Publications by authors named "Clarissa J Diamantidis"

55 Publications

Hospitalization Trajectories and Risks of ESKD and Death in Individuals With CKD.

Kidney Int Rep 2021 Jun 31;6(6):1592-1602. Epub 2021 Mar 31.

Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.

Introduction: Management of chronic kidney disease (CKD) entails high medical complexity and often results in high hospitalization burden. There are limited data on the associations of longitudinal hospital utilization patterns with adverse clinical outcomes in individuals with CKD.

Methods: We derived cumulative all-cause hospitalization trajectory groups using latent class trajectory analysis in 3012 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study who were alive and did not reach end-stage kidney disease (ESKD) within 4 years of study entry. Cox proportional hazards models tested the associations between hospitalization trajectory groups and risks of ESKD and death prior to the onset of ESKD (ESKD-censored death).

Results: Within 4 years of study entry, there were 5658 hospitalizations among 3012 participants. We identified 3 distinct subgroups of individuals with CKD based on cumulative all-cause hospitalization trajectories over 4 years: low-utilizer ( = 1066), intermediate-utilizer ( = 1802), and high-utilizer ( = 144). High-utilizers represented a patient population of lower socioeconomic status who had a greater prevalence of comorbid conditions and lower kidney function compared with intermediate- and low-utilizers. After the 4-year ascertainment period to form the trajectory subgroups, there were 544 ESKD events and 437 ESKD-censored deaths during a median follow-up time of 5.1 years. Compared with low-utilizers, intermediate-utilizers and high-utilizers were at 1.49-fold (95% confidence interval [CI] 1.22-1.84) and 1.75-fold (95% CI 1.20-2.56) higher risk of ESKD in adjusted analyses, respectively. Compared with low-utilizers, intermediate-utilizers and high-utilizers were at 1.48-fold (95% CI 1.17-1.87) and 2.58-fold (95% CI 1.74-3.83) higher risk of ESKD-censored death in adjusted analyses, respectively.

Conclusions: Trajectories of cumulative all-cause hospitalization identify subgroups of individuals with CKD who are at high risk of ESKD and death.
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http://dx.doi.org/10.1016/j.ekir.2021.03.883DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207467PMC
June 2021

Risk of Potentially Inappropriate Medications in Adults With CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study.

Am J Kidney Dis 2021 May 23. Epub 2021 May 23.

Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland.

Rationale & Objective: Adults with chronic kidney disease (CKD) may be at increased risk of adverse effects from use of potentially inappropriate medications (PIMs). Our objective was to assess whether PIM exposure has an independent association with CKD progression, hospitalizations, mortality, or falls.

Study Design: Retrospective observational study.

Setting & Participants: Chronic Renal Insufficiency Cohort (CRIC) study; 3,929 adults with CKD enrolled 2003-2008 and followed prospectively until December 2011.

Exposure: PIM exposure was defined as prescriptions for any medications to be avoided in older adults as defined by the 2015 American Geriatrics Society Beers Criteria.

Outcome: Hospitalization count, death, a composite kidney disease end point of CKD progression or initiation of kidney replacement therapy (KRT), KRT, and fall events assessed 1 year after PIM exposure.

Analytical Approach: Logistic regression and Poisson regression to estimate the associations of PIM exposure with each outcome.

Results: The most commonly prescribed PIMs were proton pump inhibitors and α-blockers. In unadjusted models, any PIM exposure (compared to none) was associated with hospitalizations, death, and fall events. After adjustment, exposure to 1, 2, or≥3 PIMs had a graded association with a higher hospitalization rate (rate ratios of 1.09 [95% CI, 1.01-1.17], 1.18 [95% CI, 1.07-1.30], and 1.35 [95% CI, 1.19-1.53], respectively) and higher odds of mortality (odds ratios of 1.19 [95% CI, 0.91-1.54], 1.62 [95% CI, 1.21-2.17], and 1.65 [95% CI, 1.14-2.41], respectively). In a cohort subset reporting falls (n=1,109), prescriptions for≥3 PIMs were associated with an increased risk of falls (adjusted OR, 2.85 [95% CI, 1.54-5.26]). PIMs were not associated with CKD progression or KRT. Age did not modify the association between PIM count and outcomes.

Limitations: Measurement bias; confounding by indication.

Conclusions: Adults of any age with CKD who are prescribed PIMs have an increased risk of hospitalization, mortality, and falls with the greatest risk occurring after more than 1 PIM prescription.
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http://dx.doi.org/10.1053/j.ajkd.2021.03.019DOI Listing
May 2021

Annual wellness visits and care management before and after dialysis initiation.

BMC Nephrol 2021 May 5;22(1):164. Epub 2021 May 5.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.

Introduction: Demands of dialysis regimens may pose challenges for primary care provider (PCP) engagement and timely preventive care. This is especially the case for patients initiating dialysis adjusting to new logistical challenges and management of symptoms and existing comorbid conditions. Since 2011, Medicare has provided coverage for annual wellness visits (AWV), which are primarily conducted by PCPs and may be useful for older adults undergoing dialysis.

Methods: We used the OptumLabs® Data Warehouse to identify a cohort of 1,794 Medicare Advantage (MA) enrollees initiating dialysis in 2014-2017 and examined whether MA enrollees (1) were seen by a PCP during an outpatient visit and (2) received an AWV in the year following dialysis initiation.

Results: In the year after initiating dialysis, 93 % of MA enrollees had an outpatient PCP visit but only 24 % received an annual wellness visit. MA enrollees were less likely to see a PCP if they had Charlson comorbidity scores between 0 and 5 than those with scores 6-9 (odds ratio (OR) = 0.59, 95 % CI: 0.37-0.95), but more likely if seen by a nephrologist (OR = 1.60, 95 % CI: 1.01-2.52) or a PCP (OR = 15.65, 95 % CI: 9.26-26.46) prior to initiation. Following dialysis initiation, 24 % of MA enrollees had an AWV. Hispanic MA enrollees were less likely (OR = 0.57, 95 % CI: 0.39-0.84) to have an AWV than White MA enrollees, but enrollees were more likely if they initiated peritoneal dialysis (OR = 1.54, 95 % CI: 1.07-2.23) or had an AWV in the year before dialysis initiation (OR = 4.96, 95 % CI: 3.88-6.34).

Conclusions: AWVs are provided at low rates to MA enrollees initiating dialysis, particularly Hispanic enrollees, and represent a missed opportunity for better care management for patients with ESKD. Increasing patient awareness and provider provision of AWV use among dialysis patients may be needed, to realize better preventive care for dialysis patients.
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http://dx.doi.org/10.1186/s12882-021-02368-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8097997PMC
May 2021

Racism and Kidney Health: Turning Equity Into a Reality.

Am J Kidney Dis 2021 06 24;77(6):951-962. Epub 2021 Feb 24.

