Prognostic Significance of Chronic Kidney Disease (CKD-EPI Equation) and Anemia in Patients with Chronic Heart Failure Secondary to Chagas Cardiomyopathy

Background. Few studies regarding chronic kidney disease (CKD) and anemia have been conducted in patients with Chagas cardiomyopathy (CC). We evaluated the risk prediction performance of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and anemia in CC patients. Methods. From 2000 to 2010, a total of 232 patients were studied in a single-center retrospective study. CKD was defined as creatinine clearance <60 mL/min/1.73 m2 according to CKD-EPI equation. Anemia was defined as hemoglobin <12 g/dL (women) and <13 g/dL (men). Cox proportional hazards models were used to establish predictors for death. Results. At baseline, 98 individuals (42.2%) had criteria for CKD and 41 (17.7%) for anemia. During follow-up, 136 patients (58.6%) died. Independently, CKD and anemia were not associated with all-cause mortality. However, when they coexisted, an additional risk was attributed for these patients. Cox proportional hazard models analysis identified systolic blood pressure (hazard ratio, 0.99; 95% confidence interval (CI), 0.98 to 1.00; P=0.015), implantable cardioverter-defibrillator (hazard ratio, 0.48; 95% CI, 0.27 to 0.85; P=0.012), left anterior fascicular block (hazard ratio, 1.52; 95% CI, 1.08 to 2.13; P=0.017), left ventricular end-diastolic diameter (hazard ratio, 1.04; 95% CI, 1.02 to 1.06; P<0.001), and serum sodium (hazard ratio, 0.95; 95% CI, 0.92 to 0.99; P=0.020) as independent predictors for death. Conclusions. CKD and anemia are not independent predictors for long-term mortality in CC patients. However, the prognosis is poorer in individuals with both comorbidities.

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Religious Service Attendance and Mortality among Adults in the United States with Chronic Kidney Disease

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph182413179 ◽

2021 ◽

Vol 18 (24) ◽

pp. 13179

Author(s):

Marino A. Bruce ◽

Roland J. Thorpe ◽

Dulcie Kermah ◽

Jenny Shen ◽

Susanne B. Nicholas ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Proportional Hazards ◽

The United States ◽

Cox Proportional Hazards ◽

Religious Service ◽

Religious Service Attendance ◽

Disease Epidemiology ◽

Cox Proportional Hazards Models ◽

Service Attendance

Religion and related institutions have resources to help individuals cope with chronic conditions, such as chronic kidney disease (CKD). The purpose of this investigation is to examine the association between religious service attendance and mortality for adults with CKD. Data were drawn from NHANES III linked to the 2015 public use Mortality File to analyze a sample of adults (n = 3558) who had CKD as defined by a single value of estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and/or albumin-to-creatinine ratio ≥17 mg/g for males or ≥25 for females. All-cause mortality was the primary outcome and religious service attendance was the primary independent variable. Cox proportional hazards models were estimated to determine the association between religious service attendance and mortality. The mortality risks for participants who attended a service at least once per week were 21% lower than their peers with CKD who did not attend a religious service at all (HR 0.79; CI 0.64–0.98). The association between religious service attendance and mortality in adults with CKD suggest that prospective studies are needed to examine the influence of faith-related behaviors on clinical outcomes in patients with CKD.

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Abstract P098: Slower Gait Speed is Associated with Increased Mortality Risk in Chronic Kidney Disease.

Circulation ◽

10.1161/circ.125.suppl_10.ap098 ◽

2012 ◽

Vol 125 (suppl_10) ◽

Author(s):

