Hemodialysis.com Kidney Disease Interviews March 24 2013

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Kidney Disease Researchers discuss their publications regarding chronic kidney disease, dialysis, hemodialysis and ESRD.

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Hemodialysis.com Kidney Disease Interviews March 24 2013

  1. 1. Hemodialysis.com Hemodialysis research, author interviews, dialysis updates and information on chronic kidney disease and end stage renal failure. Editor: Marie Benz, MD info@hemodialysis.com March 24 2013 For Informational Purposes Only: Not for Specific Medical Advice.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  2. 2. Hemodialysis.com Interviews March 24 2013For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  3. 3. Medical Disclaimer | Terms and Conditions• The contents of the Hemodialysis.com Site, such as text, graphics, images, and other material contained on the Hemodialysis.com Site ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on the Hemodialysis.com Site!• If you think you may have a medical emergency, call your doctor or 911 immediately. Hemodialysis.com does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by Hemodialysis.com or other Eminent Domains Inc (EDI) websites, EDI employees, others appearing on the Site at the invitation of Hemodialysis.com or EDI, or other visitors to the Site is solely at your own risk.• The Site may contain health- or medical-related materials that are sexually explicit. If you find these materials offensive, you may not want to use our Site. The Site and the Content are provided on an "as is" basis.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  4. 4. Effects of Cholecalciferol on Functional, Biochemical, Vascular, and Quality of Life Outcomes in Hemodialysis Patients Hemodialysis.com Interview with Dr. Grahame J. Elder Clinical A/Professor (Sydney and UNDA) Department of Renal Medicine, Westmead Hospital Osteoporosis and Bone Biology Programme, Garvan Institute Sydney• Hemodialysis.com: What are the main findings of the study?• Dr. Elder: This study is one of very few randomized controlled trials in patients on hemodialysis.assessing the effect of cholecalciferol use to improve levels of 25-hydroxyvitamin D After 6 months, patients treated with cholecalciferol had higher values of both 25- hydroxyvitamin D and calcitriol (1,25-dihydroxyvitamin D), the most active form of vitamin D than patients treated with placebo. This was achieved without adverse effects on calcium or phosphorus levels.• However, after 6 months treatment we could not discern any effect of supplementation on muscle strength or function, pulse wave velocity (an indicator of vascular stiffness and surrogate for vascular calcification) or on quality of life Whether this is because the period of supplementation was too short, the patients selected had higher values of 25-hydroxyvitamin D than many patients on dialysis, or because cholecalciferol will not influence these outcomes are questions that cannot be answered by our data.• Hemodialysis.com: Were any of the findings unexpected?• Dr. Elder: We were interested to see that phosphorus levels and phosphate binder use were lower at 6 months in patients treated with cholecalciferol. Also the rise in the TRAcP-5b, an osteoclast marker, was a surprise because we had thought that if anything, cholecalciferol might reduce parathyroid hormone levels, osteoclast activation and bone turnover. However, recent human and animal studies have reported that both osteoblasts and osteoclasts can metabolize 25- hydroxyvitamin D to 1,25-dihydroxyvitamin D, so perhaps this might have been expected. We were of course surprised to find no effect on muscle strength, which we had designated the primary outcome for the study, or on functional testing,For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  5. 5. Effects of Cholecalciferol on Functional, Biochemical, Vascular, and Quality of Life Outcomes in Hemodialysis Patients Hemodialysis.com Interview with Dr. Grahame J. Elder Clinical A/Professor (Sydney and UNDA) Department of Renal Medicine, Westmead Hospital Osteoporosis and Bone Biology Programme, Garvan Institute Sydney (cont)• Hemodialysis.com: What should clinicians and patients take away from this study?• Dr. Elder: Cholecalciferol treatment increased levels of 25-hydroxyvitamin D in patients on hemodialysis. Patients receiving this treatment have higher levels of calcitriol than those who do not and the treatment is unlikely to cause adverse effects on levels of calcium or phosphorus. The baseline data indicating positive associations of 25- hydroxyvitamin D and functional testing and an inverse relationship or 25-hydroxyvitamin D to pulse wave velocity, although of course this does not prove any benefit will derive from treatment. But on the other hand, it certainly supports the contention that treatment will do no harm.• Hemodialysis.com: What recommendations do you have for future research as a result of your study?• Dr. Elder: At baseline we found positive associations of 25-hydroxyvitamin D values and distance covered in a 6 minute walk and an inverse relationship of 25-hydroxyvitamin D values and pulse wave velocity. These findings are consistent with associations reported in a number of other studies, so it remains possible that longer studies, or studies recruiting patients with lower levels of vitamin D in the ‘deficient’ range, might find that functional tests and vascular stiffness improve over time. A number of cross sectional and some longitudinal studies have now reported that hemodialysis patients with higher 25-hydroxyvitamin D levels or calciferol (cholecalciferol or ergocalciferol) supplementation have higher levels of calcitriol as we also reported In turn, improved calcitriol levels may have positive influences on vascular tissue and cardiovascular outcomes, providing hypercalcemia and hyperphosphatemia are avoided. A longer and much larger study to assess the influence of calciferol supplementation on cardiovascular events and mortality is long overdue.• Citation:• Effects of Cholecalciferol on Functional, Biochemical, Vascular, and Quality of Life Outcomes in Hemodialysis Patients• Nathan A. Hewitt, Alicia A. O’Connor, Denise V. O’Shaughnessy, and Grahame J. Elder• CJASN CJN.02840312; published ahead of print March 14, 2013, doi:10.2215/CJN.02840312For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  6. 6. Demographic, metabolic, and blood pressure characteristics of living kidney donors spanning five decades. Hemodialysis.com Author Interview with Sandra J. Taler, M.D. Consultant, Division of Nephrology/Hypertension Associate Professor of Medicine | College of Medicine | Mayo Clinic | 200 First Street SW | Rochester, MN 55905• Hemodialysis.com: What are the main findings of the study?• Dr. Taler: We reviewed the medical records of all living kidney donors (8951 total) from 3 large transplant centers (Mayo Clinic, University of Alabama in Birmingham and University of Minnesota) since the beginning of living donation in 1963 through 2007.• We examined trends in the metabolic profile of accepted living donors by quartiles of this 44 year timespan. We saw a trend to higher donor age with fewer donors in their 20s but only 4% of donors were older than age 60 years at the time of donation. Using a consistent definition for hypertension, we found the percentage of donors with hypertension remained low and was stable over time. We did find an increasing proportion of donors were obese or had glucose intolerance in the more recent time quartiles however most had mild elevations in glucose that met acceptance criteria. There was greater tolerance for one or more metabolic abnormalities in older donors but the percentage of older donor remained quite low.• Hemodialysis.com: Were any of the findings unexpected?• Dr. Taler: Yes. We thought we might find a higher rate of hypertensive donors accepted in the more recent time quartiles. However, using the same numerical cutoffs, this was not the case. The difference relates to changes to a more strict definition for hypertension over time.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  7. 7. Demographic, metabolic, and blood pressure characteristics of living kidney donors spanning five decades. Hemodialysis.com Author Interview with Sandra J. Taler, M.D. Consultant, Division of Nephrology/Hypertension Associate Professor of Medicine | College of Medicine | Mayo Clinic | 200 First Street SW | Rochester, MN 55905 (cont)• Hemodialysis.com: What should clinicians and patients take away from this study?• Dr. Taler: As the entire United States population is aging and becoming more obese, accepted kidney donors also reflect these trends.• Hemodialysis.com: What recommendations do you have for future research as a result of your study? Dr. Taler: We are looking at outcomes for the donors in this study. It is important that living kidney donors have access to medical care so they can be evaluated and treated for hypertension, diabetes or other metabolic abnormalities should they develop.• Citation:• Demographic, metabolic, and blood pressure characteristics of living kidney donors spanning five decades.• Taler SJ, Messersmith EE, Leichtman AB, Gillespie BW, Kew CE, Stegall MD, Merion RM, Matas AJ, Ibrahim HN; RELIVE Study Group.• Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA• Am J Transplant. 2013 Feb;13(2):390-8. doi: 10.1111/j.1600-6143.2012.04321.x. Epub 2012 Nov 8.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  8. 8. Single Pediatric Kidney Transplantation in Adult Recipients : Comparable Outcomes With Standard-Criteria Deceased Donor Kidney Transplantation Hemodialysis.com Interview with: Dr Amit Sharma MD. MPhil Assistant Professor Director, Transplant Surgery Fellowship Program Hume-Lee Transplant Center Virginia Commonwealth University Richmond, Virginia, USA• Hemodialysis.com: What are the main findings of the study?