Wednesday, October 29, 2008

Sudden Cardiac Death No. 1 Risk for Patients on Dialysis

Study: Inflammation, malnutrition identified as key risk factors

By Eric Vohr
Johns Hopkins Medicine

In a 10-year study of more than a thousand kidney failure patients, sudden cardiac death emerged as the No. 1 cause of death for patients on dialysis, according to a Johns Hopkins researcher.

The study, already published online and appearing in the Nov. 2 issue of Kidney International, identified systemic inflammatory response and malnutrition as key risk factors for the fatal heart attacks.

"This is believed to be the first time anyone has taken a rigorous prospective look at why so many patients on dialysis die from sudden cardiac death, and the results could help doctors identify those at highest risk and potentially save lives," said Rulan S. Parekh, associate professor in the Department of Nephrology at the Johns Hopkins University School of Medicine.

Parekh and her team gathered their data from a cohort of 1,041 end-stage renal disease patients on dialysis who were part of Choices for Healthy Outcomes in Caring for ESRD, known as CHOICE. In a 9.5-year period, 658 of this group died. The largest number of these deaths, 146, was the result of sudden cardiac death, or SDC — in this case, unexpected deaths that occurred outside the hospital setting.

The researchers then looked at previously recorded blood test results from 122 of these 146 sudden cardiac death patients to search for a possible relationship between the deaths and levels of high-sensitivity C-reactive (hsCRP), interleukin-6 (IL-6) and albumin. The proteins IL-6 and hsCRP are both markers for widespread blood vessel and organ inflammation, while low albumin levels are associated with malnutrition.

Results showed that patients with high levels of either hsCRP or IL-6 were twice as likely to die from sudden cardiac death as those with low levels of these proteins. Low albumin levels were associated with a 1.35 times increase in the risk of dying of sudden cardiac death when compared with high levels, according to Parekh. In addition, those with low levels of albumin and high levels of hsCRP were four times more likely to die of sudden cardiac death than those with high levels of albumin and low levels of hsCRP.

"These results tell us that ESRD patients with low albumin and/or high levels of IL-6 and hsCRP are at a significantly higher risk of SCD," Parekh said.

The half-million people in the United States with ESRD are 10 to 100 times more likely than the general public to die from cardiovascular disease, depending on age, according to Parekh. They have an annual mortality rate of more than 20 percent, and one-fifth of these deaths are attributed to sudden cardiac death.

Systemic inflammatory response is common with ESRD patients and occurs when the body responds to an infectious or noninfectious attack. Parekh said that because those with kidney failure are quite ill, the chance of infection and chronic inflammation is higher. Also common with ESRD patients is malnutrition from the stress of kidney failure, loss of appetite and a highly restricted diet; compounding the issue, she said, is that Medicare does not cover oral nutritional supplements.

"When people think of heart attacks, they think of cholesterol and obesity," Parekh said, "but these are risk factors for hardening of the arteries and are not directly linked to sudden heart death among patients on dialysis."

Other researchers from Johns Hopkins who contributed to this study are Neil R. Powe, Josef Coresh, Lucy A. Meoni, Bernard G. Jaar and Nancy E. Fink, all of the School of Medicine; and Michael J. Klag, W.H. Linda Kao and Laura C. Plantinga, all of the Bloomberg School of Public Health.

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A Rise in Kidney Stones Is Seen in U.S. Children


Brendan Smialowski for The New York Times YOUNG VICTIM Tessa Cesario, 11, developed a kidney stone in February. She has since cut back on salt and is drinking more water.

To the great surprise of parents, kidney stones, once considered a disorder of middle age, are now showing up in children as young as 5 or 6.

While there are no reliable data on the number of cases, pediatric urologists and nephrologists across the country say they are seeing a steep rise in young patients. Some hospitals have opened pediatric kidney stone clinics.

“The older doctors would say in the ’70s and ’80s, they’d see a kid with a stone once every few months,” said Dr. Caleb P. Nelson, a urology instructor at Harvard Medical School who is co-director of the new kidney stone center at Children’s Hospital Boston. “Now we see kids once a week or less.”

Dr. John C. Pope IV, an associate professor of urologic surgery and pediatrics at the Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, said, “When we tell parents, most say they’ve never heard of a kid with a kidney stone and think something is terribly wrong with their child.”

In China recently, many children who drank milk tainted with melamine — a toxic chemical illegally added to watered-down milk to inflate the protein count — developed kidney stones.

