Glycemic Control and Cardiovascular Mortality in Hemodialysis Patients With Diabetes

Previous observational studies using differing methodologies have yielded inconsistent results regarding the association between glycemic control and outcomes in diabetic patients receiving maintenance hemodialysis (MHD). We examined mortality predictability of A1C and random serum glucose over time in a contemporary cohort of 54,757 diabetic MHD patients (age 63 ± 13 years, 51% men, 30% African Americans, 19% Hispanics). Adjusted all-cause death hazard ratio (HR) for baseline A1C increments of 8.0–8.9, 9.0–9.9, and ≥10%, compared with 7.0–7.9% (reference), was 1.06 (95% CI 1.01–1.12), 1.05 (0.99–1.12), and 1.19 (1.12–1.28), respectively, and for time-averaged A1C was 1.11 (1.05–1.16), 1.36 (1.27–1.45), and 1.59 (1.46–1.72). A symmetric increase in mortality also occurred with time-averaged A1C levels in the low range (6.0–6.9%, HR 1.05 [95% CI 1.01–1.08]; 5.0–5.9%, 1.08 [1.04–1.11], and ≤5%, 1.35 [1.29–1.42]) compared with 7.0–7.9% in fully adjusted models. Adjusted all-cause death HR for time-averaged blood glucose 175–199, 200–249, 250–299, and ≥300 mg/dL, compared with 150–175 mg/dL (reference), was 1.03 (95% CI 0.99–1.07), 1.14 (1.10–1.19), 1.30 (1.23–1.37), and 1.66 (1.56–1.76), respectively. Hence, poor glycemic control (A1C ≥8% or serum glucose ≥200 mg/dL) appears to be associated with high all-cause and cardiovascular death in MHD patients. Very low glycemic levels are also associated with high mortality risk

Impact of Race on Hyperparathyroidism, Mineral Disarrays, Administered Vitamin D Mimetic, and Survival in Hemodialysis Patients

Blacks have high rates of chronic kidney disease, are overrepresented among the US dialysis patients, have higher parathyroid hormone levels, but greater survival compared to nonblacks. We hypothesized that mineral and bone disorders (MBDs) have a bearing on survival advantages of black hemodialysis patients. In 139,328 thrice-weekly treated hemodialysis patients, including 32% blacks, in a large dialysis organization, where most laboratory values were measured monthly for up to 60 months (July 2001 to June 2006), we examined differences across races in measures of MBDs and survival predictabilities of these markers and administered the active vitamin D medication paricalcitol. Across each age increment, blacks had higher serum calcium and parathyroid hormone (PTH) levels and almost the same serum phosphorus and alkaline phosphatase levels and were more likely to receive injectable active vitamin D in the dialysis clinic, mostly paricalcitol, at higher doses than nonblacks. Racial differences existed in mortality predictabilities of different ranges of serum calcium, phosphorus, and PTH but not alkaline phosphatase. Blacks who received the highest dose of paricalcitol (>10 µg/week) had a demonstrable survival advantage over nonblacks (case-mix-adjusted death hazard ratio = 0.87, 95% confidence level 0.83–0.91) compared with those who received lower doses (<10 µg/week) or no active vitamin D. Hence, in black hemodialysis patients, hyperparathyroidism and hypercalcemia are more prevalent than in nonblacks, whereas hyperphosphatemia or hyperphosphatasemia are not. Survival advantages of blacks appear restricted to those receiving higher doses of active vitamin D. Examining the effect of MBD modulation on racial survival disparities of hemodialysis patients is warranted. © 2010 American Society for Bone and Mineral Research

Impact of Age, Race and Ethnicity on Dialysis Patient Survival and Kidney Transplantation Disparities

BACKGROUND: Prior studies show that African-American and Hispanic dialysis patients have lower mortality risk than whites. Recent age-stratified analyses suggest this survival advantage may be limited to younger age groups, but did not concurrently compare Hispanic, African-American, and white patients, nor account for differences in nutritional and inflammatory status as potential confounders. Minorities experience inequities in kidney transplantation access, but it is unknown whether these racial/ethnic disparities differ across age groups. METHODS: The associations between race/ethnicity with all-cause mortality and kidney transplantation were separately examined among 130,909 adult dialysis patients from a large national dialysis organization (entry period 2001-2006, follow-up through 2009) within 7 age categories using Cox proportional hazard models adjusted for case-mix and malnutrition and inflammatory surrogates. RESULTS: African-Americans had similar mortality vs. whites in younger age groups (18-40 years), but decreased mortality in older age groups (>40 years). In contrast, Hispanics had lower mortality vs. whites across all ages. In sensitivity analyses using competing risk regression to account for differential kidney transplantation rates across racial/ethnic groups, the African-American survival advantage was limited to >60 year old age categories. African-Americans and Hispanics were less likely to undergo kidney transplantation from all donor types vs. whites across all ages, and these disparities were even more pronounced for living donor kidney transplantations (LDKT). CONCLUSIONS: Hispanic dialysis patients have greater survival vs. whites across all ages; in African-Americans, this survival advantage is limited to patients >40 years old. Minorities are less likely to undergo kidney transplantation, particularly LDKT, across all ages

Outcomes Associated with a Disease Management Program for End-Stage Renal Disease

Disease-state management is gaining in use for the management of chronically ill individuals including those with diabetes mellitus, congestive heart failure, asthma, and some forms of cancer. Recently, disease management (DM) has been applied to patients with chronic kidney disease (CKD), a growing population of patients with high annual costs. CKD is ideally suited to DM since the definition of the condition is unambiguous and current care is highly fragmented. There are currently over 240 000 patients receiving dialysis for end-stage renal disease (ESRD), with projected numbers of nearly 600 000 by 2010, and nearly 9 million individuals with CKD not yet on dialysis. The total cost of care for patients with ESRD alone exceeded $US17 billion in 2000. Over 40% of costs for patients with ESRD result from hospitalizations, many of which can be avoided. In addition, much of the clinical morbidity and cost relates to associated comorbidities rather than ESRD per se, with little management presently provided for these conditions in the dialysis facility setting. DM for CKD uses field-based nurse care managers who can risk-assess patients and provide coordination of care so that the renal issues as well as comorbidities are identified and appropriately managed. Although few results from such efforts have been published, those that have, from RMS Disease Mnagement Inc., show remarkable improvements in a variety of clinical outcomes including mortality and hospitalization. Challenges to expanding DM for CKD include up-front funding to provide the needed DM, the availability of robust information systems to manage and analyze clinical and financial data, and the interest and participation of nephrologists, primary care providers and dialysis facilities, as well as other key providers to ensure that the DM approach is effective. With continuing increases in the number of patients with CKD in managed health plans, DM for this population will be even more important in the future to optimize clinical outcomes while constraining the costs of care.Disease management programmes, Kidney disorders, Pharmacoeconomics