Khaled Abdel-Kader

Acute Kidney Injury in the Elderly

The aging kidney undergoes several important anatomic and physiologic changes that increase the risk of acute kidney injury (formerly acute renal failure) in the elderly. This article reviews these changes and discusses the diagnoses frequently encountered in the elderly patient with acute kidney injury. The incidence, staging, evaluation, management, and prognosis of acute kidney injury are also examined with special focus given to older adults.

Predictors of Recurrent AKI

Recurrent AKI is common among patients after hospitalized AKI and is associated with progressive CKD. In this study, we identified clinical risk factors for recurrent AKI present during index AKI hospitalizations that occurred between 2003 and 2010 using a regional Veterans Administration database in the United States. AKI was defined as a 0.3 mg/dl or 50% increase from a baseline creatinine measure. The primary outcome was hospitalization with recurrent AKI within 12 months of discharge from the index hospitalization. Time to recurrent AKI was examined using Cox regression analysis, and sensitivity analyses were performed using a competing risk approach. Among 11,683 qualifying AKI hospitalizations, 2954 patients (25%) were hospitalized with recurrent AKI within 12 months of discharge. Median time to recurrent AKI within 12 months was 64 (interquartile range 19-167) days. In addition to known demographic and comorbid risk factors for AKI, patients with longer AKI duration and those whose discharge diagnosis at index AKI hospitalization included congestive heart failure (primary diagnosis), decompensated advanced liver disease, cancer with or without chemotherapy, acute coronary syndrome, or volume depletion, were at highest risk for being hospitalized with recurrent AKI. Risk factors identified were similar when a competing risk model for death was applied. In conclusion, several inpatient conditions associated with AKI may increase the risk for recurrent AKI. These findings should facilitate risk stratification, guide appropriate patient referral after AKI, and help generate potential risk reduction strategies. Efforts to identify modifiable factors to prevent recurrent AKI in these patients are warranted.

Resistant Hypertension and Obstructive Sleep Apnea in the Setting of Kidney Disease

Objectives: To explore the relationship between obstructive sleep apnea (OSA) and resistant hypertension in chronic kidney disease (CKD) and end-stage renal disease (ESRD). Methods: We examined sleep parameters and blood pressure (BP) in 224 community-based, non-CKD participants from the Sleep-SCORE study: 88 nondialysis-dependent CKD and 95 ESRD participants. Unattended home polysomnography with standardized scoring protocols and automated BP monitors were used. Resistant hypertension was defined as a BP of at least 140/90 mmHg despite at least three antihypertensive drugs. Results: Mean SBP of the CKD and ESRD groups were significantly higher than that of the non-CKD group [148.2 (23.8), 144.5 (26.7) vs. 132.2 mmHg (26.7), respectively; P < 0.0001] despite the use of more antihypertensive medications. The CKD and ESRD groups had higher rates of resistant hypertension than the non-CKD group (41.4, 22.6 vs. 6.7%, respectively; P < 0.0001). The severity of sleep apnea was associated with a higher risk of resistant hypertension. Although resistant hypertension was associated with severe sleep apnea in participants with ESRD [odds ratio (OR) 7.1, 95% confidence interval (CI) 2.2–23.2), there was no significant association in the non-CKD (OR 3.5, 95% CI 0.8–15.4) or CKD groups (OR 1.2, 95% CI 0.4–3.7) after accounting for case-mix. Conclusion: The association between resistant hypertension and sleep apnea appeared robust in ESRD. OSA may contribute to resistant hypertension or both may be linked to a common underlying process such as volume excess. Future studies in patients with kidney disease should further characterize the resistant hypertension–OSA relationship and determine whether treatment of underlying mechanisms may improve outcomes.

