Biomedical subjects

Michael J Klag

Publications and source records attributed to Michael J Klag.

At least 19 recordsLinked to original sources

PubMed2007

Attainment of clinical performance targets and improvement in clinical outcomes and resource use in hemodialysis care: a prospective cohort study.

BACKGROUND: Clinical performance targets are intended to improve patient outcomes in chronic disease through quality improvement, but evidence of an association between multiple target attainment and patient outcomes in routine clinical practice is often lacking. METHODS: In a national prospective cohort study (ESRD Quality, or EQUAL), we examined whether attainment of multiple targets in 668 incident hemodialysis patients from 74 U.S. not-for-profit dialysis clinics was associated with better outcomes. We measured whether the following accepted clinical performance targets were met at 6 months after study enrollment: albumin (> or =4.0 g/dl), hemoglobin (> or =11 g/dl), calcium-phosphate product (<55 mg2/dl2), dialysis dose (Kt/V> or =1.2), and vascular access type (fistula). Outcomes included mortality, hospital admissions, hospital days, and hospital costs. RESULTS: Attainment of each of the five targets was associated individually with better outcomes; e.g., patients who attained the albumin target had decreased mortality [relative hazard (RH) = 0.55, 95% confidence interval (CI), 0.41-0.75], hospital admissions [incidence rate ratio (IRR) = 0.67, 95% CI, 0.62-0.73], hospital days (IRR = 0.61, 95% CI, 0.58-0.63), and hospital costs (average annual cost reduction = 3,282 dollars, P = 0.002), relative to those who did not. Increasing numbers of targets attained were also associated, in a graded fashion, with decreased mortality (P = 0.030), fewer hospital admissions and days (P < 0.001 for both), and lower costs (P = 0.029); these trends remained statistically significant for all outcomes after adjustment (P < 0.001), except cost, which was marginally significant (P = 0.052). CONCLUSION: Attainment of more clinical performance targets, regardless of which targets, was strongly associated with decreased mortality, hospital admissions, and resource use in hemodialysis patients.

Aged↗

PubMed2006

Association of childhood socioeconomic status with subsequent coronary heart disease in physicians.

BACKGROUND: Adult socioeconomic status (SES) is an independent risk factor for the development of coronary heart disease (CHD), but whether low childhood SES has an effect in adults who have achieved high SES is unknown. METHODS: We examined the risk of CHD and mortality associated with low childhood SES in 1131 male medical students from The Johns Hopkins Precursors Study, a prospective cohort of graduates of The Johns Hopkins University School of Medicine from 1948 to 1964 with a median follow-up of 40 years. RESULTS: Of 1131 subjects, 216 (19.1%) were from low-SES families. Medical students from low-SES families were slightly older at graduation (26.8 vs 26.2 years; P = .004) and gained more weight over time (P = .01). Low childhood SES conferred a 2.40-fold increased hazard of developing CHD on or before age 50 years (95% confidence interval, 1.21-4.74) but not at older ages. The impact of low SES on early CHD was not reduced by adjusting for other CHD risk factors, including body mass index, cholesterol level, amount of exercise, depression, coffee drinking, smoking, hypertension, diabetes mellitus, and parental CHD history. Low childhood SES did not confer an increased risk of all-cause mortality. CONCLUSIONS: Low childhood SES is associated with an increased incidence of CHD before age 50 years among men with high adulthood SES. This risk is not mediated by traditional risk factors for CHD. These findings highlight the importance of childhood events on the development of CHD early in adulthood and the persistent effects of low SES.

Adult↗

PubMed2006

Functional variants in the lymphotoxin-alpha gene predict cardiovascular disease in dialysis patients.

