Hispanics Appear To Face Poorer Quality Nursing Home Care

Nursing homes serving primarily Hispanic residents provided poorer quality care compared to facilities whose patients were mostly white, according to Brown University research. Details were published recently in the Journal of the American Medical Directors Association.

Researchers reached their conclusions after looking at the rate of bed sores at nursing homes with high concentrations of Hispanic patients, compared to others with low concentrations. Hispanics at nursing homes with a high rate of Hispanic residents were more likely to have bed sores, compared to Hispanics living in nursing homes with fewer Hispanic residents.

Michael Gerardo, adjunct assistant professor of community health at the Warren Alpert Medical School of Brown University, led the research. Two others served as co-authors — Joan Teno, M.D., professor of community health and medicine and an expert on end-of-life care, and Vincent Mor, chair of the Department of Community Health, whose work focuses on nursing home care among other areas.

Gerardo and the other professors said that more research is needed to determine the implications of their findings, directed specifically at the root cause for disparities between high-quality and low-quality nursing homes.

“A systemic evaluation of the difference in the process of care between high- and low-quality nursing homes is warranted in order to reduce nursing home disparities,” Gerardo said.

Their work comes less than two years after a landmark 2007 study, published in Health Affairs, that suggests blacks are more likely than whites to live in poor-quality nursing homes. That study found that the problem was worst in the Midwest, and that inequalities in care are closely correlated to racial segregation. Mor was lead author for that study.

For the study of Hispanics in nursing homes, the researchers looked at two data sources. One, the national repository of the Minimum Data Set, is a federally mandated report of health status, function and demographics on all nursing home residents. The other, which is known as the Oscar database system, collects information on patients and nursing homes, via the Centers for Medicaid and Medicare Services.

Residents were included if they were age 65 or older, living at free-standing nursing homes in California, New Mexico, Texas, Arizona or Colorado.

Funding from the National Institutes of Health, National Institute on Aging, A National Research Service Award Institutional Training Grant and the Commonwealth Fund helped support the study.

Hispanics Appear To Face Poorer Quality Nursing Home Care

Nursing homes serving primarily Hispanic residents provided poorer quality care compared to facilities whose patients were mostly white, according to Brown University research. Details were published recently in the Journal of the American Medical Directors Association.

Researchers reached their conclusions after looking at the rate of bed sores at nursing homes with high concentrations of Hispanic patients, compared to others with low concentrations. Hispanics at nursing homes with a high rate of Hispanic residents were more likely to have bed sores, compared to Hispanics living in nursing homes with fewer Hispanic residents.

Michael Gerardo, adjunct assistant professor of community health at the Warren Alpert Medical School of Brown University, led the research. Two others served as co-authors — Joan Teno, M.D., professor of community health and medicine and an expert on end-of-life care, and Vincent Mor, chair of the Department of Community Health, whose work focuses on nursing home care among other areas.

Gerardo and the other professors said that more research is needed to determine the implications of their findings, directed specifically at the root cause for disparities between high-quality and low-quality nursing homes.

“A systemic evaluation of the difference in the process of care between high- and low-quality nursing homes is warranted in order to reduce nursing home disparities,” Gerardo said.

Their work comes less than two years after a landmark 2007 study, published in Health Affairs, that suggests blacks are more likely than whites to live in poor-quality nursing homes. That study found that the problem was worst in the Midwest, and that inequalities in care are closely correlated to racial segregation. Mor was lead author for that study.

For the study of Hispanics in nursing homes, the researchers looked at two data sources. One, the national repository of the Minimum Data Set, is a federally mandated report of health status, function and demographics on all nursing home residents. The other, which is known as the Oscar database system, collects information on patients and nursing homes, via the Centers for Medicaid and Medicare Services.

Residents were included if they were age 65 or older, living at free-standing nursing homes in California, New Mexico, Texas, Arizona or Colorado.

Funding from the National Institutes of Health, National Institute on Aging, A National Research Service Award Institutional Training Grant and the Commonwealth Fund helped support the study.

Diabetes Insipidus

What is diabetes insipidus?

Diabetes insipidus (DI) is a rare disease that causes frequent urination. The large volume of urine is diluted, mostly water. To make up for lost water, a person with DI may feel the need to drink large amounts and is likely to urinate frequently, even at night, which can disrupt sleep and, on occasion, cause bedwetting. Because of the excretion of abnormally large volumes of dilute urine, people with DI may quickly become dehydrated if they do not drink enough water. Children with DI may be irritable or listless and may have fever, vomiting, or diarrhea. Milder forms of DI can be managed by drinking enough water, usually between 2 and 2.5 liters a day. DI severe enough to endanger a person’s health is rare.

