Monday, February 20, 2012

Parenteral versus oral iron therapy for adults and children with chronic kidney disease.

Albaramki J, Hodson EM, Craig JC, et al. Parenteral versus oral iron therapy for adults and children with chronic kidney disease. Cochrane Database Syst Rev. 2012 Jan 18;1:CD007857. (Review) PMID: 22258974

 BACKGROUND: The anaemia seen in chronic kidney disease (CKD) may be exacerbated by iron deficiency. Iron can be provided through different routes, with advantages and drawbacks of each route. It remains unclear whether the potential harms and additional costs of intravenous (IV) compared with oral iron are justified.
OBJECTIVES: To determine the benefits and harms of IV iron supplementation compared with oral iron for anaemia in adults and children with CKD. SEARCH
METHODS: In March 2010 we searched the Cochrane Renal Group`s specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE and EMBASE without language restriction.
SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs in which oral and IV routes of iron administration were compared in adults and children with CKD.
DATA COLLECTION AND ANALYSIS: Two authors independently assessed study eligibility, risk of bias, and extracted data. Results were reported as risk ratios (RR) or risk differences (RD) with 95% confidence intervals (CI) for dichotomous outcomes and for continuous outcomes the mean difference (MD) was used or standardised mean difference (SMD) if different scales had been used. Statistical analyses were performed using the random-effects model. Subgroup analysis and univariate meta-regression were performed to investigate between study differences.
MAIN RESULTS: Twenty eight studies (2098 participants) were included. Risk of bias attributes were poorly performed and/or reported with low risk of bias reported in 12 (43%) studies for sequence generation, incomplete outcome reporting and selective outcome reporting and in 6 (16%) studies for allocation concealment. No study was blinded for participants, investigators and outcome assessors but all were considered at low risk of bias because the primary outcome of haemoglobin was a laboratory outcome and unlikely to be influenced by lack of blinding. Haemoglobin (22 studies, 1862 patients: MD 0.90 g/dL, 95% CI 0.44 to 1.37); ferritin (24 studies, 1751 patients: MD 243.25 mug/L, 95% CI 188.74 to 297.75); and transferrin saturation (18 studies, 1457 patients: MD 10.20%, 95% CI 5.56 to 14.83) were significantly increased by IV iron compared with oral iron. There was a significant reduction in erythropoiesis-stimulating agent (ESA) dose in patients receiving dialysis who were treated with IV iron (9 studies, 487 patients: SMD -0.76, 95% CI -1.22 to -0.30). There was a high level of heterogeneity in all analyses. Mortality and cardiovascular morbidity did not differ significantly, but were reported in few studies. Gastrointestinal side effects were more common with oral iron, but hypotensive and allergic reactions were more common with IV iron.
AUTHORS' CONCLUSIONS: The included studies provide strong evidence for increased ferritin and transferrin saturation levels, together with a small increase in haemoglobin, in patients with CKD who were treated with IV iron compared with oral iron. From a limited body of evidence, we identified a significant reduction in ESA requirements in patients treated with IV iron, and found no significant difference in mortality. Adverse effects were reported in only 50% of included studies. We therefore suggest that further studies that focus on patient-centred outcomes are needed to determine if the use of IV iron is justified on the basis of reductions in ESA dose and cost, improvements in patient quality of life, and with few serious adverse effects.

Proton Pump Inhibitors (PPIs) - Drug Safety Communication: Clostridum Difficile-Associated Diarrhea (CDAD) Can be Associated With Stomach Acid Drugs