TNF-beta that is encoded by lymphotoxin-alpha gene (LTA) regulates adhesion molecules and IL-6. Previously, a genome-wide case-control study showed that LTA gene variants predisposed to cardiovascular disease (CVD). In a prospective study of 775 dialysis patients, LTA and IL-6 gene variants were tested as independent predictors of CVD risk. Four polymorphisms in the LTA gene and one in the IL-6 gene were genotyped. CVD events were ascertained from medical records. During a mean follow-up of 2.6 yr, 294 first-incident CVD events occurred. The LTA 26Asn variant predicted higher adjusted CVD risk (hazard ratio HR 1.33 for each additional copy of Asn allele; 95% confidence interval 1.14 to 1.55; P = 0.0003). Two other nonsynonymous polymorphisms in the LTA, 13Agr and 51Pro, were associated with lower inflammatory activity and CVD risk. LTA haplotypes (based on all four single-nucleotide polymorphisms) were associated with inflammatory markers and predicted CVD risk (P = 0.005) after adjustment. These LTA genotype associations were independent of the IL-6 -174G/C genotype association that was reported recently. LTA and IL-6 gene variants independently predicted risk for CVD among dialysis patients, suggesting that susceptibility in multiple inflammatory pathways contribute to the development of CVD.

Adult↗

PubMed2006

Association of clinic vascular access monitoring practices with clinical outcomes in hemodialysis patients.

BACKGROUND: Early identification of access dysfunctions may be associated with improved patient outcomes. We examined whether patient outcomes were associated with vascular access monitoring practices in an incident dialysis cohort. METHODS: We conducted a national prospective cohort study and analyzed 363 hemodialysis patients who had a first permanent vascular access (arteriovenous fistula or graft) by 6 months after the start of dialysis. Multivariate methods were used to examine associations between monitoring practices and 6-month Kt/V (reaching Kt/V >/=1.2), access intervention, access failure, and 2-year septicemia and all-cause hospitalization and mortality. RESULTS: Patients who received monitoring weekly or more often (49%) were more likely to have an access intervention (adjusted RH = 1.40, 95% CI, 1.07-1.84) than those who received monitoring less frequently. Additionally, patients treated at clinics that reported performing regular access monitoring (80% of patients) were less likely to be hospitalized for septicemia (IRR = 0.35, 95% CI, 0.21-0.61) or for any cause (IRR = 0.77, 95% CI, 0.60-0.99). There were no statistically significant differences between patients exposed to different vascular access monitoring practices in access failure, achievement of Kt/V, or survival. CONCLUSION: Frequent monitoring of dialysis access may initially increase the number of interventions but is beneficial to longer-term outcomes, including septicemia-related and all-cause hospitalization.

Cohort Studies↗

PubMed2006

Haplotype of signal transducer and activator of transcription 3 gene predicts cardiovascular disease in dialysis patients.

Signal transducer and activator of transcription 3 (STAT3) protein has been linked to cardiovascular disease (CVD) through multiple pathways in experimental and animal studies. STAT3 gene variation was examined as a predictor of incident CVD in a subcohort of 529 incident white dialysis patients. Fifteen single-nucleotide polymorphisms of the STAT3 gene were genotyped. Haplotypes were estimated using software PHASE 2.1, and associations with first CVD event were tested using Cox proportional hazards analysis. Adjusted global tests of haplotype association with incident CVD and inflammation markers were performed using permutated P value in R-package Haplo.score. An a priori specified additive genetic model was assumed for haplotype analysis. Both genotypes (four single nucleotide polymorphisms with P < 0.001) and haplotypes (P = 0.002 overall) were associated with incident CVD. Two major haplotype blocks, blocks A and C, were identified. Compared with common haplotype A-1, A-3 was associated with a hazard ratio (HR) of 0.70 (95% confidence interval [CI] 0.51 to 0.94) for CVD events after adjustment for covariates including C-reactive protein (CRP) and interleukin 6. Compared with common haplotype C-1, C-3 was associated with an adjusted HR of 2.12 (95% CI 1.25 to 3.57) for CVD events. Associations were independent of inflammation markers, but IL-6 levels were 14% lower (geometric mean ratio 0.86; 95% CI 0.77 to 0.96) per copy of haplotype A-3 compared with haplotype A-1 in block A after adjustment for CRP and other risk factors (P = 0.008). Variation in the STAT3 gene is associated with the risk for CVD among white dialysis patients independent of serum IL-6 and CRP levels.

Aged↗

PubMed2006

IL-6 haplotypes, inflammation, and risk for cardiovascular disease in a multiethnic dialysis cohort.

