Hemodialysis.com | Reduced Kidney Function | Hyperuricemia | CV Morbidity | Dr. Neri
Author Interview: Dr Luca Neri
Doctor of Environmental and Occupational Medicine
Adjunct Instructor of Health Management and Policy
Saint Louis University - Center for Outcomes Research
St. Louis - Missouri, USA
Post Doctoral Fellow
Dipartimento di Medicina del Lavoro
Clinica del Lavoro "L. Devoto"
Divisione di Ergonomia e Psicologia del Lavoro
Università Statale degli Studi di Milano Milano - Italy
Publication: Author Interview: Dr Luca Neri
Joint Association of Hyperuricemia and Reduced GFR on Cardiovascular Morbidity: A Historical Cohort Study Based on Laboratory and Claims Data From a National Insurance Provider.
Neri L, Rocca Rey LA, Lentine KL, Hinyard LJ, Pinsky B, Xiao H, Dukes J, Schnitzler MA.
Center for Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO; Dipartimento di Medicina del Lavoro, Clinica del Lavoro "L. Devoto," Divisione di Ergonomia e Psicologia del Lavoro, Università Statale degli Studi di Milano, Milan, Italy.
Am J Kidney Dis. 2011 Sep;58(3):398-408. Epub 2011 Jul 23.
What are the main findings of the study?
We performed a historical cohort study evaluating the risk of cardiovascular events in adult beneficiaries of a national health insurance provider. We augmented billing claims data with extracts from outpatient laboratory results and prescription medications. Data were available since January 2003 to December 2006. We identified 148,217 patients who met the inclusion criteria of the study (182,730 person-years overall).
We observed that increased serum uric acid concentration was associated with excess cardiovascular hospitalization risk independent of established risk factors and severity of decreased kidney function. In our study cardiovascular risk increased at uric acid levels lower than the threshold currently defining hyperuricemia. In addition, we found that the association between serum uric acid level and cardiovascular risk was stronger in patients with more severe decreases in kidney function.
Were any of the findings unexpected?
An association between uric acid level and cardiovascular morbidity that is independent of decreased GFR is not unexpected. Contrary to other uremic toxins involved in cardiovascular risk the correlation between serum uric acid level and GFR has been found to be weak. This may be caused in part by decreased xanthine oxidase activity and enhanced serum uric acid enteric excretion observed in animal models of CKD. However because serum uric acid levels are related closely to several established risk factors for cardiovascular morbidity and mortality, observing an independent relationship has proven to be challenging. In contrast the association observed in our study was robust to adjustment for established cardiovascular risk factors.
We also observed that the association between serum uric acid level and cardiovascular disease was stronger in patients with advanced CKD. Even though uric acid has been suggested to increase cardiovascular risk via many physiopathologic pathways overlapping with CKD-related toxicity, to our best knowledge this interaction has never been reported in previous studies. We believe that this important finding warrants further studies.
What should clinicians and patients take away from this study?
Our observations suggest that the potential impact factor of a 33% urate decrease by means of xanthine oxidase inhibition in patients with serum uric acid level ≥5.7 mg/dL would be much greater in patients with moderate to advanced CKD than in those with normal or slightly decreased eGFR (60.2% vs 6.1%).
However, there is no compelling evidence indicating whether uric acid is an independent risk factor or a marker of xanthine oxidase activity, a well-known free radical generating enzyme.
Although, our historical cohort study cannot prove causality of association, it is important to notice the potential clinical relevance of competing hypothetical scenarios to prioritize research investments. Whether this decrease can be achieved is a matter of further research.
What recommendations do you have for nephrology health care providers as a result of your study?
Our observations suggest the possibility that patients with advanced CKD may experience particular
benefit from serum uric acid reduction treatments. However, whether serum uric acid level is a direct risk factor or a passive marker of xanthine oxidase activity cannot be answered by our study. These findings provide the rationale to further study the impact of therapies that decrease hyperuricemia on cardiovascular risk in the general population and patients with CKD. Even though there is not conclusive evidence that a xanthine oxidase inhibition in patient with excess uric acid levels would lead to reductions in cardiovascular risk, we believe that clinicians should be aware that uric acid levels are putative risk factors for this important complication and include serum uric acid assessment in their routine biochemistry panel for patients with CKD.
