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Kanigicherla DAK, Kehagia AA, Jamshidi B, Manounah L, Barnes A, Patrick H, Powell H, Austin C, Norton S, Willcocks L, Griffith M, Braddon F, Steenkamp R, McKane WS, Khwaja A. Prospective study of the effect of rituximab on kidney function in membranous nephropathy. Clin Kidney J 2024; 17:sfae179. [PMID: 39104870 PMCID: PMC11299108 DOI: 10.1093/ckj/sfae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Indexed: 08/07/2024] Open
Abstract
Background Patients with membranous nephropathy (MN) and poor kidney function or active disease despite previous immunosuppression are underrepresented in clinical trials. It is unknown how effective rituximab is in this population. Methods This prospective, multi-centre, single-arm, real-world study of patients with active MN [urine protein-creatinine ratio (uPCR) >350 mg/mmol and serum albumin <30 g/L, or a fall in estimated glomerular filtration rate (eGFR) of at least 20% or more over at least 3 months] evaluated rituximab in those with contraindications to calcineurin inhibitors and cytotoxic therapy. The primary outcome was change in rate of eGFR decline before and after rituximab. Complete or partial remission were defined as uPCR <30 mg/mmol or uPCR <350 mg/mmol with a ≥50% fall from baseline, respectively. Results A total of 180 patients [median age 59 years, interquartile range (IQR) 48-68] received rituximab and were followed up for a median duration of 17 months. Seventy-seven percent had prior immunosuppression. Median eGFR and uPCR at baseline were 49.2 mL/min/1.73 m2 (IQR 34.4-80.6) and 766 mg/mmol (IQR 487-1057), respectively. The annual rate of decline of eGFR fell from 13.9 to 1.7 mL/min/1.73 m2/year following rituximab (Z score = 2.48, P < .0066). At 18 months 12% and 42% of patients were in complete or partial remission, respectively. Rituximab was well tolerated; patient survival was 95.6% at 2 years and in patients in whom eGFR was available, kidney survival was 93% at 2 years. Conclusion Rituximab significantly reduced the rate of eGFR decline in active MN including those who had received prior immunosuppression or with poor baseline kidney function.
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Affiliation(s)
| | | | | | - Lina Manounah
- King's College Technology Evaluation Centre (KiTEC), UK
| | - Anna Barnes
- King's College Technology Evaluation Centre (KiTEC), UK
| | | | - Helen Powell
- National Institute for Health and Care Excellence, UK
| | - Catrin Austin
- National Institute for Health and Care Excellence, UK
| | | | | | | | - Fiona Braddon
- UK Kidney Association & UK National Registry of Rare Kidney Diseases, UK
| | - Retha Steenkamp
- UK Kidney Association & UK National Registry of Rare Kidney Diseases, UK
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Aldridge RW, Evans HER, Yavlinsky A, Moayyeri A, Bhaskaran K, Mathur R, Jordan KP, Croft P, Denaxas S, Shah AD, Blackburn RM, Moller H, Ng ESW, Hughes A, Fox S, Flowers J, Schmidt J, Hayward A, Gilbert R, Smeeth L, Hemingway H. Estimating disease burden using national linked electronic health records: a study using an English population-based cohort. Wellcome Open Res 2024; 8:262. [PMID: 39092423 PMCID: PMC11292189 DOI: 10.12688/wellcomeopenres.19470.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2024] [Indexed: 08/04/2024] Open
Abstract
Background Electronic health records (EHRs) have the potential to be used to produce detailed disease burden estimates. In this study we created disease estimates using national EHR for three high burden conditions, compared estimates between linked and unlinked datasets and produced stratified estimates by age, sex, ethnicity, socio-economic deprivation and geographical region. Methods EHRs containing primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and mortality records (Office for National Statistics) were used. We used existing disease phenotyping algorithms to identify cases of cancer (breast, lung, colorectal and prostate), type 1 and 2 diabetes, and lower back pain. We calculated age-standardised incidence of first cancer, point prevalence for diabetes, and primary care consultation prevalence for low back pain. Results 7.2 million people contributing 45.3 million person-years of active follow-up between 2000-2014 were included. CPRD-HES combined and CPRD-HES-ONS combined lung and bowel cancer incidence estimates by sex were similar to cancer registry estimates. Linked CPRD-HES estimates for combined Type 1 and Type 2 diabetes were consistently higher than those of CPRD alone, with the difference steadily increasing over time from 0.26% (2.99% for CPRD-HES vs. 2.73 for CPRD) in 2002 to 0.58% (6.17% vs. 5.59) in 2013. Low back pain prevalence was highest in the most deprived quintile and when compared to the least deprived quintile the difference in prevalence increased over time between 2000 and 2013, with the largest difference of 27% (558.70 per 10,000 people vs 438.20) in 2013. Conclusions We use national EHRs to produce estimates of burden of disease to produce detailed estimates by deprivation, ethnicity and geographical region. National EHRs have the potential to improve disease burden estimates at a local and global level and may serve as more automated, timely and precise inputs for policy making and global burden of disease estimation.