It is unknown whether IL-6, a central regulator of inflammation, is a cause of or just a marker of atherosclerosis. Studies of genetic susceptibility to inflammation, however, avoid the potential for reverse causality. Variation in IL6 gene was studied as a predictor of cardiovascular disease (CVD) risk in a cohort of 775 incident dialysis patients, in whom IL-6 levels are elevated. On the basis of published resequencing data on the IL6 gene, a phylogenetic tree with three main branches (clades 1 to 3) was constructed. Two "clade tag" polymorphisms, -174G/C and 1888G/T, and two missense variants, Pro32Ser and Asp162Val, were genotyped. Circulating IL-6 and albumin were measured a median of 5 mo after the start of dialysis. CVD events were ascertained from medical records. During a median follow-up of 2.5 yr, 294 CVD events occurred. The two coding variants, Pro32Ser (present only in black patients, 10% Ser allele) and Asp162Val (present only in white patients, 1% Val), were associated with lower levels of IL-6 and higher levels of albumin. The common variant in the promoter region, -174G/C, was strongly associated with higher CVD risk and weakly with IL-6 levels. Clade 3 (-174C carriers in the absence of 162 Val allele) was associated with higher IL-6 levels (P=0.03) and higher CVD risk (hazard ratio 1.44, P=0.006) after adjustment for covariates. The IL6 gene has functional variants that affect inflammation and risk for CVD among dialysis patients, supporting a causal role for IL6 in CVD.

Adult↗

PubMed2006

Lifetime weight patterns in male physicians: the effects of cohort and selective survival.

OBJECTIVE: The natural history of lifetime weight change is not well understood because of conflicting evidence from cross-sectional and longitudinal studies. Cross-sectional analyses find that adult weight is highest at approximately 60 years of age and lower thereafter. Longitudinal analyses have not found this pattern. Our objective was to test whether cohort effects and selective survival may explain the differences observed between cross-sectional and longitudinal studies. RESEARCH METHODS AND PROCEDURES: We analyzed data on white men from the Johns Hopkins Precursors Study (n = 1197). Weight and height were measured at enrollment during medical school. The Precursors Study collected subsequent weight measurements by self-report and follows all participants for mortality. RESULTS: In preliminary analyses that ignored cohort and survival effects, average weight increased 0.16 kg/yr to age 65 (p < 0.001) and declined 0.10 kg/yr thereafter (p = 0.002). When controlling for differing rates of weight change by cohort and survival group, the apparent decline after 65 years of age was mostly explained. DISCUSSION: These data suggest that, in white men, weight increases steadily until age 65 and then plateaus. These findings emphasize the necessity of longitudinal rather than cross-sectional data to describe lifetime weight patterns.

Age Factors↗

PubMed2006

Epidemic of childhood obesity: implications for kidney disease.

Childhood obesity has become a global epidemic. Childhood obesity has many long-term adverse effects on morbidity and mortality. The prevalence of end-stage renal disease (ESRD) has risen dramatically in the past decade in parallel with the increase in obesity. Our current understanding of the consequences of childhood obesity on kidney function and disease is very limited. The present study presents the worldwide trends in childhood obesity and reviews published studies that have examined the association between obesity and kidney disease in the pediatric and adult populations. A large number of studies have been conducted to examine the association between obesity and kidney disease in general adult populations; however, few have been conducted to examine the impact of childhood obesity on the risk of kidney disease. Findings from large cohort studies in adult general populations show that obesity increases the risk of kidney diseases. Six follow-up studies in pediatric patients were identified, and they indicate that childhood obesity is associated with an increased risk of kidney disease and the progression and mortality of kidney disease. Future studies in the pediatric populations are needed.

Adult↗

PubMed2005

Differential susceptibility to hypertension is due to selection during the out-of-Africa expansion.

