Nephrology

SAN DIEGO – Subsyndromal delirium was present in 86% of critically ill patients, results from a large observational study demonstrated. In addition, the duration of delirium was associated with increased odds of institutionalization, an association that was modified by the duration of delirium.

"In patients with less delirium, the effect of subsyndromal delirium on institutionalization was actually stronger," lead author Dr. Nathan E. Brummel said in an interview at an international conference of the American Thoracic Society, where the research was presented. "This identifies a cohort of people who previously were considered to have normal brain function, but it appears that this has long-term implications for their lives.

"Screening for delirium should occur not only in the ICU but on the wards as well. Patients who have delirium or delirium symptoms may benefit from measures used to prevent and treat this syndrome, such as the Hospital Elder Life Program, routine mobilization, and frequent reorientation through the use of nursing staff or even family members," he later added. This study data may help clinicians discuss long-term outcomes of critical illness with patients and their family members," he said.

For the study, Dr. Brummel, an instructor in medicine in the division of allergy, pulmonary and critical care medicine at Vanderbilt University Medical Center, Nashville, Tenn., and his associates evaluated 821 medical or surgical ICU patients with respiratory failure and/or shock who were enrolled in the BRAIN-ICU observational cohort study (N. Engl. J. Med. 2013;369:1306-16).

They used the Confusion Assessment Method for the ICU (CAM-ICU) to screen for delirium symptoms twice daily in the ICU and daily thereafter. The researchers considered delirium to be present if the CAM-ICU was positive. If the CAM-ICU was negative, they considered subsyndromal delirium (SSD) to be present if any delirium features were present or if inattention was present with or without other features of delirium.

SSD "is said to be present when a patient exhibits some delirium symptoms but does not meet the full delirium diagnostic criteria," the researchers wrote in their poster. "In patients without critical illness, SSD is associated with institutionalization, mortality, and cognitive decline, but these associations remain unclear in the critically ill."

The researchers tracked discharge location, mortality after hospital discharge and assessed for cognitive impairment at 3 and 12 months follow-up and used multivariate regression to determine the relationship between days of SSD and outcomes.

The mean age of the 821 patients was 61 years and their mean APACHE II score was 25. In all, 702 patients (86%) had SSD that lasted an average of 3 days. The most common SSU pattern based on the CAM-ICU was fluctuation of mental status (which occurred in 50% of assessments) and fluctuation in mental status plus altered level of consciousness (which occurred in 22% of assessments).

Dr. Brummel and his associates also found that the duration of SSD was independently associated with increased odds of institutionalization (odds ratio, 1.90), but SSD did not predict mortality or long-term cognitive impairment at 3 or 12 months. "We don’t yet understand the mechanism behind why subsyndromal delirium and institutionalization are associated," Dr. Brummel said. "It probably relates to an association between SSD and factors that drive institutionalization, such as physical disability and cognitive impairment. Once patients survived the hospital stay, subsyndromal delirium wasn’t associated with an increased risk of mortality. It may be the fact that this less severe form of brain dysfunction in the ICU does not have the same effect as the full syndrome of delirium."

He acknowledged certain limitations of the study, including the fact that the CAM-ICU only measures four features of delirium and that no assessments of cognitive or physical function were conducted at hospital discharge.

The study was supported by the National Institutes of Health, the Vanderbilt Clinical and Translational Scholars Program, and the Veterans Affairs Tennessee Valley Healthcare System Geriatric Research Education and Clinical Centers. Dr. Brummel said that he had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Subsyndromal delirium was present in 86% of critically ill patients, results from a large observational study demonstrated. In addition, the duration of delirium was associated with increased odds of institutionalization, an association that was modified by the duration of delirium.

"In patients with less delirium, the effect of subsyndromal delirium on institutionalization was actually stronger," lead author Dr. Nathan E. Brummel said in an interview at an international conference of the American Thoracic Society, where the research was presented. "This identifies a cohort of people who previously were considered to have normal brain function, but it appears that this has long-term implications for their lives.

"Screening for delirium should occur not only in the ICU but on the wards as well. Patients who have delirium or delirium symptoms may benefit from measures used to prevent and treat this syndrome, such as the Hospital Elder Life Program, routine mobilization, and frequent reorientation through the use of nursing staff or even family members," he later added. This study data may help clinicians discuss long-term outcomes of critical illness with patients and their family members," he said.

For the study, Dr. Brummel, an instructor in medicine in the division of allergy, pulmonary and critical care medicine at Vanderbilt University Medical Center, Nashville, Tenn., and his associates evaluated 821 medical or surgical ICU patients with respiratory failure and/or shock who were enrolled in the BRAIN-ICU observational cohort study (N. Engl. J. Med. 2013;369:1306-16).

They used the Confusion Assessment Method for the ICU (CAM-ICU) to screen for delirium symptoms twice daily in the ICU and daily thereafter. The researchers considered delirium to be present if the CAM-ICU was positive. If the CAM-ICU was negative, they considered subsyndromal delirium (SSD) to be present if any delirium features were present or if inattention was present with or without other features of delirium.

SSD "is said to be present when a patient exhibits some delirium symptoms but does not meet the full delirium diagnostic criteria," the researchers wrote in their poster. "In patients without critical illness, SSD is associated with institutionalization, mortality, and cognitive decline, but these associations remain unclear in the critically ill."

The researchers tracked discharge location, mortality after hospital discharge and assessed for cognitive impairment at 3 and 12 months follow-up and used multivariate regression to determine the relationship between days of SSD and outcomes.

The mean age of the 821 patients was 61 years and their mean APACHE II score was 25. In all, 702 patients (86%) had SSD that lasted an average of 3 days. The most common SSU pattern based on the CAM-ICU was fluctuation of mental status (which occurred in 50% of assessments) and fluctuation in mental status plus altered level of consciousness (which occurred in 22% of assessments).

Dr. Brummel and his associates also found that the duration of SSD was independently associated with increased odds of institutionalization (odds ratio, 1.90), but SSD did not predict mortality or long-term cognitive impairment at 3 or 12 months. "We don’t yet understand the mechanism behind why subsyndromal delirium and institutionalization are associated," Dr. Brummel said. "It probably relates to an association between SSD and factors that drive institutionalization, such as physical disability and cognitive impairment. Once patients survived the hospital stay, subsyndromal delirium wasn’t associated with an increased risk of mortality. It may be the fact that this less severe form of brain dysfunction in the ICU does not have the same effect as the full syndrome of delirium."

He acknowledged certain limitations of the study, including the fact that the CAM-ICU only measures four features of delirium and that no assessments of cognitive or physical function were conducted at hospital discharge.

The study was supported by the National Institutes of Health, the Vanderbilt Clinical and Translational Scholars Program, and the Veterans Affairs Tennessee Valley Healthcare System Geriatric Research Education and Clinical Centers. Dr. Brummel said that he had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Subsyndromal delirium was present in 86% of critically ill patients, results from a large observational study demonstrated. In addition, the duration of delirium was associated with increased odds of institutionalization, an association that was modified by the duration of delirium.

"In patients with less delirium, the effect of subsyndromal delirium on institutionalization was actually stronger," lead author Dr. Nathan E. Brummel said in an interview at an international conference of the American Thoracic Society, where the research was presented. "This identifies a cohort of people who previously were considered to have normal brain function, but it appears that this has long-term implications for their lives.

"Screening for delirium should occur not only in the ICU but on the wards as well. Patients who have delirium or delirium symptoms may benefit from measures used to prevent and treat this syndrome, such as the Hospital Elder Life Program, routine mobilization, and frequent reorientation through the use of nursing staff or even family members," he later added. This study data may help clinicians discuss long-term outcomes of critical illness with patients and their family members," he said.

For the study, Dr. Brummel, an instructor in medicine in the division of allergy, pulmonary and critical care medicine at Vanderbilt University Medical Center, Nashville, Tenn., and his associates evaluated 821 medical or surgical ICU patients with respiratory failure and/or shock who were enrolled in the BRAIN-ICU observational cohort study (N. Engl. J. Med. 2013;369:1306-16).

They used the Confusion Assessment Method for the ICU (CAM-ICU) to screen for delirium symptoms twice daily in the ICU and daily thereafter. The researchers considered delirium to be present if the CAM-ICU was positive. If the CAM-ICU was negative, they considered subsyndromal delirium (SSD) to be present if any delirium features were present or if inattention was present with or without other features of delirium.

SSD "is said to be present when a patient exhibits some delirium symptoms but does not meet the full delirium diagnostic criteria," the researchers wrote in their poster. "In patients without critical illness, SSD is associated with institutionalization, mortality, and cognitive decline, but these associations remain unclear in the critically ill."

The researchers tracked discharge location, mortality after hospital discharge and assessed for cognitive impairment at 3 and 12 months follow-up and used multivariate regression to determine the relationship between days of SSD and outcomes.

The mean age of the 821 patients was 61 years and their mean APACHE II score was 25. In all, 702 patients (86%) had SSD that lasted an average of 3 days. The most common SSU pattern based on the CAM-ICU was fluctuation of mental status (which occurred in 50% of assessments) and fluctuation in mental status plus altered level of consciousness (which occurred in 22% of assessments).

Dr. Brummel and his associates also found that the duration of SSD was independently associated with increased odds of institutionalization (odds ratio, 1.90), but SSD did not predict mortality or long-term cognitive impairment at 3 or 12 months. "We don’t yet understand the mechanism behind why subsyndromal delirium and institutionalization are associated," Dr. Brummel said. "It probably relates to an association between SSD and factors that drive institutionalization, such as physical disability and cognitive impairment. Once patients survived the hospital stay, subsyndromal delirium wasn’t associated with an increased risk of mortality. It may be the fact that this less severe form of brain dysfunction in the ICU does not have the same effect as the full syndrome of delirium."

He acknowledged certain limitations of the study, including the fact that the CAM-ICU only measures four features of delirium and that no assessments of cognitive or physical function were conducted at hospital discharge.

The study was supported by the National Institutes of Health, the Vanderbilt Clinical and Translational Scholars Program, and the Veterans Affairs Tennessee Valley Healthcare System Geriatric Research Education and Clinical Centers. Dr. Brummel said that he had no relevant financial conflicts to disclose.

[email protected]

LAS VEGAS – Many barriers to chronic kidney disease detection and screening exist in today’s health care landscape, according to Dr. Georges Saab.

For one thing, patient have a lack of knowledge about chronic kidney disease (CKD) and receive very little education about it, explained Dr. Saab of the department of medicine at Case Western Reserve University and MetroHealth Medical Center, Cleveland.

Patients lack education about CKD "because they don’t ask about it," Dr. Saab said at a meeting sponsored by the National Kidney Foundation. "They know about their hypertension, diabetes, and cholesterol, but they don’t know about kidney disease; they don’t take medications for kidney disease, so they fail to recognize it as a distinct entity."

He noted that some primary care physicians feel they lack the knowledge and skills to educate patients on CKD. Thus, measures to enhance these skills are needed. Others are not familiar with published CKD screening guidelines, and among those that are, the recommendations are not consistent in whom to screen.

Dr. Saab called for ways to improve physician and patient education on risk factors for CKD and on the impact of the disease. Such information is available from the National Kidney Foundation and the National Kidney Disease Education Program. Recently, the National Kidney Foundation launched the CKD Primary Care Initiative to identify and overcome barriers to CKD testing, detection, and management in the primary care setting. The NKF’s CKD Primary Care Initiative will disseminate CKD guidelines to PCPs around the United States through education programs, symposia, and practical implementation tools.

Other strategies that could be used include implementing clinical reminders to screen for CKD in high-risk groups, routine reporting of estimated glomerular filtration rate (eGFR), incentivizing providers for higher-quality care, including screening for CKD, and providing patients with access to their laboratory data. He notes that patients themselves may initiate the process of referral to a nephrologist if given access to their results.

Community-based screening also has the potential to eliminate or mitigate some of the patient and physician barriers to screening. Dr. Saab cited the NKF’s Kidney Early Evaluation Program (KEEP) as an example. Between 2000 and 2013, KEEP reached more than 185,000 individuals at increased risk for developing CKD. The KEEP program "is free, it’s in a nonmedical location, such as a church or town hall, and it’s managed by a trained staff and nephrologists," Dr. Saab said of the program. "It’s also short in duration – it only takes about 45 minutes – and it’s focused on CKD and related issues."

