<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_325"
                     title="MRI Reveals Risk for Kidney Failure in Diabetic Patients (CME/CE)"
                     score="0.008"
                     href="http://www.medpagetoday.com/Nephrology/Diabetes/tb/18195?impressionId=1265749889080"
                     
      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="20100101_19_222"
                     title="Benefits of Cutting Down on Salt Quantified (CME/CE)"
                     score="-0.001"
                     href="http://www.medpagetoday.com/Cardiology/Prevention/tb/18075?impressionId=1265749889080"
                     
      &lt;p&gt;Cutting daily salt intake by 3 grams a day  --  about 30% of the current average  --  could prevent 32,000 strokes and 54,000 myocardial infarctions a year, if a computer model developed by researchers at the University of California, San Francisco accurately depicts the clinical impact of salt reduction.&lt;/p&gt;
&lt;p&gt;The results of the analysis, which used a computer simulation of heart disease in U.S. adults ages 35 to 84, also suggest that even a 1 gram per day reduction in salt over the next decade would be a more cost-effective strategy for treating hypertension than use of even the cheapest antihypertensive, wrote Kirsten Bibbins-Domingo, MD, PhD, and colleagues in a paper published online by the &lt;em&gt;New England Journal of Medicine.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;Lee Goldman, MD, MPH, of Columbia University, who co-authored the paper, told &lt;em&gt;MedPage Today&lt;/em&gt; that their study builds on what has long been known about the adverse health effects of salt on a society that believes it to be the spice of life.&lt;/p&gt;
&lt;p&gt;For example, Goldman said that most people seeking a healthy choice will check food labels and restaurant menus for calorie counts and trans fats, but will not pay attention to salt.&lt;/p&gt;
&lt;p&gt;This is not the first time a call for salt reduction has been issued. As recently as last November, a meta-analysis published in &lt;em&gt;BMJ &lt;/em&gt;suggested that cutting salt intake in half  --  a reduction of about 5 grams a day or roughly a teaspoonful  --  would lower the stroke rate by 23% and reduce overall cardiovascular disease by as much as 17%.&lt;/p&gt;
&lt;p&gt;Americans, like those in many Western countries, take in an average of about 10 g of salt a day; whereas the World Health Organization recommends only 5 g per day, and the U.S. Department of Agriculture recommends daily intake be limited to 5.8 g.&lt;/p&gt;
&lt;p&gt;Bibbins-Domingo and colleagues reported that a 3 gram per day reduction in dietary salt would &quot;save 194,00 to 392,00 quality-adjusted life-years and $10 billion to $24 billion in healthcare costs annually.&quot;&lt;/p&gt;
&lt;p&gt;In an editorial that accompanied the study, Lawrence J. Appel, MD, MPH, and Cheryl A.M. Anderson, PhD, MPH, of Johns Hopkins University, wrote that &quot;the evidence supporting the call to reduce salt intake as a means of preventing cardiovascular disease is compelling.&quot;&lt;/p&gt;
&lt;p&gt;They concluded with this admonition: &quot;As we deliberate healthcare reform, let us not neglect this inexpensive, yet highly effective public health intervention for the prevention of disease.&quot;&lt;/p&gt;
&lt;p&gt;It should be noted that Appel was also first author on a position paper from the American Society of Hypertension that also called for salt reduction as public policy.&lt;/p&gt;
&lt;p&gt;Franz H. Messerli, MD, director of the hypertension program at St. Luke&apos;s-Roosevelt Hospital and a colleague of Goldman&apos;s, said the computer model used in the study was impressive but probably underestimates the benefit of reducing dietary salt &quot;because salt reduction has been shown to have a direct (blood pressure independent) effect on the heart, the brain, the kidneys, and also reduces stomach cancer and osteoporosis  --  factors that were not considered in this analysis.&quot;&lt;/p&gt;
