Clinical Associate Professor, Medicine - Nephrology
Kidney Clinic Chief, Stanford (2017 - Present)
Fellowship:University of Washington Medical Center (2015) WA
Board Certification: Nephrology, American Board of Internal Medicine (2012)
Fellowship:University of Washington Medical Center (2012) WA
Board Certification: Internal Medicine, American Board of Internal Medicine (2008)
Residency:McGaw Medical Center of Northwestern University (2008) IL
Internship:McGaw Medical Center of Northwestern University (2006) IL
Medical Education:Stanford University, Medical School Registrar (2005) CA
A Study to Evaluate the Effect of Dapagliflozin on Renal Outcomes and Cardiovascular Mortality in Patients With Chronic Kidney Disease
The purpose of this study is to evaluate the effect of dapagliflozin on renal outcomes and cardiovascular mortality in patients with chronic kidney disease.
Updates in Management and Timing of Dialysis in Acute Kidney Injury.
Journal of hospital medicine
2019; 14: E1–E7
Acute kidney injury (AKI) is a common complication in hospitalized patients and is associated with mortality, prolonged hospital length of stay, and increased healthcare costs. This paper reviews several areas of controversy in the identification and management of AKI. Serum creatinine and urine output are used to identify and stage AKI by severity. Although standardized definitions of AKI are used in research settings, these definitions do not account for individual patient factors or clinical context which are necessary components in the assessment of AKI. After treatment of reversible causes of AKI, patients with AKI should receive adequate volume resuscitation with crystalloid solutions. Balanced crystalloid solutions generally prevent severe hyperchloremia and could potentially reduce the risk of AKI, but additional studies are needed to demonstrate a clinical benefit. Intravenous albumin may be beneficial in patients with chronic liver disease either to prevent or attenuate the severity of AKI; otherwise, the use of albumin or other colloids (eg, hydroxyethyl starch) is not recommended. Diuretics should be used to treat volume overload, but they do not facilitate AKI recovery or reduce mortality. Nutrition consultation may be helpful to ensure that patients receive adequate, but not excessive, dietary protein intake, as the latter can lead to azotemia and electrolyte disturbances disproportionate to the patient's kidney failure. The optimal timing of dialysis initiation in AKI remains controversial, with conflicting results from two randomized controlled trials.
View details for PubMedID 30794134
- Testing two (of several) intravenous iron dosing strategies in hemodialysis. Annals of translational medicine 2019; 7 (Suppl 3): S129
Clinical presentation at initiation of maintenance dialysis and subsequent survival: A retrospective cohort study.
Hemodialysis international. International Symposium on Home Hemodialysis
INTRODUCTION: Clinical practice guidelines increasingly favor a more symptom-driven approach to maintenance dialysis initiation. But, little is known about the clinical presentation at dialysis initiation, such as the different kinds of signs and symptoms present at dialysis initiation, illness acuity at dialysis initiation, and how these aspects of the clinical presentation relate to subsequent survival.METHODS: This is a retrospective cohort study of a random sample of veterans who initiated dialysis between 2000 and 2009 at Veterans Affairs (VA) medical centers across the country (N = 1,691). We looked at associations between the clinical presentation (types of signs and/or symptoms and illness acuity) at the time of dialysis initiation and 1-year mortality.FINDINGS: The most common types of signs and/or symptoms at initiation were gastrointestinal (50.9%) and cardiopulmonary (48.7%). The crude mortality rate was 174.2 deaths per 1000 patients per year (95% CI 154.7, 196.1). Among different categories of signs and/or symptoms, only cardiopulmonary signs and/or symptoms were associated with a higher 1-year risk of mortality after initiation (risk ratio (RR) 1.32, 95% CI 1.05, 1.69) in adjusted analyses. Patients who were acutely ill at initiation were more likely to die during the following year as compared with those who initiated dialysis in the outpatient setting (RR 1.57, 95% CI 1.15, 2.21).DISCUSSION: With the exception of cardiopulmonary signs and/or symptoms, most signs and/or symptoms documented around the time of dialysis initiation were not associated with an increased risk of death during the year after initiation. In contrast, whether patients were acutely ill at the time of initiation was strongly associated with an increased risk of death after initiation regardless of the specific signs and/or symptoms present. Limitations of this study include retrospective study design, residual confounding, and lack of generalizability to non-VA settings.
View details for PubMedID 30285313
End-of-Life Care for Patients With Advanced Kidney Disease in the US Veterans Affairs Health Care System, 2000-2011.
