Uremic Frost

RPA Public Policy in a Minute - January 2012

2012-01-17T11:21:00.001-08:00

Kidney disease deaths move up a notch in CDC ranking

2012-01-17T09:47:00.000-08:00

Based on state records, kidney disease was the eighth leading cause of death among Americans in 2010, moving up a notch from the year before, according to preliminary data released this week by the Centers for Disease Control and Prevention. Diabetes remained as the seventh leading cause of death.

According to the CDC, kidney disease was the cause of death for 50,003 people in 2010, or 16.2 people per 100,000 population. That is a 1.3% increase over 2009, the CDC said, and one of five leading causes of death that the agency labeled as having a 'significant' increase in 2010. The other causes were Alzheimer's disease (3.3%), chronic liver disease and cirrhosis (3.3%), Parkinson's disease (4.6%), and pneumonitis due to solids and liquids (4.1%). The agency defines kidney disease as nephritis, nephrotic syndrome, and nephrosis.

There were 68,905 deaths associated with diabetes melitus in 2010, a 1% decrease from 2009.

The preliminary number of deaths in the United States for 2010 was 2,465,936. Non-Hispanic black males saw the largest year-to-year decrease in death rates (a 1.9% drop), followed by black males (1.8% decrease), and black females and non-Hispanic black females (1.5% decrease). White males had the lowest year-to-year change (0.3% decrease) in death rates. Individuals 85 years and over experienced the only statistically significant increase in death rates (1.9% increase).

By state of residence, Hawaii had the lowest mortality in 2010 with an age-adjusted death rate of 589.6 deaths per 100,000 standard population. Mortality was highest in Mississippi, with an age-adjusted death rate of 961.9 per 100,000 standard population.

The 10 most common causes of death
1 Diseases of heart
2 Malignant neoplasms
3 Chronic lower respiratory diseases
4 Cerebrovascular diseases
5 Accidents (unintentional injuries)
6 Alzheimer’s disease
7 Diabetes mellitus
8 Nephritis, nephrotic syndrome and nephrosis
9 Influenza and pneumonia
10 Intentional self-harm (suicide)

Death rates for 2010 are based on population estimates consistent with the April 1, 2010 census. Preliminary data in the CDC report are based on records of deaths received from state vital statistics offices and processed by the CDC's National Center for Health Statistics.

Novartis halts late-stage Aliskiren trial due to lack of benefit, adverse events

2011-12-20T13:20:00.000-08:00

Novartis will terminate the late-stage ALTITUDE study investigating Rasilez (aliskiren) in patients with type 2 diabetes and renal impairment on the recommendation of an independent data monitoring committee. The company indicated that the committee concluded that "patients were unlikely to benefit" from the addition of Rasilez to standard anti-hypertensives and also identified higher adverse events in this group.

"The finding comes very unexpected," commented Vontobel analyst Andrew Weiss, who had forecast peak annual sales for Rasilez of as much as $2.9 billion, assuming that the drug would have additional benefits for key organs if taken over a long period of time. Weiss said he now plans to reduce his sales estimate for the product. Meanwhile, there were suggestions that Novartis could accelerate plans to reduce its US workforce, with Deutsche Bank predicting that the drugmaker may cut up to 1000 sales jobs as a direct result of the study failure.

The trial, which included 8,606 patients with type 2 diabetes and renal impairment, was designed to evaluate the potential benefits of Rasilez to reduce the risk of cardiovascular and renal events. In the study, Rasilez was given in addition to optimal cardiovascular treatment including an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). Novartis said the trial was the first to investigate Rasilez for more than one year in this specific patient group.

However, the drugmaker noted that in patients given Rasilez in combination with standard of care, "there was an increased incidence after 18-24 months of non-fatal stroke, renal complications, hyperkalemia and hypotension." Novartis indicated that it is in talks with health authorities regarding the implications of the findings, and in the meantime will stop promotion of products containing Rasilez for use in combination with an ACE-inhibitor or ARB. Spokesman Eric Althoff said the company is also looking at the data of other similar trials, which are currently ongoing.

Novartis suggested that sales of Rasilez, which is marketed as Tekturna in the US, "are likely to be negatively impacted by the study results going forward." According to the company, revenue for Rasilez-based products for the first nine months of 2011 reached $449 million, although "product profitability" in the year was negative.

The product was approved in 2007 in the EU and US for the treatment of hypertension either as a monotherapy or in combination with other therapies. The drugmaker has been looking to expand use of the agent, and has launched several trials to examine if the compound could protect organs such as kidneys and the heart if taken over a longer period of time.

RPA's Public Policy in a Minute for Novemeber 2011

2011-11-15T09:45:00.000-08:00

Life in the Spincycle

2011-11-14T11:03:00.000-08:00

New AJKD Blog, Congrats and Best Wishes!

2011-11-07T19:43:00.000-08:00

Id like to congratulate the team of the new AJKD blog. A group of my colleagues I know (most) and respect (all).

Best of luck and all my best guys:

Kenar D. Jhaveri, MD eAJKD Blog Editor
Matthew A. Sparks, MD Blog Advisory Board Member
Sidharth Kumar Sethi, MD Blog Advisory Board Member
Tejas Desai, MD Blog Advisory Board Member
Jordan Weinstein, MD Blog Advisory Board Member
Kellie Calderon, MD Blog Advisory Board Member
Vinay Nair, DO Blog Advisory Board Member
Joel Topf, MD Blog Advisory Board Member

Description from the blog:

The American Journal of Kidney Diseases (AJKD) is the official journal of the National Kidney Foundation and is recognized worldwide as a leading clinical kidney journal. Every month AJKD publishes clinically oriented original investigations, review articles, case reports, editorials, quizzes, and teaching cases and materials describing the latest findings in kidney diseases, hypertension, dialysis, and kidney transplantation.

AJKD is pleased to now offer eAJKD, the official blog of the journal. A central goal ofeAJKD is to highlight selected journal content in an engaging, timely format. The blog will have interviews with authors, educational material, as well as podcasts and video. We are looking forward to bringing AJKD into the future and offering engaging new means for authors and readers alike to interact with the journal!

CMS ANNOUNCES STRONGER INCENTIVES TO IMPROVE ESRD TREATMENT OUTCOMES

2011-11-02T12:44:00.000-07:00

CMS ANNOUNCES STRONGER INCENTIVES TO IMPROVE ESRD TREATMENT OUTCOMES
FINAL RULE UPDATES POLICIES AND PAYMENT RATES FOR DIALYSIS FACILITIES IN 2012

The Centers for Medicare & Medicaid Services (CMS) today issued a final rule that updates Medicare policies and payment rates for 5,503 dialysis facilities paid under the End Stage Renal Disease (ESRD) Prospective Payment System (PPS) that was first implemented in calendar year (CY) 2011.

The final rule will also strengthen incentives for improved quality of care and better outcomes for beneficiaries diagnosed with ESRD through improvements to the ESRD Quality Incentive Program (QIP). The provisions in the final rule will be effective for payments to dialysis facilities furnished on or after Jan. 1, 2012; and the new requirements for the ESRD QIP described in today’s final rule will affect the payment rates in payment years (PY) 2013 and 2014.

Payment rates for dialysis treatments will increase by 2.1 percent in CY 2012, representing the ESRD market basket increase of 3.0 percent less a productivity adjustment of 0.9 percent, as required by statute. CMS estimates that Medicare payments to ESRD facilities in CY 2012 will total $8.3 billion.

“This is the second year of a four year transition to the new fully bundled payment system for certain dialysis facilities, although nearly 90 percent of facilities have chosen to forgo the transition and be paid entirely under the new system,” said Jonathan Blum, deputy administrator and director of the Center for Medicare. “We believe that the policies and rate changes we are announcing today will ensure that beneficiaries diagnosed with ESRD will continue to have access to the care they need.”

The final rule also strengthens the QIP. Under the QIP, payments to individual facilities are reduced if the facility does not achieve a certain total performance score based on their performance with respect to measures that assess the quality of dialysis care the facility provided.

The initial ESRD QIP, finalized in a rule earlier this year, will affect payments to individual facilities in PY 2012 based on their performance on performance standards CMS established with respect to two anemia management measures and one measure of dialysis adequacy.

The final rule changes the QIP performance measures for PY 2013 by retiring the anemia management measure of hemoglobin level less than 10 grams per deciliter measure from the initial measure set.

This decision is consistent with new medical evidence regarding the safety of a common treatment for anemia in dialysis patients – administration of erythropoiesis-stimulating agents (ESAs). In addition, this change is consistent with the recent labeling for ESAs approved by the U.S Food and Drug Administration (FDA). For PY 2013, CMS will give equal weight to the two finalized measures: (1) an anemia management measure of hemoglobin levels greater than 12 grams per deciliter and (2) a hemodialysis adequacy measure as measured by a Urea Reduction Ratio (URR) of at least 65 percent.

“CMS believes that new concerns about the safety of ESAs for dialysis patients strongly argue for providers to work more closely with their patients to develop anemia management strategies that respond the patient’s unique medical issues, rather than adopting a one-size fits all approach to care,” said Patrick Conway, M.D., CMS chief medical officer and director of the Agency’s Office of Clinical Standards & Quality. “This patient-centered approach should result in better treatment outcomes. We plan to monitor hemoglobin levels by facility and to transparently share this information with consumers.”

ESAs promote the production of red blood cells in patients with certain types of anemia, including anemia related to kidney disease. New medical evidence about the risks and benefits of ESA use in patients with kidney disease or kidney failure led the FDA to approve a new label for these drugs to that offers guidance on how these drugs should be prescribed and used.

CMS is continuing to work on ways to address the incentives for treating anemia in dialysis patients in various programs, including the ESRD QIP. In the meantime, CMS also plans to actively monitor patients’ clinical outcomes to ensure that the retirement of this measure does not harm patients.

“CMS stresses that it continues to believe that anemia management is a critical part of treatment for patients on dialysis,” said Dr. Conway. “The anemia management and therapy should be determined by the patient’s physician in light of the patient’s individual needs and in consultation with the patient.”

For PY 2014, CMS is retaining one anemia management measure (hemoglobin level greater than 12 grams per deciliter) and the dialysis adequacy measure (URR of at least 65 percent). CMS is also adopting four new measures that expand the breadth of the program and will give greater insight into the quality of care Medicare patients with ESRD receive in dialysis facilities. Specifically, CMS is adopting the following six measures for PY 2014:

Dialysis adequacy, as measured through the URR, which assesses the percentage of patients with a URR of at least 65 percent;
Anemia management, as measured by the rate of patients with a hemoglobin level greater than 12 grams per deciliter;
Percent of patients receiving treatment through an arteriovenous fistula or catheter– types of vascular access used to connect patients’ bloodstreams to dialysis equipment for cleansing;
Whether the facility reports certain dialysis-related infections to the Centers for Disease Control & Prevention’s National Healthcare Safety Network;
Whether the facility administers a patient experience of care survey; and
Whether the facility monitors phosphorus and calcium levels on a monthly basis.

The final rule also adopts two changes to how CMS will score a facility’s performance under the QIP—one change relates to the two-measure framework for PY 2013, and the second change outlines how CMS would score facilities on the six measures adopted for PY 2014. The PY 2014 scoring methodology will more closely align the QIP with the scoring methodology adopted for the Medicare Hospital Inpatient Value-Based Purchasing Program.

Both the ESRD PPS and the QIP were mandated by the Medicare Improvements for Patients and Providers Act of 2008. The previous ESRD payment system consisted of a composite rate payment for a defined set of services, including certain laboratory tests, drugs and other supplies, while separate payments were made for any items or services furnished as part of the dialysis treatment but for which no payment was made under the composite rate. The composite rate payment was adjusted to reflect the facility’s case mix and a limited number of patient’s characteristics. The ESRD PPS is intended to improve efficiency and reduce incentives to use more items and services than needed for appropriate care, while the QIP is intended to promote quality of care provided to Medicare beneficiaries with ESRD.

The final rule also includes several provisions that are not related to the ESRD PPS and QIP, including the extension (through CY 2011) of certain payment rate increases for ground ambulance services and certain rural area designations for purposes of air ambulance payment, and establishing a 3-year minimum lifetime requirement for equipment to be considered durable for purposes of coverage as durable medical equipment.

For more information about the final rule, please see: http://www.ofr.gov/OFRUpload/OFRData/2011-28606_PI.pdf . or

http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1

The final rule will appear in the Nov. 10, 2011, Federal Register.

For more information about the ESRD PPS and QIP, please see:

http://www.cms.gov/center/esrd.asp

Is It Beneficial to Take BP Medications at Bedtime?

2011-10-25T06:32:00.000-07:00

MONDAY, Oct. 24 (HealthDay News) -- For the millions of Americans on blood pressure-lowering drugs, a new study suggests that taking the pills at bedtime may be best.

It was known that taking blood pressure medications at different times of the day can affect patients' blood pressure patterns, but the impact on health wasn't known.

The new Spanish study included 661 patients with chronic kidney disease and hypertension. Half of them took their prescribed blood pressure-lowering drugs at bedtime and half took their medications first thing in the morning.

After an average follow-up of 5.4 years, the researchers found that patients who took at least one blood pressure-lowering drug at bedtime had better control of their blood pressure and were about one-third as likely to suffer a heart-related event such as heart attack, heart failure or stroke.

The team at the University of Vigo also found that sleep-time blood pressure provided a much more accurate measure of heart health than wake-time blood pressure.

The study was published online Oct. 24 in the Journal of the American Society of Nephrology.

"Our results indicate that cardiovascular event rates in patients with hypertension can be reduced by more than 50 percent with a zero-cost strategy of administering blood pressure-lowering medications at bedtime rather than in the morning," study author Ramon Hermida wrote in a journal news release.

One U.S. doctor said taking advantage of "chronotherapy" -- timing drug delivery to a patient's biorhythms -- might have real value.