Of KEEP data collected through 2010, roughly 20% of participants were found to have CKD (Am. J. Kidney Dis. 2012;60:692-3. At the time of screening, patients are asked if they’re aware if they have any kidney problems or not. Awareness increased from 8.8% in 2000-2002 to 16.6% in 2009-2011, "which means that the message is getting out there, and patients are getting screened a little more commonly than they were before," he said.

Community screening for CKD appears to increase patient awareness of chronic kidney disease, "and it may indirectly lead to increased screening in clinical encounters," Dr. Saab said. "For example, KEEP reports sent to PCPs may influence screening and detection, and friends and family members of those screened may also seek screening."

Another community-based initiative is the NKF’s KEEP Healthy program, designed to educate people about the kidneys and risk factors for kidney disease. A check-up for participants includes a risk survey, body mass index, blood pressure check, free educational materials, and an opportunity to speak with a health care professional.

"Awareness of CKD is low," Dr. Peter A. McCullough, chair of the NKF’s Kidney Early Evaluation Program Steering Committee, said during a separate presentation at the meeting. "We have to get to levels of awareness of diabetes, heart disease, and cancer. In kidney disease, we haven’t gotten there yet. I haven’t seen a single data set where [awareness] is more than 50%."

In his opinion, clinicians should screen for CKD with KEEP Healthy and other clinical and community approaches, "because it raises awareness for risk factors and CKD, it potentially triggers better risk factor control, it potentially helps avoid additional insults along the way, and it readies for the next steps."

Dr. Saab acknowledged limitations of community-based screening, including the fact that isolated measurements may lead to misclassification. "But that is usually the case in all screening processes," he added. "It also requires external funding, and it does attract patients who are motivated to be screened, so you may not necessarily be catching the people who aren’t aware of CKD."

Electronic health records also have the potential to improve CKD screening and detection, he said. For example, a record query can be designed to extract variables that may impact detection or screening, including those at the patient, physician, or institutional level.

"You can also identify potential patients to be screened who don’t have eGFR or albuminuria assessment," Dr. Saab said, including the elderly and those with cardiovascular disease or obesity.

The remedy for improving current shortfalls in CKD screening and detection is likely to involve some combination of amendments to clinical encounters, community-based screening, and electronic health record queries, Dr. Saab predicted.

Dr. Saab said that he had no relevant financial disclosures.

[email protected]

LAS VEGAS – Many barriers to chronic kidney disease detection and screening exist in today’s health care landscape, according to Dr. Georges Saab.

For one thing, patient have a lack of knowledge about chronic kidney disease (CKD) and receive very little education about it, explained Dr. Saab of the department of medicine at Case Western Reserve University and MetroHealth Medical Center, Cleveland.

Patients lack education about CKD "because they don’t ask about it," Dr. Saab said at a meeting sponsored by the National Kidney Foundation. "They know about their hypertension, diabetes, and cholesterol, but they don’t know about kidney disease; they don’t take medications for kidney disease, so they fail to recognize it as a distinct entity."

He noted that some primary care physicians feel they lack the knowledge and skills to educate patients on CKD. Thus, measures to enhance these skills are needed. Others are not familiar with published CKD screening guidelines, and among those that are, the recommendations are not consistent in whom to screen.

Dr. Saab called for ways to improve physician and patient education on risk factors for CKD and on the impact of the disease. Such information is available from the National Kidney Foundation and the National Kidney Disease Education Program. Recently, the National Kidney Foundation launched the CKD Primary Care Initiative to identify and overcome barriers to CKD testing, detection, and management in the primary care setting. The NKF’s CKD Primary Care Initiative will disseminate CKD guidelines to PCPs around the United States through education programs, symposia, and practical implementation tools.

Other strategies that could be used include implementing clinical reminders to screen for CKD in high-risk groups, routine reporting of estimated glomerular filtration rate (eGFR), incentivizing providers for higher-quality care, including screening for CKD, and providing patients with access to their laboratory data. He notes that patients themselves may initiate the process of referral to a nephrologist if given access to their results.

Community-based screening also has the potential to eliminate or mitigate some of the patient and physician barriers to screening. Dr. Saab cited the NKF’s Kidney Early Evaluation Program (KEEP) as an example. Between 2000 and 2013, KEEP reached more than 185,000 individuals at increased risk for developing CKD. The KEEP program "is free, it’s in a nonmedical location, such as a church or town hall, and it’s managed by a trained staff and nephrologists," Dr. Saab said of the program. "It’s also short in duration – it only takes about 45 minutes – and it’s focused on CKD and related issues."

Of KEEP data collected through 2010, roughly 20% of participants were found to have CKD (Am. J. Kidney Dis. 2012;60:692-3. At the time of screening, patients are asked if they’re aware if they have any kidney problems or not. Awareness increased from 8.8% in 2000-2002 to 16.6% in 2009-2011, "which means that the message is getting out there, and patients are getting screened a little more commonly than they were before," he said.

Community screening for CKD appears to increase patient awareness of chronic kidney disease, "and it may indirectly lead to increased screening in clinical encounters," Dr. Saab said. "For example, KEEP reports sent to PCPs may influence screening and detection, and friends and family members of those screened may also seek screening."

Another community-based initiative is the NKF’s KEEP Healthy program, designed to educate people about the kidneys and risk factors for kidney disease. A check-up for participants includes a risk survey, body mass index, blood pressure check, free educational materials, and an opportunity to speak with a health care professional.

"Awareness of CKD is low," Dr. Peter A. McCullough, chair of the NKF’s Kidney Early Evaluation Program Steering Committee, said during a separate presentation at the meeting. "We have to get to levels of awareness of diabetes, heart disease, and cancer. In kidney disease, we haven’t gotten there yet. I haven’t seen a single data set where [awareness] is more than 50%."

In his opinion, clinicians should screen for CKD with KEEP Healthy and other clinical and community approaches, "because it raises awareness for risk factors and CKD, it potentially triggers better risk factor control, it potentially helps avoid additional insults along the way, and it readies for the next steps."

Dr. Saab acknowledged limitations of community-based screening, including the fact that isolated measurements may lead to misclassification. "But that is usually the case in all screening processes," he added. "It also requires external funding, and it does attract patients who are motivated to be screened, so you may not necessarily be catching the people who aren’t aware of CKD."

Electronic health records also have the potential to improve CKD screening and detection, he said. For example, a record query can be designed to extract variables that may impact detection or screening, including those at the patient, physician, or institutional level.

"You can also identify potential patients to be screened who don’t have eGFR or albuminuria assessment," Dr. Saab said, including the elderly and those with cardiovascular disease or obesity.

The remedy for improving current shortfalls in CKD screening and detection is likely to involve some combination of amendments to clinical encounters, community-based screening, and electronic health record queries, Dr. Saab predicted.

Dr. Saab said that he had no relevant financial disclosures.

[email protected]

LAS VEGAS – Many barriers to chronic kidney disease detection and screening exist in today’s health care landscape, according to Dr. Georges Saab.

For one thing, patient have a lack of knowledge about chronic kidney disease (CKD) and receive very little education about it, explained Dr. Saab of the department of medicine at Case Western Reserve University and MetroHealth Medical Center, Cleveland.

Patients lack education about CKD "because they don’t ask about it," Dr. Saab said at a meeting sponsored by the National Kidney Foundation. "They know about their hypertension, diabetes, and cholesterol, but they don’t know about kidney disease; they don’t take medications for kidney disease, so they fail to recognize it as a distinct entity."

He noted that some primary care physicians feel they lack the knowledge and skills to educate patients on CKD. Thus, measures to enhance these skills are needed. Others are not familiar with published CKD screening guidelines, and among those that are, the recommendations are not consistent in whom to screen.

Dr. Saab called for ways to improve physician and patient education on risk factors for CKD and on the impact of the disease. Such information is available from the National Kidney Foundation and the National Kidney Disease Education Program. Recently, the National Kidney Foundation launched the CKD Primary Care Initiative to identify and overcome barriers to CKD testing, detection, and management in the primary care setting. The NKF’s CKD Primary Care Initiative will disseminate CKD guidelines to PCPs around the United States through education programs, symposia, and practical implementation tools.

Other strategies that could be used include implementing clinical reminders to screen for CKD in high-risk groups, routine reporting of estimated glomerular filtration rate (eGFR), incentivizing providers for higher-quality care, including screening for CKD, and providing patients with access to their laboratory data. He notes that patients themselves may initiate the process of referral to a nephrologist if given access to their results.

Community-based screening also has the potential to eliminate or mitigate some of the patient and physician barriers to screening. Dr. Saab cited the NKF’s Kidney Early Evaluation Program (KEEP) as an example. Between 2000 and 2013, KEEP reached more than 185,000 individuals at increased risk for developing CKD. The KEEP program "is free, it’s in a nonmedical location, such as a church or town hall, and it’s managed by a trained staff and nephrologists," Dr. Saab said of the program. "It’s also short in duration – it only takes about 45 minutes – and it’s focused on CKD and related issues."

Of KEEP data collected through 2010, roughly 20% of participants were found to have CKD (Am. J. Kidney Dis. 2012;60:692-3. At the time of screening, patients are asked if they’re aware if they have any kidney problems or not. Awareness increased from 8.8% in 2000-2002 to 16.6% in 2009-2011, "which means that the message is getting out there, and patients are getting screened a little more commonly than they were before," he said.

Community screening for CKD appears to increase patient awareness of chronic kidney disease, "and it may indirectly lead to increased screening in clinical encounters," Dr. Saab said. "For example, KEEP reports sent to PCPs may influence screening and detection, and friends and family members of those screened may also seek screening."

Another community-based initiative is the NKF’s KEEP Healthy program, designed to educate people about the kidneys and risk factors for kidney disease. A check-up for participants includes a risk survey, body mass index, blood pressure check, free educational materials, and an opportunity to speak with a health care professional.

"Awareness of CKD is low," Dr. Peter A. McCullough, chair of the NKF’s Kidney Early Evaluation Program Steering Committee, said during a separate presentation at the meeting. "We have to get to levels of awareness of diabetes, heart disease, and cancer. In kidney disease, we haven’t gotten there yet. I haven’t seen a single data set where [awareness] is more than 50%."

In his opinion, clinicians should screen for CKD with KEEP Healthy and other clinical and community approaches, "because it raises awareness for risk factors and CKD, it potentially triggers better risk factor control, it potentially helps avoid additional insults along the way, and it readies for the next steps."

Dr. Saab acknowledged limitations of community-based screening, including the fact that isolated measurements may lead to misclassification. "But that is usually the case in all screening processes," he added. "It also requires external funding, and it does attract patients who are motivated to be screened, so you may not necessarily be catching the people who aren’t aware of CKD."

Electronic health records also have the potential to improve CKD screening and detection, he said. For example, a record query can be designed to extract variables that may impact detection or screening, including those at the patient, physician, or institutional level.

"You can also identify potential patients to be screened who don’t have eGFR or albuminuria assessment," Dr. Saab said, including the elderly and those with cardiovascular disease or obesity.

The remedy for improving current shortfalls in CKD screening and detection is likely to involve some combination of amendments to clinical encounters, community-based screening, and electronic health record queries, Dr. Saab predicted.

Dr. Saab said that he had no relevant financial disclosures.

[email protected]

ORLANDO – Absence of comorbidities, larger remnant kidney volume/body surface area ratio, and larger tumor diameter were significant predictors of mild renal insufficiency following radical nephrectomy, and smaller tumor diameter was a significant predictor of severe renal insufficiency in an analysis of 53 cases.

"This is the first report to identify the remnant kidney volume/body surface area (RKV/BSA) ratio as a promising predictor of post–radical nephrectomy renal functional decline," according to Dr. Takehiro Sejima, a urologist at Tottori University, Yonago, Japan, whose research was featured in an "Outstanding Posters" session at the annual meeting of the American Urological Association.

