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Contains fulltext : 215593.pdf (Publisher’s version ) (Closed access) Although blood pressure control is a major goal in chronic kidney disease, no worldwide overview of either its achievement or antihypertensive prescriptions is currently available. To evaluate this we compared crude prevalence of uncontrolled blood pressure among 17 cohort studies, including 34 602 individuals with estimated glomerular filtration rate under 60 ml/min/1.73 m(2) and treated hypertension across four continents, and estimated observed to expected prevalence ratios, adjusted for potential confounders. Crude prevalence of blood pressure of 140/90 mm Hg or more varied from 28% to 61% and of blood pressure of 130/80 or more from 54% to 84%. Adjusted prevalence ratios indicated poorer hypertension control than expected in cohorts from European countries, India, and Uruguay, and better control in patients from North American and high-income Asian countries. Four antihypertensive drug classes or more were prescribed to more than 30% of participants in North American and some European cohorts, but this practice was less common elsewhere. Renin angiotensin-aldosterone system inhibitors were the most common antihypertensive drugs, prescribed for 54% to 91% of cohort participants. Differences for other drug classes were much stronger, ranging from 11% to 79% for diuretics, 22% to 70% for beta-blockers, and 27% to 75% for calcium-channel blockers. The confounders studied explain only a part of the international variation in blood pressure control among individuals with chronic kidney disease. Thus, considerable heterogeneity in prescription patterns worldwide calls for further investigation into the impact of different approaches on patient outcomes.

Dialysis procedure rates in Germany were changed in 2002 from per-session to weekly flat rate payments, and quality assurance was introduced in 2009 with defined treatment targets for spKt/V, dialysis frequency, treatment time, and hemoglobin. In order to understand trends in treatment parameters before and after the introduction of these changes, we analyzed data from 407 to 618 prevalent patients each year (hemodialysis over 90 days) in 14-21 centers in cross-sections of the Dialysis Outcomes and Practice Patterns Study (phases 1-4, 1998-2011). Descriptive statistics were used to report differences over time in the four quality assurance parameters along with erythropoietin-stimulating agent (ESA) and intravenous iron doses. Time trends were analyzed using linear mixed models adjusted for patient demographics and comorbidities. The proportion of patients with short treatment times (less than 4 h) and low spKt/V (below 1.2) improved throughout the study and was lowest after implementation of quality assurance. Hemoglobin levels have increased since 1998 and remained consistent since 2005, with only 8-10% of patients below 10 g/dl. About 90% of patients were prescribed ESAs, with the dose declining since peaking in 2006. Intravenous iron use was highest in 2011. Hence, trends to improve quality metrics for hemodialysis have been established in Germany even after introduction of flat rate reimbursement. Thus, analysis of facility practice patterns is needed to maintain quality of care in a cost-containment environment.

Intermittent versus continuous administration of 1,25-dihydroxyvitamin D3 in experimental renal hyperparathyroidism. Conflicting results have been reported regarding the efficacy of intermittent versus continuous administration of 1,25(OH)2D3 in renal secondary hyperparathyroidism. To address this issue we examined sham-operated control rats and hyperparathyroid rats with subtotal (5/6) nephrectomy (Nx). The Nx animals (20 to 22 animals per group) were subjected to three treatment protocols: (i) solvent treatment (Nx-solvent); (ii) two i.p. injections of 35 pmol 1,25(OH)2D3 on days 0 and 4 (Nx-bolus); and (iii) continuous infusion of 70 pmol 1,25(OH)2D3 over six days via osmotic minipump (Nx-infusion). All measurements were performed six days after start of treatment. As compared to sham-operated controls, the pre-pro-PTH/β-actin mRNA ratio was 2.04-fold higher in Nx-solvent. Both modes of administration of 1,25(OH)2D3 resulted in inhibition of PTH mRNA concentrations relative to Nx-solvent. The pre-pro-PTH/β-actin mRNA ratio was, however, significantly lower (P < 0.05) in Nx-bolus than in Nx-infusion (Nx-bolus 1.26 higher than sham-operated controls; Nx-infusion 1.65 higher than sham-operated controls). Aminoterminal PTH (N-PTH) serum concentrations were higher in Nx-solvent (52 ± 4 pg/ml) than in sham-operated controls (32 ± 3 pg/ml, P < 0.01). N-PTH concentrations in Nx-bolus (38 ± 4 pg/ml) were significantly lower than in Nx-solvent (P < 0.01) and in Nx-infusion (46 ± 4 pg/ml, P < 0.05). Parathyroid gland weight (μg/g body wt) was higher in Nx-solvent (1.30 ± 0.08 pg/ml) than in sham-operated controls (0.79 ± 0.04 pg/ml, P < 0.02). Again, parathyroid weight was lower in Nx-bolus (0.99 ± 0.014 pg/ml, P < 0.05 vs. Nx-solvent) than in Nx-infusion (1.16 ± 0.06 pg/ml). Differential effects of bolus versus infusion treatment were not explained by changes in serum calcium or phosphate. Analysis of the 1,25(OH)2D3 concentration time-profile showed higher peak concentrations in bolus-treated animals (170 to 200 pg/ml after 8 hr) than in infusion-treated animals (125 to 130 pg/ml after 48 hr). The time-averaged mean increase in 1,25(OH)2D3 serum concentrations was, however, higher in infusion-treated animals (42.3 pg/ml/24 hr) than in bolus-treated animals (26.0 pg/ml/24 hr). We conclude that the stimulation of parathyroid gland function in experimental uremia is more effectively suppressed when the same total dose of 1,25(OH)2D3 is given by intermittent bolus administration than by continuous infusion. Our results are compatible with the notion that the 1,25(OH)2D3 concentration time-profile, that is, the 1,25(OH)2D3 peak concentration, is an important determinant of the response of parathyroid glands to 1,25(OH)2D3.