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Kovesdy C.P.,Salem Medical Center | Kovesdy C.P.,University of Virginia | Kuchmak O.,Carilion Clinic | Lu J.L.,Salem Research Institute | Kalantar-Zadeh K.,University of California at Los Angeles
American Journal of Kidney Diseases | Year: 2010

Background Phosphorus binders are used to treat hyperphosphatemia in maintenance dialysis patients, in whom the use of these medications has been associated with lower mortality in some observational studies. It is not clear whether similar benefits can be seen in patients with nondialysis-dependent chronic kidney disease (CKD). Study Design Historical cohort. Setting & Participants 1,188 men with moderate and advanced nondialysis-dependent CKD at a single medical center. Predictor Administration of any phosphorus binder. Outcomes & Measurements We examined associations of any phosphorus-binder administration with all-cause mortality and the slopes of estimated glomerular filtration rate using time-varying Cox models and mixed-effects models. Associations also were examined in intention-to-treat analyses and in 133 patient-pairs matched according to propensity scores. Results 344 patients were treated with a phosphorus binder; 658 patients died (mortality rate, 141 deaths/1,000 patient-years; 95% CI, 131-153) during a median follow-up of 3.1 years. Treatment with phosphorus binders was associated with significantly lower mortality (adjusted HR, 0.61; 95% CI, 0.45-0.81; P < 0.001). Results were similar when exposure was modeled in intention-to-treat analyses and examining propensity-matched patients. Phosphorus-binder use was not associated with significant changes in kidney function loss. Limitations Results may not apply to all patients with nondialysis-dependent CKD. Conclusions Administration of phosphorus binders is associated with lower mortality in men with moderate and advanced nondialysis-dependent CKD. Clinical trials are needed to determine the risks and benefits of phosphorus-binder use in this patient population. © 2010 National Kidney Foundation, Inc. Source


Qaseem A.,The American College | Dallas P.,Virginia Polytechnic Institute and State University | Forciea M.A.,University of Pennsylvania | Starkey M.,The American College | Denberg T.D.,Carilion Clinic
Annals of Internal Medicine | Year: 2014

Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the comparative effectiveness and safety of preventive dietary and pharmacologic management of recurrent nephrolithiasis in adults.Methods: This guideline is based on published literature on this topic that was identified using MEDLINE, the Cochrane Database of Systematic Reviews (through March 2014), Google Scholar, ClinicalTrials.gov, and Web of Science. Searches were limited to English-language publications. The clinical outcomes evaluated for this guideline include symptomatic stone recurrence, pain, urinary tract obstruction with acute renal impairment, infection, procedurerelated illness, emergency department visits, hospitalizations, quality of life, and end-stage renal disease. This guideline grades the quality of evidence and strength of recommendations using ACP's clinical practice guidelines grading system. The target audience for this guideline is all clinicians, and the target patient population is all adults with recurrent nephrolithiasis (-1 prior kidney stone episode).Recommendation 1: ACP recommends management with increased fluid intake spread throughout the day to achieve at least 2 L of urine per day to prevent recurrent nephrolithiasis. (Grade: weak recommendation, low-quality evidence).Recommendation 2: ACP recommends pharmacologic monotherapy with a thiazide diuretic, citrate, or allopurinol to prevent recurrent nephrolithiasis in patients with active disease in which increased fluid intake fails to reduce the formation of stones. (Grade: weak recommendation, moderate-quality evidence). © 2014 American College of Physicians. Source


Bentley M.L.,Carilion Clinic
Journal of Pharmacy Practice | Year: 2011

Acute kidney insufficiency (AKI), or injury, is common in the critically ill patient. Minimal increases in serum creatinine (Scr) have been associated with greater morbidity, mortality, and hospital cost. In 2002, the Acute Dialysis Quality Initiative (ADQI) proposed a consensus definition (the RIFLE classification) which was modified after continuing evidence suggested that small changes in Scr (≥0.3 mg/dL) led to worsening outcomes. This group, known as the Acute Kidney Injury Network (AKIN), suggests 3 stages of worsening kidney function. Such definitions may aid in identifying patients at greatest risk and further the development of preventive strategies. This review will focus on the epidemiology and etiology of AKI as well as provide a mechanistic description of drug-induced AKI. In addition, a brief review of continuous renal replacement therapies is provided. © The Author(s) 2011. Source


Sawaya G.F.,University of California at San Francisco | Kulasingam S.,University of Minnesota | Denberg T.D.,Carilion Clinic | Qaseem A.,The American College
Annals of Internal Medicine | Year: 2015

Description: The purpose of this best practice advice article is to describe the indications for screening for cervical cancer in asymptomatic, average-risk women aged 21 years or older. Methods: The evidence reviewed in this work is a distillation of relevant publications (including systematic reviews) used to support current guidelines. Best Practice Advice 1: Clinicians should not screen averagerisk women younger than 21 years for cervical cancer. Best Practice Advice 2: Clinicians should start screening average-risk women for cervical cancer at age 21 years once every 3 years with cytology (cytologic tests without human papillomavirus [HPV] tests). Best Practice Advice 3: Clinicians should not screen averagerisk women for cervical cancer with cytology more often than once every 3 years. Best Practice Advice 4: Clinicians may use a combination of cytology and HPV testing once every 5 years in average-risk women aged 30 years or older who prefer screening less often than every 3 years. Best Practice Advice 5: Clinicians should not perform HPV testing in average-risk women younger than 30 years. Best Practice Advice 6: Clinicians should stop screening average-risk women older than 65 years for cervical cancer if they have had 3 consecutive negative cytology results or 2 consecutive negative cytology plus HPV test results within 10 years, with the most recent test performed within 5 years. Best Practice Advice 7: Clinicians should not screen averagerisk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix. © 2015 American College of Physicians. Source


Qaseem A.,The American College | Dallas P.,Virginia Polytechnic Institute and State University | Forciea M.A.,University of Pennsylvania | Starkey M.,The American College | And 2 more authors.
Annals of Internal Medicine | Year: 2014

Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the nonsurgical management of urinary incontinence (UI) in women.Methods: This guideline is based on published English-language literature on nonsurgical management of UI in women from 1990 through December 2013 that was identified using MEDLINE, the Cochrane Library, Scirus, and Google Scholar. The outcomes evaluated for this guideline include continence, improvement in UI, quality of life, adverse effects, and discontinuation due to adverse effects. It grades the evidence and recommendations by using ACP's guideline grading system. The target audience is all clinicians, and the target patient population is all women with UI.Recommendation 1: ACP recommends first-line treatment with pelvic floor muscle training in women with stress UI. (Grade: strong recommendation, high-quality evidence).Recommendation 2: ACP recommends bladder training in women with urgency UI. (Grade: strong recommendation, moderate-quality.Recommendation 3: ACP recommends pelvic floor muscle training with bladder training in women with mixed UI. (Grade: strong recommendation, moderate-quality evidence).Recommendation 4: ACP recommends against treatment with systemic pharmacologic therapy for stress UI. (Grade: strong recommendation, low-quality evidence).Recommendation 5: ACP recommends pharmacologic treatment in women with urgency UI if bladder training was unsuccessful. Clinicians should base the choice of pharmacologic agents on tolera-bility, adverse effect profile, ease of use, and cost of medication. (Grade: strong recommendation, high-quality evidence).Recommendation 6: ACP recommends weight loss and exercise for obese women with UI. (Grade: strong recommendation, moderate-quality evidence). © 2014 American College of Physicians. Source

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