Only a minority of patients with CKD progress to renal failure. Despite the potential benefits of risk stratification in the CKD population, risk prediction models are not routinely used. Our ...objective was to develop and externally validate a clinically useful and pragmatic prediction model for the 5-year risk of progression to RRT in stage 3 or 4 CKD.
We used a retrospective cohort design. The development cohort consisted of 22,460 Kaiser Permanente Northwest members with stage 3 or 4 CKD (baseline 2002-2008). The validation cohort consisted of 16,553 Kaiser Permanente Colorado members with stage 3-4 CKD (baseline 2006-2008). The final model included eight predictors: age, sex, eGFR, hemoglobin, proteinuria/albuminuria, systolic BP, antihypertensive medication use, and diabetes and its complications.
In the Northwest and Colorado cohorts, there were 737 and 360 events, and observed 5-year Kaplan-Meier risks of 4.72% (95% confidence interval 95% CI, 4.38 to 5.06) and 2.57% (95% CI, 2.30 to 2.83), respectively. Our prediction model performed extremely well in the development cohort, with a c-statistic of 0.96, an R
of 79.7%, and good calibration. We had similarly good performance in the external validation cohort, with a c-statistic of 0.95, R
of 81.2%, and good calibration. In the external validation cohort, the observed risk was slightly lower than the predicted risk in the highest-risk quintile. Using the top quintile of predicted risk as a cutpoint gave a sensitivity of 92.2%.
We developed a pragmatic prediction model and risk score for predicting the 5-year RRT risk in stage 3 and 4 CKD. This model uses variables that are typically available in routine primary care settings, and can be used to help guide important decisions such as timing of referral to nephrology and fistula placement.
Abstract Background We assessed the prevalence of preserved left ventricular ejection fraction in patients with incident heart failure and differences in the demographic and clinical characteristics ...that may differentiate patients presenting with heart failure with preserved versus reduced left ventricular ejection fraction. Methods We identified all patients with newly diagnosed heart failure between 2005 and 2008 from 4 sites in the Cardiovascular Research Network on the basis of hospital discharge and ambulatory visit diagnoses, and assigned a category of preserved, borderline, or reduced left ventricular ejection fraction using data from electronic databases and chart review. Results We identified 11,994 patients with incident heart failure; of these, 6210 (51.8%) had preserved left ventricular ejection fraction, 1870 (15.6%) had borderline systolic dysfunction, and 3914 (32.6%) had reduced left ventricular ejection fraction. For those with heart failure with preserved left ventricular ejection fraction, the mean age was 74.7 years and 57.1% were women; for those with borderline systolic dysfunction, the mean age was 71.6 years and 38.4% were women; and for those with reduced left ventricular ejection fraction, the mean age was 69.1 years and 32.6% were women. Compared with white patients, black patients were less likely to have heart failure with preserved systolic function. Those with a history of coronary artery bypass surgery, mitral or aortic valvular disease, atrial fibrillation or flutter, or a diagnosis of hypertension were more likely to have heart failure with preserved systolic function, as were those with a diverse range of noncardiac comorbid conditions, including chronic lung disease, chronic liver disease, a history of a hospitalized bleed, a history of a mechanical fall, a diagnosis of depression, and a diagnosis of dementia. Patients with a history of acute myocardial infarction and a history of ventricular fibrillation or ventricular tachycardia were less likely to have heart failure with preserved left ventricular ejection fraction. Patients with higher systolic blood pressures at baseline and lower low-density lipoprotein levels were more likely to have heart failure with preserved left ventricular ejection fraction, as were those with lower hemoglobin levels and the lowest glomerular filtration rates. Conclusions Heart failure with preserved left ventricular ejection fraction is the most common form of the heart failure syndrome among patients newly presenting with this condition, and women and older adults are especially affected. Evidence-based treatment strategies apply to less than one third of patients with newly diagnosed heart failure.
Systolic BP and Mortality in Older Adults with CKD Weiss, Jessica W; Peters, Dawn; Yang, Xiuhai ...
Clinical journal of the American Society of Nephrology,
09/2015, Letnik:
10, Številka:
9
Journal Article
Recenzirano
Odprti dostop
Optimal BP targets for older adults with CKD are unclear. This study sought to determine whether a nonlinear relationship between BP and mortality-as described for the broader CKD population and for ...older adults in the general population-is present for older adults with CKD.
A cohort of 21,015 adults age 65-105 years with a moderate or severe reduction in eGFR (<60 ml/min per 1.73 m(2)) were identified within the Kaiser Permanente Northwest Health Maintenance Organization population. The relationship between baseline systolic BP (SBP; ≤120, 121-130, 131-140, 141-150, >150 mmHg; referent, 131-140 mmHg) and all-cause mortality across age groups (65-70, 71-80, and >80 years) was examined; patients were followed for up to 11 years after cohort entry.