Hypertension is a leading cause of stroke, heart disease, and kidney failure. The genetic basis of blood pressure variation is largely unknown but is likely to involve genes that influence renal salt handling and arterial vessel tone. Here we argue that susceptibility to hypertension is ancestral and that differential susceptibility to hypertension is due to differential exposure to selection pressures during the out-of-Africa expansion. The most important selection pressure was climate, which produced a latitudinal cline in heat adaptation and, therefore, hypertension susceptibility. Consistent with this hypothesis, we show that ecological variables, such as latitude, temperature, and rainfall, explain worldwide variation in heat adaptation as defined by seven functional alleles in five genes involved in blood pressure regulation. The latitudinal cline in heat adaptation is consistent worldwide and is largely unmatched by latitudinal clines in short tandem repeat markers, control single nucleotide polymorphisms, or non-functional single nucleotide polymorphisms within the five genes. In addition, we show that latitude and one of these alleles, GNB3 (G protein beta3 subunit) 825T, account for a major portion of worldwide variation in blood pressure. These results suggest that the current epidemic of hypertension is due to exposures of the modern period interacting with ancestral susceptibility. Modern populations differ in susceptibility to these new exposures, however, such that those from hot environments are more susceptible to hypertension than populations from cold environments. This differential susceptibility is likely due to our history of adaptation to climate.

Acclimatization↗

PubMed2005

Major causes of death among men and women in China.

BACKGROUND: With China's rapid economic development, the disease burden may have changed in the country. We studied the major causes of death and modifiable risk factors in a nationally representative cohort of 169,871 men and women 40 years of age and older in China. METHODS: Baseline data on the participants' demographic characteristics, medical history, lifestyle-related risk factors, blood pressure, and body weight were obtained in 1991 with the use of a standard protocol. The follow-up evaluation was conducted in 1999 and 2000, with a follow-up rate of 93.4 percent. RESULTS: We documented 20,033 deaths in 1,239,191 person-years of follow-up. The mortality from all causes was 1480.1 per 100,000 person-years among men and 1190.2 per 100,000 person-years among women. The five leading causes of death were malignant neoplasms (mortality, 374.1 per 100,000 person-years), diseases of the heart (319.1), cerebrovascular disease (310.5), accidents (54.0), and infectious diseases (50.5) among men and diseases of the heart (268.5), cerebrovascular disease (242.3), malignant neoplasms (214.1), pneumonia and influenza (45.9), and infectious diseases (35.3) among women. The multivariate-adjusted relative risk of death and the population attributable risk for preventable risk factors were as follows: hypertension, 1.48 (95 percent confidence interval, 1.44 to 1.53) and 11.7 percent, respectively; cigarette smoking, 1.23 (95 percent confidence interval, 1.18 to 1.27) and 7.9 percent; physical inactivity, 1.20 (95 percent confidence interval, 1.16 to 1.24) and 6.8 percent; and underweight (body-mass index [the weight in kilograms divided by the square of the height in meters] below 18.5), 1.47 (95 percent confidence interval, 1.42 to 1.53) and 5.2 percent. CONCLUSIONS: Vascular disease and cancer have become the leading causes of death among Chinese adults. Our findings suggest that control of hypertension, smoking cessation, increased physical activity, and improved nutrition should be important strategies for reducing the burden of premature death among adults in China.

Adult↗

PubMed2005

Comparing the risk for death with peritoneal dialysis and hemodialysis in a national cohort of patients with chronic kidney disease.

BACKGROUND: The influence of type of dialysis on survival of patients with end-stage renal disease (ESRD) is controversial. OBJECTIVE: To compare risk for death among patients with ESRD who receive peritoneal dialysis or hemodialysis. DESIGN: Prospective cohort study. SETTING: 81 dialysis clinics in 19 U.S. states. PATIENTS: 1041 patients starting dialysis (274 patients receiving peritoneal dialysis and 767 patients receiving hemodialysis) at baseline. MEASUREMENTS: Patients were followed for up to 7 years and censored at transplantation or loss to follow-up. Cox proportional hazards regression stratified by clinic was used to compare the risk for death with peritoneal dialysis versus hemodialysis. RESULTS: Twenty-five percent of patients undergoing peritoneal dialysis and 5% of hemodialysis patients switched type of dialysis. After adjustment, the risk for death did not differ between patients undergoing peritoneal dialysis and those undergoing hemodialysis during the first year (relative hazard, 1.39 [95% CI, 0.64 to 3.06]), but the risk became significantly higher among those undergoing peritoneal dialysis in the second year (relative hazard, 2.34 [CI, 1.19 to 4.59]). After stratification, the survival rate was no different for patients who had the highest propensity of being initially treated with peritoneal dialysis. Results were consistent with adjustment based on a propensity score model and in sensitivity analyses that used as-treated models and models in which switches in type of dialysis were treated as treatment failures. Results were similar but stronger in analyses that were restricted to patients who were treated only in clinics offering both types of dialysis. LIMITATIONS: Patients were not randomly assigned to their initial type of dialysis. Also, more patients undergoing peritoneal dialysis than hemodialysis switched type of dialysis over time, and the reason for switching was often a consequence of the technique. CONCLUSIONS: The risk for death in patients with ESRD undergoing dialysis depends on dialysis type. Further studies are needed to evaluate a possible survival benefit of a timely change from peritoneal dialysis to hemodialysis.