• Dr. Sharma: Single pediatric kidney transplantation (SKT) in to adult recipients has traditionally been considered high risk due to concerns of technical complications leading to poor graft outcomes. As a result many transplant centers hesitate to utilize these kidneys for transplantation. We retrospectively compared outcomes in adult recipients after SKT (n=31), standard criteria deceased donor kidney transplantation (SCDKT, n=283), pediatric en bloc, (EBKT, n=21), living donor (LDKT, n=275) and extended criteria donor, (ECD, n=100) kidney transplantation.• The mean donor age and weight for pediatric single kidney donors were 6.3 years and 27.6 kg. The recipients selected for SKT weighed significantly less (67.6 ± 21.4 kg), p<0.0001) compared to the SCDKT recipients. There were no re-transplant candidates in SKT group while 14.5% of SCDKT recipients had previous kidney transplants. The superior quality of single pediatric kidneys was reflected by the serum creatinine which at 1-year was significantly lower than ECD, and by 5-years was lower than both SCDKT and ECD (p<0.0001). Compared to standard criteria donors (SCDKT), the single pediatric kidney transplant (SKT) group had a higher incidence of renal arterial anastomotic stenosis (6.8% vs. 0.4%, p=0.02), hydronephrosis (12.9% vs. 5.3%, p=0.02) and a higher incidence of acute rejection (9.7% vs. 6.0%, p=0.03). Subgroup analysis of the SKT cohort by donor age below 5 vs. 6-10 years (mean weight 16.4 kg vs. 32.7 kg) revealed that there were no differences in serum creatinine, patient survival or death-censured graft survival.• Hemodialysis.com: Were any of the findings unexpected?• Dr. Sharma: We did not see any significant difference in the incidence of delayed graft function between SKT (45.2%) and SCDKT (50.5%) groups. This indicates good donor-recipient weight matching that may have prevented problems due to low nephron mass. Patient survival at 1- and 5-years after single pediatric kidney transplants (SKT) was lower than SCDKT at both time points (p=0.02). Despite the higher rate of vascular and urological complications, the 5- year death-censored graft survival after SKT (81.4 ± 7.6%) was significantly superior to both SCDKT (74.5 ± 3.4%) and ECD (74.6 ± 5.8%, p=0.02).For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  9. 9. Single Pediatric Kidney Transplantation in Adult Recipients : Comparable Outcomes With Standard-Criteria Deceased Donor Kidney Transplantation Hemodialysis.com Interview with: Dr Amit Sharma MD. MPhil Assistant Professor Director, Transplant Surgery Fellowship Program Hume-Lee Transplant Center Virginia Commonwealth University Richmond, Virginia, USA (cont)• Hemodialysis.com: What should clinicians and patients take away from this study? Dr. Sharma: With careful donor and recipient selection, single pediatric kidney transplantation in to adult recipients offers superior long-term graft outcomes compared to standard criteria deceased donor kidney transplantation. Kidneys from pediatric donors who weigh more than 15 kg or with kidney size greater than 6 cm should be split and transplanted singly in order to optimize resource utilization. Recipients with certain high-risk criteria should be avoided to ensure successful graft outcomes after SKT. Post-transplant management of SKT recipients should include strict control of hypertension, aspirin for at least one year and vigilant immunosuppression monitoring to prevent rejections. In our experience, complications like arterial stenosis and hydronephrosis can be successfully managed by experienced interventional radiologists. Use of pediatric donor kidneys needs to be continuously encouraged to address the problem of organ shortage.• Hemodialysis.com: What recommendations do you have for future research as a result of your study?• Dr. Sharma: We have proposed a few strategies to optimize both the utilization and outcomes after transplantation of single pediatric kidneys in to adult recipients. These include the need for policies to expedite pediatric kidney placement in order to minimize cold ischemia times. Facilitating organ procurement and transplantation by experienced operators could reduce the technical complications. Future res earch should also focus on newer immunosuppressive strategies to lower rejection rates and further improve pediatric kidney allograft survival.• Citation:• Single Pediatric Kidney Transplantation in Adult Recipients: Comparable Outcomes With Standard-Criteria Deceased-Donor Kidney Transplantation• Sharma, Amit; Ramanathan, Rajesh; Behnke, Martha; Fisher, Robert; Posner, Marc• Transplantation:• POST AUTHOR CORRECTIONS, 15 March 2013 doi: 10.1097/TP.0b013e31828a9493For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  10. 10. Modifiable Patient Characteristics and Racial Disparities in Evaluation Completion and Living Donor Transplant Hemodialysis.com Interview with: Dr. Amy D. Waterman General Medical Sciences, Washington University School of Medicine Campus Box 8005, 660 S. Euclid Avenue, St. Louis, MO 6311• Hemodialysis.com: What are the main findings of the study?• Dr. Waterman:• In an analysis of 695 Black and White patients in kidney failure who presented for transplant and were followed over 6 years, Black patients initially presented for evaluation having received less transplant education, being less knowledgeable about transplantation, and less willing to pursue deceased or living donor transplantation than Whites.• Patients who began their transplant evaluation process with a greater knowledge of transplantation and greater motivation to receive living donor transplants were ultimately more successful at receiving a living donor transplant six year later.• Hemodialysis.com: Were any of the findings unexpected?• Dr. Waterman:• Though we knew that modifiable patient characteristics, like how much knowledge or education of transplant a patient has, were important in understanding whether patients will pursue or get a transplant, we were surprised to see that, in our analysis, these were some of the most important predictors of whether patients would pursue or get a transplant.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  11. 11. Modifiable Patient Characteristics and Racial Disparities in Evaluation Completion and Living Donor Transplant Hemodialysis.com Interview with: Dr. Amy D. Waterman General Medical Sciences, Washington University School of Medicine Campus Box 8005, 660 S. Euclid Avenue, St. Louis, MO 6311 (cont)• Hemodialysis.com: What should clinicians and patients take away from this study?• Dr. Waterman:• These findings suggest that improved education, especially for patients of color, may help more patients successfully get transplants. Educational interventions focused on helping improve patients’ transplant knowledge and motivation when patients’ kidneys are starting to fail or afterwards may reduce or overcome racial disparities in transplantation. Education in dialysis centers about transplant could be incredibly beneficial to patients’ transplant success years later.• Hemodialysis.com: What recommendations do you have for future research as a result of your study?• Dr. Waterman:• Future research should compare the potential for different educational interventions in dialysis centers and community nephrologists’ offices to help patients, especially patients of color, obtain more knowledge of transplant and become more willing to get a transplant. Research should also look at the best ways to deliver these interventions so that they can help all patients move toward transplant more quickly, easily, and cost-effectively.• Citation:• Modifiable Patient Characteristics and Racial Disparities in Evaluation Completion and Living Donor Transplant• Amy D. Waterman, John D. Peipert, Shelley S. Hyland, Melanie S. McCabe, Emily A. Schenk, and Jingxia Liu• CJASN CJN.08880812; published ahead of print March 21, 2013, doi:10.2215/CJN.08880812For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  12. 12. Estimated GFR reporting is associated with decreased NSAID drug prescribing and increased renal function Hemodialysis.com Author Interview: Dr Li Wei Senior Lecturer Department of Practice and Policy UCL School of Pharmacy Tavistock Square London WC1H 9JP• Hemodialysis.com: What are the main findings of the study?• Dr. Li: The study was a population-based longitudinal analysis using a record-linkage database in Tayside, Scotland, UK. The aim of the study was to determine NSAID prescribing before and after the implementation of estimated eGFR reporting and to evaluate renal function in patients who used NSAIDs but stopped these after the first eGFR report. The study found that prescriptions for NSAIDs significantly decreased after the implementation of eGFR reporting. eGFR reporting was associated with reduced NSAID prescriptions (adjusted OR, 0.78 95%CI 0.75-0.82). NSAID prescribing rates in the 6 months prior to April 2006 were 18.8%, 15.4% and 7.0% in patients with CKD stages 3, 4, and 5 and 15.5%, 10.7% and 6.3% respectively, after eGFR reporting commenced. In patients who stopped NSAID treatment, eGFR significantly increased from 45.9 to 46.9, 23.9 to 27.1, and 12.4 to 26.4 ml/min per 1.73m2 in 1340 stage 3 patients, 162 stage 4 patients, and 9 stage 5 patients, respectively.• Hemodialysis.com: Were any of the findings unexpected?• Dr. Li: no• Hemodialysis.com: What should clinicians and patients take away from this study?• Dr. Li: GFR reporting may result in safer prescribing. The study shows the enormous benefit to the NHS of the processing of routinely captured data. Careful monitoring of eGFR in patients taking NSAIDs is the key component of safe clinical practice.• Hemodialysis.com: What recommendations do you have for future research as a result of your study?