Diagnostic Performance of Blood Pressure Measurement Modalities in Living Kidney Donor Candidates

BACKGROUND AND OBJECTIVES

Precise BP measurement to exclude hypertension is critical in evaluating potential living kidney donors. Ambulatory BP monitoring is considered the gold standard method for diagnosing hypertension, but it is cumbersome to perform. We sought to determine whether lower BP cutoffs using office and automated BP would reduce the rate of missed hypertension in potential living donors.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We measured BP in 578 prospective donors using three modalities: (1) single office BP, (2) office automated BP (average of five consecutive automated readings separated by 1 minute), and (3) ambulatory BP. Daytime ambulatory BP was considered the gold standard for diagnosing hypertension. We assessed both the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) and the American College of Cardiology/American Heart Association (ACC/AHA) definitions of hypertension in the cohort. Empirical thresholds of office BP and automated BP for the detection of ambulatory BP-diagnosed hypertension were derived using Youden index, which maximizes the sum of sensitivity and specificity and gives equal weight to false positive and false negative values.

RESULTS

Hypertension was diagnosed in 90 (16%) prospective donors by JNC-7 criteria and 198 (34%) prospective donors by ACC/AHA criteria. Masked hypertension was found in 3% of the total cohort by JNC-7 using the combination of office or automated BP, and it was seen in 24% by ACC/AHA guidelines. Using Youden index, cutoffs were derived for both office and automated BP using JNC-7 (<123/82 and <120/78 mm Hg) and ACC/AHA (<119/79 and <116/76 mm Hg) definitions. Using these lower cutoffs, the sensitivity for detecting hypertension improved from 79% to 87% for JNC-7 and from 32% to 87% by ACC/AHA definition, with negative predictive values of 95% and 87%, respectively. Missed (masked) hypertension was reduced to 2% and 4% of the entire cohort by JNC-7and ACC/AHA, respectively.

CONCLUSIONS

The prevalence of hypertension was higher in living donor candidates using ACC/AHA compared JNC-7 definitions. Lower BP cutoffs in the clinic improved sensitivity and led to a low overall prevalence of missed hypertension in prospective living kidney donors.

Abstract 147: The Trend of In-hospital Complications During Acute Ischemic Stroke Hospitalization Among US Elderly

Background: Stroke is the fifth leading cause of death in the United States and the leading cause of long-term disability in adult. Many efforts have been devoted to improve the stroke quality of care. We aimed to examine the recent rate and trend of in-hospital complications among U.S. elderly who were hospitalized for acute ischemic stroke from 2009 to 2013.

Methods: We examined the prevalence and trend of in-hospital pneumonia, urinary tract infection (UTI), deep vein thrombosis (DVT) and pulmonary embolization (PE) among Medicare beneficiaries aged 65 years and older who were hospitalized between January 2009 and December 2013 with a primary discharge diagnosis of acute ischemic stroke. The data of patient information were obtained from the Medicare Provider Analysis and Review file. The in-hospital complications were identified using the ICD-9 CM codes that have been previously validated.

Results: A total of 1,070,574 Medicare beneficiaries were hospitalized for ischemic stroke between 2009 and 2013. The in-hospital pneumonia decreased from 17507 (7.7%) in 2009 to 14078 (6.8%) in 2013, an 11.7% decrease. The in-hospital UTI decreased from 34356 (15%) in 2009 to 29134 (14.1%) in 2013, a 6% decrease. The in-hospital DVT increased from 2263 (1.0%) in 2009 to 2605 (1.3%), a 30% increase. The in-hospital PE increased from 754 (0.3%) in 2009 to 800 (0.4%) in 2013, a 33% increase.

Conclusion: Among Medicare beneficiaries who were hospitalized for acute ischemic stroke from 2009 to 2013, the prevalence of in-hospital pneumonia and UTI decreased while DVT and PE dramatically increased. These results call for further interventions to prevent in-hospital thrombotic complications.

