Eating Chocolate Daily Can Lower CV risk by 39%

I know it is hard to fathom, but only "one small square" of chocolate (preferably dark chocolate) a day is all it takes. That's what a study published online from the European Heart Journal is telling us...

Researchers in Germany followed 19,357 people, aged between 35 and 65, for at least ten years and found that those who ate the most amount of chocolate -- an average of 7.5 grams a day -- had lower blood pressure and a 39% lower risk of having a heart attack or stroke compared to those who ate the least amount of chocolate -- an average of 1.7 grams a day. The difference between the two groups amounts to six grams of chocolate: the equivalent of less than one small square of a 100g bar.

Tough to swallow? I think not, and... it is not even an April Fool's Day joke.

Happy Doctor's Day

Who knew?! Today apparently is DOCTOR'S DAY.

From www.doctorsday.org ...


History of National Doctors' Day

National Doctors' Day is held every year on March 30th in the United States. It is a day to celebrate the contribution of physicians who serve our country by caring for its' citizens.

The first Doctor's Day observance was March 30, 1933 in Winder, Georgia.  Eudora Brown Almond, wife of Dr. Charles B. Almond, decided to set aside a day to honor physicians. This first observance included the mailing greeting cards and placing flowers on graves of deceased doctors. The red carnation is commonly used as the symbolic flower for National Doctor's Day.

On March 30, 1958, a Resolution Commemorating Doctors' Day was adopted by the United States House of Representatives. In 1990, legislation was introduced in the House and Senate to establish a national Doctor's Day. Following overwhelming approval by the United States Senate and the House of Representatives, on October 30, 1990, President George Bush signed S.J. RES. #366 (which became Public Law 101-473) designating March 30th as "National Doctor's Day."

So happy Doctor's Day to all my physician colleagues out there.

Nephrolithotomy Beats Lithotripsy for Asymptomatic Kidney Stones

When asymptomatic lower pole renal calculi require intervention, percutaneous nephrolithotomy provides a higher stone-free rate than shock wave lithotripsy, and with less scarring, Turkish researchers report.


In the April Journal of Urology, they note that asymptomatic caliceal stones require intervention within five years in more than half of cases.

To compare treatments and expectant management, Dr. Ahmet Tefekli from Haseki Teaching and Research Hospital in Istanbul and colleagues randomized 94 patients to receive nephrolithotomy, lithotripsy, or observation.

They evaluated patients' stone status with non-contrast abdominal computed tomography, and they monitored for renal scarring with dimercapto-succinic acid scintigraphy. All 31 subjects in the nephrolithotomy group were stone free at 12 months. One patient (3.2%) had scarring at 3 months. With lithotripsy, however, only 19 of 31 patients (61.3%) were stone free at 12 months, and five patients (16.1%) had renal scarring. Over an average of 20 months, 7 (18.7%) of 32 patients in the observation group required intervention, and one (3.1%) spontaneously passed the stone. No patient in the observation group had renal scarring.

"Patients with asymptomatic lower caliceal stones must be informed in detail about all management options, especially focusing on percutaneous nephrolithotomy with its outstanding outcome," the authors conclude.
They add that these results "must be further evaluated by comparison with new digital flexible ureterorenoscopy devices."

This is a small study from Turkey with limitation but it is worthy of consideration.

World Kidney Day: ASN

Nobel Prize Winning Inventor of Beta-Blockers Dies

BBC NEWS: Sir James was considered one of the great Scottish scientists of the 20th Century and is credited with having invented beta-blocker drugs in 1962.

He was born in Uddingston, Lanarkshire, grew up in Fife, and studied medicine at St Andrews University.

In 1988 he won the Nobel Prize for medicine and was given the UK's highest honour, the Order of Merit, in 2000.

Sir James died on Monday morning after a long illness.

Beta-blockers now play an essential role in the treatment of angina and heart attacks.

The Scottish scientist also went on to invent the first effective non-surgical treatment for stomach ulcers.

Medals and awards charting his career went on display at the National Museums of Scotland in Edinburgh last year.

From 1992 and to 2006, Sir James was Chancellor of the University of Dundee, where his undergraduate medical studies took place while the college was part of St Andrews University.

The Sir James Black Centre is now home to the University of Dundee's School of Life Sciences.

Kidney Walk 2010 Long Island

Support Our Team in the Kidney Walk!