American journal of kidney diseases : the official journal of the National Kidney Foundation
BACKGROUND: Little is known about patterns ofend-of-life care for patients with advanced kidneydisease not treated with maintenance dialysis.STUDY DESIGN: Case series.SETTING & PARTICIPANTS: A sample of 14,071 patients with sustained estimated glomerular filtration rates< 15mL/min/1.73m2 treated in the US Veterans Affairs health care system who died during 2000 to 2011. Before death, 12,756 of these patients had been treated with dialysis, 503 had been discussing and/or preparing for dialysis therapy, and for 812, there had been a decision not to pursue dialysis therapy.OUTCOMES: Hospitalization and receipt of an intensive procedure during the final month of life, in-hospital death, and palliative care consultation and hospice enrollment before death.RESULTS: Compared with decedents treated with dialysis, those for whom a decision not to pursue dialysis therapy had been made were less often hospitalized (57.3% vs 76.8%; OR, 0.40 [95% CI, 0.34-0.46]), less often the recipient of an intensive procedure (3.5% vs 24.6%; OR, 0.15 [95% CI, 0.10-0.22]), more often the recipient of a palliative care consultation (52.6% vs 21.6%; OR, 4.19 [95% CI, 3.58-4.90]), more often used hospice services (38.7% vs 18.2%; OR, 3.32 [95% CI, 2.83-3.89]), and died less frequently in a hospital (41.4% vs 57.3%; OR, 0.78 [95% CI, 0.74-0.82]). Hospitalization (55.5%; OR, 0.39 [95% CI, 0.32-0.46]), receipt of an intensive procedure (13.7%; OR, 0.60 [95% CI, 0.46-0.77]), and in-hospital death (39.0%; OR, 0.47 [95% CI, 0.39-0.56]) were also less common among decedents who had been discussing and/or preparing for dialysis therapy, but their use of palliative care and hospice services was similar.LIMITATIONS: Findings may not be generalizable to groups not well represented in the Veterans Affairshealth care system.CONCLUSIONS: Among decedents, patients not treated with dialysis before death received less intensive patterns of end-of-life care than those treated with dialysis. Decedents for whom there had been a decision not to pursue dialysis therapy before death were more likely to receive palliative care and hospice.
View details for PubMedID 29331475
- Second-Line Agents for the Treatment of Type 2 Diabetes and Prevention of CKD. Clinical journal of the American Society of Nephrology : CJASN 2016; 11 (12): 2104–6
Trends in the Timing and Clinical Context of Maintenance Dialysis Initiation
JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY
2015; 26 (8): 1975-1981
Whether secular trends in eGFR at dialysis initiation reflect changes in clinical presentation over time is unknown. We reviewed the medical records of a random sample of patients who initiated maintenance dialysis in the Department of Veterans Affairs (VA) in fiscal years 2000-2009 (n=1691) to characterize trends in clinical presentation in relation to eGFR at initiation. Between fiscal years 2000-2004 and 2005-2009, mean eGFR at initiation increased from 9.8±5.8 to 11.0±5.5 ml/min per 1.73 m(2) (P<0.001), the percentage of patients with an eGFR of 10-15 ml/min per 1.73 m(2) increased from 23.4% to 29.9% (P=0.002), and the percentage of patients with an eGFR>15 ml/min per 1.73 m(2) increased from 12.1% to 16.3% (P=0.01). The proportion of patients who were acutely ill at the time of initiation and the proportion of patients for whom the decision to initiate dialysis was based only on level of kidney function did not change over time. Frequencies of documented clinical signs and/or symptoms were similar during both time periods. The adjusted odds of initiating dialysis at an eGFR of 10-15 or >15 ml/min per 1.73 m(2) (versus <10 ml/min per 1.73 m(2)) during the later versus earlier time period were 1.43 (95% confidence interval [95% CI], 1.13 to 1.81) and 1.46 (95% CI, 1.09 to 1.97), respectively. In conclusion, trends in eGFR at dialysis initiation at VA medical centers do not seem to reflect changes in the clinical context in which dialysis is initiated.
View details for DOI 10.1681/ASN.2013050531
View details for Web of Science ID 000358895100021
View details for PubMedID 25700539
View details for PubMedCentralID PMC4520153
Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs
CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY
2015; 10 (8): 1418-1427
The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)-the largest non-fee-for-service health system in the United States.The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 (n=971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: (1) veterans whose dialysis was paid for by the VA, (2) veterans whose dialysis was not paid for by the VA, and (3) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR≥10 ml/min per 1.73 m(2).The adjusted probability of starting dialysis at an eGFR≥10 ml/min per 1.73 m(2) increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients (P for interaction <0.001) and those with a higher risk of 1-year mortality (P for interaction <0.001).Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk.