At a cutoff value of 115, the RKV/BSA ratio had 47.6% sensitivity and 79.2% specificity for predicting mild renal insufficiency using a receiver operating characteristic curve, Dr. Sejima said.

A total of 21 patients categorized as having mild renal insufficiency and 32 patients categorized as having severe renal insufficiency were included in the study. Those with severe renal insufficiency had a significantly greater extent of global glomerulosclerosis, compared with those with mild renal insufficiency. Also, cardiovascular disease events occurred in 11 patients with severe renal insufficiency during up to 122.5 months of follow-up; no cardiovascular disease events occurred in those with mild renal insufficiency, he said.

Estimated glomerular filtration rates were measured preoperatively, and at 6-12 months after radical nephrectomy in 175 patients. Those with a greater than 20% drop in estimated glomerular filtration rates were classified as having mild renal insufficiency, and those with a percentage decline above 40% were classified as having severe renal insufficiency.

"Our results provide physicians and patients with a useful predictor of renal functional outcomes preoperatively. The consideration of post–radical nephrectomy medical management for the prevention of cardiovascular disease, except in mild renal insufficiency patients, should be a future step toward improving the overall survival of post–radical nephrectomy patients," he concluded.

Dr. Sejima reported having no disclosures.

ORLANDO – Absence of comorbidities, larger remnant kidney volume/body surface area ratio, and larger tumor diameter were significant predictors of mild renal insufficiency following radical nephrectomy, and smaller tumor diameter was a significant predictor of severe renal insufficiency in an analysis of 53 cases.

"This is the first report to identify the remnant kidney volume/body surface area (RKV/BSA) ratio as a promising predictor of post–radical nephrectomy renal functional decline," according to Dr. Takehiro Sejima, a urologist at Tottori University, Yonago, Japan, whose research was featured in an "Outstanding Posters" session at the annual meeting of the American Urological Association.

At a cutoff value of 115, the RKV/BSA ratio had 47.6% sensitivity and 79.2% specificity for predicting mild renal insufficiency using a receiver operating characteristic curve, Dr. Sejima said.

A total of 21 patients categorized as having mild renal insufficiency and 32 patients categorized as having severe renal insufficiency were included in the study. Those with severe renal insufficiency had a significantly greater extent of global glomerulosclerosis, compared with those with mild renal insufficiency. Also, cardiovascular disease events occurred in 11 patients with severe renal insufficiency during up to 122.5 months of follow-up; no cardiovascular disease events occurred in those with mild renal insufficiency, he said.

Estimated glomerular filtration rates were measured preoperatively, and at 6-12 months after radical nephrectomy in 175 patients. Those with a greater than 20% drop in estimated glomerular filtration rates were classified as having mild renal insufficiency, and those with a percentage decline above 40% were classified as having severe renal insufficiency.

"Our results provide physicians and patients with a useful predictor of renal functional outcomes preoperatively. The consideration of post–radical nephrectomy medical management for the prevention of cardiovascular disease, except in mild renal insufficiency patients, should be a future step toward improving the overall survival of post–radical nephrectomy patients," he concluded.

Dr. Sejima reported having no disclosures.

ORLANDO – Absence of comorbidities, larger remnant kidney volume/body surface area ratio, and larger tumor diameter were significant predictors of mild renal insufficiency following radical nephrectomy, and smaller tumor diameter was a significant predictor of severe renal insufficiency in an analysis of 53 cases.

"This is the first report to identify the remnant kidney volume/body surface area (RKV/BSA) ratio as a promising predictor of post–radical nephrectomy renal functional decline," according to Dr. Takehiro Sejima, a urologist at Tottori University, Yonago, Japan, whose research was featured in an "Outstanding Posters" session at the annual meeting of the American Urological Association.

At a cutoff value of 115, the RKV/BSA ratio had 47.6% sensitivity and 79.2% specificity for predicting mild renal insufficiency using a receiver operating characteristic curve, Dr. Sejima said.

A total of 21 patients categorized as having mild renal insufficiency and 32 patients categorized as having severe renal insufficiency were included in the study. Those with severe renal insufficiency had a significantly greater extent of global glomerulosclerosis, compared with those with mild renal insufficiency. Also, cardiovascular disease events occurred in 11 patients with severe renal insufficiency during up to 122.5 months of follow-up; no cardiovascular disease events occurred in those with mild renal insufficiency, he said.

Estimated glomerular filtration rates were measured preoperatively, and at 6-12 months after radical nephrectomy in 175 patients. Those with a greater than 20% drop in estimated glomerular filtration rates were classified as having mild renal insufficiency, and those with a percentage decline above 40% were classified as having severe renal insufficiency.

"Our results provide physicians and patients with a useful predictor of renal functional outcomes preoperatively. The consideration of post–radical nephrectomy medical management for the prevention of cardiovascular disease, except in mild renal insufficiency patients, should be a future step toward improving the overall survival of post–radical nephrectomy patients," he concluded.

Dr. Sejima reported having no disclosures.

LAS VEGAS – In the opinion of Dr. David Cherney, it’s not uncommon for physicians to feel grim about the limited efficacy of available agents to treat chronic kidney disease in patients with type 1 and type 2 diabetes.

Over a 10-year period, about 20% of patients with type I diabetes treated with angiotensin-converting enzyme (ACE) monotherapy still develop progression of their kidney disease, according to Dr. Cherney of the department of medicine at the University of Toronto.

"The diabetic nephroprotection area has been incredibly disappointing in the last 5-8 years," he said at a meeting sponsored by the National Kidney Foundation. "Patients tend to progress despite therapy or have side effects, no matter what we do. Endothelial antagonists cause edema. Protein kinase C beta-antagonists have little therapeutic effect, and antioxidants such as bardoxolone caused serious side effects. None of the drugs that we think will work, based on animal studies, seem to work very well when translated into humans."

Neurohormonal pathway blockade with an ACE inhibitor or an angiotensin II receptor blocker corrects early hemodynamic abnormalities in type 1 diabetes, he noted. "But the effects are partial. Dual, renin-angiotensin-aldosterone system blockade is associated with risk. When we use dual blockade in patients with type 1 diabetes, we’re not able to reduce hyperfiltration. The development of novel and safe renal protective therapies is critical."

Enter sodium-glucose cotransporter 2 (SGLT2) inhibitors such as empagliflozin and canagliflozin, which over the past decade have demonstrated positive endocrine effects in type 2 diabetes. According to Dr. Cherney, they lower hemoglobin A_1c by about 1% and lead to 2-4 kg of weight loss.

"That’s fantastic, compared with other agents such as insulin that cause weight gain," he said. "That weight loss is sustained for up to 2 years. These agents also seem to have a very low risk of hypoglycemia, and they also lower blood pressure."

Animal models of diabetes have used SGLT2 inhibitors such as empagliflozin (developed by Boehringer Ingelheim and Eli Lilly) to demonstrate a decline in hyperfiltration, a decrease in proteinuria, and a decrease in the structural evidence of nephropathy on histology. An SGLT2 inhibitor might offer renal protection in humans with diabetes by blocking sodium reabsorption proximally, restoring distal delivery, and normalizing afferent tone and glomerular filtration rate (GFR), Dr. Cherney said.

He and his associates conducted an open-label, pilot trial of empagliflozin in patients with type 1 diabetes, known as the ATIRMA study. The objectives were to assess the impact of empagliflozin on GFR under controlled conditions of euglycemia and hyperglycemia in type 1 diabetes patients with and without hyperfiltration, as well as to examine its safety and efficacy as an add-on therapy to insulin (Circulation 2014;129:587-97).

"We hypothesized that we would reduce hyperfiltration and improve glycemic parameters in type 1 diabetes," Dr. Cherney said. In all, 40 patients with a mean age of 25 years were screened and underwent a 2-week run-in period, then took empagliflozin 25 mg once daily for 8 weeks. There were 13 patients in the normofiltration group and 27 patients in the hyperfiltration group.

At the end of 8 weeks, patients in the hyperfiltration group had a dramatic increase in 24-hour urinary glucose excretion, to 140 g/day, "which is about twice what you see in the type 2 studies," he said. "They had very dramatic tubular flow response."

Patients in the hyperfiltration group also had a 20% reduction in their hyperfiltration, a fall in hyperperfusion, an increase in renal vascular resistance, and a small reduction in blood pressure. The researchers also observed a 0.4% reduction in HbA_1c, "which was highly statistically significant," Dr. Cherney said. "We also saw that weight and waist circumference decreased, fasting capillary glucose improved significantly, and their insulin doses decreased. As a consequence, they had less hypoglycemia."

How does this compare to currently used agents? ACE inhibitors reduce hyperfiltration by about 19.7%, Dr. Cheney said, while empagliflozin decreased hyperfiltration by 19.2% – almost an identical effect.

"But remember, ACE inhibitors are associated with hyperkalemia, acute kidney injury, and other potential side effects," he noted. SGLT2 inhibitors "don’t cause hyperkalemia. They don’t cause acute kidney injury, as far as we know. And as far as we know, they don’t have any important interactions with other RAAS inhibitors."

Dr. Cherney characterized the findings from ATIRMA as "promising first steps.

"We’ve been tricked many times before with other drugs," he noted. "We can’t by any means say that this is conclusive, but we need to have long-term renal protection studies to prove their relevance. I think we can clearly say that renal studies are warranted in type 1 and type 2 diabetes."

Research is also needed to assess the interaction between SGLT2 inhibitors and other RAAS inhibitors, Dr. Cherney added, as well as how they provide primary and secondary preventive therapy in type 1 and type 2 diabetes.

Dr. Cherney disclosed that he has received research funding, consulting fees, and speaker honoraria from Boehringer Ingelheim. He has also received research funding from Astellas, consulting fees from Janssen and Astellas, and speaker honoraria from Janssen.

[email protected]

LAS VEGAS – In the opinion of Dr. David Cherney, it’s not uncommon for physicians to feel grim about the limited efficacy of available agents to treat chronic kidney disease in patients with type 1 and type 2 diabetes.

Over a 10-year period, about 20% of patients with type I diabetes treated with angiotensin-converting enzyme (ACE) monotherapy still develop progression of their kidney disease, according to Dr. Cherney of the department of medicine at the University of Toronto.

"The diabetic nephroprotection area has been incredibly disappointing in the last 5-8 years," he said at a meeting sponsored by the National Kidney Foundation. "Patients tend to progress despite therapy or have side effects, no matter what we do. Endothelial antagonists cause edema. Protein kinase C beta-antagonists have little therapeutic effect, and antioxidants such as bardoxolone caused serious side effects. None of the drugs that we think will work, based on animal studies, seem to work very well when translated into humans."

Neurohormonal pathway blockade with an ACE inhibitor or an angiotensin II receptor blocker corrects early hemodynamic abnormalities in type 1 diabetes, he noted. "But the effects are partial. Dual, renin-angiotensin-aldosterone system blockade is associated with risk. When we use dual blockade in patients with type 1 diabetes, we’re not able to reduce hyperfiltration. The development of novel and safe renal protective therapies is critical."

Enter sodium-glucose cotransporter 2 (SGLT2) inhibitors such as empagliflozin and canagliflozin, which over the past decade have demonstrated positive endocrine effects in type 2 diabetes. According to Dr. Cherney, they lower hemoglobin A_1c by about 1% and lead to 2-4 kg of weight loss.

"That’s fantastic, compared with other agents such as insulin that cause weight gain," he said. "That weight loss is sustained for up to 2 years. These agents also seem to have a very low risk of hypoglycemia, and they also lower blood pressure."

Animal models of diabetes have used SGLT2 inhibitors such as empagliflozin (developed by Boehringer Ingelheim and Eli Lilly) to demonstrate a decline in hyperfiltration, a decrease in proteinuria, and a decrease in the structural evidence of nephropathy on histology. An SGLT2 inhibitor might offer renal protection in humans with diabetes by blocking sodium reabsorption proximally, restoring distal delivery, and normalizing afferent tone and glomerular filtration rate (GFR), Dr. Cherney said.

