Kidney Stone and Heart Disease Link?

KIDNEY WALK 2009: Long Island

This is a quick reminder that you are invited to join us for a Special Weekend event, organized by National Kidney Foundation.

The goal is to increase awareness of Chronic Kidney Disease and the need for organ donation.

Date: May 31st
Location: Hofstra University, Uniondale NY
Check in: 9:30 am
Walk starts at: 10:30am

Your fellow Long Islanders need your support. This is your opportunity to get involved and make a difference in the lives of so many people, including children.

Please bring your friends, colleagues or loved ones who would like to be a part of this inspiring and live-saving event.

We look forward to seeing you!

If you have any questions about Kidney Walkor need to schedule your next appointment with a Kidney specialist, please call North Shore Nephrology

Phone: (516) 365 - 5570
email info@northshorenephrology.com

American Kidney Fund's Podcast

American Kidney Fund has released a new podcast.

Tolvaptan Tablets for Hyponatremia are now FDA Approved

The FDA has approved tolvaptan tablets for use in hyponatremia associated with heart failure, cirrhosis, and the syndrome of inappropriate antidiuretic hormone secretion (SIADH).

The drug is a vasopressin-receptor antagonist. Vaprisol (conivaptan) a simliar drug has been used in the IV form in the hospital.

Tolvaptan will be dispensed with a boxed warning that it only be started in hospitals, where sodium levels can be monitored closely. If sodium levels rise too quickly, osmotic demyelination syndrome can result (theoretically... this is scary, but VERY rare).

Link Between Obesity and Residual Renal Function After Start of Dialysis

The Americal Journal of Kidney Disease (AJKD) is publishing a study in its June 2009 issue in regards to BMI (body mass index) and residual renal function on CKD5 patients starting on hemodialysis.

Although we know that obesity is a risk factor for progressive renal disease leading to end stage... does a high BMI impact residual renal function once a patients starts dialysis?

Apparently, so. A study of 1,271 incident dialysis patients from 38 centers in The Netherlands participating in the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) between 1997 and 2006 was used to evaluate this question.

BMI assessed at 3 months after the initiation of dialysis therapy (baseline) and categorized into 4 groups: less than 20, 20 or greater to 25, 25 or greater to 30, and 30 or greater (25-29.9 = overweight; 30+ obesity).

The study wound up showing that in fact, obesity was a strong risk factor for the decline in kidney function after initiation of dialysis therapy. Whether obese dialysis patients might benefit from a healthy weight reduction needs to be studied further.

There aren't too many study showing that obesity is a good and protective state, so this is not surprising. We also know that obesity leads to worsening GFR over time... so it shouldn't be too surprising that the residual renal function will also fall quicker than in someone with a lower BMI. Nevertheless, it is a relatively small study done in the Netherlands which may not fully apply to Americans. The study also did not include BMI at the initiation of dialysis. They started collecting data 3 months after dialysis started. It is also unclear if lowering the BMI will preserve renal function once on dialysis. But, for now it seems safe (and logical) to continue to aim for an ideal BMI of 20-25.

The Fairer Sex, With Benefits

It seems chronic kidney disease may progress more slowly in women.

This is according to Adeera Levin, MD, Professor of Nephrology at the University of British Columbia in Vancouver, and colleagues.

They analyzed data from 3,444 patients with a mean age of 66 and eGFR of 27.6.

After a mean follow-up period of 47 months, 36% of women started renal replacement therapy (RRT) compared with 42% of men, Dr. Levin reported at the Canadian Society of Nephrology annual meeting in Edmonton, Alberta.

After adjusting for confounders, men were 30% more likely than women to start RRT. The mean annual decline in eGFR was 3.36 for men compared with 2.60 for women. The genders did not differ significantly with respect to mortality: 14% of each group died during the study period.

This is interesting. Unfortunately there is not much information about the comorbidities of these patients other than their age, gender and eGFR. It is also uncertain if this translates into other non-Canadian populations. Anyway, I thought it was an interesting study to share this morning.

What is the Best Method to Avoid Hypotension at Dialysis?

An article published in Dialysis and Transplantation deals with an issue common to all nephrologist and CKD5 patients on HD... intradialytic hypotension. This is simply the drop ("crash") of blood pressure in the middle of a dialysis session.