Thank you for helping me reach my fundraising goal! This is an exciting opportunity for us to work together to help people understand the need for early detection of kidney disease. In addition to raising funds for research and help for patients and their families, the Kidney Walk is a great way to bring the community together!

We will be at Hofstra University for the Long Island Kidney Walk Sunday May 23, 2010. You should consider walking with us too! With your help, we will be able to make a difference in chronic kidney disease! 

National Kidney Foundation

Statins and CKD... Is There Be a Benefit?

In JUPITER (Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin), more than 18,000 participants with low levels of LDL cholesterol but with elevated levels of C-reactive protein, a marker of inflammation, were treated with either rosuvastatin (Crestor) 20 mg or a placebo.

In a subset analysis, Paul Ridker, MD, of Harvard and Brigham and Women's Hospital in Boston, and colleagues identified 3,267 patients with chronic kidney disease (GFR < 60 ml/min).

When they analyzed outcomes of the CKD patients who were taking rosuvastatin, they found reductions of:

• 45% in the risk of experiencing one of the primary endpoints in the study -- MI, stroke, hospitalization for unstable angina, the need for arterial revascularization, or confirmed cardiovascular death (P=0.002)
• 44% in all-case mortality (P=0.005)

The researchers suggested that results of the subset analysis "support guidelines from the American Heart Association and the National Kidney Foundation to provide more aggressive cardiovascular prevention efforts among those with reduced renal function."

The data has been disappointing and inconsistent for statin use in advanced CKD patients thus far. Due to the robust data in the cardiovascular literature I believe most nephrologists have a low threshold to support the use of statin based therapy as long as there is no convincing negative data. This analysis of JUPITER is certainly welcomed by the nephrology community.

RPA's Statement on ESA Use in CKD

RPA Guidance on Use of ESAs in CKD

Creation/Revision Date: March 08, 2010

Background

In January 2010, an RPA workgroup was convened to offer guidance to RPA membership on the use of erythropoiesis-stimulating agents (ESAs) in chronic kidney disease (CKD) in the wake of studies outlining concerns regarding the safety and utility of ESA use for CKD and ESRD. It also assessed the issue of target Hb for CKD patients in light of recent trials, especially the TREAT trial, and assessed whether the results of that and other CKD trials can be extrapolated to ESRD patients.

ESA-treatment studies in nondialysis CKD have resulted in a solid body of evidence that is helpful for guiding patient care. However, like all studies of heterogeneous populations, the conclusions drawn do not necessary reflect the advantages and disadvantages of ESA use to any particular individual. Practitioners should rely on guidelines as a general basis for treatment, but care decisions should be individualized for the characteristics of the specific patient. As such, RPA offers the following recommendations for approaching the patient with CKD/ESRD and anemia:

Recommendations

1. ESA treatment in nondialysis CKD patients to a target Hb>13 gm/dl has been found to increase cardiovascular and other risks, without   consistent signs of benefit.
   
   
2. ESA treatment in nondialysis CKD to target Hgb 10-13 gm/dl has not been adequately tested. Since this limits the ability of clinicians to balance risk against benefit, RPA feels that no clear treatment recommendations can be made in this range. Practitioners should consider their patient's clinical characteristics, and include the patient in consideration of potential benefits and risks of ESA treatment in this range.  We do note a just-published systematic literature review of prospective studies examining energy and physical function in CKD patients with anemia in this range, showing that treatment of anemia with ESAs improves both of these measures.
   
   
3. ESA use for nondialysis CKD patients with Hb<10 gm/dl reduces the need for transfusions and may improve patient reported outcomes. Particularly for patients who are candidates for kidney transplantation, avoidance of blood transfusions may reduce presensitization and improve the likelihood of finding a good donor-recipient match.
   
    
4.  While there are no good, modern era studies of CKD patients with profound anemia, older, less rigorous studies show impairment in physical functioning and quality of life when ESRD patients have profound anemia. Since it is unlikely that rigorous studies of CKD/ESRD patients with profound anemia will be performed, we suggest that nephrologists consider treatment for patients with symptomatic anemia with these steps:
   
   
   a.  Evaluate patients with anemia to exclude and treat causes of anemia other than CKD.
   
   b.  Always measure iron status during anemia evaluation and replete iron when deficiency is diagnosed. ESAs should not be administered until the effect of iron repletion is assessed after 6-8 weeks.
   
   c. Consider the risks and benefits of blood transfusions and ESAs and treat anemia to achieve adequate Hb levels.
   
   d. Monitor carefully all patients treated for anemia, particularly to avoid high doses of ESAs to achieve a target  Hb. 
   
