Objectives The study objective was to assess the association between angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) use and mortality in patients with chronic ...kidney disease (CKD). Background There is insufficient evidence about the association of ACEI or ARBs with mortality in patients with CKD. Methods A logistic regression analysis was used to calculate the propensity of ACEI/ARB initiation in 141,413 U.S. veterans with nondialysis CKD who were previously unexposed to ACEI/ARB treatment. We examined the association of ACEI/ARB administration with all-cause mortality in patients matched by propensity scores using the Kaplan-Meier method and Cox models in “intention-to-treat” analyses and in generalized linear models with binary outcomes and inverse probability of treatment weights in “as-treated” analyses. Results The age of the patients at baseline was 75 ± 10 years, 8% of patients were black, and 22% were diabetic. ACEI/ARB administration was associated with a significantly lower risk of mortality both in the intention-to-treat analysis (hazard ratio: 0.81, 95% confidence interval: 0.78 to 0.84; p < 0.001) and the as-treated analysis with inverse probability of treatment weights (odds ratio: 0.37, 95% confidence interval: 0.34 to 0.41; p < 0.001). The association of ACEI/ARB treatment with lower risk of mortality was present in all examined subgroups. Conclusions In this large contemporary cohort of nondialysis-dependent patients with CKD, ACEI/ARB administration was associated with greater survival.
Background Black dialysis patients have significantly lower mortality compared with white patients, in contradistinction to the higher mortality seen in blacks in the general population. It is ...unclear whether a similar paradox exists in patients with non–dialysis-dependent chronic kidney disease (CKD), and if it does, what its underlying reasons are. Study Design Historical cohort. Setting & Participants 518,406 white and 52,402 black male US veterans with non–dialysis-dependent CKD stages 3-5. Predictor Black race. Outcomes & Measurements We examined overall and CKD stage–specific all-cause mortality using parametric survival models. The effect of sociodemographic characteristics, comorbid conditions, and laboratory characteristics on the observed differences was explored in multivariable models. Results During a median follow-up of 4.7 years, 172,093 patients died (mortality rate, 71.0 95% CI, 70.6-71.3 per 1,000 patient-years). Black race was associated with significantly lower crude mortality (HR, 0.95; 95% CI, 0.94-0.97; P < 0.001). The survival advantage was attenuated after adjustment for age (HR, 1.14; 95% CI, 1.12-1.16), but was magnified after full multivariable adjustment (HR, 0.72; 95% CI, 0.70-0.73; P < 0.001). The unadjusted survival advantage of blacks was more prominent in those with more advanced stages of CKD, but CKD stage–specific differences were attenuated by multivariable adjustment. Limitations Exclusively male patients. Conclusions Black patients with CKD have lower mortality compared with white patients. The survival advantage seen in blacks is accentuated in patients with more advanced stages of CKD, which may be explained by changes in case-mix and laboratory characteristics occurring during the course of kidney disease.
Background In contrast to the general population, higher body mass index (BMI) is associated with greater survival in patients receiving hemodialysis (HD; “obesity paradox”). We hypothesized that ...this paradoxical association between BMI and death may be modified by age and dialysis vintage. Study Design Retrospective observational study using a large HD patient cohort. Setting & Participants 123,383 maintenance HD patients treated in DaVita dialysis clinics between July 1, 2001, and June 30, 2006, with follow-up through September 30, 2009. Predictors Age, dialysis vintage, and time-averaged BMI. Time-averaged BMI was divided into 6 subgroups; <18.5, 18.5-<23.0, 23.0-<25.0, 25.0-<30.0, 30.0-<35.0, and ≥35.0 kg/m2 . BMI category of 23-<25 kg/m2 was used as the reference category. Outcomes All-cause, cardiovascular, and infection-related mortality. Results Mean BMI of study participants was 27 ± 7 kg/m2 . Time-averaged BMI was <18.5 and ≥35 kg/m2 in 5% and 11% of patients, respectively. With progressively higher time-averaged BMI, there was progressively lower all-cause, cardiovascular, and infection-related mortality in patients younger than 65 years. In those 65 years or older, even though overweight/obese patients had lower mortality compared with underweight/normal-weight patients, sequential increases in time-averaged BMI > 25 kg/m2 added no additional benefit. Based on dialysis vintage, incident HD patients had greater all-cause and cardiovascular survival benefit with a higher time-averaged BMI compared with the longer term HD patients. Limitations Causality cannot be determined, and residual confounding cannot be excluded given the observational study design. Conclusions Higher BMI is associated with lower death risk across all age and dialysis vintage groups. This benefit is more pronounced in incident HD patients and those younger than 65 years. Given the robustness of the survival advantage of higher BMI, examining interventions to maintain or even increase dry weight in HD patients irrespective of age and vintage are warranted.
Outcomes Associated With Microalbuminuria Kovesdy, Csaba P., MD; Lott, Evan H; Lu, Jun Ling, MD ...