Center for Community and Population Health Improvement, Clinical and Translational Science Institute, Duke University School of Medicine, Durham, NC; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC.

Kidney disease continues to manifest stark racial inequities in the United States, revealing the entrenchment of racism and bias within multiple facets of society, including in our institutions, practices, norms, and beliefs. In this perspective, we synthesize theory and evidence to describe why an understanding of race and racism is integral to kidney care, providing examples of how kidney health disparities manifest interpersonal and structural racism. We then describe racialized medicine and "colorblind" approaches as well as their pitfalls, offering in their place suggestions to embed antiracism and an "equity lens" into our practice. We propose examples of how we can enhance kidney health equity by enhancing our structural competency, using equity-focused race consciousness, and centering investigation and solutions around the needs of the most marginalized. To achieve equitable outcomes for all, our medical institutions must embed antiracism and equity into all aspects of advocacy, policy, patient/community engagement, educational efforts, and clinical care processes. Organizations engaged in kidney care should commit to promoting structural equity and eliminating potential sources of bias across referral practices, guidelines, research agendas, and clinical care. Kidney care providers should reaffirm our commitment to structurally competent patient care and educational endeavors in which empathy and continuous self-education about social drivers of health and inequity, racism, and bias are integral. We envision a future in which kidney health equity is a reality for all. Through bold collective and sustained investment, we can achieve this critical goal.
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http://dx.doi.org/10.1053/j.ajkd.2021.01.010DOI Listing
June 2021

Racial Differences in AKI Incidence Following Percutaneous Coronary Intervention.

J Am Soc Nephrol 2021 Mar 18;32(3):654-662. Epub 2020 Dec 18.

Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.

Background: Undergoing percutaneous coronary intervention (PCI) is a risk factor for AKI development, but few studies have quantified racial differences in AKI incidence after this procedure.

Methods: We examined the association of self-reported race (Black, White, or other) and baseline eGFR with AKI incidence among patients who underwent PCI at Duke University Medical Center between January 1, 2003, and December 31, 2013. We defined AKI as a 0.3 mg/dl absolute increase in serum creatinine within 48 hours, or ≥1.5-fold relative elevation within 7 days post-PCI from the reference value ascertained within 30 days before PCI.

Results: Of 9422 patients in the analytic cohort (median age 63 years; 33% female; 75% White, 20% Black, 5% other race), 9% developed AKI overall (14% of Black, 8% of White, 10% of others). After adjustment for demographics, socioeconomic status, comorbidities, predisposing medications, PCI indication, periprocedural AKI prophylaxis, and PCI procedural characteristics, Black race was associated with increased odds for incident AKI compared with White race (odds ratio [OR], 1.79; 95% confidence interval [95% CI], 1.48 to 2.15). Compared with Whites, odds for incident AKI were not significantly higher in other patients (OR, 1.30; 95% CI, 0.93 to 1.83). Low baseline eGFR was associated with graded, higher odds of AKI incidence ( value for trend <0.001); however, there was no interaction between race and baseline eGFR on odds for incident AKI ( value for interaction = 0.75).

Conclusions: Black patients had greater odds of developing AKI after PCI compared with White patients. Future investigations should identify factors, including multiple domains of social determinants, that predispose Black individuals to disparate AKI risk after PCI.
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http://dx.doi.org/10.1681/ASN.2020040502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920184PMC
March 2021

Clinical events and patient-reported outcome measures during CKD progression: findings from the CRIC study.

Nephrol Dial Transplant 2020 Dec 16. Epub 2020 Dec 16.

University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Background: Patients with chronic kidney disease (CKD) face risk of end-stage kidney disease (ESKD), cardiovascular disease (CVD), and death, but also decline in kidney function, quality of life (QOL), and mental and physical well-being. This study describes the multidimensional trajectories of CKD using clinical events, kidney function, and patient-reported outcome measures. We hypothesized that more advanced CKD stages would associate with more rapid decline in each outcome.

Methods: Among 3,939 participants enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study, we evaluated multidimensional disease trajectories by G- and A-stages of enrollment eGFR and albuminuria, respectively. These trajectories included clinical events (ESKD, CVD, heart failure, death), eGFR decline, and patient-reported outcome measures (kidney disease QOL [KDQOL] burden, effects, and symptoms questionnaires, as well as the short-form-12 mental and physical composite).We also evaluated a group-based multi-trajectory model to group participants on the basis of longitudinal patient-reported outcome measures and compared group assignments by enrollment G- and A-stage.

Results: Mean participant age was 58 years, 45% were women, mean baseline eGFR was 44 mL/min/1.73 m2, and median urine albumin-to-creatinine ratio was 52 mg/g. The incidence of all clinical events was greater and eGFR decline was faster with more advanced G- and A-stages. While baseline KDQOL and physical component measures were lower with more advanced G- and A-stage of CKD; changes in patient-reported outcome measures were inconsistently related to the baseline CKD stage. Groups formed on patient-reported outcome measure trajectories were fairly distinct from existing CKD staging (observed agreement, 60.6%) but also were associated with risk of ESKD, CVD, heart failure, and death.

Conclusions: More advanced baseline CKD stage was associated with higher risk of clinical events and faster eGFR decline, but was only weakly related to changes in patient-reported metrics over time.
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http://dx.doi.org/10.1093/ndt/gfaa364DOI Listing
December 2020

Mobile Health (mHealth) Technology: Assessment of Availability, Acceptability, and Use in CKD.

Am J Kidney Dis 2021 06 9;77(6):941-950.e1. Epub 2020 Dec 9.

Department of Medicine, Duke University School of Medicine, Durham, NC.

Rationale & Objective: Digital and mobile health (mHealth) technologies improve patient-provider communication and increase information accessibility. We assessed the use of technology, attitudes toward using mHealth technologies, and proficiency in using mHealth technologies among individuals with chronic kidney disease (CKD).

Study Design: Cross-sectional survey with open text responses.

Setting & Participants: Chronic Renal Insufficiency Cohort (CRIC) Study participants who completed current use and interest in using mHealth technologies questionnaires and the eHealth literacy Survey (eHEALS).

Exposure: Participant characteristics.

Outcomes: Use of technology (ie, internet, email, smartphone, and mHealth applications [apps]), interest in future mHealth use, and proficiency in using digital and mHealth technologies, or eHealth literacy, determined by eHEALS score.

Analytical Approach: Poisson regression and a qualitative content analysis of open-ended responses.

Results: Study participants (n = 932) had a mean age of 68 years old and an estimated glomerular filtration rate (eGFR) of 54 mL/min/1.73 m, and 59% were male. Approximately 70% reported current use of internet, email, and smartphones, and 35% used mHealth apps; only 27% had adequate eHealth literacy (eHEALS score ≥ 32). Participants <65 years of age (vs. ≥65), with more education, higher income, better cognition, and adequate health literacy reported more use of technology, and greater interest in using technologies. Participants of White (vs. non-White) race reported more use of internet and email but less interest in future use of mHealth. Younger age, higher annual income, and greater disease self-efficacy were associated with adequate eHealth literacy. Three themes regarding interest in using digital and mHealth technologies emerged: willingness, concerns, and barriers.

