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This study examined risk associations calibrated to the U.S. population-level incidence of end-stage renal disease and death and projected long-term incidences of ESRD. Risk projections among nondonors were lower than 15-year observed risks after donation. Nearly 30,000 people worldwide become living kidney donors each year. 1 – 3 Traditionally, living donors have been selected on the basis of an absence of risk factors for poor outcomes after donation and without a comprehensive assessment of individualized long-term risk. Although kidney donation is considered to be safe in healthy, low-risk persons, donation has lifelong implications, and the most direct effect may be an increased long-term risk of end-stage renal disease (ESRD). 4 – 7 A tool to predict a donor candidate’s long-term risk of ESRD that incorporates the combined effect of multiple demographic and health characteristics before donation could help make . . .

To assess the patterns of angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACE-I/ARB) discontinuation in the setting of chronic kidney disease (CKD) progression in real-world clinical practice. We identified incident ACE-I/ARB users with a baseline estimated glomerular filtration rate (eGFR) ≥15 mL/min/1.73 m2 and without end-stage renal disease in the Geisinger Health System between January 1, 2004, and December 31, 2015. We investigated the associations of CKD stage, hospitalizations with and without acute kidney injury (AKI), serum potassium, bicarbonate level, thiazide, and loop diuretic use with ACE-I/ARB discontinuation. Among the 53,912 ACE-I/ARB users, the mean age was 59.9 years, and 50.6% were female. More than half of users discontinued ACE-I/ARB within 5 years of therapy initiation. The risk of ACE-I/ARB discontinuation increased with more advanced CKD stage. For example, patients who initiated ACE-I/ARB with CKD stage G4 (eGFR: 15-29 mL/min/1.73 m2) were 2.09-fold (95% CI, 1.87-2.34) more likely to discontinue therapy than those with eGFR ≥ 90 mL/min/1.73 m2. Potassium level greater than 5.3 mEq/L, systolic blood pressure ≤ 90 mm Hg, bicarbonate level < 22 mmol/L, and intervening hospitalization—particularly AKI-related–were also strong risk factors for ACE-I/ARB discontinuation. Thiazide diuretic use was associated with lower risk, whereas loop diuretic use was associated with higher risk of discontinuation. In a real-world cohort, discontinuation of ACE-I/ARB was common, particularly in patients with lower eGFR. Hyperkalemia, hypotension, low bicarbonate level, and hospitalization (AKI-related, in particular) were associated with a higher risk of ACE-I/ARB discontinuation. Additional studies are needed to evaluate the risk–benefit balance of discontinuing ACE-I/ARB in the setting of CKD progression.

Background Low-income, rural pregnant women are at disproportionate risk for adverse pregnancy outcomes as well as future cardiovascular risk. Currently, less than half of eligible women enroll in the Women, Infants, and Children’s (WIC) Program. This study aims to evaluate whether integrating clinical care and social care may advance health equity and reduce health disparities by directly linking women receiving obstetric care to the Special Supplemental Nutrition Program for WIC and/or a Registered Dietitian/Nutritionist (RDN). Methods This pragmatic study is situated in real-world care and utilizes a randomized controlled trial design. A total of 240 low-income, rural, pregnant patients will be recruited from Geisinger (Pennsylvania, USA) obstetric clinics and randomized to receive one of four models: (1) Clinic; (2) Clinic-WIC; (3) Clinic-RDN, or (4) Clinic-WIC-RDN. Participants provide consent for electronic referrals that directly link their contact information from the electronic health record to WIC and/or RDN. Patients in the Clinic model receive standard prenatal care, which includes provision of basic information about WIC. The Clinic-WIC model includes a clinical decision alert to queue clinical staff to ask about WIC interest and place a referral to WIC using a social health access referral platform. In turn, WIC staff contact the pregnant woman about enrollment. The Clinic-RDN model includes a referral to an RDN for telehealth counseling to promote heart healthy eating and food resource management. The Clinic-WIC-RDN model includes referrals to both WIC and RDN. The primary outcome is difference in WIC enrollment between the Clinic and Clinic-RDN models versus the Clinic-WIC and Clinic-WIC-RDN arms at 6-months post-baseline. Secondary endpoints include WIC retention and adherence, change in participant behavior, skills, and food security, preterm delivery, birthweight, and maternal and child health outcomes. Implementation outcome measures include acceptability, appropriateness, and feasibility from the perspective of clinic and WIC staff. Discussion Study findings will inform system models that integrate clinic care and social care to improve health equity among a high-risk population. Specifically, these findings will advance implementation of strategies to increase enrollment in a widely available but underutilized food provision program during pregnancy. Trial registration ClinicalTrials.gov identifier (NCT06311799). Registered 3/13/2024.