  • AcipHex (rabeprazole sodium)
  • Dexilant (dexlansoprazole)
  • Nexium (esomeprazole magnesium) 
  • Omeprazole (omeprazole) Over-the-Counter (OTC)
  • Prevacid (lansoprazole) and OTC Prevacid 24hr
  • Prilosec (omeprazole)  and OTC
  • Protonix (pantoprazole sodium)
  • Vimovo (esomeprazole magnesium and naproxen)
  • Zegerid (omeprazole and Sodium bicarbonate) and OTC
AUDIENCE: Gastroenerology, Family Practice, Consumer
ISSUE: FDA notified the public that the use of stomach acid drugs known as proton pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile–associated diarrhea (CDAD). A diagnosis of CDAD should be considered for patients taking PPIs who develop diarrhea that does not improve. The FDA is working with manufacturers to include information about the increased risk of CDAD with use of PPIs in the drug labels.
FDA is also reviewing the risk of CDAD in users of histamine H2 receptor blockers. H2 receptor blockers are used to treat conditions such as gastroesophageal reflux disease (GERD), stomach and small intestine ulcers, and heartburn.
BACKGROUND: Proton pump inhibitors (PPIs) are marketed under various brand and generic drug names as prescription and over-the-counter (OTC) products. They work by reducing the amount of acid in the stomach. Prescription PPIs are used to treat conditions such as gastroesophageal reflux disease (GERD), stomach and small intestine ulcers, and inflammation of the esophagus. Over-the-counter PPIs are used to treat frequent heartburn.
Clostridium difficile (C. difficile) is a bacterium that can cause diarrhea that does not improve. Symptoms include watery stool, abdominal pain, and fever, and patients may go on to develop more serious intestinal conditions. The disease can also be spread in hospitals.  
RECOMMENDATION: Patients should immediately contact their healthcare professional and seek care if they take PPIs and develop diarrhea that does not improve. Information for Healthcare Professionals:
  • A diagnosis of CDAD should be considered for PPI users with diarrhea that does not improve.
  • Advise patients to seek immediate care from a healthcare professional if they experience watery stool that does not go away, abdominal pain, and fever while taking PPIs.
  • Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.
Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA's MedWatch Safety Information and Adverse Event Reporting Program:
  • Complete and submit the report Online:
  • Download form or call 1-800-332-1088 to request a reporting form, then complete and return to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178
Read the MedWatch safety alert, including a link to the FDA Drug Safety Communication, at:

New antibiotic cefpodoxime for bladder infection has disappointing results.

Health Day (2/8, Mann) reports, "New antibiotics are needed to help treat bladder infections, but the drug cefpodoxime, once thought promising, doesn't appear to be up to the task," according to a study published Feb. 8 in the Journal of the American Medical Association. The study "included 300 women aged 18 to 55 with uncomplicated bladder infections" who "received either 250 milligrams (mg) of ciprofloxacin orally twice a day for three days or 100 mg of cefpodoxime proxetil orally twice a day for three days." Dr. Thomas Hooton, a professor of clinical medicine at the University of Miami Miller School of Medicine, said, "We do have antibiotics to treat bladder infections, but due to increasing rates of resistance, we wanted to see if this other drug [cefpodoxime] was comparable to the gold standard, but it wasn't."

Court: Social Security Beneficiaries Cannot Reject Right To Medicare Benefits.

The Hill Share to FacebookShare to Twitter (2/8, Pecquet) reports in its "Healthwatch" blog, "Americans who are eligible for Medicare benefits can't give them up, a federal appeals court ruled Tuesday. The unusual case was brought by five people who would prefer not to be on Medicare because their private insurer limits hospital coverage for customers who are entitled to the government health program." The plaintiffs, "who include former House Majority Leader Dick Armey (R-Texas), sued to stop their automatic enrollment into Medicare," but the court explained in its decision that the plaintiffs "seek a legal declaration that Medicare Part A benefits cannot be paid on their behalf" and concluded that the law "does not provide a mechanism for beneficiaries to opt out."
        The AP Share to FacebookShare to Twitter (2/8) reports, "'We understand plaintiffs' frustration with their insurance situation and appreciate their desire for better private insurance coverage,' Judge Brett Kavanaugh wrote in a majority opinion joined by Douglas Ginsburg, both Republican appointees. But they agreed with the Obama administration that the law says those over age 65 who enroll in Social Security are automatically entitled to Medicare Part A, which covers services including hospital, nursing home care, hospice and home health care." Meanwhile, attorney Kent Brown, "who argued the case for the plaintiffs, says they want to keep their Social Security because they believe they earned it, but none of them want Medicare Part A," and he vowed to appeal the ruling, calling it "outrageous" and contending that it was never intended by Congress to be unable to "decline Medicare Part A and not opt out of Social Security."

Guidelines Recommend Compression Stockings For Travelers At High Risk Of DVT.

The Wall Street Journal Share to FacebookShare to Twitter (2/8, McCartney, Subscription Publication) reports that the American College of Chest Physicians has released new guidelines Share to FacebookShare to Twitter recommending that travelers at an increased risk for developing deep vein thrombosis (DVT) use compression stockings when on long flights.
        The AP Share to FacebookShare to Twitter (2/8, Tanner) reports that "the guidelines were released online Tuesday in the group's journal, Chest. They're based on a review of recent research and other medical evidence on deep vein thrombosis, blood clots that form deep in leg veins." The AP adds, "There's no proof that flying economy-class increases your chances of dangerous blood clots, according to" the "new guidelines."
        MedPage Today Share to FacebookShare to Twitter (2/8, Fiore) reports, meanwhile, that "clinicians should not recommend that all travelers use aspirin for prevention of deep vein thrombosis during long plane trips, according to" the "new recommendation."

