<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_373"
                     title="Protein in Urine Presages More Severe Problems (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Nephrology/ESRD/tb/18265?impressionId=1265782240243"
                     
      &lt;p&gt;The three-year risk of death, heart attack, and kidney failure was markedly increased in patients with baseline proteinuria, regardless of their estimated glomerular filtration rate (eGFR), researchers said.&lt;/p&gt;
&lt;p&gt;In a population-based study of nearly 1 million people, mortality was approximately doubled with heavy proteinuria among individuals stratified according to their eGFR, reported Brenda R. Hemmelgarn, MD, PhD, of the University of Calgary in Canada, and colleagues.&lt;/p&gt;
&lt;p&gt;Rates of myocardial infarction were increased by about 50% with heavy proteinuria, and end-stage renal disease and doubled levels of serum creatinine were as much as 30 times more common, the researchers reported in the Feb. 3 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;Prognosis associated with a given level of eGFR varies substantially based on the presence and severity of proteinuria,&quot; Hemmelgarn and colleagues concluded.&lt;/p&gt;
&lt;p&gt;&quot;In fact, patients with heavy proteinuria but without overtly abnormal eGFR appeared to have worse clinical outcomes than those with moderately reduced eGFR but without proteinuria.&quot;&lt;/p&gt;
&lt;p&gt;They added that the findings were important because current recommendations for managing chronic kidney disease rely on eGFR for staging purposes without consideration of proteinuria.&lt;/p&gt;
&lt;p&gt;&quot;Future revisions of the classification system for chronic kidney disease should incorporate information from proteinuria,&quot; the researchers urged.&lt;/p&gt;
&lt;p&gt;The results emerged from a laboratory registry covering some 921,000 adults in the province of Alberta who had had measurements of eGFR, serum creatinine, and urinary protein from 2002 to 2007.&lt;/p&gt;
&lt;p&gt;Proteinuria was measured with a urine dipstick or the albumin-creatinine ratio. Dipstick readings of at least 2 points were considered heavy proteinuria. Readings showing at least trace protein but less than 2 points were classed as mild; negative readings were considered normal.&lt;/p&gt;
&lt;p&gt;The stratifications of albumun-creatinine ratio were greater than 300 mg/g, 30 to 300 mg/g, and less than 30 mg/g for heavy, mild, and normal, respectively.&lt;/p&gt;
&lt;p&gt;Other registry data for the province provided outcomes in these individuals, with median follow-up of 35 months.&lt;/p&gt;
&lt;p&gt;Among individuals with eGFR rates of at least 60 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt;, death rates were 7.2 per 1,000 for those with dipstick-measured heavy proteinuria (95% CI 6.6 to 7.8) and 5.8 per 1,000 for mild proteinuria (95% CI 5.5 to 6.0) compared with 2.7 per 1,000 for those with normal urine protein (95% CI 2.6 to 2.8).&lt;/p&gt;
&lt;p&gt;At the other end of the eGFR spectrum  --  those with levels of 15 to 29.9 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt;  --  proteinuria remained an independent predictor of death: Mortality rates were 10.4 per 1,000 with heavy proteinuria (95% CI 9.3 to 11.6) and 9.1 per 1,000 with mild proteinuria (95% CI 8.2 to 10.0) versus 6.7 per 1,000 with normal urine protein (95% CI 6.2 to 7.3).&lt;/p&gt;
&lt;p&gt;These death rates reflected adjustments for a host of potential confounding factors and comorbidities, including age, sex, diabetes, hypertension, liver disease, and cardiovascular conditions.&lt;/p&gt;
&lt;p&gt;Proteinuria also predicted myocardial infarction in patients stratified by eGFR, but not as strongly. In the group with eGFR above 60 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt;, rates of MI were 1.6 per 1,000 (95% CI 1.3 to 2.0) and 0.9 (95% CI 0.9 to 1.0) for heavy and normal urinary protein, respectively, as measured by dipstick.&lt;/p&gt;
&lt;p&gt;MI rates were also increased with proteinuria in participants with eGFR below 30 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt;, the researchers reported.&lt;/p&gt;