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What is the difference between diabetes insipidus and diabetes mellitus?

DI should not be confused with diabetes mellitus (DM), which results from insulin deficiency or resistance leading to high blood glucose, also called blood sugar. DI and DM are unrelated, although they can have similar signs and symptoms, like excessive thirst and excessive urination.

DM is far more common than DI and receives more news coverage. DM has two main forms, type 1 diabetes and type 2 diabetes. DI is a different form of illness altogether.

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How is fluid in the body normally regulated?

The body has a complex system for balancing the volume and composition of body fluids. The kidneys remove extra body fluids from the bloodstream. These fluids are stored in the bladder as urine. If the fluid regulation system is working properly, the kidneys make less urine to conserve fluid when water intake is decreased or water is lost, for example, through sweating or diarrhea. The kidneys also make less urine at night when the body’s metabolic processes are slower.

The hypothalamus makes antidiuretic hormone (ADH), which directs the kidneys to make less urine.

To keep the volume and composition of body fluids balanced, the rate of fluid intake is governed by thirst, and the rate of excretion is governed by the production of antidiuretic hormone (ADH), also called vasopressin. This hormone is made in the hypothalamus, a small gland located in the brain. ADH is stored in the nearby pituitary gland and released into the bloodstream when necessary. When ADH reaches the kidneys, it directs them to concentrate the urine by reabsorbing some of the filtered water to the bloodstream and therefore make less urine. DI occurs when this precise system for regulating the kidneys’ handling of fluids is disrupted.

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What are the types of diabetes insipidus?

Central DI

The most common form of serious DI, central DI, results from damage to the pituitary gland, which disrupts the normal storage and release of ADH. Damage to the pituitary gland can be caused by different diseases as well as by head injuries, neurosurgery, or genetic disorders. To treat the ADH deficiency that results from any kind of damage to the hypothalamus or pituitary, a synthetic hormone called desmopressin can be taken by an injection, a nasal spray, or a pill. While taking desmopressin, a person should drink fluids only when thirsty and not at other times. The drug prevents water excretion, and water can build up now that the kidneys are making less urine and are less responsive to changes in body fluids.

Nephrogenic DI

Nephrogenic DI results when the kidneys are unable to respond to ADH. The kidneys’ ability to respond to ADH can be impaired by drugs—like lithium, for example—and by chronic disorders including polycystic kidney disease, sickle cell disease, kidney failure, partial blockage of the ureters, and inherited genetic disorders. Sometimes the cause of nephrogenic DI is never discovered.

Desmopressin will not work for this form of DI. Instead, a person with nephrogenic DI may be given hydrochlorothiazide (HCTZ) or indomethacin. HCTZ is sometimes combined with another drug called amiloride. The combination of HCTZ and amiloride is sold under the brand name Moduretic. Again, with this combination of drugs, one should drink fluids only when thirsty and not at other times.

Dipsogenic DI

Dipsogenic DI is caused by a defect in or damage to the thirst mechanism, which is located in the hypothalamus. This defect results in an abnormal increase in thirst and fluid intake that suppresses ADH secretion and increases urine output. Desmopressin or other drugs should not be used to treat dipsogenic DI because they may decrease urine output but not thirst and fluid intake. This fluid overload can lead to water intoxication, a condition that lowers the concentration of sodium in the blood and can seriously damage the brain. Scientists have not yet found an effective treatment for dipsogenic DI.

Gestational DI

Gestational DI occurs only during pregnancy and results when an enzyme made by the placenta destroys ADH in the mother. The placenta is the system of blood vessels and other tissue that develops with the fetus. The placenta allows exchange of nutrients and waste products between mother and fetus.

Most cases of gestational DI can be treated with desmopressin. In rare cases, however, an abnormality in the thirst mechanism causes gestational DI, and desmopressin should not be used.

Diabetes Insipidus

What is diabetes insipidus?

Diabetes insipidus (DI) is a rare disease that causes frequent urination. The large volume of urine is diluted, mostly water. To make up for lost water, a person with DI may feel the need to drink large amounts and is likely to urinate frequently, even at night, which can disrupt sleep and, on occasion, cause bedwetting. Because of the excretion of abnormally large volumes of dilute urine, people with DI may quickly become dehydrated if they do not drink enough water. Children with DI may be irritable or listless and may have fever, vomiting, or diarrhea. Milder forms of DI can be managed by drinking enough water, usually between 2 and 2.5 liters a day. DI severe enough to endanger a person’s health is rare.

