<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_280"
                     title="Better Overall Diabetes Care Lowers Nephropathy Risk (CME/CE)"
                     score="0.002"
                     href="http://www.medpagetoday.com/Nephrology/Diabetes/tb/18136?impressionId=1265797389088"
                     
      &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_2346"
                     title="Protein May Point to HIV Kidney Disease"
                     score="-0.005"
                     href="http://www.medpagetoday.com/InfectiousDisease/HIVAIDS/tb/15236?impressionId=1265797389088"
                     
       HOUSTON, July 24 -- Patients with HIV-associated nephropathy have elevated urinary levels of a protein associated with tubular injury, suggesting the marker has potential as a test for early diagnosis, investigators reported. 
              &lt;p&gt;
              &lt;p&gt;A mouse model of HIV-associated nephropathy revealed upregulation of neutrophil gelatinase-associated lipocalin (NGAL), providing additional evidence of the protein&apos;s diagnostic potential, Jonathan Barasch, MD, PhD, and colleagues reported online in the &lt;em&gt;Journal of the American Society of Nephrology&lt;/em&gt;. 
              &lt;p&gt;
              &lt;p&gt;&quot;NGAL was very specifically expressed in renal cysts -- generating the new idea that NGAL may control the development of cysts in HIV-associated nephropathy,&quot; Dr. Barasch, of Columbia University in New York, said in a statement.
              &lt;p&gt; 
              &lt;p&gt;Since the discovery of NGAL in the kidney 10 years ago, &quot;almost every paper is positive for the association of NGAL with kidney dysfunction/disease,&quot; he added. (See &lt;a href=&quot;http://www.medpagetoday.com/CriticalCare/GeneralCriticalCare/15223&quot; target=&quot;blank&quot;&gt;Urine Test Predicts Kidney Injury in ICU Patients&lt;/a&gt;) 
              &lt;p&gt;
              &lt;p&gt;Occurring predominantly in patients of African descent, HIV-associated nephropathy is characterized by nephrosis and rapid decline in kidney function. Histologically, the condition is a collapsing focal segmental glomerulosclerosis with prominent tubular damage. 
              &lt;p&gt;
              &lt;p&gt;NGAL&apos;s association with tubular injury provided a rationale for evaluating urinary levels of the protein as a marker of HIV-associated nephropathy. 
              &lt;p&gt;
              &lt;p&gt;Investigators studied 13 patients with biopsy-proven HIV-associated nephropathy and 24 race-matched HIV patients with normal kidney function, defined as an estimated glomerular filtration rate e60 ml/min and no evidence of proteinuria.
              &lt;p&gt; 
              &lt;p&gt;The patients with HIV-associated nephropathy also were compared with other HIV-positive and HIV-negative patients with other types of chronic kidney disease. 
              &lt;p&gt;
              &lt;p&gt;To obtain additional information about NGAL and HIV-associated nephropathy, investigators studied HIV-transgenic mice, which exhibit a syndrome identical to HIV nephropathy. 
              &lt;p&gt;
              &lt;p&gt;The patients with HIV-associated nephropathy had a mean urinary NGAL of 748 �g/g creatinine, which turned out to be: 
         &lt;ul&gt;     &lt;li&gt;     11 times greater than the 68 �g/g creatinine mean in HIV-positive controls without kidney disease (&lt;em&gt;P&lt;/em&gt;=0.006)
              &lt;li&gt;     Five times greater compared with HIV-positive patients who had other types of kidney disease (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05)
              &lt;li&gt;     34 times greater compared with HIV-negative patients with various types of chronic kidney disease (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05) 
              &lt;/ul&gt;&lt;p&gt;In the transgenic mice, urinary NGAL was expressed most prominently in dilated microcystic tubules. Investigators detected NGAL RNA in 39% of 2,698 microcysts but not in any noncystic tubules. 
              &lt;p&gt;
              &lt;p&gt;&quot;These data suggest the possibility that urinary NGAL may be useful to monitor the formation of renal tubular cysts and consequently distinguish HIV-associated nephropathy from common forms of chronic kidney disease . . . presenting in the HIV patient,&quot; the authors said. 
