Jointly Sponsered by:
CREDITS
Physicians
0.25 AMA PRA Category 1 Credit(s) ™
Family Physicians
0.25 Elective credits
Release Date:
Feb. 22, 2012
Expiration Date:
Feb. 22, 2013
Estimated time for completion 15.00 minutes
There is no fee for this activity.
To Receive CME Credit
In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, correctly answer all the questions in the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation.
Program Overview
Among the many issues clinicians face today, staying current with advances in medicine is becoming a major challenge. Teaching Brief® articles will allow clinicians to stay up-to-date and assimilate new information into their daily practice. The content of these Teaching Brief® articles has been validated through an independent expert peer review process.
Learning Objectives
Upon successful completion of this educational program, the reader should be able to:
1. Discuss the results of this study
2. Review the relevance and significance of the study in the broader context of clinical care
Disclosures
Robert Jasmer, MD, and Todd Neale, have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.
The staff of the Perelman School of Medicine at the University of Pennsylvania and the staff of MedPage Today have disclosed that they have no relevant financial relationships with commercial interests related directly or indirectly to this educational activity.
Accreditation
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Perelman School of Medicine at the University of Pennsylvania and MedPage Today. The Perelman School of Medicine at the University of Pennsylvania is accredited by the ACCME to provide continuing medical education for physicians.
Designation of Credit
The Perelman School Medicine at the University of Pennsylvania designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Credit for Family Physicians
MedPage Today “News-Based CME” has been reviewed and is acceptable for up to 2098 Elective credits by the American Academy of Family Physicians. AAFP accreditation begins January 1, 2012. Term of approval is for one year from this date. Each article is approved for 0.25 Elective credits. Credit may be claimed for one year from the date of each article.
By Todd Neale, Senior Staff Writer, MedPage Today
Published: February 22, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
Take Posttest
Chronic kidney disease more than doubles mortality risk in patients with type 2 diabetes, researchers found.
In an analysis of nearly two dozen randomized controlled trials involving diabetic patients, the highest mortality rates were observed in those trials that required the inclusion of patients with renal disease, according to Marc Pfeffer, MD, PhD, of Brigham and Women’s Hospital in Boston, and colleagues.
Trials that selected for patients with elevated serum creatinine or impaired estimated glomerular filtration rate (eGFR) had mortality rates of 5.9 to 8.2 per 100 patient-years, whereas the rest of the trials had rates no higher than 3.3, the researchers reported in the online Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease.
“Risk stratification by evidence of kidney disease, determined by renal function or proteinuria, should be emphasized in diabetic subjects, given its major impact on morbidity and mortality,” they wrote.
Pfeffer and colleagues examined 22 randomized trials of at least 1,000 patients with type 2 diabetes and a follow-up duration of at least one year, looking for relationships between specific inclusion and exclusion criteria and all-cause mortality. They excluded trials that selected patients with acute coronary syndromes or end-stage renal disease.
The trials included a total of 91,742 patients, of whom 7.5% died.
After intervention and control arms were combined, mortality rates among the trials ranged widely, from 0.28 to 8.24 per 100 patient-years.
Six trials had a mortality rate of less than 1 per 100 patient-years, 10 had a rate of 1 to less than 2, and three each had rates of 2 to less than 4 and 4 to less than 10.
On average, patients in the trials with the highest mortality rates — versus those in trials with the lowest rates — were older (64.2 versus 59), had a longer diabetes duration (15.2 versus 7.2 years), and had a higher systolic blood pressure (145 versus 136 mm Hg), serum creatinine (1.8 versus 0.9 mg/dL), and proteinuria prevalence (100% versus 9%).
Both the average LDL cholesterol level and prevalence of current smoking decreased across the increasing mortality categories.
“While the lower prevalence of smoking is probably related to the inclusion criteria, reports from cohorts of chronic kidney disease and heart failure demonstrated that lower cholesterol correlates with higher mortality — what is described as ‘reverse epidemiology’ in other populations of patients with advanced disease,” the authors wrote.
Selection for hypertension was common across trials in all four of the mortality categories, ranging from 69% to 97% of patients. Hypertension was not a strong predictor of mortality, but rates were lowest in primary prevention trials and those in which hypertension was the only additional inclusion criterion.
Mortality rates were higher in trials selecting for prior cardiovascular disease compared with those for which cardiovascular disease was simply permitted but not required (2.0 to 2.5 versus 0.9 to 2.0 per 100 patient-years).
The highest rates, however, occurred in the three trials that required the presence of chronic kidney disease — defined as either elevated serum creatinine or eGFR less than 60 mL/min/1.73 m2 with or without the presence of proteinuria.
The authors acknowledged that the study was limited by the lack of individual patient data, of information on the effects of medications and therapeutic interventions during the trials, and of information on the effects of the randomized treatment arms and their relationships with mortality.
Pfeffer reported links with Amgen, Novartis, sanofi-aventis, Anthera, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb, Cerenis, Eleven Biotherapeutics, GlaxoSmithKline, Hamilton Health Sciences, Karo Bio, Roche, Salutria, Servier, and the University of Oxford. He is a co-inventor on a patent that Brigham and Women’s Hospital has for the use of inhibitors of the renin-angiotensin system in selected survivors of myocardial infarction.
A coauthor reported a link with sanofi-aventis.
From the American Heart Association:
Primary source: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
Source reference:
Pfeffer M, et al “Mortality rates in trials of subjects with type 2 diabetes” JAHA 2012.
Be the first to leave a comment
