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44: Coping Strategies in Hemodialysis Patients: Associations of Satisfaction, Coping Strategies, and Outcomes in a Bronx Dialysis Population
NKF 2009 Spring Clinical Meetings Abstracts 41 EXPERIENCE WITH CONTROL OF SEVERE SECONDARY HYPERPARATHYROIDISM Barbara A Clark, Stacey Nye, Richard Marcus. Division of Nephrology and Hypertension, Allegheny General Hospital, Drexel University School of Medicine, Pittsburgh, Pa. Prior to the use of vitamin D analogues and calicimimetics, PTHectomy was the only option for severe refractory secondary hyperparathyroidism. We reviewed the efficacy of our hemodialysis unit Zemplar protocol in a group of patients with persistent severe secondary hyperparathyroidism (intact PTH levels >1000 on at least 3 occasions in 6 month period). 14 patients were identified. PTH, calcium, phosphorus levels, CaP product, and Zemplar dose were assessed at baseline then every 4 months for the next 2 years. During this period, Sensipar became clinically available and was used in 6 of the 14 patients at the discretion of their physician. 9 of the 14 patients achieved at least transient goal PTH (150-300), 3 achieved partial control (PTH 301-600). PTH levels fell from 1642+113 to 632+162pg/ml, p<0.05). 3 patients underwent PTHectomy. Hypercalcemia ( >11) occurred in 4. 9 developed elevated CaP product > 70. 4 patients died and 2 patients had calciphylaxis. In summary, severe secondary hyperparathyroidism can be medically managed in most patients with use of a Zemplar protocol. However, there is a fairly high incidence of hypercalcemia and elevated CaP product. Incorporation of the use of Sensipar into the protocol at an early stage should be considered to determine if this may decrease the risk of hypercalcemia and an elevated CaP product.
42 DOES CHRONIC METABOLIC ACIDOSIS IMPACT THE PROGRESSION OF DIABETIC NEPHROPATHY? Mark Cook and Udayan Bhatt, Ohio State University Hospitals, Columbus, Ohio, USA. BACKGROUND: Chronic metabolic acidosis (CMA) is a feature of Chronic Kidney Disease (CKD) secondary to diminished ammoniagenesis within the kidney and diminished acid excretion. CMA has been associated with adverse consequences to protein and muscle metabolism, renal osteodystrophy, impaired insulin sensitivity, beta2-microglobulin accumulation, and inflammation. Despite this, conflicting data exist regarding CMA and progression of CKD. Therefore, the purpose of this study is to further define the relationship between CMA and CKD progression in patients with diabetic nephropathy (DN). PATIENTS AND METHODS: 2149 patients with DN and CKD as defined by billing codes for DN and baseline serum creatinine (SCR) greater than or equal to 1.50 mg/dl were examined retrospectively over a 72 month period from January 2000 through December 2005. Patients with incomplete data during the review period were excluded. Inclusion criteria required no oral alkali therapy in the 72 month period of data collection. Only patients demonstrating a change of SCR less than 0.25 mg/dl per quarter year were included to eliminate artifact from acute kidney injury. Patient observations were then divided into two groups based upon average bicarbonate less than 20 mg/dl (n=410) or greater than 20 mg/dl (n=1739). SCR was observed quarterly determining change in SCR from the previous measurement. A binary outcome variable with 1 representing a worsening SCR and 0 representing a stable or improved SCR was created. Generalized linear modeling with repeated measures and logit link function was used to adjust for SCR and estimate the odds ratio (OR) for worsening SCR as a function of bicarbonate greater than or less than 20 mg/dl. RESULTS: After adjusting for SCR, the odds of increased SCR in subjects with average bicarbonate levels < 20 mg/dl was 2.45 times the odds of increased SCR in subjects with bicarbonate levels > 20 mg/dl (p<0.001). CONCLUSION: After adjusting for SCR, patients with DN and CMA had a higher likelihood of progression of CKD as compared to patients with DN without CMA. This provides significant evidence of an adverse relationship between CMA and progression of CKD.