[Top]

What is the difference between diabetes insipidus and diabetes mellitus?

DI should not be confused with diabetes mellitus (DM), which results from insulin deficiency or resistance leading to high blood glucose, also called blood sugar. DI and DM are unrelated, although they can have similar signs and symptoms, like excessive thirst and excessive urination.

DM is far more common than DI and receives more news coverage. DM has two main forms, type 1 diabetes and type 2 diabetes. DI is a different form of illness altogether.

[Top]

How is fluid in the body normally regulated?

The body has a complex system for balancing the volume and composition of body fluids. The kidneys remove extra body fluids from the bloodstream. These fluids are stored in the bladder as urine. If the fluid regulation system is working properly, the kidneys make less urine to conserve fluid when water intake is decreased or water is lost, for example, through sweating or diarrhea. The kidneys also make less urine at night when the body’s metabolic processes are slower.

The hypothalamus makes antidiuretic hormone (ADH), which directs the kidneys to make less urine.

To keep the volume and composition of body fluids balanced, the rate of fluid intake is governed by thirst, and the rate of excretion is governed by the production of antidiuretic hormone (ADH), also called vasopressin. This hormone is made in the hypothalamus, a small gland located in the brain. ADH is stored in the nearby pituitary gland and released into the bloodstream when necessary. When ADH reaches the kidneys, it directs them to concentrate the urine by reabsorbing some of the filtered water to the bloodstream and therefore make less urine. DI occurs when this precise system for regulating the kidneys’ handling of fluids is disrupted.

[Top]

What are the types of diabetes insipidus?

Central DI

The most common form of serious DI, central DI, results from damage to the pituitary gland, which disrupts the normal storage and release of ADH. Damage to the pituitary gland can be caused by different diseases as well as by head injuries, neurosurgery, or genetic disorders. To treat the ADH deficiency that results from any kind of damage to the hypothalamus or pituitary, a synthetic hormone called desmopressin can be taken by an injection, a nasal spray, or a pill. While taking desmopressin, a person should drink fluids only when thirsty and not at other times. The drug prevents water excretion, and water can build up now that the kidneys are making less urine and are less responsive to changes in body fluids.

Nephrogenic DI

Nephrogenic DI results when the kidneys are unable to respond to ADH. The kidneys’ ability to respond to ADH can be impaired by drugs—like lithium, for example—and by chronic disorders including polycystic kidney disease, sickle cell disease, kidney failure, partial blockage of the ureters, and inherited genetic disorders. Sometimes the cause of nephrogenic DI is never discovered.

Desmopressin will not work for this form of DI. Instead, a person with nephrogenic DI may be given hydrochlorothiazide (HCTZ) or indomethacin. HCTZ is sometimes combined with another drug called amiloride. The combination of HCTZ and amiloride is sold under the brand name Moduretic. Again, with this combination of drugs, one should drink fluids only when thirsty and not at other times.

Dipsogenic DI

Dipsogenic DI is caused by a defect in or damage to the thirst mechanism, which is located in the hypothalamus. This defect results in an abnormal increase in thirst and fluid intake that suppresses ADH secretion and increases urine output. Desmopressin or other drugs should not be used to treat dipsogenic DI because they may decrease urine output but not thirst and fluid intake. This fluid overload can lead to water intoxication, a condition that lowers the concentration of sodium in the blood and can seriously damage the brain. Scientists have not yet found an effective treatment for dipsogenic DI.

Gestational DI

Gestational DI occurs only during pregnancy and results when an enzyme made by the placenta destroys ADH in the mother. The placenta is the system of blood vessels and other tissue that develops with the fetus. The placenta allows exchange of nutrients and waste products between mother and fetus.

Most cases of gestational DI can be treated with desmopressin. In rare cases, however, an abnormality in the thirst mechanism causes gestational DI, and desmopressin should not be used.

Kidney Disease of Diabetes

The Burden of Kidney Failure

Each year in the United States, more than 100,000 people are diagnosed with kidney failure, a serious condition in which the kidneys fail to rid the body of wastes.¹ Kidney failure is the final stage of chronic kidney disease (CKD).

Diabetes is the most common cause of kidney failure, accounting for nearly 44 percent of new cases.¹ Even when diabetes is controlled, the disease can lead to CKD and kidney failure. Most people with diabetes do not develop CKD that is severe enough to progress to kidney failure. Nearly 24 million people in the United States have diabetes, ² and nearly 180,000 people are living with kidney failure as a result of diabetes.¹

People with kidney failure undergo either dialysis, an artificial blood-cleaning process, or transplantation to receive a healthy kidney from a donor. Most U.S. citizens who develop kidney failure are eligible for federally funded care. In 2005, care for patients with kidney failure cost the United States nearly $32 billion.¹

Source: United States Renal Data System. USRDS 2007 Annual Data Report.

