RESUMEN
OBJECTIVES: Optimizing care for patients with advanced kidney disease requires close collaboration between primary care physicians (PCPs) and nephrologists. Factors associated with PCP referral to nephrology were assessed in patients with estimated glomerular filtration rates (eGFRs) less than 30 mL/min/1.73 m2. STUDY DESIGN: Electronic health record review at an integrated health care network. METHODS: Factors associated with referral status were identified using Fisher's exact tests, t tests, and multivariable logistic regression. RESULTS: Of 133,913 patients regularly seeing PCPs between October 2017 and September 2019, 1119 had a final eGFR less than 30 mL/min/1.73 m2 and were not on renal replacement therapy. Care was provided by 185 PCPs (61 practices). Analyses were restricted to the 97.1% (n = 1087) of patients who were African American or European American. Of these, 54.6% had not been referred to nephrology. Nonreferred patients had higher numbers of PCP visits (P = .004). In contrast, referred patients were younger, were more often African American, and had PCPs at the academic medical center (all P < .0001). Referred patients had more complex medical histories with higher Charlson Comorbidity Index scores, more hospitalizations, and greater numbers of inpatient days (all P < .0001). Analyses restricted to patients with serum creatinine concentration of at least 2 mg/dL yielded similar results. Age, number of hospitalizations, ancestry, academic physician, diabetic end-organ damage, peripheral vascular disease, and tumor status were independent predictors of nephrology referral. CONCLUSIONS: Impediments to appropriately timed nephrology referrals persist in patients with high likelihoods of progression to end-stage kidney disease. Improved access to nephrology care should be rapidly addressed to meet targets in the 2019 Executive Order on Advancing American Kidney Health.
Asunto(s)
Enfermedades Renales , Nefrología , Médicos de Atención Primaria , Humanos , Riñón , Atención Primaria de Salud , Derivación y ConsultaRESUMEN
Gynecomastia can have a significant emotional and social impact on men. Although numerous drug therapies may cause this condition, we found no documented cases of gynecomastia associated with atorvastatin. We describe the development of breast enlargement and tenderness in a 52-year-old Caucasian man 6 months after his simvastatin therapy had been switched to atorvastatin. His symptoms ultimately interfered with his ability to play golf and participate in other activities. These problems resolved after atorvastatin discontinuation and did not recur despite resumption of simvastatin therapy. The gynecomastia in this patient represented a possible adverse effect of atorvastatin according to the Naranjo adverse drug reaction probability scale. The mechanism may be atorvastatin's theoretical suppression of adrenal or gonadal steroid production through effects on cholesterol synthesis. Based on this and other case reports, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) should be considered as a potential cause when evaluating otherwise unexplainable cases of gynecomastia in patients taking these drugs.