Bio


Shuchi Anand M.D. M.S. is Director of the Center for Tubulointerstitial Kidney Disease at Stanford University (http://stan.md/tikidney). She received her Medical Degree from Washington University School of Medicine in St. Louis, and completed her internal medicine training at Brigham and Women's Hospital (Partners Healthcare, Harvard Medical School) in Boston. She completed her Masters in Clinical Epidemiology and nephrology fellowship at Stanford University School of Medicine.

Dr. Anand is engaged in clinical research aimed at advancing the care of patients with kidney disease living in low-resource settings using practical tools. She has active projects in collaboration with University of Utah promote exercise programming for underserved populations, with Center for Chronic Disease Control in India to study risk factors for kidney disease in South Asians, and with Kandy Hospital Sri Lanka to investigate chronic kidney disease of unknown etiology affecting agricultural communities. During the COVID19 pandemic Dr Anand also participated in partnership to elucidate sero-epidemiology, vaccine acceptance and response to vaccination among patients on dialysis. She is part of two NIH consortia focused on improving the health of underserved populations.

Clinical Focus


  • Nephrology
  • Tubulointerstitial disease

Academic Appointments


Administrative Appointments


  • Nephrology Elective Director, Stanford University (2014 - 2021)

Boards, Advisory Committees, Professional Organizations


  • Member, Asian Nephrologists of Indian Origin (2017 - Present)
  • Organizing member, International Consortium of CKDu Collaborators (2016 - Present)
  • Board Member, International Society of Nephrology, North America and Carribean Regional Board (2017 - Present)

Professional Education


  • Fellowship: Stanford University Nephrology Fellowship (2012) CA
  • Residency: Brigham and Women's Hospital Internal Medicine Residency (2009) MA
  • Medical Education: Washington University School Of Medicine Registrar (2006) MO
  • Board Certification: American Board of Internal Medicine, Nephrology (2012)
  • Board Certification: American Board of Internal Medicine, Internal Medicine (2009)
  • Masters in Clinical Epidemiology, Stanford University School of Medicine
  • Fellowship, Stanford University School of Medicine, Nephrology
  • Residency, Brigham and Women's Hospital, Internal Medicine (2009)

Community and International Work


  • ISN Sister Center

    Topic

    Supporting peritoneal dialysis

    Partnering Organization(s)

    Kandy Hospital

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    Yes

Current Research and Scholarly Interests


Dr Anand is interested in improving care for patients with kidney disease living in low-resource settings and using practical tools. She has active projects in India and Sri Lanka. She is also involved with the Exercise is Medicine initiative, with an active pilot clinical trial in adapting the intervention for patients with advanced kidney disease.

Clinical Trials


  • Exercise is Medicine for Patients With CKD Not Recruiting

    The investigators plan to integrate and tailor the existing Exercise is Medicine framework, an evidence-based multi-level intervention program developed by the American Society of Sports Medicine, for the care of patients with advanced chronic kidney disease. In this pilot randomized control trial, investigators will compare the effects and feasibility of two intervention arms designed to start and maintain physical activity in this high-risk population (Group 1: physical activity assessment, brief counseling session + physical activity wearable versus Group 2: Group 1 intervention components + referral to a free, community-based, EIM practitioner led group exercise program).

    Stanford is currently not accepting patients for this trial.

    View full details

  • SARS-COV-2 Screening in Dialysis Facilities Not Recruiting

    Patients receiving dialysis are one of the highest risk groups for serious illness with SARS-CoV-2 infection. In addition to the inherent risks of travel to and dialysis within indoor facilities, patients receiving dialysis are more likely to be older, non-white, from disadvantaged backgrounds, and have impaired immune responses to viral infections and vaccinations. Universal testing offered at hemodialysis facilities could shield this vulnerable population from exposure, enable early identification and treatment for those affected, and reduce transmission to other patients and family members. In this pragmatic cluster randomized controlled trial as part of NIH RADx-UP Consortium, we will randomize 62 US Renal Care facilities with an estimated 2480 patients to static versus dynamic universal screening testing strategies. Static universal screening will involve offering patients SARS-CoV-2 screening tests every two weeks; the dynamic universal screening strategy will vary the frequency of testing from once every week to once every four weeks, depending on community COVID-19 case rates. We hypothesize that patients dialyzing at facilities randomized to a dynamic testing frequency responsive to community case rates will have higher test acceptability (primary outcome), experience lower rates of COVID-19 death and hospitalization, and report better experience-of-care metrics.

    Stanford is currently not accepting patients for this trial. For more information, please contact Shuchi Anand, MD, (650) 725 - 2207.

    View full details

Projects


  • CKDu in Sri Lanka: standardizing data collection for case definition and epidemiology research, Stanford University

    Working with collaborators at Kandy Teaching Hospital and University of Peradeniya to understand clinical features and epidemiology of Chronic Kidney Disease of Unknown Etiology

    Location

    Kandy, Sri Lanka

    Collaborators

    • Nishantha Nanayakkara, Dr., Kandy Teaching Hospital
  • CKD in South Asians: CARRS study, Stanford University

    Working with CCDC in New Delhi India to identify prevalence, incidence and risk factors for chronic kidney disease in a population based cohort

    Location

    New Delhi, India

    Collaborators

    • Droiraj Prabhkaran, Dr, CCDC

2023-24 Courses


Graduate and Fellowship Programs


All Publications


  • Capacity for the management of kidney failure in the International Society of Nephrology North America and the Caribbean region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA). Kidney international supplements Lowe-Jones, R., Ethier, I., Fisher, L. A., Wong, M. M., Thompson, S., Nakhoul, G., Sandal, S., Chanchlani, R., Davison, S. N., Ghimire, A., Jindal, K., Osman, M. A., Riaz, P., Saad, S., Sozio, S. M., Tungsanga, S., Cambier, A., Arruebo, S., Bello, A. K., Caskey, F. J., Damster, S., Donner, J. A., Jha, V., Johnson, D. W., Levin, A., Malik, C., Nangaku, M., Okpechi, I. G., Tonelli, M., Ye, F., Parekh, R. S., Anand, S. 2024; 13 (1): 83-96

    Abstract

    The International Society of Nephrology Global Kidney Health Atlas charts the availability and capacity of kidney care globally. In the North America and the Caribbean region, the Atlas can identify opportunities for kidney care improvement, particularly in Caribbean countries where structures for systematic data collection are lacking. In this third iteration, respondents from 12 of 18 countries from the region reported a 2-fold higher than global median prevalence of dialysis and transplantation, and a 3-fold higher than global median prevalence of dialysis centers. The peritoneal dialysis prevalence was lower than the global median, and transplantation data were missing from 6 of the 10 Caribbean countries. Government-funded payments predominated for dialysis modalities, with greater heterogeneity in transplantation payor mix. Services for chronic kidney disease, such as monitoring of anemia and blood pressure, and diagnostic capability relying on serum creatinine and urinalyses were universally available. Notable exceptions in Caribbean countries included non-calcium-based phosphate binders and kidney biopsy services. Personnel shortages were reported across the region. Kidney failure was identified as a governmental priority more commonly than was chronic kidney disease or acute kidney injury. In this generally affluent region, patients have better access to kidney replacement therapy and chronic kidney disease-related services than in much of the world. Yet clear heterogeneity exists, especially among the Caribbean countries struggling with dialysis and personnel capacity. Important steps to improve kidney care in the region include increased emphasis on preventive care, a focus on home-based modalities and transplantation, and solutions to train and retain specialized allied health professionals.

    View details for DOI 10.1016/j.kisu.2024.01.003

    View details for PubMedID 38618503

    View details for PubMedCentralID PMC11010606

  • TINU: A Multisystemic Inflammatory Disorder-Case Report and Literature Review. Case reports in nephrology Montejo-Hernandez, J., Rico-Fontalvo, J., Cabrales, J., Anand, S., Martinez-Avila, M. C., Duran-Merino, C., Arias-Restrepo, L., Gomez Duran, C. A. 2024; 2024: 3909755

    Abstract

    Background. The syndrome of tubulointerstitial nephritis and uveitis (TINU) is a rare oculorenal condition, mainly seen in children and women. The underlying cause of this disease is unknown. Case Presentation. We report a 24-year-old male without any past medical history, diagnosed with bilateral uveitis and azotemia. Biopsy revealed tubulointerstitial nephritis, consistent with TINU syndrome. Fluorescein angiogram revealed peripheral retinal vasculitis. Discussion. TINU is a rare disorder that needs to be distinguished from sarcoidosis, Sjogren's disease, and tuberculosis. Treatment is indicated in patients with progressive renal insufficiency, consisting of steroid therapy. Most patients recover kidney function. Its early recognition is important to offer the best chance of organ preservation.

    View details for DOI 10.1155/2024/3909755

    View details for PubMedID 38633468

  • Kidney biopsies among persons living in hotspots of CKDu: A position statement from the International Society of Nephrology's Consortium of Collaborators on CKDu. Kidney international Wijewickrama, E., Behera, S., Garcia, P., Avila-Casado, C., Caplin, B., Paolo, V. S., Courville, K., Friedman, D., Madero, M., Jha, V., Kambham, N., Levin, A., Anand, S., ISN i3C Working Group, Anand, S., Avila-Casado, C., Bavanandan, S., Bajpai, D., Behera, S., Brown, J. M., Caplin, B., Daniel, C., de Broe, M., Enghard, P., Fuentes, A. F., Fire, A. Z., Fischer, R. S., Friedman, D., Garcia, P., Gonzalez-Quiroz, M., Herath, C., Honsova, E., Jha, V., Johnson, R. J., Kanjanabuch, T., Kambham, N., Bandi, V. K., Levin, A., Madero, M., Mandayam, S., Mikhailov, A., Nanayakkara, N., Nishanthi, N., Nlandu, Y. M., Pippias, M., Prasad, N., Alam, M. R., Polo, V. S., Seshan, S. V., Sheikh-Hamad, D., Singh, G., Strasma, A., Tzanno-Martins, C., Ulasi, I., Vervaet, B. A., Waikar, S. S., Wijewickrama, E., Wijkstrom, J., Yang, C. 2023

    View details for DOI 10.1016/j.kint.2023.12.012

    View details for PubMedID 38160755

  • Kidney disease hotspots and water balance in a warming world. Current opinion in nephrology and hypertension Contreras Nieves, M., Powers, A., Anand, S., Vlahos, P. 2023

    Abstract

    PURPOSE OF REVIEW: Geographically localized areas with a high prevalence of kidney disease exist currently in several regions of the world. Although the exact cause is unclear, environmental exposures accelerated by climate change, particularly heat exposure and ground water contamination, are hypothesized as putative risk factors. Aiming to inform investigations of water-related exposures as risk factors for kidney disease, we excavate the history of major water sources in three regions that are described as hotspots of kidney disease: the low-lying coastal regions in El Salvador and Nicaragua, the dry central region in Sri Lanka, and the Central Valley of California.RECENT FINDINGS: Historic data indicate that these regions have experienced water scarcity to which several human-engineered solutions were applied; these solutions could be hypothesized to increase residents' exposure to putative kidney toxins including arsenic, fluoride, pesticides, and cyanobacteria. Combined with heat stress experienced in context of climate change, there is potential for multistressor effects on kidney function. Climate change will also amplify water scarcity, and even if regional water sources are not a direct risk factor for development of kidney disease, their scarcity will complicate the treatment of the relatively larger numbers of persons with kidney disease living in these hotspots.SUMMARY: Nephrologists and kidney disease researchers need to engage in systematic considerations of environmental exposures as potential risk factors for kidney disease, including water sources, their increasing scarcity, and threats to their quality due to changing climate.

    View details for DOI 10.1097/MNH.0000000000000938

    View details for PubMedID 37889529

  • Use of Wastewater Metrics to Track COVID-19 in the US. JAMA network open Varkila, M. R., Montez-Rath, M. E., Salomon, J. A., Yu, X., Block, G. A., Owens, D. K., Chertow, G. M., Parsonnet, J., Anand, S. 2023; 6 (7): e2325591

    Abstract

    Importance: Widespread use of at-home COVID-19 tests hampers determination of community COVID-19 incidence.Objective: To examine the association of county-level wastewater metrics with high case and hospitalization rates nationwide both before and after widespread use of at-home tests.Design, Setting, and Participants: This observational cohort study with a time series analysis was conducted from January to September 2022 in 268 US counties in 22 states participating in the US Centers for Disease Control and Prevention's National Wastewater Surveillance System. Participants included the populations of those US counties.Exposures: County level of circulating SARS-CoV-2 as determined by metrics based on viral wastewater concentration relative to the county maximum (ie, wastewater percentile) and 15-day percentage change in SARS-CoV-2 (ie, percentage change).Main Outcomes and Measures: High county incidence of COVID-19 as evidenced by dichotomized reported cases (current cases ≥200 per 100 000 population) and hospitalization (≥10 per 100 000 population lagged by 2 weeks) rates, stratified by calendar quarter.Results: In the first quarter of 2022, use of the wastewater percentile detected high reported case (area under the curve [AUC], 0.95; 95% CI, 0.94-0.96) and hospitalization (AUC, 0.86; 95% CI, 0.84-0.88) rates. The percentage change metric performed poorly, with AUCs ranging from 0.51 (95% CI, 0.50-0.53) to 0.57 (95% CI, 0.55-0.59) for reported new cases, and from 0.50 (95% CI, 0.48-0.52) to 0.55 (95% CI, 0.53-0.57) for hospitalizations across the first 3 quarters of 2022. The Youden index for detecting high case rates was wastewater percentile of 51% (sensitivity, 0.82; 95% CI, 0.80-0.84; specificity, 0.93; 95% CI, 0.92-0.95). A model inclusive of both metrics performed no better than using wastewater percentile alone. The performance of wastewater percentile declined over time for cases in the second quarter (AUC, 0.84; 95% CI, 0.82-0.86) and third quarter (AUC, 0.72; 95% CI, 0.70-0.75) of 2022.Conclusions and Relevance: In this study, nationwide, county wastewater levels relative to the county maximum were associated with high COVID-19 case and hospitalization rates in the first quarter of 2022, but there was increasing dissociation between wastewater and clinical metrics in subsequent quarters, which may reflect increasing underreporting of cases, reduced testing, and possibly lower virulence of infection due to vaccines and treatments. This study offers a strategy to operationalize county wastewater percentile to improve the accurate assessment of community SARS-CoV-2 infection prevalence when reliability of conventional surveillance data is declining.

    View details for DOI 10.1001/jamanetworkopen.2023.25591

    View details for PubMedID 37494040

  • Describing Natural History and Exploring Risk Factors for Kidney Function Decline in Persons With CKD of Uncertain Etiology in Sri Lanka. Kidney international reports Hewavitharana, P., Schensul, S., Lee, E., Montez-Rath, M., Senarathne, S., Liu, S., Harold, K., Hewapathiranage, S., Erandika, N., Abeysundara, H. T., Yu, X., Bhalla, V., Fire, A., Levin, A., Anand, S., Vlahos, P., Chandrajith, R., Nanayakkara, N. 2023; 8 (7): 1430-1438

    Abstract

    Chronic kidney disease of uncertain etiology (CKDu) is a leading cause of death of adults in Sri Lanka's dry region.We initiated the Kidney Progression Project (KiPP) to prospectively follow 292 persons with Chronic Kidney Disease Epidemiology Collaboration estimated glomerular filtration rate (eGFR) 20 to 60 ml/min per 1.73 m2 living in a CKDu endemic area. Using data from 3-year follow-up, we assessed kidney function decline (>30% from baseline eGFR), and the composite outcome of >30% eGFR decline, eGFR <15 ml/min or death, and explored the association of the 2 outcomes with baseline demographic, residential, and clinical parameters accounting for baseline eGFR.Median eGFR at enrollment was 28 ml/min among 71 women; 30 ml/min among 221 men; 91% to 99% had trace or no proteinuria during follow-up. At enrollment, median serum sodium, uric acid, and potassium were 143 mmol/l, 6.3 mg/dl, 4.5 meq/l, respectively among women; and 143 mmol/l, 6.9 mg/dl, 4.3 meq/l among men. Mean slope of eGFR decline was -0.5 (SD 4.9) ml/min/yr. In exploratory analyses, men with greater years of education and those living in northern region of the study area experienced lower likelihood of disease progression (hazard ratios [HR] 0.87 [0.77-0.98] per additional year and 0.33 [0.12-0.89] for northern versus other subregions, respectively). There was a suggestion that men drinking well water had higher likelihood and men living further away from reservoirs had lower likelihood of >30% decline in eGFR (HR 2.07 [0.95-4.49] for drinking well water versus not, and HR 0.58 [0.32-1.05] per kilometer distance, respectively).The overall rate of kidney function decline was slow in this CKDu cohort, similar to other nonalbuminuric CKD, and event rates were similar among men and women. Further etiologic investigations could focus on specific residence locale and water use.

    View details for DOI 10.1016/j.ekir.2023.04.010

    View details for PubMedID 37441476

    View details for PubMedCentralID PMC10334401

  • Acute kidney injury in patients treated with immune checkpoint inhibitors JOURNAL FOR IMMUNOTHERAPY OF CANCER Gupta, S., Short, S. P., Sise, M. E., Prosek, J. M., Madhavan, S. M., Soler, M., Ostermann, M., Herrmann, S. M., Abudayyeh, A., Anand, S., Glezerman, I., Motwani, S. S., Murakami, N., Wanchoo, R., Ortiz-Melo, D., Rashidi, A., Sprangers, B., Aggarwal, V., Malik, A., Loew, S., Carlos, C. A., Chang, W., Beckerman, P., Mithani, Z., Shah, C., Renaghan, A. D., De Seigneux, S., Campedel, L., Kitchlu, A., Shin, D., Rangarajan, S., Deshpande, P., Coppock, G., Eijgelsheim, M., Seethapathy, H., Lee, M. D., Strohbehn, I. A., Owen, D. H., Husain, M., Garcia-Carro, C., Bermejo, S., Lumlertgul, N., Seylanova, N., Flanders, L., Isik, B., Mamlouk, O., Lin, J. S., Garcia, P., Kaghazchi, A., Khanin, Y., Kansal, S. K., Wauters, E., Chandra, S., Schmidt-Ott, K. M., Hsu, R. K., Tio, M. C., Mothi, S., Singh, H., Schrag, D., Jhaveri, K. D., Reynolds, K. L., Cortazar, F. B., Leaf, D. E., ICPi- AKI Consortium Investigators 2023; 11 (4)
  • Feasibility and Acceptability of SARS-CoV-2 Screening among Patients Receiving Hemodialysis: A Pilot Study. Clinical journal of the American Society of Nephrology : CJASN Anand, S., Montez-Rath, M., Varkila, M., Yu, X., Block, M., Brillhart, S., Leppink, A., Hunsader, P., Owens, D. K., Chertow, G. M., Parsonnet, J., Block, G. 2023

    View details for DOI 10.2215/CJN.0000000000000137

    View details for PubMedID 36976655

  • Use of wastewater metrics to track COVID-19 in the U.S.: a national time-series analysis over the first three quarters of 2022. medRxiv : the preprint server for health sciences Varkila, M., Montez-Rath, M., Salomon, J., Yu, X., Block, G., Owens, D. K., Chertow, G. M., Parsonnet, J., Anand, S. 2023

    Abstract

    Widespread use of at-home COVID-19 tests hampers determination of community COVID-19 incidence. Using nationwide data available through the US National Wastewater Surveillance System, we examined the performance of two wastewater metrics in predicting high case and hospitalizations rates both before and after widespread use of at-home tests.We performed area under the receiver operating characteristic (ROC) curve analysis (AUC) for two wastewater metrics-viral concentration relative to the peak of January 2022 ("wastewater percentile") and 15-day percent change in SARS-CoV-2 ("percent change"). Dichotomized reported cases (≥ 200 or <200 cases per 100,000) and new hospitalizations (≥ 10 or <10 per 100,000) were our dependent variables, stratified by calendar quarter. Using logistic regression, we assessed the performance of combining wastewater metrics.Among 268 counties across 22 states, wastewater percentile detected high reported case and hospitalizations rates in the first quarter of 2022 (AUC 0.95 and 0.86 respectively) whereas the percent change did not (AUC 0.54 and 0.49 respectively). A wastewater percentile of 51% maximized sensitivity (0.93) and specificity (0.82) for detecting high case rates. A model inclusive of both metrics performed no better than using wastewater percentile alone. The predictive capability of wastewater percentile declined over time (AUC 0.84 and 0.72 for cases for second and third quarters of 2022).Nationwide, county wastewater levels above 51% relative to the historic peak predicted high COVID rates and hospitalization in the first quarter of 2022, but performed less well in subsequent quarters. Decline over time in predictive performance of this metric likely reflects underreporting of cases, reduced testing, and possibly lower virulence of infection due to vaccines and treatments.

    View details for DOI 10.1101/2023.02.06.23285542

    View details for PubMedID 36798337

    View details for PubMedCentralID PMC9934789

  • Risk Amplifiers for Vascular Disease and CKD in South Asians: When Intrinsic beta-Cell Dysfunction Meets a High-Carbohydrate Diet. Clinical journal of the American Society of Nephrology : CJASN Vijayan, M., Deshpande, K., Anand, S., Deshpande, P. 2023

    Abstract

    South Asians, comprising almost one fourth of the world population, are at higher risk of type 2 diabetes mellitus, hypertension, cardiovascular disease, and CKD compared with other ethnic groups. This has major public health implications in South Asia and in other parts of the world to where South Asians have immigrated. The interplay of various modifiable and nonmodifiable risk factors confers this risk. Traditional models of cardiometabolic disease progression and CKD evaluation may not be applicable in this population with a unique genetic predisposition and phenotype. A wider understanding of dietary and lifestyle influences, genetic and metabolic risk factors, and the pitfalls of conventional equations estimating kidney function in this population are required in providing care for kidney diseases. Targeted screening of this population for metabolic and vascular risk factors and individualized management plan for disease management may be necessary. Addressing unhealthy dietary patterns, promoting physical activity, and medication management that adheres to cultural factors are crucial steps to mitigate the risk of cardiovascular disease and CKD in this population. In South Asian countries, a large rural and urban community-based multipronged approach using polypills and community health workers to decrease the incidence of these diseases may be cost-effective.

    View details for DOI 10.2215/CJN.0000000000000076

    View details for PubMedID 36758530

  • Challenges and opportunities in interventions for chronic kidney disease of unknown origin (CKDu): report from the International Society of Nephrology Consortium of Collaborators on CKDu. Kidney international Smyth, B., Glaser, J., Butler-Dawson, J., Nanayakkara, N., Wegman, D. H., Anand, S., Levin, A., International Society of Nephrologys International Consortium of Collaborators on Chronic Kidney Disease of Unknown Etiology (i3C), Caplin, B., Correa Rotter, R., Eckardt, K., Fire, A., Friedman, D., Herath, C., Jha, V., Wijewickrama, E., Yang, C., Bajpai, D., Pippias, M., Ulasi, I., Nangaku, M. 2023; 103 (1): 6-12

    View details for DOI 10.1016/j.kint.2022.10.013

    View details for PubMedID 36603985

  • Hemoglobin Levels Among Male Agricultural Workers: Analyses From the Demographic and Health Surveys to Investigate a Marker for Chronic Kidney Disease of Uncertain Etiology. Journal of occupational and environmental medicine Lin, Y., Heng, S., Anand, S., Deshpande, S. K., Small, D. S. 2022; 64 (12): e805-e810

    Abstract

    Estimate agricultural work's effect on hemoglobin (Hgb) level in men. A negative effect may indicate presence of chronic kidney disease of uncertain etiology.We use Demographic and Health Surveys data from seven African and Asian countries and use matching to control for seven confounders.On average, Hgb levels were 0.09 g/dL lower among agricultural workers compared with matched controls. Significant effects were observed in Ethiopia, India, Lesotho, and Senegal, with effects from 0.07 to 0.30 g/dL lower Hgb level among agricultural workers. The findings were robust to multiple control groups and a modest amount of unmeasured confounding.Men engaged in agricultural work in four of the seven countries studied have modestly lower Hgb levels. Our data support integrating kidney function assessments within Demographic and Health Surveys and other population-based surveys.

