The clinical and economic burden of pneumonia in patients enrolled in Medicare receiving dialysis: a retrospective, observational cohort study

Total Hip Arthroplasty Outcomes before or after Renal Transplant: A Retrospective Large Cohort Analysis

Background

While it is known that patients with end-stage renal disease (ESRD) are at an increased risk of complications following total hip arthroplasty (THA), there is a gap in the literature in comparing patients with ESRD to patients who undergo renal transplant (RT) before or after THA. This study is to address this gap by analyzing outcomes of THA in ESRD patients, RT patients, and RT candidates.

Methods

Using the PearlDiver Mariner database, ESRD patients, RT patients, and RT candidates undergoing primary THA were identified and compared. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. Ninety-day emergency department (ED) visits and inpatient readmission were also documented.

Results

A total of 7,868 patients were included: 5,092 had ESRD, 2,520 had RT before THA, and 256 were candidates for RT. Compared to patients with ESRD, RT patients demonstrated lower rates of medical complications such as pneumonia (3.61% vs. 5.99%, p = 0.039) and transfusion (4.60% vs. 7.66%, p < 0.001). Additionally, RT patients displayed decreased rates of surgical complications, including wound complications (2.70% vs. 4.22%, p = 0.001), periprosthetic joint infection (PJI) at 1 year (2.30% vs. 4.81%, p < 0.001) and 2 years (2.58% vs. 5.42%, p < 0.001), and aseptic loosening at 2 years (0.79% vs. 1.43%, p = 0.006). Similarly, when compared to RT candidates, RT patients demonstrated a lower incidence of postoperative complications, including 1-year PJI (2.30% vs. 5.08%, p = 0.013), 2-year PJI (2.58% vs. 5.08%, p = 0.028), 1-year aseptic loosening (0.56% vs. 2.73%, p < 0.001), and 2-year aseptic loosening (0.79% vs. 2.73%, p = 0.005). RT patients also had lower rates of ED visits and hospital readmissions.

Conclusions

Compared to ESRD patients and RT candidates, patients with RT have a significantly lower likelihood of medical complications, PJI, aseptic hardware loosening, ED visits, and hospital readmission. Patients with ESRD on the RT waiting list should delay THA until after RT surgery. For those not eligible for RT, it is vital to take extra precautions to reduce the risk of complications.

Disease burden and high-risk populations for complications in patients with acute respiratory infections: a scoping review

Background

Acute respiratory infections (ARIs) represent a significant public health concern in the U.S. This study aimed to describe the disease burden of ARIs and identify U.S. populations at high risk of developing complications.

Methods

This scoping review searched PubMed and EBSCO databases to analyze U.S. studies from 2013 to 2022, focusing on disease burden, complications, and high-risk populations associated with ARIs.

Results

The study included 60 studies and showed that ARI is associated with a significant disease burden and healthcare resource utilization (HRU). In 2019, respiratory infection and tuberculosis caused 339,703 cases per 100,000 people, with most cases being upper respiratory infections and most deaths being lower respiratory infections. ARI is responsible for millions of outpatient visits, especially for influenza and pneumococcal pneumonia, and indirect costs of billions of dollars. ARI is caused by multiple pathogens and poses a significant burden on hospitalizations and outpatient visits. Risk factors for HRU associated with ARI include age, chronic conditions, and socioeconomic factors.

Conclusion

The review underscores the substantial disease burden of ARIs and the influence of age, chronic conditions, and socioeconomic status on developing complications. It highlights the necessity for targeted strategies for high-risk populations and effective pathogen detection to prevent severe complications and reduce HRU.

Exploring kidney dialysis costs in the United States: a scoping review

AIMS

The increasing prevalence of end-stage renal disease (ESRD) in the United States (US) represents a considerable economic burden due to the high cost of dialysis treatment. This review examines data from real-world studies to identify cost drivers and explore areas where dialysis costs could be reduced.

METHODS

We identified and synthesized evidence published from 2016-2023 reporting direct dialysis costs in adult US patients from a comprehensive literature search of MEDLINE, Embase, and grey literature sources (e.g. US Renal Data System reports).

RESULTS

Most identified data related to Medicare expenditures. Overall Medicare spending in 2020 was $29B for hemodialysis and $2.8B for peritoneal dialysis (PD). Dialysis costs accounted for almost 80% of total Medicare expenditures on ESRD beneficiaries. Private insurance payers consistently pay more for dialysis; for example, per person per month spending by private insurers on outpatient dialysis was estimated at $10,149 compared with Medicare spending of $3,364. Dialysis costs were higher in specific high-risk patient groups (e.g. type 2 diabetes, hepatitis C). Spending on hemodialysis was higher than on PD, but the gap in spending between PD and hemodialysis is closing. Vascular access costs accounted for a substantial proportion of dialysis costs.

LIMITATIONS

Insufficient detail in the identified studies, especially related to outpatient costs, limits opportunities to identify key drivers. Differences between the studies in methods of measuring dialysis costs make generalization of these results difficult.

CONCLUSIONS

These findings indicate that prevention of or delay in progression to ESRD could have considerable cost savings for Medicare and private payers, particularly in patients with high-risk conditions such as type 2 diabetes. More efficient use of resources is needed, including low-cost medication, to improve clinical outcomes and lower overall costs, especially in high-risk groups. Widening access to PD where it is safe and appropriate may help to reduce dialysis costs.

Nomogram-based prediction model for survival of COVID-19 patients: A clinical study

The study aim to construct an effective model for predicting the survival period of COVID-19 patients.

METHODS

Clinical data of 386 COVID-19 patients were collected from December 2022 to January 2023. The patients were randomly divided into training and validation cohorts in a 7:3 ratio. LASSO regression and multivariate Cox regression analyses were used to identify prognostic factors, and a nomogram was constructed. Nomogram was evaluated using decision curve analysis, receiver operating characteristic curve, consistency index (c-index), and calibration curve.