View details for DOI 10.2215/CJN.12731214
View details for Web of Science ID 000359172800017
View details for PubMedID 26206891
View details for PubMedCentralID PMC4527039
Associations between sex and incident chronic kidney disease in a prospective diabetic cohort
2015; 20 (7): 451-458
Women with diabetes have a higher prevalence of chronic kidney disease (CKD) risk factors compared with men, but whether they are at higher risk for incident CKD remains uncertain.This was a prospective, observational cohort study of 1464 patients with diabetes and normal renal function, recruited from primary care clinics at a vertically integrated healthcare system in Seattle, WA, USA. The primary predictor was sex. Incident CKD was defined by an estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m(2) by Chronic Kidney Disease-Epidemiology equations or sex-specific microalbuminuria (urine albumin/creatinine ratio ≥25 mg/g for women or ≥17 mg/g for men).Of the 1464 patients (52.0% women), CKD incidence rates were 154.0 and 144.3 cases per 1000 patient-years for women and men, respectively. In the competing risks regression, women had an increased risk of incident CKD (sub-hazard ratio 1.37, 95% confidence interval (CI) 1.17, 1.60) compared with men after adjustment for demographics, baseline eGFR and duration of diabetes, which persisted after additional adjustment for CKD risk factors, depressive symptoms and diabetes self-care (sub-hazard ratio 1.35, 95% CI 1.15, 1.59). Sex differences in incident CKD were consistent across age groups and appeared to be driven by differences in the development of low eGFR rather than microalbuminuria.Women with diabetes had a higher risk of incident CKD compared with men, which could not be entirely explained by differences in biologic CKD risk factors, depression or diabetes self-care. Additional work is needed determine if these sex differences contribute to worse outcomes in women with diabetes.
View details for DOI 10.1111/nep.12468
View details for Web of Science ID 000356084100003
View details for PubMedID 25807970
View details for PubMedCentralID PMC4465880
Associations between Depressive Symptoms and Incident ESRD in a Diabetic Cohort
CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY
2014; 9 (5): 920-928
Comorbid major depression is associated with adverse health outcomes in patients with diabetes, but little is known regarding its associations with long-term renal outcomes in this population. Furthermore, the impact of minor depression on renal outcomes is not known. This study evaluated associations between depressive symptoms and risk of incident ESRD in a diabetic cohort.In this prospective, observational cohort study, 3886 ambulatory adults with diabetes were recruited from primary care clinics of a large health maintenance organization in the state of Washington. Demographics, laboratory data, depressive symptoms (based on the Patient Health Questionnaire-9), and patterns of diabetes self-care were collected. Participants were considered depressed if they had the required number of depressive symptoms (≥ 5 for major or 2-4 for minor depressive symptoms), including depressed mood or anhedonia, >50% of the time for ≥ 2 weeks and a Patient Health Questionnaire-9 score ≥ 10 for major and ≥ 5 for minor depressive symptoms. Risk of incident ESRD was estimated using Cox proportional hazards regression, with predialysis death as a competing risk.During a median follow-up of 8.8 years, 87 patients (2.2%) developed ESRD. Major depressive symptoms were associated with a higher risk of incident ESRD (hazard ratio, 1.85; 95% confidence interval, 1.02 to 3.33) after adjusting for age, sex, race/ethnicity, marital status, education, smoking, body mass index, diabetes duration, hemoglobin A1c, baseline kidney function, microalbuminuria, hypertension, renin-angiotensin system blockers, and adherence to diabetes self-care. Minor depressive symptoms were not significantly associated with incident ESRD (hazard ratio, 1.08; 95% confidence interval, 0.52 to 2.25).Major depressive symptoms, but not minor depressive symptoms, were associated with a higher risk of incident ESRD over 10 years. Additional studies are needed to determine whether treatment for depression can improve renal outcomes in patients with diabetes.