"Physicians don't commonly specify which time of day patients should take their medications; however, most patients with hypertension take their antihypertensive drugs in the morning. Upon taking these medications, patients oftentimes complain of side effects, most commonly, fatigue and drowsiness," noted Dr. Robert Graham, an internist at Lenox Hill Hospital in New York City.

He believes the study reveals a "low-cost, win-win scenario" of better adherence to blood pressure medications and higher effectiveness when they're taken in the evening versus the morning. "As a result, chronotherapy may help minimize the side effects, and maximize the beneficial effects of antihypertensive medications," Graham said.

RPA's Public Policy in a Minute for Oct 2011

2011-10-17T10:01:00.001-07:00

NEJM: Long Interdialytic Interval and Mortality among Patients Receiving Hemodialysis

2011-09-22T10:05:00.000-07:00

This will come as absolutely NO SURPRISE to the healthcare professionals who care for dialysis patients. The prestigious New England Journal of Medicine has just published a study basically saying hemodialysis patients who dialyze thrice weekly have higher mortality, morbidity, hospitalizations and other assorted problems associated with the 'extra day off' surrounding a weekend.

NEJM DISCUSSION: In this study of a relatively contemporary, representative population of U.S. adults receiving hemodialysis, we found that most events studied occurred more frequently on the day after the long interdialytic interval than on other days, including all-cause mortality, mortality from cardiac causes, infection-related mortality, mortality from cardiac arrest, and mortality from myocardial infarction. Similar patterns were observed for hospital admissions with myocardial infarction, congestive heart failure, stroke, dysrhythmia, and any of these cardiovascular events. Subgroup analyses suggested that this excess of adverse events on the day after the long interdialytic interval was close to being a generalized phenomenon.

More dialysis is better. This is simple, true and a fact that is hard to get around as data continues to mount. The economics are one of the factors that will make this difficult to change. Another is patient preferences. In my experience, the majority of dialysis patients want less and less dialysis and that is an unfortunate reality. Nevertheless, it is our job to educate the dialysis patients that all things being equal, more dialysis is better and less dialysis can be hazardous to your health.

RPA's Public Policy in a Minute for Sept 2011

2011-09-22T08:28:00.000-07:00

Acne-treating antibiotic cuts catheter infections in dialysis patients

2011-08-22T07:28:00.000-07:00

A new randomized controlled clinical trial has shown that using an antibiotic that is not usually used to treat other serious infections may be a safe way to prevent bacterial infections in dialysis patients. The study, which included approximately 200 dialysis patients, was conducted by Rodrigo Peixoto Campos, MD of Pontifícia Universidade Católica do Paraná, in Curitiba, Brazil and colleagues, and appears in an upcoming issue of the Journal of the American Society of Nephrology.

Between dialysis treatments, a catheter is "locked" to prevent blood clots from forming within the device. A lock is usually made by injecting the blood thinner heparin into the catheter. In this study, researchers compared heparin use with a solution made up of the antibiotic minocycline and the chemical EDTA. Minocycline is routinely used only to treat acne, and EDTA improves the action of antibiotics, fights fungal infections, and prevents blood clots. Half of patients in the study had catheter locks containing this combination while the other half had catheter locks containing only heparin.

Among the major findings:

Patients were less likely to get a bacterial infection with minocycline-EDTA locks compared to heparin locks.
During a 90 day period, bacterial infections developed in the catheters of 19 patients in the heparin group compared with only five patients in the minocycline-EDTA group.
The catheters in the two groups functioned similarly well.

"When a dialysis clinic cannot achieve lower rates of catheter-related bacterial infections with routine catheter care protocols, the use of a catheter lock solution of minocycline-EDTA may be the next step to reduce this major complication, without the apprehension of developing bacterial resistance to systemic antibiotics," said Campos.

Nutrition for Kidney Stones

2011-08-18T09:00:00.001-07:00

Nutrition to Prevent Kidney Stones

Waist Circumference More Important than BMI as a Risk Factor

2011-08-03T12:10:00.000-07:00

MAYWOOD, Ill.—A study lead by a Loyola University Health System researcher found that the larger a kidney patient's waist circumference, the greater the chance the patient would die during the course of the study.

The study by lead researcher Holly Kramer, MD, MPH, and colleagues is published in the American Journal of Kidney Diseases.

Waist circumference was more strongly linked to mortality than another common measure of obesity, body mass index (BMI).

BMI is a height-to-weight ratio. For example, if John and Mary are both the same height, but John weighs 20 pounds more, then John will have a higher BMI than Mary. But BMI can be misleading—a muscular person with little body fat could have a BMI higher than a flabby person with little muscle mass. Waist circumference, by contrast, simply measures abdominal fat.

Researchers examined data from 5,805 adults age 45 and older who had kidney disease and participated in a study called REGARDS (Reasons for Geographic and Racial Differences in Stroke). They were followed for a median of four years, and during that time 686 kidney patients (11.8 percent) died.

The average BMI of the kidney disease patients who died was 29.2. This was lower than the average BMI, 30.3, of the patients who survived. (A BMI between 25 and 29.9 is considered overweight, while a BMI of 30 and above is obese.)

By contrast, the kidney patients who died had a larger average waist circumference (40.1 inches) than the patients who survived (39.1 inches.)

Researchers compared kidney disease patients with large waists to patients who had more normal waist sizes. After adjusting for BMI and other risk factors, women with waists equal to or greater than 42.5 inches and men with waists equal to or greater than 48 inches were 2.1 times more likely to die than those with trimmer waists (less than 31.5 inches for women and less than 37 inches for men).

Researchers concluded that in adults with kidney disease, BMI by itself may not be a useful measure to determine mortality risks associated with fat. The reason is that BMI reflects multiple components, including muscle mass as well as abdominal fat.

"In contrast," the researchers concluded, "waist circumference reflects abdominal adiposity [fat] alone and may be a useful measure to determine mortality risk associated with obesity in adults with chronic kidney disease, especially when used in conjunction with BMI."

Fresenius Makes a Couple of Big Acquisitions in Dialysis World

2011-08-03T12:04:00.000-07:00

Fresenius Medical Care AG, a worldwide dialysis provider, has snapped up a pair of U.S. competitors bringing more consolidation to an industry facing cost pressures.

Fresenius agreed to buy Liberty Dialysis Holdings for $1.7 billion, one of two acquisitions announced by the German company on Tuesday. Last year, Liberty had merged with Brentwood-based Renal Advantage.

Fresenius Medical also will buy American Access Care Holdings LLC for $385 million.

Liberty Dialysis, a closely held company based in Mercer Island, Wash., has 260 clinics with annual revenue of about $1 billion. Its deal with Fresenius is expected to close early next year.

“Fresenius has certainly shown that scale matters,” said Lisa Clive, a London-based analyst for Sanford C. Bernstein Ltd. Clive has an “outperform” recommendation on the Germany company’s stock. She said the latest deals make “strategic sense.”

Bigger dialysis chains have an advantage under a new U.S. Medicare reimbursement system. Called the bundled rate, the new system is a fixed compensation amount designed to reduce overuse of drugs that were previously separately billable, Clive said.

American Access runs outpatient clinics for procedures such as fistulas and grafts that give permanent surgical access to veins, reducing the need to use temporary catheters for dialysis blood-cleaning treatment. Using such procedures may help Fresenius reduce the number of expensive-to-treat infections, Clive said.

Shareholders of Liberty Dialysis include private equity companies KRG Capital Partners, which is based in Denver, and Bain Capital, based in Boston.

Amgen Announces Big Change for ESA Policy in CKD / ESRD

2011-07-14T12:18:00.000-07:00

Amgen Announces Modifications to U.S. Prescribing Information for Use of Erythropoiesis-Stimulating Agents in Chronic Kidney Disease

Modified Labeling Provides Different Treatment Guidance for Patients on Dialysis and Not on Dialysis

Changes to Prescribing Information Include Modification to the Boxed Warning

THOUSAND OAKS, Calif., June 24, 2011 /PRNewswire via COMTEX/—Amgen (NASDAQ: AMGN) announced today that the U.S. Food and Drug Administration (FDA) has approved modified language in the prescribing information for the use of erythropoiesis-stimulating agents (ESAs), including Aranesp® (darbepoetin alfa) and EPOGEN® (Epoetin alfa), in patients with chronic kidney disease (CKD). The modified language, including changes to the Boxed Warning, provides important new information for the treatment of patients with CKD who are on dialysis, as well as those not on dialysis, to inform prescribers and patients of safety risks that have been identified in clinical trials. In recognition of the different benefit-risk profiles of ESA therapy in patients on dialysis compared to patients not on dialysis, the modified labeling provides separate treatment guidance for these two CKD populations.

Specifically, for patients on dialysis, the label advises physicians to initiate ESA therapy when the hemoglobin level is less than 10 g/dL and guides physicians to reduce or interrupt the dose when the hemoglobin approaches or exceeds 11 g/dL. For patients not on dialysis, physicians are asked to consider initiating ESA therapy when the hemoglobin level is below 10 g/dL, when reducing red blood cell transfusion-related risks is a clinical goal and when the rate of hemoglobin decline suggests a transfusion will be likely. Further, for those not on dialysis, physicians should reduce or interrupt the dose when the hemoglobin exceeds 10 g/dL. This guidance replaces the previous label language specifying a hemoglobin target range of 10-12 g/dL for both populations. The modified prescribing information continues to recognize the benefit of reducing the need for transfusions in CKD patients.
In addition, the Boxed Warning, Warnings and Precautions and Clinical Studies sections have been modified to advise that the use of ESAs to target a hemoglobin level of greater than 11 g/dL increases the risk of serious adverse cardiovascular reactions.

For complete dosing and safety information for Aranesp and EPOGEN, see the full prescribing information.
"Amgen supports the modified ESA prescribing information as it informs physicians of important safety information," said Roger M. Perlmutter, M.D., Ph.D., executive vice president of Research and Development at Amgen. "The revised label also provides physicians with more individualized treatment guidance by distinguishing between patients undergoing dialysis as compared with those who are not on dialysis."
The language in the prescribing information was informed by the results from clinical trials, including TREAT (the Trial to Reduce Cardiovascular Events with Aranesp® Therapy), which targeted high hemoglobin levels (13 g/dL) in CKD patients who were not on dialysis and found an increased risk of stroke in the patients treated with ESAs compared to those receiving placebo. While TREAT was a study of patients who were not on dialysis, the modified Boxed Warning and other warnings in the label apply to all CKD patients.
Amgen is informing healthcare professionals about the revisions to the prescribing information through a joint "Dear Healthcare Professional" letter with Janssen Products, LP and will post the letter, along with the modified prescribing information on Amgen’s website, www.amgen.com.

Amgen is in ongoing discussions with the FDA regarding additional post-marketing required studies to further understand the benefit-risk profile of ESAs in CKD patients on dialysis and not on dialysis.

RPA- Public Policy in a Minute JULY

2011-07-13T07:10:00.000-07:00

Serum Bicarbonate and SPEED?

2011-07-11T16:09:00.000-07:00

So do you need help improving your time in the 40 yard dash? Maybe you need to pop some sodium bicarbonate supplements.

A cross sectional study published in the latest American Journal of Kidney Diseases suggests there is a link between serum bicarbonate levels and both gait speed and quadriceps strength in older adults.

In this retrospective look at over 2600 individuals over the age of 50 a lower serum bicarbonate level (defined as less than 23 mEq/L) was associated with slower gait speed and decreased quadriceps strength.

This study is flawed and obviously requires further investigation so athletes looking for an edge should not start downing baking soda just yet. Even if this association was true (and that is a big if based on this data alone) it does not mean necessarily that sodium bicarbonate supplementation will improve speed... but, I have a feeling we will hear more about this...

CMS Releases 2012 Medicare Fee Schedule, ESRD Facility Payment and Quality Rule

2011-07-07T08:48:00.000-07:00

On July 1 CMS released two rules that affect nephrologists: the proposed rule for the 2012 Medicare Fee Schedule, and a combined proposed rule for the 2012 ESRD Prospective Payment System (determining reimbursement for dialysis facilities), and the 2012 Quality Incentive Program (QIP). The fee schedule rule indicates that despite slight reductions in values for several inpatient and outpatient dialysis codes, nephrology as a specialty will experience a 0% impact (no change) based on the cumulative revisions in the fee schedule. RPA's analysis has been posted for review by members (log-in required). The entire rule may be viewed/downloaded. RPA's comments to CMS will be submitted by August 30 and will be posted at www.renalmd.org.

The most noteworthy passages in the ESRD PPS/QIP rule indicate that CMS has established an unadjusted per dialysis treatment base rate of $233.76 for 2012, and that CMS is proposing to retire the hemoglobin less than 10g/dL measure beginning with the 2013 ESRD QIP, consistent with a recent labeling change announced by the Food and Drug Administration (FDA). RPA will post a more detailed analysis of the ESRD PPS/QIP rule soon.

Are AV Fistulas Always Appropriate?

2011-07-06T12:25:00.000-07:00

Hey, I embrace the Fistula First initiative as much as the next nephrologist... but, sometimes it just doesnt make sense.

I apologize to the fistulas enthusiasts but they are just not always appropriate for dialysis patients. Moreover they are not always the preferred first or initial choice in vascular access even if there the appropriate advance time for preparation. This is especially true for patients starting on hemodialysis with advanced age, marginal functional status, multiple comorbidities and a poor life expectancy. The cold harsh reality is that the mortality rate in the hemodialysis population is high overall and for the sickest hemodialysis patients it can be extraordinarily high. So is it appropriate to advocate for all to have an arteriovenous fistula (AVF)? Furthermore, creating a fistula is a surgical procedure that is not completely benign, it is not without cost (financial, time and other opportunity costs) and it may take several follow up visits to the vascular surgeon and may many months to mature... if at all... months that the patient may not have.