RESULTS

86 patients (22.3%) died. A new nomogram for predicting the survival was established based on age, resting oxygen saturation, Blood urea nitrogen (BUN), c-reactive protein-to-albumin ratio (CAR), and pneumonia visual score. The decision curve indicated high clinical applicability. The nomogram c-indexes in the training and validation cohorts were 0.846 and 0.81, respectively. The area under the curves (AUCs) for the 15-day and 30-day survival probabilities were 0.906 and 0.869 in the training cohort, and 0.851 and 0.843 in the validation cohort. The calibration curves demonstrated consistency between predicted and actual survival probabilities.

CONCLUSIONS

Our nomogram has the capacity to assist clinical practitioners in estimating the survival rate of COVID-19 patients, thereby facilitating more optimal management strategies and therapeutic interventions with substantial clinical applicability.

Development of a new prognostic index PNPI for prognosis prediction of CKD patients with pneumonia at hospital admission

Background

The aim of this study was to investigate the relationship between pneumonia and chronic kidney disease (CKD), to elucidate potential risk factors, and to develop a new predictive model for the poor prognosis of pneumonia in CKD patients.

Method

We conducted a retrospective observational study of CKD patients admitted to Tongji Hospital between June 2012 and June 2022. Demographic information, comorbidities or laboratory tests were collected. Applying univariate and multivariate logistic regression analyses, independent risk factors associated with a poor prognosis (i.e., respiratory failure, shock, combined other organ failure, and/or death during hospitalization) for pneumonia in CKD patients were discovered, with nomogram model subsequently developed. Predictive model was compared with other commonly used pneumonia severity scores.

Result

Of 3,193 CKD patients with pneumonia, 1,013 (31.7%) met the primary endpoint during hospitalization. Risk factors predicting poor prognosis of pneumonia in CKD patients were selected on the result of multivariate logistic regression models, including chronic cardiac disease; CKD stage; elevated neutrophil to lymphocyte ratio (NLR) and D-dimer; decreased platelets, PTA, and chloride iron; and significant symptom presence and GGO presentation on CT. The nomogram model outperformed other pneumonia severity indices with AUC of 0.82 (95% CI: 0.80, 0.84) in training set and 0.83 (95% CI: 0.80, 0.86) in testing set. In addition, calibration curve and decision curve analysis (DCA) proved its efficiency and adaptability.

Conclusion

We designed a clinical prediction model PNPI (pneumonia in nephropathy patients prognostic index) to assess the risk of poor prognosis in CKD patients with pneumonia, which may be generalized after more external validation.

Retrospective Analysis of Spectrum of Infections and Antibiotic Resistance Pattern in Chronic Kidney Disease Patients on Maintenance Hemodialysis in a Tertiary Care Centre in North India

Introduction

Hemodialysis patients are at risk of infections. This study examines the spectrum of infections and antibiotic resistance patterns.

Methods

We retrospectively reviewed the records of 586 hemodialysis patients from May 2018 to April 2020 in a tertiary care hospital in North India.

Results

The study identified 99 episodes of confirmed infections. Urinary tract infections were the most common type of infections (55.5%), followed by catheter-related bloodstream infections (CRBSI) (definitive 21.2%). Other infections were pneumonia (8.1%), tuberculosis (6.1%), skin and soft tissue infection (4.0%), dengue fever (3.03%), and empyema thoracis (1.0%). Overall, Escherichia coli (33.3%) was the most common organism isolated. The most frequent uropathogens recovered were Escherichia coli (54%). In confirmed CRBSI, P. aeruginosa (23.8%) and MSSA (23.8%) were the most common pathogen isolated. K. pneumonia (37.5%) was the most common pathogen in pneumonia. Uropathogens showed the highest resistance to fluoroquinolones (93.3%-100%). Pathogens isolated in CRBSI showed maximum resistance to ciprofloxacin (100%). In pneumonia, the highest resistance was seen to third-generation cephalosporins (75%-100%).

Conclusion

Though the bacterial spectrum remains the same over time, antibiotic resistance is changing in uropathogens. There is a trend of predominance of Gram-negative bacterial infections in CRBSI. Tuberculosis incidence rate was much higher than the general population. There is a need for nationwide and worldwide continuous surveillance.

Long-term arteriovenous fistula prognosis for maintenance hemodialysis patients who accepted PIRRT by using arteriovenous fistula

BACKGROUND

Maintenance hemodialysis (MHD) patients are often admitted to the hospital for severe morbidities. Prolonged intermittent renal replacement therapy (PIRRT) is required during the hospital staying. There are controversial opinions on the use of arteriovenous fistula (AVF) as vascular access for PIRRT in MHD patients.

METHODS

Patients with AVF who accepted PIRRT in our center between January 2014 and June 2021 were retrospectively screened. AVF dysfunction and patient mortality were assessed as endpoints. Univariate and multivariate regression models were employed to identify the risk factors of AVF dysfunction.

RESULTS

About 162 patients were included in our present study. Twenty-six experienced AVF dysfunction, of whom 53.8%, 19.2%, and 27.0% had percutaneous transluminal balloon angioplasty, surgical revision, and AVF reconstruction, respectively. The accumulated AVF dysfunction rates were 11.8%, 16.2%, and 21.0% in 1, 2, and 3 years, respectively. Multivariate analysis revealed that smoking (HR 2.750, 95% CI 1.181-6.402, p = 0.019), higher platelet (PLT, HR 1.009, 95% CI 1.000-1.017, p = 0.047), higher prothrombin activity (PTA, HR 1.039, 95% CI 1.012-1.066, p = 0.004), and lower diastolic blood pressure (DBP, HR 0.963, 95% CI 0.932-0.996, p = 0.026) were independent risk factors for AVF dysfunction. During the follow-up period, 37 patients died.

CONCLUSIONS

Overall, the use of AVF for PIRRT might not dramatically increase the incidence of AVF dysfunction. And, Smoking, lower DBP, higher PLT, and higher PTA were associated with increased AVF dysfunction.

Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors

The clinical course and outcome of COVID-19 are highly variable, ranging from asymptomatic infections to severe disease and death. Understanding the risk factors of severe COVID-19 is relevant both in the clinical setting and at the epidemiological level. Here, we provide an overview of host, viral and environmental factors that have been shown or (in some cases) hypothesized to be associated with severe clinical outcomes. The factors considered in detail include the age and frailty, genetic polymorphisms, biological sex (and pregnancy), co- and superinfections, non-communicable comorbidities, immunological history, microbiota, and lifestyle of the patient; viral genetic variation and infecting dose; socioeconomic factors; and air pollution. For each category, we compile (sometimes conflicting) evidence for the association of the factor with COVID-19 outcomes (including the strength of the effect) and outline possible action mechanisms. We also discuss the complex interactions between the various risk factors.

Epidemiology of haemodialysis outcomes

Haemodialysis (HD) is the commonest form of kidney replacement therapy in the world, accounting for approximately 69% of all kidney replacement therapy and 89% of all dialysis. Over the last six decades since the inception of HD, dialysis technology and patient access to the therapy have advanced considerably, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes vary widely across the world and, overall, the rates of impaired quality of life, morbidity and mortality are high. Cardiovascular disease affects more than two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality. In addition, patients on HD have high symptom loads and are often under considerable financial strain. Despite the many advances in HD technology and delivery systems that have been achieved since the treatment was first developed, poor outcomes among patients receiving HD remain a major public health concern. Understanding the epidemiology of HD outcomes, why they might vary across different populations and how they might be improved is therefore crucial, although this goal is hampered by the considerable heterogeneity in the monitoring and reporting of these outcomes across settings.

This Review examines the epidemiology of haemodialysis outcomes — clinical, patient-reported and surrogate outcomes — across world regions and populations, including vulnerable individuals. The authors also discuss the current status of monitoring and reporting of haemodialysis outcomes and potential strategies for improvement.

Nearly 4 million people in the world are living on kidney replacement therapy (KRT), and haemodialysis (HD) remains the commonest form of KRT, accounting for approximately 69% of all KRT and 89% of all dialysis.

Dialysis technology and patient access to KRT have advanced substantially since the 1960s, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes continue to vary widely across countries, particularly among disadvantaged populations (including Indigenous peoples, women and people at the extremes of age).

Cardiovascular disease affects over two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality; mortality among patients on HD is significantly higher than that of their counterparts in the general population, and treated kidney failure has a higher mortality than many types of cancer. Patients on HD also experience high burdens of symptoms, poor quality of life and financial difficulties.

Careful monitoring of the outcomes of patients on HD is essential to develop effective strategies for risk reduction. Outcome measures are highly variable across regions, countries, centres and segments of the population. Establishing kidney registries that collect a variety of clinical and patient-reported outcomes using harmonized definitions is therefore crucial.

Evaluation of HD outcomes should include the impact on family and friends, and personal finances, and should examine inequities in disadvantaged populations, who comprise a large proportion of the HD population.

Temporal changes in cardiovascular disease and infections in dialysis across a 22-year period: a nationwide study

BACKGROUND

Cardiovascular diseases (CVD) and infections are recognized as serious complications in patients with end stage kidney disease. However, little is known about the change over time in incidence of these complications. This study aimed to investigate temporal changes in CVD and infective diseases across more than two decades in chronic dialysis patients.

METHODS

All patients that initiated peritoneal dialysis (PD) or hemodialysis (HD) between 1996 and 2017 were identified and followed until outcome (CVD, pneumonia, infective endocarditis (IE) or sepsis), recovery of kidney function, end of dialysis treatment, death or end of study (December 31st, 2017). The calendar time was divided into 5 periods with period 1 (1996-2000) being the reference period. Adjusted rate ratios were assessed using Poisson regression.

RESULTS

In 4285 patients with PD (63.7% males) the median age increased across the calendar periods from 65 [57-73] in 1996-2000 to 69 [55-76] in 2014-2017, (p <  0.0001). In 9952 patients with HD (69.2% males), the overall median age was 71 [61-78] without any changes over time. Among PD, an overall non-significant decreasing trend in rate ratios (RR) of CVD was found, (p = 0,071). RR of pneumonia increased significantly throughout the calendar with an almost two-fold increase of the RR in 2014-2017 (RR 1.71; 95% CI 1.46-2.0), (p <  0.001), as compared to the reference period. The RR of IE decreased significantly until 2009 (RR 0.43; 95% CI 0.21-0.87), followed by a return to the reference level in 2010-2013 (RR 0.87; 95% CI 0.47-1.60 and 2014-2017 (RR 1.1; 95% CI 0.59-2.04). A highly significant (p <  0.001) increase in sepsis was revealed across the calendar periods with an almost 5-fold increase in 2014-2017 (RR 4.69 95% CI 3.69-5.96). In HD, the RR of CVD decreased significantly (p <  0.001) from 2006 to 2017 (RR 0.85; 95% CI 0.79-0.92). Compared to the reference period, the RR for pneumonia was high during all calendar periods (p <  0.05). The RR of IE was initially unchanged (p = 0.4) but increased in 2010-2013 (RR 2.02; 95% CI 1.43-2.85) and 2014-2017 (RR 3.39; 95% CI 2.42-4.75). No significant changes in sepsis were seen.

CONCLUSION

Across the two last decades the RR of CVD has shown a decreasing trend in HD and PD patients, while RR of pneumonia increased significantly, both in PD and in HD. Temporal trends of IE in HD, and particularly of sepsis in PD were upwards across the last decades.

A cross-sectional survey study on influenza and pneumococcal vaccination rates and the factors affecting vaccination rates in hemodialysis patients in Kocaeli Province of Turkey

OBJECTIVE

This study aimed to investigate the rates of influenza and pneumococcal vaccinations and the factors affecting vaccination rates in hemodialysis patients.