So, this study aimed to investigate the effects of dialysate sodium profiling and gradient ultrafiltration on hypotension during hemodialysis. The below is taken from the abstract.

Methods

In this study, a single-blinded, crossover design of 4 different dialysis protocols was undertaken. Four hemodialysis protocols were administered to 40 patients to 2 mounts (12 hemodialysis sessions). A total of 40 patients experiencing hypotension episodes during hemodialysis and who agreed to participate were included in the study. All patients were administered 4 different hemodialysis protocols consecutively. Protocol 1 = linear sodium dialysate 1 (Na: 150 mEq/L and decreased by 4 mEq/L at each hour) and constant ultrafiltration; Protocol 2 = linear sodium dialysate and gradient ultrafiltration; Protocol 3 = constant sodium dialysate and gradient ultrafiltration; and Protocol 4 (standard hemodialysis) = constant sodium dialysate and constant ultrafiltration.

Results

The results of this study show that when linear sodium dialysate and gradient ultrafiltration are used concomitantly, hypotension episodes decrease, more ultrafiltration is performed, and less treatment is needed. Gradient sodium dialysate usage (Protocol 1 and 2) required fewer treatment interventions for hypotension compared to standard protocol. No significant differences were observed between standard hemodialysis and any of the other protocols after dialysis for plasma osmolarity.

Conclusion

We recommend concomitant use of gradient ultrafiltration and sodium dialysate in patients with hypotension.

---

NSN Newsletter: LONG ISLAND KIDNEY WALK 2009

Join us for a Special Weekend Event to raise awareness of Kidney Disease.

Date: May 31st

Location: Hofstra University, Uniondale, NY

Check in: 9:30 am

Walk starts at: 10:30 am

Feel free to share this Newsletter with any of your friends, loved ones or colleagues who you think might be interested in this information.

********************************************

Raising Kidney Disease Awareness on Long Island

Studies show that Kidney disease is on the rise.

Let's take a look at the recent statistics.

· Over 26 million of Americans, including children, suffer from Kidney Disorder.

· 1 in 9 Americans will eventually develop Kidney Disease in their lifetime.

· More than 340,000 of Americans are on dialysis.

· Nearly 75,000 are on the waiting list for a kidney transplant.

· More than 7,000 of our fellow Long Islanders are undergoing dialysis treatment.

To bring attention to these discouraging facts, The National Kidney Foundation has organized Kidney Walk 2009 that will take place at 10:30 am on Sunday,

May 31st at Hofstra University in Hempstead.

The goal of this occasion is to raise funds for Kidney patients and their loved ones and improve the well-being of individuals who have been affected by this condition.

Let's join efforts and make a difference in the lives of many people.

For more information, you may visit http://walk.kidney.org/site/PageServer

A Few Main Reasons to Participate in Kidney Walk 2009:

· It's an opportunity to raise awareness of Kidney disease and educate people about the significance of early detection.

· As a practicing physician I know that it is difficult to detect the symptoms of a Kidney disease. Unfortunately, they may not appear until Kidney failure occurs. We want every individual to be aware of that.

· Many individuals do not take all the necessary steps to protect their health. So, on May 31^st hundreds of participants will call attention to the prevention of Kidney disorder and the need for organ donation. You can become one of them!

· More than eighty percent of every dollar raised for the NFK will go to support many vital programs and services for Kidney patients and their families, as well as professional training and research.

Now you can become a part of this inspiring and life-saving event.

Just click on http://walk.kidney.org/site/PageServer

We look forward to seeing you!

To schedule an appointment for a Kidney check-up, please call now (516) 365- 5570 or email: info@northshorenephrology.com

Sodium Bicarbonate Looking Good for CIN prevention

A meta-analysis of 17 randomised controlled trials has shown that pre-procedural treatment with sodium bicarbonate based hydration is the optimal treatment strategy to prevent contrast-induced nephropathy (CIN). The research, published in the open access journal BMC Medicine, shows that although the benefit may have been overestimated by previous studies, sodium bicarbonate is clearly superior to normal saline.