To investigate the association between serum potassium, mortality, and kidney outcomes in the general population and whether potassium-altering medications modify these associations. We studied 15,539 adults in the Atherosclerosis Risk in Communities Study. Cox proportional hazard regression was used to investigate the association of serum potassium at baseline (1987-1989), evaluated categorically (hypokalemia, <3.5 mmol/L; normokalemia, ≥3.5 and <5.5 mmol/L; hyperkalemia, ≥5.5 mmol/L) and continuously using linear spline terms (knots at 3.5 and 5.5 mmol/L), with mortality, sudden cardiac death, incident chronic kidney disease, and end-stage renal disease. The end date of follow-up for all outcomes was December 31, 2012. We also evaluated whether classes of potassium-altering medications modified the association between serum potassium and adverse outcomes. Overall, 413 (2.7%) of the participants had hypokalemia and 321 (2.1%) had hyperkalemia. In a fully adjusted model, hyperkalemia was significantly associated with mortality (hazard ratio, 1.24; 95% CI, 1.04-1.49) but not sudden cardiac death, chronic kidney disease, or end-stage renal disease. Hypokalemia as a categorical variable was not associated with any outcome; however, associations of hypokalemia with all-cause mortality and kidney outcomes were observed among those who were not taking potassium-wasting diuretics (all P for interaction, <.001). Higher values of serum potassium were associated with a higher risk of mortality in the general population. Lower levels of potassium were associated with adverse kidney outcomes and mortality among participants not taking potassium-wasting diuretics.

Background Proteinuria screening is recommended for patients with hypertension to screen for kidney disease and identify those at elevated risk for cardiovascular disease. However, screening rates among hypertensive patients are low. Home testing strategies may be useful in improving proteinuria screening adherence. Methods We conducted an individual-level, randomized trial at 55 primary care clinic sites in the Geisinger Health System to evaluate the effectiveness of a strategy using home smartphone urinalysis test (Dip.io) to complete proteinuria screening in previously unscreened non-diabetic patient portal users with hypertension. All patients received an educational letter and a standing urinalysis lab order, and then were randomized to control (usual care) or intervention. Intervention arm participants were invited to complete proteinuria screening with a mailed home smartphone urinalysis test. Co-primary outcomes were completion of proteinuria screening and number of albuminuria cases (albumin/creatinine ratio [ACR] ≥ 30 mg/g or protein/creatinine ratio ≥ 150 mg/g) at the end of 3 months. We also evaluated patient satisfaction with the home test, and compliance with recommendations for patients with newly detected albuminuria. Results A total of 999 patients were randomized to intervention or control. Out of 499 patients assigned to the intervention arm, 253 were reached by phone, and 69/97 (71.1%) consented patients completed the home test. Overall, the intervention increased proteinuria screening completion (28.9% vs. 18.0%; p  < 0.001) with no effect on the number of albuminuria cases (4 vs. 4) although only 6/57 (10.5%) patients with trace or 1+ urine dipstick protein had a follow-up quantitative test. Among the 55 patients who completed a survey after the home test, 89% preferred testing at home rather than the physician’s office. Conclusions A strategy using a home urinalysis smartphone test increased proteinuria screening rates in previously unscreened patients with hypertension and may be useful in increasing rates of proteinuria screening compliance. Future studies should evaluate use of home testing kits to screen for and confirm albuminuria, and determine whether improving early detection of kidney disease can improve future kidney health. Trial registration Clinical Trial Registry: NCT03470701 (First posted 3/20/2018) https://clinicaltrials.gov/ct2/show/NCT03470701 . This study was retrospectively registered.