    View details for DOI 10.1097/JOM.0000000000002703

    View details for PubMedID 36472566

    View details for PubMedCentralID PMC9731347

  • Estimated glomerular filtration rate trajectories in south Asians: Findings from the cardiometabolic risk reduction in south Asia study. The Lancet regional health. Southeast Asia Jagannathan, R., Anand, S., Hogan, J., Mandal, S., Kondal, D., Gupta, R., Patel, S. A., Anjana, R. M., Deepa, M., Ali, M. K., Mohan, V., Tandon, N., Narayan, K. M., Prabhakaran, D. 2022; 6: 100062

    Abstract

    Few longitudinal data characterize kidney function decline among South Asians, one of the world's largest population groups. We aimed to identify estimated glomerular filtration rate (eGFR) trajectories in a population-based cohort from India and assess predictors of rapid kidney function decline.We used 6-year longitudinal data from participants of a population-representative study from Delhi and Chennai, India who had at least two serum creatinine measures and baseline CKD-EPI eGFR> 60 ml/min/1.73m2 (n=7779). We used latent class trajectory modeling to identify patterns of kidney function trajectory (CKD-EPI eGFR) over time. In models accounting for age, sex, education, and city, we tested the association between 15 hypothesized risk factors and rapid kidney function decline.Baseline mean eGFR was 108 (SD 16); median eGFR was 110 [IQR: 99-119] ml/min/1.73m2. Latent class trajectory modeling and functional characterization identified three distinct patterns of eGFR: class-1 (no decline; 58%) annual eGFR change 0.2 [0.1, 0.3]; class-2 (slow decline; 40%) annual eGFR change -0.2 [-0.4, -0.1], and class-3 (rapid decline; 2%) annual eGFR change -2.7 [-3.4, -2.0] ml/min/1.73m2. Albuminuria (>30 mg/g) was associated with rapid eGFR decline (OR for class-3 vs class-1: 5.1 [95% CI: 3.2; 7.9]; class-3 vs. class-2: 4.3 [95% CI:2.7; 6.6]). Other risk factors including self-reported diabetes, cardiovascular disease, peripheral arterial disease, and metabolic biomarkers such as HbA1c and systolic blood pressure were associated with rapid eGFR decline phenotype but potential 'non-traditional' risk factors such as manual labor or household water sources were not.Although mean and median eGFRs in our population-based cohort were higher than those reported in European cohorts, we found that a sizeable number of adults residing in urban India are experiencing rapid kidney function decline. Early and aggressive risk modification among persons with albuminuria could improve kidney health among South Asians.The CARRS study has been funded with federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, under Contract No. HHSN2682009900026C and P01HL154996. Dr. Anand was supported by NIDDK K23DK101826 and R01DK127138.

    View details for DOI 10.1016/j.lansea.2022.100062

    View details for PubMedID 37383342

    View details for PubMedCentralID PMC10305991

  • Author Correction: Impact of the COVID-19 pandemic on the kidney community: lessons learned and future directions. Nature reviews. Nephrology Geetha, D., Kronbichler, A., Rutter, M., Bajpai, D., Menez, S., Weissenbacher, A., Anand, S., Lin, E., Carlson, N., Sozio, S., Fowler, K., Bignall, R., Ducharlet, K., Tannor, E. K., Wijewickrama, E., Hafidz, M. I., Tesar, V., Hoover, R., Crews, D., Varnell, C., Danziger-Isakov, L., Jha, V., Mohan, S., Parikh, C., Luyckx, V. 2022

    View details for DOI 10.1038/s41581-022-00635-3

    View details for PubMedID 36127498

    View details for PubMedCentralID PMC9487852

  • Shorter versus longer corticosteroid duration and recurrent immune checkpoint inhibitor-associated AKI. Journal for immunotherapy of cancer Gupta, S., Garcia-Carro, C., Prosek, J. M., Glezerman, I., Herrmann, S. M., Garcia, P., Abudayyeh, A., Lumlertgul, N., Malik, A. B., Loew, S., Beckerman, P., Renaghan, A. D., Carlos, C. A., Rashidi, A., Mithani, Z., Deshpande, P., Rangarajan, S., Shah, C. V., Seigneux, S. D., Campedel, L., Kitchlu, A., Shin, D. S., Coppock, G., Ortiz-Melo, D. I., Sprangers, B., Aggarwal, V., Benesova, K., Wanchoo, R., Murakami, N., Cortazar, F. B., Reynolds, K. L., Sise, M. E., Soler, M. J., Leaf, D. E., ICPi-AKI Consortium, ICPi-AKI Consortium collaborators, Campedel, L., Salem, J., Bagnis, C. I., Gupta, S., Leaf, D. E., Singh, H., Motwani, S. S., Murakami, N., Tio, M. C., Mothi, S. S., Selamet, U., Loew, S., Schmidt-Ott, K. M., Chang, W., Jhaveri, K. D., Wanchoo, R., Khanin, Y., Hirsch, J. S., Sakhiya, V., Stalbow, D., Wu, S., Ortiz-Melo, D. I., Ostermann, M., Lumlertgul, N., Seylanova, N., Cennamo, A., Rigg, A., Shaunak, N., Kibbelaar, Z. A., Benesova, K., Deshpande, P., Sise, M. E., Reynolds, K. L., Seethapathy, H. S., Lee, M., Strohbhen, I. A., Herrmann, S. M., Isik, B., Glezerman, I. G., Cortazar, F. B., Aggarwal, V., Chandra, S., Prosek, J. M., Madhavan, S. M., Owen, D. H., Husain, M., Beckerman, P., Mini, S., Anand, S., Garcia, P., Kaghazchi, A., Rangarajan, S., Shin, D. S., Cherry, G., Carlos, C. A., Hsu, R. K., Kisel, A., Rashidi, A., Kansal, S. K., Albert, N., Carter, K., Donley, V., Young, T., Cigoi, H., Seigneux, S. D., Koessler, T., Ben Sprangers, E. W., Shah, C. V., Eijgelsheim, M., Mithani, Z., Pagan, J. A., Coppock, G., Hogan, J. J., Abudayyeh, A., Mamlouk, O., Lin, J. S., Page, V., Kitchlu, A., Short, S. A., Renaghan, A. D., Gaughan, E. M., Bilal Malik, A., Soler, M. J., Garcia-Carro, C., Bermejo, S., Felip, E., Munoz-Couselo, E., Carreras, M. J. 2022; 10 (9)

    Abstract

    BACKGROUND: Corticosteroids are the mainstay of treatment for immune checkpoint inhibitor-associated acute kidney injury (ICPi-AKI), but the optimal duration of therapy has not been established. Prolonged use of corticosteroids can cause numerous adverse effects and may decrease progression-free survival among patients treated with ICPis. We sought to determine whether a shorter duration of corticosteroids was equally efficacious and safe as compared with a longer duration.METHODS: We used data from an international multicenter cohort study of patients diagnosed with ICPi-AKI from 29 centers across nine countries. We examined whether a shorter duration of corticosteroids (28 days or less) was associated with a higher rate of recurrent ICPi-AKI or death within 30 days following completion of corticosteroid treatment as compared with a longer duration (29-84days).RESULTS: Of 165 patients treated with corticosteroids, 56 (34%) received a shorter duration of treatment and 109 (66%) received a longer duration. Patients in the shorter versus longer duration groups were similar with respect to baseline and ICPi-AKI characteristics. Five of 56 patients (8.9%) in the shorter duration group and 12 of 109 (11%) in the longer duration group developed recurrent ICPi-AKI or died (p=0.90). Nadir serum creatinine in the first 14, 28, and 90 days following completion of corticosteroid treatment was similar between groups (p=0.40, p=0.56, and p=0.89, respectively).CONCLUSION: A shorter duration of corticosteroids (28 days or less) may be safe for patients with ICPi-AKI. However, the findings may be susceptible to unmeasured confounding and further research from randomized clinical trials is needed.

    View details for DOI 10.1136/jitc-2022-005646

    View details for PubMedID 36137651

  • Impact of the COVID-19 pandemic on the kidney community: lessons learned and future directions. Nature reviews. Nephrology Geetha, D., Kronbichler, A., Rutter, M., Bajpai, D., Menez, S., Weissenbacher, A., Anand, S., Lin, E., Carlson, N., Sozio, S., Fowler, K., Bignall, R., Ducharlet, K., Tannor, E. K., Wijewickrama, E., Hafiz, M. I., Tesar, V., Hoover, R., Crews, D., Varnell, C., Danziger-Isakov, L., Jha, V., Mohan, S., Parikh, C., Luyckx, V. 2022

    Abstract

    The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected patients with kidney disease, causing significant challenges in disease management, kidney research and trainee education. For patients, increased infection risk and disease severity, often complicated by acute kidney injury, have contributed to high mortality. Clinicians were faced with high clinical demands, resource shortages and novel ethical dilemmas in providing patient care. In this review, we address the impact of COVID-19 on the entire spectrum of kidney care, including acute kidney injury, chronic kidney disease, dialysis and transplantation, trainee education, disparities in health care, changes in health care policies, moral distress and the patient perspective. Based on current evidence, we provide a framework for the management and support of patients with kidney disease, infection mitigation strategies, resource allocation and support systems for the nephrology workforce.

    View details for DOI 10.1038/s41581-022-00618-4

    View details for PubMedID 36002770

  • SARS-CoV-2 Infection during the Omicron Surge among Patients Receiving Dialysis: The Role of Circulating Receptor-Binding Domain Antibodies and Vaccine Doses. Journal of the American Society of Nephrology : JASN Montez-Rath, M. E., Garcia, P., Han, J., Cadden, L., Hunsader, P., Morgan, C., Kerschmann, R., Beyer, P., Dittrich, M., Block, G. A., Parsonnet, J., Chertow, G. M., Anand, S. 2022

    Abstract

    It is unclear whether circulating antibody levels conferred protection against SARS-CoV-2 infection among patients receiving dialysis during the Omicron-dominant period.We followed monthly semiquantitative SARS-CoV-2 RBD IgG index values in a randomly selected nationwide cohort of patients receiving dialysis and ascertained SARS-CoV-2 infection during the Omicron-dominant period of December 25, 2021 to January 31, 2022 using electronic health records. We estimated the relative risk for documented SARS-CoV-2 infection by vaccination status and by circulating RBD IgG using a log-binomial model accounting for age, sex, and prior COVID-19.Among 3576 patients receiving dialysis, 901 (25%) received a third mRNA vaccine dose as of December 24, 2021. Early antibody responses to third doses were robust (median peak index IgG value at assay limit of 150). During the Omicron-dominant period, SARS-CoV-2 infection was documented in 340 (7%) patients. Risk for infection was higher among patients without vaccination and with one to two doses (RR, 2.1; 95% CI, 1.6 to 2.8, and RR, 1.3; 95% CI, 1.0 to 1.8 versus three doses, respectively). Irrespective of the number of vaccine doses, risk for infection was higher among patients with circulating RBD IgG <23 (506 BAU/ml) (RR range, 2.1 to 3.2, 95% CI, 1.3 to 3.4 and 95% CI, 2.2 to 4.5, respectively) compared with RBD IgG ≥23.Among patients receiving dialysis, a third mRNA vaccine dose enhanced protection against SARS-CoV-2 infection during the Omicron-dominant period, but a low circulating RBD antibody response was associated with risk for infection independent of the number of vaccine doses. Measuring circulating antibody levels in this high-risk group could inform optimal timing of vaccination and other measures to reduce risk of SARS-CoV-2 infection.

    View details for DOI 10.1681/ASN.2022040504

    View details for PubMedID 35973733

  • Acute Kidney Injury in Patients Receiving Pembrolizumab Combination Therapy versus Pembrolizumab Monotherapy for Advanced Lung Cancer. Kidney international Gupta, S., Strohbehn, I. A., Wang, Q., Hanna, P. E., Seethapathy, R., Prosek, J. M., Herrmann, S. M., Abudayyeh, A., Malik, A. B., Loew, S., Carlos, C. A., Chang, W., Beckerman, P., Mithani, Z., Shah, C. V., Renaghan, A. D., De Seigneux, S., Campedel, L., Kitchlu, A., Shin, D. S., Coppock, G., Lumlertgul, N., Garcia, P., Ortiz-Melo, D. I., Rashidi, A., Sprangers, B., Aggarwal, V., Benesova, K., Jhaveri, K. D., Cortazar, F. B., Weins, A., Zuo, Y., Mooradian, M. J., Reynolds, K. L., Leaf, D. E., Sise, M. E., ICPi-AKI Consortium 2022

    View details for DOI 10.1016/j.kint.2022.07.019

    View details for PubMedID 35964800

  • Unraveling the Mysteries of CKD of Uncertain Etiology. Clinical journal of the American Society of Nephrology : CJASN Garcia, P., Anand, S. 2022

    View details for DOI 10.2215/CJN.08430722

    View details for PubMedID 35944912

  • Plasma exchange for severe immune-related adverse events from checkpoint inhibitors: an early window of opportunity? Immunotherapy advances Katsumoto, T. R., Wilson, K. L., Giri, V. K., Zhu, H., Anand, S., Ramchandran, K. J., Martin, B. A., Yunce, M., Muppidi, S. 2022; 2 (1): ltac012

    Abstract

    Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of several advanced malignancies leading to durable remission in a subset of patients. Their rapidly expanding use has led to an increased frequency of immune-related adverse events (irAEs). The pathogenesis of irAEs is poorly understood but may involve aberrant activation of T cells leading to inflammatory cytokine release or production of pathogenic antibodies leading to organ damage. Severe irAEs can be extremely debilitating and, in some cases, life threatening. IrAEs may not always be corticosteroid responsive or may require excessively high, often toxic, corticosteroid doses. Therapeutic plasma exchange (PLEX) is a treatment modality that has shown promising results for the management of certain severe irAEs, including irAEs that are not mentioned in current treatment guidelines. PLEX may attenuate ongoing irAEs and prevent delayed irAEs by accelerating clearance of the ICI, or by acutely removing pathogenic antibodies, cytokines, and chemokines. Here, we summarize examples from the literature in which PLEX was successfully used for the treatment of irAEs. We posit that timing may be a critical factor and that earlier utilization of PLEX for life-threatening irAEs may result in more favorable outcomes. In individuals at high risk for irAEs, the availability of PLEX as a potential therapeutic mitigation strategy may encourage life-saving ICI use or rechallenge. Future research will be critical to better define which indications are most amenable to PLEX, particularly to establish the optimal place in the sequence of irAE therapies and to assess the ramifications of ICI removal on cancer outcomes.

    View details for DOI 10.1093/immadv/ltac012

    View details for PubMedID 35814850

    View details for PubMedCentralID PMC9257781

  • SARS-CoV-2 Booster Vaccine Response among Patients Receiving Dialysis. Clinical journal of the American Society of Nephrology : CJASN Garcia, P., Han, J., Montez-Rath, M., Sun, S., Shang, T., Parsonnet, J., Chertow, G., Anand, S., Schiller, B., Abra, G. 2022

    Abstract

    N/A.

    View details for DOI 10.2215/CJN.00890122

    View details for PubMedID 35383042

  • SARS-CoV-2 infection during the Omicron surge among patients receiving dialysis: the role of circulating receptor-binding domain antibodies and vaccine doses. medRxiv : the preprint server for health sciences Montez-Rath, M. E., Garcia, P., Han, J., Cadden, L., Hunsader, P., Morgan, C., Kerschmann, R., Beyer, P., Dittrich, M., Block, G. A., Anand, S., Parsonnet, J., Chertow, G. M. 2022

    Abstract

    Background: It is unclear whether a third dose of mRNA platform vaccines, or antibody response to prior infection or vaccination confer protection from the Omicron variant among patients receiving dialysis.Methods: Monthly since February 2021, we tested plasma from 4,697 patients receiving dialysis for antibodies to the receptor-binding domain (RBD) of SARS-CoV-2. We assessed semiquantitative median IgG index values over time among patients vaccinated with at least one dose of the two mRNA vaccines. We ascertained documented COVID-19 diagnoses after December 25, 2021 and up to January 31, 2022. We estimated the relative risk for documented SARS-CoV-2 infection by vaccination status using a log-binomial model accounting for age, sex, and prior clinical COVID-19. Among patients with RBD IgG index value available during December 1-December 24, 2021, we also evaluated the association between the circulating RBD IgG titer and risk for Omicron variant SARS-CoV-2 infection.Results: Of the 4,697 patients we followed with monthly RBD assays, 3576 are included in the main analysis cohort; among these, 852 (24%) were unvaccinated. Antibody response to third doses was robust (median peak index IgG value at assay limit of 150, equivalent to 3270 binding antibody units/mL). Between December 25-January 31, 2022, SARS-CoV-2 infection was documented 340 patients (7%), 115 (36%) of whom were hospitalized. The final doses of vaccines were given a median of 272 (25 th , 75 th percentile, 245-303) days and 58 (25 th , 75 th percentile, 51-95) days prior to infection for the 1-2 dose and 3 dose vaccine groups respectively. Relative risks for infection were higher among patients without vaccination (RR 2.1 [95%CI 1.6, 2.8]), and patients with 1-2 doses (RR 1.3 [95%CI 1.0, 1.8]), compared with patients with three doses of the mRNA vaccines. Relative risks for infection were higher among patients with RBD index values < 23 (506 BAU/mL), compared with RBD index value a 23 (RR 2.4 [95%CI 1.9, 3.0]). The higher risk for infection among patients with RBD index values < 23 was present among patients who received three doses (RR 2.1 [95%CI 1.3, 3.4]).Conclusions: Among patients receiving hemodialysis, patients unvaccinated, without a third mRNA vaccine dose, or those lacking robust circulating antibody response are at higher risk for Omicron variant infection. Low circulating antibodies could identify the subgroup needing intensified surveillance, prophylaxis or treatment in this patient population.

    View details for DOI 10.1101/2022.03.15.22272426

    View details for PubMedID 35313586

  • Trust-free service measurement and payments for decentralized cellular networks HotNets '22 Anand, S., Arslan, S., Chopra, R., Katti, S., Vaddiraju, M. K., Rana, R., Sheng, P., Tyagi, H., Viswanath, P. 2022: 8

    View details for DOI 10.1145/3563766.3564093

  • SARS-CoV-2 Vaccine Antibody Response and Breakthrough Infection in Patients Receiving Dialysis. Annals of internal medicine Anand, S., Montez-Rath, M. E., Han, J., Garcia, P., Cadden, L., Hunsader, P., Morgan, C., Kerschmann, R., Beyer, P., Dittrich, M., Block, G. A., Chertow, G. M., Parsonnet, J. 1800

    Abstract

    BACKGROUND: Whether breakthrough SARS-CoV-2 infections after vaccination are related to the level of postvaccine circulating antibody is unclear.OBJECTIVE: To determine longitudinal antibody-based response and risk for breakthrough infection after SARS-CoV-2 vaccination.DESIGN: Prospective study.SETTING: Nationwide sample from dialysis facilities.PATIENTS: 4791 patients receiving dialysis.MEASUREMENTS: Remainder plasma from a laboratory processing routine monthly tests was used to measure qualitative and semiquantitative antibodies to the receptor-binding domain (RBD) of SARS-CoV-2. To evaluate whether peak or prebreakthrough RBD values were associated with breakthrough infection, a nested case-control analysis matched each breakthrough case patient to 5 control patients by age, sex, and vaccination month and adjusted for diabetes status and region of residence.RESULTS: Of the 4791 patients followed with monthly RBD assays, 2563 were vaccinated as of 14 September 2021. Among the vaccinated patients, the estimated proportion with an undetectable RBD response increased from 6.6% (95% CI, 5.5% to 7.8%) 14 to 30 days after vaccination to 20.2% (CI, 17.0% to 23.3%) 5 to 6 months after vaccination. Estimated median index values decreased from 91.9 (CI, 78.6 to 105.2) 14 to 30 days after vaccination to 8.4 (CI, 7.6 to 9.3) 5 to 6 months after vaccination. Breakthrough infections occurred in 56 patients, with samples collected a median of 21 days before breakthrough infection. Compared with prebreakthrough index RBD values of 23 or higher (equivalent to ≥506 binding antibody units per milliliter), prebreakthrough RBD values less than 10 and values from 10 to less than 23 were associated with higher odds for breakthrough infection (rate ratios, 11.6 [CI, 3.4 to 39.5] and 6.0 [CI, 1.5 to 23.6], respectively).LIMITATIONS: Single measure of vaccine response; ascertainment of COVID-19 diagnosis from electronic health records.CONCLUSION: The antibody response to SARS-CoV-2 vaccination wanes rapidly in persons receiving dialysis. In this population, the circulating antibody response is associated with risk for breakthrough infection.PRIMARY FUNDING SOURCE: Ascend Clinical Laboratory.

    View details for DOI 10.7326/M21-4176

    View details for PubMedID 34904856

  • Water sources and kidney function: investigating chronic kidney disease of unknown etiology in a prospective study NPJ CLEAN WATER Vlahos, P., Schensul, S. L., Anand, S., Shipley, E., Diyabalanage, S., Hu, C., Ha, T., Staniec, A., Haider, L., Schensul, J. J., Hewavitharane, P., Silva, T., Chandrajith, R., Nanayakkara, N. 2021; 4 (1)
  • Perceptions of physical activity and technology enabled exercise interventions among people with advanced chronic kidney disease: a qualitative study. BMC nephrology Weber, M. B., Ziolkowski, S., Bootwala, A., Bienvenida, A., Anand, S., Lobelo, F. 2021; 22 (1): 373

    Abstract

    BACKGROUND: Exercise improves health outcomes and quality of life in persons with chronic kidney disease (CKD). The numbers of persons with advanced CKD meeting physical activity guidelines however is low. We undertook a qualitative study of men and women aged 36-74 from various race/ethnic populations with advanced CKD not requiring dialysis to describe their experiences and opinions around prior physical activity, motivating factors for and barriers to exercise, and perceptions of exercise-promoting technology and group-based programming designed to improve physical activity levels.METHODS: Nineteen persons with advanced CKD not requiring dialysis were interviewed at two high volume nephrology clinics enriched with racial/ethnic minority patients (Emory University and Santa Clara Valley Medical Center). We used thematic analysis to identify dominant themes (n=4) and subthemes (n=19) around exercise experience, barriers, motivators, views, and preferences.RESULTS: Four dominant themes and 19 subthemes were identified. The most common motivators to exercise included physical and mental health benefits, appearance, improvement in energy levels, and potential social interaction in group-based programs. Common barriers included health concerns, particularly complications related to other co-morbidities, as well as time and transportation constraints. Participants were skeptical of exercise programs solely reliant on technology.CONCLUSIONS: The use of group-based exercise programs may motivate persons with CKD to increase exercise levels, while programs entirely based on technology may be less effective.

    View details for DOI 10.1186/s12882-021-02591-9

    View details for PubMedID 34758729

  • Obesity and Incident Kidney Disease: Busting the Myth of Metabolically Healthy Obesity. American journal of kidney diseases : the official journal of the National Kidney Foundation Anand, S., Chertow, G. M., Beddhu, S. 2021

    View details for DOI 10.1053/j.ajkd.2021.08.008

    View details for PubMedID 34728104

  • COVID19 Vaccine Type and Humoral Immune Response in Patients Receiving Dialysis. Journal of the American Society of Nephrology : JASN Garcia, P., Anand, S., Han, J., Montez-Rath, M., Sun, S., Shang, T., Parsonnet, J., Chertow, G., Schiller, B., Abra, G. 2021

    View details for DOI 10.1681/ASN.2021070936

    View details for PubMedID 34645698

  • Acute kidney injury in patients treated with immune checkpoint inhibitors. Journal for immunotherapy of cancer Gupta, S., Short, S. A., Sise, M. E., Prosek, J. M., Madhavan, S. M., Soler, M. J., Ostermann, M., Herrmann, S. M., Abudayyeh, A., Anand, S., Glezerman, I., Motwani, S. S., Murakami, N., Wanchoo, R., Ortiz-Melo, D. I., Rashidi, A., Sprangers, B., Aggarwal, V., Malik, A. B., Loew, S., Carlos, C. A., Chang, W., Beckerman, P., Mithani, Z., Shah, C. V., Renaghan, A. D., Seigneux, S. D., Campedel, L., Kitchlu, A., Shin, D. S., Rangarajan, S., Deshpande, P., Coppock, G., Eijgelsheim, M., Seethapathy, H., Lee, M. D., Strohbehn, I. A., Owen, D. H., Husain, M., Garcia-Carro, C., Bermejo, S., Lumlertgul, N., Seylanova, N., Flanders, L., Isik, B., Mamlouk, O., Lin, J. S., Garcia, P., Kaghazchi, A., Khanin, Y., Kansal, S. K., Wauters, E., Chandra, S., Schmidt-Ott, K. M., Hsu, R. K., Tio, M. C., Sarvode Mothi, S., Singh, H., Schrag, D., Jhaveri, K. D., Reynolds, K. L., Cortazar, F. B., Leaf, D. E., ICPi-AKI Consortium 2021; 9 (10)

    Abstract

    BACKGROUND: Immune checkpoint inhibitor-associated acute kidney injury (ICPi-AKI) has emerged as an important toxicity among patients with cancer.METHODS: We collected data on 429 patients with ICPi-AKI and 429 control patients who received ICPis contemporaneously but who did not develop ICPi-AKI from 30 sites in 10 countries. Multivariable logistic regression was used to identify predictors of ICPi-AKI and its recovery. A multivariable Cox model was used to estimate the effect of ICPi rechallenge versus no rechallenge on survival following ICPi-AKI.RESULTS: ICPi-AKI occurred at a median of 16 weeks (IQR 8-32) following ICPi initiation. Lower baseline estimated glomerular filtration rate, proton pump inhibitor (PPI) use, and extrarenal immune-related adverse events (irAEs) were each associated with a higher risk of ICPi-AKI. Acute tubulointerstitial nephritis was the most common lesion on kidney biopsy (125/151 biopsied patients [82.7%]). Renal recovery occurred in 276 patients (64.3%) at a median of 7 weeks (IQR 3-10) following ICPi-AKI. Treatment with corticosteroids within 14 days following ICPi-AKI diagnosis was associated with higher odds of renal recovery (adjusted OR 2.64; 95% CI 1.58 to 4.41). Among patients treated with corticosteroids, early initiation of corticosteroids (within 3 days of ICPi-AKI) was associated with a higher odds of renal recovery compared with later initiation (more than 3 days following ICPi-AKI) (adjusted OR 2.09; 95% CI 1.16 to 3.79). Of 121 patients rechallenged, 20 (16.5%) developed recurrent ICPi-AKI. There was no difference in survival among patients rechallenged versus those not rechallenged following ICPi-AKI.CONCLUSIONS: Patients who developed ICPi-AKI were more likely to have impaired renal function at baseline, use a PPI, and have extrarenal irAEs. Two-thirds of patients had renal recovery following ICPi-AKI. Treatment with corticosteroids was associated with improved renal recovery.