He and his associates conducted an open-label, pilot trial of empagliflozin in patients with type 1 diabetes, known as the ATIRMA study. The objectives were to assess the impact of empagliflozin on GFR under controlled conditions of euglycemia and hyperglycemia in type 1 diabetes patients with and without hyperfiltration, as well as to examine its safety and efficacy as an add-on therapy to insulin (Circulation 2014;129:587-97).

"We hypothesized that we would reduce hyperfiltration and improve glycemic parameters in type 1 diabetes," Dr. Cherney said. In all, 40 patients with a mean age of 25 years were screened and underwent a 2-week run-in period, then took empagliflozin 25 mg once daily for 8 weeks. There were 13 patients in the normofiltration group and 27 patients in the hyperfiltration group.

At the end of 8 weeks, patients in the hyperfiltration group had a dramatic increase in 24-hour urinary glucose excretion, to 140 g/day, "which is about twice what you see in the type 2 studies," he said. "They had very dramatic tubular flow response."

Patients in the hyperfiltration group also had a 20% reduction in their hyperfiltration, a fall in hyperperfusion, an increase in renal vascular resistance, and a small reduction in blood pressure. The researchers also observed a 0.4% reduction in HbA_1c, "which was highly statistically significant," Dr. Cherney said. "We also saw that weight and waist circumference decreased, fasting capillary glucose improved significantly, and their insulin doses decreased. As a consequence, they had less hypoglycemia."

How does this compare to currently used agents? ACE inhibitors reduce hyperfiltration by about 19.7%, Dr. Cheney said, while empagliflozin decreased hyperfiltration by 19.2% – almost an identical effect.

"But remember, ACE inhibitors are associated with hyperkalemia, acute kidney injury, and other potential side effects," he noted. SGLT2 inhibitors "don’t cause hyperkalemia. They don’t cause acute kidney injury, as far as we know. And as far as we know, they don’t have any important interactions with other RAAS inhibitors."

Dr. Cherney characterized the findings from ATIRMA as "promising first steps.

"We’ve been tricked many times before with other drugs," he noted. "We can’t by any means say that this is conclusive, but we need to have long-term renal protection studies to prove their relevance. I think we can clearly say that renal studies are warranted in type 1 and type 2 diabetes."

Research is also needed to assess the interaction between SGLT2 inhibitors and other RAAS inhibitors, Dr. Cherney added, as well as how they provide primary and secondary preventive therapy in type 1 and type 2 diabetes.

Dr. Cherney disclosed that he has received research funding, consulting fees, and speaker honoraria from Boehringer Ingelheim. He has also received research funding from Astellas, consulting fees from Janssen and Astellas, and speaker honoraria from Janssen.

[email protected]

LAS VEGAS – In the opinion of Dr. David Cherney, it’s not uncommon for physicians to feel grim about the limited efficacy of available agents to treat chronic kidney disease in patients with type 1 and type 2 diabetes.

Over a 10-year period, about 20% of patients with type I diabetes treated with angiotensin-converting enzyme (ACE) monotherapy still develop progression of their kidney disease, according to Dr. Cherney of the department of medicine at the University of Toronto.

"The diabetic nephroprotection area has been incredibly disappointing in the last 5-8 years," he said at a meeting sponsored by the National Kidney Foundation. "Patients tend to progress despite therapy or have side effects, no matter what we do. Endothelial antagonists cause edema. Protein kinase C beta-antagonists have little therapeutic effect, and antioxidants such as bardoxolone caused serious side effects. None of the drugs that we think will work, based on animal studies, seem to work very well when translated into humans."

Neurohormonal pathway blockade with an ACE inhibitor or an angiotensin II receptor blocker corrects early hemodynamic abnormalities in type 1 diabetes, he noted. "But the effects are partial. Dual, renin-angiotensin-aldosterone system blockade is associated with risk. When we use dual blockade in patients with type 1 diabetes, we’re not able to reduce hyperfiltration. The development of novel and safe renal protective therapies is critical."

Enter sodium-glucose cotransporter 2 (SGLT2) inhibitors such as empagliflozin and canagliflozin, which over the past decade have demonstrated positive endocrine effects in type 2 diabetes. According to Dr. Cherney, they lower hemoglobin A_1c by about 1% and lead to 2-4 kg of weight loss.

"That’s fantastic, compared with other agents such as insulin that cause weight gain," he said. "That weight loss is sustained for up to 2 years. These agents also seem to have a very low risk of hypoglycemia, and they also lower blood pressure."

Animal models of diabetes have used SGLT2 inhibitors such as empagliflozin (developed by Boehringer Ingelheim and Eli Lilly) to demonstrate a decline in hyperfiltration, a decrease in proteinuria, and a decrease in the structural evidence of nephropathy on histology. An SGLT2 inhibitor might offer renal protection in humans with diabetes by blocking sodium reabsorption proximally, restoring distal delivery, and normalizing afferent tone and glomerular filtration rate (GFR), Dr. Cherney said.

He and his associates conducted an open-label, pilot trial of empagliflozin in patients with type 1 diabetes, known as the ATIRMA study. The objectives were to assess the impact of empagliflozin on GFR under controlled conditions of euglycemia and hyperglycemia in type 1 diabetes patients with and without hyperfiltration, as well as to examine its safety and efficacy as an add-on therapy to insulin (Circulation 2014;129:587-97).

"We hypothesized that we would reduce hyperfiltration and improve glycemic parameters in type 1 diabetes," Dr. Cherney said. In all, 40 patients with a mean age of 25 years were screened and underwent a 2-week run-in period, then took empagliflozin 25 mg once daily for 8 weeks. There were 13 patients in the normofiltration group and 27 patients in the hyperfiltration group.

At the end of 8 weeks, patients in the hyperfiltration group had a dramatic increase in 24-hour urinary glucose excretion, to 140 g/day, "which is about twice what you see in the type 2 studies," he said. "They had very dramatic tubular flow response."

Patients in the hyperfiltration group also had a 20% reduction in their hyperfiltration, a fall in hyperperfusion, an increase in renal vascular resistance, and a small reduction in blood pressure. The researchers also observed a 0.4% reduction in HbA_1c, "which was highly statistically significant," Dr. Cherney said. "We also saw that weight and waist circumference decreased, fasting capillary glucose improved significantly, and their insulin doses decreased. As a consequence, they had less hypoglycemia."

How does this compare to currently used agents? ACE inhibitors reduce hyperfiltration by about 19.7%, Dr. Cheney said, while empagliflozin decreased hyperfiltration by 19.2% – almost an identical effect.

"But remember, ACE inhibitors are associated with hyperkalemia, acute kidney injury, and other potential side effects," he noted. SGLT2 inhibitors "don’t cause hyperkalemia. They don’t cause acute kidney injury, as far as we know. And as far as we know, they don’t have any important interactions with other RAAS inhibitors."

Dr. Cherney characterized the findings from ATIRMA as "promising first steps.

"We’ve been tricked many times before with other drugs," he noted. "We can’t by any means say that this is conclusive, but we need to have long-term renal protection studies to prove their relevance. I think we can clearly say that renal studies are warranted in type 1 and type 2 diabetes."

Research is also needed to assess the interaction between SGLT2 inhibitors and other RAAS inhibitors, Dr. Cherney added, as well as how they provide primary and secondary preventive therapy in type 1 and type 2 diabetes.

Dr. Cherney disclosed that he has received research funding, consulting fees, and speaker honoraria from Boehringer Ingelheim. He has also received research funding from Astellas, consulting fees from Janssen and Astellas, and speaker honoraria from Janssen.

[email protected]

LAS VEGAS – Seventeen percent of severely obese adolescents slated for bariatric surgery in the Teen-Longitudinal Assessment of Bariatric Surgery study already had micro- or macroalbuminuria.

At a meeting sponsored by the National Kidney Foundation, Dr. Nianzhou Xiao said that future reports from the ongoing Teen-LABS study will provide the answer to a critical question: Is this worrisome loss of kidney function so early in life reversible via surgical weight loss?

Dr. Xiao presented a cross-sectional baseline report on 242 severely obese adolescents with a median body mass index of 50.5 kg/m². Fourteen percent had microalbuminuria and another 3.1% had macroalbuminuria. Although the group’s mean estimated glomerular filtration rate was 107.6 mL/min per 1.73 m², 3% of the teens had an eGFR below 60 mL/min 1.73 m², which is the definition of stage 3 chronic kidney disease.

In addition, 45% of the teens were hypertensive before surgery, 74% were dyslipidemic, and 13.6% had diabetes. The group’s median serum ferritin was 37 mcg/L, noted Dr. Xiao of Cincinnati Children’s Hospital Medical Center.

Multivariate analysis identified two independent risk factors for an elevated albumin to creatinine ratio: female gender, with an associated 2.34-fold increased risk, and elevated serum ferritin. For every 10 mcg/L of ferritin, the likelihood of an elevated albumin-to-creatinine ratio rose by 7%.

An estimated 4%-6% of U.S. children and adolescents are severely obese, defined as a body mass index of 35 kg/m² or more or a body weight above the 120th percentile. The ongoing Teen-LABS study is the most comprehensive examination of kidney status in severely obese adolescents undergoing bariatric surgery.

Teen-LABS is funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Xiao reported having no financial conflicts.

[email protected]

LAS VEGAS – Seventeen percent of severely obese adolescents slated for bariatric surgery in the Teen-Longitudinal Assessment of Bariatric Surgery study already had micro- or macroalbuminuria.

At a meeting sponsored by the National Kidney Foundation, Dr. Nianzhou Xiao said that future reports from the ongoing Teen-LABS study will provide the answer to a critical question: Is this worrisome loss of kidney function so early in life reversible via surgical weight loss?

Dr. Xiao presented a cross-sectional baseline report on 242 severely obese adolescents with a median body mass index of 50.5 kg/m². Fourteen percent had microalbuminuria and another 3.1% had macroalbuminuria. Although the group’s mean estimated glomerular filtration rate was 107.6 mL/min per 1.73 m², 3% of the teens had an eGFR below 60 mL/min 1.73 m², which is the definition of stage 3 chronic kidney disease.

In addition, 45% of the teens were hypertensive before surgery, 74% were dyslipidemic, and 13.6% had diabetes. The group’s median serum ferritin was 37 mcg/L, noted Dr. Xiao of Cincinnati Children’s Hospital Medical Center.

Multivariate analysis identified two independent risk factors for an elevated albumin to creatinine ratio: female gender, with an associated 2.34-fold increased risk, and elevated serum ferritin. For every 10 mcg/L of ferritin, the likelihood of an elevated albumin-to-creatinine ratio rose by 7%.

An estimated 4%-6% of U.S. children and adolescents are severely obese, defined as a body mass index of 35 kg/m² or more or a body weight above the 120th percentile. The ongoing Teen-LABS study is the most comprehensive examination of kidney status in severely obese adolescents undergoing bariatric surgery.

Teen-LABS is funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Xiao reported having no financial conflicts.

[email protected]

LAS VEGAS – Seventeen percent of severely obese adolescents slated for bariatric surgery in the Teen-Longitudinal Assessment of Bariatric Surgery study already had micro- or macroalbuminuria.

At a meeting sponsored by the National Kidney Foundation, Dr. Nianzhou Xiao said that future reports from the ongoing Teen-LABS study will provide the answer to a critical question: Is this worrisome loss of kidney function so early in life reversible via surgical weight loss?

Dr. Xiao presented a cross-sectional baseline report on 242 severely obese adolescents with a median body mass index of 50.5 kg/m². Fourteen percent had microalbuminuria and another 3.1% had macroalbuminuria. Although the group’s mean estimated glomerular filtration rate was 107.6 mL/min per 1.73 m², 3% of the teens had an eGFR below 60 mL/min 1.73 m², which is the definition of stage 3 chronic kidney disease.

In addition, 45% of the teens were hypertensive before surgery, 74% were dyslipidemic, and 13.6% had diabetes. The group’s median serum ferritin was 37 mcg/L, noted Dr. Xiao of Cincinnati Children’s Hospital Medical Center.