Hitinder Gurm from the University of Michigan worked with a team of international researchers to study the results of trials featuring a total of 2633 people to assess the effectiveness of saline versus sodium bicarbonate for the prevention of CIN. According to Gurm, "Contrast agents are administered in millions of procedures annually worldwide. In the USA and Europe, contrast-induced nephropathy (CIN) is the third leading cause of acute renal failure in hospitalized patients, accounting for about 10% of hospital-acquired renal failure. Although CIN is generally limited to a transient decline of renal function, it cannot be regarded as a benign complication – as many as 30% of cases result in lasting kidney damage".

The authors found that CIN occurred in 109 of the 1327 patients treated with sodium bicarbonate and in 175 of the 1306 patients who received normal saline. The number needed to prevent one case of CIN was 16. The exact mechanism of CIN is still unknown, but sodium bicarbonate is thought to prevent it by increasing the alkalinity of tubular fluid and thereby limiting free radical production. Gurm said, "Six studies monitored the degree of alkalinization and all but one found a significant increase. Interestingly this one study did not find a benefit of sodium bicarbonate. Therefore, it could be hypothesized that the bicarbonate should be dosed to achieve urinary alkalinization".

My take: For now, my regimen will remain Mucomyst (NAC) and IVF with D5W + 150 mEq NaHCO3/L pericath. The NAC is more or less standard at 600mg BID at least in the hospitals I work in... but, there are positive studies in using 1200mg po BID as well.. as well as IV NAC which is not currently available. In regards to the rate of the IVF, that is a more difficult question. Unfortunately the patients we see who are at highest risk for CIN, have more comorbidites, may be older with compromised CV status and there is no one-size-fits-all IVF rate.

Of course, not mentioned in the piece is the inteventionalist's role. The choice of contrast dye and the amount play a big role. All the NAC and sodium bicarbonate in the world are unlikely to help much in a 80 yo WF with CHF, DM, proteinuria (>1g/d) and an eGFR 30ml/min who gets 300+ cc dye for a diagnostic procedure and then another 150+cc for an intervention.

Nocturnal Dialysis

Dialysis takes hours of kidney disease patients' time several days a week, so why not do it at night while sleeping?

Overnight dialysis is more convenient for some patients and offers significant benefits over shorter daytime treatments, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN). The findings indicate that overnight dialysis is a viable alternative for patients in dialysis clinics where there are constraints on time and resources.

Dialysis removes waste products from the blood, usually in three to four hours of treatments three days a week. Unfortunately, even this difficult schedule may not be frequent enough to maintain many patients' health. Some clinics offer an alternative: three weekly overnight dialysis sessions lasting six hours or more.

To test the effectiveness of this alternative schedule, Dr. Joanna Ruth Powell (Western Infirmary, United Kingdom) and her colleagues compared the health of patients who received long overnight dialysis sessions with those who received conventional dialysis during the day. During 10 years of study, 146 patients in their clinic chose long overnight dialysis (approximately 11% of their dialysis patients). Patients ranged vastly in age with 30 over the age of 70 years. The overnight therapy was well tolerated with only a third of patients converting back to conventional dialysis after an average of approximately two years, mostly for preferential rather than medical reasons.

The investigators studied various health parameters of 106 of their patients, with equal numbers receiving overnight dialysis and conventional dialysis (for at least one year). The patients who underwent overnight dialysis had lower rates of anemia and reduced levels of urea in their blood.

Previous studies have found that overnight dialysis also reduces patients' blood pressure, blood phosphate levels, and risk of premature death compared with conventional dialysis. This study did not observe these benefits, however.

The researchers concluded that long overnight dialysis is a practical way for clinics to offer longer dialysis sessions that are well tolerated by most patients with kidney disease.

Dipyridamole and ASA for AV Graft Patency?

Arteriovenous graft stenosis leading to thrombosis is a major cause of complications in patients undergoing hemodialysis. Procedural interventions may restore patency but are costly. Although there is no proven pharmacologic therapy, dipyridamole may be promising because of its known vascular antiproliferative activity. A study done in this weeks New England Journal of Medicine addresses this issue.

The study conducted was randomized, double-blind, placebo-controlled trial of extended-release dipyridamole, at a dose of 200 mg, and aspirin, at a dose of 25 mg, given twice daily after the placement of a new arteriovenous graft until the primary outcome, loss of primary unassisted patency (i.e., patency without thrombosis or requirement for intervention), was reached.

Treatment with dipyridamole plus aspirin had a significant but modest effect in reducing the risk of stenosis and improving the duration of primary unassisted patency of newly created grafts.