METHODS

The study included 360 hemodialysis patients. Patients' data were collected via a questionnaire form applied during a face-to-face interview.

RESULTS

Of the patients, 51.4% vaccinated at least once with influenza vaccine and 14.4% vaccinated with pneumococcal vaccine. While 31.4% of the patients had annual vaccination regularly for influenza, 20% were vaccinated irregularly. Of the patients with missing vaccination, 76.2% reported the reason for not being vaccinated as lack of knowledge about the relevant vaccine. At initial evaluation in the beginning of the study, the percentage of patients vaccinated with both influenza and pneumococcal vaccines was 10.8%. After informing the patients in the face-to-face interview, 89.7% of them reported that they planned to have both vaccines (p < 0.001). The rate of vaccine refusal, which was 17.8% at the initial evaluation, reduced to 10.3% at the end of the interview (p < 0.001). The most common source of information about influenza and pneumococcal vaccines (44%-43.3%, respectively) was dialysis nurses. Majority of the patients (87%) were vaccinated in the hemodialysis units.

CONCLUSION

The rates of pneumococcal and influenza vaccinations in dialysis patients were observed to be below the targeted rates and the main reason for such low rates was lack of information/recommend. All health care professionals, providing the patients with information about vaccinations, using communication tools such as media, phone, mails that facilitate to reach large populations more easily may enhance vaccination rates.

The clinical significance of neutrophil-lymphocyte ratio in patients treated with hemodialysis complicated with lung infection

ABSTRACT

The goal of this work was to investigate the potential significance of neutrophil-lymphocyte ratio (NLR) in patients treated with maintenance hemodialysis (MHD).Herein, we retrospectively reviewed the electronic medical records of 100 patients with end-stage renal failure who were treated with MHD. All patients enrolled in this study met the inclusion criteria and were followed. The differences in each indicator between the two groups were compared using the Wilcoxon rank-sum test. On the other hand, Spearman correlation and logistic regression analysis were used to explore the correlation and risk factors for pulmonary infection between NLR and other indicators. Finally, we determined the optimal cut-off values for NLR, hypersensitive c-reactive protein (hs-CRP), and procalcitonin (PCT) diagnosis of pulmonary infection using the receiver operating characteristic curve.We found that NLR was positively correlated with age, PCT, hs-CRP, and hospital stay, but negatively correlated with hemoglobin, red blood cell, and Albumin. The expression levels of PCT, hs-CRP, and NLR in the infected group decreased significantly than those before treatment. Multiple regression analysis revealed that NLR is an important independent risk factor for MHD patients with pulmonary infection. Additionally, receiver operating characteristic curve analysis showed that the sensitivity, specificity, and area under the curve were 87.76%, 100%, and 0.920 when using NLR combined with hs-CRP to predict pulmonary infection in MHD patients, whereas that of NLR combined with PCT were 87.76%, 96.08%, and 0.944, respectively.Findings from this study suggested that NLR is an independent risk factor for MHD patients with pulmonary infection, which can effectively predict pulmonary infection. Moreover, sensitivity and specificity were greatly enhanced when using NLR combined with PCT/hs-CRP to predict pulmonary infection in MHD patients.

Mandatory Mask-Wearing and Hand Hygiene Associated With Decreased Infectious Diseases Among Patients Undergoing Regular Hemodialysis: A Historical-Control Study

Background: Infections are the second leading cause of death among patients undergoing hemodialysis. However, preventive measures against infectious diseases are limited and have not been made mandatory for patients.

Objective: To investigate the incidence of infectious diseases before and during the coronavirus disease (COVID-19) pandemic.

Design: A historical comparative study of a prospective cohort.

Setting(s): February 1, 2015 to January 31, 2020 was defined as the period before the mitigative confrontation of the COVID-19 pandemic in China. The period from February 1 to June 29, 2020 was defined as the period of mitigative confrontation of the COVID-19 pandemic in China.

Participants: A cohort of patients undergoing hemodialysis whose infectious disease episodes were documented prospectively in the hemodialysis unit of the Third Affiliated Hospital of Guangzhou Medical University since February 1, 2015.

Methods: Mandatory mask-wearing and reinforced hand-hygiene education were implemented to prevent COVID-19 from January 23, 2020 in China. The incidence of infectious episodes, including catheter-related infection, digestive tract infection, upper respiratory tract infection (UTRI), pneumonia, and infection at other sites, were documented and compared in the periods before and during the pandemic.

Results: The historical control group consisted of 157 patients, with 79 patients in the COVID-19 prevention group. The mask-wearing rate of patients increased from 1.5 to 100%. Hand sanitizer consumption increased significantly during the COVID-19 pandemic. The compliance rates of hand hygiene increased from 66, 75.5, to 55% in physicians, nurses, and other employees before the pandemic to 90.5, 92.5, and 76.5%, respectively. The incidences of UTRI and pneumonia decreased during the pandemic (p < 0.001). Notably, catheter-related and digestive tract infections also decreased during the pandemic (p = 0.003 and 0.034, respectively). A matched-pair study was conducted to further analyze the 79 individual changes in the incidences of infectious disease before and during the pandemic. As a result, the incidences of UTRI, pneumonia, catheter-related infections, digestive tract infections, and infections at other sites all decreased during the pandemic.

Conclusions: The present study indicated an association between mandatory mask-wearing and reinforced hand hygiene education and decreased respiratory, catheter-related, and digestive tract infection episodes in the hemodialysis unit.

Outcomes of coronavirus 2019 infection in patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Information on coronavirus disease 2019 (COVID-19) infection in patients with chronic kidney disease (CKD) remains limited. To understand the influence of COVID-19 infection in patients with pre-existing CKD, we conducted a systematic review and meta-analysis to evaluate and compare the risks of all-cause mortality, hospitalization, and critical progression between patients with and without CKD.

