Publications by authors named "Neil R Powe"

307 Publications

Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report From the NKF-ASN Task Force.

Am J Kidney Dis 2021 Apr 9. Epub 2021 Apr 9.

Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA. Electronic address:

For almost 2 decades, equations that use serum creatinine, age, sex, and race to estimate glomerular filtration rate (GFR) have included "race" as Black or non-Black. Given considerable evidence of disparities in health and health care delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important non-GFR determinants of serum creatinine and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: (1) clarify the problem and examine evidence, (2) evaluate different approaches to address use of race in GFR estimation, and (3) make recommendations. In phase 1, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.
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http://dx.doi.org/10.1053/j.ajkd.2021.03.008DOI Listing
April 2021

Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report from the NKF-ASN Task Force.

J Am Soc Nephrol 2021 Apr 9. Epub 2021 Apr 9.

Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California

For almost two decades, equations that use serum creatinine, age, sex, and race to eGFR have included "race" as Black or non-Black. Given considerable evidence of disparities in health and healthcare delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important non GFR determinants of serum creatinine and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: () clarify the problem and examine evidence, () evaluate different approaches to address use of race in GFR estimation, and () make recommendations. In phase one, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.
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http://dx.doi.org/10.1681/ASN.2021010039DOI Listing
April 2021

Experiences of Latinx Individuals Hospitalized for COVID-19: A Qualitative Study.

JAMA Netw Open 2021 03 1;4(3):e210684. Epub 2021 Mar 1.

Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco.

Importance: Latinx individuals, particularly immigrants, are at higher risk than non-Latinx White individuals of contracting and dying from coronavirus disease 2019 (COVID-19). Little is known about Latinx experiences with COVID-19 infection and treatment.

Objective: To describe the experiences of Latinx individuals who were hospitalized with and survived COVID-19.

Design, Setting, And Participants: The qualitative study used semistructured phone interviews of 60 Latinx adults who survived a COVID-19 hospitalization in public hospitals in San Francisco, California, and Denver, Colorado, from March 2020 to July 2020. Transcripts were analyzed using qualitative thematic analysis. Data analysis was conducted from May 2020 to September 2020.

Main Outcomes And Measures: Themes and subthemes that reflected patient experiences.

Results: Sixty people (24 women and 36 men; mean [SD] age, 48 [12] years) participated. All lived in low-income areas, 47 participants (78%) had more than 4 people in the home, and most (44 participants [73%]) were essential workers. Four participants (9%) could work from home, 12 (20%) had paid sick leave, and 21 (35%) lost their job because of COVID-19. We identified 5 themes (and subthemes) with public health and clinical care implications: COVID-19 was a distant and secondary threat (invincibility, misinformation and disbelief, ingrained social norms); COVID-19 was a compounder of disadvantage (fear of unemployment and eviction, lack of safeguards for undocumented immigrants, inability to protect self from COVID-19, and high-density housing); reluctance to seek medical care (worry about health care costs, concerned about ability to access care if uninsured or undocumented, undocumented immigrants fear deportation); health care system interactions (social isolation and change in hospital procedures, appreciation for clinicians and language access, and discharge with insufficient resources or clinical information); and faith and community resiliency (spirituality, Latinx COVID-19 advocates).

Conclusions And Relevance: In interviews, Latinx patients with COVID-19 who survived hospitalization described initial disease misinformation and economic and immigration fears as having driven exposure and delays in presentation. To confront COVID-19 as a compounder of social disadvantage, public health authorities should mitigate COVID-19-related misinformation, immigration fears, and challenges to health care access, as well as create policies that provide work protection and address economic disadvantages.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.0684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953277PMC
March 2021

Allocation of National Institutes of Health Funding by Disease Category in 2008 and 2019.

JAMA Netw Open 2021 01 4;4(1):e2034890. Epub 2021 Jan 4.

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Importance: Prior research suggests an association between burden of disease and National Institutes of Health (NIH) funding. The allocation of NIH funding should reflect, to some extent, the health needs of the population, along with other factors.

Objective: To examine the factors associated with NIH funding in 2019 for 46 diseases.

Design, Setting, And Participants: This cohort study used disability-adjusted life-years to measure the 2008 and 2019 US burden of disease and compared them with NIH categoric funding for 46 diseases.

Exposures: Disability-adjusted life-years to measure the 2008 and 2019 US burden of disease, 2016 health spending, and 2008 NIH funding levels for 46 diseases.

Main Outcomes And Measures: 2019 NIH funding levels for 46 diseases.

Results: The 46 diseases accounted for 62 392 713 of 94 399 784 disability-adjusted life-years (66.1%) in 2008 and 75 706 718 of 111 074 472 disability-adjusted life-years (68.2%) in 2019, representing more than 66% of all disability-adjusted life-years in both years. By dollar volume, Alzheimer and dementia increased the most, with approximately $1.8 billion more funding in 2019 than 2008 (from $530 million in 2008 to $2398 million in 2019, a 352% increase), whereas interpersonal violence had the greatest decrease, $95 million, in 2019 NIH funding (from $236 million in 2008 to $141 million in 2019, a 40% decrease). For the 46 diseases in this study, the variable with the greatest association with NIH funding in 2019 was the level of NIH funding in 2008, with a simple correlation of 0.88. Burden of disease and changes in burden of disease were not statistically significantly associated with NIH funding levels once the prior level of funding was included in the model. The models suggested that a 1% higher level of NIH funding in 2008 was associated with a 0.91% higher level of NIH funding in 2019.