Recommendations based on extensive systematic literature search, meta-analysis and expert opinion exist for patients with gout which provide a valid guide for the management of this condition (Zhang et al. Ann Rheum Dis 2006;65:1312-1324). Patients with hyperuricemia and no gout should be prescribed with uric acid lowering life-style and diet regimens (Choi HK, Current Opinion in Rheumatology, 2010, 22:165–172) which have been shown to decrease the long-term risk of gout flares and reduce insulin-resistance, a condition often associated to excess uric acid levels.
Abstract:
BACKGROUND:
Hyperuricemia is common in patients with chronic kidney disease (CKD). We assessed the relationship of increased serum uric acid levels with cardiovascular risk across levels of kidney function. STUDY DESIGN:
Historical cohort study. SETTING & PARTICIPANTS:
Study data were drawn from administrative records of a national private health insurer (2003-2006). We included all adult beneficiaries with concurrently measured serum creatinine and serum uric acid. Patients with acute kidney failure or undergoing renal replacement therapy at baseline were excluded. PREDICTORS:
Serum uric acid concentration and estimated glomerular filtration rate (eGFR). OUTCOMES & MEASUREMENTS:
Cardiovascular diagnoses (myocardial infarction, subacute coronary heart disease, heart failure, cerebrovascular disease, or peripheral arterial disease) ascertained from billing claims. Cox proportional hazard models were used to test the association of predictors with cardiovascular morbidity. Models were adjusted for sociodemographic characteristics, selected comorbid conditions, and laboratory results. RESULTS:
In 148,217 eligible patients, mean eGFR was 84 mL/min/1.73 m(2) and the prevalence of CKD stages 3-5 was 6.0%. Hyperuricemia (serum uric acid >7 mg/dL) was found in 15.6% of patients. The 40-month cumulative incidence of cardiovascular events (mean follow-up, 15.3 months) was 8.1%. Cardiovascular risk was associated independently with uric acid level, and this association was stronger in patients with lower eGFRs. LIMITATIONS:
Observational design, lack of information for mortality and potential confounders, single creatinine and uric acid assessment. CONCLUSIONS:
Serum uric acid concentration was an independent correlate of cardiovascular morbidity, and this association was stronger in patients with severely decreased eGFR. This investigation provides a rationale for further study of serum uric acid-lowering interventions on cardiovascular risk in the general population and patients with CKD.
Home Dialysis Summit Recommends Policy Changes to Increase Home Dialysis Usage
WASHINGTON, April 25, 2012 /PRNewswire -- On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates -- leaders in the kidney disease patient, clinician, facility and industry communities -- on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment. Many of the organizers also announced they have formed a new alliance, called the Alliance for Home Dialysis, to advance the recommendations identified at the Summit.
The Summit's "Report of the Delegates" highlights key findings from a March 29th meeting in Washington, DC where experts probed why, despite widely accepted and well-documented benefits of home dialysis -- improved outcomes, enhanced patient satisfaction, improved quality of life, and lower costs-- fewer than ten percent of the more than 390,000 current U.S. dialysis patients receive treatment at home. Current rates of home dialysis utilization reflect a steep decline from the 1970s, when almost 40% of U.S. dialysis patients were treated in-home.
Specifically, delegates found that policymakers should work with stakeholders in the dialysis community to confront three areas:
Accessibility: Patients and clinicians face array of hurdles in education, training, and infrastructure that hinder equalized access to home dialysis.
Accountability: Utilization of home dialysis can be improved through measures within government programs that are designed to recognize and support excellence in the delivery of home dialysis services.
Aligning Incentives: Reimbursement policies, regulation of new technologies and other policy incentives can be realigned to better support federal policy goals of expanding access to home dialysis.
The Report includes 15 recommendations to serve these goals, including that federal policymakers should:
Maintain parity for home and in-center dialysis in Medicare reimbursement;
Support home dialysis mentoring programs, particularly those that use existing patients as mentors; and
Align federal and state regulatory requirements for home therapies, such as revising the Centers for Medicare and Medicaid Services Conditions for Coverage requirements, to reflect differences in home and in-center dialysis.
Summit supporters will begin work through the new Alliance to dialogue with federal policymakers and advance policy improvements in the three consensus areas that emerged at the Summit.
SOURCE National Summit on Home Dialysis Policy
National Kidney Foundation's Top 10 Things Every Dialysis Patient Should Know.
You have treatment choices. Options exist for how, where and when you dialyze. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home. You and your doctor will decide which place is best, based on your medical condition and your wishes. There are different types of dialysis - peritoneal and hemodialysis. Work with your health care team to determine a treatment plan that makes you feel comfortable. Recent studies show that the majority of patients beginning in-center hemodialysis (HD) know very little, if anything, about the option to dialyze at home. Once informed, 40% or more of patients are interested in this treatment option, and yet less than 10% actually begin home dialysis. If you're dissatisfied with the type of dialysis treatment that you're receiving, ask your healthcare team if another type of dialysis treatment would be better.