Journal of the American College of Cardiology,
04/2013, Letnik:
61, Številka:
15
Journal Article
Recenzirano
Odprti dostop
Objectives This study sought to compare the association of microalbuminuria with outcomes in patients with different comorbidities. Background The risk of adverse outcomes associated with lower ...levels proteinuria has been found to be linearly decreasing with even low-normal levels of microalbuminuria. It is unclear whether comorbid conditions change these associations. Methods We examined the association of urine microalbumin-creatinine ratio (UACR) with mortality and the slopes of estimated glomerular filtration rate (eGFR) in a nationally representative cohort of 298,875 U.S. veterans. Associations of UACR with all-cause mortality overall and in subgroups of patients with and without diabetes mellitus, hypertension, cardiovascular disease, congestive heart failure, and advanced chronic kidney disease (CKD) were examined in Cox models, and with the slopes of eGFR in linear and logistic regression models. Results Very low levels of UACR were linearly associated with decreased mortality and less progression of CKD overall: adjusted mortality hazard ratio and estimated glomerular filtration rate slope (95% confidence interval CI) associated with UACR ≥200 μg/mg, compared to <5 μg/mg were 1.53 (95% CI: 1.38 to 1.69, p < 0.001) and −1.59 (95% CI: −1.83 to −1.35, p < 0.001). Similar linearity was present in all examined subgroups, except in patients with CKD in whom a U-shaped association was present and in whom a UACR of 10 to 19 was associated with the best outcomes. Conclusions The association of UACR with mortality and with progressive CKD is modified in patients with CKD, who experience higher mortality and worse progression of CKD with the lowest levels of UACR. Proteinuria-lowering interventions in patients with advanced CKD should be implemented cautiously, considering the potential for adverse outcomes.
Abstract Purpose Hyperglycemia during or after cardiac surgery is a common finding that is associated with poor outcome. Very few data, however, are available regarding a correlation between ...admission blood glucose and outcomes after coronary artery bypass grafting (CABG). Thus, the goal of the current study was to examine the relationship between admission blood glucose and outcome after emergency CABG surgery. Materials and Methods A retrospective analysis to evaluate whether admission hyperglycemia associated with increased morbidity or mortality was performed in patients after emergency CABG surgery. The records of all the patients undergoing emergency CABG surgery between January 1999 and December 2010 at the University of Virginia Health System were reviewed. Postoperative in-hospital mortality and complications were considered as study end points. Results A total of 240 patients met the final inclusion criteria. Overall mortality was 14.1%. The median admission blood glucose in patients who died 7.4 (interquartile range, 5.9-10.1) mmol/L was significantly higher compared with survivors 6.1 (interquartile range, 5.4-7.2; P < .01). Furthermore, 59% of the patients who died had admission blood glucose levels higher than 6.6 mmol/L, whereas only 35% of the patients who survived had similar blood glucose levels ( P = .01). On multivariable analysis, admission blood glucose was identified as an independent risk factor for death after emergency CABG ( P = .01; odds ratio, 1.16; 95% confidence interval, 1.04-1.29). Admission blood glucose was further identified as independently associated with increased risk for a composite outcome of death, postoperative renal failure or stroke ( P = .01; odds ratio, 1.14; 95% confidence interval, 1.03-1.27). Conclusions Our study shows for the first time that admission blood glucose is correlated with increased morbidity and mortality among patients undergoing emergency CABG surgery.
Objective The purpose of this study was to examine the effect of perioperative statin administration on renal outcomes after cardiac surgery. Design A retrospective chart review. Setting A university ...hospital. Participants Patients presenting for cardiac surgery. Interventions The records of 2,760 patients admitted for coronary artery bypass graft (CABG) surgery from 1997 to 2006 were reviewed. In-hospital mortality, the need for renal replacement therapy (RRT), and acute renal failure (ARF) were considered the primary outcomes. Univariate and multiple logistic regression analyses were performed to assess the relationship between each outcome and statin therapy while adjusting for other patient characteristics. Main Results Of the 2,760 patients, 1,557 were taking preoperative statins. On univariate analysis, the mortality rate for patients receiving statins was 2.4% versus 4.2% for those not receiving statins ( p = 0.008). The requirement for RRT was 1.9% for patients receiving statins versus 3.6% for those not receiving statins ( p = 0.011). The incidence of ARF was not statistically significant between groups (28% v 27.5%). On multivariate analysis, statin therapy was associated with a 43% decrease in the risk of death and a 46% decrease in the risk of RRT, but statins were not associated with a decreased risk of ARF. Also, the beneficial effects of statins were age-dependent, with younger patients experiencing a greater advantage. Conclusions The preoperative use of statins is associated with decreased in-hospital mortality and a reduction in the need for RRT.
Summary In this Health Policy article, we selected and reviewed evidence synthesised by nine knowledge networks established by WHO to support the Commission on the Social Determinants of Health. We ...have indicated the part that national governments and civil society can play in reducing health inequity. Government action can take three forms: (1) as provider or guarantor of human rights and essential services; (2) as facilitator of policy frameworks that provide the basis for equitable health improvement; and (3) as gatherer and monitor of data about their populations in ways that generate health information about mortality and morbidity and data about health equity. We use examples from the knowledge networks to illustrate some of the options governments have in fulfilling this role. Civil society takes many forms: here, we have used examples of community groups and social movements. Governments and civil society can have important positive roles in addressing health inequity if political will exists.
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