Sharon Worcester

ATLANTA – Variants in the gene encoding apolipoprotein L1 are associated with a nearly twofold increased risk of chronic kidney disease progression in African American patients, according to an analysis of data from the Chronic Renal Insufficiency Cohort and the African American Study of Kidney Disease and Hypertension.

In addition, kidney function is lost at double the rate in patients with the apolipoprotein L1 (APOL1) renal risk variants.

The findings – which persisted regardless of chronic kidney disease (CKD) etiology and well-controlled blood pressure – may explain, in part, the markedly increased risk of end-stage renal disease (ESRD) in African American patients, compared with European American patients, Dr. Afshin Parsa of the University of Maryland, Baltimore, reported at Kidney Week 2013.

The findings were published simultaneously online Nov. 9 in the New England Journal of Medicine (2013 Nov. 9 [doi:10.1056/NEJMoa1310345]), and will appear in the Dec. 5 print issue.

In the CRIC (Chronic Renal Insufficiency Cohort) study, 2,955 patients with CKD, nearly half of whom (46%) had diabetes, were evaluated based on whether they had zero or one copy of the APOL1 variants (low-risk group) or two copies of the variants (high-risk group). The primary outcomes in that cohort were the slope in the estimated glomerular filtration rate (eGFR), and the composite of ESRD, or a reduction of 50% in the eGFR from baseline, said Dr. Parsa, who was one of the CRIC investigators.

Among black patients in the high-risk group, the decline in eGFR was significantly more rapid and the rate of the composite renal outcome significantly higher than in white patients in that group, regardless of diabetes status. The rate of decline was similar among black and white patients in the low-risk group.

Among African American patients with diabetes in the low-risk group, white patients with diabetes, and African American patients with diabetes in the high-risk group, the eGFR slopes were –2.7, –1.5, and –4.3 mL/min per 1.73 m² per year, respectively. Among those without diabetes, the corresponding slopes were –0.7, –1.0, and –2.9.

The adjusted hazard ratios for a renal event were 1.95 and 1.40 for African American patients, compared with white patients in the high-risk and low-risk groups with diabetes, respectively. The corresponding hazard ratios among those without diabetes were 2.68 and 1.57. The adjusted hazard ratio for the composite renal outcome was 1.61 for African American patients in the high-risk vs. the low-risk groups.

In the AASK (African American Study of Kidney Disease and Hypertension) study, 693 African American patients with hypertension-related chronic kidney disease and without diabetes were evaluated, and the primary outcome measure was a composite of end-stage renal disease or a doubling of the serum creatinine level.

The primary outcome occurred in 58.1% of those in the high risk group, compared with 36.6% of those in the low-risk group (hazard ratio, 1.88). No interactions between APOL1 status and trial interventions or the presence of baseline proteinuria were seen in AASK, Dr. Parsa said during a press briefing at the conference, which was sponsored by the American Society of Nephrology.

Also, the effect of APOL1 on CKD progression was not confounded by blood pressure levels, he noted.

The findings of the current analysis build on those from landmark 2008 research that led to identification of the APOL1 gene variants as a risk factor for kidney disease not associated with diabetes, he said, adding that the current findings are the first to provide direct evidence that the APOL1 high-risk variants are associated with increased disease progression over time.

This could potentially lead to genotyping of African Americans to assess their risk for disease progression, and could also lead to new treatment strategies for slowing the progression of CKD, the investigators said, noting that such strategies are currently limited.

The findings do not, however, fully explain the well-documented racial disparities in ESRD. In the United States, African Americans patients have about twice the risk of ESRD as do white patients, even after accounting for differences in socioeconomic and clinical risk factors.

The study results highlight the need to identify other risk factors that can account for residual disparities in end-stage renal disease between African American and white patients, they concluded.

This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Parsa reported having no disclosures.

ATLANTA – Variants in the gene encoding apolipoprotein L1 are associated with a nearly twofold increased risk of chronic kidney disease progression in African American patients, according to an analysis of data from the Chronic Renal Insufficiency Cohort and the African American Study of Kidney Disease and Hypertension.

In addition, kidney function is lost at double the rate in patients with the apolipoprotein L1 (APOL1) renal risk variants.

The findings – which persisted regardless of chronic kidney disease (CKD) etiology and well-controlled blood pressure – may explain, in part, the markedly increased risk of end-stage renal disease (ESRD) in African American patients, compared with European American patients, Dr. Afshin Parsa of the University of Maryland, Baltimore, reported at Kidney Week 2013.

The findings were published simultaneously online Nov. 9 in the New England Journal of Medicine (2013 Nov. 9 [doi:10.1056/NEJMoa1310345]), and will appear in the Dec. 5 print issue.

In the CRIC (Chronic Renal Insufficiency Cohort) study, 2,955 patients with CKD, nearly half of whom (46%) had diabetes, were evaluated based on whether they had zero or one copy of the APOL1 variants (low-risk group) or two copies of the variants (high-risk group). The primary outcomes in that cohort were the slope in the estimated glomerular filtration rate (eGFR), and the composite of ESRD, or a reduction of 50% in the eGFR from baseline, said Dr. Parsa, who was one of the CRIC investigators.

Among black patients in the high-risk group, the decline in eGFR was significantly more rapid and the rate of the composite renal outcome significantly higher than in white patients in that group, regardless of diabetes status. The rate of decline was similar among black and white patients in the low-risk group.

Among African American patients with diabetes in the low-risk group, white patients with diabetes, and African American patients with diabetes in the high-risk group, the eGFR slopes were –2.7, –1.5, and –4.3 mL/min per 1.73 m² per year, respectively. Among those without diabetes, the corresponding slopes were –0.7, –1.0, and –2.9.

The adjusted hazard ratios for a renal event were 1.95 and 1.40 for African American patients, compared with white patients in the high-risk and low-risk groups with diabetes, respectively. The corresponding hazard ratios among those without diabetes were 2.68 and 1.57. The adjusted hazard ratio for the composite renal outcome was 1.61 for African American patients in the high-risk vs. the low-risk groups.

In the AASK (African American Study of Kidney Disease and Hypertension) study, 693 African American patients with hypertension-related chronic kidney disease and without diabetes were evaluated, and the primary outcome measure was a composite of end-stage renal disease or a doubling of the serum creatinine level.

The primary outcome occurred in 58.1% of those in the high risk group, compared with 36.6% of those in the low-risk group (hazard ratio, 1.88). No interactions between APOL1 status and trial interventions or the presence of baseline proteinuria were seen in AASK, Dr. Parsa said during a press briefing at the conference, which was sponsored by the American Society of Nephrology.

Also, the effect of APOL1 on CKD progression was not confounded by blood pressure levels, he noted.

The findings of the current analysis build on those from landmark 2008 research that led to identification of the APOL1 gene variants as a risk factor for kidney disease not associated with diabetes, he said, adding that the current findings are the first to provide direct evidence that the APOL1 high-risk variants are associated with increased disease progression over time.

This could potentially lead to genotyping of African Americans to assess their risk for disease progression, and could also lead to new treatment strategies for slowing the progression of CKD, the investigators said, noting that such strategies are currently limited.

The findings do not, however, fully explain the well-documented racial disparities in ESRD. In the United States, African Americans patients have about twice the risk of ESRD as do white patients, even after accounting for differences in socioeconomic and clinical risk factors.

The study results highlight the need to identify other risk factors that can account for residual disparities in end-stage renal disease between African American and white patients, they concluded.

This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Parsa reported having no disclosures.

ATLANTA – Variants in the gene encoding apolipoprotein L1 are associated with a nearly twofold increased risk of chronic kidney disease progression in African American patients, according to an analysis of data from the Chronic Renal Insufficiency Cohort and the African American Study of Kidney Disease and Hypertension.

In addition, kidney function is lost at double the rate in patients with the apolipoprotein L1 (APOL1) renal risk variants.

The findings – which persisted regardless of chronic kidney disease (CKD) etiology and well-controlled blood pressure – may explain, in part, the markedly increased risk of end-stage renal disease (ESRD) in African American patients, compared with European American patients, Dr. Afshin Parsa of the University of Maryland, Baltimore, reported at Kidney Week 2013.

The findings were published simultaneously online Nov. 9 in the New England Journal of Medicine (2013 Nov. 9 [doi:10.1056/NEJMoa1310345]), and will appear in the Dec. 5 print issue.

In the CRIC (Chronic Renal Insufficiency Cohort) study, 2,955 patients with CKD, nearly half of whom (46%) had diabetes, were evaluated based on whether they had zero or one copy of the APOL1 variants (low-risk group) or two copies of the variants (high-risk group). The primary outcomes in that cohort were the slope in the estimated glomerular filtration rate (eGFR), and the composite of ESRD, or a reduction of 50% in the eGFR from baseline, said Dr. Parsa, who was one of the CRIC investigators.

Among black patients in the high-risk group, the decline in eGFR was significantly more rapid and the rate of the composite renal outcome significantly higher than in white patients in that group, regardless of diabetes status. The rate of decline was similar among black and white patients in the low-risk group.

Among African American patients with diabetes in the low-risk group, white patients with diabetes, and African American patients with diabetes in the high-risk group, the eGFR slopes were –2.7, –1.5, and –4.3 mL/min per 1.73 m² per year, respectively. Among those without diabetes, the corresponding slopes were –0.7, –1.0, and –2.9.

The adjusted hazard ratios for a renal event were 1.95 and 1.40 for African American patients, compared with white patients in the high-risk and low-risk groups with diabetes, respectively. The corresponding hazard ratios among those without diabetes were 2.68 and 1.57. The adjusted hazard ratio for the composite renal outcome was 1.61 for African American patients in the high-risk vs. the low-risk groups.

In the AASK (African American Study of Kidney Disease and Hypertension) study, 693 African American patients with hypertension-related chronic kidney disease and without diabetes were evaluated, and the primary outcome measure was a composite of end-stage renal disease or a doubling of the serum creatinine level.

The primary outcome occurred in 58.1% of those in the high risk group, compared with 36.6% of those in the low-risk group (hazard ratio, 1.88). No interactions between APOL1 status and trial interventions or the presence of baseline proteinuria were seen in AASK, Dr. Parsa said during a press briefing at the conference, which was sponsored by the American Society of Nephrology.

Also, the effect of APOL1 on CKD progression was not confounded by blood pressure levels, he noted.

The findings of the current analysis build on those from landmark 2008 research that led to identification of the APOL1 gene variants as a risk factor for kidney disease not associated with diabetes, he said, adding that the current findings are the first to provide direct evidence that the APOL1 high-risk variants are associated with increased disease progression over time.

This could potentially lead to genotyping of African Americans to assess their risk for disease progression, and could also lead to new treatment strategies for slowing the progression of CKD, the investigators said, noting that such strategies are currently limited.

The findings do not, however, fully explain the well-documented racial disparities in ESRD. In the United States, African Americans patients have about twice the risk of ESRD as do white patients, even after accounting for differences in socioeconomic and clinical risk factors.

The study results highlight the need to identify other risk factors that can account for residual disparities in end-stage renal disease between African American and white patients, they concluded.

This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Parsa reported having no disclosures.

Adding renal-artery stenting to comprehensive medical therapy did not confer significant benefit with respect to the prevention of clinical events in patients with atherosclerotic renal-artery stenosis and hypertension or chronic kidney disease in the randomized controlled CORAL trial.

During a median follow-up of 43 months in the multicenter, open-label trial, the rate of a primary composite endpoint consisting of death from cardiovascular or renal causes, myocardial infarction, stroke, hospitalization for heart failure, progressive renal insufficiency, or the need for renal replacement therapy did not differ significantly between 459 patients randomized to receive medical therapy plus renal-artery stenting, and 472 patients randomized to receive medical therapy alone (35.1% and 35.8%, respectively; hazard ratio with stenting, 0.94), Dr. Christopher J. Cooper reported at the American Heart Association scientific sessions.