CJASN this month reports on "Re-evaluating the Fistula First Initiative in Octogenarians". I wholeheartedly agree with their conclusion that "vascular access planning should include assessment of the functional status and life expectancy"... this is especially true since not only are we starting more and more 80 year olds on dialysis... we are starting plenty of 90+ year olds as well.

NSAIDs Suck

2011-07-05T07:07:00.000-07:00

OK, so the title is a bit harsh. But that's how I am feeling today, and I guess I succeeded in getting your attention.

I was called in consultation to see a 76 yr old lady with diabetes, hypertension and arthritis yesterday. She was in renal failure without any history of CKD (Chronic Kidney Disease). The culprit - ATC (around the clock) Advil. I am hopeful she will avoid dialysis but her kidneys took a big hit.

It is no secret that Nephrologists are no fans of NSAIDs. Some of the adverse reactions a Nephrologist may see includes:

Nephrotoxicity (direct toxicity to the kidney)
Renal papillary necrosis (death of tissue in the kidney)
Hypertension
Edema (fluid retention)

But wait thats not all!

NSAIDs are associated with disorders of the bone marrow, severe rashes, and ringing in the ear. Then there is the potential of life threatening gastrointestinal (GI) bleeding, congestive heart failure, stroke and heart attacks.

But wait... thats not all! Now a new study is linking NSAID use to irregular heart rhythm called atrial fibrillation or atrial flutter(AFIB/FLUTTER). NSAID users have a 40% higher risk of developing A FIB/FLUTTER and those using COX2-inhibitors (an segment of NSAIDs that includes medications such as Celebrex, Vioxx) have a 70% increased risk. This risk is higher in the elderly.

Now before I get a Pfizer rep knocking on my door, I am not saying avoid Advil at all costs (or it's peers). NSAIDs in general are a worthwhile class of medications and have their place. But if you are of advanced age (or even if not) and rely on using NSAIDs chronically to relieve arthritis or aches and pains... please be aware of the potential consequences. Sometimes common medications that are over the counter are seen as more benign than they really are. Please be cautious and ask your physician if there are any questions.

ASN Recognizes Nephrology Bloggers

2011-07-04T12:24:00.000-07:00

Glad to see the ASN recognizing the blogosphere. Congrats to my fellow bloggers being included in this month's ASN: Kidney New's Podcast.

Conall O' Seaghdha MD and Matt Sparks MD from Renal Fellows Network
Kenar Jhaveri MD from Nephron Power

Dont worry guys, I know you fought long and hard to include me along with you in the interview.... :)

Cheers!

RPA- Public Policy in a Minute JUNE

2011-06-15T08:25:00.001-07:00

CJASN: Popularity of Nephrology Declining

2011-06-13T15:16:00.000-07:00

Summary Interest in nephrology as a career is declining and has been on the decline for nearly one decade. From 2002 to 2009, all internal medicine subspecialties except geriatric medicine increased the number of available fellowship positions. However, only two subspecialties attracted fewer United States medical graduates (USMGs) in 2009 than in 2002: geriatric medicine and nephrology. This drop occurred at a time when demand for nephrologists is increasing and when the specialty is having a harder time benefiting from the substantial contribution of international medical graduates (IMGs).

Today's USMGs possess fundamentally different career and personal goals from their teachers and mentors. Medical students report receiving minimal exposure to nephrology in clinical rotations, and they perceive that the specialty is too complex, uninteresting, and lacks professional opportunity.

Meanwhile, the demographics of kidney disease in the United States, as well as recent national health policy developments, indicate a growing need for nephrologists. Efforts to improve the educational continuum in nephrology and enhance mentorship are essential to restoring interest in nephrology for USMGs, maintaining its appeal among IMGs, and developing a workforce sufficient to meet future demand for renal care.

Chinese teen sells his kidney for an iPad 2

2011-06-13T15:08:00.000-07:00

A Chinese teenager was so desperate to acquire the new iPad 2 that he sold one of his kidneys for just £2,000 to pay for it, according to reports.

The 17-year-old boy, identified only by his surname, "Zheng", confessed to his mother that he had sold the kidney after spotting an online advertisement offering cash to anyone prepared to become an organ donor.

"I wanted to buy an iPad2, but I didn't have the money," the boy told Shenzhen TV in the southern province of Guangdong, "When I surfed the internet I found an advert posted online by agent saying they were able to pay RMB20,000 to buy a kidney." After negotiations, the boy travelled north to the city of Chenzhou in Hunan Province where the kidney was removed at a local hospital which discharged him after three days, paying a total of RMB22,000 for the organ.

Trading organs online is a common practice in China, despite repeated attempts by China's government to stamp out the practice. Last year Japanese television reported that a group of "transplant tourists" had paid £50,000 to receive new kidneys in China.

According to official statistics more than a million people in China need a transplant every year, but fewer than 10,000 receive organs, driving an almost unstoppable black-market organ trade that enriches brokers, doctors and corrupt government officials.

The boy, who has suffered complications following the surgery, returned home but was unable to keep what he had done from his mother.

Some Clarity Regarding Vitamin D Screening?

2011-06-07T07:50:00.000-07:00

People at high risk for vitamin D deficiency (e.g., Hispanics, blacks, pregnant women, obese individuals) should be screened for low vitamin D levels, but population screening is not recommended, according to new guidelines from the Endocrine Society published in the Journal of Clinical Endocrinology and Metabolism.

Circulating serum levels of 25-hydroxyvitamin D below 20 ng/mL should be considered deficient, the society says.

The society also offers recommended dietary intakes for at-risk groups, as well as guidance on using vitamin D2 or D3 supplements for treatment. It recommends against using supplementation to prevent cardiovascular disease or death or to enhance quality of life.

Down Goes the Food Pyramid

2011-06-05T04:42:00.000-07:00

WASHINGTON, June 2, 2011 – First Lady Michelle Obama and Agriculture Secretary Tom Vilsack today unveiled the federal government’s new food icon, MyPlate, to serve as a reminder to help consumers make healthier food choices. MyPlate is a new generation icon with the intent to prompt consumers to think about building a healthy plate at meal times and to seek more information to help them do that by going to www.ChooseMyPlate.gov .

The new MyPlate icon emphasizes the fruit, vegetable, grains, protein and dairy food groups.

“This is a quick, simple reminder for all of us to be more mindful of the foods that we’re eating and as a mom, I can already tell how much this is going to help parents across the country,” said First Lady Michelle Obama. “When mom or dad comes home from a long day of work, we’re already asked to be a chef, a referee, a cleaning crew. So it’s tough to be a nutritionist, too. But we do have time to take a look at our kids’ plates. As long as they’re half full of fruits and vegetables, and paired with lean proteins, whole grains and low-fat dairy, we’re golden. That’s how easy it is.”

“With so many food options available to consumers, it is often difficult to determine the best foods to put on our plates when building a healthy meal,” said Secretary Vilsack. “MyPlate is an uncomplicated symbol to help remind people to think about their food choices in order to lead healthier lifestyles. This effort is about more than just giving information, it is a matter of making people understand there are options and practical ways to apply them to their daily lives.”

Originally identified in the Child Obesity Task Force report which noted that simple, actionable advice for consumers is needed, MyPlate will replace the MyPyramid image as the government’s primary food group symbol as an easy-to-understand visual cue to help consumers adopt healthy eating habits consistent with the 2010 Dietary Guidelines for Americans. MyPyramid will remain available to interested health professionals and nutrition educators in a special section of the new website. ChooseMyPlate.gov provides practical information to individuals, health professionals, nutrition educators, and the food industry to help consumers build healthier diets with resources and tools for dietary assessment, nutrition education, and other user-friendly nutrition information. As Americans are experiencing epidemic rates of overweight and obesity, the online resources and tools can empower people to make healthier food choices for themselves, their families, and their children. Later this year, USDA will unveil an exciting “go-to” online tool that consumers can use to personalize and manage their dietary and physical activity choices.Over the next several years, USDA will work with First Lady Michelle Obama’s Let’sMove! initiative and public and private partners to promote MyPlate and ChooseMyPlate.gov as well as the supporting nutrition messages and “how-to” resources.

The 2010 Dietary Guidelines for Americans, launched in January of this year, form the basis of the federal government’s nutrition education programs, federal nutrition assistance programs, and dietary advice provided by health and nutrition professionals. The Guidelines messages include:

Balance Calories
• Enjoy your food, but eat less.
• Avoid oversized portions.
Foods to Increase
• Make half your plate fruits and vegetables.
• Switch to fat-free or low-fat (1%) milk.
• Make at least half your grains whole grains
Foods to Reduce
• Compare sodium (salt) in foods like soup, bread, and frozen meals, and choose foods with lower numbers.
• Drink water instead of sugary drinks.

Coupled with these tested, actionable messages will be the “how-tos” for consumer behavior change. A multi-year campaign calendar will focus on one action-prompting message at a time starting with “Make Half Your Plate Fruits and Vegetables.”

“What we have learned over the years is that consumers are bombarded by so many nutrition messages that it makes it difficult to focus on changes that are necessary to improve their diet,” said Secretary Vilsack. “This new campaign calendar will help unify the public and private sectors to coordinate efforts and highlight one desired change for consumers at a time.”

As part of this new initiative, USDA wants to see how consumers are putting MyPlate in to action by encouraging consumers to take a photo of their plates and share on Twitter with the hash-tag #MyPlate. USDA also wants to see where and when consumers think about healthy eating. Take the Plate and snap a photograph with MyPlate to share with our USDA Flickr Photo Group.

FDA Finds No Link Between ARBs and Cancer

2011-06-03T07:34:00.000-07:00

[06-02-2011] The U.S. Food and Drug Administration (FDA) has completed a review of the potential risk of cancer associated with the class of medications known as angiotensin receptor blockers (ARBs). FDA has concluded that treatment with an ARB medication does not increase a patient’s risk of developing cancer.

One more time for all of us who prescibe and use ARBs...Since this is unlikely to get nearly as much attention as the premature reports that ARBs increase the cancer risk...

THE FDA HAS ANNOUNCED THAT ARBs DO NOT INCREASE THE RISK OF CANCER.

Mortality and Serum Sodium: Do Patients Die from or with Hyponatremia?

2011-05-18T14:34:00.000-07:00

Interesting article in CJASN this month out of Rochester, NY regarding mortality and hyponatremia.

It is well known that severe hyponatremia (defined as Na <120) carries a high mortality rate. But is the mortality a consequence of the hyponatremia itself, or the underlying disease causing the hyponatremia?

This study showed that it was the nature of the underlying illness rather than the severity of the hyponatremia that best explained the associated mortality. Furthermore, it was noted that neurologic symptoms were surprisingly uncommon in those dying from / with hyponatremia.

RPA- Public Policy in a Minute May 2011

2011-05-17T11:58:00.001-07:00

Are Bisphosphonates Right for Females with CKD?

2011-05-11T11:40:00.000-07:00

BY: JEFFREY T. COHEN, MD

On April 30, 2011, Renal and Urology News reported data on bisphosphonate use and chronic kidney disease from this year’s annual National Kidney Foundation meeting in Las Vegas. The data suggests that female patients with non-dialysis dependent chronic kidney disease (NDD-CKD) derive mortality benefit from treatment with bisphosphonates. The study involved over 9000 women, demonstrating a significant 21% decreased mortality risk after adjusting for age, smoking status, blood pressure, and other variables.

Bisphosphonates are the most commonly prescribed class of drugs to treat osteoporosis in the U.S. Bone is continuously undergoing formation as well as breakdown; bisphosphonates inhibit bone breakdown, and therefore favor bony formation, and a net gain of bone mass. Clinically, strong data exists proving that bisphosphonates not only increase bony mass, but also markedly reduce fracture risk in osteoporotic women. (FIT trial, Ensrud KE et al. Arch Intern Med 1997;157:2617.)

The kidneys play a primary role in calcium, phosphorous, and vitamin D homeostasis. It therefore should not be surprising that patients with NDD-CKD suffer from suboptimal bony integrity, what we as physicians call “renal osteodystrophy”. Renal osteodystrophy is quite complicated. Not only does the mechanism of dysfunction vary amongst CKD patients, but we as nephrologists have very limited ability to predict which patients will develop which bony characteristics.

With regard to the topic of bisphosphonate use in CKD patients, we have many more questions than answers. What effect would adding a bisphoshonate have to a given CKD patient’s bone structure? Is widespread use of bisphosphonates in osteoporotic CKD patients worthwhile? Is it appropriate to attempt to make generalizations on the effects of bisphosphonates on CKD patients, given the differences in their bony makeup? Unfortunately, with regard to all of these questions, we lack prospective data with clinically important end points.

Although I do not yet have access to all of the details from the data presented at the Las Vegas meeting, I find the data offered in Renal and Urology News to be somewhat troubling. Firstly, while mortality was lower in the NDD-CKD patients treated with bisphosphonates, frequency of adverse cardiovascular outcomes was not lower in the bisphosphonate group. It is difficult to reconcile this divergence in findings, given that the majority of deaths in NDD-CKD patients are in fact from cardiovascular causes. Furthermore, the median length of follow-up was 3.2 and 4.2 years in the treated and untreated groups, respectively. This seems an enormous difference in follow-up for a study involving thousands of patients. Therefore, while the potential use of bisphosphonates in CKD is a fascinating topic, I will certainly wait for more data before adding a bisphosphonate to the medication regimen of my osteoporotic CKD patients.

Therefore, While it’s a very important topic, determining if elderly women with CKD can benefit from bisphosphonates, I’ll wait for more data/RCTs before looking to add bisphosphonates to the medication regimen of my elderly female CKD patients.

NKF Kidney Walk: Join us SUNDAY May 15 at Hofstra University

2011-05-11T10:09:00.001-07:00

Dear Team Captains, Walkers and Volunteers:
The countdown continues and we are just days away from the 4th Annual Long Island Kidney Walk!
The following information is meant to make your Walk day easier. If you need further details or have any other questions, please just let me know!