METHODS

We selected randomized controlled trials (RCTs), prospective or retrospective observational, case-control, cross-sectional, and case-series studies analyzing outcomes of COVID-19 infection in patients with pre-existing CKD from the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases published on the Internet before 16 July 2020.

RESULTS

A total of 27 studies comprising 77,856 patients with COVID-19 infection was identified; 3922 patients with pre-existing CKD were assigned CKD group, and 73,934 patients were assigned to the non-CKD group. The pooled analysis showed that patients with CKD had a significantly higher risk of all-cause mortality and hospitalization than those without CKD [odds ratio (OR) 2.25, 95% confidence interval (CI) 1.91-2.66, p < 0.001; OR 4.29, 95% CI 2.93-6.28, p < 0.001; respectively]. Patients with CKD had a higher risk of critically ill conditions than those without CKD in the pooled analysis of studies with multivariable adjustment (adjusted OR 2.12, 95% CI 0.95-4.77, p = 0.07) and in the analysis of all included studies (OR 1.27, 95% CI 0.71-2.26, p = 0.41), but both analyses did not attain statistical significance.

CONCLUSION

COVID-19 infected patients with CKD had significantly increased risks of all-cause mortality and hospitalization compared with those without CKD.

Improving influenza and pneumococcal vaccination uptake among incident peritoneal dialysis patients: a quality improvement initiative

INTRODUCTION

Influenza and pneumococcal vaccination rates among peritoneal dialysis (PD) patients remain suboptimal, despite availability of vaccinations and health recommendations.

AIM

The primary aim was to improve influenza and pneumococcal vaccination rates among incident PD patients at our center to 80%. A secondary aim was to develop a sustainable workflow for vaccination in PD patients.

DESIGN

A quality improvement (QI) initiative to increase vaccination rate among incident PD patients was conducted in a tertiary care hospital in Singapore from Jul 2017 to Dec 2018. Key drivers and barriers to success were identified through root cause analysis. Change ideas focusing on improving opportunities, access and enhancement of reminder systems were implemented using Plan-Do-Study-Act methodology. Vaccination rates were monitored at 3-month intervals.

RESULTS

Total of 249 patients were eligible for vaccination. The baseline vaccination rate for influenza, pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) were 63%, 54% and 14%, respectively. Root-cause analyses revealed several practice-related barriers, including lack of physician recommendation, time constraints and ineffective reminder systems. Multifaceted interventions, such as the provision of vaccination at non-traditional clinical settings, physician audit and feedback, utilisation of reminder tools, successfully increased influenza, PCV13 and PPSV23 vaccination rates to 86%, 85% and 63%, respectively.

CONCLUSION

A robust influenza and pneumococcal vaccination program implemented using a standardized QI methodology and multidisciplinary approach is effective in improving and sustaining influenza and pneumococcal vaccination uptake among PD patients.

The Involvement of Chronic Kidney Disease and Acute Kidney Injury in Disease Severity and Mortality in Patients with COVID-19: A Meta-Analysis

BACKGROUND

A meta-analysis was performed to evaluate the association of chronic kidney disease (CKD) and acute kidney injury (AKI) with the clinical prognosis of patients with coronavirus disease 2019 (COVID-19).

METHODS

The PubMed, EMBASE, Cochrane Library, medRxiv, Social Science Research Network, and Research Square databases (from December 1, 2019 to May 15, 2020) were searched to identify studies that reported the associations of CKD/AKI and disease severity/mortality. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated and meta-regression was performed.

RESULTS

In total, 42 studies enrolling 8,932 participants were included in this meta-analysis. The quality of most included studies was moderate to high. Compared with patients without previously diagnosed CKD, those with CKD had a significantly increased risk of progressing to a severe condition (OR 2.31, 95% CI 1.64-3.24) or death (OR 5.11, 95% CI 3.36-7.77). Similarly, compared with patients without AKI, those with AKI had a significantly increased risk of progressing to a severe condition (OR 11.88, 95% CI 9.29-15.19) or death (OR 30.46, 95% CI 18.33-50.59). Compared with patients with previously diagnosed CKD, those with AKI were more likely to progress to a severe condition (pgroup < 0.001, I2 = 98.3%) and even to death (pgroup < 0.001, I2 = 96.5%). Age had a significant impact on the association between CKD and disease severity (p = 0.001) but had no impact on the associations between AKI and disease severity (p = 0.80), between CKD and mortality (p = 0.51), or between AKI and mortality (p = 0.86). Four important complications (cardiac injury, shock, acute respiratory distress syndrome, and liver injury) did not significantly affect the associations between CKD/AKI and disease severity/mortality, indicating that CKD/AKI may be independent clinical prognostic indicators for patients with COVID-19.

CONCLUSIONS

In COVID-19 patients, CKD/AKI was associated with worse outcomes compared with those without CKD/AKI. AKI was associated with higher risks of severity and mortality than CKD.

The impact of COVID-19 in diabetic kidney disease and chronic kidney disease: A population-based study

BACKGROUND

The spectrum of pre-existing renal disease is known as a risk factor for severe COVID-19 outcomes. However, little is known about the impact of COVID-19 on patients with diabetic nephropathy in comparison to patients with chronic kidney disease.

METHODS

We used the Mexican Open Registry of COVID-19 patients 11 to analyze anonymized records of those who had symptoms related to COVID-19 to analyze the rates of SARS-CoV-2 infection, development of COVID-19 pneumonia, admission, intubation, Intensive Care Unit admission and mortality. Robust Poisson regression was used to relate sex and age to each of the six outcomes and find adjusted prevalences and adjusted prevalence ratios. Also, binomial regression models were performed for those outcomes that had significant results to generate probability plots to perform a fine analysis of the results obtained along age as a continuous variable.