IntroductionWeight loss, consumption of a Dietary Approaches to Stop Hypertension dietary pattern, reduced sodium intake and increased physical activity have been shown to lower blood pressure (BP). Use of web-based tools and telehealth to deliver lifestyle counselling could be potentially scalable solutions to improve BP through behavioural modification though limited data exists to support these approaches in clinical practice.Methods and analysisThis randomised controlled trial will compare the efficacy of a telehealth versus self-directed lifestyle intervention in lowering 24-hour SBP in patients with overweight/obesity (body mass index ≥25 kg/m2) and 24-hour SBP 120–160 mm Hg. All participants receive personalised recommendations to improve dietary quality based on a web-based Food Frequency Questionnaire, access to an online comprehensive weight management programme and a smartphone dietary app. The telehealth arm additionally includes weekly calls with registered dietitian nutritionists who use motivational interviewing. The primary outcome is change from baseline to 12 weeks in 24-hour SBP. Secondary outcomes include changes from baseline in 24-hour diastolic BP, daytime SBP, nighttime SP, daytime diastolic BP, nighttime diastolic BP, total Healthy Eating Index-2015 score, weight, waist circumference and physical activity. Other prespecified outcomes will include change in individual components of the Healthy Eating Index-2015 score, and satisfaction with the Healthy BP research study measured on a 5-point Likert scale.Ethics and disseminationThe study has been approved by the Geisinger Institutional Review Board. Results will be disseminated through peer-reviewed publications and conference presentations.Trial registration numberNCT03700710.

Objective Newer antidiabetic medications such as sodium‐glucose co‐transporter 2 inhibitors (SGLT2i) and glucagon‐like peptide 1 receptor agonists (GLP1RA) result in weight loss in clinical trials. However, the real‐world effectiveness remains unclear. The magnitude of weight change associated with antidiabetic medication using real‐world data was examined. Methods Patients with diabetes who initiated SGLT2i (n = 906), GLP1RA (n = 782), dipeptidyl peptidase‐4 inhibitors (DPP4i, n = 1881), or sulfonylureas (n = 3255) in Geisinger Health System were identified. Outcomes were percent weight change per year and time to 5% weight loss. Propensity scores were used to account for differences across groups. Results The mean ± SD age of patients was 57.5 ± 14.1 years, 3381 (49.5%) were female, and 6450 (94.5%) had body mass index ≥25 kg/m2. Compared with sulfonylureas, newer antidiabetic medications were associated with significant weight loss (−3.2% [95% confidence interval: −3.8%, −2.6%] per year for SGLT2i; −2.9% [−3.6%, −2.3%] per year for GLP1RA; and −1.7% [−2.1%, −1.3%] per year for DPP4i). SGLT2i and GLP1RA were also associated with significant weight loss compared with DPP4i. Among patients with overweight or obesity, SGLT2i and GLP1RA users were more likely to achieve 5% weight loss compared with sulfonylureas and DPP4i. Conclusions In real‐world practice, SGLT2i and GLP1RA were associated with significant weight loss compared with sulfonylureas and DPP4i. These results may further motivate uptake of SGLT2i and GLP1RA, especially among patients who were overweight or had obesity.

To quantify the risk of hyperkalemia and acute kidney injury (AKI) when spironolactone use is added on to loop diuretic use among patients with heart failure, and to evaluate whether the risk is modified by level of kidney function. We identified 17,110 patients with heart failure treated with loop diuretics between January 1, 2004, and December 31, 2016 within the Geisinger Health System. We estimated the incidence of hyperkalemia and AKI associated with spironolactone initiation, and used target trial emulation methods to minimize confounding by indication. During a mean follow-up of 134 mo, 3229 of 17,110 patients (18.9%) initiated spironolactone. Incidence rates of hyperkalemia and AKI in patients using spironolactone with a loop diuretic were 2.9 and 10.1 events per 1000 person-months, respectively. In propensity score–matched analyses, spironolactone initiation was associated with higher hyperkalemia and AKI risk compared with loop alone (hazard ratio, 1.69; 95% CI, 1.35 to 2.10; P<.001, and hazard ratio, 1.12; 95% CI, 1.00 to 1.26; P=.04, respectively). There were no differences in the relative risk of either outcome associated with spironolactone by level of kidney function. The addition of spironolactone to loop diuretics in patients with heart failure was associated with higher risk of hyperkalemia and AKI; these risks must be weighed against the potential benefits of spironolactone.

