Scott A. Rasgon

An Intervention for Employment Maintenance Among Blue-Collar Workers With End-Stage Renal Disease

An evaluation study was conducted to test the benefit of a predialysis intervention in assisting blue-collar workers with end-stage renal disease (ESRD) to maintain employment. Patients with ESRD were recruited from a large southern California health maintenance organization. In a nonrandomized control trial, employment status among 45 ESRD patients who received a predialysis orientation program followed by in-center dialysis was compared with that of 57 ESRD patients dialyzed at community centers not providing predialysis intervention. Participants had a mean age of 50 years. Sixty-two percent of participants were men and 38% were women. The sample was predominantly Afro-American (35.8%), Hispanic (28.9%), and white (24%). Employment status was assessed prior to dialysis and at least 6 months after beginning maintenance dialysis treatments. The intervention consisted of physician referral to a licensed clinical social worker prior to the initiation of in-center maintenance dialysis treatments, social worker assessment, patient education and counseling, orientation to the dialysis unit, and follow-up care from physicians, licensed clinical social workers, and other team members. A significantly higher proportion of blue-collar workers who received the intervention continued working after beginning dialysis (46.7%) when contrasted with control group blue-collar workers who did not receive the early intervention (23.5%) (chi-squared text = 3.78, P < 0.05). Odds ratio calculations showed that blue-collar workers who received the intervention were 2.8 times more likely to continue working than control group blue-collar workers. The effectiveness of the intervention highlights the importance of early psychosocial intervention in assisting in-center hemodialysis patients in maintaining employment.

Sleep Apnea in Early and Advanced Chronic Kidney Disease* Kaiser Permanente Southern California Cohort

BACKGROUND Sleep apnea (SA) has been reported to be highly prevalent in the dialysis population. The reported rates of SA in dialysis are severalfold greater than the 2 to 4% estimated in the general population. This study sought to determine whether an association exists between SA and early stages of chronic kidney disease (CKD) where SA may represent an important comorbidity and potential risk factor in kidney disease. METHODS Cross-sectional study of adults from an integrated health plan with documented serum creatinine levels in the period January 1, 2002, through December 31, 2004. SA diagnosis determined by International Classification of Diseases, ninth revision, coding for SA and Current Procedural Terminology coding for positive airway pressure devices. Kidney function was determined by the estimated glomerular filtration rate (eGFR). Logistic was regression used to estimate the relative risk for SA. RESULTS The overall prevalence of SA was 2.5% in the study population that included subjects with normal renal function and those with CKD. The odds ratios (ORs) for SA by eGFRs of 75 to 89, 60 to 74, 45 to 59, 30 to 44, and 15 to 29 mL/min per 1.73 m(2), respectively, compared to normal kidney function, after adjustment for age, sex, and number of visits, were as follows: 1.22 (95% confidence interval [CI], 1.18 to 1.25); 1.32 (95% CI, 1.27 to 1.37); 1.42 (95% CI, 1.35 to 1.50); 1.37 (95% CI, 1.25 to 1.50); and 1.32 (95% CI, 1.13 to 1.55). The increased ORs for eGFRs > 45 mL/min per 1.73 m(2) were sustained even after controlling for diabetes, heart failure, and hypertension. CONCLUSION This study demonstrated an increased risk of SA in patients with early CKD. Further evidence of a causal relationship should be sought in the hope that the detection and management of SA may improve the course of CKD.

Increased risk of renal cell cancer among women using diuretics in the United States

Use of prescription diuretics and incidence of renal cell cancer have increased in the United States in the past 25 years. Recent interview-based epidemiologic studies have reported an association between diuretic use and renal cell cancer risk. Our study evaluated this hypothesis using, for the first time, medical records as the source of the information on prescription diuretic use. Using medical records of women from a prepaid health plan, we identified 191 cases and 191 controls matched on age, membership duration, and membership at diagnosis. Diuretics use and history of potential confounding factors were ascertained by a standardized review of the medical records of each subject, without reference to case or control status. There was a strong and statistically significant association between renal cell cancer and prescription diuretics (odds ratio [OR] adjusted for hypertension, smoking, and obesity = 2.9, 95 percent confidence interval [CI]=1.7–4.7). Risk tended to increase with dose, measured by number of prescriptions. Since renal cancer can induce hypertension, which is treated by diuretics, and thereby confound the association with diuretics, we examined diuretic use 10 or more years prior to diagnosis when secondary hypertension would be unlikely. The OR for prescriptions 10 or more years before diagnosis was 3.5 (CI=1.7–7.4). Our results support earlier reports of an excess risk of renal cell cancer among users of prescription diuretics and indicate need for further study to evaluate this relationship, especially due to the extensive use of diuretics and the increasing incidence of this cancer.