Furthermore, no significant differences were seen between the treatment groups in the rates of the individual components of the composite primary endpoint, or in all-cause mortality. There was, however, a consistent, modest improvement in systolic blood pressure in the stent group (–2.33 mm Hg vs. the medication only group), noted Dr. Cooper of the University of Toledo (Ohio) and his coinvestigators.

The findings of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial were published online simultaneously with the Nov. 18 presentation (N. Engl. J. Med. 2013 Nov. 18 [doi:10.1056/NE/NEJMoa1310753]).

CORAL comprised adults with a mean age of 69 years who had atherosclerotic renal-artery stenosis and either chronic kidney disease or systolic hypertension (despite taking at least two antihypertensive drugs). They were recruited during May 2005–January 2010.

Mandated medications as per the study protocol (unless contraindicated) included the angiotensin II type-1 receptor blocker candesartan with or without hydrochlorothiazide, and the combination agent amlodipine-atorvastatin dose-adjusted on the basis of blood pressure and lipid status.

The findings are important because renal artery stenosis is present in 1%-5% of people with hypertension, and in up to 7% of those over age 65 years, the investigators noted.

Although uncontrolled studies in the 1990s suggested that renal-artery angioplasty or stenting results in significant reductions in systolic blood pressure and stabilization of chronic kidney disease (findings which led to a 364% increase in the number of procedures among Medicare beneficiaries between 1996 and 2000), subsequent randomized trials failed to show a benefit of renal-artery angioplasty on blood pressure or of renal-artery stenting on kidney function, they noted.

The current study is among the first to specifically assess clinical outcomes, and based on the findings, "it is clear that medical therapy without stenting is the preferred management strategy for the majority of people with atherosclerotic renal-artery stenosis," they said.

"A key issue in the interpretation of our results is whether the medical therapy that was given to CORAL participants can be replicated in clinical practice. The medical therapy in our study included the use of an angiotensin-receptor blocker, with or without a thiazide-type diuretic, with the addition of amlodipine for blood-pressure control. In addition, participants received antiplatelet therapy and atorvastatin for management of lipid levels, and diabetes was managed according to clinical practice guidelines," they wrote, noting that with this regimen, "patients who received medical treatment alone had remarkably good cardiovascular and renal outcomes, despite their advanced age and the high rates of hypertension, diabetes, chronic kidney disease, and other coexisting cardiovascular conditions."

The National Heart, Lung, and Blood Institute and the National Institutes of Health funded the trial, with support from Cordis – which donated a short-tip Angioguard device – and Pfizer. AstraZeneca and Pfizer donated medications. Dr. Cooper reported having no conflicts of interest. Detailed disclosures for all investigators are available with the full text of the article at nejm.org.

Adding renal-artery stenting to comprehensive medical therapy did not confer significant benefit with respect to the prevention of clinical events in patients with atherosclerotic renal-artery stenosis and hypertension or chronic kidney disease in the randomized controlled CORAL trial.

During a median follow-up of 43 months in the multicenter, open-label trial, the rate of a primary composite endpoint consisting of death from cardiovascular or renal causes, myocardial infarction, stroke, hospitalization for heart failure, progressive renal insufficiency, or the need for renal replacement therapy did not differ significantly between 459 patients randomized to receive medical therapy plus renal-artery stenting, and 472 patients randomized to receive medical therapy alone (35.1% and 35.8%, respectively; hazard ratio with stenting, 0.94), Dr. Christopher J. Cooper reported at the American Heart Association scientific sessions.

Furthermore, no significant differences were seen between the treatment groups in the rates of the individual components of the composite primary endpoint, or in all-cause mortality. There was, however, a consistent, modest improvement in systolic blood pressure in the stent group (–2.33 mm Hg vs. the medication only group), noted Dr. Cooper of the University of Toledo (Ohio) and his coinvestigators.

The findings of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial were published online simultaneously with the Nov. 18 presentation (N. Engl. J. Med. 2013 Nov. 18 [doi:10.1056/NE/NEJMoa1310753]).

CORAL comprised adults with a mean age of 69 years who had atherosclerotic renal-artery stenosis and either chronic kidney disease or systolic hypertension (despite taking at least two antihypertensive drugs). They were recruited during May 2005–January 2010.

Mandated medications as per the study protocol (unless contraindicated) included the angiotensin II type-1 receptor blocker candesartan with or without hydrochlorothiazide, and the combination agent amlodipine-atorvastatin dose-adjusted on the basis of blood pressure and lipid status.

The findings are important because renal artery stenosis is present in 1%-5% of people with hypertension, and in up to 7% of those over age 65 years, the investigators noted.

Although uncontrolled studies in the 1990s suggested that renal-artery angioplasty or stenting results in significant reductions in systolic blood pressure and stabilization of chronic kidney disease (findings which led to a 364% increase in the number of procedures among Medicare beneficiaries between 1996 and 2000), subsequent randomized trials failed to show a benefit of renal-artery angioplasty on blood pressure or of renal-artery stenting on kidney function, they noted.

The current study is among the first to specifically assess clinical outcomes, and based on the findings, "it is clear that medical therapy without stenting is the preferred management strategy for the majority of people with atherosclerotic renal-artery stenosis," they said.

"A key issue in the interpretation of our results is whether the medical therapy that was given to CORAL participants can be replicated in clinical practice. The medical therapy in our study included the use of an angiotensin-receptor blocker, with or without a thiazide-type diuretic, with the addition of amlodipine for blood-pressure control. In addition, participants received antiplatelet therapy and atorvastatin for management of lipid levels, and diabetes was managed according to clinical practice guidelines," they wrote, noting that with this regimen, "patients who received medical treatment alone had remarkably good cardiovascular and renal outcomes, despite their advanced age and the high rates of hypertension, diabetes, chronic kidney disease, and other coexisting cardiovascular conditions."

The National Heart, Lung, and Blood Institute and the National Institutes of Health funded the trial, with support from Cordis – which donated a short-tip Angioguard device – and Pfizer. AstraZeneca and Pfizer donated medications. Dr. Cooper reported having no conflicts of interest. Detailed disclosures for all investigators are available with the full text of the article at nejm.org.

Adding renal-artery stenting to comprehensive medical therapy did not confer significant benefit with respect to the prevention of clinical events in patients with atherosclerotic renal-artery stenosis and hypertension or chronic kidney disease in the randomized controlled CORAL trial.

During a median follow-up of 43 months in the multicenter, open-label trial, the rate of a primary composite endpoint consisting of death from cardiovascular or renal causes, myocardial infarction, stroke, hospitalization for heart failure, progressive renal insufficiency, or the need for renal replacement therapy did not differ significantly between 459 patients randomized to receive medical therapy plus renal-artery stenting, and 472 patients randomized to receive medical therapy alone (35.1% and 35.8%, respectively; hazard ratio with stenting, 0.94), Dr. Christopher J. Cooper reported at the American Heart Association scientific sessions.

Furthermore, no significant differences were seen between the treatment groups in the rates of the individual components of the composite primary endpoint, or in all-cause mortality. There was, however, a consistent, modest improvement in systolic blood pressure in the stent group (–2.33 mm Hg vs. the medication only group), noted Dr. Cooper of the University of Toledo (Ohio) and his coinvestigators.

The findings of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial were published online simultaneously with the Nov. 18 presentation (N. Engl. J. Med. 2013 Nov. 18 [doi:10.1056/NE/NEJMoa1310753]).

CORAL comprised adults with a mean age of 69 years who had atherosclerotic renal-artery stenosis and either chronic kidney disease or systolic hypertension (despite taking at least two antihypertensive drugs). They were recruited during May 2005–January 2010.

Mandated medications as per the study protocol (unless contraindicated) included the angiotensin II type-1 receptor blocker candesartan with or without hydrochlorothiazide, and the combination agent amlodipine-atorvastatin dose-adjusted on the basis of blood pressure and lipid status.

The findings are important because renal artery stenosis is present in 1%-5% of people with hypertension, and in up to 7% of those over age 65 years, the investigators noted.

Although uncontrolled studies in the 1990s suggested that renal-artery angioplasty or stenting results in significant reductions in systolic blood pressure and stabilization of chronic kidney disease (findings which led to a 364% increase in the number of procedures among Medicare beneficiaries between 1996 and 2000), subsequent randomized trials failed to show a benefit of renal-artery angioplasty on blood pressure or of renal-artery stenting on kidney function, they noted.

The current study is among the first to specifically assess clinical outcomes, and based on the findings, "it is clear that medical therapy without stenting is the preferred management strategy for the majority of people with atherosclerotic renal-artery stenosis," they said.

"A key issue in the interpretation of our results is whether the medical therapy that was given to CORAL participants can be replicated in clinical practice. The medical therapy in our study included the use of an angiotensin-receptor blocker, with or without a thiazide-type diuretic, with the addition of amlodipine for blood-pressure control. In addition, participants received antiplatelet therapy and atorvastatin for management of lipid levels, and diabetes was managed according to clinical practice guidelines," they wrote, noting that with this regimen, "patients who received medical treatment alone had remarkably good cardiovascular and renal outcomes, despite their advanced age and the high rates of hypertension, diabetes, chronic kidney disease, and other coexisting cardiovascular conditions."

The National Heart, Lung, and Blood Institute and the National Institutes of Health funded the trial, with support from Cordis – which donated a short-tip Angioguard device – and Pfizer. AstraZeneca and Pfizer donated medications. Dr. Cooper reported having no conflicts of interest. Detailed disclosures for all investigators are available with the full text of the article at nejm.org.

A multifaceted intervention was effective for improving postdischarge medication adherence among patients hospitalized for acute coronary syndrome but had no effect on achievement of blood pressure and cholesterol level goals, in a prospective randomized clinical trial.

The intervention, which involved pharmacist-led medication reconciliation and tailoring, patient education, collaboration between pharmacists and physicians, and voice messaging reminders, was associated with an 89.3% medication adherence rate among 122 patients randomized to the intervention groups, compared with a 73.9% adherence rate among 119 patients randomized to receive usual care, Dr. P. Michael Ho of the Denver Veterans Administration Medical Center, reported on Nov. 17 at the American Heart Association scientific sessions.

The mean proportion of days covered was significantly higher in the intervention group than in the usual care group (0.94 vs. 0.87 days), and a greater proportion of patients in the intervention group were adherent to clopidogrel (86.8% vs. 70.7%), statins (93.2% vs. 71.3%), and ACE inhibitors and angiotensin receptor blockers (93.1% vs. 81.7%). No significant difference was seen between the groups with respect to use of beta-blockers (88.1% vs. 84.8%), Dr. Ho reported. The findings were published simultaneously with the presentation (JAMA Intern Med Nov.18 [doi:10.1001/jamainternmed.2013.12944]).

Despite the improved adherence to treatment, no differences were seen in the percentage of patients achieving blood pressure goals or LDL cholesterol goals, although there was a trend toward greater blood pressure control (58.6% vs. 48.9%), decline in systolic blood pressure (–12 vs. –4 mm Hg), and decline in diastolic blood pressure (–5 vs. –3 mm Hg) for intervention vs. usual care patients, respectively, he said.

Also, adherent patient were more likely to get follow-up LDL cholesterol laboratory evaluations, and "accordingly we saw declines in LDL-C levels in both intervention and usual care patients, which may have attenuated the intervention effect on LDL-C levels," he wrote in the JAMA article, noting that additional studies in larger patient samples are needed to assess the association between adherence and these clinical outcomes.

The cost of the intervention, based on the pharmacist time spent, cardiologist time spent, and pill box cost, was about $360/patient. Medication cost differences did not differ significantly between the intervention and usual care groups.

Patients in the study had been hospitalized for acute coronary syndrome at Department of Veterans Affairs Medical Centers in Denver, Seattle, Durham, N.C., or Little Rock, Ark., and were discharged during 2010 or 2011. They were randomized to the intervention or usual care group prior to discharge.