• Dr. Li: The study was confined to a single NHS region, and a further study on different populations and a further questionnaire survey of physician behavior would strengthen the study finding.• Citation:• Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function• Wei L, Macdonald TM, Jennings C, Sheng X, Flynn RW, Murphy MJ.• of Practice and Policy, UCL School of Pharmacy, London, UK [2] Medicines Monitoring Unit, Division of Medical Sciences, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK. Kidney Int. 2013 Mar 13. doi: 10.1038/ki.2013.76. [Epub ahead of print]For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  13. 13. Effect of serum FGF-23, MGP and fetuin-A on calcium-phosphate metabolism in maintenance hemodialysis patients Hemodialysis.com Interview with Jian-Ying Niu Division of Nephrology the Fifth People’s Hospital of Shanghai 200240 China• Hemodialysis.com: What are the main findings of the study?• Answer: In this study, we enrolled 64 patients (30 males,34 females, 60.6+-11.3 years of age) who received an average dialysis vintage of 6.88+- 2.94 years, and evaluated the serum level of FGF-23, MGP and fetuin-A, as well as the coronary artery calcification score (CACS) with coronary artery computed tomography scan.• There were 13 (20.31%), 16 (25%), and 35 (54.69%) patients exhibited a CACS of 0–100, 100–400, and >400, respectively. The dialysis vintage, serum FGF-23, fetuin-A, phosphorus and high-density lipoprotein-C levels were identified as independent variables of CACS by stepwise multiple regression analysis. The area under receiver operating characteristic curve indicated that serum FGF-23 and fetuin-A were useful for identifying CAC in MHD patients. The cut-off value corresponding to the highest Youden’s index was serum FGF-23 ≥ 256 pg/mL and fetuin-A ≤ 85mg/mL, which was defined as the optimal predictors of CAC.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  14. 14. Effect of serum FGF-23, MGP and fetuin-A on calcium-phosphate metabolism in maintenance hemodialysis patients Hemodialysis.com Interview with Jian-Ying Niu Division of Nephrology the Fifth People’s Hospital of Shanghai 200240 China (cont)• Hemodialysis.com: Were any of the findings unexpected?• Answer: Our study did not find that MGP was closely related to CAC in MHD patients. This may be due to small sample size, measurement of overall serum MGP without differentiation between ucMGP and active MGP, and unknown vitamin K status in MHD patients.• It is reported in literature[1] that increased serum uncarboxylated MGP (ucMGP) is associated with the severity of aorta calcification.• ucMGP can be used as a surrogate marker of vascular calcification in CKD patients. The ucMGP level is inversely correlated with CAC. A study in 53 MHD patients[2] documented that the baseline ucMGP level in MHD patients was 4.5 times higher than that in normal subjects. This confirms that vitamin K deficiency is prevalent in MHD patients. Daily supplementation of exogenous vitamin K can reduce ucMGP level, which provides support for improving vascular calcification in MHD patients.• [1]Schurgers LJ, Barreto DV, Barreto FC, et al. The circulating inactive form of matrix gla protein is a surrogate marker for vascular calcification in chronic kidney disease: a preliminary report. Clin J Am Soc Nephrol..2010; 5:568–575.• [2]Westenfeld R, Schafer C, Smeets R, et al. Fetuin-A (AHSG) prevents extraosseous calci fication induced by uraemia and phosphate challenge in mice. Nephrol Dial Transplant. 2007; 22:1537–1546.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  15. 15. Effect of serum FGF-23, MGP and fetuin-A on calcium-phosphate metabolism in maintenance hemodialysis patients Hemodialysis.com Interview with Jian-Ying Niu Division of Nephrology the Fifth People’s Hospital of Shanghai 200240 China (cont)• Hemodialysis.com: What should clinicians and patients take away from this study?• Answer: CAC is prevalent in MHD patients. In this study, stepwise multiple regression analysis found that serum FGF-23 and fetuin-A levels are closely associated with the severity of CAC in MHD patients. ROC curve also confirmed that both serum FGF-23 and Fetuin-A are biomarkers for identifying CAC in MHD patient with good sensitivity and specificity. These two markers are useful for clinical prediction of CAC, especially in combination or in series.They are expected to be used as promising diagnostic markers for predicting CAC in MHD patients.• Hemodialysis.com: What recommendations do you have for future research as a result of your study?• Answer: As mentioned before, our study did not find that MGP was closely related to CAC in MHD patients. This may be due to small sample size, measurement of overall serum MGP without differentiation between ucMGP and active MGP, and unknown vitamin K status in MHD patients. Therefore, further study is required to clarify the exact role of MGP in CAC in MHD patients.• Citation:• Effect of serum FGF-23, MGP and fetuin-A on calcium-phosphate metabolism in maintenance hemodialysis patients• Xiao DM, Wu Q, Fan WF, Ye XW, Niu JY, Gu Y.• Division of Nephrology, the Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China; Division of Internal Medicine, Ningbo First Hospital, Medical School of Ningbo University, Ningbo, China. Hemodial Int. 2013 Mar 12. doi: 10.1111/hdi.12033. [Epub ahead of print]For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  16. 16. High incidence of mild hypernatremia in females using ecstasy at a rave party Hemodialysis.com Interview with Geetruida D. van Dijken Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, the Netherlands• Hemodialysis.com: What are the main findings of the study?• Answer: We decided to study the incidence of hypernatremia in subjects using 3, 4–methylenedioxymethamphetamine (MDMA) at an indoor rave party. Only 3% of males, but no less than ~25% of females attending a rave party and using MDMA developed mild hypernatremia during the event. Especially females are therefore probably also at risk of developing severe symptomatic hypernatremia. Not using MDMA is obviously the best option to prevent MDMA–induced hypernatremia. However, accepting the fact that millions use the drug every weekend, strategies should also be developed to prevent hypernatremia in subjects choosing to take MDMA. This would include matching the electrolyte content of the fluids and food ingested to that of the fluids that are lost during the use of MDMA, mainly by perspiration. Users of MDMA and emergency health care workers should become more aware of the relatively high incidence of MDMA– induced hypernatremia and of potential strategies to prevent this complication.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  17. 17. High incidence of mild hypernatremia in females using ecstasy at a rave party Hemodialysis.com Interview with Geetruida D. van Dijken Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, the Netherlands (cont)• Hemodialysis.com: Were any of the findings unexpected?• Answer: An intriguing observation is that the mean plasma sodium concentration in females not using MDMA at the rave party was significantly lower than in males not taking the drug, although there were no frank cases of hypernatremia in these females. Due to the design of the study, the plasma sodium concentrations at entry are not known, and it cannot be excluded that the initial values in females were already lower than in males.• Although the plasma sodium concentration appears to be slightly lower in females in the luteal phase compared with males, there is no gender specific normal range for the plasma sodium concentration in females not stratified for the phase of the luteal cycle and males. Consequently, it is possible that exercise and stress-induced ADH secretion combined with intake of hypotonic fluids caused the reduction in plasma sodium concentration in female ravers not using MDMA. In this respect, the situation may be similar to the hypernatremia induced by long distance running, which also occurs more frequently in females than males and may have a similar pathophysiology.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  18. 18. High incidence of mild hypernatremia in females using ecstasy at a rave party Hemodialysis.com Interview with Geetruida D. van Dijken Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, the Netherlands (cont)• Hemodialysis.com: What should clinicians and patients take away from this study?• Answer: When you see a patient in your hospital that feels unwell after using ecstasy / MDMA please remember that hyponatremia could be a cause.• Even a low dose of ecstasy can cause hyponatremia and after a short time of ingestion. Especially in women we found a high percentage of hyponatremia. Advising users to drink a lot of fluids seems unwise. Normal saline should not be administered readily by healthcare workers. If necessary for resuscitation hypertonic fluids can be considered.• Hemodialysis.com: What recommendations do you have for future research as a result of your study?• Answer: We would like to research preventative measurements, for instance drinking soup when using MDMA.• Citation:• High incidence of mild hypernatremia in females using ecstasy at a rave party• Geetruida D. van Dijken, Renske E. Blom, Ronald J. Hené, and Walther H. Boer• Nephrol. Dial. Transplant. first published online March 8, 2013 doi:10.1093/ndt/gft023For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  19. 19. Association Between Aristolochic Acid and CKD: A Cross-sectional Survey in China. Hemodialysis.com Interview with Authors Wenke Wang and Jian Zhang Hospital Authority Toxicology Reference Laboratory Princess Margaret Hospital, Hong Kong SAR, China• Hemodialysis.com: What are the main findings of the study?• Response: Altogether, 467 participants reported long-term AA intake, with an adjusted prevalence of 1.5% (95% CI, 1.2%-1.7%).