The increase in the United States is attributed to a host of factors, including a food additive that is both legal and ubiquitous: salt.

Though most of the research on kidney stones comes from adult studies, experts believe it can be applied to children. Those studies have found that dietary factors are the leading cause of kidney stones, which are crystallizations of several substances in the urine. Stones form when these substances become too concentrated.

Forty to 65 percent of kidney stones are formed when oxalate, a byproduct of certain foods, binds to calcium in the urine. (Other common types include calcium phosphate stones and uric acid stones.) And the two biggest risk factors for this binding process are not drinking enough fluids and eating too much salt; both increase the amount of calcium and oxalate in the urine.

Excess salt has to be excreted through the kidneys, but salt binds to calcium on its way out, creating a greater concentration of calcium in the urine and the kidneys.

“What we’ve really seen is an increase in the salt load in children’s diet,” said Dr. Bruce L. Slaughenhoupt, co-director of pediatric urology and of the pediatric kidney stone clinic at the University of Wisconsin. He and other experts mentioned not just salty chips and French fries, but also processed foods like sandwich meats; canned soups; packaged meals; and even sports drinks like Gatorade, which are so popular among schoolchildren they are now sold in child-friendly juice boxes.

Children also tend not to drink enough water. “They don’t want to go to the bathroom at school; they don’t have time, so they drink less,” said Dr. Alicia Neu, medical director of pediatric nephrology and the pediatric stone clinic at Johns Hopkins Children’s Center in Baltimore. Instead, they are likely to drink only once they’re thirsty — but that may be too little, too late, especially for children who play sports or are just active.

“Drinking more water is the most important step in the prevention of kidney stones,” Dr. Neu said.

The incidence of kidney stones in adults has also been rising, especially in women, and experts say they see more adults in their 20s and 30s with stones; in the past, it was more common in adults in their 40s and 50s.

“It’s no longer a middle-aged disease,” Dr. Nelson said. “Most of us suspect what we’re seeing in children is the spillover of the overall increase in the whole population.”

The median age of children with stones is about 10.

Many experts say the rise in obesity is contributing to kidney stones in children as well as adults. But not all stone centers are seeing overweight children, and having a healthy weight does not preclude kidney stones. “Of the school-age and adolescent kids we’ve seen, most of them appear to be reasonably fit, active kids,” Dr. Nelson said. “We’re not seeing a parade of overweight Nintendo players.”

Dr. Slaughenhoupt has seen more overweight children at his clinic. “We haven’t compared our data yet,” he said, “but my sense is that children with stones are bigger, and some of them are morbidly obese.”

Dr. Pope, in Nashville, agreed. His hospital lies in the so-called stone belt, a swath of Southern states with a higher incidence of kidney stones, and he said doctors there saw two to three new pediatric cases a week.

“There’s no question in my mind that it is largely dietary and directly related to the childhood obesity epidemic,” he said.

Fifty to 60 percent of children with kidney stones have a family history of the disease. “If you have a family history, it’s important to recognize your kids are at risk at some point in their life,” Dr. Nelson said. “That means instilling lifelong habits of good hydration, balanced diet, and avoiding processed high-salt, high-fat foods.”

There is also evidence that sucrose, found in sodas, can also increase risk of stones, as can high-protein weight-loss diets, which are growing in popularity among teenagers.

A common misconception is that people with kidney stones should avoid calcium. In fact, dairy products have been shown to reduce the risk of stones, because the dietary calcium binds with oxalate before it is absorbed by the body, preventing it from getting into the kidneys.

Children with kidney stones can experience severe pain in their side or stomach when a stone is passing through the narrow ureter through which urine travels from the kidneys to the bladder. Younger children may have a more vague pain or stomachache, making the condition harder to diagnose. Children may feel sick to their stomach, and often there is blood in the urine.

One Saturday last February, 11-year-old Tessa Cesario of Frederick, Md., began having back pains. An aspiring ballerina who dances en pointe five nights a week, she was used to occasional aches and strains. But this one was so intense that her parents took her to the doctor.

The pediatrician ordered an X-ray, and when he phoned with the results, her parents were astonished.

“I was afraid he was calling to say she pulled something and wouldn’t be able to dance,” said her mother, Theresa Cesario. Instead, they were told that Tessa had a kidney stone.

