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Wu J, Li X, Zhang H, Lin L, Li M, Chen G, Wang C. Development and validation of a prediction model for all-cause mortality in maintenance dialysis patients: a multicenter retrospective cohort study. Ren Fail 2024; 46:2322039. [PMID: 38415296 PMCID: PMC10903750 DOI: 10.1080/0886022x.2024.2322039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/17/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The mortality risk varies considerably among individual dialysis patients. This study aimed to develop a user-friendly predictive model for predicting all-cause mortality among dialysis patients. METHODS Retrospective data regarding dialysis patients were obtained from two hospitals. Patients in training cohort (N = 1421) were recruited from the Fifth Affiliated Hospital of Sun Yat-sen University, and patients in external validation cohort (N = 429) were recruited from the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine. The follow-up endpoint event was all-cause death. Variables were selected by LASSO-Cox regression, and the model was constructed by Cox regression, which was presented in the form of nomogram and web-based tool. The discrimination and accuracy of the prediction model were assessed using C-indexes and calibration curves, while the clinical value was assessed by decision curve analysis (DCA). RESULTS The best predictors of 1-, 3-, and 5-year all-cause mortality contained nine independent factors, including age, body mass index (BMI), diabetes mellitus (DM), cardiovascular disease (CVD), cancer, urine volume, hemoglobin (HGB), albumin (ALB), and pleural effusion (PE). The 1-, 3-, and 5-year C-indexes in the training set (0.840, 0.866, and 0.846, respectively) and validation set (0.746, 0.783, and 0.741, respectively) were consistent with comparable performance. According to the calibration curve, the nomogram predicted survival accurately matched the actual survival rate. The DCA showed the nomogram got more clinical net benefit in both the training and validation sets. CONCLUSIONS The effective and convenient nomogram may help clinicians quantify the risk of mortality in maintenance dialysis patients.
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Affiliation(s)
- Jingcan Wu
- Department of Nephrology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
- Guangdong Provincial Key Laboratory of Biomedical Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Xuehong Li
- Department of Nephrology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
- Guangdong Provincial Key Laboratory of Biomedical Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Hong Zhang
- Department of Nephrology, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Lin Lin
- Department of Nephrology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
- Guangdong Provincial Key Laboratory of Biomedical Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Man Li
- Guangdong Provincial Key Laboratory of Biomedical Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Gangyi Chen
- Department of Nephrology, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Cheng Wang
- Department of Nephrology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
- Guangdong Provincial Key Laboratory of Biomedical Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
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Wasik H, Chadha V, Galbiati S, Warady B, Atkinson M. Dialysis Outcomes for Children With Lupus Nephritis Compared to Children With Other Forms of Nephritis: A Retrospective Cohort Study. Am J Kidney Dis 2021; 79:626-634. [PMID: 34461164 DOI: 10.1053/j.ajkd.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/16/2021] [Indexed: 01/12/2023]
Abstract
RATIONALE & OBJECTIVE Children with lupus nephritis (LN) are at high risk of developing kidney failure requiring initiation of kidney replacement therapy. This study compared outcomes among children with LN on dialysis with children with non-lupus glomerular disease and investigated risk factors for adverse outcomes among children with LN on dialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Children and adolescents aged 6-20 years with LN (n = 231) and non-lupus glomerular disease (n = 1,726) who initiated maintenance dialysis 1991-2018 and were enrolled in the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry. EXPOSURE Lupus nephritis. OUTCOME Hospitalization, mortality, and time to transplant. ANALYTICAL APPROACH Contingency tables were used to compare hospitalizations, and multivariable cause-specific hazards models were used to compare rates of death and transplantation in children with LN compared with those with non-lupus glomerular disease. Using data from children with LN, multivariable logistic regression models were fit to evaluate the risk factors for hospitalization, and multivariable Cox regression models were fit to evaluate factors associated with kidney transplantation. RESULTS Children with LN were more likely to be hospitalized in the first year after dialysis initiation (63.3% vs 48.6%, P < 0.001) and were less likely to receive a kidney transplant in the first 3 years after dialysis initiation (year 0-1: adjusted hazard ratio [AHR], 0.36 [95% CI, 0.23-0.57], P < 0.001; year 1-3: AHR, 0.73 [95% CI, 0.54-0.98], P = 0.04). Anemia was associated with hospitalization after dialysis initiation (adjusted OR, 4.44 [95% CI, 1.44-13.66], P = 0.01). Non-White race was associated with a lower rate of kidney transplantation (AHR, 0.47 [95% CI, 0.27-0.82], P = 0.01). LN was not associated with death while on dialysis (AHR, 1.21 [95% CI, 0.47-3.11], P = 0.7). LIMITATIONS The NAPRTCS registry does not collect information on lupus disease activity or medication doses and has limited data on medication use. CONCLUSIONS Children and adolescents with LN on dialysis are at higher risk for adverse outcomes including hospitalization and lower rates of kidney transplantation compared with children with non-lupus glomerular disease receiving maintenance dialysis.
