RESEARCH HIGHLIGHTS CLINICAL TRIALS
PRE-ECLAMPSIA
Lifestyle intervention reduces CKD risk associated with type 2 diabetes A secondary analysis of the Action for Health in Diabetes (Look AHEAD) randomized controlled trial has revealed that sustained weight loss might reduce the likelihood of very-high-risk chronic kidney disease (CKD) in patients with type 2 diabetes meilitus (T2DM). "Weight loss is part of standard treatment recommendations for overweight or obese persons with T2DM, but there is remarkably little evidence of its long term value,” explains lead author William Knowler of the NIH Institute of Diabetes and Digestive Kidney Diseases, AZ, USA. In the Look AHEAD trial, patients received either intensive lifestyle intervention (ILI), targeting a >7% decrease in body weight, or diabetes-specific support and education. Despite no significant differences in the primary study outcomes (death from cardiovascular causes or nonfatal myocardial infarction, stroke or hospitalization with angina), ILI resulted in a 31% reduction in risk of very-high-risk
L O W -D O S E FOR
A S P IR IN
P R E -E C L A M P S IA
In lig h t o f new e vid e n ce , th e US Preventive
CKD—as defined by KDIGO guidelines— after a median follow-up duration of 8 years. The researchers partly attribute this finding to significant reductions in body weight, blood glucose and systolic blood pressure in the ILI group, in which patients also used fewer antihypertensives. Knowler concludes that “controlling blood pressure and glycaemia with medication is often not fully successful in preventing kidney disease in patients with T2DM. Lifestyle interventions aimed at weight loss should be considered as an additional intervention.” He adds that longer term follow-up might reveal other significant differences in renal outcomes.
th a n o th e rs . “ W hile p re -ecla m psia du rin g
Peter Sidaway
w ith p re -ecla m psia, b u t did n o t a d voca te
S e rvice s Task Force (USPSTF) has revised its re co m m e n d a tio n on th e use o f asp irin in pregnancy, now re co m m e n d in g low d o s e s in w om en w ho are a t high ris k o f de ve lo p in g p re -ecla m psia. The p a th o g e n e s is o f pre -ecla m psia is un know n, a lth o u g h so m e w o m en cle arly have a high er ris k o f th is c o m p lic a tio n a pre vio us pregnancy is th e s tro n g e s t ris k factor, a n u m b e r o f ch ro n ic c o n d itio n s a ls o p u t w om en a t high risk, in clu d in g high blood p re ssu re , d ia b e te s and a u to im m u n e d is e a s e s ,” e xp la in s lead a u th o r M ichael LeFevre, on b e h a lf o f th e USPSTF. The 1 9 9 6 USPSTF re c o m m e n d a tio n s a ckn ow led ge d th a t low -dose a s p irin m ig h t reduce th e ris k o f pre te rm b irth in w om en ro u tin e use be ca u se th e evidence
Original article The LookAHEAD Research Group. Effect of a long-term behavioural weight loss intervention on nephropathy in overweight or obese adults with
a v a ila b le a t th e tim e w as in s u ffic ie n t. F urthe rm o re, d e s p ite evid e n ce th a t su g g e ste d a sp irin use d u rin g pregnancy
type 2 diabetes: a secondary analysis of the LookAHEAD
m ig h t lead to p la ce n ta l a b ru p tio n , th e
randomised clinical trial. Lancet Diabetes Endocrinol.