Characteristics and Outcomes of Patients With Aortic Stenosis and Chronic Kidney Disease

Background We sought to study longer term survival in patients with aortic stenosis ( AS ) and nondialysis chronic kidney disease ( CKD ). Methods and Results We studied 839 patients (aged 78±9 years and 51% male) with CKD and AS on echocardiogram from 2005 to 2012. Longer term all-cause and cardiovascular mortality was compared with a CKD group without AS , propensity matched for age, sex, race, left ventricular ejection fraction and CKD stage. Cox models were used to evaluate all-cause mortality and competing-risks regression models censored at time of aortic valve replacement to evaluate cardiac mortality in patients with AS and CKD . Overall, 511 (61%), 252 (30%), and 76 (9%) patients had CKD stages 3a, 3b, and 4, respectively; 93% had hypertension, 28% had diabetes mellitus, and 37% had coronary artery disease. In total, 185 (22%) had mild AS, 355 (42%) had moderate AS, and 299 (36%) had severe AS (66 symptomatic). Patients with CKD and AS had higher cardiac and all-cause mortality compared with controls with CKD and no AS ( P<0.001). Among patients with AS and CKD , there were 156 (19%) aortic valve replacements and 454 (54%) deaths (203 cardiac deaths) at 4.0±2.3 years of follow-up. Lower estimated glomerular filtration rate (hazard ratio per 10 mL/min per 1.73 m2: 1.18; 95% CI, 1.08-1.29) was associated with increased risk of all-cause mortality but not cardiac mortality (hazard ratio: 1.12; 95% CI, 0.97-1.30; P=0.13). Of patients undergoing aortic valve replacement, 61% had improvement in estimated glomerular filtration rate within 1 year (median percentage change=+2.8% per month). Conclusions Among patients with nondialysis CKD , AS is associated with significantly higher cardiac and all-cause mortality; lower estimated glomerular filtration rate is associated with increased mortality, and aortic valve replacement was associated with improved survival.

Dramatic secular changes in prognosis for kidney transplant candidates in the United States

Over recent decades, numerous clinical advances and policy changes have affected outcomes for candidates of kidney transplantation in the United States. We examined the national Scientific Registry for Transplant Recipients for adult (18+) solitary kidney transplant candidates placed on the waiting list for primary listing from 2001 to 2015. We evaluated rates of mortality, transplantation, and waitlist removal. Among 340 115 candidates there were significant declines in mortality (52 deaths/1000 patient years in 2001-04 vs 38 deaths/1000 patient years in 2012-15) and transplant rates (304 transplants/1000 patient years in 2001-04 vs 212 transplants/1000 patient years in 2012-15) and increases in waitlist removals (15 removals/1000 patient years in 2001-04 vs 25/1000 patient years in 2012-15) within the first year after listing. At 5 years an estimated 37% of candidates listed in 2012-15 were alive without transplant as compared to 22% in 2001-04. Declines in mortality over time were significantly more pronounced among African Americans, candidates with longer dialysis duration, and those with diabetes (P < .001). Cumulatively, results indicate dramatic changes in prognoses for adult kidney transplant candidates, likely impacted by selection criteria, donor availability, regulatory oversight, and clinical care. These trends are important considerations for prospective policy development and research, clinical and patient decision-making, and evaluating the impact on access to care.

Ureteral Wall Injury with Ureteral Access Sheaths: A Randomized Prospective Trial

Objective: To compare two commercially available ureteral access sheaths in their ability to access the renal collecting system and assess ureteral wall trauma using a prospective, randomized trial. Patients and Methods: Ninety-five patients undergoing ureteroscopy for renal stones were randomized to Cook Flexor™ or Boston Scientific Navigator HD™ 12/14F sheaths. If the initial sheath failed to advance, an alternate sheath was attempted. The primary outcome was the difference in these access sheaths to obtain access to the upper collecting system and the postoperative ureteral injury using standardized five-point classification system. Results: The overall success rate for sheath placement was 87.4% and did not differ for sheath groups. The Navigator HD was successful in 43% of the Flexor failures and was subjectively rated as easier to place (p = 0.018). Male gender, large stone burden, longer time of sheath insertion, and a more difficult subjective rating for sheath placement were associated with high-grade (grade 2 or 3) ureteral injury. Limitations include a small sample size and absence of long-term follow-up. Conclusion: Sheaths had equal success of placement and there was no significant difference in ureteral wall injury between the two sheaths. Subjectively difficult sheath placement and longer time of placement were associated with high-grade injury, suggesting that surgeons should carry a low threshold for switching to a smaller sheath when resistance is felt or if placement time is long. Clinical Trial number: Nct03349099.

