associated with an increased risk of death, cardiovascular events or progression to dialysis initiation. Hemodialysis.com: Were any of the findings unexpected? We expected to find a relationship between metabolic syndrome and death and cardiovascular disease given the association of metabolic syndrome with these adverse outcomes in the general population. It is possible that once patients have this advanced kidney disease (the mean eGFR was 18.0 ± 7.0 ml/min/1.73m2 in this study) there is no longer an increased risk of death and cardiovascular events with the presence of metabolic syndrome. Read the rest of the interview on Hemodialysis.com

20 Low dietary potassium intake is associated with an increase risk of metabolic syndrome in US adults. Hemodialysis.com Author Interview: Jessica Kendrick, MD Assistant Professor Division of Renal Diseases and Hypertension University of Colorado School of Medicine Denver Health Medical Center 660 Bannock, Mail Code 4000 Denver, CO Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Adult participants with lower dietary potassium intake had a higher risk of metabolic syndrome. We studied 25,754 US adult participants from the National Health and Nutrition Examination Survery ( ). After adjustment for age, sex, race, smoking, body mass index, eGFR and serum albumin, subjects in the lowest quartile of potassium intake had a 35% increased risk of metabolic syndrome compared to subjects in the highest quartile of potassium intake. Hemodialysis.com: Were any of the findings unexpected? These findings are not unexpected given that high dietary potassium intake has been shown to decrease blood pressure and to decrease the risk of cardiovascular disease but the relationship between potassium intake and metabolic syndrome has not been previously reported. Read the rest of the interview on Hemodialysis.com

21 Kidney Disease Is an Independent Risk Factor for Maternal Mortality in Pregnancy Hemodialysis.com Author Interview: Jessica Kendrick, MD Assistant ProfessorDivision of Renal Diseases and Hypertension University of Colorado School of MedicineDenver Health Medical Center 660 Bannock, Mail Code 4000 Denver, CO Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Pregnant women with kidney disease have an increased risk of adverse maternal outcomes including maternal mortality independent of underlying comorbid conditions that can occur with kidney disease. Using data from an integrated healthcare system we identified 646 pregnancies from women with kidney disease and 62,757 pregnancies from women without kidney disease for comparison. Compared to women without kidney disease, those with kidney disease had a three-fold increased risk of death after adjusting for age, race, history of diabetes, chronic hypertension, liver disease and connective tissue disorders (OR 3.38, 95% CI ). Furthermore, women with kidney disease had an increased risk of preterm delivery (OR 1.95, 95% CI ), delivery via Cesarean section (OR 1.38, 95% CI ) and longer length of stay in the hospital (OR 1.39, 95% CI ). Hemodialysis.com: Were any of the findings unexpected? These findings were not completely unexpected given that kidney disease is associated with an increased risk of death in most patient populations studied. However, this is the first study to show in a large patient population that kidney disease is associated with an increased risk of death in pregnant women. Read the rest of the interview on Hemodialysis.com

22 Reasons for Phosphate Binder Discontinuation Vary by Binder Type Hemodialysis.com Author Interview: Thomas Alfieri, PhD Hemodialysis.com Editor Marie Benz: What are the main findings of the study? In this retrospective analysis of electronic medical records, 30,933 reasons for phosphate binder discontinuation were classified; approximately half of the records (50.1%) provided no specific reason for discontinuation. The second and third largest categories of reasons cited for discontinuation were "Lab Results” (27.4%) and “Patient Not Tolerating” (10.8%). Within the “Patient Not Tolerating” category, “GI Upset” was the most common reason. Hemodialysis.com: Were any of the findings unexpected? Yes, while the distribution of binder type in the sample was representative of actual binder distribution in the large dialysis organization’s patient population, the distribution of patients not tolerating by phosphate binder was not equivalent to the distribution of phosphate binder use within the total sample. Specifically, while patients on lanthanum carbonate accounted for 14% of the total sample, they comprised 40% of the “Patient Not Tolerating” category and were similarly over-represented in 4 of the 5 “Patient Not Tolerating” subcategories. Read the rest of the interview on Hemodialysis.com

