Saturday, June 26, 2010

Reverse epidemiology in ESRD: Digoxin

Conventional risk factors of cardiovascular disease and mortality in the general population such as obesity, hypercholesterolemia, and hypertension appear to be paradoxically protective and are associated with increased survival among dialysis patients (Kalantar-Zadeh et al, Kidney Int. 2003). Also, it was reported recently that there is paradoxical increase in the risk of stroke among dialysis patients receiving warfarin therapy for atrial fibrillation (Chan et al, JASN Oct 2009). Now there is an addition to the list of reverse epidemiology in ESRD. In the current issue of JASN, Chan and colleagues report increased mortality with digoxin use in ESRD patients (Chan et al, JASN, June 2010). In this study, authors compared 4549 dialysis patients on digoxin with 116,315 dialysis patients who were not on digoxin. This is a retrospective study. However, authors did propensity score analysis to match patients with similar comorbidities in both groups. It was found that digoxin use was associated with 28% increased risk of death. This was most pronounced in patients with lower predialysis serum potassium of less than 4.3 mEq/L. It is likely that hypokalemia, which frequently occurs immediately post dialysis in our ESRD patients, enhances the toxicity of digoxin. In conclusion, we all apply same principles of medicine learnt from general population to our dialysis patients. It seems we have to re-examine everything in our ESRD population.

Tuesday, June 22, 2010

Survey on innovative teaching tools

Dr. Jhaveri of Nephron Power and Online Transplant Center is conducting a survey on innovative teaching tools. Please see the link -

Monday, June 21, 2010

Billing and Coding Seminars

Renal Physicians Association (RPA) has excellent series of presentations on billing, coding and documentation. These are very helpful for all practicing nephrologists especially for those going to practice in the community.

Sunday, June 20, 2010

SNP of Caveolin-1 gene is associated with renal allograft function

Caveolin-1 is the primary structural component of caveolae which are cell membrane invaginations on endothelial cells, adipocytes, fibroblasts and pneumocytes etc. It is anti-fibrotic and is shown to be reduced in conditions such as scleroderma and idiopathic pulmonary fibrosis. In a recently published JAMA paper (Moore et al, JAMA, April 2010), it was shown that donor single nucleotide polymorphism in gene encoding for Caveolin-1 was associated with long term renal transplant outcomes. Authors investigated this SNP in 785 white kidney transplant donors and their respective recipients with median follow up of 81 months post transplantation. It was found that donor genotype AA, compared to AC and CC genotypes, was associated with increased risk of allograft failure (Hazard ratio of about 2). The findings were confirmed in another independent cohort within UK. This is an interesting study that may not alter our clinical practice at present but will atleaset open new avenues in renal fibosis research if the findings are replicable in other studies.

Tuesday, June 15, 2010

Renal outcomes after preeclampsia

Recently, I had to look up this topic after one of my patients posed this question. In the largest study that I could find on this topic (Vikse et al, NEJM, Aug 2008), outcomes data on 570,433 women from national registries of Norway were reviewed. The relative risk of ESRD among women with history of preeclampsia was 3.2 to 6.7 compared to women without history of preeclampsia, with risk being higher in women who had preeclampsia in more than one pregnancy or if preeclampsia resulted in low birth weight or preterm infant. This translates into an absolute risk of less than 1% after a mean time of 17 years after first pregnancy. The main limitation of this study is that it is based on administrative database and is not a prospective study. There is a systematic review and metanalysis on this topic in the current issue of AJKD (McDonald et al, AJKD, June 2010). In this review, data from 7 cohort studies involving 273 patients with preeclampsia and 333 patients with uncomplicated pregnancies were analyzed. It was found that, after a mean of 7.1 years postpartum, 31% of women with history of preeclampsia had microalbuminuria compared to 7% of controls.

Monday, June 14, 2010