• After adjusting for age and sex, long-term AA intake was associated with eGFR < 60 mL/min/1.73 m2 and albuminuria, with ORs of 2.20 (95% CI, 1.51-3.12) and 1.67 (95% CI, 1.27-2.20), respectively.• Adjusting for other covariates attenuated the ORs, which were 1.83 (95% CI, 1.22-2.74) and 1.39 (95% CI, 1.03-1.87) for eGFR < 60 mL/min/1.73m2 and albuminuria, respectively.• A positive association between accumulated time of AA intake and kidney damage also was observed, with fully adjusted ORs of 1.07 (95% CI, 1.03-1.12) per 6-month longer intake for eGFR < 60 mL/min/1.73 m2 and 1.04 (95% CI, 1.01-1.08) per 6-month longer intake for albuminuria.• Hemodialysis.com: Were any of the findings unexpected?• Response: AA has been shown to be associated with urothelial cancer in many studies, which might be related to the formation of AA-DNA adducts. Hematuria is one of the major clinical manifestations of urothelial cancer. However, we did not observe an association between long-term AA intake and hematuria in our study.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  20. 20. Association Between Aristolochic Acid and CKD: A Cross-sectional Survey in China. Hemodialysis.com Interview with Authors Wenke Wang and Jian Zhang Hospital Authority Toxicology Reference Laboratory Princess Margaret Hospital, Hong Kong SAR, China (cont)• Hemodialysis.com: What should clinicians and patients take away from your report?• Response: Our nationwide study showed long-term intake of medications containing AA is prevalent in China and is associated with the presence of CKD.• Strategies to eliminate those medications from the market should be strengthened, which could constitute a cost- effective way to cope with the challenge of CKD in China.• Hemodialysis.com: What recommendations do you have for future research as a result of this study?• First, if use of medications containing AA information can be reported from prescriptions would be more reliable.• Second, we would get more information about more and more herbs containing AA, and try our best to estimate the mean dose of AA, so that the dose-related effects may be assessed.• Third, we would get more information on markers of tubular injury.• Finally, the cross-sectional design of the study makes inference of a causal relationship between CKD and AA impossible. Maybe we can carry out a cohort study or A case-control study to reveal the causal relationship between CKD and AA.• Citation:• Association Between Aristolochic Acid and CKD: A Cross-sectional Survey in China.• Zhang J, Zhang L, Wang W, Wang H; China National Survey of Chronic Kidney Disease Working Group.• Division of Nephrology, Chifeng Second Hospital; Chifeng, China. Am J Kidney Dis. 2013 Mar 2. pii: S0272-6386(13)00032-2. doi: 10.1053/j.ajkd.2012.12.027. [Epub ahead of print]For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  21. 21. Stress and Burnout Among Nephrology Dialysis Staff Hemodialysis.com Author Interview: Macaulay Onuigbo MD MSc FWACP FASN MBA Associate Professor of Medicine, College of Medicine, Mayo Clinic, Rochester, MN. Nephrologist, Mayo Clinic Health System, Eau Claire, WI Vice Chairman, Nephrology department, MCHSEC. MBA Executive. (cont)• Hemodialysis.com: Why was the study carried out in the first place?• Dr. Onuigbo: The concept of burnout in the workplace was introduced in the late 1970s, mainly in a US context. Healthcare delivery is generally acknowledged to be a stressful industry but few studies in this area are available. Even far less reported is stress or burnout in nephrology and/or dialysis practices.• The potential impact of the recent increasing role of the EMR in the healthcare workplace was also investigated here especially with reference to the effects of an EMR on provider perceptions of work stress and burnout. This was even more pertinent following our recent report in the Wisconsin Medical Journal of the new unrecognized syndrome of “Physician Cognitive Drift” as it relates to some unintended consequences of the EMR and as a major source of physician stress in the healthcare workplace.• Hemodialysis.com: What is the Methodology of the study?• Dr. Onuigbo: This was a cross-sectional hand delivered questionnaire-based survey of physicians, nurses, dialysis technicians, social workers and dieticians in a nephrology-dialysis practice in a Northwestern Wisconsin Mayo Clinic Dialysis Unit. The questionnaire used for this survey is the Oldenburg Burnout Inventory (OLBI) and the survey was carried out in January 2012.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  22. 22. Stress and Burnout Among Nephrology Dialysis Staff Hemodialysis.com Author Interview: Macaulay Onuigbo MD MSc FWACP FASN MBA Associate Professor of Medicine, College of Medicine, Mayo Clinic, Rochester, MN. Nephrologist, Mayo Clinic Health System, Eau Claire, WI Vice Chairman, Nephrology department, MCHSEC. MBA Executive. (cont)• Hemodialysis.com: What are the main findings of the study?• Dr. Onuigbo: Eighteen survey questionnaires were distributed across the clinic and 16 (89%) were returned in a completed form, giving a response rate of 89%. The participating staff was mostly female nurses, age range 30-60, average age about 40 years.• The average emotional exhaustion score on the OLBI was 2.66, consistent with a low level of emotional exhaustion. The average disengagement score was 2.45, consistent with a low level of disengagement.• One recurring source of stressors for the staff revolved around the non user- friendliness of the EMR system(s) – the so-called EMR-induced stresses – including too much time spent on data entry, the simultaneous use of multiple and non- interlined EMR systems, slow EMR systems and so on.• Hemodialysis.com: Were any of the findings unexpected?• Dr. Onuigbo: We were surprised at the low level of stress and burnout, in general, evident from this dialysis staff survey. The low level of emotional exhaustion and disengagement reported amongst was pleasantly surprising. Higher levels had been anticipated, especially with the inclusion of the dialysis nurses who have often expressed higher levels of anxiety about work-related stressors.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  23. 23. Stress and Burnout Among Nephrology Dialysis Staff Hemodialysis.com Author Interview: Macaulay Onuigbo MD MSc FWACP FASN MBA Associate Professor of Medicine, College of Medicine, Mayo Clinic, Rochester, MN. Nephrologist, Mayo Clinic Health System, Eau Claire, WI Vice Chairman, Nephrology department, MCHSEC. MBA Executive. (cont)• Hemodialysis.com: What should clinicians and patients take away from your report?• Dr. Onuigbo: The urgent need for solutions to healthcare related stress and burnout calls for more studies. Stress and burnout among healthcare personnel is an understudied phenomenon and demands more studies. Staff stress and burnout could lead to reduced staff retention, medical and other errors and overall poor employee productivity. Furthermore, the mixture of both clerical staff and clinical staff may have diluted down the average stress and burnout scores obtained from this dialysis staff survey. Moreover, the near absent participation of physicians may have also affected the study results,• The addition of the EMR has often led to an escalation of staff stress and burnout and requires close monitoring. Some solutions offered by participating staff to ease EMR-induced stress included the following:• v More robust, user-friendly, fast, agile, nimble and flexible EMR (No Cognitive Drift).• v Reduced redundancy of multiple EMRs requiring multiple data entry procedures.• v The involvement of providers early in the IT design, implementation and ongoing review of the EMR.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  24. 24. Stress and Burnout Among Nephrology Dialysis Staff Hemodialysis.com Author Interview: Macaulay Onuigbo MD MSc FWACP FASN MBA Associate Professor of Medicine, College of Medicine, Mayo Clinic, Rochester, MN. Nephrologist, Mayo Clinic Health System, Eau Claire, WI Vice Chairman, Nephrology department, MCHSEC. MBA Executive.• Hemodialysis.com: What recommendations do you have for future research as a result of this study?• Dr. Onuigbo: Larger studies, focused on specific healthcare professionals with significant emphasis on stressful work-arounds for nurses, EMR-induced stress for physicians and other providers, and better EMR training to reduce staff stress and burnout would be necessary.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  25. 25. Stress and Burnout Among Nephrology Dialysis Staff Hemodialysis.com Author Interview: Macaulay Onuigbo MD MSc FWACP FASN MBA Associate Professor of Medicine, College of Medicine, Mayo Clinic, Rochester, MN. Nephrologist, Mayo Clinic Health System, Eau Claire, WI Vice Chairman, Nephrology department, MCHSEC. MBA Executive.• REFERENCES• Onuigbo MA. Physician ‘cognitive drift’ and medication errors–unintended consequences of the modern EMR. WMJ. 2012 Oct;111(5):198.• Halbesleben JRB, Wakefield DS, Wakefield BJ. Work- arounds in health care settings: Literature review and research agenda. Health Care Management Review: January/March 2008 – Volume 33 – Issue 1 – pp 2-12• Dahlin M, Runeson B, Jönsson M, Öjehagen A. Stress in medical students at KI and Lund University. What do we have in common and what is different? http://ki.se/ki/jsp/polopoly.jsp?d=1274&a=2274&cid=1289 &l=en.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  26. 26. Experience of HeRO Dialysis Graft Placement in a Challenging Population Hemodialysis.com Interview with: Harry Schanzer, M.D., F.A.C.S. Clinical Professor of Surgery Division of Vascular Surgery Mount Sinai School of Medicine• Hemodialysis.com: What are the main findings of the study?