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Affiliation(s)
- Heather Wasik
- Division of Pediatric Nephrology, SUNY Upstate Medical University, Syracuse, New York.
| | - Vimal Chadha
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | | | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Meredith Atkinson
- Division of Pediatric Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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The Impact of CKD Anaemia on Patients: Incidence, Risk Factors, and Clinical Outcomes-A Systematic Literature Review. Int J Nephrol 2020; 2020:7692376. [PMID: 32665863 PMCID: PMC7349626 DOI: 10.1155/2020/7692376] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/25/2020] [Indexed: 12/15/2022] Open
Abstract
Anaemia is a common consequence of chronic kidney disease (CKD); however, the risk factors for its development and its impact on outcomes have not been well synthesised. Therefore, we undertook a systematic review to fully characterise the risk factors associated with the presence of anaemia in patients with CKD and a contemporary synthesis of the risks of adverse outcomes in patients with CKD and anaemia. We searched MEDLINE, EMBASE, and the Cochrane Library from 2002 until 2018 for studies reporting the incidence or prevalence of anaemia and associated risk factors and/or associations between haemoglobin (Hb) or anaemia and mortality, major adverse cardiac events (MACE), hospitalisation, or CKD progression in adult patients with CKD. Extracted data were summarised as risk factors related to the incidence or prevalence of anaemia or the risk (hazard ratio (HR)) of outcome by Hb level (<10, 10-12, >12 g/dL) in patients not on dialysis and in those receiving dialysis. 191 studies met the predefined inclusion criteria. The risk factor most associated with the prevalence of anaemia was CKD stage, followed by age and sex. Mean HRs (95% CI) for all-cause mortality in patients with CKD on dialysis with Hb <10, 10-12, and >12 g/dL were 1.56 (1.43-1.71), 1.17 (1.09-1.26), and 0.91 (0.87-0.96), respectively. Similar patterns were observed for nondialysis patients and for the risks of hospitalisation, MACE, and CKD progression. This is the first known systematic review to quantify the risk of adverse clinical outcomes based on Hb level in patients with CKD. Anaemia was consistently associated with greater mortality, hospitalisation, MACE, and CKD progression in patients with CKD, and risk increased with anaemia severity. Effective treatments that not only treat the anaemia but also reduce the risk of adverse clinical outcomes are essential to help reduce the burden of anaemia and its management in CKD.
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Saunders MR, Lee H, Chin MH. Early winners and losers in dialysis center pay-for-performance. BMC Health Serv Res 2017; 17:816. [PMID: 29216894 PMCID: PMC5721658 DOI: 10.1186/s12913-017-2764-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 11/23/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We examined the association of dialysis facility characteristics with payment reductions and change in clinical performance measures during the first year of the United States Centers for Medicare & Medicaid Services (CMS) End Stage Renal Disease Quality Incentive Plan (ESRD QIP) to determine its potential impact on quality and disparities in dialysis care. METHODS We linked the 2012 ESRD QIP Facility Performance File to the 2007-2011 American Community Survey by zip code and dichotomized the QIP total performance scores-derived from percent of patients with urea reduction rate > 65, hemoglobin < 10 g/dL, and hemoglobin > 12 g/dL-as 'any' versus 'no' payment reduction. We characterized associations between payment reduction and dialysis facility characteristics and neighborhood demographics, and examined changes in facility outcomes between 2007 and 2010. RESULTS In multivariable analysis, facilities with any payment reduction were more likely to have longer operation (OR 1.03 per year), a medium or large number of stations (OR 1.31 and OR 1.42, respectively), and a larger proportion of African Americans (OR 1.25, highest versus lowest quartile), all p < 0.05. Most improvement in clinical performance was due to reduced overtreatment of anemia, a decline in the percentage of patients with hemoglobin ≥ 12 g/dL; for-profits and facilities in African American neighborhoods had the greatest reduction. CONCLUSIONS In the first year of CMS pay-for-performance, most clinical improvement was due to reduced overtreatment of anemia. Facilities in African American neighborhoods were more likely to receive a payment reduction, despite their large decline in anemia overtreatment.
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Affiliation(s)
- Milda R. Saunders
- University of Chicago Medicine, 5841 S. Maryland, MC 2007, Chicago, IL 60637 USA
| | - Haena Lee
- Institute for Social Research, University of Michigan, 426 Thompson St., #3428, Ann Arbor, MI USA
| | - Marshall H. Chin
- University of Chicago Medicine, 5841 S. Maryland, MC 2007, Chicago, IL 60637 USA
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Gafter-Gvili A, Ayalon-Dangur I, Cooper L, Shochat T, Rahamimov R, Gafter U, Mor E, Grossman A. Posttransplantation anemia in kidney transplant recipients: A retrospective cohort study. Medicine (Baltimore) 2017; 96:e7735. [PMID: 28796058 PMCID: PMC5556224 DOI: 10.1097/md.0000000000007735] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
We sought to assess the frequency and predictors of early and late posttransplantation anemia (PTA). In addition, we aimed to assess the outcomes of patients with anemia and to assess the impact of anemia on mortality, graft function, and graft failure.Patients who underwent kidney transplantation in a single center during a 4-year period were included. Predictors associated with the development of anemia at 6 months (early PTA) or 2 years (late PTA) were evaluated in a univariate and multivariate analyses. The effects of anemia and other variables on mortality and graft function were assessed.A total of 266 kidney transplant recipients were included. The prevalence of PTA at 6 months (early PTA) was 51.3% and at 2 years (late PTA) was 36.6%. Female sex was significantly associated with early PTA. Patients with early PTA proceeded to late PTA. Patients with both early and late PTA had a higher mortality rate at 4 years compared to patients without anemia. On multivariable analysis, lower Hb at 2 years posttransplantation (hazard ratio [HR] 0.716, 95% confidence intervals [CI] 0.541-0.948, for every increment of 1 g/dL) was significantly associated with mortality. Patients with late PTA suffered a decline in eGFR compared to patients without anemia (P = .026). Furthermore, a lower Hb at 2 years posttransplantation was also associated with graft failure (HR 0.775, 95% CI 0.619-0.969, for every increment of 1 g/dL).Post-transplantation anemia is significantly associated with late mortality, with a decline in graft function and with an increased incidence of graft failure.
