Publications

INTRODUCTION

We sought to determine the effects of brief exposures to low concentrations of tobacco secondhand smoke (SHS) on arterial flow-mediated dilation (FMD, a nitric oxide-dependent measure of vascular endothelial function), in a controlled animal model never before exposed to smoke. In humans, SHS exposure for 30 min impairs FMD. It is important to gain a better understanding of the acute effects of exposure to SHS at low concentrations and for brief periods of time.

METHODS

We measured changes in FMD in rats exposed to a range of real-world levels of SHS for durations of 30 min, 10 min, 1 min, and 4 breaths (roughly 15 s).

RESULTS

We observed a dose-response relationship between SHS particle concentration over 30 min and post-exposure impairment of FMD, which was linear through the range typically encountered in smoky restaurants and then saturated at higher concentrations. One min of exposure to SHS at moderate concentrations was sufficient to impair FMD.

CONCLUSIONS

Brief SHS exposure at real-world levels reversibly impairs FMD. Even 1 min of SHS exposure can cause reduction of endothelial function.

BACKGROUND

Chronic disease registries have been successful at promoting the delivery of guideline-concordant primary care for patients with diabetes and hypertension, but not for chronic kidney disease (CKD). To understand whether a registry could be designed to improve CKD management in primary care, we explored primary care provider attitudes about the benefits (or lack thereof) of a CKD registry compared with other chronic diseases and the key facilitators of successfully implementing a CKD registry in safety-net primary care.

STUDY DESIGN

Qualitative, using semistructured interviews.

SETTING & PARTICIPANTS

We conducted and recorded semistructured 1-hour interviews with medical directors and quality improvement champions from safety-net adult primary care clinics in San Francisco.

ANALYTIC APPROACH

Recordings were transcribed and analyzed using a grounded theory approach until thematic saturation was achieved.

RESULTS

20 primary care providers were interviewed. 4 themes relevant to the development of a successful CKD registry for safety-net primary care were identified: (1) provider beliefs that a CKD registry could aid in the delivery of team-based high-quality CKD care; (2) clinic workflow redesign and staffing are key facilitators to successful implementation of a CKD registry; (3) unique complexities of CKD, such as varying etiologies, may limit the use of a CKD registry by nonphysicians; and (4) a CKD registry is aligned with current primary care priorities and health care delivery strategies.

LIMITATIONS

Small sample size and reliance on clinician leaders within one health care delivery system.

CONCLUSIONS

A CKD registry directed at the entire health care team, with the functionality to track, standardize, and enhance CKD care through decision support, has the potential to improve the management of CKD in safety-net primary care settings. These data directly informed the development of a CKD registry in these settings in San Francisco.

BACKGROUND

Identifying potentially modifiable risk factors is critically important for reducing the burden of chronic kidney disease. We sought to examine the association of body mass index (BMI) with kidney function decline in a cohort of young adults with preserved glomerular filtration at baseline.

STUDY DESIGN

Longitudinal cohort.

SETTING & PARTICIPANTS

2,839 black and white young adults with cystatin C-based estimated glomerular filtration rate (eGFRcys)>90mL/min/1.73m(2) taking part in the year-10 examination (in 1995-1996) of the Coronary Artery Risk Development in Young Adults (CARDIA) Study.

PREDICTOR

BMI, categorized as 18.5-24.9 (reference), 25.0-29.9, 30.0-39.9, and ≥40.0kg/m(2).

OUTCOMES

Trajectory of kidney function decline, rapid decline (>3% per year), and incident eGFRcys <60mL/min/1.73m(2) over 10 years of follow-up.

MEASUREMENTS

GFRcys estimated from the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation for calibrated cystatin C at CARDIA years 10, 15, and 20.

RESULTS

At year 10, participants had a mean age of 35.1 years, median eGFRcys of 114mL/min/1.73m(2), and 24.5% had BMI≥30.0kg/m(2). After age 30 years, average eGFRcys was progressively lower with each increment in BMI after adjustment for baseline age, race, sex, hyperlipidemia, smoking status, and physical activity. Higher BMI category was associated with successively higher odds of rapid decline (for 25.0-29.9, 30.0-39.9, and ≥40.0kg/m(2), adjusted ORs were 1.50 [95% CI, 1.21-1.87], 2.01 [95% CI, 1.57-2.87], and 2.57 [95% CI, 1.67-3.94], respectively). 18 participants (0.6%) had incident eGFRcys<60mL/min/1.73m(2). In unadjusted analysis, higher BMI category was associated with incident eGFRcys<60mL/min/1.73m(2) (for 25.0-29.9, 30.0-39.9, and ≥40.0kg/m(2), ORs were 5.17 [95% CI, 1.10-25.38], 7.44 [95% CI, 1.54-35.95], and 5.55 [95% CI, 0.50-61.81], respectively); adjusted associations were no longer significant.

LIMITATIONS

Inability to describe kidney function before differences by BMI category were already evident. Absence of data for measured GFR or GFR estimated from serum creatinine level.

CONCLUSIONS

Higher BMI categories are associated with greater declines in kidney function in a cohort of young adults with preserved GFR at baseline. Clinicians should vigilantly monitor overweight and obese patients for evidence of early kidney function decline.