53CONTENT AND CHARACTERISTICS OF CHRONIC KIDNEY DISEASE DISCUSSION IN PRIMARY CARE VISITS WITH DIABETIC PATIENTS Kimberly Carter , T. Alp Ikizler, Kerri Cavanaugh Vanderbilt University Medica l Center, Nashville, TN, USA Primary care providers (PCPs) are fundamental to managing patients at risk for or bearing chronic kidney disease (CKD), but little is known about the discussion of CKD during routine visits. We examined 101 audio-recordings of visits in an academic resident and attending clinic and described the occurrence and characteristics of the CKD dialogue between PCPs and adults with diabetes. Health literacy (HL) was determined using REALM. The patients were median (IQR) age 56 (49, 64) years, 48% male, 50% Black, 19% with low HL, A1C 7.6% (6.6%, 8.4%), and 51% with CKD. Nearly half of all visits (48%) discussed CKD. However, median time of CKD talk was 33 (18, 76) seconds, accounting for only 3% (range 1%-28%) of visit time.

Overall, no patient or provider characteristics were associated with having a CKD discussion, except for total visit time (p=0.09) Compared to adequate HL patients, low HL patients were less likely to have CKD discussed (22% vs. 61%; p=0.038). After adjusting for age and visit time, patients with low HL were nearly five-fold less likely to have a discussion of CKD (AOR [95% CI]: 5.76 [1.01 – 32.7]). In conclusion, the majority of CKD dialogue focuses on ordering or reviewing laboratory tests. Placing importance on the discussion of risk and prevention of CKD could improve awareness amongst diabetic patients. This can be achieved by better tools to communicate with low literacy patients with CKD.

54LEFT VENTRICULAR HYPERTROPHY (LVH) AND HEART RATE VARIABILITY (HRV) IN CHRONIC KIDNEY DISEASE (CKD) Preeti Chandra*1, Robin Sands , Brenda Gillespie1, Nathan Levin 2, Peter Kotanko2, Margaret Kiser3, Frederic Finkelstein4, David Sengstock5, Sanjay Rajagopalan,6 and Rajiv Saran,1,5Dept. of Cardiology and Radiology, Ohio State Univ., Columbus, OH. Patients with CKD are at high risk of cardiovascular disease (CVD). Low HRV and left ventricular hypertrophy (LVH) are independently associated with high CVD mortality. Kidney disease is associated with autonomic dysfunction and LVH. We explored the relationship between HRV and LVH as risk factors for CVD outcomes. The RRI-CKD Study is a 4-center prospective cohort study of CKD stages 3-5 (n=834). A subset underwent both HRV testing by 24-hour Holter and two-dimensional guided M-mode echocardiographic studies (n=204). LVH was defined as LV mass index ≥ 110 g/m 2 for males and ≥ 134 g/m 2 for females. Multiple linear regression was used to assess predictors of LVH. Mean age was 60 ± 15, 51% male, 78% white, 31% diabetic (DM), 89% hypertensive and 37% with h/o of CVD. In unadjusted analysis, patients with LVH had significantly lower HRV compared to patients without LVH (see table). In this cohort, high LVMI was associated with older age, male gender, non-white race, history of CVD, higher systolic blood pressure, phosphorus, lower serum albumin and hemoglobin. After adjustment for these variables, the relationship with LVMI remained significant for night SDNN and SDANN. Altered autonomic dysfunction in patients with CKD may partially explain elevated LVH and increased CVD outcomes with LVH in these patients.

Yes (n=54) No (n=150) pvalueMean 24 hour Heart Rate (bpm) 72.7 ± 11.2 73.6 ± 10.3 0.5993

Time Domain (ms)Standard deviation (SD) of all normal to normal R-R (NN) intervals (SDNN) 97.5 ± 34.1 108.9 ± 36.0 0.0455

SD of 5-min avearage NN intervals (SDANN) 80.8 ± 27.0 92.1 ± 31.1 0.0189Average 5-minute SDNN over 24 hours (ASDNN) 35.3 (17.0, 186.9) 44.0 (17.5, 194.9) 0.0437

Frequency Domain (ms2)

Very Low Frequency 717.5 (163, 7,532) 1111 (36, 6,252) 0.0190Low Frequency 181 (16, 7,151) 354 (21.0, 11977) 0.0028High Frequency 92 (11, 11445) 131 (7.0, 15123.0) 0.6398Low/High Frequency Ratio 1.8 (0.2, 9.4) 2.9 (0.2, 12) 0.0006Total power 1148.0 (282, 25436) 1699 (256, 30828) 0.0283