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Affiliation(s)
- Anat Gafter-Gvili
- Department of Medicine A, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Ayalon-Dangur
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine E, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
| | - Lisa Cooper
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Geriatrics, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
| | - Tzippy Shochat
- Bio-Statistical Unit, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
| | - Ruth Rahamimov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Nephrology and Hypertension, Rabin Medical Center, Petah Tikva, Israel
| | - Uzi Gafter
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Nephrology and Hypertension, Rabin Medical Center, Petah Tikva, Israel
| | - Eytan Mor
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Transplantation, Rabin Medical Center, Beilinson Campus, Israel
| | - Alon Grossman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine E, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
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Martin ER, Smith MT, Maroni BJ, Zuraw QC, deGoma EM. Clinical Trial of Vadadustat in Patients with Anemia Secondary to Stage 3 or 4 Chronic Kidney Disease. Am J Nephrol 2017; 45:380-388. [PMID: 28343225 DOI: 10.1159/000464476] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 02/16/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Therapeutic options for the treatment of anemia secondary to chronic kidney disease (CKD) remain limited. Vadadustat (AKB-6548) is an oral hypoxia-inducible factor prolyl-hydroxylase domain (HIF-PHD) inhibitor that is being investigated for the treatment of anemia secondary to CKD. METHODS A phase 2a, multicenter, randomized, double-blind, placebo-controlled, dose-ranging trial (NCT01381094) was undertaken in adults with anemia secondary to CKD stage 3 or 4. Eligible subjects were evenly randomized to 5 groups: 240, 370, 500, or 630 mg of once-daily oral vadadustat or placebo for 6 weeks. All subjects received low-dose supplemental oral iron (50 mg daily). The primary endpoint was the mean absolute change in hemoglobin (Hb) from baseline to the end of treatment. Secondary endpoints included iron indices, safety, and tolerability. RESULTS Ninety-three subjects were randomized. Compared with placebo, vadadustat significantly increased Hb after 6 weeks in a dose-dependent manner (analysis of variance; p < 0.0001). Vadadustat increased the total iron-binding capacity and decreased concentrations of ferritin and hepcidin. The proportion of subjects with at least 1 treatment-emergent adverse event was similar between vadadustat- and placebo-treated groups. No significant changes in blood pressure, vascular endothelial growth factor, C-reactive protein, or total cholesterol were observed. Limitations of this study included its small sample size and short treatment duration. CONCLUSIONS Vadadustat increased Hb levels and improved biomarkers of iron mobilization and utilization in patients with anemia secondary to stage 3 or 4 CKD. Global multicenter, randomized phase 3 trials are ongoing in non-dialysis-dependent and dialysis-dependent patients.
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Mehrotra A, Leung WY, Joson T. Nutritional vitamin D supplementation and health-related outcomes in hemodialysis patients: a protocol for a systematic review and meta-analysis. Syst Rev 2015; 4:13. [PMID: 25874904 PMCID: PMC4339010 DOI: 10.1186/s13643-015-0002-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 01/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prevalence of vitamin D deficiency in hemodialysis patients is high. While most hemodialysis patients are treated with activated vitamin D (1,25[OH]2D) to prevent renal osteodystrophy, clinical practices of the screening and treatment of 25(OH)2D deficiency are highly variable. It is unclear if nutritional vitamin D supplementation with D2 or D3 provides an additional clinical benefit beyond that provided by activated vitamin D treatment in this population. METHODS/DESIGN We will conduct a systematic review of nutritional vitamin D (D2/D3) supplementation and health-related outcomes in hemodialysis patients according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary objective is to assess the impact of nutritional vitamin D supplementation on clinical outcomes relevant in hemodialysis patients, such as mortality, cardiovascular events, infections, and fractures. Secondary outcomes will include anemia, hyperparathyroidism, medication use (erythrocyte-stimulating agents, activated vitamin D), and quality of life. We will search MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov for randomized, controlled trials of nutritional vitamin D supplementation (ergocalciferol/D2 or cholecalciferol/D3) in chronic hemodialysis patients. The Cochrane Risk Assessment Tool will be used to assess the quality of eligible studies. We will perform meta-analyses using standard techniques for the outcomes listed above if pooling is deemed appropriate/sufficient. The results of this systematic review may highlight gaps in our knowledge of the relevance of nutritional vitamin D in end-stage renal disease, allowing for the informed design of clinical trials assessing the impact of nutritional vitamin D therapy in the hemodialysis population in the future. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014013931.