African Americans, American Indians, and Hispanics/Latinos develop diabetes, CKD, and kidney failure at rates higher than Caucasians. Scientists have not been able to explain these higher rates. Nor can they explain fully the interplay of factors leading to kidney disease of diabetes—factors including heredity, diet, and other medical conditions, such as high blood pressure. They have found that high blood pressure and high levels of blood glucose increase the risk that a person with diabetes will progress to kidney failure.

¹United States Renal Data System. USRDS 2007 Annual Data Report. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, U.S. Department of Health and Human Services; 2007.

²National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics, 2007. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services, 2008.

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The Course of Kidney Disease

Diabetic kidney disease takes many years to develop. In some people, the filtering function of the kidneys is actually higher than normal in the first few years of their diabetes.

Over several years, people who are developing kidney disease will have small amounts of the blood protein albumin begin to leak into their urine. This first stage of CKD is called microalbuminuria. The kidney’s filtration function usually remains normal during this period.

As the disease progresses, more albumin leaks into the urine. This stage may be called macroalbuminuria or proteinuria. As the amount of albumin in the urine increases, the kidneys’ filtering function usually begins to drop. The body retains various wastes as filtration falls. As kidney damage develops, blood pressure often rises as well.

Overall, kidney damage rarely occurs in the first 10 years of diabetes, and usually 15 to 25 years will pass before kidney failure occurs. For people who live with diabetes for more than 25 years without any signs of kidney failure, the risk of ever developing it decreases.

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Diagnosis of CKD

People with diabetes should be screened regularly for kidney disease. The two key markers for kidney disease are eGFR and urine albumin.

• eGFR. eGFR stands for estimated glomerular filtration rate. Each kidney contains about 1 million tiny filters made up of blood vessels. These filters are called glomeruli. Kidney function can be checked by estimating how much blood the glomeruli filter in a minute. The calculation of eGFR is based on the amount of creatinine, a waste product, found in a blood sample. As the level of creatinine goes up, the eGFR goes down.

  Kidney disease is present when eGFR is less than 60 milliliters per minute.

  The American Diabetes Association (ADA) and the National Institutes of Health (NIH) recommend that eGFR be calculated from serum creatinine at least once a year in all people with diabetes.

• Urine albumin. Urine albumin is measured by comparing the amount of albumin to the amount of creatinine in a single urine sample. When the kidneys are healthy, the urine will contain large amounts of creatinine but almost no albumin. Even a small increase in the ratio of albumin to creatinine is a sign of kidney damage.

  Kidney disease is present when urine contains more than 30 milligrams of albumin per gram of creatinine, with or without decreased eGFR.

  The ADA and the NIH recommend annual assessment of urine albumin excretion to assess kidney damage in all people with type 2 diabetes and people who have had type 1 diabetes for 5 years or more.

Kidney Disease of Diabetes

The Burden of Kidney Failure

Each year in the United States, more than 100,000 people are diagnosed with kidney failure, a serious condition in which the kidneys fail to rid the body of wastes.¹ Kidney failure is the final stage of chronic kidney disease (CKD).

Diabetes is the most common cause of kidney failure, accounting for nearly 44 percent of new cases.¹ Even when diabetes is controlled, the disease can lead to CKD and kidney failure. Most people with diabetes do not develop CKD that is severe enough to progress to kidney failure. Nearly 24 million people in the United States have diabetes, ² and nearly 180,000 people are living with kidney failure as a result of diabetes.¹

People with kidney failure undergo either dialysis, an artificial blood-cleaning process, or transplantation to receive a healthy kidney from a donor. Most U.S. citizens who develop kidney failure are eligible for federally funded care. In 2005, care for patients with kidney failure cost the United States nearly $32 billion.¹

Source: United States Renal Data System. USRDS 2007 Annual Data Report.

African Americans, American Indians, and Hispanics/Latinos develop diabetes, CKD, and kidney failure at rates higher than Caucasians. Scientists have not been able to explain these higher rates. Nor can they explain fully the interplay of factors leading to kidney disease of diabetes—factors including heredity, diet, and other medical conditions, such as high blood pressure. They have found that high blood pressure and high levels of blood glucose increase the risk that a person with diabetes will progress to kidney failure.

