NN&I - May 2010
Clinical www.nephronline.comMay 2010 Nephrology News & Issues 31Lab testing can direct care to high-risk patientsNew research indicates that automated laboratory reporting is associated with a significant increase in patient refer -rals to a kidney specialist.A study published in the March 24-31 issue of the Journal of the American Medical Association by Brenda R. Hemmelgarn, MD, PhD, and colleagues of the University of Calgary in Canada evaluated the association of estimated glomerular filtration rate (GFR) reporting with referral to a neph-rologist, health care resource use, and management of patients with CKD. The community-based study includ-ed more than 1.1 million (1,135,968) participants who were identified from a laboratory database in Alberta, Pre-dialysis care impacts survivalPre-dialysis care can improve survival rates in the first year of treatment, new findings presented at the National Kidney Foundation's Spring Clinical Meetings show.Records were reviewed of 192,307 patients who started dialysis between June 1, 2005, and May 31, 2007, to investigate whether those with a good access and adequate hemoglobin and albumin levels would have a survival advantage. Fifty-nine percent did not have any of the three criteria, 30% had one, 9% achieved two, and just 2% had met all three goals. The more goals achieved, the more likely a patient was to survive; com-pared to people who had met none of the goals, people meeting one goal had a 19% lower risk of death; meeting two goals cut death risk by 47%; and meeting every goal reduced mortality by 66%.The goal that brought the biggest survival benefit was having an arterio- venous graft or fistula in place, which in itself reduced mortality 44%. Optimum albumin levels reduced mortality by 33%, while adequate hemoglobin reduced death risk by 6%. Compiled by Rebecca ZumoffCanada, and followed up from May 2003 to March 2007.After a three-month transition peri-od following estimated GFR reporting, the rate of first outpatient patient visits to a nephrologist (estimated GFR less than 60 mL/min/1.73 m2) increased significantly, corresponding to a rela -tive increase of 68% from the beginning of the study. This rate of increase was even greater for participants with esti-mated GFR of less than 30 mL/min/1.73 m2, the group for whom current clini-cal practice guidelines emphasize the value of timely nephrologist referrals. For these patients, women experienced a greater increase in the rate of first visits to a nephrologist. There was no increase for men, and the increase was predominantly seen in patients ages 46 to 65 and those 86 years or older, as well as those with hypertension, diabe -tes, and other co-existing illnesses.Among patients without CKD, there was no association between estimated GFR reporting and rate of first outpatient nephrologist visits. The rate of all outpa-tient nephrologist visits for patients with CKD following estimated GFR reporting (including visits among individuals with and without prior nephrologist visits) also increased significantly.Vitamin D levels have different effects on atherosclerosis in blacks and whitesEvidence from a Wake Forest University School of Medicine study suggests that supplementing vitamin D may have different effects based on patient race. In black individuals, the supplement could actually do harm. The study is the first to show a positive relationship between calcified plaque in large arteries and circulat -ing vitamin D levels in black patients. It appears in the March issue of the Journal of Clinical Endocrinology and Metabolism . "We found that higher cir -culating levels of vitamin D in blacks were associated with more calcium in the artery walls," said study lead investigator Barry I. Freedman, MD, of the Wake Forest University School of Medicine. "This is the opposite effect of what is felt to occur in white patients and shows that the accepted 'normal' range of vitamin D may be different between blacks and whites." Blacks generally have lower vitamin D levels than whites, partly because their darker skin pigmentation limits the amount of the vitamin produced by sunlight. Blacks also consume fewer dairy products and ingest less dietary calcium than whites, said Freedman, who is with the Maya Angelou Center for Health Equity at Wake Forest. Despite these lower vitamin D levels and dietary calcium ingestion, blacks naturally experience lower rates of osteoporosis and have far less calcium in their arteries. Studies further reveal that black patients with diabetes have half as many heart attacks as whites, when provided with equal access to health care. This shows that lower lev-els of calcified atherosclerotic plaque in blacks are associated with a lower risk of heart disease. However, blacks in the general community have higher rates of heart attack than whites, potentially due to unequal access to medical care, Freedman said. Clinical_NNI0510_5.indd 31 4/16/10 11:40:09 AM
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