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Lee J, Kim J, Ju HJ, An SJ, Woo B. A Longitudinal Dose-Response Curve Between Leisure-Time Physical Activity and the Prevalence of Diabetes Based on the Different Levels of Cognitive Function Among Older Adults. Am J Alzheimers Dis Other Demen 2024; 39:15333175241241891. [PMID: 38549562 PMCID: PMC11072067 DOI: 10.1177/15333175241241891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
This study investigated a dose-response relationship between Leisure-Time Physical Activity participation (LTPA) and the risk of diabetes and a comparison of the risk across different cognitive function groups among older adults. The Health and Retirement Study data were used from 2012 to 2020 (n = 18 746). This study conducted a Cox Proportional Hazard Regression to investigate the Dose-Response Curve between the prevalence of diabetes and the covariates following a level of LTPA participation. The result presented that the Odds Ratio continuously decreased as the level of LTPA participation increased. Among the three cognitive function groups, the high group (OR = .43, P < .05) and the mid group (OR = .71, P < .05) had a larger negative slope coefficient than the low group. This study found that LTPA participation reduces the risk of diabetes and gives evidence for the importance of cognitive function in reducing the prevalence of diabetes.
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Affiliation(s)
- Jungjoo Lee
- School of Health Professions, College of Nursing and Health Professions, University of Southern Mississippi, Hattiesburg, MS, USA
| | - Junhyoung Kim
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Hyo Jin Ju
- Department of Medical Humanities, The Convergence Institute of Healthcare and Medical Science, Catholic Kwandong University, Incheon, South Korea
| | - Sang Joon An
- Department of Neurology, The Convergence Institute of Healthcare and Medical Science, International St. Mary’s Hospital, Catholic Kwandong University, Incheon, South Korea
| | - Bomi Woo
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, TX, USA
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Huijben JA, Kramer A, Kerschbaum J, de Meester J, Collart F, Arévalo OLR, Helve J, Lassalle M, Palsson R, Ten Dam M, Casula A, Methven S, Ortiz A, Ferraro PM, Segelmark M, Mingo PU, Arici M, Reisæter AV, Stendahl M, Stel VS, Jager KJ. Increasing numbers and improved overall survival of patients on kidney replacement therapy over the last decade in Europe: an ERA Registry study. Nephrol Dial Transplant 2022; 38:1027-1040. [PMID: 35974693 PMCID: PMC10064979 DOI: 10.1093/ndt/gfac165] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The aim of this study was to describe the trends in the incidence, prevalence and survival of patients on kidney replacement therapy (KRT) for end-stage kidney disease (ESKD) across Europe from 2008 to 2017. METHODS Data from renal registries in 9 countries and 16 regions that provided individual patient data to the ERA Registry from 2008 to 2017 were included. These registries cover 34% of the general population in Europe. Crude and standardized incidence and prevalence per million population (pmp) were determined. Trends over time were studied using Joinpoint regression. Survival probabilities were estimated using Kaplan-Meier analysis and hazard ratios (HRs) using Cox regression analysis. RESULTS The standardized incidence of KRT was stable (annual percentage change [APC]: -1.48 [-3.15; 0.21]) from 2008 (146.0 pmp) to 2011 (141.6 pmp), followed by a slight increase (APC: 1.01 [0.43; 1.60]) to 148.0 pmp in 2017, although trends in incidence varied across countries. This increase was primarily due to a rise in the incidence of KRT in men older than 65 years. Moreover, as a cause of kidney failure, diabetes mellitus is increasing. The standardized prevalence increased from 2008 (990.0 pmp) to 2017 (1166.8 pmp) (APC: 1.82 [1.75; 1.89]). Patient survival on KRT improved in the time period 2011-2013 compared with 2008-2010 (adjusted HR: 0.94 [0.93; 0.95). CONCLUSION This study showed an overall increase in the incidence and prevalence of KRT for ESKD as well as an increase in the KRT patient survival over the last decade in Europe.
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Affiliation(s)
- Jilske A Huijben
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam UMC, Academic Medical Center, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Anneke Kramer
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam UMC, Academic Medical Center, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Julia Kerschbaum
- Austrian Dialysis and Transplant Registry, Department of Internal Medicine IV - Nephrology and Hypertension, Medical University Innsbruck, Austria
| | - Johan de Meester
- Department of Nephrology, Dialysis and Hypertension, Dutch-speaking Belgian Renal Registry (NBVN), Sint-Niklaas, Belgium
| | | | - Olga Lucía Rodríguez Arévalo
- Valencia Region Renal Registry, Dirección General de Salut Publica i Adiccions, Valencia, Spain.,Doctoral student of the Technologies for Health and Well-being program, Universidad Politécnica de Valencia, Valencia, Spain
| | - Jaakko Helve
- Finnish Registry for Kidney Diseases, Helsinki, Finland.,Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mathilde Lassalle
- REIN Registry, Agence de la Biomédecine, Saint-Denis La Plaine, France
| | - Runolfur Palsson
- Division of Nephrology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Marc Ten Dam
- Dutch Registry RENINE, Nefrovisie, Utrecht, The Netherlands
| | - Anna Casula
- UK Renal Registry, the Renal Association, Bristol, UK
| | - Shona Methven
- Department of Renal Medicine, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
| | - Alberto Ortiz
- School of Medicine, IIS-Fundacion Jimenez Diaz, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
| | - Pietro Manuel Ferraro
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mårten Segelmark
- Department of Clinical Sciences, Division of Nephrology, Lund University and Skane University Hospital, Lund, Sweden.,Swedish Renal Registry, Department of Internal Medicine, Ryhov County Hospital, Jönköping, Sweden
| | - Pablo Ucio Mingo
- Coordinador Autonómico de Trasplantes de Castilla y León, Dirección General de Planificación y Asistencia Sanitaria, Valladolid, Castilla y León, Spain
| | - Mustafa Arici
- Department of Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Anna Varberg Reisæter
- Department of Transplantation Medicine, Oslo University hospital, Rikshospitalet, Norway
| | - Maria Stendahl
- Swedish Renal Registry, Department of Internal Medicine, Ryhov County Hospital, Jönköping, Sweden
| | - Vianda S Stel
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam UMC, Academic Medical Center, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Kitty J Jager
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam UMC, Academic Medical Center, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Workie SG, Zewale TA, Wassie GT, Belew MA, Abeje ED. Survival and predictors of mortality among chronic kidney disease patients on hemodialysis in Amhara region, Ethiopia, 2021. BMC Nephrol 2022; 23:193. [PMID: 35606716 PMCID: PMC9125902 DOI: 10.1186/s12882-022-02825-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 05/17/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Despite the high economic and mortality burden of chronic kidney disease, studies on survival and predictors of mortality among patients on hemodialysis in Ethiopia especially in the Amhara region are scarce considering their importance to identify some modifiable risk factors for early mortality to improve the patient's prognosis. So, this study was done to fill the identified gaps. The study aimed to assess survival and predictors of mortality among end-stage renal disease patients on hemodialysis in Amhara regional state, Ethiopia, 2020/2021. METHOD Institution-based retrospective record review was conducted in Felege Hiwot, Gonder, and Gambi hospitals from March 5 to April 5, 2021. A total of 436 medical records were selected using a simple random sampling technique. A life table was used to estimate probabilities of survival at different time intervals. Multivariable cox regression was used to identify risk factors for mortality. RESULT Out of the 436 patients 153 (35.1%) had died. The median survival time was 345 days with a mortality rate of 1.89 per 1000 person-days (95%CI (1.62, 2.22)). Patients live in rural residences (AHR = 1.48, 95%CI (1.04, 2.12)), patients whose cause of CKD was hypertension (AHR = 1.49, 95%CI (1.01, 2.23)) and human immune virus (AHR = 2.22, 95%CI (1.41, 3.51)), and patients who use a central venous catheter (AHR = 3.15, 95%CI (2.08, 4.77)) had increased risk of death while staying 4 h on hemodialysis (AHR = 0.43, 95%CI (0.23, 0.80)) decreases the risk of death among chronic kidney disease patients on hemodialysis. CONCLUSIONS The overall survival rate and median survival time of chronic kidney disease patients on hemodialysis were low in the Amhara region as compared with other developing Sub-Saharan African counties.
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Affiliation(s)
- Sewnet Getaye Workie
- Department of Public Health, School of Public Health, College of Medicine and Health Science, Debre Berhan University, PO box 445, Debre Berhan, Ethiopia
| | - Taye Abuhay Zewale
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Science, Bahir Dar University, PO box 79, Bahir Dar, Ethiopia
| | - Gizachew Tadesse Wassie
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Science, Bahir Dar University, PO box 79, Bahir Dar, Ethiopia
| | - Makda Abate Belew
- Department of Nursing, School of Nursing and Midwifery, College of Medicine and Health Science, Debre Berhan University, PO box 445, Debre Berhan, Ethiopia
| | - Eleni Dagnaw Abeje
- Department of Nursing, School of Nursing and Midwifery, College of Medicine and Health Science, Debre Berhan University, PO box 445, Debre Berhan, Ethiopia
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Helve J, Haapio M, Groop PH, Finne P. Primary kidney disease modifies the effect of comorbidities on kidney replacement therapy patients' survival. PLoS One 2021; 16:e0256522. [PMID: 34415958 PMCID: PMC8378722 DOI: 10.1371/journal.pone.0256522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 08/09/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Comorbidities are associated with increased mortality among patients receiving long-term kidney replacement therapy (KRT). However, it is not known whether primary kidney disease modifies the effect of comorbidities on KRT patients' survival. METHODS An incident cohort of all patients (n = 8696) entering chronic KRT in Finland in 2000-2017 was followed until death or end of 2017. All data were obtained from the Finnish Registry for Kidney Diseases. Information on comorbidities (coronary artery disease, peripheral vascular disease, left ventricular hypertrophy, heart failure, cerebrovascular disease, malignancy, obesity, underweight, and hypertension) was collected at the start of KRT. The main outcome measure was relative risk of death according to comorbidities analyzed in six groups of primary kidney disease: type 2 diabetes, type 1 diabetes, glomerulonephritis (GN), polycystic kidney disease (PKD), nephrosclerosis, and other or unknown diagnoses. Kaplan-Meier estimates and Cox regression were used for survival analyses. RESULTS In the multivariable model, heart failure increased the risk of death threefold among PKD and GN patients, whereas in patients with other kidney diagnoses the increased risk was less than twofold. Obesity was associated with worse survival only among GN patients. Presence of three or more comorbidities increased the age- and sex-adjusted relative risk of death 4.5-fold in GN and PKD patients, but the increase was only 2.5-fold in patients in other diagnosis groups. CONCLUSIONS Primary kidney disease should be considered when assessing the effect of comorbidities on survival of KRT patients as it varies significantly according to type of primary kidney disease.