RESULTS

The adjusted prevalence analysis revealed that that there was a a 87.9% excess probability of developing COVID-19 pneumonia in patients with diabetic nephropathy, a 5% excess probability of being admitted, a 101.7% excess probability of intubation and a 20.8% excess probability of a fatal outcome due to COVID-19 pneumonia in comparison to CKD patients (p<0.01).  Conclusions: Patients with diabetic nephropathy had nearly a twofold rate of COVID-19 pneumonia, a higher probability of admission, a twofold probability of intubation and a higher chance of death once admitted compared to patients with chronic kidney disease alone. Also, both diseases had higher COVID-19 pneumonia rates, intubation rates and case-fatality rates compared to the overall population.

Hospital admissions for community-acquired, ventilator-associated and nonventilator hospital-acquired pneumonia in COPD patients in Spain (2016-2017)

BACKGROUND

To examine the incidence, characteristics and outcomes of community-acquired pneumonia (CAP), ventilator-associated pneumonia (VAP) and nonventilator hospital-acquired pneumonia (NV-HAP) in patients with or without COPD; compare in-hospital outcomes; and identify factors associated with in-hospital mortality (IHM) for pneumonia.

METHODS

We carried out a retrospective observational study using the hospital discharge records from 2016-17 of the Spanish National Health System. Propensity score matching was used for data analysis.

RESULTS

We found 245,905 patients (≥40 years) with pneumonia; we identified CAP in 228,139 patients (19.85% with COPD), VAP in 2,771 patients (8.55% with COPD) and NV-HAP in 14,995 patients (14.17% with COPD). The incidence for the three types of pneumonia was higher in COPD patients (CAP: incidence rate ratio (IRR) 2.23, 95% CI 2.21-2.26; VAP: IRR 1.25, 95% CI 1.08-1.42; and NV-HAP: IRR 1.55, 95% CI 1.48-1.63). The IHM for CAP was 10.35% in COPD patients and 12.91% in the controls (p<0.001). In patients with VAP and NV-HAP, IHM was not significantly different between those with and without COPD (43.88% vs. 41.77%;p=0.643 and 29.21% vs. 30.57%;p=0.331, respectively). Factors associated with IHM for all types of pneumonia analyzed in COPD patients were older age and receiving dialysis.

CONCLUSIONS

The incidence of hospitalizations for all types of pneumonia was significantly higher in COPD patients than in the non-COPD population. In contrast, IHM was significantly lower among COPD patients with CAP than among matched non-COPD patients. Higher mortality rates in COPD patients with any pneumonia type were associated with increasing age and receiving dialysis.

COVID-19 and the Kidney: From Epidemiology to Clinical Practice

The new respiratory infectious disease coronavirus disease 2019 (COVID-19) that originated in Wuhan, China, in December 2019 and caused by a new strain of zoonotic coronavirus, named severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), to date has killed over 630,000 people and infected over 15,000,000 worldwide. Most of the deceased patients had pre-existing comorbidities; over 20% had chronic kidney disease (CKD). Furthermore, although SARS-CoV-2 infection is characterized mainly by diffuse alveolar damage and acute respiratory failure, acute kidney injury (AKI) has developed in a high percentage of cases. As AKI has been shown to be associated with worse prognosis, we believe that the impact of SARS-CoV-2 on the kidney should be investigated. This review sets out to describe the main renal aspects of SARS-CoV-2 infection and the role of the virus in the development and progression of kidney damage. In this article, attention is focused on the epidemiology, etiology and pathophysiological mechanisms of kidney damage, histopathology, clinical features in nephropathic patients (CKD, hemodialysis, peritoneal dialysis, AKI, transplantation) and prevention and containment strategies. Although there remains much more to be learned with regards to this disease, nonetheless it is our hope that this review will aid in the understanding and management of SARS-CoV-2 infection.

Impact of the COVID-19 pandemic on the management of patients with end-stage renal disease

A novel infectious disease, coronavirus disease-2019 (COVID-19), spread globally since December 2019. Without effective treatment and vaccination, the strategies to restrain this disease are only keeping social distance, maintaining personal hygiene, quarantine, and isolation. However, thrice-a-week treatment is inevitable for all hemodialysis patients. In addition to the high risk of cluster infection and compromised immunity in patients with end-stage renal disease (ESRD), an atypical disease presentation could also make the medial system neglect these patients during CVOID-19 pandemic. To avoid COVID-19 transmission among patients on dialysis, the major societies of nephrology around the world have provided their guidelines for screening, dialysis facilities adjustment, and health education, respectively. In this review, we summarized the main contents and differences of these guidelines and addressed the prompt management for patients with ESRD to reduce the risk of infection during COVID-19 pandemic.

Impact of renal function on admission in COVID-19 patients: an analysis of the international HOPE COVID-19 (Health Outcome Predictive Evaluation for COVID 19) Registry

Background

Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Despite its international aggressive extension, with a significant morbidity and mortality, the impact of renal function on its prognosis is uncertain.

Methods

Analysis from the international HOPE-Registry (NCT04334291). The objective was to evaluate the association between kidney failure severity on admission with the mortality of patients with SARS-CoV-2 infection. Patients were categorized in 3 groups according to the estimated glomerular filtration rate on admission (eGFR > 60 mL/min/1.73 m², eGFR 30–60 mL/min/1.73 m² and eGFR < 30 mL/min/1.73 m²).

Results

758 patients were included: mean age was 66 ± 18 years, and 58.6% of patient were male. Only 8.5% of patients had a history of chronic kidney disease (CKD); however, 30% of patients had kidney dysfunction upon admission (eGFR < 60 mL/min/1.73 m²). These patients received less frequently pharmacological treatment with hydroxychloroquine or antivirals and had a greater number of complications such as sepsis (11.9% vs 26.4% vs 40.8%, p < 0.001) and respiratory failure (35.4% vs 72.2% vs 62.0%, p < 0.001) as well as a higher in-hospital mortality rate (eGFR > 60 vs eGFR 30-60 vs and eGFR < 30, 18.4% vs 56.5% vs 65.5%, p < 0.001). In multivariate analysis: age, hypertension, renal function, 0² saturation < 92% and lactate dehydrogenase elevation on admission independently predicted all-cause mortality.