What are the Risk Factors for One-Year Mortality in Older Patients with Chronic Kidney Disease? An Analysis of the Cleveland Clinic CKD Registry

BACKGROUND

Prognostic factors after dialysis initiation among older chronic kidney disease (CKD) patients are not well studied. In this study, we examined the risk factors associated with 1-year mortality after dialysis initiation among older CKD patients.

METHODS

In this retrospective study, we included 621 CKD patients from an electronic medical record based CKD registry that was linked to the United States Renal Data System data. In terms of age, they were all ≥65. We examined the associations of various demographic factors, comorbid conditions, relevant laboratory parameters, the presence of arteriovenous fistula, and inability to take care of oneself with 1-year mortality after dialysis initiation using Cox proportional hazards model.

RESULTS

In our study cohort, 224 older patients died during the first year of dialysis initiation and the estimated survival at 1 year was 65% (95% CI 62-69). After adjusting for covariates, increasing age by each year (Hazard ratio 1.04 [95% CI 1.02-1.06]), congestive heart failure (CHF; 1.57 [1.13-2.18]), an absence of AVF (3.0 [1.7-5.1]) and lack of nephrology care prior to dialysis initiation (1.93 [1.39-2.70]) were associated with increased risk of 1-year mortality. Nearly 60% of deaths were due to non-cardiovascular (CV) causes including cancer.

CONCLUSION

Risk factors portending high 1-year mortality in older CKD patients are increasing age, CHF, an absence of AVF, and lack of pre-dialysis nephrology care. Clinicians need to be aware of non-CV risks of high mortality in these patients.

Fructose increases risk for kidney stones: potential role in metabolic syndrome and heat stress

Background

Fructose intake, mainly as table sugar or high fructose corn syrup, has increased in recent decades and is associated with increased risk for kidney stones. We hypothesized that fructose intake alters serum and urinary components involved in stone formation.

Methods

We analyzed a previously published randomized controlled study that included 33 healthy male adults (40–65 years of age) who ingested 200 g of fructose (supplied in a 2-L volume of 10% fructose in water) daily for 2 weeks. Participants were evaluated at the Unit of Nephrology of the Mateo Orfila Hospital in Menorca. Changes in serum levels of magnesium, calcium, uric acid, phosphorus, vitamin D, and intact PTH levels were evaluated. Urine magnesium, calcium, uric acid, phosphorus, citrate, oxalate, sodium, potassium, as well as urinary pH, were measured.

Results

Ingestion of fructose was associated with an increased serum level of uric acid (p < 0.001), a decrease in serum ionized calcium (p = 0.003) with a mild increase in PTH (p < 0.05) and a drop in urinary pH (p = 0.02), an increase in urine oxalate (p = 0.016) and decrease in urinary magnesium (p = 0.003).

Conclusions

Fructose appears to increase urinary stone formation in part via effects on urate metabolism and urinary pH, and also via effects on oxalate. Fructose may be a contributing factor for the development of kidney stones in subjects with metabolic syndrome and those suffering from heat stress.

Trial registration

ClinicalTrials.gov NCT00639756 March 20, 2008.

Patients prioritize waitlist over posttransplant outcomes when evaluating kidney transplant centers

Factors that patients value when choosing a transplant center have not been well studied. In order to guide the improvement of patient-facing materials, we conducted an anonymous electronic survey of patients that assessed the relative importance of patient experience, practical considerations, transplant center reputation, center experience, and waitlist when selecting a transplant center. A total of 409 respondents completed the survey, of whom 68% were kidney transplant recipients and 32% had chronic kidney disease or were on dialysis. Participants had mean age 56 ± 12 years and were predominantly female (61%), white (79%), and had an associate's degree or higher (68%). Participants most often prioritized waitlist when evaluating transplant centers (transplanted 26%, chronic kidney disease 40%), and waitlist was almost twice as likely as outcomes to be ranked most important (30% vs 17%). Education level and transplant status were significantly associated with factors used for center prioritization. Waitlisted respondents most commonly (48%) relied on physicians for information when selecting a center, while a minority cited transplant-specific organizations. In order to improve shared decision-making, materials outlining center-specific waitlist features should be prioritized. Novel patient-oriented metrics for measuring transplant center quality that align with patient priorities must be explored.