&lt;p&gt;End-stage renal disease was enormously more common with dipstick-measured heavy proteinuria, independent of baseline eGFR.&lt;/p&gt;
&lt;p&gt;Individuals with eGFR above 60 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt; were diagnosed with the condition at a rate of 1.0 per 1,000 (95% CI 0.7 to 1.4) if they had heavy proteinuria, compared with 0.03 per 1,000 (95% CI 0.02 to 0.09) among those with normal urine protein.&lt;/p&gt;
&lt;p&gt;A five-fold difference in rates of end-stage renal disease was still apparent among those with eGFR below 30 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt;: 65.9 (95% CI 52.3 to 82.9) versus 12.7 per 1,000 (95% CI 9.3 to 17.3) for heavy versus normal protein, respectively.&lt;/p&gt;
&lt;p&gt;These results were confirmed when cross-checked against the more accurate albumin-creatinine ratio, Hemmelgarn and colleagues indicated.&lt;/p&gt;
&lt;p&gt;Each 10-fold increase in albumin-creatinine ratio was associated with the following relative rates of the major study outcomes, after adjusting for eGFR:&lt;ul&gt; &lt;li&gt;Death: 1.22 (95% CI 1.21 to 1.24)&lt;/li&gt; &lt;li&gt;MI: 1.18 (95% CI 1.14 to 1.21)&lt;/li&gt; &lt;li&gt;Doubling of serum creatinine: 1.76 (95% CI 1.70 to 1.82)&lt;/li&gt; &lt;li&gt;End-stage renal disease: 1.92 (95% CI 1.81 to 2.04)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Hemmelgarn and colleagues noted several limitations to the study including the fact that the sample was restricted to outpatients undergoing laboratory evaluations for kidney function and urinary protein, and the data were based on single measurements. Missing were data on alcohol, tobacco, and antihypertensive drug use, which might have affected the findings.&lt;/p&gt;
&lt;p&gt;The researchers also indicated that the follow-up period may have been too short to fully evaluate risks of progression to kidney failure.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Support for the study came from the Alberta Heritage Foundation for Medical Research, the Canadian Institutes of Health Research, Alberta Health and Wellness, and internal funds.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_330"
                     title="Immune Cells Point to Skin Cancer Risk after Transplants (CME/CE)"
                     score="0.008"
                     href="http://www.medpagetoday.com/Nephrology/KidneyTransplantation/tb/18200?impressionId=1265782240243"
                     
      Monitoring two types of immune cells in kidney transplant recipients might identify patients with an increased risk of skin cancer, British investigators reported.&lt;br&gt;
&lt;br&gt;Increased levels of T-regulatory cells (Tregs) more than doubled the risk of squamous cell cancer of the skin. Decreased levels of natural killer (NK) cells were associated with more than a five-fold increased risk of skin cancer.&lt;br&gt;
&lt;br&gt;Both immune parameters had substantially greater predictive power than a history of squamous-cell skin cancer, according to an online report in the &lt;em&gt;Journal of the American Society of Nephrology&lt;/em&gt; by a team of Oxford University investigators.&lt;/p&gt;
&lt;p&gt;&quot;Squamous cell cancer of the skin affects about 30% of kidney transplant patients after 10 years of immunosuppression,&quot; Robert Carroll, MD, currently of Queen Elizabeth Hospital in Woodville, Australia, observed in a statement.&lt;/p&gt;
&lt;p&gt;&quot;A small number of patients develop multiple skin cancers per year, but there is no laboratory test to determine which transplant recipients will develop multiple skin cancers in the future.&quot;&lt;/p&gt;
&lt;p&gt;&quot;If a test can confirm high risk of skin cancer development, this may help clinicians to tailor immunosuppressive regimens for individual patients,&quot; he added.&lt;/p&gt;
&lt;p&gt;Long-term immunosuppression, such as that required for transplant recipients, confers an increased risk of squamous-cell skin cancer.&lt;/p&gt;