The median times at risk were 3.15 years, 3.53 years, and 2.76 years for adults age 65-70, 71-80, and >80 years, respectively. Mortality during follow-up was 19.6% for those age 65-70 years, 33.4% for those age 71-80 years, and 55.7% for those age >80 years. The relationship between SBP and mortality varied as a function of age. The risk of death was highest for patients with the lowest SBP in all age groups. Only among adults age 65-70 years was an SBP>140 mmHg associated with a higher risk of death compared with the referent category. Patterns of age modification of the relationship between SBP and mortality were consistent in all sensitivity analyses.
In a cohort of older adults, the relationship between SBP and mortality varied systematically with age. A relationship between higher SBP and mortality was present only for younger members of this cohort and not for those older than 70. These results raise the question of whether the relative benefits and harms of lowering BP to recommended targets for older adults with CKD may vary as a function of age.
There is scant evidence on the effect that chronic kidney disease (CKD) confers on clinically meaningful outcomes among patients with heart failure with preserved left ventricular ejection fraction ...(HF-PEF).
We identified a community-based cohort of patients with HF. Electronic medical record data were used to divide into HF-PEF and reduced left ventricular EF on the basis of quantitative and qualitative estimates. Level of CKD was assessed by estimated glomerular filtration rate (eGFR) and by dipstick proteinuria. We followed patients for a median of 22.1 months for outcomes of death and hospitalization (HF-specific and all-cause). Multivariable Cox regression estimated the adjusted relative-risk of outcomes by level of CKD, separately for HF-PEF and HF with reduced left ventricular EF. We identified 14 579 patients with HF-PEF and 9762 with HF with reduced left ventricular EF. When compared with patients with eGFR between 60 and 89 mL/min per 1.73 m(2), lower eGFR was associated with an independent graded increased risk of death and hospitalization. For example, among patients with HF-PEF, the risk of death was nearly double for eGFR 15 to 29 mL/min per 1.73 m(2) and 7× higher for eGFR<15 mL/min per 1.73 m(2), with similar findings in those with HF with reduced left ventricular EF.
CKD is common and an important independent predictor of death and hospitalization in adults with HF across the spectrum of left ventricular systolic function. Our study highlights the need to develop new and effective interventions for the growing number of patients with HF complicated by CKD.
Background Providers need a reliable way to identify patients with chronic kidney disease (CKD) at the highest risk of progression to end-stage renal disease so they can intervene to slow progression ...and refer patients to nephrology for comanagement. We developed a risk score to predict the 5-year risk of renal replacement therapy (RRT) in patients with stage 3 or 4 CKD. Study Design Retrospective cohort study. Setting & Participants Participants were members of a health maintenance organization and met Kidney Disease Outcomes Quality Initiative criteria for stage 3 or 4 CKD during 1999 or 2000: two estimated glomerular filtration rate values of 15 to 59 mL/min/1.73 m2. Predictor Characteristics collected during routine clinical practice. Outcomes & Measurements We ascertained the onset of RRT (dialysis or kidney transplantation) using the health maintenance organization databases. Cox regression predicted patient risk of RRT and generated a risk scoring system. Results 9,782 patients experienced a 3.3% five-year progression to RRT (95% confidence interval, 2.9 to 3.7). Using 6 characteristics (age, sex, estimated glomerular filtration rate, diabetes, anemia, and hypertension), the risk score discriminated the highest risk patients effectively: 19.0% of patients in the highest risk quintile experienced progression, and 0.2% of patients in the lowest risk quintile experienced progression. The c statistic also showed effective discrimination: 0.89 on a scale of 0.5 to 1.0. Predicted and observed risks agreed within 1.0%—effective calibration. We present a range of predicted risk cutoff values from 1% to 20% and their test properties for decision makers' consideration. Limitations Characteristics were measured without a protocol. Conclusions The risk score can help providers identify patients with CKD at the highest risk of progression to improve referral to nephrology for comanagement. A separate risk score for mortality also is needed.
Achievement of quality metrics in chronic kidney disease (CKD), specifically urinary albumin testing and angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use, ...remained lower in Kaiser Permanente Northwest compared with other Kaiser Permanente regions. We were interested if more frequent testing of urine albumin (ACR) improved CKD quality metrics.
We implemented a quality improvement project automating ACR testing using an informatics tool in patients with stage 3 CKD linked to an electronic health record (EHR) alert recommending ACEi or ARB initiation in patients with renal indication.