    View details for DOI 10.1136/jitc-2021-003467

    View details for PubMedID 34625513

  • Estimated SARS-CoV-2 Seroprevalence in US Patients Receiving Dialysis 1 Year After the Beginning of the COVID-19 Pandemic. JAMA network open Anand, S., Montez-Rath, M., Han, J., Cadden, L., Hunsader, P., Kerschmann, R., Beyer, P., Boyd, S. D., Garcia, P., Dittrich, M., Block, G. A., Parsonnet, J., Chertow, G. M. 2021; 4 (7): e2116572

    Abstract

    Importance: Seroprevalence studies complement data on detected cases and attributed deaths in assessing the cumulative spread of the SARS-CoV-2 virus.Objective: To estimate seroprevalence of SARS-CoV-2 antibodies in patients receiving dialysis and adults in the US in January 2021 before the widespread introduction of COVID-19 vaccines.Design, Setting, and Participants: This cross-sectional study used data from the third largest US dialysis organization (US Renal Care), which has facilities located nationwide, to estimate SARS-CoV-2 seroprevalence among US patients receiving dialysis. Remainder plasma (ie, plasma that would have otherwise been discarded) of all patients receiving dialysis at US Renal Care facilities from January 1 to 31, 2021, was tested for SARS-CoV-2 antibodies. Patients were excluded if they had a documented dose of SARS-CoV-2 vaccination or if a residence zip code was missing from electronic medical records. Crude seroprevalence estimates from this sample (January 2021) were standardized to the US adult population using the 2018 American Community Survey 1-year estimates and stratified by age group, sex, self-reported race/ethnicity, neighborhood race/ethnicity composition, neighborhood income level, and urban or rural status. These data and case detection rates were then compared with data from a July 2020 subsample of patients who received dialysis at the same facilities.Exposures: Age, sex, race/ethnicity, and region of residence as well as neighborhood race/ethnicity composition, poverty, population density, and urban or rural status.Main Outcomes and Measures: The spike protein receptor-binding domain total antibody assay (Siemens Healthineers; manufacturer-reported sensitivity of 100% and specificity of 99.8%) was used to estimate crude SARS-CoV-2 seroprevalence in the unweighted sample, and then the estimated seroprevalence rates for the US dialysis and adult populations were calculated, adjusting for age, sex, and region.Results: A total of 21 464 patients (mean [SD] age, 63.1 [14.2] years; 12 265 men [57%]) were included in the unweighted sample from January 2021. The patients were disproportionately older (aged 65-79 years, 7847 [37%]; aged ≥80 years, 2668 [12%]) and members of racial/ethnic minority groups (Hispanic patients, 2945 [18%]; non-Hispanic Black patients, 4875 [29%]). Seroprevalence of SARS-CoV-2 antibodies was 18.9% (95% CI, 18.3%-19.5%) in the sample, with a seroprevalence of 18.7% (95% CI, 18.1%-19.2%) standardized to the US dialysis population, and 21.3% (95% CI, 20.3%-22.3%) standardized to the US adult population. In the unweighted sample, younger persons (aged 18-44 years, 25.9%; 95% CI, 24.1%-27.8%), those who self-identified as Hispanic or living in Hispanic neighborhoods (25.1%; 95% CI, 23.6%-26.4%), and those living in the lowest-income neighborhoods (24.8%; 95% CI, 23.2%-26.5%) were among the subgroups with the highest seroprevalence. Little variability was observed in seroprevalence by geographic region, population density, and urban or rural status in the January 2021 sample (largest regional difference, 1.2 [95% CI, 1.1-1.3] higher odds of seroprevalence in residents of the Northeast vs West).Conclusions and Relevance: In this cross-sectional study of patients receiving dialysis in the US, fewer than 1 in 4 patients had evidence of SARS-CoV-2 antibodies 1 year after the first case of SARS-CoV-2 infection was detected in the US. Results standardized to the US population indicate similar prevalence of antibodies among US adults. Vaccine introduction to younger individuals, those living in neighborhoods with a large population of racial/ethnic minority residents, and those living in low-income neighborhoods may be critical to disrupting the spread of infection.

    View details for DOI 10.1001/jamanetworkopen.2021.16572

    View details for PubMedID 34251441

  • Antibody Response to COVID-19 Vaccination in Patients Receiving Dialysis. Journal of the American Society of Nephrology : JASN Anand, S., Montez-Rath, M., Han, J., Garcia, P., Cadden, L., Hunsader, P., Kerschmann, R., Beyer, P., Dittrich, M., Block, G., Boyd, S., Parsonnet, J., Chertow, G. 2021

    View details for DOI 10.1681/ASN.2021050611

    View details for PubMedID 34117129

  • Serial SARS-CoV-2 Receptor-Binding Domain Antibody Responses in Patients Receiving Dialysis. Annals of internal medicine Anand, S., Montez-Rath, M. E., Han, J., Garcia, P., Cadden, L., Hunsader, P., Kerschmann, R., Beyer, P., Boyd, S. D., Chertow, G. M., Parsonnet, J. 2021

    Abstract

    BACKGROUND: Assessing the evolution of SARS-CoV-2 immune response among patients receiving dialysis can define its durability in a highly clinically relevant context because patients receiving dialysis share the characteristics of persons most susceptible to SARS-CoV-2 infection.OBJECTIVE: To evaluate the persistence of SARS-CoV-2 receptor-binding domain (RBD) IgG in seroprevalent patients receiving dialysis.DESIGN: Prospective.SETTING: Nationwide sample from dialysis facilities.PATIENTS: 2215 patients receiving dialysis who had evidence of SARS-CoV-2 infection as of July 2020.MEASUREMENTS: Remainder plasma from routine monthly laboratories was used to measure semiquantitative RBD IgG index value over 6 months.RESULTS: A total of 2063 (93%) seroprevalent patients reached an assay detectable response (IgG index value ≥1). Most (n = 1323, 60%) had responses in July with index values classified as high (IgG ≥10); 1003 (76%) remained within this stratum. Adjusted median index values declined slowly but continuously (July vs. December values were 21 vs. 13; P < 0.001). The trajectory of the response did not vary by age group, sex, race/ethnicity, or diabetes status. Patients without an assay detectable response (n = 137) were more likely to be White and in the younger (18 to 44 years) or older (≥80 years) age groups and less likely to have diabetes and hypoalbuminemia.LIMITATION: Lack of data on symptoms or reverse transcriptase polymerase chain reaction diagnosis, cohort of persons who survived infection, and use of a semiquantitative assay.CONCLUSION: Despite impaired immunity, most seropositive patients receiving dialysis maintained RBD antibody levels over 6 months. A slow and continual decline in median antibody levels over time was seen, but no indication that subgroups with impaired immunity had a shorter-lived humoral response was found.PRIMARY FUNDING SOURCE: Ascend Clinical Laboratories.

    View details for DOI 10.7326/M21-0256

    View details for PubMedID 34000201

  • Immune Checkpoint Inhibitor Pneumonitis: Heterogeneity in Clinical Management Filsoof, D., Padda, S. K., Garcia, P., Stedman, M., Neal, J. W., Wakelee, H. A., Ramchandran, K., Das, M., Ramsey, M., Bedi, H. S., Sung, A., Raj, R., Anand, S., de Boer, K., Katsumoto, T. R. AMER THORACIC SOC. 2021
  • Pragmatic Application of Computed Tomography Lung Texture Analysis in Immune Checkpoint Inhibitor Pneumonitis: An Exploratory Study Filsoof, D., Im, J., Garcia, P., Stedman, M., Anand, S., Neal, J. W., Wakelee, H. A., Ramchandran, K., Das, M., Padda, S. K., Sharifi, H., Mooney, J. J., Tsai, E. B., Lin, M. C., Guo, H., Leung, A., Katsumoto, T. R., de Boer, K., Raj, R. AMER THORACIC SOC. 2021
  • SARS-CoV-2 Vaccine Acceptability in Patients on Hemodialysis: A Nationwide Survey. Journal of the American Society of Nephrology : JASN Garcia, P., Montez-Rath, M. E., Moore, H., Flotte, J., Fults, C., Block, M. S., Han, J., Dittrich, M., Parsonnet, J., Chertow, G. M., Block, G. A., Anand, S. 2021

    Abstract

    BACKGROUND: Patients on dialysis are at increased risk for COVID-19-related complications. However, a substantial fraction of patients on dialysis belong to groups more likely to be hesitant about vaccination.METHODS: With the goal of identifying strategies to increase COVID-19 vaccine uptake among patients on hemodialysis, we conducted a nationwide vaccine acceptability survey, partnering with a dialysis network to distribute an anonymized English and Spanish language online survey in 150 randomly selected facilities in the United States. We used logistic regression to evaluate characteristics of vaccine-hesitant persons.RESULTS: A total of 1515 (14% of eligible) patients responded; 20% of all responders, 29% of patients aged 18-44 years, and 29% of Black responders reported being hesitant to seek the COVID-19 vaccine, even if the vaccine was considered safe for the general population. Odds of vaccine hesitancy were higher among patients aged 18-44 years versus those 45-64 years (odds ratio [OR], 1.5; 95% confidence interval [95% CI], 1.0 to 2.3), Black patients versus non-Hispanic White patients (OR, 1.9; 95% CI, 1.3 to 2.7), Native Americans or Pacific Islanders versus non-Hispanic White patients (OR, 2.0; 95% CI, 1.1 to 3.7), and women versus men (OR, 1.6; 95% CI, 1.2 to 2.0). About half (53%) of patients who were vaccine hesitant expressed concerns about side effects. Responders' main information sources about COVID-19 vaccines were television news and dialysis staff (68% and 38%, respectively).CONCLUSIONS: A substantial proportion of patients receiving in-center hemodialysis in the United States are hesitant about seeking COVID-19 vaccination. Facilitating uptake requires outreach to younger patients, women, and Black, Native American, or Pacific Islander patients, and addressing concerns about side effects.

    View details for DOI 10.1681/ASN.2021010104

    View details for PubMedID 33927004

  • Coronavirus Disease 2019 in Patients with End-Stage Kidney Disease on Hemodialysis in Guatemala. Kidney international reports Sosa, R., Garcia, P., Cipriano, E. O., Hernandez, A., Hernandez, E. E., Chavez, P. I., Manchinelli, A., Morales, O. A., Flores, L. E., Romero, H. J., Raquec, Y., Sapon, B. F., Soch, K. E., Anand, S., Sanchez-Polo, V. 2021

    Abstract

    Introduction: COVID-19 is public health concern across the world. Data on the epidemiology among patients on hemodialysis in Latin America and low and middle-income countries is limited.Methods: Using electronic medical records from the second largest dialysis network in Guatemala, we performed a retrospective analysis of all adult patients on hemodialysis with the diagnosis of COVID-19 to estimate incidence of infection, and describe the demographics, comorbidities, and outcomes. We stratified incidence rate by region. We reviewed data from May 1 to July 31, 2020, with outcome data ascertained up to August 28, 2020.Results: Of 3201 patients undergoing hemodialysis, 325 patients were diagnosed with COVID-19 (incidence rate: 102 per 1,000 patients on hemodialysis, compared with 3 per 1,000 in the general population). Incidence was higher in the Central region (207 per 1,000) and lowest in the Southeast region with 33 per 1,000, and unlike in the general population, incidence was lower in Guatemalan city. Mean age of the COVID-19 diagnosed patients was 51.1 (SD 14.8) years, and 84 (25.8%) were female. The median length of hospital stay was 12 days [IQR 10-16]. 229 (69.8%) of the patients recovered, 90 patients died (27.7%), and 6 (1.8%) patients were still in the hospital at the time of last follow-up.Conclusion: In summary, incidence of diagnosed COVID-19 in Guatemalan patients on hemodialysis was much higher than reported in the general population, with outcomes similar to those described in high income countries. Rural regions had higher incidence rates than the major metropolitan area.

    View details for DOI 10.1016/j.ekir.2021.01.028

    View details for PubMedID 33532670

  • Laboratory correlates of SARS-CoV-2 seropositivity in a nationwide sample of patients on dialysis in the U.S. PloS one Anand, S., Montez-Rath, M. E., Han, J., Garcia, P., Bozeman, J., Kerschmann, R., Beyer, P., Parsonnet, J., Chertow, G. M. 2021; 16 (4): e0249466

    Abstract

    Patients on dialysis are at high risk for death due to COVID-19, yet a significant proportion do survive as evidenced by presence of SARS-CoV-2 antibodies in 8% of patients in the U.S. in July 2020. It is unclear whether patients with seropositivity represent the subgroup with robust health status, who would be more likely to mount a durable antibody response. Using data from a July 2020 sample of 28,503 patients receiving dialysis, we evaluated the cross-sectional association of SARS-CoV-2 seropositivity with laboratory surrogates of patient health. In separate logistic regression models, we assessed the association of SARS-CoV-2 seropositivity with seven laboratory-based covariates (albumin, creatinine, hemoglobin, sodium, potassium, phosphate, and parathyroid hormone), across the entire range of the laboratory and in comparison to a referent value. Models accounted for age, sex, region, race and ethnicity, and county-level COVID-19 deaths per 100,000. Odds of seropositivity for albumin 3 and 3.5 g/dL were 2.1 (95% CI 1.9-2.3) and 1.3 (1.2-1.4) respectively, compared with 4 g/dL. Odds of seropositivity for serum creatinine 5 and 8 mg/dL were 1.8 (1.6-2.0) and 1.3 (1.2-1.4) respectively, compared with 12.5 mg/dL. Lower values of hemoglobin, sodium, potassium, phosphate, and parathyroid hormone were associated with higher odds of seropositivity. Laboratory values associated with poorer health status and higher risk for mortality were also associated with higher likelihood of SARS-CoV-2 antibodies in patients receiving dialysis.

    View details for DOI 10.1371/journal.pone.0249466

    View details for PubMedID 33857168

  • Prevalence, risk factors and predicted risk of cardiac events in chronic kidney disease of uncertain aetiology in Sri Lanka: A tubular interstitial nephropathy. PloS one Hettiarachchi, T. W., Fernando, B. N., Sudeshika, T., Badurdeen, Z., Anand, S., Kularatne, A., Wijetunge, S., Abeysundara, H. T., Nanayakkara, N. 2021; 16 (4): e0249539

    Abstract

    Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with 'traditional' chronic kidney disease (CKD). However, chronic kidney disease of uncertain aetiology (CKDu), a tubular interstitial nephropathy is typically minimally proteinuric without high rates of associated hypertension or vascular disease and it is unknown if the rates of CVD are similar. This study aimed to identify the prevalence and the risk of CVD in patients with CKDu. This cross-sectional study included patients with confirmed CKDu who were attending two renal clinics in CKDu endemic-area. A detailed medical history, blood pressure, electrocardiogram (resting and six minutes vigorous walking), echocardiograms, appropriate laboratory parameters and medical record reviews were used to collect data at baseline. The WHO/Pan American Health Organization, cardiovascular risk calculator was employed to determine the future risk of CVD. The clinics had recorded 132 number of patients with CKDu, of these 119 consented to participation in the study. The mean age was 52 (± 9.5) years and mean eGFR was 51.1 (± 27.61); a majority (81.5% (n = 97)) were males. Thirty-four patients (28.6%) had evidence of ischaemic heart disease (IHD). Troponin-I (p = 0.02), Age >50 years (p = 0.01) and hyperuricemia (p = 0.01) were significantly associated with IHD in CKDu. Left ventricular hypertrophy was reported in 20.2% (n = 24). According to the risk calculator, 97% of the enrolled patients were at low risk (<10%) for experiencing a cardiovascular event within the next 10 years. Patients with CKDu have low prevalence and risk for CVD, implying that a majority are likely to survive to reach end-stage kidney disease. Our findings highlight the need for developing strategies to minimize the progression of CKDu to end-stage renal disease.

    View details for DOI 10.1371/journal.pone.0249539

    View details for PubMedID 33852602

  • Diagnostic Yield of Population-Based Screening for Chronic Kidney Disease in Low-Income, Middle-Income, and High-Income Countries. JAMA network open Tonelli, M., Tiv, S., Anand, S., Mohan, D., Garcia Garcia, G., Gutiérrez Padilla, J. A., Klarenbach, S., Navarro Blackaller, G., Seck, S., Wang, J., Zhang, L., Muntner, P. 2021; 4 (10): e2127396

    Abstract

    Population-based screening for chronic kidney disease (CKD) is sometimes recommended based on the assumption that detecting CKD is associated with beneficial changes in treatment. However, the treatment of CKD is often similar to the treatment of hypertension or diabetes, which commonly coexist with CKD.To determine the frequency with which population-based screening for CKD is associated with a change in recommended treatment compared with a strategy of measuring blood pressure and assessing glycemia.This cohort study was conducted using data obtained from studies that evaluated CKD in population-based samples from China (2007-2010), India (2010-2014), Mexico (2007-2008), Senegal (2012), and the United States (2009-2014), including a total of 126 242 adults screened for CKD. Data were analyzed from January 2020 to March 2021.The primary definition of CKD was estimated glomerular filtration rate less than 60 mL/min/1.73 m2. For individuals with CKD, the need for a treatment change was defined as not taking an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker or having blood pressure levels of 140/90 mm Hg or greater. For individuals with CKD who also had diabetes, the need for a treatment change was also defined as having hemoglobin A1c levels of 8% or greater or fasting glucose levels of 178.4 mg/dL (9.9 mmol/L) or greater. Case finding was defined as testing for CKD only in adults with hypertension or diabetes.Among 126 242 adults screened for CKD, there were 47 204 patients in the China cohort, 9817 patients in the India cohort, 51 137 patients in the Mexico cohort, 2441 patients in the Senegal cohort, and 15 643 patients in the US cohort. The mean age of participants was 49.6 years (95% CI, 49.5-49.7 years) in the China cohort, 42.9 years (95% CI, 42.6-43.2 years) in the India cohort, 51.6 years (95% CI, 51.5-51.7 years) in the Mexico cohort, 48.2 years (95% CI, 47.5-48.9 years) in the Senegal cohort, and 47.3 years (95% CI, 46.6-48.0 years) in the US cohort. The proportion of women was 57.3% (95% CI, 56.9%-57.7%) in the China cohort, 53.4% (95% CI, 52.4%-54.4%) in the India cohort, 68.8% (95% CI, 68.4%-69.2%) in the Mexico cohort, 56.0% (95% CI, 54.0%-58.0%) in the Senegal cohort, and 51.9% (51.0%-52.7%) in the US cohort. The prevalence of CKD was 2.5% (95% CI, 2.4%-2.7%) in the China cohort, 2.3% (95% CI, 2.0%-2.6%) in the India cohort, 10.6% (95% CI, 10.3%-10.9%) in the Mexico cohort, 13.1% (95% CI, 11.7%-14.4%) in the Senegal cohort, and 6.8% (95% CI, 6.2%-7.5%) in the US cohort. Screening for CKD was associated with the identification of additional adults whose treatment would change (beyond those identified by measuring blood pressure and glycemia) per 1000 adults: China: 8 adults (95% CI, 8-9 adults); India: 5 adults (95% CI, 4-7 adults); Mexico: 26 adults (95% CI, 24-27 adults); Senegal: 59 adults (95% CI, 50-69 adults); and the US: 19 adults (95% CI, 16-23 adults). Case finding was associated with the identification of 46.2% (95% CI, 45.1%-47.4%) to 86.4% (95% CI, 85.4%-87.3%) of individuals with CKD depending on the country, an increase in the proportion of individuals requiring a treatment change by as much 89.6% (95% CI, 80.4%-99.3%) in the US, and a decrease in the proportion of individuals needing GFR measurements by as much as 57.8% (95% CI, 56.3%-59.3%) in the US.This study found that most additional individuals with CKD identified by population-based screening programs did not need a change in treatment compared with a strategy of measuring blood pressure and assessing glycemia and that case finding was more efficient than screening for early detection of CKD.

    View details for DOI 10.1001/jamanetworkopen.2021.27396

    View details for PubMedID 34605917

  • SARS-CoV-2 vaccine antibody response and breakthrough infection in dialysis. medRxiv : the preprint server for health sciences Anand, S., Montez-Rath, M. E., Han, J., Garcia, P., Cadden, L., Hunsader, P., Morgan, C., Kerschmann, R., Beyer, P., Dittrich, M., Block, G. A., Chertow, G. M., Parsonnet, J. 2021

    Abstract

    Patients receiving dialysis are a sentinel population for groups at high risk for death and disability from COVID-19. Understanding correlates of protection post-vaccination can inform immunization and mitigation strategies.Monthly since January 2021, we tested plasma from 4791 patients receiving dialysis for antibodies to the receptor-binding domain (RBD) of SARS-CoV-2 using a high-throughput assay. We qualitatively assessed the proportion without a detectable RBD response and among those with a response, semiquantitative median IgG index values. Using a nested case-control design, we matched each breakthrough case to five controls by age, sex, and vaccination-month to determine whether peak and pre-breakthrough RBD IgG index values were associated with risk for infection post-vaccination.Among 2563 vaccinated patients, the proportion without a detectable RBD response increased from 6.6% [95% CI 5.5-8.1] in 14-30 days post-vaccination to 20.2% [95% CI 17.1-23.8], and median index values declined from 92.7 (95% CI 77.8-107.5) to 3.7 (95% CI 3.1-4.3) after 5 months. Persons with SARS-CoV-2 infection prior-to-vaccination had higher peak index values than persons without prior infection, but values equalized by 5 months (p=0.230). Breakthrough infections occurred in 56 patients, with samples collected a median of 21 days pre-breakthrough. Peak and pre-breakthrough RBD values <23 (equivalent to <506 WHO BAU/mL) were associated with higher odds for breakthrough infection (OR: 3.7 [95% CI 2.0-6.8] and 9.8 [95% CI 2.9-32.8], respectively).The antibody response to SARS-CoV-2 vaccination wanes rapidly, and in persons receiving dialysis, the persisting antibody response is associated with risk for breakthrough infection.

