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Martino AM, Santos J, Giron A, Schomberg J, Goodman LF, Nahmias J, Nguyen DV, Grigorian A, Olaya J, Yu P, Guner YS. Variability in Standardized Mortality Rates Among Pediatric Traumatic Brain Injury Patients: A Comparative Analysis of Trauma Centers. J Pediatr Surg 2024:S0022-3468(24)00166-0. [PMID: 38580548 DOI: 10.1016/j.jpedsurg.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/01/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Traumatic brain injury (TBI) causes significant morbidity and mortality in pediatric patients and care is highly variable. Standardized mortality ratio (SMR) summarizes the mortality rate of a specific center relative to the expected rates across all centers, adjusted for case-mix. This study aimed to evaluate variations in SMRs among pediatric trauma centers for TBI. METHODS Patients aged 1-18 diagnosed with TBI within the National Trauma Data Bank (NTDB) from 2017 to 2019 were included. Center-specific SMRs and 95% confidence intervals identified centers with mortality rates significantly better or worse than the median SMR for all centers. RESULTS 316 centers with 10,598 patients were included. SMRs were risk-adjusted for patient risk factors. Unadjusted mortality ranged from 16.5 to 29.5%. Three centers (1.5%) had significantly better SMR (SMR <1) and three centers (1.5%) had significantly worse SMR (SMR >1). Significantly better centers had a lower proportion of neurosurgical intervention (2.4% vs. 11.8%, p < 0.001), a higher proportion of supplemental oxygen administration (93.7% vs. 83.5%, p = 0.004) and venous thromboembolism prophylaxis (53.2% vs. 40.6%, p < 0.001) compared to significantly worse centers. CONCLUSIONS This study identified centers that have significantly higher and lower mortality rates for pediatric TBI patients relative to the overall median rate. These data provide a benchmark for pediatric TBI outcomes and institutional quality improvement. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective Comparative Study.
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Affiliation(s)
- Alice M Martino
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA.
| | - Jeffrey Santos
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Andreina Giron
- Division of Pediatric Surgery, Children's Hospital Orange County, Orange, CA, USA
| | - John Schomberg
- Division of Pediatric Surgery, Children's Hospital Orange County, Orange, CA, USA
| | - Laura F Goodman
- Division of Pediatric Surgery, Children's Hospital Orange County, Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine Medical Center, Orange, CA, USA
| | - Danh V Nguyen
- Department of Medicine, Division of General Internal Medicine, University of California Irvine Medical Center, Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine Medical Center, Orange, CA, USA
| | - Joffre Olaya
- Division of Pediatric Neurosurgery, Children's Hospital Orange County, Orange, CA, USA
| | - Peter Yu
- Division of Pediatric Surgery, Children's Hospital Orange County, Orange, CA, USA
| | - Yigit S Guner
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA; Division of Pediatric Surgery, Children's Hospital Orange County, Orange, CA, USA
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You AS, Kalantar-Zadeh K, Brent GA, Narasaki Y, Daza A, Sim JJ, Kovesdy CP, Nguyen DV, Rhee CM. Impact of Thyroid Status on Incident Kidney Dysfunction and Chronic Kidney Disease Progression in a Nationally Representative Cohort. Mayo Clin Proc 2024; 99:39-56. [PMID: 38176833 PMCID: PMC10795379 DOI: 10.1016/j.mayocp.2023.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 08/12/2023] [Accepted: 08/29/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE To examine the relationship between thyroid status and incident kidney dysfunction/chronic kidney disease (CKD) progression. PATIENTS AND METHODS We examined incident thyroid status, ascertained by serum thyrotropin (TSH) levels measured from January 1, 2007, through December 31, 2018, among 4,152,830 patients from the Optum Labs Data Warehouse, containing deidentified retrospective administrative claims data from a large national health insurance plan and electronic health record data from a nationwide network of provider groups. Associations of thyroid status, categorized as hypothyroidism, euthyroidism, or hyperthyroidism (TSH levels >5.0, 0.5-5.0, and <0.5 mIU/L, respectively), with the composite end point of incident kidney dysfunction in patients without baseline kidney dysfunction and CKD progression in those with baseline CKD were examined using Cox models. RESULTS Patients with hypothyroidism and hyperthyroidism had higher risk of incident kidney dysfunction/CKD progression in expanded case-mix analyses (reference: euthyroidism): adjusted hazard ratios (aHRs) (95% CIs) were 1.37 (1.34 to 1.40) and 1.42 (1.39 to 1.45), respectively. Incrementally higher TSH levels in the upper reference range and TSH ranges for subclinical, mild overt, and overt hypothyroidism (≥3.0-5.0, >5.0-10.0, >10.0-20.0, and >20.0 mIU/L, respectively) were associated with increasingly higher risk of the composite end point (reference: TSH level, 0.5 to <3.0 mIU/L): aHRs (95% CIs) were 1.10 (1.09 to 1.11), 1.37 (1.34 to 1.40), 1.70 (1.59 to 1.83), and 1.70 (1.50 to 1.93), respectively. Incrementally lower TSH levels in the subclinical (<0.5 mIU/L) and overt (<0.1 mIU/L) hyperthyroid ranges were also associated with the composite end point: aHRs (95% CIs) were 1.44 (1.41 to 1.47) and 1.48 (1.39 to 1.59), respectively. CONCLUSION In a national cohort, TSH levels in the upper reference range or higher (≥3.0 mIU/L) and below the reference range (<0.5 mIU/L) were associated with incident kidney dysfunction/CKD progression.
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Affiliation(s)
- Amy S You
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Gregory A Brent
- Division of Endocrinology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA; Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Yoko Narasaki
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Andrea Daza
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Southern California, Los Angeles, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Danh V Nguyen
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA; Division of General Internal Medicine, University of California Irvine, Orange, CA
| | - Connie M Rhee
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA.