&lt;p&gt;Estimates of the magnitude have ranged as high as 200 times greater than the general population, the authors wrote. Additionally, 3% of organ transplant recipients require extensive plastic surgery each year as a result of skin cancer lesions.&lt;/p&gt;
&lt;p&gt;Age at transplantation and the immunosuppression dosage are the principal determinants of skin-cancer risk, and the dosage of immunosuppression also influences the risk of metastasis from squamous-cell cancer of the skin.&lt;/p&gt;
&lt;p&gt;In the general population, cancer has been associated with increased levels of Tregs, including CDR&lt;sup&gt;+&lt;/sup&gt;CD25&lt;sup&gt;high&lt;/sup&gt;FOXP3&lt;sup&gt;+&lt;/sup&gt; and CD8&lt;sup&gt;+&lt;/sup&gt;CD28&lt;sup&gt;-&lt;/sup&gt; cells. The same types of cells could play a role in the risk of skin cancer among organ transplant recipients, the authors wrote.&lt;/p&gt;
&lt;p&gt;Within the tumor microenvironment, Tregs may impair the antitumor activity of CD8&lt;sup&gt;+&lt;/sup&gt; and NK cell. However, in organ transplant recipients, Tregs help control or prevent rejections and may help improve long-term outcomes.&lt;/p&gt;
&lt;p&gt;Different immunosuppressive drugs affect Tregs differently, the authors continued. Sirolimus (Rapamune), for example, increases the number of FOXP3&lt;sup&gt;+&lt;/sup&gt; cells, whereas cyclosporine decreases Treg numbers.&lt;/p&gt;
&lt;p&gt;&quot;Tregs have not been assessed in relation to cancer after transplantation,&quot; the authors wrote. &quot;We therefore investigated the hypothesis that squamous-cell cancer in kidney transplant recipients would be associated with an increased number of Tregs.&quot;&lt;/p&gt;
&lt;p&gt;To examine the hypothesis, investigators phenotyped peripheral blood from 65 kidney transplant recipients with squamous skin cancer and 51 recipients without skin cancer, matched for age, sex, and duration of immunosuppression.&lt;/p&gt;
&lt;p&gt;They also quantified lymphocyte populations in skin cancer lesions from a subset of 25 patients and matched them with 25 other nontransplant patients with squamous cell cancer of the skin.&lt;/p&gt;
&lt;p&gt;The kidney transplant recipients had a median follow-up of 340 days. The investigators found that a concentration of &amp;gt;35 peripheral FOXP3&lt;sup&gt;+&lt;/sup&gt;CD4&lt;sup&gt;+&lt;/sup&gt;CD127&lt;sup&gt;low&lt;/sup&gt; regulatory T cells/&amp;#181;L was associated with a hazard ratio for squamous cell skin cancer of 2.48 (95% CI 1.04 to 5.98).&lt;/p&gt;
&lt;p&gt;An NK cell count &amp;lt;100 cells/&amp;#181;L was associated with a skin cancer hazard ratio of 5.6 (95% CI 1.31 to 24). A history of squamous cell cancer of the skin increased the risk of skin cancer recurrence by a third (HR 1.33, 95% CI 1.15 to 1.53).&lt;/p&gt;
&lt;p&gt;&quot;If similar immune phenotypes are predictive in other kidney transplant recipient populations, then immune phenotype method has the potential to inform immunosuppressive regimen manipulation in kidney transplant recipients at high risk for developing multiple squamous cell cancers,&quot; the authors concluded.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors had no relevant disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_331"
                     title="Physicians Must Treat Transplant Tourists"
                     score="0.006"
                     href="http://www.medpagetoday.com/Gastroenterology/LiverTransplantation/tb/18203?impressionId=1265782240243"
                     
      &lt;p&gt;Patients who travel to foreign countries for organ transplants may return with more problems than they left with  --  and physicians here have a moral responsibility to treat them, researchers asserted in a transplant journal.&lt;/p&gt;