Automated Clinical Reminders for Primary Care Providers in the Care of CKD: A Small Cluster-Randomized Controlled Trial

BACKGROUND Primary care physicians (PCPs) care for most non-dialysis-dependent patients with chronic kidney disease (CKD). Studies suggest that PCPs may deliver suboptimal CKD care. One means to improve PCP treatment of CKD is clinical decision support systems (CDSSs). STUDY DESIGN Cluster-randomized controlled trial. SETTING & PARTICIPANTS 30 PCPs in a university-based outpatient general internal medicine practice and their 248 patients with moderate to advanced CKD who had not been referred to a nephrologist. INTERVENTION 2 CKD educational sessions were held for PCPs in both arms. The 15 intervention-arm PCPs also received real-time automated electronic medical record alerts for patients with estimated glomerular filtration rates <45 mL/min/1.73 m(2) recommending renal referral and urine albumin quantification if not done within the prior year. OUTCOMES Primary outcome was referral to a nephrologist; secondary outcomes were albuminuria/proteinuria assessment, CKD documentation, optimal blood pressure (ie, <130/80 mm Hg), and use of renoprotective medications. RESULTS The intervention and control arms did not differ in renal referrals (9.7% vs 16.5%, respectively; between-group difference, -6.8%; 95% CI, -15.5% to 1.8%; P = 0.1) or proteinuria assessments (39.3% vs 30.1%, respectively; between-group difference, 9.2%; 95% CI, -2.7% to 21.1%; P = 0.1). For intervention and control patients without a baseline proteinuria assessment, 27.7% versus 16.3%, respectively, had one at follow-up (P = 0.06). After controlling for clustering, these findings were largely unchanged and no significant differences were apparent between groups. LIMITATIONS Small single-center university-based practice, use of a passive CDSS that required PCPs to trigger the electronic order set. CONCLUSIONS PCPs were willing to partake in a randomized trial of a CDSS to improve outpatient CKD care. Although CDSSs may have potential, larger studies are needed to further explore how best to deploy them to enhance CKD care.

Numeracy Skills in CKD: Correlates and Outcomes

BACKGROUND AND OBJECTIVES Healthcare providers communicate the risks and benefits of treatments using frequencies, percentages, or proportions. However, many patients lack the numerical skills needed to interpret this information accurately to make informed choices. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS We assessed numeracy, the capacity to use and comprehend numbers, in a prospective cohort study of 187 patients with stage 4 to 5 chronic kidney disease or ESRD. Patients completed a three-item numeracy test and were assessed for global mental status, cognitive function, type of hemodialysis access, and kidney transplant use. We examined the association of numeracy with healthcare use and other cognitive and sociodemographic variables. RESULTS Over 50% of patients answered one or fewer numeracy questions correctly. Although African Americans (P = 0.0001), women (P = 0.05), and the unemployed (P = 0.0004) demonstrated lower numeracy skills, numeracy deficits were prevalent in every subgroup. In analyses adjusted for demographics and length of follow-up, higher numeracy was significantly associated with receipt of a transplant or active waiting list status. Numeracy was not associated with dialysis modality or hemodialysis vascular access. CONCLUSION Similar to prior findings in the general population, these findings indicate that poor numeracy skills are very common in patients with advanced chronic kidney disease and end-stage renal disease. Additional research is needed to further explore whether poor numeracy is a barrier to receipt of a kidney transplant. Clinicians caring for patients with kidney disease should consider using tools to enhance communication and overcome limited numeracy skills.

