Suboptimal blood pressure control in chronic kidney disease stage 3: baseline data from a cohort study in primary care

BACKGROUND: Poorly controlled hypertension is independently associated with mortality, cardiovascular risk and disease progression in chronic kidney disease (CKD). In the UK, CKD stage 3 is principally managed in primary care, including blood pressure (BP) management. Controlling BP is key to improving outcomes in CKD. This study aimed to investigate associations of BP control in people with CKD stage 3. METHODS: 1,741 patients with CKD 3 recruited from 32 general practices for the Renal Risk in Derby Study underwent medical history, clinical assessment and biochemistry testing. BP control was assessed by three standards: National Institute for Health and Clinical Excellence (NICE), National Kidney Foundation Kidney Disease Outcome Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Descriptive statistics were used to compare characteristics of people achieving and not achieving BP control. Univariate and multivariate logistic regression was used to identify factors associated with BP control. RESULTS: The prevalence of hypertension was 88%. Among people with hypertension, 829/1426 (58.1%) achieved NICE BP targets, 512/1426 (35.9%) KDOQI targets and 859/1426 (60.2%) KDIGO targets. Smaller proportions of people with diabetes and/or albuminuria achieved hypertension targets. 615/1426 (43.1%) were only taking one antihypertensive agent. On multivariable analysis, BP control (NICE and KDIGO) was negatively associated with age (NICE odds ratio (OR) 0.27; 95% confidence interval (95% CI) 0.17-0.43) 70–79 compared to <60), diabetes (OR 0.32; 95% CI 0.25-0.43)), and albuminuria (OR 0.56; 95% CI 0.42-0.74)). For the KDOQI target, there was also association with males (OR 0.76; 95% CI 0.60-0.96)) but not diabetes (target not diabetes specific). Older people were less likely to achieve systolic targets (NICE target OR 0.17 (95% CI 0.09,0.32) p < 0.001) and more likely to achieve diastolic targets (OR 2.35 (95% CI 1.11,4.96) p < 0.001) for people >80 compared to < 60). CONCLUSIONS: Suboptimal BP control was common in CKD patients with hypertension in this study, particularly those at highest risk of adverse outcomes due to diabetes and or albuminuria. This study suggests there is scope for improving BP control in people with CKD by using more antihypertensive agents in combination while considering issues of adherence and potential side effects

Inventory Signals

How does operational competence translate into market value, when firms cannot credibly communicate their competence to the market? I consider the example of inventory and fill rates. When the market sees a high-inventory firm, it cannot tell whether the inventory is due to incompetence or a strategy to enhance fill rate. Firms might decide to signal their competence to the market by carrying less inventory. I show conditions for separating and pooling perfect Bayesian equilibria. I also provide empirical evidence for this theory that inventory has a signaling role. The theory could potentially provide a framework that describes one way in which a range of operational competences such as purchasing and outsourcing, translate to market value. Practically, it has implications for firms, such as how to strategically communicate to the market, reward managers, or even whether to go public and be subject to market pressures

Effect of prostaglandin inhibition on sodium chloride reabsorption in the diluting segment of the conscious dog

Effect of prostaglandin inhibition on sodium chloride in the diluting segment of the conscious dog. To determine if renal prostaglandins (PG) affect sodium chloride transport in the diluting segment, we measured the free water clearance (CH2O) during a control phase (C) and again 7 days later during an experimental phase (E) with indomethacin or carprofan (to induce acute prostaglandin inhibition) in each of 10 conscious dogs. In five studies, E preceeded C by 7 days. After a water diuresis was established (UOsm < 70 mOsm/kg), the animals were infused with progressively increasing rates of hypotonic sodium chloride. Before sodium chloride was infused, urinary PGE excretion rate was less in E than it was in C and remained so during all hypotonic expansion periods. At each infusion rate, CH2O in C and E did not differ. GFR, degree of volume expansion, medullary and papillary solutes, serum sodium and serum potassium concentrations, and blood pressure in C and E did not differ. At maximum delivery rates, fractional sodium reabsorption in the diluting segment was not different in C and E; also fractional sodium excretion was not different in C and E. Conclusion. The observation that suppression of PGE excretion does not affect CH2O suggests that renal PGE does not modify sodium chloride transport in the ascending limb of the loop of Henle's water-diuresing mechanism of the conscious dog.Effet de l'inhibition des prostaglandins sur la réabsorption de chlorure de sodium par le segment de dilution chez le chien éveillé. Afin de déterminer si les prostaglandines rénales (PG) affectent le transport de chlorure de sodium dans le segment de dilution, la clearance de l'eau libre (CH2O) a été mesurée pendant la période de contrôle (C) et à nouveau 7 jours plus tard durant une phase expérimentale (E) au cours de l'inhibition des prostaglandines par l'indométhacine ou le carprofan chez 10 chiens éveillés. Dans 5 expériences, E a précédé C de 7 jours. Après qu'une diurèse aqueuse ait été établie (UOsm < 70 mOsm/kg), les animaux ont reçu des débits progressivement croissants de chlorure de sodium hypotonique. Avant l'administration de chlorure de sodium, l'excrétion urinaire de PGE était plus basse pendant E que pendant C et l'est demeurée pendant toute l'expansion hypotonique. Pour chaque débit de perfusion CH2O pendant C et E n'était pas différente. Le débit de filtration glomérulaire, le degré d'expansion, les substances dissoutes contenues dans la médullaire, la natrémie, la kaliémie, et la pression artérielle n'étaient pas différents entre C et E. Aux débits de perfusion les plus élevés, la réabsorption fractionnelle du sodium dans le segment de dilution n'était pas différente entre C et E; il en était de même pour l'excrétion fractionnelle du sodium. En conclusion, l'observation de l'absence d'effet sur CH2O de la suppression de l'excrétion de PGE suggère que PGE rénale ne modifie pas le transport de chlorure de sodium dans la branche ascendante de l'anse de Henle chez le chien éveillé, en diurèse aqueuse

Renal association clinical practice guideline in post-operative care in the kidney transplant recipient

These guidelines cover the care of patients from the period following kidney transplantation until the transplant is no longer working or the patient dies. During the early phase prevention of acute rejection and infection are the priority. After around 3-6 months, the priorities change to preservation of transplant function and avoiding the long-term complications of immunosuppressive medication (the medication used to suppress the immune system to prevent rejection). The topics discussed include organization of outpatient follow up, immunosuppressive medication, treatment of acute and chronic rejection, and prevention of complications. The potential complications discussed include heart disease, infection, cancer, bone disease and blood disorders. There is also a section on contraception and reproductive issues.Immediately after the introduction there is a statement of all the recommendations. These recommendations are written in a language that we think should be understandable by many patients, relatives, carers and other interested people. Consequently we have not reworded or restated them in this lay summary. They are graded 1 or 2 depending on the strength of the recommendation by the authors, and AD depending on the quality of the evidence that the recommendation is based on