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1.  Healthy Behaviors, Risk Factor Control and Awareness of Chronic Kidney Disease 
American journal of nephrology  2013;37(2):135-143.
Background/Aims
The association between chronic kidney disease (CKD) awareness and healthy behaviors is unknown. We examined whether CKD self-recognition is associated with healthy behaviors and achieving risk-reduction targets known to decrease risk of cardiovascular morbidity and CKD progression.
Methods
CKD awareness, defined as a “yes” response to “Has a doctor or other health professional ever told you that you had kidney disease?”, was examined among adults with CKD (eGFR < 60 ml/min/1.73 m2) who participated in the REasons for Geographic and Racial Differences in Stroke study. Odds of participation in healthy behaviors (tobacco avoidance, avoidance of regular NSAID use, physical activity) and achievement of risk reduction targets (ACEI/ARB use, systolic blood pressure (SBP) control and glycemic control among those with diabetes) among those aware vs. unaware of their CKD were determined by logistic regression, controlling for socio-demographics, access to care and co-morbid conditions. SBP control was defined as < 130 mmHg (primary definition) or < 140 mmHg (secondary definition).
Results
Of 2,615 participants, only 6% (n=166) were aware of having CKD. Those who were aware had 82% higher odds of tobacco avoidance compared to those unaware [adjusted odds ratio =1.82, 95% CI (1.02–3.24)]. CKD awareness was not associated other healthy behaviors or achievement of risk-reduction targets.
Conclusions
Awareness of CKD was only associated with participation in one healthy behavior and was not associated with achievement of risk-reduction targets. To encourage adoption of healthy behaviors, a better understanding of barriers to participation in CKD-healthy behaviors is needed. Keywords: chronic kidney disease, awareness, behaviors, self-management
doi:10.1159/000346712
PMCID: PMC3649001  PMID: 23392070
Chronic kidney disease; awareness; self-management; behaviors
2.  Acute Kidney Injury and Mortality in Hospitalized Patients 
American Journal of Nephrology  2012;35(4):349-355.
Background
The objective of this study was to determine the incidence of acute kidney injury (AKI) and its relation with mortality among hospitalized patients.
Methods
Analysis of hospital discharge and laboratory data from an urban academic medical center over a 1-year period. We included hospitalized adult patients receiving two or more serum creatinine (sCr) measurements. We excluded prisoners, psychiatry, labor and delivery, and transferred patients, ‘bedded outpatients’ as well as individuals with a history of kidney transplant or chronic dialysis. We defined AKI as (a) an increase in sCr of ≥0.3 mg/dl; (b) an increase in sCr to ≥150% of baseline, or (c) the initiation of dialysis in a patient with no known history of prior dialysis. We identified factors associated with AKI as well as the relationships between AKI and in-hospital mortality.
Results
Among the 19,249 hospitalizations included in the analysis, the incidence of AKI was 22.7%. Older persons, Blacks, and patients with reduced baseline kidney function were more likely to develop AKI (all p < 0.001). Among AKI cases, the most common primary admitting diagnosis groups were circulatory diseases (25.4%) and infection (16.4%). After adjustment for age, sex, race, admitting sCr concentration, and the severity of illness index, AKI was independently associated with in-hospital mortality (adjusted odds ratio 4.43, 95% confidence interval 3.68–5.35).
Conclusions
AKI occurred in over 1 of 5 hospitalizations and was associated with a more than fourfold increased likelihood of death. These observations highlight the importance of AKI recognition as well as the association of AKI with mortality in hospitalized patients.
doi:10.1159/000337487
PMCID: PMC3362180  PMID: 22473149
Acute kidney injury; Chronic kidney disease; Mortality; Health services
3.  Chronic Kidney Disease and Risk of Death from Infection 
American Journal of Nephrology  2011;34(4):330-336.
Background
Infection, bacteremia and sepsis are major sources of morbidity and mortality in patients with end-stage renal disease. This study sought to determine the association between predialysis chronic kidney disease (CKD) and infection-related mortality.
Methods
We analyzed participants in the Third National Health and Nutrition Examination Survey (NHANES III). The study included adults ≥45- years-old without end-stage renal disease. Estimated glomerular filtration rate (eGFR) was categorized as ≥60, 45–59.9 and <45 ml/min per 1.73 m2, and urinary albumin-to-creatinine ratio (ACR) as <30, 30–299.9 and ≥300 mg/g. The study identified infection-related mortality, including septicemia, respiratory, abdominal and gastrointestinal, cardiac, kidney and genitourinary, neurologic, and other infections over a median of 13 years using the National Death Index.
Results
Of 7,400 participants included in the study, 206 died from infections. Compared to individuals with eGFR ≥60 ml/min per 1.73 m2, infection-related mortality was higher for those with lower eGFR [adjusted HR = 1.36 (95% CI: 0.81, 2.30) and 2.36 (1.04, 5.38) for eGFR of 45–59.9 and <45 ml/min per 1.73 m2, respectively; p trend = 0.06]. Compared to individuals with ACR <30 mg/g, infection-related mortality was higher for ACR levels of 30–299 and ≥300 mg/g [adjusted HR = 1.68 (95% CI: 0.97, 2.92) and 2.84 (0.92, 8.74), p trend = 0.02].