The intervention, which lasted 1 year following discharge, involved:

• Medication reconciliation and tailoring by a pharmacist who met with patients via an in-person clinic visit or by telephone. The pharmacist addressed medication problems or adverse effects, reconciled differences in medications, provided a pill box and instructions for use if needed, and called a month later to follow up, synchronize refill dates, answer questions, and encourage adherence.

• Patient education at the point of discharge, and afterward by the pharmacist at 1-week and 1-month visits. Thereafter, educational messages were provided via automated voice messages and pharmacist phone calls.

• Collaborative care involving pharmacist and primary care clinician or cardiologist communications.

• Voice messaging at regularly scheduled intervals to remind patients about medications and refills.

Studies show that postdischarge adherence to cardioprotective drug regimens is often poor among patients hospitalized for acute coronary syndrome. For example, several studies have shown that a third of those who were taking their cardiac medications at discharge discontinued at least one medication by 1 month, and only about 60% were still taking statin medications at 1 year. Cohort and population-based studies show that lower adherence to cardioprotective drug regimens after acute MI are associated with a higher 1-year and long-term mortality, Dr. Ho noted.

In the current study, the intervention improved the proportion of adherent patients by about 15% and the mean adherence to the four medications combined by about 7%, Dr. Ho said, noting that the findings, along with those from prior intervention studies, "provide an increasing evidence base of interventions to improve adherence to cardiac medication regimens after ACS discharge."

"It will be important for us to continue to follow up patients longer to assess whether the higher adherence in the intervention group translates into improved clinical outcomes," he wrote, noting that he and his colleagues plan to follow the patients beyond the initial 12 months to assess for differences in outcomes and costs in the longer term.

This study is limited by a number of factors, including the largely male patient population at the VA medical centers where it was conducted, and the use of pharmacy refill data rather than pill counts to assess adherence.

This study was funded by Veterans Health Administration Health Service Research & Development Investigator-Initiated Awards. The authors reported having no disclosures.

A multifaceted intervention was effective for improving postdischarge medication adherence among patients hospitalized for acute coronary syndrome but had no effect on achievement of blood pressure and cholesterol level goals, in a prospective randomized clinical trial.

The intervention, which involved pharmacist-led medication reconciliation and tailoring, patient education, collaboration between pharmacists and physicians, and voice messaging reminders, was associated with an 89.3% medication adherence rate among 122 patients randomized to the intervention groups, compared with a 73.9% adherence rate among 119 patients randomized to receive usual care, Dr. P. Michael Ho of the Denver Veterans Administration Medical Center, reported on Nov. 17 at the American Heart Association scientific sessions.

The mean proportion of days covered was significantly higher in the intervention group than in the usual care group (0.94 vs. 0.87 days), and a greater proportion of patients in the intervention group were adherent to clopidogrel (86.8% vs. 70.7%), statins (93.2% vs. 71.3%), and ACE inhibitors and angiotensin receptor blockers (93.1% vs. 81.7%). No significant difference was seen between the groups with respect to use of beta-blockers (88.1% vs. 84.8%), Dr. Ho reported. The findings were published simultaneously with the presentation (JAMA Intern Med Nov.18 [doi:10.1001/jamainternmed.2013.12944]).

Despite the improved adherence to treatment, no differences were seen in the percentage of patients achieving blood pressure goals or LDL cholesterol goals, although there was a trend toward greater blood pressure control (58.6% vs. 48.9%), decline in systolic blood pressure (–12 vs. –4 mm Hg), and decline in diastolic blood pressure (–5 vs. –3 mm Hg) for intervention vs. usual care patients, respectively, he said.

Also, adherent patient were more likely to get follow-up LDL cholesterol laboratory evaluations, and "accordingly we saw declines in LDL-C levels in both intervention and usual care patients, which may have attenuated the intervention effect on LDL-C levels," he wrote in the JAMA article, noting that additional studies in larger patient samples are needed to assess the association between adherence and these clinical outcomes.

The cost of the intervention, based on the pharmacist time spent, cardiologist time spent, and pill box cost, was about $360/patient. Medication cost differences did not differ significantly between the intervention and usual care groups.

Patients in the study had been hospitalized for acute coronary syndrome at Department of Veterans Affairs Medical Centers in Denver, Seattle, Durham, N.C., or Little Rock, Ark., and were discharged during 2010 or 2011. They were randomized to the intervention or usual care group prior to discharge.

The intervention, which lasted 1 year following discharge, involved:

• Medication reconciliation and tailoring by a pharmacist who met with patients via an in-person clinic visit or by telephone. The pharmacist addressed medication problems or adverse effects, reconciled differences in medications, provided a pill box and instructions for use if needed, and called a month later to follow up, synchronize refill dates, answer questions, and encourage adherence.

• Patient education at the point of discharge, and afterward by the pharmacist at 1-week and 1-month visits. Thereafter, educational messages were provided via automated voice messages and pharmacist phone calls.

• Collaborative care involving pharmacist and primary care clinician or cardiologist communications.

• Voice messaging at regularly scheduled intervals to remind patients about medications and refills.

Studies show that postdischarge adherence to cardioprotective drug regimens is often poor among patients hospitalized for acute coronary syndrome. For example, several studies have shown that a third of those who were taking their cardiac medications at discharge discontinued at least one medication by 1 month, and only about 60% were still taking statin medications at 1 year. Cohort and population-based studies show that lower adherence to cardioprotective drug regimens after acute MI are associated with a higher 1-year and long-term mortality, Dr. Ho noted.

In the current study, the intervention improved the proportion of adherent patients by about 15% and the mean adherence to the four medications combined by about 7%, Dr. Ho said, noting that the findings, along with those from prior intervention studies, "provide an increasing evidence base of interventions to improve adherence to cardiac medication regimens after ACS discharge."

"It will be important for us to continue to follow up patients longer to assess whether the higher adherence in the intervention group translates into improved clinical outcomes," he wrote, noting that he and his colleagues plan to follow the patients beyond the initial 12 months to assess for differences in outcomes and costs in the longer term.

This study is limited by a number of factors, including the largely male patient population at the VA medical centers where it was conducted, and the use of pharmacy refill data rather than pill counts to assess adherence.

This study was funded by Veterans Health Administration Health Service Research & Development Investigator-Initiated Awards. The authors reported having no disclosures.

A multifaceted intervention was effective for improving postdischarge medication adherence among patients hospitalized for acute coronary syndrome but had no effect on achievement of blood pressure and cholesterol level goals, in a prospective randomized clinical trial.

The intervention, which involved pharmacist-led medication reconciliation and tailoring, patient education, collaboration between pharmacists and physicians, and voice messaging reminders, was associated with an 89.3% medication adherence rate among 122 patients randomized to the intervention groups, compared with a 73.9% adherence rate among 119 patients randomized to receive usual care, Dr. P. Michael Ho of the Denver Veterans Administration Medical Center, reported on Nov. 17 at the American Heart Association scientific sessions.

The mean proportion of days covered was significantly higher in the intervention group than in the usual care group (0.94 vs. 0.87 days), and a greater proportion of patients in the intervention group were adherent to clopidogrel (86.8% vs. 70.7%), statins (93.2% vs. 71.3%), and ACE inhibitors and angiotensin receptor blockers (93.1% vs. 81.7%). No significant difference was seen between the groups with respect to use of beta-blockers (88.1% vs. 84.8%), Dr. Ho reported. The findings were published simultaneously with the presentation (JAMA Intern Med Nov.18 [doi:10.1001/jamainternmed.2013.12944]).

Despite the improved adherence to treatment, no differences were seen in the percentage of patients achieving blood pressure goals or LDL cholesterol goals, although there was a trend toward greater blood pressure control (58.6% vs. 48.9%), decline in systolic blood pressure (–12 vs. –4 mm Hg), and decline in diastolic blood pressure (–5 vs. –3 mm Hg) for intervention vs. usual care patients, respectively, he said.

Also, adherent patient were more likely to get follow-up LDL cholesterol laboratory evaluations, and "accordingly we saw declines in LDL-C levels in both intervention and usual care patients, which may have attenuated the intervention effect on LDL-C levels," he wrote in the JAMA article, noting that additional studies in larger patient samples are needed to assess the association between adherence and these clinical outcomes.

The cost of the intervention, based on the pharmacist time spent, cardiologist time spent, and pill box cost, was about $360/patient. Medication cost differences did not differ significantly between the intervention and usual care groups.

Patients in the study had been hospitalized for acute coronary syndrome at Department of Veterans Affairs Medical Centers in Denver, Seattle, Durham, N.C., or Little Rock, Ark., and were discharged during 2010 or 2011. They were randomized to the intervention or usual care group prior to discharge.

The intervention, which lasted 1 year following discharge, involved:

• Medication reconciliation and tailoring by a pharmacist who met with patients via an in-person clinic visit or by telephone. The pharmacist addressed medication problems or adverse effects, reconciled differences in medications, provided a pill box and instructions for use if needed, and called a month later to follow up, synchronize refill dates, answer questions, and encourage adherence.

• Patient education at the point of discharge, and afterward by the pharmacist at 1-week and 1-month visits. Thereafter, educational messages were provided via automated voice messages and pharmacist phone calls.

• Collaborative care involving pharmacist and primary care clinician or cardiologist communications.

• Voice messaging at regularly scheduled intervals to remind patients about medications and refills.

Studies show that postdischarge adherence to cardioprotective drug regimens is often poor among patients hospitalized for acute coronary syndrome. For example, several studies have shown that a third of those who were taking their cardiac medications at discharge discontinued at least one medication by 1 month, and only about 60% were still taking statin medications at 1 year. Cohort and population-based studies show that lower adherence to cardioprotective drug regimens after acute MI are associated with a higher 1-year and long-term mortality, Dr. Ho noted.

In the current study, the intervention improved the proportion of adherent patients by about 15% and the mean adherence to the four medications combined by about 7%, Dr. Ho said, noting that the findings, along with those from prior intervention studies, "provide an increasing evidence base of interventions to improve adherence to cardiac medication regimens after ACS discharge."

"It will be important for us to continue to follow up patients longer to assess whether the higher adherence in the intervention group translates into improved clinical outcomes," he wrote, noting that he and his colleagues plan to follow the patients beyond the initial 12 months to assess for differences in outcomes and costs in the longer term.

This study is limited by a number of factors, including the largely male patient population at the VA medical centers where it was conducted, and the use of pharmacy refill data rather than pill counts to assess adherence.

This study was funded by Veterans Health Administration Health Service Research & Development Investigator-Initiated Awards. The authors reported having no disclosures.

ATLANTA – A novel, low-resource bedside diagnostic tool that measures saliva urea nitrogen appears useful for identifying patients with advanced acute kidney injury who have an increased likelihood of requiring dialysis.

In a study involving 44 patients, the tool – a dipstick that measures saliva urea nitrogen (SUN), a marker of kidney function – reliably discriminated Acute Kidney Injury Network (AKIN) stage 3 AKI from earlier AKI stages, Dr. Roberto Picoits-Filho reported at Kidney Week 2013.

SUN, as measured using the dipstick, was significantly correlated with blood urea nitrogen, or BUN (R_s = 0.77), irrespective of AKIN stage or AKI etiology, Dr. Picoits-Filho reported during a press briefing at the conference, which was sponsored by the American Society of Nephrology

The diagnostic performances of the tests were comparable: For SUN, the area under the curve of a receiver operating characteristic curve (AUC ROC) was 0.76, and for BUN the value was 0.69, he said.

"We saw that the test was actually very good, particularly in patients with very severe stages of kidney injury, which is important, because those are the patients who most likely will need to go into dialysis or more complex treatment," said Dr. Picoits-Filho of the Pro-rim Foundation and Pontifícia Universidade Católica do Parana, Curitiba, Brazil.

Patients included in the study were adults (mean age, 59.5 years; 58% women) who were hospitalized with prerenal (67%), renal (24%), or postrenal (9%) suspected AKI. A third had AKIN stage 1 disease, 27% had stage 2 disease, and 40% had stage 3 disease.

