Brooke Heubner

The Brain in Kidney Disease (BRINK) Cohort Study: Design and Baseline Cognitive Function

BACKGROUNDnThe Brain in Kidney Disease (BRINK) Study aims to identify mechanisms that contribute to increased risk for cognitive impairment in patients with chronic kidney disease (CKD). We describe the rationale, design, and methods of the study and report baseline recruitment and cognitive function results.nnnSTUDY DESIGNnLongitudinal observational cohort study of the epidemiology of cognitive impairment in CKD. The primary aim is to characterize the association between (1) baseline and incident stroke, white matter disease, estimated glomerular filtration rate (eGFR), inflammation, microalbuminuria, and dialysis initiation and (2) cognitive decline over 3 years in a CKD cohort with a mean eGFR<45 mL/min/1.73 m(2).nnnSETTING & PARTICIPANTSnCommunity-dwelling participants 45 years or older recruited from 4 health systems into 2 groups: reduced eGFR, defined as eGFR<60 mL/min/1.73 m(2) (non-dialysis dependent), and control, defined as eGFR≥60 mL/min/1.73 m(2).nnnPREDICTORneGFR group.nnnOUTCOMESnPerformance on cognitive function tests and structural brain magnetic resonance imaging.nnnMEASUREMENTSnSequential cognitive and physical function testing, serum and urine biomarker measurement, and brain magnetic resonance images over 3 years.nnnRESULTSnOf 554 participants, mean age was 69.3 years; 333, 88, and 133 had eGFRs<45 (non-dialysis dependent, nontransplantation), 45 to <60, and ≥60 (controls) mL/min/1.73 m(2), respectively. Mean eGFR in reduced-eGFR participants was 34.3 mL/min/1.73 m(2). Baseline cognitive performance was significantly associated with eGFR in all domains except language. Participants with eGFRs<30 mL/min/1.73 m(2) performed significantly worse than those with eGFRs≥30 mL/min/1.73 m(2) on tests of memory, processing speed, and executive function. Participants with reduced eGFRs overall scored worst on the Immediate Brief Visual-Spatial Memory Test-Revised.nnnLIMITATIONSnHealthy cohort bias, competing risk for death versus cognitive decline.nnnCONCLUSIONSnCognitive function was significantly worse in participants with eGFRs<30 mL/min/1.73 m(2). Future BRINK analyses will measure risk factors for cognitive decline using the longitudinal data.

Effect of intravenous iron use on hospitalizations in patients undergoing hemodialysis: a comparative effectiveness analysis from the DEcIDE-ESRD study

BACKGROUNDnIntravenous iron use in hemodialysis patients has greatly increased over the last decade, despite limited studies on the safety of iron.nnnMETHODSnWe studied the association of receipt of intravenous iron with hospitalizations in an incident cohort of hemodialysis patients. We examined 9544 patients from Dialysis Clinic, Inc. (DCI). We ascertained intravenous iron use from DCI electronic medical record and USRDS data files, and hospitalizations through Medicare claims. We examined the association between iron exposure accumulated over 1-, 3- or 6-month time windows and incident hospitalizations in the follow-up period using marginal structural models accounting for time-dependent confounders. We performed sensitivity analyses including recurrent events models for multiple hospitalizations and models for combined outcome of hospitalization and death.nnnRESULTSnThere were 22 347 hospitalizations during a median follow-up of 23 months. Higher cumulative dose of intravenous iron was not associated with all-cause, cardiovascular or infectious hospitalizations [HR 0.97 (95% CI: 0.77-1.22) for all-cause hospitalizations comparing >2100 mg versus 0-900 mg of iron over 6 months]. Findings were similar in models examining the risk of hospitalizations in 1- and 3-month windows [HR 0.88 (95% CI: 0.79-0.99) and HR 0.88 (95% CI: 0.74-1.03), respectively] or the risk of combined outcome of hospitalization and death in the 6-month window [HR 0.98 (95% CI: 0.78-1.23)].nnnCONCLUSIONSnHigher cumulative dose of intravenous iron may not be associated with increased risk of hospitalizations in hemodialysis patients. While clinical trials are needed, employing higher iron doses to reduce erythropoiesis-stimulating agents does not appear to increase morbidity in routine clinical care.

Impact of increased time at the highest urgency category on heart transplant outcomes for candidates with ventricular assist devices.

BACKGROUNDnVentricular assist devices (VADs) have improved survival among end-stage heart disease patients. Since 2002, heart transplant candidates with VADs have been afforded 30 days of elective time at the highest urgency category (Status 1A) under Organ Procurement and Transplantation Network (OPTN) policy. We aimed to determine the effect of increasing elective time at the highest urgency category for heart transplant candidates with VADs. This analysis was requested by OPTN during its evaluation of heart allocation policy.nnnMETHODSnWe simulated several allocation schemes wherein elective Status 1A time was increased to 45, 60, and 90 days; results were compared with a baseline simulation of 30 days and with the actual observed heart transplant waiting list cohort.nnnRESULTSnThe simulations showed that increasing elective Status 1A time for candidates with VADs did not substantially change waiting list mortality overall or for sub-groups of concern, which were candidates with VADs listed at a lower-urgency category (Status 1B), those with with VAD complications, total artificial heart, or intraaortic balloon pump support; or those with extracorporeal membrane oxygenation. Across the different time allowances, the average post-transplant death rate remained stable. It also remained stable for recipients previously listed as Status 1A or 1B categories for VAD and for recipients with VAD complications or an intraaortic balloon pump at transplant, on extracorporeal membrane oxygenation, and those without devices.nnnCONCLUSIONSnOur results suggest that increasing time in the highest urgency category for candidates with VADs would not improve waiting list mortality or post-transplant outcomes for heart transplant candidates overall.

Incidence of Acute Coronary Syndrome in the General Medicare Population, 1992 to 2009: A Real-World Perspective

2. Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J; American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology/American Heart Association Cardiac Rehabilitation/Secondary Prevention Performance Measures Writing Committee. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. Circulation. 2007;116(14):1611-1642.

COGNITIVE IMPAIRMENT IN MODERATE CHRONIC KIDNEY DISEASE: THE BRAIN IN KIDNEY DISEASE (BRINK) STUDY

negative in a nonfluent and two semantic impaired patients. Ab42 in CSF were inversely correlated with total tau and positively with PIB PET. Conclusions: There were differences of cortical atrophy patterns among the three subgroups and of anatomic correlates according to specific clinical symptoms like initial presenting symptoms, repetition failure, and prosopagnosia. PIB-PET had reflected amyloid burden in Korean PPA patients too. Based on the findings with clinical features, voxel-based analysis of SPGR MRI, PIB-PET and CSF biomarkers, logopenic subgroup might had some common pathology of Alzheimer’s disease.