Conclusions

Renal failure on admission in patients with SARS-CoV-2 infection is frequent and is associated with a greater number of complications and in-hospital mortality. Our data comes from a multicenter registry and therefore does not allow to have a precise mortality risk assessment. More studies are needed to confirm these findings.

Electronic supplementary material

The online version of this article (10.1007/s40620-020-00790-5) contains supplementary material, which is available to authorized users.

Household Costs Associated with Hospitalization of Children with Severe Pneumonia in Quito, Ecuador

Pneumonia remains a leading cause of morbidity and mortality in young children. The total cost of pneumonia-related hospitalization, including household-level cost, is poorly understood. To better understand this burden in an urban setting in South America, we incorporated a cost study into a trial assessing zinc supplements in treatment of severe pneumonia among children aged 2-59 months at a public hospital in Quito, Ecuador, which provides such treatment at no charge. Data were collected from children's caregivers at hospitalization and discharge on out-of-pocket payments for medical and nonmedical items, and on employment and lost work time. Analyses encompassed three categories: direct medical costs, direct nonmedical costs, and indirect costs, which covered foregone wages (from caregivers' self-reported lost earnings) and opportunity cost of caregivers' lost time (based on the unskilled labor wage in Ecuador). Caregivers of 153 children completed all questionnaires. Overall, 57% of children were aged less than 12 months, and 46% were female. Just over 50% of mothers and fathers had completed middle school. Most reported direct costs, which averaged $33. Most also reported indirect costs, the mean of which was $74. Fifty-seven reported lost earnings (mean = $79); 29 reported lost time (estimated mean cost = $37). Stratified analyses revealed similar costs for children < 12 months and ≥ 12 months, with variations for specific items. Costs for hospital-based treatment of severe pneumonia in young children represent a major burden for households in low- to middle-income settings, even when such treatment is intended to be provided at no cost.

Incidence and outcomes of hospitalization for community-acquired, ventilator-associated and non-ventilator hospital-acquired pneumonias in patients with type 2 diabetes mellitus in Spain

INTRODUCTION

To describe the incidence and compare in-hospital outcomes of community-acquired pneumonia (CAP), ventilator-associated pneumonia (VAP) and non-ventilator hospital-acquired pneumonia (NV-HAP) among patients with or without type 2 diabetes mellitus (T2DM) using propensity score matching.

RESEARCH DESIGN AND METHODS

This was a retrospective observational epidemiological study using the 2016-2017 Spanish Hospital Discharge Records.

RESULTS

Of 245 221 admissions, CAP was identified in 227 524 (27.67% with T2DM), VAP was identified in 2752 (18.31% with T2DM) and NV-HAP was identified in 14 945 (25.75% with T2DM). The incidence of pneumonia was higher among patients with T2DM (CAP: incidence rate ratio (IRR) 1.44, 95% CI 1.42 to 1.45; VAP: IRR 1.24, 95% CI 1.12 to 1.37 and NV-HAP: IRR 1.38, 95% CI 1.33 to 1.44). In-hospital mortality (IHM) for CAP was 12.74% in patients with T2DM and 14.16% in matched controls (p<0.001); in patients with VAP and NV-HAP, IHM was not significantly different between those with and without T2DM (43.65% vs 41.87%, p=0.567, and 29.02% vs 29.75%, p=0.484, respectively). Among patients with T2DM, older age and dialysis were factors associated with IHM for all types of pneumonia. In patients with VAP, the risk of IHM was higher in females (OR 1.95, 95% CI 1.28 to 2.96).

CONCLUSION

The incidence rates of all types of pneumonia were higher in patients with T2DM. Higher mortality rates in patients with T2DM with any type of pneumonia were associated with older age, comorbidities and dialysis.

COVID-19 en el enfermo renal. Revisión breve

En diciembre de 2019 se identificó en China una nueva subespecie de coronavirus al que denominaron SARS-CoV-2, responsable de la enfermedad posterior a la que la OMS llamó COVID-19. La enfermedad se ha propagado rápidamente provocando una pandemia mundial. Todavía se desconoce mucho del SARS-CoV-2, pero las primeras investigaciones respaldan la hipótesis de que la gravedad de la COVID-19 viene condicionada por la respuesta hiperinflamatoria que se produce en nuestro organismo al contacto con el SARS-CoV-2. La gravedad del cuadro se relaciona con la insuficiencia respiratoria que provoca, no obstante, existen estudios que no limitan la afectación pulmonar. Investigaciones apuntan a que el mecanismo de acceso del SARS-CoV-2 al organismo está muy relacionado con la enzima ACE2. Enzima que entre otros tejidos, se puede encontrar en el epitelio de las células tubulares renales. Esta es la causa por la que existen datos de pacientes con COVID-19 que tienen una gran afectación en la función renal y pueden cursar con IRA (factor de mal pronóstico). Por este motivo, unido a que las comorbilidades asociadas con una mayor mortalidad durante la infección COVID-19 son comunes en los pacientes con enfermedad renal crónica, creemos necesario conocer los resultados que aportan los diferentes estudios realizados sobre esa materia.