    View details for DOI 10.1101/2021.10.12.21264860

    View details for PubMedID 34671782

    View details for PubMedCentralID PMC8528091

  • Development and validation of high definition phenotype-based mortality prediction in critical care units. JAMIA open Sun, Y., Kaur, R., Gupta, S., Paul, R., Das, R., Cho, S. J., Anand, S., Boutilier, J. J., Saria, S., Palma, J., Saluja, S., McAdams, R. M., Kaur, A., Yadav, G., Singh, H. 2021; 4 (1): ooab004

    Abstract

    Objectives: The objectives of this study are to construct the high definition phenotype (HDP), a novel time-series data structure composed of both primary and derived parameters, using heterogeneous clinical sources and to determine whether different predictive models can utilize the HDP in the neonatal intensive care unit (NICU) to improve neonatal mortality prediction in clinical settings.Materials and Methods: A total of 49 primary data parameters were collected from July 2018 to May 2020 from eight level-III NICUs. From a total of 1546 patients, 757 patients were found to contain sufficient fixed, intermittent, and continuous data to create HDPs. Two different predictive models utilizing the HDP, one a logistic regression model (LRM) and the other a deep learning long-short-term memory (LSTM) model, were constructed to predict neonatal mortality at multiple time points during the patient hospitalization. The results were compared with previous illness severity scores, including SNAPPE, SNAPPE-II, CRIB, and CRIB-II.Results: A HDP matrix, including 12 221 536 minutes of patient stay in NICU, was constructed. The LRM model and the LSTM model performed better than existing neonatal illness severity scores in predicting mortality using the area under the receiver operating characteristic curve (AUC) metric. An ablation study showed that utilizing continuous parameters alone results in an AUC score of >80% for both LRM and LSTM, but combining fixed, intermittent, and continuous parameters in the HDP results in scores >85%. The probability of mortality predictive score has recall and precision of 0.88 and 0.77 for the LRM and 0.97 and 0.85 for the LSTM.Conclusions and Relevance: The HDP data structure supports multiple analytic techniques, including the statistical LRM approach and the machine learning LSTM approach used in this study. LRM and LSTM predictive models of neonatal mortality utilizing the HDP performed better than existing neonatal illness severity scores. Further research is necessary to create HDP-based clinical decision tools to detect the early onset of neonatal morbidities.

    View details for DOI 10.1093/jamiaopen/ooab004

    View details for PubMedID 33796821

  • Group-Based Exercise in CKD Stage 3b to 4: A Randomized Clinical Trial. Kidney medicine Anand, S., Ziolkowski, S. L., Bootwala, A., Li, J., Pham, N., Cobb, J., Lobelo, F. 2021; 3 (6): 951-961.e1

    Abstract

    We aimed to test interventions to improve physical activity in persons with advanced chronic kidney disease not yet receiving dialysis.Randomized controlled trial with parallel-group design.We embedded a pragmatic referral to exercise programming in high-volume kidney clinics servicing diverse populations in San Jose, CA, and Atlanta, GA. We recruited 56 participants with estimated glomerular filtration rates < 45 mL/min/1.73 m2.We randomly assigned participants to a mobile health (mHealth) group-wearable activity trackers and fitness professional counseling, or an Exercise is Medicine intervention framework (EIM) group-mHealth components plus twice-weekly small-group directed exercise sessions customized to persons with kidney disease. We performed assessments at baseline, 8 weeks at the end of active intervention, and 16 weeks after passive follow-up and used multilevel mixed models to assess between-group differences.Activity tracker total daily step count.Of 56 participants, 86% belonged to a racial/ethnic minority group; randomly assigned groups were well balanced on baseline step count. In intention-to-treat analyses, the EIM and mHealth groups both experienced declines in daily step counts, but there was an attenuated reduction in light intensity physical activity (standard error 0.2 [5.8] vs -8.5 [5.4] min/d; P = 0.08) in the EIM compared with the mHealth group at 8 weeks. In as-treated analyses, total daily step count, distance covered, and light and moderate-vigorous activity minutes per day improved in the EIM group and declined in the mHealth group at 8 weeks (standard error +335 [506] vs -884 [340] steps per day; P = 0.05; P < 0.05 for secondary measures), but group differences faded at 16 weeks. There were no differences in quality-of-life and mental health measures during the study.Small sample size, limited duration of study, assessment of intermediate outcomes (steps per day).A clinic-integrated referral to small-group exercise sessions is feasible, safe, and moderately effective in improving physical activity in an underserved population with high comorbid conditions.Normon S Coplon Applied Pragmatic Clinical Research program.NCT03311763.

    View details for DOI 10.1016/j.xkme.2021.04.022

    View details for PubMedID 34939004

    View details for PubMedCentralID PMC8664706

  • COVID19 vaccine type and humoral immune response in patients receiving dialysis. medRxiv : the preprint server for health sciences Garcia, P., Anand, S., Han, J., Montez-Rath, M., Sun, S., Shang, T., Parsonnet, J., Chertow, G. M., Schiller, B., Abra, G. 2021

    Abstract

    Patients on dialysis vaccinated with the attenuated adenovirus SARS-CoV-2 vaccine might mount an impaired response to vaccination.We evaluated the humoral vaccination response among 2,099 fully vaccinated patients receiving dialysis. We used commercially available assays (Siemens) to assess prevalence of no response or diminished response to COVID-19 vaccination by vaccine type. We defined "no seroconversion" as lack of change from negative to positive in total RBD Ig antibody, no detectable response on semiquantitative RBD IgG antibody (index value <1) as "no RBD IgG response", and a semiquantitative RBD IgG index value <10 as "diminished RBD IgG response".Of the 2,099 fully vaccinated patients on dialysis, the proportion receiving the mRNA1273, BNT162b2, and Ad26.COV2.S were 62% (n=1316), 20% (n=416) and 18% (n=367), respectively. A third (33.3%) of patients receiving the attenuated adenovirus Ad26.COV2.S vaccine failed to seroconvert and an additional 36% had no detectable or diminished IgG response even 28-60 days post vaccination.One in three fully vaccinated patients receiving dialysis had evidence of an impaired immune response to the attenuated adenovirus Ad26.COV2.S vaccine.

    View details for DOI 10.1101/2021.08.02.21261516

    View details for PubMedID 34373862

    View details for PubMedCentralID PMC8351784

  • International consensus definitions of clinical trial outcomes for kidney failure: 2020. Kidney international Levin, A., Agarwal, R., Herrington, W. G., Heerspink, H. L., Mann, J. F., Shahinfar, S., Tuttle, K. R., Donner, J., Jha, V., Nangaku, M., de Zeeuw, D., Jardine, M. J., Mahaffey, K. W., Thompson, A. M., Beaucage, M., Chong, K., Roberts, G. V., Sunwold, D., Vorster, H., Warren, M., Damster, S., Malik, C., Perkovic, V., participant authors of the International Society of Nephrologys 1st International Consensus Meeting on Defining Kidney Failure in Clinical Trials, Anand, S., Argent, N., Babak, E., Banerjee, D., Barratt, J., Bello, A. K., Bernardo, A. A., Blais, J., Canovatchel, W., Caskey, F. J., Coresh, J., de Boer, I. H., Eckardt, K., Evans, R. D., Feldman, H. I., Fogo, A. B., Gudmundsdottir, H., Hamano, T., Harris, D. C., Hauske, S. J., Haynes, R., Herzog, C. A., Hiemstra, T., Idorn, T., Inker, L., Ishida, J. H., Johnson, D. W., Jones-Burton, C., Joseph, A., Koitka-Weber, A., Kretzler, M., Lawatscheck, R., Liew, A., Moist, L., Naicker, S., Nakashima, R., Patel, U., Filho, R. P., Rose, J. B., Rosenberg, N. L., Sinsakul, M., Smoyer, W. E., Sola, L., Sood, A. R., Stengel, B., Taal, M. W., Tanaka, M., Tonelli, M., Tong, A., Toto, R., Trask, M., Ulasi, I. I., Wanner, C., Wheeler, D. C., Wolthers, B. O., Wright, H. M., Yamada, Y., Zakharova, E. 2020; 98 (4): 849–59

    Abstract

    Kidney failure is an important outcome for patients, clinicians, researchers, healthcare systems, payers, and regulators. However, no harmonized international consensus definitions of kidney failure and key surrogates of progression to kidney failure exist specifically for clinical trials. The International Society of Nephrology convened an international multi-stakeholder meeting to develop consensus on this topic. A core group, experienced in design, conduct, and outcome adjudication of clinical trials, developed a database of 64 randomized trials and the 163 included definitions relevant to kidney failure. Using an iterative process, a set of proposed consensus definitions were developed and subsequently vetted by the larger multi-stakeholder group of 83 participants representing 18 different countries. The consensus of the meeting participants was that clinical trial kidney failure outcomes should be comprised of a composite that includes receipt of a kidney transplant, initiation of maintenance dialysis, and death from kidney failure; it may also include outcomes based solely on laboratory measurements of glomerular filtration rate: a sustained low glomerular filtration rate and a sustained percent decline in glomerular filtration rate. Discussion included important considerations, such as (i) recognition of existing nomenclature for kidney failure; (ii) applicability across resource settings; (iii) ease of understanding for all stakeholders; and (iv) avoidance of inappropriate complexity so that the definitions can be used across ranges of populations and trial methodologies. The final definitions reflect the consensus for use in clinical trials.

    View details for DOI 10.1016/j.kint.2020.07.013

    View details for PubMedID 32998816

  • Past Sodium Intake, Contemporary Sodium Intake, and Cardiometabolic Health in Southwest Coastal Bangladesh. Journal of the American Heart Association Naser, A. M., Rahman, M., Unicomb, L., Doza, S., Selim, S., Chaity, M., Luby, S. P., Anand, S., Staimez, L., Clasen, T. F., Gujral, U. P., Gribble, M. O., Narayan, K. M. 2020: e014978

    Abstract

    Background We compared the relationship of past and contemporary sodium (Na) intake with cardiometabolic biomarkers. Methods and Results A total of 1191 participants' data from a randomized controlled trial in coastal Bangladesh were analyzed. Participants provided 24-hour urine Na (24UNa) data for 5 monthly visits. Their fasting blood glucose, total cholesterol, triglycerides, high-density lipoprotein, blood pressure, and 24-hour urine protein were measured at the fifth visit. Participants' mean 24UNa over the first 4 visits was the past Na, and 24UNa of the fifth visit was the contemporary Na intake. We estimated the prevalence ratios of elevated cardiometabolic biomarkers and metabolic syndrome across 24UNa tertiles by multilevel logistic regression using participant-, household-, and community-level random intercepts. Models were adjusted for age, sex, body mass index, smoking, physical activity, alcohol consumption, sleep hours, religion, and household wealth. Compared with participants in tertile 1 of past urine Na, those in tertile 3 had 1.46 (95% CI, 1.08-1.99) times higher prevalence of prediabetes or diabetes mellitus, 5.49 (95% CI, 2.73-11.01) times higher prevalence of large waist circumference, and 1.60 (95% CI, 1.04-2.46) times higher prevalence of metabolic syndrome. Compared with participants in tertile 1 of contemporary urine Na, those in tertile 3 had 1.93 (95% CI, 1.24-3.00) times higher prevalence of prediabetes or diabetes mellitus, 3.14 (95% CI, 1.45-6.83) times higher prevalence of proteinuria, and 2.23 (95% CI, 1.34-3.71) times higher prevalence of large waist circumference. Conclusions Both past and contemporary Na intakes were associated with higher cardiometabolic disease risk.

    View details for DOI 10.1161/JAHA.119.014978

    View details for PubMedID 32875927

  • Associations of drinking rainwater with macro-mineral intake and cardiometabolic health: a pooled cohort analysis in Bangladesh, 2016-2019. NPJ clean water Naser, A. M., Rahman, M., Unicomb, L., Parvez, S. M., Islam, S., Doza, S., Khan, G. K., Ahmed, K. M., Anand, S., Luby, S. P., Shamsudduha, M., Gribble, M. O., Venkat Narayan, K. M., Clasen, T. F. 2020; 3: 20

    Abstract

    This study explores the associations of drinking rainwater with mineral intake and cardiometabolic health in the Bangladeshi population. We pooled 10030 person-visit data on drinking water sources, blood pressure (BP) and 24-h urine minerals. Fasting blood glucose (FBG) was measured in 3724 person-visits, and lipids in 1118 person-visits. We measured concentrations of sodium (Na), potassium (K), calcium (Ca) and magnesium (Mg) in 253 rainwater, 935 groundwater and 130 pond water samples. We used multilevel linear or gamma regression models with participant-, household- and community-level random intercepts to estimate the associations of rainwater consumption with urine minerals and cardiometabolic biomarkers. Rainwater samples had the lowest concentrations of Na, K, Ca and Mg. Rainwater drinkers had lower urine minerals than coastal groundwater drinkers: -13.42 (95% CI: -18.27, -8.57) mmol Na/24 h, -2.00 (95% CI: -3.16, -0.85) mmol K/24 h and -0.57 (95% CI: -1.02, -0.16) mmol Mg/24 h. The ratio of median 24-hour urinary Ca for rainwater versus coastal groundwater drinkers was 0.72 (95% CI: 0.64, 0.80). Rainwater drinkers had 2.15 (95% CI: 1.02, 3.27) mm Hg higher systolic BP, 1.82 (95% CI: 1.19, 2.54) mm Hg higher diastolic BP, 0.59 (95% CI: 0.17, 1.01) mmol/L higher FBG and -2.02 (95% CI: -5.85, 0.81) mg/dl change in high-density lipoprotein cholesterol compared with the coastal groundwater drinkers. Drinking rainwater was associated with worse cardiometabolic health measures, which may be due to the lower intake of salubrious Ca, Mg and K.

    View details for DOI 10.1038/s41545-020-0067-5

    View details for PubMedID 33777415

    View details for PubMedCentralID PMC7610435

  • Associations of drinking rainwater with macro-mineral intake and cardiometabolic health: a pooled cohort analysis in Bangladesh, 2016-2019 NPJ CLEAN WATER Naser, A., Rahman, M., Unicomb, L., Parvez, S., Islam, S., Doza, S., Khan, G., Ahmed, K., Anand, S., Luby, S. P., Shamsudduha, M., Gribble, M. O., Narayan, K., Clasen, T. F. 2020; 3 (1)
  • Fibroblast Growth Factor-23 and a Vegetarian Diet. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation Anand, S., Jagannathan, R., Gupta, R., Mohan, S., Prabhakaran, D., Wolf, M. 2020

    Abstract

    OBJECTIVE: Sparse data exist on population distributions of serum fibroblast growth factor-23 (FGF23) levels from developing, middle-income economies. FGF23 levels may differ substantially across regions based on differences in diet and urbanization. In a population-based study from North India, we tested the hypothesis that urinary phosphate excretion and FGF23 levels are lower among rural compared with urban participants, and among vegetarian compared with nonvegetarian participants.METHODS: We measured 24-hour urinary phosphate, and serum parathyroid hormone and FGF23 in a subsample of the population-based Cardiometabolic Risk Reduction in South Asia and Indian Council of Medical Research Coronary Heart Disease surveys. We categorized participants according to diet and residence: urban nonvegetarians (n=70), urban vegetarians (n=564), and rural vegetarians (n=558). Using least square means, we compared the groups' 24-hour urinary phosphate (with urban vegetarians as reference) and FGF23 levels after accounting for age, sex, diabetes, and body mass index.RESULTS: Among 1,192 study participants, mean FGF23 was 41±18 pg/mL, median parathyroid hormone was 44 (interquartile range [IQR] 31-60) pg/mL, and median 24-hour urinary phosphate excretion was 419 (IQR: 47-622) mg/day. Urinary phosphate was significantly higher in rural compared with urban vegetarians (median, 503; IQR, 334-543 versus 365; IQR, 199-399mg/day), but adjusted mean FGF23 levels did not differ across study groups.CONCLUSION: In rural and urban India, urinary phosphate excretion was low, but FGF23 levels did not differ by residence or dietary preference. Homogenously low dietary phosphate intake across different settings and diets may partly explain the lack of differences in FGF23.

    View details for DOI 10.1053/j.jrn.2020.02.004

    View details for PubMedID 32247648

  • Potassium Intake in India: Opportunity for Mitigating Risks of High-Sodium Diets. American journal of preventive medicine Anand, S., Shivashankar, R., Kondal, D., Garg, V., Khandelwal, S., Gupta, R., Krishnan, A., Amarchand, R., Poulter, N., Reddy, K. S., Prabhakaran, D., Mohan, S. 2020; 58 (2): 302–12

    Abstract

    INTRODUCTION: Most Indians are vegetarian or eat very little meat, which could imply high potassium intake. Because a high-potassium diet could counterbalance the adverse health effects of high-sodium intake, this study aimed to describe potassium relative to sodium intake and investigate the relationship between blood pressure and potassium intake relative to sodium intake in rural and urban India.METHODS: Investigators collected 24-hour urines from 1,445 participants in a subset of 2 population-based surveys in North India in 2012-2013. Standardized questionnaires were used to collect information on demography, behaviors (tobacco, alcohol consumption, physical activity, and diet [food frequency and 24-hour recall]), and medical history. After evaluating expected versus measured creatinine excretion, the authors calculated median urine potassium excretion and sodium/potassium ratio, according to sex and urban or rural residence, and estimated least square means for the urine measures by participant demographics and comorbidities, after accounting for caloric intake. Two-year blood pressure follow-up data were available in the urban study, and ANCOVA regression was used to determine the association with urine measures. All the statistical analyses of the data were done in January 2019.RESULTS: Acceptable 24-hour urine collections were available in 1,397 participants (rural, n=730). Median urine potassium excretions were 1,492 (IQR=1,012-2,063) and 975 (615-1,497) mg/day; sodium/potassium ratios met the recommended target of <1 in 2.9% rural and 6.6% urban participants. Rural participants did not have higher potassium or lower (better) sodium/potassium ratios when diagnosed with hypertension or other cardiovascular conditions. Higher potassium excretion was associated with lower blood pressure during follow-up among the urban participants (mean systolic blood pressure, 129 vs 133 mm Hg in highest vs lowest potassium excretion tertiles; p=0.029).CONCLUSIONS: Low potassium intake in India warrants dietary policies promoting intake of potassium-rich foods to improve heart health. This approach may be more acceptable than programs focused on sodium reduction alone.

    View details for DOI 10.1016/j.amepre.2019.09.017

    View details for PubMedID 31959324

  • Consequences of access to water from managed aquifer recharge systems for blood pressure and proteinuria in south-west coastal Bangladesh: a stepped-wedge cluster-randomized trial. International journal of epidemiology Naser, A. M., Doza, S. n., Rahman, M. n., Unicomb, L. n., Ahmed, K. M., Anand, S. n., Selim, S. n., Shamsudduha, M. n., Narayan, K. M., Chang, H. n., Clasen, T. F., Gribble, M. O., Luby, S. P. 2020

    Abstract

    Drinking-water salinity has been associated with high blood pressure (BP) among communities in south-west coastal Bangladesh. We evaluated whether access to water from managed aquifer recharge (MAR)-a hydrogeological intervention to lower groundwater salinity by infiltrating rainwater into the aquifers-can reduce community BP.We conducted a stepped-wedge cluster-randomized trial with five monthly visits between December 2016 and April 2017 in 16 communities. At each visit following baseline, four communities were randomized to access MAR water. Systolic BP was the primary outcome, measured during each visit using Omron® HEM-907 devices. We also measured participants' 24-hour urinary sodium and households' drinking- and cooking-water salinity each visit. We used multilevel regression models to estimate the effects of MAR-water access on participants' BP. The primary analysis was intention-to-treat.In total, 2911 person-visits were conducted in communities randomized to have MAR-water access and 2834 in communities without MAR-water access. Households without MAR-water access predominantly used low-salinity pond water and 42% (range: 26-50% across visits) of households exclusively consumed MAR water when access was provided. Communities randomized to MAR-water access had 10.34 [95% confidence interval (CI): 1.11, 19.58] mmol/day higher mean urinary sodium, 1.96 (95% CI: 0.66, 3.26; p = 0.004) mmHg higher mean systolic BP and 1.44 (95% CI: 0.40, 2.48; p = 0.007) mmHg higher mean diastolic BP than communities without MAR-water access.Our findings do not support the scale-up of MAR systems as a routine drinking-water source, since communities that shifted to MAR water from the lower-salinity pond-water source had higher urinary sodium and BP.

    View details for DOI 10.1093/ije/dyaa098

    View details for PubMedID 32653912

  • Using GIS Mapping to Track Hot Spots of Kidney Disease in California. The New England journal of medicine Anand, S. n., Staniec, A. n., Montez-Rath, M. n., Vlahos, P. n. 2020; 382 (23): 2265–67

    View details for DOI 10.1056/NEJMc2001023

    View details for PubMedID 32492310

  • Prevention and management of CVD in LMICs: why do ethnicity, culture, and context matter? BMC medicine Anand, S. n., Bradshaw, C. n., Prabhakaran, D. n. 2020; 18 (1): 7

    Abstract

    Low- and middle-income countries now experience the highest prevalence and mortality rates of cardiovascular disease.While improving the availability and delivery of proven, effective therapies will no doubt mitigate this burden, we posit that studies evaluating cardiovascular disease risk factors, management strategies and service delivery, in diverse settings and diverse populations, are equally critical to improving outcomes in low- and middle-income countries. Focusing on examples drawn from four cardiovascular diseases - coronary artery disease, stroke, diabetes and kidney disease - we argue that ethnicity, culture and context matter in determining the risk factors for disease as well as the comparative effectiveness of medications and other interventions, particularly diet and lifestyle interventions.We believe that a host of cohort studies and randomized control trials currently being conducted or planned in low- and middle-income countries, focusing on previously understudied race/ethnic groups, have the potential to increase knowledge about the cause(s) and management of cardiovascular diseases across the world.

    View details for DOI 10.1186/s12916-019-1480-9

    View details for PubMedID 31973762

  • Characteristics and Outcomes of Individuals With Pre-existing Kidney Disease and COVID-19 Admitted to Intensive Care Units in the United States. American journal of kidney diseases : the official journal of the National Kidney Foundation Flythe, J. E., Assimon, M. M., Tugman, M. J., Chang, E. H., Gupta, S. n., Shah, J. n., Sosa, M. A., DeMauro Renaghan, A. n., Melamed, M. L., Wilson, F. P., Neyra, J. A., Rashidi, A. n., Boyle, S. M., Anand, S. n., Christov, M. n., Thomas, L. F., Edmonston, D. n., Leaf, D. E. 2020

    Abstract

    Underlying kidney disease is an emerging risk factor for more severe COVID-19 illness. We examined the clinical courses of critically ill COVID-19 patients with and without pre-existing kidney disease and investigated the association between degree of underlying kidney disease and in-hospital outcomes.Retrospective cohort study SETTINGS & PARTICIPANTS: 4,264 critically ill COVID-19 patients (143 dialysis patients, 521 chronic kidney disease [CKD] patients, and 3,600 patients without CKD) admitted to ICUs at 68 hospitals in the United States.Presence (versus absence) of pre-existing kidney disease OUTCOME(S): In-hospital mortality (primary); respiratory failure, shock, ventricular arrhythmia/ cardiac arrest, thromboembolic event, major bleed, and acute liver injury (secondary) ANALYTICAL APPROACH: We used standardized differences to compare patient characteristics (values >0.10 indicate a meaningful difference between groups) and multivariable adjusted Fine and Gray survival models to examine outcome associations.Dialysis patients had a shorter time from symptom onset to ICU admission compared to other groups (median [quartile 1-quartile 3] days: 4 [2-9] for dialysis patients; 7 [3-10] for CKD patients; 7 [4-10] for patients without pre-existing kidney disease). More dialysis patients (25%) reported altered mental status than those with CKD (20%, standardized difference = 0.12) and no kidney disease (12%, standardized difference = 0.36). Half of dialysis and CKD patients died within 28-days of ICU admission versus 35% of patients without pre-existing kidney disease. Compared to patients without pre-existing kidney disease, dialysis patients had a higher risk of 28-day in-hospital death (adjusted HR 1.41; 95% CI 1.09, 1.81), while patients with CKD had an intermediate risk (adjusted HR 1.25; 95% CI 1.08, 1.44).Potential residual confounding CONCLUSIONS: Findings highlight the high mortality of individuals with underlying kidney disease and severe COVID-19, underscoring the importance of identifying safe and effective COVID-19 therapies for this vulnerable population.