Unstimulated saliva was applied to the dipstick to measure whether SUN concentrations were 5-14, 15-24, 25-34, 35-54, 55-74, or 75 or greater mg/dL; BUN was measured concomitantly.

The findings are notable because while AKI in the intensive care unit setting is usually due to acute tubular necrosis, a large proportion of AKI cases outside of the ICU are due to prerenal AKI, which is reversible if diagnosed early and treated aggressively, Dr. Picoits-Filho said.

One way of detecting AKI early on in both the hospital and outpatient settings is by criteria defined by recent consensus: "basically by glomerular filtration rate, but also by urine output," he said.

By using serum creatinine to estimate GFR, you can actually detect patients with AKI. This defines risk for developing more severe AKI (and can help in preventing the need for renal replacement therapy), and also predicts in-hospital mortality, he said.

"The problem is that you need a laboratory facility to get this measurement, and this is not always available, especially in remote areas of the world," he added.

The current findings suggest the SUN dipstick could improve the diagnosis of advanced AKI and aid in triaging patients – particularly in remote areas with limited access to clinical chemistry facilities – and may improve outcomes, he said.

While the test did not prove efficient as a screening tool for chronic kidney disease, it could potentially have a role in monitoring those with chronic kidney disease, he noted.

This study was supported by the Renal Research Institute, New York, and the International Society of Nephrology. Dr. Picoits-Filho reported having no other disclosures.

ATLANTA – A novel, low-resource bedside diagnostic tool that measures saliva urea nitrogen appears useful for identifying patients with advanced acute kidney injury who have an increased likelihood of requiring dialysis.

In a study involving 44 patients, the tool – a dipstick that measures saliva urea nitrogen (SUN), a marker of kidney function – reliably discriminated Acute Kidney Injury Network (AKIN) stage 3 AKI from earlier AKI stages, Dr. Roberto Picoits-Filho reported at Kidney Week 2013.

SUN, as measured using the dipstick, was significantly correlated with blood urea nitrogen, or BUN (R_s = 0.77), irrespective of AKIN stage or AKI etiology, Dr. Picoits-Filho reported during a press briefing at the conference, which was sponsored by the American Society of Nephrology

The diagnostic performances of the tests were comparable: For SUN, the area under the curve of a receiver operating characteristic curve (AUC ROC) was 0.76, and for BUN the value was 0.69, he said.

"We saw that the test was actually very good, particularly in patients with very severe stages of kidney injury, which is important, because those are the patients who most likely will need to go into dialysis or more complex treatment," said Dr. Picoits-Filho of the Pro-rim Foundation and Pontifícia Universidade Católica do Parana, Curitiba, Brazil.

Patients included in the study were adults (mean age, 59.5 years; 58% women) who were hospitalized with prerenal (67%), renal (24%), or postrenal (9%) suspected AKI. A third had AKIN stage 1 disease, 27% had stage 2 disease, and 40% had stage 3 disease.

Unstimulated saliva was applied to the dipstick to measure whether SUN concentrations were 5-14, 15-24, 25-34, 35-54, 55-74, or 75 or greater mg/dL; BUN was measured concomitantly.

The findings are notable because while AKI in the intensive care unit setting is usually due to acute tubular necrosis, a large proportion of AKI cases outside of the ICU are due to prerenal AKI, which is reversible if diagnosed early and treated aggressively, Dr. Picoits-Filho said.

One way of detecting AKI early on in both the hospital and outpatient settings is by criteria defined by recent consensus: "basically by glomerular filtration rate, but also by urine output," he said.

By using serum creatinine to estimate GFR, you can actually detect patients with AKI. This defines risk for developing more severe AKI (and can help in preventing the need for renal replacement therapy), and also predicts in-hospital mortality, he said.

"The problem is that you need a laboratory facility to get this measurement, and this is not always available, especially in remote areas of the world," he added.

The current findings suggest the SUN dipstick could improve the diagnosis of advanced AKI and aid in triaging patients – particularly in remote areas with limited access to clinical chemistry facilities – and may improve outcomes, he said.

While the test did not prove efficient as a screening tool for chronic kidney disease, it could potentially have a role in monitoring those with chronic kidney disease, he noted.

This study was supported by the Renal Research Institute, New York, and the International Society of Nephrology. Dr. Picoits-Filho reported having no other disclosures.

ATLANTA – A novel, low-resource bedside diagnostic tool that measures saliva urea nitrogen appears useful for identifying patients with advanced acute kidney injury who have an increased likelihood of requiring dialysis.

In a study involving 44 patients, the tool – a dipstick that measures saliva urea nitrogen (SUN), a marker of kidney function – reliably discriminated Acute Kidney Injury Network (AKIN) stage 3 AKI from earlier AKI stages, Dr. Roberto Picoits-Filho reported at Kidney Week 2013.

SUN, as measured using the dipstick, was significantly correlated with blood urea nitrogen, or BUN (R_s = 0.77), irrespective of AKIN stage or AKI etiology, Dr. Picoits-Filho reported during a press briefing at the conference, which was sponsored by the American Society of Nephrology

The diagnostic performances of the tests were comparable: For SUN, the area under the curve of a receiver operating characteristic curve (AUC ROC) was 0.76, and for BUN the value was 0.69, he said.

"We saw that the test was actually very good, particularly in patients with very severe stages of kidney injury, which is important, because those are the patients who most likely will need to go into dialysis or more complex treatment," said Dr. Picoits-Filho of the Pro-rim Foundation and Pontifícia Universidade Católica do Parana, Curitiba, Brazil.

Patients included in the study were adults (mean age, 59.5 years; 58% women) who were hospitalized with prerenal (67%), renal (24%), or postrenal (9%) suspected AKI. A third had AKIN stage 1 disease, 27% had stage 2 disease, and 40% had stage 3 disease.

Unstimulated saliva was applied to the dipstick to measure whether SUN concentrations were 5-14, 15-24, 25-34, 35-54, 55-74, or 75 or greater mg/dL; BUN was measured concomitantly.

The findings are notable because while AKI in the intensive care unit setting is usually due to acute tubular necrosis, a large proportion of AKI cases outside of the ICU are due to prerenal AKI, which is reversible if diagnosed early and treated aggressively, Dr. Picoits-Filho said.

One way of detecting AKI early on in both the hospital and outpatient settings is by criteria defined by recent consensus: "basically by glomerular filtration rate, but also by urine output," he said.

By using serum creatinine to estimate GFR, you can actually detect patients with AKI. This defines risk for developing more severe AKI (and can help in preventing the need for renal replacement therapy), and also predicts in-hospital mortality, he said.

"The problem is that you need a laboratory facility to get this measurement, and this is not always available, especially in remote areas of the world," he added.

The current findings suggest the SUN dipstick could improve the diagnosis of advanced AKI and aid in triaging patients – particularly in remote areas with limited access to clinical chemistry facilities – and may improve outcomes, he said.

While the test did not prove efficient as a screening tool for chronic kidney disease, it could potentially have a role in monitoring those with chronic kidney disease, he noted.

This study was supported by the Renal Research Institute, New York, and the International Society of Nephrology. Dr. Picoits-Filho reported having no other disclosures.

ORLANDO – A brief intervention regarding driving safety is effective for encouraging the use of a new parent resource that promotes safe driving among teens, according to Jean Thatcher Shope, Ph.D.

In a prospective study, 133 trained pediatricians each delivered the 2-minute intervention to up to 35 individual parents, directing them to the Checkpoints web-based safe driving program. More than 50% of the parents visited the website. The parents clicked on an average of 4.2 pages and spent an average of 3.5 minutes at the site, Dr. Shope reported at the annual meeting of the American Academy of Pediatrics (AAP).

©Vladimir Piskunov/iStockphoto.com

The Checkpoints Program is a free, evidence-based program that encourages parents to set limits on teen driving and to monitor novice drivers. It was developed by study coauthor Bruce Simons-Morton, Ed.D., at the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The website includes teen driving statistics resources to help parents keep their teen drivers safe, and information about state-specific teen driving laws. It also includes an interactive component to help parents create a parent-teen driving agreement that addresses driving hours, number of passengers allowed, and other factors that can be modified over time as the driver becomes more experienced.

The website pages viewed most often were those on teen driving risks, site account registration, and state-specific teen driving laws, said Dr. Shope of the University of Michigan Transportation Research Institute, Ann Arbor.

Participating pediatricians were trained to deliver the brief intervention to parents of teens aged 14-17 years. The pediatricians used scripted materials, provided parents with a key chain imprinted with the website address, and referred parents to the website (youngdriverparenting.org), which will be sustained by the AAP. Parents were encouraged to register and use the interactive Checkpoints agreement and other materials.

The intervention was developed by Dr. Shope and her colleagues in collaboration with Pediatric Research in Office Settings (PROS) and the AAP’s practice-based research network.

Just a short message from a credible professional resource is effective for prompting the parents of teens to visit the Checkpoints website, Dr. Shope said, adding that with motor vehicle crashes topping the list of causes of death among teens, effective prevention measures above and beyond graduated driver licensing are needed.

Teen drivers whose parents are actively engaged in monitoring their driving are less risky drivers, and having a pediatrician deliver a brief intervention that guides parents to an evidence-based, web-based program has the potential to reach many families and to greatly enhance teen driver safety, she added.

This study was funded by the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control.

ORLANDO – A brief intervention regarding driving safety is effective for encouraging the use of a new parent resource that promotes safe driving among teens, according to Jean Thatcher Shope, Ph.D.

In a prospective study, 133 trained pediatricians each delivered the 2-minute intervention to up to 35 individual parents, directing them to the Checkpoints web-based safe driving program. More than 50% of the parents visited the website. The parents clicked on an average of 4.2 pages and spent an average of 3.5 minutes at the site, Dr. Shope reported at the annual meeting of the American Academy of Pediatrics (AAP).

©Vladimir Piskunov/iStockphoto.com

The Checkpoints Program is a free, evidence-based program that encourages parents to set limits on teen driving and to monitor novice drivers. It was developed by study coauthor Bruce Simons-Morton, Ed.D., at the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The website includes teen driving statistics resources to help parents keep their teen drivers safe, and information about state-specific teen driving laws. It also includes an interactive component to help parents create a parent-teen driving agreement that addresses driving hours, number of passengers allowed, and other factors that can be modified over time as the driver becomes more experienced.

The website pages viewed most often were those on teen driving risks, site account registration, and state-specific teen driving laws, said Dr. Shope of the University of Michigan Transportation Research Institute, Ann Arbor.

Participating pediatricians were trained to deliver the brief intervention to parents of teens aged 14-17 years. The pediatricians used scripted materials, provided parents with a key chain imprinted with the website address, and referred parents to the website (youngdriverparenting.org), which will be sustained by the AAP. Parents were encouraged to register and use the interactive Checkpoints agreement and other materials.

The intervention was developed by Dr. Shope and her colleagues in collaboration with Pediatric Research in Office Settings (PROS) and the AAP’s practice-based research network.

Just a short message from a credible professional resource is effective for prompting the parents of teens to visit the Checkpoints website, Dr. Shope said, adding that with motor vehicle crashes topping the list of causes of death among teens, effective prevention measures above and beyond graduated driver licensing are needed.

Teen drivers whose parents are actively engaged in monitoring their driving are less risky drivers, and having a pediatrician deliver a brief intervention that guides parents to an evidence-based, web-based program has the potential to reach many families and to greatly enhance teen driver safety, she added.

This study was funded by the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control.

ORLANDO – A brief intervention regarding driving safety is effective for encouraging the use of a new parent resource that promotes safe driving among teens, according to Jean Thatcher Shope, Ph.D.

In a prospective study, 133 trained pediatricians each delivered the 2-minute intervention to up to 35 individual parents, directing them to the Checkpoints web-based safe driving program. More than 50% of the parents visited the website. The parents clicked on an average of 4.2 pages and spent an average of 3.5 minutes at the site, Dr. Shope reported at the annual meeting of the American Academy of Pediatrics (AAP).