Conclusions And Relevance: In this study, NIH spending for most diseases seemed to be based primarily on the level of NIH spending more than 10 years earlier, despite changes in burden of disease. Congress and the NIH should examine the allocation process to ensure NIH investments are responsive to changes in the health of the population.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.34890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7841468PMC
January 2021

Recalibrating the Use of Race in Medical Research.

JAMA 2021 Feb;325(7):623-624

Division of Cardiology, Department of Internal Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.

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http://dx.doi.org/10.1001/jama.2021.0003DOI Listing
February 2021

The Pathogenesis of Race and Ethnic Disparities: Targets for Achieving Health Equity.

Authors:
Neil R Powe

Clin J Am Soc Nephrol 2021 Jan 13. Epub 2021 Jan 13.

Department of Medicine, University of California, San Francisco, California, and Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, California

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http://dx.doi.org/10.2215/CJN.12640820DOI Listing
January 2021

In Search of a Better Equation - Performance and Equity in Estimates of Kidney Function.

N Engl J Med 2021 Feb 6;384(5):396-399. Epub 2021 Jan 6.

From the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Department of Biomedical Informatics (J.A.D., A.K.M.) and the Program in Health Sciences and Technology (J.A.D.), Harvard Medical School, and the Division of Nephrology (L.A.I., A.S.L.) and the Institute for Clinical Research and Health Policy Studies (H.T.), Tufts Medical Center - all in Boston; and the Department of Medicine, University of California, San Francisco, and Priscilla Chan and Mark Zuckerberg San Francisco General Hospital - both in San Francisco (N.R.P.).

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http://dx.doi.org/10.1056/NEJMp2028243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084706PMC
February 2021

Race and Genetic Ancestry in Medicine - A Time for Reckoning with Racism.

N Engl J Med 2021 Feb 6;384(5):474-480. Epub 2021 Jan 6.

From the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York, New York (L.N.B.); the Departments of Medicine (J.R.E., J.W., N.B., N.R.P., E.Z., E.G.B.), Pediatrics (E.F.-A., J.W.), Laboratory Medicine (A.H.B.W.), and Epidemiology and Biostatistics (K.B.-D.), Priscilla Chan and Mark Zuckerberg San Francisco General Hospital (K.B.-D., N.R.P.), the Division of General Internal Medicine and the Institute of Human Genetics, Helen Diller Family Comprehensive Cancer Center (E.Z.), and the Department of Bioengineering and Therapeutic Sciences (E.G.B.), University of California, San Francisco, San Francisco, Bay Area Pediatrics, Oakland (M.A.L.), the Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte (R.A.K.), and the Department of Neurogenetics, University of California, Los Angeles, Los Angeles (N.A.Z.) - all in California; the Centro de Neumología Pediátrica, San Juan, PR (J.R.R.-S.); Emory University School of Medicine, Atlanta (J.R.G.); and the School of Medicine, University of Virginia, Charlottesville (D.S.W.).

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http://dx.doi.org/10.1056/NEJMms2029562DOI Listing
February 2021

Clinical Implications of Removing Race From Estimates of Kidney Function.

JAMA 2021 Jan;325(2):184-186

Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jama.2020.22124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7711563PMC
January 2021

Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker Use Among Hypertensive US Adults With Albuminuria.

Hypertension 2021 Jan 16;77(1):94-102. Epub 2020 Nov 16.

From the Department of Medicine (C.D.C., N.R.P., T.B., D.S.T.).

Since 2003, US hypertension guidelines have recommended ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin receptor blockers) as first-line antihypertensive therapy in the presence of albuminuria (urine albumin/creatinine ratio ≥300 mg/g). To examine national trends in guideline-concordant ACE inhibitor/ARB utilization, we studied adults participating in the National Health and Nutrition Examination Surveys 2001 to 2018 with hypertension (defined by self-report of high blood pressure, systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg, or use of antihypertensive medications). Among 20 538 included adults, the prevalence of albuminuria ≥300 mg/g was 2.8% in 2001 to 2006, 2.8% in 2007 to 2012, and 3.2% in 2013 to 2018. Among those with albuminuria ≥300 mg/g, no consistent trends were observed for the proportion receiving ACE inhibitor/ARB treatment from 2001 to 2018 among persons with diabetes, without diabetes, or overall. In 2013 to 2018, ACE inhibitor/ARB usage in the setting of albuminuria ≥300 mg/g was 55.3% (95% CI, 46.8%-63.6%) among adults with diabetes and 33.4% (95% CI, 23.1%-45.5%) among those without diabetes. Based on US population counts, these estimates represent 1.6 million adults with albuminuria ≥300 mg/g currently not receiving ACE inhibitor/ARB therapy, nearly half of whom do not have diabetes. ACE inhibitor/ARB underutilization represents a significant gap in preventive care delivery for adults with hypertension and albuminuria that has not substantially changed over time.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.16281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725867PMC
January 2021

Patient-reported outcomes and experiences in the transition of undocumented patients from emergency to scheduled hemodialysis.

Kidney Int 2021 01 28;99(1):198-207. Epub 2020 Oct 28.

Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA.