    View details for DOI 10.1053/j.ajkd.2020.09.003

    View details for PubMedID 32961244

  • Prevalence of SARS-CoV-2 antibodies in a large nationwide sample of patients on dialysis in the USA: a cross-sectional study. Lancet (London, England) Anand, S. n., Montez-Rath, M. n., Han, J. n., Bozeman, J. n., Kerschmann, R. n., Beyer, P. n., Parsonnet, J. n., Chertow, G. M. 2020

    Abstract

    Many patients receiving dialysis in the USA share the socioeconomic characteristics of underserved communities, and undergo routine monthly laboratory testing, facilitating a practical, unbiased, and repeatable assessment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence.For this cross-sectional study, in partnership with a central laboratory that receives samples from approximately 1300 dialysis facilities across the USA, we tested the remainder plasma of 28 503 randomly selected adult patients receiving dialysis in July, 2020, using a spike protein receptor binding domain total antibody chemiluminescence assay (100% sensitivity, 99·8% specificity). We extracted data on age, sex, race and ethnicity, and residence and facility ZIP codes from the anonymised electronic health records, linking patient-level residence data with cumulative and daily cases and deaths per 100 000 population and with nasal swab test positivity rates. We standardised prevalence estimates according to the overall US dialysis and adult population, and present estimates for four prespecified strata (age, sex, region, and race and ethnicity).The sampled population had similar age, sex, and race and ethnicity distribution to the US dialysis population, with a higher proportion of older people, men, and people living in majority Black and Hispanic neighbourhoods than in the US adult population. Seroprevalence of SARS-CoV-2 was 8·0% (95% CI 7·7-8·4) in the sample, 8·3% (8·0-8·6) when standardised to the US dialysis population, and 9·3% (8·8-9·9) when standardised to the US adult population. When standardised to the US dialysis population, seroprevalence ranged from 3·5% (3·1-3·9) in the west to 27·2% (25·9-28·5) in the northeast. Comparing seroprevalent and case counts per 100 000 population, we found that 9·2% (8·7-9·8) of seropositive patients were diagnosed. When compared with other measures of SARS-CoV-2 spread, seroprevalence correlated best with deaths per 100 000 population (Spearman's ρ=0·77). Residents of non-Hispanic Black and Hispanic neighbourhoods experienced higher odds of seropositivity (odds ratio 3·9 [95% CI 3·4-4·6] and 2·3 [1·9-2·6], respectively) compared with residents of predominantly non-Hispanic white neighbourhoods. Residents of neighbourhoods in the highest population density quintile experienced increased odds of seropositivity (10·3 [8·7-12·2]) compared with residents of the lowest density quintile. County mobility restrictions that reduced workplace visits by at least 5% in early March, 2020, were associated with lower odds of seropositivity in July, 2020 (0·4 [0·3-0·5]) when compared with a reduction of less than 5%.During the first wave of the COVID-19 pandemic, fewer than 10% of the US adult population formed antibodies against SARS-CoV-2, and fewer than 10% of those with antibodies were diagnosed. Public health efforts to limit SARS-CoV-2 spread need to especially target racial and ethnic minority and densely populated communities.Ascend Clinical Laboratories.

    View details for DOI 10.1016/S0140-6736(20)32009-2

    View details for PubMedID 32987007

  • Acute Kidney Injury in Children Hospitalized With Diarrheal Illness in the United States. Hospital pediatrics Bradshaw, C., Han, J., Chertow, G. M., Long, J., Sutherland, S. M., Anand, S. 2019

    Abstract

    OBJECTIVES: To determine the incidence, correlates, and consequences of acute kidney injury (AKI) among children hospitalized with diarrheal illness in the United States.METHODS: Using data from Kids' Inpatient Database in 2009 and 2012, we studied children hospitalized with a primary diagnosis of diarrheal illness (weighted N = 113195). We used the International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes 584.5 to 584.9 to capture AKI. We calculated the incidence, correlates, and consequences (mortality, length of stay [LOS], and costs) of AKI associated with hospitalized diarrheal illness using stepwise logistic regression and generalized linear models.RESULTS: The average incidence of AKI in children hospitalized with diarrheal illness was 0.8%. Hospital location and teaching status were associated with the odds of AKI, as were older age, solid organ transplant, hypertension, chronic kidney disease, and rheumatologic and hematologic conditions. The development of AKI in hospitalized diarrheal illness was associated with an eightfold increase in the odds of in-hospital mortality (odds ratio 8.0; 95% confidence interval [CI] 4.2-15.4). AKI was associated with prolonged LOS (mean increase 3.0 days; 95% CI 2.3-3.8) and higher hospital cost (mean increase $9241; 95% CI $4661-$13820).CONCLUSIONS: Several demographic factors and comorbid conditions are associated with the risk of AKI in children hospitalized with diarrheal illness. Although rare, development of AKI in this common pediatric condition is associated with increased mortality, LOS, and hospital cost.

    View details for DOI 10.1542/hpeds.2019-0220

    View details for PubMedID 31771950

  • Mineral and bone disorder and management in the China Dialysis Outcomes and Practice Patterns Study. Chinese medical journal Wang, J., Bieber, B. A., Hou, F., Port, F. K., Anand, S. 2019

    Abstract

    BACKGROUND: Despite a growing population of patients starting hemodialysis in China, little is known about markers of mineral bone disease (MBD) and their management. We present data on prevalence and correlates of hypocalcemia, hyperphosphatemia, and secondary hyperparathyroidism from the China Dialysis Outcomes and Practice Patterns Study (DOPPS), with evaluation of whether these laboratory markers triggered changes in management.METHODS: We compared the frequency of measurement and prevalence of poor control of MBD markers in China DOPPS with other DOPPS regions. We also used generalized estimating equations to assess correlates of MBD markers, and separate models to assess predictors of vitamin D and phosphate binder prescriptions in the China DOPPS.RESULTS: Severe hyperphosphatemia (>7 mg/dL) and secondary hyperparathyroidism (>600 pg/mL) were common (27% and 21% prevalence, respectively); both were measured infrequently (14.9% and 3.2% of patients received monthly measurements in China). Frequency of dialysis sessions was positively associated with hyperphosphatemia; presence of residual kidney function was negatively associated with both hyperphosphatemia and secondary hyperparathyroidism. Laboratory measures indicating poor control of MBD were not associated with subsequent prescription of active vitamin D or phosphate binder.CONCLUSIONS: There are substantial opportunities for improvement and standardization of MBD management in China. Development of country-specific guidelines may yield realistic targets and standardization of medication use accounting for availability and cost.

    View details for DOI 10.1097/CM9.0000000000000533

    View details for PubMedID 31764181

  • Medical Record Documentation of Goals-of-Care Discussions Among Older Veterans With Incident Kidney Failure. American journal of kidney diseases : the official journal of the National Kidney Foundation Bradshaw, C. L., Gale, R. C., Chettiar, A., Ghaus, S. J., Thomas, I., Fung, E., Lorenz, K., Asch, S. M., Anand, S., Kurella Tamura, M. 2019

    Abstract

    RATIONALE & OBJECTIVE: Elicitation and documentation of patient preferences is at the core of shared decision making and is particularly important among patients with high anticipated mortality. The extent to which older patients with incident kidney failure undertake such discussions with their providers is unknown and its characterization was the focus of this study.STUDY DESIGN: Retrospective cohort study.SETTING & PARTICIPANTS: A random sample of veterans 67 years and older with incident kidney failure receiving care from the US Veterans Health Administration between 2005 and2010.EXPOSURES: Demographic and facility characteristics, as well as predicted 6-month mortality risk after dialysis initiation and documentation of resuscitation preferences.OUTCOMES: Documented discussions of dialysis treatment and supportive care.ANALYTICAL APPROACH: We reviewed medical records over the 2 years before incident kidney failure and up to 1 year afterward to ascertain the frequency and timing of documented discussions about dialysis treatment, supportive care, and resuscitation. Logistic regression was used to identify factors associated with these documented discussions.RESULTS: The cohort of 821 veterans had a mean age of 80.9±7.2 years, and 37.2% had a predicted 6-month mortality risk>20% with dialysis. Documented discussions addressing dialysis treatment and resuscitation were present in 55.6% and 77.1% of patients, respectively. Those addressing supportive care were present in 32.4%. The frequency of documentation varied by mortality risk and whether the patient ultimately started dialysis. In adjusted analyses, the frequency and pattern of documentation were more strongly associated with geographic location and receipt of outpatient nephrology care than with patient demographic or clinical characteristics.LIMITATIONS: Documentation may not fully reflect the quality and content of discussions, and generalizability to nonveteran patients is limited.CONCLUSIONS: Among older veterans with incident kidney failure, discussions of dialysis treatment are decoupled from other aspects of advance care planning and are suboptimally documented, even among patients at high risk for mortality.

    View details for DOI 10.1053/j.ajkd.2019.07.024

    View details for PubMedID 31679746

  • Global Health Training Opportunities in North American Nephrology Fellowships KIDNEY INTERNATIONAL REPORTS Rope, R., Perl, J., Anand, S., Kalantar-Zadeh, K., Levin, A., Fogo, A., Cheung, A., Eddy, A., Garg, A., Kasiske, B., Barton, E., Finkelstein, F., Bargman, J., Gill, J., Cerda, J., Bonventre, J., Ingelfinger, J., Yeates, K., Sotomayor, K., Berend, K., Sharma, K., Dworkin, L., Tonelli, M., Weir, M., Rocco, M., Trask, M., Wolf, M., Mehta, R., Harris, R., Andreoli, S., Shankland, S., Quaggin, S., Vachharajani, T., Int Soc Nephrology North Amer Cari 2019; 4 (7): 904–7

    View details for DOI 10.1016/j.ekir.2019.04.019

    View details for Web of Science ID 000477755600002

    View details for PubMedID 31384697

    View details for PubMedCentralID PMC6662156

  • The Economic Benefits of Community-based Stand-alone Hemodialysis Units (SAUs) in Kerala Reply KIDNEY INTERNATIONAL REPORTS Bradshaw, C., Narayanan, S., Narayanan, R., Anand, S. 2019; 4 (6): 898–99
  • Drinking Water Salinity, Urinary Macro-Mineral Excretions, and Blood Pressure in the Southwest Coastal Population of Bangladesh JOURNAL OF THE AMERICAN HEART ASSOCIATION Naser, A., Rahman, M., Unicomb, L., Doza, S., Gazi, M., Alam, G., Karim, M., Uddin, M., Khan, G., Ahmed, K., Shamsudduha, M., Anand, S., Narayan, K., Chang, H. H., Luby, S. P., Gribble, M. O., Clasen, T. F. 2019; 8 (9)
  • Prevalence of and risk factors for chronic kidney disease of unknown aetiology in India: secondary data analysis of three population-based cross-sectional studies. BMJ open O'Callaghan-Gordo, C., Shivashankar, R., Anand, S., Ghosh, S., Glaser, J., Gupta, R., Jakobsson, K., Kondal, D., Krishnan, A., Mohan, S., Mohan, V., Nitsch, D., P A, P., Tandon, N., Narayan, K. M., Pearce, N., Caplin, B., Prabhakaran, D. 2019; 9 (3): e023353

    Abstract

    OBJECTIVES: To assess whether chronic kidney disease of unknown aetiology (CKDu) is present in India and to identify risk factors for it using population-based data and standardised methods.DESIGN: Secondary data analysis of three population-based cross-sectional studies conducted between 2010 and 2014.SETTING: Urban and rural areas of Northern India (states of Delhi and Haryana) and Southern India (states of Tamil Nadu and Andhra Pradesh).PARTICIPANTS: 12500 individuals without diabetes, hypertension or heavy proteinuria.OUTCOME MEASURES: Mean estimated glomerular filtration rate (eGFR) and prevalence of eGFR below 60mL/min per 1.73m2 (eGFR <60) in individuals without diabetes, hypertension or heavy proteinuria (proxy definition of CKDu).RESULTS: The mean eGFR was 105.0±17.8mL/min per 1.73m2. The prevalence of eGFR <60 was 1.6% (95% CI=1.4 to 1.7), but this figure varied markedly between areas, being highest in rural areas of Southern Indian (4.8% (3.8 to 5.8)). In Northern India, older age was the only risk factor associated with lower mean eGFR and eGFR <60 (regression coefficient (95%CI)=-0.94 (0.97 to 0.91); OR (95%CI)=1.10 (1.08 to 1.11)). In Southern India, risk factors for lower mean eGFR and eGFR <60,respectively, were residence in a rural area (-7.78 (-8.69 to -6.86); 4.95 (2.61 to 9.39)), older age (-0.90 (-0.93 to -0.86); 1.06 (1.04 to 1.08)) and less education (-0.94 (-1.32 to -0.56); 0.67 (0.50 to 0.90) for each 5years at school).CONCLUSIONS: CKDu is present in India and is not confined to Central America and Sri Lanka. Identified risk factors are consistent with risk factors previously reported for CKDu in Central America and Sri Lanka.

    View details for DOI 10.1136/bmjopen-2018-023353

    View details for PubMedID 30850400

  • Paying for Hemodialysis in Kerala, India: A Description of Household Financial Hardship in the Context of Medical Subsidy. Kidney international reports Bradshaw, C., Gracious, N., Narayanan, R., Narayanan, S., Safeer, M., Nair, G. M., Murlidharan, P., Sundaresan, A., Retnaraj Santhi, S., Prabhakaran, D., Kurella Tamura, M., Jha, V., Chertow, G. M., Jeemon, P., Anand, S. 2019; 4 (3): 390-398

    Abstract

    Many low- and middle-income countries are implementing strategies to increase dialysis availability as growing numbers of people reach end-stage renal disease. Despite efforts to subsidize care, the economic sustainability of chronic dialysis in these settings remains uncertain. We evaluated the association of medical subsidy with household financial hardship related to hemodialysis in Kerala, India, a state with high penetrance of procedure-based subsidies for patients on dialysis.Patients on maintenance hemodialysis at 15 facilities in Kerala were administered a questionnaire that ascertained demographics, dialysis details, and household finances. We estimated direct and indirect costs of hemodialysis, and described the use of medical subsidy. We evaluated whether presence of subsidy (private, charity, or government-sponsored) was associated with lower catastrophic health expenditure (defined as ≥40% of nonsubsistence expenditure spent on dialysis) or distress financing.Of the 835 patients surveyed, 759 (91%) reported their households experienced catastrophic health expenditure, and 644 (77%) engaged in distress financing. Median dialysis-related expenditure was 80% (25th-75th percentile: 60%-90%) of household nonsubsistence expenditure. Government subsidies were used by 238 (29%) of households, 139 (58%) of which were in the lowest income category. Catastrophic health expenditure was present in 215 (90%) of households receiving government subsidy and 332 (93%) without subsidy.Provision of medical subsidy in Kerala, India was not associated with lower rates of household financial hardship related to long-term hemodialysis therapy. Transparent counseling on impending costs and innovative strategies to mitigate household financial distress are necessary for persons with end-stage renal disease in resource-limited settings.

    View details for DOI 10.1016/j.ekir.2018.12.007

    View details for PubMedID 30899866

    View details for PubMedCentralID PMC6409432

  • Paying for Hemodialysis in Kerala, India: A Description of Household Financial Hardship in the Context of Medical Subsidy KIDNEY INTERNATIONAL REPORTS Bradshaw, C., Gracious, N., Narayanan, R., Narayanan, S., Safeer, M., Nair, G. M., Murlidharan, P., Sundaresan, A., Santhi, S., Prabhakaran, D., Tamura, M., Jha, V., Chertow, G. M., Jeemon, P., Anand, S. 2019; 4 (3): 390–98
  • Prospective Biopsy-Based Study of CKD of Unknown Etiology in Sri Lanka CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Anand, S., Montez-Rath, M. E., Adasooriya, D., Ratnatunga, N., Kambham, N., Wazil, A., Wijetunge, S., Badurdeen, Z., Ratnayake, C., Karunasena, N., Schensul, S. L., Valhos, P., Haider, L., Bhalla, V., Levin, A., Wise, P. H., Chertow, G. M., Barry, M., Fire, A. Z., Nanayakkara, N. 2019; 14 (2): 224–32
  • Epidemiology, molecular, and genetic methodologies to evaluate causes of CKDu around the world: report of the Working Group from the ISN International Consortium of Collaborators on CKDu. Kidney international Anand, S. n., Caplin, B. n., Gonzalez-Quiroz, M. n., Schensul, S. L., Bhalla, V. n., Parada, X. n., Nanayakkara, N. n., Fire, A. n., Levin, A. n., Friedman, D. J. 2019; 96 (6): 1254–60

    View details for DOI 10.1016/j.kint.2019.09.019

    View details for PubMedID 31759481

  • Chronic kidney diseases in agricultural communities: report from a workshop. Kidney international Mendley, S. R., Levin, A. n., Correa-Rotter, R. n., Joubert, B. R., Whelan, E. A., Curwin, B. n., Koritzinsky, E. H., Gaughan, D. M., Kimmel, P. L., Anand, S. n., Ordunez, P. n., Reveiz, L. n., Rohlman, D. S., Scammell, M. K., Wright, R. O., Star, R. A. 2019

    Abstract

    In June 2018, the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute of Environmental Health Sciences sponsored a workshop to identify research gaps in an increasingly common form of chronic kidney disease in agricultural communities, often termed "CKDu." The organizers invited a broad range of experts who provided diverse expertise and perspectives, many of whom had never addressed this particular epidemic. Discussion was focused around selected topics, including identifying and mitigating barriers to research in CKDu, creating a case definition, and defining common data elements. All hypotheses regarding etiology were entertained, and meeting participants discussed potential research strategies, choices in study design, and novel tools that may prove useful in this disease. Achievements of the workshop included robust cross-disciplinary discussion and preliminary planning of research goals and design. Specific challenges in implementing basic and clinical research and interventions in low- and middle-income countries were recognized. A balanced approach to leveraging local resources and capacity building without overreaching was emphasized.

    View details for DOI 10.1016/j.kint.2019.06.024

    View details for PubMedID 31563333

  • Early detection of chronic kidney disease in low-income and middle-income countries: development and validation of a point-of-care screening strategy for India. BMJ global health Bradshaw, C., Kondal, D., Montez-Rath, M. E., Han, J., Zheng, Y., Shivashankar, R., Gupta, R., Srinivasapura Venkateshmurthy, N., Jarhyan, P., Mohan, S., Mohan, V., Ali, M. K., Patel, S., Venkat Narayan, K. M., Tandon, N., Prabhakaran, D., Anand, S. 2019; 4 (5): e001644

    Abstract

    Introduction: Although deaths due to chronic kidney disease (CKD) have doubled over the past two decades, few data exist to inform screening strategies for early detection of CKD in low-income and middle-income countries.Methods: Using data from three population-based surveys in India, we developed a prediction model to identify a target population that could benefit from further CKD testing, after an initial screening implemented during home health visits. Using data from one urban survey (n=8698), we applied stepwise logistic regression to test three models: one comprised of demographics, self-reported medical history, anthropometry and point-of-care (urine dipstick or capillary glucose) tests; one with demographics and self-reported medical history and one with anthropometry and point-of-care tests. The 'gold-standard' definition of CKD was an estimated glomerular filtration rate <60mL/min/1.73m2 or urine albumin-to-creatinine ratio ≥30mg/g. Models were internally validated via bootstrap. The most parsimonious model with comparable performance was externally validated on distinct urban (n=5365) and rural (n=6173) Indian cohorts.Results: A model with age, sex, waist circumference, body mass index and urine dipstick had a c-statistic of 0.76 (95% CI 0.75 to 0.78) for predicting need for further CKD testing, with external validation c-statistics of 0.74 and 0.70 in the urban and rural cohorts, respectively. At a probability cut-point of 0.09, sensitivity was 71% (95% CI 68% to 74%) and specificity was 70% (95% CI 69% to 71%). The model captured 71% of persons with CKD and 90% of persons at highest risk of complications from untreated CKD (ie, CKD stage 3A2 and above).Conclusion: A point-of-care CKD screening strategy using three simple measures can accurately identify high-risk persons who require confirmatory kidney function testing.

    View details for DOI 10.1136/bmjgh-2019-001644

    View details for PubMedID 31544000

  • The International Society of Nephrology's International Consortium ofCollaborators on Chronic Kidney Disease ofUnknown Etiology: report of the working groupon approaches to population-level detection strategies and recommendations foraminimumdataset. Kidney international Caplin, B., Yang, C., Anand, S., Levin, A., Madero, M., Saran, R., Jayasinghe, S., De Broe, M., Yeates, K., Tonelli, M., Jakobsson, K., Strani, L., Ruggiero, A., Glaser, J., Martin, E., Pearce, N., Wijewickrama, E., International Society of Nephrologys International Consortium of Collaborators on Chronic Kidney Disease of Unknown Etiology (i3C) 2019; 95 (1): 4–10

    View details for PubMedID 30606428

  • The Authors Reply. Kidney international reports Bradshaw, C. n., Narayanan, S. n., Narayanan, R. n., Anand, S. n. 2019; 4 (6): 898–99

    View details for DOI 10.1016/j.ekir.2019.03.019

    View details for PubMedID 31194144

    View details for PubMedCentralID PMC6551533

  • Kidney progression project (KiPP): Protocol for a longitudinal cohort study of progression in chronic kidney disease of unknown etiology in Sri Lanka GLOBAL PUBLIC HEALTH Vlahos, P., Schensul, S. L., Nanayakkara, N., Chandrajith, R., Haider, L., Anand, S., Silva, K., Schensul, J. J. 2019; 14 (2): 214–26

    Abstract

    Over the last two decades, a global epidemic of chronic kidney disease of unknown etiology (CKDu) has emerged in rural, arid, agricultural, lowland areas. Endemic regions have reported 15 to 20% prevalence among residents aged 30-60 years. CKDu is a progressive and irreversible disease resulting in renal failure and death in the absence of dialysis or a kidney transplant. While much of the research has focused on identifying etiology, this project seeks to ascertain factors associated with the rapidity of kidney disease progression in one of Sri Lanka's CKDu endemic areas. A sample of 296 male and female residents aged 21 to 65 with moderate CKD, as measured by their serum creatinine level, and a clinical diagnosis of CKDu are followed using quarterly serum testing to track the rate of progression. A baseline survey administered to the entire sample addresses potential risk factors, supplemented by a short survey focusing on changes through time. Concurrently water, soil and air are tested at the local and household levels. The study is the first to foster a multi-disciplinary approach that focuses on disease progression, identifying behavioural and exposure risk factors for rapid kidney function decline, in this progressively fatal disease.

    View details for PubMedID 30095037

  • Mineral and bone disorder and management in the China Dialysis Outcomes and Practice Patterns Study. Chinese medical journal Wang, J. n., Bieber, B. A., Hou, F. F., Port, F. K., Anand, S. n. 2019; 132 (23): 2775–82

    Abstract

    Despite a growing population of patients starting hemodialysis in China, little is known about markers of mineral bone disease (MBD) and their management. We present data on prevalence and correlates of hypocalcemia, hyperphosphatemia, and secondary hyperparathyroidism from the China Dialysis Outcomes and Practice Patterns Study (DOPPS), with evaluation of whether these laboratory markers triggered changes in management.We compared the frequency of measurement and prevalence of poor control of MBD markers in China DOPPS with other DOPPS regions. We also used generalized estimating equations to assess correlates of MBD markers, and separate models to assess predictors of vitamin D and phosphate binder prescriptions in the China DOPPS.Severe hyperphosphatemia (>7 mg/dL) and secondary hyperparathyroidism (>600 pg/mL) were common (27% and 21% prevalence, respectively); both were measured infrequently (14.9% and 3.2% of patients received monthly measurements in China). Frequency of dialysis sessions was positively associated with hyperphosphatemia; presence of residual kidney function was negatively associated with both hyperphosphatemia and secondary hyperparathyroidism. Laboratory measures indicating poor control of MBD were not associated with subsequent prescription of active vitamin D or phosphate binder.There are substantial opportunities for improvement and standardization of MBD management in China. Development of country-specific guidelines may yield realistic targets and standardization of medication use accounting for availability and cost.

    View details for DOI 10.1097/CM9.0000000000000533

    View details for PubMedID 31856047

  • Comparison of Urinary Sodium and Blood Pressure Relationship From the Spot Versus 24-Hour Urine Samples. Journal of the American Heart Association Naser, A. M., Rahman, M. n., Unicomb, L. n., Doza, S. n., Anand, S. n., Chang, H. H., Luby, S. P., Clasen, T. F., Narayan, K. M. 2019; 8 (21): e013287

    Abstract

    Background We compared the relationship between sodium (Na) intake and blood pressure when Na intake was estimated from first- and second-morning spot urine samples using the INTERSALT (International Study on Salt and Blood Pressure) formula, versus directly measured 24-hour samples. Methods and Results We collected 24-hour urine and first- and second-morning voids of 383 participants in coastal Bangladesh for 2 visits. We measured participants' blood pressure using an Omron® HEM-907 monitor. To assess the shape of the relationship between urinary Na and blood pressure, we created restricted cubic spline plots adjusted for age, sex, body mass index, smoking and alcohol consumption, physical activities, religion, sleep hours, and household wealth. To assess multicollinearity, we reported variance inflation factors, tolerances, and Leamer's and Klein's statistics following linear regression models. The mean daily urinary Na was 122 (SD 26) mmol/d for the first; 122 (SD 27) mmol/d for the second; and 134 (SD 70) mmol/d for the 24-hour samples. The restricted cubic spline plots illustrated no association between first-morning urinary Na and systolic blood pressure until the 90th percentile distribution followed by a downward relationship; a nonlinear inverse-V-shaped relationship between second-morning urinary Na and systolic blood pressure; and a monotonic upward relationship between 24-hour urinary Na and systolic blood pressure. We found no evidence of multicollinearity for the 24-hour urinary Na model. Conclusions The urinary Na and systolic blood pressure relationship varied for 3 urinary Na measurements. Twenty-four-hour urinary Na captured more variability of Na intake compared with spot urine samples, and its regression models were not affected by multicollinearity.