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Affiliation(s)
- Jaakko Helve
- Finnish Registry for Kidney Diseases, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko Haapio
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Per-Henrik Groop
- Finnish Registry for Kidney Diseases, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Institute of Genetics, Folkhälsan Research Center Biomedicum Helsinki, Helsinki, Finland
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | - Patrik Finne
- Finnish Registry for Kidney Diseases, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Toapanta-Gaibor N, Suñer-Poblet M, Cintra-Cabrera M, Pérez-Valdivia M, Suárez-Benjumea A, Gonzalez-Roncero F, Bernal-Blanco G, Rocha-Castilla J, Gentil-Govantes M. Reasons for Noninclusion on the Kidney Transplant Waiting List: Analysis in a Set of Hemodialysis Centers. Transplant Proc 2018; 50:553-554. [DOI: 10.1016/j.transproceed.2017.09.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 09/21/2017] [Indexed: 11/24/2022]
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Haapio M, Helve J, Grönhagen-Riska C, Finne P. One- and 2-Year Mortality Prediction for Patients Starting Chronic Dialysis. Kidney Int Rep 2017; 2:1176-1185. [PMID: 29270526 PMCID: PMC5733880 DOI: 10.1016/j.ekir.2017.06.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 05/24/2017] [Accepted: 06/20/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction Mortality risk of patients with end-stage renal disease (ESRD) is highly elevated. Methods to estimate individual mortality risk are needed to provide individualized care and manage expanding ESRD populations. Many mortality prediction models exist but have shown deficiencies in model development (data comprehensiveness, validation) and in practicality. Therefore, our aim was to design 2 easy-to-apply prediction models for 1- and 2-year all-cause mortality in patients starting long-term renal replacement therapy (RRT). Methods We used data from the Finnish Registry for Kidney Diseases with complete national coverage of RRT patients. Model training group included all incident adult patients who started long-term dialysis in Finland in 2000 to 2008 (n = 4335). The external validation cohort consisted of those who entered dialysis in 2009 to 2012 (n = 1768). Logistic regression with stepwise variable selection was used for model building. Results We developed 2 prognostic models, both of which only included 6 to 7 variables (age at RRT start, ESRD diagnosis, albumin, phosphorus, C-reactive protein, heart failure, and peripheral vascular disease) and showed sufficient discrimination (c-statistic 0.77 and 0.74 for 1- and 2-year mortality, respectively). Due to a significantly lower mortality in the newer cohort, the models, to a degree, overestimated mortality risk. Discussion Mortality prediction algorithms could be more widely implemented into management of ESRD patients. The presented models are practical with only a limited number of variables and fairly good performance.
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Affiliation(s)
- Mikko Haapio
- Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Correspondence: Mikko Haapio, Helsinki University Hospital, P.O. Box 372, FI-00029 HUS, Finland.Helsinki University HospitalP.O. Box 372FI-00029 HUSFinland
| | - Jaakko Helve
- Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Patrik Finne
- Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Finnish Registry for Kidney Diseases, Helsinki, Finland
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Robinson BM, Akizawa T, Jager KJ, Kerr PG, Saran R, Pisoni RL. Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and haemodialysis practices. Lancet 2016; 388:294-306. [PMID: 27226132 PMCID: PMC6563337 DOI: 10.1016/s0140-6736(16)30448-2] [Citation(s) in RCA: 249] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
More than 2 million people worldwide are being treated for end-stage kidney disease (ESKD). This Series paper provides an overview of incidence, modality use (in-centre haemodialysis, home dialysis, or transplantation), and mortality for patients with ESKD based on national registry data. We also present data from an international cohort study to highlight differences in haemodialysis practices that affect survival and the experience of patients who rely on this therapy, which is both life-sustaining and profoundly disruptive to their quality of life. Data illustrate disparities in access to renal replacement therapy of any kind and in the use of transplantation or home dialysis, both of which are widely considered preferable to in-centre haemodialysis for many patients with ESKD in settings where infrastructure permits. For most patients with ESKD worldwide who are treated with in-centre haemodialysis, overall survival is poor, but longer in some Asian countries than elsewhere in the world, and longer in Europe than in the USA, although this gap has reduced. Commendable haemodialysis practice includes exceptionally high use of surgical vascular access in Japan and in some European countries, and the use of longer or more frequent dialysis sessions in some countries, allowing for more effective volume management. Mortality is especially high soon after ESKD onset, and improved preparation for ESKD is needed including alignment of decision making with the wishes of patients and families.
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Affiliation(s)
- Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA; Department of Internal Medicine and Nephrology, University of Michigan, Ann Arbor, MI, USA.
| | - Tadao Akizawa
- Showa University School of Medicine, Shinagawa, Tokyo, Japan
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam-Zuidoost, Netherlands
| | - Peter G Kerr
- Monash Medical Centre and Monash University Clayton, Clayton, VIC, Australia
| | - Rajiv Saran
- Department of Internal Medicine and Nephrology, University of Michigan, Ann Arbor, MI, USA
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Yang H, Chen YH, Hsieh TF, Chuang SY, Wu MJ. Prediction of Mortality in Incident Hemodialysis Patients: A Validation and Comparison of CHADS2, CHA2DS2, and CCI Scores. PLoS One 2016; 11:e0154627. [PMID: 27148867 PMCID: PMC4858249 DOI: 10.1371/journal.pone.0154627] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 04/16/2016] [Indexed: 11/24/2022] Open
Abstract
Background The CHADS2 and CHA2DS2 scores are usually applied for stroke prediction in atrial fibrillation patients, and the Charlson comorbidity index (CCI) is a commonly used scale for assessing morbidity. The role in assessing mortality with score system in hemodialysis is not clear and comparisons are lacking. We aimed at evaluating CHADS2, CHA2DS2, and CCI scores to predict mortality in incident hemodialysis patients. Methods Using data from the Nation Health Insurance system of Taiwan (NHIRD) from 1 January 2005 to 31 December 2009, individuals ≧20 y/o who began hemodialysis identified by procedure code and receiving dialysis for > 3 months were included for our study. Renal transplantation patients after dialysis or PD patients were excluded. We calculated the CHADS2, CHA2DS2, and CCI score according to the ICD-9 code and categorized the patients into three groups in each system: 0–1, 2–3, over 4. A total of 3046 incident hemodialysis patients enrolled from NHIRD were examined for an association between the separate scoring systems (CHADS2, CHA2DS2, and CCI score) and mortality. Results CHADS2 and CHA2DS2 scores revealed good predictive value for total mortality (CHADS2 AUC = 0.805; CHA2DS2 AUC = 0.790). However, the CCI score did not reveal a similarly satisfying result (AUC = 0.576). Conclusions Our results show that CHADS2 and CHA2DS2 scores can be applied for mortality prediction in incident hemodialysis patients.
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Affiliation(s)
- Hsun Yang
- Department of Nephrology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Yi-Hsin Chen
- Department of Nephrology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
- * E-mail:
| | - Teng-Fu Hsieh
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Department of Medical Research, Taichung Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Shiun-Yang Chuang
- Department of Medical Research, Taichung Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Ming-Ju Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
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Djukanović L, Dimković N, Marinković J, Djurić Ž, Knežević V, Lazarević T, Ljubenović S, Marković R, Rabrenović V. Association between Hemodialysis Patient Outcomes and Compliance with KDOQI and KDIGO Targets for Mineral and Bone Metabolism. Nephron Clin Pract 2016; 132:168-74. [PMID: 26914677 DOI: 10.1159/000443848] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 01/06/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Increased mortality of hemodialysis (HD) patients is associated with chronic kidney disease-mineral and bone disorders (CKD-MBD), and therefore, their correction may improve patient survival. Differences in targets recommended by KDOQI and KDIGO CKD-MBD guidelines directed us to compare the relative numbers of patients achieving these targets and to examine possible associations between compliance with the targets and patient outcome. METHODS A total of 1,744 patients (61.2% males, aged 58.7 ± 12.5 years) dialyzed in 20 HD centers in Serbia were monitored for 3 years. The number of participants achieving KDOQI/KDIGO guideline targets for serum phosphorus, calcium, and iPTH was determined. The Cox proportional hazards model was used to select variables significantly associated with risk of time to death. RESULTS A majority of patients were dialyzed thrice weekly for 4 h; 86.3% of them used phosphate binders and 49.3% vitamin D3. Proportions of patients achieving KDOQI and KDIGO targets were 49.5 and 44.4% for phosphorus, 53.2 and 76.7% for calcium, 21 and 42.8% for iPTH. Multivariate Cox analysis selected serum phosphorus level outside the KDIGO target, as well as serum iPTH levels outside KDOQI and KDIGO targets as significant mortality predictors. Areas under the receiver operating characteristic curves showed that achievement of both guideline targets for iPTH had similar survival predictive values. CONCLUSION Serum phosphorus levels outside KDIGO targets and iPTH levels outside both KDOQI and KDIGO targets were associated with a significantly higher risk of death. These findings may be useful in the management of CKD-MBD and for establishing local guidelines.