              &lt;p&gt;
              &lt;p&gt;&quot;In this light,&quot; they said, &quot;the very high levels of urinary NGAL associated with HIV-associated nephropathy may provide a rationale for biopsy and aggressive HAART therapy to prevent progression of HIV-associated nephropathy to end-stage renal disease.&quot; 
              &lt;p&gt;
              &lt;p&gt;The authors acknowledge, though, that more research is needed, especially &quot;in a large cohort where we can determine the temporal relationships between NGAL expression and disease onset and between NGAL expression and HAART.&quot; 
              &lt;p&gt;
             &lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt;The authors disclosed that Columbia University and Cincinnati Children&apos;s Hospital Medical Center (institution of one coauthor) have received licensing fees from Biosite and Abbott Diagnostics. 
       &lt;/td&gt;&lt;/tr&gt;&lt;/table&gt; &lt;p&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_439"
                     title="High-Dose ARB Treatment Cuts Proteinuria"
                     score="-0.006"
                     href="http://www.medpagetoday.com/Nephrology/ESRD/tb/12852?impressionId=1265797389088"
                     
      CALGARY, Alberta, Feb. 11 -- Proteinuria declined dramatically in patients with chronic kidney disease treated with supramaximal doses of candesartan (Atacand), data from a multicenter study demonstrated. 
              &lt;p&gt;
              &lt;p&gt;Compared with patients on 16 mg a day of candesartan, those treated with 128 mg a day had a 33% decrease in proteinuria after 30 weeks, Ellen Burgess, M.D., of the University of Calgary, and colleagues reported online in the &lt;em&gt;Journal of the American Society of Nephrology&lt;/em&gt;. 
              &lt;p&gt;
              &lt;p&gt;Blood pressure reduction did not differ among patients randomized to four different doses of the angiotensin receptor blocker (ARB), the investigators said. 
              &lt;p&gt;
              &lt;p&gt;Nor did they observe any dose-related increase in adverse events, although hyperkalemia led a small percentage of patients to withdraw from the study. 
              &lt;p&gt;
              &lt;p&gt;&quot;This study demonstrated that using the ARB candesartan at the dosage of 128 mg/d, a dosage much higher than the maximum dosage recommended for the treatment of hypertension or heart failure, results in a further significant reduction in urinary protein excretion,&quot; the authors concluded. 
              &lt;p&gt;
              &lt;p&gt;&quot;The additional antiproteinuric effect of high-dosage candesartan is independent of blood pressure reduction,&quot; they added. &quot;The antiproteinuric effect of candesartan 128 mg was consistently observed [across the range of protein excretion] and in the patient groups with and without diabetes.&quot; 
              &lt;p&gt;
              &lt;p&gt;High levels of proteinuria predict renal deterioration. Blood pressure reduction also lowers proteinuria, but studies have shown that use of an ACE inhibitor or an ARB reduces proteinuria and the rate of deterioration in renal function, the authors noted. 
              &lt;p&gt;
              &lt;p&gt;Maximal antiproteinuric benefits in the kidney appear to require much higher doses of ACE inhibitors or ARBs than those used to treat hypertension, they continued. However, previous studies of high-dose ARB therapy yielded inconsistent results in patients with diabetes and microalbuminuria. 
              &lt;p&gt;
              &lt;p&gt;In an effort to clarify the risks and benefits of high-dose ARB therapy in chronic kidney disease, investigators conducted a randomized clinical trial to compare supramaximal doses of candesartan with the highest approved dose in Canada (16 mg/d when the trial started). 
              &lt;p&gt;
              &lt;p&gt;The study included 269 patients with primary glomerular diseases, diabetes, or hypertensive glomerulosclerosis and persistent proteinuria ?1 g/d, despite at least seven weeks of treatment with candesartan 16 mg/d. 
              &lt;p&gt;
              &lt;p&gt;The median baseline urine protein excretion was 2.66 g/d, and 53.9% of the patients had diabetic nephropathy. 
              &lt;p&gt;
              &lt;p&gt;The patients were randomized to continue treatment with candesartan 16 mg/d or to receive 64 or 128 mg/d. 
              &lt;p&gt;
              &lt;p&gt;Follow-up continued for 30 weeks, and the primary endpoint was the change from baseline in the geometric mean of 24-hour urine protein excretion. 