    View details for DOI 10.1161/JAHA.119.013287

    View details for PubMedID 31615314

  • Physical activity promotion for patients transitioning to dialysis using the "Exercise is Medicine" framework: a multi-center randomized pragmatic trial (EIM-CKD trial) protocol BMC NEPHROLOGY Jagannathan, R., Ziolkowski, S., Weber, M., Cobb, J., Pham, N., Long, J., Anand, S., Lobelo, F. 2018; 19: 230

    Abstract

    Patients on dialysis are physically inactive, with most reporting activity levels below the fifth percentile of healthy age-matched groups. Several small studies have reported efficacy of diverse exercise interventions among persons with CKD and those on dialysis. However, no single intervention has been widely adopted in real-world practice, despite a clear need in this vulnerable population with high rates of mortality, frailty, and skilled nursing hospitalizations.We describe a pragmatic clinical trial for an exercise intervention among patients transitioning to dialysis. We will use an existing framework - Exercise is Medicine (EIM) - developed by the American College of Sports Medicine. After undertaking formative qualitative research to tailor the EIM framework to the advanced CKD population (eGFR < 30 ml/min/1.73m2), we will randomize 96 patients from two regions-Atlanta and Bay Area-in two intervention arms with incremental levels of clinical-community integration: physical activity assessment during Nephrology clinical visit, brief counseling at pre-dialysis education, and physical activity wearable (group 1) versus group 1 intervention components plus a referral to a free, EIM practitioner-led group exercise program over 16 weeks (group 2; 8 week core intervention; 8-week follow up). We will assess efficacy by comparing between group differences in minutes/week of objectively measured moderate intensity physical activity. To evaluate implementation, we will use questionnaires for assessing barriers to referral, participation and retention along the path of the intervention. Further we will have a plan for dissemination of the intervention by partnering with relevant stakeholders.The overall goal is to inform the development of a practical, cost-conscious intervention "package" that addresses barriers and challenges to physical activity commonly faced by patients with advanced CKD and can be disseminated amongst interested practices.ClinicalTrials.gov identifier (Dated:10/17/2017): NCT03311763 .

    View details for PubMedID 30208854

  • Solutions for India's Leading Health Challenge: Adopting recommendations from the Disease Control Priorities Network. The National medical journal of India Anand, S., Prabhakara, D. 2018; 31 (5): 257–61

    View details for DOI 10.4103/0970-258X.261177

    View details for PubMedID 31267988

  • EXPANDING CAPD IN LOW-RESOURCE SETTINGS: A DISTANCE LEARNING APPROACH PERITONEAL DIALYSIS INTERNATIONAL Rope, R., Nanayakkara, N., Wazil, A., Dickowita, S., Abeyeskera, R., Gunerathne, L., Adoosoriya, D., Karunasena, N., Rathnayake, C., Anand, S., Saxena, A. 2018; 38 (5): 343–48

    Abstract

    Despite growing need, treatment for end-stage renal disease is limited in low- and middle-income countries due to resource restraints. We describe the development of an educational curriculum and quality improvement program to support continuous ambulatory peritoneal dialysis (CAPD) performed primarily by non-nephrology providers in Sri Lanka.We developed a program of education, outcome tracking, and expert consultation to support providers in Kandy, Sri Lanka. Education included videos and in-person didactics covering core topics in CAPD. Event-tracking sheets recorded root causes and management of infections and hospitalizations. Conferences reviewed clinical cases and overall clinic management. We evaluated the patient census, peritonitis rates, and root causes and management of infections over 1 year.The curriculum was published through the International Society of Nephrology online academy. High provider turnover limited curriculum assessments. The CAPD patient census rose from 63 to 116 during the year. The peritonitis rate declined significantly, from 0.8 episodes per patient-year in the first 6 months to 0.4 in the latter 6 months, though the most common root causes of peritonitis, related to contamination events and hygiene, persisted. The appropriate ascertainment of culture data and prescription of antibiotics also increased.Our project supported the expansion of a CAPD program in a resource-limited setting, while also improving peritonitis outcomes. Ongoing challenges include ensuring a durable educational system for rotating providers, tracking outcomes beyond peritonitis, and formalizing management protocols. Our program can serve as an example of how established dialysis programs can support the burgeoning work of providers in resource-limited setting.

    View details for PubMedID 29793981

  • Urinary Excretion of Sodium, Potassium, Calcium and Magnesium and Blood Pressure Among a Population of >=20-Year-Olds: Evidence From Southwest Coastal Bangladesh Titu, A., Rahman, M., Unicomb, L., Doza, S., Ahmed, K., Selim, S., Anand, S., Chang, H., Luby, S., Clasen, T., Gribble, M., Narayan, K. LIPPINCOTT WILLIAMS & WILKINS. 2018
  • Acute Kidney Injury Due to Diarrheal Illness Requiring Hospitalization: Data from the National Inpatient Sample JOURNAL OF GENERAL INTERNAL MEDICINE Bradshaw, C., Zheng, Y., Silver, S. A., Chertow, G. M., Long, J., Anand, S. 2018; 33 (9): 1520–27
  • m-Power Heart Project - a nurse care coordinator led, mHealth enabled intervention to improve the management of hypertension in India: study protocol for a cluster randomized trial TRIALS Venkateshmurthy, N., Ajay, V. S., Mohan, S., Jindal, D., Anand, S., Kondal, D., Tandon, N., Rao, M., Prabhakaran, D. 2018; 19: 429

    Abstract

    The proportion of patients with controlled hypertension (< 140/90 mmHg) is very low in India. Thus, there is a need to improve blood pressure management among patients with uncontrolled hypertension through innovative strategies directed at health system strengthening.We designed an intervention consisting of two important components - an electronic decision support system (EDSS) used by a trained nurse care coordinator (NCC). Based on preliminary data, we hypothesized that this intervention will be able to reduce mean systolic blood pressure by 6.5 mmHg among those with uncontrolled blood pressure in the intervention arm compared to the standard treatment arm (paper-based hypertension treatment guidelines). The study will adopt a cluster randomized trial design with the community health center (CHC) as the unit of randomization. The trial will be conducted in Visakhapatnam district (southern India). A total of 1876 participants aged ≥30 years with high blood pressure - systolic blood pressure (SBP) ≥ 160 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg will be enrolled from 12 CHCs. The intervention consists of trained NCCs equipped with an evidence-based hypertension treatment algorithm in the form of the EDSS with regular SMSs to patients with hypertension to promote hypertension treatment and blood pressure control for 12 months. The primary outcome will be difference in the mean change of SBP, from baseline to 12 months, between the intervention and the standard treatment arm. The secondary outcomes are the difference in mean change of DBP; difference in the proportion of patients with controlled blood pressure (< 140/90 mmHg); difference in mean change of fasting blood sugar, HbA1C, eGFR, and albumin to creatinine ratio; difference in the proportion of patients visiting the CHC regularly (number of actual visits to the CHC/number of visits suggested by the EDSS > 80%); difference in proportion of patients compliant to anti-hypertensive medication/s; cost-effectiveness of intervention versus enhanced care. All the outcomes will be assessed at 12 months.The study is expected to provide evidence on the effectiveness of NCC-led, EDSS-based hypertension management in India and can likely offer an exemplar for improving cardiovascular disease (CVD) management in India within the resource-constrained public healthcare system.ClinicalTrials.gov, ID: NCT03164317 ). Registered retrospectively on 23 May 2017 (first patient enrolled on 6 April 2017) because the authors did not receive a response to their original registration submission (5 January 2017) to the Clinical Trial Registry - India (CTRI).

    View details for PubMedID 30086778

  • Twice-Weekly Hemodialysis and Clinical Outcomes in the China Dialysis Outcomes and Practice Patterns Study KIDNEY INTERNATIONAL REPORTS Yan, Y., Wang, M., Zee, J., Schaubel, D., Tu, C., Qian, J., Bieber, B., Wang, M., Chen, N., Li, Z., Port, F. K., Robinson, B. M., Anand, S. 2018; 3 (4): 889–96

    Abstract

    In China, a quarter of patients are undergoing 2-times weekly hemodialysis. Using data from the China Dialysis Outcomes and Practice Patterns Study (DOPPS), we tested the hypothesis that whereas survival and hospitalizations would be similar in the presence of residual kidney function (RKF), patients without RKF would fare worse on 2-times weekly hemodialysis.In our cohort derived from 15 units randomly selected from each of 3 major cities (total N = 45), we generated a propensity score for the probability of dialysis frequency assignment, estimated a survival function by propensity score quintiles, and averaged stratum-specific survival functions to generate mean survival time. We used the proportional rates model to assess hospitalizations. We stratified all analyses by RKF, as reported by patients (urine output <1 vs. ≥1 cup/day).Among 1265 patients, 123 and 133 were undergoing 2-times weekly hemodialysis with and without evidence of RKF. Over 2.5 years, adjusted mean survival times were similar for 2- versus 3-times weekly dialysis groups: 2.20 versus 2.23 and 2.20 versus 2.15 for patients with and without RKF (P = 0.65). Hazard ratios for hospitalization rates were similar for 2- versus 3-times weekly groups, with (1.15, 95% confidence interval = 0.66-2.00) and without (1.10, 95% confidence interval 0.68-1.79]) RKF. The normalized protein catabolic rate was lower and intradialytic weight gain was not substantially higher in the 2- versus 3-times weekly dialysis group, suggesting greater restriction of dietary sodium and protein.In our study of patients in China's major cities, we could not detect differences in survival and hospitalization for those undergoing 2- versus 3-times weekly dialysis, regardless of RKF. Our findings indicate the need for pragmatic studies regarding less frequent dialysis with associated nutritional management.

    View details for PubMedID 29988994

  • Acute Kidney Injury Due to Diarrheal Illness Requiring Hospitalization: Data from the National Inpatient Sample. Journal of general internal medicine Bradshaw, C., Zheng, Y., Silver, S. A., Chertow, G. M., Long, J., Anand, S. 2018

    Abstract

    BACKGROUND: Diarrheal illness is a major reason for hospitalization, but data on consequent acute kidney injury (AKI) are sparse.OBJECTIVE: To determine the incidence of AKI in infectious and non-infectious diarrheal illness requiring hospitalization and to identify correlates and outcomes of diarrhea-associated AKI.DESIGN: Using data from the 2012 National Inpatient Sample (NIS), we created a cohort of patients with a primary diagnosis of diarrheal illness. Diarrheal illness, disease correlates, and AKI were defined by ICD-9 diagnosis codes. We used logistic regression with backward variable selection to determine factors independently associated with AKI in infectious and non-infectious diarrheal illness, as well as to determine the association of AKI with in-hospital mortality. We used generalized linear models to assess differences in length of stay and costs of hospitalization.MAIN MEASURES: The primary outcome was AKI in hospitalized diarrheal illness. Secondary outcomes were in-hospital mortality, length of stay, and cost of hospitalization associated with AKI.KEY RESULTS: One in ten adults hospitalized with diarrheal illness experienced AKI, with higher incidence rates in older adults. Chronic kidney disease (CKD) and hypertension were associated with increased odds of AKI (all diarrhea OR 4.81, 95% CI 4.52 to 5.12 and OR 1.33, 95% CI 1.27 to 1.40, respectively). AKI in diarrheal illness was associated with substantial increase in mortality (OR 5.05, 95% CI 4.47 to 5.72), length of stay (mean increase 1.7days [95% CI 1.6 to 1.8]), and cost of hospitalization (mean increase $4411 [95% CI 4023 to 4800]).CONCLUSION: Acute kidney injury is common and consequential among patients hospitalized for diarrheal illness. Persons with CKD and hypertension are the most susceptible, possibly due to diminished renal reserve and exacerbating effects of treatment with diuretics and renin-angiotensin-aldosterone system blockers. Proactive management of these unique pharmacologic and physiologic factors is necessary to prevent AKI in this vulnerable population.

    View details for PubMedID 29916026

  • Improving the prognosis of patients with severely decreased glomerular filtration rate (CKD G4+): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference KIDNEY INTERNATIONAL Eckardt, K., Bansal, N., Coresh, J., Evans, M., Grams, M. E., Herzog, C. A., James, M. T., Heerspink, H. L., Pollock, C. A., Stevens, P. E., Tamura, M., Tonelli, M. A., Wheeler, D. C., Winkelmayer, W. C., Cheung, M., Hemmelgarn, B. R., Conference Participants 2018; 93 (6): 1281–92

    Abstract

    Patients with severely decreased glomerular filtration rate (GFR) (i.e., chronic kidney disease [CKD] G4+) are at increased risk for kidney failure, cardiovascular disease (CVD) events (including heart failure), and death. However, little is known about the variability of outcomes and optimal therapeutic strategies, including initiation of kidney replacement therapy (KRT). Kidney Disease: Improving Global Outcomes (KDIGO) organized a Controversies Conference with an international expert group in December 2016 to address this gap in knowledge. In collaboration with the CKD Prognosis Consortium (CKD-PC) a global meta-analysis of cohort studies (n = 264,515 individuals with CKD G4+) was conducted to better understand the timing of clinical outcomes in patients with CKD G4+ and risk factors for different outcomes. The results confirmed the prognostic value of traditional CVD risk factors in individuals with severely decreased GFR, although the risk estimates vary for kidney and CVD outcomes. A 2- and 4-year model of the probability and timing of kidney failure requiring KRT was also developed. The implications of these findings for patient management were discussed in the context of published evidence under 4 key themes: management of CKD G4+, diagnostic and therapeutic challenges of heart failure, shared decision-making, and optimization of clinical trials in CKD G4+ patients. Participants concluded that variable prognosis of patients with advanced CKD mandates individualized, risk-based management, factoring in competing risks and patient preferences.

    View details for PubMedID 29656903

  • Cardiovascular, respiratory, and related disorders: key messages from Disease Control Priorities, 3rd edition LANCET Prabhakaran, D., Anand, S., Watkins, D., Gaziano, T., Wu, Y., Mbanya, J., Nugent, R., Dis Control Priorities Cardiovasc 2018; 391 (10126): 1224–36

    Abstract

    Cardiovascular, respiratory, and related disorders (CVRDs) are the leading causes of adult death worldwide, and substantial inequalities in care of patients with CVRDs exist between countries of high income and countries of low and middle income. Based on current trends, the UN Sustainable Development Goal to reduce premature mortality due to CVRDs by a third by 2030 will be challenging for many countries of low and middle income. We did systematic literature reviews of effectiveness and cost-effectiveness to identify priority interventions. We summarise the key findings and present a costed essential package of interventions to reduce risk of and manage CVRDs. On a population level, we recommend tobacco taxation, bans on trans fats, and compulsory reduction of salt in manufactured food products. We suggest primary health services be strengthened through the establishment of locally endorsed guidelines and ensured availability of essential medications. The policy interventions and health service delivery package we suggest could serve as the cornerstone for the management of CVRDs, and afford substantial financial risk protection for vulnerable households. We estimate that full implementation of the essential package would cost an additional US$21 per person in the average low-income country and $24 in the average lower-middle-income country. The essential package we describe could be a starting place for low-income and middle-income countries developing universal health coverage packages. Interventions could be rolled out as disease burden demands and budgets allow. Our outlined interventions provide a pathway for countries attempting to convert the UN Sustainable Development Goal commitments into tangible action.

    View details for PubMedID 29108723

  • Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition LANCET Jamison, D. T., Alwan, A., Mock, C. N., Nugent, R., Watkins, D., Adeyi, O., Anand, S., Atun, R., Bertozzi, S., Bhutta, Z., Binagwaho, A., Black, R., Blecher, M., Bloom, B. R., Brouwer, E., Bundy, D. P., Chisholm, D., Cieza, A., Cullen, M., Danforth, K., de Silva, N., Debas, H. T., Donkor, P., Dua, T., Fleming, K. A., Gallivan, M., Garcia, P. J., Gawande, A., Gaziano, T., Gelband, H., Glass, R., Glassman, A., Gray, G., Habte, D., Holmes, K. K., Horton, S., Hutton, G., Jha, P., Knaul, F. M., Kobusingye, O., Krakauer, E. L., Kruk, M. E., Lachmann, P., Laxminarayan, R., Levin, C., Looi, L., Madhav, N., Mahmoud, A., Mbanya, J., Measham, A., Elena Medina-Mora, M., Medlin, C., Mills, A., Mills, J., Montoya, J., Norheim, O., Olson, Z., Omokhodion, F., Oppenheim, B., Ord, T., Patel, V., Patton, G. C., Peabody, J., Prabhakaran, D., Qi, J., Reynolds, T., Ruacan, S., Sankaranarayanan, R., Sepulveda, J., Skolnik, R., Smith, K. R., Temmerman, M., Tollman, S., Verguet, S., Walker, D. G., Walker, N., Wu, Y., Zhao, K. 2018; 391 (10125): 1108–20

    Abstract

    The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

    View details for PubMedID 29179954

  • Chronic kidney disease care models in low- and middle-income countries: a systematic review BMJ GLOBAL HEALTH Stanifer, J. W., Von Isenburg, M., Chertow, G. M., Anand, S. 2018; 3 (2): e000728

    Abstract

    The number of persons with chronic kidney disease (CKD) living in low- and middle-income countries (LMIC) is increasing rapidly; yet systems built to care for them have received little attention. In order to inform the development of scalable CKD care models, we conducted a systematic review to characterise existing CKD care models in LMICs.We searched PubMed, Embase and WHO Global Health Library databases for published reports of CKD care models from LMICs between January 2000 and 31 October 2017. We used a combination of database-specific medical subject headings and keywords for care models, CKD and LMICs as defined by the World Bank.Of 3367 retrieved articles, we reviewed the full text of 104 and identified 17 articles describing 16 programmes from 10 countries for inclusion. National efforts (n=4) focused on the prevention of end-stage renal disease through enhanced screening, public awareness campaigns and education for primary care providers. Of the 12 clinical care models, nine focused on persons with CKD and the remaining on persons at risk for CKD; a majority in the first category implemented a multidisciplinary clinic with allied health professionals or primary care providers (rather than nephrologists) in lead roles. Four clinical care models used a randomised control design allowing for assessment of programme effectiveness, but only one was assessed as having low risk for bias; all four showed significant attenuation of kidney function decline in the intervention arms.Overall, very few rigorous CKD care models have been reported from LMICs. While preliminary data indicate that national efforts or clinical CKD care models bolstering primary care are successful in slowing kidney function decline, limited data on regional causes of CKD to inform national campaigns, and on effectiveness and affordability of local programmes represent important challenges to scalability.

    View details for PubMedID 29629191

  • Do attributes of persons with chronic kidney disease differ in low-income and middle-income countries compared with high-income countries? Evidence from population-based data in six countries BMJ GLOBAL HEALTH Anand, S., Zheng, Y., Montez-Rath, M. E., Wei, W., Perico, N., Carminati, S., Narayan, K., Tandon, N., Mohan, V., Jha, V., Zhang, L., Remuzzi, G., Prabahkaran, D., Chertow, G. M. 2017; 2 (4): e000453

    Abstract

    Kidney biopsies to elucidate the cause of chronic kidney disease (CKD) are performed in a minority of persons with CKD living in high-income countries, since associated conditions-that is, diabetes mellitus, vascular disease or obesity with pre-diabetes, prehypertension or dyslipidaemia-can inform management targeted at slowing CKD progression in a majority. However, attributes of CKD may differ substantially among persons living in low-income and middle-income countries (LMICs). We used data from population or community-based studies from five LMICs (China, urban India, Moldova, Nepal and Nigeria) to determine what proportion of persons with CKD living in diverse regions fit one of the three major clinical profiles, with data from the US National Health Nutrition and Examination Survey as reference. In the USA, urban India and Moldova, 79.0%-83.9%; in China and Nepal, 62.4%-66.7% and in Nigeria, 51.6% persons with CKD fit one of three established risk profiles. Diabetes was most common in urban India and vascular disease in Moldova (50.7% and 33.2% of persons with CKD in urban India and Moldova, respectively). In Nigeria, 17.8% of persons with CKD without established risk factors had albuminuria ≥300 mg/g, the highest proportion in any country. While the majority of persons with CKD in LMICs fit into one of three established risk profiles, the proportion of persons who have CKD without established risk factors is higher than in the USA. These findings can inform tailored CKD detection and management systems and highlight the importance of studying potential causes and outcomes of CKD without established risk factors in LMICs.

    View details for PubMedID 29071132

  • Twice-Weekly Hemodialysis in China: Can It Be A Better Option for Initiation or Maintenance Dialysis Therapy? Seminars in dialysis Yan, Y., Ramirez, S., Anand, S., Qian, J., Zuo, L. 2017; 30 (3): 277-281

    Abstract

    Cumulative evidence indicates it may be worthwhile revisiting the twice-weekly hemodialysis (HD) regimen as a valid option for individualized or incremental treatments for selected patients with end-stage renal disease. In this article, we will review the current evidences on the potential pros and cons of twice-weekly HD compared to thrice-weekly HD including China's experience in the practice of twice-weekly HD. A prudent patient selection and close dialysis adequacy monitoring might be necessary for this medical treatment choice. More randomized prospective controlled studies for the critical evaluation of twice-weekly dialysis are encouraged.

    View details for DOI 10.1111/sdi.12588

    View details for PubMedID 28345136

  • Drinking water salinity and kidney health in southwest coastal Bangladesh: baseline findings of a community-based stepped-wedge randomised trial Naser, A., Rahman, M., Unicomb, L., Doza, S., Ahmed, K., Uddin, M., Selim, S., Gribble, M. O., Anand, S., Clasen, T. F., Luby, S. P. ELSEVIER SCIENCE INC. 2017: 15
  • Prevalence of chronic kidney disease and risk factors for its progression: A cross-sectional comparison of Indians living in Indian versus US cities PLOS ONE Anand, S., Kondal, D., Montez-Rath, M., Zheng, Y., Shivashankar, R., Singh, K., Gupta, P., Gupta, R., Ajay, V. S., Mohan, V., Pradeepa, R., Tandon, N., Ali, M. K., Narayan, K. M., Chertow, G. M., Kandula, N., Prabhakaran, D., Kanaya, A. M. 2017; 12 (3)

    Abstract

    While data from the latter part of the twentieth century consistently showed that immigrants to high-income countries faced higher cardio-metabolic risk than their counterparts in low- and middle-income countries, urbanization and associated lifestyle changes may be changing these patterns, even for conditions considered to be advanced manifestations of cardio-metabolic disease (e.g., chronic kidney disease [CKD]).Using cross-sectional data from the Center for cArdiometabolic Risk Reduction in South Asia (CARRS, n = 5294) and Mediators of Atherosclerosis in South Asians Living in America (MASALA, n = 748) studies, we investigated whether prevalence of CKD is similar among Indians living in Indian and U.S. cities. We compared crude, age-, waist-to-height ratio-, and diabetes- adjusted CKD prevalence difference. Among participants identified to have CKD, we compared management of risk factors for its progression. Overall age-adjusted prevalence of CKD was similar in MASALA (14.0% [95% CI 11.8-16.3]) compared with CARRS (10.8% [95% CI 10.0-11.6]). Among men the prevalence difference was low (prevalence difference 1.8 [95% CI -1.6,5.3]) and remained low after adjustment for age, waist-to-height ratio, and diabetes status (-0.4 [-3.2,2.5]). Adjusted prevalence difference was higher among women (prevalence difference 8.9 [4.8,12.9]), but driven entirely by a higher prevalence of albuminuria among women in MASALA. Severity of CKD--i.e., degree of albuminuria and proportion of participants with reduced glomerular filtration fraction--was higher in CARRS for both men and women. Fewer participants with CKD in CARRS were effectively treated. 4% of CARRS versus 51% of MASALA participants with CKD had A1c < 7%; and 7% of CARRS versus 59% of MASALA participants blood pressure < 140/90 mmHg. Our analysis applies only to urban populations. Demographic--particularly educational attainment--differences among participants in the two studies are a potential source of bias.Prevalence of CKD among Indians living in Indian and U.S. cities is similar. Persons with CKD living in Indian cities face higher likelihood of experiencing end-stage renal disease since they have more severe kidney disease and little evidence of risk factor management.