You can compare in-center dialysis facilities online. Information on over 5,600 US-based dialysis centers is available online through the Medicare website. To help you make choices about your care, you can compare different facilities side-by-side and evaluate each facility based upon clinic characteristics and quality measures. You can search for dialysis facilities by name or geographic proximity. After completing an initial facility comparison to determine which facilities best meet your needs - such as the number of hemodialysis stations at a particular location and whether there are evening shifts available - visit the facilities that you're most interested in. Talk to the staff and other patients, as well as your doctor to ensure that this dialysis facility is a good fit for you.
There are ways to prepare ahead for an emergency. Ask your dialysis facility about their emergency plan in case of a snow storm, fire, power outage or other natural disaster. As back up, make sure you have the names, locations and phone numbers of other dialysis units and hospitals in your area. Since regular community transportation services may not be working in an emergency, be prepared to make other arrangements for getting to dialysis. You may need to contact the police and Emergency Medical Services (EMS) for assistance. If you dialyze at home, make sure you have at least two weeks' worth of unexpired supplies on hand. If you have to miss a dialysis treatment, begin your emergency meal plan.
There is an easy way to transfer patient records between clinics. There is an easy, secure way for your health care team to transfer your treatment records online. In 2009, the Centers for Medicare and Medicaid Services (CMS) created a centralized web-based data collection system called CROWNWeb to help reduce and eliminate patient treatment interruptions. This central system helps to streamline patient care regardless of the reason for changing dialysis centers. For example, if you've been admitted to the hospital, or if you needed to relocate during an emergency evacuation, your doctors and health care team can access up-to-date information about your dialysis so that you continue to receive appropriate care no matter where you are.
You can travel while on dialysis.
Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized, but you need to plan ahead by making an appointment for dialysis at another center before you go. The staff at your center may help you make these appointments.
You can be your own best advocate. Know what key questions to ask your doctor or other healthcare professionals. Take notes so that you can refer back to them later. Partner with your doctor and decide on a treatment plan together. Advocate for yourself and share how you're feeling.
You have many rights. You as a patient have a great deal of control over your treatments. Patients have a bill of rights which includes receiving quality care, counseling about your medical information, and an expectation of privacy.
You also have responsibilities. Once you decide on a course of treatment, it's important to follow the recommendations of your health care team. If you decide to receive in-center dialysis, arrive at dialysis on time so that you can receive the full treatment without delays.
You can receive insurance coverage. If you have end stage renal failure, you are likely eligible for Medicare insurance coverage. Speak with your health care team and social worker for help filling out insurance paperwork.
You may need to follow a special diet. When your kidneys are not working properly, you may not be able to eat everything you like, and you may need to limit how much you drink. Your diet may vary according to the type of dialysis you receive. It is important to speak with a renal dietitian so that you are able to understand what you can and cannot eat based on your full health history.
Dialysis patients can work. Many dialysis patients can go back to work or school after they have gotten used to dialysis. After establishing a dialysis routine, many patients have more energy and find that they are able to time to work around this new schedule. Some patients even find creative ways to work remotely from dialysis with the use of a laptop or cell phone, depending on their field of expertise.
New Book to Help Educate Patients with Chronic Kidney Disease who may be facing Dialysis or Hemodialysis:
Help, I Need Dialysis! How to have a good future with kidney disease
By Dori Schatell, MS and Dr. John Agar
An internationally known nephrologist and life-long kidney patient educator explain how dialysis works, each of the ways to do it, and how your treatment choice may affect your diet, energy level, work, travel, sexuality and fertility, sleep, and survival. Comprehensive and fully referenced, this book is a must-read if you face the life-changing choices that come with kidney failure.
The information on hemodialysis is for informational purposes only and is not intended as specific medical advice or to be a substitute for medical advice from your physician or health care provider.
Please check with a physician if you need a diagnosis and/or for treatments as well as information regarding your specific condition.
Please read Medical Disclaimer as term of condition for usage of this website.
If you are experiencing urgent medical conditions, call 9-1-1
____________________________________________________
Editor: Marie Benz, MD
President: Robert L. Benz, MD FACP
Copyright 2012 EminentDomains.com®. All Rights Reserved. Our Success is Linked to Yours®
