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Posts Tagged ‘hemoglobin A1c’

I met with Dr. Asad Khan for lunch at a recent medical conference.  Dr. Khan and I are old friends from our training days back in West Virginia.  I was a new nurse practitioner (still wet behind ears) in Cardiothoracic Surgery, and Dr. Khan was completing his last year of his nephrology [kidney] fellowship. At that time, West Virginia University had a robust cardiothoracic surgery program and performed cardiac surgery on a large ESRD (end-stage renal disease) population [patients on dialysis.]

As I worked with the soft-spoken Karachi-born physician, I came to rely on him frequently for his excellent clinical judgement and insight.  Now that I have the chance to sit down and catch up with Dr. Khan – I take the opportunity to find out more about his current practice as the Director of six Davita hemodialysis centers in and around College Station, Texas, and to ask Dr. Khan to talk about ways people can prevent and treat renal insufficiency / kidney damage.

Cartagena Surgery: Wow.. It’s good to see you.  It’s been a long time.  Would you tell me more about your current practice?

Dr. Khan:  As I mentioned previously, I am now the Director of several dialysis centers in Texas.  These free-standing clinics have a lot of expanded programs that are very different from the hospital dialysis program [where we trained.]

Cartagena Surgery:  Earlier you mentioned something about bedtime dialysis.  Would you tell me more about that?  I know dialysis can be exhausting – it sounds like an interesting program.  Do patients show up in their pajamas?

Dr. Khan:  Actually, despite the fact that Davita’s nocturnal dialysis programs exist nationwide, not very many patients chose this option.  But it is a good alternative to standard daytime programs, because it allows patients to maximize their time.  By dialysing at night while sleeping, patients are free to pursue their normal activities during the day; work, school or other activities of daily living without interrupting their daily schedule for dialysis.  And yes, some of them do arrive in their pajamas.

Cartagena Surgery:  What steps can people take to protect their kidneys, and prevent chronic kidney disease?

Dr. Khan:  Well the best way people can prevent kidney damage is to prevent and treat the two main diseases that cause kidney damage; namely hypertension and diabetes.   By remaining physically active, eating healthy foods (and following a low- salt diet), and maintaining a healthy weight (BMI less than 25) people can reduce the risk of developing both of these harmful diseases.

Even if they already have high blood pressure or diabetes – these basics tenets of health & wellness can help people control these conditions with the addition of medications.  We know through decades of cardiovascular research such as the Framingham Study and the more recent NHANES surveys that hypertension and diabetes play a big role in the development of coronary disease.  But the results regarding the role of hypertension and kidney disease were surprising.

Several recent cardiac risk studies showed that not only did kidney disease accelerate the development of coronary artery disease (CAD) and dramatically increase the risk of cardiac death – but that even minor elevations of blood pressure over time were correlated with greatly increased risk of chronic kidney disease (CKD).

Most people don’t realize that even a ten point increase in baseline blood pressure (from 130 systolic to 140 systolic) translates to kidney disease/ kidney failure occurring SEVEN years earlier.

Studies also show that one of the most important ways to prevent on-going kidney disease is medication compliance.  When people take the anti-hypertensive medications as prescribed, there is a significant reduction in the development and advancement of chronic renal disease.

Cartagena Surgery:  You mentioned the role of diabetes and hyperglycemia in the development of kidney disease.  Would you explain a bit more about that?

Dr. Khan:  As you know, diabetes is diagnosed relatively late in this country.  The average person has already had diabetes for over seven years prior to receiving a formal medical diagnosis, and this doesn’t even include the vast numbers of people who are told that they have ‘pre-diabetes’ but aren’t given any medications to control it.  All of these people – these undiagnosed people – ALREADY have kidney damage.  I know you give a lecture on the role of diabetes and CAD – and  talk about the importance of treating and preventing proteinuria.  This proteinuria, or protein in the urine is a sign of the damage that is already occurring in this population.   While the detection of this condition is relatively easy – from a simple urine sample – it’s often overlooked.  By the same token, the treatment of this condition, using relatively inexpensive medications called ace-inhibitors (or ARBS) is essential, but not often stressed to patients.  Many of these patients don’t even know WHY these medications have been prescribed for them.  If you don’t know why you are taking something – then you are less likely to take it regularly.