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Martino AM, Nguyen DV, Delaplain PT, Dinh P, Jancelewicz T, Harting MT, Yu PT, Di Nardo M, Gowda S, Goodman LF, Yu Y, Guner YS. Center Volume and Survival Relationship for Neonates With Congenital Diaphragmatic Hernia Treated With Extracorporeal Life Support. Pediatr Crit Care Med 2023; 24:987-997. [PMID: 37346002 DOI: 10.1097/pcc.0000000000003313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
OBJECTIVES Literature is emerging regarding the role of center volume as an independent variable contributing to improved outcomes. A higher volume of index procedures may be associated with decreased morbidity and mortality. This association has not been examined for the subgroup of infants with congenital diaphragmatic hernia (CDH) receiving extracorporeal life support (ECLS). Our study aims to examine the risk-adjusted association between center volume and outcomes in CDH-ECLS neonates, hypothesizing that higher center volume confers a survival advantage. DESIGN Multicenter, retrospective comparative study using the Extracorporeal Life Support Organization database. SETTING One hundred twenty international pediatric centers. PATIENTS Neonates with CDH managed with ECLS from 2000 to 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The cohort included 4,985 neonates with a mortality rate of 50.6%. For the 120 centers studied, mean center volume was 42.4 ± 34.6 CDH ECLS cases over the 20-year study period. In an adjusted model, higher ECLS volume was associated with lower odds of mortality: odds ratio (OR) 0.995 (95% CI, 0.992-0.999; p = 0.014). For an increase in one sd in volume, that is, 1.75 cases annually, the OR for mortality was lower by 16.7%. Volume was examined as a categorical exposure variable where low-volume centers (fewer than 2 cases/yr) were associated with 54% higher odds of mortality (OR, 1.54; 95% CI, 1.03-2.29) compared with high-volume centers. On-ECLS complications (mechanical, neurologic, cardiac, hematologic metabolic, and renal) were not associated with volume. The likelihood of infectious complications was higher for low- (OR, 1.90; 95% CI, 1.06-3.40) and medium-volume (OR, 1.87; 95% CI, 1.03-3.39) compared with high-volume centers. CONCLUSIONS In this study, a survival advantage directly proportional to center volume was observed for CDH patients managed with ECLS. There was no significant difference in most complication rates. Future studies should aim to identify factors contributing to the higher mortality and morbidity observed at low-volume centers.
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Affiliation(s)
- Alice M Martino
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine, Irvine, CA
| | - Patrick T Delaplain
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
| | - Peter Dinh
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Peter T Yu
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sharada Gowda
- Division of Neonatalogy, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Laura F Goodman
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA
| | - Yangyang Yu
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA
| | - Yigit S Guner
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA
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Rhee CM, You AS, Narasaki Y, Brent GA, Sim JJ, Kovesdy CP, Kalantar-Zadeh K, Nguyen DV. Development and Validation of a Prediction Model for Incident Hypothyroidism in a National Chronic Kidney Disease Cohort. J Clin Endocrinol Metab 2023; 108:e1374-e1383. [PMID: 37186674 PMCID: PMC11009786 DOI: 10.1210/clinem/dgad261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 04/15/2023] [Accepted: 05/09/2023] [Indexed: 05/17/2023]
Abstract
CONTEXT Hypothyroidism is a common yet under-recognized condition in patients with chronic kidney disease (CKD), which may lead to end-organ complications if left untreated. OBJECTIVE We developed a prediction tool to identify CKD patients at risk for incident hypothyroidism. METHODS Among 15 642 patients with stages 4 to 5 CKD without evidence of pre-existing thyroid disease, we developed and validated a risk prediction tool for the development of incident hypothyroidism (defined as thyrotropin [TSH] > 5.0 mIU/L) using the Optum Labs Data Warehouse, which contains de-identified administrative claims, including medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees as well as electronic health record data. Patients were divided into a two-thirds development set and a one-third validation set. Prediction models were developed using Cox models to estimate probability of incident hypothyroidism. RESULTS There were 1650 (11%) cases of incident hypothyroidism during a median follow-up of 3.4 years. Characteristics associated with hypothyroidism included older age, White race, higher body mass index, low serum albumin, higher baseline TSH, hypertension, congestive heart failure, exposure to iodinated contrast via angiogram or computed tomography scan, and amiodarone use. Model discrimination was good with similar C-statistics in the development and validation datasets: 0.77 (95% CI 0.75-0.78) and 0.76 (95% CI 0.74-0.78), respectively. Model goodness-of-fit tests showed adequate fit in the overall cohort (P = .47) as well as in a subcohort of patients with stage 5 CKD (P = .33). CONCLUSION In a national cohort of CKD patients, we developed a clinical prediction tool identifying those at risk for incident hypothyroidism to inform prioritized screening, monitoring, and treatment in this population.
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Affiliation(s)
- Connie M Rhee
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
| | - Amy S You
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
| | - Yoko Narasaki
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
| | - Gregory A Brent
- Division of Endocrinology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
| | - John J Sim
- Division of Nephrology, Kaiser Permanente Southern California, Los Angeles, CA 90027, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN 38104, USA
- Section of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN 38104, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Danh V Nguyen
- Division of General Internal Medicine and Primary Care, University of California Irvine, Orange, CA 92868, USA
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Qian Q, Nguyen DV, Telesca D, Kurum E, Rhee CM, Banerjee S, Li Y, Senturk D. Multivariate spatiotemporal functional principal component analysis for modeling hospitalization and mortality rates in the dialysis population. Biostatistics 2023:kxad013. [PMID: 37337346 DOI: 10.1093/biostatistics/kxad013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/14/2023] [Accepted: 05/30/2023] [Indexed: 06/21/2023] Open
Abstract
Dialysis patients experience frequent hospitalizations and a higher mortality rate compared to other Medicare populations, in whom hospitalizations are a major contributor to morbidity, mortality, and healthcare costs. Patients also typically remain on dialysis for the duration of their lives or until kidney transplantation. Hence, there is growing interest in studying the spatiotemporal trends in the correlated outcomes of hospitalization and mortality among dialysis patients as a function of time starting from transition to dialysis across the United States Utilizing national data from the United States Renal Data System (USRDS), we propose a novel multivariate spatiotemporal functional principal component analysis model to study the joint spatiotemporal patterns of hospitalization and mortality rates among dialysis patients. The proposal is based on a multivariate Karhunen-Loéve expansion that describes leading directions of variation across time and induces spatial correlations among region-specific scores. An efficient estimation procedure is proposed using only univariate principal components decompositions and a Markov Chain Monte Carlo framework for targeting the spatial correlations. The finite sample performance of the proposed method is studied through simulations. Novel applications to the USRDS data highlight hot spots across the United States with higher hospitalization and/or mortality rates and time periods of elevated risk.
