Background: Studies suggests that in the general population, hyperlipidemia may confer higher risk of developing chronic kidney disease (CKD). But, there is conflicting data as to whether statins can protect renal function or slow renal degradation. We sought to examine the impact of statins on the association of low-density lipoprotein cholesterol (LDL) and risk of incident CKD. Methods: Our cohort included 1,439,756 US veterans without chronic kidney disease (CKD), but with LDL measured between 2004-2006, who were followed until 2014. Incident CKD was defined as over 3 estimated glomerular filtration rate (eGFR) measurements <60 mL/min/1.73m 2 at least 90 days apart. Patients with a statin prescription at the time of LDL measurement were identified. Cox models were used to estimate the associations between LDL with incident CKD. Model adjustments include demographics, comorbidities, smoking status, prescription of fibrate or niacin, body mass index, albumin, high-density lipoprotein cholesterol, and triglycerides. Results: The cohort included 5% females, 16% African Americans, 26% diabetics, and 30% statin-users, with a mean age of 60±13 years. The median [IQR] of LDL and eGFR were 109 [88,133] mg/dL and 83 [72,94] mL/min/1.73m 2 , respectively. A J-shaped association between LDL and incident CKD were observed in both those on statin and not on a statin after adjustment. Low LDL (<70 mg/dL) was associated with a higher risk of incident CKD compared to the reference (LDL 70-<100 mg/dL) regardless of statin use. High LDL ≥160 mg/dL was associated with the highest of risks of incident CKD (HR: 1.08, 95% CI: 1.04, 1.13, and HR: 1.10, 95% CI: 1.07, 1.12, for statin use and no statin use, respectively). Conclusion: Both high and low LDL were associated with higher incident CKD risk independent of statin use in this US veteran cohort. Further studies are needed to understand how to manage cardiovascular disease risk by lowering LDL while simultaneously reducing risk of CKD.

Introduction

Anticoagulation is commonly used for stroke prevention among patients with atrial fibrillation (AF); however, end-stage renal disease (ESRD) patients on hemodialysis are at higher risk of bleeding and stroke, even without anticoagulation. It is unclear if patients should be continued on anticoagulation at the time of transition to ESRD. In this study, we validated risk scores for stroke and bleeding in this population and assessed risk of stroke and bleeding among warfarin users compared to nonusers.

Methods

We utilized a cohort of 28,620 pre-dialysis US veterans transitioning to hemodialysis between October 2007 and March 2015. Incident rates for the risks of stroke and bleeding were ascertained based upon CHA2DS2-VASc or HAS-BLED scores, respectively. A propensity score-based competing risk analysis was used to assess risk of stroke and bleeding.

Findings

The mean age of our cohort was 77 ± 9 years, and the median CHA2DS2-VASc and HAS-BLED scores were 7 (5, 8) and 3 (3, 4), respectively. Increasing CHA2DS2-VASc and HAS-BLED scores were predictive of increasing stroke and bleeding rates, respectively. However, warfarin use did not appear to affect the risk of stroke and bleeding (p-interaction = 0.84 for stroke and 0.24 for bleeding). Warfarin use was associated with a higher risk of stroke (adjusted SHR 1.44, 95% CI: 1.23-1.69) and a higher risk of bleeding (adjusted SHR 1.38, 95% CI: 1.25-1.52) when accounting for the competing risk of death.

Discussion

There was no difference in incidence rates of stroke or bleeding among warfarin users versus nonusers. Warfarin was associated with a higher risk of stroke and bleeding after considering mortality risk.

Objectives

We sought to report medical student and faculty perceptions of the purpose and utility of questions on clinical rounds.

Methods

We developed and administered a survey to third and fourth-year medical students and teaching physicians. The survey elicited attitudes about using questions to teach on rounds in both benign and malignant learning environments.

Results

Ninety-seven percent of faculty and 85% of students predicted they will use questions to teach. Nine percent of students described learning-impairing stress during benign bedside teaching. Fifty-nine percent of faculty felt questions were mostly for teaching; 74% of students felt questions were mostly for evaluation. Forty-six percent of students felt questions underestimated their knowledge. Students felt questions were more effective for classroom teaching than bedside teaching. Faculty and students agreed that a malignant environment detrimentally affected learning and performance.

Conclusions

Students and faculty supported the use of questions to teach and evaluate, especially in benign teaching environments. Many students described stress severe enough to affect their learning and performance, even when questioned in benign teaching environments. Faculty underestimated the degree to which students experience stress-related learning impairment and the degree to which students see questions as evaluation rather than teaching. Nearly half of students felt that questions underestimated their own knowledge. Students feel more stress and less learning when questioned with a patient present. Faculty must realize that even in the best learning environment some students experience stress-impaired learning and performance, perhaps because of the conflict between learning and evaluation.

Background: Chronic kidney disease (CKD) patients have displayed a paradoxical association between total cholesterol (TC) and mortality, where CKD patients with elevated TC did not display an increased mortality risk. However, this TC-mortality relationship amongst CKD patients requires further study using large databases to assess the impact CKD stage, pharmacologic therapy, and patient population has. Methods: Retrospectively, two cohorts were studied using LIPROVET and NHANES data. Among the cohorts, there were 2,131,536 LIPROVET US veterans examined from 2004-2006 and 39,899 NHANES patients from 1999-2014. We examined the association of TC and statin use with all-cause mortality in patients with eGFR <60 and eGFR ≥60 mL/min/1.73m 2 using Cox Proportional Hazards model. Models were adjusted for demographics, comorbidities, smoking status, alcohol intake, income, education, laboratory measures, and medications. Those with TC≥200 mg/dL not on statin were used as reference. Results: The LIPROVET patients had a mean age of 63±14 and were 81% White and 5% female. LIPROVET patients with TC<200 mg/dL not on statin had a higher mortality risk compared to reference across all levels of adjustment and eGFR. Whereas those on statin, regardless of TC levels, had a lower to null mortality risk in the fully adjusted model. NHANES patients had a mean age 48±19 and were 46% White and 50% male. NHANES patients with TC<200 mg/dL not on statin had a trend of higher to null mortality risk compared to reference across eGFR groups after full adjustment. Those on statin, independent of TC levels, had a significantly lower mortality rate across all eGFR groups. Conclusion: Compared to patients with TC≥200mg/dL not on statin, patients with lower TC without statin had a higher mortality risk, while patients with statin had lower mortality risk regardless of TC level across all eGFR groups. Physicians may consider initiating or continuing statin therapy for CKD patients independent of TC level.