[cartagena surgery: as we discussed in a previous post – these medications are a type of blood pressure medication, but are often used for other reasons such as the prevention of diabetic nephropathy – aka diabetes-related kidney disease.]

Cartagena Surgery: well, thank you for all your time today, I know you have to get back to your conference – you’ve given us some great information. 

Readers – if you have questions or want to know more, (or if you have kidney disease) you can contact Dr. Khan directly.  (He also an internal medicine specialist – and was a primary care physician for several years before becoming a nephrologist, so he’s an expert at treating hypertension, diabetes and other chronic medical conditions besides kidney disease.)

Dr. Asad Khan, MD

Bryan Kidney Center Inc

2110 E Villa Maria Rd

Bryan, TX  77802

 (979) 402-3152

In related news –

a new article published in Medpage Today reports that aggressive treatment for pre-diabetes (including a hemoglobin A1C of 5.7% ) is more cost-effective in long run (by preventing costly diabetes-related complications.)

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Busy day today – I am giving a talk with the local Mended Hearts chapter as part of “Heart Month.”  Mended Hearts is a patient-run organization/ support group for people who have had heart attacks, stents or heart surgery.  It’s a place where people can go for encouragement, education or support after a life-changing cardiac event.  I’ve worked with Mended Hearts in the past, so I was pleased when they invited me to give one of my favorite talks this weekend. (I’ve been giving variations on this talk since 2008).

(Some people might consider it a bit ironic that I am giving a lecture on prevention to a group of people who have already been diagnosed with CAD – but we are also talking about overall wellness/ and preventing future events.)

It’s one of my favorite lectures because it’s an informal style presentation – so I encourage listeners to participate in the discussion – and ask questions.  We also review a case study at the end – where we have a bit of role reversal as I invite listeners to be the NP for a minute and devise treatment strategies for the imaginary patient..  (and my audience usually does a great job – which just proves how powerful a motivated person can be when it comes to healthcare.. If all people were like my audiences, people would be a lot healthier.)   I’ve included a quick summary of my lecture here for interested readers.  (Just the basics – for more specific or detailed information such as information on lipo-proteins, see your doctor.)

Aggressive Risk Factor Reduction 

When talking about healthcare and risk factor reduction, we need to use measurable, and achievable goals.. No ‘nebulous’ statements like ‘improve blood pressure’, or ‘lose weight.’  Instead – we give concrete, and specific goals based on the most relevant and up-to-date clinical evidence.

1.  Hypertension / Blood pressure control – normal B/P is 110/ 70.   National guidelines for diabetics recommends systolic blood pressure less than 130, and a diastolic b/p less than 90.

2.  Hyperlipidemia/ dyslipidemia

LDL cholesterol less than 70

HDL greater than 50

– statin therapy recommended for all diabetics.
3.  Microaluminuriasmall protein particles found in urine.  This is an early indicator of on-going kidney damage.   All diabetics should be on an ace-inhibitor (the ‘prils’ such as lisinopril, fosinopril, enalapril).

These medications will help SLOW the damage, but the best treatment is TIGHT glucose control.

4.  Hyperglycemia – (not diabetes)

Hyperglycemia causes damage.  Period.  This includes so-called ‘pre-diabetes’ and gestational diabetes (see slides for more information.)

– Check your hemoglobin A1c, and control your glucose

– Fasting and post-prandial (2 hours after meals) glucose testing.  Remember that post-prandial readings will rise earlier in the course of the disease, so if you re only testing in the mornings – you might miss crucial information needed for your treatment.

– Currently ONLY metformin and insulin therapies have been shown to have long-term benefits.  (The twenty – plus other medications may make ‘the numbers’ look pretty – but there is little long-term evidence to support their use.

Previously, we skirted around to test ALL of our cardiothoracic patients as part of a screening protocol – new guidelines recommend screening of all hospital patients.

5. Endothelial inflammation – hyperglycemia ‘encourages’ endothelial inflammation and vascular damage (it’s the hallmark of the disease) so the best way to treat this is with anti-platelet therapy such as a baby aspirin (ASA).  Recent literature suggests that ASA may do more harm than good in some people, so check with your doctor..

There’s a lot more information to go over (it’s a 45 minute talk) so I’ve decided to post my lecture slides here for anyone to use, but I do ask that people please give appropriate credit.  Cardiac Complications of Diabetes ppt slides.

More references:

Australian treatment guidelines

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