Undocumented immigrants with kidney failure can only access dialysis after presenting critically ill to an emergency department in most states within the United States. How access to scheduled dialysis might improve or harm patient experience is currently unknown. To clarify this, we assessed patient reported outcomes and experiences of undocumented patients who transitioned from emergency to scheduled dialysis. Pre-post intervention interviews were conducted using a mixed-methods study (questionnaires and interviews) in a Colorado hospital. Measures included the Kidney Disease Quality of Life Short Form-36 (KDQOL SF-36), Edmonton Symptom Assessment System, Trust in Physician Scale, and CHOICE Satisfaction Scale. Interviews were evaluated using thematic analysis. Thirty patients participated, and 26 completed the post-transition interview (two participants died, two did not transition to scheduled dialysis). Following transition, patients significantly improved on all five KDQOL SF-36 subscales including 116% for burden of kidney disease, 42% for kidney disease effects, 27% for symptoms/problems, 23% for physical and 13% for mental health composite. Patients reported significant improvement in seven symptoms consisting of 100% for nausea, 57% for pain, 94% for appetite and shortness of breath, 87% for anxiety, 86% for depression, 65% for tiredness, and 60% for drowsiness. Trust and satisfaction with care were unchanged. Five identified themes corroborated patient-reported outcomes but indicated continuing challenges associated with anxiety about navigating changes in care, increased burden on family and employers, relief in receiving consistent care, immediate and remarkable health gains, and restoring hope and humanity. Thus, providing healthcare access to standard dialysis for undocumented immigrants improved quality of life and mitigated debilitating symptoms but brought new challenges in healthcare navigation as well as family burden and work.
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http://dx.doi.org/10.1016/j.kint.2020.07.024DOI Listing
January 2021

"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

Exploring reasons for state-level variation in incidence of dialysis-requiring acute kidney injury (AKI-D) in the United States.

BMC Nephrol 2020 08 10;21(1):336. Epub 2020 Aug 10.

Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.

Background: There is considerable state-level variation in the incidence of dialysis-requiring acute kidney injury (AKI-D). However, little is known about reasons for this geographic variation.

Methods: National cross-sectional state-level ecological study based on State Inpatient Databases (SID) and the Behavioral Risk Factor Surveillance System (BRFSS) in 2011. We analyzed 18 states and six chronic health conditions (diabetes mellitus [diabetes], hypertension, chronic kidney disease [CKD], arteriosclerotic heart disease [ASHD], cancer (excluding skin cancer), and chronic obstructive pulmonary disease [COPD]). Associations between each of the chronic health conditions and AKI-D incidence was assessed using Pearson correlation and multiple regression adjusting for mean age, the proportion of males, and the proportion of non-Hispanic whites in each state.

Results: The state-level AKI-D incidence ranged from 190 to 1139 per million population. State-level differences in rates of hospitalization with chronic health conditions (mostly < 3-fold difference in range) were larger than the state-level differences in prevalence for each chronic health condition (mostly < 2.5-fold difference in range). A significant correlation was shown between AKI-D incidence and prevalence of diabetes, ASHD, and COPD, as well as between AKI-D incidence and rate of hospitalization with hypertension. In regression models, after adjusting for age, sex, and race, AKI-D incidence was associated with prevalence of and rates of hospitalization with five chronic health conditions--diabetes, hypertension, CKD, ASHD and COPD--and rates of hospitalization with cancer.

Conclusions: Results from this ecological analysis suggest that state-level variation in AKI-D incidence may be influenced by state-level variations in prevalence of and rates of hospitalization with several chronic health conditions. For most of the explored chronic conditions, AKI-D correlated stronger with rates of hospitalizations with the health conditions rather than with their prevalences, suggesting that better disease management strategies that prevent hospitalizations may translate into lower incidence of AKI-D.
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http://dx.doi.org/10.1186/s12882-020-02000-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418406PMC
August 2020

Black Kidney Function Matters: Use or Misuse of Race?

Authors:
Neil R Powe

JAMA 2020 Aug;324(8):737-738

Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco.

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http://dx.doi.org/10.1001/jama.2020.13378DOI Listing
August 2020

Nonsurgical Periodontal Therapy in CKD: Findings of the Kidney and Periodontal Disease (KAPD) Pilot Randomized Controlled Trial.

Kidney Med 2020 Jan-Feb;2(1):49-58. Epub 2019 Dec 2.

Department of Medicine, University of California, San Francisco, CA.

Rationale & Objective: Observational studies have suggested that periodontal disease may be a modifiable risk factor for chronic kidney disease (CKD). The Kidney and Periodontal Disease (KAPD) Study was designed to determine the feasibility of conducting a periodontal disease treatment trial among a high-risk (mostly poor and racial/ethnic minority) population and estimate the magnitude and variability of kidney and inflammatory biomarker levels in response to intensive periodontal treatment.

Study Design: Single-center, unmasked, intention-to-treat, randomized, controlled, pilot trial with 2:1 allocation to the treatment and comparison groups.

Setting & Participants: English- and Spanish-speaking individuals aged 20 to 75 years receiving primary care within the San Francisco Community Health Network with evidence of both moderate to severe periodontal disease and CKD.

Intervention: Immediate intensive nonsurgical periodontal treatment versus rescue treatment for progressive disease at baseline and 4, 8, and 12 months.

Outcomes: Feasibility and process outcomes. Levels of biomarkers of kidney function, kidney injury, and systemic inflammation obtained at baseline and 4 and 12 months.