A33 43 PREVALENCE OF CKD IS HIGH IN PERSONS WITH UNDIAGNOSED AND PRE-HYPERTENSION IN THE U.S. Deidra C. Crews, Laura C. Plantinga, Edgar R. Miller, III, Rajiv Saran, Elizabeth Hedgeman, Sharon Saydah, Paul Eggers and Neil R. Powe, for the CDC CKD Surveillance Team Johns Hopkins University, Baltimore, Maryland; University of Michigan, Ann Arbor, Michigan; and National Center for Health Statistics, Hyattsville, Maryland, United States Hypertension (HTN) is known to be both a cause and a consequence of chronic kidney disease (CKD), but the prevalence of CKD throughout the diagnostic spectrum of HTN has not been wellestablished. We determined the prevalence of CKD within blood pressure categories (JNC-7) in 17,794 adults (20+ years old) surveyed by NHANES during 1999-2006. We included all participants who had measured blood pressure, self-reported HTN and CKD diagnosis (yes or no), serum creatinine for eGFR determination (MDRD equations), measurement of urine albumin excretion, and self-report of awareness of kidney disease (yes or no). Diagnosed HTN was defined as selfreport of provider diagnosis (n=5,832); HTN was defined by measured systolic and diastolic (SBP, DBP). Undiagnosed HTN was defined as SBP ≥140 mmHg or DBP ≥90 mmHg, without a report of provider diagnosis (n=3,046); pre-HTN was defined as SBP ≥120 and <140 mmHg or DBP ≥80 and <90 mmHg (n=3,719); and no HTN was defined as SBP <120 mmHg and DBP <80 mmHg (n=5,197). CKD was defined as eGFR <60 ml/min/m2 or the presence of albuminuria (urinary albumin-creatinine ratio greater than 30 mg/g). We examined CKD prevalence overall and by participant characteristics; adjustment for age, sex, and race was performed using multivariable logistic regression. Persons with undiagnosed and pre-HTN had a prevalence of CKD of 17.5% and 17.3%, respectively, in comparison to 27.5% of persons with diagnosed HTN and 13.4% in those without HTN. Approximately one third (35%) of CKD cases occurred in those with either undiagnosed or pre-HTN. In this group, only 2-4% reported being aware of having CKD. CKD prevalence is high among those with undiagnosed and pre-HTN. This population, with two potentially unrecognized conditions, should be targeted for further screening and prevention efforts.
44 COPING STRATEGIES IN HEMODIALYSIS PATIENTS: ASSOCIATIONS OF SATISFACTION, COPING STRATEGIES, AND OUTCOMES IN A BRONX DIALYSIS POPULATION Amanda Cyrulnik, Michal L. Melamed, and Amanda C. Raff Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA Coping strategies in patients on hemodialysis (HD) may include problem oriented/active coping, emotion based coping, and risk-taking coping behaviors. No one coping mechanism has been shown to be objectively adaptive, however, risk-taking coping behavior has been shown to be maladaptive. The purpose of this study was to examine coping mechanisms in HD patients in a Bronx dialysis population. 86 patients were interviewed using a modified Dialysis Satisfaction Survey. The mean age of patients was 56.7, 48.8% were females, 66.3% were black, and the mean time on dialysis was 36 months. In addition to demographic data, patients reported overall satisfaction with their dialysis treatment, the impact of dialysis on their lives, and the impact of dialysis on their mood. Patients were asked to name three strategies used to cope with their treatment. Four objective measures of patient compliance and outcomes, Kt/v, PO4 level, missed treatments, and excessive interdialytic fluid gain, were recorded. Data was analyzed using the Student’s t-test and Chi-square tests. Patients who reported a negative impact of dialysis on mood were more likely to be female (p = 0.007) and younger (p = 0.03). A majority of the self-reported coping skills employed by the patients were problem oriented/active coping skills. No statistically significant relationship was found between any type of coping mechanism and satisfaction, impact, mood, or objective measures of outcome. This study has shown that female sex and younger age are associated with a self-reported negative impact of dialysis. However, both negative impact scores and trends toward lower satisfaction with care did not correlate adversely with objective measures of compliance. Nor do types of coping skills correlate with either satisfaction or outcomes. The relationship of coping skills, satisfaction, and outcomes are complex and future research will be needed to define these relationships and develop innovative interventions to improve both patient satisfaction and objective outcomes.
42 DOES CHRONIC METABOLIC ACIDOSIS IMPACT THE PROGRESSION OF DIABETIC NEPHROPATHY? Mark Cook and Udayan Bhatt, Ohio State University Hospitals, Columbus, Ohio, USA. BACKGROUND: Chronic metabolic acidosis (CMA) is a feature of Chronic Kidney Disease (CKD) secondary to diminished ammoniagenesis within the kidney and diminished acid excretion. CMA has been associated with adverse consequences to protein and muscle metabolism, renal osteodystrophy, impaired insulin sensitivity, beta2-microglobulin accumulation, and inflammation. Despite this, conflicting data exist regarding CMA and progression of CKD. Therefore, the purpose of this study is to further define the relationship between CMA and CKD progression in patients with diabetic nephropathy (DN). PATIENTS AND METHODS: 2149 patients with DN and CKD as defined by billing codes for DN and baseline serum creatinine (SCR) greater than or equal to 1.50 mg/dl were examined retrospectively over a 72 month period from January 2000 through December 2005. Patients with incomplete data during the review period were excluded. Inclusion criteria required no oral alkali therapy in the 72 month period of data collection. Only patients demonstrating a change of SCR less than 0.25 mg/dl per quarter year were included to eliminate artifact from acute kidney injury. Patient observations were then divided into two groups based upon average bicarbonate less than 20 mg/dl (n=410) or greater than 20 mg/dl (n=1739). SCR was observed quarterly determining change in SCR from the previous measurement. A binary outcome variable with 1 representing a worsening SCR and 0 representing a stable or improved SCR was created. Generalized linear modeling with repeated measures and logit link function was used to adjust for SCR and estimate the odds ratio (OR) for worsening SCR as a function of bicarbonate greater than or less than 20 mg/dl. RESULTS: After adjusting for SCR, the odds of increased SCR in subjects with average bicarbonate levels < 20 mg/dl was 2.45 times the odds of increased SCR in subjects with bicarbonate levels > 20 mg/dl (p<0.001). CONCLUSION: After adjusting for SCR, patients with DN and CMA had a higher likelihood of progression of CKD as compared to patients with DN without CMA. This provides significant evidence of an adverse relationship between CMA and progression of CKD.