©Vladimir Piskunov/iStockphoto.com

The Checkpoints Program is a free, evidence-based program that encourages parents to set limits on teen driving and to monitor novice drivers. It was developed by study coauthor Bruce Simons-Morton, Ed.D., at the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The website includes teen driving statistics resources to help parents keep their teen drivers safe, and information about state-specific teen driving laws. It also includes an interactive component to help parents create a parent-teen driving agreement that addresses driving hours, number of passengers allowed, and other factors that can be modified over time as the driver becomes more experienced.

The website pages viewed most often were those on teen driving risks, site account registration, and state-specific teen driving laws, said Dr. Shope of the University of Michigan Transportation Research Institute, Ann Arbor.

Participating pediatricians were trained to deliver the brief intervention to parents of teens aged 14-17 years. The pediatricians used scripted materials, provided parents with a key chain imprinted with the website address, and referred parents to the website (youngdriverparenting.org), which will be sustained by the AAP. Parents were encouraged to register and use the interactive Checkpoints agreement and other materials.

The intervention was developed by Dr. Shope and her colleagues in collaboration with Pediatric Research in Office Settings (PROS) and the AAP’s practice-based research network.

Just a short message from a credible professional resource is effective for prompting the parents of teens to visit the Checkpoints website, Dr. Shope said, adding that with motor vehicle crashes topping the list of causes of death among teens, effective prevention measures above and beyond graduated driver licensing are needed.

Teen drivers whose parents are actively engaged in monitoring their driving are less risky drivers, and having a pediatrician deliver a brief intervention that guides parents to an evidence-based, web-based program has the potential to reach many families and to greatly enhance teen driver safety, she added.

This study was funded by the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control.

ATLANTA – Mindfulness meditation may improve blood pressure in hypertensive patients with chronic kidney disease, according to findings from a small randomized study.

This study involved 15 patients who had stage 3 chronic kidney disease and hypertension. Compared with a control condition involving blood pressure education, mindfulness meditation was associated with significantly greater reductions in systolic blood pressure (–10.2 vs. –0.8 mm Hg), diastolic blood pressure (–6.4 vs. –1.8 mm Hg), and mean arterial pressure (–7.7 vs. –1.4 mm Hg), Dr. Jeanie Park reported at Kidney Week 2013, sponsored by the American Society of Nephrology.

©Jupiterimages

Mindfulness meditation – a "type of meditation that is focused on awareness of sensations of the present moment without any type of cognitive elaboration of those sensations, without judgment, without trying to modify those sensations" – also was associated with a significantly greater reduction in muscle sympathetic nerve activity as measured using microneurography (–10.7 vs. 1.9 bursts/min), said Dr. Park of Emory University, Atlanta.

Study participants were male veterans who completed two study visits, undergoing – in randomized crossover fashion – 14 minutes of guided mindfulness meditation at one visit, and 14 minutes of a control condition involving blood pressure education at one visit.

Because a lower breathing rate was observed during mindfulness meditation, a subset of the patients completed a third visit in which they used controlled breathing as a second control measure. During this visit, they lowered their breathing rate to the same rate achieved during mindfulness meditation.

"What we saw was that during mindfulness meditation, there was a significant reduction in sympathetic nerve activity compared with the control, but during controlled breathing ... there was no difference in sympathetic activity. This suggests that slow breathing by itself is not sufficient to lower blood pressure and sympathetic activity, and that there is something unique about mindfulness meditation that might be modulating sympathetic activity and blood pressure in our patients," Dr. Park said.

Although mindfulness meditation has been shown in prior studies to have "modest but meaningful" effects in patients with high blood pressure, the current findings are among the first to demonstrate an association between mindfulness meditation and decreased blood pressure in hypertensive patients with chronic kidney disease. The effect appeared to be mediated by an acute reduction in sympathetic nervous system activity, Dr. Park said.

Chronic kidney disease is characterized by chronic sympathetic nervous system overactivity, which contributes to hypertension and mortality, she explained.

"In clinical practice, we aim to counteract sympathetic activity to lower blood pressure. We do this using antihypertensive medications such as beta-blockers and [clonazepam], but the problem with these medications is that oftentimes their use is limited due to their side effects ... so there certainly is a need to investigate alternative or additive therapies to counteract sympathetic activity and lower blood pressure in our patient group," she said.

The findings of this study suggest that mindfulness meditation may have real physiological effects on autonomic control, and may prove useful as a complementary therapy in chronic kidney disease patients, she concluded, noting that future studies are needed to determine whether long-term reductions in blood pressure can be achieved by using mindfulness meditation.

Dr. Park reported having no disclosures.

ATLANTA – Mindfulness meditation may improve blood pressure in hypertensive patients with chronic kidney disease, according to findings from a small randomized study.

This study involved 15 patients who had stage 3 chronic kidney disease and hypertension. Compared with a control condition involving blood pressure education, mindfulness meditation was associated with significantly greater reductions in systolic blood pressure (–10.2 vs. –0.8 mm Hg), diastolic blood pressure (–6.4 vs. –1.8 mm Hg), and mean arterial pressure (–7.7 vs. –1.4 mm Hg), Dr. Jeanie Park reported at Kidney Week 2013, sponsored by the American Society of Nephrology.

©Jupiterimages

Mindfulness meditation – a "type of meditation that is focused on awareness of sensations of the present moment without any type of cognitive elaboration of those sensations, without judgment, without trying to modify those sensations" – also was associated with a significantly greater reduction in muscle sympathetic nerve activity as measured using microneurography (–10.7 vs. 1.9 bursts/min), said Dr. Park of Emory University, Atlanta.

Study participants were male veterans who completed two study visits, undergoing – in randomized crossover fashion – 14 minutes of guided mindfulness meditation at one visit, and 14 minutes of a control condition involving blood pressure education at one visit.

Because a lower breathing rate was observed during mindfulness meditation, a subset of the patients completed a third visit in which they used controlled breathing as a second control measure. During this visit, they lowered their breathing rate to the same rate achieved during mindfulness meditation.

"What we saw was that during mindfulness meditation, there was a significant reduction in sympathetic nerve activity compared with the control, but during controlled breathing ... there was no difference in sympathetic activity. This suggests that slow breathing by itself is not sufficient to lower blood pressure and sympathetic activity, and that there is something unique about mindfulness meditation that might be modulating sympathetic activity and blood pressure in our patients," Dr. Park said.

Although mindfulness meditation has been shown in prior studies to have "modest but meaningful" effects in patients with high blood pressure, the current findings are among the first to demonstrate an association between mindfulness meditation and decreased blood pressure in hypertensive patients with chronic kidney disease. The effect appeared to be mediated by an acute reduction in sympathetic nervous system activity, Dr. Park said.

Chronic kidney disease is characterized by chronic sympathetic nervous system overactivity, which contributes to hypertension and mortality, she explained.

"In clinical practice, we aim to counteract sympathetic activity to lower blood pressure. We do this using antihypertensive medications such as beta-blockers and [clonazepam], but the problem with these medications is that oftentimes their use is limited due to their side effects ... so there certainly is a need to investigate alternative or additive therapies to counteract sympathetic activity and lower blood pressure in our patient group," she said.

The findings of this study suggest that mindfulness meditation may have real physiological effects on autonomic control, and may prove useful as a complementary therapy in chronic kidney disease patients, she concluded, noting that future studies are needed to determine whether long-term reductions in blood pressure can be achieved by using mindfulness meditation.

Dr. Park reported having no disclosures.

ATLANTA – Mindfulness meditation may improve blood pressure in hypertensive patients with chronic kidney disease, according to findings from a small randomized study.

This study involved 15 patients who had stage 3 chronic kidney disease and hypertension. Compared with a control condition involving blood pressure education, mindfulness meditation was associated with significantly greater reductions in systolic blood pressure (–10.2 vs. –0.8 mm Hg), diastolic blood pressure (–6.4 vs. –1.8 mm Hg), and mean arterial pressure (–7.7 vs. –1.4 mm Hg), Dr. Jeanie Park reported at Kidney Week 2013, sponsored by the American Society of Nephrology.

©Jupiterimages

Mindfulness meditation – a "type of meditation that is focused on awareness of sensations of the present moment without any type of cognitive elaboration of those sensations, without judgment, without trying to modify those sensations" – also was associated with a significantly greater reduction in muscle sympathetic nerve activity as measured using microneurography (–10.7 vs. 1.9 bursts/min), said Dr. Park of Emory University, Atlanta.

Study participants were male veterans who completed two study visits, undergoing – in randomized crossover fashion – 14 minutes of guided mindfulness meditation at one visit, and 14 minutes of a control condition involving blood pressure education at one visit.

Because a lower breathing rate was observed during mindfulness meditation, a subset of the patients completed a third visit in which they used controlled breathing as a second control measure. During this visit, they lowered their breathing rate to the same rate achieved during mindfulness meditation.

"What we saw was that during mindfulness meditation, there was a significant reduction in sympathetic nerve activity compared with the control, but during controlled breathing ... there was no difference in sympathetic activity. This suggests that slow breathing by itself is not sufficient to lower blood pressure and sympathetic activity, and that there is something unique about mindfulness meditation that might be modulating sympathetic activity and blood pressure in our patients," Dr. Park said.

Although mindfulness meditation has been shown in prior studies to have "modest but meaningful" effects in patients with high blood pressure, the current findings are among the first to demonstrate an association between mindfulness meditation and decreased blood pressure in hypertensive patients with chronic kidney disease. The effect appeared to be mediated by an acute reduction in sympathetic nervous system activity, Dr. Park said.

Chronic kidney disease is characterized by chronic sympathetic nervous system overactivity, which contributes to hypertension and mortality, she explained.

"In clinical practice, we aim to counteract sympathetic activity to lower blood pressure. We do this using antihypertensive medications such as beta-blockers and [clonazepam], but the problem with these medications is that oftentimes their use is limited due to their side effects ... so there certainly is a need to investigate alternative or additive therapies to counteract sympathetic activity and lower blood pressure in our patient group," she said.

The findings of this study suggest that mindfulness meditation may have real physiological effects on autonomic control, and may prove useful as a complementary therapy in chronic kidney disease patients, she concluded, noting that future studies are needed to determine whether long-term reductions in blood pressure can be achieved by using mindfulness meditation.

Dr. Park reported having no disclosures.

ATLANTA – Adding abatacept to low-dose intravenous cyclophosphamide did not improve the rate of complete renal response at 1 year, compared with IV cyclophosphamide alone, in patients with class III or IV lupus nephritis in the randomized, controlled ACCESS Trial.

The phase II findings suggested, however, that abatacept reduced the need for maintenance immunosuppression, and they also demonstrated for the first time that low-dose IV cyclophosphamide may have applicability in racially and ethnically diverse patients with lupus nephritis, Dr. Brad H. Rovin reported at Kidney Week 2013.

The overall complete renal response rates were similar at 33% and 31%, respectively, in 134 patients with class III or IV lupus nephritis who were enrolled in the trial, treated with a steroid taper and 500 mg of IV cyclophosphamide every 2 weeks for 6 weeks followed by 2 mg/kg of azathioprine daily. Patients then were randomized to receive abatacept or placebo at week 0, 2, and 4 and then monthly.

Complete plus partial responses occurred in 59% of patients in each arm, Dr. Rovin said at the conference, which was sponsored by the American Society of Nephrology.

Patients in the study had a urine protein-to-creatinine ratio (UPCR) greater than 1. Complete renal response was defined as a UPCR of less than 0.5, serum creatinine at normal or within 25% of baseline, and prednisone dose tapered to 10 mg daily or less. African Americans comprised 39% of the cohort, and Hispanic/Mestizo patients comprised 40%.

Among the African American patients, 33% in the treatment group, compared with 16% in the placebo group, achieved complete renal response. This difference was not statistically significant.

This finding is important, because while low-dose cyclophosphamide – the "Euro-Lupus regimen" – has been shown to be as effective as standard and more toxic higher dosing, studies had primarily included a European Caucasian population. It was unclear whether the low-dose regimen would be as effective in a multiracial and multiethnic population, said Dr. Rovin of Ohio State University Medical Center.

