Physician Knowledge and Practice Patterns Relating to Diabetic Nephropathy

Several well-controlled trials in patients with heart failure have shown that the use of angiotensin-converting enzyme (ACE) inhibitors, in combination with a diuretic, causes a reduction in mortality and morbidity,...

To assess the current evidence on the potential benefit of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) on cancer recurrence and survival, we comprehensively searched PubMed, Embase, and the Cochrane Library from their inception to April 2013. Two authors screened out duplicates and independently reviewed the eligibility of each study. We included comparative studies comparing the use and nonuse of ACEIs or ARBs in cancer patients. Primary outcomes were disease-free survival (DFS) and overall survival. We included 11 studies with 4964 participants in the final analysis. The meta-analysis showed that the use of ACEIs or ARBs resulted in a significant improvement in DFS [hazard ratio (HR) 0.60; 95% confidence interval (CI) 0.41-0.87; P=0.007)] and overall survival (HR 0.75; 95% CI 0.57-0.99; P=0.04). Even when cancer stage was classified into low (I/II) or high (III/IV), DFS improvement was applied to both low stage (HR 0.56; 95% CI 0.32-0.96; P=0.04) and high stage (HR 0.59; 95% CI 0.37-0.94; P=0.03). Analysis according to cancer type showed benefits in urinary tract cancer (HR 0.22), colorectal cancer (HR 0.22), pancreatic cancer (HR 0.58), and prostate cancer (HR 0.14), but not in breast cancer and hepatocellular cancer. This meta-analysis provides evidence that the use of ACEIs or ARBs in cancer patients can lead to a 40 and 25% reduction in the risk of cancer recurrence and mortality.

Aim: Since patients with lysosomal storage disorders (LSDs) often apply to primary care physicians initially, these doctors play a crucial role in the early diagnosis of LSDs. In this study, we aimed to determine the knowledge and awareness of primary care physicians regarding LSDs. Materials and Methods: We conducted a survey between January 2016 and April 2016 among primary care physicians from various regions of Turkey. Invitation e-mail was randomly sent to the individual e-mail address of each physician for a web-based survey. The questionnaire globally consisted of three sections with a total of 30 questions. In the first part of the survey, demographic characteristics of physicians (age, gender, career information) were recorded. The second section consisted of questions on LSDs for the evaluation of knowledge among physicians. In the third section of survey, questions were about the reasons of insufficient knowledge on LSDs and possible solutions to raise awareness. Results: A total of 261 primary care physicians [109 females (41.8%), mean age 40.1±8.8 years] were enrolled in the study. The mean working time was 14.9±8.6 years. Among the participants, 75.8% and 88.8% stated that they had never encountered an LSD patient before and never considered LSDs as a differential diagnosis for any patient, respectively. Fifteen percent of physicians stated that they had no idea about the clinical findings and symptoms of LSD. Another 26.2% of the participants stated that LSD is screened during the neonatal screening program in Turkey. Mean “total knowledge score” of the physicians was 13.47±5.85 points [median=15.0 (10.5-18.0)] out of 25. Six (2.3%) primary care physicians had a total score of “0”. Only 1 of them scored “25” points. Conclusion: Knowledge of primary care physicians on LSDs is not satisfactory in Turkey. Undergraduate medical education and postgraduate educations play a key role to raise awareness.

The extent to which age plays a role in the underutilization of angiotensin-converting enzyme (ACE) inhibitors in heart failure patients has not been well studied. We studied age-related variation in the use of ACE inhibitors in older Medicare beneficiaries discharged alive in Alabama with a diagnosis of heart failure with left ventricular systolic dysfunction. A total of 285 patients had a mean age +/- SD of 78 +/- 6.9 years; 59% were female and 21% were African American. Of the 285 patients, 181 (63%) were prescribed ACE inhibitors at discharge. Therapy with ACE inhibitors was initiated in 47% of the patients. Compared with patients 65 to 74 years, those 85 years and older had lower odds of receiving ACE inhibitors at discharge. Among patients not admitted on an ACE inhibitor, those 85 years and older also had lower odds of ACE inhibitor therapy being initiated. The overall rate of ACE inhibitor use was low, and age of 85 years and older was independently associated with lower use and initiation of ACE inhibitors. Opportunities remain to increase the use of ACE inhibitors in older patients with heart failure.