Cardiovascular Diseases↗

PubMed2005

High lipoprotein(a) levels and small apolipoprotein(a) size prospectively predict cardiovascular events in dialysis patients.

Lipoprotein(a) [Lp(a)] levels are increased in dialysis patients, suggesting that they may play a role in the elevated atherosclerotic cardiovascular disease (ASCVD) risk in this population. Few prospective studies of Lp(a) level, apolipoprotein(a) [apo(a)] size, and ASCVD have been performed in the dialysis population. An inception cohort of 833 incident dialysis patients were followed prospectively. Baseline Lp(a) was measured by apo(a) size-independent ELISA and apo(a) size by Western blot after SDS-agarose gel electrophoresis. A combined prospective nonfatal and fatal ASCVD end point included myocardial infarction, coronary revascularization, cerebrovascular accident, carotid endarterectomy, peripheral revascularization, gangrene, or limb amputation. Survival analyses were performed with adjustment for baseline demographics, comorbid conditions, ASCVD risk factors, albumin, lipids, and C-reactive protein. Median follow-up was 27.4 mo, with 297 ASCVD events, 130 non-ASCVD deaths, and seven losses to follow-up over 1649 person-years. In multivariate Cox regression models, both high Lp(a) concentration (>/=53 nmol/L) and low molecular weight (LMW) apo(a) isoforms (</=22 Kringle-IV repeats) predicted ASCVD events (relative hazard [RH] = 1.38, P = 0.02; RH = 1.58, P < 0.0005, respectively). In models that included both Lp(a) concentration and apo(a) size, only apo(a) size remained associated with ASCVD. Among those with both LMW apo(a) and Lp(a) level >123 nmol/L, the relative hazard (RH) of ASCVD was 1.73 (P < 0.0005), compared with high molecular weight apo(a) and Lp(a) level <123 nmol/L. No interactions by age, race, gender, diabetes, or ASCVD were present. Both LMW apo(a) size and high Lp(a) level predict ASCVD risk in dialysis patients, but the association of ASCVD with LMW isoforms is stronger than the association with high Lp(a) concentration.

Aged↗

PubMed2005

Incidence of atherosclerosis by race in the dialysis morbidity and mortality study: a sample of the US ESRD population.

White individuals who are on dialysis experience much higher overall and cardiovascular mortality rates than black individuals despite a more favorable risk factor profile, but the incidence of nonfatal cardiovascular disease (CVD) to this racial disparity has not been well studied. A longitudinal study of 16,103 people who had ESRD and were enrolled in the United Renal Data System from 1993 to 1996 was conducted. The incidence of new and recurrent atherosclerotic CVD (ASCVD) events was determined using Medicare claims for hospitalizations and mortality among blacks and whites, stratified by ASCVD at baseline. ASCVD was defined as coronary heart disease, peripheral vascular disease, and cerebrovascular disease. Incidence of new ASCVD in people without ASCVD at baseline was 146.9 per 1000 person-years in whites and 118.7 per 1000 person-years in blacks. Incidence of recurrent ASCVD was 404.1 per 1000 person-years in whites and 317.5 per 1000 person-years in blacks. Whites were 1.35 (95% confidence interval, 1.18 to 1.55) times more likely to develop incident ASCVD compared with blacks and 1.25 (95% confidence interval, 1.14 to 1.36) times more likely to develop recurrent disease after adjusting for traditional CVD and dialysis-related risk factors. Excess risk for recurrent ASCVD in whites compared with blacks was consistently present no matter the duration of dialysis: Hazard ratio 1.42 for 0 to 6 mo and 1.40 for 6 to 12 mo. Whites who are treated with dialysis have a higher incidence of ASCVD than blacks who are on dialysis, both new and recurrent. Although differences in survival before the initiation of dialysis may contribute to the observed difference in ASCVD risk, it is not explained by baseline traditional and dialysis-related ASCVD risk factors.

