| | This Month in AJKD
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Comprehensive Public Health Strategies for Preventing the Development, Progression, and Complications of CKD: Report of an Expert Panel Convened by the Centers for Disease Control and Prevention
Andrew S. Levey, Anton C. Schoolwerth, Nilka Ríos Burrows, Desmond E. Williams, Karma Rabon Stith, William McClellan
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 522-535)
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Randomized and Observational Studies in Nephrology: How Strong Is the Evidence?
, 30 January 2009
Tom Greene
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 377-388)
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Facility Hemodialysis Vascular Access Use and Mortality in Countries Participating in DOPPS: An Instrumental Variable Analysis
, 16 January 2009
Ronald L. Pisoni, Charlotte J. Arrington, Justin M. Albert, Jean Ethier, Naoki Kimata, Mahesh Krishnan, Hugh C. Rayner, Akira Saito, Jeffrey J. Sands, Rajiv Saran, Brenda Gillespie, Robert A. Wolfe, Friedrich K. Port
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 475-491)
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Vascular Access Practice in Hemodialysis: Instrumental in Determining Patient Mortality
Kevan R. Polkinghorne
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 359-362)
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Hospital Performance and Differences by Kidney Function in the Use of Recommended Therapies After Non–ST-Elevation Acute Coronary Syndromes
, 22 December 2008
Uptal D. Patel, Fang-Shu Ou, E. Magnus Ohman, W. Brian Gibler, Charles V. Pollack, Eric D. Peterson, Matthew T. Roe
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 426-437)
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Connecting the C's: Coronaries, Creatinine, Compliance, CRUSADE
Alan K. Berger, Charles A. Herzog
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 366-369)
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The ABCs of Cardioprotection in Dialysis Patients: A Systematic Review
, 20 November 2008
James B. Wetmore, Theresa I. Shireman
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 457-466)
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Albuminuria, Cognitive Functioning, and White Matter Hyperintensities in Homebound Elders
, 15 December 2008
Daniel E. Weiner, Keith Bartolomei, Tammy Scott, Lori Lyn Price, John L. Griffith, Irwin Rosenberg, Andrew S. Levey, Marshal F. Folstein, Mark J. Sarnak
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 438-447)
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Add-Ons
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Cystatin C and Carotid Intima-Media Thickness in Asymptomatic Adults: The Multi-Ethnic Study of Atherosclerosis (MESA)
, 29 September 2008
Anh L. Bui, Ronit Katz, Bryan Kestenbaum, Ian H. de Boer, Linda F. Fried, Joseph F. Polak, Bruce A. Wasserman, Mark J. Sarnak, David Siscovick, Michael G. Shlipak
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 389-398)
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Proteinuria and Stroke: A Meta-analysis of Cohort Studies
, 15 December 2008
Toshiharu Ninomiya, Vlado Perkovic, Christine Verdon, Federica Barzi, Alan Cass, Martin Gallagher, Meg Jardine, Craig Anderson, John Chalmers, Jonathan C. Craig, Rachel Huxley
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 417-425)
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Serum Phosphorus Concentrations in the Third National Health and Nutrition Examination Survey (NHANES III)
, 07 November 2008
Ian H. de Boer, Tessa C. Rue, Bryan Kestenbaum
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 399-407)
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The Ubiquitous Nature and Elusive Role of Phosphorus and Vascular Calcification
Jordi Goldstein-Fuchs, Denis Fouque
American Journal of Kidney Diseases
March 2009 (Vol. 53, Issue 3, Pages 363-365)
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CDC Expert Panel Report on CKD Prevention  See Levey et al, pages 522-535. Chronic kidney disease (CKD) is a public health threat in the United States, with increasing prevalence, high costs, and poor outcomes. The tools to reduce the burden of CKD are already available, but a comprehensive public health approach has not yet been developed. In this issue, Levey et al, on behalf of a Centers for Disease Control (CDC) expert panel on CKD prevention, outline recommendations for a comprehensive public health strategy to prevent the development, progression, and complications of CKD in the United States. The expert panel adapted strategies for primary, secondary, and tertiary prevention for chronic diseases to the conceptual model for development, progression, and complications of CKD; reviewed epidemiologic data from US federal agencies; and discussed ways of integrating public health efforts from various agencies and organizations. Finally, the panel recommended a 10-point plan to the CDC to improve surveillance, screening, education, and awareness directed at 3 target populations: people with CKD or at increased risk of developing CKD; providers, hospitals, and clinical laboratories; and the general public. Strength of Evidence in Randomized and Observational Nephrology Studies See Greene, pages 377-388; Pisoni et al, pages 475-491; and Polkinghorne, pages 359-362. In this issue, Dr Greene critically examines 2 perspectives on determining the strength of evidence from observational studies and randomized clinical trials (RCTs). The first perspective asserts the strict superiority of RCTs for demonstrating efficacy and emphasizes the susceptibility of observational studies to bias which cannot be corrected without invoking untestable assumptions. The second perspective examines counterarguments citing limitations of RCTs, systematic reviews of the concordance between results of observational studies and RCTs, and methodological advances which have strengthened the inferences that can be made from observational data. Dr Greene supports an integrative approach which targets the use of observational studies and RCTs at different stages of the research process based on their respective strengths and weaknesses, and which seeks to maximize the total information gained by joint evaluation of both types of evidence. A related article by Pisoni et al applies one of these newer methods (using an instrumental variable) to data from DOPPS to decrease treatment-by-indication bias in analyzing the relationship between vascular access type and survival. The results by Pisoni et al confirm and strengthen prior reports that lower use of catheters and grafts is associated with higher patient survival. An accompanying editorial by Dr Polkinghorne provides additional insights and predicts that similar statistical models will be increasingly employed to answer important clinical questions not easily amenable to randomized trials. Adherence to Guideline-Recommended Therapies for Acute Myocardial Infarction in CKD See Patel et al, pages 426-437; Berger and Herzog, pages 366-369; and Wetmore and Shireman, pages 457-466. Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular disease (CVD) events and death, yet there is widespread underuse of guideline-recommended therapies for CVD in this high-risk population. In this issue, Patel et al examine the relationship between CKD and hospital quality indicator performance on the utilization of evidence-based therapies for acute myocardial infarction using data from the CRUSADE registry, an observational cohort of 81,374 patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) treated at 327 hospitals between 2003 and 2006. Hospitals were ranked into 4 groups (“leading” group had top performance and “lagging” group had worst performance) based on the proportion of patients without contraindications who were provided standard pharmacologic therapies. Looking at each group, the authors examined the relationship between adherence to guideline therapy (in-hospital prescriptions of aspirin, clopidogrel, heparin, and GP2b3a inhibitors and discharge prescriptions for aspirin, clopidogrel, lipid-lowering agents, and ACE inhibitors) and level of kidney function. Patients with lower levels of kidney function admitted with NSTE-ACS were less likely to receive evidence-based therapies. Treatment disparities related to CKD were most evident at top-performing hospitals. An editorial by Dr. Berger concludes that the CRUSADE registry provides strong documentation for the underutilization of pharmacologic therapies in ACS patients with CKD and asks what factors explain this phenomenon. Also in this issue, Wetmore and Shireman systematically review randomized controlled trials and observational studies of the association between morbidity and mortality and the use of ACE inhibitors, β-blockers, and calcium channel blockers in dialysis patients. Cerebrovascular Disease and Kidney Disease See Weiner et al, 438-447; Bui et al, pages 389-398 ; and Ninomaya et al, pages 417-425. Three articles examining the relationship between cerebrovascular disease and kidney disease appear in this issue. In the first article, Weiner et al evaluate the association between albuminuria and both cognitive impairment and brain white matter changes in an elderly population, and, in adjusted analyses, describe significantly worse executive functioning and greater white matter disease in individuals with higher levels of albuminuria. This pattern was present even at levels consistent with microalbuminuria. A second article by Bui et al used data from the Multi-Ethnic Study of Atherosclerosis (MESA) to explore whether serum cystatin C level is associated with carotid intima-media thickness (IMT) in adults without known cardiovascular disease. While the association between higher cystatin C level and greater IMT was significant in univariate analyses, the statistical significance diminished after adjustment for age, sex, and race/ethnicity and was no longer significant after further adjustment for cardiovascular risk factors. In the final article, Ninomiya et al evaluated the relationship between clinical stroke and proteinuria in a meta-analysis of 10 cohort studies including over 140,000 individuals. They note a 71% greater risk of stroke in individuals with proteinuria compared with those without proteinuria (95% CI, 1.39 to 2.10), with heterogeneity across studies in part explained by differing ascertainment of proteinuria. Serum Phosphate Concentrations in NHANES III See de Boer et al, pages 399-407; and Goldstein-Fuchs and Fouque, pages 363-367. High-normal serum phosphate concentrations have been associated with cardiovascular events and mortality in large prospective cohort studies of individuals with and without kidney disease. However, aside from late-stage kidney disease, reasons explaining the variability in phosphate levels among individuals are largely unknown. In this issue, de Boer et al examine nutritional variables and cardiovascular risk factors in relation to serum phosphate concentrations among 15,513 participants in the Third National Health and Nutrition Examination Survey (NHANES III), a population-based nationally representative cohort. They found that dietary intake of phosphorus and phosphorus-rich foods were only weakly associated with serum phosphate concentrations. However, higher serum phosphate levels were associated with greater cardiovascular risk, as estimated by the Framingham coronary heart disease risk scores. In aggregate, demographic, nutritional, cardiovascular, and kidney function variables explained only 12% of the variation in serum phosphate concentrations. An editorial by Goldstein-Fuchs and Foque concludes that while dietary phosphorus intake does not appear to affect serum phosphorus levels when GFR is in normal and near normal ranges, much is still unknown about the role of dietary phosphorus and serum phosphorus in atherosclerosis and clinical cardiovascular disease. KDOQI Guidelines for Nutrition in Children, 2008 Update See KDOQI Supplement Regular evaluation of nutritional status and provisions of adequate nutrition are key components in the overall management of children with CKD. Included as a supplement to this issue, the KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 Update reinforces the 2000 guidelines by: (1) incorporating new data, (2) expanding the target population to include patients with CKD stages 2 to 5, including kidney transplant recipients, (3) addressing new topics not covered in the previous guideline, including dietary modification of sodium, potassium, fluid, calcium, and phosphorus intake, (4) incorporating updated references to dietary recommendations, anthropometric reference values, and growth charts for the healthy population, and (5) reconciling discrepancies between the pediatric nutrition guidelines and the more recent KDOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in CKD as well as the KDOQI Clinical Practice Guidelines for Hemodialysis Adequacy. PII: S0272-6386(09)00092-4 doi:10.1053/S0272-6386(09)00092-4 | |
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