American journal of kidney diseases : the official journal of the National Kidney Foundation
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Randomized Controlled Trial Multicenter Study
Economic analysis of cinacalcet in combination with low-dose vitamin D versus flexible-dose vitamin D in treating secondary hyperparathyroidism in hemodialysis patients.
The ACHIEVE (Optimizing the Treatment of Secondary Hyperparathyroidism: A Comparison of Sensipar and Low Dose Vitamin D vs Escalating Doses of Vitamin D Alone) trial evaluated the efficacy of treatment with cinacalcet plus low-dose activated vitamin D analogues (Cinacalcet-D) compared with vitamin D analogues alone (Flex-D) in attaining KDOQI (Kidney Disease Outcomes Quality Initiative) targets for secondary hyperparathyroidism (SHPT). The economic implications of these treatment regimens have not been explored. ⋯ Cinacalcet combined with vitamin D analogues was no more effective than vitamin D analogues in achieving the primary ACHIEVE end point and incurred greater costs. This conclusion was not tempered substantially by the cost of vitamin D analogues or oral phosphate binders. Whether the additional costs of cinacalcet are warranted will require longer term models to determine whether changes in serum levels of mineral metabolic markers translate into lower morbidity, mortality, and downstream costs.
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The objective was to determine the cost-effectiveness of treating anemic patients with chronic kidney disease (CKD) with erythropoiesis-stimulating agents (ESAs) to a low (9-10.9 g/dL), intermediate (11-12 g/dL), or high (> 12 g/dL) hemoglobin level target compared with a strategy of managing anemia without ESAs. ⋯ Using ESAs to target a hemoglobin level > 12 g/dL is associated with worse clinical outcomes and significant additional cost compared with using ESAs to target lower hemoglobin levels (9-12 g/dL). Given a lack of studies comparing low (9-10.9 g/dL) and intermediate (11-12 g/dL) hemoglobin targets for clinical outcomes, including quality of life, the most cost-effective hemoglobin level target within the range of 9-12 g/dL is uncertain, although aiming for higher targets within this range will lead to higher costs.
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Hypokalemia is a common electrolyte disorder. Transient causes of hypokalemia are due to cell shift, whereas sustained hypokalemia is caused by either inadequate intake or excessive potassium loss. Evaluation of the intake, distribution, and excretion of potassium should include the following: (1) a careful history, including use of drugs, medications, and the presence of vomiting or diarrhea; (2) physical examination, including orthostatic changes in blood pressure and heart rate; and (3) measurement of urine and plasma electrolytes. ⋯ A primary increase in distal delivery should be associated with volume depletion, whereas a primary increase in mineralocorticoid level generally is associated with volume expansion and hypertension. In patients with a primary increase in mineralocorticoid activity, it is useful to measure plasma renin activity and plasma aldosterone levels. Complications of hypokalemia include muscle weakness, rhabdomyolysis, cardiac arrhythmias, impaired urinary concentrating ability, and glucose intolerance.
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Editorial Comment
Remote ischemic preconditioning: is the groove in the heart?
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Comparative Study
Association of urinary biomarkers with disease severity in patients with autosomal dominant polycystic kidney disease: a cross-sectional analysis.
Disease monitoring of autosomal dominant polycystic kidney disease (ADPKD) will become more important with potential upcoming therapeutic interventions. Because serum creatinine level is considered of limited use and measurement of effective renal blood flow (ERBF) and total renal volume are time consuming and expensive, there is a need for other biomarkers. We aimed to investigate which urinary markers have increased levels in patients with ADPKD; whether these urinary markers are associated with measured glomerular filtration rate (mGFR), ERBF, and total renal volume; and whether these associations are independent of albuminuria (urine albumin excretion [UAE]). ⋯ Levels of markers for multiple parts of the nephron are increased in patients with ADPKD. In addition to measurement of UAE, measurement of urinary β(2)-microglobulin, KIM-1, H-FABP, MCP-1, and especially NGAL could be of value for determination of disease severity in patients with ADPKD.