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Affiliation(s)
- Anita Mehrotra
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1243, New York, NY, 10029, USA.
| | - Wai-Yin Leung
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1243, New York, NY, 10029, USA.
| | - Tannia Joson
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1243, New York, NY, 10029, USA.
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Lorch JA, Pollak VE. Continuous quality improvement in daily clinical practice: a proof of concept study. PLoS One 2014; 9:e97066. [PMID: 24844323 PMCID: PMC4028191 DOI: 10.1371/journal.pone.0097066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 04/14/2014] [Indexed: 01/23/2023] Open
Abstract
Continuous Quality Improvement (CQI) is an iterative process of: planning to improve a product or process, plan implementation, analyzing and comparing results against those expected, and corrective action on differences between actual and expected results. It is little used in clinical medicine. Anemia, a complex problem in End Stage Renal Disease patients, served to test the ability of an unique electronic medical record (EMR) optimized for daily care to empower CQI in practice. We used data collected during daily care, stored in the EMR, and organized to display temporal relationships between clinical, laboratory, and therapeutic events. Our aims were optimal hemoglobin with minimum epoetin, and maintaining stable hemoglobin and epoetin. The study was done on 250 patients treated by maintenance hemodialysis (HD), receiving epoetin prior to February 1, 2010 and followed to July 31, 2011. Repleting iron, ensuring iron sufficiency, slow epoetin reduction, and decision support tools enabling data display over long periods in patient-centered reports were key elements. Epoetin dose, adjusted 6–8 weekly, was based on current clinical conditions and past responses. Hemoglobin increased by months 1–2; epoetin decreased from month 4. By months 16–18, epoetin had decreased 42% to 9,720 units/week while hemoglobin increased 8% to 123.6 g/L. Hemoglobin and epoetin were stable from month 7 onward. New epoetin orders decreased 83%. Transferrin saturation increased after the study start. Individual patient hemoglobin variation decreased by 23%, range by 27%. Mortality, 11.78 per 100 patient years, was 42% less than United States dialysis patient mortality. Allowable epoetin charges decreased by $15.33 per treatment and were $22.88 less than current Medicare allowance. The study validates the hypothesis that an EMR optimized for daily patient care can empower CQI in clinical medicine and serve to monitor medical care quality and cost.
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Affiliation(s)
- Jonathan A. Lorch
- Department of Medicine, Weill Cornell Medical College and The Rogosin Institute, New York, New York, United States of America
| | - Victor E. Pollak
- Department of Medicine, University of Colorado Health Sciences Center, Aurora, Colorado, United States of America
- MIQS, Inc., Boulder, Colorado, United States of America
- * E-mail:
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Suttorp MM, Hoekstra T, Mittelman M, Ott I, Franssen CFM, Dekker FW. Effect of erythropoiesis-stimulating agents on blood pressure in pre-dialysis patients. PLoS One 2013; 8:e84848. [PMID: 24391978 PMCID: PMC3877353 DOI: 10.1371/journal.pone.0084848] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 11/19/2013] [Indexed: 11/29/2022] Open
Abstract
Introduction Erythropoiesis-Stimulating Agents (ESA) are hypothesized to increase cardiovascular mortality in patients with chronic kidney disease. One of the proposed mechanisms is the elevation of blood pressure (BP) by ESA. Therefore, we aimed to determine whether the use of ESA was associated with antihypertensive treatment and higher BP. Materials and Methods In this cohort 502 incident pre-dialysis patients were included who started specialized pre-dialysis care in 25 clinics in the Netherlands. Data on medication including ESA use and dose, co-morbidities and BP were routinely collected every 6 months. Antihypertensive treatment and BP were compared for patients with and without ESA at baseline. Differences in antihypertensive medication and BP during pre-dialysis care were estimated with linear mixed models adjusted for age, sex, body mass index, cardiovascular disease, diabetes mellitus and estimated glomerular filtration rate. Results At baseline, 95.6% of patients with ESA were treated with antihypertensive medication and 73.1% of patients without ESA. No relevant difference in BP was found. During pre-dialysis care patients with ESA used 0.77 (95% CI 0.63;0.91) more classes of antihypertensive drugs. The adjusted difference in systolic blood pressure (SBP) was −0.3 (95% CI −2.7;2.0) mmHg and in diastolic blood pressure (DBP) was −1.0 (95% CI −2.1;0.3) mmHg for patients with ESA compared to patients without ESA. Adjusted SBP was 3.7 (95% CI −1.6;9.0) mmHg higher in patients with a high ESA dose compared to patients with a low ESA dose. Conclusions Our study confirms the hypertensive effect of ESA, since ESA treated patients received more antihypertensive agents. However, no relevant difference in BP was found between patients with and without ESA, thus the increase in BP seems to be controlled for by antihypertensive medication.