Limitations: Residual confounding, ascertainment bias.

Conclusions: Many individuals with CKD currently use the internet and smartphones and are interested in using mHealth in the future, but few use mHealth apps or have adequate eHealth literacy. mHealth technologies present an opportunity to engage individuals with CKD, especially members of racial or ethnic minority groups because those groups reported greater interest in using mHealth technology than the nonminority population. Further research is needed to identify strategies to overcome inadequate eHealth literacy.
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http://dx.doi.org/10.1053/j.ajkd.2020.10.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154635PMC
June 2021

Multiple, objectively measured sleep dimensions including hypoxic burden and chronic kidney disease: findings from the Multi-Ethnic Study of Atherosclerosis.

Thorax 2021 07 4;76(7):704-713. Epub 2020 Dec 4.

Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA.

Background: Poor sleep may contribute to chronic kidney disease (CKD) through several pathways, including hypoxia-induced systemic and intraglomerular pressure, inflammation, oxidative stress and endothelial dysfunction. However, few studies have investigated the association between multiple objectively measured sleep dimensions and CKD.

Methods: We investigated the cross-sectional association between sleep dimensions and CKD among 1895 Multi-Ethnic Study of Atherosclerosis Sleep Ancillary Study participants who completed in-home polysomnography, wrist actigraphy and a sleep questionnaire. Using Poisson regression models with robust variance, we estimated separate prevalence ratios (PR) and 95% CIs for moderate-to-severe CKD (glomerular filtration rate <60 mL/min/1.73 m or albuminuria >30 mg/g) among participants according to multiple sleep dimensions, including very short (≤5 hours) sleep, Apnoea-Hypopnoea Index and sleep apnoea-specific hypoxic burden (SASHB) (total area under the respiratory event-related desaturation curve divided by total sleep duration, %min/hour)). Regression models were adjusted for sociodemographic characteristics, health behaviours and clinical characteristics.

Results: Of the 1895 participants, mean age was 68.2±9.1 years, 54% were women, 37% were white, 28% black, 24% Hispanic/Latino and 11% Asian. Several sleep metrics were associated with higher adjusted PR of moderate-to-severe CKD: very short versus recommended sleep duration (PR=1.40, 95% CI 1.06 to 1.83); SASHB (Box-Cox transformed SASHB: PR=1.06, 95% CI 1.02 to 1.12); and for participants in the highest quintile of SASHB plus sleep apnoea: PR=1.28, 95% CI 1.01 to 1.63.

Conclusions: Sleep apnoea associated hypoxia and very short sleep, likely representing independent biological mechanisms, were associated with a higher moderate-to-severe CKD prevalence, which highlights the potential role for novel interventions.
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http://dx.doi.org/10.1136/thoraxjnl-2020-214713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175452PMC
July 2021

Opioid Prescribing in the 2016 Medicare Fee-for-Service Population.

J Am Geriatr Soc 2021 Feb 20;69(2):485-493. Epub 2020 Nov 20.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.

Background And Objectives: Opioid use and misuse are prevalent and remain a national crisis. This study identified beneficiary characteristics associated with filling opioid prescriptions, variation in opioid dosing, and opioid use with average daily doses (ADDs) equal to 120 morphine milligram equivalents (MMEs) or more in the 100% Medicare fee-for-service (FFS) population.

Design, Setting, Participants, And Measurements: In a cohort of FFS beneficiaries with 12 months of Medicare Part D coverage in 2016, we examined patient factors associated with filling an opioid prescription (n = 20,880,490) and variation in ADDs (n = 7,325,031) in a two-part model. Among those filling opioids, we also examined the probability of ADD equal to 120 MMEs or more via logistic regression.

Results: About 35% of FFS beneficiaries had one or more opioid prescription fills in 2016 and 1.5% had ADDs equal to 120 MMEs or more. Disability-eligible beneficiaries and beneficiaries with multiple chronic conditions were more likely to fill opioids, to have higher ADDs or were more likely to have ADD equal to 120 MMEs or more. Beneficiaries with chronic obstructive pulmonary disease (COPD) were more likely to fill opioids (odds ratio (OR) = 1.47, 95% confidence interval (CI) = 1.46-1.47), have higher ADDs (rate ratio = 1.06, 95% CI = 1.06-1.06) when filled and were more likely to have ADD equal to 120 MMEs or more (OR = 1.23, 95% CI = 1.21-1.24). Finally, black and Hispanic beneficiaries were less likely to fill opioids, had lower overall doses and were less likely to have ADDs equal to 120 MMEs or more compared to white beneficiaries.

Conclusion: Several beneficiary subgroups have underappreciated risk of adverse events associated with ADD equal to 120 MMEs or more that may benefit from opioid optimization interventions that balance pain management and adverse event risk, especially beneficiaries with COPD who are at risk for respiratory depression.
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http://dx.doi.org/10.1111/jgs.16911DOI Listing
February 2021

Transplant social worker and donor financial assistance to increase living donor kidney transplants among African Americans: The TALKS Study, a randomized comparative effectiveness trial.

Am J Transplant 2021 06 4;21(6):2175-2187. Epub 2021 Jan 4.

Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.

Lack of donors hinders living donor kidney transplantation (LDKT) for African Americans. We studied the effectiveness of a transplant social worker intervention (TALK SWI) alone or paired with living donor financial assistance to activate African Americans' potential living kidney donors. African Americans (N = 300) on the transplant waiting list were randomly assigned to usual care; TALK SWI; or TALK SWI plus Living Donor Financial Assistance. We quantified differences in live kidney donor activation (composite rate of live donor inquiries, completed new live donor evaluations, or live kidney donation) after 12 months. Participants' mean age was 52 years, 56% were male, and 43% had annual household income less than $40,000. Most previously pursued LDKT. Participants were highly satisfied with TALK social workers, but they rarely utilized Financial Assistance. After 12 months, few (n = 39, 13%) participants had a new donor activation event (35 [12%] new donor inquiries; 17 [6%] new donor evaluations; 4 [1%] LDKT). There were no group differences in donor activation events (subdistribution hazard ratio [95% CI]: 1.09 [0.51-2.30] for TALK SWI and 0.92 [0.42-2.02] for TALK SWI plus Financial Assistance compared to Usual Care, p = 91). Alternative interventions to increase LDKT for African Americans on the waiting list may be needed. Trial registration: ClinicalTrials.gov (NCT02369354).
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http://dx.doi.org/10.1111/ajt.16403DOI Listing
June 2021

Fragmentation of care as a barrier to optimal ESKD management.

Semin Dial 2020 11 31;33(6):440-448. Epub 2020 Oct 31.

Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.

Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.
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http://dx.doi.org/10.1111/sdi.12929DOI Listing
November 2020

Advanced CKD Care and Decision Making: Which Health Care Professionals Do Patients Rely on for CKD Treatment and Advice?

Kidney Med 2020 Sep-Oct;2(5):532-542.e1. Epub 2020 Jun 15.

Division of General Internal Medicine, Duke University School of Medicine, Durham, NC.

Rationale & Objective: Chronic kidney disease (CKD) care is often fragmented across multiple health care providers. It is unclear whether patients rely mostly on their nephrologists or non-nephrologist providers for medical care, including CKD treatment and advice.

Study Design: Cross-sectional study.

Setting & Participants: Adults receiving nephrology care at CKD clinics in Pennsylvania.

Predictors: Frequency, duration, and patient-centeredness (range, 1 [least] to 4 [most]) of participants' nephrology care.

Outcome: Participants' reliance on nephrologists, primary care providers, or other specialists for medical care, including CKD treatment and advice.

Analytical Approach: Multivariable logistic regression to quantify associations between participants' reliance on their nephrologists (vs other providers) and their demographics, comorbid conditions, kidney function, and nephrology care.

Results: Among 1,412 patients in clinics targeted for the study, 676 (48%) participated. Among these, 453 (67%) were eligible for this analysis. Mean age was 71 (SD, 12) years, 59% were women, 97% were white, and 65% were retired. Participants were in nephrology care for a median of 3.8 (IQR, 2.0-6.6) years and completed a median of 4 (IQR, 3-5) nephrology appointments in the past 2 years. Half (56%) the participants relied primarily on their nephrologists, while 23% relied on primary care providers, 18% relied on all providers equally, and 3% relied on other specialists. Participants' adjusted odds of relying on their nephrologists were higher for those in nephrology care for longer (OR, 1.08 [95% CI, 1.02-1.15];  = 0.02), those who completed more nephrology visits in the previous 2 years (OR, 1.16 [95% CI, 1.05-1.29];  = 0.005), and those who perceived their last interaction with their nephrologists as more patient-centered (OR, 2.63 [95% CI, 1.70-4.09];  < 0.001).

Limitations: Single health system study.

Conclusions: Many nephrology patients relied on non-nephrologist providers for medical care. Longitudinal patient-centered nephrology care may encourage more patients to follow nephrologists' recommendations.
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http://dx.doi.org/10.1016/j.xkme.2020.05.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568072PMC
June 2020

"I Wish Someone Had Told Me That Could Happen": A Thematic Analysis of Patients' Unexpected Experiences With End-Stage Kidney Disease Treatment.

J Patient Exp 2020 Aug 3;7(4):577-586. Epub 2019 Sep 3.

Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.

Background: Preparedness regarding prognosis and treatment options enables patients to cope with uncertainties, make value-based treatment decisions, and set treatment goals. Yet, little is known about the expectedness of end-stage kidney disease (ESKD) patients' treatment experiences beyond their desire for better treatment education.

Objective: To describe unexpected adverse treatment experiences among ESKD patients.

Method: The authors conducted 7 focus groups with 55 dialysis patients and living-donor kidney transplantation recipients receiving medical care in Baltimore, Maryland. Data were analyzed thematically. Themes present in different treatment groups were highlighted to provide insight into common experiences.

Results: The authors identified 5 themes: (1) psychological reactions, (2) constrained freedom of choice, (3) treatment delivery and logistics, (4) morbidity, and (5) finances.

Conclusion: Patients were unprepared for nonclinical, logistical, and clinical aspects of ESKD treatment. The need for providers' use of tailored preparatory techniques and the development of pretreatment interventions to help patients know what to expect from and feel psychologically prepared for treatment, particularly with respect to nonclinical implications, is critical. These efforts have great potential to improve patients' treatment experiences.
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http://dx.doi.org/10.1177/2374373519872088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534108PMC
August 2020

Racial Differences in the Effectiveness of a Multifactorial Telehealth Intervention to Slow Diabetic Kidney Disease.

Med Care 2020 11;58(11):968-973

Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Change (ADAPT).

Background: African Americans are significantly more likely than non-African Americans to have diabetes, chronic kidney disease, and uncontrolled hypertension, increasing their risk for kidney function decline.

Objective: The objective of this study was to compare how African Americans and non-African Americans with diabetes responded to a multifactorial telehealth intervention designed to slow kidney function decline.

Research Design: Secondary analysis of a randomized trial. Primary care patients (N=281, 56% African American) were allocated to either: (1) a multifactorial, pharmacist-delivered phone-based telehealth intervention focused on behavioral and medication management of diabetic kidney disease; or (2) an education control.

Measures: The primary study outcome was change in estimated glomerular filtration rate (eGFR). Linear mixed models were used to explore the moderating effect of race on the relationship between study arm and eGFR decline over time; the mean annual rate of eGFR decline was estimated by race and study arm.

Results: Findings demonstrated a differential intervention effect on kidney function over time by race (Pinteraction=0.005). Among African Americans, the intervention arm had significantly greater preservation of eGFR over time than the control arm (difference in the annual rate of eGFR decline=1.5 mL/min/1.73 m; 95% confidence interval: 0.04, 3.02). For non-African Americans, the intervention arm had a faster decline in eGFR over time than the control arm (difference in the annual rate of eGFR decline=-1.7 mL/min/1.73 m; 95% confidence interval: -3.3, -0.02).

Conclusion: A multifactorial, pharmacist-delivered telehealth intervention for diabetic kidney disease may be more effective for slowing eGFR decline among African Americans than non-African Americans.
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http://dx.doi.org/10.1097/MLR.0000000000001387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7572637PMC
November 2020

Association of Opioids and Nonsteroidal Anti-inflammatory Drugs With Outcomes in CKD: Findings From the CRIC (Chronic Renal Insufficiency Cohort) Study.

Am J Kidney Dis 2020 08 18;76(2):184-193. Epub 2020 Apr 18.

Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD. Electronic address:

Rationale & Objective: Safe analgesic choices are limited in chronic kidney disease (CKD). We conducted a comparative analysis of harm from opioids versus nonsteroidal anti-inflammatory drugs (NSAIDs) in CKD.

Study Design: Prospective cohort study.

Setting & Participants: 3,939 patients with CKD in the Chronic Renal Insufficiency Cohort (CRIC) Study.

Exposures: 30-day analgesic use reported at annual visits.

Outcomes: A composite outcome of 50% glomerular filtration rate reduction and kidney failure requiring kidney replacement therapy (KRT), as well as the outcomes of kidney failure requiring KRT, hospitalization, and pre-kidney failure death.

Analytical Approach: Marginal structural models with time-updated exposures.