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Affiliation(s)
- Qi Qian
- Department of Biostatistics, University of California, Los Angeles, CA 90095, USA
| | - Danh V Nguyen
- Department of Medicine, University of California, Irvine, CA 92868, USA
| | - Donatello Telesca
- Department of Biostatistics, University of California, Los Angeles, CA 90095, USA
| | - Esra Kurum
- Department of Statistics, University of California, Riverside, CA 92521, USA
| | - Connie M Rhee
- Department of Medicine, University of California, Irvine, CA 92868, USA
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California School of Medicine, Irvine, CA 92868, USA
| | - Sudipto Banerjee
- Department of Biostatistics, University of California, Los Angeles, CA 90095, USA
| | - Yihao Li
- Department of Biostatistics, University of California, Los Angeles, CA 90095, USA
| | - Damla Senturk
- Department of Biostatistics, University of California, Los Angeles, CA 90095, USA
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Gowda SH, Almaazmi A, Hagan J, Niemyjski E, Vogel AM, Jancelewicz T, Di Nardo M, Harting MT, Fernandes CJ, Nguyen DV, Guner YS. Inhaled Nitric Oxide Utilization in Congenital Diaphragmatic Hernia Treated With Extracorporeal Life Support: A Propensity Score Analysis. ASAIO J 2023; 69:504-510. [PMID: 37040072 DOI: 10.1097/mat.0000000000001901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
Although used commonly, ability of inhaled nitric oxide (iNO) to improve outcomes in infants with congenital diaphragmatic hernia (CDH) who receive extracorporeal life support (ECLS) remains controversial. We sought to determine the association between pre-ECLS use of iNO and mortality in infants with CDH from the Extracorporeal Life Support Organization (ELSO) Registry. Neonates who underwent ECLS for CDH were identified from the ELSO Registry from 2009 to 2019. Patients were categorized into those treated with iNO versus not prior to initiating ECLS. Patients were then matched 1:1 for case-mix based on pre-ECLS covariates using the propensity score (PS) for iNO treatment. The matched groups were compared for mortality. The matched cohorts were also compared for ELSO-defined systems-based complications as secondary outcomes. There were a total of 3,041 infants with an overall mortality of 52.2% and a pre-ECLS iNO use rate of 84.8%. With 1:1 matching, there were 461 infants with iNO use and 461 without iNO use. Following matching, use of iNO was not associated with a difference in mortality (odds ratio [OR] = 0.805; 95% confidence interval [CI], 0.621-1.042; p = 0.114). Results were similar in unadjusted analyses, and after controlling for covariates in the full cohort of patients and in the 1:1 matched data. Patients receiving iNO had significantly higher odds of renal complications (OR = 1.516; 95% CI, 1.141-2.014; p = 0.004), but no other significant differences were observed among secondary outcomes. ECLS use of iNO in CDH patients was not associated with a difference in mortality. Future randomized controlled studies are needed to delineate the utility of iNO in CDH patients.
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Affiliation(s)
- Sharada H Gowda
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Ahmed Almaazmi
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Joseph Hagan
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Emily Niemyjski
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Adam M Vogel
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Caraciolo J Fernandes
- From the Departments of Surgery and Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine, Irvine, California
| | - Yigit S Guner
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
- Department of Surgery, University of California Irvine Medical Center, Orange, California
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Kürüm E, Nguyen DV, Banerjee S, Li Y, Rhee CM, Şentürk D. A Bayesian multilevel time-varying framework for joint modeling of hospitalization and survival in patients on dialysis. Stat Med 2022; 41:5597-5611. [PMID: 36181392 PMCID: PMC9931182 DOI: 10.1002/sim.9582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/02/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
Abstract
Over 782 000 individuals in the United States have end-stage kidney disease with about 72% of patients on dialysis, a life-sustaining treatment. Dialysis patients experience high mortality and frequent hospitalizations, at about twice per year. These poor outcomes are exacerbated at key time periods, such as the fragile period after transition to dialysis. In order to study the time-varying effects of modifiable patient and dialysis facility risk factors on hospitalization and mortality, we propose a novel Bayesian multilevel time-varying joint model. Efficient estimation and inference is achieved within the Bayesian framework using Markov chain Monte Carlo, where multilevel (patient- and dialysis facility-level) varying coefficient functions are targeted via Bayesian P-splines. Applications to the United States Renal Data System, a national database which contains data on nearly all patients on dialysis in the United States, highlight significant time-varying effects of patient- and facility-level risk factors on hospitalization risk and mortality. Finite sample performance of the proposed methodology is studied through simulations.
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Affiliation(s)
- Esra Kürüm
- Department of Statistics, University of California, Riverside, CA, USA
| | - Danh V. Nguyen
- Department of Medicine, University of California Irvine, CA, USA
| | - Sudipto Banerjee
- Department of Biostatistics, University of California, Los Angeles, CA, USA
| | - Yihao Li
- Department of Biostatistics, University of California, Los Angeles, CA, USA
| | - Connie M. Rhee
- Department of Medicine, University of California Irvine, CA, USA
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, CA, USA
| | - Damla Şentürk
- Department of Biostatistics, University of California, Los Angeles, CA, USA
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Tayek JA, Stolz AA, Nguyen DV, Fleischman MW, Donovan JA, Alcorn JM, Chao DCK, Asghar A, Morgan TR. A phase II, multicenter, open-label, randomized trial of pegfilgrastim for patients with alcohol-associated hepatitis. EClinicalMedicine 2022; 54:101689. [PMID: 36267499 PMCID: PMC9576807 DOI: 10.1016/j.eclinm.2022.101689] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In trials conducted in India, recombinant granulocyte colony stimulating factor (GCSF) improved survival in alcohol-associated hepatitis (AH). The aim of this trial was to determine the safety and efficacy of pegfilgrastim, a long-acting recombinant GCSF, in patients with AH in the United States. METHODS This prospective, randomized, open label trial conducted between March 2017 and March 2020 randomized patients with a clinical diagnosis of AH and a Maddrey discriminant function score ≥32 to standard of care (SOC) or SOC+pegfilgrastim (0.6 mg subcutaneously) on Day 1 and Day 8 (clinicaltrials.gov NCT02776059). SOC was 28 days of either pentoxifylline or prednisolone, as determined by the patient's primary physician. The second injection of pegfilgrastim was not administered if the white blood cell count exceeded 30,000/mm3 on Day 8. Primary outcome was survival at Day 90. Secondary outcomes included the incidence of acute kidney injury (AKI), hepatorenal syndrome (HRS), hepatic encephalopathy, or infections. FINDINGS The study was terminated early due to COVID19 pandemic. Eighteen patients were randomized to SOC and 16 to SOC+pegfilgrastim. All patients received prednisolone as SOC. Nine patients failed to receive a second dose of pegfilgrastin due to WBC > 30,000/mm3 on Day 8. Survival at 90 days was similar in both groups (SOC: 0.83 [95% confidence interval [CI]: 0.57-0.94] vs. pegfilgrastim: 0.73 [95% CI: 0.44-0.89]; p > 0.05; CI for difference: -0.18-0.38). The incidences of AKI, HRS, hepatic encephalopathy, and infections were similar in both treatment arms and there were no serious adverse events attributed to pegfilgrastim. INTERPRETATION This phase II trial found no survival benefit at 90 days among subjects with AH who received pegfilgrastim+prednisolone compared with subjects receiving prednisolone alone. FUNDING was provided by the United States National Institutes of Health and National Institute on Alcohol Abuse and Alcoholism U01-AA021886 and U01-AA021884.