Intra-Arterial versus Intravenous Contrast and Renal Injury in Chronic Kidney Disease: A Propensity-Matched Analysis

BACKGROUND/AIMS

contrast-induced nephropathy (CIN) is well described following an administration of intraarterial contrast, but its occurrence after intravenous (IV) contrast is being questioned. We evaluated the incidence of acute kidney injury (AKI), post-contrast AKI (PC-AKI), CIN, dialysis and mortality in patients with chronic kidney disease (CKD) undergoing non-contrast computed tomography (NCCT) or contrast CT (CCT) or coronary angiography (CoA).

METHODS

We identified individuals who had CoA or CCT or NCCT between 2010 and 2015 in the Cleveland Clinic CKD registry. We used propensity scores to match patients in the 3 groups. We evaluated the proportion of patients that developed AKI and CIN across the groups with chi-square tests. We generated Kaplan-Meier plots comparing mortality and ESRD among patients who developed AKI (in the NCCT group), PC (multifactorial AKI, CIN) AKI and no AKI.

RESULTS

Out of 251 eligible patients, 200 who had CoA were matched to each of the other CT scan groups. The incidence of AKI was 27% in CoA, 24% in CCT and 24% in NCCT (p = 0.72). The incidence of CIN AKI was 16.5% in CoA and 12.5% in CCT (p = 0.26). The Kaplan-Meier survival at 2 years was 74.8 (95% CI 63.8-87.7) for those with CIN and 53.2 (95% CI 39.7-71.4) for those with multifactorial AKI and 56.5 (95% CI 43.4-73.6) for those with AKI-NCCT and 71.4 (95% CI 67.2-76.0) for those without AKI. The Kaplan-Meier ESRD-free estimates at 2 years were 89.9 (95% CI 80.8-100) for those with CIN and 89.4 (95% CI 78.7-100) for those with multifactorial AKI and 77.4 (95% CI 63.6-94.3) for those with AKI-NCCT and 94.4 (95% CI 91.9-97.1) for those without AKI.

CONCLUSION

The administration of both IV and intra-arterial contrast is associated with a risk of AKI. Multifactorial AKI was associated with worse outcomes, while CIN was associated with better outcomes.

Significantly Lower Rates of Kidney Transplantation among Candidates Listed with the Veterans Administration: A National and Local Comparison

BACKGROUND

The process for evaluating kidney transplant candidates and applicable centers is distinct for patients with Veterans Administration (VA) coverage. We compared transplant rates between candidates on the kidney waiting list with VA coverage and those with other primary insurance.

METHODS

Using the Scientific Registry of Transplant Recipients database, we obtained data for all adult patients in the United States listed for a primary solitary kidney transplant between January 2004 and August 2016. Of 302,457 patients analyzed, 3663 had VA primary insurance coverage.

RESULTS

VA patients had a much greater median distance to their transplant center than those with other insurance had (282 versus 22 miles). In an adjusted Cox model, compared with private pay and Medicare patients, VA patients had a hazard ratio (95% confidence interval) for time to transplant of 0.72 (0.68 to 0.76) and 0.85 (0.81 to 0.90), respectively, and lower rates for living and deceased donor transplants. In a model comparing VA transplant rates with rates from four local non-VA competing centers in the same donor service areas, lower transplant rates for VA patients than for privately insured patients persisted (hazard ratio, 0.72; 95% confidence interval, 0.65 to 0.79) despite similar adjusted mortality rates. Transplant rates for VA patients were similar to those of Medicare patients locally, although Medicare patients were more likely to die or be delisted after waitlist placement.

CONCLUSIONS

After successful listing, VA kidney transplant candidates appear to have persistent barriers to transplant. Further contemporary analyses are needed to account for variables that contribute to such differential transplant rates.

Cause-Specific Mortality in Patients with Chronic Kidney Disease and Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is associated with death in patients with chronic kidney disease (CKD). We examined the associations between AF and cause-specific mortality in a large CKD population.