CDC Survey Finds Bread Is Top Source Of Sodium In US Diet.

ABC World News (2/7, story 7, 0:35, Sawyer) reported that "the Center for Diseases Control said nine out of ten adults eat too much salt. And the number one source of their salt is a surprise -- bread and rolls."
        The CBS Evening News (2/7, story 9, 0:20, Pelley) reported, "The Centers for Disease Control said today that salty snacks like potato chips are not our biggest source of sodium."
        NBC Nightly News (2/7, story 8, 2:25, Williams) reported that CDC Director Thomas Frieden, MD, said, "We're eating more food made by others, in restaurants or prepared food from grocery stores. And when other people make food for us, they put a lot more salt in it." NBC's Costello added, "More fruits, veggies and home cooking are the solution, says the CDC."
        The AP Share to FacebookShare to Twitter (2/8, Stobbe) reports, "Bread and rolls are the No. 1 source of salt in the American diet, accounting for more than twice as much sodium as salty junk food like potato chips. That surprising finding comes in a government report released Tuesday that includes a list of the top 10 sources of sodium." CDC officials "are encouraging consumers to read labels and, for example, buy brands of bread that have lower sodium." CDC Director Frieden noted, "Potato chips, pretzels, and popcorn -- which we think of as the saltiest foods in our diet -- are only No. 10."
        "Most sodium in the US diet comes from bread, lunch meat, pizza, chicken, soup, and burgers, the CDC found," according to the National Journal Share to FacebookShare to Twitter (2/8, Fox, Subscription Publication). In a statement, CDC Director Frieden said, "We're encouraged that some food manufacturers are already taking steps to reduce sodium," noting that manufacturers such as Kraft and Leprino Foods are "actively working on providing customers and consumers with healthier options."
        The NPR Share to FacebookShare to Twitter (2/8, Barclay) "The Salt" blog reports, "According to the CDC, the average American consumes about 3,300 milligrams of sodium per day, not including any salt that may be added during a meal. ... The US Dietary Guidelines recommend no more than 2,300 mg a day, except if you're over 51 years or African American or have high blood pressure, diabetes or chronic kidney disease."
        The Atlanta Journal-Constitution Share to FacebookShare to Twitter (2/8, Jeffries) lists the "10 types of foods are responsible for more than 40 percent of people's sodium intake," according to the CDC list. The foods are "breads and rolls; luncheon meat, such as deli ham or turkey; pizza; poultry; soups; cheeseburgers and other sandwiches; cheese; pasta dishes; meat dishes such as meat loaf; and snack foods such as potato chips, pretzels and popcorn." The Journal-Constitution points out that "breads and rolls aren't saltier than many of the other foods on the CDC list, but people tend to eat a lot of them," which makes them the cop source of salt in the diet.
        CQ Share to FacebookShare to Twitter (2/8, Subscription Publication) quotes a statement by CDC Director Frieden, who said, "Too much sodium raises blood pressure, which is a major risk factor for heart disease and stroke." He added, "These diseases kill more than 800,000 Americans each year and contribute an estimated $273 billion in health care costs."
        MedPage Today Share to FacebookShare to Twitter (2/8, Fiore) notes, "The data come from the 'What We Eat in America' portion of the National Health and Nutrition Examination Survey (NHANES) 2007-2008. NHANES is a survey that relies on self-reported data, a fact that may introduce bias and also raises questions about the generalizability of its findings." The study Share to FacebookShare to Twitter is published in the CDC's Morbidity and Mortality Weekly Report. The Los Angeles Times Share to FacebookShare to Twitter (2/8, Muskal) "Nation Now" blog also covers the story.