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Otero González A, Iglesias Forneiro A, Camba Caride MJ, Pérez Melón C, Borrajo Prol MP, Novoa Fernández E, Arenas Moncaleano IG, Uribe Moya S, Lagoa Labrador F. Supervivencia en hemodiálisis vs. diálisis peritoneal y por transferencia de técnica. Experiencia en Ourense 1976-2012. Nefrologia 2015; 35:562-6. [DOI: 10.1016/j.nefro.2015.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/03/2015] [Indexed: 10/22/2022] Open
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de Waal D, Heaslip E, Callas P. Medical Nutrition Therapy for Chronic Kidney Disease Improves Biomarkers and Slows Time to Dialysis. J Ren Nutr 2015; 26:1-9. [PMID: 26391566 DOI: 10.1053/j.jrn.2015.08.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 08/04/2015] [Accepted: 08/07/2015] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To investigate whether medical nutrition therapy (MNT) provided by a registered dietitian experienced in chronic kidney disease (CKD) slows the progression of disease and improves nutrition-related biomarkers. DESIGN Retrospective cohort study. SUBJECTS The cohort included 265 participants from a regional nephrology center in a rural state; 147 of who received MNT were compared to a group that did not receive MNT and had started dialysis over a 10-year period. INTERVENTION MNT by a registered dietitian with expertise in CKD. MAIN OUTCOME MEASURE Average time to dialysis, based on stage of CKD at baseline, was compared between groups. In addition, the effect of MNT on the change in biochemical measures for estimated glomerular filtration rate, blood urea nitrogen, albumin, CKD Mineral and Bone Disorder (MBD) markers (phosphorous, calcium, and intact parathyroid hormone) at baseline and at follow-up (dialysis initiation or most recent laboratories if dialysis was not started) was assessed. RESULTS MNT group had less of a decline in estimated glomerular filtration rate than the non-MNT group (0.3 vs. 9.9 mL/minute/1.73 m(2), respectively) a mean difference of 9.6 (P < 0.001). When adjusted for stage using linear regression, the mean difference was greater (11.4, P < .001). Using survival analysis and Cox proportional hazards regression, the non-MNT group was 3.15 more likely to initiate dialysis. Stratified by Stages 3 and 4 that hazard ratio increased (3.47 and 3.45, respectively). Albumin and markers of CKD-MBD were more likely to be within normal limits in the MNT group. The results indicate that better outcomes occur when MNT is given at CKD Stage 3 or 4 rather than CKD Stage 5. CONCLUSIONS Results suggest that people with CKD who received MNT were less likely to start dialysis and had improved nutritional biomarkers than participants who did not receive MNT.
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Affiliation(s)
- Desirée de Waal
- Department of Nephrology, University of Vermont Medical Center, Burlington, Vermont.
| | - Emily Heaslip
- The Community Health Centers of Burlington, Burlington, Vermont
| | - Peter Callas
- Department of Medical Biostatistics, University of Vermont, Burlington, Vermont
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Djukanović L, Dimković N, Marinković J, Andrić B, Bogdanović J, Budošan I, Cvetičanin A, Djordjev K, Djordjević V, Djurić Ž, Lilić BH, Jovanović N, Jelačić R, Knežević V, Kostić S, Lazarević T, Ljubenović S, Marić I, Marković R, Milenković S, Milićević O, Mitić I, Mićunović V, Mišković M, Pilipović D, Plješa S, Radaković M, Stanojević MS, Janković BT, Vojinović G, Šefer K. Compliance with guidelines and predictors of mortality in hemodialysis. Learning from Serbia patients. Nefrologia 2015; 35:287-95. [PMID: 26299172 DOI: 10.1016/j.nefro.2015.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 02/22/2015] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The aims of the study were to determine the percentage of patients on regular hemodialysis (HD) in Serbia failing to meet KDOQI guidelines targets and find out factors associated with the risk of time to death and the association between guidelines adherence and patient outcome. METHODS A cohort of 2153 patients on regular HD in 24 centers (55.7% of overall HD population) in Serbia were followed from January 2010 to December 2012. The percentage of patients failing to meet KDOQI guidelines targets of dialysis dose (Kt/V>1.2), hemoglobin (>110g/L), serum phosphorus (1.1-1.8mmol/L), calcium (2.1-2.4mmol/L) and iPTH (150-300pg/mL) was determined. Cox proportional hazards analysis was used to select variables significantly associated with the risk of time to death. RESULTS The patients were on regular HD for 5.3±5.3 years, dialyzed 11.8±1.9h/week. Kt/V<1.2 had 42.4% of patients, hemoglobin <110g/L had 66.1%, s-phosphorus <1.1mmol/L had 21.7% and >1.8mmol/L 28.6%, s-calcium <2.1mmol/L had 11.7% and >2.4mmol/L 25.3%, iPTH <150pg/mL had 40% and >300pg/mL 39.7% of patients. Using Cox model (adjustment for patient age, gender, duration of HD treatment) age, duration of HD treatment, hemoglobin, iPTH and diabetic nephropathy were selected as significant independent predictors of time to death. When targets of five examined parameters were included in Cox model, target for KtV, hemoglobin and iPTH were found to be significant independent predictors of time to death. CONCLUSION Substantial proportion of patients examined failed to meet KDOQI guidelines targets. The relative risk of time to death was associated with being outside the targets for Kt/V, hemoglobin and iPTH.
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Affiliation(s)
| | - Nada Dimković
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | | | | | | | - Ivana Budošan
- Department of Nephrology, Clinical Center of Vojvodina, Novi Sad, Serbia
| | - Anica Cvetičanin
- Nephrology Ward, Health Center Srem, Mitrovica, Srem Mitrovica, Serbia
| | | | | | - Živka Djurić
- Department of Nephrology, Clinical Centre Zvezdara, Belgrade, Serbia
| | | | | | - Rosa Jelačić
- Department of Nephrology, General Hospital Zrenjanin, Zrenjanin, Serbia
| | - Violeta Knežević
- Department of Nephrology, Clincal Center of Vojvodina, Novi Sad, Serbia
| | | | - Tatjana Lazarević
- Department of Nephrology, Clinical Center of Kragujevac, Kragujevac, Serbia
| | | | - Ivko Marić
- Department of Nephrology, Lazarevac, Serbia
| | | | | | | | - Igor Mitić
- Department of Nephrology, Clincal Center of Vojvodina, Novi Sad, Serbia
| | | | - Milena Mišković
- Hemodialysis Ward, Health Center Obrenovac, Obrenovac, Serbia
| | - Dragana Pilipović
- Hemodialysis Ward, Health Center Bačka Palanka, Bačka Palanka, Serbia
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The Effects of Survival Predictors Before Hemodialysis Initiation is Different in Adults and the Elderly. INT J GERONTOL 2015. [DOI: 10.1016/j.ijge.2014.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Ponticelli C, Podestà MA, Graziani G. Renal transplantation in elderly patients. How to select the candidates to the waiting list? Transplant Rev (Orlando) 2014; 28:188-92. [PMID: 25154797 DOI: 10.1016/j.trre.2014.07.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/22/2014] [Indexed: 01/09/2023]
Abstract
Today, old age does not represent a formal contraindication to kidney transplantation. Rather, there is evidence that in elderly patients renal transplantation offers longer life expectancy and better quality of life in comparison with dialysis. Yet, the results of renal transplantation in recipients older than 65years are inferior to those observed in younger adults, death with functioning graft representing a major cause of failure. Therefore, the selection of aged patients is of paramount importance. Apart from the routine clinical and biological investigations, three aspects have been relatively neglected by the transplant community and may require a careful analysis in elderly candidates to transplantation: the presence and degree of frailty, the presence of comorbidities and the adherence to prescriptions. Although there are rapid and simple tests for assessing the degree of frailty in the elderly, there is no clear cut-off value to decide whether a patient should be accepted or not. With advanced age the prevalence and severity of cardiovascular events and other diseases tend to increase. The use of combined age-comorbidity indices may be helpful to identify patients at high risk of mortality. Another critical point is the poor unintentional adherence to treatment, often caused by forgetfulness and mild cognitive impairment. These drawbacks may be further enhanced by a high number of pills to take and by changes in the dosage or type of prescriptions. A careful screening of the presence and degree of frailty, comorbidity and poor compliance to treatment is highly recommended before admitting older candidates to the waiting list for transplantation.
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Affiliation(s)
- Claudio Ponticelli
- Nephrology and Dialysis unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano (Milano), Italy.
| | - Manuel Alfredo Podestà
- Nephrology and Dialysis unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano (Milano), Italy
| | - Giorgio Graziani
- Nephrology and Dialysis unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano (Milano), Italy
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Akolekar D, Forsythe JLR, Oniscu GC. Impact of patient characteristics and comorbidity profile on activation of patients on the kidney transplantation waiting list. Transplant Proc 2014; 45:2115-22. [PMID: 23953520 DOI: 10.1016/j.transproceed.2013.03.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 03/06/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this study was to examine which demographic and comorbidity factors affected the activation of patients with end-stage renal disease on the national kidney transplantation waiting list. METHODS This was a prospective cohort study across 13 transplantation centers in the United Kingdom from October 1, 2006 to September 30, 2007. Data were collected for all new adult patients (n = 1530) referred to the renal transplantation assessment clinic. The proportion of patients who were activated to the waiting list after a minimum one year follow-up was estimated. Factors influencing activation of patients on the waiting list were examined. RESULTS A total of 872 (58.9%) patients were activated to the transplantation waiting list. The likelihood of activation to the transplantation waiting list was lower in patients older than 65 years (P = .021), nonwhite ethnicity (P < .0001), smokers (P < .0001), and those in whom diabetes was the cause of renal failure (P = .004). Multivariate analysis showed that there was an adverse impact of comorbidity such as ischemic heart disease (P = .003), diabetes (P = .006), and peripheral vascular disease (P = .007) on the likelihood of activation to the waiting list. CONCLUSION Patient characteristics and comorbidity are associated with the probability of activation of patients to the waiting list.
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Affiliation(s)
- D Akolekar
- Transplant Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, United Kingdom
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Kolesnyk I, Noordzij M, Kolesnyk M, Kulyzky M, Jager KJ. Renal replacement therapy in Ukraine: epidemiology and international comparisons. Clin Kidney J 2014; 7:330-5. [PMID: 25852905 PMCID: PMC4377756 DOI: 10.1093/ckj/sfu037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 03/27/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Little is known about the status of renal replacement therapy (RRT) in the post-Soviet countries. We therefore investigated the epidemiology and treatment outcomes of RRT in Ukrainian patients and put the results into an international perspective. METHODS Data from the Ukrainian National Renal Registry for patients on RRT between 1 January 2010 and 31 December 2012 were selected. We calculated the incidence and prevalence of RRT per million population (pmp) and the 3-, 12- and 24-month patient survival using the Kaplan-Meier method and Cox regression. RESULTS There were 5985 prevalent patients on RRT on 31 December 2012 (131.2 pmp). Mean age was 46.5 ± 13.8 years, 56% men and 74% received haemodialysis (HD), while peritoneal dialysis and kidney transplantation both represented 13%. The most common cause of end-stage renal disease was glomerulonephritis (51%), while only 12% had diabetes. In 2012, 1129 patients started dialysis (incidence 24.8 pmp), with 80% on HD. Mean age was 48 ± 14 years, 58% men and 20% had diabetes. Three, 12- and 24-month patient survival on dialysis was 95.1%, 86.0% and 76.4%, respectively. The transplant rate in 2012 was 2.1 pmp. CONCLUSIONS The incidence and prevalence of RRT and the transplantation rate in Ukraine are among the lowest in Europe, suggesting that the need for RRT is not being met. Strategies to reduce the RRT deficit include the development and improvement of transplantation and home-based dialysis programmes. Further evaluation of the quality of Ukrainian RRT care is needed.