Aged↗

PubMed2005

Type of vascular access and survival among incident hemodialysis patients: the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study.

Arteriovenous fistulae (AVF) have advantages over arteriovenous grafts (AVG) and central venous catheters (CVC), but whether AVF are associated independently with better survival is unclear. Recent studies showing such a survival benefit did not include early access experience or account for changes in access type over time and did not include data on some important confounders. Reported here are survival rates stratified by the type of access in use up to 3 yr after initiation of hemodialysis among 616 incident patients who were enrolled in the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study. A total of 1084 accesses (185 AVF, 296 AVG, 603 CVC) were used for a total of 1381 person-years. At initiation, 409 (66%) patients were using a CVC, 122 (20%) were using an AVG, and 85 (14%) were using an AVF. After 6 mo, 34% were using a CVC, 40% were using an AVG, and 26% were using an AVF. Annual mortality rates were 11.7% for AVF, 14.2% for AVG, and 16.1% for CVC. Adjusted relative hazards (RH) of death compared with AVF were 1.5 (95% confidence interval, 1.0 to 2.2) for CVC and 1.2 (0.8 to 1.8) for AVG. The increased hazards associated with CVC, as compared with AVF, were stronger in men (n = 334; RH = 2.0; P = 0.01) than women (n = 282; RH = 1.0 for CVC; P = 0.92). These results strongly support existing clinical practice guidelines and suggest that the use of venous catheters should be minimized to reduce the frequency of access complications and to improve patient survival, especially among male hemodialysis patients.

Adult↗

PubMed2005

Frequency of patient-physician contact in chronic kidney disease care and achievement of clinical performance targets.

OBJECTIVE: To examine whether the frequency of physician contact is associated with accepted quality of care measures reflecting clinical performance in chronic kidney disease patients. DESIGN: Prospective cohort study of end-stage renal disease patients begun in 1995, followed for 2.5 years. SETTING: 76 not-for-profit US dialysis clinics. STUDY PARTICIPANTS: 678 incident hemodialysis patients for whom we had information on average frequency of patient-physician contact at each clinic (low, monthly or less frequent; intermediate, between monthly and weekly; high, more than weekly), determined by clinic survey. MAIN OUTCOME MEASURES: Achievement of accepted 6 month clinical performance targets of albumin (> or =3.5 g/dl), calcium-phosphate (Ca-P) product (<60 mg(2)/dl(2)), dialysis dose (Kt/V > or = 1.2), vascular access type (fistula), and hemoglobin (> or =11 g/dl). RESULTS: By logistic regression, patients treated at clinics reporting less frequent physician contact had lower odds of achieving most targets, statistically significantly for albumin [low, adjusted odds ratio (OR) = 0.83, 95% confidence interval (CI), 0.55-1.25; intermediate, adjusted OR = 0.62, 95% CI, 0.42-0.93; reference, high] and dialysis dose (low, adjusted OR = 0.26, 95% CI, 0.08-0.89; intermediate, adjusted OR = 0.67, 95% CI, 0.20-2.27); however, they had greater odds of achieving the hemoglobin target (low, adjusted OR = 1.94, 95% CI, 1.24-3.04; intermediate, adjusted OR = 1.89, 95% CI, 1.27-2.83). Additionally, the number of targets reached was statistically significantly lower in the monthly or less group (adjusted OR = 0.43, 95% CI, 0.20-0.94). CONCLUSIONS: More frequent patient-physician contact is positively associated with the achievement of clinical performance targets in chronic kidney disease care.

Aged↗

PubMed2005

Beta-fibrinogen haplotypes and the risk for cardiovascular disease in a dialysis cohort.