An Unforgettable Transplant

The Associate Press is reporting, Natalie Cole now has a new kidney.

Representatives for the 59-year-old singer say she underwent a successful kidney transplant. Cole will postpone her summer tour as she recovers.

The daughter of the late Nat King Cole has been on dialysis since September. She still continued her concert tour in support of her latest album, "Still Unforgettable."

The Grammy-winner announced she was diagnosed with hepatitis C in February 2008. Her kidneys failed after treatment and she had since been seeking a donor.

Hopefully she will continue to use her influence and this experience to bring further awareness to CKD.

Have a Coke... and some Hypokalemia?

Cola-based soft drinks are possibly the refreshments with the largest sales worldwide. In addition to the possible detrimental effects of moderate, chronic cola consumption, it has been proposed that the consumption of large amounts of these cola-based drinks may result in severe hypokalaemia.

A review in the International Journal of Clinical Practice discusses the clinical significance of these disturbances and summarizes the pathophysiological mechanism that may underlie the development of this rare, but potentially severe, side effect.

They conclude that several lines of evidence suggest that the chronic consumption of large amounts of cola soft drinks may adversely affect potassium homeostasis and result in potentially severe conditions such as hypokalaemic myopathy.

This study presents some alarming case studies of cola-induced hypokalaemia brought on by chronic consumption of up to 10 liters per day of sugar-sweetened cola. I am not surprised that 10 liters intake of nearly anything could have adverse effects. If someone is drinking 10 liters of cola drinks a day, I suspect there may have other problems as well. I am not sure this translates into 'normal' even moderate cola drinking of a liter or two a day (which I would consider large). If so, I suspect it may not be clinically significant and would take these ridiculous outliers to yield more substantial results. Hence, I wouldn't advise no more colas based upon the fear of hypokalemia. Nevertheless, it is a nice tid bit to keep in your back pocket in the differential diagnosis of hypokalemia for the future.

30 ROCK - Give a Kidney Song

I couldn't resist...

EuReGene: The European Renal Genome Project

A new project is underway, the European Renal Genome Project. Their goal is a noble one, it is to discover genes responsible for renal development and disease, their proteins and their actions.

To achieve this goal, the website states, "we have established a consortium of leading scientists, clinicians and SME partners that will focus on the development of novel technologies and discovery tools in functional genomics and their application to kidney research".

"Ultimately, identification of disease genes will lead to a better understanding of renal disease processes, to improved diagnosis and to new concepts in therapy".

The best feature of the site to me, is the online renal atlas. The online "Kidney Atlas Data Portal" is pretty cool.

Here are the main components of the atlas:

EuReGene's primary Gene Expression Database

Xenopus Gene Expression Database (XGEbase)

Kidney Section Viewer and Query Database

Adult Nephron Graphical Query Database

Whole Mount 3D Models of Highlighted Kidney Structures

Video of Kidney Development Morphology

Phenotype data

Check it out

Are all ARBs Similar? Is it Just a Class-Effect?

There is new study coming out of Italy that reports, Telmisartan plus amlodipine is superior to losartan plus amlodipine in reducing microalbuminuria in hypertensive patients with type 2 diabetes.

240 well controlled diabetics (HbA1 <7.0) with hypertension and microalbuminuria (urinary albumin excretion rate [UAER] greater than 30 and less than 300 mg/24 hours were studied.

Roberto Fogari, MD, and his colleagues randomized subjects to receive telmisartan 80 mg/amlodipine 2.5 mg (T/A) or losartan 50 mg/amlodipine 2.5 mg (L/A) daily for 52 weeks. At four weeks, doses were titrated upward for patients who did not respond. After 16 weeks, non-responders were given transdermic clonidine (0.1 md/day). At 20 weeks, patients whose microalbuminuria was not controlled were dropped from the study.

The reduction in UAER was significantly greater in the T/A recipients than in the L/A group (54.9% vs. 38.5%), despite similar decreases in BP.

I prefer Micardis (Telmisartan) to Cozaar (Losartan) and so I am not terribly suprised. But, I believe there is a flaw in using 80 mg of Micardis (the highest available dose) and only 50 mg of Cozaar. I would have preferred to see he comparison made with 100 mg of Cozaar. It is also a small study, done in Italy with diabetics who are under great control. Does this translate into American diabetics? What about the majority of diabetics...those who do not have such stellar diabetic control. What about patients who spill more proteinuria? Although, I believe there are subtle differences between the ARBs, this study is hardly conclusive.