• Dr. Schanzer: Eleven patients with central venous occlusive disease underwent 12 HeRO placements as a last ditch effort for long-term hemodialysis access. At one year, primary and secondary patencies were 9.1% and 45.5%. Four HeRO grafts were never cannulated, and the remaining 11 had a functional patency of an average of 14 months• Hemodialysis.com: Were any of the findings unexpected?• Dr. Schanzer: These findings were surprising for us, since recent published studies demonstrated a secondary patency at 24 months as high as 86.7%.1 It is possible that our subset of patients had more severe central venous occlusive disease than in the other studies, although it is difficult to compare since detailed descriptions of the patient population in the studies with higher patency were not included. Our inferior results may also be due to the small sample size and less than aggressive approach to maintaining secondary patency with declotting procedures.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  27. 27. Experience of HeRO Dialysis Graft Placement in a Challenging Population Hemodialysis.com Interview with: Harry Schanzer, M.D., F.A.C.S. Clinical Professor of Surgery Division of Vascular Surgery Mount Sinai School of Medicine (cont)• Hemodialysis.com: What should clinicians and patients take away from this study?• Dr. Schanzer: The group of patients who require the HeRO graft for dialysis is especially challenging. In order for the HeRO to be a consideration, all other upper extremity hemodialysis accesses excluding catheters, must have been exhausted.2 Furthermore, each of these patients is unique, and we believe that the range in patency rates is likely due to the variety of anatomic hurdles that must be overcome. The most important concept to be taken away from this study is that even if the HeRO only remains functional for 1 year, that is one year without a catheter. Studies have reported tunneled dialysis catheter rates of infection-associated mortality up to 34%,3 thus fewer days with a catheter may reduce morbidity and mortality. Finally, in order to maintain secondary patency in these devices, close follow-up and aggressive declotting is necessary.• Hemodialysis.com: What recommendations do you have for future research as a result of your study?• Dr. Schanzer: Prospective studies with larger samples of patients need to be conducted. It is imperative that the patients be stratified according to their anatomic difficulty of creating a successful permanent hemodialysis access. Consequently, determining which patients will benefit the most from the HeRO may contribute to improved patency rates and longer functionality.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  28. 28. Experience of HeRO Dialysis Graft Placement in a Challenging Population Hemodialysis.com Interview with: Harry Schanzer, M.D., F.A.C.S. Clinical Professor of Surgery Division of Vascular Surgery Mount Sinai School of Medicine (cont)• Citation:• Experience of HeRO Dialysis Graft Placement in a Challenging Population.• Kokkosis AA, Abramowitz SD, Schwitzer J, Schanzer H, Teodorescu VJ. Vasc Endovascular Surg. 2013 Mar 10. [Epub ahead of print]• References:• 1. Gage SM, Katzman HE, Ross JR, Hohmann SE, Sharpe CA, Butterly DW, Lawson JH. Multi-center experience of 164 consecutive Hemodialysis Reliable Outflow [HeRO] graft implants for hemodialysis treatment. Eur J Vasc Endovasc Surg. 2012 Jul;44(1):93-9• 2. Steerman SN, Wagner J, Higgins JA, Kim C, Mirza A, Pavela J, Panneton JM, Glickman MH. Outcomes comparison of HeRO and lower extremity arteriovenous grafts in patients with long-standing renal failure. J Vasc Surg. 2013 Mar;57(3):776-83. doi: 10.1016/j.jvs.2012.09.040. Epub 2013 Jan 11.• 3. Danese M, Griffiths R, Dylan M, Yu H, Dubois R, Nissenson A. Mortality differences among organisms causing septicemia in haemodialysis patients. Hemodial Int, 10 (2006), pp. 56–62For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  29. 29. he Associations between Race and Geographic Area and Quality-of-Care Indicators in Patients Approaching ESRD Hemodialysis.com: Interview with Guofen Yan, Ph.D. Associate Professor Department of Public Health Sciences, School of Medicine University of Virginia Charlottesville, Virginia 22908-07• Hemodialysis.com: What are the main findings of the study?• Dr. Yan: A body of evidence has established that timely receipt of care from a kidney specialist over the course of chronic kidney disease (CKD) is important for receiving optimal kidney care, including slowing the disease, improving survival while on long-term dialysis, and increasing the likelihood of receiving a kidney transplant. While clinical guidelines recommend that all patients in later stages of CKD be under the care of kidney specialists, 25% to 50% of patients on dialysis in the United States had not received such care before they developed kidney failure, or end-stage renal disease (ESRD).• We undertook a national study to examine whether geography plays any role in access to pre–ESRD care among black and white CKD patients. We analyzed information from 404,622 white and black adult patients receiving dialysis between 2005 and 2010 and residing in 3,076 counties across the United States. The counties were grouped into large metropolitan, medium/small metropolitan, suburban, and rural counties.• We found that pre-ESRD care measures are highly variable among geographic areas defined by urban/rural characteristics. Fewer patients received nephrologist care for more than 12 months before developing ESRD in large-metro (25.7%) and rural (26.9%) counties than in medium/small- metro counties (31.6%). In all four geographic areas, black patients received less pre-ESRD care than their white counterparts. In large-metro counties, black patients were 27% less likely than whites to receive nephrologist care for more than 12 months before developing ESRD. In rural counties, they were 16% less likely. In suburban and rural counties, black patients were 30% to 52% less likely than whites to see a dietitian before developing ESRD.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  30. 30. he Associations between Race and Geographic Area and Quality-of-Care Indicators in Patients Approaching ESRD Hemodialysis.com: Interview with Guofen Yan, Ph.D. Associate Professor Department of Public Health Sciences, School of Medicine University of Virginia Charlottesville, Virginia 22908-07 (cont)• Hemodialysis.com: Were any of the findings unexpected?• Dr. Yan: We found that for all the pre-ESRD care measures examined, the difference across the four types of geographic areas was much greater for black patients than white patients. For example, in large-metro counties, the proportions of receiving dietitian care for white and black patients were both about 19%; however, in rural counties, only 8% of rural black patients (more than a 50% reduction from 19% in large-metro) received such care, compared with 16.8% of rural white patients. Consequently, in certain geographic areas black patients were substantially less likely to have received kidney specialist care than white patients, such as very limited access to dietitian care for black patients living in rural counties.• Hemodialysis.com: What should clinicians and patients take away from this study?• Dr. Yan: A Healthy People 2020 objective is to increase the proportion of CKD patients who receive nephrologist care at least 12 months before the start of renal replacement therapy. Our study shows that currently the proportion ranges from 21% to 33%, depending on the geographic location and race. Possible explanations for the lower proportions include differences in referral patterns between healthcare providers in different geographic areas, noncompliance of patients to the referral, limited access to kidney specialists in some geographic areas, or financial constraints for patients with low socioeconomic status. We need national concerted efforts, from health care providers, policy makers, and patients, to identify and remove the barriers to access to kidney specialists.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  31. 31. he Associations between Race and Geographic Area and Quality-of-Care Indicators in Patients Approaching ESRD Hemodialysis.com: Interview with Guofen Yan, Ph.D. Associate Professor Department of Public Health Sciences, School of Medicine University of Virginia Charlottesville, Virginia 22908-07 (cont)• Hemodialysis.com: What recommendations do you have for future research as a result of your study?• Dr. Yan: The significant geographic differences in receiving pre-kidney failure care and the substantially large racial differences in certain geographic areas highlight the complexity of the issue. Many health care policies are driven by the degree of urbanization of a given county, but the recommendations are often based on limited data. Our findings suggest improving receipt of key pre-ESRD indicators will require more refined regional characterization of health care needs and resources, working with kidney organizations around employment opportunities for new graduates. Healthcare polices directed at eliminating pre-ESRD care disparities must take these complexities and granular data into consideration. Future studies to delineate the factors that are responsible for urban-rural differences as well as variations within counties may allow for more strategic and public health oriented approaches to improve care for all Americans with CKD.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  32. 32. he Associations between Race and Geographic Area and Quality-of-Care Indicators in Patients Approaching ESRD Hemodialysis.com: Interview with Guofen Yan, Ph.D. Associate Professor Department of Public Health Sciences, School of Medicine University of Virginia Charlottesville, Virginia 22908-07 (cont)• Citation:• The Associations between Race and Geographic Area and Quality- of-Care Indicators in Patients Approaching ESRD• Yan G, Cheung AK, Ma JZ, Yu AJ, Greene T, Oliver MN, Yu W, Norris KC.