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Affiliation(s)
- Inna Kolesnyk
- Ukrainian Renal Registry , Institute of Nephrology , Kiev , Ukraine
| | - Marlies Noordzij
- ERA-EDTA Registry, Department of Medical Informatics , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Mykola Kolesnyk
- Ukrainian Renal Registry , Institute of Nephrology , Kiev , Ukraine
| | - Mykola Kulyzky
- Ukrainian Renal Registry , Institute of Nephrology , Kiev , Ukraine
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
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Hemke AC, Heemskerk MBA, van Diepen M, Weimar W, Dekker FW, Hoitsma AJ. Survival prognosis after the start of a renal replacement therapy in the Netherlands: a retrospective cohort study. BMC Nephrol 2013; 14:258. [PMID: 24256551 PMCID: PMC4225578 DOI: 10.1186/1471-2369-14-258] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 11/06/2013] [Indexed: 11/21/2022] Open
Abstract
Background There is no single model available to predict the long term survival for patients starting renal replacement therapy (RRT). The available models either predict survival on dialysis until transplantation, survival on the transplant waiting list, or survival after transplantation. The aim of this study was to develop a model that includes dialysis survival and survival after an eventual transplantation. Methods From the Dutch renal replacement registry, patients of 16 years of age or older were included if they started RRT between 1995 and 2005, still underwent RRT at baseline (90 days after the start of RRT) and were not registered at a non-renal organ transplant waiting list (N = 13868). A prediction model of 10-year patient survival after baseline was developed through multivariate Cox regression analysis, in one half of the research group. Age at start, sex, primary renal disease (PRD) and therapy at baseline were included as possible predictors. A sensitivity analysis has been performed to determine whether listing on the transplant waiting list should be added. The predictive performance of the model was internally validated. Calibration and discrimination were computed in the other half of the research group. Another sensitivity analysis was to assess whether the outcomes differed if the model was developed and tested in two geographical regions, which were less similar than the original development and validation group. No external validation has been performed. Results Survival probabilities were influenced by age, sex, PRD and therapy at baseline (p < 0.001). The calibration and discrimination both showed very reasonable results for the prediction model (C-index = 0.720 and calibration slope for the prognostic index = 1.025, for the 10 year survival). Adding registration on the waiting list for renal transplantation as a predictor did not improve the discriminative power of the model and was therefore not included in the model. Conclusions With the presented prediction model, it is possible to give a reasonably accurate estimation on the survival chances of patients who start with RRT, using a limited set of easily available data.
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Affiliation(s)
- Aline C Hemke
- Organ Centre, Dutch Transplant Foundation, Leiden, the Netherlands.
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Fotheringham J, Jacques RM, Fogarty D, Tomson CRV, El Nahas M, Campbell MJ. Variation in centre-specific survival in patients starting renal replacement therapy in England is explained by enhanced comorbidity information from hospitalization data. Nephrol Dial Transplant 2013; 29:422-30. [PMID: 24052459 DOI: 10.1093/ndt/gft363] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Unadjusted survival on renal replacement therapy (RRT) varies widely from centre to centre in England. Until now, missing data on case mix have made it impossible to determine whether this variation reflects genuine differences in the quality of care. Data linkage has the capacity to reduce missing data. METHODS Modelling of survival using Cox proportional hazards of data returned to the UK Renal Registry on patients starting RRT for established renal failure in England. Data on ethnicity, socioeconomic status and comorbidity were obtained by linkage to the Hospital Episode Statistics database, using data from hospitalizations prior to starting RRT. RESULTS Patients with missing data were reduced from 61 to 4%. The prevalence of comorbid conditions was remarkably similar across centres. When centre-specific survival was compared after adjustment solely for age, survival was below the 95% limit for 6 of 46 centres. The addition of variables into the multivariable model altered the number of centres that appeared to be 'outliers' with worse than expected survival as follows: ethnic origin four outliers, socioeconomic status eight outliers and year of the start of RRT four outliers. The addition of a combination of 16 comorbid conditions present at the start of RRT reduced the number of centres with worse than expected survival to one. CONCLUSIONS Linked data between a national registry and hospital admission dramatically reduced missing data, and allowed us to show that nearly all the variation between English renal centres in 3-year survival on RRT was explained by demographic factors and by comorbidity.
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Affiliation(s)
- James Fotheringham
- School for Health and Related Research, University of Sheffield, Sheffield, UK
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Ros S, Remón C, Qureshi AR, Quiros P, Lindholm B, Carrero JJ. Increased risk of fatal infections in women starting peritoneal dialysis. Perit Dial Int 2013; 33:487-94. [PMID: 24084838 PMCID: PMC3797666 DOI: 10.3747/pdi.2012.00243] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 07/25/2013] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although cardiovascular disease (CVD) is an important cause of morbidity and mortality in patients with end-stage renal disease, non-CVD causes account for more than 50% of total deaths. We previously showed that, compared with men, women starting dialysis-- both hemodialysis and peritoneal dialysis (PD)--have higher non-CVD mortality rates. Here, we evaluate sex-specific outcomes in a large cohort of incident PD patients. METHODS Incident de novo PD patients from the Andalusian SICATA Registry for 1999 - 2010, with follow-up until 31 December 2010 or up to 5 years, were investigated for fatal outcomes. Causes of death were extracted from medical records. The analysis used traditional and competing-risk Cox models for all-cause and cause-specific mortality in men and women, correcting in the competing-risk models for the events of kidney transplantation and transfer to hemodialysis. RESULTS A total of 1458 patients (57% men; mean overall age: 55.3 ± 17.0 years) initiated PD in Andalusia during the study period. During follow-up, 350 deaths, 355 renal transplantation procedures, and 331 transfers to hemodialysis were recorded. Vascular disease and diabetic nephropathy were the most frequent causes of kidney failure in men; other causes were more common in women. In the traditional Cox model, both sexes showed a similar all-cause mortality risk [crude hazard ratio (HR): 0.90; 95% confidence interval (CI): 0.72 to 1.12]. However, with respect to specific causes of death, women showed a borderline lower risk of both CVD (crude HR: 0.71; 95% CI: 0.50 to 0.99) and non-CVD mortality from other than infection (crude HR: 0.81; 95% CI: 0.57 to 1.15). In contrast, the risk of death from infection was almost doubled in women compared with men (crude HR: 1.92; 95% CI: 1.15 to 3.20), a finding that held true after multivariate adjustment for age, primary renal disease, period of inclusion, and initial PD modality (adjusted HR: 1.76; 95% CI: 1.03 to 3.01). This result was confirmed even taking into consideration the competing events of kidney transplantation and transfer to hemodialysis. CONCLUSIONS Compared with men starting PD, women starting PD are at higher risk of mortality from infection. More stringent screening measures and corrective efforts in women might be indicated.
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Affiliation(s)
- Silvia Ros
- Divisions of Baxter Novum and Renal Medicine,1 Karolinska Institutet, Stockholm, Sweden
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Abstract
Most patients starting dialysis can choose between peritoneal dialysis and haemodialysis. There is little evidence proving that one form of dialysis is better than the other; although there may be an early advantage to peritoneal dialysis (PD) in young patients with residual function this effect is short-lived. Technique failure develops after years on PD so dialysis modality will often change during a long dialysis career. Quality of life studies, which must be interpreted carefully, indicate that patients require information about the impact of dialysis on their lifestyle as well as health-related outcomes so that they can choose the most suitable dialysis modality. Increasing numbers of frail elderly patients are starting dialysis; support in the home by nursing staff may facilitate the use of PD in this group. In the UK guidelines prioritise the patient's choice of dialysis modality (where feasible) based on good quality predialysis education. Cost of treatment is generally lower on PD, which is particularly recommended for patients with residual renal function and few comorbidities.
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Kramer A, Jager KJ, Fogarty DG, Ravani P, Finne P, Pérez-Panadés J, Prütz KG, Arias M, Heaf JG, Wanner C, Stel VS. Association between pre-transplant dialysis modality and patient and graft survival after kidney transplantation. Nephrol Dial Transplant 2013; 27:4473-80. [PMID: 23235955 DOI: 10.1093/ndt/gfs450] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Previous studies have found inconsistent associations between pre-transplant dialysis modality and subsequent post-transplant survival. We aimed to examine this relationship using the instrumental variable method and to compare the results with standard Cox regression. METHODS We included 29 088 patients (age >20 years) from 16 European national or regional renal registries who received a first kidney transplant between 1 January 1999 and 31 December 2008 and were on dialysis before transplantation for a period between 90 days and 10 years. Standard multivariable Cox regression examined the association of individually assigned pre-transplant dialysis modality with post-transplant patient and graft survival. To decrease confounding-by-indication through unmeasured factors, we applied the instrumental variable method that used the case-mix adjusted centre percentage of peritoneal dialysis (PD) as predictor variable. RESULTS Standard analyses adjusted for age, sex, primary renal disease, donor type, duration of dialysis, year of transplantation and country suggested that PD before transplantation was associated with better patient [hazard ratio, HR (95% CI) = 0.83 (0.76-0.91)] and graft survival (HR (95% CI) 0.90 (0.84-0.96)) when compared with haemodialysis (HD). In contrast, the instrumental variable analysis showed that a 10% increase in the case-mix adjusted centre percentage of patients on PD was neither associated with post-transplant patient survival [HR (95% CI = 1.00 (0.97-1.04)] nor with graft survival [HR (95% CI) = 1.01 (0.98-1.04)]. CONCLUSIONS The instrumental variable method failed to confirm the associations found in standard Cox regression between pre-transplant dialysis modality and patient and graft survival after transplantation. The lack of association in instrumental variable analysis may be due to better control of residual confounding.