Is Hypertension Caused by a Common Virus?

A new study suggests for the first time that cytomegalovirus (CMV), a common viral infection affecting between 60 and 99 percent of adults worldwide, is a cause of high blood pressure.

Led by researchers at Beth Israel Deaconess Medical Center (BIDMC) and published in the May 15, 2009 issue of PLoS Pathogens, the findings further demonstrate that, when coupled with other risk factors for heart disease, the virus can lead to the development of atherosclerosis, or hardening of the arteries.

"CMV infects humans all over the world," explains co-senior author Clyde Crumpacker, MD, an investigator in the Division of Infectious Diseases at BIDMC and Professor of Medicine at Harvard Medical School. "This new discovery may eventually provide doctors with a whole new approach to treating hypertension, with anti-viral therapies or vaccines becoming part of the prescription."

This study was funded by grants from the National Heart, Lung and Blood Institute of the National Institutes of Health.

Kidney Stone Article for Long Island Press

I wrote this article which was just published online by the Long Island Press....

It was a typical day for John, a 33-year-old firefighter. He is strong, healthy and physically active. When John experienced sudden pain in his right lower back region, he thought he just pulled a muscle and completely ignored it.

However, the pain continued throughout the evening. As time passed, it was becoming more intense and eventually radiated to his groin. Not knowing how to handle the situation, John decided to take Tylenol without even mentioning it to his wife, and tried to go to sleep. An hour later John was in the emergency room with excruciating, unbearable pain. There was an intravenous line attached to his hand, and he was receiving fluids and narcotic pain medications to treat his kidney stone.

This is not an uncommon scenario and nearly everyone has predisposition towards this disorder. What people should keep in mind is that kidney stones can develop surprisingly easily and have a very high prevalence in our society. Nearly 10 percent of adults will develop at least one stone by the age of 70. As summer approaches and the temperature rises, so does the risk for kidney stone disease.

So, how could John have avoided the emergency room, along with the pain and suffering that come with a kidney stone?

When it comes to kidney stone prevention, there are three most important things people should do, regardless of their age: stay well hydrated, stay well hydrated and stay well hydrated.

The best and most effective way to prevent kidney stones is to minimize the risk factors. There are several risk factors every individual should be aware of. The most essential one is low fluid intake which leads to low urinary volume. Other causes include a personal or family history of kidney stones, certain dietary factors, chronic urinary tract infections and some other specific medical conditions.

So, you are probably wondering how much fluid you should drink? Was your mother right about eight cups of water a day? The answer is two-fold. It depends on the size of the cup, as well as your individual hydration status and needs. The general goal for people who are at risk for stone formation is to drink enough fluid to produce at least two liters of urine a day. This may require drinking at least 2 to 2.5 L daily.

A good rule of thumb is to drink until your urine appears clear. If it is too dark, you might need to increase your fluid intake. Water is usually your best bet. But according to some studies, lemonade and certain diet sodas (Sunkist Diet Orange and Diet 7 Up) may have additional benefits. Alcoholic and caffeinated beverages, as well as colas are to be discouraged.

Once a patient has passed a stone, there is a strong possibility that another stone will be passed in his or her lifetime. Since kidney stones may be hereditary, the risk factors can be passed on to the next generation. Preventive measures should be life-long, especially after the first stone episode. Careful risk assessment and monitoring with your physician is highly-recommended. Needless to say, you don’t want to end up in the emergency room like John.

Twitter

If you are on TWITTER, feel free to follow me @simonprince

Twitter is where you can find me for a quick question and more.

Birth Weight Link to Blood Pressure Grows Throughout Life

More from the ASH (American Society of Hypertension)...

A study presented at the ASH enforces the strong association between systolic BP and birth weight.

The study was presented as an abstract and given orally. We will await further details and eventual publication in a peer reviewed journal. It is however, not a unique finding. It is just more evidence that babies of low birth weight ( LBW, defined as a baby weighing less than 2.5 kg (5.5 lbs)) have an increasing risk for HTN as they grow older. The association was stronger in LBW boys than in girls (P=0.004), and in whites compared with blacks (P=0.02). There are some theoretical explanations but, the reason still are uncertain.