METHODS

We included 62,459 patients with estimated glomerular filtration rate 15-59 mL/min/1.73 m2 (6,639 patients with AF and 55,820 without AF) followed in a large health care system. Outcomes included overall and cause-specific deaths (a) cardiovascular; (b) malignancy; and (c) non-cardiovascular/non-malignancy causes. Cox regression models for overall mortality and separate competing risk models for each major cause of death category were used to evaluate their respective associations with AF.

RESULTS

During a median follow-up of 4.1 years, 19,094 patients died; cause of death was known for 18,854 patients. After multivariable adjustment (demographics, comorbidities, relevant laboratory data, medication use, and kidney function), AF was associated with 23% (95% CI 18-29%) higher risk of all-cause mortality, 45% (95% CI 31-61%) higher risk of cardiovascular mortality and 13% (95% CI 3-22%) lower risk of malignancy-related mortality. Exclusion of patients with malignancy yielded similar results except for a lack of association between AF and malignancy-related deaths. Results were consistent across various stages of CKD.

CONCLUSIONS

In a non-dialysis-dependent CKD population, the presence of AF was associated with higher all-cause and cardiovascular mortality. These data suggest that patients with both CKD and AF are at high cardiovascular risk, and thus clinical practice (or trials) should aim at reducing the overall excess cardiovascular mortality (not stroke alone) in patients with AF and CKD.

The Association Between Lung Recipient Travel Distance and Posttransplant Survival

Introduction:

Recipient travel distance may be an unrecognized burden in lung transplantation.

Design:

Retrospective single-center cohort study of all adult (≥18 years) first-time lung-only transplants from January 1, 2010, until February 28, 2017. Recipient distance to transplant center was calculated using the linear distance from the recipient’s home zip code to the Cleveland Clinic in Cleveland, Ohio.

Results:

569 recipients met inclusion criteria. Posttransplant graft survival was 85%, 88%, 91%, and 91% at 1 year and 49%, 52%, 57%, and 56% at 5 years posttransplant for recipient travel distances of ≤50, >50 to ≤250, >250 to ≤500, and >500 miles, respectively ( P = .10).

Discussion:

We found no significant relationship between recipient travel distance and posttransplant graft survival. In carefully selected recipients, travel distance is not a significant barrier to successful posttransplant outcomes which may be important for patient decision-making and donor allocation policy. These data should be validated in a national cohort.

Mood, body image, fear of kidney failure, life satisfaction, and decisional stability following living kidney donation: Findings from the KDOC study

Prior studies demonstrate that most living kidney donors (LKDs) report no adverse psychosocial outcomes; however, changes in psychosocial functioning at the individual donor level have not been routinely captured. We studied psychosocial outcomes predonation and at 1, 6, 12, and 24 months postdonation in 193 LKDs and 20 healthy controls (HCs). There was minimal to no mood disturbance, body image concerns, fear of kidney failure, or life dissatisfaction, indicating no incremental changes in these outcomes over time and no significant differences between LKDs and HCs. The incidence of any new-onset adverse outcomes postdonation was as follows: mood disturbance (16%), fear of kidney failure (21%), body image concerns (13%), and life dissatisfaction (10%). Multivariable analyses demonstrated that LKDs with more mood disturbance symptoms, higher anxiety about future kidney health, low body image, and low life satisfaction prior to surgery were at highest risk of these same outcomes postdonation. It is important to note that some LKDs showed improvement in psychosocial functioning from pre- to postdonation. Findings support the balanced presentation of psychosocial risks to potential donors as well as the development of a donor registry to capture psychosocial outcomes beyond the mandatory 2-year follow-up period in the United States.

Expanding clarity or confusion? Volatility of the 5-tier ratings assessing quality of transplant centers in the United States