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Affiliation(s)
- Anneke Kramer
- ERA–EDTA Registry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Ng YY, Hung YN, Wu SC, Ko PJ, Hwang SM. Progression in comorbidity before hemodialysis initiation is a valuable predictor of survival in incident patients. Nephrol Dial Transplant 2013; 28:1005-1012. [DOI: 10.1093/ndt/gfs512] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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van de Luijtgaarden MW, Jager KJ, Stel VS, Kramer A, Cusumano A, Elliott RF, Geue C, MacLeod AM, Stengel B, Covic A, Caskey FJ. Global differences in dialysis modality mix: the role of patient characteristics, macroeconomics and renal service indicators. Nephrol Dial Transplant 2013; 28:1264-75. [DOI: 10.1093/ndt/gft053] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Impact of a modified data capture period on Liu comorbidity index scores in Medicare enrollees initiating chronic dialysis. BMC Nephrol 2013; 14:51. [PMID: 23446357 PMCID: PMC3599670 DOI: 10.1186/1471-2369-14-51] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 02/21/2013] [Indexed: 12/02/2022] Open
Abstract
Background The Liu Comorbidity Index uses the United States Renal Data System (USRDS) to quantify comorbidity in chronic dialysis patients, capturing baseline comorbidities from days 91 through 270 after dialysis initiation. The 270 day survival requirement results in sample size reductions and potential survivor bias. An earlier and shorter time-frame for data capture could be beneficial, if sufficiently similar comorbidity information could be ascertained. Methods USRDS data were used in a retrospective observational study of 70,114 Medicare- and Medicaid-eligible persons who initiated chronic dialysis during the years 2000–2005. The Liu index was modified by changing the baseline comorbidity capture period to days 1–90 after dialysis initiation for persons continuously enrolled in Medicare. The scores resulting from the original and the modified comorbidity indices were compared, and the impact on sample size was calculated. Results The original Liu comorbidity index could be calculated for 75% of the sample, but the remaining 25% did not survive to 270 days. Among 52,937 individuals for whom both scores could be calculated, the mean scores for the original and the modified index were 7.4 ± 4.0 and 6.4 ± 3.6 points, respectively, on a 24-point scale. The most commonly calculated difference between scores was zero, occurring in 44% of patients. Greater comorbidity was found in those who died before 270 days. Conclusions A modified version of the Liu comorbidity index captures the majority of comorbidity in persons who are Medicare-enrolled at the time of chronic dialysis initiation. This modification reduces sample size losses and facilitates inclusion of a sicker portion of the population in whom early mortality is common.
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Couchoud C, Villar E. End-stage renal disease epidemic in diabetics: is there light at the end of the tunnel? Nephrol Dial Transplant 2013; 28:1073-6. [DOI: 10.1093/ndt/gfs559] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Temme J, Kramer A, Jager KJ, Lange K, Peters F, Müller GA, Kramar R, Heaf JG, Finne P, Palsson R, Reisæter AV, Hoitsma AJ, Metcalfe W, Postorino M, Zurriaga O, Santos JP, Ravani P, Jarraya F, Verrina E, Dekker FW, Gross O. Outcomes of male patients with Alport syndrome undergoing renal replacement therapy. Clin J Am Soc Nephrol 2012; 7:1969-76. [PMID: 22997344 DOI: 10.2215/cjn.02190312] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with the hereditary disease Alport syndrome commonly require renal replacement therapy (RRT) in the second or third decade of life. This study compared age at onset of RRT, renal allograft, and patient survival in men with Alport syndrome receiving various forms of RRT (peritoneal dialysis, hemodialysis, or transplantation) with those of men with other renal diseases. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with Alport syndrome receiving RRT identified from 14 registries in Europe were matched to patients with other renal diseases. A linear spline model was used to detect changes in the age at start of RRT over time. Kaplan-Meier method and Cox regression analysis were used to examine patient and graft survival. RESULTS Age at start of RRT among patients with Alport syndrome remained stable during the 1990s but increased by 6 years between 2000-2004 and 2005-2009. Survival of patients with Alport syndrome requiring dialysis or transplantation did not change between 1990 and 2009. However, patients with Alport syndrome had better renal graft and patient survival than matched controls. Numbers of living-donor transplantations were lower in patients with Alport syndrome than in matched controls. CONCLUSIONS These data suggest that kidney failure in patients with Alport syndrome is now being delayed compared with previous decades. These patients appear to have superior patient survival while undergoing dialysis and superior patient and graft survival after deceased-donor kidney transplantation compared with patients receiving RRT because of other causes of kidney failure.
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Affiliation(s)
- Johanna Temme
- Dept Nephrology&Rheumatology, University Medical Center Göttingen, Göttingen, Germany
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Kramer A, Stel VS, Caskey FJ, Stengel B, Elliott RF, Covic A, Geue C, Cusumano A, Macleod AM, Jager KJ. Exploring the association between macroeconomic indicators and dialysis mortality. Clin J Am Soc Nephrol 2012; 7:1655-63. [PMID: 22837275 DOI: 10.2215/cjn.10461011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Mortality on dialysis varies greatly worldwide, with patient-level factors explaining only a small part of this variation. The aim of this study was to examine the association of national-level macroeconomic indicators with the mortality of incident dialysis populations and explore potential explanations through renal service indicators, incidence of dialysis, and characteristics of the dialysis population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Aggregated unadjusted survival probabilities were obtained from 22 renal registries worldwide for patients starting dialysis in 2003-2005. General population age and health, macroeconomic indices, and renal service organization data were collected from secondary sources and questionnaires. Linear modeling with log-log transformation of the outcome variable was applied to establish factors associated with survival on dialysis. RESULTS Two-year survival on dialysis ranged from 62.3% in Iceland to 89.8% in Romania. A higher gross domestic product per capita (hazard ratio=1.02 per 1000 US dollar increase), a higher percentage of gross domestic product spent on healthcare (1.10 per percent increase), and a higher intrinsic mortality of the dialysis population (i.e., general population-derived mortality risk of the dialysis population in that country standardized for age and sex; hazard ratio=1.04 per death per 10,000 person years) were associated with a higher mortality of the dialysis population. The incidence of dialysis and renal service indicators were not associated with mortality on dialysis. CONCLUSIONS Macroeconomic factors and the intrinsic mortality of the dialysis population are associated with international differences in the mortality on dialysis. Renal service organizational factors and incidence of dialysis seem less important.
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Affiliation(s)
- Anneke Kramer
- European Renal Association-European Dialysis and TransplantationAssociation Registry, Academic Medical Center, University of Amsterdam, The Netherlands.
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Taghipour S, Banjevic D, Fernandes J, Miller AB, Montgomery N, Harvey BJ, Jardine AKS. Incidence of invasive breast cancer in the presence of competing mortality: the Canadian National Breast Screening Study. Breast Cancer Res Treat 2012; 134:839-51. [PMID: 22689090 DOI: 10.1007/s10549-012-2113-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 05/23/2012] [Indexed: 12/29/2022]
Abstract
Mortality due to causes other than breast cancer is a potential competing risk which may alter the incidence probability of breast cancer and as such should be taken into account in predictive modelling. We used data from the Canadian National Breast Screening Study (CNBSS), which consist of two randomized controlled trials designed to evaluate the efficacy of mammography among women aged 40-59. The participants in the CNBSS were followed up for incidence of breast cancer and mortality due to breast cancer and other causes; this allowed us to construct a breast cancer risk prediction model while taking into account mortality for the same study population. In this study, we use 1980-1989 as the study period. We exclude the prevalent cancers from the CNBSS to estimate the probability of developing breast cancer, given the fact that women were cancer-free at the beginning of the follow-up. By the end of 1989, from 89,434 women, 944 (1.1 %) were diagnosed with invasive breast cancer, 922 (1.0 %) died from causes other than breast cancer, and 87,568 (97.9 %) were alive and not diagnosed with invasive breast cancer. We constructed a risk prediction model for invasive breast cancer based on 39 risk factors collected at the time of enrolment or the initial physical examination of the breasts. Age at entry (HR 1.07, 95 % CI 1.05-1.10), lumps ever found in left or right breast (HR 1.92, 95 % CI 1.19-3.10), abnormality in the left breast (HR 1.26, 95 % CI 1.07-1.48), history of other breast disease, family history of breast cancer score (HR 1.01, 95 % CI 1.00-1.01), years menstruating (HR 1.02, 95 % CI 1.01-1.03) and nulliparity (HR 1.70, 95 % CI 1.23-2.36) are the model's predictors. We investigated the effects of time-dependent factors. The model is well calibrated with a moderate discriminatory power (c-index 0.61, 95 % CI 0.59-0.63); we use it to predict the 9-year risk of developing breast cancer for women of different age groups. As an example, we estimated the probability of invasive cancer at 5 years after enrolment to be 0.00448, 0.00556, 0.00691, 0.00863, and 0.01034, respectively, for women aged 40, 45, 50, 55, and 59, all of whom had never noted lumps in their breasts, had 32 years of menstruating, 1-2 live births, no other types of breast disease and no abnormality found in their left breasts. The results of this study can be used by clinicians to identify women at high risk of breast cancer for screening intervention and to recommend a personalized intervention plan. The model can be also utilized by a woman as a breast cancer risk prediction tool.
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Utilization Patterns of IV Iron and Erythropoiesis Stimulating Agents in Anemic Chronic Kidney Disease Patients: A Multihospital Study. Anemia 2012; 2012:248430. [PMID: 22577528 PMCID: PMC3345210 DOI: 10.1155/2012/248430] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 01/24/2012] [Indexed: 01/06/2023] Open
Abstract
Intravenous (IV) iron and Erythropoiesis Stimulating Agents (ESAs) are recommended for anemia management in chronic kidney disease (CKD). This retrospective cohort study analyzed utilization patterns of IV iron and ESA in patients over 18 years of age admitted to University Health System Hospitals with a primary or secondary diagnosis of CKD between January 1, 2006 to December 31, 2008. A clustered binomial logistic regression using the GEE methodology was used to identify predictors of IV iron utilization. Only 8% (n = 6678) of CKD patients on ESA therapy received IV iron supplementation in university hospitals. Those receiving iron used significantly less amounts of ESAs. Patient demographics (age, race, primary payer), patient clinical conditions (admission status, severity of illness, dialysis status), and physician specialty were identified as predictors of IV iron use in CKD patients. Use of IV iron with ESAs was low despite recommendations from consensus guidelines. The low treatment rate of IV iron represents a gap in treatment practices and signals an opportunity for healthcare improvement in CKD anemic patients.