Results: KAPD randomly assigned 51 participants to the immediate (34 participants) or rescue (17 participants) groups. 14% dropped out of the study (4 immediate, 3 rescue) and 80% completed all 4 visits of the 12-month protocol (28 immediate, 13 rescue). Fewer than half the teeth recommended for extraction were extracted and 40% of immediate group visits were outside the protocol window. Bleeding on probing and probing depth improved more in the immediate group than in the rescue group; there was no significant separation in periodontal status. Levels of markers of vascular endothelial and systemic injury declined in both groups.

Limitations: No true control group.

Conclusions: This 12-month, pilot, randomized, controlled trial successfully recruited and retained a high-risk population but was less successful observing treatment adherence, treatment effect, and variability of biomarker levels. Although KAPD did not meet all of its goals, important lessons learned can be applied to future studies.

Funding: National Institute of Diabetes and Digestive and Kidney Disease (Bethesda, MD; grant number 1K23DK093710-01A1) and Harold Amos Medical Faculty Development Program of the Robert Wood Johnson Foundation, Princeton, NJ. Funders had no role in study design; collection, analysis, or interpretation of data; writing the report; or the decision to submit the report for publication.

Trial Registration: NCT01802216.
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http://dx.doi.org/10.1016/j.xkme.2019.09.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380373PMC
December 2019

Interventions to Improve Blood Pressure Control Among Socioeconomically Disadvantaged Patients With CKD: Kidney Awareness Registry and Education Pilot Randomized Controlled Trial.

Kidney Med 2019 Sep-Oct;1(5):242-252. Epub 2019 Aug 30.

Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA.

Rationale & Objective: Sustainable interventions that enhance chronic kidney disease (CKD) management are not often studied in safety-net primary care, in which populations bear a disproportionate burden of disease and experience translational gaps between research and practice. We tested the feasibility of implementing and the impact of 2 technology-enhanced interventions designed to enhance CKD care delivery.

Study Design: A 2×2 randomized controlled pilot trial.

Setting & Participants: Primary care provider teams (n = 6) and 137 patients with CKD aged 18 to 75 years from 2 safety-net primary care clinics, 2013 to 2015.

Interventions: Primary care provider teams were randomly assigned to access a CKD registry with point-of-care notifications and quarterly feedback or a usual-care registry for 12 months. Patients within provider teams were randomly assigned to participate in a CKD self-management support program or usual care for 12 months.

Outcomes: We examined recruitment, randomization, and participation in each intervention. We also examined the impact of each intervention and their combination on change in systolic blood pressure (SBP), albuminuria, and patient self-reported behavioral measures after 12 months.

Results: Among potentially eligible patients identified using the electronic health record, 24% were eligible for study participation, of whom 35% (n = 137) were enrolled. Mean age was 55 years, 41% were non-English speaking, and 93% were of racial/ethnic minority. Mean baseline estimated glomerular filtration rate was 70.5 (SD = 30.3) mL/min/1.73 m; mean baseline SBP was 131 (SD = 21.8) mm Hg. Nearly 90% of clinicians reported that the CKD registry influenced their CKD management. More than 95% of patients randomly assigned to CKD self-management support engaged regularly with the intervention. Estimated changes in SBP over 1 year were nonstatistically different in each of the 3 intervention groups compared with usual care: (usual care: 0.5 [95% CI, -5.2 to 6.3] mm Hg; CKD registry only: -5.4 [95% CI, -12.2 to 1.4] mm Hg; CKD self-management support only: -6.4 [95% CI, -13.7 to 1.0] mm Hg; and CKD registry plus CKD self-management support: -0.5 [-5.5 to 4.5] mm Hg), though differences were larger among those with baseline SBPs > 140/90 mm Hg. Decreases in albuminuria were similarly nonstatistically different in each of the intervention groups compared with usual care. No differences were observed in patient self-reported behaviors.

Limitations: Single health system.

Conclusions: Patient and provider interventions to improve CKD care are feasible to implement in low-income settings with promising results among those with uncontrolled blood pressure.

Funding: National Institute of Diabetes and Digestive and Kidney Diseases.

Trial Registration: ClinicalTrials.gov, number: NCT01530958.
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http://dx.doi.org/10.1016/j.xkme.2019.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380406PMC
August 2019

National Trends in the Prevalence of Chronic Kidney Disease Among Racial/Ethnic and Socioeconomic Status Groups, 1988-2016.

JAMA Netw Open 2020 07 1;3(7):e207932. Epub 2020 Jul 1.

Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: The overall prevalence of chronic kidney disease (CKD) has stabilized in the United States in recent years. However, it is unclear whether all major sociodemographic groups experienced this trend.

Objective: To examine trends in CKD prevalence across major sociodemographic groups as defined by race/ethnicity and socioeconomic status.

Design, Setting, And Participants: This repeated cross-sectional study used data from the National Health and Nutrition Examination Surveys for 1988 to 1994 and every 2 years from 1999 to 2016 on individuals 20 years or older with information on race/ethnicity, socioeconomic status, and serum creatinine levels. Statistical analysis was conducted from May 1, 2017, to April 6, 2020.

Exposures: Race/ethnicity and socioeconomic status.

Main Outcomes And Measures: Prevalence of CKD was defined as an estimated glomerular filtration rate of 15 to 59 mL/min/1.73 m2.