4th Annual Long Island
KIDNEY WALK
Hofstra University
Hempstead, NY
Sunday, May 15th, 2011

10 THINGS TO KNOW ABOUT THE KIDNEY WALK
1. The Kidney Walk is at the Field Hockey Stadium at Hofstra University.
2. You can park for free in the parking lot right alongside the field (handicap spaces available as well).
3. To get to Hofstra University, please visit this website to find the driving directions most helpful to you:
www.hofstra.edu/about/infocenter
4. The Walk is RAIN OR SHINE! Check-in begins at 9:30 a.m. and the Walk program starts at 10:30 a.m.
5. ALL walkers should go to the Check-In tent upon arrival. This is where you will receive a t-shirt and tote bag ticket (if applicable).
6. All team captains are encouraged to meet their team members at the “Team Captain Tent.” There will be materials there to make your team banners!
7. The Walk is a 5K (3.1 mile) non-competitive walk around the Hofstra University campus. It is wheelchair, stroller and leashed pet friendly!
8. There will be a tribute banner for everyone to sign. Please look for it near the stage so you can add a message about your loved one. This banner will be leading the Walk.
9. Event highlights include celebrity guests, live music, giveaways, snacks, refreshments, children’s activities, and much, much more!
10. This Walk will give you a chance to celebrate life with members of the kidney community!
Again, please contact us with any questions. We are excited to see you on Sunday and are extremely thankful for all of your efforts and hard work.

Warmest regards,
Lindsay Gilman
Community Development Manager
212.889.2210 ext. 203

Media Partner

Kidney Walk
© 2010 National Kidney Foundation, Inc.
30 East 33rd Street, New York, NY 10016
1-800-622-9010 | walk@kidney.org

Click here to view this message as HTML in your browser.
Click here to forward this message.
Click here to change your email preferences.

nonprofit software

The UN-fairer Sex

2011-05-02T14:54:00.000-07:00

Contrast induced nephropathy is a common condition and remains a big topic in nephrology with all the contrast dye procedures that are being done on a daily basis in nearly all hospitals worldwide. Some of the common risk factors for contrast induced nephropathy (CIN) include a decreased creatinine clearance, proteinuria, diabetes, advanced age, heart failure, dehydration and others have been speculated...

A poster presented at the National Kidney Foundation sponsored Spring Clinical Meeting shows data supporting a new risk factor... female sex.

Women who received contrast dye for coronary angiography had a 61% increased risk of developing contrast-induced nephropathy when compared with men (P=0.003).

What is the REAL Link Between Salt and Hypertension?

2011-04-18T13:39:00.000-07:00

Salt intake raises blood pressure because it makes it harder for the cardiovascular system to simultaneously juggle the regulation of blood pressure and body temperature, according to new research from Case Western Reserve University School of Medicine and Kent State University.

For decades, medical researchers have sought to understand how salt causes salt-induced high blood pressure to no avail. Some individuals, described as "salt sensitive" experience an increase in blood pressure following the ingestion of salt, whereas others, termed "salt resistant" do not. Until now, scientists have been unable to explain why some individuals are salt sensitive and others are salt resistant. This inability to explain why salt raises blood pressure in some individuals but not others has hampered the development of a comprehensive theory as to what causes most cases of high blood pressure.

Since the cardiovascular system is responsible for maintaining normal blood pressure and also helps control body temperature by conducting heat from the muscles and internal organs to the skin's surface, a team of researchers led by Robert P. Blankfield, MD, MS, clinical professor of family medicine at Case Western Reserve University School of Medicine, and a member of the Department of Family Medicine at University Hospitals Case Medical Center and Ellen L. Glickman, PhD, professor of exercise science at Kent State University, tested whether these dual roles of the cardiovascular system might help explain how salt ingestion leads to salt-sensitive hypertension.

The researchers examined the effect of salt and water consumption versus just water upon a group of 22 healthy men without high blood pressure. The study participants' blood pressure, rectal temperature, cardiac index (the volume of blood pumped by the heart per minute), and urine output were monitored at one, two, and three hours after the men ingested either salt and water or water alone. Changes in rectal temperature were compared between the men identified as salt sensitive versus those who were salt resistant.

The study found that the ingestion of salt and water lowered body temperature more than the ingestion of water by itself. In addition, body temperature decreased more in individuals who are salt resistant than in individuals who are salt sensitive.

"It appears that salt sensitive individuals maintain core body temperature equilibrium more effectively than salt resistant individuals, but experience increased blood pressure in the process," Blankfield said. "Conversely, salt resistant individuals maintain blood pressure equilibrium more effectively than salt sensitive individuals following salt and water intake, but experience a greater temperature reduction in the process."

Matthew D. Muller, PhD, postdoctoral research fellow at the Penn State College of Medicine, and the paper's first author explained, "If our results are generalizable, it would be possible to account for the role of salt in the development of salt-sensitive hypertension: salt and water loading raises blood pressure in salt sensitive individuals, and the elevated blood pressure persists for a finite period of time during and after the salt and water intake. These transient blood pressure elevations, whether brief or prolonged, might initiate the complex changes within the walls of the arteries and arterioles that characterize individuals with essential hypertension."

Muller added, "Nowadays, physicians tell their patients that no one knows what causes high blood pressure. Since we can now explain why salt-sensitive hypertension develops, a theory that will explain all hypertension may be possible. Thus, physicians may one day be able to tell their patients that the cause of high blood pressure is understood, and physicians may also be able to explain to their patients what must be done to avoid developing this chronic medical condition."

The findings are described in a manuscript published in the April 14th issue of the journal Hypertension Research.

Comparison of Dietary Phosphate Absorption - Lanthanum Vs. Sevelamer in Healthy Volunteers: A Balance Study

2011-04-18T13:24:00.000-07:00

Lanthanum carbonate and sevelamer carbonate are noncalcium phosphate binders used to treat hyperphosphatemia in patients with chronic kidney disease.

This is the first study to compare phosphate absorption from a standardized meal ingested with a typical clinical dose of these binders.

Study Design: Randomized open-label crossover study.Settings & Participants: Healthy volunteers were confined to a clinical research center during 4 study periods. Of 31 volunteers randomly assigned, 19 completed all treatments and 18 were analyzed in the pharmacodynamic set (1 was excluded because of vomiting).Intervention: Participants were assigned in random order to meal alone, meal plus lanthanum carbonate (1 tablet containing 1,000 mg of elemental lanthanum), and meal plus sevelamer carbonate (three 800-mg tablets).

Conclusions: In healthy volunteers, 1,000 mg of lanthanum carbonate decreased phosphate absorption by 45% compared with a 21% decrease with 2,400 mg of sevelamer carbonate.

Does this make you more likely to use Fosrenol?

RPA's Public Policy in a Minute for April 2011

2011-04-18T09:30:00.001-07:00

Diet drug, Xenical tied to kidney damage

2011-04-14T06:52:00.000-07:00

(Reuters Health) - In another blow to diet drugs, Canadian researchers are reporting a link between Roche's Xenical and an increase in kidney injuries.

Tapping into healthcare databases from the province of Ontario, they found that 0.5 percent of new orlistat users were hospitalized for kidney problems in the year before starting on the drug. Over the next year, that number jumped to 2 percent.

Dr. Matthew Weir, who worked on the study, said a few earlier case reports had found kidney problems in people on Xenical, but that it wasn't listed among the drug's side effects.

"I'd just like to add that this study should be interpreted cautiously," he noted in an email to Reuters Health. "It is observational and cannot prove causality."

Last year, U.S. health officials warned about rare cases of liver damage in patients on Xenical or GlaxoSmithKline's Alli. The active ingredient of both drugs -- called orlistat -- inhibits the absorption of fat in the gut.

The new study is based on 953 new users of orlistat and is published in the Archives of Internal Medicine.

"This is an important study and it illustrates that anyone taking so-called 'weight loss' drugs should be under the care of a trusted physician," said Dr. Donald E. Greydanus, a pediatrician at Michigan State University, who was not involved in the study but has written on obesity treatments.

"There is no safe panacea drug that works and that has no side effects," he told Reuters Health in an email.

Alternative treatments for obesity include diet, exercise, behavior changes and surgery, but all of them have their own problems.

"I think the take-home message should be that patients on orlistat should have their kidney function carefully monitored," Weir said, "but since orlistat is available (over-the-counter) in the US, this may be easier said than done."

Scientists Say They Have Created Human Kidneys From Stem Cells

2011-04-14T06:48:00.000-07:00

British scientists have created human kidneys from stem cells in a breakthrough which could result in transplant patients growing their own organs.

The artificial organs were created in a laboratory using human amniotic fluid and animal foetal cells.

They are currently half a centimetre in length - the same size as kidneys found in an unborn baby.

Scientists at Edinburgh University hope they will grow into full-size organs when transplanted into a human.

The breakthrough could lead to patients creating their own replacement organs without the risk of rejection, a common complication in transplant procedures.

Physiologist Jamie Davies, a professor of experimental anatomy at Edinburgh University, said: 'It sounds a bit science fiction-like but it's not.

'The idea is to start with human stem cells and end up with a functioning organ.

'We have made pretty good progress with that. We can make something that has the complexity of a normal, foetal kidney.'

Edith Helm, 76, first woman to receive kidney transplant

2011-04-12T12:45:00.000-07:00

April 11, 2011|By J.M. Lawrence, Boston Globe Correspondent

Edith Helm was a 20-year-old newlywed from Oklahoma in the spring of 1956 when doctors said she had months to live. Her kidneys were failing fast.

Doctors at what was then Peter Bent Brigham Hospital in Boston had performed the first kidney transplant in history two years earlier. But they had never tried the operation on a woman. Mrs. Helm was the first.

When she died Wednesday at age 76 in Chandler, Okla., from complications of dementia, she was the world’s longest-surviving transplant recipient and the first kidney transplant patient to give birth.

Her kidney came from her identical twin, Wanda Foster, who lives in Davenport, Okla.

“She never brought it up again,’’ Foster said in an interview with the Globe. “It was just like she got her life, and she lived it. That’s what she did.’’

Mrs. Helm worked most of her life as a cook in school cafeterias and at a senior center in Chandler, her sister said. Her greatest joy was her offspring: a son, a daughter, and grandchildren.

As young women, Mrs. Helm and her sister put their trust in their doctors and never looked back.

“I don’t think I even gave an extra thought,’’ Foster said of her decision to give her sister a kidney. “They said it could help her. I really hadn’t thought anything different. That’s what we wanted.’’

Mrs. Helm “was at death’s door’’ when she came to Boston, said Dr. Joseph E. Murray, the last surviving member of the team that performed the first kidney transplants.

“Fortunately, she lived a wonderful life,’’ said Dr. Murray, who is now 92 and lives in Wellesley.

He recalled consulting with a priest before doing the surgery “about the extra danger’’ to a woman of child-bearing age. “We received encouragement,’’ he said. “And the family wanted to go ahead.’’

“We were concerned about the kidney being traumatized by the birth of a baby’s head. We worried around operating on a woman, but we went ahead, after explaining it to the family very carefully,’’ he said.

The first kidney recipient in history was Richard Herrick, who died eight years after his 1954 surgery from problems unrelated to the kidney he received from his twin brother Ronald, who died in December.

Richard Herrick visited Mrs. Helm and her sister in the hospital before their surgery. News photographers later captured Mrs. Helm leaving the hospital with her husband, Lee, a dairy worker, in August 1956.

“I’ve never been operated on before, never been east before, never been on a plane before. This has really been an experience,’’ Mrs. Helm told The Globe then.

Captopril Turns 30 Years Old Today

2011-04-06T13:00:00.000-07:00

Sorry.. been very busy and havent been able to add much to the blog lately.. I am however thrilled to announce the birth of my second son, Grayson Evan Prince last week!

This is a historic day in the history of Nephrology, so I would be remiss if I didnt give a shout out to good 'ol Captopril. The original ACE inhibitor got it's FDA approval 30 years ago today...

Happy 30th Birthday Captopril!

Can't say I use you that much these days.. but, got to show some respect for the granddaddy of the RAS blockers.

More Data Proving ACEi and ARB to be a Bad Combination

2011-03-23T12:17:00.000-07:00

Maximizing the RAS (Renin-Angiotension System) blockade has been a core principle in nephrology for decades. ACE inhibitors came first (Captopril was approved by the FDA on April 6th 1981 (Happy (almost) 30 yr anniversary!)) and remain a very well established class with plenty of solid, supporting data. The ARBs (angiotensin receptor blockers) came next. The data has not been quite as stellar compared to the ACE inhibitors, but the tolerability is exquisite and they are quite popular. The combination of ACE inhibitors and ARBs use was inevitable. Unfortunately, the data has not supported this combo and now there is more damning data out to disappoint the ACEi/ARB enthusiasts.

A population based longitudinal study just published in the Canadian Medical Association Journal adds to the mounting data against the combination use of ACEi and ARB. Monotherapy with either ACEi or ARB was compared with the combination of ACEi/ARB. The results were not pretty for those who still advocate for the combination therapy. Renal dysfunction and hyperkalemia were significantly more prevalent in the combination group.

There still seems to be a limited role for combination therapy particularly in proteinuric renal disease, but patient must be monitored closely. Similarly without compelling positive data, I am against the use of Renin blockers (aliskiren (Tekturna)) with either ACEi or ARB (or all 3?!). Unfortunately some marketeers are supportive of this approach and some practitioners are a bit misguided. All too often these days I see combination ACEi / ARB used solely for blood pressure control... this practice should be discouraged.

Whole Grain Cereal May Help Control Blood Pressure

2011-03-23T05:53:00.000-07:00

TUESDAY, March 22 (HealthDay News) -- Eating breakfast cereal -- especially whole grain cereal -- may reduce the risk of developing high blood pressure, a new study suggests.

"We found about a 20 percent decreased risk of developing hypertension in those who consumed whole grain breakfasts cereals at least seven times a week," said lead researcher Dr. Jinesh Kochar, of Beth Israel Deaconess Medical Center in Boston and the VA Boston Healthcare System.