Presence of LVH

55CKD STAGE 3 IN THE PRESENCE OF MICROALBUMINURIA (MA) HAS EQUIVALENT MORTALITY RISK AS PRIOR MI Alexander Chang, David Shoham, Holly Kramer. Loyola University Medical Center, Maywood, IL A graded and inverse relationship between estimated glomerular filtration rate(eGFR) and cardiovascular (CV) disease and death exists at eGFR<60ml/min/m2. National Kidney Foundation guidelines propose that CKD be considered a coronary risk equivalent. Mortality rates in adults with CKD stage 3 +/- albuminuria (albumin/creatinine ratio > 30 mg/g) and no diabetes were compared with mortality rates among adults with a previous myocardial infarction(MI) and no CKD or diabetes mellitus (DM) and with mortality rates in adults with DM and no previous MI +/- CKD. We used data from the Third National Health and Nutrition Examination Survey (1988-1994) linked with the National Death Index through December 31, 2006. Analyses accounted for the complex survey design. Poisson regression was used to determine adjusted incidence rates for all-cause mortality for each group: 1-Prior MI, no CKD or DM(n=303); 2-CKD stage 3 without MA, no MI or DM (n=481); 3-CKD stage 3 with MA, no MI or DM(n=169); 4-DM, no CKD, no MI(n=920); 5-DM with CKD, no MI (n=655). Mean age for the 5 groups was 64, 72, 74, 56, and 65 years, respectively, and mean eGFR was 85, 52, 48, 98, and 75 ml/min/m2,respectively. CKD stage 3 with MA(group 2) had similar adjusted mortality rates(0.95, 0.78-1.17) compared to group 1, demonstrating that CKD stage 3 with MA has equivalent mortality risk as a prior MI.

0.5

11.

52

20 40 60 80age (yr)

1-MI, GFR>60, ACR<30* 2-CKD 3, ACR<30, no MI*3-CKD 3, ACR>30, no MI* 4-DM, no CKD, no MI5-DM w/CKD, no MI *Excluded diabetics

Mortality rates per person-year by age

56LIFESTYLE BEHAVIORS AND INCIDENT CHRONIC KIDNEY DISEASE (CKD): THE CARDIA STUDY Alexander Chang, David Jacobs, Kiang Liu, Kirsten Bibbins-Domingo, Britt Newsome, David Shoham, Ramon Durazo, Holly Kramer. LUMC, Maywood, IL, UMN, Minneapolis, MN, NWU, Chicago, IL, UCSF, San Francisco, CA, UAB, Birmingham, AL. Lifestyle likely influences risk of CKD, yet few studies have explored the impact of lifestyle behaviors such as smoking, exercise, and diet. The purpose of this study was to investigate whether lifestyle behaviors in addition to age, sex, and race can accurately predict incident CKD. We used data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a longitudinal study of cardiovascular risk factors in 18-30 year old black and white adults at year 0 in 1985-1986. The analysis was limited to participants with eGFR>80ml/min/m2 by CKD-EPI formula and no HTN or DM at baseline. Our definition of incident CKD required the presence of microalbuminuria (ACR ≥ 25mg/g after adjustment for sex and race (A/kC where k=0.68 if male, k=0.88 if black) or eGFR<60ml/min/m2 at years 20 in addition to either years 10 or 15. We used logistic regression to examine univariate associations between CKD and baseline BMI, smoking status, exercise, and dietary score, which was composed of 7 categories (fruit intake, low-fat dairy, nuts, whole grains, sodium, sugar-sweetened beverages, and red/processed meats) based on the Dietary Approaches to Stop HTN (DASH) diet. Significant variables (p<0.05) were placed in the multivariate model below (AUC 0.80). Notably, individuals who did not follow a DASH-like diet had increased risk for incident CKD (40% increased odds for each unit increase; p<0.001). Modifiable lifestyle factors including diet, obesity, and smoking predict incident CKD. Baseline Predictors of CKD Individual OR Multivariate OR Age(per 1-yr increase) 1.09 (1.03-1.15) 1.08(1.02-1.15) Male gender 3.14(2.04-2.64) 3.44(2.20-5.39) Black race 5.09(3.16-8.21) 3.35(2.03-5.53) Obese (BMI≥30) 3.08(1.89-5.03) 2.95(1.80-4.84) Current smoking 1.66(1.09-2.52) 1.44(0.94-2.22) Diet score (0-7) 7=Worst 1.45(1.23-1.70) 1.40(1.19-1.65)

NKF 2011 Spring Clinical Meetings Abstracts

Am J Kidney Dis. 2011;57(4):A1-A108A30