   
5. The CKD population has differences from the patients who have reached ESRD and are treated with hemodialysis. Hemodialysis patients often have more co-morbidities and are sicker than nondialysis CKD patients. Hemodialysis is associated with its own unique clinical     problems. The hemodialysis procedure itself causes chronic blood loss and may reduce the quality of life. Therefore, the benefits of ESAs are likely to be valued more in this population. Moreover, studies of ESA treatment in hemodialysis have been more consistent in indicating improved quality of life. Thus, RPA believes that hemodialysis represents a different clinical setting than nondialysis CKD, and that the current target hemoglobin range of 10.0 to 12.0 gm/dl represents a prudent range for these patients. Especially large doses of ESA should be avoided because of possible increased risk

        

Footnote

A recent study (JAMA 303:857) of mortality risk for hemodialysis patients with anemia using the USRDS data base gives us evidence that both the degree of anemia and the dose of ESA impact mortality. At low Hct (<30%) mortality was high compared with higher Hct, and dialysis centers using higher doses of ESA had lower mortality rates than centers using lower ESA doses. For patients with high Hct (>36%), mortality was the lowest, but higher doses of ESAs were associated with higher mortality rates. While this was not a prospective, randomized controlled trial, its method examining prescribing patterns in individual dialysis facilities, showing association between anemia management practice and mortality risk, is of interest.

Does Kayexalate Really Work?

Now this is an interesting development... surely Kayexalate, a classic remedy for hyperkalemia works, doesn't it? That's we have all been taught since medical school. It is used daily in hospitals throughout the country, it is called in emergently for patients with hyperkalemia, and given with a retention enema to be held in by the patient for at least 30 mins to achieve extra efficacy.

The science seemed sound and the FDA approved Kayexalate (Sodium polystyrene sulfonate or SPS), an ion-exchange resin designed to bind potassium in the colon, as a treatment for hyperkalemia in 1958. That was four years before pharmaceutical manufacturers were required to prove the effectiveness and safety of their drugs. When the more stringent FDA guidelines were put in place, SPS was grandfathered in as a treatment for hyperkalemia.

Products containing ion exchange resins have been used for nearly half a century to treat patients with hyperkalemia, but no previous studies have provided convincing evidence that the drugs work, Richard H. Sterns, MD, of Rochester General Hospital in Rochester, N.Y., and colleagues reported online in the Journal of the American Society of Nephrology. 

"We can find no convincing evidence that SPS increases fecal potassium losses in experimental animals or humans and no evidence that adding sorbitol to the resin increases its effectiveness as a treatment for hyperkalemia," Sterns and colleagues wrote. "There is growing concern, however, that suspensions of SPS in sorbitol can be harmful."

"If Kayexalate or SPS in sorbitol were presented to the FDA as new drugs with the data available today, it is doubtful that either would pass muster," the authors concluded.

"Clinicians must weigh uncontrolled studies showing benefit against uncontrolled studies showing harm. It would be wise to exhaust other alternatives for managing hyperkalemia before turning to these largely unproven and potentially harmful therapies."

Very interesting news indeed. I was never a huge fan of Kayexalate but have used my fair share of this suspension throughout the years. We all know when serum potassium levels are elevated there are 3 major ways to eliminate extra potassium: through the urinary tract, the gastrointestinal tract, or via dialysis.  It seems we should be more careful about trying to eliminate excess potassium through the GI tract as the method of choice by using SPS and should maintain a healthy skepticism going forward.

New Improved Hemodialysis Catheter

Yes, we all know 'Fistual First'... but, in the real world we also understand that catheters have their place and are often necessary. The patient who shows up at the ED with a creatinine of 12 and K of 7 doesnt have time for the creation and maturation of a native fistual. Accepting that catheters are necessary, any improvements on the catheters we use for our patients should be welcomed.

MedGadget  is reporting that r⁴ Vascular out of Maple Grove, Minnesota has released a new catheter for patients on long-term hemodialysis. The Duraspan catheter aims to prevent thrombus accumulation thanks to its biomimetic coating that discourages clot formation.

A novel coating on the catheter surface mimics the glycocalyx layer found on natural endothelial tissue surfaces in vessel walls. Laboratory tests of the Duraspan™ catheter have demonstrated an 87% reduction in platelet adhesion and thrombus accumulation compared to uncoated catheters. 