Although a considerable volume of data supporting induction or aggravation of psoriasis because of angiotensin-converting enzyme (ACE) inhibitor use exists, it remains insufficient for definitive conclusions. Therefore, we aimed to evaluate the association between ACE inhibitor use and psoriasis incidence through a systematic literature review and meta-analysis. We searched for qualifying studies across PubMed, Web of Science, and Embase. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to evaluate the strength of the association between ACE inhibitor use and psoriasis incidence. Eight studies with a total of 54,509 patients with a psoriasis diagnosis were included in this meta-analysis. The pooled OR for psoriasis incidence among ACE inhibitor users was 1.52 (95% CI, 1.16–2.00) compared to that among non-users. From subgroup analysis by continent, the OR for ACE inhibitor users versus non-users was 2.37 (95% CI 1.28–4.37) in Asia. Per the subgroup analysis by climate, the OR for ACE inhibitor users vs non-users in dry climate was 3.45 (95% CI: 2.05–5.79) vs 1.32 (95% CI 1.01–1.73) in temperate climate. Our results reveal a significant association between ACE inhibitor use and psoriasis incidence.

Hypertension is a frequent comorbidity often following the development of diabetic nephropathy among individuals with type 1 diabetes and affecting most patients with type 2 diabetes at the time of diagnosis. Multiple prospective randomized placebo-controlled trials demonstrate that tight blood pressure control among patients with diabetic nephropathy reduces the rates of macrovascular and microvascular complications. While randomized trials exist and support a blood pressure goal of <140/90 mm Hg for patients with nondiabetic kidney disease, there are no prospective data regarding a specific blood pressure goal on progression of diabetic nephropathy. Retrospective data analyses from trials show a linear relationship between either baseline or achieved study blood pressure and progression of nephropathy. Very high albuminuria is a hallmark of diabetic nephropathy with reductions by either angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blocker (ARB) monotherapy associated with slowed nephropathy progression. However, combination antihypertensive therapy, while decreasing proteinuria, augments the risk of hyperkalemia, hypotension, and kidney dysfunction. Given the lack of trial data for a BP goal among patients with diabetic nephropathy, prospective trials are needed to define the optimal blood pressure necessary to preserve kidney function. At present, guideline blood pressure goals of less than 140/90 mm Hg and the use of ACEi or ARB therapy for those with more than 300 mg of albuminuria are mandated.

Angiotensin-converting enzyme inhibitors decrease the risk of radiation pneumonitis after stereotactic body radiation therapy

It has been suggested that use of the antihypertensive drugs angiotensin-converting enzyme (ACE) inhibitors and β-blockers may decrease the risk of primary liver cancer; thus, the objective of this study was to evaluate whether use of ACE inhibitors and/or β-blockers is associated with a lower risk of liver cancer. Nested case-control study. United Kingdom Clinical Practice Research Datalink. We identified 490 cases with hypertension and a first-time (incident) diagnosis of primary liver cancer between 1988 and 2011. To account for an induction period, the index date was defined as the date of the first recorded liver cancer diagnosis minus 1year. Controls were selected from patients with hypertension in the CPRD during the study period with a recorded diagnosis of hypertension who had no diagnosis of liver cancer and were free of any other cancer (except nonmelanoma skin cancer) before the index date; they were matched up to a 4:1 ratio to cases based on index date (same index date as that of their matched case), age (same year of birth), sex, general practice, and number of years of recorded history in the CPRD before the index date (1909 controls). Both cases and controls were required to have at least 2years of recorded activity in the database before the index date. Exposure was defined as receipt of two or more prescriptions for ACE inhibitors and/or β-blockers before the index date; the reference group was nonuse (0-1 prescription) of ACE or β-blocker prescriptions before the index date. We also examined the effect of duration of use and, separately, the effect of individual drugs within each medication class on risk of liver cancer, and conducted analyses restricted to patients without liver disease or diabetes mellitus. Conditional logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). No association was found between use of ACE inhibitors and/or β-blockers and the risk of liver cancer compared with nonuse (adjusted OR 1.14, 95% CI 0.85-1.55). No significant differences were noted in risk by duration of use or by individual drugs, or after restricting the analyses to patients without diabetes or liver disease. Use of ACE inhibitors and/or β-blockers was not associated with reduced risk of primary liver cancer compared with nonuse of these drugs in persons with hypertension.