Soda Linked to Lung Disease

Direct Medpage Link

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More bad news for soda lovers: in addition to obesity and heart disease, the sugary drinks may be tied to asthma and chronic obstructive pulmonary disease (COPD), Australian researchers found.
People who consumed at least a half a liter of soft drinks a day were more than twice as likely to develop either lung condition compared with those who didn't partake at all (OR 2.33, 95% CI 1.51 to 3.60), Zumin Shi, MD, of the University of Adelaide in Australia, and colleagues reported in Respirology.
The cross-sectional study, however, couldn't prove causality, and researchers not involved in the study suspect an overall unhealthy diet effect might be at play.
"High soda intake is a good marker for poor overall diet, and poor overall attention to health," David Katz, MD, director of the Prevention Research Center at Yale University in New Haven, Conn., said in an email to MedPage Today. "It likely suggests greater exposure to everything from tobacco smoke to air pollution."
Sugar-sweetened beverages have long been linked to a host of poor health outcomes, including stroke and heart disease, but no study has yet assessed potential ties to asthma or COPD, the researchers said.
There are many potential explanations for the increased burden of asthma in Western countries -- less exposure to indoor allergens, improved hygiene, and use of antibiotics (the "hygiene hypothesis"), as well as poor diet and increased obesity -- but fewer noted risk factors for COPD.
Smoking, of course, is a major one, but up to 50% of airway obstruction can't be explained away by cigarette use, they wrote, thus the need to identify novel risk factors.
The group looked at data from the South Australian Monitoring and Surveillance System on 16,907 adults, mean age 46.7, who responded to phone interviews from March 2008 to June 2010.
The prevalence of asthma and COPD, based on self-reported doctor diagnosis, was 12.5% and 4.4%, respectively.
Though the vast majority (72%) said they didn't drink any soda at all, 11.4% reported taking down more than a half a liter of soft drinks every day. In addition to carbonated brand-name soft drinks, lemonade, flavored mineral water, and sports drinks were consumed.
Shi and colleagues found that folks who drank this level of soda had a higher prevalence of asthma and COPD than those who didn't drink any (14.7% versus 11.9% and 6% versus 4.2%, respectively).
In multivariate analyses adjusting for sociodemographic factors, intake of fruit and vegetables, and other life style factors, drinking half a liter of soda a day was associated with an odds ratio of 1.26 for asthma (95% CI 1.01 to 1.58) and an OR of 1.79 for COPD (95% CI 1.32 to 2.43) compared with never drinking soda.
The researchers also saw combined effects for drinking soda and smoking. Consuming more than half a liter a day and being a current smoker carried a 6.6-fold greater risk of COPD and a 1.5-fold higher risk of asthma than not smoking and drinking soda, they reported.
"The combined effect of soft drink consumption and smoking on asthma/COPD emphasizes the importance of lifestyle factor clustering in the etiology of asthma/COPD," they wrote. "Promoting a healthy lifestyle should be encouraged as one means of preventing asthma/COPD."
The mechanisms behind the relationships, however, are unclear. Both asthma and COPD are associated with inflammation, and it could be that foods promoting oxidative stress and inflammation could affect the pathogenesis of these diseases, they wrote.
Drinking soda has also been tied to a higher risk of obesity, which in turn leads to a greater likelihood of developing both lung diseases, they said.
And studies have shown that chemicals such as phthalates from plastic bottles, as well as allergies to preservatives such as nitrites and sulphites, may be linked to asthma.
In addition to not being able to prove causality, the study was limited by its reliance on self-reported data.
Still, Shi and colleagues concluded that "regardless of whether there is a cause-and-effect relationship, the public health implications of consumption of large volumes of soft drink are substantial."
The researchers reported no conflicts of interest.

Guideline: Metformin Preferred To Best Control HbA1c In Type 2 Diabetes.

MedPage Today Share to FacebookShare to Twitter (2/7, Fiore) reports, "Metformin should be the first drug of choice in oral therapy for type 2 diabetics who don't respond to diet and lifestyle changes, according to a new guideline Share to FacebookShare to Twitter " published Feb. 7 in the Annals of Internal Medicine. "A second agent can be added if metformin monotherapy fails to control hyperglycemia, but there's insufficient evidence to recommend one secondary agent over another," the guideline from the American College of Physicians (ACP) explains.
        However, even though "metformin is more effective with fewer side effects" and costs less, "the ACP is recommending that metformin only be prescribed after someone has tried to change his or her lifestyle," HealthDay Share to FacebookShare to Twitter (2/7, Gordon) reports. HealthDay adds, "There are currently 11 different classes of medications approved by the US Food and Drug Administration for the treatment of type 2 diabetes, according to the guidelines." 

Reminder that one MUST HAVE Reasonably intact renal function to get metformin

Everolimus May Shrink Rare Type Of Benign Kidney Tumor.

MedPage Today Share to FacebookShare to Twitter (2/7, Phend) reports, "The cancer drug everolimus (Afinitor) appears to shrink a rare type of benign kidney tumor often seen with tuberous sclerosis," according to research presented at the Genitourinary Cancers Symposium. Investigators found that "daily oral treatment shrank 42% of angiomyolipomas to at least half their original volume, whereas no placebo-treated patients saw any tumor regression (P<0.0001)." The researchers also found that "the toxicity was low, without any excess in infections, in the randomized EXIST-2 trial."