ASH: Almost Any Choice Good for Initial Antihypertensive, Except ARBs?

ASH: Lower BP Is Not Always Best (AKA Return of the J-Curve)

Which Group of Chronic Disease Patients Takes the Most Pills?

Congrats dialyzors! This should come to absolutely no ones surprise. Especially for our CKD 5'ers out there... but patient on dialysis have the dubious distinction of being the group with the highest pill burden.

A study to be released in the Clinical Journal of the American Society of Nephrology and sponsored by Shire (manufacturer of Fosrenol), reveals the average dialysis takes 19 pills per day. Again.... 19 pills per day. This obviously does not take into account the IV medications given at dialysis (epogen, iron, vitamin D analogues). About a quarter of the 233 chronic dialysis patients in the study took at least 25 pills!

A big percentage of the pills is likely to be the phosphorous binders (Renagel/Renvela, PhosLo), so it is fitting Shire would point this out in their study... but, nonetheless it is what it is, and I do not doubt the numbers here.

A New Equation to Estimate GFR... Better than MDRD?

A more accurate equation to estimate GFR may have just been unveiled. The Annals of Internal Medicine is reporting details of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.

In the validation data set, the CKD-EPI equation performed better than the Modification of Diet in Renal Disease Study equation, especially at higher GFR (P < 0.001 for all subsequent comparisons), with less bias, improved precision and greater accuracy.

Although the sample contained a limited amount of elderly people, racial and ethnic minorities... authors concluded the CKD-EPI equation to be more accurate than the MDRD equation and feel that it could (should) replace it for clinical use.

Now, we need new apps for our BlackBerrys and iPhones!

Fresenius Medical Care Launches National Retail Pharmacy for Dialysis Patients

Fresenius Medical Care North America, operator of the nation’s leading network of dialysis facilities, today announced the launch of its new national retail pharmacy, Fresenius Medical Care Rx. The pharmacy can provide dialysis patients with all of their prescriptions, over-the-counter medications and diabetic testing supplies directly through the mail at no additional cost.

Fresenius Medical Care Rx gives patients the convenience of ordering medications and supplies from a single source and provides access to a pharmacist with specialized training and expertise in the pharmaceutical requirements of patients living with kidney disease, 24 hours a day, seven days a week.

The pharmacy is based in Nashville, Tenn., in a 12,000-square-foot facility, which has a call center and professional pharmacy staff. Services will include monthly reminders for refills, direct billing to insurance companies, and physician-assistance programs that include reports to monitor adherence.

This Just in, Napoleon is Still Dead. But, Did He Die of Kidney Failure?

A new book released two days ago in Denmark, casts doubt on the widely held belief that Napoleon died of poisoning (slowly, and by arsenic).

In the book, “Napoleon’s Nyrer (Napoleon’s Kidneys),” retired Danish nephrologist Arne W. S. Sorensen studied numerous sources—such as Napoleon’s diary, autopsy reports and family statements—and argues that Napoleon suffered from kidney disease most of his life.

"From a young age, Napoleon suffered chronic shrinking around his urinary canal, chronic infections in his withered bladder, a kidney illness and obstructive nephropathy that led to deadly complications,"Sorensen told Agence France-Presse. "He had pain urinating for a long time, to the point that one day he said: 'it will kill me.'"

An English version of this new book is in the works.

Do Primary Care Doctors Do Just as Well in Treating Hypertension?

Well the answer according to a recent article in the BMC Family Practice Journal is, no.

This study was undertaken by means of a survey. The survey was pertaining to physician opinion regarding the treatment of hypertension. Items consisted of questions regarding: 1) knowledge of hypertension treatment guidelines; 2) barriers to hypertension control (physician vs. patient); and 3) self-estimation of physician treatment of hypertension.

This was admittedly a small survey of 28 family practitioners and internists. Most thought the biggest barrier to effective BP control was non-compliance (contradictory to reported practice behavior). Half the physicians failed to recommend more intensive treatment with lower BP goals in patients with diabetes and CKD.

The article concludes by stating, "(this) data provides crucial formative data to enhance the content validity of physician education efforts currently underway to improve the treatment of blood pressure in the primary care setting."

Is there a link between elevated Uric Acid and Mortality in CKD patients?