&lt;p&gt;But Messerli found it difficult to lead the victory parade, noting &quot;this is a modeling study and statements such as &apos;A modest reduction of 1 gm per day would be more cost-effective than using medication to lower blood pressure in all persons with hypertension&apos; are to be taken with a good grain of salt.&quot;&lt;/p&gt;
&lt;p&gt;Messerli&apos;s measured response was not echoed by his colleagues in the hypertension world.&lt;/p&gt;
&lt;p&gt;For example, Henry Black, MD, president of the American Society of Hypertension, and director of hypertension research at the New York University School of Medicine said that, although the paper extended the findings of many other studies, it is &quot;more comprehensive and is especially useful by comparing the benefits of [sodium] and [salt] reduction to those of other widely accepted public health approaches that the public and governmental bodies have embraced, including drug treatment.&quot;&lt;/p&gt;
&lt;p&gt;Clyde Yancy, MD, president of the American Heart Association, said that while the study was a computer modeling analysis that may be as good as it gets because &quot;it would be impossible to do a randomized trial in large numbers of high versus low sodium consumption, and the use of modeling with reasonable assumptions represents a solid if not ideal alternative.&quot;&lt;/p&gt;
&lt;p&gt;Moreover, Yancy argued that &quot;the costs and effort involved in setting and/or changing policy&quot; require strong imperatives, and he thought the data reported today &quot;provide that imperative.&quot;&lt;/p&gt;
&lt;p&gt;Three grams of salt comes to about a teaspoonful, but Goldman said it was foolish to think of sodium reduction in terms of such measurements because so much sodium comes from processed foods and from restaurant food. Achieving the needed reduction requires a concerted national effort.&lt;/p&gt;
&lt;p&gt;Bibbins-Domingo noted that their study was limited &quot;by any uncertainty concerning the data entered into the model.&quot;&lt;/p&gt;
&lt;p&gt;Also they noted that they did not &quot;account fully for the possible effects of salt reduction that are unrelated to control of blood pressure  --  for example, potential improvements in outcomes for the increasing numbers of patients with heart failure or prevention of other serious conditions, such as end-stage renal disease.&quot;&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 study was supported in part by a grant from the American Heart Association Western States Affiliate and a grant from the University of California, San Francisco Clinical and Translational Sciences Institute.&lt;/p&gt;&lt;p&gt;The authors said they had &quot;no potential conflicts of interest relevant to this article.&quot;&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_681"
                     title="Failing Kidney Drives Stroke Risk in Atrial Fibrillation"
                     score="-0.005"
                     href="http://www.medpagetoday.com/CriticalCare/Strokes/tb/13146?impressionId=1265749889080"
                     
      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_3798"
                     title="Sleep Apnea Raises BP for Kidney Transplant Patients (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Pulmonary/SleepDisorders/tb/17122?impressionId=1265749889080"
                     
      &lt;p&gt;Sleep apnea is common among kidney transplant patients, and those with the sleep disorder have higher systolic blood pressure despite taking more antihypertensive medications, a new study found.&lt;/p&gt;
&lt;p&gt;Among transplant patients, 18% had mild obstructive sleep apnea, 11% moderate sleep apnea and 14% severe sleep apnea, according to a&lt;strong&gt; &lt;/strong&gt;study published online Nov. 19 in the &lt;em&gt;Clinical Journal of the American Society of Nephrology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Of transplant patients with sleep apnea, 51% required treatment with three or more drugs for high blood pressure, compared to 31% of transplant patients without apnea (&lt;em&gt;P&lt;/em&gt;=0.022), according to Miklos Z. Molnar, MD, of Semmelweis University in Budapest, and colleagues.&lt;/p&gt;