A33 43 PREVALENCE OF CKD IS HIGH IN PERSONS WITH UNDIAGNOSED AND PRE-HYPERTENSION IN THE U.S. Deidra C. Crews, Laura C. Plantinga, Edgar R. Miller, III, Rajiv Saran, Elizabeth Hedgeman, Sharon Saydah, Paul Eggers and Neil R. Powe, for the CDC CKD Surveillance Team Johns Hopkins University, Baltimore, Maryland; University of Michigan, Ann Arbor, Michigan; and National Center for Health Statistics, Hyattsville, Maryland, United States Hypertension (HTN) is known to be both a cause and a consequence of chronic kidney disease (CKD), but the prevalence of CKD throughout the diagnostic spectrum of HTN has not been wellestablished. We determined the prevalence of CKD within blood pressure categories (JNC-7) in 17,794 adults (20+ years old) surveyed by NHANES during 1999-2006. We included all participants who had measured blood pressure, self-reported HTN and CKD diagnosis (yes or no), serum creatinine for eGFR determination (MDRD equations), measurement of urine albumin excretion, and self-report of awareness of kidney disease (yes or no). Diagnosed HTN was defined as selfreport of provider diagnosis (n=5,832); HTN was defined by measured systolic and diastolic (SBP, DBP). Undiagnosed HTN was defined as SBP ≥140 mmHg or DBP ≥90 mmHg, without a report of provider diagnosis (n=3,046); pre-HTN was defined as SBP ≥120 and <140 mmHg or DBP ≥80 and <90 mmHg (n=3,719); and no HTN was defined as SBP <120 mmHg and DBP <80 mmHg (n=5,197). CKD was defined as eGFR <60 ml/min/m2 or the presence of albuminuria (urinary albumin-creatinine ratio greater than 30 mg/g). We examined CKD prevalence overall and by participant characteristics; adjustment for age, sex, and race was performed using multivariable logistic regression. Persons with undiagnosed and pre-HTN had a prevalence of CKD of 17.5% and 17.3%, respectively, in comparison to 27.5% of persons with diagnosed HTN and 13.4% in those without HTN. Approximately one third (35%) of CKD cases occurred in those with either undiagnosed or pre-HTN. In this group, only 2-4% reported being aware of having CKD. CKD prevalence is high among those with undiagnosed and pre-HTN. This population, with two potentially unrecognized conditions, should be targeted for further screening and prevention efforts.
44 COPING STRATEGIES IN HEMODIALYSIS PATIENTS: ASSOCIATIONS OF SATISFACTION, COPING STRATEGIES, AND OUTCOMES IN A BRONX DIALYSIS POPULATION Amanda Cyrulnik, Michal L. Melamed, and Amanda C. Raff Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA Coping strategies in patients on hemodialysis (HD) may include problem oriented/active coping, emotion based coping, and risk-taking coping behaviors. No one coping mechanism has been shown to be objectively adaptive, however, risk-taking coping behavior has been shown to be maladaptive. The purpose of this study was to examine coping mechanisms in HD patients in a Bronx dialysis population. 86 patients were interviewed using a modified Dialysis Satisfaction Survey. The mean age of patients was 56.7, 48.8% were females, 66.3% were black, and the mean time on dialysis was 36 months. In addition to demographic data, patients reported overall satisfaction with their dialysis treatment, the impact of dialysis on their lives, and the impact of dialysis on their mood. Patients were asked to name three strategies used to cope with their treatment. Four objective measures of patient compliance and outcomes, Kt/v, PO4 level, missed treatments, and excessive interdialytic fluid gain, were recorded. Data was analyzed using the Student’s t-test and Chi-square tests. Patients who reported a negative impact of dialysis on mood were more likely to be female (p = 0.007) and younger (p = 0.03). A majority of the self-reported coping skills employed by the patients were problem oriented/active coping skills. No statistically significant relationship was found between any type of coping mechanism and satisfaction, impact, mood, or objective measures of outcome. This study has shown that female sex and younger age are associated with a self-reported negative impact of dialysis. However, both negative impact scores and trends toward lower satisfaction with care did not correlate adversely with objective measures of compliance. Nor do types of coping skills correlate with either satisfaction or outcomes. The relationship of coping skills, satisfaction, and outcomes are complex and future research will be needed to define these relationships and develop innovative interventions to improve both patient satisfaction and objective outcomes.