No differences were seen between the treatment and control groups with respect to anti-dsDNA or complement levels and/or the frequency of serious or infectious adverse events or study withdrawals.

Of note, azathioprine was stopped in treatment group patients who achieved complete renal response – but not control group patients who achieved complete renal response. These patients were followed to 52 weeks. At that time, 50% and 62% of the treatment group and control group patients, respectively, who were complete responders at 24 weeks still met the criteria for complete response, Dr. Rovin said.

While abatacept did not increase complete response rates, the treatment was associated with maintenance of complete renal response to 1 year despite discontinuation of maintenance immunosuppression in the treated patients and continued azathioprine treatment in the control group. This suggests that abatacept may reduce the need for maintenance immunosuppression, he said.

While it was disappointing that the addition of abatacept to background induction therapy with low-dose IV cyclophosphamide and corticosteroids did not improve the complete renal response rate in this study – despite murine models suggesting that the use of abatacept and IV cyclophosphamide act synergistically to arrest lupus nephritis progression – the findings offer two very important lessons for clinical practice, he said.

"We can take the low-dose cyclophosphamide regimen and potentially use that with good results in our [multiethnic, multiracial] patient population that we see here in this country, and I think that’s a huge step forward. It gives us another option to use besides mycophenolate mofetil and high-dose cyclophosphamide," he said, adding that the low-dose IV cyclophosphamide regimen is well tolerated and delivers a total dose of only 3 g of the drug – a dose that generally does not predispose to premature ovarian failure.

This is particularly important, because women of childbearing years comprise a majority of the patient population with lupus nephritis, he explained.

"We know from the Euro-Lupus trial that the low-dose regimen, over 10 years, provided the same maintenance of renal function as the high-dose regimen, so we have very good long-term follow-up. We don’t quite have that yet with mycophenolate mofetil, so I think that for those of us who are very frequent users of cyclophosphamide, this is a very good alternative to the high-dose, highly toxic regimen that has for so long been the standard of care," he said.

This study was funded by the National Institute of Allergy and Infectious Diseases via the Immune Tolerance Network. Bristol Myers Squibb provided the study drug. Dr. Rovin reported ties to Genentech, Questcor, TEVA, Biogen-IDEC, HGS, Johnson & Johnson, Roche, BMS, and TG Therapeutics.

ATLANTA – Adding abatacept to low-dose intravenous cyclophosphamide did not improve the rate of complete renal response at 1 year, compared with IV cyclophosphamide alone, in patients with class III or IV lupus nephritis in the randomized, controlled ACCESS Trial.

The phase II findings suggested, however, that abatacept reduced the need for maintenance immunosuppression, and they also demonstrated for the first time that low-dose IV cyclophosphamide may have applicability in racially and ethnically diverse patients with lupus nephritis, Dr. Brad H. Rovin reported at Kidney Week 2013.

The overall complete renal response rates were similar at 33% and 31%, respectively, in 134 patients with class III or IV lupus nephritis who were enrolled in the trial, treated with a steroid taper and 500 mg of IV cyclophosphamide every 2 weeks for 6 weeks followed by 2 mg/kg of azathioprine daily. Patients then were randomized to receive abatacept or placebo at week 0, 2, and 4 and then monthly.

Complete plus partial responses occurred in 59% of patients in each arm, Dr. Rovin said at the conference, which was sponsored by the American Society of Nephrology.

Patients in the study had a urine protein-to-creatinine ratio (UPCR) greater than 1. Complete renal response was defined as a UPCR of less than 0.5, serum creatinine at normal or within 25% of baseline, and prednisone dose tapered to 10 mg daily or less. African Americans comprised 39% of the cohort, and Hispanic/Mestizo patients comprised 40%.

Among the African American patients, 33% in the treatment group, compared with 16% in the placebo group, achieved complete renal response. This difference was not statistically significant.

This finding is important, because while low-dose cyclophosphamide – the "Euro-Lupus regimen" – has been shown to be as effective as standard and more toxic higher dosing, studies had primarily included a European Caucasian population. It was unclear whether the low-dose regimen would be as effective in a multiracial and multiethnic population, said Dr. Rovin of Ohio State University Medical Center.

No differences were seen between the treatment and control groups with respect to anti-dsDNA or complement levels and/or the frequency of serious or infectious adverse events or study withdrawals.

Of note, azathioprine was stopped in treatment group patients who achieved complete renal response – but not control group patients who achieved complete renal response. These patients were followed to 52 weeks. At that time, 50% and 62% of the treatment group and control group patients, respectively, who were complete responders at 24 weeks still met the criteria for complete response, Dr. Rovin said.

While abatacept did not increase complete response rates, the treatment was associated with maintenance of complete renal response to 1 year despite discontinuation of maintenance immunosuppression in the treated patients and continued azathioprine treatment in the control group. This suggests that abatacept may reduce the need for maintenance immunosuppression, he said.

While it was disappointing that the addition of abatacept to background induction therapy with low-dose IV cyclophosphamide and corticosteroids did not improve the complete renal response rate in this study – despite murine models suggesting that the use of abatacept and IV cyclophosphamide act synergistically to arrest lupus nephritis progression – the findings offer two very important lessons for clinical practice, he said.

"We can take the low-dose cyclophosphamide regimen and potentially use that with good results in our [multiethnic, multiracial] patient population that we see here in this country, and I think that’s a huge step forward. It gives us another option to use besides mycophenolate mofetil and high-dose cyclophosphamide," he said, adding that the low-dose IV cyclophosphamide regimen is well tolerated and delivers a total dose of only 3 g of the drug – a dose that generally does not predispose to premature ovarian failure.

This is particularly important, because women of childbearing years comprise a majority of the patient population with lupus nephritis, he explained.

"We know from the Euro-Lupus trial that the low-dose regimen, over 10 years, provided the same maintenance of renal function as the high-dose regimen, so we have very good long-term follow-up. We don’t quite have that yet with mycophenolate mofetil, so I think that for those of us who are very frequent users of cyclophosphamide, this is a very good alternative to the high-dose, highly toxic regimen that has for so long been the standard of care," he said.

This study was funded by the National Institute of Allergy and Infectious Diseases via the Immune Tolerance Network. Bristol Myers Squibb provided the study drug. Dr. Rovin reported ties to Genentech, Questcor, TEVA, Biogen-IDEC, HGS, Johnson & Johnson, Roche, BMS, and TG Therapeutics.

ATLANTA – Adding abatacept to low-dose intravenous cyclophosphamide did not improve the rate of complete renal response at 1 year, compared with IV cyclophosphamide alone, in patients with class III or IV lupus nephritis in the randomized, controlled ACCESS Trial.

The phase II findings suggested, however, that abatacept reduced the need for maintenance immunosuppression, and they also demonstrated for the first time that low-dose IV cyclophosphamide may have applicability in racially and ethnically diverse patients with lupus nephritis, Dr. Brad H. Rovin reported at Kidney Week 2013.

The overall complete renal response rates were similar at 33% and 31%, respectively, in 134 patients with class III or IV lupus nephritis who were enrolled in the trial, treated with a steroid taper and 500 mg of IV cyclophosphamide every 2 weeks for 6 weeks followed by 2 mg/kg of azathioprine daily. Patients then were randomized to receive abatacept or placebo at week 0, 2, and 4 and then monthly.

Complete plus partial responses occurred in 59% of patients in each arm, Dr. Rovin said at the conference, which was sponsored by the American Society of Nephrology.

Patients in the study had a urine protein-to-creatinine ratio (UPCR) greater than 1. Complete renal response was defined as a UPCR of less than 0.5, serum creatinine at normal or within 25% of baseline, and prednisone dose tapered to 10 mg daily or less. African Americans comprised 39% of the cohort, and Hispanic/Mestizo patients comprised 40%.

Among the African American patients, 33% in the treatment group, compared with 16% in the placebo group, achieved complete renal response. This difference was not statistically significant.

This finding is important, because while low-dose cyclophosphamide – the "Euro-Lupus regimen" – has been shown to be as effective as standard and more toxic higher dosing, studies had primarily included a European Caucasian population. It was unclear whether the low-dose regimen would be as effective in a multiracial and multiethnic population, said Dr. Rovin of Ohio State University Medical Center.

No differences were seen between the treatment and control groups with respect to anti-dsDNA or complement levels and/or the frequency of serious or infectious adverse events or study withdrawals.

Of note, azathioprine was stopped in treatment group patients who achieved complete renal response – but not control group patients who achieved complete renal response. These patients were followed to 52 weeks. At that time, 50% and 62% of the treatment group and control group patients, respectively, who were complete responders at 24 weeks still met the criteria for complete response, Dr. Rovin said.

While abatacept did not increase complete response rates, the treatment was associated with maintenance of complete renal response to 1 year despite discontinuation of maintenance immunosuppression in the treated patients and continued azathioprine treatment in the control group. This suggests that abatacept may reduce the need for maintenance immunosuppression, he said.

While it was disappointing that the addition of abatacept to background induction therapy with low-dose IV cyclophosphamide and corticosteroids did not improve the complete renal response rate in this study – despite murine models suggesting that the use of abatacept and IV cyclophosphamide act synergistically to arrest lupus nephritis progression – the findings offer two very important lessons for clinical practice, he said.

"We can take the low-dose cyclophosphamide regimen and potentially use that with good results in our [multiethnic, multiracial] patient population that we see here in this country, and I think that’s a huge step forward. It gives us another option to use besides mycophenolate mofetil and high-dose cyclophosphamide," he said, adding that the low-dose IV cyclophosphamide regimen is well tolerated and delivers a total dose of only 3 g of the drug – a dose that generally does not predispose to premature ovarian failure.

This is particularly important, because women of childbearing years comprise a majority of the patient population with lupus nephritis, he explained.

"We know from the Euro-Lupus trial that the low-dose regimen, over 10 years, provided the same maintenance of renal function as the high-dose regimen, so we have very good long-term follow-up. We don’t quite have that yet with mycophenolate mofetil, so I think that for those of us who are very frequent users of cyclophosphamide, this is a very good alternative to the high-dose, highly toxic regimen that has for so long been the standard of care," he said.

This study was funded by the National Institute of Allergy and Infectious Diseases via the Immune Tolerance Network. Bristol Myers Squibb provided the study drug. Dr. Rovin reported ties to Genentech, Questcor, TEVA, Biogen-IDEC, HGS, Johnson & Johnson, Roche, BMS, and TG Therapeutics.

ATLANTA – The global prevalence of maintenance dialysis for end-stage renal disease has increased 165% over the past 2 decades – a rate that has far outpaced that of population growth in most regions of the world, according to Dr. Bernadette A. Thomas.

The findings – the first to quantify the global burden of end-stage renal disease – underscore a need for improved detection of early chronic kidney disease and for treatment aimed at preventing end-stage renal disease (ESRD), because a continued rise in the prevalence of maintenance dialysis may not be sustainable, Dr. Thomas of the University of Washington, Seattle, said at Kidney Week 2013.

From 1990 to 2010, the global prevalence of maintenance dialysis in areas with universal dialysis access increased 134%, after adjustment for population growth and aging. The increase was 145% among women and 123% among men. Even in countries with a lack of universal access, the adjusted prevalence increased by 102% (116% for women and 90% for men).

The regions that did not experience an increase in dialysis prevalence included Oceania, South Asia, Central Sub-Saharan Africa, Eastern Europe, and tropical Latin America, Dr. Thomas said at the conference, which was sponsored by the American Society of Nephrology.

The findings are based on data extracted from the Global Burden of Disease database, the largest existing database for global causes of morbidity and mortality. Prevalence estimates were based on national and regional ESRD registries and a structured literature review. Data from 23 countries with universal dialysis access and from 138 countries with partial access were included; data from 26 countries that lack routine access were excluded.

"The statistics are appalling," American Society of Nephrology President Bruce A. Molitoris of Indiana University, Indianapolis, noted during a press briefing. Dr. Molitoris called for stepped-up efforts to educate the public about the importance of kidney health.