View details for DOI 10.2215/CJN.08670813
View details for Web of Science ID 000335519300015
View details for PubMedID 24677559
View details for PubMedCentralID PMC4011449
Diabetes Self-Care, Major Depression, and Chronic Kidney Disease in an Outpatient Diabetic Population
NEPHRON CLINICAL PRACTICE
2013; 124 (1-2): 106-112
The associations between major depression and chronic kidney disease (CKD) in patients with diabetes are incompletely characterized. Depressed patients with diabetes are known to have worse diabetes self-care, but it is not known whether this mediates the association between depression and CKD in this population.We conducted a cross-sectional study of the associations between major depressive symptoms and CKD in the Pathways Study (n = 4,082), an observational cohort of ambulatory diabetic patients from a managed care setting. Depression status was ascertained using the Patient Health Questionnaire-9 (PHQ-9). Stepwise logistic regression models examined the associations between depression and impaired estimated glomerular filtration rate (<60 ml/min/1.73 m(2)) or microalbuminuria, after adjustment for demographics, CKD risk factors, and diabetes self-care variables.Clinically significant depression symptoms (PHQ-9 ≥10) were associated with a greater risk of microalbuminuria after adjustment for demographic variables (OR 1.54, 95% CI 1.21-1.95) and traditional CKD risk factors (OR 1.36, 95% CI 1.04-1.77); this association persisted after additional adjustment for diabetes self-care (OR 1.34, 95% CI 1.02-1.75). Depression was not associated with impaired estimated glomerular filtration rate in any of the models.In this cohort of diabetic subjects, clinically significant depression symptoms were associated with microalbuminuria, which could not be entirely explained by differences in diabetes self-care.
View details for DOI 10.1159/000355551
View details for Web of Science ID 000328704800016
View details for PubMedID 24192760
View details for PubMedCentralID PMC3897267
Sex Disparities in Diabetes Process of Care Measures and Self-Care in High-Risk Patients
JOURNAL OF DIABETES RESEARCH
Patients with chronic diabetic complications experience high morbidity and mortality. Sex disparities in modifiable factors such as processes of care or self-care activities have not been explored in detail, particularly in these high-risk patients. Sex differences in processes of care and self-care activities were assessed in a cross-sectional analysis of the Pathways Study, an observational cohort of primary care diabetic patients from a managed care organization (N = 4,839). Compared to men, women had decreased odds of dyslipidemia screening (adjusted odds ratio (AOR) 0.73, 95% CI 0.62-0.85), reaching low-density lipoprotein goal (AOR 0.70, 95% CI 0.58-0.86), and statin use (AOR 0.69, 95% CI 0.58-0.81); women had 19% greater odds of reaching hemoglobin A1c <7% (95% CI 1.02-1.41). There were no sex differences in hemoglobin A1c testing, microalbuminuria screening, or angiotensin-converting enzyme inhibitor use. Women were less likely to report regular exercise but had better adherence to healthy diet, glucose monitoring, and self-foot examination compared to men. Patterns of sex differences were consistent in subjects with diabetic complications. Significant sex disparities exist in diabetes process of care measures and self-care, even amongst patients known to have chronic diabetic complications.
View details for DOI 10.1155/2013/575814
View details for Web of Science ID 000318673200001
View details for PubMedID 23671877
View details for PubMedCentralID PMC3647593
Risk Factor, Age and Sex Differences in Chronic Kidney Disease Prevalence in a Diabetic Cohort: The Pathways Study
AMERICAN JOURNAL OF NEPHROLOGY
2012; 36 (3): 245-251
Women with diabetes experience a disproportionately greater burden of diabetic kidney disease (DKD) risk factors compared to men; however, sex-specific differences in DKD are not well defined. The effect of age on sex differences in DKD is unknown.We performed a cross-sectional analysis of the prevalence of DKD (eGFR <60 ml/min/1.73 m(2) or microalbuminuria), advanced DKD (eGFR <30 ml/min/1.73 m(2)), and common DKD risk factors in the Pathways Study (n = 4,839), a prospective cohort study of diabetic patients from a managed care setting. Subjects were stratified by age <60 and ≥60 years to examine for differences by age. Logistic regression models examined the association between sex and prevalence of DKD and risk factors.Women of all ages had 28% decreased odds of DKD (OR 0.72, 95% CI 0.62-0.83); however, they had a greater prevalence of advanced DKD (OR 1.67, 95% CI 1.05-2.64), dyslipidemia (OR 1.42, 95% CI 1.16-1.74), and obesity (OR 1.87, 95% CI 1.60-2.20) compared to men. Women had similar odds of hypertension and poor glycemic control as men. Women ≥60 years had increased odds of advanced DKD, hypertension, dyslipidemia, and obesity compared to similarly aged men. Women <60 years had increased odds of obesity compared to their male counterparts.Women with diabetes had an increased prevalence of advanced DKD and common DKD risk factors compared to men and these disparities were most prominent amongst the elderly.
View details for DOI 10.1159/000342210
View details for Web of Science ID 000309383800006
View details for PubMedID 22964976
View details for PubMedCentralID PMC3510352