"Along with other healthy lifestyles, such as low sodium intake and physical activity, getting whole grain from this readily available source can cut down the risk of developing chronic hypertension," he added.

Findings from the study, which received no private industry funding, were scheduled for presentation Tuesday at an American Heart Association conference in Atlanta.

For the study, Kochar's team collected data on 13,368 male doctors who took part in the Physicians Health Study I, a landmark trial begun in 1982.

None of the men had high blood pressure at the start of the study, but during more than 16 years of follow-up, 7,267 men developed hypertension, the researchers found.

High blood pressure, which puts people at risk for heart disease and stroke, is a leading cause of death in the United States. The men were separated into four groups based on their cereal consumption.

When researchers adjusted only for age, they found that the men who ate cereal at least once a week reduced their risk of high blood pressure 8 percent compared with men who ate no cereal. Consuming cereal two to six times a week lowered the risk 16 percent, and eating it seven or more times a week dropped the risk 25 percent.

When Kochar's group adjusted their findings to take into account smoking history, weight, alcohol intake, fruit and vegetable consumption, physical activity and history of diabetes in addition to age, the difference was still significant but smaller -- 12 percent for those eating two to six servings a week and 19 percent for men eating seven or more bowls.

The association with lower blood pressure was stronger for whole grain cereals than refined grain cereals, the researchers found.

Kochar speculates the effect is partly because of whole grain cereal's high fiber content. Whole grains are also a good source of micronutrients, and they increase insulin sensitivity and reduce inflammation, he said.

Commenting on the study, Dr. David L. Katz, director of the Prevention Research Center at Yale University School of Medicine, said that "there has long been evidence that whole grain intake can lower blood pressure fairly acutely, and it is associated with lower blood pressure over time."

A number of mechanisms may produce this beneficial effect, he said. "They contain vitamins and minerals, such as potassium, that may directly relax blood vessels," Katz said. Another contributing factor is soluble fiber, "which helps lower blood sugar, lipid and insulin levels, and, in turn, lowers blood pressure," he added.

There's another obvious, but often overlooked explanation, Katz said: "Eating more whole grains means eating less of something else."

"When one considers the many high-sodium fast-food breakfast options, it may be as much what a bowl of cereal knocks out of one's diet, as what it puts in, that helps lower blood pressure and enhance health," Katz said.

More cereal might mean fewer scones and donuts, for example. Experts note that research presented at meetings has not been subjected to the same type of rigorous scrutiny given to research published in peer-reviewed medical journals.

More information

For more information on hypertension, visit the American Heart Association.

2011 RPA Annual Meeting - Day 3

2011-03-21T09:40:00.001-07:00

Are We Wasting Our Time Chasing Mineral and Bone Metabolic Abnormalities?

2011-03-21T06:00:00.000-07:00

Ouch... wouldnt this be a kick in the proverbial crotch...

After all this time and energy the nephrology community may be under the faulty assumption that abnormalities in biomarkers of mineral metabolism should be routinely treated to improve cardiovascular outcomes in patients with chronic kidney disease. This is what is being suggested by a large meta-analysis publish in the Journal of the American Medical Association (JAMA).

The meta-analysis evaluated 8380 citations and 47 cohort studies (N = 327,644 patients) met the inclusion criteria.

The risk of death increased 18% for every 1-mg/dL increase in serum phosphorus (relative risk [RR], 1.18 [95% confidence interval {CI}, 1.12-1.25]). There was no significant association between all-cause mortality and serum level of parathyroid hormone (RR per 100-pg/mL increase, 1.01 [95% CI, 1.00-1.02]) or serum level of calcium (RR per 1-mg/dL increase, 1.08 [95% CI, 1.00-1.16]). Data for the association between serum level of phosphorus, parathyroid hormone, and calcium and cardiovascular death were each available in only 1 adequately adjusted cohort study. Lack of adjustment for confounding variables was not a major limitation of the available studies.

Conclusions: The evidentiary basis for a strong, consistent, and independent association between serum levels of calcium and parathyroid hormone and the risk of death and cardiovascular events in chronic kidney disease is poor. There appears to be an association between higher serum levels of phosphorus and mortality in this population.

2011 RPA Annual Meeting Day 1

2011-03-20T06:56:00.001-07:00

2011 RPA Annual Meeting Day 2

2011-03-20T06:54:00.000-07:00

Use of Aspirin Associates with Longer Primary Patency of Hemodialysis Grafts

2011-03-20T06:49:00.000-07:00

This a long debated topic... the Journal of the American Society of Nephrology is weighing in with a new study addressing ASA and access patency.

Extended-release dipyridamole plus low-dose aspirin (ERDP/ASA) has been known to prolong primary unassisted graft patency of newly created hemodialysis arteriovenous grafts, but the individual contributions of each component are unknown. This study analyzed whether use of aspirin at baseline associated with primary unassisted graft patency among participants in a randomized trial that compared ERDP/ASA and placebo in newly created grafts.

Use of aspirin at baseline associated with a dose-dependent prolongation of primary unassisted graft patency that approached statistical significance (adjusted HR, 0.83; 95% CI: 0.68 to 1.01; P = 0.06). Use of aspirin at baseline did not associate with prolongation of cumulative graft patency or participant survival. In conclusion, use of aspirin associates with a trend toward longer primary unassisted patency of newly placed hemodialysis grafts similar to that observed for ERDP/ASA.

A trend is not a striking finding... the p value is a bit higher than 0.05 and the CI crosses (barely) 1.0. There are some concerns in this study including the number of patients, the optimal dose of ASA, and follow up being capped at 1 year out. Nevertheless in the absence of a contraindication it may be a good idea to recommend ASA for patients with AVG.

CMS Will Not Change CKD - ESA Policy

2011-03-20T06:35:00.000-07:00

WASHINGTON -- The Centers for Medicare and Medicaid Services (CMS) announced it likely won't change its payment policy on erythropoiesis stimulating agents (ESAs) used to treat anemia in kidney patients.

Currently CMS payment policies for the drugs including epoetin alfa (Procrit and Epogen) and darbepoetin alfa (Aranesp) vary by region.

In a draft decision released Wednesday, CMS indicated it will not issue a national coverage determination (NCD) for ESAs because of a lack of evidence on whether their use makes kidney transplant patients less likely to reject the organ.

"Despite an exhaustive search, we identified no high-quality, randomized clinical trials that were of sufficient design, duration, and power to definitely determine that ESAs provided clinical benefits other than increasing hemoglobin..." CMS wrote in the draft decision.
The agency will seek comments on its proposal to not issue a coverage decision, and will issue a final decision in June.

Wednesday's decision is just what a Medicare Evidence Development & Coverage Advisory Committee (MedCAC) decided in January when it voted that there isn't enough evidence to make any scientific decision on ESAs.

"This is just a reminder how many data there aren't," MedCAC chairman Clifford Goodman, PhD, said after that meeting.

Anemia is a serious problem for kidney disease patients and one that gets worse as the disease progresses. The destruction of renal function in chronic kidney disease patients causes a loss of erythropoietin, which can cause anemia.

ESAs work by replicating erythropoietin, a protein made by the kidney that stimulates bone marrow cells to produce red blood cells. That increase in the number of red blood cells often makes therapeutic transfusions -- the traditional treatment for anemic kidney disease patients -- unnecessary.

Some say that repeated blood transfusions lead to the development of antibodies that fight a transplanted kidney, so eliminating transfusions will make a patient's body more likely to accept the new kidney. And one way to eliminate transfusions is by using ESAs.
But in its proposed memo, CMS officials said they found no evidence to definitively support that claim.

"The evidence for transfusion reduction is limited because of the absence of validated criteria for transfusion, the absence of defined study protocols for transfusion, and the use of noninferiority (or equivalence) study designs that lacked a placebo arm," CMS officials wrote.

The FDA approved the first ESA in 1989.

In recent years, the safety of ESAs has come under scrutiny, and a number of studies were published that linked ESAs to an increased risk of MI, heart failure, stroke, blood clots, and even death.

In March 2007, the FDA required ESAs to carry a black box warning, recommending they be used at the lowest dose necessary to prevent the need for transfusions.

The FDA convened an advisory panel to revisit safety issues of darbepoetin alpha and in October 2010, an FDA panel voted overwhelmingly to recommend that the agency allow continued use of the drug for chronic kidney disease patients who are not on dialysis.
CMS' ultimate decision will have ramifications for those on private insurance as well as Medicare, since private health insurers tend to take their coverage cues from Medicare.

Happy World Kidney Day!

2011-03-10T10:53:00.001-08:00

Kidney Walk 2011 Long Island - MAY 15th @ Hofstra University

2011-03-09T15:58:00.000-08:00

Satellite Healthcare Launches Kidneys Do That Website

2011-03-08T14:01:00.000-08:00

SAN JOSE, Calif.—Satellite Healthcare has launched the informational website KidneysDoThat.org to help raise awareness and answer questions about kidney disease.

“KidneysDoThat.org is a fantastic resource for people whose lives are affected in any way by kidney disease,” said Kim Hernandez, manager of marketing communications for Satellite Healthcare. “There’s a lot of information available online about the disease, but much of it is quite complex and overwhelming. Kidneys Do That was created to educate the online community about our kidneys in a fun, user-friendly and easily accessible format.”

Visitors to KidneysDoThat.org will find straightforward information in clear terms about all things having to do with some of the hardest working organs in our bodies, according to Satellite. Through short informative videos; guides offering kidney health tips; information about diabetes, high blood pressure and high cholesterol (leading contributors to kidney disease); “kidney-friendly” nutritional guidelines; and recipes, the site aims to help anyone who has been diagnosed with kidney disease, cares about someone who has, or is simply seeking to learn more. It also provides connections to useful resources such as how and where to get tested for the disease.

NEJM: Diuretic Strategies in Patients with Acute Decompensated Heart Failure

2011-03-03T07:31:00.000-08:00

Acute decompensated heart failure is the most common cause of hospital admissions among patients older than 65 years of age and is responsible for more than 1 million hospitalizations annually in the United States. Intravenous loop diuretics are an essential component of current treatment and are administered to approximately 90% of patients who are hospitalized with heart failure.2 Despite decades of clinical experience with these agents, prospective data to guide the use of loop diuretics are sparse, and current guidelines are based primarily on expert opinion.

In a prospective, double-blind, randomized trial, we assigned 308 patients with acute decompensated heart failure to receive furosemide administered intravenously by means of either a bolus every 12 hours or continuous infusion and at either a low dose (equivalent to the patient's previous oral dose) or a high dose (2.5 times the previous oral dose). The protocol allowed specified dose adjustments after 48 hours. The coprimary end points were patients' global assessment of symptoms, quantified as the area under the curve (AUC) of the score on a visual-analogue scale over the course of 72 hours, and the change in the serum creatinine level from baseline to 72 hours.

CONCLUSION: Among patients with acute decompensated heart failure, there were no significant differences in patients' global assessment of symptoms or in the change in renal function when diuretic therapy was administered by bolus as compared with continuous infusion or at a high dose as compared with a low dose

FDA Approves Another ARB

2011-02-28T11:11:00.000-08:00

Takeda Pharmaceutical won U.S. approval on Friday to sell a new once-daily pill for adults with high blood pressure called Edarbi (azilsartan medoxomil)

Takeda's medicine, Edarbi, was more effective in clinical trials than two older drugs - Novartis AG's Diovan and Daiichi Sankyo's, Benicar, the Food and Drug Administration said. The company said the studies measured blood pressure at a doctor's office and over a 24-hour period outside a doctor's office.

All three medicines are classified as ARBs or angiotensin receptor blockers. They all lower blood pressure by blocking the action of angiotensin II, a hormone that constricts blood vessels.

Similar to all ACE inhibitors and ARBs, Edarbi will carry a boxed warning, the strongest type for prescription drugs, saying use should be avoided by pregnant women. Taking Edarbi during the second or third trimester can cause injury or death to a fetus, the FDA said.

Higher Education Linked to Lower Blood Pressure

2011-02-28T10:24:00.000-08:00

WASHINGTON — The more advanced degrees a person has, the lower their blood pressure, a study published online has found.

An analysis of some 4,000 patient records from the 30-year Framingham Offspring Study found that, controlling only for age, women with 17 years or more of education -- a master's degree or doctorate -- had systolic blood pressure readings 3.26 millimeters of mercury lower than female high school drop-outs.

Men who went to graduate school had systolic blood pressure readings that were 2.26 mmHg lower than their counterparts who did not finish high school, the study, published online in the open access journal BMC Public Health, says.

The same inverse relationship between education and blood pressure was also seen, although to a lesser degree, in men and women who got associate's or bachelor's degrees at university but did not continue on to graduate school.

They showed greater blood pressure benefits than high school drop-outs but lesser benefits than holders of master's degrees or doctorates, the study found.

Even after controlling for influences such as smoking, drinking, obesity and blood pressure medication, the benefits persisted, although at a lower level.

The study could help explain the widely documented association in developed countries between education and lower risk of heart disease, said lead author Eric Loucks, an assistant professor of public health at Brown University in Rhode Island.

Blood pressure is "one of the biological underpinnings of heart disease," said Loucks, urging policy-makers who want to improve public health to think about improving access to education.

The study focused on systolic blood pressure over diastolic blood pressure because "systolic hypertension is substantially more common than diastolic hypertension, and systolic blood pressure contributes more to the global disease burden attributable to hypertension than diastolic blood pressure."

Survey on Medicare's Kidney Disease Education Benefit

2011-02-28T10:15:00.000-08:00

Survey on Medicare's Kidney Disease Education Benefit

RPA would like to learn about the level of participation by nephrologists/nephrology practices in CKD education. For those who are not utilizing the Kidney Disease Education (KDE) benefit, we would like to learn the reasons for that as well including the perceived obstacles or other issues of concern related to implementing KDE in your practices. We would appreciate if you could take 15 minutes from your day to answer the questions on the survey located at http://www.zoomerang.com/Survey/WEB22BVDGPACHE/.