The authors identified 321 elderly Kansas Medicaid patients with congestive heart failure and examined angiotensin-converting enzyme (ACE) inhibitor use. Using retrospective claims data, ACE inhibitor use was quantified and daily doses compared to a target enalapril-equivalent dose of 20 mg. The cohort patients averaged 80 years of age, 84% were female, and 70% resided primarily in a nursing home. Only 37.8% received an ACE inhibitor. Users were younger than nonusers (t=2.00; p=0.046), but there was no gender difference (odds ratio [OR], 1.4; 95% confidence interval [CI], 0.73, 2.6). ACE inhibitor users averaged eight prescriptions annually, providing approximately 257 medication days (70% of the study period). The average enalapril-equivalent daily dose was 10.6 mg, and only 22% received the target dose. Nursing home residents were less likely to receive an ACE inhibitor than ambulatory patients (OR, 0.55; 95% CI, 0.34, 0.89) but equally likely to receive target doses (OR, 1.3; 95% CI, 0.34, 4.9). ACE inhibitor use in the Kansas Medicaid congestive heart failure population is not consistent with practice guidelines, particularly among older and/or nursing home patients.

Angiotensin-converting enzyme (ACE) inhibitors have been FDA-approved for treating refractory hypertension since 1981. Since then, clinical investigations support the benefits of ACE inhibition (ACE-I) in pathologies like congestive heart failure, myocardial infarction, diabetes mellitus, chronic renal insufficiency, and atherosclerotic cardiovascular disease. Both, clinical trials and animal models of type I and type II diabetes have shown that hyperactivity of the angiotensin II signaling pathway contributes to the development of diabetes and its complications, and that blockade of the renin-angiotensin system prevents new onset diabetes and reduces the risk of diabetic complications. Furthermore, ACE inhibitors are generally well tolerated and have few contraindications. This article describes ACE as a target molecule and gives an overview on the clinical evidence that supports the use of ACE inhibitors in diabetes.

Background: Depression occurs in 3-8% of the population of the world and ranks fourth in the world's most prevalent diseases. Based on data from Riskesdas 2013, the rate of mental disorders (depression and anxiety) reached 6% for ages 15 and older. The mental disorder most prevalent in primary care is the depressive disorder (10%), but the diagnosis of depression by general practitioners in primary care is only 1%. Coverage of mental health in primary care is low, partly because primary care physicians who are in Community and Primary Health Care Centers (Puskesmas) are still experiencing difficulties in diagnosing mental disorders, especially depression.Objective: To determine the effectiveness of mhGAP training in improving the knowledge and skills of primary care physicians in diagnosing and treating depression in Gunungkidul.Research Methods: This study was a quasi-experimental research with pretest-posttest design with one group, in order to find a causal relationship involving one treatment group.Results: The knowledge of the primary care physician improved about diagnosis of depression before and after intervention training modules, p=0.000. Patients with depression mostly suffered in the female group ages 19-60 years old. An increase in the diagnosis of depression after training mhGAP with validation by a psychiatric specialist was at 49.41%.Conclusion: Training with modules mhGAP improved education for physicians in the diagnosis of depression and improved referral rates of depression cases from community health centers to district hospitals in Wonosari.

Background:Diabetic nephropathy is glomerular sclerosis caused by diabetic microvascular disease, which is one of the most serious complications of diabetes. At present, the traditional treatment of diabetic nephropathy is mainly based on the control of blood pressure, blood sugar, blood lipids, and other basic treatments using angiotensin converting enzyme inhibitor/angiotensin receptor blocker, the clinical reports of relying solely on angiotensin converting enzyme inhibitor/ angiotensin receptor blocker to delay the course of diabetic nephropathy are not optimistic. Yuquan pill (YQP), a classic traditional Chinese medicine prescription, has clinical reports that it can effectively assist in the treatment of diabetic nephropathy with minimal side effects. However, there has been no systematic review of the YQP in the treatment of diabetic nephropathy. This article systematically evaluated the effectiveness and safety of YQP clinical applications.Methods:The database search include seven databases, including PubMed, Embase, Cochrane Library, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure, Chinese Scientific Journal Database, and Wanfang database. The search date was set as a randomized controlled trial from the establishment of the database to April 21, 2021. The main outcome indicators include urinealbumin excretion rate, serum creatinine, urea nitrogen, Total effective rate. The analysis software uses Stata 15.Results:This study will analyze multiple outcome indicators such as clinical efficacy, urinary albumin excretion rate, blood creatinine value, urea nitrogen, and symptom scores. Provides a the latest evidence for YQP in the treatment of diabetic nephropathy (DN).Conclusion:The results of this study will provide evidence for the efficacy of YQP in the treatment of DN.INPLASY Registration number:INPLASY202150030.

