193

BLOOD PRESSURE (BP) CONTROL IN PATIENTS WITH CHRONIC KIDNEY DISEASE (CKD) IN THE SETTING OF A NURSE PRACTITIONER (NP) MANAGED CKD CLINIC MODEL naima ogletree, schawana thaxton, jerry yee, sandeep soman. henry ford hospital, detroit, mi, usa. Limited data exists about the effectiveness of care delivered by a nurse practitioner managed chronic kidney disease (CKD) clinic on BP control. Mean BP varies from 131-157/80-91 even for patients enrolled in major clinical trials of patients with CKD involving BP analysis. Rates of achieving BP of less than the target of 130/80 for CKD patients vary from 17 to 22%. A single-centre historical prospective review of a cohort of patients who attended the CKD clinic at Henry Ford Health System between July 2005 and June 2007 was conducted. Care in this clinic is provided by NPs, who consult with physicians when needed. Data was available for 487 patients followed in the CKD clinic in the above period and analyzed over eight quarters in this time period. Mean number of visits with the nurse practitioner were 5.74± 4.9 (range 1-25). Of the 487 patients, there were 408 (83.8%) African Americans, 65 (13.3%) Caucasians, and 2.8% others. 50.3% (242) were females, and 49.7% (245) males. Mean age was 70.9 ± 13.1 yrs. At total of 2254 BP readings were available for analysis. For all the readings available, mean SBP was 135.41±20.4 mm Hg (range 78-218) and DBP was 68.8 ± 11.57 mm Hg (range 30-150). The mean of the average systolic and diastolic BP for each individual for this period was 136.06 ± 17.1 and 70.8± 10.7 mm Hg respectively. Mean number of BP medications was 2.88±1.32, and 68.5% patients were on at least one medication to suppress the renin angiotensin axis. Average BP was less than 125/75, 130/80, 140/80 and 140/90 mm Hg in 25.5%, 36.8%, 59.4% and 62.8% patients respectively. Results show BP targets achieved in this model of NP managed CKD clinic providing care to predominantly African American patients was comparable to results obtained in various tertiary clinics reported in the literature. Further analysis is required to see if this effect on BP control extends across other domains of CKD care in this CKD clinic model.

194

OUTCOMES ASSOCIATED WITH HYPERURICEMIA IN CHRONIC KIDNEY DISEASE. Jude O Ojie, Sajid M George, Smriti Sharma, Alan Brijbassie, Kamyar Kalantar-Zadeh, Csaba P Kovesdy; Nephrology, Salem VA Medical Center, Salem, VA; Internal Medicine, Carilion Clinic, Roanoke, VA; Harbor-UCLA, Torrance, CA, United States. Hyperuricemia is common in patients with chronic kidney disease (CKD), but it is unclear if it is associated with clinical outcomes in this patient population. We examined the association between hyperuricemia and outcomes (all cause mortality, the composite of mortality or dialysis, and the incidence of new onset end stage renal disease [ESRD] separately) in 788 male US veterans (age 67.8 ± 10.9 years, 26% Black) with CKD not yet on dialysis (estimated glomerular filtration rate [eGFR] 37.1 ± 17.1 ml/min/1.73m2). Association with mortality were examined in a time-dependent unadjusted Cox model and after adjustment for case mix (age, race, co-morbidities, smoking, blood pressure, eGFR, proteinuria, serum calcium, phosphorus, and medication use) and surrogates for malnutrition-inflammation complex (body mass index, serum albumin, cholesterol, white blood cell count, percent of lymphocytes and blood hemoglobin). There were a total of 289 deaths and 182 patients developed ESRD. Higher uric acid level was associated with a trend toward increased mortality (adjusted hazard ratios [95% CI] for uric acid levels 6.3 -7.8, 7.81- 9.3 and > 9.3, compared to <6.3 mg/dl: 1.93 [1.31- 2.84], 1.40 [0.93- 2.13], and 1.84 [1.23- 2.74]; P = 0.051 for trend). Higher uric acid level was also associated with a higher incidence of ESRD (adjusted hazard ratios [95%CI] for uric acid levels 6.3 -7.8, 7.81- 9.3 and > 9.3, compared to <6.3 mg/dl: 0.91 [0.52-1.59], 1.12 [0.66-1.94] and 1.49 [0.85-2.59]; P = 0.043 for trend). The association between uric acid level and the composite outcome were similar. Higher serum uric acid level is associated with higher mortality and a higher incidence of ESRD in patients with CKD who are not yet on dialysis, independent of confounders, including eGFR. Clinical trials are needed to determine if lowering of serum uric acid could improve outcomes in CKD.