Baback Roshanravan ◽

Cassiane Robinson-Cohen ◽

Kushang V Patel ◽

Greg Levin ◽

Ian H de Boer ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Gait Speed ◽

Proportional Hazards ◽

Prognostic Significance ◽

Continuous Variable ◽

Hazard Ratio ◽

Risk Of Death ◽

Social Security Death Index

Objective: Skeletal muscle dysfunction (sarcopenia) is an under-recognized complication of chronic kidney disease (CKD) that may have important clinical consequences. Gait speed is associated with sarcopenia and comorbid disease burden among older adults; however, little is known about the prognostic significance of gait speed in CKD. We determined the association of gait speed with all-cause mortality in a prospective cohort of non-dialysis CKD patients. Methods: We measured usual gait speed over 4-meters in 309 participants from a prospective study of non-dialysis CKD. Included subjects had an estimated glomerular filtration rate (eGFR ckdepi ) <90mL/min/1.73m 2 , were stroke-free and did not require a wheelchair for ambulation. Study coordinators assessed mortality during follow-up by phone contacts, medical record review, and the social security death index. We evaluated gait speed continuously, and using a cut point of 0.8 m/s, consistent with previous studies. We used Cox's proportional hazards to estimate the association of gait speed with mortality after adjustment for age, sex, race, smoking, diabetes, pre-existing CAD, BMI, eGFR and hemoglobin. Results: Median follow-up time was 2.7 years; range 27 days to 4.8 years. The mean age was 58.9 ± 13 years and mean eGFR by cystatin C (eGFR cysc ) was 48.5 ± 23mL/min/1.73m 2 . There were a total of 31 deaths (10.4%) during follow-up. Unadjusted mortality rates were 23 and 80 deaths per 1,000 person-years among participants who had a gait speed of >0.8m/s versus ≤0.8m/s, respectively. After full adjustment, gait speed ≤0.8m/s was associated with a 2.8-fold greater risk of death compared to a gait speed >0.8 m/s. Gait speed was also strongly associated with mortality when analyzed as a continuous variable ( Table ) and a stronger predictor of death than age, history of CAD, or diabetes. No. Deaths (%) Model 1 + Model 2 # Hazard Ratio 95% CI Hazard Ratio 95% CI Gait speed * 32(10) 0.74 (0.64-0.86) 0.75 (0.64-0.87) >0.8m/s 13 (6) Reference Reference ≤0.8m/s 19(19) 3.49 (1.54-7.95) 2.84 (1.25-6.48) * Gait speed analyzed continuously per 10cm/s increase in speed. +Model 1: Adjusted for age, sex, race, study site #Model 2: adds smoking, BMI, eGFR cysc , diabetes, prevalent coronary disease. Conclusion: Gait speed is strongly associated with death in a cohort of middle-aged CKD patients.

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Association of Arterial Stiffness With Kidney Function Among Adults Without Chronic Kidney Disease

American Journal of Hypertension ◽

10.1093/ajh/hpaa097 ◽

2020 ◽

Vol 33 (11) ◽

pp. 1003-1010

Author(s):

Seiji Itano ◽

Yuichiro Yano ◽

Hajime Nagasu ◽

Hirofumi Tomiyama ◽

Hiroshi Kanegae ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Arterial Stiffness ◽

Kidney Function ◽

Proportional Hazards ◽

Multivariable Analysis ◽

Cox Proportional Hazards ◽

Kidney Dysfunction ◽

Cox Proportional Hazards Models ◽

Egfr Decline

Abstract BACKGROUND Our aims were to assess whether arterial stiffness is associated with a higher risk for kidney dysfunction among persons without chronic kidney disease (CKD). METHODS We analyzed data from the national health checkup system in Japan; for our analyses, we selected records of individuals who completed assessments of cardio-ankle vascular index (CAVI) and kidney function from 2005 to 2016. We excluded participants who had CKD at baseline, defined as the presence of proteinuria or estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2. We compared 2 groups of CAVI measurements—the highest quartile (≧8.1) and the combined lower 3 quartiles (<8.1). We used Cox proportional hazards models to assess associations between these 2 groups and subsequent CKD events, proteinuria, eGFR <60 ml/min/1.73 m2, and rapid eGFR decline (greater than or equal to −3 ml/min/1.73 m2 per year). RESULTS The mean age of the 24,297 included participants was 46.2 years, and 60% were female. Over a mean follow-up of 3.1 years, 1,435 CKD events occurred. In a multivariable analysis, the hazard ratios with 95% confidence intervals (CIs) for the highest vs. combined lower quartiles of CAVI measurements were 1.3 (1.1, 1.5) for CKD events, 1.3 (0.96, 1.62) for proteinuria, 1.4 (1.1, 1.7) for eGFR <60 ml/min/1.73 m2, and the odds ratio with 95% CI was 1.3 (1.1, 1.4) for rapid eGFR decline. CONCLUSIONS Persons with CAVI measurements ≧8.1 had a higher risk for CKD events compared with their counterparts with CAVI measurements <8.1. Greater arterial stiffness among adults without CKD may be associated with kidney dysfunction.