“I thought older men get kidney stones, not kids,” Ms. Cesario said.

The treatment for kidney stones is similar in children and adults. Doctors try to let the stone pass, but if it is too large, if it blocks the flow of urine or if there is a sign of infection, it is removed through one of two types of minimally invasive surgery.

Shock-wave lithotripsy is a noninvasive procedure that uses high-energy sound waves to blast the stones into fragments that are then more easily passed. In ureteroscopy, an endoscope is inserted through the ureter to retrieve or obliterate the stone.

Tessa Cesario is taking a wait-and-see approach. Her stone is not budging, so her parents are putting off surgery until they can work it into her dance schedule. In the meantime, she has vastly reduced her salt intake by cutting back on sandwich meats, processed soups and chips.

And, her mother said, “she drinks a ton more water.”

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Police say teen driver hit 107 mph in a construction zone

By KVAL Web Staff

COTTAGE GROVE, Ore. -- Police jailed a Springfield teen after she sped away from a state trooper through a construction zone at 107 mph -- and then told the trooper she was having trouble seeing while talking on her cell phone, according to Oregon State Police.

Kimberly Messer, 18, from Springfield, Ore., was arrested on charges of reckless driving and recklessly endangering another person and lodged in the Lane County Jail, according to OSP.

OSP Trooper Ryan Hockema tried to stop a red 1995 Ford Mustang he spotted going 87 mph near a construction site. According to the trooper, the vehicle then accelerated to speeds as high as 107 mph in the work zone while failing to maintain the travel lane, following other vehicles too closely and making unsafe lane changes.

The driver, Messer, allegedly told the trooper she had trouble seeing while talking on her cell phone before stopping for the officer, according to OSP.

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Starbucks as an economic indicator


Over at Slate, resident business expert Daniel Gross has an interesting article that, in essence, makes a correlation between the state of a country's banking crisis and how invasive Starbucks has become there. For instance, London and Spain are being hit extremely hard by the financial crisis and they both have high densities of Starbucks.

It's an article straight out of Thomas Friedman's theories (Gross references Friedman's Golden Arches Theory of Conflict Prevention) and while it may work for international banking, it got me wondering if the theory would also hold up a little closer to home.

Have U.S. cities with high percentages of Starbucks been hit harder by the housing and banking burst than cities with lower percentages?

When it comes to a housing crisis, yes. This survey from 2006 shows the city with the most Starbucks per capita to be Las Vegas. Guess what state has had the nation's highest foreclosure rate for 20 straight months? Yep, Nevada. (Las Vegas ranks seventh-highest among cities in foreclosure rate.) Foreclosures have hit hardest in California, which makes up nearly a third of all foreclosures in the United States. California's number-one city in terms of foreclosures is Stockton, followed by Merced, Modesto and Vallejo-Fairfield. Stockton and Vallejo had the eighth-highest number of Starbucks per capita. Modesto lies between San Francisco and Sacramento, which has the fourth-highest number of Starbucks per capita.

More correlations: Denver is sixth in Starbucks density and Colorado Springs is 13; Colorado has the eighth-highest foreclosure rate. Georgia is sixth in foreclosures; capital city Atlanta is seventh in Starbucks density. Ohio is seventh in foreclosures and Cincinnati is 10th in Starbucks density.

When it comes to the banking crisis, things get murkier. BusinessWeek put together a list of 20 cities that are going to be hit hardest by the financial meltdown. Coming in at number-one was Darien, Connecticut, which only has one Starbucks for its 20,000- plus population. The number-two city was Bloomington, Illinois, population 50,000 and home of two Starbucks. Going through the list it was clear that towns in Connecticut, New Jersey and New York are going to be hardest hit. Yet none of those states have especially high Starbucks densities.

Going a little deeper into the numbers I realize why. New Jersey, New York and Connecticut are all prime Dunkin' Donuts territories. Darien, Connecticut, has only one Starbucks but two Dunkin' Donuts. A quick search of Google Maps reveals 395 Starbucks near Manhattan and 295 Dunkin' Donuts. The same search reveals 409 Starbucks in smaller San Francisco and not one Dunkin' Donuts.

The conclusion: The housing bubble is mainly in the West and South, which is strong Starbucks country. The financial meltdown is mainly in the East and Northeast, which is as much Dunkin' Donuts territory as it is Starbucks.

Either way, I am still glad that Kansas City doesn't have that many Starbucks.

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