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Key Words
- ACLF, acute on chronic liver failure
- AH, alcohol-related hepatitis
- AKI, acute kidney injury
- Alcoholic hepatitis
- CTCAE, common terminology criteria for adverse events
- DF, discriminant function
- DSMB, data safety monitoring board
- FDA, food and drug administration
- FU, follow-up
- GCSF, granulocyte colony stimulating factor
- HIV, human immunodeficiency virus
- HRS, hepatorenal syndrome
- INR, international normalized ratio
- NIAAA, national institute on alcohol abuse and alcoholism
- Pegfilgrastim
- Phase II
- Randomized clinical trial
- SD, standard deviation
- SOC, standard of care
- WBC, white blood cell count
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Affiliation(s)
- John A Tayek
- Department of Medicine, Harbor-UCLA Medical Center and Lundquist Institute, Torrance, CA, United States
| | - Andrew A Stolz
- LAC-USC Medical Center, Los Angeles, CA and the Hepatology Section, Division of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Danh V Nguyen
- Division of General Internal Medicine, Department of Medicine, University of California, Irvine, CA, United States
| | - M Wayne Fleischman
- Department of Medicine, Harbor-UCLA Medical Center and Lundquist Institute, Torrance, CA, United States
| | - John A Donovan
- LAC-USC Medical Center, Los Angeles, CA and the Hepatology Section, Division of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Joseph M Alcorn
- Division of Gastroenterology, Department of Medicine University of New Mexico, Albuquerque, New Mexico and Medical Service, Raymond G. Murphy VA Medical Center, Albuquerque, NM, United States
| | - Daniel C-K Chao
- Gastroenterology Section, Medical Service, VA Healthcare System, Loma Linda, CA, United States
| | - Aliya Asghar
- Research Service, VA Healthcare System, Long Beach, CA, United States
| | - Timothy R Morgan
- Gastroenterology Section, Medical Service, VA Healthcare System, Long Beach, CA, United States
- Division of Gastroenterology, Department of Medicine, University of California, Irvine, CA, United States
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Guner YS, Harting MT, Jancelewicz T, Yu PT, Di Nardo M, Nguyen DV. Variation across centers in standardized mortality ratios for congenital diaphragmatic hernia receiving extracorporeal life support. J Pediatr Surg 2022; 57:606-613. [PMID: 35193755 DOI: 10.1016/j.jpedsurg.2022.01.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/13/2022] [Accepted: 01/20/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND We sought to elucidate the degree of variation across centers by calculating center-specific standardized mortality ratios (SMRs) for infants with congenital diaphragmatic hernia (CDH) requiring extracorporeal life support (ECLS). METHODS The Extracorporeal Life Support Organization (ELSO) registry data (2000-2019) were used to estimate SMRs. Center-specific SMRs and their 95% confidence intervals (CIs) were used to identify centers with mortality as significantly worse (SW), significantly better (SB), or not different (ND) relative to the median standardized mortality rate. RESULTS We identified 4,223 neonates with CDH from 109 centers. SMRs were risk-adjusted for pre-ECLS case-mix (birthweight, sex, race, 5 min Apgar, blood gases, gestational age, hernia side, prenatal diagnosis, pre-ECLS arrest, and comorbidities). Observed (unadjusted) mortality rates across centers varied substantially (range: 14.3%-90.9%; interquartile range [IQR]: 42.9%-62.1%). Thirteen centers (11.9%) had SB SMRs< 1 (SMR 0.52 to 0.84), 7 centers (6.4%) had SW SMRs>1 (SMR 1.25 to 1.43), and 89 centers (81.7%) had SMRs ND relative to the median SMR rate across all centers (i.e., SMR not different from one). Descriptive analyses demonstrated that SB centers had a lower proportion of cases with renal complications, infectious complications and discontinuation of ECLS owing to complications, as well as differences in pre-ECLS treatments and timing of CDH repair, compared to SW and ND centers. CONCLUSION This study specifically identified ECLS centers with higher and lower survival for patients with CDH, which may serve as a benchmark for institutional quality improvement. Future studies are needed to identify those specific processes at those centers that leads to favorable outcomes with the goal of improving care globally. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yigit S Guner
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, United States; Department of Surgery, University of California Irvine Medical Center, Orange, CA, United States.