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The burden of comorbidity in people with chronic kidney disease stage 3: a cohort study

BMC Nephrology ◽

10.1186/s12882-015-0189-z ◽

2015 ◽

Vol 16 (1) ◽

Cited By ~ 73

Author(s):

Simon D. S. Fraser ◽

Paul J. Roderick ◽

Carl R. May ◽

Natasha McIntyre ◽

Christopher McIntyre ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Proportional Hazards ◽

Chronic Kidney Disease Stage ◽

Prognostic Significance ◽

Cox Proportional Hazards ◽

Disease Stage ◽

Treatment Burden ◽

Painful Condition ◽

Ckd Stage

Abstract Background Multimorbidity is a growing concern for healthcare systems, with many countries experiencing demographic transition to older population profiles. Chronic kidney disease (CKD) is common but often considered in isolation. The extent and prognostic significance of its comorbidities is not well understood. This study aimed to assess the extent and prognostic significance of 11 comorbidities in people with CKD stage 3. Methods A prospective cohort of 1741 people with CKD stage 3 was recruited from primary care between August 2008 and March 2010. Participants underwent medical history, clinical assessment, blood and urine sampling. Comorbidity was defined by self-reported doctor-diagnosed condition, disease-specific medication or blood results (hemoglobin), and treatment burden as number of ongoing medications. Logistic regression was used to identify associations with greater treatment burden (taking >5 medications) and greater multimorbidity (3 or more comorbidities). Kaplan Meier plots and multivariate Cox proportional hazards models were used to investigate associations between multimorbidity and all-cause mortality. Results One thousand seven hundred forty-one people were recruited, mean age 72.9 +/−9 years. Mean baseline eGFR was 52 ml/min/1.73 m2. Only 78/1741 (4 %) had no comorbidities, 453/1741 (26 %) had one, 508/1741 (29 %) had two and 702/1741 (40 %) had >2. Hypertension was common (88 %), 30 % had ‘painful condition’, 24 % anemia, 23 %, ischaemic heart disease, 17 % diabetes and 12 % thyroid disorders. Median medication use was 5 medications (interquartile range 3–8) and increased with degree of comorbidity. Greater treatment burden and multimorbidity were independently associated with age, smoking, increasing body mass index and decreasing eGFR. Treatment burden was also independently associated with lower education status. After median 3.6 years follow-up, 175/1741 (10 %) died. Greater multimorbidity was independently associated with mortality (hazard ratio 2.81 (95 % confidence intervals 1.72–4.58), p < 0.001) for 3 or more comorbidities vs 0 or 1). Conclusions Isolated CKD was rare and multimorbidity the norm in this cohort of people with moderate CKD. Increasing multimorbidity was associated with greater medication burden and poorer survival. CKD management should include consideration of comorbidities.

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Sarcopenia is an independent predictor of hospitalization in chronic kidney disease outpatients

10.1101/516096 ◽

2019 ◽

Author(s):

Hye Yun Jeong ◽

Wooyeol Ahn ◽

Jun Chul Kim ◽

Yu Bum Choi ◽

Jinkwon Kim ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Muscle Strength ◽