Results: Participants were followed up for a median of 6.84 years, with 391 (9.9%) and 612 (15.5%) reporting baseline opioid and NSAID use, respectively. Time-updated opioid use was associated with the kidney disease composite outcome, kidney failure with KRT, death (HRs of 1.4 [95% CI, 1.2-1.7], 1.4 [95% CI, 1.1-1.7], and 1.5 [95% CI, 1.2-2.0], respectively), and hospitalization (rate ratio [RR], 1.7; 95% CI, 1.6-1.9) versus opioid nonusers. Similar results were found in an analysis restricted to a subcohort of participants reporting ever using other (nonopioid and non-NSAID) analgesics or tramadol. Time-updated NSAID use was associated with increased risk for the kidney disease composite (HR, 1.2; 95% CI, 1.0-1.5) and hospitalization (RR, 1.1; 95% CI, 1.0-1.3); however, these associations were not significant in the subcohort. The association of NSAID use with the kidney disease composite outcome varied by race, with a significant risk in blacks (HR, 1.3; 95% CI, 1.0-1.7). NSAID use was associated with lower risk for kidney failure with KRT in women and individuals with glomerular filtration rate<45mL/min/1.73m (HRs of 0.63 [95% CI, 0.45-0.88] and 0.77 [95% CI, 0.59-0.99], respectively).

Limitations: Limited periods of recall of analgesic use and potential confounding by indication.

Conclusions: Opioid use had a stronger association with adverse events than NSAIDs, with the latter's association with kidney disease outcomes limited to specific subgroups, notably those of black race.
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http://dx.doi.org/10.1053/j.ajkd.2019.12.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7387229PMC
August 2020

Associations of perceived information adequacy and knowledge with pursuit of live donor kidney transplants and living donor inquiries among African American transplant candidates.

Clin Transplant 2020 03 2;34(3):e13799. Epub 2020 Mar 2.

Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.

We studied associations between perceived adequacy of live donor kidney transplant (LDKT) information or knowledge with pursuit of LDKT or receipt of live donor inquiries among 300 African American kidney transplant candidates. Participants reported via questionnaire how informed or knowledgeable they felt regarding LDKT. Participants also reported their pursuit of LDKT, categorized as "low" (no discussion with family or friends about LDKT and no identified donor), "intermediate" (discussed LDKT with family but no identified donor) or "high" (discussed LDKT with family and identified a potential donor). We reviewed participants' electronic health records to identify potential donors' transplant center inquiries on participants' behalves. A minority of participants reported they felt "very" or "extremely" well informed about LDKT (39%) or had "a great deal" of LDKT knowledge (38%). Participants perceiving themselves as "very" or "extremely" (vs "not" or "slightly") well informed about LDKT had statistically significantly greater odds of intermediate or high (vs low) pursuit of LDKT (odds ratio [95% confidence interval] 2.71 [1.02-7.17]). Perceived LDKT knowledge was not associated with pursuit of LDKT. Neither perceived information adequacy nor knowledge was associated with living donor inquiries. Efforts to better understand the role of education in the pursuit of LDKT among African American transplant candidates are needed.
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http://dx.doi.org/10.1111/ctr.13799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7135970PMC
March 2020

Primary Care Providers' Acceptance of Pharmacists' Recommendations to Support Optimal Medication Management for Patients with Diabetic Kidney Disease.

J Gen Intern Med 2020 01 28;35(1):63-69. Epub 2019 Oct 28.

Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA.

Background: Patients with diabetic kidney disease (DKD) often struggle with blood pressure control. In team-based models of care, pharmacists and primary care providers (PCPs) play important roles in supporting patients' blood pressure management.

Objective: To describe whether PCPs' acceptance of pharmacists' recommendations impacts systolic blood pressure (SBP) at 36 months.

Design: An observational analysis of a subset of participants randomized to the intervention arm of the Simultaneous risk factor control using Telehealth to slOw Progression of Diabetic Kidney Disease (STOP-DKD) study.

Participants: STOP-DKD participants for whom (1) the pharmacist made at least one recommendation to the PCP; (2) there were available data regarding the PCP's corresponding action; and (3) there were SBP measurements at baseline and 36 months.

Intervention: Participants received monthly telephone calls with a pharmacist addressing health behaviors and medication management. Pharmacists made medication-related recommendations to PCPs.

Main Measures: We fit an unadjusted generalized linear mixed model to assess the association between the number of pharmacists' recommendations for DKD and blood pressure management and PCPs' acceptance of such recommendations. We used a linear regression model to evaluate the association between PCP acceptance and SBP at 36 months, adjusted for baseline SBP.

Key Results: Pharmacists made 176 treatment recommendations (among 59 participants), of which 107 (61%) were accepted by PCPs. SBP significantly declined by an average of 10.5 mmHg (p < 0.01) among 47 of 59 participants who had valid measurements at baseline and 36 months. There was a significant association between the number of pharmacist recommendations and the odds of PCP acceptance (OR 1.19; 95%CI 1.00, 1.42; p < 0.05), but no association between the number of accepted recommendations and SBP.

Conclusions: Pharmacists provided actionable medication-related recommendations. We identified a significant decline in SBP at 36 months, but this reduction was not associated with recommendation acceptance.

Trial Registration: NCT01829256.
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http://dx.doi.org/10.1007/s11606-019-05403-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957634PMC
January 2020

Lab-based and diagnosis-based chronic kidney disease recognition and staging concordance.

BMC Nephrol 2019 09 14;20(1):357. Epub 2019 Sep 14.

Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, USA.

Background: Chronic kidney disease (CKD) is often under-recognized and poorly documented via diagnoses, but the extent of under-recognition is not well understood among Medicare beneficiaries. The current study used claims-based diagnosis and lab data to examine patient factors associated with clinically recognized CKD and CKD stage concordance between claims- and lab-based sources in a cohort of Medicare beneficiaries.

Methods: In a cohort of fee-for-service (FFS) beneficiaries with CKD based on 2011 labs, we examined the proportion with clinically recognized CKD via diagnoses and factors associated with clinical recognition in logistic regression. In the subset of beneficiaries with CKD stage identified from both labs and diagnoses, we examined concordance in CKD stage from both sources, and factors independently associated with CKD stage concordance in logistic regression.

Results: Among the subset of 206,036 beneficiaries with lab-based CKD, only 11.8% (n = 24,286) had clinically recognized CKD via diagnoses. Clinical recognition was more likely for beneficiaries who had higher CKD stages, were non-elderly, were Hispanic or non-Hispanic Black, lived in core metropolitan areas, had multiple chronic conditions or outpatient visits in 2010, or saw a nephrologist. In the subset of 18,749 beneficiaries with CKD stage identified from both labs and diagnoses, 70.0% had concordant CKD stage, which was more likely if beneficiaries were older adults, male, lived in micropolitan areas instead of non-core areas, or saw a nephrologist.

Conclusions: There is significant under-diagnosis of CKD in Medicare FFS beneficiaries, which can be addressed with the availability of lab results.
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http://dx.doi.org/10.1186/s12882-019-1551-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6744668PMC
September 2019

Primary care physicians' perceptions of barriers and facilitators to management of chronic kidney disease: A mixed methods study.