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Affiliation(s)
- Marit M. Suttorp
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
| | - Tiny Hoekstra
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Moshe Mittelman
- Department of Medicine, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Ilka Ott
- Deutsches Herzzentrum der Technischen Universität München, München, Germany
| | - Casper F. M. Franssen
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Friedo W. Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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Yoder LAG, Xin W, Norris KC, Yan G. Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities. Am J Kidney Dis 2013; 62:1130-40. [PMID: 23810689 DOI: 10.1053/j.ajkd.2013.05.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 05/15/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Higher numbers of registered nurses (RNs) per patient have been associated with improved patient outcomes in acute-care facilities. Variation in and associations of patient care staffing levels and hemodialysis facility characteristics have not been examined previously. STUDY DESIGN Cross-sectional study using Poisson regression to examine associations between patient care staffing levels and hemodialysis facility characteristics. SETTING & PARTICIPANTS 4,800 US hemodialysis facilities in the 2009 Centers for Medicare & Medicaid (CMS) End-Stage Renal Disease Annual Facility Survey (CMS-2744 form). PREDICTORS Facility characteristics, including profit status, freestanding status, chain affiliation, and geographic region, adjusted for facility size, capacity, functional type, and urbanicity. OUTCOMES Patient care staffing levels, including ratios of RNs, licensed practical nurses (LPNs), patient care technicians (PCTs), composite staff (RN + LPN + PCT), social workers, and dietitians to in-center hemodialysis patients. RESULTS After adjusting for background facility characteristics, ratios of RNs and LPNs to patients were 35% (P < 0.001) and 42% (P < 0.001) lower, respectively, but the PCT to patient ratio was 16% (P < 0.001) higher in for-profit than nonprofit facilities (rate ratios of 0.65 [95% CI, 0.63-0.68], 0.58 [95% CI, 0.51-0.65], and 1.16 [95% CI, 1.12-1.19], respectively). Regionally, compared to the Northeast, the adjusted RN to patient ratio was 14% (P < 0.001) lower in the Midwest, 25% (P < 0.001) lower in the South, and 18% (P < 0.001) lower in the West. Even after additional adjustments, the large for-profit chains had significantly lower RN and LPN to patient ratios than the largest nonprofit chain, but a significantly higher PCT to patient ratio. Overall composite staffing levels also were lower in for-profit and chain-affiliated facilities. The patterns hold when hospital-based units were excluded. LIMITATIONS Nursing hours were not available. Two part-time staff were counted as one full-time equivalent, which may not always be accurate. CONCLUSIONS The significant variation in patient care staffing levels and its associations with facility characteristics warrants inclusion in future large-scale hemodialysis outcomes studies. End-stage renal disease networks and hemodialysis facilities should attend to quality assurance and performance improvement initiatives that maximize licensed nurse staffing levels in hemodialysis facilities.
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Affiliation(s)
- Laura A G Yoder
- University of Virginia School of Nursing, Charlottesville, VA
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Singh AK. How Can Erythropoeitin-Stimulating Agent Use be Reduced in Chronic Dialysis Patients? Semin Dial 2013; 26:531-4. [DOI: 10.1111/sdi.12104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ajay K. Singh
- Renal Division; Brigham and Women's Hospital and Harvard Medical School Boston; Boston Massachusetts
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Abstract
Renal anaemia is a frequent complication in patients with chronic kidney disease (CKD). Severe anaemia (haemoglobin <90 g/l) is associated with increased risks of mortality and cardiac complications, such as left ventricular hypertrophy and cardiovascular disease, and impaired quality of life. Randomized controlled trials have tested the hypothesis that increasing haemoglobin level using erythropoiesis-stimulating agents (ESAs) lowers these risks and improves quality of life. Use of ESAs to normalize haemoglobin levels (to ≥130 g/l) versus the partial correction of anaemia (to haemoglobin levels of 90-110 g/l) has repeatedly been shown to have no cardiac benefit and to be associated with no incremental improvement in outcomes and quality of life (except fatigue), but has been shown to be associated with an increased risk of cardiovascular events and death. Use of more-intense iron dosing has been proposed in order to reduce ESA dosing but liberal intravenous iron therapy is also associated with complications, and its long-term safety has not yet been adequately investigated. For patients with CKD on dialysis, US medication labels recommend administering ESAs at doses sufficient to avoid transfusions, whereas European and Canadian labels recommend targeting haemoglobin levels of 100-120 g/l and 110-120 g/l, respectively. Treatment of anaemia to haemoglobin levels of 90-110 g/l in patients with CKD accomplishes what we want--a reduced need for transfusions and possible reductions in fatigue, while avoiding high doses of ESA or iron in order to achieve a specific haemoglobin goal.