25-Hydroxyvitamin D Levels and Hypertension Rates

Vitamin D deficiency has been linked to cardiovascular disease and risk factors including hypertension. The authors sought to determine prevalence rates of hypertension in adults tested for 25‐hydroxyvitamin D categorized by their levels and evaluate odds ratios for hypertension at lower 25‐hydroxyvitamin D levels compared with optimal levels. A cross‐sectional study was conducted January 1, 2004, through December 31, 2006, of patients aged 18 years and older within a large ethnically diverse population. Diagnosis of hypertension was determined by International Statistical Classification of Diseases and Related Health Problems codes. Patients were categorized into quartiles according to 25‐hydroxyvitamin D levels: ideal (≥40 ng/mL), adequate (30–39 ng/mL), deficient (15–29 ng/mL), and severely deficient (<15 ng/mL). Prevalence rates of hypertension and odds ratios were calculated for each 25‐hydroxyvitamin D quartile, adjusting for age, sex, race, and renal insufficiency. A total of 2722 individuals met the inclusion criteria for the study. The overall prevalence of hypertension in the study population was 24%. Hypertension rates were 52%, 41%, 27%, and 20% in 25‐hydroxyvitamin D quartiles <15 ng/mL, 15 to 29 ng/mL, 30 to 39 ng/mL, and ≥40 ng/mL, respectively (P<.001). Odds ratios (95% confidence intervals) for hypertension adjusting for age, sex, race, and renal insufficiency were 2.7 (1.4–5.2), 2.0 (1.5–2.6), and 1.3 (1.2–1.6) for 25‐hydroxyvitamin D levels <15 ng/mL, 15 to 29 ng/mL, and 30 to 39 ng/mL, respectively, compared with the ≥40 ng/mL group. This study demonstrates increased rates of hypertension in individuals who tested for lower levels of 25‐hydroxyvitamin D starting at levels <40 ng/mL. This retrospective analysis raises the question of whether supplementing to optimal vitamin D levels can prevent or improve hypertension. J Clin Hypertens (Greenwich). 2011;13:170–177.

Vitamin D supplementation and recombinant human erythropoietin utilization in vitamin D-deficient hemodialysis patients.

INTRODUCTION We sought to examine the impact of ergocalciferol (ERGO) on recombinant human erythropoietin (EPO) use in a cohort of 25-OH vitamin D (25-D)-deficient hemodialysis (HD) patients. METHODS Baseline 25-D levels were obtained for all patients who received HD >6 months in our unit. Patients with levels between 10 and 30 ng/mL received ERGO 50,000 IU x 4 doses and patients with levels <10 ng/mL received 50,000 IU x 6 doses over a 4-month period. Monthly dose of EPO was recorded at baseline and after ERGO supplementation. RESULTS Baseline 25-D levels were <30 ng/mL in 89% of tested patients. Eighty-one patients were included in this study. Mean baseline 25-D level was 15.3 ± 7.1 ng/mL and increased to 28.5 ± 8.6 ng/mL after ERGO (p<0.0001), and median baseline EPO dose was 21,933 U/month (interquartile range [IQR] 13,867-35,967) and decreased to 18,400 U/month (IQR 11,050-33,000) after ERGO (p=0.17). Forty-six patients (57%) required less EPO after ERGO compared with baseline: 15,450 U/month (IQR 10,056-23,575) vs. 26,242 U/month (IQR 15,717-40,167), respectively (p<0.0001). Thirty-five patients (43%) required a higher dose of EPO after ERGO, 26,350 U/month (IQR 15,875-46,075) vs. 17,667 U/month (IQR 12,021-23,392), respectively (p=0.016). Mean age, sex, vintage, diabetes status, race and 25-D levels did not differ in these 2 groups of patients, either at baseline or after ERGO. Monthly hemoglobin, iron saturation, albumin, intact parathyroid hormone, calcium and phosphorus were unchanged after ERGO in these 2 groups. CONCLUSIONS ERGO use in 25-D-deficient HD patients may lessen the need for EPO. We recommend more aggressive supplementation with ERGO in future studies to achieve levels >30 ng/mL.

Positive relationship of sleep apnea to hyperaldosteronism in an ethnically diverse population.