23 Extracellular Volume Control to Decrease Hospitalizations Hemodialysis.com Author Interview: Thomas F. Parker, III, MD Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Renal Ventures Management, DaVita, Inc., and Fresenius Medical Care combined resources in a self-funded quality initiative to determine if objective measurement of extracellular volume control (ECV) removal and attainment of normalized ECV could reduce all ‑ cause and ECV-related hospitalizations at the facility level. Fifteen centers participated in this study with 8 centers doing the Education Only (E) Program and 7 centers doing the Education + Crit-Line (EM) Program. Before E and EM implementation, all-cause and ECV-related hospital rates were similar between the 2 groups. In the EM group, all-cause hospitalization rate was significantly higher pre-intervention compared with post-intervention (mean ± SD; pre, ± 3.51 hospitalizations/1000 treatments vs. post, ± p < 0.05). More importantly was the clinical difference in fluid-related hospitalizations per 1000 treatments and hospital days per 1000 treatments: 1.02 ± 0.65 vs ± 0.39 and 4.17 ± 2.59 vs ± 1.71, respectively. Hospitalization rates and days did not change substantially in the E group. Hemodialysis.com: Were any of the findings unexpected? This study was powered to assess the clinical significance of an intervention to decrease hospitalizations. Given the number of facilities, we were surprised by the decrement in hospitalizations. We saw facility level differences reach statistical significance for all-cause hospitalizations. The differences between pre- and post- intervention in the EM group were not statistically significance for fluid-related events and fluid-related hospitalized days, but the clinical significance was remarkable. We hypothesized that a larger number of centers would have reached statistical significance. Read the rest of the interview on Hemodialysis.com

24 Factors Associated with Persistent Pain in Hemodialysis Hemodialysis.com Author Interview: Ahraaz Wyne, MD Resident Physician PGY3, Dept. Of Medicine London Health Sciences Center University of Western Ontario Hemodialysis.com Editor Marie Benz: What are the main findings of the study? 76% of ESRD patients continue to suffer from ongoing pain despite taking analgesics and only 24% have controlled pain. 13% of patients with ongoing pain have no prescribed analgesics whatsoever! Patients with ongoing pain despite analgesics did not differ from those with controlled pain in their comorbidities, burden of psychiatric disease, use of analgesic or adjuvant psychiatric medication or the use of alternative healthcare resources. The majority of patients with ongoing pain despite analgesic therapy felt that their physicians were indeed working diligently to help their pain Hemodialysis.com: Were any of the findings unexpected? More than two-thirds of patients with ongoing pain despite analgesic therapy would reject more analgesics if offered, and most of these patients reported polypharmacy, fear of addiction and heavy medication burden as their primary concerns with receiving more analgesics. Read the rest of the interview on Hemodialysis.com

25 Racial Differences in Initial Dialysis Access and Hospitalizations among Home Hemodialysis Patients Hemodialysis.com Author Interview: Luis A. Bent-Shaw, MD University of Washington, Division of Nephrology Hemodialysis.com Author Interview: Luis A. Bent-Shaw, MD University of Washington, Division of Nephrology Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Answer: We found than in our home hemodialysis program, African Americans were more likely to start home training without fistulas compared to whites. However, there was no difference in hospitalizations between these two groups. Hemodialysis.com: Were any of the findings unexpected? Answer: These findings are consistent with what we know about hemodialysis access in the general ESRD population. Minorities and women are less likely to receive AV fistulas than men, however these differences have not been extensively documented in home hemodialysis patients. Read the rest of the interview on Hemodialysis.com

