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    <recommendedItem id="20100101_19_280"
                     title="Better Overall Diabetes Care Lowers Nephropathy Risk (CME/CE)"
                     score="0.003"
                     href="http://www.medpagetoday.com/Nephrology/Diabetes/tb/18136?impressionId=1265774130883"
                     
      &lt;p&gt;Simultaneously achieving tight glucose control and other targets in diabetes reduces the risk of kidney complications, researchers found.&lt;/p&gt;
&lt;p&gt;An aggressive multifactorial intervention appeared to delay diabetic nephropathy better when more targets were achieved (&lt;em&gt;P&lt;/em&gt;=0.002 for trend) in a longitudinal study of Chinese patients led by Ming-Chia Hsieh, MD, PhD, of Kaohsiung Medical University Hospital in Kaohsiung, Taiwan.&lt;/p&gt;
&lt;p&gt;The risk of new-onset microalbuminaria dropped 27.1% for those who met the American Diabetes Association-recommended goal of less than 7% glycosylated hemoglobin (&lt;em&gt;P&lt;/em&gt;=0.03), the researchers reported in the Jan. 25 &lt;em&gt;Archives of Internal Medicine&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Reaching the systolic blood pressure goal of less than 130 mm Hg reduced this risk 35.5% (&lt;em&gt;P&lt;/em&gt;=0.002). Achieving the HDL cholesterol goal  --  over 50 mg/dL for women and 40 mg/dL for men  --  reduced the risk by 28.5% (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;&quot;The control of microalbuminuria may halt progress to overt nephropathy and reduce occurrence of cardiovascular events in these patients,&quot; Hsieh&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;They suggested that this type of intensive intervention &quot;can be used at the very early stages of diabetic renal disease.&quot;&lt;/p&gt;
&lt;p&gt;Prior studies had suggested that intensive therapy could prevent nephropathy in patients who had already started showing signs of progression.&lt;/p&gt;
&lt;p&gt;So to see if starting earlier would be as effective, Hsieh and colleagues initiated a longitudinal cohort study of 1,290 patients with type 2 diabetes and normoalbuminuria in which participants received intensified treatment to meet ADA-recommended goals on glucose, blood pressure, cholesterol, and triglycerides.&lt;/p&gt;
&lt;p&gt;To this end, patients got the combined efforts of a physician, nurse, and dietitian working together on counseling and patient education to modify behavior.&lt;/p&gt;
&lt;p&gt;By the end of the intervention patients were more likely to have switched from single agent glucose-lowering treatment to insulin plus an oral hypoglycemic agent and to have gone on an antihypertensive (74% versus 48% baseline), statin (58.1% versus 28.0% baseline), and fibrate (14.0% versus 3.0% baseline).&lt;/p&gt;
&lt;p&gt;By the end of the study period, the mean glycosylated hemoglobin was 7.3%, while blood pressure averaged 129.3/74.4 mm Hg. Mean LDL cholesterol was 98.6 mg/dL, triglycerides were at 116.0 mg/dL, and mean HDL cholesterol was 53.6 mg/dL.&lt;/p&gt;
&lt;p&gt;Over the 4.5 years of follow-up, 16.4% of patients developed new-onset microalbuminuria.&lt;/p&gt;
&lt;p&gt;Unlike attainment of HDL cholesterol, glycosylated hemoglobin, and systolic blood pressure goals, reaching those for LDL cholesterol, diastolic blood pressure, and triglycerides appeared to have little impact on kidney function.&lt;/p&gt;
&lt;p&gt;But the more targets patients reached, the less likely they were to develop microalbuminuria (&lt;em&gt;P&lt;/em&gt;=0.002).&lt;/p&gt;
&lt;p&gt;The majority of participants in the study reached one or two of the treatment targets (71.4%) and 8.1% achieved three.&lt;/p&gt;
&lt;p&gt;Those who did reach two or three of the goals were at significantly lower risk of new-onset microalbuminuria than the 20.5% who didn&apos;t reach any of the goals (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Those who reached one target tended to be at lower risk as well, but the effect was not significant compared with reaching none of the goals (&lt;em&gt;P&lt;/em&gt;=0.35).&lt;/p&gt;
&lt;p&gt;One of the concerns with the tight glucose control goal has been hypoglycemia. In the study, 217 patients had at least one episode. Four cases involved major hypoglycemia, though without clinical morbidity or mortality.&lt;/p&gt;