              &lt;p&gt;
              &lt;p&gt;In the 128-mg candesartan group, the geometric mean of 24-hour urine protein excretion decreased from 2.85 g/d at baseline to 1.79 g/d at the end of the study. That compared with a decline from 2.80 to 2.59 g/d in the 16-mg group (&lt;em&gt;P&lt;/em&gt;&lt;0.0001). 
              &lt;p&gt;
              &lt;p&gt;Urinary protein excretion decreased from 2.83 g/d at baseline to 2.20 g/d at the end of study (&lt;em&gt;P&lt;/em&gt;=0.0492). However, the difference did not meet the predefined criteria for statistical significance. 
              &lt;p&gt;
              &lt;p&gt;The percentage change in 24-hour urine protein excretion averaged 7.49% in the 16-mg group, 22.23% in those on 64 mg, and 36.95% in the 128-mg group. 
              &lt;p&gt;
              &lt;p&gt;The differences translated into a 16.91% improvement in the 64-mg group versus the 16-mg group and a 33.05% improvement in the 128-mg group. 
              &lt;p&gt;
              &lt;p&gt;A per-protocol analysis demonstrated a 44.34% greater reduction in urinary protein excretion with the 128-mg dose of candesartan versus 16 mg. 
              &lt;p&gt;
              &lt;p&gt;Serum creatinine levels increased by 7.85%, 8.82%, and 6.74% in the 16-, 64-, and 128-mg groups, but did not differ significantly. 
              &lt;p&gt;
              &lt;p&gt;The investigators documented 32 serious adverse events in 24 of the 269 patients in the study, and 24 patients withdrew from the study because of adverse events: 11 in the 16-mg group, five in the 64-mg group, and eight in the 128-mg group. Eleven patients withdrew because of elevated serum potassium levels (5.5 mmol/L), but the withdrawals were evenly distributed across the three dosage groups. 
              &lt;p&gt;
              &lt;p&gt;The researchers suggested that the small number of patients with elevated serum potassium levels may have been due to the exclusion of patients with a serum level greater than 5.5 mmol/L at baseline or on more than one occasion in the six months before the first visit. 
              &lt;p&gt;
              &lt;p&gt;&quot;Because better reduction in proteinuria may result in better renal and cardiovascular outcomes for high-risk patients with proteinuria, more studies are required to find the optimal dosage for reduction of proteinuria and to explore the effects of that dosage on renal as well as cardiovascular outcome endpoints,&quot; the authors said.  
              &lt;p&gt;
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt;AstraZeneca Canada supported the study.
              &lt;p&gt;The authors reported no disclosures.&lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
       
    </recommendedItem>
    <recommendedItem id="20090101_19_681"
                     title="Failing Kidney Drives Stroke Risk in Atrial Fibrillation"
                     score="-0.006"
                     href="http://www.medpagetoday.com/CriticalCare/Strokes/tb/13146?impressionId=1265797389088"
                     
      OAKLAND, Calif., March 5 -- Proteinuria on top of atrial fibrillation increases stroke risk by more than 50%, and that risk also increases steadily as kidney function declines, researchers said.
              &lt;p&gt; 
              &lt;p&gt;By itself, atrial fibrillation is a major risk factor for stroke, but when atrial fibrillation patients begin spilling protein into urine, the risk of thromboembolism climbs to 1.54 (95% confidence interval 1.29 to 1.85) after adjustment for known stroke risk factors (prior stroke, age, hypertension, diabetes, and heart failure) and other confounders, said Alan S. Go, M.D., of the division of research at Kaiser Permanente of Northern California.
              &lt;p&gt; 
              &lt;p&gt;They reported their findings in the March 17 issue of &lt;em&gt;Circulation, Journal of the American Heart Association.&lt;/em&gt;
              &lt;p&gt;
              &lt;p&gt;The link between atrial fibrillation and chronic kidney disease emerged from the ATRIA (Assembly of the Anticoagulation and Risk Factors in Atrial Fibrillation) cohort study of 13,535 adults with nonvalvular atrial fibrillation and no prior kidney transplant.
              &lt;p&gt; 
              &lt;p&gt;During follow-up off anticoagulation therapy involving more than 10,000 patients, there were 676 documented ischemic events, including 637 ischemic strokes. 