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School, Children's Memorial Hermann Hospital, University of Texas, Houston, TX, United States
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Peter T Yu
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, United States; Department of Surgery, University of California Irvine Medical Center, Orange, CA, United States
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine, Irvine, CA, United States
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10
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Narasaki Y, You AS, Malik S, Moore LW, Bross R, Cervantes MK, Daza A, Kovesdy CP, Nguyen DV, Kalantar-Zadeh K, Rhee CM. Dietary potassium intake, kidney function, and survival in a nationally representative cohort. Am J Clin Nutr 2022; 116:1123-1134. [PMID: 36026516 PMCID: PMC9535513 DOI: 10.1093/ajcn/nqac215] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/05/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND In healthy adults, higher dietary potassium intake is recommended given that potassium-rich foods are major sources of micronutrients, antioxidants, and fiber. Yet among patients with advanced kidney dysfunction, guidelines recommend dietary potassium restriction given concerns about hyperkalemia leading to malignant arrhythmias and mortality. OBJECTIVES Given sparse data informing these recommendations, we examined associations of dietary potassium intake with mortality in a nationally representative cohort of adults from the NHANES. METHODS We examined associations between daily dietary potassium intake scaled to energy intake (mg/1000 kcal), ascertained by 24-h dietary recall, and all-cause mortality among 37,893 continuous NHANES (1999-2014) participants stratified according to impaired and normal kidney function (estimated glomerular filtration rates <60 and ≥60 mL · min-1 · 1.73 m-2, respectively) using multivariable Cox models. We also examined the impact of the interplay between dietary potassium, source of potassium intake (animal- compared with plant-based sources), and coexisting macronutrient and mineral consumption upon mortality. RESULTS Among participants with impaired and normal kidney function, the lowest tertile of dietary potassium scaled to energy intake was associated with higher mortality (ref: highest tertile) [adjusted HR (aHR): 1.18; 95% CI: 1.02, 1.38 and aHR: 1.17; 95% CI: 1.06, 1.28, respectively]. Compared with high potassium intake from plant-dominant sources, participants with low potassium intake from animal-dominant sources had higher mortality irrespective of kidney function. Among participants with impaired kidney function, pairings of low potassium intake with high protein, low fiber, or high phosphorus consumption were each associated with higher death risk. CONCLUSIONS Lower dietary potassium scaled to energy intake was associated with higher mortality, irrespective of kidney function. There was also a synergistic relation of higher potassium intake, plant-based sources, and macronutrient/mineral consumption with survival. Further studies are needed to elucidate pathways linking potassium intake and coexisting dietary factors with survival in populations with and without chronic kidney disease.
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Affiliation(s)
- Yoko Narasaki
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Health Center, Long Beach, CA, USA
| | - Amy S You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Health Center, Long Beach, CA, USA
| | - Shaista Malik
- Division of Cardiology, University of California Irvine, Orange, CA, USA
| | - Linda W Moore
- Department of Surgery and Transplantation, Houston Methodist Hospital, Houston, TX, USA
| | - Rachelle Bross
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Mackenzie K Cervantes
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA, USA
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Andrea Daza
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Health Center, Long Beach, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Danh V Nguyen
- Division of General Internal Medicine, University of California Irvine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Health Center, Long Beach, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Health Center, Long Beach, CA, USA
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Lo RH, Kalantar-Zadeh K, You AS, Ayus JC, Streja E, Park C, Sohn P, Nakata T, Narasaki Y, Brunelli SM, Kovesdy CP, Nguyen DV, Rhee CM. Dysnatremia and risk of bloodstream infection in dialysis patients. Clin Kidney J 2022; 15:2322-2330. [PMID: 36381361 PMCID: PMC9664572 DOI: 10.1093/ckj/sfac197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Indexed: 12/02/2022] Open
Abstract
Background Emerging data suggest that sodium disarrays including hyponatremia are potential risk factors for infection ensuing from impairments in host immunity, which may be exacerbated by coexisting conditions (i.e. mucosal membrane and cellular edema leading to breakdown of microbial barrier function). While dysnatremia and infection-related mortality are common in dialysis patients, little is known about the association between serum sodium levels and the risk of bloodstream infection in this population. Methods Among 823 dialysis patients from the national Biospecimen Registry Grant Program who underwent serum sodium testing over the period January 2008–December 2014, we examined the relationship between baseline serum sodium levels and subsequent rate of bloodstream infection. Bloodstream infection events were directly ascertained using laboratory blood culture data. Associations between serum sodium level and the incidence of bloodstream infection were estimated using expanded case mix–adjusted Poisson regression models. Results In the overall cohort, ∼10% of all patients experienced one or more bloodstream infection events during the follow-up period. Patients with both lower sodium levels <134 mEq/l and higher sodium levels ≥140 mEq/l had higher incident rate ratios (IRRs) of bloodstream infection in expanded case mix analyses (reference 136–<138 mEq/l), with adjusted IRRs of 2.30 [95% confidence interval (CI) 1.19–4.44], 0.77 (95% CI 0.32–1.84), 1.39 (95% CI 0.78–2.47), 1.88 (95% CI 1.08–3.28) and 1.96 (95% CI 1.08–3.55) for sodium levels <134, 134–<136, 138–<140, 140–<142 and ≥142 Eq/l, respectively. Conclusions Both lower and higher baseline serum sodium levels were associated with a higher rate of subsequent bloodstream infections in dialysis patients. Further studies are needed to determine whether correction of dysnatremia ameliorates infection risk in this population.
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Affiliation(s)
- Robin H Lo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
- Tibor Rubin Long Beach Veterans Affairs Medical Center , Long Beach, CA , USA
| | - Amy S You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
| | - Juan Carlos Ayus
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
- Renal Consultants , Houston, TX , USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
- Tibor Rubin Long Beach Veterans Affairs Medical Center , Long Beach, CA , USA
| | - Christina Park
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
- University of Washington School of Public Health , Seattle, WA , USA
| | - Peter Sohn
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
| | - Tracy Nakata
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
| | - Yoko Narasaki
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
| | | | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center , Memphis, TN , USA
- Nephrology Section, Memphis Veterans Affairs Medical Center , Memphis, TN , USA
| | - Danh V Nguyen
- Division of General Internal Medicine, University of California Irvine , Orange, CA , USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine , Orange, CA , USA
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Nguyen DV, Kurum E, Senturk D. The Use of Putative Dialysis Initiation Time in Comparative Outcomes of Patients with Advanced Chronic Kidney Disease: Methodological Aspects. Int J Stat Med Res 2022; 11:128-135. [PMID: 37284525 PMCID: PMC10241465 DOI: 10.6000/1929-6029.2022.11.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The latest data from the United States Renal Data Systems show over 134,000 individuals with end-stage kidney disease (ESKD) starting dialysis in the year 2019. ESKD patients on dialysis, the default treatment strategy, have high mortality and hospitalization, especially in the first year of dialysis. An alternative treatment strategy is (non-dialysis) conservative management (CM). The relative effectiveness of CM with respect to various patient outcomes, including survival, hospitalization, and health-related quality of life among others, especially in elderly ESKD or advanced chronic kidney disease patients with serious comorbidities, is an active area of research. A technical challenge inherent in comparing patient outcomes between CM and dialysis patient groups is that the start of follow-up time is "not defined" for patients on CM because they do not initiate dialysis. One solution is the use of putative dialysis initiation (PDI) time. In this work, we examine the validity of the use of PDI time to determine the start of follow-up for longitudinal retrospective and prospective cohort studies involving CM. We propose and assess the efficacy of estimating PDI time using linear mixed effects model of kidney function decline over time via simulation studies. We also illustrate how the estimated PDI time can be used to effectively estimate the survival distribution.