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Affiliation(s)
- Robert W. Aldridge
- Institute of Health Informatics, University College London, London, England, NW1 2DA, UK
| | - Hannah E. R. Evans
- Institute of Health Informatics, University College London, London, England, NW1 2DA, UK
| | - Alexei Yavlinsky
- Institute of Health Informatics, University College London, London, England, NW1 2DA, UK
| | - Alireza Moayyeri
- Institute of Health Informatics, University College London, London, England, NW1 2DA, UK
| | - Krishnan Bhaskaran
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Rohini Mathur
- Wolfson Institute of Population Health, Queen Mary University of London, London, England, EC1M 6BQ, UK
| | - Kelvin P. Jordan
- School of Medicine, Keele University, Staffordshire, England, ST5 5BG, UK
| | - Peter Croft
- School of Medicine, Keele University, Staffordshire, England, ST5 5BG, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, England, NW1 2DA, UK
| | - Anoop D. Shah
- Institute of Health Informatics, University College London, London, England, NW1 2DA, UK
| | - Ruth M. Blackburn
- Institute of Health Informatics, University College London, London, England, NW1 2DA, UK
| | - Henrik Moller
- Cancer Epidemiology & Population Health, King's College London, London, England, WC2R 2LS, UK
| | - Edmond S. W. Ng
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Andrew Hughes
- Department of Health and Social Care, Office for Health Improvement and Disparities, London, SW1H 0EU, UK
| | - Sebastian Fox
- Department of Health and Social Care, Office for Health Improvement and Disparities, London, SW1H 0EU, UK
| | - Julian Flowers
- Institute of Health Informatics, University College London, London, England, NW1 2DA, UK
| | - Jurgen Schmidt
- Department of Health and Social Care, Office for Health Improvement and Disparities, London, SW1H 0EU, UK
| | - Andrew Hayward
- Institute of Epidemiology and Health Care, University College London, London, England, WC1E 6BT, UK
| | - Ruth Gilbert
- Institute of Health Informatics, University College London, London, England, NW1 2DA, UK
| | - Liam Smeeth
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Harry Hemingway
- Institute of Health Informatics, University College London, London, England, NW1 2DA, UK
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3
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Diao K, Wang J, Zhang Y, Huang Y, Shan Y. The mediating effect of personal mastery and perceived social support between emotional intelligence and social alienation among patients receiving peritoneal dialysis. Front Public Health 2024; 12:1392224. [PMID: 38939568 PMCID: PMC11210390 DOI: 10.3389/fpubh.2024.1392224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/06/2024] [Indexed: 06/29/2024] Open
Abstract
Aim This study aims to assess the extent of social alienation in patients undergoing peritoneal dialysis and examine how personal mastery and perceived social support mediate the association between emotional intelligence and social alienation in this patient population. Methods This study adopts a cross-sectional survey design. A total of 192 patients were recruited from a tertiary hospital located in Henan Province, China, using a convenience sampling method. We have developed a structural equation model to investigate the mediating influence of personal mastery and perceived social support on the emotional intelligence and social alienation of patients undergoing Peritoneal dialysis. Results Peritoneal patients exhibited an social alienation score of 42.01 ± 3.15. Elevated EI levels (coefficient = -0.616, p < 0.001) were significantly correlated with reduced social alienation. The mediation model demonstrated that personal mastery and perceived social support fully mediated the impact of emotional intelligence on social alienation. Conclusion The social alienation of peritoneal dialysis patients is serious, and healthcare professionals should pay attention to patients' social alienation, improve patients' emotional intelligence through relevant interventions, increase personal mastery and perceived social support, and finally reduce social alienation.
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Affiliation(s)
- Keke Diao
- The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Jiajia Wang
- The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanjun Zhang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Yijia Huang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Yan Shan
- The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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4
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Borucki JP, Woods R, Fielding A, Webb LA, Hernon JM, Lines SW, Stearns AT. Postoperative decline in renal function after rectal resection and all-cause mortality: a retrospective cohort study. Colorectal Dis 2023; 25:2225-2232. [PMID: 37803491 DOI: 10.1111/codi.16768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/20/2023] [Accepted: 08/14/2023] [Indexed: 10/08/2023]
Abstract
AIM Fluid loss, dehydration and resultant kidney injury are common when a diverting ileostomy is formed during rectal cancer surgery, the consequences of which are unknown. The aim of this retrospective single-site cohort study is to evaluate the impact of sustained postoperative renal dysfunction after rectal resection on long-term renal impairment and survival. METHOD All patients with rectal adenocarcinoma undergoing resection between January 2003 and March 2017 were included, with follow-up to June 2020. The primary outcome was impact on long-term mortality attributed to a 25% or greater drop in estimated glomerular filtration rate (eGFR) following rectal resection. Secondary outcomes were the long-term effect on renal function resulting from the same drop in eGFR and the effect on long-term mortality and renal function of a 50% drop in eGFR. We also calculated the effect on mortality of a 1% drop in eGFR. RESULTS A total of 1159 patients were identified. Postoperative reductions in eGFR of 25% and 50% were associated with long-term overall mortality with adjusted hazard ratios of 1.84 (1.22-2.77) (p = 0.004) and 2.88 (1.45-5.71) (p = 0.002). The median survival of these groups was 86.0 (64.0-108.0) months and 53.3 (7.8-98.8) months compared with 144.5 (128.1-160.9) months for controls. Long-term effects on renal function were demonstrated, with those who sustained a >25% drop in renal function having a 38.8% mean decline in eGFR at 10 years compared with 10.2% in controls. CONCLUSION Persistent postoperative declines in renal function may be linked to long-term mortality. Further research is needed to assess causal relationships and prevention.
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Affiliation(s)
- Joseph P Borucki
- Department of General Surgery, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, UK
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - Rebecca Woods
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - Alexandra Fielding
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - Lucy-Ann Webb
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - James M Hernon
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
| | - Simon W Lines
- Department of Nephrology, St Bernard's Hospital, Gibraltar, Gibraltar
| | - Adam T Stearns
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
- Norwich Surgical Training and Research Academy, Level 3 Centre, Norfolk and Norwich University Hospital, Norwich, UK
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Tan R, Li D, Hu N, Qiu J, Zeng Z, Cai W, Zhong Y, Zhang X, Pai P, Wang K, Tang D, Dai Y. Integrated proteome and malonylome analyses reveal the potential meaning of TLN1 and ACTB in end-stage renal disease. Proteome Sci 2023; 21:18. [PMID: 37833721 PMCID: PMC10571336 DOI: 10.1186/s12953-023-00211-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 07/16/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND End-stage renal disease (ESRD) is a condition that is characterized by the loss of kidney function. ESRD patients suffer from various endothelial dysfunctions, inflammation, and immune system defects. Lysine malonylation (Kmal) is a recently discovered post-translational modification (PTM). Although Kmal has the ability to regulate a wide range of biological processes in various organisms, its specific role in ESRD is limited. METHODS In this study, the affinity enrichment and liquid chromatography-tandem mass spectrometry (LC-MS/MS) techniques have been used to create the first global proteome and malonyl proteome (malonylome) profiles of peripheral blood mononuclear cells (PBMCs) from twenty patients with ESRD and eighty-one controls. RESULTS On analysis, 793 differentially expressed proteins (DEPs) and 12 differentially malonylated proteins (DMPs) with 16 Kmal sites were identified. The Rap1 signaling pathway and platelet activation pathway were found to be important in the development of chronic kidney disease (CKD), as were DMPs TLN1 and ACTB, as well as one malonylated site. One conserved Kmal motif was also discovered. CONCLUSIONS These findings provided the first report on the Kmal profile in ESRD, which could be useful in understanding the potential role of lysine malonylation modification in the development of ESRD.