Proportional Hazards ◽

Handgrip Strength ◽

Cox Proportional Hazards ◽

Chronic Illnesses ◽

Free Survival ◽

Cox Proportional Hazards Models ◽

Appendicular Skeletal Muscle

AbstractBackgroundPatients with chronic kidney disease (CKD) experience much more marked and earlier muscle wasting than subjects who do not have chronic illnesses. However, a few studies that have examined sarcopenia have been reported in CKD patients. We investigated the prevalence of sarcopenia in predialysis and dialysis outpatients with CKD and explored its relationship with the clinical outcomes.MeasurementsSarcopenia was defined as reduced muscle strength accompanied by decreased adjusted appendicular skeletal muscle (ASM), while those patients who exhibited only one of these characteristics were categorized as presarcopenic patients. ASM was measured by bioimpedence analysis, and muscle strength was evaluated by handgrips. ASM was adjusted by weight (ASM/wt). Patients were prospectively followed for up to 2 years.ResultsOne hundred seventy-nine patients were recruited (114 male and 65 female patients who were classified into 103 predialysis patients and 76 dialysis patients, with 44.7% having diabetes). Their mean age was 60.6 ± 13.5 years old. The prevalence of sarcopenia was 9.5%, while 55.9% of the patients were categorized as presarcopenic. The ASM/wt index showed significant correlations with age, handgrip strength, HOMA-IR and frailty scores. Multivariate Cox proportional hazards models demonstrated that the risk of hospitalization was significantly higher for patients with presarcopenia [hazard ratio (HR), 2.48; 95% confidence interval (CI), 1.180–5.230], and the risk of hospitalization was much higher for patients with sarcopenia than for patients in the nonsarcopenic group (HR, 9.11; 95% CI, 2.295–25.182)ConclusionsSarcopenia and presarcopenia, which were defined using the ASM/wt index and handgrip strength, predicted a poorer, hospitalization-free survival in CKD patients

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Chronic kidney disease and risk of atrial fibrillation and heart failure in general population-based cohorts – the BiomarCaRE project

European Heart Journal ◽

10.1093/eurheartj/ehab724.0449 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

M Rehm ◽

D Rothenbacher ◽

L Iacoviello ◽

S Costanzo ◽

H Tunstall-Pedoe ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

General Population ◽

Proportional Hazards ◽

Population Based ◽

Cox Proportional Hazards ◽

Adverse Outcomes ◽

Cox Proportional Hazards Models

Abstract Background Chronic kidney disease (CKD) has a complicated relationship with the heart, leading to many adverse outcomes. Purpose The aim of the study was to evaluate the relationship between CKD and the incidence of atrial fibrillation (AF) and heart failure (HF) along with mortality as a competing risk in general population cohorts. Methods This study was conducted as part of the BiomarCaRE project using harmonised data from 12 population-based cohorts (n=40,212) from Europe. Cox proportional hazards models were used to determine hazard ratios (HRs) for the incidence of AF and HF in CKD and with competing mortality risk after adjusting for covariates. Results Mean age at baseline was 51.1 (standard deviation 11.9) years, and 49.3% were men. Overall, 3.5% had CKD at baseline. The rate for incident AF was 3.9 per 1000 person-years during follow-up. The HR for AF for those with CKD compared with those without was 1.23 (95% CI 1.00–1.52, p=0.0465) after adjustment for covariates. The rate for incident HF was 3.9 per 1000 person-years and the associated risk in the presence of CKD was HR 1.67 (95% CI 1.39–2.01). In subjects with CKD, N-terminal pro-B-type natriuretic peptide (NT-proBNP) showed an association with AF, while NT-proBNP and C-reactive protein (CRP) showed an association with HF. Conclusion CKD is an independent risk factor for subsequent AF and even more so for HF. In patients with CKD, NT-proBNP was clearly associated with subsequent risk of AF. In addition to this marker, hs-CRP was also associated with risk of subsequent HF. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): 7th framework programme collaborative project, grant agreement no. HEALTH-F2-2011_278913. Atrial Fibrillation and HF in CKD

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Effect of Body Mass Index on the Association Between Alcohol Consumption and the Development of Chronic Kidney Disease

10.21203/rs.3.rs-569097/v1 ◽

2021 ◽

Author(s):

Yusaku Hashimoto ◽

Sawako Kato ◽

Yoshinari Yasuda ◽

Takuji Ishimoto ◽

Hiroaki Kawashiri ◽

...