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Affiliation(s)
- Danh V. Nguyen
- Department of Medicine, University of California Irvine, Orange, CA 92868, USA
| | - Esra Kurum
- Department of Statistics, University of California, Riverside, CA 92521, USA
| | - Damla Senturk
- Department of Biostatistics, University of California, Los Angeles, CA 90095, USA
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Rhee CM, Budoff M, Brent G, You AS, Stenvinkel P, Novoa A, Flores F, Hamal S, Dailing C, Kinninger A, Nakata T, Kovesdy CP, Nguyen DV, Kalantar-Zadeh K. Serum Thyrotropin Elevation and Coronary Artery Calcification in Hemodialysis Patients. Cardiorenal Med 2022; 12:106-116. [PMID: 35551382 PMCID: PMC9452456 DOI: 10.1159/000525037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 05/03/2022] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Hypothyroidism is highly prevalent in end-stage kidney disease patients, and emerging data show that lower circulating thyroid hormone levels lead to downregulation of vascular calcification inhibitors and coronary artery calcification (CAC) in this population. To date, no studies have examined the association of serum thyrotropin (TSH), the most sensitive and specific single biochemical metric of thyroid function, with CAC risk in hemodialysis patients. METHODS In secondary analyses of patients from the Anti-Inflammatory and Anti-Oxidative Nutrition in Hypoalbuminemic Dialysis Patients trial, we examined serum TSH levels and CAC risk assessed by cardiac computed tomography scans collected within a 90-day period. We evaluated the relationship between serum TSH with CAC Volume (VS) and Agatston score (AS) (defined as >100 mm3 and >100 Houndsfield Units, respectively) using multivariable logistic regression. RESULTS Among 104 patients who met eligibility criteria, higher TSH levels in the highest tertile were associated with moderately elevated CAC VS and AS in case-mix-adjusted analyses (ref: lowest tertile): adjusted ORs (95% CIs) 4.26 (1.18, 15.40) and 5.53 (1.44, 21.30), respectively. TSH levels >3.0 mIU/L (ref: ≤3.0 mIU/L) were also associated with moderately elevated CAC VS and AS. In secondary analyses, point estimates of incrementally lower direct free thyroxine levels trended toward elevated CAC VS and AS, although associations did not achieve statistical significance. CONCLUSIONS In hemodialysis patients, higher serum TSH was associated with elevated CAC VS and AS. Further studies are needed to determine if thyroid hormone supplementation can attenuate CAC burden in this population.
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Affiliation(s)
- Connie M. Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Matthew Budoff
- Lundquist Institute at Harbor UCLA Medical Center, Torrance, CA
| | - Gregory Brent
- Division of Endocrinology, Diabetes and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles, CA,Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Amy S. You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Peter Stenvinkel
- Department of Renal Medicine M99, Karolinska Institutet, Stockholm, Sweden
| | - Alejandra Novoa
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Fred Flores
- Lundquist Institute at Harbor UCLA Medical Center, Torrance, CA
| | - Sajad Hamal
- Lundquist Institute at Harbor UCLA Medical Center, Torrance, CA
| | | | - April Kinninger
- Lundquist Institute at Harbor UCLA Medical Center, Torrance, CA
| | - Tracy Nakata
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Danh V. Nguyen
- Division of General Internal Medicine, University of California Irvine School of Medicine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA,Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
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You AS, Budoff M, Zeb I, Ahmadi N, Novoa A, Flores F, Hamal S, Kinninger A, Dailing C, Nakata T, Kovesdy CP, Nguyen DV, Brent GA, Kalantar-Zadeh K, Rhee CM. Elevated serum thyrotropin levels and endothelial dysfunction in a prospective hemodialysis cohort. Hemodial Int 2022; 26:57-65. [PMID: 34231302 PMCID: PMC10753993 DOI: 10.1111/hdi.12964] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/13/2021] [Accepted: 06/19/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Thyroid dysfunction is a highly prevalent yet under-recognized complication in hemodialysis patients. In the general population, hypothyroidism has been associated with endothelial dysfunction due to impaired vasodilator synthesis and activity. Little is known about the association of serum thyrotropin (TSH), the most sensitive and specific single biochemical metric of thyroid function, with endothelial function in hemodialysis patients. METHODS In a secondary analysis of 99 patients from the Anti-inflammatory and anti-oxidative nutrition in hypoalbuminemic dialysis patients (AIONID) trial, we examined measurements of serum TSH and endothelial function ascertained by fingertip digital thermal monitoring (DTM), a novel method used to measure micro-vascular reactivity, collected within a 90-day period. DTM was used to measure changes in fingertip temperature during and after an ischemic stimulus (blood pressure cuff occlusion) as an indicator of changes in blood flow, and two DTM indices were assessed, namely adjusted (a) Temperature Rebound (TR), defined as the maximum temperature rebound post-cuff deflation, and adjusted (b) Area Under the Temperature Curve (TMP-AUC), defined as area under the curve between the maximum and minimum temperatures. We examined the relationship between serum TSH with impaired TR (separately) and TMP-AUC (both defined as less than the median level of observed values) using multivariable logistic regression. FINDINGS In unadjusted and case-mix analyses, higher serum TSH levels (defined as the three highest quartiles) were associated with lower (worse) TR (ref: lowest TSH quartile): ORs (95% CI) 2.64 (1.01-6.88) and 2.85 (1.08-7.57), respectively. In unadjusted and case-mix analyses, higher TSH levels were associated with lower (worse) TMP-AUC: ORs (95% CI) 2.64 (1.01-6.88) and 2.79 (1.06-7.38), respectively. DISCUSSION In HD patients, higher serum TSH levels were associated with worse micro-vascular reactivity measured by DTM. Further studies are needed to determine if thyroid hormone supplementation improves endothelial function in hemodialysis patients with lower levels of thyroid function.