26 Hemoglobin Trends in Incident End-Stage Renal Disease Patients from Hemodialysis.com Author Interview: Scott Sibbel PhD Hemodialysis.com Editor Marie Benz: What are the main findings of the study? In this retrospective analysis, we used the first hemoglobin (Hb) on dialysis as a surrogate for the impact of the changes to the erythropoiesis-stimulating agent (ESA) labels for predialysis patients. We studied incident patients and found that the proportion of patients beginning dialysis with a Hb of < 10 g/dL increased and incident patient mean Hb concentrations decreased from January 2008 to March Specifically, the distribution of mean Hb concentration at dialysis initiation shifted, moving from a mode of 10.5 g/dL in January 2008 to a mode of 9.5 g/dL in January The proportion of patients with Hb < 10 g/dL showed a concurrent increase (42.0%–56.6%). Initial Hb levels appeared to plateau after June 2009, and a decline was observed after the United States Food and Drug Association (FDA) label change in late June Thus, we observed modest but steady reductions in Hb levels that temporally correspond to revised FDA guidelines and label changes for ESAs in the same time period. Hemodialysis.com: Were any of the findings unexpected? The initial changes in physicians’ practice patterns for anemia management in United States predialysis patients were noted by Dr. Collins at the National Kidney Foundation Spring 2012 Meetings. It was surprising how quickly after the FDA label change that practice changed further, with physicians becoming even more conservative in managing anemia before dialysis. Read the rest of the interview on Hemodialysis.com

27 Dietary Habits, Poverty, and Chronic Kidney Disease in an Urban Population Dietary Habits, Poverty, and Chronic Kidney Disease in an Urban Population Deidra C. Crews, MD, ScM, FASN Assistant Professor of Medicine Johns Hopkins University School of Medicine Division of Nephrology Hemodialysis.com Editor Marie Benz: What prompted you to do the study? Dr. Crews: We and others have found a relationship between poverty and chronic kidney disease (CKD) in prior studies. In this study, we were interested in determining the role that dietary habits may play in this disparity. Hemodialysis.com: What is your main take home message? Dr. Crews: An unhealthy diet is strongly associated with kidney disease among poor individuals. Dietary interventions and public policy addressing the needs of this population may help to reduce disparities in kidney disease. Hemodialysis.com: Simply, how did you do your study? Dr. Crews: Ours was a cross-sectional study conducted as part of the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study, which is cohort of adults living in Baltimore City, Maryland. The HANDLS study is a National Institute on Aging Intramural Study. Our study included 2,058 participants out of the 3,700 HANDLS study participants. Mean age was 48 years. Using data the participants provided on the foods that they had eaten in a 24 hour period, we assessed their adherence to a Dietary Approaches to Stop Hypertension (DASH) style diet. DASH diet adherence has been associated with better health outcomes in a number of studies. We related participants' adherence to DASH with the prevalence of CKD in this population. CKD was defined as an estimated glomerular filtration rate <60 ml/min/1.73m(2) in our primary analysis. We stratified all our analyses by poverty status. Abstract: [SA-OR002] Read the rest of the interview on Hemodialysis.com

28 Blood Pressure Control among CKD Patients in a Public Health System Blood Pressure Control among CKD Patients in a Public Health System Delphine Tuot, MDCM, MAS Department of Medicine, Division of Nephrology University of California, San Francisco Hemodialysis.com Editor Marie Benz: What is the background of the study? Dr. Tuot: Individuals with chronic kidney disease (CKD) of racial/ethnic minorities are more likely to develop end-stage renal disease (ESRD) than their white counterparts and tend to do so more quickly. Reasons for this are not clear and are likely multi-factorial, but may in part, be due to poorer blood pressure (BP) control among racial/ethnic minorities. Public health care delivery systems disproportionately care for vulnerable patients, including those of racial/ethnic minorities, and can serve as front-line agents to reduce disparities of care. Our goal was to compare prevalence and odds of uncontrolled BP among patients with CKD in the Community Health Network of San Francisco (CHNSF), an integrated health care delivery system that cares for San Francisco’s uninsured and publically insured residents, compared to national estimates, using data from the National Health Examination and Nutrition Survey (NHANES). Hemodialysis.com: What are the main findings of the study? Dr. Tuot: We demonstrate that overall, adjusted prevalence of uncontrolled BP among patients with CKD in the CHNSN is nearly 20% higher than national estimates. However, differences in BP control among patients with CKD of different race/ethnicities were smaller in the CHNSF compared to the national average. The CHNSF appears to provide more equitable care to patients with CKD, compared to the national average. Read the rest of the interview on Hemodialysis.com

