Addressing Inpatient Hyponatremia Through Targeted Automatic E-consults: A Pilot Randomized Trial.

Background: Hyponatremia is the most common electrolyte abnormality in hospitalized patients. Treatment of hyponatremia is associated with improved outcomes, but more than one in three cases of new onset hyponatremia is not corrected by the time of hospital discharge. Nephrologist input may improve the diagnosis and treatment of hyponatremia, but specialist resources are limited.

Evaluating a low anion gap: A practical approach.

In teaching and in practice, little attention is given to a low anion gap. This oversight can result in a missed opportunity to diagnose acute or chronic disorders requiring treatment. In this article, we review the constituents of the anion gap, build a differential diagnosis for a low anion gap using case examples, and provide a stepwise approach to diagnostic testing to evaluate this abnormal finding.

Incidence and Risk Factors for Dialysis Reinitiation among Patients with a History of Dialysis Dependency.

Background And Objectives: Recovery of kidney function after the start of maintenance dialysis can occur, but data on the incidence and risk factors for restarting dialysis after recovery of kidney function in this population are limited.

Design, Setting, Participants, & Measurements: We conducted a retrospective study of adult Medicare beneficiaries who started dialysis between 2005 and 2015 according to the United States Renal Data System but who had recovery of kidney function (defined as a ≥90-day dialysis-free interval). We identified risk factors that were associated with the risk for the reinitiation of dialysis within a 3-year time frame following the recovery of kidney function and at any time during follow-up using Cox proportional hazards models.

Electronic Decision Support for Management of CKD in Primary Care: A Pragmatic Randomized Trial.

Rationale & Objective: Most adults with chronic kidney disease (CKD) in the United States are cared for by primary care providers (PCPs). We evaluated the feasibility and preliminary effectiveness of an electronic clinical decision support system (eCDSS) within the electronic health record with or without pharmacist follow-up to improve the management of CKD in primary care.

Study Design: Pragmatic cluster-randomized trial.

Screening for CKD To Improve Processes of Care among Nondiabetic Veterans with Hypertension: A Pragmatic Cluster-Randomized Trial.

Background And Objectives: We conducted a pilot, pragmatic, cluster-randomized trial to evaluate feasibility and preliminary effectiveness of screening for CKD using a triple-marker approach (creatinine, cystatin C, and albumin/creatinine ratio), followed by education and guidance, to improve care of hypertensive veterans in primary care. We used the electronic health record for identification, enrollment, intervention delivery, and outcome ascertainment.

Design, Setting, Participants, & Measurements: We randomized 1819 veterans without diabetes but with hypertension (41 clusters) into three arms: () CKD screening followed by patient and provider education; () screening, education, plus pharmacist comanagement; or () usual care.

A Pragmatic Cluster Randomized Trial of an Electronic Clinical Decision Support System to Improve Chronic Kidney Disease Management in Primary Care: Design, Rationale, and Implementation Experience.

Background: The diagnosis of chronic kidney disease (CKD) is based on laboratory results easily extracted from electronic health records; therefore, CKD identification and management is an ideal area for targeted electronic decision support efforts. Early CKD management frequently occurs in primary care settings where primary care providers (PCPs) may not implement all the best practices to prevent CKD-related complications. Few previous studies have employed randomized trials to assess a CKD electronic clinical decision support system (eCDSS) that provided recommendations to PCPs tailored to each patient based on laboratory results.

Validating laboratory defined chronic kidney disease in the electronic health record for patients in primary care.

Background: Electronic health record (EHR) data is increasingly used to identify patients with chronic kidney disease (CKD). EHR queries used to capture CKD status, identify comorbid conditions, measure awareness by providers, and track adherence to guideline-concordant processes of care have not been validated.

Methods: We extracted EHR data for primary-care patients with two eGFRcreat 15-59 mL/min/1.

Implementation of a pragmatic randomized trial of screening for chronic kidney disease to improve care among non-diabetic hypertensive veterans.

Background: Whether screening for chronic kidney disease (CKD) can improve the care of persons at high risk for complications remains uncertain. We describe the design and early implementation experience of a pilot, cluster-randomized pragmatic trial to evaluate the feasibility, implementation, and effectiveness of a "triple marker" CKD screening program (creatinine, cystatin C and albumin to creatinine ratio) for improving care among hypertensive veterans seen in primary care at one Veterans Administration Hospital.

Methods/design: Non-diabetic hypertensive veterans age 18-80 without known CKD were randomized in clusters determined by primary care provider (unit of randomization) into three arms.

Uric acid levels, kidney function, and cardiovascular mortality in US adults: National Health and Nutrition Examination Survey (NHANES) 1988-1994 and 1999-2002.

Background: Chronic kidney disease (CKD) and hyperuricemia often coexist, and both conditions are increasing in prevalence in the United States. However, their shared role in cardiovascular risk remains highly debated.

Study Design: Cross-sectional and longitudinal.

Temporal changes in incidence of dialysis-requiring AKI.

The population epidemiology of AKI is not well described. Here, we analyzed data from the Nationwide Inpatient Sample, a nationally representative dataset, to identify cases of dialysis-requiring AKI using validated International Classification of Diseases, Ninth Revision (ICD-9) codes. From 2000 to 2009, the incidence of dialysis-requiring AKI increased from 222 to 533 cases per million person-years, averaging a 10% increase per year (incidence rate ratio=1.

Dialysis-requiring acute renal failure increases the risk of progressive chronic kidney disease.

To determine whether acute renal failure (ARF) increases the long-term risk of progressive chronic kidney disease (CKD), we studied the outcome of patients whose initial kidney function was normal or near normal but who had an episode of dialysis-requiring ARF and did not develop end-stage renal disease within 30 days following hospital discharge. The study encompassed 556,090 adult members of Kaiser Permanente of Northern California hospitalized over an 8 year period, who had pre-admission estimated glomerular filtration rates (eGFR) equivalent to or greater than 45 ml/min/1.73 m(2) and who survived hospitalization.

Some methodological issues in studying the long-term renal sequelae of acute kidney injury.

There has been great interest recently in better understanding how an episode of acute kidney injury (AKI) affects risk of development or acceleration of chronic kidney disease. This area of epidemiology research presents several methodological challenges that have not been sufficiently discussed in the literature. These are related to the current consensus definitions of AKI; the determination of 'baseline' renal function before the AKI episode; and the possibility that observed associations between AKI and future adverse events are confounded by differences in the severity of baseline chronic kidney disease.