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Affiliation(s)
- Amy S. You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California, USA
| | - Matthew Budoff
- Lundquist Institute, Harbor UCLA Medical Center, Torrance, California, USA
| | - Irfan Zeb
- Division of Cardiology, West Virginia University, Morgantown, West Virginia, USA
| | - Naser Ahmadi
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Alejandra Novoa
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California, USA
| | - Ferdinand Flores
- Lundquist Institute, Harbor UCLA Medical Center, Torrance, California, USA
| | - Sajad Hamal
- Lundquist Institute, Harbor UCLA Medical Center, Torrance, California, USA
| | - April Kinninger
- Lundquist Institute, Harbor UCLA Medical Center, Torrance, California, USA
| | | | - Tracy Nakata
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Danh V. Nguyen
- Division of General Internal Medicine, University of California Irvine School of Medicine, Orange, California, USA
| | - Gregory A. Brent
- Division of Endocrinology, Diabetes and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Connie M. Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California, USA
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Li Y, Nguyen DV, Kürüm E, Rhee CM, Banerjee S, Şentürk D. Multilevel Varying Coefficient Spatiotemporal Model. Stat (Int Stat Inst) 2021; 11. [DOI: 10.1002/sta4.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Yihao Li
- Department of Biostatistics University of California Los Angeles CA USA
| | - Danh V. Nguyen
- Department of Medicine University of California Irvine Orange CA USA
| | - Esra Kürüm
- Department of Statistics University of California Riverside CA USA
| | - Connie M. Rhee
- Department of Medicine University of California Irvine Orange CA USA
- Harold Simmons Center for Chronic Disease Research and Epidemiology University of California Irvine School of Medicine Orange CA USA
| | - Sudipto Banerjee
- Department of Biostatistics University of California Los Angeles CA USA
| | - Damla Şentürk
- Department of Biostatistics University of California Los Angeles CA USA
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Stopenski S, Guner YS, Jolley J, Major C, Hatfield T, Ebanks AH, Nguyen DV, Jancelewicz T, Harting MT, Yu PT. Inborn Versus Outborn Delivery in Neonates With Congenital Diaphragmatic Hernia. J Surg Res 2021; 270:245-251. [PMID: 34710705 DOI: 10.1016/j.jss.2021.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/25/2021] [Accepted: 09/13/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a morbid and potentially fatal condition that challenges providers. The aim of this study is to compare outcomes in neonates with prenatally diagnosed CDH that are inborn (delivered in the institution where definitive care for CDH is provided) versus outborn. METHODS Prenatally diagnosed CDH cases were identified from the Congenital Diaphragmatic Hernia Study Group (CDHSG) database between 2007 and 2019. Using risk adjustment based on disease severity, we compared inborn versus outborn status using baseline risk and multivariable logistic regression models. The primary endpoint was mortality and the secondary endpoint was need for extracorporeal life support (ECLS). RESULTS Of 4195 neonates with prenatally diagnosed CDH, 3087 (73.6%) were inborn and 1108 (26.4%) were outborn. There was no significant difference in birth weight, gestational age, or presence of additional congenital anomalies. There was no difference in mortality between inborn and outborn infants (32.6% versus 33.8%, P = 0.44) or ECLS requirement (30.9% versus 31.5%, P = 0.73). Among neonates requiring ECLS, outborn status was a risk factor for mortality (OR 1.51, 95% CI 1.13-2.01, P = 0.006). After adjusting for post-surgical defect size, which is not known prenatally, outborn status was no longer a risk factor for mortality for infants requiring ECLS. CONCLUSIONS Risk of mortality and need for ECLS for inborn CDH patients is not different to outborn infants. Future studies should be directed to establishing whether highest risk infants are at risk for worse outcomes based on center of birth.
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Affiliation(s)
- Stephen Stopenski
- Department of Surgery, University of California Irvine, Orange, California.
| | - Yigit S Guner
- Department of Surgery, University of California Irvine, Orange, California; Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
| | - Jennifer Jolley
- Department of Obstetrics and Gynecology, University of California Irvine, Orange, California
| | - Carol Major
- Department of Obstetrics and Gynecology, University of California Irvine, Orange, California
| | - Tamera Hatfield
- Department of Obstetrics and Gynecology, University of California Irvine, Orange, California
| | - Ashley H Ebanks
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, Texas
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine, Orange, California
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, Texas
| | - Peter T Yu
- Department of Surgery, University of California Irvine, Orange, California; Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
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Estes JP, Şentürk D, Kürüm E, Rhee CM, Nguyen DV. Fixed Effects High-Dimensional Profiling Models in Low Information Context. Int J Stats Med Res 2021; 10:118-131. [PMID: 35465259 PMCID: PMC9033160 DOI: 10.6000/1929-6029.2021.10.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Profiling or evaluation of health care providers, including hospitals or dialysis facilities, involves the application of hierarchical regression models to compare each provider’s performance with respect to a patient outcome, such as unplanned 30-day hospital readmission. This is achieved by comparing a specific provider’s estimate of unplanned readmission rate, adjusted for patient case-mix, to a normative standard, typically defined as an “average” national readmission rate across all providers. Profiling is of national importance in the United States because the Centers for Medicare and Medicaid Services (CMS) policy for payment to providers is dependent on providers’ performance, which is part of a national strategy to improve delivery and quality of patient care. Novel high dimensional fixed effects (FE) models have been proposed for profiling dialysis facilities and are more focused towards inference on the tail of the distribution of provider outcomes, which is well-suited for the objective of identifying sub-standard (“extreme”) performance. However, the extent to which estimation and inference procedures for FE profiling models are effective when the outcome is sparse and/or when there are relatively few patients within a provider, referred to as the “low information” context, have not been examined. This scenario is common in practice when the patient outcome of interest is cause-specific 30-day readmissions, such as 30-day readmission due to infections in patients on dialysis, which is only about ~ 8% compared to the > 30% for all-cause 30-day readmission. Thus, we examine the feasibility and effectiveness of profiling models under the low information context in simulation studies and propose a novel correction method to FE profiling models to better handle sparse outcome data.