&lt;p&gt;&quot;Medical tourism&quot; has been on the rise as demand for organs outpaces supply and U.S. healthcare costs skyrocket, Thomas D. Schiano, MD, and Rosamond Rhodes, PhD, of Mount Sinai School of Medicine, reported in &lt;em&gt;Liver Transplantation&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Researchers have estimated that 300 medical tourism transplants occurred between 2004 and 2006, with more than 40% of transplant tourists residing in New York or California, which have only 18% of the total U.S. population. (See &lt;a href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/12564&quot; mce_href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/12564&quot; target=&quot;_blank&quot;&gt;International Medical Trade Turns Big Business&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;Yet physicians have had little guidance on delivering care to these patients, and some transplant centers may turn them away, based on their actions, Schiano and Rhodes wrote.&lt;/p&gt;
&lt;p&gt;Their questions about treatment arose with a 46-year-old Chinese patient who had been put on a waiting list for a liver transplant here because of end-stage liver disease.&lt;/p&gt;
&lt;p&gt;The patient waited on the list for a year as his disease progressed from 18 points to 21 points on a 40-point severity scale.&lt;/p&gt;
&lt;p&gt;Rather than wait any longer, the patient flew to China and had a liver transplant there.&lt;/p&gt;
&lt;p&gt;Many transplanted organs in China come from executed prisoners, raising concerns about disease. Also, foreign transplants may be compromised by poor organ matching, unhealthy donors, and post-transplant infections, while some transplant centers abroad may use substandard surgical techniques, the researchers said.&lt;/p&gt;
&lt;p&gt;Foreign centers are also less likely to send patients home with adequate records and education than centers here, they asserted.&lt;/p&gt;
&lt;p&gt;Three months after his transplant in China, the patient came back to the clinic at Mount Sinai for follow-up care because he was about to run out of imunosuppressive medication.&lt;/p&gt;
&lt;p&gt;Two months after that, the patient developed sepsis due to diffuse intrahepatic biliary stricturing related to hepatic artery thrombosis.&lt;/p&gt;
&lt;p&gt;He required three additional hospitalizations for biliary sepsis, and at that point, retransplantation was the only viable option, Schiano said.&lt;/p&gt;
&lt;p&gt;However, members of the medical team had conflicting views about giving the patient another new liver.&lt;/p&gt;
&lt;p&gt;&quot;He was a medically suitable candidate,&quot; Schiano and Rhodes wrote, &quot;but there was disagreement about whether it was morally right to provide him with a transplant.&quot;&lt;/p&gt;
&lt;p&gt;The clinicians had few ethical guidelines to refer to in making their decision because many deal solely with moral issues related to donors and foreign medical standards.&lt;/p&gt;
&lt;p&gt;For example, the International Society for Heart and Lung Transplantation issued a statement against accepting organs from prisoners in April 2007, and the American Association for the Study of Liver Diseases and the International Liver Transplant Society endorsed similar policies.&lt;/p&gt;
&lt;p&gt;The American Medical Association&apos;s guidelines on medical tourism focus on best practices  --  for example, the procedure must be voluntary, it can&apos;t limit the alternatives offered to patients, and patients should only be referred to accredited institutions.&lt;/p&gt;
&lt;p&gt;While the United Network for Organ Sharing (UNOS)&apos;s statement on medical tourism does maintain that the medical community has an obligation to provide care for these patients, it stops short of offering further direction to transplant programs.&lt;/p&gt;
&lt;p&gt;&quot;Little guidance is provided for dealing with the specific problems of patients who choose to become transplant tourists,&quot; Schiano and Rhodes wrote.&lt;/p&gt;
&lt;p&gt;Instead, they created some ethical guidance for the &quot;moral quandary.&quot;&lt;/p&gt;
&lt;p&gt;Physicians have a &quot;professional obligation to promote the good of patients&quot; as well as a &quot;professional responsibility to adhere to medicine&apos;s commitment to nonjudgmental regard,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;&quot;Taken together, the moral principles of beneficence and nonjudgmental regard direct us to treat potential or returning transplant tourists as we would treat other patients under our care by focusing on providing the medical treatment and support they need,&quot; they continued.&lt;/p&gt;