Hyperuricemia has been a controversial subject for quite some time. Elevated serum uric acid levels are sometimes difficult to make heads or tails of. Sure, if the person has a history of gout or uric acid nephrolithiasis, it is pretty easy. We treat to keep uric acid down (usually to levels less than 6.5 with a combination of diet / medication (allopurinol or the newer CKD-friendly Uloric)). Uric acid is also used as a 'soft' indicator of hydration status. Uric acid is mainly reabsorbed at the level of the proximal tubule and in the setting of decreased renal perfusion, more uric acid is absorbed proximally leading to serum uric acid levels that are relatively elevated.

But, what if there is no gout or uric acid stone disease? What should you do with isolated hyperuricemia? Is there anything to worry about?

The American Journal of Kidney Disease (AJKD) reports this month on the long term outcomes of CKD patients with elevated serum uric acid levels. The report uses data from the MDRD study and included 838 patients with Stage 3 and 4 CKD. The conclusion: hyperuricemia appears to be an independent risk factor for all-cause and CVD mortality, but not kidney failure.

Is this just an association, or a stronger link? Should we be treating patients with hyperurecmia more aggressively? Should we be targeting lower uric acid levels? Will treating hyperuricemia with medications such as allopurinol or Uloric help to decrease this trend? More research will be needed, but it certainly is an interesting association. For now I will be continuing to obtain uric acid levels routinely (they have been taken out of most traditional metabolic panels and require a separate order).

Does race effect bacteremia rates in dialysis patients?

A new study being presented in Renal and Urology News reports Hispanic dialysis patients suffer from a higher incidence of catheter related bacteremia compared with African Americans.

Although this was a small study, the rate of catheter related bacteremia per 1,000 catheter-days, was 1.57 for Hispanics vs. 0.2 for African Americans. The mean catheter duration was similar albeit slightly less in the Hispanic patients: 158.8 days compared with 171.7 days in the African American dialysis patient group.

The researchers, who reported their findings here at the National Kidney Foundation 2009 Spring Clinical Meetings, stated that the higher rate of catheter-related bacteremia in Hispanics is likely due to their higher incidence of risk factors and comorbidities such as diabetes.

Does CKD increase the risk of Lung and other Cancers?

We have know for quite sometime that people with ESRD/ CKD 5 have increased risk of certain malignancies. But, when does that risk start? Earlier than Stage 5? An abstract available online by the Journal of the American Society of Nephrology represents a study that will be out in print soon which addresses this question.

The aim of this study was to determine whether moderate CKD increases the risk for cancer among older people. They linked the Blue Mountains Eye Study, a prospective population-based cohort study of 3,654 residents aged 49 to 97 yr, and the New South Wales Cancer Registry. During a mean follow-up of 10.1 years.

711 (19.5%) cancers occurred in these 3,654 residents. Men, but not women with at least stage 3 CKD had a significantly increased risk for cancer. For men, the increase risk began with an estimated GFR of 55 ml/min (stage 3 CKD).

The researchers discovered that men with moderate kidney dysfunction had a 39-percent increased risk of developing cancer over the risk seen in men with normal kidney function. Risk increased as kidney function declined, and men with significant kidney dysfunction had a threefold increased risk above normal. The risk for lung and urinary tract cancers, but not prostate cancer, was higher among men with kidney disease.

Interesting observational study from the other side of the world... Is it applicable here? What to do with this information? Change in screening recommendations? Who knows... but something to think about.

FDA Approves a Polypill... but wait, not that one

This is exciting for me. As a specialist in clinical hypertension, I see tons of people with high blood pressure on a daily basis. The field of hypertension continues to move to multiple medications with different mechanisms to be used together to get the blood pressure to goal. Previously, the approach was more of starting one class of anti-hypertensive, titrate up to the maximum dose and then add on another medication if we can not get to our BP goals.

Today, we are starting off with low dose combination therapy from the get-go. Personally, I am a big fan of all the ARB-HCTZ and ARB-CCB combos (sorry to all my drug reps, I am not going to be more specific).

The Polypill has been discussed previously and has received a lot of attention from the media. It is a pill composed of an ACE inhibitor, beta-blocker, thiazide diuretic, statin and aspirin. This may have great impact worldwide. While we await approval in the USA... the FDA did approve a 'mini-Polypill'.