    View details for DOI 10.1371/journal.pone.0173554

    View details for PubMedID 28296920

  • Barriers to Increasing Use of Peritoneal Dialysis in Bangladesh: A Survey of Patients and Providers PERITONEAL DIALYSIS INTERNATIONAL Savla, D., Ahmed, S., Yeates, K., Matthew, A., Anand, S. 2017; 37 (2): 234-U134

    Abstract

    Despite a lower requirement for technology and equipment than hemodialysis (HD), peritoneal dialysis (PD) is an underutilized modality in low- and middle-income countries (LMICs). Bangladesh has the lowest use of PD in the world (fewer than 2% of prevalent patients). We evaluated nephrologists' attitudes toward PD and examined differences between patients on HD and PD in Dhaka. We asked nephrologists to fill out an English-language questionnaire. Using convenience sampling but targeting both public and private hospitals in Dhaka, we asked trained nurses to administer a Bangla-language questionnaire to patients on HD (n = 116) and PD (n = 41). We validated the questionnaires on a sub-sample (n = 10 for each group). Of the 43 nephrologists surveyed, 27 (63%) had patients on PD. When compared with nephrologists without patients on PD, those with patients on PD were less likely to believe that survival and quality of life on PD was worse than on HD (odds ratio [OR] = 0.21, 95% confidence interval [CI] 0.05 - 0.83 and OR = 0.11, 95% CI 0.02 - 0.67 respectively) but were not more likely to have received training for PD. Nephrologists named cost of PD as the predominant barrier to increasing use of PD, followed by concerns about patient hygiene and lack of trained nurses. Fifty-two HD patients (45%) did not know about a home-based modality. When compared with patients on HD, patients on PD were more likely to have been educated by non-nephrologists about dialysis, to be "forewarned" about the need for dialysis, to be paying fully, and to be living in a permanent home with a non-communal water source. Some barriers to increasing access to PD-i.e., patient living conditions and cost-are unique to LMICs. Our study also highlights that issues encountered in high-income countries-i.e., nephrologists' subjective preference and lack of patient knowledge about an alternate modality to HD-may play a role as well.

    View details for DOI 10.3747/pdi.2016.00177

    View details for PubMedID 28360370

  • Tackling the Fallout From Chronic Kidney Disease of Unknown Etiology: Why We Need to Focus on Providing Peritoneal Dialysis in Rural, Low-Resource Settings KIDNEY INTERNATIONAL REPORTS Nanayakkara, N., Wazil, A. M., Gunerathne, L., Dickowita, S., Rope, R., Ratnayake, C., Saxena, A., Anand, S. 2017; 2 (1): 1–4

    View details for PubMedID 29142936

  • Can twice weekly hemodialysis expand patient access under resource constraints? Hemodialysis international. International Symposium on Home Hemodialysis Savla, D., Chertow, G. M., Meyer, T., Anand, S. 2016

    Abstract

    The convention of prescribing hemodialysis on a thrice weekly schedule began empirically when it seemed that this frequency was convenient and likely to treat symptoms for a majority of patients. Later, when urea was identified as the main target and marker of clearance, studies supported the prevailing notion that thrice weekly dialysis provided appropriate clearance of urea. Today, national guidelines on hemodialysis from most countries recommend patients receive at least thrice weekly therapy. However, resource constraints in low- and middle-income countries (LMIC) have resulted in a substantial proportion of patients using less frequent hemodialysis in these settings. Observational studies of patients on twice weekly dialysis show that twice weekly therapy has noninferior survival rates compared with thrice weekly therapy. In fact, models of urea clearance also show that twice weekly therapy can meet urea clearance "targets" if patients have significant residual function or if they follow a protein-restricted diet, as may be common in LMIC. Greater reliance on twice weekly therapy, at least at the start of hemodialysis, therefore has potential to reduce health care costs and increase access to renal replacement therapy in low-resource settings; however, randomized control trials are needed to better understand long-term outcomes of twice versus thrice weekly therapy.

    View details for DOI 10.1111/hdi.12501

    View details for PubMedID 27966247

  • Clinical nephrology research in low-resource settings: opportunities, priorities, and challenges for young investigators Proceedings from the 10th Conference on Kidney Disease in Disadvantaged Populations in Cape Town, South Africa, March 2015 CLINICAL NEPHROLOGY Anand, S., Stanifer, J. W., Thomas, B. 2016; 86: S8-S13

    Abstract

    The increased recognition of the growing, worldwide burden of kidney disease has led to calls for prioritizing nephrology research in a global context. However, many challenges exist for young investigators interested in studying kidney disease in low-resource global settings. A lack of clear research priorities, limited funding options, poor infrastructure, difficulty forming partnerships, and unestablished paths for career advancement are a few examples. To discuss these issues, we held a moderated panel discussion in March 2015 as part of the 10th Conference on Kidney Disease in Disadvantaged Populations in Cape Town, South Africa. A group of senior investigators discussed research priorities for studying kidney disease in a global context, collaborations for clinical research, and strategies for dealing with the unique challenges faced by young investigators working in this field.

    View details for DOI 10.5414/CNP86S110

    View details for Web of Science ID 000389592800003

    View details for PubMedCentralID PMC5467768

  • Pemetrexed-Induced Nephrogenic Diabetes Insipidus AMERICAN JOURNAL OF KIDNEY DISEASES Fung, E., Anand, S., Bhalla, V. 2016; 68 (4): 628-632

    Abstract

    Pemetrexed is an approved antimetabolite agent, now widely used for treating locally advanced or metastatic nonsquamous non-small cell lung cancer. Although no electrolyte abnormalities are described in the prescribing information for this drug, several case reports have noted nephrogenic diabetes insipidus with associated acute kidney injury. We present a case of nephrogenic diabetes insipidus without severely reduced kidney function and propose a mechanism for the isolated finding. Severe hypernatremia can lead to encephalopathy and osmotic demyelination, and our report highlights the importance of careful monitoring of electrolytes and kidney function in patients with lung cancer receiving pemetrexed.

    View details for DOI 10.1053/j.ajkd.2016.04.016

    View details for Web of Science ID 000383892200024

    View details for PubMedID 27241854

  • Sex differences in obesity, dietary habits, and physical activity among urban middle-class Bangladeshis. International journal of health sciences Saquib, J., Saquib, N., Stefanick, M. L., Khanam, M. A., Anand, S., Rahman, M., Chertow, G. M., Barry, M., Ahmed, T., Cullen, M. R. 2016; 10 (3): 363-372

    Abstract

    The sustained economic growth in Bangladesh during the previous decade has created a substantial middle-class population, who have adequate income to spend on food, clothing, and lifestyle management. Along with the improvements in living standards, has also come negative impact on health for the middle class. The study objective was to assess sex differences in obesity prevalence, diet, and physical activity among urban middle-class Bangladeshi.In this cross-sectional study, conducted in 2012, we randomly selected 402 adults from Mohammedpur, Dhaka. The sampling technique was multi-stage random sampling. We used standardized questionnaires for data collection and measured height, weight, and waist circumference.Mean age (standard deviation) was 49.4 (12.7) years. The prevalence of both generalized (79% vs. 53%) and central obesity (85% vs. 42%) were significantly higher in women than men. Women reported spending more time watching TV and spending less time walking than men (p<.05); however, men reported a higher intake of unhealthy foods such as fast food and soft drinks.We conclude that the prevalence of obesity is significantly higher in urban middle-class Bangladeshis than previous urban estimates, and the burden of obesity disproportionately affects women. Future research and public health efforts are needed to address this severe obesity problem and to promote active lifestyles.

    View details for PubMedID 27610059

  • Anemia Management in the China Dialysis Outcomes and Practice Patterns Study BLOOD PURIFICATION Zuo, L., Wang, M., Hou, F., Yan, Y., Chen, N., Qian, J., Wang, M., Bieber, B., Pisoni, R. L., Robinson, B. M., Anand, S. 2016; 42 (1): 33-43

    Abstract

    As the utilization of hemodialysis increases in China, it is critical to examine anemia management.Using data from the China Dialysis Outcomes and Practice Patterns Study (DOPPS), we describe hemoglobin (Hgb) distribution and anemia-related therapies.Twenty one percent of China's DOPPS patients had Hgb <9 g/dl, compared with ≤10% in Japan and North America. A majority of medical directors targeted Hgb ≥11. Patients who were female, younger, or recently hospitalized had higher odds of Hgb <9; those with insurance coverage or on twice weekly dialysis had lower odds of Hgb <9. Iron use and erythropoietin-stimulating agents (ESAs) dose were modestly higher for patients with Hgb <9 compared with Hgb in the range 10-12.A large proportion of hemodialysis patients in China's DOPPS do not meet the expressed Hgb targets. Less frequent hemodialysis, patient financial contribution, and lack of a substantial increase in ESA dose at lower Hgb concentrations may partially explain this gap. Video Journal Club 'Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=442741.

    View details for DOI 10.1159/000442741

    View details for Web of Science ID 000377999600008

    View details for PubMedID 27045519

    View details for PubMedCentralID PMC4919113

  • Prevalence of chronic kidney disease in two major Indian cities and projections for associated cardiovascular disease KIDNEY INTERNATIONAL Anand, S., Shivashankar, R., Ali, M. K., Kondal, D., Binukumar, B., Montez-Rath, M. E., Ajay, V. S., Pradeepa, R., Deepa, M., Gupta, R., Mohan, V., Narayan, K. M., Tandon, N., Chertow, G. M., Prabhakaran, D. 2015; 88 (1): 178-185

    Abstract

    India is experiencing an alarming rise in the burden of noncommunicable diseases, but data on the incidence of chronic kidney disease (CKD) are sparse. Using the Center for Cardiometabolic Risk Reduction in South Asia surveillance study (a population-based survey of Delhi and Chennai, India) we estimated overall, and age-, sex-, city-, and diabetes-specific prevalence of CKD, and defined the distribution of the study population by the Kidney Disease Improving Global Outcomes (KDIGO) classification scheme. The likelihood of cardiovascular events in participants with and without CKD was estimated by the Framingham and Interheart Modifiable Risk Scores. Of the 12,271 participants, 80% had complete data on serum creatinine and albuminuria. The prevalence of CKD and albuminuria, age standardized to the World Bank 2010 world population, was 8.7% (95% confidence interval: 7.9-9.4%) and 7.1% (6.4-7.7%), respectively. Nearly 80% of patients with CKD had an abnormally high hemoglobin A1c (5.7 and above). Based on KDIGO guidelines, 6.0, 1.0, and 0.5% of study participants are at moderate, high, or very high risk for experiencing CKD-associated adverse outcomes. The cardiovascular risk scores placed a greater proportion of patients with CKD in the high-risk categories for experiencing cardiovascular events when compared with participants without CKD. Thus, 1 in 12 individuals living in two of India's largest cities have evidence of CKD, with features that put them at high risk for adverse outcomes.

    View details for DOI 10.1038/ki.2015.58

    View details for PubMedID 25786102

  • Understanding acute kidney injury in low resource settings: a step forward BMC NEPHROLOGY Anand, S., Cruz, D. N., Finkelstein, F. O. 2015; 16

    Abstract

    Attention has recently been focused on addressing the problem of acute kidney injury in both the developed and developing world. Little information is actually available on the incidence and management of AKI in low resource settings. Thus, the paper by Bagasha in the current issue of BMC Nephrology makes an important contribution to our understanding of this serious and potentially remediable problem.

    View details for DOI 10.1186/1471-2369-16-5

    View details for Web of Science ID 000348538600002

    View details for PubMedID 25592690

  • Two-times weekly hemodialysis in China: frequency, associated patient and treatment characteristics and Quality of Life in the China Dialysis Outcomes and Practice Patterns study. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association Bieber, B., Qian, J., Anand, S., Yan, Y., Chen, N., Wang, M., Wang, M., Zuo, L., Hou, F. F., Pisoni, R. L., Robinson, B. M., Ramirez, S. P. 2014; 29 (9): 1770-1777

    Abstract

    Renal replacement therapy is rapidly expanding in China, and two-times weekly dialysis is common, but detailed data on practice patterns are currently limited. Using cross-sectional data from the China Dialysis Outcomes and Practice Patterns Study (DOPPS), we describe the hemodialysis practice in China compared with other DOPPS countries, examining demographic, social and clinical characteristics of patients on two-times weekly dialysis.The DOPPS protocol was implemented in 2011 among a cross-section of 1379 patients in 45 facilities in Beijing, Guangzhou and Shanghai. Data from China were compared with a cross section of 11 054 patients from the core DOPPS countries (collected 2009-11). Among China DOPPS patients, logistic and linear regression were used to describe the association of dialysis frequency with patient and treatment characteristics and quality of life.A total of 26% of the patients in China were dialyzing two times weekly, compared with < 5% in other DOPPS regions. Standardized Kt/V was lowest in China (2.01) compared with other regions (2.12-2.27). Female sex, shorter dialysis vintage, lower socioeconomic status, less health insurance coverage, and lack of diabetes and hypertension were associated with dialyzing two times weekly (versus three times weekly). Patients dialyzing two times per week had longer treatment times and lower standardized Kt/V, but similar quality of life scores.Two-times weekly dialysis is common in China, particularly among patients, who started dialysis more recently, have a lower comorbidity burden and have financial constraints. Quality of life scores do not differ between the two-times and three-times weekly groups. The effect on clinical outcomes merits further study.

    View details for DOI 10.1093/ndt/gft472

    View details for PubMedID 24322579

    View details for PubMedCentralID PMC4155454

  • Aging and chronic kidney disease: the impact on physical function and cognition. journals of gerontology. Series A, Biological sciences and medical sciences Anand, S., Johansen, K. L., Kurella Tamura, M. 2014; 69 (3): 315-322

    Abstract

    Evidence has recently been building that the presence of chronic kidney disease (CKD) is an independent contributor to decline in physical and cognitive functions in older adults. CKD affects 45% of persons older than 70 years of age and can double the risk for physical impairment, cognitive dysfunction, and frailty. To increase awareness of this relatively new concept of CKD as a risk factor for accelerated aging, we review studies on the association of CKD with physical function, frailty, and cognitive function. We also present a summary of the proposed mechanisms for these associations.

    View details for DOI 10.1093/gerona/glt109

    View details for PubMedID 23913934

  • Aging and Chronic Kidney Disease: The Impact on Physical Function and Cognition JOURNALS OF GERONTOLOGY SERIES A-BIOLOGICAL SCIENCES AND MEDICAL SCIENCES Anand, S., Johansen, K. L., Tamura, M. K. 2014; 69 (3): 315-322

    Abstract

    Evidence has recently been building that the presence of chronic kidney disease (CKD) is an independent contributor to decline in physical and cognitive functions in older adults. CKD affects 45% of persons older than 70 years of age and can double the risk for physical impairment, cognitive dysfunction, and frailty. To increase awareness of this relatively new concept of CKD as a risk factor for accelerated aging, we review studies on the association of CKD with physical function, frailty, and cognitive function. We also present a summary of the proposed mechanisms for these associations.

    View details for DOI 10.1093/gerona/glt109

    View details for Web of Science ID 000333384800011

  • High prevalence of chronic kidney disease in a community survey of urban Bangladeshis: a cross-sectional study. Globalization and health Anand, S., Khanam, M. A., Saquib, J., Saquib, N., Ahmed, T., Alam, D. S., Cullen, M. R., Barry, M., Chertow, G. M. 2014; 10: 9-?

    Abstract

    The burden of chronic kidney disease (CKD) will rise in parallel with the growing prevalence of type two diabetes mellitus in South Asia but is understudied. Using a cross-sectional survey of adults living in a middle-income neighborhood of Dhaka, Bangladesh, we tested the hypothesis that the prevalence of CKD in this group would approach that of the U.S. and would be strongly associated with insulin resistance.We enrolled 402 eligible adults (>30 years old) after performing a multi-stage random selection procedure. We administered a questionnaire, and collected fasting serum samples and urine samples. We used the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation to estimate glomerular filtration rate, and sex-specific cut offs for albuminuria: > 1.9 mg/mmol (17 mg/g) for men, and >2.8 mg/mmol (25 mg/g) for women. We assessed health-related quality of life using the Medical Outcomes Study Short Form-12 (SF-12).A total of 357 (89%) participants with serum samples comprised the analytic cohort. Mean age of was 49.5 (± 12.7) years. Chronic kidney disease was evident in 94 (26%). Of the participants with CKD, 58 (62%) had albuminuria only. A participant with insulin resistance had a 3.6-fold increase in odds of CKD (95% confidence interval 2.1 to 6.4). Participants with stage three or more advanced CKD reported a decrement in the Physical Health Composite score of the SF-12, compared with participants without CKD.We found an alarmingly high prevalence of CKD-particularly CKD associated with insulin resistance-in middle-income, urban Bangladeshis.

    View details for DOI 10.1186/1744-8603-10-9

    View details for PubMedID 24555767

    View details for PubMedCentralID PMC3944963

  • Global Perspective of Kidney Disease NUTRITION IN KIDNEY DISEASE, 2ND EDITION Anand, S., Khanam, M., Finkelstein, F. O., ByhamGray, L. D., Burrowes, J. D., Chertow, G. M. 2014: 11–23
  • High prevalence of chronic kidney disease in a community survey of urban Bangladeshis: a cross-sectional study. Globalization and health Anand, S., Khanam, M. A., Saquib, J., Saquib, N., Ahmed, T., Alam, D. S., Cullen, M. R., Barry, M., Chertow, G. M. 2014; 10 (1): 9-?

    Abstract

    The burden of chronic kidney disease (CKD) will rise in parallel with the growing prevalence of type two diabetes mellitus in South Asia but is understudied. Using a cross-sectional survey of adults living in a middle-income neighborhood of Dhaka, Bangladesh, we tested the hypothesis that the prevalence of CKD in this group would approach that of the U.S. and would be strongly associated with insulin resistance.We enrolled 402 eligible adults (>30 years old) after performing a multi-stage random selection procedure. We administered a questionnaire, and collected fasting serum samples and urine samples. We used the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation to estimate glomerular filtration rate, and sex-specific cut offs for albuminuria: > 1.9 mg/mmol (17 mg/g) for men, and >2.8 mg/mmol (25 mg/g) for women. We assessed health-related quality of life using the Medical Outcomes Study Short Form-12 (SF-12).A total of 357 (89%) participants with serum samples comprised the analytic cohort. Mean age of was 49.5 (± 12.7) years. Chronic kidney disease was evident in 94 (26%). Of the participants with CKD, 58 (62%) had albuminuria only. A participant with insulin resistance had a 3.6-fold increase in odds of CKD (95% confidence interval 2.1 to 6.4). Participants with stage three or more advanced CKD reported a decrement in the Physical Health Composite score of the SF-12, compared with participants without CKD.We found an alarmingly high prevalence of CKD-particularly CKD associated with insulin resistance-in middle-income, urban Bangladeshis.

    View details for DOI 10.1186/1744-8603-10-9

    View details for PubMedID 24555767

    View details for PubMedCentralID PMC3944963

  • Vitamin d deficiency and mortality in patients receiving dialysis: the comprehensive dialysis study. Journal of renal nutrition Anand, S., Chertow, G. M., Johansen, K. L., Grimes, B., Dalrymple, L. S., Kaysen, G. A., Kurella Tamura, M. 2013; 23 (6): 422-427

    Abstract

    Although several studies have shown poorer survival among individuals with 25-hydroxy (OH) vitamin D deficiency, data on patients receiving dialysis are limited. Using data from the Comprehensive Dialysis Study (CDS), we tested the hypothesis that patients new to dialysis with low serum concentrations of 25-OH vitamin D would experience higher mortality and hospitalizations.The CDS is a prospective cohort study.We recruited participants from 56 dialysis units located throughout the United States.We obtained data on demographics, comorbidites, and laboratory values from the CDS Patient Questionnaire as well as the Medical Evidence Form (CMS form 2728). Participants provided baseline serum samples for 25-OH vitamin D measurements.We ascertained time to death and first hospitalization as well as number of first-year hospitalizations via the U.S. Renal Data System standard analysis files. We used Cox proportional hazards to determine the association between 25-OH vitamin D tertiles and survival and hospitalization. For number of hospitalizations in the first year, we used negative binomial regression.The analytic cohort was composed of 256 patients with Patient Questionnaire data and 25-OH vitamin D concentrations. The mean age of participants was 62 (±14.0) years, and mean follow-up was 3.8 years. Patients with 25-OH vitamin D concentrations in the lowest tertile (<10.6 ng/mL) at the start of dialysis experienced higher mortality (adjusted hazard ratio 1.75, 95% confidence interval [CI] 1.03-2.97) as well as hospitalization (adjusted hazard ratio 1.76, 95% CI 1.24-2.49). Patients in the lower 2 tertiles (<15.5 ng/mL) experienced a higher rate of hospitalizations in the first year (incidence rate ratio 1.70 [95% CI 1.06-2.72] for middle tertile, 1.66 [95% CI 1.10-2.51] for lowest tertile).We found a sizeable increase in mortality and hospitalization for patients on dialysis with severe 25-OH vitamin D deficiency.

    View details for DOI 10.1053/j.jrn.2013.05.003

    View details for PubMedID 23876600

  • Vitamin D Deficiency and Mortality in Patients Receiving Dialysis: The Comprehensive Dialysis Study JOURNAL OF RENAL NUTRITION Anand, S., Chertow, G. M., Johansen, K. L., Grimes, B., Dalrymple, L. S., Kaysen, G. A., Tamura, M. K. 2013; 23 (6): 422-427

    Abstract

    Although several studies have shown poorer survival among individuals with 25-hydroxy (OH) vitamin D deficiency, data on patients receiving dialysis are limited. Using data from the Comprehensive Dialysis Study (CDS), we tested the hypothesis that patients new to dialysis with low serum concentrations of 25-OH vitamin D would experience higher mortality and hospitalizations.The CDS is a prospective cohort study.We recruited participants from 56 dialysis units located throughout the United States.We obtained data on demographics, comorbidites, and laboratory values from the CDS Patient Questionnaire as well as the Medical Evidence Form (CMS form 2728). Participants provided baseline serum samples for 25-OH vitamin D measurements.We ascertained time to death and first hospitalization as well as number of first-year hospitalizations via the U.S. Renal Data System standard analysis files. We used Cox proportional hazards to determine the association between 25-OH vitamin D tertiles and survival and hospitalization. For number of hospitalizations in the first year, we used negative binomial regression.The analytic cohort was composed of 256 patients with Patient Questionnaire data and 25-OH vitamin D concentrations. The mean age of participants was 62 (±14.0) years, and mean follow-up was 3.8 years. Patients with 25-OH vitamin D concentrations in the lowest tertile (<10.6 ng/mL) at the start of dialysis experienced higher mortality (adjusted hazard ratio 1.75, 95% confidence interval [CI] 1.03-2.97) as well as hospitalization (adjusted hazard ratio 1.76, 95% CI 1.24-2.49). Patients in the lower 2 tertiles (<15.5 ng/mL) experienced a higher rate of hospitalizations in the first year (incidence rate ratio 1.70 [95% CI 1.06-2.72] for middle tertile, 1.66 [95% CI 1.10-2.51] for lowest tertile).We found a sizeable increase in mortality and hospitalization for patients on dialysis with severe 25-OH vitamin D deficiency.

    View details for DOI 10.1053/j.jrn.2013.05.003

    View details for Web of Science ID 000327007600007

  • High prevalence of type 2 diabetes among the urban middle class in Bangladesh BMC PUBLIC HEALTH Saquib, N., Khanam, M. A., Saquib, J., Anand, S., Chertow, G. M., Barry, M., Ahmed, T., Cullen, M. R. 2013; 13

    Abstract

    The prevalence of type-2 diabetes and metabolic syndrome are increasing in the developing world; we assessed their prevalence among the urban middle class in Bangladesh.In this cross-sectional survey (n = 402), we randomly selected consenting adults (≥ 30 years) from a middle-income neighborhood in Dhaka. We assessed demography, lifestyle, and health status, measured physical indices and blood pressure and obtained blood samples. We evaluated two primary outcomes: (1) type-2 diabetes (fasting blood glucose ≥ 7.0 mmol/L or hemoglobin A1C ≥ 6.5% (48 mmol/mol) or diabetes medication use) and (2) insulin resistance (type-2 diabetes or metabolic syndrome using International Diabetes Federation criteria).Mean age and Quételet's (body mass) index were 49.4 ± 12.6 years and 27.0 ± 5.1 kg/m²; 83% were married, 41% had ≥12 years of education, 47% were employed, 47% had a family history of diabetes. Thirty-five percent had type-2 diabetes and 45% had metabolic syndrome. In multivariate models older age and family history of diabetes were significantly associated with type-2 diabetes. Older age, female sex, overweight or obese, high wealth index and positive family history of diabetes were significantly associated with insulin resistance. Participants with type-2 diabetes or insulin resistance had significantly poorer physical health only if they had associated cardiovascular disease.The prevalence of type-2 diabetes and metabolic syndrome among the middle class in Dhaka is alarmingly high. Screening services should be implemented while researchers focus on strategies to lessen the incidence and morbidity associated with these conditions.