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Affiliation(s)
- Ruqi Tan
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen, Guangdong, 518020, P.R. China
- Department of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, 518053, Guangdong, China
| | - Dandan Li
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen, Guangdong, 518020, P.R. China
- Experimental Center, Shenzhen Pingle Orthopedic Hospital (Shenzhen Pingshan Traditional Chinese Medicine Hospital), Shenzhen, Guangdong, 518118, China
| | - Nan Hu
- Key Renal Laboratory of Shenzhen, Department of Nephrology, The Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen, 518020, Guangdong, China
| | - Jing Qiu
- Key Renal Laboratory of Shenzhen, Department of Nephrology, The Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen, 518020, Guangdong, China
| | - Zhipeng Zeng
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen, Guangdong, 518020, P.R. China
| | - Wanxia Cai
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen, Guangdong, 518020, P.R. China
| | - Yafang Zhong
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen, Guangdong, 518020, P.R. China
| | - Xinzhou Zhang
- Key Renal Laboratory of Shenzhen, Department of Nephrology, The Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen, 518020, Guangdong, China
| | - Pearl Pai
- Department of Nephrology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, 518053, Guangdong, China
| | - Kang Wang
- Key Renal Laboratory of Shenzhen, Department of Nephrology, The Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen, 518020, Guangdong, China.
| | - Donge Tang
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen, Guangdong, 518020, P.R. China.
| | - Yong Dai
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen, Guangdong, 518020, P.R. China.
- The First Affiliated Hospital, School of Medicine, Anhui University of Science and Technology, Huainan, Anhui, 232001, China.
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6
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Murphy D, Firoozi S, Herzog CA, Banerjee D. Cardiac Troponin, Kidney Function, Heart Failure and Mortality After Myocardial Infarction in Patients With and Without Kidney Impairment. Am J Cardiol 2023; 204:383-391. [PMID: 37579521 DOI: 10.1016/j.amjcard.2023.07.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023]
Abstract
Cardiac troponins (cTn) are routinely measured for the diagnosis and prognosis of myocardial infarction (MI). The relation between troponin levels, estimated glomerular filtration rate (eGFR), postinfarction heart failure (HF), and mortality is unclear in patients with kidney impairment. This is a retrospective, cross-sectional study of patients presenting to the Emergency Department at a single tertiary center. Participants presenting with confirmed type I MI from January 1, 2019, to December 31, 2021, were analyzed from the Myocardial Ischemia National Audit Project database. Main outcomes were acute HF, measured using Killip class, and inpatient mortality. Peak cardiac troponin T (cTnT) level was a secondary outcome. Data on 2,815 patients (67±14 years, 28% female) were analyzed. Ordinal logistic regression analysis was used to test for predictors of increasing Killip class. Binary logistic regression was used to test for predictors of inpatient mortality. Analysis of a sub-sample matched for age and diabetes mellitus status showed increased mortality in patients with eGFR <60 ml/min/1.73 m2 (12.2% vs 4.4%, p <0.001). Multivariate predictors of acute HF included log-transformed peak cTnT, eGFR, body mass index (BMI), and diabetes mellitus status. Multivariate predictors of inpatient mortality included log-transformed peak cTnT, eGFR, age, BMI, and Killip class 3/4. On multivariate analysis, eGFR, ST-elevation MI diagnosis, BMI, male gender, diabetes mellitus status, and hypertension were all predictive of peak cTnT after MI. In conclusion, peak cTnT level and eGFR at presentation after MI are independent predictors of acute HF severity and death in patients with and without kidney impairment.
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Affiliation(s)
- Daniel Murphy
- Cardiology Clinical Academic Group, Institute of Medical and Biomedical Education, St George's, University of London, Cranmer Terrace, London, United Kingdom; Department of Renal and Transplant Medicine, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, United Kingdom
| | - Sami Firoozi
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, United Kingdom
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin Healthcare and University of Minnesota, Minneapolis, Minnesota
| | - Debasish Banerjee
- Cardiology Clinical Academic Group, Institute of Medical and Biomedical Education, St George's, University of London, Cranmer Terrace, London, United Kingdom; Department of Renal and Transplant Medicine, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, United Kingdom.
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7
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Aryee A, Rockenschaub P, Robson J, Priebe M, Ahmed Z, Fhogartaigh CN, Ball D, Hayward A, Shallcross L. Hospital admission after primary care consultation for community-onset lower urinary tract infection: a cohort study of risks and predictors using linked data. Br J Gen Pract 2023; 73:e694-e701. [PMID: 37487642 PMCID: PMC10394611 DOI: 10.3399/bjgp.2022.0592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/05/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) are a common indication for antibiotic prescriptions, reductions in which would reduce antimicrobial resistance (AMR). Risk stratification of patients allows reductions to be made safely. AIM To identify risk factors for hospital admission following UTI, to inform targeted antibiotic stewardship. DESIGN AND SETTING Retrospective cohort study of East London primary care patients. METHOD Hospital admission outcomes following primary care consultation for UTI were analysed using linked data from primary care, secondary care, and microbiology, from 1 April 2012 to 31 March 2017. The outcomes analysed were urinary infection-related hospital admission (UHA) and all-cause hospital admission (AHA) within 30 days of UTI in primary care. Odds ratios between specific variables (demographic characteristics, prior antibiotic exposure, and comorbidities) and the outcomes were predicted using generalised estimating equations, and fitted to a final multivariable model including all variables with a P-value <0.1 on univariable analysis. RESULTS Of the 169 524 episodes of UTI, UHA occurred in 1336 cases (0.8%, 95% confidence interval [CI] = 0.7 to 0.8) and AHA in 6516 cases (3.8%, 95% CI = 3.8 to 3.9). On multivariable analysis, increased odds of UHA were seen in patients aged 55-74 years (adjusted odds ratio [AOR] 1.49) and ≥75 years (AOR 3.24), relative to adults aged 16-34 years. Increased odds of UHA were also associated with chronic kidney disease (CKD; AOR 1.55), urinary catheters (AOR 2.01), prior antibiotics (AOR 1.38 for ≥3 courses), recurrent UTI (AOR 1.33), faecal incontinence (FI; AOR 1.47), and diabetes mellitus (DM; AOR 1.37). CONCLUSION Urinary infection-related hospital admission after primary care consultation for community-onset lower UTI was rare; however, increased odds for UHA were observed for some patient groups. Efforts to reduce antibiotic prescribing for suspected UTI should focus on patients aged <55 years without risk factors for complicated UTI, recurrent UTI, DM, or FI.