Results: A total of 54 554 participants (mean [SE] age, 46.2 [0.2] years; 51.7% female) were examined. The age-, sex- and race/ethnicity-adjusted overall prevalence of stage 3 and 4 CKD increased from 3.9% in 1988-1994 to 5.2% in 2003-2004 (difference, 1.3%; 95% CI, 0.9%-1.7%; P < .001 for change) and remained relatively stable thereafter at 5.1% in 2015-2016 (difference, -0.1%; 95% CI, -0.7% to 0.4%; P = .61 for change). The trend in adjusted CKD prevalence differed significantly by race/ethnicity (P = .009 for interaction). In non-Hispanic white and non-Hispanic black persons, CKD prevalence increased between 1988-1994 and 2003-2004 and remained stable thereafter. Among Mexican American persons, CKD prevalence was lower than in other racial/ethnic groups and remained stable between 1988-1994 and 2003-2004 but nearly doubled (difference, 2.1%; 95% CI, 0.9%-3.3%; P = .001 for change) between 2003-2004 and 2015-2016 to rates similar to those in other racial/ethnic groups. There were higher rates of CKD prevalence among groups with lower educational level and income (eg, 5.8% vs 4.3% and 4.3% vs 3.1% in low vs high education and income, respectively, in 1988-1994), but trends in CKD prevalence mirrored those for the overall population. The higher CKD prevalence among individuals with lower educational level and income remained largely consistent throughout the entire period. Results were similar in most subgroups when including albuminuria to define CKD.

Conclusions And Relevance: The prevalence of CKD in the United States has stabilized overall in recent years but has increased among Mexican American persons. More important, gaps in CKD prevalence across racial/ethnic groups and levels of socioeconomic status largely persisted over 28 years. There is a need to identify and address causes of increasing CKD prevalence among Mexican American persons and a need to renew efforts to effectively mitigate persistent disparities in CKD prevalence.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.7932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366187PMC
July 2020

Prevalence and Persistence of Uremic Symptoms in Incident Dialysis Patients.

Kidney360 2020 Feb;1(2):86-92

Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi.

Background: Uremic symptoms are major contributors to the poor quality of life among patients on dialysis, but whether their prevalence or intensity has changed over time is unknown.

Methods: We examined responses to validated questionnaires in two incident dialysis cohort studies, the Choices for Health Outcomes in Caring for ESRD (CHOICE) study (=926, 1995-1998) and the Longitudinal United States/Canada Incident Dialysis (LUCID) study (=428, 2011-2017). We determined the prevalence and severity of uremic symptoms-anorexia, nausea/vomiting, pruritus, sleepiness, difficulty concentrating, fatigue, and pain-in both cohorts.

Results: In CHOICE and LUCID, respectively, mean age of the participants was 58 and 60 years, 53% and 60% were male, and 28% and 32% were black. In both cohorts, 54% of the participants had diabetes. Median time from dialysis initiation to the symptoms questionnaires was 45 days for CHOICE and 77 days for LUCID. Uremic symptom prevalence in CHOICE did not change from baseline to 1-year follow-up and was similar across CHOICE and LUCID. Baseline symptom prevalence in CHOICE and LUCID was as follows: anorexia (44%, 44%, respectively), nausea/vomiting (36%, 43%), pruritus (72%, 63%), sleepiness (86%, 68%), difficulty concentrating (55%, 57%), fatigue (89%, 77%), and pain (82%, 79%). In both cohorts, >80% of patients had three or more symptoms and >50% had five or more symptoms. The correlation between individual symptoms was low (<0.5 for all comparisons). In CHOICE, no clinical or laboratory parameter was strongly associated with multiple symptoms.

Conclusions: The burden of uremic symptoms among patients on dialysis is substantial and has not changed in the past 15 years. Improving quality of life will require identification of the factors that underlie the pathogenesis of uremic symptoms and better ways of removing the toxins that are responsible.
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http://dx.doi.org/10.34067/kid.0000072019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7289028PMC
February 2020

Kidney Disease, Race, and GFR Estimation.

Clin J Am Soc Nephrol 2020 Aug 11;15(8):1203-1212. Epub 2020 May 11.

Division of Nephrology, Tufts Medical Center, Boston, Massachusetts.

Assessment of GFR is central to clinical practice, research, and public health. Current Kidney Disease Improving Global Outcomes guidelines recommend measurement of serum creatinine to estimate GFR as the initial step in GFR evaluation. Serum creatinine is influenced by creatinine metabolism as well as GFR; hence, all equations to estimate GFR from serum creatinine include surrogates for muscle mass, such as age, sex, race, height, or weight. The guideline-recommended equation in adults (the 2009 Chronic Kidney Disease Epidemiology Collaboration creatinine equation) includes a term for race (specified as black versus nonblack), which improves the accuracy of GFR estimation by accounting for differences in non-GFR determinants of serum creatinine by race in the study populations used to develop the equation. In that study, blacks had a 16% higher average measured GFR compared with nonblacks with the same age, sex, and serum creatinine. The reasons for this difference are only partly understood, and the use of race in GFR estimation has limitations. Some have proposed eliminating the race coefficient, but this would induce a systematic underestimation of measured GFR in blacks, with potential unintended consequences at the individual and population levels. We propose a more cautious approach that maintains and improves accuracy of GFR estimates and avoids disadvantaging any racial group. We suggest full disclosure of use of race in GFR estimation, accommodation of those who decline to identify their race, and shared decision making between health care providers and patients. We also suggest mindful use of cystatin C as a confirmatory test as well as clearance measurements. It would be preferable to avoid specification of race in GFR estimation if there was a superior, evidence-based substitute. The goal of future research should be to develop more accurate methods for GFR estimation that do not require use of race or other demographic characteristics.
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http://dx.doi.org/10.2215/CJN.12791019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409747PMC
August 2020

CKD Awareness Among US Adults by Future Risk of Kidney Failure.