Outcomes of patients receiving solid organ transplants in the United States are systematically aggregated into bi-annual Program-Specific Reports (PSRs) detailing risk-adjusted survival by transplant center. Recently, the Scientific Registry of Transplant Recipients (SRTR) issued 5-tier ratings evaluating centers based on risk-adjusted 1-year graft survival. Our primary aim was to examine the reliability of 5-tier ratings over time. Using 10 consecutive PSRs for adult kidney transplant centers from June 2012 to December 2016 (n = 208), we applied 5-tier ratings to center outcomes and evaluated ratings over time. From the baseline period (June 2012), 47% of centers had at least a 1-unit tier change within 6 months, 66% by 1 year, and 94% by 3 years. Similarly, 46% of centers had at least a 2-unit tier change by 3 years. In comparison, 15% of centers had a change in the traditional 3-tier rating at 3 years. The 5-tier ratings at 4 years had minimal association with baseline rating (Kappa 0.07, 95% confidence interval [CI] -0.002 to 0.158). Centers had a median of 3 different 5-tier ratings over the period (q1 = 2, q3 = 4). Findings were consistent for center volume, transplant rate, and baseline 5-tier rating. Cumulatively, results suggest that 5-tier ratings are highly volatile, limiting their utility for informing potential stakeholders, particularly transplant candidates given expected waiting times between wait listing and transplantation.

High-density lipoprotein cholesterol and causes of death in chronic kidney disease

BACKGROUND

Recent data suggest a U-shaped association between high-density lipoprotein cholesterol (HDL-c) and death in chronic kidney disease (CKD). However, whether the increased mortality in patients with extreme levels is explained by specific causes of death remains unclear.

OBJECTIVES

We studied the associations between HDL-c and cause-specific deaths in CKD.

METHODS

We included 38,377 patients with estimated glomerular filtration rate 15-59 mL/min/1.73 m². We classified deaths into 3 major categories: (1) cardiovascular; (2) malignant; and (3) noncardiovascular/nonmalignant causes. We fitted Cox regression models for overall mortality and separate competing risk models for each major cause of death category to evaluate their respective associations with categories of HDL-c (≤30, 31-40, 41-50 [referent], 51-60, >60 mg/dL). Separate analyses were conducted for men and women.

RESULTS

During a median follow-up of 4.5 years, 9665 patients died. After adjusting for relevant covariates, in both sexes, HDL-c 31 to 40 mg/dL and ≤30 mg/dL were associated with higher risk of all-cause mortality, cardiovascular mortality, malignancy-related deaths, and noncardiovascular/nonmalignancy-related deaths. HDL-c >60 mg/dL was associated with lower all-cause (hazard ratio: 0.75, 95% confidence interval: 0.69, 0.81), cardiovascular, malignancy-related, and noncardiovascular/nonmalignancy-related deaths among women but not in men. Similar results were noted when HDL-c was examined as a continuous measure.

CONCLUSIONS

In a non-dialysis-dependent CKD population, HDL-c ≤40 mg/dL was associated with risk of higher all-cause, cardiovascular, malignant, and noncardiovascular/nonmalignant mortality in men and women. HDL >60 mg/dL was associated with lower risk of all-cause, cardiovascular, malignant, and noncardiovascular/nonmalignant mortality in women but not in men.

Associations of dysnatremias with mortality in chronic kidney disease

Background

Hyponatremia and hypernatremia are associated with death in the general population and those with chronic kidney disease (CKD). We studied the associations between dysnatremias, all-cause mortality and causes of death in a large cohort of Stage 3 and 4 CKD patients.

Methods

We included 45 333 patients with Stage 3 and 4 CKDs followed in a large healthcare system. Associations between hyponatremia (<136 mmol/L) and hypernatremia (>145), and all-cause mortality and causes of death (cardiovascular, malignancy related and non-cardiovascular/non-malignancy related) were studied using Cox proportional hazards and competing risk models.

Results

Dysnatremias were found in 9.2% of the study population. In separate multivariable Cox proportional hazards models using baseline serum sodium levels and time-dependent repeated measures, both hyponatremia and hypernatremia were associated with all-cause mortality. In the competing risk analyses, hyponatremia was significantly associated with increased risk for various cause-specific mortality categories [cardiovascular (hazard ratio, HR 1.16, 95% confidence interval, CI: 1.04, 1.30), malignancy related (HR 1.48, 95% CI: 1.33, 1.65) and non-cardiovascular/non-malignancy deaths (HR 1.25, 95% CI: 1.13, 1.39)], while hypernatremia was significantly associated with higher non-cardiovascular/non-malignancy mortality only (HR 1.36, 95% CI: 1.08, 1.72).