s p e c ific ris k s fo r th o s e a t high ris k o f
doi: 10.1 01 6/S 2213-8587114)70156-1
pre -ecla m psia w e re ill d e fin e d . F ollow ing a m e ta -a n a lysis o f newly ava ila b le evide nce fro m random ized co n tro lle d tria ls and o th e r re le va n t
DIALYSIS
s tu d ie s , a 14% re d u ctio n in th e ris k
Optimal timing of arteriovenous fistula placement in elderly patients
o f p re te rm b irth co m b in e d w ith a 24%
Early arteriovenous fistula (AVF) creation is generally considered to be the best strategy when planning a vascular access for haemodialysis (HD). However, new data suggest that very early AVF placement is not beneficial in elderly patients. Using data from the US Renal Data System linked with Medicare claims data, Tammy Hod and colleagues identified 17,511 patients aged >67 years who had an AVF placed prior to HD initiation. Only 54.9% of these patients initiated HD using an AVF; 45.1% used a central venous catheter or arteriovenous graft. The researchers report that the odds ratio (OR) for initiation of HD using an AVF increased as time from AVF creation to HD initiation increased from 1-3 months (OR 0.49) to 3-6 m onths (OR 0.93) and 6-9 months (OR 0.99), but then levelled off. Moreover, the mean number of interventional access procedures per patient increased from 0.64 in those
whose AVFs were created 1-3 months before HD initiation to 0.72 in those whose AVFs were created >12 months predialysis. The researchers conclude that in elderly patients placing AVFs >6-9 months before initiation of HD is not advantageous. “This study challenges the perception that placing an AVF earlier rather than later is always the right thing to do,” says Hod. “Increased awareness of the unfavourable consequences of placing an AVF too early—such as the need for interventions to maintain patency—may reduce the number of patients who have unusable accesses a year or more before HD initiation or who have AVFs placed but never start HD.” Ellen F. Carney
re d u ctio n in th e ris k o f pre -ecla m psia w as d e te c te d in w om en d e em e d to be a t high ris k o f d e v e lo p in g th is c o m p lic a tio n . No s ig n ific a n t s h o rt te rm or long-term ad ve rse e ffe c ts o f low -dose a sp irin u se d u rin g pregnancy w ere d e te c te d in po oled a n a lyse s. The re c o m m e n d a tio n s ackn ow led ge th a t, a lth o u g h no d e ve lo p m e n ta l h a rm s have been re p o rte d , evide nce o f long-term o u tc o m e s o f e xp osu re to a sp irin
in utero
is very lim ite d . “ For w om en a t high risk, we d e te rm in e d th a t low -dose (8 1 m g daily) a sp irin he lp s pre ven t pre -ecla m psia and th e b e n e fits outw eigh th e ris k o f h a rm s ,” c o n clu d e s LeFevre. He a d d s: “ w om en sh o u ld a lso ta lk to th e ir d o c to r o r nu rse to d is c u s s s te p s th e y can ta k e to im p rove th e ir he alth b e fore be co m in g pre gn ant, in clu d in g ach ie vin g and m a in ta in in g a health y w eigh t, q u ittin g s m o k in g and m an ag ing ch ro n ic c o n d itio n s , such a s high blood p re ssu re and d ia b e te s ."
Peter Sidaway
Original article Hod.T. et a/. Arteriovenous fistula placement in the elderly: when is the optimal tim e.7. Am. Soc. Nephrol. doi:10.1681/ASN.2013070740
Original article LeFevre, M. L Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement. Ann. Intern. Med. doi:10.7326/M 14-1884
NATURE REVIEWS
NEPH RO LOG Y
VOLUME 10 | NOVEMBER 2014
613
Copyright of Nature Reviews Nephrology is the property of Nature Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
PRE-ECLAMPSIA
Lifestyle intervention reduces CKD risk associated with type 2 diabetes A secondary analysis of the Action for Health in Diabetes (Look AHEAD) randomized controlled trial has revealed that sustained weight loss might reduce the likelihood of very-high-risk chronic kidney disease (CKD) in patients with type 2 diabetes meilitus (T2DM). "Weight loss is part of standard treatment recommendations for overweight or obese persons with T2DM, but there is remarkably little evidence of its long term value,” explains lead author William Knowler of the NIH Institute of Diabetes and Digestive Kidney Diseases, AZ, USA. In the Look AHEAD trial, patients received either intensive lifestyle intervention (ILI), targeting a >7% decrease in body weight, or diabetes-specific support and education. Despite no significant differences in the primary study outcomes (death from cardiovascular causes or nonfatal myocardial infarction, stroke or hospitalization with angina), ILI resulted in a 31% reduction in risk of very-high-risk
L O W -D O S E FOR
A S P IR IN
P R E -E C L A M P S IA
In lig h t o f new e vid e n ce , th e US Preventive
CKD—as defined by KDIGO guidelines— after a median follow-up duration of 8 years. The researchers partly attribute this finding to significant reductions in body weight, blood glucose and systolic blood pressure in the ILI group, in which patients also used fewer antihypertensives. Knowler concludes that “controlling blood pressure and glycaemia with medication is often not fully successful in preventing kidney disease in patients with T2DM. Lifestyle interventions aimed at weight loss should be considered as an additional intervention.” He adds that longer term follow-up might reveal other significant differences in renal outcomes.