Caloric restriction may not improve outcomes in some ventilator-dependent patients.

MedPage Today (2/6, Bankhead) reports, "Caloric restriction failed to improve outcomes in ventilator-dependent patients with acute lung injury, results of an NIH-sponsored, multicenter trial showed." The trial showed that "60-day mortality and infection rates...did not differ between treatment groups, according to data reported simultaneously at the Society of Critical Care Medicine meeting...and online in" the Journal of the American Medical Association. An accompanying editorial argued, however, that "this study was not designed or powered as an equivalence study and does not provide definitive data to inform clinicians about how much nutritional support is enough, how early it should be started, or even if there should be 'no nutrition provision' in the initial phase of critical illness."

Most patients with Guillain-Barre syndrome may be vaccinated safely.

Reuters (2/4, Grens) reported a study in Clinical Infectious Diseases suggesting that most patients diagnosed with Guillain-Barré syndrome can safely receive vaccines and may not suffer flare-ups after vaccination. Previously, the Centers for Disease Control and Prevention had warned against giving flu shots to patients who developed Guillain-Barré within six weeks of a flu vaccination. In the study, 550 patients received about 1,000 vaccines, and none experienced a flare up to two months after being vaccinated. In addition, two patients who had developed Guillain-Barré within six weeks of a flu vaccination received a flu shot and did not experience a flare.

Eating Purple Potatoes May Lower BP Without Weight Gain.

WebMD Share to FacebookShare to Twitter (2/4, Nierenberg) reported, "When overweight people included two servings of purple potatoes a day in their diet for a month, they not only reduced their blood pressure, they also didn't gain weight in the process," according to a study published online in the Journal of Agricultural and Food Chemistry. The study of 18 middle-aged overweight adults revealed that "compared to those who went spud-free, purple potato eaters had on average drop of slightly more than 4% in diastolic pressure (the bottom number in a reading) and a drop of more than 3% in systolic pressure (the top number)." What's more, even though "potato eaters took in more calories compared to adults given no potatoes, their weight didn't change."

FYI: normal kidney function

Lack of Sunlight, Vitamin D Tied to Stroke Risk

Lack of Sunlight, Vitamin D Tied to Stroke Risk CME
NEW ORLEANS -- Too much sunlight is bad for the skin, but not enough may be a risk factor for stroke, according to a study presented here at the American Stroke Association’s International Stroke Conference.full story

Sunday, February 19, 2012

H. Pylori Infection Associated With Increased Risk For Type 2 Diabetes.

Reuters Share to FacebookShare to Twitter (2/3, Grens) reports that according to a study Share to FacebookShare to Twitter published online Jan. 25 in the journal Diabetes Care, individuals who have infections caused by Helicobacter pylori (H. pylori), the same bacteria that causes ulcers, may face double the risk of developing type 2 diabetes over time, compared to people who are not infected with H. pylori. Researchers arrived at this conclusion after following some 800 people over the course of 10 years. At study start, none of the participants had type 2 diabetes.

Oral Antibiotics May Be Effective For Treating Acute Pyelonephritis In Children.

Reuters Share to FacebookShare to Twitter (2/3, Boggs) reports when treating children with acute pyelonephritis, oral antibiotics seem to be just as effective as sequential IV/oral antibiotics, according to a study Share to FacebookShare to Twitter published online Jan. 30 in Pediatrics. The researchers randomly assigned 171 children with a first case of acute pyelonephritis to one of two treatment groups. The first group of children took an oral antibiotic called cefixime for 10 days. The second group, the sequential treatment group, received IV ceftriaxone for four days and subsequently took oral cefixime for six days. The study found that rates for renal scarring in the intent-to-treat analysis and per-protocol analysis were comparable for both groups.

Methotrexate May Be Safely Resumed After Renal Injury In Kids With Cancer.

Reuters Share to FacebookShare to Twitter (2/3) reports that according to a study Share to FacebookShare to Twitter published online Jan. 17 in the journal Cancer, glucarpidase rescue is associated with complete renal recovery following high-dose therapy with methotrexate in children with cancer who develop acute kidney injury. In their study of 20 children who received glucarpidase within a 96-hour timeframe following development of acute renal injury and then recovered, researchers then challenged 13 of the kids about one month later with either a full or lowered dose of methotrexate. Notably, 11 of those 13 youngsters were able to complete their course of methotrexate.