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Haapio M, Helve J, Kurimo P, Forslund T, Grönhagen-Riska C, Finne P. Decline in glomerular filtration rate during pre-dialysis phase and survival on chronic renal replacement therapy. Nephrol Dial Transplant 2011; 27:1157-63. [PMID: 21810761 DOI: 10.1093/ndt/gfr423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Estimated glomerular filtration rate (eGFR) is widely used in follow-up and assessment of patients before start of chronic renal replacement therapy (RRT). Reported data on impact of eGFR decline pattern during pre-dialysis phase on consequent survival on RRT are, however, non-existent. METHODS Using the database of the Finnish Registry for Kidney Diseases, we conducted a cohort study of all incident adult patients (n = 457) entering chronic RRT in Finland in 1998, with follow-up until 31 December 2008. We included those (n = 319) with three serum creatinine measurements (at ∼12 and 3 months and 1 to 2 weeks prior to RRT start) and calculated their slopes of eGFR using the modification of diet in renal disease formula. According to eGFR slopes (in mL/min/1.73m(2)/year), patients were divided into tertiles: most rapid (>8.5, n = 107), intermediate (3.4-8.5, n = 107) and slowest decline (<3.4, n = 105). RESULTS Median survival time was 5.6 (95% confidence interval 4.2-7.0) years. Compared to the patient group with the slowest eGFR decline, age- and gender-adjusted relative risk of death was 1.1 (0.8-1.5) in the intermediate group and 1.7 (1.2-2.4, P = 0.002) in the most rapid decline group. When further adjusting for kidney disease diagnosis, comorbidities, use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, body mass index, blood haemoglobin and serum albumin, the association was no longer significant. CONCLUSIONS Rapid decline in eGFR before entering chronic RRT associates with increased mortality on RRT. The elevated mortality appears to be caused by known risk factors for death on RRT.
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Affiliation(s)
- Mikko Haapio
- Division of Nephrology, Helsinki University Central Hospital, Helsinki, Finland.
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Helve J, Haapio M, Groop PH, Grönhagen-Riska C, Finne P. Comorbidities and survival of patients with type 1 diabetes on renal replacement therapy. Diabetologia 2011; 54:1663-9. [PMID: 21465326 DOI: 10.1007/s00125-011-2140-6] [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] [Received: 09/10/2010] [Accepted: 03/17/2011] [Indexed: 11/30/2022]
Abstract
AIMS/HYPOTHESIS Comorbidities are frequent among type 1 diabetes patients on renal replacement therapy, yet the effect of comorbidities on survival is unknown. Our aim was to estimate this effect. METHODS An incident cohort of all patients with type 1 diabetes entering chronic renal replacement therapy (n = 656) in Finland between 2000 and 2008 was followed until death or the end of follow-up on 31 December 2008. All data were obtained from the Finnish Registry for Kidney Diseases, which collects information on comorbidities at the start of renal replacement therapy. The main outcome measure was relative risk of death according to comorbidities. RESULTS At start of renal replacement therapy, 22% of the patients with type 1 diabetes had coronary artery disease, 19% peripheral vascular disease, 11% cerebrovascular disease, 33% left ventricular hypertrophy and 7% heart failure. All these comorbidities were significant predictors of death in univariate analyses (RR 1.6-4.9). The 5 year survival probability of patients without comorbidities was 74%, while it was 56% and 37%, respectively, for those with one or more than one comorbidity. When the comorbidities were studied in a multivariate model, adjusting for age and sex, peripheral vascular disease (RR 1.9), left ventricular hypertrophy (RR 1.7) and heart failure (RR 2.5) remained independent risk factors for death. Calculations indicated that one-third of deaths in the study population could be attributed to comorbidities. CONCLUSIONS/INTERPRETATION Among patients with type 1 diabetes entering renal replacement therapy, comorbidities are common and strong predictors of death. Therefore, it is essential to identify and adequately treat comorbidities.
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Affiliation(s)
- J Helve
- Finnish Registry for Kidney Diseases, Kumpulantie 1 A, 6th floor, FI-00520 Helsinki, Finland.
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Icks A, Haastert B, Genz J, Giani G, Hoffmann F, Trapp R, Koch M. Time-dependent impact of diabetes on the mortality of patients on renal replacement therapy: a population-based study in Germany (2002-2009). Diabetes Res Clin Pract 2011; 92:380-5. [PMID: 21420753 DOI: 10.1016/j.diabres.2011.02.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 02/07/2011] [Accepted: 02/14/2011] [Indexed: 11/15/2022]
Abstract
AIMS To estimate the impact of diabetes on the mortality of patients with incident renal replacement therapy (RRT). METHODS We assessed the mortality of 544 incident RRT patients aged ≥ 30 years between 2002 and 2009 (57.9% men, mean age 70.3 years, 49.6% patients with diabetes) by analyzing the data of all dialysis centers covering a German region. We compared the estimated time-dependent hazard ratios of patients with and without diabetes by using the Cox proportional-hazards regression model. RESULTS Overall, 319 patients had died (158 diabetic), approximately 50% after 3 years. Up to about 3 years, the mortality rate was lower in diabetic than in nondiabetic patients. Thereafter, the survival curves crossed (interaction diabetes × time, p = 0.002; adjusted hazard ratios for diabetes: baseline, 0.66; year 1, 0.84; year 2, 1.05; year 3, 1.33; year 4, 1.68). The results were similar in men and women; however, the interaction of diabetes and time was significant only in men (p = 0.004). Further significant risk factors of mortality were age, sex, initial central venous catheter, cardiovascular disease, and malignancy. CONCLUSIONS In this population-based study, the influence of diabetes was time-dependent, with a lower mortality in diabetic versus non-diabetic patients in the first three years but a higher mortality in these patients after 3 years. Results were similar in men and women.
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Affiliation(s)
- Andrea Icks
- Department of Public Health, Faculty of Medicine, Heinrich-Heine-University, Düsseldorf, Germany.
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Collier T, Steenkamp R, Tomson C, Caskey F, Ansell D, Roderick P, Nitsch D. Patterns and effects of missing comorbidity data for patients starting renal replacement therapy in England, Wales and Northern Ireland. Nephrol Dial Transplant 2011; 26:3651-8. [PMID: 21436380 DOI: 10.1093/ndt/gfr111] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Renal Registries play a key role in assessing quality of care and outcomes of renal replacement therapy and comparisons of outcomes between groups should adjust for differences in comorbidities. This study aimed to describe patterns of missing comorbidity data and differences in survival between patients with comorbidity data returned and those with missing comorbidity data. METHODS Trends in comorbidity data returns by year (1998-2006) and within centres were examined using descriptive statistics. Survival of patients was described using Kaplan-Meier graphs (log-rank tests) and hazard ratios were calculated using Cox proportional hazard models. Last follow-up was at 31 December 2007. A range of sensitivity analyses were carried out, including multiple imputation. RESULTS Among 34,059 patients, there were 62% who had no comorbidity data. The completeness of comorbidity data increased markedly from 17% in 1998 to 47% in 2003, but had fallen back to 37% by the year 2006. Those with a missing comorbidity generally do considerably worse than those without the comorbidity and in most cases more closely follow the survival curve of those with the comorbidity. Multiple imputation analysis suggested that those with missing information on comorbidity have higher prevalence of comorbidity than seen in those with available data. Treating missing comorbidity entries as indication of absent comorbidity (i.e. a tick only if yes policy) would lead to an attenuation of the effect of comorbidity on survival. CONCLUSIONS Missing data lead to difficulties in performing between centre comparisons. A 'tick if present policy' in comorbidity data collection should be discouraged. Much more work is needed to fully understand why levels of missing comorbidity data are so high and to identify strategies to improve recording.
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Affiliation(s)
- Timothy Collier
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Couchoud C, Villar E. Sources d’erreur dans les analyses de survie : spécificités des patients insuffisants rénaux chroniques terminaux. Nephrol Ther 2011; 7:27-31. [DOI: 10.1016/j.nephro.2010.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Revised: 10/04/2010] [Accepted: 10/11/2010] [Indexed: 02/02/2023]
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Moist LM, Richards HA, Miskulin D, Lok CE, Yeates K, Garg AX, Trpeski L, Chapman A, Amuah J, Hemmelgarn BR. A validation study of the Canadian Organ Replacement Register. Clin J Am Soc Nephrol 2011; 6:813-8. [PMID: 21258038 DOI: 10.2215/cjn.06680810] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Accurate and complete documentation of patient characteristics and comorbidities in renal registers is essential to control bias in the comparison of outcomes across groups of patients or dialysis facilities. The objectives of this study were to assess the quality of data collected in the Canadian Organ Replacement Register (CORR) compared with the patient's medical charts. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This cohort study of a representative sample of adult, incident patients registered in CORR in 2005 to 2006 examined the prevalence, sensitivity, specificity, positive and negative predictive values, and κ of comorbid conditions and agreement in coding of patient demographics and primary renal disease between CORR and the patient's medical record. The effect of coding variation on patient survival was evaluated. RESULTS Medical records on 1125 patients were reviewed. Agreement exceeded 97% for health card number, date of birth, and sex and 71% (range 46.6 to 89.1%) for the primary renal disease. Comorbid conditions were under-reported in CORR. Sensitivities ranged from 0.89 (95% confidence interval 0.80, 0.92) for hypertension to 0.47 (0.38, 0.55) for peripheral vascular disease. Specificity was >0.93 for all comorbidities except hypertension. Hazard ratios for death were similar whether calculated using data from CORR or the medical record. CONCLUSIONS Comorbid conditions are under-reported in CORR; however, the associated risks of mortality were similar whether using the CORR data or the medical record data, suggesting that CORR data can be used in clinical research with minimal concern for bias.
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Affiliation(s)
- Louise M Moist
- Division of Nephrology, London Health Sciences Centre, and the University of Western Ontario, London, Ontario, Canada.