              &lt;p&gt; 
              &lt;p&gt;&quot;The rate of thromboembolism off warfarin increased significantly with lower eGFR,&quot; Dr. Go wrote. Moreover, the event rate was &quot;higher with documented proteinuria at every level of estimated glomerular filtration rate.&quot;
              &lt;p&gt; 
              &lt;p&gt;Dr. Go and colleagues concluded that clinicians &quot;should consider ascertaining information about the level of estimated glomerular filtration rate and the presence of proteinuria in patients with atrial fibrillation, which may improve the risk stratification for decision-making about the use of antithrombotic therapy for stroke prevention.&quot;
              &lt;p&gt; 
              &lt;p&gt;The mean age of patients in the study was 71.6, and 42.8% were women. The patients were treated for atrial fibrillation from July 1, 1996 though December 31, 1997, with follow-up through September 30, 2003.
              &lt;p&gt; 
              &lt;p&gt;At baseline, 7,690 patients had estimated glomerular filtration rates of 60 mL or higher, 2,499 had reduced rates -- defined as 45 to 59 mL -- and 1,338 had rates lower than 45 mL. 
              &lt;p&gt; 
              &lt;p&gt;Among patients with normal creatinine clearance, 697 (9.1%) had documented proteinuria, as did 382 (15.3%) of those with estimated glomerular filtration rates in the 45 to 59 mL range and 333 (24.9%) of those with rates lower than 45 mL.
              &lt;p&gt; 
              &lt;p&gt;There was a graded, increased risk of thromboembolism associated with a lower level of estimated glomerular filtration rate. Compared with a glomerular filtration rate of 60 mL per min per 1.73 m&lt;sup&gt;2&lt;/sup&gt;, the adjusted relative risk for thromboembolism was 1.16 (95% CI, 0.95 to 1.40) for eGFR 45 to 59 mL and 1.39 (95% CI, 1.13 to 1.71) for eGFR &lt;45 (&lt;em&gt;P&lt;/em&gt;&lt;0.0082 for trend).
              &lt;p&gt; 
              &lt;p&gt;Dr. Go conceded that the stroke rate among ESRD patients is &quot;high overall, and risk factors for stroke such as hypertension, diabetes mellitus, coronary artery disease, and heart failure are common.&quot;
              &lt;p&gt; 
              &lt;p&gt;But less was known about stroke risk in patients who had not yet progressed to kidney replacement therapy and who have their condition complicated by atrial fibrillation. 
              &lt;p&gt; 
              &lt;p&gt;&quot;Thus our study provides novel insights in demonstrating that the presence and severity of [chronic kidney disease] (as reflected by eGFR and proteinuria) are associated with a higher risk of ischemic stroke and other thromboembolism in patients with [atrial fibrillation] independently of known risk factors for stroke in [atrial fibrillation],&quot; Dr. Go said.
              &lt;p&gt; 
              &lt;p&gt;He noted that the study was limited by a small number of patients for whom baseline kidney function was not known. Additionally, he and his colleagues were not able to characterize the type of ischemic stroke, although &quot;the majority of strokes in the setting of [atrial fibrillation] are cardioembolic.&quot;
              &lt;p&gt; 
              &lt;p&gt;Also, researchers used the Modification of Diet in Renal Disease equation to estimate glomerular filtration rate, an approach that has not been validated in nonblack ethnic minorities. As a result, Dr. Go said, &quot;misclassification may be present in such patients in our study sample.&quot;
              &lt;p&gt; 
              &lt;p&gt;Finally, the study was conducted in Northern California in a population that is considered representative of insured adults in that region, but may not be representative of the nation as a whole.
              &lt;p&gt; 
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt; The study was funded by a Public Health Services research grant from the National Institute on Aging and by the Edith and Eliot Shoolman Fund of the Massachusetts General Hospital.
              &lt;p&gt; 
              &lt;p&gt;Dr. Go disclosed research grants from the National Institute on Aging, and the National Heart, Lung, and Blood Institute. &lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_2174"
                     title="EHR Aids Management of Chronic Disease"
                     score="-0.006"
                     href="http://www.medpagetoday.com/Nephrology/GeneralNephrology/tb/15026?impressionId=1265797389088"
                     
       LITTLE FALLS, N.J., July 9 -- Using an electronic health record (EHR) to better coordinate referrals to specialists may benefit patients, researchers have found. 