• Department of Public Health Sciences and , ‖Department of Family Medicine, University of Virginia School of Medicine, Charlottesville, Virginia;, †Division of Nephrology & Hypertension and, §Division of Epidemiology, University of Utah, Salt Lake City, Utah;, ‡Dornsife College of Letters, Arts, and Sciences and Keck School of Medicine, University of Southern California, Los Angeles, California, ¶Charles R. Drew University of Medicine and Science, Los Angeles, California. Clin J Am Soc Nephrol. 2013 Mar 14. [Epub ahead of print]For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  33. 33. The CKD Enigma – Statistics and Myths about CKD: Conflicting ESRD and Death Rates in the Literature Hemodialysis.com Interview with Macaulay Onuigbo MD MSc FWACP FASN MBA Associate Professor of Medicine, College of Medicine, Mayo Clinic, Rochester, MN. Nephrologist, Mayo Clinic Health System, Eau Claire, WI Vice Chairman, Nephrology department, MCHSEC.MBA Executive• Hemodialysis.com: Why was the study carried out in the first place?• Dr. Onuigbo: Over the years, the CKD literature had demonstrated a huge disparity in the reported annual death rates and annual ESRD rates among different CKD cohorts both here in the USA and around the world. There is this unproven yet commonly accepted consensus that “most CKD patients die (of CV events) before they reach ESRD”. Yet there are reports out there in the nephrology literature showing much higher ESRD rates than death rates in CKD cohort studies. Keith et al (2004) reported an ESRD Rate of 20% and a higher Death Rate of 50% after 5 years, among a CKD cohort of 27,998 patients in a managed care organization. Quite the opposite, Menon et al (2008) demonstrated a higher ESRD Rate of 60% and a Death Rate of 15% after 88 months in 1,666 patients in the Modification of Diet in Renal Disease (MDRD) study. Onuigbo & Onuigbo (2009), in a single-center Mayo Clinic study revealed an ESRD Rate of 18% and a Death Rate of 13% after 4 years among a 100-patient high risk CKD cohort in an angiotensin inhibition withdrawal study.• We therefore set out to compare projected annual ESRD incidence among the general US CKD population based on current literature versus actual US ESRD incidence as reported in the United States Renal Data System (USRDS) for the year ending December 2008.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  34. 34. The CKD Enigma – Statistics and Myths about CKD: Conflicting ESRD and Death Rates in the Literature Hemodialysis.com Interview with Macaulay Onuigbo MD MSc FWACP FASN MBA Associate Professor of Medicine, College of Medicine, Mayo Clinic, Rochester, MN. Nephrologist, Mayo Clinic Health System, Eau Claire, WI Vice Chairman, Nephrology department, MCHSEC.MBA Executive (cont)• Hemodialysis.com: What was the Methodology of the study?• Dr. Onuigbo: In mid-2012, we carried out a snap shot cross-sectional US 2007 CKD population-wide analysis of projected annualized ESRD incidence based on the weighted rates from the three cited sources. We then compared these estimates with actual US ESRD incidence as reported in USRDS 2010 report for 2008.• A 2007 US CDC report indicated that 16.5% of the U.S. population 20 years of age and older had CKD with eGFR <60 ml/min/1.73 sq m BSA, thus affecting >20 million adult Americans.• The above 3 cited studies combined, give a weighted average annualized ESRD Rate of ~4.2% among the US CKD population.• Hemodialysis.com: What are the main findings of the study?• Dr. Onuigbo: Projections for new ESRD resulted in an estimated 840,000 new ESRD cases in 2008.• According to the 2010 USRDS Annual Data Report, the actual reported new ESRD incidence in 2008 was in fact only 112,476 (FIGURE). This represented a gross overestimation by about 650% of the ESRD incidence in the US for the year ending 2008 – clearly a colossal failure of epidemiological analysis.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  35. 35. The CKD Enigma – Statistics and Myths about CKD: Conflicting ESRD and Death Rates in the Literature Hemodialysis.com Interview with Macaulay Onuigbo MD MSc FWACP FASN MBA Associate Professor of Medicine, College of Medicine, Mayo Clinic, Rochester, MN. Nephrologist, Mayo Clinic Health System, Eau Claire, WI Vice Chairman, Nephrology department, MCHSEC.MBA Executive (cont)• Hemodialysis.com: Were any of the findings unexpected?• Dr. Onuigbo: The magnitude of the disparity between estimated ESRD rates and the actual ESRD incidence for 2008 was mind- boggling. Similar results would be obtained for annual death rates comparisons. Thus, the natural history of CKD remains unclear and the nephrology literature is rife with very dissimilar and conflicting data regarding ESRD Rates and Death Rates among different reported CKD cohorts.• Moreover, these results simply confirm the conclusions of the recently released (August 2012) US Preventive Services Task Force (USPSTF) Report on CKD screening which concluded that we know surprisingly little about whether screening adults with no signs or symptoms of CKD will improve health outcomes and that clinicians and patients deserve better information on CKD.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  36. 36. The CKD Enigma – Statistics and Myths about CKD: Conflicting ESRD and Death Rates in the Literature Hemodialysis.com Interview with Macaulay Onuigbo MD MSc FWACP FASN MBA Associate Professor of Medicine, College of Medicine, Mayo Clinic, Rochester, MN. Nephrologist, Mayo Clinic Health System, Eau Claire, WI Vice Chairman, Nephrology department, MCHSEC.MBA Executive (cont)• Hemodialysis.com: What should clinicians and patients take away from your report?• Dr. Onuigbo: That we as physicians in general, and nephrologists in particular, still do not understand the true natural history of CKD, its prognostication, ESRD prediction, and the true ESRD Rates and Death Rates among CKD cohorts.• The clear heterogeneity of the so-called “CKD patient” is brought into prominence as we review the very misleading concept of classifying and prognosticating all CKD patients as if CKD represented one homogenous patient population.• Current consensus that ‘most CKD patients all die of cardiovascular events before reaching ESRD’ is simply a myth, is unfounded, and untrue.• Bansal and Hsu in a 2008 analysis of the long-term outcomes of patients with chronic kidney disease echoed the observation that the disparate ESRD and mortality rates in various CKD populations as reported by various studies in the literature only emphasized the heterogeneity of CKD populations.• No one-size-fits-all approach in medicine can be dangerous.• Patient care, more so CKD care, MUST be individualized, one CKD patient at a time.• More studies into the ramifications of these findings as they relate to CKD care, CKD planning and management call for more studies.• Hemodialysis.com: What recommendations do you have for future research as a result of this study?• More critical investigation of longitudinal patient-level analysis of renal, morbidity and mortality outcomes among CKD patients is needed here in the USA and worldwide.• Furthermore, the notion that CKD represented a single disease entity is dangerous and must be abandoned.• The role of the nephrologist in enhancing CKD outcomes and the role of CKD screening, we as nephrologists must acknowledge, remain unclear and unknown, respectively, and these questions urgently demand further objective dispassionate study.• Finally, in a recent publication, we had introduced the new concept of “Symptomatic” versus “Asymptomatic” CKD – this again calls for more studies and validation.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  37. 37. The CKD Enigma – Statistics and Myths about CKD: Conflicting ESRD and Death Rates in the Literature Hemodialysis.com Interview with Macaulay Onuigbo MD MSc FWACP FASN MBA Associate Professor of Medicine, College of Medicine, Mayo Clinic, Rochester, MN. Nephrologist, Mayo Clinic Health System, Eau Claire, WI Vice Chairman, Nephrology department, MCHSEC.MBA Executive (cont)• REFERENCES• 1. Keith DS, Nichols GA, Gullion CM, Brown JB, Smith DH. Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization. Arch Intern Med 2004;164:659–63.• 2. Centers for Disease Control and Prevention (CDC): Prevalence of chronic kidney disease and associated risk factors – United States, 1999–2004. MMWR Morb Mortal Wkly Rep 2007; 56: 161–165.• 3. Menon V, Wang X, Sarnak MJ, et al. Long-term outcomes in nondiabetic chronic kidney disease. Kidney Int 2008;73:1310–15.• 4. Bansal N, Hsu CY. Long-term outcomes of patients with chronic kidney disease. Nat Clin Pract Nephrol 2008;4:532–3.• 5. Onuigbo MA. The natural history of chronic kidney disease revisited–a 72-month Mayo Health System Hypertension Clinic practice-based research network prospective report on end-stage renal disease and death rates in 100 high-risk chronic kidney disease patients: a call for circumspection. Adv Perit Dial. 2009;25:85-8.• 6. Editorial on this article. Ian H de Boer. Chronic Kidney Disease – A Challenge for all ages. JAMA 2012;308(22):2401-2402.• 7. Moyer VA; on behalf of the U.S. Preventive Services Task Force. Screening for Chronic Kidney Disease: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012 Aug 28. doi: 10.7326/0003- 4819-157-8-201210160-00533. [Epub ahead of print].• 8. Onuigbo MA. The CKD Enigma with Misleading Statistics and Myths about CKD, and Conflicting ESRD and Death Rates in the Literature: Results of a 2008 US Population-Based Cross-Sectional CKD Outcomes Analysis. State-of- the-Art-Review. Ren Fail. 2013 Feb 8. [Epub ahead of print].For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  38. 