Multivariate analysis identified two independent risk factors for an elevated albumin to creatinine ratio: female gender, with an associated 2.34-fold increased risk, and elevated serum ferritin. For every 10 mcg/L of ferritin, the likelihood of an elevated albumin-to-creatinine ratio rose by 7%.

An estimated 4%-6% of U.S. children and adolescents are severely obese, defined as a body mass index of 35 kg/m² or more or a body weight above the 120th percentile. The ongoing Teen-LABS study is the most comprehensive examination of kidney status in severely obese adolescents undergoing bariatric surgery.

Teen-LABS is funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Xiao reported having no financial conflicts.

[email protected]

NEW YORK – Valproic acid might be effective for treating hyperactive delirium, results of a small, retrospective study suggest.

Among 16 patients with hyperactive delirium, 13 had complete resolution of delirium according to the DSM-IV-TR criteria, reported Dr. Yelizaveta I. Sher, an instructor in psychiatry and behavioral science at Stanford (Calif.) University.

"You should definitely consider this medication where antipsychotics are ineffective or there are concerns about side effects from antipsychotics, and you need rapid control of agitation," Dr. Sher said at the annual meeting of the American Psychiatric Association.

Delirium is the most frequent psychiatric diagnosis in general hospital settings and has been reported to occur in up to 85% of patients in intensive care units (ICUs), she noted.

"It prolongs hospital stays and significantly increases morbidity and mortality of these patients," Dr. Sher said.

Antipsychotic agents are usually first-line pharmacological therapies for delirium, but these agents are sometimes ineffective in this setting, and are associated with adverse events such as prolongation of the QT interval, and with extrapyramidal side effects such as akathisia, tremors, and, less frequently, the neuroleptic malignant syndrome, Dr. Sher said.

Antispychotics also are less-than-ideal agents for treatment of agitation associated with acute delirium after traumatic brain injury or from alcohol withdrawal, she added.

Valproic acid is the most widely used agent for the treatment of seizures worldwide, and is approved in the United States for seizures, migraine prophylaxis, and acute manic or mixed bipolar episodes. It often is used off-label for treatment of agitation, neuropathic pain, and personality disorder, according to Dr. Sher.

In addition, its use has been explored in agitated patients with dementia, agitation in traumatic brain injury, and corticosteroid-induced mania.

The use of valproic acid has been associated with neural tube defects in fetuses and must be avoided in women who are pregnant. It also has been associated with mild blood dyscrasias, abnormal liver function tests, and, in patients with urea-cycle enzyme deficiencies, symptomatic hyperammonemia, Dr. Sher cautioned.

Medication interactions with valproic acid include a decrease in blood levels of up to 80% when it is used with meropenem, and an increase in warfarin levels when valproic acid is used with the anticoagulant. Valproic acid also can decrease clearance of carbamazepine, lamotrigine, nortriptyline, and amitriptyline.

Dr. Sher and her colleagues conducted a retrospective study of charts for patients with episodes of hyperactive delirium who were treated with adjunct valproic acid by a consulting or liaison psychiatrist on the psychosomatic medicine service at their center from Aug. 1, 2011, through Aug. 31, 2012. All the patients had hyperactive or mixed delirium as defined by Dr. Benjamin Liptzin’s criteria (Am. J. Psychiatry 1991;148:454-7).

For their investigation, Dr. Sher and her associates reviewed daily notes from the primary ICU team and nurse; daily mental status examination results; daily medication use and doses of psychotropic medications, sedatives, and related medications; daily lab data; descriptions of agitation; and important clinical events such as the use of restraints, extubation, and death.

They identified 16 patients (14 men and 2 women) treated for hyperactive delirium, all but 3 of whom were treated in the ICU. Of this group, 15 patients had received multiple drug treatments for delirium and/or agitation prior to valproic acid use.

The average dose of valproic acid used on days 2-5 was 1,133-1,258 mg per 24 hours in divided daily doses.

As noted before, 13 patients had complete resolution of delirium, at an average of 7.2 days from the start of valproic acid. Two patients had resolution of delirium within 2 days, 4 within 3 days, 2 within 4 days, 1 within 5 days, and the remaining 4 patients at 10, 12 (2 patients), and 31 days.

In all patients, agitation was markedly decreased as rated by mental status examination, agitation scale ratings, and reduced need for sedatives.

In three patients, meropenem might have affected valproic acid levels; two of the patients developed thrombocytopenias.

A randomized controlled trial of valproic acid for the treatment of hyperactive delirium in the ICU is underway, Dr. Sher noted.

The study was internally funded. Dr. Sher reported having no financial disclosures.

NEW YORK – Valproic acid might be effective for treating hyperactive delirium, results of a small, retrospective study suggest.

Among 16 patients with hyperactive delirium, 13 had complete resolution of delirium according to the DSM-IV-TR criteria, reported Dr. Yelizaveta I. Sher, an instructor in psychiatry and behavioral science at Stanford (Calif.) University.

"You should definitely consider this medication where antipsychotics are ineffective or there are concerns about side effects from antipsychotics, and you need rapid control of agitation," Dr. Sher said at the annual meeting of the American Psychiatric Association.

Delirium is the most frequent psychiatric diagnosis in general hospital settings and has been reported to occur in up to 85% of patients in intensive care units (ICUs), she noted.

"It prolongs hospital stays and significantly increases morbidity and mortality of these patients," Dr. Sher said.

Antipsychotic agents are usually first-line pharmacological therapies for delirium, but these agents are sometimes ineffective in this setting, and are associated with adverse events such as prolongation of the QT interval, and with extrapyramidal side effects such as akathisia, tremors, and, less frequently, the neuroleptic malignant syndrome, Dr. Sher said.

Antispychotics also are less-than-ideal agents for treatment of agitation associated with acute delirium after traumatic brain injury or from alcohol withdrawal, she added.

Valproic acid is the most widely used agent for the treatment of seizures worldwide, and is approved in the United States for seizures, migraine prophylaxis, and acute manic or mixed bipolar episodes. It often is used off-label for treatment of agitation, neuropathic pain, and personality disorder, according to Dr. Sher.

In addition, its use has been explored in agitated patients with dementia, agitation in traumatic brain injury, and corticosteroid-induced mania.

The use of valproic acid has been associated with neural tube defects in fetuses and must be avoided in women who are pregnant. It also has been associated with mild blood dyscrasias, abnormal liver function tests, and, in patients with urea-cycle enzyme deficiencies, symptomatic hyperammonemia, Dr. Sher cautioned.

Medication interactions with valproic acid include a decrease in blood levels of up to 80% when it is used with meropenem, and an increase in warfarin levels when valproic acid is used with the anticoagulant. Valproic acid also can decrease clearance of carbamazepine, lamotrigine, nortriptyline, and amitriptyline.

Dr. Sher and her colleagues conducted a retrospective study of charts for patients with episodes of hyperactive delirium who were treated with adjunct valproic acid by a consulting or liaison psychiatrist on the psychosomatic medicine service at their center from Aug. 1, 2011, through Aug. 31, 2012. All the patients had hyperactive or mixed delirium as defined by Dr. Benjamin Liptzin’s criteria (Am. J. Psychiatry 1991;148:454-7).

For their investigation, Dr. Sher and her associates reviewed daily notes from the primary ICU team and nurse; daily mental status examination results; daily medication use and doses of psychotropic medications, sedatives, and related medications; daily lab data; descriptions of agitation; and important clinical events such as the use of restraints, extubation, and death.

They identified 16 patients (14 men and 2 women) treated for hyperactive delirium, all but 3 of whom were treated in the ICU. Of this group, 15 patients had received multiple drug treatments for delirium and/or agitation prior to valproic acid use.

The average dose of valproic acid used on days 2-5 was 1,133-1,258 mg per 24 hours in divided daily doses.

As noted before, 13 patients had complete resolution of delirium, at an average of 7.2 days from the start of valproic acid. Two patients had resolution of delirium within 2 days, 4 within 3 days, 2 within 4 days, 1 within 5 days, and the remaining 4 patients at 10, 12 (2 patients), and 31 days.

In all patients, agitation was markedly decreased as rated by mental status examination, agitation scale ratings, and reduced need for sedatives.

In three patients, meropenem might have affected valproic acid levels; two of the patients developed thrombocytopenias.

A randomized controlled trial of valproic acid for the treatment of hyperactive delirium in the ICU is underway, Dr. Sher noted.

The study was internally funded. Dr. Sher reported having no financial disclosures.

NEW YORK – Valproic acid might be effective for treating hyperactive delirium, results of a small, retrospective study suggest.

Among 16 patients with hyperactive delirium, 13 had complete resolution of delirium according to the DSM-IV-TR criteria, reported Dr. Yelizaveta I. Sher, an instructor in psychiatry and behavioral science at Stanford (Calif.) University.

"You should definitely consider this medication where antipsychotics are ineffective or there are concerns about side effects from antipsychotics, and you need rapid control of agitation," Dr. Sher said at the annual meeting of the American Psychiatric Association.

Delirium is the most frequent psychiatric diagnosis in general hospital settings and has been reported to occur in up to 85% of patients in intensive care units (ICUs), she noted.

"It prolongs hospital stays and significantly increases morbidity and mortality of these patients," Dr. Sher said.

Antipsychotic agents are usually first-line pharmacological therapies for delirium, but these agents are sometimes ineffective in this setting, and are associated with adverse events such as prolongation of the QT interval, and with extrapyramidal side effects such as akathisia, tremors, and, less frequently, the neuroleptic malignant syndrome, Dr. Sher said.

Antispychotics also are less-than-ideal agents for treatment of agitation associated with acute delirium after traumatic brain injury or from alcohol withdrawal, she added.

Valproic acid is the most widely used agent for the treatment of seizures worldwide, and is approved in the United States for seizures, migraine prophylaxis, and acute manic or mixed bipolar episodes. It often is used off-label for treatment of agitation, neuropathic pain, and personality disorder, according to Dr. Sher.

In addition, its use has been explored in agitated patients with dementia, agitation in traumatic brain injury, and corticosteroid-induced mania.

The use of valproic acid has been associated with neural tube defects in fetuses and must be avoided in women who are pregnant. It also has been associated with mild blood dyscrasias, abnormal liver function tests, and, in patients with urea-cycle enzyme deficiencies, symptomatic hyperammonemia, Dr. Sher cautioned.

Medication interactions with valproic acid include a decrease in blood levels of up to 80% when it is used with meropenem, and an increase in warfarin levels when valproic acid is used with the anticoagulant. Valproic acid also can decrease clearance of carbamazepine, lamotrigine, nortriptyline, and amitriptyline.

Dr. Sher and her colleagues conducted a retrospective study of charts for patients with episodes of hyperactive delirium who were treated with adjunct valproic acid by a consulting or liaison psychiatrist on the psychosomatic medicine service at their center from Aug. 1, 2011, through Aug. 31, 2012. All the patients had hyperactive or mixed delirium as defined by Dr. Benjamin Liptzin’s criteria (Am. J. Psychiatry 1991;148:454-7).

For their investigation, Dr. Sher and her associates reviewed daily notes from the primary ICU team and nurse; daily mental status examination results; daily medication use and doses of psychotropic medications, sedatives, and related medications; daily lab data; descriptions of agitation; and important clinical events such as the use of restraints, extubation, and death.

They identified 16 patients (14 men and 2 women) treated for hyperactive delirium, all but 3 of whom were treated in the ICU. Of this group, 15 patients had received multiple drug treatments for delirium and/or agitation prior to valproic acid use.

The average dose of valproic acid used on days 2-5 was 1,133-1,258 mg per 24 hours in divided daily doses.

As noted before, 13 patients had complete resolution of delirium, at an average of 7.2 days from the start of valproic acid. Two patients had resolution of delirium within 2 days, 4 within 3 days, 2 within 4 days, 1 within 5 days, and the remaining 4 patients at 10, 12 (2 patients), and 31 days.

In all patients, agitation was markedly decreased as rated by mental status examination, agitation scale ratings, and reduced need for sedatives.

In three patients, meropenem might have affected valproic acid levels; two of the patients developed thrombocytopenias.

A randomized controlled trial of valproic acid for the treatment of hyperactive delirium in the ICU is underway, Dr. Sher noted.