Objective Approximately, 50–60% of patients with sleep apnea have hypertension. To explore a mechanism of this relationship, we compared its prevalence in a hypertensive population with and without hyperaldosteronism. Methods Using the Kaiser Permanente Southern California database, hypertensive individuals who had plasma aldosterone and plasma renin activity measured between 1 January 2006 and 31 December 2007 were evaluated. Hyperaldosteronism was defined as an aldosterone : renin ratio more than 30 and plasma aldosterone more than 20 ng/dl or an aldosterone : renin ratio more than 50 (ng/dl : ng/ml per h). Hypertension was identified by International Classification of Disease, Ninth Revision (ICD-9) coding and sleep apnea was defined by ICD-9 coding or procedural coding for dispensation of positive airway devices. Results Of 3428 hypertensive patients, 575 (17%) had hyperaldosteronism. Sleep apnea was present in 18% (105) with hyperaldosteronism vs. 9% (251) without hyperaldosteronism (P < 0.001). Odds ratio for sleep apnea in patients with hyperaldosteronism was 1.8 (95% confidence interval 1.3–2.6) after controlling for other sleep apnea risk factors. No ethnic group was at greater risk for sleep apnea. Conclusion The prevalence of sleep apnea in a diverse hypertensive population is increased in patients with hyperaldosteronism, even when controlling for other sleep apnea risk factors.

Comparison of Outcomes of Peritoneal Dialysis Catheters Placed by the Fluoroscopically Guided Percutaneous Method versus Directly Visualized Surgical Method

PURPOSE To compare complications in catheters placed by the fluoroscopically guided percutaneous method versus directly visualized surgery. MATERIALS AND METHODS A retrospective cohort analysis was performed. Mechanical complication rate data, including catheter leakage, malfunction, malposition, and bleeding, were compared between the two groups over a 1-year follow-up period. Additionally, exit site infection rates, tunnel infection rates, and peritonitis episodes were evaluated based on the incidence within 30 days of insertion and 30 days to 1 year after insertion. RESULTS A total of 101 patients were analyzed (52 in the fluoroscopic guidance group, 49 in the direct visualization group). Prevalence of diabetes was similar: 56% in the directly visualized surgery group and 47% in the fluoroscopically guided treatment group (P = .37). Although the difference was not significant, complication rates tended to be higher in the directly visualized surgery group compared with the percutaneous placement group. These included catheter leakage (13% vs 4%; P = .093), malfunction (11% vs 9%; P = .73), malposition (13% vs 6%; P = .20), and bleeding (8% vs 2%; P = .21). There were no differences in early and late exit site infections and tunnel infections. Late peritonitis rates were lower in the percutaneous placement group (20%) than in the direct visualization group (42%) (P = .018). Diabetic patients had approximately six times greater risk of catheter malfunction than nondiabetic patients regardless of method of catheter insertion. CONCLUSIONS Placement of peritoneal dialysis catheters percutaneously with fluoroscopic guidance is as safe as placement with direct visualization techniques.

Agranulocytosis related to vancomycin therapy.

A patient with renal failure due to Goodpastures syndrome was treated with vancomycin. After he had received 3 g of the drug, his white blood cell count fell to a level of 200/microliter. Bone marrow biopsy disclosed severe myeloid hypoplasia. The patient subsequently recovered fully from this episode of vancomycin-induced agranulocytosis, but he eventually died of other causes. Vancomycin-related leukopenia has been reported, but the severely depressed white blood cell count and myeloid hypoplasia observed in this patient have not previously been described. Vancomycin must be excluded as the cause of leukopenia in any patient who is receiving this drug.

Review article: Managing sleep apnoea in kidney diseases.

A higher prevalence of sleep apnoea (SA) has been observed in the chronic kidney disease (CKD) population compared with estimates in the general population. Increased rates of SA have been described in patients with various renal‐related diagnoses including dialysis, renal transplant, early‐stage CKD and proteinuria. The mechanism or underlying aetiology for this association is different for each type of kidney disease. The extracellular fluid volume and metabolic derangements that characterize the uremic state likely contributes to SA in the dialysis population. SA causing direct renal insults from haemodynamic changes, ischaemic stress, or an intermediary condition such as hypertension, can lead to early CKD and proteinuria. While renal transplantation has cured SA in some patients, the post‐transplant state is itself a risk factor for SA. The high prevalence of SA in kidney disease and the associated clinical implications warrant vigilance in diagnosis and treatment of SA in the CKD patient. This review focuses on the prevalence of SA in patients with CKD including dialysis and transplant patients, and those with early‐stage CKD and proteinuria. SA may vary in form and aetiology depending on type or stage of CKD. Based on these associations, we discuss our rationale for recommendations on screening and management of SA specific to the CKD population.

Impact of Predialysis Care on Clinical Outcomes

Introduction:  A structured predialysis multidisciplinary team program is beneficial in improving quality of life in patients with end‐stage renal disease (ESRD). Educating pre‐ESRD patients about their disease is vital in their care. Patients who can identify signs and symptoms of impending problems can seek help and avoid complications that may lead to hospital admissions. Our dialysis center offers two predialysis classes in a structured format. The first class is for those patients with mild to moderate renal disease, whereas the second class is for those with advanced renal disease who are expected to need dialysis in 3 to 6 months. The patients are followed by a multidisciplinary team once they are enrolled in our chronic kidney disease program.