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Affiliation(s)
- Walter H Hörl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
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Rozen-Zvi B, Gafter-Gvili A, Zingerman B, Levy-Drummer RS, Levy L, Mor E, Gafter U, Rahamimov R. Intravenous iron supplementation after kidney transplantation. Clin Transplant 2012; 26:608-14. [DOI: 10.1111/j.1399-0012.2012.01602.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2011] [Indexed: 11/28/2022]
Affiliation(s)
- Benaya Rozen-Zvi
- Department of Neprology and Hypertension; Rabin Medical Center; Petah Tikva; Israel
| | - Anat Gafter-Gvili
- Department of Internal Medicine E; Rabin Medical Center; Petah Tikva; Israel
| | - Boris Zingerman
- Department of Neprology and Hypertension; Rabin Medical Center; Petah Tikva; Israel
| | | | - Liora Levy
- Sackler Medical School; Tel-Aviv University; Tel-Aviv; Israel
| | - Eitan Mor
- Department of Organ Transplantation; Rabin Medical Center; Petah Tikva; Israel
| | - Uzi Gafter
- Department of Neprology and Hypertension; Rabin Medical Center; Petah Tikva; Israel
| | - Ruth Rahamimov
- Department of Neprology and Hypertension; Rabin Medical Center; Petah Tikva; Israel
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Haemodialysis in an emerging centre in a developing country: a two year review and predictors of mortality. BMC Nephrol 2011; 12:50. [PMID: 21962220 PMCID: PMC3198883 DOI: 10.1186/1471-2369-12-50] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 10/02/2011] [Indexed: 11/15/2022] Open
Abstract
Background Haemodialysis is the most common form of renal replacement therapy in Nigeria. The high cost of haemodialysis has made optimal therapy of end-stage renal disease difficult in Nigeria. This paper is a review of data collected over two years of provision of dialysis services in a new tertiary hospital in Southern Nigeria. Methods This retrospective analysis is done on data obtained from the patient case files and dialysis records in the first two years of provision of dialysis services in our centre. A gender comparison of the patients' baseline sociodemographic, clinical and biochemical was performed and a logistic regression model used to assess the predictors of mortality. Results A total of 98 patients had 471 sessions in the two years under review. Males and females had similar characteristics at baseline except for a higher median serum urea in the males. The commonest causes of end-stage renal disease were chronic glomerulonephritis (34.5%), hypertension (32.1%) and diabetes mellitus (17.9%). The main predictor of mortality was under treatment with haemodialysis due to inability to pay for more than a few dialysis sessions. Conclusions This study has highlighted the unchanging demographics of our advanced kidney failure patients. Efforts should be aimed at subsidizing the cost of dialysis for our teeming population of dialysis dependent chronic kidney disease patients.
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Derebail VK, Nachman PH, Key NS, Ansede H, Falk RJ, Rosamond WD, Kshirsagar AV. Variant hemoglobin phenotypes may account for differential erythropoiesis-stimulating agent dosing in African-American hemodialysis patients. Kidney Int 2011; 80:992-999. [PMID: 21849972 DOI: 10.1038/ki.2011.247] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
African-American patients with end-stage renal disease have historically lower hemoglobin concentrations and higher requirements of erythropoiesis-stimulating agent (ESA). While disparities in health-care access may partially explain these findings, the role of variant hemoglobin, such as sickle trait, has not been investigated. To clarify this, we evaluated 154 African-American patients receiving in-center hemodialysis with available hemoglobin phenotyping. The primary exposure was any abnormal hemoglobin variant and the primary outcome of higher-dose ESA was defined as a dose of 6500 or more units per treatment. Logistic regression assessed the association between variant hemoglobin and higher-dose ESA. Covariates included age, gender, diabetes, iron parameters, intravenous iron dose, parathyroid hormone, albumin, phosphorus, body mass index, vascular access type, hospitalization/missed treatments, smoking status, alcohol abuse, and gastrointestinal bleeding. Of 33 patients with variant hemoglobin, 24 had HbAS and 9 had HbAC. Univariate odds of higher-dose ESA among those with hemoglobin variants were twice that of those with the normal HbAA phenotype (odds ratio 2.05). In multivariate models, the likelihood of higher-dose ESA had an odds ratio of 3.31 and the nature of this relationship did not change in Poisson regression or sensitivity analyses. Hence, our findings may explain, in part, the difference in ESA dosing between Caucasians and African-Americans with end-stage renal disease but await further study.
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Affiliation(s)
- Vimal K Derebail
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - Patrick H Nachman
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nigel S Key
- Division of Hematology and Oncology, and Program in Hemostasis and Thrombosis, Department of Medicine, Carolina Cardiovascular Biology Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Abhijit V Kshirsagar
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Molnar MZ, Mehrotra R, Duong U, Kovesdy CP, Kalantar-Zadeh K. Association of hemoglobin and survival in peritoneal dialysis patients. Clin J Am Soc Nephrol 2011; 6:1973-81. [PMID: 21784829 DOI: 10.2215/cjn.01050211] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Interventional trials and some observational studies show target hemoglobin >13 g/dl to be associated with higher mortality in erythropoiesis-stimulating agent-treated (ESA-treated) hemodialysis patients; data for peritoneal dialysis (PD) patients are limited. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We tested our hypothesis that higher and lower achieved hemoglobin levels are associated with increased mortality in 9269 ESA-treated PD patients from all DaVita dialysis clinics during the time period July 2001 through June 2006 followed through June 2007 using a time-dependent analysis. RESULTS Lower hemoglobin was associated with significantly higher all-cause mortality in ESA-treated PD patients: with hemoglobin of 11.0 to <12.0 g/dl as reference, the time-dependent adjusted death hazard ratios for hemoglobin levels of 10.0 to <11.0, 9.0 to <10.0, and ≤9.0 g/dl were 1.12 (1.00 to 1.24), 1.30 (1.12 to 1.50), and 1.38 (1.14 to 1.67), respectively. The time-dependent adjusted hazard ratios for cardiovascular death with hemoglobin levels of 10.0 to <11.0, 9.0 to <10.0, and ≤9.0 g/dl were 1.11 (0.93 to 1.32), 1.37 (1.09 to 1.72), and 1.12 (0.79 to 1.57), respectively. The same trend for association of lower hemoglobin level with higher mortality was seen in African-American and non-African American men and women. In contrast, there was no association between higher achieved hemoglobin and all-cause or cardiovascular mortality in ESA-treated PD patients. CONCLUSIONS Lower, but not higher, achieved hemoglobin is associated with higher mortality in ESA-treated PD patients. Randomized controlled trials are needed to examine the target hemoglobin level with lowest mortality in PD patients.