The study was internally funded. Dr. Sher reported having no financial disclosures.

LAS VEGAS – A serum uric acid level of 7 mg/dL or more was independently associated with a 62% increased risk of hip fracture among older men participating in the Cardiovascular Health Study.

This finding confirms the clinical relevance of prior translational work pointing to a link between uric acid and bone health, Dr. Tapan Mehta observed at a meeting sponsored by the National Kidney Foundation.

Doug Brunk/Frontline Medicial News

He and his coinvestigators had suspected the existence of such a link, based upon their prior observations that uric acid inhibits expression of 1-alpha hydroxylase protein in vivo and that elevated uric acid levels are associated with higher parathyroid hormone levels in humans.

A key question now under study in clinical trials is whether lowering uric acid levels in the absence of symptomatic gout provides ancillary benefits to the kidneys.

The Cardiovascular Health Study was a National Heart, Lung, and Blood Institute–funded, population-based, observational study conducted to identify cardiovascular risk factors in men and women aged 65 years and older. In this analysis, Dr. Mehta reported on 1,963 male and 2,729 female participants with baseline serum uric acid levels available.

During a median 11 years of follow-up, 156 first-incident hip fractures occurred. The association between hyperuricemia and increased fracture risk was confined to men, 430 of whom had a baseline serum uric acid of 7 mg/dL or more.

Participants with an elevated uric acid were disproportionately black, obese, in less than good health, and had significantly higher levels of insulin, C-reactive protein, and cystatin C. In a multivariate regression analysis adjusted for demographics, body mass index, alcohol, smoking, physical activity, diabetes, C-reactive protein, hypertension, and known cardiovascular disease, men with a serum uric acid of 7 mg/dL or higher remained at 62% greater risk of hip fracture, compared with those with a uric acid below 7 mg/dL, according to Dr. Mehta of the University of Colorado, Denver.

High uric acid is known to increase the risk of gout, kidney stones, and more rapid progression of chronic kidney disease. It has also been linked to hypertension.

Possible mechanisms that might explain the link between increased serum uric acid and hip fractures include the fact that uric acid suppresses vitamin D activation. Also, uric acid inhibits expression of 1-alpha hydroxylase protein, and higher uric acid levels are associated with higher levels of parathyroid hormone. In addition, uric acid may cause inflammation in bone, which would be expected to increase fragility. But all of these thoughts on mechanism remain speculative for now, according to the nephrologist.

The absence of a relationship between hyperuricemia and hip fractures in older women in the Cardiovascular Health Study suggests other factors are more important than uric acid levels in women.

Dr. Mehta reported having no financial conflicts regarding this study.

[email protected]

LAS VEGAS – A serum uric acid level of 7 mg/dL or more was independently associated with a 62% increased risk of hip fracture among older men participating in the Cardiovascular Health Study.

This finding confirms the clinical relevance of prior translational work pointing to a link between uric acid and bone health, Dr. Tapan Mehta observed at a meeting sponsored by the National Kidney Foundation.

Doug Brunk/Frontline Medicial News

He and his coinvestigators had suspected the existence of such a link, based upon their prior observations that uric acid inhibits expression of 1-alpha hydroxylase protein in vivo and that elevated uric acid levels are associated with higher parathyroid hormone levels in humans.

A key question now under study in clinical trials is whether lowering uric acid levels in the absence of symptomatic gout provides ancillary benefits to the kidneys.

The Cardiovascular Health Study was a National Heart, Lung, and Blood Institute–funded, population-based, observational study conducted to identify cardiovascular risk factors in men and women aged 65 years and older. In this analysis, Dr. Mehta reported on 1,963 male and 2,729 female participants with baseline serum uric acid levels available.

During a median 11 years of follow-up, 156 first-incident hip fractures occurred. The association between hyperuricemia and increased fracture risk was confined to men, 430 of whom had a baseline serum uric acid of 7 mg/dL or more.

Participants with an elevated uric acid were disproportionately black, obese, in less than good health, and had significantly higher levels of insulin, C-reactive protein, and cystatin C. In a multivariate regression analysis adjusted for demographics, body mass index, alcohol, smoking, physical activity, diabetes, C-reactive protein, hypertension, and known cardiovascular disease, men with a serum uric acid of 7 mg/dL or higher remained at 62% greater risk of hip fracture, compared with those with a uric acid below 7 mg/dL, according to Dr. Mehta of the University of Colorado, Denver.

High uric acid is known to increase the risk of gout, kidney stones, and more rapid progression of chronic kidney disease. It has also been linked to hypertension.

Possible mechanisms that might explain the link between increased serum uric acid and hip fractures include the fact that uric acid suppresses vitamin D activation. Also, uric acid inhibits expression of 1-alpha hydroxylase protein, and higher uric acid levels are associated with higher levels of parathyroid hormone. In addition, uric acid may cause inflammation in bone, which would be expected to increase fragility. But all of these thoughts on mechanism remain speculative for now, according to the nephrologist.

The absence of a relationship between hyperuricemia and hip fractures in older women in the Cardiovascular Health Study suggests other factors are more important than uric acid levels in women.

Dr. Mehta reported having no financial conflicts regarding this study.

[email protected]

LAS VEGAS – A serum uric acid level of 7 mg/dL or more was independently associated with a 62% increased risk of hip fracture among older men participating in the Cardiovascular Health Study.

This finding confirms the clinical relevance of prior translational work pointing to a link between uric acid and bone health, Dr. Tapan Mehta observed at a meeting sponsored by the National Kidney Foundation.

Doug Brunk/Frontline Medicial News

He and his coinvestigators had suspected the existence of such a link, based upon their prior observations that uric acid inhibits expression of 1-alpha hydroxylase protein in vivo and that elevated uric acid levels are associated with higher parathyroid hormone levels in humans.

A key question now under study in clinical trials is whether lowering uric acid levels in the absence of symptomatic gout provides ancillary benefits to the kidneys.

The Cardiovascular Health Study was a National Heart, Lung, and Blood Institute–funded, population-based, observational study conducted to identify cardiovascular risk factors in men and women aged 65 years and older. In this analysis, Dr. Mehta reported on 1,963 male and 2,729 female participants with baseline serum uric acid levels available.

During a median 11 years of follow-up, 156 first-incident hip fractures occurred. The association between hyperuricemia and increased fracture risk was confined to men, 430 of whom had a baseline serum uric acid of 7 mg/dL or more.

Participants with an elevated uric acid were disproportionately black, obese, in less than good health, and had significantly higher levels of insulin, C-reactive protein, and cystatin C. In a multivariate regression analysis adjusted for demographics, body mass index, alcohol, smoking, physical activity, diabetes, C-reactive protein, hypertension, and known cardiovascular disease, men with a serum uric acid of 7 mg/dL or higher remained at 62% greater risk of hip fracture, compared with those with a uric acid below 7 mg/dL, according to Dr. Mehta of the University of Colorado, Denver.

High uric acid is known to increase the risk of gout, kidney stones, and more rapid progression of chronic kidney disease. It has also been linked to hypertension.

Possible mechanisms that might explain the link between increased serum uric acid and hip fractures include the fact that uric acid suppresses vitamin D activation. Also, uric acid inhibits expression of 1-alpha hydroxylase protein, and higher uric acid levels are associated with higher levels of parathyroid hormone. In addition, uric acid may cause inflammation in bone, which would be expected to increase fragility. But all of these thoughts on mechanism remain speculative for now, according to the nephrologist.

The absence of a relationship between hyperuricemia and hip fractures in older women in the Cardiovascular Health Study suggests other factors are more important than uric acid levels in women.

Dr. Mehta reported having no financial conflicts regarding this study.

[email protected]

LAS VEGAS – Slightly more than half of primary care physicians reported being unfamiliar with 14-year-old guidelines on nondiabetic chronic kidney disease, but 75% said they were willing to improve how they cared for patients with the condition, results from a Web-based survey showed.

Most non–dialysis-dependent chronic kidney disease (CKD) patients are cared for by their primary care physicians (PCPs). Studies suggest many CKD patients receive suboptimal care. Recently, CKD clinical practice guidelines were updated with additional emphasis on albuminuria, according to a report published in advance of its presentation by Dr. Khaled Abdel-Kader at a meeting sponsored by the National Kidney Foundation.

"Rigorous studies are needed to help identify systematic interventions that can overcome identified barriers and improve optimal CKD care delivery," Dr. Abdel-Kader said in an interview following his presentation. "Based on our findings, while overcoming knowledge deficits and attitudinal barriers remains important, many primary care physicians set appropriate care goals in CKD, but systems are needed to help them and their patients achieve these goals," (BMC Nephrol. 2014 April 22 [doi:10.1186/1471-2369-15-64]).

Dr. Neil Skolnik noted that CKD is an incredibly important topic, affecting more than 15% of the U.S. population. "This is an excellent study with a very good response rate for an e-mail survey, indicating that primary care physicians are interested in the care of patients with CKD.

"This interest is reflected in the answers provided on the survey. With half of primary care physicians unfamiliar with the CKD guidelines, and 75% expressing interest in improving their care of patients with CKD, the next step should focus on how to best disseminate information about the guidelines and provide tools for primary care physicians to best implement the guidelines," said Dr. Skolnik, who is professor of family and community medicine at Temple University, Philadelphia.

Dr. Abdel-Kader and his associates used data from the American Medical Association to conduct a cross-sectional, Web-based survey of PCPs in the United States in an effort to explore their understanding of CKD guidelines, self-reported practice behaviors, and barriers to implementing guideline recommendations, including albuminuria testing. The National Kidney Foundation issued its most recent update to its guidelines in 2000.

Of the 848 PCPs who opened an e-mail about the study, 165 (19.5%) responded. The majority of respondents (88%) spent at least half of their time in clinical care, and 46% were in private practice, said Dr. Abdel-Kader of the department of medicine at Vanderbilt University in Nashville, Tenn.

Nearly all respondents (96%) felt that glomerular filtration rate (GFR) values were helpful, while 75% and 91% reported testing for albuminuria in nondiabetic hypertensive patients with an estimated GFR (eGFR) of greater than 60 mL/min per 1.73 m² or less than 60 mL/min per 1.73 m², respectively. "However, frequent barriers cited included a lack of effect on management, limited time, and the perceived absence of guidelines recommending albuminuria testing," Dr. Abdel-Kader said.

"While PCPs expressed very high agreement with the definition of CKD in patients with marked decrements in eGFR (eGFR less than 45 mL/min per 1.73 m²) or decrements in eGFR coupled with albuminuria, agreement was less robust when eGFR was greater than 60 mL/min per 1.73 m² or in CKD stage 3a without albuminuria."

Most respondents (an average of 78%) felt that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improved outcomes in patients with CKD, yet agreement was lower with severe vs. moderate albuminuria (78% vs. 85%, respectively; P = .03).

Slightly more than half of primary care physicians (51%) reported being unfamiliar with chronic kidney disease guidelines, yet 75% were receptive to systematic interventions in addition to CME to improve their care of CKD patients. "The importance of albuminuria in CKD has become a point of emphasis in guidelines relatively recently, and its value in CKD may not be clearly understood by many PCPs," Dr. Abdel-Kader said. "This is likely contributing to suboptimal targeting of CKD treatments in high-risk and low-risk patients. Working with PCPs to develop systematic interventions that help streamline and improve CKD care without disrupting work flow may have significant potential to improve CKD patient care."

The survey did have certain limitations, including its low response rate, he said. "Our respondents were younger and more likely to be internists than the PCPs we targeted," he noted. "Prior studies have shown that these characteristics tend to associate with greater familiarity with CKD guidelines and recommendations. Hence, recognition of CKD and guideline familiarity may be lower in the general PCP community than we document in our survey."

The study was supported by the National Institutes of Health. Dr. Abdel-Kader said he had no relevant financial conflicts to disclose.

[email protected]

LAS VEGAS – Slightly more than half of primary care physicians reported being unfamiliar with 14-year-old guidelines on nondiabetic chronic kidney disease, but 75% said they were willing to improve how they cared for patients with the condition, results from a Web-based survey showed.