29 Dietary Patterns and Kidney Disease: A Longitudinal Analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) Dietary Patterns and Kidney Disease: A Longitudinal Analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) Julie Lin, MD, MPH, FASN Associate Physician Renal Division Brigham and Women's Hospital Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Dr. Lin: Our investigative team sought to assess the generalizability of the previously reported associations between dietary patterns and progression of kidney function decline in the almost entirely Caucasian study population of older women in the Nurses' Health Study (NHS) in an ethnically diverse and younger population represented by the Multi-Ethnic Study of Atherosclerosis (MESA). Mesa is a cohort study of cardiovascular disease funded by the National Heart, Lung, and Blood Institute (NHLBI). Specifically, we hypothesized that less healthy eating patterns (higher in “fats and processed meats” or “beans, tomatoes, and processed grains”) would be associated with faster decline of kidney function (estimated glomerular filtration rate or eGFR) whereas healthy patterns (higher in “vegetables and fish” and “whole grains and fruit”) would inversely associated. A second set of hypotheses postulated that unhealthy dietary patterns would be associated with greater increases in albuminuria over time while healthy dietary patterns would be associated with less progression of albuminuria. To our surprise and disappointment, we did not observe any statistically significant associations between any of the dietary patterns and either of the kidney outcomes of interest with the exception of higher adherence to the “vegetables and fish” pattern being associated with an increase in albuminuria over time, which was the opposite of what we expected. In retrospect, limitations and challenges of this study included the relatively short follow-up time of 5 years for the kidney parameters (whereas the Nurses’ Health Study had 11 years of follow up for change in estimated glomerular filtration rate) as well as the potential confounding factor of substantially different dietary patterns in the different ethnic groups. Read the rest of the interview on Hemodialysis.com

30 Association between Major Depression and Chronic Kidney Disease in an Outpatient Diabetic Population Association between Major Depression and Chronic Kidney Disease in an Outpatient Diabetic Population Margaret Yu, MD Nephrology Fellows University of Washington Seattle WA, Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Answer: We found that in patients with diabetes, major depression WAS associated with greater odds of having chronic kidney disease. This finding was primarily due to a strong relationship between major depression and microalbuminuria, rather than a relationship between major depression and low estimated glomerular filtration rate (eGFR), although major depression tended to increase in prevalence with increasing stage of chronic kidney disease. Hemodialysis.com: Were any of the findings unexpected? Answer: We were surprised to find that major depression had such a strong relationship with microalbuminuria. This is important because microalbuminuria is the first indication of diabetic kidney disease and is a potent predictor for kidney disease progression. Read the rest of the interview on Hemodialysis.com

31 Mortality and Cardiovascular Events Are Associated with Low Hemoglobin Mortality and Cardiovascular Events Are Associated with Low Hemoglobin Prof. Francesco Locatelli, MD, FRCP Department of Nephrology and Dialysis, Ospedale A. Manzoni Hemodialysis.com Editor Marie Benz: What are the main findings of the study? The analysis of the MIRCERA trials database shows that fatal AEs, myocardial infarction and strokes, individually and in combination, were associated with low Hb (Hb < 10 g/dl) in ESA-treated CKD patients. Similarly, Hb levels >1 g/dl below the patients` individual baseline Hb was associated with higher risk of clinical events. Additionally, clinical events occurred with similar frequency at Hb levels 11 to < 12 g/dl and 12 to < 13 g/dl Besides this, at Hb > 13 g/dl the RRs for fatal AEs and myocardial infarction were not increased, but there was a higher RR for stroke. Hemodialysis.com: Were any of the findings unexpected? The data of this analysis indicate that the CKD patients between Hb 11 to < 13 g/dl exhibit the lowest risk for fatal AEs, myocardial infarction and stroke. Read the rest of the interview on Hemodialysis.com