PLoS One 2019 22;14(8):e0221325. Epub 2019 Aug 22.

The Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland, United States of America.

Background: Given the high prevalence of chronic kidney disease (CKD), primary care physicians (PCPs) frequently manage early stage CKD. Nonetheless, there are challenges in providing optimal CKD care in the primary care setting. This study sought to understand PCPs' perceptions of barriers and facilitators to the optimal management of CKD.

Study Design: Mixed methods study.

Settings And Participants: Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC and San Francisco, CA.

Methodology: We used a self-administered questionnaire and conducted 4 focus groups of PCPs (n = 8 PCPs/focus group) in each city to identify key barriers and facilitators to management of patients with CKD in primary care.

Analytic Approach: We conducted descriptive analyses of the survey data. Major themes were identified from audio-recorded interviews that were transcribed and coded by the research team.

Results: Of 32 participating PCPs, 31 (97%) had been in practice for >10 years, and 29 (91%) practiced in a non-academic setting. PCPs identified multiple barriers to managing CKD in primary care including at the level of the patient (e.g., low awareness of CKD, poor adherence to treatment recommendations), the provider (e.g., staying current with CKD guidelines), and the health care system (e.g., inflexible electronic medical record, limited time and resources). PCPs desired electronic prompts and lab decision support, concise guidelines, and healthcare financing reform to improve CKD care.

Conclusions: PCPs face substantial but modifiable barriers in providing care to patients with CKD. Interventions that address these barriers and promote facilitative tools may improve PCPs' effectiveness and capacity to care for patients with CKD.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221325PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6705804PMC
March 2020

Association of functional and structural social support with chronic kidney disease among African Americans: the Jackson Heart Study.

BMC Nephrol 2019 07 15;20(1):262. Epub 2019 Jul 15.

Duke University, Durham, NC, USA.

Background: There is limited evidence on the relationship between social support and renal outcomes in African Americans. We sought to determine the association of social support with prevalent chronic kidney disease (CKD) and kidney function decline in an African American cohort. We also examined whether age modifies the association between social support and kidney function decline.

Methods: We identified Jackson Heart Study (JHS) participants with baseline (Exam in 2000-2004) functional and structural social support data via the Interpersonal Support Evaluation List (ISEL) and social network size questions, respectively. With ISEL as our primary exposure variable, we performed multivariable regression models to evaluate the association between social support and prevalent CKD [estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2 or urine albumin-creatinine ratio (ACR) ≥30 mg/g], eGFR decline, and rapid renal function decline (RRFD) (> 30% decrease in eGFR over approximately 10 years). All models were adjusted for baseline sociodemographics, diabetes, hypertension, smoking status, and body mass index; models for eGFR decline and RRFD were additionally adjusted for eGFR and ACR. In models for eGFR decline, we assessed for interaction between age and social support. For secondary analyses, we replaced ISEL with its individual domains (appraisal, belonging, self-esteem, and tangible) and social network size in separate models as exposure variables.

Results: Of 5301 JHS participants, 4015 (76%) completed the ISEL at baseline. 843 (21%) had low functional social support (ISEL score < 32). Participants with low (vs. higher) functional social support were more likely to have lower income (47% vs. 28%), be current or former tobacco users (39% vs. 30%), have diabetes (25% vs. 21%) or CKD (14% vs. 12%). After multivariable adjustment, neither ISEL or social network size were independently associated with prevalent CKD, eGFR decline, or RRFD. Of the ISEL domains, only higher self-esteem was associated with lower odds of prevalent CKD [OR 0.94 (95% CI 0.89-0.99)]. The associations between social support measures and eGFR decline were not modified by age.

Conclusions: In this African-American cohort, social support was not associated with prevalent CKD or kidney function decline. Further inquiry of self-esteem's role in CKD self-management and renal outcomes is warranted.
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http://dx.doi.org/10.1186/s12882-019-1432-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6633656PMC
July 2019

DASH Diet and Blood Pressure Among Black Americans With and Without CKD: The Jackson Heart Study.

Am J Hypertens 2019 09;32(10):975-982

Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.

Background: The Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure (BP) more effectively in blacks compared to other US racial subgroups. Considering chronic kidney disease (CKD) raises BP through complex mechanisms, DASH may affect BP differently among blacks with and without CKD. We compared the association of DASH accordance to BP and prevalent hypertension among blacks with and without CKD.

Methods: Our study involved 3,135 black Americans enrolled in the Jackson Heart Study (2000-2004) with diet and office BP data. Using linear models adjusted for demographics, health behaviors, and clinical factors, we determined the association of a modified DASH score (excluding sodium intake, ranging from 0 to 8 with increasing DASH accordance) with BP. We performed tests for interaction between DASH score and CKD status.

Results: Among participants (mean age: 55 years; hypertension: 60%; CKD: 19%), the median DASH score was similar among participants with and without CKD (1.0 [interquartile range (IQR): 0.5-2] and 1.0 [IQR: 0.5-1.5]). CKD status modified the association of the DASH score with systolic BP (SBP) and diastolic BP (DBP; P interactions were 0.06 and <0.01). Among participants without CKD, SBP and DBP were not associated with the DASH score (-0.4 [95% confidence interval: -1.0, 0.1] mm Hg and -0.1 [-0.4, 0.2] mm Hg per one unit higher DASH score). Among participants with CKD, one unit higher DASH score was associated with lower SBP by 1.6 (0.5, 2.6) mm Hg and lower DBP by 0.9 (0.3, 1.5) mm Hg.

Conclusions: Despite low DASH scores overall, better DASH accordance was associated with lower BP among Black Americans with CKD.
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http://dx.doi.org/10.1093/ajh/hpz090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6758942PMC
September 2019

Addressing Diabetes and Poorly Controlled Hypertension: Pragmatic mHealth Self-Management Intervention.

J Med Internet Res 2019 04 9;21(4):e12541. Epub 2019 Apr 9.

Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States.

Background: Patients with diabetes and poorly controlled hypertension are at increased risk for adverse renal and cardiovascular outcomes. Identifying these patients early and addressing modifiable risk factors is central to delaying renal complications such as diabetic kidney disease. Mobile health (mHealth), a relatively inexpensive and easily scalable technology, can facilitate patient-centered care and promote engagement in self-management, particularly for patients of lower socioeconomic status. Thus, mHealth may be a cost-effective way to deliver self-management education and support.

Objective: This feasibility study aimed to build a population management program by identifying patients with diabetes and poorly controlled hypertension who were at risk for adverse renal outcomes and evaluate a multifactorial intervention to address medication self-management. We recruited patients from a federally qualified health center (FQHC) in an underserved, diverse county in the southeastern United States.