Conclusions
Reduced eGFR and albuminuria are associated with increased risk for infection-related mortality. Efforts are needed to reduce its incidence and mitigate the effects of infections among individuals with CKD.
doi:10.1159/000330673
PMCID: PMC3169360  PMID: 21860228
Chronic kidney disease; Infection; Sepsis; Mortality
4.  Poverty and Racial Disparities in Kidney Disease: The REGARDS Study 
American Journal of Nephrology  2010;32(1):38-46.
There are pronounced disparities among black compared to white Americans for risk of end-stage renal disease. This study examines whether similar relationships exist between poverty and racial disparities in chronic kidney disease (CKD) prevalence.
Methods
We studied 22,538 participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort study. We defined individual poverty as family income below USD 15,000 and a neighborhood as poor if 25% or more of the households were below the federal poverty level.
Results
As the estimated glomerular filtration rate (GFR) declined from 50–59 to 10–19 ml/min/ 1.73 m2, the black:white odds ratio (OR) for impaired kidney function increased from 0.74 (95% CI 0.66, 0.84) to 2.96 (95% CI 1.96, 5.57). Controlling for individual income below poverty, community poverty, demographic and comorbid characteristics attenuated the black:white prevalence to an OR of 0.65 (95% CI 0.57, 0.74) among individuals with a GFR of 59–50 ml/min/1.73 m2 and an OR of 2.21 (95% CI 1.25, 3.93) among individuals with a GFR between 10 and 19 ml/min/ 1.73 m2.
Conclusion
Household, but not community poverty, was independently associated with CKD and attenuated but did not fully account for differences in CKD prevalence between whites and blacks.
doi:10.1159/000313883
PMCID: PMC2914392  PMID: 20516678
Chronic kidney disease; Poverty; Racial disparities
5.  Physical and Psychological Burden of Chronic Kidney Disease among Older Adults 
American Journal of Nephrology  2010;31(4):309-317.
Introduction
The purpose of the study is to determine if functional status and quality of life (QoL) vary with glomerular filtration rate (GFR) among older adults.
Methods
We studied adults aged 45 years and older participating in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort study. Data included demographic and health information, serum creatinine and hemoglobin, the 4-item Center for Epidemiologic Studies Depression Scale (CES-D-4), the 4-item Cohen's Perceived Stress Scale (PSS-4), reported health status and inactivity and the Medical Outcomes Study Short Form-12 (SF-12) QoL scores.
Results
CKD (GFR <60 ml/min/1.73 m2) was present in 11.6% of the subjects. As GFR declined, the SF-12 physical component score, adjusted for other participant attributes, declined from 38.9 to 35.9 (p = 0.0001). After adjustment for other risk factors, poorer personal health scores (p < 0.0001) and decreased physical activity (p < 0.0001) were reported as GFR declined. In contrast, after adjusting for other participant characteristics, depression scores and stress scores and the mental component score of the SF-12 were not associated with kidney function.
Conclusion
Older individuals with CKD in the US population experience an increased prevalence of impaired QoL that cannot be fully explained by other individual characteristics.
doi:10.1159/000285113
PMCID: PMC2859227  PMID: 20164652
Functional status; Quality of life; Chronic kidney disease; End-stage renal disease; Glomerular filtration rate; REGARDS cohort study; Medical Outcomes Study Short Form-12
6.  Chronic Kidney Disease Is Often Unrecognized among Patients with Coronary Heart Disease: The REGARDS Cohort Study 
American Journal of Nephrology  2008;29(1):10-17.
Introduction
Individuals with kidney disease are at increased risk for coronary heart disease (CHD) and CHD is associated with an increased prevalence of chronic kidney disease (CKD). Awareness of CKD may potentially influence diagnostic decisions, life-style changes and pharmacologic interventions targeted at modifiable CHD risk factors. We describe here the degree to which persons with CHD are aware of their CKD.
Methods
The Reasons for Geographical and Racial Difference in Stroke (REGARDS) cohort study, a population-based sample of US residents aged 45 and older. We included in our analyses 28,112 REGARDS participants recruited as of June 2007. We estimated GFR (eGFR) using the MDRD equation, defined CKD as a GFR <60 ml/min/1.73 m2, and ascertained awareness of chronic kidney disease and coronary heart disease through self-report. We used the odds ratio to compare the association between awareness of kidney disease, as measured by GFR <60 ml/min/1.73 m2, among individuals with and without self-reported CHD by both the presence of CKD and the severity of impaired kidney function.
Results
Coronary heart disease was reported by 3,803 (14.1%) of subjects, and 11.3% of subjects had CKD by eGFR. Among all individuals with a GFR <60 ml/min/ 1.73 m2, 9.6% reported having been told by a physician that they had kidney disease. Among those with CHD and CKD, 5.0% were aware of their CKD compared to 2.0% in those without CHD [OR (95% CI) = 2.57 (2.08, 3.28)]. This difference persisted after controlling for the level of kidney function [aOR (95% CI) = 1.87 (1.43, 2.41)].
Conclusion
There was a high prevalence of CKD and a low prevalence of awareness of kidney disease among older adults in the US population with or without coronary heart disease. These findings support recent recommendations that patients with cardiovascular disease be systematically screened for and educated about CKD.
doi:10.1159/000148645
PMCID: PMC2786017  PMID: 18663284
Screening; Cardiovascular disease; Chronic kidney disease

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