38. Disentangling the Ultrafiltration Rate–Mortality Association: The Respective Roles of Session Length and Weight Gain Hemodialysis.com Author Interview: Dr. Jennifer E. Flythe Renal Division, Department of Medicine, Brigham and Women’s Hospital 75 Francis Street, MRB-4, Boston, MA 02115• Hemodialysis.com: What are the main findings of the study?• Dr. Flythe: High ultrafiltration rates during hemodialysis (HD) have been associated with increased all-cause and cardiovascular mortality. The ultrafiltration rate, however, is determined by both dialysis session length (DSL) and interdialytic weight gain (IDWG). Both short DSL and high IDWG have been linked to increased mortality, but these variables are often collinear so their independent associations with mortality have not been adequately investigated. We undertook this study to determine the associations of DSL and IDWG (independently of each other) with mortality in a population of chronic HD patients with adequate clearance.• Our study results demonstrate that among chronic HD patients, both short DSL and high IDWG play important roles in the UFR–mortality association. Short DSL is associated with increased mortality independently of IDWG, and high IDWG is associated with increased mortality, independently of DSL. We also showed that these relationships follow dose-response patterns.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  39. 39. Disentangling the Ultrafiltration Rate–Mortality Association: The Respective Roles of Session Length and Weight Gain Hemodialysis.com Author Interview: Dr. Jennifer E. Flythe Renal Division, Department of Medicine, Brigham and Women’s Hospital 75 Francis Street, MRB-4, Boston, MA 02115 (cont)• Hemodialysis.com: Were any of the findings unexpected?• Dr. Flythe: Interestingly, our analyses showed no statistical interaction between DSL and IDWG, suggesting that the extension of DSL (to at least 240 minutes) would be favorable regardless of the patient’s IDWG and that limiting IDWG (to <3 kg) would be favorable regardless of the patient’s session length.• Hemodialysis.com: What should clinicians and patients take away from this study?• Dr. Flythe: Since both IDWG and DSL are independently associated with mortality, targeting either (or both) may be favorable for patients. Extending DSL to at least 240 minutes and reducing weight gain to <3kg should be considered for all patients regardless of baseline adequate clearance and ambient IDWG (or DSL). One potential intervention is to titrate DSL on a session-to-session basis based on interval IDWG.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  40. 40. Disentangling the Ultrafiltration Rate–Mortality Association: The Respective Roles of Session Length and Weight Gain Hemodialysis.com Author Interview: Dr. Jennifer E. Flythe Renal Division, Department of Medicine, Brigham and Women’s Hospital 75 Francis Street, MRB-4, Boston, MA 02115 (cont)• Hemodialysis.com: What recommendations do you have for future research as a result of your study?• Dr. Flythe: Prospective studies of the efficacy of targeted interventions are needed. Assessment of patient opinion regarding potential interventions is also needed.• Citation:• Disentangling the Ultrafiltration Rate–Mortality Association: The Respective Roles of Session Length and Weight Gain• Jennifer E. Flythe, Gary C. Curhan, and Steven M. Brunelli• Disentangling the Ultrafiltration Rate–Mortality Association: The Respective Roles of Session Length and Weight Gain CJASN CJN.09460912; published ahead of print March 14, 2013, doi:10.2215/CJN.09460912For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  41. 41. Value of Myocardial Perfusion Imaging in Renal Transplant Evaluation Angina.com Interview with: Dr. Chong Ghee Chew Department of Nuclear Medicine, PET and Bone Mineral Densitometry, Royal Adelaide Hospital, Adelaide, SA• Angina.com: What are the main findings of the study?• Answer: This is a retrospective audit of the cardiac outcomes of renal failure patients who had been transplanted in South Australia between 1999 to 2009, who had myocardial perfusion SPECT scan for the transplant assessment. The results represent ”real world” outcomes as the scans were performed in the 3 major teaching hospitals in SA. 2 endpoints – “soft” = inpatient care with angina +/- PCI +/- CABG, and “hard” = inpatient care with myocardial infarction or cardiac death. With a negative scan this cohort had a statistically significant lower soft endpoint event rate than a positive scan …3.9% vs 20.8%, hazard ratio of 4.4 at 5 years post scan. The hard endpoint event rate was also lower for those with a negative scan but the difference did not reach statistical significance. The event rates of hard and soft endpoints were no different for the negative scans that were performed with a tachycardic stress (treadmill exercise, dobutamine or external wire right atrial pacing) versus dipyridamole induced coronary vasodilatation.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  42. 42. Value of Myocardial Perfusion Imaging in Renal Transplant Evaluation Angina.com Interview with: Dr. Chong Ghee Chew Department of Nuclear Medicine, PET and Bone Mineral Densitometry, Royal Adelaide Hospital, Adelaide, SA (cont)• Angina.com: Were any of the findings unexpected?• Answer: No• Angina.com: What should clinicians and patients take away from this study?• Answer: Myocardial perfusion SPECT scan is a good predictor of cardiac events in renal failure patients who are being considered for transplantation.• This is a valid test for transplant assessment.• Angina.com: What further research do you recommend as a result of your study?• The study did not include patients who were assessed but were not transplanted. We are planning another similar audit to look at this cohort.• Citation:• ACC 2013 American College Cardiology Presentation Spring 2013For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  43. 43. Association of BP Variability with Mortality among African Americans with CKD Hemodialysis.com Interview with Dr. Ciaran J. McMullan Renal Division and Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital 41 Avenue Louis Pasteur, Suite 121, Boston, MA 02115• Hemodialysis.com: What are the main findings of the study?• Dr. McMullan: A person’s blood pressure may change up and down from day to day. Some people have small day to day changes in blood pressure, and some people have large day to day changes. In a population of African Americans with kidney disease, we found that large day to day changes in blood pressure predicted a much greater risk of dying, even after controlling for other things that predict death. Thus, larger changes in blood pressure from day to day could identify a high risk group of African Americans with kidney disease; in addition, it means that scientists should examine why people have large day to day changes in blood pressure, as this may turn out to be a new area of therapy research.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  44. 44. Association of BP Variability with Mortality among African Americans with CKD Hemodialysis.com Interview with Dr. Ciaran J. McMullan Renal Division and Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital 41 Avenue Louis Pasteur, Suite 121, Boston, MA 02115 (cont)• Hemodialysis.com: Were any of the findings unexpected?• Dr. McMullan: In our study of African Americans who had kidney disease, we found that the people whose blood pressure changed a lot from day to day were three times more likely to die that those people whose blood pressure only changed a little. In addition, people in the group with large day to day blood pressure changes were particularly susceptible to cardiovascular deaths with rates of cardiovascular mortality almost five times that of the group with small day to day changes in blood pressure.• Hemodialysis.com: What should clinicians and patients take away from this study?• Dr. McMullan: Clinicians involved in the care of patients with kidney disease should pay attention to the fluctuations seen in blood pressure measured from clinic visit to clinic visit. These fluctuations may not simply be random but may carry important information about risk.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  45. 45. Association of BP Variability with Mortality among African Americans with CKD Hemodialysis.com Interview with Dr. Ciaran J. McMullan Renal Division and Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital 41 Avenue Louis Pasteur, Suite 121, Boston, MA 02115 (cont)• Hemodialysis.com: What recommendations do you have for future research as a result of your study?• Dr. McMullan: We need to first understand why people’s blood pressure changes from day to day. Second, we need to understand if these ups and downs in blood pressure actually cause damage to the heart and blood vessels or, rather, are just of marker of something else that is causing damage.• Citation:• Association of BP Variability with Mortality among African Americans with CKD• Ciaran J. McMullan, George L. Bakris, Robert A. Phillips, and John P. Forman• Association of BP Variability with Mortality among African Americans with CKD CJASN CJN.10131012; published ahead of print March 14, 2013, doi:10.2215/CJN.10131012For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  46. 46. Antimicrobial Use in Outpatient Hemodialysis Units Hemodialysis.com Interview with: Dr. Graham Snyder Beth Israel Deaconess Medical Center 110 Francis St Boston, MA 02215• Hemodialysis.com: What are the main findings of the study?• Dr. Snyder: We looked at antimicrobial use in two Boston-area hemodialysis units in two ways: over a nearly three-year retrospective time period, we calculated the total amount of antimicrobials used, and prospectively over a one-year time period we analyzed each dose of parenteral antimicrobial administered in the hemodialysis units.