Most non–dialysis-dependent chronic kidney disease (CKD) patients are cared for by their primary care physicians (PCPs). Studies suggest many CKD patients receive suboptimal care. Recently, CKD clinical practice guidelines were updated with additional emphasis on albuminuria, according to a report published in advance of its presentation by Dr. Khaled Abdel-Kader at a meeting sponsored by the National Kidney Foundation.

"Rigorous studies are needed to help identify systematic interventions that can overcome identified barriers and improve optimal CKD care delivery," Dr. Abdel-Kader said in an interview following his presentation. "Based on our findings, while overcoming knowledge deficits and attitudinal barriers remains important, many primary care physicians set appropriate care goals in CKD, but systems are needed to help them and their patients achieve these goals," (BMC Nephrol. 2014 April 22 [doi:10.1186/1471-2369-15-64]).

Dr. Neil Skolnik noted that CKD is an incredibly important topic, affecting more than 15% of the U.S. population. "This is an excellent study with a very good response rate for an e-mail survey, indicating that primary care physicians are interested in the care of patients with CKD.

"This interest is reflected in the answers provided on the survey. With half of primary care physicians unfamiliar with the CKD guidelines, and 75% expressing interest in improving their care of patients with CKD, the next step should focus on how to best disseminate information about the guidelines and provide tools for primary care physicians to best implement the guidelines," said Dr. Skolnik, who is professor of family and community medicine at Temple University, Philadelphia.

Dr. Abdel-Kader and his associates used data from the American Medical Association to conduct a cross-sectional, Web-based survey of PCPs in the United States in an effort to explore their understanding of CKD guidelines, self-reported practice behaviors, and barriers to implementing guideline recommendations, including albuminuria testing. The National Kidney Foundation issued its most recent update to its guidelines in 2000.

Of the 848 PCPs who opened an e-mail about the study, 165 (19.5%) responded. The majority of respondents (88%) spent at least half of their time in clinical care, and 46% were in private practice, said Dr. Abdel-Kader of the department of medicine at Vanderbilt University in Nashville, Tenn.

Nearly all respondents (96%) felt that glomerular filtration rate (GFR) values were helpful, while 75% and 91% reported testing for albuminuria in nondiabetic hypertensive patients with an estimated GFR (eGFR) of greater than 60 mL/min per 1.73 m² or less than 60 mL/min per 1.73 m², respectively. "However, frequent barriers cited included a lack of effect on management, limited time, and the perceived absence of guidelines recommending albuminuria testing," Dr. Abdel-Kader said.

"While PCPs expressed very high agreement with the definition of CKD in patients with marked decrements in eGFR (eGFR less than 45 mL/min per 1.73 m²) or decrements in eGFR coupled with albuminuria, agreement was less robust when eGFR was greater than 60 mL/min per 1.73 m² or in CKD stage 3a without albuminuria."

Most respondents (an average of 78%) felt that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improved outcomes in patients with CKD, yet agreement was lower with severe vs. moderate albuminuria (78% vs. 85%, respectively; P = .03).

Slightly more than half of primary care physicians (51%) reported being unfamiliar with chronic kidney disease guidelines, yet 75% were receptive to systematic interventions in addition to CME to improve their care of CKD patients. "The importance of albuminuria in CKD has become a point of emphasis in guidelines relatively recently, and its value in CKD may not be clearly understood by many PCPs," Dr. Abdel-Kader said. "This is likely contributing to suboptimal targeting of CKD treatments in high-risk and low-risk patients. Working with PCPs to develop systematic interventions that help streamline and improve CKD care without disrupting work flow may have significant potential to improve CKD patient care."

The survey did have certain limitations, including its low response rate, he said. "Our respondents were younger and more likely to be internists than the PCPs we targeted," he noted. "Prior studies have shown that these characteristics tend to associate with greater familiarity with CKD guidelines and recommendations. Hence, recognition of CKD and guideline familiarity may be lower in the general PCP community than we document in our survey."

The study was supported by the National Institutes of Health. Dr. Abdel-Kader said he had no relevant financial conflicts to disclose.

[email protected]

LAS VEGAS – Slightly more than half of primary care physicians reported being unfamiliar with 14-year-old guidelines on nondiabetic chronic kidney disease, but 75% said they were willing to improve how they cared for patients with the condition, results from a Web-based survey showed.

Most non–dialysis-dependent chronic kidney disease (CKD) patients are cared for by their primary care physicians (PCPs). Studies suggest many CKD patients receive suboptimal care. Recently, CKD clinical practice guidelines were updated with additional emphasis on albuminuria, according to a report published in advance of its presentation by Dr. Khaled Abdel-Kader at a meeting sponsored by the National Kidney Foundation.

"Rigorous studies are needed to help identify systematic interventions that can overcome identified barriers and improve optimal CKD care delivery," Dr. Abdel-Kader said in an interview following his presentation. "Based on our findings, while overcoming knowledge deficits and attitudinal barriers remains important, many primary care physicians set appropriate care goals in CKD, but systems are needed to help them and their patients achieve these goals," (BMC Nephrol. 2014 April 22 [doi:10.1186/1471-2369-15-64]).

Dr. Neil Skolnik noted that CKD is an incredibly important topic, affecting more than 15% of the U.S. population. "This is an excellent study with a very good response rate for an e-mail survey, indicating that primary care physicians are interested in the care of patients with CKD.

"This interest is reflected in the answers provided on the survey. With half of primary care physicians unfamiliar with the CKD guidelines, and 75% expressing interest in improving their care of patients with CKD, the next step should focus on how to best disseminate information about the guidelines and provide tools for primary care physicians to best implement the guidelines," said Dr. Skolnik, who is professor of family and community medicine at Temple University, Philadelphia.

Dr. Abdel-Kader and his associates used data from the American Medical Association to conduct a cross-sectional, Web-based survey of PCPs in the United States in an effort to explore their understanding of CKD guidelines, self-reported practice behaviors, and barriers to implementing guideline recommendations, including albuminuria testing. The National Kidney Foundation issued its most recent update to its guidelines in 2000.

Of the 848 PCPs who opened an e-mail about the study, 165 (19.5%) responded. The majority of respondents (88%) spent at least half of their time in clinical care, and 46% were in private practice, said Dr. Abdel-Kader of the department of medicine at Vanderbilt University in Nashville, Tenn.

Nearly all respondents (96%) felt that glomerular filtration rate (GFR) values were helpful, while 75% and 91% reported testing for albuminuria in nondiabetic hypertensive patients with an estimated GFR (eGFR) of greater than 60 mL/min per 1.73 m² or less than 60 mL/min per 1.73 m², respectively. "However, frequent barriers cited included a lack of effect on management, limited time, and the perceived absence of guidelines recommending albuminuria testing," Dr. Abdel-Kader said.

"While PCPs expressed very high agreement with the definition of CKD in patients with marked decrements in eGFR (eGFR less than 45 mL/min per 1.73 m²) or decrements in eGFR coupled with albuminuria, agreement was less robust when eGFR was greater than 60 mL/min per 1.73 m² or in CKD stage 3a without albuminuria."

Most respondents (an average of 78%) felt that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improved outcomes in patients with CKD, yet agreement was lower with severe vs. moderate albuminuria (78% vs. 85%, respectively; P = .03).

Slightly more than half of primary care physicians (51%) reported being unfamiliar with chronic kidney disease guidelines, yet 75% were receptive to systematic interventions in addition to CME to improve their care of CKD patients. "The importance of albuminuria in CKD has become a point of emphasis in guidelines relatively recently, and its value in CKD may not be clearly understood by many PCPs," Dr. Abdel-Kader said. "This is likely contributing to suboptimal targeting of CKD treatments in high-risk and low-risk patients. Working with PCPs to develop systematic interventions that help streamline and improve CKD care without disrupting work flow may have significant potential to improve CKD patient care."

The survey did have certain limitations, including its low response rate, he said. "Our respondents were younger and more likely to be internists than the PCPs we targeted," he noted. "Prior studies have shown that these characteristics tend to associate with greater familiarity with CKD guidelines and recommendations. Hence, recognition of CKD and guideline familiarity may be lower in the general PCP community than we document in our survey."

The study was supported by the National Institutes of Health. Dr. Abdel-Kader said he had no relevant financial conflicts to disclose.

[email protected]

LAS VEGAS – The majority of patients with proteinuria who are admitted to hospitals affiliated with academic medical centers are not placed on life-prolonging therapy, results from a small study showed.

In addition, the 41% of patients with the condition were taking NSAIDS, which can worsen kidney function.

Image courtesy of Dr. Javier Neyra

"Recognizing proteinuria and initiating the appropriate treatment are extremely important," Dr. Vishesh Kumar, a resident physician at Albany (N.Y.) Medical College, said in an interview following a meeting sponsored by the National Kidney Foundation, where the study was presented.

"If left untreated, proteinuria has been associated with cardiovascular mortality and progression of kidney disease. Both are very poor outcomes, and both can be either slowed in their onset, or in some cases prevented altogether. Our study has shed some light onto the scope of the problem."

Dr. Kumar, along with Dr. Arif Asif, professor of medicine at the medical college, and their associates conducted a multicenter retrospective study that set out to identify patients admitted to the hospital service with proteinuria and to establish whether they were optimally treated. "We know that it is easy to screen for proteinuria using a simple urine dipstick," he said. "We also have several antiproteinuric agents [to use] such as ACE [angiotensin-converting enzyme] inhibitors, angiotensin II receptor blockers, spironolactone, diltiazem, and verapamil. These medications have been shown in landmark trials in nephrology to help to reduce proteinuria, improve cardiovascular mortality, and slow the progression of kidney disease."

The study population included 298 patients (mean age, 60 years) who were admitted to two hospitals over a 6-month period. Of the 298 patients, 199 (66%) were confirmed to have proteinuria. Of these, 74 (37%) were treated with an antiproteinuric agent, and 81 (41%) were taking NSAIDs. Dr. Kumar said that he and his colleagues were very surprised "by the fact that many patients with proteinuria were taking NSAIDs, which can worsen proteinuria, and many of which are available over the counter. We have a huge opportunity for improvement of care in these patients."

He also reported that 63 of the patients (32%) had proteinuria and hypertension. Among this subset of patients, only 27 (43%) received an antiproteinuric agent.

Dr. Kumar acknowledged that certain limitations of the study, including its small sample size and the fact that "we did not collect any data involving these patients’ primary care. One could generalize that patients that come into hospital may not have as good a relationship with primary care providers and may not be screened with a urine analysis as an outpatient as frequently. Many of these things can be addressed in future studies."

The researchers reported having no financial conflicts of interest.

LAS VEGAS – The majority of patients with proteinuria who are admitted to hospitals affiliated with academic medical centers are not placed on life-prolonging therapy, results from a small study showed.

In addition, the 41% of patients with the condition were taking NSAIDS, which can worsen kidney function.

Image courtesy of Dr. Javier Neyra

"Recognizing proteinuria and initiating the appropriate treatment are extremely important," Dr. Vishesh Kumar, a resident physician at Albany (N.Y.) Medical College, said in an interview following a meeting sponsored by the National Kidney Foundation, where the study was presented.

"If left untreated, proteinuria has been associated with cardiovascular mortality and progression of kidney disease. Both are very poor outcomes, and both can be either slowed in their onset, or in some cases prevented altogether. Our study has shed some light onto the scope of the problem."

Dr. Kumar, along with Dr. Arif Asif, professor of medicine at the medical college, and their associates conducted a multicenter retrospective study that set out to identify patients admitted to the hospital service with proteinuria and to establish whether they were optimally treated. "We know that it is easy to screen for proteinuria using a simple urine dipstick," he said. "We also have several antiproteinuric agents [to use] such as ACE [angiotensin-converting enzyme] inhibitors, angiotensin II receptor blockers, spironolactone, diltiazem, and verapamil. These medications have been shown in landmark trials in nephrology to help to reduce proteinuria, improve cardiovascular mortality, and slow the progression of kidney disease."