Conclusions

In those with CKD, hyponatremia was associated with all-cause mortality, cardiovascular, malignancy and non-cardiovascular/non-malignancy-related deaths. Hypernatremia was associated with all-cause and non-cardiovascular/non-malignancy-related deaths. Further studies are needed to elucidate the mechanisms of differences in cause-specific death among CKD patients with hyponatremia and hypernatremia.

Residential Area Life Expectancy: Association With Outcomes and Processes of Care for Patients With ESRD in the United States

BACKGROUND

The effects of underlying noncodified risks are unclear on the prognosis of patients with end-stage renal disease (ESRD). We aimed to evaluate the association of residential area life expectancy with outcomes and processes of care for patients with ESRD in the United States.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Adult patients with incident ESRD between 2006 and 2013 recorded in the US Renal Data System (n=606,046).

PREDICTOR

The primary exposure was life expectancy in the patient's residential county estimated by the Institute for Health Metrics and Evaluation.

OUTCOMES

Death, placement on the kidney transplant wait list, living and deceased donor kidney transplantation, and posttransplantation graft loss.

RESULTS

Median life expectancies of patients' residences were 75.6 (males) and 80.4 years (females). Compared to the highest life expectancy quintile and adjusted for demographic factors, disease cause, and multiple comorbid conditions, the lowest quintile had adjusted HRs for mortality of 1.20 (95% CI, 1.18-1.22); placement onto the waiting list, 0.68 (95% CI, 0.67-0.70); living donor transplantation, 0.53 (95% CI, 0.51-0.56); posttransplantation graft loss, 1.35 (95% CI, 1.27-1.43); and posttransplantation mortality, 1.29 (95% CI, 1.19-1.39). Patients living in areas with lower life expectancy were less likely to be informed about transplantation, be under the care of a nephrologist, or receive an arteriovenous fistula as the initial dialysis access. Results remained consistent with additional adjustment for zip code-level median income, population size, and urban-rural locality.

LIMITATIONS

Potential residual confounding and attribution of effects to individuals based on residential area-level data.

CONCLUSIONS

Residential area life expectancy, a proxy for socioeconomic, environmental, genetic, and behavioral factors, was independently associated with mortality and process-of-care measures for patients with ESRD. These results emphasize the underlying effect on health outcomes of the environment in which patients live, independent of patient-level factors. These findings may have implications for provider assessments.

The Living Donor Lost Wages Trial: Study Rationale and Protocol

PURPOSE OF REVIEW

This paper describes the background, rationale, and design of an NIH-funded, single-center study to test the impact of offering reimbursement for donor lost wages incurred during the post-nephrectomy recovery period on the live donor kidney transplant (LDKT) rate in newly evaluated kidney transplant candidates, to examine whether offering reimbursement for donor lost wages reduces racial disparity in LDKT rates, and to determine whether higher reimbursement amounts lead to higher LDKT rates.

RECENT FINDINGS

LDKT is the optimal treatment for renal failure. However, living kidney donation has declined in the past decade, particularly among men, younger adults, blacks, and low-income adults. There is evidence that donation-related costs may deter both transplant candidates and potential donors from considering LDKT. Lost wages is a major source of financial loss for some living donors and, unlike travel and lodging expenses, is not reimbursed by financial assistance programs.

SUMMARY

The study addresses the transplant community's call to reduce the financial burden of living donation and examine its impact on LDKT rates. Findings have the potential to influence policy, clinical practice, LDKT access, and income-related and racial disparities in LDKT and living donation.

Abstract 3: Increasing Use of Intravenous Thrombolytic Therapy was Associated With Decline in Ischemic Stroke Mortality in Medicare Beneficiaries

Background: Mortality due to stroke has declined over the past 2 decades. Intravenous thrombolytic therapy improves the functional outcome, but its contribution in reducing stroke mortality is not clear. We aim to examine the trend of ischemic stroke case fatality in recent years in relation to the utilization of thrombolytic therapy.

Methods: We examined the trend of risk-adjusted one-year mortality and intravenous thrombolytic therapy in Medicare beneficiaries aged ≥65 years who were hospitalized between January 1, 2009 and December 31, 2013 with a primary discharge diagnosis of acute ischemic stroke. The data of the patient information were obtained from the Medicare Provider Analysis and Review file. Cox proportional hazards models were generated to adjust for patient demographics and comorbidities. All statistical analyses were performed using SAS Version 9.4 software.