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Nitsch D, Steenkamp R, Tomson CRV, Roderick P, Ansell D, MacGregor MS. Outcomes in patients on home haemodialysis in England and Wales, 1997-2005: a comparative cohort analysis. Nephrol Dial Transplant 2010; 26:1670-7. [DOI: 10.1093/ndt/gfq561] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Eckardt KU, Kim J, Kronenberg F, Aljama P, Anker SD, Canaud B, Molemans B, Stenvinkel P, Schernthaner G, Ireland E, Fouqueray B, Macdougall IC. Hemoglobin variability does not predict mortality in European hemodialysis patients. J Am Soc Nephrol 2010; 21:1765-75. [PMID: 20798262 DOI: 10.1681/asn.2009101017] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Patients with CKD exhibit significant within-patient hemoglobin (Hb) level variability, especially with the use of erythropoiesis stimulating agents (ESAs) and iron. Analyses of dialysis cohorts in the United States produced conflicting results regarding the association of Hb variability with patient outcomes. Here, we determined Hb variability in 5037 European hemodialysis (HD) patients treated over 2 years to identify predictors of high variability and to evaluate its association with all-cause and cardiovascular disease (CVD) mortality. We assessed Hb variability with various methods using SD, residual SD, time-in-target (11.0 to 12.5 g/dl), fluctuation across thresholds, and area under the curve (AUC). Hb variability was significantly greater among incident patients than prevalent patients. Compared with previously described cohorts in the United States, residual SD was similar but fluctuations above target were less frequent. Using logistic regression, age, body mass index, CVD history, dialysis vintage, serum albumin, Hb, angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) use, ESA use, dialysis access type, dialysis access change, and hospitalizations were significant predictors of high variability. Multivariable adjusted Cox regression showed that SD, residual SD, time-in-target, and AUC did not predict all-cause or CVD mortality during a median follow-up of 12.4 months (IQR: 7.7 to 17.4). However, patients with consistently low levels of Hb (<11 g/dl) and those who fluctuated between the target range and <11 g/dl had increased risks for death (RR 2.34; 95% CI: 1.24 to 4.41 and RR 1.74; 95% CI: 1.00 to 3.04, respectively). In conclusion, although Hb variability is common in European HD patients, it does not independently predict mortality.
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Affiliation(s)
- Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Erlangen, Germany.
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Traynor JP, Thomson PC, Simpson K, Ayansina DT, Prescott GJ, Mactier RA. Comparison of patient survival in non-diabetic transplant-listed patients initially treated with haemodialysis or peritoneal dialysis. Nephrol Dial Transplant 2010; 26:245-52. [DOI: 10.1093/ndt/gfq361] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Is the inverse relation between blood pressure and mortality normalized in 'low-risk' dialysis patients? J Hypertens 2010; 28:439-45. [PMID: 19940787 DOI: 10.1097/hjh.0b013e3283349a3c] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND SBP is a potent predictor of mortality. However, in hemodialysis populations, the relation between SBP and mortality is a matter of debate. In hemodialysis patients, low SBP rather than high SBP has been related to mortality. It has been suggested that this inverse relationship is 'normalized' in dialysis patients with a low mortality risk and that short-term and long-term effects of SBP might differ. DESIGN We analyzed the relationship of mortality and SBP in 1111 incident hemodialysis patients participating in the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) cohort. Long-term and short-term effects were studied in patients with (n = 452) and without (n = 659) cardiovascular comorbidity. RESULTS Maximal follow-up was 7.5 years; 477 patients died. Two-year mortality rate was 44 and 20% in the groups with and without cardiovascular comorbidity, respectively. Both in the whole group and in both subpopulations, low SBP was associated with an increased mortality. The increased mortality risk associated with low SBP was especially observed as a short-term effect (6 months). In neither group did we observe a significant long-term effect between SBP and mortality. CONCLUSION Our data do not support the hypothesis that the inverse relation between SBP and mortality is 'normalized' in a dialysis population with a low absolute mortality risk. Neither do our data support the hypothesis that elevated SBP increases mortality risk in the long-term.
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Genestier S, Meyer N, Chantrel F, Alenabi F, Brignon P, Maaz M, Muller S, Faller B. Prognostic Survival Factors in Elderly Renal Failure Patients Treated with Peritoneal Dialysis: A Nine-Year Retrospective Study. Perit Dial Int 2010; 30:218-26. [DOI: 10.3747/pdi.2009.00043] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Few studies specifically investigating elderly patients on peritoneal dialysis (PD) have been conducted and great uncertainty remains on the factors involved in the vital prognosis. The objective of this study was to describe our population of patients aged 75 years or older at the time PD was initiated and to study their survival in terms of the relevant nephro-geriatric criteria inventoried at the beginning of treatment. Methods We retrospectively analyzed the data of all the elderly patients that began first-line PD in our center between 1 January 1997 and 31 July 2006 ( n = 112). Results Mean duration of survival on PD was 19.6 ± 13.9 months; by the end of the study 87 patients had died and 7 had been transferred to hemodialysis. The Cox model multivariate analysis of survival allowed us to select 5 independent predictive variables that had a considerable impact on survival: absence of nephrologic care before dialysis, associated comorbidities (Charlson Comorbidity Index), loss of physical and/or mental autonomy (AGGIR group), and polymedication. Above and beyond the weight of these clinical variables, institutionalization or, more generally, social isolation was a determining factor for the duration of survival in PD. Conclusion Any patient considered for peritoneal dialysis should be evaluated by a multidisciplinary team in collaboration with geriatric specialists for both the overall medical situation and the social and family environment.
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Affiliation(s)
| | - Nicolas Meyer
- Hôpital Pasteur, Colmar; Laboratoire de Biostatistique et Méthodologie, Hôpital Civil, Strasbourg, France
| | | | | | - Pierre Brignon
- Service de Néphrologie, Hôpital Civil, Strasbourg, France
| | - Mehadji Maaz
- Service de Néphrologie, Hôpital Civil, Strasbourg, France
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Lacson E, Wang W, Lester K, Ofsthun N, Lazarus JM, Hakim RM. Outcomes associated with in-center nocturnal hemodialysis from a large multicenter program. Clin J Am Soc Nephrol 2009; 5:220-6. [PMID: 19965529 DOI: 10.2215/cjn.06070809] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The objective of this study was to evaluate epidemiology and outcomes of a large in-center nocturnal hemodialysis (INHD) program. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This case-control study compared patients who were on thrice-weekly INHD from 56 Fresenius Medical Care, North America facilities with conventional hemodialysis patients from 244 facilities within the surrounding geographic area. All INHD cases and conventional hemodialysis control subjects who were active as of January 1, 2007, were followed until December 31, 2007, for evaluation of mortality and hospitalization. RESULTS As of January 1, 2007, 655 patients had been on INHD for 51 +/- 73 d. Patients were younger, there were more male and black patients, and vintage was longer, but they had less diabetes compared with 15,334 control subjects. Unadjusted hazard ratio was 0.59 for mortality and 0.76 for hospitalization. After adjustment for case mix and access type, only hospitalization remained significant. Fewer INHD patients were hospitalized (48 versus 59%) with a normalized rate of 9.6 versus 13.5 hospital days per patient-year. INHD patients had greater interdialytic weight gains but lower BP. At baseline, hemoglobin values were similar, whereas albumin and phosphorus values favored INHD. Mean equilibrated Kt/V was higher in INHD patients related to longer treatment time, despite lower blood and dialysate flow rates. CONCLUSIONS Patients who were on INHD exhibited excellent quality indicators, with better survival and lower hospitalization rates. The relative contributions of patient selection versus effect of therapy on outcomes remain to be elucidated in prospective clinical trials.
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Affiliation(s)
- Eduardo Lacson
- Clinical Science, Epidemiology, and Research, Fresenius Medical Care, North America, Waltham, Massachusetts 02451-1457, USA.
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Sawhney S, Djurdjev O, Simpson K, Macleod A, Levin A. Reply. Nephrol Dial Transplant 2009. [DOI: 10.1093/ndt/gfp443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Miskulin D, Bragg-Gresham J, Gillespie BW, Tentori F, Pisoni RL, Tighiouart H, Levey AS, Port FK. Key comorbid conditions that are predictive of survival among hemodialysis patients. Clin J Am Soc Nephrol 2009; 4:1818-26. [PMID: 19808231 DOI: 10.2215/cjn.00640109] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Abstracting information about comorbid illnesses from the medical record can be time-consuming, particularly when a large number of conditions are under consideration. We sought to determine which conditions are most prognostic and whether comorbidity continues to contribute to a survival model once laboratory and clinical parameters have been accounted for. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Comorbidity data were abstracted from the medical records of Dialysis Outcomes and Practice Pattern Study (DOPPS) I, II, and III participants using a standardized questionnaire. Models that were composed of different combinations of comorbid conditions and case-mix factors were compared for explained variance (R(2)) and discrimination (c statistic). RESULTS Seventeen comorbid conditions account for 96% of the total explained variance that would result if 45 comorbidities that were expected to be predictive of survival were added to a demographics-adjusted survival model. These conditions together had more discriminatory power (c statistic 0.67) than age alone (0.63) or serum albumin (0.60) and were equivalent to a combination of routine laboratory and clinical parameters (0.67). The strength of association of the individual comorbidities lessened when laboratory/clinical parameters were added, but all remained significant. The total R(2) of a model adjusted for demographics and laboratory/clinical parameters increased from 0.13 to 0.17 upon addition of comorbidity. CONCLUSIONS A relatively small list of comorbid conditions provides equivalent discrimination and explained variance for survival as a more extensive characterization of comorbidity. Comorbidity adds to the survival model a modest amount of independent prognostic information that cannot be substituted by clinical/laboratory parameters.
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Affiliation(s)
- Dana Miskulin
- Division of Nephrology, Tufts Medical Center, 800 Washington Street, Box 391, Boston, MA 02111, USA.