195

COMPARISON OF OUTCOMES OF TRANSPOSED UPPER ARM FISTULAS, BRACHIOCEPHALIC FISTULAS, AND UPPER ARM GRAFTS IN HEMODIALYSIS PATIENTS. Jeremy O’Neal, Ivan D. Maya, Michael Allon, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama. Patients without suitable vascular anatomy for a forearm fistula typically receive an AV access in the upper arm. The three access choices are a brachio-cephalic fistula (BCF), a transposed (brachio-basilic or brachio-cephalic) fistula (TF), or an upper arm graft (UAG). There are few publications comparing the outcomes of these 3 types of upper arm vascular access. We queried a prospective, computerized database to identify 679 patients who had an elective placement of an upper arm access during a 7-year period. There were no significant differences in age, sex, race, diabetes, HTN, PVD, CAD or CVA among the 3 patient groups. Access outcomes are summarized in the Table.

GAU FT FCB Number of patients 289 101 289 Primary failure (%) 41* 13 14 Median survival w/o primary failure, days

1178 1641 595*

Median survival with primary failure, days

300 1494* 401

* P < 0.002 vs. the other 2 access types Primary access failure (failure prior to maturation) was similar for TF and UAG, but much lower than for BCF. When primary failures were EXCLUDED, cumulative access survival (time to permanent failure) was similar for BCF and TF, but much higher than for UAG. However, when primary failures were INCLUDED, access survival was similar for BCF and UAG, but much lower than for TF In summary, among the 3 types of upper arm access, TF have the best cumulative survival, due to the combination of low PRIMARY failure (similar to UAG) and low SECONDARY failure (similar to BCF). Thus, transposed fistulas should be the access of choice in the upper arm.

196

COST-EFFECTIVENESS OF ALISKIREN AS ADD ON TO LOSARTAN AND OPTIMAL AN TIHYPERTENSIVE THERAPY IN PATIENTS WITH TYPE 2 DIABETES, HYPERTENSION AND NEPHROPATHY IN THE UK SETTING James L Palmer1, Veronica C Munk 2, Robert W Kotchie3, Gabor Vincze2, Alan Charney4, Daniel MD Tucker1, Lieven Annemans5

1 IMS Health, Basel, Switzerland , 2 Novartis Pharma AG Basel, Switzerland, 3 IMS Health, London, UK, 4 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA, 5 Ghent University, Ghent, Belgium AVOID (Aliskiren in the Evaluatio n of Proteinuria in Diabetes) was a multicentre, randomized, double-blind, 6-month study designed to assess the effect of adding aliskiren, an oral direct renin inhibitor, to losartan and optimal antihypertensive therapy (excluding ACE inhibitors), on the reduction in urinary albumin to creatinine ratio (UACR) in patients with hypertension, type 2 diabetes, and nephropathy with residual proteinuria. A cost-effectiveness model was developed to estimate the progression to end-stage renal disease (ESRD) and to project the associated costs and clinical outcomes of aliskiren in the UK setting. A published model was adapted to incorporate treatment effects from AVOID, where aliskiren reduced mean UACR by 20% (p=0.0009). Transition probabilities from AVOID were used until patients reached UACR >1,900µg/g, with probabilities from IDNT (Irbesartan in Diabetic Nephropathy Trial) used thereafter. Short-term therapy benefits associated with aliskiren were projected to increase life expectancy by 0.0983 years, improve quality-adjusted life expectancy by 0.0878 quality-adjusted life years (QALYs) and reduce the cumulative incidence of ESRD by 2.51% compared to placebo. An incremental cost-effectiveness ratio of £12,073 per QALY gained was calculated for aliskiren, which is well below the willingness-to-pay threshold of £30,000 per QALY gained. The additional renal protection provided by aliskiren would be considered cost-effective in the UK setting in the patient group studied.

NKF 2008 Spring Clinical Meetings AbstractsA76