&lt;p&gt;Overall, 37 patients died from any cause during the study period.&lt;/p&gt;
&lt;p&gt;A &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/13818&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/13818&quot; target=&quot;_blank&quot;&gt;review&lt;/a&gt; of recent large trials of aggressive glycemic control  --  U.K. Prospective Diabetes Study (UKPDS) and the U.S.-based ACCORD, ADVANCE, and VA Diabetes trials  --  suggested a two- to threefold increased risk of severe hypoglycemia without macrovascular benefits.&lt;/p&gt;
&lt;p&gt;In the recent &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/9739&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/9739&quot; target=&quot;_blank&quot;&gt;ACCORD&lt;/a&gt; trial, tight glucose control that brought hemoglobin A1c close to 6%, with a target of less than the standard 7.0%, resulted in 22% excess mortality risk.&lt;/p&gt;
&lt;p&gt;The search for a reason behind this risk has yet to turn up a culprit. &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/ADA/14635&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/ADA/14635&quot; target=&quot;_blank&quot;&gt;Analyses&lt;/a&gt; have suggested that hypoglycemia isn&apos;t to blame and that the lower A1c levels themselves aren&apos;t a problem.&lt;/p&gt;
&lt;p&gt;In the wake of the negative findings from ACCORD, ADVANCE, and the VA trials, leading diabetologists had suggested that pushing too hard in people who couldn&apos;t reach the targets might have been at fault.&lt;/p&gt;
&lt;p&gt;Rather than a one-size-fits all approach, the ADA guidelines suggest individualizing treatment targets.&lt;/p&gt;
&lt;p&gt;Hsieh&apos;s group acknowledged that &quot;even with close attention, not all our patients could achieve the ADA-recommended goals,&quot; but re-emphasized that for patients who could achieve targets, there were benefits.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that their study was limited by lack of a comparison group, no data on genetic factors, and use of potentially arbitrary treatment target cutoff points.&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 researchers reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_4200"
                     title="Bypass Anemia Drugs in Chronic Kidney Disease, Expert Says (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Nephrology/GeneralNephrology/tb/17684?impressionId=1265774130883"
                     
      Anemia in most chronic kidney disease patients should be managed with iron supplements or blood transfusions, if anything, rather than erythrocyte-stimulating agents, a leading nephrologist has recommended.&lt;br&gt;
&lt;br&gt;The only good case for long-term use of erythropoietin drugs in this population is in those who are transplant candidates or have severe anemia with a hemoglobin under 9 g/dl that cannot be managed with transfusions, Ajay K. Singh, of Harvard and Brigham and Women&apos;s Hospital in Boston, concluded.&lt;br&gt;
&lt;br&gt;&quot;Avoiding use of erythrocyte-stimulating agents in managing anemia in nondialysis patients with chronic kidney disease is now the soundest approach,&quot; he wrote in an editorial online in the &lt;em&gt;Journal of the American Society Nephrology&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;This guidance comes in the wake of the TREAT trial findings that &quot;turned the world of anemia management upside down,&quot; Singh said.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;That &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/ASN/16724&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/ASN/16724&quot; target=&quot;_blank&quot;&gt;landmark trial&lt;/a&gt;, reported nearly two months ago at the American Society of Nephrology meeting and simultaneously online in the &lt;em&gt;New England Journal of Medicine&lt;/em&gt;, showed darbepoetin alfa (Aranesp) was no better than placebo in mortality or cardiovascular or renal outcomes in patients with comorbid diabetes.&lt;/p&gt;
&lt;p&gt;But the drug nearly doubled stroke risk and increased thromboembolism and possibly cancer as well.&lt;/p&gt;