Methods: Patients were identified via electronic health record. Inclusion criteria were age between 18 and 75 years, diagnosis of type 2 diabetes, poorly controlled hypertension over the last 12 months (mean clinic systolic blood pressure [SBP] ≥140 mm Hg and/or diastolic blood pressure [DBP] ≥90 mm Hg), access to a mobile phone, and ability to receive text messages and emails. The intervention consisted of monthly telephone calls for 6 months by a case manager and weekly, one-way informational text messages. Engagement was defined as the number of phone calls completed during the intervention; individuals who completed 4 or more calls were considered engaged. The primary outcome was change in SBP at the conclusion of the intervention.

Results: Of the 141 patients enrolled, 84.0% (118/141) of patients completed 1 or more phone calls and had follow-up SBP measurements for analysis. These patients were on average 56.9 years of age, predominately female (73/118, 61.9%), and nonwhite by self-report (103/118, 87.3%). The proportion of participants with poor baseline SBP control (50/118, 42.4%) did not change significantly at study completion (53/118, 44.9%) (P=.64). Participants who completed 4 or more phone calls (98/118, 83.1%) did not experience a statistically significant decrease in SBP when compared to those who completed fewer calls.

Conclusion: We did not reduce uncontrolled hypertension even among the more highly engaged. However, 83% of a predominately minority and low-income population completed at least 67% of the multimodal mHealth intervention. Findings suggest that combining an automated electronic health record system to identify at-risk patients with a tailored mHealth protocol can provide education to this population. While this intervention was insufficient to effect behavioral change resulting in better hypertension control, it does suggest that this FQHC population will engage in low-cost population health applications with a potentially promising impact.

Trial Registration: ClinicalTrials.gov NCT02418091; https://clinicaltrials.gov/ct2/show/NCT02418091 (Archived by WebCite at http://www.webcitation.org/76RBvacVU).
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http://dx.doi.org/10.2196/12541DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6477575PMC
April 2019

Evaluation of Allostatic Load as a Mediator of Sleep and Kidney Outcomes in Black Americans.

Kidney Int Rep 2019 Mar 18;4(3):425-433. Epub 2018 Dec 18.

Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.

Introduction: Poor sleep associates with adverse chronic kidney disease (CKD) outcomes yet the biological mechanisms underlying this relation remain unclear. One proposed mechanism is allostatic load, a cumulative biologic measure of stress.

Methods: Using data from 5177 Jackson Heart Study participants with sleep measures available, we examined the association of self-reported sleep duration: very short, short, recommended, and long (≤5, 6, 7-8, or ≥9 hours per 24 hours, respectively) and sleep quality (high, moderate, low) with prevalent baseline CKD, and estimated glomerular filtration rate (eGFR) decline and incident CKD at follow-up. CKD was defined as eGFR <60 ml/min per 1.73 m or urine albumin-to-creatinine ratio ≥30 mg/g. Models were adjusted for demographics, comorbidities, and kidney function. We further evaluated allostatic load (quantified at baseline using 11 biomarkers from neuroendocrine, metabolic, autonomic, and immune domains) as a mediator of these relations using a process analysis approach.

Results: Participants with very short sleep duration (vs. 7-8 hours) had greater odds of prevalent CKD (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.03-1.66). Very short, short, or long sleep duration (vs. 7-8 hours) was not associated with kidney outcomes over a median follow-up of 8 years. Low sleep quality (vs. high) associated with greater odds of prevalent CKD (OR 1.26, 95% CI 1.00-1.60) and 0.18 ml/min per 1.73 m (95% CI 0.00-0.36) faster eGFR decline per year. Allostatic load did not mediate the associations of sleep duration or sleep quality with kidney outcomes.

Conclusions: Very short sleep duration and low sleep quality were associated with adverse kidney outcomes in this all-black cohort, but allostatic load did not appear to mediate these associations.
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http://dx.doi.org/10.1016/j.ekir.2018.12.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6409364PMC
March 2019

Patients' and Nephrologists' Evaluation of Patient-Facing Smartphone Apps for CKD.

Clin J Am Soc Nephrol 2019 04 21;14(4):523-529. Epub 2019 Mar 21.

Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan.

Background And Objectives: Many aspects of CKD management rely heavily on patient self-care, including medication and dietary adherence, self-monitoring of BP, and daily physical activity. Growing evidence suggests that incorporating smartphone-based applications can support self-care in CKD and chronic disease more generally.

Design, Setting, Participants, & Measurements: We identified applications targeting patients with CKD by conducting a search of the US Apple App Store (iOS) and Google Play Store (Android) using the following four phrases: "kidney disease," "renal," "dialysis," and "kidney transplant." We considered the first 50 applications for each search term on each application store. We adapted a previously described framework for assessment of mobile health applications to account for kidney disease-specific content areas and evaluated applications on their types of patient engagement, quality, usability, and safety. Engagement and quality were assessed by both a patient and a nephrologist, usability was assessed by a patient, and safety was assessed by a nephrologist. Overall, two patients with CKD and three nephrologists performed the evaluations. We examined pairwise correlations between patient, nephrologist, and consumer ratings of application quality.

Results: Our search strategy identified 174 unique applications on Android and 165 unique applications on iOS. After excluding applications that were not related to kidney disease, were not patient facing, or were last updated before 2014, 12 Android-only applications, 11 iOS-only applications, and five dual-platform applications remained. Patient and nephrologist application quality ratings, assessed by the net promoter score, were not correlated (=0.36; =0.06). Consumer ratings on the application stores did not correlate with patient ratings of application quality (=0.34; =0.18).

Conclusions: Only a small subset of CKD applications was highly rated by both patients and nephrologists. Patients' impressions of application quality are not directly linked to consumer application ratings or nephrologist impressions.
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http://dx.doi.org/10.2215/CJN.10370818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6450346PMC
April 2019

Usability Testing of a Sick-Day Protocol in CKD.

Clin J Am Soc Nephrol 2019 04 13;14(4):583-585. Epub 2019 Mar 13.

Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland;

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http://dx.doi.org/10.2215/CJN.13221118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6450344PMC
April 2019

Modifiers of Plasma 25-Hydroxyvitamin D and Chronic Kidney Disease Outcomes in Black Americans: The Jackson Heart Study.

J Clin Endocrinol Metab 2019 06;104(6):2267-2276

Department of Medicine, Duke University School of Medicine, Durham, North Carolina.

Background: 25-hydroxyvitamin D [25(OH)D] is lower in black compared with white Americans but is not consistently associated with outcomes in this group, possibly due to genetic and other biological differences. We examined the association of plasma 25(OH)D and renal outcomes in black Americans with a focus on effect modifiers.

Methods: We studied associations between baseline 25(OH)D with (i) annual rate of estimated glomerular filtration rate (eGFR) decline and (ii) incident chronic kidney disease (CKD) in the Jackson Heart Study, a prospective cohort of black Americans. Plasma 25(OH)D levels were corrected for monthly variation in sunlight exposure using the residual method. We used adjusted generalized linear models to evaluate outcomes and assessed potential effect modification by diabetes mellitus, vitamin D binding protein (DBP) genotype, obesity, dietary sodium intake, and use of renin-angiotensin-aldosterone system inhibitors.