This is for hypertension and is the first pill to contain 3-drugs in one. This anti-hypertensive Polypill is EXFORGE HCT. Exforge is a combination ARB-CCB (Diovan and Norvasc) and now hydrochlorothiazide will be introduced. As with other combination pills, the titration is alittle more tricky... now with three medication in one pill, it will be even more so. But, many patients are already on these medications separately and decreasing pill burden has clearly been shown to improve compliance. I am very much in favor of Exforge HCT and look forward to using it in my patients.

Doses will range from 5 mg amlodipine (Norvasc) / 160 mg valsartan (Diovan) / 12.5 mg hydrochlorothiazide (HCTZ) to a maximum of 10/320/25.

Maybe not so suprisingly I have not heard of Lotrel HCT. Lotrel is a combination of ACE-inhibitor, Lotensin (benazepril) and CCB, amlodipine. I still use Lotrel often as well. The benefit of Lotrel is that the ACE-inihibitor component is now generic. Lotrel HCT could be a similiar triple drug combo with the ACE-inhibitor instead of the ARB used in Exforge HCT.

The cold harsh reality is that pharmaceutical companies do not have an incentive to make and market a cheap, generic Lotrel HCT.

Urine Screening to Detect Coronary Artery Disease?

The interventional Cardiologists are just gonna love this! Who needs an invasive angiogram? Or even stress tests, ultra expensive CT scans, MRIs... when you can do a simple urine test.

That is exactly what is being proposed. Proteome analysis, a screening requiring only a patient's urine specimen, shows promise as a reliable and noninvasive way to diagnose atherosclerosis and coronary artery disease in the future, according to research presented at the American Heart Association's Arteriosclerosis, Thrombosis and Vascular Biology Annual Conference 2009.

Proteome analysis shows protein patterns in body fluids, such as blood or urine. Using two techniques to analyze specimens (mass spectrometry and capillary electrophoresis), scientists can simultaneously characterize thousands of proteins in one examination.

Constantin von zur Muehlen, M.D., the study's lead author and cardiologist at the University Hospital Freiburg, Department of Cardiology in Freiburg, Germany explains that certain protein fragments can only be found in coronary artery disease patients, and this patient group established the proteome pattern. The 17 protein fragments that the researchers identified as being associated with atherosclerotic disease were collagen fragments, known to be present on the surface of atherosclerotic plaques.

The researchers then applied the proteome pattern in another group of patients with atherosclerotic disease of the coronary arteries. The investigators compared the results of the urine proteome screenings from 67 patients presenting with symptoms of coronary artery disease to patients' results from coronary angiography, the current gold standard used to rule out or confirm coronary artery disease.

"The accuracy of the urine proteome pattern to identify coronary artery disease was 84 percent," Muehlen said.

Larger studies will be needed to confirm the findings of this study before proteome analysis can be used as a reliable screening method in patients, Muehlen said. "However, our data suggest that proteome analysis shows great promise. It is easy to use, shows a high reproducibility and does not hurt."

Hydroxycut is CUT by the FDA

You have all seen the advertisements. What you haven't see I guess is the same guy on the right in the 'after picture' later in the hospital with a CPK of 50,000 with a rip-roaring rhabdomyolysis.

The FDA has placed an official warning to consumers asking that they immediately stop using Hydroxycut products by Lovate Health Sciences Inc. of Oakville, Ontario and distributed by Lovate Health Sciences USA of Blasdell, NY.

The FDA has received 23 reports of serious health problems ranging from jaundice and elevated liver enzymes, an indicator of potential liver injury, to liver damage requiring liver transplants. One death due to liver failure has been reported to FDA. Other health problems reported include seizures; cardiovascular disorders; and rhabdomyolysis, a type of muscle damage that can lead to other serious health problems such as kidney failure.

Unfortunately, this news is not shocking. Furthermore, Hydroxycut is unlikely to be alone with this side effect profile. It is more than likely that similar products have the potential for such problems. When products promise results that are too good to me true, watch out.

So don't forget to include Hydroxycut (or similar products) in your differential of rhabdomyolysis as your hanging your fifteenth bag of IVF (with or without sodium bicarbonate which remains controversial and I feel patient / case specific). This is also a good example of how medical professionals must remember to ask about over the counter medications, herbs and supplements while taking a complete history.