32 Vascular Access Type and the Trajectory of the Inflammatory Markers in Hemodialysis Patients Neil R. Powe, MD, MPH, MBA Chief, Medical Services, San Francisco General Hospital Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Dr. Powe: This is one of the few studies to report association of vascular access type and inflammatory markers in a longitudinal study. We found Central Venous Catheters and Arteriovenous Grafts are associated with a greater state of inflammation as measured by CRP levels in incident hemodialysis patients. Moreover, levels of CRP decreased over time with the highest value at 30 days after the insertion of the access as compared to the CRP values at greater than180 days (p=0.02). Hemodialysis.com: Were any of the findings unexpected? Dr. Powe: IL-6 levels are higher in patients with end-stage renal disease and maybe associated with vascular access dysfunction. In our study we did not find any association with the type of vascular access. Read the rest of the interview on Hemodialysis.com

33 Blood Pressure Control among CKD Patients in a Public Health System Blood Pressure Control among CKD Patients in a Public Health System Neil R. Powe, MD, MPH, MBA Chief, Medical Services, San Francisco General Hospital Hemodialysis.com Editor Marie Benz: What is the background of your study? Dr. Powe: Individuals with chronic kidney disease (CKD) of racial/ethnic minorities are more likely to develop end-stage renal disease (ESRD) than their white counterparts and tend to do so more quickly. Reasons for this are not clear and are likely multi-factorial, but may in part, be due to poorer blood pressure (BP) control among racial/ethnic minorities. Public health care delivery systems disproportionately care for vulnerable patients, including those of racial/ethnic minorities, and can serve as front-line agents to reduce disparities of care. Our goal was to compare prevalence and odds of uncontrolled BP among patients with CKD in the Community Health Network of San Francisco (CHNSF, an integrated health care delivery system that cares for San Francisco’s uninsured and publically insured residents, compared to national estimates, using data from the National Health Examination and Nutrition Survey (NHANES). Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Dr. Powe: We demonstrate that overall, adjusted prevalence of uncontrolled BP among patients with CKD in the CHNSN is nearly 20% higher than national estimates. However, differences in BP control among patients with CKD of different race/ethnicities were smaller in the CHNSF compared to the national average. The CHNSF appears to provide more equitable care to patients with CKD, compared to the national average. Read the rest of the interview on Hemodialysis.com

34 Progression to End-Stage Renal Disease among Patients with Preemptive Vascular Access Placement Progression to End-Stage Renal Disease among Patients with Preemptive Vascular Access Placement Nisha Bansal, MD, MAS Assistant Professor, Division of Nephrology University of California, San Francisco Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Answer: Among patients with advanced chronic kidney disease who had preemptive vascular access creation, approximately half required dialysis within 1 year. Hemodialysis.com: Were any of the findings unexpected? Yes, we found that the mean eGFR at the time of vascular access creation was low (16 ml/min/1.73 m2) and yet only half required hemodialysis within 1 year. Hemodialysis.com: What should clinicians and patients take away from your report? Timely vascular access creation is an important part of advanced CKD care. However, better tools are needed to predict short-term progression to ESRD to guide timely placement of AV fistulae. Read the rest of the interview on Hemodialysis.com

35 Incident Atrial Fibrillation and Risk of End-Stage Renal Disease in Adults with Chronic Kidney Disease Incident Atrial Fibrillation and Risk of End-Stage Renal Disease in Adults with Chronic Kidney Disease Nisha Bansal, MD, MAS Assistant Professor, Division of Nephrology University of California, San Francisco Hemodialysis.com Editor Marie Benz: What are the main findings of the study? In this large population of adults with CKD, we found that incident atrial fibrillation was independently associated with greater risk of ESRD. Hemodialysis.com: Were any of the findings unexpected? The association between kidney disease and atrial fibrillation may be bi-directional. Hemodialysis.com: What should clinicians and patients take away from your report? Further studies are needed to explore the mechanisms that explain the association between development of atrial fibrillation and subsequent ESRD among patients with CKD. Read the rest of the interview on Hemodialysis.com