Happy World Kidney Day

Dallas Cowboy TE Supporting World Kidney Day

With his Truly Blessed Foundation, Martellus Bennett (tight end for the Dallas Cowboys) will support World Kidney Day tomorrow by supporting initiatives that raise awareness regarding diabetes and the role it plays in chronic kidney disease.

Bennett lost a loved one in 2009 to diabetes and a grandmother was recently diagnosed with the disease.

Bennett, along with his brother, Michael, who plays for Tampa Bay, and his father Michael Sr., is urging the public to take advantage of the free kidney health screenings that will take place at Dallas City Hall on Thursday.

"I am honored to stand with my sons in support of an initiative that potentially could mobilize hundreds, thousands or hundreds of thousands of people to become proactive - get the facts - and take charge of their kidney health and overall well-being. Many people afflicted with diabetes and/or kidney disease may have lacked the resources or the awareness to prevent the progression of their illnesses," Michael Bennett, Sr., President of Truly Blessed Foundation, said in a press release. "It is my solemn hope that through this effort that provides free health screenings to any member of the community willing to partake, that number will diminish tremendously. I'm hopeful."

Are We Overly Concerned About NSF in CKD Patients?

Over the past decade or so, the concern about nephrogenic systemic fibrosis (NSF) has blossomed. NSF is no doubt a devastating condition, but are we just a little too concerned about NSF? NSF has been reported in patients who have severe renal impairment and have been exposed to a gadolinium (Gd)-based contrast agent during magnetic resonance imaging (MRI). Accordingly, many patients with CKD who could benefit by this imaging modality have been turned away for fear of NSF.

A recent study in the Clinical Journal of the American Society of Nephrology has taken another look at the safety of Gd-MRI in patients with CKD and varying levels of estimated GFR (eGFR).

The study was retrospective analysis of 2053 unselected patients from the United Kingdom who had CKD and had received Gd-MRI between 1999 and 2009, so as to determine the risk for NSF related to level of CKD, nature of Gd preparation, and Gd dosage.

Results: Overall, 2053 patients (63.5% men; mean age 60.6 ± 15.7 years) had 2278 Gd-MRI scans; their mean eGFR was 40.7 ± 23.7 ml/min. A total of 918 (44.7%) patients had stage 3, 491 (23.9%) had stage 4, and 117 (5.7%) had predialysis stage 5 CKD. No cases of NSF were identified during an average follow-up period of 28.6 ± 18.2 months.

Conclusions: In this study, no patients developed NSF during extended follow-up, even after multiple Gd doses in some. Gd-MRI can be safely undertaken in the majority of patients with CKD, but caution is merited for dialysis patients and those with acute kidney injury, with relative caution for predialysis patients with stage 5 CKD.

This is one study from the UK with limitations. But, I tend to agree that perhaps we have gone from not recognizing this devastating affliction... to now becoming a little overly concerned about NSF. Perhaps we should consider softening restrictions to Gd-MRIs which in many centers are not being allowed in any patient with a CrCl < 30 ml/min due to the fear of NSF.

New NephSAP released: Hypertension

For those of you paying attention I will not reiterate my feelings for NephSAP. Well, maybe just a few words... while I think the content is great, I can't make it through the first 5 minutes of any of these podcasts. I have since given up trying. Although, I may attempt to use the podcast to help my teething baby boy get some sleep....

Nevertheless, for those for you interested... the new NephSAP is available: Volume 9, Number 2 - Hypertension .... enjoy!

ARB Use in Children for Proteinuria

So, how do we treat children with proteinuric renal disease? Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy? Maybe... but where is the data? Until now, no large, randomized, double-blind trials in children with proteinuria treated with ACE inhibitors or ARBs have previously been reported. Enter a new study published in the latest issue of the Clinical Journal of the American Society of Nephrology.

This study lasted 12-week, it was a double-blind, multinational study that investigated the effects of losartan 0.7 to 1.4 mg/kg per day compared with placebo (normotensive stratum) or amlodipine 0.1 to 0.2 mg/kg per day up to 5 mg/d (hypertensive stratum) on proteinuria (morning-void urinary protein-creatinine ratio, baseline ≥0.3 g/g) in 306 children up to 17 years of age. At twelve weeks of treatment with losartan significantly reduced proteinuria compared with amlodipine/placebo: losartan –35.8% (95% confidence interval: –27.6% to –43.1%) versus amlodipine/placebo 1.4% (95% confidence interval: –10.3% to 14.5%), P ≤ 0.001.  Adverse event incidence was low and comparable in all groups.