Vitamin D Supplementation: Is it ClinicallyNecessary?

2011-02-28T07:47:00.000-08:00

By: Alicia Notkin, MD

Drink your milk, soak up some sun, or at least fill your vitamin D prescription?

Over a billion people in the world are thought to have vitamin D deficiency or insufficiency (usually defined as a serum level less than 30mg/ml). Risk factors include old or young age, darker skin, post-menopausal status, and chronic kidney disease (CKD). Deficiency is associated with albuminuria (protein in the urine), hypertension, dyslipidemia, insulin resistance/diabetes, and increased cardiovascular disease and mortality, making it a concern beyond just our bone health.

A recent review in the January issue of the Clinical Journal of the American Society of Nephrology looked at 17 observational trials and 5 randomized controlled trials in which chronic kidney disease and transplant patients were given prescription strength ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3), both forms of 25-hydroxy vitamin D. Renal patients were of particular interest since the kidney is the primary organ that converts 25-hydroxy vitamin D to 1,25-dihydroxy vitamin D (traditionally thought to be the “active” and more clinically relevant form of vitamin D).

The review essentially showed that supplementation increased levels of 25-hydroxy vitamin D, but also decreased levels of parathyroid hormone (elevated in many renal patients and subsequently a player in bone disease in renal patients). There was a small amount of hypercalcemia (defined as a calcium level greater than 10.2 mg/dl) and hyperphosphatemia (defined as a phosphorus level greater than 4.6 mg/dl), the two of which together have, in other studies, been shown to have an association with increased cardiovascular mortality.

Most of the studies included in this review were of low to moderate quality (as higher quality studies are presently unavailable). Additionally, long-term efficacy was not evaluated, and important outcomes such as cardiovascular disease, skeletal effects, and mortality were not evaluated. Furthermore, the appropriate dosing and the possibility of certain groups having particular benefit were not looked into.

So basically, we know that vitamin D deficiency is associated with many common medical conditions (albuminuria, hypertension, etc. as stated above). We know from this article that supplementation can improve the deficiency and also decrease parathyroid hormone release. What we are still left without, though, is whether or not this improvement in the vitamin D level translates to something more clinically important such as mortality… for the vitamin D enthusiasts, we hope it does.

Urine-sniffing Dogs to Screen for Prostate Cancer

2011-02-22T12:51:00.000-08:00

Arnhem, The Netherlands, 7 February 2011 -- In the February 2011 issue of European Urology, Jean-Nicolas Cornu and colleagues reported the evaluation of the efficacy of prostate cancer (PCa) detection by trained dogs on human urine samples. In their article, the researchers affirm that volatiles organic compounds (VOCs) in urine have been proposed as cancer biomarkers.

In the study, a Belgian Malinois shepherd was trained by the clicker training method (operant conditioning) to scent and recognize urine of people having PCa. All urine samples were frozen for preservation and heated to the same temperature for all tests. After a learning phase and a training period of 24 months, the dog's ability to discriminate PCa and control urine was tested in a double-blind procedure.

Urine was obtained from 66 patients referred to an urologist for elevated prostate-specific antigen or abnormal digital rectal examination. All patients underwent prostate biopsy and two groups were considered: 33 patients with cancer and 33 controls presenting negative biopsies. The dog completed all the runs and correctly designated the cancer samples in 30 of 33 cases. Of the three cases wrongly classified as cancer, one patient was re-biopsied and a PCa was diagnosed. The sensitivity and specificity were both 91%.

This study shows that dogs can be trained to detect PCa by smelling urine with a significant success rate. It also suggests that PCa gives an odor signature to urine. Identification of the VOCs involved could lead to a potentially useful screening tool for PCa.

Whether this can be validated or not, it is certainly easier, cheaper and less invasive than a PSA, digital rectal exam and prostate biopsy.

ACO's Beginning to Take Form

2011-02-18T10:04:00.000-08:00

Below is an article from Renal Business Today

By Keith Chartier

Like many physicians, Long Island, N.Y.-nephrologist Simon Prince sees a volatile situation in which more and more physician practices are becoming hospital owned amid a turbulent healthcare landscape.

In fact, a recent survey of 58,000 physicians by the Medical Group Management Association found that 55 percent of physician practices were hospital owned in 2009. In 2008, 50 percent were hospital owned, and approximately 30 percent were five years before.

“There are a lot of reasons in which docs are doing that— decreasing reimbursement, fear of the unknown of what’s coming in healthcare reform and just people throwing the towel and not wanting to deal with it, rising administrative burdens, oversight, tech requirements, etc.,” Prince said.

However, he believes there is still a critical mass of independent, private-practice doctors who like being autonomous. “We still need to come together, because it’s just too hard to remain in your silo,” Prince added. “Those days are over, but private practice still isn’t dead. The sky isn’t falling. There is still some opportunity if we can come together.”

This past summer, Prince spearheaded the development of Beacon IPA, which includes a network of more than 200 local physicians who can share costs, risks and accountability for quality of clinical care. It’s a model that may sound familiar to the healthcare hot topic of the day: accountable care organizations (ACOs).

Prince is well aware of the possibility of ACOs, and has already started laying the groundwork of moving Beacon IPA into an ACO when and if that day comes. In the meantime, the organization is striving to help physicians maintain some semblance of autonomy in a merger-happy world.

“We are striving to evolve into an accountable care organization (ACO) and make a difference in healthcare,” added Prince. “ACOs have rapidly gained importance under the healthcare reform legislation introduced by President Obama. Although many questions remain about the viability of ACOs, we at Beacon embrace its philosophy. Beacon IPA is owned and operated by physicians, and we will make every doctor in our network accountable for their performance. The success of our venture will be of great benefit to all parties involved, including our patients, physicians and insurers.”

ACO Basics

When healthcare reform passed in early 2010, ACOs were tucked deep within the law's pages and weren't on the forefront of the national consciousness. That should change this year as Medicare works to set the rules and regulations that will govern ACOs, which are set to start no later than Jan. 1, 2012.

Under the law, qualifying provider groups are to work together to manage and coordinate care for Medicare fee-for service beneficiaries. In addition, the law stipulates that ACOs that meet quality performance standards are eligible to receive payments for shared savings.

According to the law, the following groups are eligible to participate in ACOs: physicians and practitioners in group practice arrangements, networks of individual practices, partnerships or joint venture arrangements between hospitals and ACO professionals, hospitals employing physicians and practitioners, and any other group Medicare deems appropriate.

Also, an ACO must have an established, formal legal structure, and it will also be required to participate in the program for no less than three years. Another eligibility criterion is that ACOs must have at least 5,000 patients in order to participate. In addition, ACOs are mandated to have a leadership and management structure that includes clinical and administrative systems. ACOs must also have defined processes to promote evidenced-based medicine, report the necessary data to evaluate quality and cost measures (this could incorporate requirements of other programs, such as the Physician Quality Reporting Initiative (PQRI), electronic prescribing (eRx), and electronic health records (EHR), and coordinate care

Shared Risk

It has been argued that the current fee-for-service payment system rewards volume and intensity rather than efficiency and effectiveness of care, often penalizing those systems that attempt to improve care. In contrast, the ACO system, in a perfect world, would reduce cost while increasing quality of care. There are, however, risks.

“What all docs are worried is that you share in the risk,” Prince said of ACOs. “That’s the biggest unknown. Who is going to share in the risk? If they’re going to put the risk back on to the ACO and onto the physician, it’s going to be more difficult and we could start self selecting which patients we want to include in our ACO.”

Click here to read the rest of the article.

Wrong Patient Recieved Kidney Shutting Down USC's Transplant Program

2011-02-18T07:27:00.000-08:00

USC University Hospital halted kidney transplants last month after a kidney was accidentally transplanted into the wrong patient, according to a spokesman for the program that coordinates organ transplants in Los Angeles.
The patient who received the wrong kidney escaped harm, apparently because the kidney happened to be an acceptable match, said Bryan Stewart, spokesman for the program, OneLegacy, which was notified of the error by the hospital.
The hospital, which performs about two transplants a week, confirmed in a statement that it had voluntarily halted transplants Jan. 29 after a "process error" was discovered. The hospital did not detail the nature of the error and declined to answer questions. It said no patients were harmed.
The incident has triggered investigations by the state Department of Public Health and by the United Network for Organ Sharing (UNOS), which oversees the transplant system for the U.S. government. Neither agency has released any findings.
"The hospital inactivated the program while clinical protocols are assessed and additional safeguards to the kidney transplant program are developed," the hospital's statement said.
The hospital said transplants may resume as early as Friday.
The hospital said it notified UNOS on Feb. 4 that it had voluntarily halted the kidney program.

UNOS' review requires the hospital to submit a "corrective action plan" that must be approved by the agency, the hospital said.

RPA February 2011 Public Policy in a Minute

2011-02-15T07:02:00.000-08:00

Top 10 Nephrology Fellowship Programs

2011-02-09T09:44:00.000-08:00

Although the methodology in any list like this is open to criticism and certainly the order may be debatable... but, it is hard to argue with the members of this list. Click here for the gallery courtesy of Renal Business Today.

1. The Mayo School of Graduate Medical Education

2. Johns Hopkins University

3. Cleveland Clinic

4. New York-Presbyterian University Hospital of Columbia and Cornell

5. Massachusetts General Hospital

6. Ronald Reagan UCLA Medical Center

7. University of California, San Francisco Medical Center

8. Barnes-Jewish Hospital

9. Vanderbilt University Medical Center

10. Hospital of the University of Pennsylvania

Wake Forest Baseball Coach Donates Kidney To His Outfielder

2011-02-08T15:41:00.000-08:00

Tom Walter has certainly gone above and beyond what is expected of him as the baseball coach at Wake Forest University. Yesterday morning at Emory University Hospital he donated his kidney to his Freshman OF, Kevin Jordan. Kevin was drafted last year by the New York Yankees in the 19th round last year and had a bright future. But unfortunately he became ill. He lost 30lbs, took a medical leave and was diagnosed with a rapidly progressive ANCA associated vasculitis which culminated in ESRD and he was started on renal replacement therapy with home hemodialysis. But now he is off dialysis and recovering with his baseball coach's transplanted kidney.

Kevin Jordan is hopeful to resume his baseball career next year... with a huge dept of gratitude to his coach.

See related video.

Prevention of Dialysis Catheter Malfunction with TPA

2011-01-28T13:27:00.000-08:00

This is from MedPage as a follow up to the PreCLOT (Prevention of Dialysis Catheter Lumen Occlusion with TPA) Study featured in the New England Journal of Medicine.

The use of rt-PA instead of heparin once weekly (with heparin used the other two treatments), as compared with the use of heparin three times a week, as a locking solution for central venous catheters significantly reduced the incidence of catheter malfunction and bacteremia.

Financial Incentives for Hypertensive Control Fail

2011-01-26T12:08:00.000-08:00

It is simple economics, right? Incentivize to change behavior and influence a positive outcome.

So does pay for performance work? It seems the answer is... sometimes. But not always.

A new interesting study was just published in the British Medical Journal looking at the effect on providing financial incentives to improve performance of physicians in regards to hypertension control.

The conclusion of this study: Pay for performance had no discernible effects on processes of care or on hypertension related clinical outcomes. Generous financial incentives, as designed in the UK pay for performance policy, may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions.

This study can interpreted several ways. I certainly think pay for performance has its place and could yield positive results. But, it is nice to have the supporting data. Here there is seemingly no support for P4P in hypertension control...or is there a flaw in the design of the study? Perhaps the incentive is not large enough to lead to the desired change.Either way, hypertension is a challenging chronic condition and might not be the best suited to test the P4P hypothesis.

"Turns out its bad news bears wen ur wizz is brown"

2011-01-26T11:16:00.000-08:00

Twelve Iowa football players are recovering after being admitted to University of Iowa Hospitals and Clinics Monday evening, the school said in a statement Tuesday.

The university indicated Tuesday that all of the players are out of immediate medical danger but confirmed the need for treatment was "likely related" to offseason drills

Freshman tight end C.J. Fiedorowicz said, "in the hospital ... turns out its bad news bears wen ur wizz is brown" ...words to live by...

Apparently these student athletes had severe rhabdomyolysis as a consequence of strenuous exercise during off-season training sessions.

Rhabdomyolysis is a syndrome characterized by muscle breakdown and the release of intracellular muscle constituents into the circulation. Myoglobin, a heme-containing protein, is released from damaged muscle. Myoglobin is rapidly excreted in the urine, and can lead to the production of red to brown urine. There are several causes of rhabdomyolysis, but often it is self-inflicted and seen in athletes such as marathon runners after prolonged exhaustive exercising. The severity however may range from asymptomatic elevations in serum muscle enzymes to life-threatening cases associated with extreme enzyme elevations, electrolyte imbalances, and acute renal failure which may even require renal replacement therapy. The vast majority of cases are asymptomatic and self-limited.

To guard against this condition it is helpful to use common sense. Listen to your body, please do not overdo it... and stay very well hydrated when engaging in prolonged strenuous activities.

Periodontal Disease and Mortality in Hemodialysis Patients

2011-01-22T12:02:00.000-08:00

The relationship between periodontitis and outcomes in patients treated with long-term hemodialysis has been controversial.

The American Journal of Kidney Diseases has just published a prospective observational study of 253 hemodialysis patients at a single hospital based dialysis unit in Taiwan.

During the 6-year follow-up, 102 patients died. Death occurred in 70.6%, 41.8%, and 24.0% of patients with severe, moderate, and mild/no periodontitis, respectively.

There may be an association between periodontal disease and mortality in HD patients. But, this is a single study from Taiwan. Also, what happens if we aggressively treat periodontal disease? Would that decrease the mortality rate? Should we as nephrologists screen and strongly advocate for periodontal health in our HD patients? How often should we refer our patients to the Dentist? More studies will surely follow.