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Affiliation(s)
- Anna Aryee
- Institute of Health Informatics, University College London, London
| | | | - John Robson
- Clinical Effectiveness Group, Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Marian Priebe
- Clinical Effectiveness Group, Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Zaheer Ahmed
- Clinical Effectiveness Group, Wolfson Institute of Population Health, Queen Mary University of London, London
| | | | | | - Andrew Hayward
- Institute of Epidemiology and Health Care, University College London, London
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London
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8
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Hospitalisation events in people with chronic kidney disease as a component of multimorbidity: parallel cohort studies in research and routine care settings. BMC Med 2021; 19:278. [PMID: 34794437 PMCID: PMC8603496 DOI: 10.1186/s12916-021-02147-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/29/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) typically co-exists with multimorbidity (presence of 2 or more long-term conditions: LTCs). The associations between CKD, multimorbidity and hospitalisation rates are not known. The aim of this study was to examine hospitalisation rates in people with multimorbidity with and without CKD. Amongst people with CKD, the aim was to identify risk factors for hospitalisation. METHODS Two cohorts were studied in parallel: UK Biobank (a prospective research study: 2006-2020) and Secure Anonymised Information Linkage Databank (SAIL: a routine care database, Wales, UK: 2011-2018). Adults were included if their kidney function was measured at baseline. Nine categories of participants were used: zero LTCs; one, two, three and four or more LTCs excluding CKD; and one, two, three and four or more LTCs including CKD. Emergency hospitalisation events were obtained from linked hospital records. RESULTS Amongst 469,339 UK Biobank participants, those without CKD had a median of 1 LTC and those with CKD had a median of 3 LTCs. Amongst 1,620,490 SAIL participants, those without CKD had a median of 1 LTC and those with CKD had a median of 5 LTCs. Compared to those with zero LTCs, participants with four or more LTCs (excluding CKD) had high event rates (rate ratios UK Biobank 4.95 (95% confidence interval 4.82-5.08)/SAIL 3.77 (3.71-3.82)) with higher rates if CKD was one of the LTCs (rate ratios UK Biobank 7.83 (7.42-8.25)/SAIL 9.92 (9.75-10.09)). Amongst people with CKD, risk factors for hospitalisation were advanced CKD, age over 60, multiple cardiometabolic LTCs, combined physical and mental LTCs and complex patterns of multimorbidity (LTCs in three or more body systems). CONCLUSIONS People with multimorbidity have high rates of hospitalisation. Importantly, the rates are two to three times higher when CKD is one of the multimorbid conditions. Further research is needed into the mechanism underpinning this to inform strategies to prevent hospitalisation in this very high-risk group.
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9
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The risk of non-steroidal anti-inflammatory drug-induced heart failure in people with chronic kidney disease: a systematic review. J Public Health (Oxf) 2021. [DOI: 10.1007/s10389-021-01654-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Abstract
Aim
To examine the risk of non-steroidal anti-inflammatory drug-induced heart failure in patients with chronic kidney disease.
Methods
Embase, Medline, CENTRAL, Web of Science, and Google Scholar were searched for papers published in English between 1st January 1999 and 31st May 2020. Papers were included if some participants had chronic kidney disease, were exposed to non-steroidal anti-inflammatory drugs, and where heart failure was measured as an outcome. Papers were assessed for risk of bias using the Cochrane Risk of Bias 2 tool for randomised controlled trials, and ROBINS-I for observational studies.
Results
A total of 2480 independent papers were retrieved. Following abstract screening, 165 full texts were reviewed to identify seven eligible papers: two randomised controlled trials, four cohort studies, and one case-control study. For chronic kidney disease (stage 3–5), relative risk for heart failure ranged from 0.3 to 1.9 with 95% confidence interval 0.04 to 15.1. Results were not pooled due to study heterogeneity. We attributed bias to heterogenous populations studied, probable confounding due to partially adjusted risk estimates, and heterogenous measurement of the heart failure outcome.
Conclusion
Overall, there are only a few studies to refute or support an increased risk of heart failure associated with taking non-steroidal anti-inflammatory drugs in patients with chronic kidney disease, and therefore no robust evidence was available.
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10
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Schonmann Y, Mansfield KE, Mulick A, Roberts A, Smeeth L, Langan SM, Nitsch D. Inflammatory skin diseases and the risk of chronic kidney disease: population-based case-control and cohort analyses. Br J Dermatol 2021; 185:772-780. [PMID: 33730366 DOI: 10.1111/bjd.20067] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Emerging evidence suggests an association between common inflammatory skin diseases and chronic kidney disease (CKD). OBJECTIVES To explore the association between CKD stages 3-5 (CKD3-5) and atopic eczema, psoriasis, rosacea and hidradenitis suppurativa. METHODS We undertook two complementary analyses; a prevalent case-control study and a cohort study using routinely collected primary care data [UK Clinical Practice Research Datalink (CPRD)]. We matched individuals with CKD3-5 in CPRD in March 2018 with up to five individuals without CKD for general practitioner practice, age and sex. We compared the prevalence of CKD3-5 among individuals with and without each inflammatory skin disease. We included individuals in CPRD with diabetes mellitus (2004-2018) in a cohort analysis to compare the incidence of CKD3-5 among people with and without atopic eczema and psoriasis. RESULTS Our study included 56 602 cases with CKD3-5 and 268 305 controls. Cases were more likely than controls to have a history of atopic eczema [odds ratio (OR) 1·14, 99% confidence interval (CI) 1·11-1·17], psoriasis (OR 1·13, 99% CI 1·08-1·19) or hidradenitis suppurativa (OR 1·49, 99% CI 1·19-1·85), but were slightly less likely to have been diagnosed with rosacea (OR 0·92, 99% CI 0·87-0·97), after adjusting for age, sex, practice (matching factors), index of multiple deprivation, diabetes, smoking, harmful alcohol use and obesity. Results remained similar after adjusting for hypertension and cardiovascular disease. In the cohort with diabetes (N = 335 827), there was no evidence that CKD3-5 incidence was associated with atopic eczema or psoriasis. CONCLUSIONS Atopic eczema, psoriasis and hidradenitis suppurativa are weakly associated with CKD3-5. Future research is needed to elucidate potential mechanisms and the clinical significance of our findings.
