Bessie A. Young

Hepatitis C Virus Infection and the Prevalence of Renal Insufficiency

BACKGROUNDnHepatitis C virus (HCV) is associated with pathologic changes in the kidney. However, the association between HCV and renal dysfunction is not well defined.nnnDESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTSnThis study estimated the prevalence of renal insufficiency among veterans who received care through the Veterans Affairs Puget Sound Health Care System. The study population consisted of veterans who underwent HCV antibody testing between January 1, 1999, and December 31, 2004, and had at least one primary care or medical subspecialty visit and at least one outpatient creatinine measurement within the 18 mo before antibody testing. Veterans were excluded when they had a history of chronic dialysis, creatinine >5 mg/dl, or renal transplantation. Study data were extracted from the electronic medical record. Renal insufficiency was defined as a creatinine level > or =1.5 mg/dl. Multivariate logistic regression was performed to estimate the risk for renal insufficiency associated with HCV. Among 25,782 eligible veterans, 1928 were HCV antibody positive and 23,854 were HCV antibody negative.nnnRESULTSnAlthough the proportion with renal insufficiency was lower for antibody-positive versus -negative veterans (4.8 versus 6.0%), after adjustment for age, race, gender, diabetes, and hypertension, HCV-positive veterans had a 40% higher odds for renal insufficiency (odds ratio 1.40; 95% confidence interval 1.11 to 1.76) as compared with HCV-negative veterans.nnnCONCLUSIONSnHCV was associated with an increased prevalence of renal insufficiency.

Improving Depression Care in Patients with Diabetes and Multiple Complications

AbstractBACKGROUND: Depression is common in patients with diabetes, but it is often inadequately treated within primary care. Competing clinical demands and treatment resistance may make it especially difficult to improve depressive symptoms in patients with diabetes who have multiple complications.n OBJECTIVE: To determine whether a collaborative care intervention for depression would be as effective in patients with diabetes who had 2 or more complications as in patients with diabetes who had fewer complications.n DESIGN: The Pathways Study was a randomized control trial comparing collaborative care case management for depression and usual primary care. This secondary analysis compared outcomes in patients with 2 or more complications to patients with fewer complications.n PATIENTS: Three hundred and twenty-nine patients with diabetes and comorbid depression were recruited through primary care clinics of a large prepaid health plan.n MEASUREMENTS: Depression was assessed at baseline, 3, 6, and 12 months with the 20-item depression scale from the Hopkins Symptom Checklist. Diabetes complications were determined from automated patient records.n RESULTS: The Pathways collaborative care intervention was significantly more successful at reducing depressive symptoms than usual primary care in patients with diabetes who had 2 or more complications. Patients with fewer than 2 complications experienced similar reductions in depressive symptoms in both intervention and usual care.n CONCLUSION: Patients with depression and diabetes who have multiple complications may benefit most from collaborative care for depression. These findings suggest that with appropriate intervention depression can be successfully treated in patients with diabetes who have the highest severity of medical problems.

Relationship Styles and Mortality in Patients With Diabetes

OBJECTIVE Prior research has shown that less social support is associated with increased mortality in individuals with chronic illnesses. We set out to determine whether lower propensity to seek support as indicated by relationship style, based on attachment theory, is associated with mortality in patients with diabetes. RESEARCH DESIGN AND METHODS A total of 3,535 nondepressed adult patients with type 1 and type 2 diabetes enrolled in a health maintenance organization in Washington State were surveyed at baseline and followed for 5 years. Relationship style was assessed at baseline. Patients with a greater propensity to seek support were classified as having an interactive relationship style and those less inclined to seek support as having an independent relationship style. We collected Washington State mortality data and used Cox proportional hazards models to estimate relative risk (RR) of death for relationship style groups. RESULTS The rate of death in the independent and interactive relationship style groups was 39 and 29 per 1,000 individuals, respectively. Unadjusted RR of death was 1.33 (95% CI 1.12–1.58), indicating an increased risk of death among individuals with an independent relationship style. After adjustment for demographic and clinical covariates, those with an independent relationship style still had a greater risk of death compared with those with an interactive relationship style (hazard ratio 1.20 [95% CI 1.01–1.43]). CONCLUSIONS In a large sample of adult patients with diabetes, a lower propensity to reach out to others is associated with higher mortality over 5 years. Further research is needed to examine possible mechanisms for this relationship and to develop appropriate interventions.