Background Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1RA) are increasingly recommended in type 2 diabetes. Hypoglycemia is a serious adverse effect of glucose-lowering agents. Real-world comparison of hypoglycemic risks among SGLT2i, GLP1RA, dipeptidyl peptidase-4 inhibitor (DPP4i), and sulfonylureas is limited. Objective Quantify the risk of hypoglycemia associated with SGLT2i, GLP1RA, DPP4i, and sulfonylureas (the primary reference group). Design Retrospective cohort study conducted using electronic health records from Geisinger Health, Pennsylvania (2015–2019). Participants A total of 10,713 patients with type 2 diabetes who newly received SGLT2i ( n =1487), GLP1RA ( n =1241), DPP4i ( n =2938), or sulfonylureas ( n =5047). Propensity score–based inverse probability of treatment weighting was used to balance patient characteristics across four treatment groups simultaneously. Main Measures Hypoglycemia was defined as capillary blood glucose <70 mg/dL; severe hypoglycemia was defined as capillary blood glucose <54 mg/dL. A weighted Cox proportional hazards regression model was used to estimate the risk of outcomes for pairwise comparisons of SGTL2i, GLP1RA, DPP4i, and sulfonylureas. Key Results Median follow-up was 21.3 months. Compared with sulfonylureas, the risk of hypoglycemia was lower with SGLT2i (hazard ratio 0.60 [95% confidence interval 0.48–0.75]), GLP1RA (0.49 [0.34–0.69]), and DPP4i (0.60 [0.48–0.78]). The risk of severe hypoglycemia was also lower with SGLT2i (0.43 [0.35–0.74]), GLP1RA (0.50 [0.28–0.87]), and DPP4i (0.64 [0.46–0.90]) compared to sulfonylureas. The risks of hypoglycemia and severe hypoglycemia were similar across the SGLT2i, GLP1RA, and DPP4i groups (SGLT2i vs. DPP4i: 0.95 [0.67–1.34]; GLP1RA vs. DPP4i: 0.81 [0.55–1.19]; SGLT2i vs. GLP1RA: 1.17 [0.76–1.82] for hypoglycemia). Conclusion SGLT2i and GLP1RA confer a lower risk of hypoglycemia compared with sulfonylureas and similar risk compared with DPP4i. Given the known cardiovascular benefits associated with SGLT2i and GL1PRA, our results suggesting the safety of SGLT2i and GL1PRA further support their use.

Interest in the health effects of dietary phosphorus is burgeoning, yet sources and trends in phosphorus consumption have not been well characterized. We describe trends in and primary sources of dietary phosphorus in a nationally representative sample of 34,741 US adults, 20+ years old (NHANES 2001–2014). Dietary sources of phosphorus were estimated in nine food groups and 26 food categories. Phosphorus consumption was expressed in absolute intake, phosphorus density, and proportion contributed by dietary sources. Between 2001 and 2014, dietary phosphorus intake increased from 1345 to 1399 mg/day (p-trend = 0.02), while calorie intake slightly declined (p-trend = 0.1). Grains were the largest dietary phosphorus source, followed by meats, and milk products. Soft drinks accounted for just 3.3% of total dietary phosphorus. Phosphorus intake from grains increased 68 mg/day (p < 0.001), 25 mg/day from meats (p = 0.02), and decreased 75 mg/day (p < 0.001) from milk products. Dietary phosphorus intake and the phosphorus density of the diet are increasing. Grains are an important dietary phosphorus source that has increased in total consumption and phosphorus density. Further research is needed to determine if this is due to individuals’ selection of grains or the composition of those available.