              &lt;p&gt;&lt;p&gt;Implementation of the EHR in 2005 was associated with more timely consultations with nephrologists, which resulted in better management of patients at high risk for end-stage renal disease (ESRD), said Brian J. Lee, MD, of Kaiser Permanente Hawaii. 
              &lt;p&gt;The findings were reported online in &lt;em&gt;BMJ&lt;/em&gt;. 
              &lt;p&gt;Between 2004 and 2008, the proportion of referrals occurring within four months of the onset of ESRD dropped from 32% to 12% (&lt;em&gt;P&lt;/em&gt;=0.001). 
              &lt;p&gt;The proportion of patients starting hemodialysis with a mature arteriovenous fistula increased from 16% to 35% (&lt;em&gt;P&lt;/em&gt;=0.006), and the proportion starting hemodialysis as outpatients increased from 35% to 56% (&lt;em&gt;P&lt;/em&gt;=0.003).  
              &lt;p&gt;&quot;This pilot illustrates the benefits of leveraging technology and the expertise within a multispecialty group practice,&quot; Dr. Lee said. &quot;In the past, specialists have been limited to helping only those patients who were referred to them.&quot; 
              &lt;p&gt;&quot;Now that we can use databases . . . to provide data on individual patients,&quot; he continued, &quot;our specialists can proactively find and recommend treatments for patients who could really use their help.&quot; 
              &lt;p&gt;Yet despite a trend toward early intervention by nephrologists and specialists, the researchers said, most patients were still managed by primary care physicians. 
              &lt;p&gt;Late referrals, however, are associated with higher mortality and rates of hospital admission, particularly among kidney patients. 
              &lt;p&gt;So the researchers conducted a longitudinal study of 10,000 members of Kaiser Permanente Hawaii with chronic kidney disease. They looked at time periods before and after implementation of an EHR.  
              &lt;p&gt;Dr. Lee, who developed the computer program that included a profile for every patient, said test results were used to rank the patients from high to low risk. 
              &lt;p&gt;When considered together, glomerular filtration rate and proteinuria were highly predictive of risk. They identified three specific laboratory criteria for patients at high risk: glomerular filtration rate &amp;lt;20 ml/min/1.73 m&lt;sup&gt;2&lt;/sup&gt;; glomerular filtration rate &amp;lt;40 ml/min/1.73 m&lt;sup&gt;2&lt;/sup&gt; plus urinary protein:creatinine ratio &amp;gt;2; and urinary protein:creatinine ratio &amp;gt;4. Laboratory criteria for low-risk status were glomerular filtration rate 30 ml/min/1.73 m&lt;sup&gt;2&lt;/sup&gt; and &amp;lt;1 g proteinuria. 
              &lt;p&gt;The nephrologists reviewed the patients&apos; electronic records and sent primary care physicians a message requesting a nephrology visit if patients had an abnormal GFR, abnormal protein-to-creatinine ratio, or other key variable. 
              &lt;p&gt;The researchers found that the initiative reduced the rate of late referrals for patients who&apos;d already developed ESRD before seeing a kidney specialist. 
              &lt;p&gt;Yet despite a trend toward early intervention by nephrologists and specialists, the researchers said, most patients were still managed by primary care physicians. 
              &lt;p&gt;&quot;The increase in referrals of patients at high risk and the accompanying decrease in referrals of patients at low risk indicate that our initiative increased the efficient use of nephrology resources,&quot; the researchers said. 
              &lt;p&gt;They added that the approach might be applicable to other specialties. 
              &lt;p&gt;For instance, diabetologists could use HbA1c to refer patients for diabetes treatment, pain specialists could use the number of opioid prescriptions to identify patients with unmet needs, and cardiologists could use ejection fraction to risk-stratify patients with congestive heart failure. 
              &lt;p class=&quot;MsoNormal&quot;&gt;
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt; The study was supported by Kaiser Permanente Hawaii, where the authors are employed.&lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
    </recommendedItem>
</recommendedContent>