Conclusions: Losartan significantly lowered proteinuria and was well tolerated after 12 weeks in children aged 1 to 17 years with proteinuria with or without hypertension, a population that has not previously been rigorously studied.

Urinary Netrin: New Marker for AKI?

Despite all the new and novel ways we discover to diagnose acute kidney injury (AKI) early, nothing has been able to unseat the good 'ol serum creatinine measurement. Aside from the expense of newer markers, there is the laboratory or turn around time issue as well as the question of clinical relevence. Nevertheless, there is a new marker on the block, Netrin-1.

Netrin-1 is a laminin-related axon guidance molecule that is highly induced and excreted in the urine after AKI in animals. A new study in the Clinical Journal of the American Society of Nephrology set to determined the utility of urinary netrin-1 levels to predict AKI in humans undergoing cardiopulmonary bypass (CPB).

The results suggest that netrin-1 is an early, predictive biomarker of AKI after CPB and may allow for the reliable early diagnosis and prognosis of AKI after CPB, before the rise in serum creatinine. Whether this is clinically relevant or will be commercially available is unclear. It is uncertain how this information should materially change the typical post operative ATN patient course or what the health care provider could do differently by obtaining this information. Can they link the early finding of an elevated netrin levels in the urine and a change in the clinical course of a typical post-op ATN? Until then, I will stick to the good old fashioned serum creatinine.

Can Pycnogenol Counteract Kidney Damage and Improve Hypertension?

What is PYCNOGENOL?

A natural plant extract from the bark of the maritime pine tree which grows exclusively along the coast of southwest France in Les Landes de Gascogne. The extract has four basic properties – it’s a powerful antioxidant, acts as a natural anti-inflammatory, selectively binds to collagen and elastin, and finally, it aids in the production of endothelial nitric oxide which helps to dilate blood vessels.
 

Could it be helpful for kidney protection? 

Maybe... A study was recently published in the Journal of Cardiovascular Pharmacology and Therapeutics reveals some data that is starting to build the case for pycnogenol as a renoprotective agent.

The randomized, controlled study conducted by the G D’Annunzio University in Italy investigated 55 hypertensive patients who showed early signs of impaired kidney function, as judged by elevated amounts of proteins found in their urine. There were two groups, one group was given Ramipril, the other group was given Ramipril plus Pycnogenol. The group taking Pycnogenol as an adjunct to Ramipril had a decrease in proteinuria of nearly double compared with anti-hypertensive medication taken alone.

The study also found a statistically significant decrease in patients’ blood pressure when taking Pycnogenol in conjunction with Ramipril. When treated exclusively with Ramipril, systolic blood pressure values dropped by more than 30 percent and diastolic blood pressure values dropped approximately 8 percent. The addition of Pycnogenol decreased both systolic and diastolic pressures by an additional 3 percent to 6 percent. Pycnogenol also was found to lower the patients’ elevated levels of inflammatory marker CRP, a blood protein associated with the risk for acute cardiovascular events such as heart attack, reducing values to a healthy level.

This is obviously a very small study from Italy that needs to be replicated on a much bigger scale. The optimal dose, drug interactions and side effect profile of this supplement is also unclear. Nevertheless, it is worthy of consideration.

Kidney Foundation of Canada

The American Kidney Fund Video

athenahealth and Falcon Launch Integrated Web-Based EHR and Practice Management for Nephrology

DENVER—DaVita Inc. and athenahealth Inc. announced a partnership to deliver an integrated, Web-based electronic health record (EHR) and revenue cycle management service to nephrologists across the country.

"The seamless integration of Falcon EHR and athenaCollector offers a dynamic turnkey solution that enables nephrologists to focus their time, expense, and resources on the most important matters—delivering superior patient care and clinical outcomes," said Anthony Gabriel, Chief Information Officer of DaVita.

The athenaCollector service is a patented knowledge-base of payer reimbursement process rules known as athenaRules, which acts as a proactive utility that is continually updated based on the interactions and experiences of the more than 22,000 medical providers using the system.

When new claim denial trends are encountered, the rules are refreshed and the information is made available to all clients on the network. This enables the system to produce cleaner and more accurate claims with every instance of use.

Falcon EHR helps nephrology practices streamline the workflow of the entire office staff, prevent gaps in communication and response times, and support individual physician preferences for documentation.