Keyword(s):

Body Mass Index ◽

Chronic Kidney Disease ◽

Alcohol Consumption ◽

Kidney Disease ◽

Body Mass ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

The Body ◽

Cox Proportional Hazards Models ◽

Increased Risk

Abstract Although previous studies demonstrated that alcohol consumption is associated with low chronic kidney disease (CKD) risk, they did not consider individual body mass and metabolic capacity. We examined whether the body mass index (BMI) affects the association between drinking and CKD. We defined CKD as an estimated glomerular filtration rate decline < 60 mL/min/1.73 m2 and/or dipstick proteinuria (≥ 1+). Participants were 11,175 Japanese individuals aged 40–74 years without baseline CKD who underwent annual health checkups. Daily alcohol consumption was estimated from a questionnaire, and the participants were categorized as "infrequent drinkers," "light drinkers (< 20 g/day)," "moderate drinkers (20–40 g/day)," and "heavy drinkers (≥ 40 g/day)." Over a median 5-year observation period, 936 participants developed CKD. Cox proportional hazards models revealed that light drinkers had a significantly reduced risk of CKD compared with infrequent drinkers (P = 0.01). Stratified by BMI, the low BMI (< 18.5 kg/m2) group had an increased risk of CKD even in light drinkers, while the high BMI (≥ 25.0 kg/m2) group had a decreased risk of CKD regardless of alcohol consumption. Taken together, alcohol consumption did not reduce the CKD risk in all populations; individual tolerance must be considered.

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Effect of zinc deficiency on chronic kidney disease progression and effect modification by hypoalbuminemia

PLoS ONE ◽

10.1371/journal.pone.0251554 ◽

2021 ◽

Vol 16 (5) ◽

pp. e0251554

Author(s):

Atsuyuki Tokuyama ◽

Eiichiro Kanda ◽

Seiji Itano ◽

Megumi Kondo ◽

Yoshihisa Wada ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Zinc Deficiency ◽

Primary Outcome ◽

Proportional Hazards ◽

Serum Zinc ◽

Cox Proportional Hazards ◽

Ckd Progression ◽

Cox Proportional Hazards Models ◽

End Stage

Serum zinc (Zn) levels tend to be low in chronic kidney disease (CKD) patients. This cohort study was conducted to investigate the relationship between zinc deficiency and CKD progression. Patients were classified into two groups based on Zn levels < 60 μg/dl (low-Zn group, n = 160) and ≥ 60 μg/dl (high-Zn group, n = 152). The primary outcome was defined as end-stage kidney disease (ESKD) or death and was examined over a 1-year observation period. Overall, the mean Zn level was 59.6 μg/dl and the median eGFR was 20.3 ml/min/1.73 m2. The incidence of the primary outcome was higher in the low-Zn group (p<0.001). Various Cox proportional hazards models adjusted for baseline characteristics showed higher risks of the primary outcome in the low-Zn group than in the high-Zn group. Competing risks analysis showed that low Zn levels were associated with ESKD but not with death. Moreover, in propensity score-matched analysis, the low-Zn group showed a higher risk of the primary outcome [adjusted hazard ratio 1.81 (95% confidence interval 1.02, 3.24)]. Furthermore, an interaction was observed between Zn and serum albumin levels (interaction p = 0.026). The results of this study indicate that zinc deficiency is a risk factor for CKD progression.

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Sarcopenia is an independent predictor of hospitalization in chronic kidney disease outpatients

10.21203/rs.3.rs-57337/v1 ◽

2020 ◽

Author(s):

Hye Yun Jeong ◽

Taeyoung Yang ◽

Hyeyeon Lee ◽

Wooyeol Ahn ◽

Jun Chul Kim ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Muscle Strength ◽