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Servilla KS, Singh AK, Hunt WC, Harford AM, Miskulin D, Meyer KB, Bedrick EJ, Rohrscheib MR, Tzamaloukas AH, Johnson HK, Zager PG. Anemia management and association of race with mortality and hospitalization in a large not-for-profit dialysis organization. Am J Kidney Dis 2009; 54:498-510. [PMID: 19628315 DOI: 10.1053/j.ajkd.2009.05.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Accepted: 05/14/2009] [Indexed: 11/11/2022]
Abstract
BACKGROUND The optimal hemoglobin target and possible toxicity of epoetin therapy in hemodialysis patients are controversial. Previous studies suggest that African American patients use higher doses of epoetin and have better survival compared with white hemodialysis patients. STUDY DESIGN Retrospective longitudinal cohort. SETTING & PARTICIPANTS Epoetin-exposed incident hemodialysis patients (N = 12,733; African Americans, n = 4,801; white, n = 7,386) treated in Dialysis Clinic Inc facilities during 2000 to 2006. PREDICTORS Hemoglobin, epoetin, iron. OUTCOMES Mortality, hospitalization. MEASUREMENTS Proportional hazards models with time-varying covariates. RESULTS Hemoglobin concentrations less than 10 g/dL in whites and less than 11 g/dL in African Americans were associated with increased mortality and hospitalization versus the referent hemoglobin level of 11 to 11.9 g/dL. Hemoglobin levels of 13 g/dL or greater in whites were associated with decreased noncardiovascular mortality. Six-month cumulative epoetin doses of 20,000 U/wk or greater were associated with increased mortality and hospitalization versus the referent group (8,000 to 12,499 U/wk). Epoetin doses less than 8,000 U/wk were associated with decreased risk. Higher epoetin doses were associated with increased mortality at hemoglobin concentrations of 10 to 12.9 g/dL and with increased hospitalization at all hemoglobin concentrations of 10 g/dL or greater. Higher epoetin doses were associated with increased mortality and hospitalization within each tertile of serum albumin concentration. These patterns did not differ by race. LIMITATIONS Treatment-by-indication bias and unidentified confounders cannot be excluded. Small sample sizes in the highest and lowest hemoglobin strata decrease statistical power. CONCLUSIONS Relationships between hemoglobin concentration and mortality differed between African Americans and whites. Additionally, the relationship of lower mortality with greater achieved hemoglobin concentration seen in white patients was observed for all-cause, but not cardiovascular, mortality. A higher cumulative epoetin dose was associated with worse outcomes, even in patients with albumin levels greater than 4 g/dL. There were no statistically significant interactions between race and epoetin dose. Further studies are needed to confirm and to define the mechanism of these findings.
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Affiliation(s)
- Karen S Servilla
- Nephrology Section, New Mexico Veterans Affairs Health Care System, Albuquerque, NM, USA
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Vlatkovic V, Trbojevic-Stankovic J, Stojimirovic B. Malnutrition-inflammation complex syndrome and hepatitis C in maintenance hemodialysis patients. Ther Apher Dial 2009; 13:113-20. [PMID: 19379150 DOI: 10.1111/j.1744-9987.2009.00665.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Protein-energy malnutrition and inflammation are among the leading causes of poor outcome in hemodialysis patients. Hepatitis C virus (HCV) infection is accompanied by elevated proinflammatory mediators, also found in dialysis patients with malnutrition-inflammation complex syndrome. We aimed to study the rate and characteristics of malnutrition-inflammation complex syndrome (MICS) in hemodialysis patients, especially those with hepatitis C. The study included 147 patients (mean age 55.1 +/- 12.9 years), 24.5% of whom were HCV-positive, undergoing adequate hemodialysis three times a week for the last 52.7 +/- 52.5 months. Parameters of nutrition and inflammation were investigated to evaluate MICS. HCV-positive vs. HCV-negative patients had significantly higher hematocrit (29.6 +/- 4.5 g/dL vs. 28.1 +/- 4.3, P < 0.05), uric acid (345.8 +/- 96.5 vs. 321.3 +/- 118.8 micromol/mL, P < 0.05), aspartate aminotransferase (AST, also known as serum glutamic oxaloacetic transaminase [SGOT]) (23.3 +/- 14.9 vs. 17.8 +/- 9 U/L, P < 0.008), alanine aminotransferase (ALT, also known as serum glutamic pyruvic transaminase [SGPT]) (41.2 +/- 28.7 vs. 26.6 +/- 17.1 U/L, P < 0.0003), serum creatinine (980.4 +/- 219.1 vs. 888.4 +/- 202.9 micromol/mL, P < 0.022), intact parathyroid hormone (329.7 +/- 630.5 vs. 110.2 +/- 145.3 pg/mL, P < 0.002), malnutrition-inflammation score (7.4 +/- 5.2 vs. 5.6 +/- 4.1, P < 0.038), and Charlson comorbidity index (4.5 +/- 1.5 vs. 4 +/- 1.4, P < 0.05). MICS had a prevalence of 20-40% in our study. HCV-positive patients had a significantly higher prevalence of MICS than HCV-negative patients (30-40% vs. 20-30%).
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Affiliation(s)
- Vlastimir Vlatkovic
- International Dialysis Center, Banja Luka, Republic of Srpska, Bosnia and Herzegovina.
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Jager KJ, Zoccali C. Comorbidity data collection by renal registries--a remaining challenge. Nephrol Dial Transplant 2009; 24:2311-3. [DOI: 10.1093/ndt/gfp257] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Clinical outcomes in elderly kidney transplant recipients are related to acute rejection episodes rather than pretransplant comorbidity. Transplantation 2009; 87:1045-51. [PMID: 19352126 DOI: 10.1097/tp.0b013e31819cdddd] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Deciding whether an elderly patient with end-stage renal disease is a candidate for kidney transplantation can be difficult. We aimed to evaluate pre- and early posttransplant risk factors that could predict outcome in elderly kidney recipients. METHODS Data from all elderly (>or= 70 years, n=354), senior (60-69 years, n=577), and control (45-54 years, n=563) patients receiving their first kidney transplant at our center from 1990 to 2005 were retrieved. Patient and graft survival were analyzed in a Cox model addressing the common risk factors including Charlson comorbidity index (CCI), pretransplant dialysis time, and early acute rejection episodes. RESULTS Acute rejection in the first 90 days, Hazard ratio (HR) 1.74 (1.34-2.25); time on dialysis, HR 1.02 (1.01-1.03) per month; and donor age more than 60 years, HR 1.52 (1.14-2.01) predicted mortality in the elderly. CCI score did not predict mortality in the elderly, HR 1.05 (0.98-1.12); but did so both in senior, HR 1.17 (1.08-1.27) and control recipients, HR 1.33 (1.19-1.48). Delayed graft function, HR 3.69 (2.01-6.79); donor age more than 60 years, HR 2.42 (1.30-4.49); and presence of human leukocyte antigen antibodies, HR 3.96 (1.38-11.37) were independent predictors for death-censored graft loss in the elderly. CONCLUSION Adequate immunosuppression with low frequency of rejection episodes improves the outcome for elderly kidney recipients as does a reduction of time on dialysis. CCI score at transplantation does not seem helpful in the selection of elderly patients for kidney transplantation but plays a significant role in patients under 70 years of age.
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Lacson E, Wang W, Lazarus JM, Hakim RM. Hemodialysis facility-based quality-of-care indicators and facility-specific patient outcomes. Am J Kidney Dis 2009; 54:490-7. [PMID: 19406544 DOI: 10.1053/j.ajkd.2009.01.260] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Accepted: 01/13/2009] [Indexed: 11/11/2022]
Abstract
BACKGROUND We evaluated whether incremental achievement of up to 8 facility quality goals was associated with improvement in facility-specific mortality and hospitalization rates. STUDY DESIGN Prospective observational study. SETTING & PARTICIPANTS 1,085 Fresenius Medical Care, North America facilities providing hemodialysis (HD) for 25 or more patients during January 2006. MEASUREMENTS The facility average for the period up to December 31, 2006, was used to determine achievement of each goal for equilibrated Kt/V, missed HD treatments, hemoglobin level, bicarbonate level, albumin level, phosphorus level, fistulae, and HD catheters. Linear regression models were used to relate facility-wide achievement of goals with facility-specific hospital days and standardized mortality ratios. RESULTS Most facilities (64%) achieved 2 to 4 of 8 goals, with only 8% meeting more than 5 quality goals. Achieving more than 5 goals averaged 3.5 fewer hospital days/patient-year and 20% lower standardized mortality ratios (all P < 0.001). The incremental number of goals met also was associated with improvement in facility mortality (P < 0.001) and hospital days (P < 0.001). Catheter and albumin level goals were achieved least (6% and 9% of facilities, respectively), but they had the best outcomes. Facilities achieving more than 5 goals had older patients (64.0 versus 61.5 years; P < 0.001), fewer African American patients (16% versus 38%; P < 0.001), and fewer women (44% versus 46%; P = 0.003) compared with the average. LIMITATIONS Observational design with residual confounding from unmeasured patient-, facility-, and treatment-related factors. CONCLUSIONS Achieving more facility quality goals was significantly associated with better facility-based measurements of patient outcomes. Although these results do not establish a causal relationship, findings agree with the present practice of monitoring facility performance for continuous quality improvement.
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Affiliation(s)
- Eduardo Lacson
- Clinical Science, Epidemiology, and Research, Fresenius Medical Care North America, Waltham, MA 02451-1457, USA.
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Sawhney S, Djurdjev O, Simpson K, Macleod A, Levin A. Survival and dialysis initiation: comparing British Columbia and Scotland registries. Nephrol Dial Transplant 2009; 24:3186-92. [DOI: 10.1093/ndt/gfp189] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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The outcomes of continuous ambulatory and automated peritoneal dialysis are similar. Kidney Int 2009; 76:97-107. [PMID: 19340090 DOI: 10.1038/ki.2009.94] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recent reports indicate a decreased mortality risk for patients on chronic peritoneal dialysis in the United States. We sought to determine whether a higher use of automated versus continuous ambulatory peritoneal dialysis was associated with this improvement. Analyses were carried out using data from the United States Renal Data System on 66,381 incident patients on chronic peritoneal dialysis in the years 1996-2004 that were adjusted for demographic, clinical, laboratory and dialysis facility characteristics. Patients were followed until the time of transfer to other modes of dialysis, transplant, or death, whichever occurred first, or until their last follow-up through September 2006. Over time, the risks were substantially reduced such that the adjusted hazard ratios for death or technique failure of these patients in the 2002-2004 period were 0.55 (0.53, 0.57) and 0.62 (0.59, 0.64), respectively, compared with those of incident patients during the years 1996-1998. The risk improvements for both modes of dialysis were, however, found to be similar. Under intent-to-treat, time-dependent, and as-treated analysis, there was little or no difference in risk for death or in technique failure. Thus, the improved chronic peritoneal dialysis outcomes cannot be attributed to a greater use of automated peritoneal dialysis.
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