August 2008: Volume 34, Number 8
American Academy of Pediatrics Updates Guidelines for Lipids in Children
In new guidelines published in the July issue of the journal Pediatrics, the American Academy of Pediatrics issued and updated several recommendations for hypercholesterolemia in children: a healthful diet, including low-fat dairy products, for children older than 2 years and, for obese children younger than 2 years; nutritional counseling and increased exercise for children and adolescents with high LDL-cholesterol; screening with a fasting lipid profile for children with CVD risk factors and/or high-risk or unknown family history; weight management as the primary treatment for obese children or those with high LDL cholesterol or low HDL cholesterol; and for such children 8 years or older and whose LDL is 500 mg/dL or greater, considering pharmacologic therapy, with lower LDL thresholds for children who are at least 10 years old, depending on other risk factors (Pediatrics 2008;122:198–208).
High Homocysteine, Fibrinogen Levels Boost Risk for CKD
Elevated levels of homocysteine and fibrinogen account for 38% of the increased mortality risk associated with chronic kidney disease (CKD), according to a new report in the American Journal of Cardiology (2008;101:1741-46). The investigators enrolled 4,680 consecutive new patients over a 9-year period in the observational cohort study and assessed them for various serum values. They found that CKD, defined by an eGFR of ≤60 mL/min/1.73m2, was associated with a more than doubled incidence of death. During 22 months’ follow-up, there were 278 deaths. Each patient’s eGFR was calculated via the MDRD equation, which comprises serum creatinine, body weight, age, and race. There were 524 patients with an eGFR of ≤60 and 5,156 whose eGFR was >60. The investigators used a formula to account for adjusted and unadjusted hazard ratios for mortality. They also created several models including different clinical parameters. They found that when eGFR was included, the only clinical value that predicted mortality was homocysteine (adjusted HR 1.92) and fibrinogen (adjusted HR 2.99). Patients with the lowest tertile of homocysteine level also had the lowest mortality risk of all patients with CKD.
Diabetes Risk Increases Even Within Healthy Glucose Range
In a large cohort of HMO participants followed over a 3-year period, the risk of incident type 2 diabetes increased by 6% with every increase of 1 mg/dL in plasma glucose even when glucose was below the 110-mg/dL threshold previously established as impairment of fasting glucose, according to findings published in the American Journal of Medicine (2008;121:519–24). Of 46,578 participants, there were 1,854 who developed type 2 diabetes. Mean follow-up was 81 months for all subjects, average participant age was 57.5 years, and 40% were men. When those who developed diabetes were categorized by baseline glucose level, the portion of the total incident-diabetes subgroup was larger with each larger glucose range. Those with glucose < 85 mg/dL made up 9.4% of new cases. Those whose glucose was 65–89 mg/dL were 14.2%. Those in the range of 90–94 mg/dL were 28.1% of new cases, and those with 95–99 mg/dL were nearly half of the new diabetes cases, at 48.3%. Each increase of 1 mg/dL had a hazard ratio for incident diabetes of 1.06 after confounding factors were controlled for. Among the cohort at large, the risk of developing diabetes was 4% among participants with normal blood glucose levels and 11.3% among those with impaired fasting glucose.