How to Overcome Barriers and Establish a Successful Home HD Program

Home hemodialysis (HD) is an underused dialysis modality in the United States, even though it provides an efficient and probably cost-effective way to provide more frequent or longer dialysis. With the advent of newer home HD systems that are easier for patients to learn, use, and maintain, patient and provider interest in home HD is increasing. Although barriers for providers are similar to those for peritoneal dialysis, home HD requires more extensive patient training, nursing education, and infrastructure support in order to maintain a successful program. In addition, because many physicians and patients do not have experience with home HD, reluctance to start home HD programs is widespread. This in-depth review describes barriers to home HD, focusing on patients, individual physicians and practices, and dialysis facilities, and offers suggestions for how to overcome these barriers and establish a successful home HD program.

Variations on a theme

A 57-year-old man presented to the emergency department with a 2-week history of progressive dyspnea on exertion, edema of the legs, a nonproductive cough, and scant hemoptysis. He also reported occasional passage of bright red blood from his rectum and intermittent nausea and vomiting during the previous 4 days.

Renin-Angiotensin System Blocker Fetopathy

Chronic hypertension in pregnant women is associated with significant maternal and fetal morbidity and mortality, and is thought to complicate approximately 5% of the 4 million pregnancies in the US annually.1 Pregnant women with chronic hypertension are at risk for developing adverse complications, such as maternal preeclampsia, stroke, renal failure, and death.2 In addition, adverse fetal outcomes, such as intrauterine growth restriction, preterm birth, and death, are more likely among pregnant women with chronic hypertension than those without. For example, in one study, the risk of cardiac congenital malformations was increased in pregnancies of women with both treated (OR 1.6, 95% CI 1.4-1.9) and untreated hypertension (OR 1.5, 95% CI 1.3-1.7).3 The prevalence of chronic hypertension (7.7%) and use of antihypertensive agents (4.2%) in women of childbearing age (20-44 years) is relatively low.4 However, among those who use antihypertensive agents, the use of angiotensin converting enzyme inhibitors (ACEIs) (44%) or angiotensin receptor blockers (ARBs) (20.4%) is prevalent and greater than that of diuretics (47.9%), thus, increasing the potential risk of inadvertent first trimester exposure of the fetus.4 Given the recent changes in hypertensive guideline recommendations5 and the prevalence of underlying risk factors in the general population, such as chronic kidney disease and diabetes,1 the potential for exposure of a fetus to ACEIs or ARBs during the first trimester is substantial among women of child-bearing age with chronic hypertension, diabetes, or kidney disease.

Survival with short-daily hemodialysis

In thrice‐weekly hemodialysis, survival correlates with the length of time (t) of each dialysis and the dose (Kt/V), and deaths occur most frequently on Mondays and Tuesdays. We studied the influence of t and Kt/V on survival in 262 patients on short‐daily hemodialysis (SDHD) and also noted death rate by weekday. Contingency tables, Kaplan‐Meier analysis, regression analysis, and stepwise Cox proportional hazard analysis were used to study the associations of clinical variables with survival. Patients had been on SDHD for a mean of 2.1 (range 0.1–11) years. Mean dialysis time was 12.9 ± 2.3u2003h/wk and mean weekly stdKt/V was 2.7 ± 0.5. Fifty‐two of the patients died (20%) and 8‐year survival was 54 ± 5%. In an analysis of 4 groups by weekly dialysis time, 5‐year survival continuously increased from 45 ± 8% in those dialyzing <12 hours to 100% in those dialyzing >15 hours without any apparent threshold. There was no association between Kt/V and survival. In Cox proportional hazard analysis, 4 factors were independently associated with survival: age in years Hazard Ratio (HR)=1.05, weekly dialysis hours HR=0.84, home dialysis HR=0.50, and secondary renal disease HR=2.30. Unlike conventional HD, no pattern of excessive death occurred early in the week during SDHD. With SDHD, longer time and dialysis at home were independently associated with improved survival, while Kt/V was not. Homedialysis and dialysis 15+u2003h/wk appear to maximize survival in SDHD.