&lt;p&gt;Physicians shouldn&apos;t deny patients post-transplantation care, and they ought to provide emergent care at the very least. They may refer the patient to another transplant center for long-term follow-up if they regard it as unethical to continue treatment.&lt;/p&gt;
&lt;p&gt;Patients should also be informed about the possibility of transplant tourism when they are not eligible for a transplant in the U.S. or when they are likely to die before reaching the top of the transplant list, Schiano and Rhodes wrote.&lt;/p&gt;
&lt;p&gt;&quot;Patients should not be threatened with abandonment by a center&apos;s refusal to provide care upon their return,&quot; they added.&lt;/p&gt;
&lt;p&gt;As for the 46-year-old patient who was transplanted in China, the Mount Sinai team decided a transplant program must treat all patients on the basis of their need &quot;regardless of what they might have done or how they secured their transplant organ.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Although [the patient] had a long, complicated transplantation course,&quot; they wrote, &quot;he is currently doing well.&quot;&lt;/p&gt;
&lt;p&gt;Mount Sinai has seen a total of nine patients who pursued transplants in China. Three of those had post-transplant problems but had been turned away elsewhere &quot;because several transplant centers in our region do not render care to transplant tourists,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Seven of those nine patients have hepatitis B. Another three had had a renal transplant in India, and subsequently developed liver failure, the authors reported.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_325"
                     title="MRI Reveals Risk for Kidney Failure in Diabetic Patients (CME/CE)"
                     score="0.005"
                     href="http://www.medpagetoday.com/Nephrology/Diabetes/tb/18195?impressionId=1265782240243"
                     
      So-called silent strokes, visible on cerebral MRI scans, predict kidney failure in patients with type 2 diabetes, Japanese researchers said.&lt;br&gt;
&lt;br&gt;After an average follow-up of 7.5 years, diabetic patients with evidence of small cerebral infarctions at baseline later suffered death or kidney failure at more than twice the rate seen in patients who had not had silent strokes, reported Takashi Uzu, MD, of Shiga University of Medical Sciences in Shiga, Japan, and colleagues.&lt;br&gt;
&lt;br&gt;Silent strokes are a consequence of cerebral microvascular disease and thus may logically accompany the development of similar abnormalities in renal blood vessels, ultimately leading to kidney failure, the researchers explained online in the &lt;em&gt;Journal of the American Society of Nephrology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;It is important to identify individuals who are at risk of progression of diabetic renal disease,&quot; Uzu and colleagues wrote.&lt;/p&gt;
&lt;p&gt;The current standard prognostic test is the albumin-creatinine ratio, but it is not entirely adequate for the purpose, they suggested: &quot;Recent clinical studies have shown that renal insufficiency can occur in the absence of microalbuminuria in patients with type 2 diabetes.&quot;&lt;/p&gt;
&lt;p&gt;But they acknowledged that brain MRI scans would be too expensive and inconvenient for routine prognostic testing.&lt;/p&gt;
&lt;p&gt;&quot;New strategies are needed to determine the presence of renal and/or extrarenal microvascular diseases,&quot; Uzu and colleagues wrote.&lt;/p&gt;
&lt;p&gt;Their study involved 608 patients with type 2 diabetes who had no clinical signs of cerebrovascular or cardiovascular disease or overt nephropathy. Their mean age at baseline was about 60 and the average glycated hemoglobin level was about 8.6%.&lt;/p&gt;