BACKGROUND: Elevated plasma fibrinogen levels are common in dialysis patients and may be related to an elevated risk for cardiovascular disease (CVD). We tested the hypothesis that genetic variation in the beta-fibrinogen ( FGB ) gene, shown to explain 1% to 5% of fibrinogen level variation in the general population, has an important role in elevated fibrinogen levels and excess CVD risk in dialysis patients. METHODS: Plasma fibrinogen was measured in 735 dialysis patients a median of 3 months from the start of dialysis therapy by using an automated clot-rate assay. Seven polymorphisms of the FGB gene were determined. Haplotype analysis was conducted using the Phase program to estimate haplotypes, with stratification for race. CVD events were ascertained from medical records. RESULTS: During a median follow-up of 2.1 years, 279 CVD events occurred. Genotype frequencies were in Hardy-Weinberg equilibrium. Four common haplotypes identified were not associated with fibrinogen levels or CVD risk in the entire cohort or after stratification by race. The -455A allele, known to increase gene expression in vitro, was marginally associated with fibrinogen levels only in patients without diabetes (regression coefficient [beta], 20 mg/dL [for +1 copy of the A allele; P = 0.06]), adjusted for age, sex, race, smoking, baseline dialysis modality, comorbidity, and history of diabetes and CVD. Post hoc analysis showed that -249C-->T (defining haplotype 3) was associated with greater fibrinogen levels and CVD risk among patients without diabetes and current smokers. CONCLUSION: The FGB gene likely does not have an important role in determining the variation in elevated plasma fibrinogen levels or excess CVD risk in dialysis patients.

Adult↗

PubMed2005

Comparison of intravenous pamidronate to standard therapy for osteoporosis: use in patients unable to take oral bisphosphonates.

BACKGROUND: Bisphosphonates are potent therapies for osteoporosis, but some patients cannot tolerate oral forms. Our study sought to examine the effectiveness and safety of intravenous pamidronate as an alternate osteoporotic therapy in these patients. METHODS: We conducted a retrospective study of 26 patients treated with intermittent, intravenous pamidronate (30 mg every 3 months) and 52 matched controls treated with standard therapy, all with osteoporosis. Primary outcome was response to therapy, defined as either stabilization or increase in bone mineral density. Secondary outcomes were patient safety and tolerability. RESULTS: At an average of 16.1 months of follow up, 64% of pamidronate-treated patients responded to therapy at the lumbar spine, 65% at the femoral neck, and 63% at the trochanter. These response rates were not significantly different than those of the standard care group in which 69% were receiving oral bisphosphonates. Adverse events were uncommon and included mild, diffuse myalgias and flu-like symptoms. CONCLUSIONS: Intravenous pamidronate is a well-tolerated osteoporosis therapy that has an effect on bone density comparable to standard therapy in patients unable to take oral bisphosphonates.

Administration, Oral↗

PubMed2005

Preferences, knowledge, communication and patient-physician discussion of living kidney transplantation in African American families.

It is unknown whether patient-physician discussion about live kidney transplantation (LT) among African Americans (AA) is affected by preferences, knowledge and family discussions regarding LT. We recruited 182 AA dialysis patients and their families and assessed the relation of preferences, knowledge and family discussions regarding LT to the occurrence of patient-physician discussion using multivariable logistic regression. Most patients (76%) desired a transplant, and most patients (93%), spouses (91%) and children (88%) had knowledge of LT. Nearly half of the families discussed transplantation. Only 68% of patients and less than half of their spouses (41%) and children (31%) had discussed transplantation with physicians. Patient-physician discussion was more common among patients: whose spouses acknowledged their interest in transplantation (adjusted odds ratio (AOR) (95% CI):3.5 (1.61-7.8)); who discussed transplantation with spouses (AOR(95% CI):5.25 (2.22-12.41)); whose spouses agreed that they discussed transplantation with patients (AOR (95%CI):5.20 (1.76-15.37)) and whose children discussed transplantation with patients' physicians (AOR (95%CI):7.4 (1.3-40.0)). Universal patient-physician discussion of LT does not occur despite patient preferences. Rates of family-physician discussions are low, and rates of family discussions vary. Early family-physician discussion of LT, use of allied health professionals to promote family discussion of LT and the institution of culturally appropriate programs to enhance discussion of LT in AA families could improve rates of discussion and enhance patients' access to LT.

Adult↗