Am J Kidney Dis 2020 08 15;76(2):174-183. Epub 2020 Apr 15.

Departments of Medicine, University of California San Francisco, San Francisco, CA; Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA.

Rationale & Objective: Persons with chronic kidney disease (CKD) are often unaware of their disease status. Efforts to improve CKD awareness may be most effective if focused on persons at highest risk for progression to kidney failure.

Study Design: Serial cross-sectional surveys.

Setting & Participants: Nonpregnant adults (aged≥20 years) with CKD glomerular filtration rate categories 3-4 (G3-G4) who participated in the National Health and Nutrition Examination Survey from 1999 to 2016 (n = 3,713).

Predictor: 5-year kidney failure risk, estimated using the Kidney Failure Risk Equation. Predicted risk was categorized as minimal (<2%), low (2%-<5%), intermediate (5%-<15%), or high (≥15%).

Outcome: CKD awareness, defined by answering "yes" to the question "Have you ever been told by a doctor or other health professional that you had weak or failing kidneys?"

Analytical Approach: Prevalence of CKD awareness was estimated within each risk group using complex sample survey methods. Associations between Kidney Failure Risk Equation risk and CKD awareness were assessed using multivariable logistic regression. CKD awareness was compared with awareness of hypertension and diabetes during the same period.

Results: In 2011 to 2016, unadjusted CKD awareness was 9.6%, 22.6%, 44.7%, and 49.0% in the minimal-, low-, intermediate-, and high-risk groups, respectively. In adjusted analyses, these proportions did not change over time. Awareness of CKD, including among the highest risk group, remains consistently below that of hypertension and diabetes and awareness of these conditions increased over time.

Limitations: Imperfect sensitivity of the "weak or failing kidneys" question for ascertaining CKD awareness.

Conclusions: Among adults with CKD G3-G4 who have 5-year estimated risks for kidney failure of 5%-<15% and≥15%, approximately half were unaware of their kidney disease, a gap that has persisted nearly 2 decades.
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http://dx.doi.org/10.1053/j.ajkd.2020.01.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7387135PMC
August 2020

Perspectives of African-American Family Members about Kidney Failure Treatment.

Nephrol Nurs J 2020 Jan-Feb;47(1):53-65

Eleanor Easley Chair and Professor of Medicine, the School of Medicine; Chief of the Division of General Internal Medicine, Department of Medicine.

Understanding African-American families' experiences with treatment for kidney failure is necessary for informing the delivery of family-centered care and the design of appropriate interventions. This qualitative study explored treatment-related questions, concerns, and family impacts among African-American family members of patients with pre-kidney failure and kidney failure. Thirty-five family members participated in focus groups stratified by patients' treatment experiences (pre-kidney failure, in-center hemodialysis, peritoneal dialysis, awaiting living-donor kidney transplantation, or post-transplantation). Family members raised questions and concerns about the psychological, lifestyle, and practical aspects of treatment. Similarly, discussions about family impacts emphasized psychosocial effects, lifestyle consequences, and the provision and receipt of support. Efforts to address these questions, concerns, and perceived family impacts through additional research, early and tailored education, and supportive interventions are needed.
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March 2020

Markers of mineral metabolism and vascular access complications: The Choices for Healthy Outcomes in Caring for ESRD (CHOICE) study.

Hemodial Int 2020 01 1;24(1):43-51. Epub 2019 Dec 1.

Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

Introduction: Vascular access dysfunction is a major cause of morbidity in patients with end-stage renal disease (ESRD) on chronic hemodialysis. The effects of abnormalities in mineral metabolism on vascular access are unclear. In this study, we evaluated the association of mineral metabolites, including 25-hydroxy vitamin D (25(OH)D) and fibroblast growth factor-23 (FGF-23), with vascular access complications.

Methods: We included participants from the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study who were using an arteriovenous fistula (AVF; n = 103) or arteriovenous graft (AVG; n = 116). Serum levels of 25(OH)D, FGF-23, parathyroid hormone (PTH), calcium, phosphorus, C-reactive protein (CRP) and interleukin-6 (IL-6) were assessed from stored samples. Participants were followed for up to 1 year or until a vascular access intervention or replacement.

Findings: A total of 24 participants using an AVF and 43 participants using an AVG experienced access intervention. Those with 25(OH)D level in the lowest tertile (<11 ng/mL) had an increased risk of AVF intervention compared to those with higher 25(OH)D levels (adjusted relative hazard [aHR] = 3.28; 95% confidence interval [CI]: 1.31, 8.20). The highest tertile of FGF-23 (>3750 RU/mL) was associated with greater risk of AVF intervention (aHR = 2.56; 95% CI: 1.06, 6.18). Higher PTH was associated with higher risk of AVF intervention (aHR = 1.64 per SD of log(PTH); 95% CI: 1.02, 2.62). These associations were not observed in participants using an AVG. None of the other analytes were significantly associated with AVF or AVG intervention.

Discussion: Low levels of 25(OH)D and high levels of FGF-23 and PTH are associated with increased risk of AVF intervention. Abnormalities in mineral metabolism are risk factors for vascular access dysfunction and potential therapeutic targets to improve outcomes.
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http://dx.doi.org/10.1111/hdi.12798DOI Listing
January 2020

Improving Access to Kidney Transplantation: Business as Usual or New Ways of Doing Business?