"We have targeted the patients in the past [via] patient education, and we have not presented, I think, a fair outlook to the public of the potential importance of kidney disease," he said.

Up to one-third of U.S. residents will, at some point in their lives, have severe kidney disease, Dr. Molitoris said, and 8% of African Americans and 3.6% of the total population will go on dialysis or need a transplant.

"And yet, people think they are immune to kidney disease," he cautioned. "The field is in need of innovation; the field is in need of individualization of care. And to do that, we have to have public awareness."

Kidney disease ranks near the bottom when it comes to research funding, and public awareness will go a long way toward changing that, he added.

Dr. Molitoris said he is optimistic that as the pharmaceutical industry continues taking an interest in kidney disease, and as public awareness increases, funding – and therefore innovation – will also increase. He said he envisions a time when the public will be as aware of their kidney function level as they are of their cholesterol level.

"With what is going on in science and technology and biology, it’s not a far leap for us to make major strides," he said.

The study by Dr. Thomas was supported by a private foundation. Dr. Thomas reported having no relevant financial disclosures. Dr. Molitoris reported consultancy, ownership interest, research funding, honoraria, and/or a scientific advisory or membership role for numerous companies. He also reported a patent/invention with FAST Diagnostics, Indiana University.

ATLANTA – The global prevalence of maintenance dialysis for end-stage renal disease has increased 165% over the past 2 decades – a rate that has far outpaced that of population growth in most regions of the world, according to Dr. Bernadette A. Thomas.

The findings – the first to quantify the global burden of end-stage renal disease – underscore a need for improved detection of early chronic kidney disease and for treatment aimed at preventing end-stage renal disease (ESRD), because a continued rise in the prevalence of maintenance dialysis may not be sustainable, Dr. Thomas of the University of Washington, Seattle, said at Kidney Week 2013.

From 1990 to 2010, the global prevalence of maintenance dialysis in areas with universal dialysis access increased 134%, after adjustment for population growth and aging. The increase was 145% among women and 123% among men. Even in countries with a lack of universal access, the adjusted prevalence increased by 102% (116% for women and 90% for men).

The regions that did not experience an increase in dialysis prevalence included Oceania, South Asia, Central Sub-Saharan Africa, Eastern Europe, and tropical Latin America, Dr. Thomas said at the conference, which was sponsored by the American Society of Nephrology.

The findings are based on data extracted from the Global Burden of Disease database, the largest existing database for global causes of morbidity and mortality. Prevalence estimates were based on national and regional ESRD registries and a structured literature review. Data from 23 countries with universal dialysis access and from 138 countries with partial access were included; data from 26 countries that lack routine access were excluded.

"The statistics are appalling," American Society of Nephrology President Bruce A. Molitoris of Indiana University, Indianapolis, noted during a press briefing. Dr. Molitoris called for stepped-up efforts to educate the public about the importance of kidney health.

"We have targeted the patients in the past [via] patient education, and we have not presented, I think, a fair outlook to the public of the potential importance of kidney disease," he said.

Up to one-third of U.S. residents will, at some point in their lives, have severe kidney disease, Dr. Molitoris said, and 8% of African Americans and 3.6% of the total population will go on dialysis or need a transplant.

"And yet, people think they are immune to kidney disease," he cautioned. "The field is in need of innovation; the field is in need of individualization of care. And to do that, we have to have public awareness."

Kidney disease ranks near the bottom when it comes to research funding, and public awareness will go a long way toward changing that, he added.

Dr. Molitoris said he is optimistic that as the pharmaceutical industry continues taking an interest in kidney disease, and as public awareness increases, funding – and therefore innovation – will also increase. He said he envisions a time when the public will be as aware of their kidney function level as they are of their cholesterol level.

"With what is going on in science and technology and biology, it’s not a far leap for us to make major strides," he said.

The study by Dr. Thomas was supported by a private foundation. Dr. Thomas reported having no relevant financial disclosures. Dr. Molitoris reported consultancy, ownership interest, research funding, honoraria, and/or a scientific advisory or membership role for numerous companies. He also reported a patent/invention with FAST Diagnostics, Indiana University.

ATLANTA – The global prevalence of maintenance dialysis for end-stage renal disease has increased 165% over the past 2 decades – a rate that has far outpaced that of population growth in most regions of the world, according to Dr. Bernadette A. Thomas.

The findings – the first to quantify the global burden of end-stage renal disease – underscore a need for improved detection of early chronic kidney disease and for treatment aimed at preventing end-stage renal disease (ESRD), because a continued rise in the prevalence of maintenance dialysis may not be sustainable, Dr. Thomas of the University of Washington, Seattle, said at Kidney Week 2013.

From 1990 to 2010, the global prevalence of maintenance dialysis in areas with universal dialysis access increased 134%, after adjustment for population growth and aging. The increase was 145% among women and 123% among men. Even in countries with a lack of universal access, the adjusted prevalence increased by 102% (116% for women and 90% for men).

The regions that did not experience an increase in dialysis prevalence included Oceania, South Asia, Central Sub-Saharan Africa, Eastern Europe, and tropical Latin America, Dr. Thomas said at the conference, which was sponsored by the American Society of Nephrology.

The findings are based on data extracted from the Global Burden of Disease database, the largest existing database for global causes of morbidity and mortality. Prevalence estimates were based on national and regional ESRD registries and a structured literature review. Data from 23 countries with universal dialysis access and from 138 countries with partial access were included; data from 26 countries that lack routine access were excluded.

"The statistics are appalling," American Society of Nephrology President Bruce A. Molitoris of Indiana University, Indianapolis, noted during a press briefing. Dr. Molitoris called for stepped-up efforts to educate the public about the importance of kidney health.

"We have targeted the patients in the past [via] patient education, and we have not presented, I think, a fair outlook to the public of the potential importance of kidney disease," he said.

Up to one-third of U.S. residents will, at some point in their lives, have severe kidney disease, Dr. Molitoris said, and 8% of African Americans and 3.6% of the total population will go on dialysis or need a transplant.

"And yet, people think they are immune to kidney disease," he cautioned. "The field is in need of innovation; the field is in need of individualization of care. And to do that, we have to have public awareness."

Kidney disease ranks near the bottom when it comes to research funding, and public awareness will go a long way toward changing that, he added.

Dr. Molitoris said he is optimistic that as the pharmaceutical industry continues taking an interest in kidney disease, and as public awareness increases, funding – and therefore innovation – will also increase. He said he envisions a time when the public will be as aware of their kidney function level as they are of their cholesterol level.

"With what is going on in science and technology and biology, it’s not a far leap for us to make major strides," he said.

The study by Dr. Thomas was supported by a private foundation. Dr. Thomas reported having no relevant financial disclosures. Dr. Molitoris reported consultancy, ownership interest, research funding, honoraria, and/or a scientific advisory or membership role for numerous companies. He also reported a patent/invention with FAST Diagnostics, Indiana University.

ATLANTA – The global prevalence of maintenance dialysis for end-stage renal disease has increased 165% over the past 2 decades – a rate that has far outpaced that of population growth in most regions of the world, according to Dr. Bernadette A. Thomas.

The findings – the first to quantify the global burden of end-stage renal disease – underscore a need for improved detection of early chronic kidney disease and for treatment aimed at preventing end-stage renal disease (ESRD), because a continued rise in the prevalence of maintenance dialysis may not be sustainable, Dr. Thomas of the University of Washington, Seattle, said at Kidney Week 2013.

From 1990 to 2010, the global prevalence of maintenance dialysis in areas with universal dialysis access increased 134%, after adjustment for population growth and aging. The increase was 145% among women and 123% among men. Even in countries with a lack of universal access, the adjusted prevalence increased by 102% (116% for women and 90% for men).

The regions that did not experience an increase in dialysis prevalence included Oceania, South Asia, Central Sub-Saharan Africa, Eastern Europe, and tropical Latin America, Dr. Thomas said at the conference, which was sponsored by the American Society of Nephrology.

The findings are based on data extracted from the Global Burden of Disease database, the largest existing database for global causes of morbidity and mortality. Prevalence estimates were based on national and regional ESRD registries and a structured literature review. Data from 23 countries with universal dialysis access and from 138 countries with partial access were included; data from 26 countries that lack routine access were excluded.

"The statistics are appalling," American Society of Nephrology President Bruce A. Molitoris of Indiana University, Indianapolis, noted during a press briefing. Dr. Molitoris called for stepped-up efforts to educate the public about the importance of kidney health.

"We have targeted the patients in the past [via] patient education, and we have not presented, I think, a fair outlook to the public of the potential importance of kidney disease," he said.

Up to one-third of U.S. residents will, at some point in their lives, have severe kidney disease, Dr. Molitoris said, and 8% of African Americans and 3.6% of the total population will go on dialysis or need a transplant.

"And yet, people think they are immune to kidney disease," he cautioned. "The field is in need of innovation; the field is in need of individualization of care. And to do that, we have to have public awareness."

Kidney disease ranks near the bottom when it comes to research funding, and public awareness will go a long way toward changing that, he added.

Dr. Molitoris said he is optimistic that as the pharmaceutical industry continues taking an interest in kidney disease, and as public awareness increases, funding – and therefore innovation – will also increase. He said he envisions a time when the public will be as aware of their kidney function level as they are of their cholesterol level.

"With what is going on in science and technology and biology, it’s not a far leap for us to make major strides," he said.

The study by Dr. Thomas was supported by a private foundation. Dr. Thomas reported having no relevant financial disclosures. Dr. Molitoris reported consultancy, ownership interest, research funding, honoraria, and/or a scientific advisory or membership role for numerous companies. He also reported a patent/invention with FAST Diagnostics, Indiana University.

ATLANTA – The global prevalence of maintenance dialysis for end-stage renal disease has increased 165% over the past 2 decades – a rate that has far outpaced that of population growth in most regions of the world, according to Dr. Bernadette A. Thomas.

The findings – the first to quantify the global burden of end-stage renal disease – underscore a need for improved detection of early chronic kidney disease and for treatment aimed at preventing end-stage renal disease (ESRD), because a continued rise in the prevalence of maintenance dialysis may not be sustainable, Dr. Thomas of the University of Washington, Seattle, said at Kidney Week 2013.

From 1990 to 2010, the global prevalence of maintenance dialysis in areas with universal dialysis access increased 134%, after adjustment for population growth and aging. The increase was 145% among women and 123% among men. Even in countries with a lack of universal access, the adjusted prevalence increased by 102% (116% for women and 90% for men).

The regions that did not experience an increase in dialysis prevalence included Oceania, South Asia, Central Sub-Saharan Africa, Eastern Europe, and tropical Latin America, Dr. Thomas said at the conference, which was sponsored by the American Society of Nephrology.

The findings are based on data extracted from the Global Burden of Disease database, the largest existing database for global causes of morbidity and mortality. Prevalence estimates were based on national and regional ESRD registries and a structured literature review. Data from 23 countries with universal dialysis access and from 138 countries with partial access were included; data from 26 countries that lack routine access were excluded.

"The statistics are appalling," American Society of Nephrology President Bruce A. Molitoris of Indiana University, Indianapolis, noted during a press briefing. Dr. Molitoris called for stepped-up efforts to educate the public about the importance of kidney health.

"We have targeted the patients in the past [via] patient education, and we have not presented, I think, a fair outlook to the public of the potential importance of kidney disease," he said.

Up to one-third of U.S. residents will, at some point in their lives, have severe kidney disease, Dr. Molitoris said, and 8% of African Americans and 3.6% of the total population will go on dialysis or need a transplant.

"And yet, people think they are immune to kidney disease," he cautioned. "The field is in need of innovation; the field is in need of individualization of care. And to do that, we have to have public awareness."

Kidney disease ranks near the bottom when it comes to research funding, and public awareness will go a long way toward changing that, he added.