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Affiliation(s)
- Miklos Z Molnar
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Center at Harbor-UCLA Medical Center, 1124 West Carson Street, C1-Annex, Torrance, California 90502, USA
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Kaufman JS. Relationship of Erythropoiesis-Stimulating Agent Dose and Responsiveness and Adverse Outcomes in CKD. Am J Kidney Dis 2011; 57:661-3. [DOI: 10.1053/j.ajkd.2011.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 02/02/2011] [Indexed: 11/11/2022]
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Sun Y, Kassam H, Adeniyi M, Martinez M, Agaba EI, Onime A, Servilla KS, Raj DSC, Murata GH, Tzamaloukas AH. Hospital admissions in elderly patients on chronic hemodialysis. Int Urol Nephrol 2011; 43:1229-36. [PMID: 21360163 DOI: 10.1007/s11255-011-9913-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 02/05/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND The purpose of this study was to determine whether number of hospital admissions per patient per year (n/[pt-yr]) and hospital days per patient per year (d/[pt-yr]) differ between elderly and younger patients on chronic hemodialysis (HD). PATIENTS AND METHODS In a retrospective cohort analysis of incident HD patients in one dialysis unit over 15 years, we compared 166 HD patients older than 70 years (77.1 ± 4.7 yrs) at the onset of HD (group A) and 216 patients younger than 70 years both at onset (57.1 ± 7.6 yrs) and at the end of the HD period (group B). Eighty (48.2%) of group A and 141 (65.3%) patients of group B had diabetes mellitus. RESULTS No differences were noted in the overall hospitalization rate, presented as mean, {95% Confidence interval} (group A 2.40 {2.04-2.75}, group B 2.03 {1.89-2.16} n[pt-yr]) and days/[pt-year] (group A 33.6 {25.3-41.8}, group B 24.1 {18.9-29.23}). Group A had higher number of hospitalization days (P = 0.012) for surgery or trauma and higher rate (P = 0.045) and days (P = 0.041) of hospitalization for miscellaneous causes, primarily pulmonary disease, or malignancy. Among diabetic patients, group A had only a greater number of hospital days for cardiac disease (P = 0.050). Among patients without diabetes, group A had a higher number for hospital days for surgery or trauma (P = 0.027). All other univariate comparisons were not significant. Multiple linear regression identified comorbidity, quantified by the Charlson index, Caucasian race and poor compliance with the HD schedule as predictors of admission rate and days per year for vascular access issues and comorbidity, poor compliance, and advanced age at onset of HD as predictors of admission for causes other than vascular access related. CONCLUSION Hospitalizations, which affect quality of life, differ little between elderly and younger patients on HD. Therefore, hospitalizations do not constitute an argument for restricting access to HD to elderly patients.
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Affiliation(s)
- Yijuan Sun
- Medicine Service, Raymond G Murphy Veterans Affairs Medical Center and Department of Medicine, University of New Mexico School of Medicine, 1501 San Pedro, SE, Albuquerque, New Mexico 87108, USA
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Harford AM, Zager PG. Mortality Risk in Dialysis Patients with Naturally Higher Hemoglobins. J Am Soc Nephrol 2011; 22:205-6. [DOI: 10.1681/asn.2010121281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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What is causing the mortality in treating the anemia of chronic kidney disease: erythropoietin dose or hemoglobin level? Curr Opin Nephrol Hypertens 2010; 19:420-4. [PMID: 20689425 DOI: 10.1097/mnh.0b013e32833cf1d6] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article examines the potential mechanisms underlying adverse risk observed in four randomized controlled trials of anemia correction in chronic kidney disease (CKD) patients. RECENT FINDINGS The Normal Hematocrit Study, Cardiovascular Risk Reduction by Early Anemia Treatment with Epoetin-beta, Correction of Hemoglobin and Outcomes in Renal Insufficiency, and Trial to Reduce Cardiovascular Events with Aranesp Therapy demonstrate increased risk of mortality and/or cardiovascular complications with targeting of a higher hemoglobin (Hb) in CKD patients. Although a higher Hb level was targeted in these trials, erythropoiesis-stimulating agent (ESA) exposure itself might account for the observed increased risk. This is because, in these trials, achieving a normal or near normal Hb was associated with improved survival and reduced cardiovascular risk. Indeed, it was the 'targeting' of a higher Hb with ESA that seemed to be the problem. Observational data, although conflicting, on the whole provide support for high dosage of ESA being harmful but cannot, by their very nature, prove causality. SUMMARY After 20 years of ESA use, is it plausible that ESAs could be toxic? How does one reconcile conflicting observational data with a hypothesis that postulates ESA toxicity? Does the biology of erythropoietin provide a mechanistic explanation? The answers to these questions, among others, will be important in charting a future role for ESAs in treating CKD anemia.