JAMA 2019 09;322(10):931-933

Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco.

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http://dx.doi.org/10.1001/jama.2019.12784DOI Listing
September 2019

The relation between dialysis-requiring acute kidney injury and recovery from end-stage renal disease: a national study.

BMC Nephrol 2019 09 2;20(1):342. Epub 2019 Sep 2.

Division of Nephrology, Department of Medicine, University of California, San Francisco, 533 Parnassus Ave, U404, Box 0532, San Francisco, CA, 94143-0532, USA.

Background: Approximately 4-6% of incident end stage renal disease (ESRD) patients in the U.S. recover enough kidney function to discontinue dialysis but there is considerable geographic variation. We undertook this study to investigate whether state-level variations in renal recovery among incident ESRD patients correlated with state-level variations in incidence of acute kidney injury requiring dialysis (AKI-D).

Methods: We conducted a national cross-sectional ecological study at the state-level using data from State Inpatient Databases and U.S. Renal Data System. All hospital admissions and all ESRD patients in 18 US states (AZ, AR, CA, FL, IA, KY, MA, MD, MI, NJ, NM, NY, NV, OR, RI, SC, VT, and WA) were included. Correlation between AKI-D incidence and rate of renal recovery across states was determined using Pearson's r (overall and in subgroups). We also calculated partial correlations adjusted for sex and age.

Results: AKI-D incidence ranged from 99.0 per million population (pmp) in Vermont to 490.4 pmp in Nevada. Rate of renal recovery among incident ESRD patients ranged from 8.8 pmp in Massachusetts to 29.3 pmp in Florida. A positive correlation between AKI-D incidence and rate of renal recovery among incident ESRD patients at state level was found overall (unadjusted r = 0.67; p = 0.002) and in age, sex, and race subgroups. The overall correlation persisted after adjusting for age (adjusted r = 0.62; p < 0.001) and sex (adjusted r = 0.65; p < 0.001).

Conclusion: Our findings suggest that AKI-D incidence is an important driver of renal recovery rates among incident ESRD patients.
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http://dx.doi.org/10.1186/s12882-019-1483-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6720077PMC
September 2019

Trends in Quality of Care for Patients with CKD in the United States.

Clin J Am Soc Nephrol 2019 08 11;14(8):1142-1150. Epub 2019 Jul 11.

Department of Medicine, University of California, San Francisco, California.

Background And Objectives: Improving the quality of CKD care has important public health implications to delay disease progression and prevent ESKD. National trends of the quality of CKD care are not well established. Furthermore, it is unknown whether gaps in quality of care are due to lack of physician awareness of CKD status of patients or other factors.

Design, Setting, Participants, & Measurements: We performed a national, serial, cross-sectional study of visits to office-based ambulatory care practices for adults with diagnosed CKD from the years 2006 to 2014. We assessed the following quality indicators: () BP measurement, () uncontrolled hypertension, () uncontrolled diabetes, () angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use among patients with hypertension, () statin use if age ≥50 years old, and (6) nonsteroidal anti-inflammatory drug use. Using multivariable linear regression and chi-squared analysis, we examined the change in quality performance over time.

Results: Between 2006 and 2014, there were 7099 unweighted visits for patients with CKD representing 186,961,565 weighted visits. There was no difference in the prevalence of uncontrolled hypertension (>130/80 mm Hg) over time (46% in 2006-2008 versus 48% in 2012-2014; =0.50). There was a high prevalence of uncontrolled diabetes in 2012-2014 (40% for hemoglobin A1c >7%). The prevalence of ACEi/ARB use decreased from 45% in 2006-2008 to 36% in 2012-2014, which did not reach statistical significance (=0.07). Statin use in patients with CKD who were 50 years or older was low and remained unchanged from 29% in 2006-2008 to 31% in 2012-2014 (=0.92).

Conclusions: In a nationally representative dataset, we found that patients with CKD had a high prevalence of uncontrolled hypertension and diabetes and a low use of statins that did not improve over time and was not concordant with guidelines.
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http://dx.doi.org/10.2215/CJN.00060119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682807PMC
August 2019

Family Members' Experiences With Dialysis and Kidney Transplantation.

Kidney Med 2019 Jul-Aug;1(4):171-179. Epub 2019 Jun 28.

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

Rationale & Objective: Understanding whether family members' experiences with patients' treatment for end-stage kidney disease (ESKD) were expected could guide the development of family-centered interventions that enhance the preparedness of patients and their care partners for kidney replacement therapies. We explored unexpected negative experiences with ESKD treatments among family members of dialysis and posttransplantation patients to identify meaningful directions for family-centered research and clinical care.

Study Design: Qualitative study.

Setting & Participants: 8 focus groups comprising 49 family members of dialysis patients and living donor kidney transplant recipients undergoing medical care in Baltimore, MD.

Analytical Approach: Focus groups were stratified by patients' treatment (in-center hemodialysis, home hemodialysis, peritoneal dialysis, or living donor kidney transplantation) and family members' self-reported race (African American vs non-African American), resulting in 2 groups per treatment experience. Inductive thematic analysis was used to identify themes in focus group transcripts. Themes shared across different treatment groups were highlighted to provide insight into common experiences.