• Over a 35-month retrospective period there were over 2,300 antimicrobial doses given in the two hemodialysis units, which equates to an overall antimicrobial use rate of 33 doses per 100 patient- months. For any given month, the range of antimicrobial use was between 5 doses and 67 doses per 100 patient-months. Vancomycin was the most commonly administered antimicrobial, accounting for approximately two-thirds of doses (overall, 22 doses per 100 patient-months), followed by cefazolin (5 doses per 100 patient-months) and third/fourth-generation cephalosporins (3 doses per 100 patient-months); other antimicrobials were given less frequently. In the 12-month prospective period, we followed 278 patients in the two hemodialysis units, 89 (32%) of whom received at least one parenteral dose of antimicrobial. Of the 1,003 doses given during that time, we could determine the appropriateness of indication in 926 (92%). Nearly 30% (276/926) of these doses had an inappropriate indication, including prescribing for conditions not meeting guidelines-based criteria to diagnose infection (146, 53%), use when a more narrow spectrum antimicrobial could have been chosen (74, 27%), and for surgical prophylaxis beyond recognized indication for prophylaxis (58, 20%). Over one-third of vancomycin and third/fourth- generation cephalosporin doses were inappropriately indicated.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  47. 47. Antimicrobial Use in Outpatient Hemodialysis Units Hemodialysis.com Interview with: Dr. Graham Snyder Beth Israel Deaconess Medical Center 110 Francis St Boston, MA 02215 (cont)• Hemodialysis.com: Were any of the findings unexpected?• Dr. Snyder: To date, there has been very little data reported on antimicrobial prescribing practices in the hemodialysis setting.• From nationwide data collected through the United States Renal Data System (USRDS), we know that approximately 40% of patients receiving chronic hemodialysis have at least one billing claim for an antimicrobial each year, and that vancomycin constitutes about two-thirds of prescribed antimicrobials. Our data showing that approximately 32% of patients receive a parenteral dose of antimicrobials and approximately two-thirds of the antimicrobial doses are vancomycin is consistent with USRDS data.• Lastly, two prior studies (Green K, Am J Kidney Dis 2000;35:64-68; Zvonar R, Nephrol Dial Transplant 2008;23:3690-3695) have shown that for vancomycin, at least 10-33% of antimicrobials are inappropriately indicated, and most frequently for not choosing an antimicrobial with a more narrow spectrum of activity and for treating conditions unlikely to be a true infection.• The data from our study is in agreement with these findings, and expands on the findings in these studies. A significant novel finding of our study was the substantial (and frequently inappropriately indicated) use of third/fouth-generation cephalosporins.• This is important because based on USRDS data the use of these agents is increasing, and the use of these agents relates very closely to antimicrobial resistant gram-negative bacterial infections, which have a high and increasing prevalence among the dialysis population.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  48. 48. Antimicrobial Use in Outpatient Hemodialysis Units Hemodialysis.com Interview with: Dr. Graham Snyder Beth Israel Deaconess Medical Center 110 Francis St Boston, MA 02215 (cont)• Hemodialysis.com: What should clinicians and patients take away from this study?• Dr. Snyder: There is room for improvement in antimicrobial prescribing practices, including reducing use when not indicated and choosing the most appropriate antimicrobial for a given infectious condition.• In addition to minimizing the risk of adverse effects directly attributable to the antimicrobials, limiting inappropriate use of antimicrobials has the potential to lead to a decrease in the emergence and spread of antimicrobial resistant bacteria among patients receiving hemodialysis. This effect on resistant bacteria may subsequently reduce the spread of these bacteria from patients receiving hemodialysis to other hospitalized patients and individuals in the community as well.• Hemodialysis.com: What recommendations do you have for future research as a result of your study?• Dr. Snyder: In addition to confirming these findings in other hemodialysis populations, our results may be used to help tailor antimicrobial stewardship interventions.• Interventions particularly worthy of investigation may include vancomycin and cephalosporin prescribing, decision support for surgical prophylaxis, and clinical management of skin/soft tissue infections. Future studies may identify patient populations among those receiving chronic hemodialysis who are particularly likely to receive antimicrobials and inappropriately indicated antimicrobials, and therefore also guide antimicrobial stewardship efforts.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  49. 49. Antimicrobial Use in Outpatient Hemodialysis Units Hemodialysis.com Interview with: Dr. Graham Snyder Beth Israel Deaconess Medical Center 110 Francis St Boston, MA 02215 (cont)• Citation:• Antimicrobial Use in Outpatient Hemodialysis Units• Snyder GM, Patel PR, Kallen AJ, Strom JA, Tucker JK, D’Agata EM.• Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Infect Control Hosp Epidemiol. 2013 Apr;34(4):349-57. doi: 10.1086/669869. Epub 2013 Feb 18.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  50. 50. Cinacalcet Improves Endothelial Dysfunction and Cardiac Hypertrophy in Patients on Hemodialysis with Secondary Hyperparathyroidism Hemodialysis.com Interview with: Cheol Whee Park, M.D. Professor of Internal Medicine Seoul St. Mary’s Hospital Division of Nephrology, Department of Internal Medicine The Catholic University of Korea Seoul, Republic of Korea• Hemodialysis.com: What are the main findings of the study?• Answer: Secondary hyperparathyroidism (SHPT) is a common complication of end-stage renal failure and it is associated with high morbidity and mortality. Furthermore, SHPT affects the cardiovascular system related to cardiovascular calcification and cardiomyopathy. The calcium- sensing receptor (CaSR) is expressed in cardiomyocytes, endothelial cells and vascular smooth muscle cells, which raises the possibility that this receptor may be implicated in the pathophysiology of cardiovascular disease and constitute a potential therapeutic target.• The recently published EVOLVE trial did not support the notion that cinacalcet, a calcimimetic of the second generation, reduces the risk of death or major cardiovascular event in hemodialysis patients with moderate-to-severe secondary hyperparathyroidism (SHPT). However, the findings from the EVOLVE trial are probably inconclusive because of low statistical power. Therefore, important questions regarding the clinical benefits of cinacalcet on cardiovascular system in hemodialysis patients in the setting of SHPT are remained to solve.• In this regard, our prospective, open-labeled, controlled, crossover clinical study found that cinacalcet hydrochloride treatment without vitamin D ameliorates endothelial dysfunction and inflammation, cardiac diastolic dysfunction, and cardiac hypertrophy by decreasing oxidative stress and improving endothelial dysfunction with increasing the serum nitric oxide (NOx) production in hemodialysis patients with SHPT.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice
  51. 51. Cinacalcet Improves Endothelial Dysfunction and Cardiac Hypertrophy in Patients on Hemodialysis with Secondary Hyperparathyroidism Hemodialysis.com Interview with: Cheol Whee Park, M.D. Professor of Internal Medicine Seoul St. Mary’s Hospital Division of Nephrology, Department of Internal Medicine The Catholic University of Korea Seoul, Republic of Korea (cont)• Hemodialysis.com: Were any of the findings unexpected?• Answer: We were interested in the evidence that cinacalcet without Vit D could improve vascular endothelial dysfunction and inflammation.• The combination treatment with cinacalcet and low dose vitamin D are found to be associated with the attenuation of cardiovascular calcification in hemodialysis patients; however, the effects of cinacalcet alone (without vitamin D) on cardiac and endothelial functions have not been well defined in hemodialysis patients with SHPT. In contrast, we demonstrated that cinacalcet along significantly improves vascular endothelial dysfunction and inflammation, diastolic cardiac dysfunction, and LVH. These findings suggest that cinacalcet itself might improve the endothelial dysfunction, arterial stiffness and cardiac diastolic dysfunction, and left ventricular hypertrophy related to ameliorate oxidative stress and NOx production in the hemodialysis patients with SHPT. Recent studies also demonstrated that cinacalcet protects vascular damage in the nerve by improving NOx production and vasodilation.• Hemodialysis.com: What should clinicians and patients take away from this study?• Answer: Despite effective improvement of biochemical parameters of dialysis patients with SHPT, the intention-to-treat analysis of the EVOLVE trial did not support the notion that cinacalcet significantly reduces the risk of death or major cardiovascular events in dialysis patients with moderate-to-severe SHPT. In contrast, the simultaneous reduction of serum calcium, phosphorus and intact parathyroid hormone (iPTH) as well as the increased CaSR in the cardiovascular system are favorable mechanisms for attenuating the progression of vascular calcification and cardiac hypertrophy in dialysis patients with SHPT. Our study added some favorable data to the question regarding whether cinacalcet without Vit D might reduce oxidative stress and improve endothelial function in hemodialysis patients in SHPT.For Informational Purposes Only. Not for Read more interviews on Hemodialysis.comSpecific Medical Advice

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