Results: Among 5164 participants with 25(OH)D available, plasma 25(OH)D was 14.5 ± 6.5 ng/mL (mean ± SD), and eGFR was 94.1 ± 22.0 mL/min/1.73 m2. Over a median of 8 years, eGFR decline was 1.3 ± 2.0 mL/min/1.73 m2 per year in 3228 participants with complete data, and 220 out of 1803 eligible participants developed incident CKD. Overall, 25(OH)D was not associated with eGFR decline in fully adjusted models. However, higher 25(OH)D was associated with slower eGFR decline among those with diabetes: each 5 ng/mL higher 25(OH)D was associated with a 0.27 mL/min/1.73 m2/y slower eGFR decline (95% CI, 0.13 to 0.41; P < 0.001). Higher 25(OH)D was not associated with incident CKD overall, but it was associated with lower odds of incident CKD among participants with the GG or GT genotype at rs7041 in the gene encoding DBP [OR, 0.69 per 5 ng/mL higher 25(OH)D; 95% CI, 0.51 to 0.93; P-interaction = 0.005]. Other interactions were not significant.

Conclusion: These findings support a potential benefit of higher 25(OH)D for kidney health in black Americans with diabetes or specific variants in DBP.
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http://dx.doi.org/10.1210/jc.2018-01747DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6489693PMC
June 2019

Low use of routine medical care among African Americans with high CKD risk: the Jackson Heart Study.

BMC Nephrol 2019 01 10;20(1):11. Epub 2019 Jan 10.

Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.

Background: Use of routine medical care (RMC) is advocated to address ethnic/racial disparities in chronic kidney disease (CKD) risks, but use is less frequent among African Americans. Factors associated with low RMC use among African Americans at risk of renal outcomes have not been well studied.

Methods: We examined sociodemographic, comorbidity, healthcare access, and psychosocial (discrimination, anger, stress, trust) factors associated with low RMC use in a cross-sectional study. Low RMC use was defined as lack of a physical exam within one year among participants with CKD (estimated glomerular filtration rate < 60 mL/min/1.73m or urine albumin-to-creatinine ratio > 30 mg/g) or CKD risk factors (diabetes or hypertension). We used multivariable logistic regression to estimate the odds of low RMC use at baseline (2000-2004) for several risk factors.

Results: Among 3191 participants with CKD, diabetes, or hypertension, 2024 (63.4%) were ≥ 55 years of age, and 700 (21.9%) reported low RMC use. After multivariable adjustment, age < 55 years (OR 1.61 95% CI 1.31-1.98), male sex (OR 1.71; 1.41-2.07),
Conclusions: High-risk African Americans who were younger, male, less-educated, and with low trust in providers were more likely to report low RMC use. Efforts to improve RMC use by targeting these populations could mitigate African Americans' disparities in CKD risks.
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http://dx.doi.org/10.1186/s12882-018-1190-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6327442PMC
January 2019

Long-term exposure to ambient air pollution and renal function in African Americans: the Jackson Heart Study.

J Expo Sci Environ Epidemiol 2019 06 12;29(4):548-556. Epub 2018 Nov 12.

Duke University School of Medicine, Durham, NC, USA.

Renal dysfunction is prevalent in the US among African Americans. Air pollution is associated with renal dysfunction in mostly white American populations, but has not been studied among African Americans. We evaluated cross-sectional associations between 1-year and 3-year fine particulate matter (PM) and ozone (O) concentrations, and renal function among 5090 African American participants in the Jackson Heart Study. We used mixed-effect linear regression to estimate associations between 1-year and 3-year PM and O and estimated glomerular filtration rate (eGFR), urine albumin/creatinine ratio (UACR), serum creatinine, and serum cystatin C, adjusting for: sociodemographic factors, health behaviors, and medical history and accounting for clustering by census tract. At baseline, JHS participants had mean age 55.4 years, and 63.8% were female; mean 1-year and 3-year PM concentrations were 12.2 and 12.4 µg/m, and mean 1-year and 3-year O concentrations were 40.2 and 40.7 ppb, respectively. Approximately 6.5% of participants had reduced eGFR (< 60 mL/min/1.73m) and 12.7% had elevated UACR (> 30 mg/g), both indicating impaired renal function. Annual and 3-year O concentrations were inversely associated with eGFR and positively associated with serum creatinine; annual and 3-year PM concentrations were inversely associated with UACR. We observed impaired renal function associated with increased O but not PM exposure among African Americans.
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http://dx.doi.org/10.1038/s41370-018-0092-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511484PMC
June 2019

Dietary Phosphorus and Ambulatory Blood Pressure in African Americans: The Jackson Heart Study.

Am J Hypertens 2019 01;32(1):94-103

Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.

Background: Higher dietary phosphorus is associated with left ventricular hypertrophy and mortality, which are blood pressure (BP)-related outcomes. For this reason, we hypothesized that dietary phosphorus may be associated with adverse clinic and ambulatory BP patterns.

Methods: Our study included 973 African American adults enrolled in the Jackson Heart Study (2000-2004) with 24-hour ambulatory BP monitoring (ABPM) data at baseline. We quantified dietary phosphorus from a validated Food Frequency Questionnaire as follows: (i) absolute daily intake, (ii) ratio of phosphorus-to-protein intake, (iii) phosphorus density, and (iv) energy-adjusted phosphorus intake. Using multivariable linear regression, we determined associations between dietary phosphorus intake and systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure in clinic and over daytime, nighttime, and 24-hour periods from ABPM. Extent of nocturnal BP dipping was also assessed. Using logistic regression, we modeled relationships between dietary phosphorus intake and clinically relevant qualitative BP phenotypes, such as masked, sustained, or white-coat hypertension and normotension.

Results: There were no statistically significant associations between phosphorus intake and SBP or pulse pressure in adjusted models. Most metrics of higher phosphorus intake were associated with lower daytime, nighttime, and clinic DBP. Higher phosphorus intake was not associated with clinic or ABPM-defined hypertension overall, but most metrics of higher phosphorus intake were associated with lower odds of sustained hypertension compared to sustained normotension, white-coat hypertension, and masked hypertension. There were no associations between dietary phosphorus and nocturnal BP dipping.

Conclusions: These data do not support a role for higher phosphorus intake and higher BP in African Americans.
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http://dx.doi.org/10.1093/ajh/hpy126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6284751PMC
January 2019

The dilemma of lumping versus splitting evidence: Study design: systematic reviews.

BJOG 2019 Mar 19;126(4):458. Epub 2018 Jun 19.

Duke University School of Medicine, Durham, USA.

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http://dx.doi.org/10.1111/1471-0528.15202DOI Listing
March 2019
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