&lt;p&gt;Nephrologists are still trying to digest these findings for their own practices, said Jeffrey S. Berns, MD, of the University of Pennsylvania in Philadelphia.&lt;/p&gt;
&lt;p&gt;&quot;I&apos;m not even sure whether we have a good sense of whether we should be applying this to nonchronic kidney disease patients, in other words, those who are on dialysis already as opposed to those who have chronic kidney disease who are not yet on dialysis,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Singh agreed, writing, &quot;My guess is that most nephrologists will be confused, some perhaps incredulous.&quot;&lt;/p&gt;
&lt;p&gt;Two other &lt;a href=&quot;http://www.medpagetoday.com/Nephrology/GeneralNephrology/4540&quot; mce_href=&quot;http://www.medpagetoday.com/Nephrology/GeneralNephrology/4540&quot; target=&quot;_blank&quot;&gt;large trials&lt;/a&gt; of nondialysis patients with chronic kidney disease have also weighed in on the issue, both open-label comparisons.&lt;/p&gt;
&lt;p&gt;In CHOIR, epoetin-alfa (Procrit) targeted to a hemoglobin of 13.5 g/dl raised the composite rate of death, MI, heart failure, hospitalization, and stroke by 34% compared with target of 11.3 g/dl.&lt;/p&gt;
&lt;p&gt;In CREATE, immediate anemia treatment with epoetin-beta (Micera) targeted to a hemoglobin of 13 to 15 g/dl increased risk of a first cardiovascular adverse event by 22%, though it was not statistically significant, compared with a late strategy holding off treatment (targeted to 10.5 to 11.5 g/dl) until hemoglobin levels dipped below 10.5 g/dl.&lt;/p&gt;
&lt;p&gt;Despite differences between the agents and treated populations, the results of all three trials are &quot;complementary rather than contradictory,&quot; Singh said.&lt;/p&gt;
&lt;p&gt;Given the risks observed, with only minor quality-of-life benefits from active treatment compared with placebo, he said the best evidence for nondialysis chronic kidney disease patients suggests the following: &lt;ul&gt; &lt;li&gt;Focus on iron therapy, exclusion of occult bleeding, and suppression of any inflammation in patients with mild to moderate anemia (hemoglobin 9 to 11 g/dl), even those with mild symptoms and low-level fatigue.&lt;/li&gt; &lt;li&gt;Oral iron should be tried for the first three months of anemia management, with intravenous iron attempted only if this fails.&lt;/li&gt; &lt;li&gt;Worsening anemia to under 9 g/dl should be treated with &quot;rescue&quot; short course erythrocyte-stimulating agents or a blood transfusion.&lt;/li&gt; &lt;li&gt;Use a high threshold for erythrocyte-stimulating agents, even in symptomatic patients with a history of cancer or those undergoing chemotherapy.&lt;/li&gt; &lt;li&gt;For transplant candidates or severe anemia that cannot be managed with blood transfusions, consider a dose of 500 to 1,000 U per week of epoetin-alfa (or its equivalent in darbepoetin).&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;However, Berns called these recommendations too conservative.&lt;/p&gt;
&lt;p&gt;&quot;I think what we need to do is figure out what the right level of erythrocyte-stimulating agent treatment is and the right level of hemoglobin to trigger erythrocyte-stimulating agent use,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;, &quot;and then make an individualized decision.&quot;&lt;/p&gt;
&lt;p&gt;He noted that many physicians are likely to reserve judgement until quality-of-life data from secondary and subgroup analyses from TREAT emerge.&lt;/p&gt;
&lt;p&gt;&quot;People are not going to be impressed by a very small quality-of-life benefit in a very select group of patients,&quot; he said in an interview.&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;Singh reported being principal investigator of the CHOIR study and a member of the executive committee for the TREAT study. He reported conflicts of interest with Ortho Biotech Clinical Affairs, Johnson &amp;amp; Johnson, Fibrogen, Amgen, Roche, Watson, and AMAG.&lt;/p&gt;&lt;p&gt;Berns reported having served on advisory or executive committees for and received consulting income from Amgen, Affymax, GlaxoSmithKline, and Wyeth.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_22"
                     title="Metabolic Acidosis Predicts Mortality In ICU Patients"
                     score="-0.007"
                     href="