Dr. Molitoris said he is optimistic that as the pharmaceutical industry continues taking an interest in kidney disease, and as public awareness increases, funding – and therefore innovation – will also increase. He said he envisions a time when the public will be as aware of their kidney function level as they are of their cholesterol level.

"With what is going on in science and technology and biology, it’s not a far leap for us to make major strides," he said.

The study by Dr. Thomas was supported by a private foundation. Dr. Thomas reported having no relevant financial disclosures. Dr. Molitoris reported consultancy, ownership interest, research funding, honoraria, and/or a scientific advisory or membership role for numerous companies. He also reported a patent/invention with FAST Diagnostics, Indiana University.

ATLANTA – The global prevalence of maintenance dialysis for end-stage renal disease has increased 165% over the past 2 decades – a rate that has far outpaced that of population growth in most regions of the world, according to Dr. Bernadette A. Thomas.

The findings – the first to quantify the global burden of end-stage renal disease – underscore a need for improved detection of early chronic kidney disease and for treatment aimed at preventing end-stage renal disease (ESRD), because a continued rise in the prevalence of maintenance dialysis may not be sustainable, Dr. Thomas of the University of Washington, Seattle, said at Kidney Week 2013.

From 1990 to 2010, the global prevalence of maintenance dialysis in areas with universal dialysis access increased 134%, after adjustment for population growth and aging. The increase was 145% among women and 123% among men. Even in countries with a lack of universal access, the adjusted prevalence increased by 102% (116% for women and 90% for men).

The regions that did not experience an increase in dialysis prevalence included Oceania, South Asia, Central Sub-Saharan Africa, Eastern Europe, and tropical Latin America, Dr. Thomas said at the conference, which was sponsored by the American Society of Nephrology.

The findings are based on data extracted from the Global Burden of Disease database, the largest existing database for global causes of morbidity and mortality. Prevalence estimates were based on national and regional ESRD registries and a structured literature review. Data from 23 countries with universal dialysis access and from 138 countries with partial access were included; data from 26 countries that lack routine access were excluded.

"The statistics are appalling," American Society of Nephrology President Bruce A. Molitoris of Indiana University, Indianapolis, noted during a press briefing. Dr. Molitoris called for stepped-up efforts to educate the public about the importance of kidney health.

"We have targeted the patients in the past [via] patient education, and we have not presented, I think, a fair outlook to the public of the potential importance of kidney disease," he said.

Up to one-third of U.S. residents will, at some point in their lives, have severe kidney disease, Dr. Molitoris said, and 8% of African Americans and 3.6% of the total population will go on dialysis or need a transplant.

"And yet, people think they are immune to kidney disease," he cautioned. "The field is in need of innovation; the field is in need of individualization of care. And to do that, we have to have public awareness."

Kidney disease ranks near the bottom when it comes to research funding, and public awareness will go a long way toward changing that, he added.

Dr. Molitoris said he is optimistic that as the pharmaceutical industry continues taking an interest in kidney disease, and as public awareness increases, funding – and therefore innovation – will also increase. He said he envisions a time when the public will be as aware of their kidney function level as they are of their cholesterol level.

"With what is going on in science and technology and biology, it’s not a far leap for us to make major strides," he said.

The study by Dr. Thomas was supported by a private foundation. Dr. Thomas reported having no relevant financial disclosures. Dr. Molitoris reported consultancy, ownership interest, research funding, honoraria, and/or a scientific advisory or membership role for numerous companies. He also reported a patent/invention with FAST Diagnostics, Indiana University.

ORLANDO – Most children presenting to the emergency department with a limp have a traumatic etiology, and in most cases, a thorough history and physical examination coupled with radiographs are sufficient for diagnosis, a retrospective study of cases at a tertiary care pediatric emergency department showed.

Of 16,056 children aged 10 months to 18 years (mean, 2.2 years) who presented to the ED between Jan. 1, 2010, and April 1, 2010, 1,776 (11%) presented with a musculoskeletal complaint, and 779 had a lower-extremity injury, a limp, and/or an inability to bear weight. Among those 779 patients, the most common diagnoses were sprain or strain (26%), contusion (19%), fracture (14%), cellulitis/abscess (9%), and abrasion/laceration/puncture (8%), Dr. Johnathan J. Whitaker reported at the annual meeting of the American Academy of Pediatrics.

Of the 779 patients, 527 (68%) had a traumatic injury and 252 (32%) had an atraumatic etiology.

Transient synovitis was discovered in 15 patients (1.9%), and septic arthritis was discovered in 2 patients (0.3%). Other causes of a limp, from among more than 50 diagnoses, were animal bites, an ingrown or avulsed toenail, back spasm, sickle cell crisis, apophysitis, a burn injury, frostbite, slipped capital femoral epiphysis (SCFE), psoas abscess, deep venous thrombosis, rhabdomyolysis, and testicular torsion, said Dr. Whitaker of the Philadelphia College of Osteopathic Medicine.

Overall, 59 patients (7.6%) were admitted, with most of those having a fracture (36%) or an infection (27%). Others who were admitted had transient synovitis (8.5%), sickle cell crisis (6.8%), or SCFE (1.7%).

Several differences were seen between patients who were admitted and patients who were not admitted, including average age, mechanism of injury, presence of a fever, inability to bear weight, past medical history, serum white blood cell count level, and the use of advanced imaging or a laboratory work-up for diagnosis.

For example, among those with a traumatic etiology, the average age was 14 years; among those with an atraumatic etiology, the average age was 10 years. Only 1% of those with a traumatic etiology had a fever, compared with 5% of those with an atraumatic etiology, Dr. Whitaker said.

The inability to bear weight, the presence of a fever greater than 101.5  F, younger age, and an atraumatic mechanism of injury were significant predictors of admission; increased age and a traumatic mechanism of injury were significantly associated with a decreased likelihood of admission, Dr. Whitaker said.

"Limping primarily results from orthopedic diagnoses. However, limping is a chief complaint for a wide variety of other diagnoses," he said.

Though limited by a relatively small number of limp-related presenting complaints and the fact that the study was conducted during winter months – which may have an impact on the types of injuries seen, the findings suggest that laboratory studies and advanced imaging to assist in establishing a diagnosis that may require admission or urgent treatment are best utilized for younger children with an atraumatic mechanism of injury, the inability to bear weight, or a fever upon presentation, he said.

Dr. Whitaker reported having no relevant financial disclosures.

ORLANDO – Most children presenting to the emergency department with a limp have a traumatic etiology, and in most cases, a thorough history and physical examination coupled with radiographs are sufficient for diagnosis, a retrospective study of cases at a tertiary care pediatric emergency department showed.

Of 16,056 children aged 10 months to 18 years (mean, 2.2 years) who presented to the ED between Jan. 1, 2010, and April 1, 2010, 1,776 (11%) presented with a musculoskeletal complaint, and 779 had a lower-extremity injury, a limp, and/or an inability to bear weight. Among those 779 patients, the most common diagnoses were sprain or strain (26%), contusion (19%), fracture (14%), cellulitis/abscess (9%), and abrasion/laceration/puncture (8%), Dr. Johnathan J. Whitaker reported at the annual meeting of the American Academy of Pediatrics.

Of the 779 patients, 527 (68%) had a traumatic injury and 252 (32%) had an atraumatic etiology.

Transient synovitis was discovered in 15 patients (1.9%), and septic arthritis was discovered in 2 patients (0.3%). Other causes of a limp, from among more than 50 diagnoses, were animal bites, an ingrown or avulsed toenail, back spasm, sickle cell crisis, apophysitis, a burn injury, frostbite, slipped capital femoral epiphysis (SCFE), psoas abscess, deep venous thrombosis, rhabdomyolysis, and testicular torsion, said Dr. Whitaker of the Philadelphia College of Osteopathic Medicine.

Overall, 59 patients (7.6%) were admitted, with most of those having a fracture (36%) or an infection (27%). Others who were admitted had transient synovitis (8.5%), sickle cell crisis (6.8%), or SCFE (1.7%).

Several differences were seen between patients who were admitted and patients who were not admitted, including average age, mechanism of injury, presence of a fever, inability to bear weight, past medical history, serum white blood cell count level, and the use of advanced imaging or a laboratory work-up for diagnosis.

For example, among those with a traumatic etiology, the average age was 14 years; among those with an atraumatic etiology, the average age was 10 years. Only 1% of those with a traumatic etiology had a fever, compared with 5% of those with an atraumatic etiology, Dr. Whitaker said.

The inability to bear weight, the presence of a fever greater than 101.5  F, younger age, and an atraumatic mechanism of injury were significant predictors of admission; increased age and a traumatic mechanism of injury were significantly associated with a decreased likelihood of admission, Dr. Whitaker said.

"Limping primarily results from orthopedic diagnoses. However, limping is a chief complaint for a wide variety of other diagnoses," he said.

Though limited by a relatively small number of limp-related presenting complaints and the fact that the study was conducted during winter months – which may have an impact on the types of injuries seen, the findings suggest that laboratory studies and advanced imaging to assist in establishing a diagnosis that may require admission or urgent treatment are best utilized for younger children with an atraumatic mechanism of injury, the inability to bear weight, or a fever upon presentation, he said.

Dr. Whitaker reported having no relevant financial disclosures.

ORLANDO – Most children presenting to the emergency department with a limp have a traumatic etiology, and in most cases, a thorough history and physical examination coupled with radiographs are sufficient for diagnosis, a retrospective study of cases at a tertiary care pediatric emergency department showed.

Of 16,056 children aged 10 months to 18 years (mean, 2.2 years) who presented to the ED between Jan. 1, 2010, and April 1, 2010, 1,776 (11%) presented with a musculoskeletal complaint, and 779 had a lower-extremity injury, a limp, and/or an inability to bear weight. Among those 779 patients, the most common diagnoses were sprain or strain (26%), contusion (19%), fracture (14%), cellulitis/abscess (9%), and abrasion/laceration/puncture (8%), Dr. Johnathan J. Whitaker reported at the annual meeting of the American Academy of Pediatrics.

Of the 779 patients, 527 (68%) had a traumatic injury and 252 (32%) had an atraumatic etiology.

Transient synovitis was discovered in 15 patients (1.9%), and septic arthritis was discovered in 2 patients (0.3%). Other causes of a limp, from among more than 50 diagnoses, were animal bites, an ingrown or avulsed toenail, back spasm, sickle cell crisis, apophysitis, a burn injury, frostbite, slipped capital femoral epiphysis (SCFE), psoas abscess, deep venous thrombosis, rhabdomyolysis, and testicular torsion, said Dr. Whitaker of the Philadelphia College of Osteopathic Medicine.

Overall, 59 patients (7.6%) were admitted, with most of those having a fracture (36%) or an infection (27%). Others who were admitted had transient synovitis (8.5%), sickle cell crisis (6.8%), or SCFE (1.7%).

Several differences were seen between patients who were admitted and patients who were not admitted, including average age, mechanism of injury, presence of a fever, inability to bear weight, past medical history, serum white blood cell count level, and the use of advanced imaging or a laboratory work-up for diagnosis.

For example, among those with a traumatic etiology, the average age was 14 years; among those with an atraumatic etiology, the average age was 10 years. Only 1% of those with a traumatic etiology had a fever, compared with 5% of those with an atraumatic etiology, Dr. Whitaker said.

The inability to bear weight, the presence of a fever greater than 101.5  F, younger age, and an atraumatic mechanism of injury were significant predictors of admission; increased age and a traumatic mechanism of injury were significantly associated with a decreased likelihood of admission, Dr. Whitaker said.

"Limping primarily results from orthopedic diagnoses. However, limping is a chief complaint for a wide variety of other diagnoses," he said.

Though limited by a relatively small number of limp-related presenting complaints and the fact that the study was conducted during winter months – which may have an impact on the types of injuries seen, the findings suggest that laboratory studies and advanced imaging to assist in establishing a diagnosis that may require admission or urgent treatment are best utilized for younger children with an atraumatic mechanism of injury, the inability to bear weight, or a fever upon presentation, he said.

Dr. Whitaker reported having no relevant financial disclosures.