Kidney Problems Linked to Skipping Heart Meds

2011-01-22T11:39:00.000-08:00

World's First Kidney Donor Dies

2011-01-22T11:35:00.000-08:00

Ronald Herrick, a man who donated a kidney to his dying twin brother 56 years ago in the world's first successful organ transplant has recently died at age 79.

Herrick donated a kidney to his identical twin, Richard, in a pioneering operation on 23 December 1954.

The successful surgery kept Herrick's brother alive for eight years and was the first successful organ transplant, according to the United Network for Organ Sharing. Lead surgeon Dr Joseph Murray went on to win the Nobel prize.

The operation proved that transplants were possible and led to thousands of other successful kidney transplants, and later the transplant of other organs.

Doctors around the world had tried a few transplants before the breakthrough operation, without success, said Murray, who went on to perform another 18 transplants between identical twins.

"This operation rejuvenated the whole field of transplantation," said Murray, 91, who lives in Wellesley, Massachusetts.

"There were other people studying transplants in four or five different countries, but the fact that it worked so well with the identical twins was a tremendous stimulus."

Herrick grew up on a farm in Rutland, Massachusetts, and later served in the US army.

He was 23 when he donated a kidney to his brother, who was dying from chronic nephritis, an inflammation of the kidneys. Murray thought the odds of a transplanted organ being accepted would be enhanced since they were identical twins.

Before the operation, many opposed the idea of transplanting an organ, equating it with desecration of a body. Others argued it was unethical to operate on healthy humans, and editors of medical journals wrote that it was contrary to the Hippocratic oath to never do harm to anyone, Murray said.

But Herrick was not dissuaded from the operation. "He was the only one in the world who could save his brother's life, so he was going to do it," said Cynthia Herrick. "There was no question about it."

sorta NEW BP MED - Nexiclon

2011-01-22T11:31:00.000-08:00

NEXICLON XR is a unique oral form of clonidine that is taken once per day, usually at bedtime. Available in both a liquid and a tablet form, NEXICLON XR allows you to take your medication the way that your doctor decides is best for you. The technology behind NEXICLON XR allows for gradual release of clonidine over an extended period of time, eliminating the need to take the medicine more than once per day.

“The launch of NEXICLON XR is a milestone for our company,” said Jay Shepard, president and CEO of NextWave Pharmaceuticals. “These novel formulations of clonidine will provide unique dosing options for patients. We are proud to showcase it as our first FDA-approved drug. Our mission at NextWave is to develop products, such as NEXICLON XR, that address the unmet needs of patients; we are excited about this launch as well as the further development of other extended-release products we have in our pipeline.”

Well, from someone who prescribes a lot of Clonidine for hypertension, I am glad to see a sustained release oral prep. Funny how the press release didnt speak too much about the cost...

American Heart Association Calling for Further Sodium Reduction

2011-01-22T11:26:00.000-08:00

The American Heart Association has issued a call to action for the public, health professionals, the food industry and the government to intensify efforts to reduce the amount of sodium Americans consume daily.

In an advisory, published in Circulation: Journal of the American Heart Association, the association sets out the science behind the American Heart Association’s recommendation for the general population, which is to consume no more than 1500 milligrams (mg) of sodium a day because of the harmful effects of sodium – elevated blood pressure and increased risk of stroke, heart attacks and kidney disease. Elevated blood pressure (hypertension) is a major public health problem – approximately 90 percent of all Americans will develop hypertension over their lifetime.

Sodium consumption is currently more than two times higher than the recommended upper limit of 1,500 mg daily, with 77 percent of that consumption coming from packaged, processed and restaurant foods. “Even a modest decline in intake – say 400 mg per day –would produce benefits that are substantial and warrant implementation,” say the advisory authors. The 2005 United States Dietary Guidelines for Americans recommended a sodium intake limit of 2,300 mg per day, which many health experts say is too much for most Americans. Earlier this year, the Dietary Guidelines Advisory Committee recommended to the secretaries of the United States Departments of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) that the goal should be modified to 1,500 mg per day for the general population. The advisory committee consists of leading scientists who reviewed the most recent scientific studies and created a set of recommendations that are being reviewed by the secretaries.

American Dietetic Association releases CKD Nutrition Guidelines

2011-01-12T13:57:00.000-08:00

As you may know, we released our eBook, "The Kidney Diet: How to Eat in Order to Protect Your Kidneys and Avoid Dialysis" a few months ago. Now following our lead (I kid, I kid) is the American Dietetic Association.

The American Dietetic Association has released recommendations and ratings for Chronic Kidney Disease (CKD) Evidence-Based Nutrition Practice Guideline.

Family Guy : New Kidney in Town

2011-01-10T12:21:00.000-08:00

For those of you like me who love upscale, high-brow humor must also appreciate, The Family Guy. Flipping around the TV channels last night... lo and behold (I cant believe I just used that in a sentence) there was actually a Family Guy episode that centered around nephrology.

The tough issues relating to the difficulties of living on hemodialysis, the crisis of organ shortage and even xenotransplantation was tackled in this gripping episode. In fact, I hear Peter Griffin may be nominated for a Golden Globe Award.

If you can carve out some time it is worth a viewing... and hopefully yields a few good laughs.

NBC Nightly News Reports - 'Diagnosing dialysis': An investigative report Part 3

2011-01-04T11:27:00.000-08:00

Visit msnbc.com for breaking news, world news, and news about the economy

NBC Nightly News Reports - 'Diagnosing dialysis': An investigative report Part 2

2011-01-04T11:25:00.002-08:00

Visit msnbc.com for breaking news, world news, and news about the economy

NBC Nightly News Reports - 'Diagnosing dialysis': An investigative report

2011-01-04T11:25:00.000-08:00

Visit msnbc.com for breaking news, world news, and news about the economy

Another Triple Drug Pill for HTN Gains FDA Nod

2010-12-28T12:57:00.000-08:00

You knew it was just a matter of time...

After the barrage for angiotensin receptor blocker combination pills, here comes more of the same with the renin inhibitor, aliskiren.

Meet AMTURNIDE, a combination of the direct renin inhibitor, aliskiren - calcium channel blocker, amlodipine - diuretic, hydrochlorothiazide.

Not surprisingly, the adverse reactions mirror that of each of its three components.

The available doses will come in the following flavors:

150 / 5/ 12.5 mg
300 / 5/ 12.5 mg
300 / 5/ 25 mg
300 / 10 / 12.5 mg
300 / 10 / 25 mg

Vegetarian Diet Beneficial in Advanced CKD

2010-12-28T12:10:00.000-08:00

All phosphorous is not created equal.

This is the hypothesis tested in study recently published by the Clinical Journal of the American Society of Nephrology. The researchers, led by Dr Sharon Moe of the Indiana University School of Medicine conducted a small (9 pts), quick (1 week) study of patients with advanced CKD (with an average eGFR 32) to investigate the difference between dietary phosphorous from meat protein versus a vegetarian diet.

Despite equivalent protein and phosphorus concentrations in the two diets, patients had lower blood phosphorus levels and decreased phosphorus excretion in the urine when they were on the vegetarian diet compared with the meat-based diet.

The authors concluded that their study demonstrates that the source of protein in the diet has a significant effect on phosphorus levels in patients with CKD. Therefore, dietary counseling of patients with CKD must include information on not only the amount of phosphorous but also the source of protein from which it derives.

“These results, if confirmed in longer studies, provide rationale for recommending a predominance of grain-based vegetarian sources of protein to patients with CKD. This diet would allow increased protein intake without adversely affecting phosphorus levels,” the researchers wrote.

Online blogging during conferences

2010-12-24T13:47:00.000-08:00

A nice article co-authored by my local nephrologist and blogging colleague, Dr Kenar Jhaveri recently made it into KI. Congrats on the article and thanks for the Uremic Frost mention Kenar... I was wondering why I had a spike in traffic since I have been relatively quiet here lately.

The article examines the utility of the new e-learning methods including blogging, social media, podcasts and videos. It is a worthy read. Please check out Dr Jhaveri's blog, Nephron Power.

Dialysis Patient Citizens

2010-12-16T16:05:00.000-08:00

This is an important site for dialysis patients and one worth highlighting.

DPC is a nonprofit patient organization dedicated to improving dialysis patients’ quality of life by developing awareness of dialysis issues, advocating for dialysis patients, improving the partnership between patients and caregivers, and promoting favorable public policy.

Dialysis Patients Citizens from Prosperitas Worldwide on Vimeo.

Preoperative Proteinuria Predicts Adverse Renal Outcomes after CABG

2010-12-15T15:43:00.000-08:00

Readers of this blog may by now realize I have a particular interest in open heart surgery. I have been involved in countless consultations for pre-op and post-op renal insufficiency.

I often see patients pre-op with diminished GFR and they are at an increased risk for post-op AKI following open heart surgery. Often it is hard to tell and some do better than anticipated, while unfortunately others do worse... and may in fact require renal replacement therapy. While the intra-op variable cannot be minimized, all things being equal it would be nice to better risk stratify patients prior to OHS.

A study published in the Journal of the American Society of Nephrology looked at proteinuria by dipstick prior to OHS to see if it would predict post-op AKI or renal replacement therapy (RRT).

The investigators performed a secondary analysis of a prospectively enrolled cohort of adult patients undergoing coronary artery bypass grafting (CABG) at a medical center and its two affiliate hospitals between 2003 and 2007. This excluded patients with stage 5 CKD or those who received dialysis previously. They defined proteinuria, measured with a dipstick, as mild (trace to 1+) or heavy (2+ to 4+). Among a total of 1052 patients, cardiac surgery–associated acute kidney injury (CSA-AKI) developed in 183 (17.4%) patients and required renal replacement therapy (RRT) in 50 (4.8%) patients. In a multiple logistic regression model, mild and heavy proteinuria each associated with an increased odds of CSA-AKI, independent of CKD stage and the presence of diabetes mellitus (mild: OR 1.66, 95% CI 1.09 to 2.52; heavy: OR 2.30, 95% CI 1.35 to 3.90). Heavy proteinuria also associated with increased odds of postoperative RRT (OR 7.29, 95% CI 3.00 to 17.73).

Although this is one study fraught with issues, this data suggest that preoperative proteinuria is a strong predictor of CSA-AKI among patients undergoing CABG. More studies are needed, but this is not a surprising finding. It is simple, quick and cheap to measure proteinuria and IMHO it should be checked routinely on patients pre-op to risk stratify prior to OHS.

Advancing Interest in Nephrology

2010-12-14T13:04:00.000-08:00

Transplants for HIV Positive Patients

2010-12-14T13:03:00.002-08:00

Incompatible Donors

2010-12-14T13:03:00.001-08:00

Kidney Donor Lifespan and the Perception of Danger

2010-12-14T13:03:00.000-08:00

Wormwood for Poorly Responsive IgA Nephropathy

2010-12-09T10:30:00.000-08:00

Sounds odd, but yes... wormwood may be helpful for patients suffering with IgA Nephropathy (IgAN).

Before we get to this study, you may be asking the same question I did initially.... What is "wormwood"?

Apparently wormwood is a plant (shown here). For more information you can review Wikipedia like I did.

Back to IgAN... There is a general consensus and we typically use RAS (renin-angiotensin system) blockers now as first line therapy. But, unfortunately RAS blockers are not completely effective in most cases of clinically significant IgAN. There was some data on fish oil, but that remains controversial. Recent data has supported the role of TNF (tumor necrosis factor) in the pathogensis of IgAN. In vitro studies have shown that wormwood may decrease TNF levels. Therefore a study was designed to look at wormwood in patients with IgAN. The study was published in this month's American Journal of Kidney Diseases. This was a small pilot study of 10 patients with biopsy proven IgAN, normal kidney funtion and at least a 3 month history of proteinuria between 500-3500 mg /day despite RAS blockers.

The patients took 1.8 grams/ day of the wormwood preparation for 6 months while continuing on the RAS blockers. The results were spectacular with sharp reductions in proteinuria, stable renal function and even decreased mean arterial pressure.

* However, it should go without saying... but, I will say it anyway. This study is a PILOT. It is tiny (10 patients). It is short (6 months). It was not blinded. There was no control group. Creatinine clearance was preserved at baseline. Is the dose chosen for the wormwood prep the optimal dose? What are the long term effects of using wormwood?

Ultimately, wormwood (although fun to say), is not ready for primetime in the treatment of IgAN. But, I suspect there will be follow up studies to examine its possibly exciting potential.

Kidney School Gets Well Deserved Honor

2010-12-02T14:40:00.000-08:00

Kidney School, an excellent online educational site I often refer my patients to has been awarded the 2010 Aesculapius Award of Excellence from the non-profit, Bethesda, Md.-based Health Improvement Institute for excellence in communicating health information on the Web.

Kidney School is a free online education program for people with stages 3–5 chronic kidney disease (CKD). Since its launch in 2002, Kidney School has become the largest CKD education program in the world, reaching nearly 400,000 visitors each year. Kidney School was completely redesigned and updated in 2010.

Sixteen interactive modules written at the 6th-grade reading level let patients and family members learn about kidney disease, treatment options, coping skills, lab test, diet and nutrition, and more. It can be accessed 24/7 at www.kidneyschool.org. No registration is required.

NEJM: The FHN Trial Group

2010-11-22T12:37:00.000-08:00

So, does more = better?

The FHN trial group has just reported their findings in the NEJM.

The researchers aimed to determine whether increasing the frequency of in-center hemodialysis would result in beneficial changes in left ventricular mass, self-reported physical health, and other intermediate outcomes among patients undergoing maintenance hemodialysis.

Patients were randomly assigned to undergo hemodialysis six times per week (frequent hemodialysis, 125 patients) or three times per week (conventional hemodialysis, 120 patients) for 12 months.