&lt;p&gt;Despite taking more blood pressure medications, patients with sleep apnea had higher systolic blood pressure readings on average (147 &amp;#177; 21 mmHg) than those without the sleep disorder (139 &amp;#177; 18 mmHg; &lt;em&gt;P&lt;/em&gt;=0.059).&lt;/p&gt;
&lt;p&gt;&quot;We suggest that screening for obstructive sleep apnea should be routinely performed, and appropriate treatment should be offered for transplant patients,&quot; Molnar wrote.&lt;/p&gt;
&lt;p&gt;Patients on a waiting list for kidney transplantation also were found to have a high prevalence of sleep apnea.&lt;/p&gt;
&lt;p&gt;The National Institutes of Health estimates that about one out of 25 middle-age men and one out of 50 middle-age women in the U.S. have sleep apnea, which causes patients to stop breathing momentarily during sleep because of an obstructed airway.&lt;/p&gt;
&lt;p&gt;Previous studies have shown that sleep apnea is more common in patients with chronic kidney disease, and researchers have theorized that this might contribute to higher rates of cardiovascular disease in that population. Few studies, however, have explored the relationship between sleep apnea, cardiovascular risk, and kidney transplants.&lt;/p&gt;
&lt;p&gt;Molnar and colleagues conducted a cross-sectional study of 100 kidney transplant patients who were selected for inclusion in December 2006 and 50 patients on a transplant waiting list.&lt;/p&gt;
&lt;p&gt;The patients underwent an overnight polysomnography test to determine whether they had sleep apnea and, if so, the severity of their disorder. The average age of the patients was 50.&lt;/p&gt;
&lt;p&gt;Patients with apnea were grouped by severity of their disorder, based on their score on the apnea-hypopnea index (AHI): &lt;ul&gt; &lt;li&gt; Mild, AHI &amp;#8805;5 to &amp;lt;15&lt;/li&gt; &lt;li&gt;Moderate, AHI &amp;#8805;15 to &amp;lt;30&lt;/li&gt; &lt;li&gt;Severe, AHI&amp;#8805;30 &lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Patients were considered to have obstructive apnea if their condition was moderate or severe. The participants were also tested for blood pressure and cholesterol, and their 10-year coronary heart disease risk was estimated using the Framingham score (based on total cholesterol).&lt;/p&gt;
&lt;p&gt;&quot;We propose that the higher blood pressure in transplant patients with obstructive sleep apnea may contribute to the high cardiovascular morbidity and mortality of transplant patients,&quot; the authors concluded.&lt;/p&gt;
&lt;p&gt;The researchers found that sleep apnea was associated with age (&lt;em&gt;P&lt;/em&gt;=0.34), body mass index (&lt;em&gt;P&lt;/em&gt;=0.45), neck circumference (&lt;em&gt;P&lt;/em&gt;=0.4), abdominal circumference (&lt;em&gt;P&lt;/em&gt;=0.51) and hemoglobin levels (&lt;em&gt;P&lt;/em&gt;=0.24) in transplant patients. Kidney patients on transplant waiting lists had rates of sleep apnea similar to those of patients who had undergone transplants already.&lt;/p&gt;
&lt;p&gt;The authors cautioned that participants in the study all came from a single outpatient facility and that their results need to be confirmed by more statistically powerful studies.&lt;/p&gt;
&lt;p&gt;The cross-sectional design precluded making conclusions about causation.&lt;/p&gt;
&lt;p&gt;They also noted that only motivated or symptomatic patients were likely to accept the stress of the polysomnography test, which probably reduced the chances of &quot;good sleepers&quot; participating.&lt;/p&gt;
&lt;p&gt;&quot;We cannot exclude the presence of this bias in our study,&quot; they wrote.&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 study was funded by the National Research Fund, Hungarian Kidney Foundation, and the Foundation for Prevention in Medicine, Hungarian Academy of Sciences, and Canadian Home Healthcare.&lt;/p&gt;&lt;p&gt;The authors reported no financial conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_191"
                     title="Cerebral Amyloid Angiopathy, Found in Sharon, Explains Many Strokes"
                     score="-0.006"
                     href="