Disparities in Electronic Health Record Patient Portal Use in Nephrology Clinics

BACKGROUND AND OBJECTIVES Electronic health record (EHR) patient portals allow individuals to access their medical information with the intent of patient empowerment. However, little is known about portal use in nephrology patients. We addressed this gap by characterizing adoption of an EHR portal, assessing secular trends, and examining the association of portal adoption and BP control (<140/90 mmHg). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients seen between January 1, 2010, and December 31, 2012, at any of four university-affiliated nephrology offices who had at least one additional nephrology follow-up visit before June 30, 2013, were included. Sociodemographic characteristics, comorbidities, clinical measurements, and office visits were abstracted from the EHR. Neighborhood median household income was obtained from the American Community Survey 2012. RESULTS Of 2803 patients, 1098 (39%) accessed the portal. Over 87% of users reviewed laboratory results, 85% reviewed their medical information (e.g., medical history), 85% reviewed or altered appointments, 77% reviewed medications, 65% requested medication refills, and 31% requested medical advice from their renal provider. In adjusted models, older age, African-American race (odds ratio [OR], 0.50; 95% confidence interval [95% CI], 0.39 to 0.64), Medicaid status (OR, 0.53; 95% CI, 0.36 to 0.77), and lower neighborhood median household income were associated with not accessing the portal. Portal adoption increased over time (2011 versus 2010: OR, 1.38 [95% CI, 1.09 to 1.75]; 2012 versus 2010: OR, 1.95 [95% CI, 1.44 to 2.64]). Portal adoption was correlated with BP control in patients with a diagnosis of hypertension; however, in the fully adjusted model this was somewhat attenuated and no longer statistically significant (OR, 1.11; 95% CI, 0.99 to 1.24). CONCLUSION While portal adoption appears to be increasing, greater attention is needed to understand why vulnerable populations do not access it. Future research should examine barriers to the use of e-health technologies in underserved patients with CKD, interventions to address them, and their potential to improve outcomes.

Characterizing pre-dialysis care in the era of eGFR reporting: a cohort study.

BackgroundChronic kidney disease (CKD) is a common disorder associated with increased morbidity and mortality. Primary care physicians (PCPs) care for the majority of pre-dialysis CKD patients; however, PCPs often do not recognize the presence of CKD based on serum creatinine levels. Prior studies suggest that PCPs and nephrologists deliver suboptimal CKD care. One strategy to improve disease awareness and treatment is estimated glomerular filtration rate (eGFR) reporting. We examined PCP and nephrologist CKD practices before and after routine eGFR reporting.MethodsWe conducted a retrospective cohort study of patients with CKD 3b-4 (eGFR < 45) seen at a university-based, outpatient primary care clinic. Using a chi-square or Fishers exact test, we compared co-management rates, renal protective strategies, CKD documentation, and laboratory processes of care in 274 patients and 266 patients seen in a 6-month period prior to and following eGFR implementation, respectively.ResultsCKD co-management increased from 22.6% pre-eGFR to 48.5% post-eGFR (P < 0.0001). eGFR reporting did not improve angiotensin converting enzyme inhibitor or angiotensin receptor blocker use or quantitative urinary testing. However, non-steroidal anti-inflammatory drug avoidance (pre-eGFR 81.8% vs. post- eGFR 90.6%, P = 0.003) and phosphorus and parathyroid hormone testing improved (pre-eGFR vs. post-eGFR: 32.5% vs. 51.5%, P < 0.0001; 12.4% vs. 36.1%, P < 0.0001 respectively).ConclusionsA marked increase in CKD co-management was observed following eGFR implementation. Although some improvements in processes of care were noted, this did not include angiotensin converting enzyme inhibitor or angiotensin receptor blocker use. Overall care remained suboptimal despite eGFR reporting; further strategies are needed to improve PCP and nephrologist CKD care.

Association of Sleep Disordered Breathing With Cognitive Dysfunction in CKD Stages 4–5

BACKGROUND Sleep-disordered breathing and cognitive impairment are common in patients with chronic kidney disease (CKD). Sleep-disordered breathing is known to be a risk factor for cognitive dysfunction in the general population, but this association has not been studied in patients with CKD. STUDY DESIGN Cross-sectional study. SETTINGS & PARTICIPANTS A cohort of 169 patients with CKD stages 4-5. PREDICTORS Sleep-disordered breathing; covariates included demographics, diabetes, cardiovascular disease, depression, and dialysis modality. OUTCOMES Cognitive impairment, generally defined as a score 1.5 standard deviations or more from the age- and education level-adjusted normative cognitive test score. MEASUREMENTS Standardized health interview, neurocognitive assessment, sleep-related questionnaires, and polysomnography. RESULTS Sleep-disordered breathing (apnea-hypopnea index >15) was diagnosed in 83 (49.1%) individuals. This group had a significantly higher prevalence of nocturnal hypoxemia (65.8% vs 26.8%; P < 0.001) and excessive daytime sleepiness (38.6% vs 20.7%; P = 0.01). In addition, this group had significantly lower scores in tests measuring verbal memory, working memory, attention, and psychomotor speed. Sleep-disordered breathing was associated with higher risk of immediate verbal memory impairment after adjustment for known confounders (adjusted OR, 2.67; 95% CI, 1.17-6.08). However, in a subgroup analysis of older adults (aged >60 years), there were no significant differences in cognitive testing between the groups with and without sleep-disordered breathing. LIMITATIONS Cross-sectional design, limited sample size. CONCLUSIONS Sleep-disordered breathing is associated with cognitive impairments, especially impaired verbal memory, in patients with advanced CKD. However, the impact appeared limited in older adults. Early evaluation and management of sleep-disordered breathing in patients with CKD may provide an opportunity to improve cognitive function.

Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD

BACKGROUND AND OBJECTIVES Despite the potential benefits of conservative management, providers rarely discuss it as a viable treatment option for patients with advanced CKD. This survey was to describe the knowledge, attitudes, and practices of nephrologists and primary care providers regarding conservative management for patients with advanced CKD in the United States. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We developed a questionnaire on the basis of a literature review to include items assessing knowledge, attitudes, and self-reported practices of conservative management for patients with advanced CKD. Potential participants were identified using the American Medical Association Physician Masterfile. We then conducted a web-based survey between April and May of 2015. RESULTS In total, 431 (67.6% nephrologists and 32.4% primary care providers) providers completed the survey for a crude response rate of 2.7%. The respondents were generally white, men, and in their 30s and 40s. Most primary care provider (83.5%) and nephrology (78.2%) respondents reported that they were likely to discuss conservative management with their older patients with advanced CKD. Self-reported number of patients managed conservatively was >11 patients for 30.6% of nephrologists and 49.2% of primary care providers. Nephrologists were more likely to endorse difficulty determining whether a patient with CKD would benefit from conservative management (52.8% versus 36.2% of primary care providers), whereas primary care providers were more likely to endorse limited information on effectiveness (49.6% versus 24.5% of nephrologists) and difficulty determining eligibility for conservative management (42.5% versus 14.3% of nephrologists). There were also significant differences in knowledge between the groups, with primary care providers reporting more uncertainty about relative survival rates with conservative management compared with different patient groups. CONCLUSIONS Both nephrologists and primary care providers reported being comfortable with discussing conservative management with their patients. However, both provider groups identified lack of United States data on outcomes of conservative management and characteristics of patients who would benefit from conservative management as barriers to recommending conservative management in practice.

Laboratory Test Surveillance following Acute Kidney Injury

Background Patients with hospitalized acute kidney injury (AKI) are at increased risk for accelerated loss of kidney function, morbidity, and mortality. We sought to inform efforts at improving post-AKI outcomes by describing the receipt of renal-specific laboratory test surveillance among a large high-risk cohort. Methods We acquired clinical data from the Electronic health record (EHR) of 5 Veterans Affairs (VA) hospitals to identify patients hospitalized with AKI from January 1st, 2002 to December 31st, 2009, and followed these patients for 1 year or until death, enrollment in palliative care, or improvement in renal function to estimated GFR (eGFR) ≥60 L/min/1.73 m2. Using demographic data, administrative codes, and laboratory test data, we evaluated the receipt and timing of outpatient testing for serum concentrations of creatinine and any as well as quantitative proteinuria recommended for CKD risk stratification. Additionally, we reported the rate of phosphorus and parathyroid hormone (PTH) monitoring recommended for chronic kidney disease (CKD) patients. Results A total of 10,955 patients admitted with AKI were discharged with an eGFR<60 mL/min/1.73 m2. During outpatient follow-up at 90 and 365 days, respectively, creatinine was measured on 69% and 85% of patients, quantitative proteinuria was measured on 6% and 12% of patients, PTH or phosphorus was measured on 10% and 15% of patients. Conclusions Measurement of creatinine was common among all patients following AKI. However, patients with AKI were infrequently monitored with assessments of quantitative proteinuria or mineral metabolism disorder, even for patients with baseline kidney disease.