At 1 and 2 years after implementation of ACR testing, ACR testing increased from 26.9% prior to implementation to 83% at 1 year and 77% at 2 year after implementation (p < 0.001). However, ACEi or ARB use did not increase significantly (65.8% vs 65.7% vs 66.4%, p = 0.54). There was also no significant change in other quality metrics, including diabetes control, hypertension control, and comanagement of higher-risk CKD patients.
In patients with stage 3 CKD, increased ACR testing via automated testing linked with EHR alert did not result in an improvement in CKD quality metrics.
Background Prognostic risk scores can help clinicians intervene on higher risk patients and counsel them. Our objective is to identify characteristics that predict the rate of progression to renal ...replacement therapy (RRT) and evaluate how those characteristics predict mortality and a composite end point (RRT and mortality). Study Design Retrospective cohort study. Setting & Participants We conducted the study at Kaiser Permanente Northwest, a health maintenance organization. We followed up members with an estimated glomerular filtration rate (eGFR) that indicated chronic kidney disease (2 eGFRs < 60 mL/min/1.73 m2 <1.0 mL/s/1.73 m2 at least 90 days apart). Predictors We measured baseline clinical characteristics between January 1997 and June 2000 by using electronic medical records and patients’ histories of hospitalization. Outcomes & Measurements We calculated adjusted hazard ratios and concordance statistics for progression to RRT, mortality, and the composite by using Cox regression. Results Patients (n = 6,541) were followed up for up to 5 years. We observed 1.6 progressions to RRT/100 person-years and 11.4 deaths/100 person-years. The 6 characteristics of age, sex, eGFR, diabetes, hypertension, and anemia predicted RRT effectively (c statistic, 0.91). However, hypertension and age predicted in the opposite direction for mortality and its composite end point. The c statistic decreased: mortality (0.70), mortality and RRT (0.71). Limitations Characteristics were measured without a protocol; extensive missing data prevented the evaluation of known risk factors (eg, proteinuria). Conclusions Predicting RRT effectively requires a separate risk score. Predicting the composite end point would favor characteristics that predict mortality because it is 7 times as common as RRT.
Identifying heart failure patients most likely to suffer poor outcomes is an essential part of delivering interventions to those most likely to benefit. We sought a comprehensive account of heart ...failure events and their cumulative economic burden by examining patient characteristics that predict increased cost or poor outcomes.
We collected electronic medical data from members of a large HMO who had a heart failure diagnosis and an echocardiogram from 1999-2004, and followed them for one year. We examined the role of demographics, clinical and laboratory findings, comorbid disease and whether the heart failure was incident, as well as mortality. We used regression methods appropriate for censored cost data.
Of the 4,696 patients, 8% were incident. Several diseases were associated with significantly higher and economically relevant cost changes, including atrial fibrillation (15% higher), coronary artery disease (14% higher), chronic lung disease (29% higher), depression (36% higher), diabetes (38% higher) and hyperlipidemia (21% higher). Some factors were associated with costs in a counterintuitive fashion (i.e. lower costs in the presence of the factor) including age, ejection fraction and anemia. But anemia and ejection fraction were also associated with a higher death rate.
Close control of factors that are independently associated with higher cost or poor outcomes may be important for disease management. Analysis of costs in a disease like heart failure that has a high death rate underscores the need for economic methods to consider how mortality should best be considered in costing studies.
Individuality of the plasma sodium concentration Zhang, Zheng; Duckart, Jonathan; Slatore, Christopher G ...
American journal of physiology. Renal physiology,
06/2014, Letnik:
306, Številka:
12
Journal Article
Recenzirano
Odprti dostop
Older literature has suggested that the plasma sodium concentration is not individual, that it is neither intrinsic to an individual nor reproducible, longitudinally. We recently observed that the ...plasma sodium concentration is heritable. Because demonstrable heritability requires individuality of the relevant phenotype, we hypothesized that the plasma sodium concentration was substantially individual. In two large health plan-based cohorts, we demonstrated individuality of the plasma sodium concentration over a 10-yr interval; the intraclass correlation coefficient (ICC) averaged 0.4-0.5. The individuality of plasma sodium increased significantly with age. Plasma sodium individuality was equal to or only slightly less than that for plasma glucose but was less than the individuality for creatinine. The individuality of plasma sodium was further confirmed by comparing the Pearson correlation coefficient for within-individual versus between-individual pairs of sodium determinations and via application of the agreement index. Furthermore, the distribution of all sodium determinations for all participants within a population was similar to the distribution for the mean sodium concentration for individuals within that population. Therefore, the near-normal distribution of plasma sodium measurements within a population is likely not attributable to assay-specific factors but rather to genuine and durable biological variability in the osmotic set point. In aggregate, these data strongly support the individuality of the plasma sodium concentration. They further indicate that serial plasma sodium values for any given individual tend to cluster around a patient-specific set point and that these set points vary among individuals.
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