36 Association between Kidney Function and Telomere Length: The Heart and Soul Study Association between Kidney Function and Telomere Length: The Heart and Soul Study Nisha Bansal, MD, MAS Assistant Professor, Division of Nephrology University of California, San Francisco Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Many chronic diseases are associated with short telomere lenth and accelerated telomere shortening. In our study, we found that reduced kidney function was associated with shorter telomere length and accelerated telomere shortening, however these associations were entirely explained by age. Hemodialysis.com: What recommendations do you have for future research as a result of this study? Telomere length is a very interesting and novel cardiovascular risk factor in the general population, but may not be an independent risk factor for mortality among patients with chronic kidney disease. Read the rest of the interview on Hemodialysis.com

37 Long Chain n-3 Fatty Acids and Risk of Sudden Cardiac Death in Patients Starting Hemodialysis Long Chain n-3 Fatty Acids and Risk of Sudden Cardiac Death in Patients Starting Hemodialysis Allon Friedman, M.D., FASN Associate Professor of Medicine Division of Nephrology Indiana University School of Medicine Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Dr. Allon: We found that levels of blood long chain omega-3 polyunsaturated fatty acids (PUFA) (the same ones found in fish oil) measured at the time of initiating hemodialysis were powerfully and inversely related to the risk of sudden cardiac death during the following year, even after controlling for a number of important and influential factors. In fact, the relationship held true even during the highest risk first three-month period. Hemodialysis.com: Were any of the findings unexpected? Dr. Allon: Our hypothesis, which was based on previous laboratory and clinical work performed in populations without kidney disease, was essentially confirmed by our results. If anything, the statistical relationships we found were even stronger than what we had expected. Read the rest of the interview on Hemodialysis.com

38 Association between Variability in eGFR and Mortality Association between Variability in eGFR and Mortality Dr. Tanvir Chowdhury Turin Dr. Brenda R Hemmelgarn University of Calgary, Hemodialysis.com Editor Marie Benz: What are the main findings of the study? We observed an independent and graded association between variability in kidney function and mortality. The higher the magnitude of the fluctuation in eGFR, the higher was the risk of death. Hemodialysis.com: Were any of the findings unexpected? Chronic kidney disease is a dynamic condition where the kidney function changes over time. While the magnitude in the rate of change in eGFR over time has been associated with an increased risk of death, whether variability in serial eGFR measurements is also associated with risk of adverse outcomes is not clear. Hemodialysis.com: What should clinicians and patients take away from your report? A better assessment of future adverse outcome risk of patients might be possible bu utilizing the information about the dynamics of changes in kidney function over time (rate of change and variability). Read the rest of the interview on Hemodialysis.com

39 Risk of Infectious and Non-Infectious Complications of Permanent Hemodialysis Access Risk of Infectious and Non-Infectious Complications of Permanent Hemodialysis Access Dr. Pietro Ravani, PhD, MSc, MD, FNCPS(I), Assoc. Prof. of Medicine Calgary Hemodialysis.com Editor Marie Benz: What are the main findings of the study? The risks of thrombosis, access infections and sepsis are very high after access placement and decline over time in all permanent access type; risks patterns are similar in incident and prevalent patients. Hemodialysis.com: Were any of the findings unexpected? Some clinicians believe the risk for infectious complications may increase over time especially in catheter users; we were unable to to support this hypothesis. Hemodialysis.com: What should clinicians and patients take away from your report? Prevention therapies should be considered initially, when baseline risks are higher. Read the rest of the interview on Hemodialysis.com

40 ASN 2012 Abstract: Association between Type of Hemodialysis Access and Clinical Outcomes: Meta-Analysis of Cohort Studies ASN 2012 Abstract: Association between Type of Hemodialysis Access and Clinical Outcomes: Meta-Analysis of Cohort Studies Dr. Pietro Ravani, PhD, MSc, MD, FNCPS(I), Assoc. Prof. of Medicine Calgary Hemodialysis.com Editor Marie Benz: What are the main findings of the study? Most available data compare outcomes by access used rather than access intended; selection bias is high in available data. Hemodialysis.com: Were any of the findings unexpected? Insufficient information exists from studies comparing access intended as opposed to access achieved in a given patient. Hemodialysis.com: What should clinicians and patients take away from your report? Fistula may not be superior to catheters in all patients. Read the rest of the interview on Hemodialysis.com


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