th a n o th e rs . “ W hile p re -ecla m psia du rin g
Peter Sidaway
w ith p re -ecla m psia, b u t did n o t a d voca te
S e rvice s Task Force (USPSTF) has revised its re co m m e n d a tio n on th e use o f asp irin in pregnancy, now re co m m e n d in g low d o s e s in w om en w ho are a t high ris k o f de ve lo p in g p re -ecla m psia. The p a th o g e n e s is o f pre -ecla m psia is un know n, a lth o u g h so m e w o m en cle arly have a high er ris k o f th is c o m p lic a tio n a pre vio us pregnancy is th e s tro n g e s t ris k factor, a n u m b e r o f ch ro n ic c o n d itio n s a ls o p u t w om en a t high risk, in clu d in g high blood p re ssu re , d ia b e te s and a u to im m u n e d is e a s e s ,” e xp la in s lead a u th o r M ichael LeFevre, on b e h a lf o f th e USPSTF. The 1 9 9 6 USPSTF re c o m m e n d a tio n s a ckn ow led ge d th a t low -dose a s p irin m ig h t reduce th e ris k o f pre te rm b irth in w om en ro u tin e use be ca u se th e evidence
Original article The LookAHEAD Research Group. Effect of a long-term behavioural weight loss intervention on nephropathy in overweight or obese adults with
a v a ila b le a t th e tim e w as in s u ffic ie n t. F urthe rm o re, d e s p ite evid e n ce th a t su g g e ste d a sp irin use d u rin g pregnancy
type 2 diabetes: a secondary analysis of the LookAHEAD
m ig h t lead to p la ce n ta l a b ru p tio n , th e
randomised clinical trial. Lancet Diabetes Endocrinol.
s p e c ific ris k s fo r th o s e a t high ris k o f
doi: 10.1 01 6/S 2213-8587114)70156-1
pre -ecla m psia w e re ill d e fin e d . F ollow ing a m e ta -a n a lysis o f newly ava ila b le evide nce fro m random ized co n tro lle d tria ls and o th e r re le va n t
DIALYSIS
s tu d ie s , a 14% re d u ctio n in th e ris k
Optimal timing of arteriovenous fistula placement in elderly patients
o f p re te rm b irth co m b in e d w ith a 24%
Early arteriovenous fistula (AVF) creation is generally considered to be the best strategy when planning a vascular access for haemodialysis (HD). However, new data suggest that very early AVF placement is not beneficial in elderly patients. Using data from the US Renal Data System linked with Medicare claims data, Tammy Hod and colleagues identified 17,511 patients aged >67 years who had an AVF placed prior to HD initiation. Only 54.9% of these patients initiated HD using an AVF; 45.1% used a central venous catheter or arteriovenous graft. The researchers report that the odds ratio (OR) for initiation of HD using an AVF increased as time from AVF creation to HD initiation increased from 1-3 months (OR 0.49) to 3-6 m onths (OR 0.93) and 6-9 months (OR 0.99), but then levelled off. Moreover, the mean number of interventional access procedures per patient increased from 0.64 in those
whose AVFs were created 1-3 months before HD initiation to 0.72 in those whose AVFs were created >12 months predialysis. The researchers conclude that in elderly patients placing AVFs >6-9 months before initiation of HD is not advantageous. “This study challenges the perception that placing an AVF earlier rather than later is always the right thing to do,” says Hod. “Increased awareness of the unfavourable consequences of placing an AVF too early—such as the need for interventions to maintain patency—may reduce the number of patients who have unusable accesses a year or more before HD initiation or who have AVFs placed but never start HD.” Ellen F. Carney
re d u ctio n in th e ris k o f pre -ecla m psia w as d e te c te d in w om en d e em e d to be a t high ris k o f d e v e lo p in g th is c o m p lic a tio n . No s ig n ific a n t s h o rt te rm or long-term ad ve rse e ffe c ts o f low -dose a sp irin u se d u rin g pregnancy w ere d e te c te d in po oled a n a lyse s. The re c o m m e n d a tio n s ackn ow led ge th a t, a lth o u g h no d e ve lo p m e n ta l h a rm s have been re p o rte d , evide nce o f long-term o u tc o m e s o f e xp osu re to a sp irin
in utero
is very lim ite d . “ For w om en a t high risk, we d e te rm in e d th a t low -dose (8 1 m g daily) a sp irin he lp s pre ven t pre -ecla m psia and th e b e n e fits outw eigh th e ris k o f h a rm s ,” c o n clu d e s LeFevre. He a d d s: “ w om en sh o u ld a lso ta lk to th e ir d o c to r o r nu rse to d is c u s s s te p s th e y can ta k e to im p rove th e ir he alth b e fore be co m in g pre gn ant, in clu d in g ach ie vin g and m a in ta in in g a health y w eigh t, q u ittin g s m o k in g and m an ag ing ch ro n ic c o n d itio n s , such a s high blood p re ssu re and d ia b e te s ."
Peter Sidaway
Original article Hod.T. et a/. Arteriovenous fistula placement in the elderly: when is the optimal tim e.7. Am. Soc. Nephrol. doi:10.1681/ASN.2013070740
Original article LeFevre, M. L Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement. Ann. Intern. Med. doi:10.7326/M 14-1884
NATURE REVIEWS
NEPH RO LOG Y
VOLUME 10 | NOVEMBER 2014
613
Copyright of Nature Reviews Nephrology is the property of Nature Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