Results: We identified 4 themes that described family members' unexpected negative treatment experiences: becoming a care partner (unanticipated responsibilities and sleep disruptions), adverse psychological treatment responses in patients (eg, depression) and family members (eg, anxiety), treatment delivery and logistics (insufficient information, medication regimen, and logistical inconveniences), and patient morbidity (dialysis-related health problems and fatigue). All themes were relevant to discussions in the in-center hemodialysis, peritoneal dialysis, and transplantation groups, whereas psychological responses and morbidity themes did not reflect discussions in home hemodialysis groups.

Limitations: Data collection occurred from 2008 to 2009; family members were recruited through patients undergoing care in 1 geographic area; 1 family member participant per patient.

Conclusions: Family members described a broad range of unexpected negative experiences with ESKD treatments. Efforts to prepare families for ESKD treatments through more family-centered care, early and tailored education, and interventions targeting care partner preparedness, health provider-family member communication, and relationship dynamics in family member-patient dyads are needed.
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http://dx.doi.org/10.1016/j.xkme.2019.06.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380377PMC
June 2019

The Status of Provision of Standard Outpatient Dialysis for US Undocumented Immigrants with ESKD.

Clin J Am Soc Nephrol 2019 08 6;14(8):1258-1260. Epub 2019 Jun 6.

Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, California; and.

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http://dx.doi.org/10.2215/CJN.03460319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682810PMC
August 2019

Albuminuria Testing by Race and Ethnicity among Patients with Hypertension with and without Diabetes.

Am J Nephrol 2019 5;50(1):48-54. Epub 2019 Jun 5.

UCSF, Division of Nephrology at Zuckerberg San Francisco General Hospital, San Francisco, California, USA,

Background: Detection of chronic kidney disease (CKD) with urine albumin-to-creatinine ratio (UACR) among patients with hypertension (HTN) provides an opportunity for early treatment, potentially mitigating risk of CKD progression and cardiovascular complications. Differences in UACR testing patterns among racial/ethnic populations at risk for CKD could contribute to known disparities in CKD complications.

Methods: We examined the prevalence of UACR testing among low-income adult primary care patients with HTN, defined by a new administrative code for HTN or 2 clinic blood pressures >140/90 mm Hg between January 1, 2014, and January 1, 2017, in one public health-care delivery system with a high prevalence of end-stage kidney disease among race/ethnic minorities. Logistic regression was used to identify odds of UACR testing within 1 year of a HTN diagnosis, overall, and by racial/ethnic subgroup, adjusted for demographic factors, estimated glomerular filtration rate, and HTN severity. Models were also stratified by diabetes status.

Results: The cohort (n = 16,414) was racially/ethnically diverse (16% White, 21% Black, 34% Asian, 19% Hispanic, and 10% other) and 51% female. Only 35% of patients had UACR testing within 1 year of a HTN diagnosis. Among individuals without diabetes, odds of UACR testing were higher among Asians, Blacks, and Other subgroups compared to Whites (adjusted OR [aOR] 1.19; 95% CI 1.00-1.42 for Blacks; aOR 1.33; 1.13-1.56 for Asians; aOR 1.30; 1.04-1.60 for Other) but were not significantly different between Hispanics and Whites (aOR 1.17; 0.97-1.39). Among individuals with diabetes, only Asians had higher odds of UACR testing compared to Whites (aOR 1.35; 1.12-1.63).

Conclusions: Prevalence of UACR testing among low-income patients with HTN is low in one public health-care delivery system, with higher odds of UACR testing among racial/ethnic minority subgroups compared to Whites without diabetes and similar odds among those with diabetes. If generalizable, less albuminuria testing may not explain higher prevalence of kidney failure in racial/ethnic minorities.
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http://dx.doi.org/10.1159/000500706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6620121PMC
August 2020

Poor accordance to a DASH dietary pattern is associated with higher risk of ESRD among adults with moderate chronic kidney disease and hypertension.

Kidney Int 2019 06 4;95(6):1433-1442. Epub 2019 Mar 4.

Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, California, USA; Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California, USA.

The Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure, an important risk factor for chronic kidney disease (CKD) and end-stage renal disease (ESRD). However, it is unclear whether adherence to a DASH diet confers protection against future ESRD, especially among those with pre-existing CKD and hypertension. We examined whether a DASH diet is associated with lower risk of ESRD among 1,110 adults aged ≥ 20 years with hypertension and CKD (estimated glomerular filtration rate, eGFR 30-59 ml/min/1.73 m) enrolled in the National Health and Nutrition Examination Survey (1988-1994). Baseline DASH diet accordance score was assessed using a 24-hour dietary recall questionnaire. ESRD was ascertained by linkage to the U.S. Renal Data System registry. We used the Fine-Gray competing risks method to estimate the relative hazard (RH) for ESRD after adjusting for sociodemographics, clinical and nutritional factors, eGFR, and albuminuria. Over a median follow-up of 7.8 years, 18.4% of subjects developed ESRD. Compared to the highest quintile of DASH diet accordance, there was a greater risk of ESRD among subjects in quintiles 1 (RH=1.7; 95% CI 1.1-2.7) and 2 (RH 2.2; 95% CI 1.1-4.1). Significant interactions were observed with diabetes status and race/ethnicity, with the strongest association between DASH diet adherence and ESRD risk observed in individuals with diabetes and in non-Hispanic blacks. Low accordance to a DASH diet is associated with greater risk of ESRD in adults with moderate CKD and hypertension, particularly in non-Hispanic blacks and persons with diabetes.
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http://dx.doi.org/10.1016/j.kint.2018.12.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6602537PMC
June 2019