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Affiliation(s)
- Y Schonmann
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Department of Quality Measurements and Research, Clalit Health Services, Tel Aviv, Israel.,Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - K E Mansfield
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - A Mulick
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - A Roberts
- Nottingham Support Group for Carers of Children with Eczema, Nottingham, UK
| | - L Smeeth
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - S M Langan
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,St John's Institute of Dermatology, Guy's & St Thomas' Hospital NHS Foundation Trust and King's College London, London, UK.,Health Data Research, London, UK
| | - D Nitsch
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Renal Department, Royal Free London NHS Foundation Trust, London, UK.,UK Renal Registry, Bristol, UK
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11
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Burden of Chronic Kidney Disease by KDIGO Categories of Glomerular Filtration Rate and Albuminuria: A Systematic Review. Adv Ther 2021; 38:180-200. [PMID: 33231861 PMCID: PMC7854398 DOI: 10.1007/s12325-020-01568-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/10/2020] [Indexed: 12/19/2022]
Abstract
Introduction The Kidney Disease: Improving Global Outcomes (KDIGO) 2012 guidelines recommend classifying patients by glomerular filtration rate (GFR) and albuminuria to predict chronic kidney disease (CKD) prognosis. The aim of this systematic review was to explore the epidemiological burden of CKD stratified by the KDIGO 2012 categories. Methods MEDLINE® and Embase were searched for observational studies of patients with CKD with results stratified according to the KDIGO 2012 classification. Investigated outcomes were prevalence, incidence, and risk factors and complications of CKD, including mortality. Results The review included ten observational studies with 3033 to 46,949 participants, conducted in the USA, China, France, Italy and Spain. The most frequently reported outcome was the prevalence of CKD (GFR categories G3–5), ranging from 2% to 17%. Most participants were normoalbuminuric, with 0.4–3.2% macroalbuminuric, and most fell within the KDIGO 2012 low-risk or moderate-risk groups, with 0.9–5.6% in the high-risk and 0.3–4.8% in the very high-risk groups. Although scarce, data on the prevalence of comorbidities in CKD according to the KDIGO classification suggest that they increase with albuminuria severity. Conclusions Patients with CKD frequently have complications, but only a small proportion have severely increased albuminuria or fall within the KDIGO high-risk or very high-risk groups. These groups, however, are associated with the highest burden of disease, as comorbidities are more prevalent with increasing albuminuria severity. New studies framed by the KDIGO 2012 classification are needed to address key gaps in the understanding of CKD burden and outcomes. Electronic supplementary material The online version of this article (10.1007/s12325-020-01568-8) contains supplementary material, which is available to authorized users.
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12
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Schrauben SJ, Chen HY, Lin E, Jepson C, Yang W, Scialla JJ, Fischer MJ, Lash JP, Fink JC, Hamm LL, Kanthety R, Rahman M, Feldman HI, Anderson AH. Hospitalizations among adults with chronic kidney disease in the United States: A cohort study. PLoS Med 2020; 17:e1003470. [PMID: 33306688 PMCID: PMC7732055 DOI: 10.1371/journal.pmed.1003470] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 11/05/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Adults with chronic kidney disease (CKD) are hospitalized more frequently than those without CKD, but the magnitude of this excess morbidity and the factors associated with hospitalizations are not well known. METHODS AND FINDINGS Data from 3,939 participants enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study between 2003 and 2008 at 7 clinical centers in the United States were used to estimate primary causes of hospitalizations, hospitalization rates, and baseline participant factors associated with all-cause, cardiovascular, and non-cardiovascular hospitalizations during a median follow up of 9.6 years. Multivariable-adjusted Poisson regression was used to identify factors associated with hospitalization rates, including demographics, blood pressure, estimated glomerular filtration rate (eGFR), and proteinuria. Hospitalization rates in CRIC were compared with rates in the Nationwide Inpatient Sample (NIS) from 2012. Of the 3,939 CRIC participants, 45.1% were female, and 41.9% identified as non-Hispanic black, with a mean age of 57.7 years, and the mean eGFR is 44.9 ml/min/1.73m2. CRIC participants had an unadjusted overall hospitalization rate of 35.0 per 100 person-years (PY) [95% CI: 34.3 to 35.6] and 11.1 per 100 PY [95% CI: 10.8 to 11.5] for cardiovascular-related causes. All-cause, non-cardiovascular, and cardiovascular hospitalizations were associated with older age (≥65 versus 45 to 64 years), more proteinuria (≥150 to <500 versus <150 mg/g), higher systolic blood pressure (≥140 versus 120 to <130 mmHg), diabetes (versus no diabetes), and lower eGFR (<60 versus ≥60 ml/min/1.73m2). Non-Hispanic black (versus non-Hispanic white) race/ethnicity was associated with higher risk for cardiovascular hospitalization [rate ratio (RR) 1.25, 95% CI: 1.16 to 1.35, p-value < 0.001], while risk among females was lower [RR 0.89, 95% CI: 0.83 to 0.96, p-value = 0.002]. Rates of cardiovascular hospitalizations were higher among those with ≥500 mg/g of proteinuria irrespective of eGFR. The most common causes of hospitalization were related to cardiovascular (31.8%), genitourinary (8.7%), digestive (8.3%), endocrine, nutritional or metabolic (8.3%), and respiratory (6.7%) causes. Hospitalization rates were higher in CRIC than the NIS, except for non-cardiovascular hospitalizations among individuals aged >65 years. Limitations of the study include possible misclassification by diagnostic codes, residual confounding, and potential bias from healthy volunteer effect due to its observational nature. CONCLUSIONS In this study, we observed that adults with CKD had a higher hospitalization rate than the general population that is hospitalized, and even moderate reductions in kidney function were associated with elevated rates of hospitalization. Causes of hospitalization were predominantly related to cardiovascular disease, but other causes contributed, particularly, genitourinary, digestive, and endocrine, nutritional, and metabolic illnesses. High levels of proteinuria were observed to have the largest association with hospitalizations across a wide range of kidney function levels.