Calcium accumulation in the aortic valve is a hallmark of aortic sclerosis and aortic stenosis. Because lipoproteins, angiotensin-converting enzyme, and angiotensin II colocalize with calcium in aortic valve lesions, we hypothesized an association between angiotensin-converting enzyme inhibitor (ACEI) use and lowered aortic valve calcium (AVC) accumulation, as measured by electron beam computed tomography. Rates of change in volumetric AVC scores were determined retrospectively for 123 patients who had undergone 2 serial electron beam computed tomographic scans. The mean (+/-SD) interscan interval was 2.5 (+/-1.7) years; 80 patients did not receive ACEIs and 43 received ACEIs. The relationship of ACEI use to median rates of AVC score change (both unadjusted and adjusted for baseline AVC scores and coronary heart disease risk factors) was determined. We also examined the relationship of ACEI use to the likelihood of and adjusted odds ratio for definite progression (AVC change >2 times the median interscan variability). Unadjusted and adjusted median rates of AVC score change were significantly higher in the no-ACEI group than in the ACEI group (adjusted median AVC changes [95% confidence interval]: relative, 28.7%/y [18.9%-38.5%/y] vs 11.0%/y [-1.9% to 24.0%/y], P = .04; absolute: 25.1/y [19.7-30.5/y] vs 12.2/y [4.5-19.9/y], P = .02). The adjusted odds ratio (95% confidence interval) for definite AVC progression was significantly lower for patients who received ACEIs (0.29 [0.11-0.75], P = .01). This retrospective study finds a significant association between ACEI use and a lower rate of AVC accumulation. The results support the need for prospective, randomized trials of ACEIs in calcific aortic valve disease.

The Reduction in End Points in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) study and the Irbesartan Diabetic Nephropathy Trial (IDNT) are two recently reported trials with hard end points, conducted in patients in advanced stages of diabetic nephropathy. Two other studies--the Irbesartan Microalbuminuria Study (IRMA)-2 and the Microalbuminuria Reduction with Valsartan study (MARVAL)--were trials conducted in patients with type 2 diabetes with microalbuminuria, a cardiovascular risk factor associated with early-stage diabetic nephropathy. These trials all had a common theme--that is, does an angiotensin receptor blocker (ARB) interfere with the natural history of diabetic nephropathy in a blood pressure-independent fashion? Without question, the results of these trials legitimatize the use of the ARB class in forestalling the deterioration in renal function, which is almost inevitable in the patient with untreated diabetic nephropathy. These data can now be added to the vast array of evidence supporting angiotensin-converting enzyme (ACE) inhibitor use in patients with nephropathy associated with type 1 diabetes. It now appears a safe conclusion that the patient with diabetic nephropathy should receive therapy with an agent that interrupts the renin-angiotensin system. These studies have not resolved the question as to whether an ACE inhibitor or an ARB is the preferred agent in people with nephropathy from type 1 diabetes, though the optimal doses of these drugs remain to be determined. Head-to-head studies comparing ACE inhibitors to ARBs in diabetic nephropathy are not likely to occur, so it is unlikely that comparable information will be forthcoming with ACE inhibitors. An evidence-based therapeutic approach derived from these trials would argue for ARBs to be the foundation of therapy in the patient with type 2 diabetes and nephropathy.

Recent reports indicate increased risk of renal failure with long-term use of angiotensin-converting enzyme inhibitors (ACEI) in diabetes. End-stage renal disease (ESRD) in diabetes has increased despite ACEI and angiotensin receptor blocker (ARB) use. This study questions renal protection by ACEI or ARB. Our hypothesis is that uncontrolled hyperglycemia is central to diabetic ESRD while tight glucose control is renoprotective. Cultured endothelial cells show morphological damage that increases with duration of exposure to high glucose and is prevented by insulin and more so by a combination of insulin and heparin. Findings from individual patients are compared to clinical trial results wherein ACEI or ARB was emphasized as the prime therapy to prevent progression of diabetic nephropathy to ESRD. Serum creatinine (Scr) changes were the main indicator of renoprotective effects in clinical trials. Creatinine clearance (Ccl), an important marker of glomerular filtration rate, was seldom reported. Our observations show that ACEI-treated patients develop progressive renal failure, whereas renal function remains stable with optimum glucose control. Clinical trials showed that reduction of proteinuria, with ACEI, reduces the risk of ESRD. Our studies show that reduction of proteinuria with use of ACEI or ARB parallels a reduction in Ccl, suggesting that a change in proteinuria is related to Ccl changes. Scr changes are small, giving a deceptive view of renal protection. Our observations find no evidence of renal protection with ACEI or ARB use in diabetes. Laboratory studies and clinical observations suggest that adequate glucose control is the key to renal protection in diabetes.