¹United States Renal Data System. USRDS 2007 Annual Data Report. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, U.S. Department of Health and Human Services; 2007.

²National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics, 2007. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services, 2008.

[Top]

The Course of Kidney Disease

Diabetic kidney disease takes many years to develop. In some people, the filtering function of the kidneys is actually higher than normal in the first few years of their diabetes.

Over several years, people who are developing kidney disease will have small amounts of the blood protein albumin begin to leak into their urine. This first stage of CKD is called microalbuminuria. The kidney’s filtration function usually remains normal during this period.

As the disease progresses, more albumin leaks into the urine. This stage may be called macroalbuminuria or proteinuria. As the amount of albumin in the urine increases, the kidneys’ filtering function usually begins to drop. The body retains various wastes as filtration falls. As kidney damage develops, blood pressure often rises as well.

Overall, kidney damage rarely occurs in the first 10 years of diabetes, and usually 15 to 25 years will pass before kidney failure occurs. For people who live with diabetes for more than 25 years without any signs of kidney failure, the risk of ever developing it decreases.

[Top]

Diagnosis of CKD

People with diabetes should be screened regularly for kidney disease. The two key markers for kidney disease are eGFR and urine albumin.

• eGFR. eGFR stands for estimated glomerular filtration rate. Each kidney contains about 1 million tiny filters made up of blood vessels. These filters are called glomeruli. Kidney function can be checked by estimating how much blood the glomeruli filter in a minute. The calculation of eGFR is based on the amount of creatinine, a waste product, found in a blood sample. As the level of creatinine goes up, the eGFR goes down.

  Kidney disease is present when eGFR is less than 60 milliliters per minute.

  The American Diabetes Association (ADA) and the National Institutes of Health (NIH) recommend that eGFR be calculated from serum creatinine at least once a year in all people with diabetes.

• Urine albumin. Urine albumin is measured by comparing the amount of albumin to the amount of creatinine in a single urine sample. When the kidneys are healthy, the urine will contain large amounts of creatinine but almost no albumin. Even a small increase in the ratio of albumin to creatinine is a sign of kidney damage.

  Kidney disease is present when urine contains more than 30 milligrams of albumin per gram of creatinine, with or without decreased eGFR.

  The ADA and the NIH recommend annual assessment of urine albumin excretion to assess kidney damage in all people with type 2 diabetes and people who have had type 1 diabetes for 5 years or more.

Chronic Kidney Disease: A Family Affair

Chronic kidney disease (CKD) is the permanent loss of kidney function. CKD may be the result of physical injury or a disease that damages the kidneys, such as diabetes or high blood pressure. When the kidneys are damaged, they do not remove wastes and extra water from the blood as well as they should.

CKD is a family affair because you may be at risk if you have a blood relative with kidney failure.

CKD is a silent condition. In the early stages, you will not notice any symptoms. CKD often develops so slowly that many people don't realize they're sick until the disease is advanced and they are rushed to the hospital for life-saving dialysis.

A Growing Problem
CKD is a growing problem in the United States. Between 1990 and 2000, the number of people with kidney failure requiring dialysis or transplantation virtually doubled to 380,000. If this trend continues, the number of people with kidney failure will approach 700,000 by 2010. The annual cost of treating kidney failure in the United States has already topped $20 billion.

Kidney failure is only a part of the picture. Experts estimate that 20 million Americans have significantly reduced kidney function, and even a small loss of kidney function can double a person's risk of developing cardiovascular disease. Many of these people will experience heart attacks or strokes before they become aware of their kidney disease. So identifying and treating CKD early can help prevent heart problems as well as postpone kidney failure.

Between 1990 and 2000, the number of people with kidney failure requiring dialysis or transplantation more than doubled.

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Who is at risk?

Risk factors are conditions that make you more likely to develop a disease. The leading risk factors for CKD are

• diabetes



• high blood pressure



• family history of kidney failure

Having diabetes increases your risk of developing CKD. In fact, diabetes is the leading cause of kidney failure. High blood pressure is the second leading cause.

CKD runs in families, so you may have an increased risk if your mother, father, sister, or brother has kidney failure.

Some racial groups are also at increased risk for CKD.

• African Americans are nearly four times as likely to develop kidney failure as white Americans.



• American Indians have nearly three times the risk compared to whites.



• Hispanic Americans have nearly twice the risk of non-Hispanic whites.

Screening for kidney disease includes simple blood and urine tests.

If you have diabetes or high blood pressure, or a close family member with kidney failure, you should get checked for kidney disease, especially if you're a member of one of the racial or ethnic groups at higher risk for CKD.