&lt;p&gt;Participants underwent cerebral MRI scans at baseline, with 177 showing evidence of silent cerebral infarctions, defined as focal lesions of at least 3 mm in diameter with low signal intensity on T1-weighted images and high intensity with T2 weighting. Dilated perivascular spaces were distinguished from infarcts with proton density scans. Patients with positive findings who had a history of stroke or transient ischemic attack were excluded.&lt;/p&gt;
&lt;p&gt;Those with silent infarctions at baseline differed significantly from other participants according to several parameters. Not surprisingly, patients with cerebral infarcts on average were somewhat older (63 versus 57), had had diabetes for a longer period of time (9.8 years versus 7.6), had higher blood pressure (146.8 mm Hg systolic versus 136.5 ), and were more likely to have a history of smoking (58% versus 46%). All differences were significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.01.&lt;/p&gt;
&lt;p&gt;On the other hand, baseline fasting plasma glucose and glycated hemoglobin levels were both significantly lower in the patients who&apos;d had silent infarctions: mean 163 mg/dL versus 176 for glucose and 8.3% versus 8.7% for HbA1c (&lt;em&gt;P&lt;/em&gt;&amp;#8804;0.01 for both).&lt;/p&gt;
&lt;p&gt;Patients were followed for up to 10 years, with a mean of 7.5. The primary outcome was end-stage renal disease or death, and Uzu and colleagues chose a secondary outcome combining dialysis with doubling of serum creatinine.&lt;/p&gt;
&lt;p&gt;Kaplan-Meier curves for the patients with and without silent infarctions at baseline indicated that the primary outcome occurred at equal rates through the first four years of follow-up, but then the curves diverged abruptly.&lt;/p&gt;
&lt;p&gt;At year eight, approximately 6% of the noninfarcted group had experienced the primary outcome, compared with 21% of those who&apos;d had silent strokes (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001), according to Uzu and colleagues.&lt;/p&gt;
&lt;p&gt;Curves for the secondary outcome began diverging by year three. At year eight, about 6% of the noninfarct participants had gone to dialysis or had serum creatinine levels double, whereas these endpoints occurred in nearly 30% of the infarct group (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001).&lt;/p&gt;
&lt;p&gt;Overall, the hazard ratio associated with baseline silent cerebral infarctions for the primary outcome during follow-up was 2.44 (95% CI 1.36 to 4.38).&lt;/p&gt;
&lt;p&gt;The hazard ratio for death alone was somewhat smaller (1.61, 95% CI 0.71 to 3.62), indicating that most of the risk measured by the primary outcome was actually in end-stage renal disease.&lt;/p&gt;
&lt;p&gt;For the secondary outcome, the hazard ratio was 4.79 (95% CI 2.72 to 8.46).&lt;/p&gt;
&lt;p&gt;All the hazard ratios reflected adjustments for age, sex, duration of diabetes, body mass index, smoking status, HbA1c, blood pressure, serum lipids, and standard lab indices of kidney function at baseline.&lt;/p&gt;
&lt;p&gt;Estimated glomerular filtration rate (eGFR) during follow-up also decreased faster in patients with silent strokes. After five years, mean eGFR had fallen by 8 ml/min/m&lt;sup&gt;2&lt;/sup&gt; in the patients without silent infarcts at baseline compared with 10.5 ml/min/m&lt;sup&gt;2&lt;/sup&gt; in those with cerebral microvascular disease.&lt;/p&gt;
&lt;p&gt;The researchers noted that the study was conducted at two clinical sites, which used somewhat different MRI procedures. But they also indicated that the prevalence of silent infarctions did not differ between the sites.&lt;/p&gt;
&lt;p&gt;Other limitations included use of an older creatinine assay, inclusion of larger silent infarcts which could reflect macrovascular disease, and more patients in the cerebral infarct group who were taking renin-angiotensin system blocking drugs, which have renal impairment as an adverse effect.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;External funding for the study was not reported.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_6_292"
                     title="Kidneys from Blacks After Cardiac Death Give Black Recipients Better Graft Survival"
                     score="-0.005"
                     href="