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Affiliation(s)
- Sarah J. Schrauben
- Renal, Electrolyte-Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Hsiang-Yu Chen
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Eugene Lin
- Department of Medicine, Division of Nephrology; Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, United States of America
| | - Christopher Jepson
- ECRI Institute, Plymouth Meeting, Pennsylvania, United States of America
| | - Wei Yang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Julia J. Scialla
- Department of Medicine, Division of Nephrology, University of Virginia School of Medicine, Charlotte, Virginia, United States of America
| | - Michael J. Fischer
- Medical Service, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, United States of America
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - James P. Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Jeffrey C. Fink
- Department of Medicine, University of Maryland, Baltimore, Maryland, United States of America
| | - L. Lee Hamm
- Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Radhika Kanthety
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Harold I. Feldman
- Renal, Electrolyte-Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Amanda H. Anderson
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, United States of America
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13
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Uncoded chronic kidney disease in primary care: a cross-sectional study of inequalities and cardiovascular disease risk management. Br J Gen Pract 2020; 70:e785-e792. [PMID: 33077509 DOI: 10.3399/bjgp20x713105] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/02/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Uncoded chronic kidney disease (CKD) is associated with poorer quality of care. AIM To ascertain the proportion and determinants of CKD, which have not been formally recorded (Read coded), and identify differences in management and quality-of-care measures for patients with coded and uncoded CKD. DESIGN AND SETTING Cross-sectional survey undertaken in an ethnically diverse adult population using primary care electronic health records (EHRs) from GP clinics in Lambeth, South London, UK. METHOD Multivariable logistic regression analysis examined the association of demographic factors, selected comorbidities, deprivation, and cardiovascular disease risk management in CKD, with coding status as outcome. RESULTS In total, the survey involved 286 162 adults, of whom 9325 (3.3%) were identified with CKD stage 3-5 (assigned as CKD based on estimated glomerular filtration rate [eGFR] values). Of those identified with CKD, 4239 (45.5%) were Read coded, and 5086 (54.5%) were uncoded. Of those identified with CKD stage 3-5, individuals aged ≥50 years were more likely to be coded for CKD, compared with those aged <50 years. Lower levels of coding were independently associated with deprivation and black Caribbean, black African, South Asian, and non-stated ethnicities, compared with white ethnicity. Prescribed statin and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker medications were associated with increased odds of coded CKD. CONCLUSION This study found that >50% of CKD was uncoded and, for those patients, quality of care was lower compared with those with coded CKD. Future research and practices should focus on areas of greater deprivation and targeted initiatives for those aged <50 years and of black African, black Caribbean, South Asian, or non-stated ethnic groups. Possible areas for improvement include diagnostic coding support, automated CKD recording, and clinical decision support (based on adjusted eGFR results) in the GP clinical records.
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14
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Tsang JY, Murray J, Kingdon E, Tomson C, Hallas K, Campbell S, Blakeman T. Guidance for post-discharge care following acute kidney injury: an appropriateness ratings evaluation. BJGP Open 2020; 4:bjgpopen20X101054. [PMID: 32546580 PMCID: PMC7465579 DOI: 10.3399/bjgpopen20x101054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with poor health outcomes, including increased mortality and rehospitalisation. National policy and patient safety drivers have targeted AKI as an example to ensure safer transitions of care. AIM To establish guidance to promote high-quality transitions of care for adults following episodes of illness complicated by AKI. DESIGN & SETTING An appropriateness ratings evaluation was undertaken using the RAND/UCLA Appropriateness Method (RAM). The Royal College of General Practitioners (RCGP) AKI working group developed a range of clinical scenarios to help identify the necessary steps to be taken following discharge of a patient from secondary care into primary care in the UK. METHOD A 10-person expert panel was convened to rate 819 clinical scenarios, testing the most appropriate time and action following hospital discharge. Specifically, the scenarios focused on determining the appropriateness and urgency for planning: an initial medication review; monitoring of kidney function; and assessment for albuminuria. RESULTS Taking no action (that is, no medication review; no kidney monitoring; or no albuminuria testing) was rated inappropriate in all cases. In most scenarios, there was consensus that both the initial medication review and kidney function monitoring should take place within 1-2 weeks or 1 month, depending on clinical context. However, patients with heart failure and poor kidney recovery were rated to require expedited review. There was consensus that assessment for albuminuria should take place at 3 months after discharge following AKI. CONCLUSION Systems to support tailored and timely post-AKI discharge care are required, especially in high-risk populations, such as people with heart failure.
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Affiliation(s)
- Jung Yin Tsang
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care and Health Services Research, Institute of Population Health, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre (PTSRC), University of Manchester, Manchester, UK
| | - Jonathan Murray
- Renal Unit, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- Academic Health Science Network for the North East and North Cumbria (AHSN NENC), Newcastle upon Tyne, UK
| | - Edward Kingdon
- Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
- Kent Surrey Sussex Academic Health Science Network (KSS AHSN), Crawley, UK
| | - Charlie Tomson
- Department of Renal Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Kyle Hallas
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care and Health Services Research, Institute of Population Health, University of Manchester, Manchester, UK
| | - Stephen Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre (PTSRC), University of Manchester, Manchester, UK
| | - Tom Blakeman
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care and Health Services Research, Institute of Population Health, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre (PTSRC), University of Manchester, Manchester, UK
- RCGP Clinical Champion for Kidney Care, Royal College of General Practitioners, London, UK
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15
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Ramer SJ, Baddour NA, Siew ED, Salat H, Bian A, Stewart TG, Wong SPY, Jhamb M, Abdel-Kader K. Nephrology Provider Surprise Question Response and Hospitalizations in Older Adults with Advanced CKD. Am J Nephrol 2020; 51:641-649. [PMID: 32721980 PMCID: PMC7789871 DOI: 10.1159/000509046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/13/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Older adults with advanced non-dialysis-dependent chronic kidney disease (NDD-CKD) face a high risk of hospitalization and related adverse events. METHODS This prospective cohort study followed nephrology clinic patients ≥60 years old with NDD-CKD stages 4-5. After an eligible patient's office visit, study staff asked the patient's provider to rate the patient's risk of death within the next year using the surprise question ("Would you be surprised if this patient died in the next 12 months?") with a 5-point Likert scale response (1, "definitely not surprised" to 5, "very surprised"). We used a statewide database to ascertain hospitalization during follow-up. RESULTS There were 488 patients (median age 72 years, 51% female, 17% black) with median estimated glomerular filtration rate 22 mL/min/1.73 m2. Over a median follow-up of 2.1 years, the rates of hospitalization per 100 person-years in the respective response groups were 41 (95% confidence interval [CI]: 34-50), "very surprised"; 65 (95% CI: 55-76), "surprised"; 98 (95% CI: 85-113), "neutral"; 125 (95% CI: 107-144), "not surprised"; and 120 (95% CI: 94-151), "definitely not surprised." In a fully adjusted cumulative probability ordinal regression model for proportion of follow-up time spent hospitalized, patients whose providers indicated that they would be "definitely not surprised" if they died spent a greater proportion of follow-up time hospitalized compared with those whose providers indicated that they would be "very surprised" (odds ratio 2.4, 95% CI: 1.0-5.7). There was a similar association for time to first hospitalization. CONCLUSION Nephrology providers' responses to the surprise question for older patients with advanced NDD-CKD were independently associated with proportion of future time spent hospitalized and time to first hospitalization. Additional studies should examine how to use this information to provide patients with anticipatory guidance on their possible clinical trajectory and to target potentially preventable hospitalizations.