Proportional Hazards ◽

Handgrip Strength ◽

Cox Proportional Hazards ◽

Chronic Illnesses ◽

Free Survival ◽

Cox Proportional Hazards Models ◽

Appendicular Skeletal Muscle

Abstract Background/AimsPatients with chronic kidney disease (CKD) experience much more marked and earlier muscle wasting than subjects who do not have chronic illnesses. However, a few studies that have examined sarcopenia have been reported in CKD patients. We investigated the prevalence of sarcopenia in predialysis and dialysis outpatients with CKD and explored its relationship with the clinical outcomes.MethodsSarcopenia was defined as reduced muscle strength accompanied by decreased adjusted appendicular skeletal muscle (ASM), while those patients who exhibited only one of these characteristics were categorized as presarcopenic patients. ASM was measured by bioimpedence analysis, and muscle strength was evaluated by handgrips. ASM was adjusted by weight (ASM/wt). Patients were prospectively followed for up to 2 years.ResultsOne hundred seventy-nine patients were recruited (114 male and 65 female patients who were classified into 103 predialysis patients and 76 dialysis patients, with 44.7% having diabetes). Their mean age was 60.6 ± 13.5 years old. The prevalence of sarcopenia was 9.5%, while 55.9% of the patients were categorized as presarcopenic. The ASM/wt index showed significant correlations with age, handgrip strength, HOMA-IR and frailty scores. Multivariate Cox proportional hazards models demonstrated that the risk of hospitalization was significantly higher for patients with presarcopenia [hazard ratio (HR), 2.48; 95% confidence interval (CI), 1.180–5.230], and the risk of hospitalization was much higher for patients with sarcopenia than for patients in the nonsarcopenic group (HR, 9.11; 95% CI, 2.295–25.182)ConclusionsSarcopenia and presarcopenia, which were defined using the ASM/wt index and handgrip strength, predicted a poorer, hospitalization-free survival in CKD patients.

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Abstract P087: Goldberger's Electrocardiographic Criteria For Left Ventricular Dysfunction Associated With Increased Mortality

Circulation ◽

10.1161/circ.143.suppl_1.p087 ◽

2021 ◽

Vol 143 (Suppl_1) ◽

Author(s):

Kang Rui Xiang ◽

Elsayed Z Soliman ◽

Prashant Bhave ◽

Matthew J Singleton

Keyword(s):

Left Ventricular Dysfunction ◽

Cardiovascular Mortality ◽

Ventricular Dysfunction ◽

Proportional Hazards ◽

Prognostic Significance ◽

Left Ventricular ◽

Cox Proportional Hazards ◽

Cox Proportional Hazards Models ◽

Increased Risk ◽

Poor Outcomes

Goldberger’s Electrocardiographic Criteria for Left Ventricular Dysfunction Associated with Increased Mortality Introduction: The ability of the Goldberger electrocardiographic (ECG) triad criteria to detect left ventricular dysfunction (LVD) is well-established. However, the prognostic significance of this triad as a predictor of poor outcomes is not known. Hypothesis: We hypothesized that the Goldberger ECG-LVD triad is associated with increased all-cause mortality and cardiovascular mortality in the general population. Methods: This analysis included 8,426 participants (60.5 ± 13.6 years, 51.5% women, 50% non-Hispanic white) from the Third National Health and Nutrition Examination Survey. The Goldberger ECG-LVD triad was defined as follows: high precordial QRS voltage (SV1 or SV2 + RV5 or RV6 ≥3500 μV); low limb lead QRS voltage (mean QRS amplitude in each of the limb leads ≤ 800 μV); and poor R wave progression (RV4/SV4 <1). Mortality was ascertained using the National Death Index. Results: At baseline, 1,384 (47.3%) of the participants had at least one of the criteria of Goldberger triad (1,193 had only one and 191 participants had 2 or more). During a median follow up of 13.8 years, 3,184 deaths occurred, of which 1,405 were cardiovascular. In multivariable-adjusted Cox proportional hazards models, presence of at least one of the Goldberger triad criteria (vs. none) was associated with increased risk of all-cause (HR 1.17, 95% CI 1.08 – 1.26, p = <0.0001) and cardiovascular mortality (1.19, 1.06 – 1.33, p = 0.003). Conclusion: The Goldberger ECG-LVD triad for left ventricular dysfunction is associated with increased all-cause and cardiovascular mortality and may offer prognostic value, in addition to its diagnostic utility.

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