Kidney disease is associated with in-hospital death of patients with COVID-19

In December 2019, a coronavirus 2019 (COVID-19) disease outbreak occurred in Wuhan, Hubei Province, China, and rapidly spread to other areas worldwide. Although diffuse alveolar damage and acute respiratory failure were the main features, the involvement of other organs needs to be explored. Since information on kidney disease in patients with COVID-19 is limited, we determined the prevalence of acute kidney injury (AKI) in patients with COVID-19. Further, we evaluated the association between markers of abnormal kidney function and death in patients with COVID-19. This was a prospective cohort study of 701 patients with COVID-19 admitted in a tertiary teaching hospital that also encompassed three affiliates following this major outbreak in Wuhan in 2020 of whom 113 (16.1%) died in hospital. Median age of the patients was 63 years (interquartile range, 50-71), including 367 men and 334 women. On admission, 43.9% of patients had proteinuria and 26.7% had hematuria. The prevalence of elevated serum creatinine, elevated blood urea nitrogen and estimated glomerular filtration under 60 ml/min/1.73m2 were 14.4, 13.1 and 13.1%, respectively. During the study period, AKI occurred in 5.1% patients. Kaplan-Meier analysis demonstrated that patients with kidney disease had a significantly higher risk for in-hospital death. Cox proportional hazard regression confirmed that elevated baseline serum creatinine (hazard ratio: 2.10, 95% confidence interval: 1.36-3.26), elevated baseline blood urea nitrogen (3.97, 2.57-6.14), AKI stage 1 (1.90, 0.76-4.76), stage 2 (3.51, 1.49-8.26), stage 3 (4.38, 2.31-8.31), proteinuria 1+ (1.80, 0.81-4.00), 2+∼3+ (4.84, 2.00-11.70), and hematuria 1+ (2.99, 1.39-6.42), 2+∼3+ (5.56,2.58- 12.01) were independent risk factors for in-hospital death after adjusting for age, sex, disease severity, comorbidity and leukocyte count. Thus, our findings show the prevalence of kidney disease on admission and the development of AKI during hospitalization in patients with COVID-19 is high and is associated with in-hospital mortality. Hence, clinicians should increase their awareness of kidney disease in patients with severe COVID-19.

The relationship between neutrophil-to-lymphocyte ratio and the first occurrence of pneumonia in peritoneal dialysis patients

BACKGROUND

Although neutrophil-to-lymphocyte ratio (NLR) is closely associated with pneumonia in the general population, its relationship is unclear in peritoneal dialysis (PD) patients.

METHODS

This is a cohort study consisting of 739 PD patients and dividing into two groups. Kaplan-Meier curves were applied to observe the incidence of the first occurrence of pneumonia, competitive risk analysis was conducted to compare whether there was a significant difference in each NLR group in the presence of other competing events, multivariable COX regression analysis was used to evaluate the hazard ratios (HRs), as well as forest plot was used to analyze the relationship between NLR and the first occurrence of pneumonia in different subgroups.

RESULTS

Of all the patients, 116 cases of first-time pneumonia were recorded. The first-time pneumonia incidence rate was 71.67/1000 patient-years in high NLR group, which was markedly higher than that of 45.81/1000 patient-years in low NLR group. Kaplan-Meier curves indicated significant differences in the incidence of the first occurrence of pneumonia between two groups (log-rank test p = 0.015). The competitive risk model suggested a significant difference in the cumulative incidence of first pneumonia between the two groups (p = 0.032). Compared to low NLR group, adjusted Cox model showed that high NLR group was associated with increased risk of pneumonia incidence (HR, 1.51; 95% CI 1.04-2.21; p = 0.031). Forest plot showed no interaction was found in subgroups.

CONCLUSIONS

The risk of pneumonia was significantly increasing in PD patients with high NLR, which may have a certain guiding significance for the clinic.

The deacetylase sirtuin 6 protects against kidney fibrosis by epigenetically blocking β-catenin target gene expression

Fibrosis is a common pathologic pathway of progressive kidney disease involving complex signaling networks. The deacetylase sirtuin 6 (sirt6) was recently implicated in kidney injury. However, it remains elusive whether and how sirt6 contributes to the regulation of kidney fibrosis. Here, we demonstrate that sirt6 protects against kidney interstitial fibrosis through epigenetic regulation of β-catenin signaling. Sirt6 is markedly upregulated during fibrogenesis following obstructed nephropathy and kidney ischemia-reperfusion injury. Pharmacological inhibition of sirt6 deacetylase activity aggravates kidney fibrosis in obstructed nephropathy. Consistently, knockdown of sirt6 in mouse kidney proximal tubular epithelial cells aggravates transforming growth factor-β-induced fibrosis in vitro. Mechanistically, sirt6 deficiency results in augmented expression of the downstream target proteins of β-catenin signaling. We further show that sirt6 interacts with β-catenin during transforming growth factor-β treatment and binds to the promoters of β-catenin target genes, resulting in the deacetylation of histone H3K56 to prevent the transcription of fibrosis-related genes. Thus, our data reveal the anti-fibrotic function of sirt6 by epigenetically attenuating β-catenin target gene expression.

Hospitalization Among Individuals Waitlisted For Kidney Transplant

BACKGROUND

For patients waitlisted for a deceased-donor kidney, hospitalization is associated with a lower likelihood of transplantation and worse posttransplant outcomes. However, individual-, neighborhood-, and regional-level risk factors for hospitalization throughout the waitlist period and specific causes of hospitalization in this population are unknown.

METHODS

We used United States Renal Data System Medicare-linked data on patients waitlisted between 2005 and 2013 with continuous enrollment in Medicare parts A and B (n = 53 810) to examine the association between annual hospitalization rate and a variety of demographic, clinical, and social factors. We used multilevel multivariable ordinal logistic regression to estimate odds ratios.

RESULTS

Factors associated with significantly increased hospitalization rates among waitlisted individuals included older age, female sex, more years on dialysis before waitlisting, tobacco use, panel-reactive antibody greater than 0, public insurance or no insurance at end-stage renal disease diagnosis, more regional acute care hospital beds, and urban residence (all P < 0.05). Among patients dialysis-dependent when waitlisted, individuals with arteriovenous fistulas were significantly less likely than individuals with indwelling catheters or grafts to be hospitalized (odds ratios, 0.79 and 0.82, respectively, both P < 0.001). The most common causes of hospitalization were complications related to devices, implants, and grafts; hypertension; and sepsis.

CONCLUSIONS

Individual- and regional-level variables were significantly associated with hospitalization while waitlisted, suggesting that personal, health system, and geographic factors may impact patients' risk. Conditions related to dialysis access and comorbidities were common hospitalization causes, underscoring the importance proper access management and care for additional chronic health conditions.