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Roach JL, Turenne MN, Hirth RA, Wheeler JRC, Sleeman KS, Messana JM. Using race as a case-mix adjustment factor in a renal dialysis payment system: potential and pitfalls. Am J Kidney Dis 2010; 56:928-36. [PMID: 20888100 DOI: 10.1053/j.ajkd.2010.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 08/09/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Racial disparities in health care are widespread in the United States. Identifying contributing factors may improve care for underserved minorities. To the extent that differential utilization of services, based on need or biological effect, contributes to outcome disparities, prospective payment systems may require inclusion of race to minimize these adverse effects. This research determines whether costs associated with end-stage renal disease (ESRD) care varied by race and whether this variance affected payments to dialysis facilities. STUDY DESIGN We compared the classification of race across Medicare databases and investigated differences in cost of care for long-term dialysis patients by race. SETTING & PARTICIPANTS Medicare ESRD database including 890,776 patient-years in 2004-2006. PREDICTORS Patient race and ethnicity. OUTCOMES Costs associated with ESRD care and estimated payments to dialysis facilities under a prospective payment system. RESULTS There were inconsistencies in race and ethnicity classification; however, there was significant agreement for classification of black and nonblack race across databases. In predictive models evaluating the cost of outpatient dialysis care for Medicare patients, race is a significant predictor of cost, particularly for cost of separately billed injectable medications used in dialysis. Overall, black patients had 9% higher costs than nonblack patients. In a model that did not adjust for race, other patient characteristics accounted for only 31% of this difference. LIMITATIONS Lack of information about biological causes of the link between race and cost. CONCLUSIONS There is a significant racial difference in the cost of providing dialysis care that is not accounted for by other factors that may be used to adjust payments. This difference has the potential to affect the delivery of care to certain populations. Of note, inclusion of race into a prospective payment system will require better understanding of biological differences in bone and anemia outcomes, as well as effects of inclusion on self-reported race.
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Affiliation(s)
- Jesse L Roach
- University of Michigan, Kidney Epidemiology and Cost Center, Ann Arbor, MI 48103-4262, USA
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Agarwal AK, Singh AK. Therapy with Erythropoiesis-Stimulating Agents and Renal and Nonrenal Outcomes. Heart Fail Clin 2010; 6:323-32. [DOI: 10.1016/j.hfc.2010.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Singh AK. The FDA's perspective on the risk for rapid rise in hemoglobin in treating CKD anemia: Quo Vadis. Clin J Am Soc Nephrol 2010; 5:553-6. [PMID: 20203166 DOI: 10.2215/cjn.00490110] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Adeseun GA, Berns JS. Erythropoietin Bundling: Innovative Remuneration or the Dawn of EPO-Profiling? Semin Dial 2010; 23:88-90. [DOI: 10.1111/j.1525-139x.2009.00689.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cherukuri A, Bhandari S. Analysis of risk factors for mortality of incident patients commencing dialysis in East Yorkshire, UK. QJM 2010; 103:41-8. [PMID: 19959632 DOI: 10.1093/qjmed/hcp164] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The change in the demographics and the presence of multiple risk factors and co-morbidities in UK patients starting dialysis may lead to poor survival on dialysis. Many of these risk factors are present in the pre-dialysis period allowing a potential window of opportunity to intervene with risk modification measures. AIM To examine various potential factors that may predict early and overall mortality. DESIGN AND METHODS We carried out an observational prospective study of a cohort of incident patients starting dialysis in a UK centre. Univariate analysis of factors and co-morbidities potentially affecting survival on dialysis were analysed to potential predictors. Factors affecting 1 year mortality were analysed using the t-test, the Mann-Whitney U-test or the chi-square test as appropriate. Mortality over the 5-year follow-up period was analysed using the Kaplan-Meier method. RESULTS Ninety-four patients [predominantly Caucasian (98%)], of mean age 63 years (15.6) (56% > 65 years) with a slight male preponderance were studied. Vascular disease (39%) and sepsis (33%) accounted for most of the deaths and a significant proportion of mortality was seen in the first year (56%). Patients with early mortality were older (68 vs. 61 years, P = 0.05) with lower haemoglobin (8.4 vs. 9.4 g/dl, P = 0.01) at the start of dialysis, commenced dialysis with a lower eGFR (5.4 vs. 6.5 ml/min/1.73 m(2), P = 0.06) and had more peripheral vascular disease (PVD) (39% mortality in patients with PVD vs. 18.5% in those without PVD, P = 0.04). Diabetes mellitus, high calcium phosphate product, older age and presence of vascular co-morbidities including ischaemic heart disease and peripheral vascular disease were associated with overall mortality over the 5-year follow-up period. SUMMARY In this study, elevated calcium phosphate product and diabetes mellitus in addition to the presence of vascular disease were associated with poor survival. Patients with low haemoglobin and lower first pre-dialysis eGFR suffered higher early mortality. These potentially modifiable factors that could be identified in the pre-dialysis stage provide a valuable opportunity for intervention.
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Affiliation(s)
- A Cherukuri
- Department of Renal Medicine, Hull and East Yorkshire Hospitals NHS Trust, UK
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Sherman RA. Briefly Noted. Semin Dial 2010. [DOI: 10.1111/j.1525-139x.2009.00687.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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