Results: This study included 1,165,960 Medicare Beneficiaries. The one-year risk-adjusted mortality showed a steady declined from 29.7% in 2009 to 24.4% in 2013, 17.8% decline over the five year period. This was parallel to the 59.7% increase of intravenous thrombolytic therapy utilization, from 5.21% in 2009 to 8.32% in 2013. The mortality decline was only observed in patients who received intravenous thrombolytic therapy (HR 0.86; 95% CI 0.82-0.91), but not in those who did not receive thrombolytic therapy (HR 0.99; 95% CI 0.97-1.01) (Table).

Conclusion: The increasing use of intravenous thrombolytic therapy was associated with decline in risk-adjusted one-year mortality after ischemic stroke. The reasons for the mortality decline among those who received thrombolytic therapy needs further explanation.

Community Risk Score for Evaluating Health Care Disparities in Hematopoietic Cell Transplantation

There is a critical need for tools to comprehensively describe disparities in hematopoietic cell transplant (HCT) recipients. We conducted a retrospective cohort study to evaluate a Community Risk Score (CRS) tool for this purpose. CRS included 10 community health indicators based on county or state of residence obtained from several secondary data sources and a composite score was assigned to each county (range 0 to 40), that was further categorized into six tiers (I to VI) with higher tiers indicating poor community health. CRS was assessed for 509 allogeneic and 1033 autologous HCT recipients from 2003 to 2013. Our cohort represented allogeneic and autologous HCT recipients from 300 and 431 unique ZIP codes from 99 and 125 counties in 15 and 16 states, although 86% and 90% patients were from Ohio, respectively. A greater proportion of patients had adverse individual community risk indicators in higher-risk tiers (P < .001 for trend for all). In multivariable analysis, clear trends toward association of CRS with outcomes were not observed. For autologous HCTs, Tier III has higher risks of relapse mortality (hazard ratio [HR] 2.2, P = .02) and all-cause mortality (HR 1.8, P = 0.03). In conclusion, CRS was able to categorize patients into groups representing greater levels of health care disparities. We did not see a clear association between CRS and transplant outcomes, although our cohort was limited to a relatively small group of counties. Community-based risk score model may serve as a tool for evaluating disparities in HCT recipients, but its validation in a nationally representative cohort of patients is needed.

Preanalytic Factors Associated With Hemolysis in Emergency Department Blood Samples

Context.—

Hemolysis of emergency department blood samples is a common occurrence and has a negative impact on health care delivery.

Objectives.—

To determine the effect of preanalytic factors (straight stick, intravenous [IV] line, needle gauge, location of blood draw, syringe versus vacuum tube use, tourniquet time) on hemolysis in emergency department blood samples.

Design.—

A single 65 000-visit emergency department's electronic health record was queried for emergency department potassium results and blood draw technique for all samples obtained in calendar year 2014, resulting in 54 531 potassium results. Hemolyzed potassium was measured by hemolysis index. Comparisons of hemolysis by sampling technique were conducted by χ2 tests.

Results.—

Overall hemolysis was 10.0% (5439 of 54 531). Hemolysis among samples obtained from straight stick was significantly less than among those obtained with IV line (5.4% [33 of 615] versus 10.2% [4821 of 47 266], P &lt; .001). For IV-placed blood draws, antecubital location had a statistically significant lower overall hemolysis compared with other locations: 7.4% (2117 of 28 786) versus 14.6% (2622 of 17 960) (P &lt; .001). For blood drawn with a syringe compared with vacuum, hemolysis was 13.0% (92 of 705) and 11.0% (1820 of 16 590), respectively (P = .09, not significant). For large-gauge IV blood draws versus smaller-gauge IV lines, a lower hemolysis was also observed (9.3% [3882 of 41 571] versus 16.7% [939 of 5633]) (P &lt; .001). For IV-drawn blood with tourniquet time less than 60 seconds, hemolysis was 10.3% (1362 of 13 162) versus 13.9% for more than 60 seconds (532 of 3832), P &lt; .001.

Conclusions.—

This study confirmed previous findings that straight stick and antecubital location are significantly associated with reduced hemolysis and indicated that shorter tourniquet time and larger gauge for IV draws were significantly associated with lower hemolysis.