    View details for DOI 10.1186/1471-2458-13-1032

    View details for Web of Science ID 000329293000002

    View details for PubMedID 24172217

    View details for PubMedCentralID PMC3924340

  • Obesity Prevalence Soars among Urban Middle-class in Bangladesh Saquib, J., Saquib, N., Anand, S., Khanam, M., Chertow, G., Cullen, M. LIPPINCOTT WILLIAMS & WILKINS. 2013
  • Longitudinal Measures of Serum Albumin and Prealbumin Concentrations in Incident Dialysis Patients: The Comprehensive Dialysis Study JOURNAL OF RENAL NUTRITION Dalrymple, L. S., Johansen, K. L., Chertow, G. M., Grimes, B., Anand, S., McCulloch, C. E., Kaysen, G. A. 2013; 23 (2): 91-97

    Abstract

    Serum albumin and prealbumin concentrations are strongly associated with the risk of death in dialysis patients. Our study examined the association among demographic characteristics, body composition, comorbidities, dialysis modality and access, inflammation, and longitudinal measures of albumin and prealbumin concentrations in incident dialysis patients. DESIGN, SETTING, SUBJECTS, AND OUTCOME MEASURES: The Comprehensive Dialysis Study is a prospective cohort study of incident dialysis patients; in this report, we examined the data from 266 Nutrition substudy participants who donated serum. The independent variables of interest were baseline age, sex, race, Quetélet's (body mass) index, dialysis modality and access, diabetes, heart failure, atherosclerotic vascular disease, serum creatinine level, and longitudinal measures of C-reactive protein. The outcomes of interest (dependent variables) were longitudinal measures of albumin and prealbumin concentrations, recorded at study entry and thereafter every 3 months for 1 year.In multivariable mixed linear models, female sex, peritoneal dialysis, hemodialysis with a catheter, and higher C-reactive protein concentrations were associated with lower serum albumin concentrations, and serum albumin concentrations increased slightly over the year. In comparison, prealbumin concentrations did not significantly change over time; female sex, lower body mass index, diabetes, atherosclerotic vascular disease, and higher C-reactive protein concentrations were associated with lower prealbumin concentrations. Serum creatinine had a curvilinear relation with serum albumin and prealbumin.Serum albumin level increases early in the course of dialysis, whereas prealbumin level does not, and the predictors of serum concentrations differ at any given time. Further understanding of the mechanisms underlying differences between albumin and prealbumin kinetics in dialysis patients may lead to an improved approach to the management of protein-energy wasting.

    View details for DOI 10.1053/j.jrn.2012.03.001

    View details for Web of Science ID 000315198700009

    View details for PubMedID 22633987

    View details for PubMedCentralID PMC3434280

  • Association of Physical Activity with Survival among Ambulatory Patients on Dialysis: The Comprehensive Dialysis Study CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Johansen, K. L., Kaysen, G. A., Dalrymple, L. S., Grimes, B. A., Glidden, D. V., Anand, S., Chertow, G. M. 2013; 8 (2): 248-253

    Abstract

    Despite high mortality and low levels of physical activity (PA) among patients starting dialysis, the link between low PA and mortality has not been carefully evaluated.The Comprehensive Dialysis Study was a prospective cohort study that enrolled patients who started dialysis between June 2005 and June 2007 in a random sample of dialysis facilities in the United States. The Human Activity Profile (HAP) was administered to estimate PA among 1554 ambulatory enrolled patients in the Comprehensive Dialysis Study. Patients were followed until death or September 30, 2009, and the major outcome was all-cause mortality.The average age was 59.8 (14.2) years; 55% of participants were male, 28% were black, and 56% had diabetes mellitus. The majority (57.3%) had low fitness estimated from the HAP score. The median follow-up was 2.6 (interquartile range, 2.2-3.1) years. The association between PA and mortality was linear across the range of scores (1-94). After multivariable adjustment, lower adjusted activity score on the HAP was associated with higher mortality (hazard ratio, 1.30; 95% confidence interval, 1.23-1.39 per 10 points). Patients in the lowest level of fitness experienced a 3.5-fold (95% confidence interval, 2.54-4.89) increase in risk of death compared with those with average or above fitness.Low levels of PA are strongly associated with mortality among patients new to dialysis. Interventions aimed to preserve or enhance PA should be prospectively tested.

    View details for DOI 10.2215/CJN.08560812

    View details for Web of Science ID 000314488800013

    View details for PubMedID 23124787

    View details for PubMedCentralID PMC3562868

  • Physical activity and self-reported symptoms of insomnia, restless legs syndrome, and depression: The comprehensive dialysis study HEMODIALYSIS INTERNATIONAL Anand, S., Johansen, K. L., Grimes, B., Kaysen, G. A., Dalrymple, L. S., Kutner, N. G., Chertow, G. M. 2013; 17 (1): 50-58

    Abstract

    Symptoms of sleep and mood disturbances are common among patients on dialysis and are associated with significant decrements in survival and health-related quality of life. We used data from the Comprehensive Dialysis Study (CDS) to examine the association of self-reported physical activity with self-reported symptoms of insomnia, restless legs syndrome (RLS), and depression in patients new to dialysis. The CDS collected data on physical activity, functional status, and health-related quality of life from 1678 patients on either peritoneal (n = 169) or hemodialysis (n = 1509). The Human Activity Profile was used to measure self-reported physical activity. Symptoms were elicited in the following manner: insomnia using three questions designed to capture difficulty in initiating or maintaining sleep, RLS using three questions based on the National Institutes of Health workshop, and depression using the two-item Patient Health Questionnaire. We obtained data on symptoms of insomnia and depression for 1636, and on symptoms of RLS for 1622 (>98%) patients. Of these, 863 (53%) reported one of three insomnia symptoms as occurring at a persistent frequency. Symptoms of RLS and depression occurred in 477 (29%) and 451 (28%) of patients, respectively. The Adjusted Activity Score of the Human Activity Profile was inversely correlated with all three conditions in models adjusting for demographics, comorbid conditions, and laboratory variables. Sleep and mood disturbances were commonly reported in our large, diverse cohort of patients new to dialysis. Patients who reported lower levels of physical activity were more likely to report symptoms of insomnia, RLS, and depression.

    View details for DOI 10.1111/j.1542-4758.2012.00726.x

    View details for PubMedID 22812496

  • The Gap between Estimated Incidence of End-Stage Renal Disease and Use of Therapy. PloS one Anand, S., Bitton, A., Gaziano, T. 2013; 8 (8): e72860

    Abstract

    Relatively few data exist on the burden of end-stage renal disease (ESRD) and use of renal replacement therapy (RRT)-a life-saving therapy-in developing regions. No study has quantified the proportion of patients who develop ESRD but are unable to access RRT.We performed a comprehensive literature search to estimate use and annual initiation of RRT worldwide, and present these estimates according to World Bank regions. We also present estimates of survival and of etiology of diseases in patients undergoing RRT. Using data on prevalence of diabetes and hypertension, we modeled the incidence of ESRD related to these risk factors in order to quantify the gap between ESRD and use of RRT in developing regions.We find that 1.9 million patients are undergoing RRT worldwide, with continued use and annual initiation at 316 and 73 per million population respectively. RRT use correlates directly (Pearson's r = 0.94) with regional income. Hemodialysis remains the dominant form of RRT but there is wide regional variation in its use. With the exception of the Latin American and Caribbean region, it appears that initiation of RRT in developing regions is restricted to fewer than a quarter of patients projected to develop ESRD. This results in at least 1.2 million premature deaths each year due to lack of access to RRT as a result of diabetes and elevated blood pressure and as many as 3.2 million premature deaths due to all causes of ESRD.Thus, the majority of patients projected to reach ESRD due to diabetes or hypertension in developing regions are unable to access RRT; this gap will increase with rising prevalence of these risk factors worldwide.

    View details for DOI 10.1371/journal.pone.0072860

    View details for PubMedID 24023651

    View details for PubMedCentralID PMC3758352

  • The gap between estimated incidence of end-stage renal disease and use of therapy. PloS one Anand, S., Bitton, A., Gaziano, T. 2013; 8 (8)

    Abstract

    Relatively few data exist on the burden of end-stage renal disease (ESRD) and use of renal replacement therapy (RRT)-a life-saving therapy-in developing regions. No study has quantified the proportion of patients who develop ESRD but are unable to access RRT.We performed a comprehensive literature search to estimate use and annual initiation of RRT worldwide, and present these estimates according to World Bank regions. We also present estimates of survival and of etiology of diseases in patients undergoing RRT. Using data on prevalence of diabetes and hypertension, we modeled the incidence of ESRD related to these risk factors in order to quantify the gap between ESRD and use of RRT in developing regions.We find that 1.9 million patients are undergoing RRT worldwide, with continued use and annual initiation at 316 and 73 per million population respectively. RRT use correlates directly (Pearson's r = 0.94) with regional income. Hemodialysis remains the dominant form of RRT but there is wide regional variation in its use. With the exception of the Latin American and Caribbean region, it appears that initiation of RRT in developing regions is restricted to fewer than a quarter of patients projected to develop ESRD. This results in at least 1.2 million premature deaths each year due to lack of access to RRT as a result of diabetes and elevated blood pressure and as many as 3.2 million premature deaths due to all causes of ESRD.Thus, the majority of patients projected to reach ESRD due to diabetes or hypertension in developing regions are unable to access RRT; this gap will increase with rising prevalence of these risk factors worldwide.

    View details for DOI 10.1371/journal.pone.0072860

    View details for PubMedID 24023651

    View details for PubMedCentralID PMC3758352

  • High prevalence of type 2 diabetes among the urban middle class in Bangladesh. BMC public health Saquib, N., Khanam, M. A., Saquib, J., Anand, S., Chertow, G. M., Barry, M., Ahmed, T., Cullen, M. R. 2013; 13: 1032-?

    Abstract

    The prevalence of type-2 diabetes and metabolic syndrome are increasing in the developing world; we assessed their prevalence among the urban middle class in Bangladesh.In this cross-sectional survey (n = 402), we randomly selected consenting adults (≥ 30 years) from a middle-income neighborhood in Dhaka. We assessed demography, lifestyle, and health status, measured physical indices and blood pressure and obtained blood samples. We evaluated two primary outcomes: (1) type-2 diabetes (fasting blood glucose ≥ 7.0 mmol/L or hemoglobin A1C ≥ 6.5% (48 mmol/mol) or diabetes medication use) and (2) insulin resistance (type-2 diabetes or metabolic syndrome using International Diabetes Federation criteria).Mean age and Quételet's (body mass) index were 49.4 ± 12.6 years and 27.0 ± 5.1 kg/m²; 83% were married, 41% had ≥12 years of education, 47% were employed, 47% had a family history of diabetes. Thirty-five percent had type-2 diabetes and 45% had metabolic syndrome. In multivariate models older age and family history of diabetes were significantly associated with type-2 diabetes. Older age, female sex, overweight or obese, high wealth index and positive family history of diabetes were significantly associated with insulin resistance. Participants with type-2 diabetes or insulin resistance had significantly poorer physical health only if they had associated cardiovascular disease.The prevalence of type-2 diabetes and metabolic syndrome among the middle class in Dhaka is alarmingly high. Screening services should be implemented while researchers focus on strategies to lessen the incidence and morbidity associated with these conditions.

    View details for DOI 10.1186/1471-2458-13-1032

    View details for PubMedID 24172217

  • Causal or Casual?-The Association Between Consumption of Artificially Sweetened Carbonated Beverages and Vascular Disease JOURNAL OF GENERAL INTERNAL MEDICINE Anand, S., Winkelmayer, W. C. 2012; 27 (9): 1100-1101

    View details for DOI 10.1007/s11606-012-2126-1

    View details for Web of Science ID 000307511300004

    View details for PubMedID 22692638

    View details for PubMedCentralID PMC3515003

  • Obesity and the relationship between pre-hypertension and chronic kidney disease: can we really isolate the effect of pre-hypertension? KIDNEY INTERNATIONAL Anand, S., Arce, C. M., Sainani, K. L. 2012; 82 (4): 489-489

    View details for DOI 10.1038/ki.2012.144

    View details for Web of Science ID 000307078000017

    View details for PubMedID 22846814

  • Combining Angiotensin Receptor Blockers With ACE Inhibitors in Elderly Patients AMERICAN JOURNAL OF KIDNEY DISEASES Anand, S., Tamura, M. K. 2012; 59 (1): 11-14

    View details for DOI 10.1053/j.ajkd.2011.09.002

    View details for Web of Science ID 000298153600006

    View details for PubMedID 21995968

  • Vitamin D deficiency, self-reported physical activity and health-related quality of life: the Comprehensive Dialysis Study NEPHROLOGY DIALYSIS TRANSPLANTATION Anand, S., Kaysen, G. A., Chertow, G. M., Johansen, K. L., Grimes, B., Dalrymple, L. S., Tamura, M. K. 2011; 26 (11): 3683-3688

    Abstract

    As research has identified a wide array of biological functions of vitamin D, the consequences of vitamin D deficiency in persons with chronic kidney disease has attracted increased attention. The objective of this study was to determine the extent of 25-hydroxyvitamin D (25-OH vitamin D) deficiency and its associations with self-reported physical activity and health-related quality of life (HRQoL) among participants of the Comprehensive Dialysis Study (CDS).The nutrition substudy of the CDS enrolled patients new to dialysis from 68 dialysis units throughout the USA. Baseline 25-OH vitamin D concentration was measured using the Direct Enzyme Immunoassay (Immunodiagnostic Systems Inc.). Physical activity was measured with the Human Activity Profile (HAP); the Medical Outcomes Study Short Form-12 (SF-12) was employed to measure HRQoL.Mean age of the participants (n = 192) was 62 years. There were 124 participants (65%) with 25-OH vitamin D concentrations < 15 ng/mL, indicating deficiency, and 64 (33%) with 25-OH vitamin D ≥ 15 to <30 ng/mL, indicating insufficiency. After adjusting for age, sex, race/ethnicity, diabetes, season and center, lower 25-OH vitamin D concentrations were independently associated with lower scores on the HAP and on the Mental Component Summary of the SF-12 (P < 0.05 for both), but not with the Physical Component Summary of the SF-12.In a well-characterized cohort of incident dialysis patients, lower 25-OH vitamin D concentrations were associated with lower self-reported physical activity and poorer self-reported mental health.

    View details for DOI 10.1093/ndt/gfr098

    View details for PubMedID 21430182

  • Association of Self-reported Physical Activity With Laboratory Markers of Nutrition and Inflammation: The Comprehensive Dialysis Study JOURNAL OF RENAL NUTRITION Anand, S., Chertow, G. M., Johansen, K. L., Grimes, B., Tamura, M. K., Dalrymple, L. S., Kaysen, G. A. 2011; 21 (6): 429-437

    Abstract

    Patients on dialysis maintain extremely low levels of physical activity. Prior studies have demonstrated a direct correlation between nutrition and physical activity but provide conflicting data on the link between inflammation and physical activity. Using a cohort of patients new to dialysis from the Comprehensive Dialysis Study (CDS), we examined associations of self-reported physical activity with laboratory markers of nutrition and inflammation.Between June 2005 and June 2007, CDS collected data on self-reported physical activity, nutrition, and health-related quality of life from patients starting dialysis in 296 facilities located throughout the United States. Baseline serum samples were collected from participants in a nutrition sub-study of CDS.Serum albumin and prealbumin were measured as markers of nutrition, and C-reactive protein (CRP) and α-1-acid glycoprotein as markers of inflammation. Self-reported physical activity was characterized by the maximum activity score (MAS) and adjusted activity score (AAS) of the Human Activity Profile.The mean age of participants in the analytic cohort (n = 201) was 61 years. The MAS and AAS were below the 10th and first percentile, respectively, in comparison with healthy 60 year-old norms. Both activity scores were directly correlated with albumin (r(2) = 0.3, P < .0001) and prealbumin (r(2) = 0.3, P < .0001), and inversely correlated with CRP (AAS: r(2) = -0.2, P = .01; MAS: r(2) = -0.1, P = .08). In multivariate analyses adjusting for age, gender, race/ethnicity, diabetes status, and center, both activity scores were directly correlated with prealbumin and inversely correlated with CRP.Patients new to dialysis with laboratory-based evidence of malnutrition and/or inflammation are likely to report lower levels of physical activity.

    View details for DOI 10.1053/j.jrn.2010.09.007

    View details for PubMedID 21239185

  • Cytomegalovirus in the transplanted kidney: a report of two cases and review of prophylaxis. NDT plus Anand, S., Yabu, J. M., Melcher, M. L., Kambham, N., Laszik, Z., Tan, J. C. 2011; 4 (5): 342-345

    View details for DOI 10.1093/ndtplus/sfr074

    View details for PubMedID 25984184

  • Cytomegalovirus in the transplanted kidney: a report of two cases and review of prophylaxis CLINICAL KIDNEY JOURNAL Anand, S., Yabu, J. M., Melcher, M. L., Kambham, N., Laszik, Z., Tan, J. C. 2011; 4 (5): 342–45
  • Comparison of CKD awareness in a screening population using the Modification of Diet in Renal Disease (MDRD) study and CKD Epidemiology Collaboration (CKD-EPI) equations. American journal of kidney diseases Kurella Tamura, M., Anand, S., Li, S., Chen, S., Whaley-Connell, A. T., Stevens, L. A., Norris, K. C. 2011; 57 (3): S17-23

    Abstract

    Low awareness of chronic kidney disease (CKD) may reflect uncertainty about the accuracy or significance of a CKD diagnosis in individuals otherwise perceived to be low risk. Whether reclassification of CKD severity using the CKD Epidemiology Collaboration (CKD-EPI) equation to estimate glomerular filtration rate (GFR) modifies estimates of CKD awareness is unknown.In this cross-sectional study, we used data collected from 2000-2009 for 26,213 participants in the Kidney Early Evaluation Program (KEEP), a community-based screening program, with CKD based on GFR estimated using the 4-variable Modification of Diet in Renal Disease (MDRD) Study equation and measurement of albuminuria. We assessed CKD awareness after CKD stage was reclassified using the CKD-EPI equation.Of 26,213 participants with CKD based on GFR estimated using the MRDR equation (eGFR(MDRD)), 23,572 (90%) also were classified with CKD based on eGFR(CKD-EPI). Based on eGFR(MDRD), 9.5% of participants overall were aware of CKD, as were 4.9%, 6.3%, 9.2%, 41.9%, and 59.2% with stages 1-5, respectively. Based on eGFR(CKD-EPI), 10.0% of participants overall were aware of CKD, as were 5.1%, 6.6%, 10.0%, 39.3%, and 59.4% with stages 1-5, respectively. Reclassification to a less advanced CKD stage using eGFR(CKD-EPI) was associated with lower odds for awareness (OR, 0.58; 95% CI, 0.50-0.67); reclassification to a more advanced stage was associated with higher odds for awareness (OR, 1.50; 95% CI, 1.05-2.13) after adjustment for confounding factors. Of participants unaware of CKD, 10.6% were reclassified as not having CKD using eGFR(CKD-EPI).Using eGFR(CKD-EPI) led to a modest increase in overall awareness rates, primarily due to reclassification of low-risk unaware participants.

    View details for DOI 10.1053/j.ajkd.2010.11.008

    View details for PubMedID 21338846

  • Comparison of CKD Awareness in a Screening Population Using the Modification of Diet in Renal Disease (MDRD) Study and CKD Epidemiology Collaboration (CKD-EPI) Equations AMERICAN JOURNAL OF KIDNEY DISEASES Tamura, M. K., Anand, S., Li, S., Chen, S., Whaley-Connell, A. T., Stevens, L. A., Norris, K. C. 2011; 57 (3): S17-S23
  • The elderly patients on hemodialysis. Minerva urologica e nefrologica = The Italian journal of urology and nephrology Anand, S., Kurella Tamura, M., Chertow, G. M. 2010; 62 (1): 87-101

    Abstract

    Nephrologists care for an increasing number of elderly patients on hemodialysis. As such, an understanding of the overlap among complications of hemodialysis and geriatric syndromes is crucial. This article reviews hemodialysis management issues including vascular access, hypertension, anemia and bone and mineral disorders with an attention towards the distinct medical needs of the elderly. Key concepts of geriatrics frailty, dementia and palliative care are also discussed, as nephrologists frequently participate in decision-making directed toward balancing longevity, functional status and the burden of therapy.

    View details for PubMedID 20424572

  • The elderly patients on hemodialysis MINERVA UROLOGICA E NEFROLOGICA Anand, S., Tamura, M. K., Chertow, G. M. 2010; 62 (1): 87-101

    Abstract

    Nephrologists care for an increasing number of elderly patients on hemodialysis. As such, an understanding of the overlap among complications of hemodialysis and geriatric syndromes is crucial. This article reviews hemodialysis management issues including vascular access, hypertension, anemia and bone and mineral disorders with an attention towards the distinct medical needs of the elderly. Key concepts of geriatrics frailty, dementia and palliative care are also discussed, as nephrologists frequently participate in decision-making directed toward balancing longevity, functional status and the burden of therapy.

    View details for Web of Science ID 000208661300008

  • Growing Epidemic of Coronary Heart Disease in Low- and Middle-Income Countries CURRENT PROBLEMS IN CARDIOLOGY Gaziano, T. A., Bitton, A., Anand, S., Abrahams-Gessel, S., Murphy, A. 2010; 35 (2): 72-115

    Abstract

    Coronary heart disease (CHD) is the single largest cause of death in the developed countries and is one of the leading causes of disease burden in developing countries. In 2001, there were 7.3 million deaths due to CHD worldwide. Three-fourths of global deaths due to CHD occurred in the low- and middle-income countries. The rapid rise in CHD burden in most of the low- and middle-income countries is due to socio-economic changes, increase in lifespan, and acquisition of lifestyle-related risk factors. The CHD death rate, however, varies dramatically across the developing countries. The varying incidence, prevalence, and mortality rates reflect the different levels of risk factors, other competing causes of death, availability of resources to combat cardiovascular disease, and the stage of epidemiologic transition that each country or region finds itself. The economic burden of CHD is equally large but solutions exist to manage this growing burden.

    View details for DOI 10.1016/j.cpcardio1.2009.10.002

    View details for Web of Science ID 000277951000002

    View details for PubMedID 20109979

  • The global cost of nonoptimal blood pressure JOURNAL OF HYPERTENSION Gaziano, T. A., Bitton, A., Anand, S., Weinstein, M. C. 2009; 27 (7): 1472-1477

    Abstract

    Suboptimal blood pressure including established nonoptimal blood pressure has been shown to have significant economic consequences in developed countries. However, no exhaustive study has been done to evaluate its potential costs, globally. We, therefore, set out to estimate the global economic cost of nonoptimal blood pressure.Estimates for healthcare costs attributed to suboptimal blood pressure for those over the age of 30 were made for all the World Bank regions. Annual and 10-year estimates using Markov models were made for the cost of treating nonoptimal blood pressure and its main sequelae: stroke and myocardial infarction.Suboptimal blood pressure cost US$370,000,000,000 globally in 2001. This represents about 10% of the world's overall healthcare expenditures. In the Eastern Europe and Central Asia region, high blood pressure consumed 25% of all health expenditures. Over a 10-year period, elevated blood pressure may cost nearly $1,000,000,000,000 globally in health spending, if current blood pressure levels persist. Indirect costs could be as high as $3,600,000,000,000 annually.Suboptimal blood pressure is responsible for a large and an increasing economic and health burden in developing countries. Although the majority of the current absolute expenditure occurs in the high-income countries, an ever-increasing proportion of the cost is going to be carried by developing countries.

    View details for DOI 10.1097/HJH.0b013e32832a9ba3

    View details for Web of Science ID 000267783800022

    View details for PubMedID 19474763