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Affiliation(s)
- Sarah J Ramer
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medical Center, New York, New York, USA
| | - Nicolas A Baddour
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Center for Kidney Disease, Nashville, Tennessee, USA
| | - Huzaifah Salat
- Department of Medicine, St. Barnabas Hospital Health System, Bronx, New York, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Susan P Y Wong
- Health Service Research and Development Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA,
- Vanderbilt Center for Kidney Disease, Nashville, Tennessee, USA,
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16
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Ng MSN, Miaskowski C, Cooper B, Hui YH, Ho EHS, Mo SKL, Wong SSH, Wong CL, So WKW. Distinct Symptom Experience Among Subgroups of Patients With ESRD Receiving Maintenance Dialysis. J Pain Symptom Manage 2020; 60:70-79.e1. [PMID: 31981596 DOI: 10.1016/j.jpainsymman.2020.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/08/2020] [Accepted: 01/08/2020] [Indexed: 01/12/2023]
Abstract
CONTEXT Patients with end-stage renal disease receiving dialysis experience multiple concurrent symptoms. A person-centered understanding of patients' symptom experiences may offer insights into individualized management. OBJECTIVES We identified subgroups of patients based on their symptom experiences and the characteristics that differentiated among these subgroups. Outcomes associated with these subgroups were evaluated. METHODS A total of 354 patients on dialysis were recruited at two regional hospitals in Hong Kong. While the Dialysis Symptom Index was adopted to assess symptoms, the Kidney Disease Quality of Life 36 and Karnofsky Performance Status Scale were used to evaluate the quality of life outcomes. Information on health care utilization and mortality were retrieved from medical records. Subgroups of patients were identified using latent class analysis based on the occurrence ratings. Differences in characteristics and outcomes were determined using Chi-squared test, analysis of variance, and Cox regression analysis. RESULTS Three latent classes were identified: low (37.8%), moderate physical-low psychological (29.7%), and moderate physical-high psychological (32.5%). Higher comorbidity burden and lower serum albumin levels differentiated between the low and moderate physical-low psychological classes. The moderate physical-high psychological class had the highest number of symptoms, poorest quality of life outcomes, and more unscheduled clinic visits. A shorter mean survival time (421 vs. 431 days) was also found. CONCLUSION Consistent with findings in other chronic conditions, subgroups of patients on dialysis have unique symptom experiences. Therefore, an individualized approach to symptom management is warranted. Our findings offer a phenotypic characterization for research on the underlying mechanisms for these symptom experiences.
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Affiliation(s)
| | | | - Bruce Cooper
- University of California, San Francisco, California, USA
| | - Yun Ho Hui
- United Christian Hospital, Hong Kong, China
| | - Eva Hau Sim Ho
- Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | | | | | - Cho Lee Wong
- The Chinese University of Hong Kong, Hong Kong, China
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17
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Ganz T, Aronoff GR, Gaillard CAJM, Goodnough LT, Macdougall IC, Mayer G, Porto G, Winkelmayer WC, Wish JB. Iron Administration, Infection, and Anemia Management in CKD: Untangling the Effects of Intravenous Iron Therapy on Immunity and Infection Risk. Kidney Med 2020; 2:341-353. [PMID: 32734254 PMCID: PMC7380433 DOI: 10.1016/j.xkme.2020.01.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Patients with chronic kidney disease (CKD) are at increased risk for infection, attributable to immune dysfunction, increased exposure to infectious agents, loss of cutaneous barriers, comorbid conditions, and treatment-related factors (eg, hemodialysis and immunosuppressant therapy). Because iron plays a vital role in pathogen reproduction and host immunity, it is biologically plausible that intravenous iron therapy and/or iron deficiency influence infection risk in CKD. Available data from preclinical experiments, observational studies, and randomized controlled trials are summarized to explore the interplay between intravenous iron and infection risk among patients with CKD, particularly those receiving maintenance hemodialysis. The current evidence base, including data from a recent randomized controlled trial, suggests that proactive judicious use of intravenous iron (in a manner that minimizes the accumulation of non-transferrin-bound iron) beneficially replaces iron stores while avoiding a clinically relevant effect on infection risk. In the absence of an urgent clinical need, intravenous iron therapy should be avoided in patients with active infection. Although serum ferritin concentration and transferrin saturation can help guide clinical decision making about intravenous iron therapy, definition of an optimal iron status and its precise determination in individual patients remain clinically challenging in CKD and warrant additional study.
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Affiliation(s)
- Tomas Ganz
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | | | | | - Lawrence T Goodnough
- Department of Pathology, Stanford University, Stanford, CA.,Department of Medicine (Hematology), Stanford University, Stanford, CA
| | - Iain C Macdougall
- Department of Renal Medicine, King's College Hospital, London, United Kingdom
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Graça Porto
- Pathology and Molecular Immunology Department, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal.,i3S, Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - Wolfgang C Winkelmayer
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| | - Jay B Wish
- Division of Nephrology, Indiana University Health, Indianapolis, IN
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18
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Goto NA, Weststrate ACG, Oosterlaan FM, Verhaar MC, Willems HC, Emmelot-Vonk MH, Hamaker ME. The association between chronic kidney disease, falls, and fractures: a systematic review and meta-analysis. Osteoporos Int 2020; 31:13-29. [PMID: 31720721 PMCID: PMC6946749 DOI: 10.1007/s00198-019-05190-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 10/04/2019] [Indexed: 12/31/2022]
Abstract
Patients with chronic kidney disease (CKD) are more likely to experience falls and fractures due to renal osteodystrophy and the high prevalence of risk factors for falls. However, it is not well established how great the risk is for falls and fractures for the different stages of CKD compared to the general population. The objective of this systematic review and meta-analysis was to assess whether, and in which degree, CKD was associated with falls and fractures in adults. A systematic search in PubMed, Embase, CINAHL, and The Cochrane Library was performed on 7 September 2018. All retrospective, cross-sectional, and longitudinal studies of adults (18 years of older) that studied the association between CKD, fractures, and falls were included. Additional studies were identified by cross-referencing. A total of 39 publications were included, of which two publications assessed three types of outcome and four publications assessed two types of outcome. Ten studies focused on accidental falling; seventeen studies focused on hip, femur, and pelvis fractures; seven studies focused on vertebral fractures; and thirteen studies focused on any type of fracture without further specification. Generally, the risk of fractures increased when kidney function worsened, with the highest risks in the patients with stage 5 CKD or dialysis. This effect was most pronounced for hip fractures and any type of fractures. Furthermore, results on the association between CKD and accidental falling were contradictory. Compared to the general population, fractures are highly prevalent in patients with CKD. Besides more awareness of timely fracture risk assessment, there also should be more focus on fall prevention.