Conclusions:

Frequent hemodialysis, as compared with conventional hemodialysis, was associated with favorable results with respect to the composite outcomes of death or change in left ventricular mass and death or change in a physical-health composite score but prompted more frequent interventions related to vascular access. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others)
___

This is not surprising to many of us (including yours truly) who have supported more dialysis. Now there are two big questions. The first question is, who is going to pay for it? The more interesting question I believe is... even if we can prove this is better method of dialyzing patients, and let us take a leap and I will wave a magic wand, the economics work and it gets paid for... will the majority of hemodialysis patients agree to 6 days week?

SHARP Trial Results 2010

2010-11-22T09:58:00.000-08:00

Study of Heart and Renal Protection (SHARP) Study

2010-11-22T09:57:00.000-08:00

The Study of Heart and Renal Protection (SHARP) concluded that around a quarter of all heart attacks, strokes, and operations to open blocked arteries could be avoided in people with chronic kidney disease by using the combination of ezetimibe and simvastatin (Vytorin) to lower blood cholesterol levels.

The SHARP study involved almost 9,500 volunteers aged 40 or over with chronic kidney disease recruited from 380 hospitals in 18 countries. Volunteers were randomly allocated to take either cholesterol-lowering therapy with a tablet containing ezetimibe 10mg daily and simvastatin 20mg daily, or matching dummy "placebo" tablets for an average of 5 years.

Summary of major findings:

Taking the combination of ezetimibe and simvastatin long-term reduced the risk of heart attacks, strokes and operations to open blocked arteries by about one quarter in people with chronic kidney disease, irrespective of the severity of their disease
This combination treatment reduced risk safely, and may be particularly good for kidney patients as it avoids the possibility of side-effects with high statin doses
There was no support for previous concerns with ezetimibe about possible adverse effects on cancer, and no evidence of an increased risk of muscle or liver problems

Could Pomegranate Juice Help or Hurt Dialysis Patients?

2010-11-21T06:01:00.000-08:00

In a study published as an abstract and presented at the ASN conference researchers would a possible link between pomegranate juice and the prevention of infections in dialysis patients.

The rationale for evaluating pomegranate's potential benefits in dialysis patients came from the recognition that oxidative stress and inflammation play a key role in the pathogenesis of kidney disease.

Researchers randomized 101 dialysis patients. Those who consumed pomegranate juice had a rate of first infection-related hospitalization of 32.5/1,000 patient-months compared with 54.9 in the placebo group (P=0.11). The difference in the rate of second infection-related hospitalization achieved statistical significance (3.1 versus 17.9/1,000 patient-months, P=0.01).

First and second hospitalizations for cardiovascular causes were reduced by 36% and 44%, respectively, in patients randomized to pomegranate juice, but did not change in the placebo group.

No adverse effects attributable to the pomegranate juice were observed during the study, said Batya Kristal, MD, of Western Galilee Hospital in Nahariya. However, she pointed out that pomegranates contain high concentrations of potassium, creating a potential for potassium overload in dialysis patients.

And therein lies the rub....

Maybe for those PD patients, or HD patients on a 3K or ones who tend towards hypokalemia. But in general promoting the use of a high potassium drink such as pomegranate juice is a slippery slope.

Renal Sympathetic Nerve Ablation for Resistant Hypertension

2010-11-19T15:53:00.000-08:00

Written by: Jeff Cohen, MD

Hypertension, or high blood pressure, is defined as systolic blood pressure (top number) above 140 millimeters of mercury and/or diastolic blood pressure (bottom number) above 90. It is a quite common disorder, affecting approximately 30% of adult Americans. It is the most common reason for medical office visits for non-pregnant adults, and is the most common reason for prescription medication use. Moreover, it is one of the chief risk factors for heart attack, stroke, kidney disease, and death itself. We tend to estimate that every 20/10-point rise in blood pressure above 120/80 doubles the risk for heart attack or stroke.

While hypertension is treatable with medications, half of all Americans on medications for hypertension maintain blood pressures above 140/90. Therefore, a treatment for hypertension besides medications and lifestyle optimization (low salt intake, aerobic exercise, weight loss for obese patients, alcohol limitation, and smoking cessation) could prove quite valuable. And renal sympathetic nerve ablation (RSNA), the procedure described in Newsday this past Wednesday, may end up being the medical equivalent of gold.

The Newsday article alludes to The Symplicity HTN-2 Trial, published online by Lancet on November 17, 2010. In the trial, fifty-two hypertensive patients underwent the procedure, and their blood pressures dropped on average by 32/12 at the office (down from 178/97 to 146/85). In my opinion, these results are nothing short of incredible. Based on the idea that heart attack/stroke risk doubles with every 20/10 rise in blood pressure, this procedure should more than halve the rate of heart attack and stroke in these patients. It would also notably reduce risk for kidney disease, lessen the need for leg amputation…the list goes on and on.

RSNA, although I have never seen it performed, sounds very much like a cardiac catheterization procedure. It involves placing a catheter into one of the main arteries in the groin (femoral artery), and with x-ray guidance, directing the catheter into the major arteries of the kidneys (renal arteries). Because placement of balloons or stents into vessels is not involved, the procedure is likely not very painful, and should not require much medication for sedation or pain control. Like cardiac catheterization, I would assume the procedure requires less than an hour to perform.

A couple things must be noted. First, the procedure requires intravenous contrast, just like cardiac catheterization. Therefore, patients with kidney dysfunction would be at risk for further loss of kidney function. Second, the trial lasted only six months; we cannot know for certain that the antihypertensive effects from the procedure will persist for years. We also cannot know for sure that the drop in blood pressure from RSNA will translate into a reduction in heart attacks and strokes. Finally, fifty-one of the fifty-two people (98%) who had the procedure performed were Caucasian. Therefore, we don’t know whether other races will benefit from RSNA. It is of particular importance that we test out RSNA in African-Americans given their high rate of uncontrolled hypertension and associated medical complications.

So while RSNA is not yet available to be performed in the U.S. (it is available in England and Austrilia), it has the potential to be one of the top medical breakthroughs of the 21^st century.

RPA- Public Policy in a Minute NOVEMBER

2010-11-16T07:13:00.000-08:00

Diabetes Drug as Cure for Polycystic Kidney Disease?

2010-11-15T15:36:00.000-08:00

CAUTION: we have been down this road before.... but, some new research suggests there maybe another possibility to help those who suffer from PCKD... Actos.

Yes, actos (pioglitazone) a drug used in diabetes has been shown in a rat model to retard the growth of fluid-filled cysts of the most common genetic disorder, polycystic kidney disease. The study is published in the PPAR Research Journal this month.

"We thought that since this class of drugs inhibits the body's chloride channels, then it would be a good candidate to treat PKD, a disease in which excessive chloride and water are transported into the cysts of the kidneys and the liver causing them to expand," said Bonnie L. Blazer-Yost, PhD, professor of biology at the IUPUI School of Science and corresponding author of the new study.

"The idea of using a chloride channel inhibitor to treat PKD is not new. What is new is our finding that an insulin sensitizing agent like pioglitazone inhibits chloride channels. The finding that pioglitazone, which has already been approved by the Food and Drug Administration for diabetes, can halt cyst progression and may be an effective and well-tolerated treatment for this chronic disease, is exciting. Confirmation of these results in other animal models of PKD would be a useful next step."

Most recently it was the disappointment with sirolimus and everolimus... there was some exciting animal model studies that did not pan out when tried in humans. That said, if a PCKD patient has diabetes, Actos may be a fine choice. I would however be cautious in recommending Actos for non-diabetics without more data.

GUEST POST: Osteoporosis in Early CKD

2010-11-15T11:28:00.000-08:00

Addressing and Preventing Osteoporosis in CKD Patients

Osteoporosis is a considerable health concern for many people, but it’s especially prevalent in those who have been diagnosed with CKD. And that means that it’s even more important for CKD patients to take action against bone density loss. Many medications typically used to combat osteoporosis in normal people are questionable for CKD patients because of the potential for complications with thyroid and other issues, but there are alternative ways to address bone density problems. Some of the most noninvasive and potentially successful bone density management strategies for CKD patients are listed below. While it can be frustrating and time-consuming to attack osteoporosis, it’s important to make the commitment and find practical ways to apply professional advice to your unique situation. Here, you’ll find specific recommendations to help you actively implement head knowledge in your everyday life.

Increased Risk Factors

For senior stage 3 CKD patients, studies show that the likelihood of breaking a hip is twice that of an elderly person with normal renal function. It has also been found that dialysis patients are four times more likely to experience hip fractures than normal individuals in the same age group. Because CKD is often accompanied by a mineral and bone disorder, complex abnormalities in the bones themselves are likely to occur. To counteract this phenomenon, natural solutions like supplements, exercise, and maintaining a healthy weight are important considerations. They’re the most effective ways to address the problem without experiencing negative side effects or rendering other medications ineffective.

Natural Vitamin Supplements

There are three main vitamins that can help CKD patients fight off osteoporosis and associated health issues: calcium, vitamin D, and vitamin K.

It’s recommended that you consume 1,000 to 1,200 milligrams of calcium daily in order to maintain good bone health, and foods that can help you attain that amount include calcium-fortified cereal, calcium-fortified soy milk, yogurt, sardines with bones, hard cheeses, and more. For a full list, check out the NIH’s Calcium Factsheet.

At least 600 IUs of Vitamin D every day can help you build up your bone density, too – and because this amount is under review for being potentially low, you can always consume more. Cod liver oil, salmon and other fish, mushrooms exposed to ultraviolet light, vitamin D-fortified orange juice, and many dairy products contain high percentages of what you need (see the Vitamin D Factsheet for more information).

You should be consuming about 80 micrograms of vitamin K, which can prevent weakening and fracturing of bones, each day. It can be found in overwhelmingly high percentages in the following foods: kale, spinach, collard greens, Swiss chard, turnip greens, fresh parsley, romaine lettuce, and more leafy greens. Getting your daily salad can help you fight osteoporosis, so enjoy your vitamin K with your favorite dressing and fixings.

Weight-Bearing Exercise

You can strengthen your bones and muscles with regular weight-bearing exercise, but you’ll have to keep your exercise routine consistent for at least four months in order to start building bone density. It’s tough to be patient, so make sure you understand how important this is to your health, make a strong commitment, and keep it. You can find ways to enjoy your daily exercise by choosing some from the following list that appeal to you, incorporating elements like music, or taking classes with friends. Here are some of the best weight-bearing exercises for CKD patients.

· Brisk walking, jogging, or running – the more weight you can bear, the better, so the fastest pace that’s comfortable for you is best. If you already have trouble with brittle bones, be careful and don’t overdo your workout.

· Aerobics classes – using small free weights and other equipment in addition to your body weight can help you increase bone density.

· Dancing – if you enjoy music and movement, this could be the perfect way for you to fight osteoporosis.

· Racket sports – tennis, racquetball, squash, and other similar games involve a lot of running and encourage you to build your upper body as well.

· Weight lifting – this is probably the most obvious solution, but be careful not to lift too much at first and keep your reps manageable.

· Team sports – try softball, basketball, baseball, football, volleyball, soccer, and any other sport that involves a lot of running and upper body movement.

Be sure to avoid activities that have increased potential for severe falls, such as ice skating, downhill skiing, or even cycling. As frustrating as it may be, you need to limit yourself to safe exercise that can help you develop healthier bone density before attempting more dangerous activities.

Diet Management

Being severely overweight can put undue strain on your bones, but at the same time, losing weight can leach away vital bone density. Weighing in with a normal BMI is a sure sign that you shouldn’t lose any pounds – this will help decrease the risk of losing bone density. Calculate your BMI here and, if you’re not overweight, focus on maintaining your current weight or even gaining a few pounds. If you have CKD, you should consult your doctor before starting any diet or exercise regimen.

Bio: Maria Rainier is a freelance writer and blog junkie. She is currently a resident blogger at First in Education, researching various online programs and blogging about student life issues. In her spare time, she enjoys square-foot gardening, swimming, and avoiding her laptop.

Does Early Initiation of Dialysis Lead to Increased Mortality?

2010-11-12T14:23:00.000-08:00

AMA Releases Social Media Guidelines for Physicians

2010-11-12T03:22:00.000-08:00

The American Medical Association this week adopted a social media use policy to help physicians protect patient privacy, and physicians' personal and professional reputations.

"Using social media can help physicians create a professional presence online, express their personal views and foster relationships, but it can also create new challenges for the patient-physician relationship," says AMA Board Member Mary Anne McCaffree, MD. "The AMA's new policy outlines a number of considerations physicians should weigh when building or maintaining a presence online."

The new policy encourages physicians to:

Use privacy settings to safeguard personal information on social networking sites.
Monitor their own Internet presence to ensure that the personal and professional information on their own sites and content posted about them by others, is accurate and appropriate.
Maintain appropriate boundaries of the patient-physician relationship when interacting with patients online and ensure patient privacy and confidentiality is maintained.
Consider separating personal and professional content online.
Recognize that actions online and content posted can negatively affect their reputations among patients and colleagues, and may even have consequences for their medical careers.

The policy on professionalism when using social media was adopted this week at AMA's semi-annual policy making meeting in San Diego.

Archives of Internal Medicine: Early Start of Hemodialysis May Be Harmful

2010-11-11T13:19:00.000-08:00

the Atlantic: “God Help You. You're on Dialysis.”

2010-11-10T16:19:00.000-08:00

"Every year, more than 100,000 Americans start dialysis. One in four of them will die within 12 months—a fatality rate that is one of the worst in the industrialized world. Oh, and dialysis arguably costs more here than anywhere else. Although taxpayers cover most of the bill, the government has kept confidential clinic data that could help patients make better decisions. How did our first foray into near-universal coverage, begun four decades ago with such great hope, turn out this way? And what lessons does it hold for the future of health-care reform?"

This is from the December 2010 edition of Atlantic Magazine.... an intriguing article worthy of a read.

NPR Podcast: Medicare's Chief MD Speaks About Dialysis

2010-11-10T12:52:00.000-08:00