The study population included 298 patients (mean age, 60 years) who were admitted to two hospitals over a 6-month period. Of the 298 patients, 199 (66%) were confirmed to have proteinuria. Of these, 74 (37%) were treated with an antiproteinuric agent, and 81 (41%) were taking NSAIDs. Dr. Kumar said that he and his colleagues were very surprised "by the fact that many patients with proteinuria were taking NSAIDs, which can worsen proteinuria, and many of which are available over the counter. We have a huge opportunity for improvement of care in these patients."

He also reported that 63 of the patients (32%) had proteinuria and hypertension. Among this subset of patients, only 27 (43%) received an antiproteinuric agent.

Dr. Kumar acknowledged that certain limitations of the study, including its small sample size and the fact that "we did not collect any data involving these patients’ primary care. One could generalize that patients that come into hospital may not have as good a relationship with primary care providers and may not be screened with a urine analysis as an outpatient as frequently. Many of these things can be addressed in future studies."

The researchers reported having no financial conflicts of interest.

LAS VEGAS – The majority of patients with proteinuria who are admitted to hospitals affiliated with academic medical centers are not placed on life-prolonging therapy, results from a small study showed.

In addition, the 41% of patients with the condition were taking NSAIDS, which can worsen kidney function.

Image courtesy of Dr. Javier Neyra

"Recognizing proteinuria and initiating the appropriate treatment are extremely important," Dr. Vishesh Kumar, a resident physician at Albany (N.Y.) Medical College, said in an interview following a meeting sponsored by the National Kidney Foundation, where the study was presented.

"If left untreated, proteinuria has been associated with cardiovascular mortality and progression of kidney disease. Both are very poor outcomes, and both can be either slowed in their onset, or in some cases prevented altogether. Our study has shed some light onto the scope of the problem."

Dr. Kumar, along with Dr. Arif Asif, professor of medicine at the medical college, and their associates conducted a multicenter retrospective study that set out to identify patients admitted to the hospital service with proteinuria and to establish whether they were optimally treated. "We know that it is easy to screen for proteinuria using a simple urine dipstick," he said. "We also have several antiproteinuric agents [to use] such as ACE [angiotensin-converting enzyme] inhibitors, angiotensin II receptor blockers, spironolactone, diltiazem, and verapamil. These medications have been shown in landmark trials in nephrology to help to reduce proteinuria, improve cardiovascular mortality, and slow the progression of kidney disease."

The study population included 298 patients (mean age, 60 years) who were admitted to two hospitals over a 6-month period. Of the 298 patients, 199 (66%) were confirmed to have proteinuria. Of these, 74 (37%) were treated with an antiproteinuric agent, and 81 (41%) were taking NSAIDs. Dr. Kumar said that he and his colleagues were very surprised "by the fact that many patients with proteinuria were taking NSAIDs, which can worsen proteinuria, and many of which are available over the counter. We have a huge opportunity for improvement of care in these patients."

He also reported that 63 of the patients (32%) had proteinuria and hypertension. Among this subset of patients, only 27 (43%) received an antiproteinuric agent.

Dr. Kumar acknowledged that certain limitations of the study, including its small sample size and the fact that "we did not collect any data involving these patients’ primary care. One could generalize that patients that come into hospital may not have as good a relationship with primary care providers and may not be screened with a urine analysis as an outpatient as frequently. Many of these things can be addressed in future studies."

The researchers reported having no financial conflicts of interest.

LAS VEGAS – Moderate intake of wine was associated with a 37% lower prevalence of chronic kidney disease in healthy adults, compared with no wine consumption at all, according to an analysis of data from the National Health and Nutrition Examination Survey.

In addition, survey respondents with chronic kidney disease (which increases the risk of cardiovascular disease) who drank less than one glass of wine a day had 29% lower odds of cardiovascular disease, compared with those who drank no wine at all.

"Since this is an observational study and we looked at the data as a cross-sectional analysis, we can’t say that there’s a cause and effect relationship," lead author Dr. Tapan Mehta emphasized in an interview at a meeting sponsored by the National Kidney Foundation. "But this is the first time that [the link between] wine intake and cardiovascular disease risk has been studied in patients who have kidney disease."

Dr. Mehta, of the division of renal disease and hypertension at the University of Colorado Anschutz Medical Center, Aurora, and his associates performed a cross-sectional analysis of 5,852 men and women aged 21 years and older who participated in the National Health and Nutrition Examination Survey (NHANES) between 2003 and 2006. The researchers analyzed wine intake in three categories: none, less than one glass per day, and one or more glasses per day. They examined the prevalence of chronic kidney disease (defined as MDRD [Modification of Diet in Renal Disease Study Group] estimated glomerular filtration rate of less than 60 mL/min per 1.73 m² or albumin/creatinine ratio of 30 mg/g or greater) according to wine intake. Next, they examined the relationship between wine intake and cardiovascular disease (CVD), defined as history of angina, myocardial infarction, or stroke.

The mean age of study participants was 48 years, and 52% were female. Of the 5,852 individuals, 2,455 drank less than one glass of wine per day, and 1,031 had kidney disease.

In unadjusted analysis, those who drank less than one glass of wine per day had a 0.63 reduced odds of chronic kidney disease (CKD), compared with those who did not drink wine (P less than .0001). This association remained significant after adjustment for demographics, waist circumference, diabetes, hypertension, HDL cholesterol, and triglycerides (odds ratio, 0.75; P = .004).

The researchers observed that the relationship between wine intake and kidney disease appeared to be driven by a significant association between consumption of less than one glass of wine per day and microalbuminuria, which was defined as an albumin/creatinine ratio of 30 mg/g or greater (OR, 0.62; P = .006). No association between wine intake and an estimated glomerular filtration rate of less than 60 mL/min per 1.73 m² was seen. "We didn’t expect that," Dr. Mehta said.

When the analysis was limited to the 1,031 individuals with CKD, the odds of CVD was 0.71 (P =.02) for those drinking less than one glass of wine per day, compared with nondrinkers after adjustment for demographics and CVD risk factors.

Dr. Mehta acknowledged certain limitations of the study, including its observational design and the potential for recall bias in the food intake component of NHANES. "Also, there is no specification as to red wine or white wine consumption," he said. "We also did not look at other alcohol, such as beer or liquor."

Dr. Mehta had no relevant financial conflicts to disclose.

[email protected]

Doug Brunk/Frontline Medical News

LAS VEGAS – Moderate intake of wine was associated with a 37% lower prevalence of chronic kidney disease in healthy adults, compared with no wine consumption at all, according to an analysis of data from the National Health and Nutrition Examination Survey.

In addition, survey respondents with chronic kidney disease (which increases the risk of cardiovascular disease) who drank less than one glass of wine a day had 29% lower odds of cardiovascular disease, compared with those who drank no wine at all.

"Since this is an observational study and we looked at the data as a cross-sectional analysis, we can’t say that there’s a cause and effect relationship," lead author Dr. Tapan Mehta emphasized in an interview at a meeting sponsored by the National Kidney Foundation. "But this is the first time that [the link between] wine intake and cardiovascular disease risk has been studied in patients who have kidney disease."

Dr. Mehta, of the division of renal disease and hypertension at the University of Colorado Anschutz Medical Center, Aurora, and his associates performed a cross-sectional analysis of 5,852 men and women aged 21 years and older who participated in the National Health and Nutrition Examination Survey (NHANES) between 2003 and 2006. The researchers analyzed wine intake in three categories: none, less than one glass per day, and one or more glasses per day. They examined the prevalence of chronic kidney disease (defined as MDRD [Modification of Diet in Renal Disease Study Group] estimated glomerular filtration rate of less than 60 mL/min per 1.73 m² or albumin/creatinine ratio of 30 mg/g or greater) according to wine intake. Next, they examined the relationship between wine intake and cardiovascular disease (CVD), defined as history of angina, myocardial infarction, or stroke.

The mean age of study participants was 48 years, and 52% were female. Of the 5,852 individuals, 2,455 drank less than one glass of wine per day, and 1,031 had kidney disease.

In unadjusted analysis, those who drank less than one glass of wine per day had a 0.63 reduced odds of chronic kidney disease (CKD), compared with those who did not drink wine (P less than .0001). This association remained significant after adjustment for demographics, waist circumference, diabetes, hypertension, HDL cholesterol, and triglycerides (odds ratio, 0.75; P = .004).

The researchers observed that the relationship between wine intake and kidney disease appeared to be driven by a significant association between consumption of less than one glass of wine per day and microalbuminuria, which was defined as an albumin/creatinine ratio of 30 mg/g or greater (OR, 0.62; P = .006). No association between wine intake and an estimated glomerular filtration rate of less than 60 mL/min per 1.73 m² was seen. "We didn’t expect that," Dr. Mehta said.

When the analysis was limited to the 1,031 individuals with CKD, the odds of CVD was 0.71 (P =.02) for those drinking less than one glass of wine per day, compared with nondrinkers after adjustment for demographics and CVD risk factors.

Dr. Mehta acknowledged certain limitations of the study, including its observational design and the potential for recall bias in the food intake component of NHANES. "Also, there is no specification as to red wine or white wine consumption," he said. "We also did not look at other alcohol, such as beer or liquor."

Dr. Mehta had no relevant financial conflicts to disclose.

[email protected]

Doug Brunk/Frontline Medical News

LAS VEGAS – Moderate intake of wine was associated with a 37% lower prevalence of chronic kidney disease in healthy adults, compared with no wine consumption at all, according to an analysis of data from the National Health and Nutrition Examination Survey.

In addition, survey respondents with chronic kidney disease (which increases the risk of cardiovascular disease) who drank less than one glass of wine a day had 29% lower odds of cardiovascular disease, compared with those who drank no wine at all.

"Since this is an observational study and we looked at the data as a cross-sectional analysis, we can’t say that there’s a cause and effect relationship," lead author Dr. Tapan Mehta emphasized in an interview at a meeting sponsored by the National Kidney Foundation. "But this is the first time that [the link between] wine intake and cardiovascular disease risk has been studied in patients who have kidney disease."

Dr. Mehta, of the division of renal disease and hypertension at the University of Colorado Anschutz Medical Center, Aurora, and his associates performed a cross-sectional analysis of 5,852 men and women aged 21 years and older who participated in the National Health and Nutrition Examination Survey (NHANES) between 2003 and 2006. The researchers analyzed wine intake in three categories: none, less than one glass per day, and one or more glasses per day. They examined the prevalence of chronic kidney disease (defined as MDRD [Modification of Diet in Renal Disease Study Group] estimated glomerular filtration rate of less than 60 mL/min per 1.73 m² or albumin/creatinine ratio of 30 mg/g or greater) according to wine intake. Next, they examined the relationship between wine intake and cardiovascular disease (CVD), defined as history of angina, myocardial infarction, or stroke.

The mean age of study participants was 48 years, and 52% were female. Of the 5,852 individuals, 2,455 drank less than one glass of wine per day, and 1,031 had kidney disease.

In unadjusted analysis, those who drank less than one glass of wine per day had a 0.63 reduced odds of chronic kidney disease (CKD), compared with those who did not drink wine (P less than .0001). This association remained significant after adjustment for demographics, waist circumference, diabetes, hypertension, HDL cholesterol, and triglycerides (odds ratio, 0.75; P = .004).

The researchers observed that the relationship between wine intake and kidney disease appeared to be driven by a significant association between consumption of less than one glass of wine per day and microalbuminuria, which was defined as an albumin/creatinine ratio of 30 mg/g or greater (OR, 0.62; P = .006). No association between wine intake and an estimated glomerular filtration rate of less than 60 mL/min per 1.73 m² was seen. "We didn’t expect that," Dr. Mehta said.

When the analysis was limited to the 1,031 individuals with CKD, the odds of CVD was 0.71 (P =.02) for those drinking less than one glass of wine per day, compared with nondrinkers after adjustment for demographics and CVD risk factors.

Dr. Mehta acknowledged certain limitations of the study, including its observational design and the potential for recall bias in the food intake component of NHANES. "Also, there is no specification as to red wine or white wine consumption," he said. "We also did not look at other alcohol, such as beer or liquor."

Dr. Mehta had no relevant financial conflicts to disclose.

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Doug Brunk/Frontline Medical News