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Affiliation(s)
- N A Goto
- Dianet Dialysis Center, Utrecht, The Netherlands.
- Department of Geriatrics, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands.
| | - A C G Weststrate
- Department of Internal Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - F M Oosterlaan
- Department of Geriatrics, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - M C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H C Willems
- Department of Geriatrics, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - M H Emmelot-Vonk
- Department of Geriatrics, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - M E Hamaker
- Department of Geriatrics, Diakonessenhuis Utrecht, Utrecht, The Netherlands
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Wong E, Ballew SH, Daya N, Ishigami J, Rebholz CM, Matsushita K, Grams ME, Coresh J. Hospitalization Risk among Older Adults with Chronic Kidney Disease. Am J Nephrol 2019; 50:212-220. [PMID: 31311014 PMCID: PMC6726535 DOI: 10.1159/000501539] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 06/14/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Chronic kidney disease (CKD) risk staging is based on estimated glomerular filtration rate (eGFR) and albumin-creatinine ratio (ACR). However, the relationship between all-cause hospitalization risk and the current CKD staging system has not been well studied among older adults, despite a high prevalence of CKD and a high risk of hospitalization in old age. METHODS Among 4,766 participants of the Atherosclerosis Risk in Communities study, CKD was staged according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, using creatinine-based eGFR (eGFRcr) and ACR. Incidence rates of all-cause hospitalization associated with each CKD risk group were analyzed using negative binomial regression. Additionally, cause-specific hospitalization risks for cardiovascular, infectious, kidney, and other diseases were estimated. The impacts of using cystatin C-based eGFR (eGFRcys) to estimate the prevalence of CKD and risks of hospitalization were also quantified. RESULTS Participants experienced 5,548 hospitalizations and 29% had CKD. Hospitalization rates per 1,000 person-years according to KDIGO risk categories were 208-223 ("low risk"), 288-376 ("moderately increased risk"), 363-548 ("high risk"), and 499-1083 ("very high risk"). The increased risk associated with low eGFR and high ACR persisted in adjusted analyses, examinations of cause-specific hospitalizations, and when CKD was staged by eGFRcys or eGFRcr-cys, a combined equation based on both creatinine and cystatin C. In comparison to eGFRcr, staging by eGFRcys increased the prevalence of CKD to 50%, but hospitalization risks remained similarly high. DISCUSSION/CONCLUSION In older adults, decreased eGFR, increased ACR, and KDIGO risk stages based on a combination of these measures, were strong risk factors for hospitalization. These relationships were consistent, regardless of the marker used to estimate GFR, but the use of cystatin C resulted in a substantially higher prevalence of CKD than the use of creatinine. Older adults in the population with very high risk stages of CKD have hospitalization rates exceeding 500 per 1,000 person-years.
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Affiliation(s)
- Eugenia Wong
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA,
| | - Shoshana H Ballew
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Natalie Daya
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Junichi Ishigami
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Casey M Rebholz
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Morgan E Grams
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Josef Coresh
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Improving coding and primary care management for patients with chronic kidney disease: an observational controlled study in East London. Br J Gen Pract 2019; 69:e454-e461. [PMID: 31160369 DOI: 10.3399/bjgp19x704105] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/21/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The UK national chronic kidney disease (CKD) audit in primary care shows diagnostic coding in the electronic health record for CKD averages 70%, with wide practice variation. Coding is associated with improvements to risk factor management; CKD cases coded in primary care have lower rates of unplanned hospital admission. AIM To increase diagnostic coding of CKD (stages 3-5) and primary care management, including blood pressure to target and prescription of statins to reduce cardiovascular disease risk. DESIGN AND SETTING Controlled, cross-sectional study in four East London clinical commissioning groups (CCGs). METHOD Interventions to improve coding formed part of a larger system change to the delivery of renal services in both primary and secondary care in East London. Quarterly anonymised data on CKD coding, blood pressure values, and statin prescriptions were extracted from practice computer systems for 1-year pre- and post-initiation of the intervention. RESULTS Three intervention CCGs showed significant coding improvement over a 1 year period following the intervention (regression for post-intervention trend P<0.001). The CCG with highest coding rates increased from 76-90% of CKD cases coded; the lowest coding CCG increased from 52-81%. The comparison CCG showed no change in coding rates. Combined data from all practices in the intervention CCGs showed a significant increase in the proportion of cases with blood pressure achieving target levels (difference in proportion P<0.001) over the 2-year study period. Differences in statin prescribing were not significant. CONCLUSION Clinically important improvements to coding and management of CKD in primary care can be achieved by quality improvement interventions that use shared data to track and monitor change supported by practice-based facilitation. Alignment of clinical and CCG priorities and the provision of clinical targets, financial incentives, and educational resource were additional important elements of the intervention.
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Silva ECD, Taminato M, Fonseca CDD, Moraes GMD, Longo MCB, Grothe CE, Belasco AGS, Barbosa DA. Use of vitamin D and infection in patients with chronic kidney disease. Rev Bras Enferm 2018; 71:2792-2799. [DOI: 10.1590/0034-7167-2018-0640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/07/2018] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: To evaluate the effectiveness of vitamin D supplementation as protection factor against infection of patients with chronic kidney disease on conservative treatment. Method: Retrospective cohort study carried out between 2013 and 2016 in the Conservative Treatment Outpatient Clinics (Ambulatório de Tratamento Conservador) of the Hypertension and Kidney Hospital (Hospital do Rim e Hipertensão) of the Universidade Federal de São Paulo. Data on sociodemographic factors, comorbidity, infection episodes and use or nonuse of vitamin D supplementation for at least 6 months were collected from medical records. The primary outcomes considered in both groups were: presence or absence of infection anywhere on the body (bloodstream, urinary, respiratory and surgical sites). Results: A total of 263 patients were included and those who received (n=43) vitamin D had 59% less chance of developing infections (OR=0.41; 95%CI; 0.15-0.99), when compared to those who did not receive. Conclusion: Vitamin D supplementation was a protective factor against infections of all causes.
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