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Affiliation(s)
| | - Damla Şentürk
- Department of Biostatistics, University of California, Los Angeles, CA 90095, USA
| | - Esra Kürüm
- Department of Statistics, University of California, Riverside, CA 92521, USA
| | - Connie M. Rhee
- Department of Medicine, University of California Irvine, Orange, CA 92868, USA
| | - Danh V. Nguyen
- Department of Medicine, University of California Irvine, Orange, CA 92868, USA
- Address correspondence to this author at the Department of Medicine, University of California Irvine, 333 City Blvd. West, City Tower, Suite 400, Orange, CA 92868, USA;
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Narasaki Y, Park E, You AS, Daza A, Peralta RA, Guerrero Y, Novoa A, Amin AN, Nguyen DV, Price D, Kalantar-Zadeh K, Rhee CM. Continuous glucose monitoring in an end-stage renal disease patient with diabetes receiving hemodialysis. Semin Dial 2021; 34:388-393. [PMID: 34378258 DOI: 10.1111/sdi.13009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 07/05/2021] [Accepted: 07/18/2021] [Indexed: 12/29/2022]
Abstract
Diabetes is the leading cause of end-stage renal disease (ESRD) and contributes to heightened morbidity and mortality in dialysis patients. Given that ESRD patients are susceptible to hypoglycemia and hyperglycemia via multiple pathways, adequate glycemic monitoring and control is a cornerstone in diabetic kidney disease management. In ESRD, existing glycemic metrics such as glycated hemoglobin, self-monitored blood glucose, fructosamine, and glycated albumin have limitations in accuracy, convenience, and accessibility. In contrast, continuous glucose monitoring (CGM) provides automated, less invasive glucose measurements and more comprehensive glycemic data versus conventional metrics. Here, we report a 48-year-old male with ESRD due to diabetes receiving thrice-weekly hemodialysis who experienced decreased patient-burden, greater glucose monitoring adherence, improved glycemic parameters, and reduction in hypoglycemia after transitioning to CGM. Through this case, we discuss how CGM is a practical, convenient patient-centered tool that may improve metabolic outcomes and quality of life in ESRD patients with diabetes.
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Affiliation(s)
- Yoko Narasaki
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Elisa Park
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Amy S You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Andrea Daza
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Rene Amel Peralta
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Yalitzi Guerrero
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Alejandra Novoa
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Alpesh N Amin
- Department of Medicine, University of California Irvine School of Medicine, Orange, California, USA
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine School of Medicine, Orange, California, USA
| | | | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine School of Medicine, Orange, California, USA
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Narasaki Y, Okuda Y, Kalantar SS, You AS, Novoa A, Nguyen T, Streja E, Nakata T, Colman S, Kalantar-Zadeh K, Nguyen DV, Rhee CM. Dietary Potassium Intake and Mortality in a Prospective Hemodialysis Cohort. J Ren Nutr 2021; 31:411-420. [PMID: 33121888 PMCID: PMC8614638 DOI: 10.1053/j.jrn.2020.05.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 04/11/2020] [Accepted: 05/03/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Among hemodialysis patients, clinical practice guidelines recommend dietary potassium restriction given concerns about potential hyperkalemia leading to malignant arrhythmias and mortality. However, there are sparse data informing recommendations for dietary potassium intake in this population. We thus sought to examine the relationship between dietary potassium intake and death risk in a prospective cohort of hemodialysis patients. DESIGN AND METHODS Among 415 hemodialysis patients from the prospective "Malnutrition, Diet, and Racial Disparities in Chronic Kidney Disease" cohort recruited across 16 outpatient dialysis clinics, information regarding dietary potassium intake was obtained using Food Frequency Questionnaires administered over October 2011 to March 2015. We first examined associations of baseline dietary potassium intake categorized as tertiles with mortality risk using Cox regression. We then examined clinical characteristics associated with low dietary potassium intake (defined as the lowest tertile) using logistic regression. RESULTS In expanded case-mix Cox analyses, patients whose dietary potassium intake was in the lowest tertile had higher mortality (ref: highest tertile) (adjusted hazard ratio 1.74, 95% confidence interval 1.14-2.66). These associations had even greater magnitude of risk following adjustment for laboratory and nutritional covariates (adjusted hazard ratio 2.65, 95% confidence interval 1.40-5.04). In expanded case-mix restricted cubic spline analyses, there was a monotonic increase in mortality risk with incrementally lower dietary potassium intake. In expanded case-mix logistic regression models, female sex; higher serum bicarbonate; and lower dietary energy, protein, and fiber intake were associated with low dietary potassium intake. CONCLUSIONS In a prospective cohort of hemodialysis patients, lower dietary potassium intake was associated with higher mortality risk. These findings suggest that excessive dietary potassium restriction may be deleterious in hemodialysis patients, and further studies are needed to determine the optimal dietary potassium intake in this population.
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Affiliation(s)
- Yoko Narasaki
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California; Department of Clinical Nutrition and Food Management, Tokushima University Graduate School of Nutrition and Biosciences, Tokushima, Japan; Japan Society for the Promotion of Science, Tokyo, Japan; Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yusuke Okuda
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California
| | - Sara S Kalantar
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California; University of California, Berkeley, Berkeley, California
| | - Amy S You
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California
| | - Alejandra Novoa
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California
| | - Theresa Nguyen
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California; Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Tracy Nakata
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California
| | | | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California; Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Danh V Nguyen
- Division of General Internal Medicine, University of California, Irvine, Orange, California
| | - Connie M Rhee
- Division of Nephrology and Hypertension, Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California, Irvine, Orange, California.
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Li Y, Nguyen DV, Banerjee S, Rhee CM, Kalantar-Zadeh K, Kürüm E, Şentürk D. Multilevel modeling of spatially nested functional data: Spatiotemporal patterns of hospitalization rates in the US dialysis population. Stat Med 2021; 40:3937-3952. [PMID: 33902165 DOI: 10.1002/sim.9007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/15/2021] [Accepted: 04/08/2021] [Indexed: 11/12/2022]
Abstract
End-stage renal disease patients on dialysis experience frequent hospitalizations. In addition to known temporal patterns of hospitalizations over the life span on dialysis, where poor outcomes are typically exacerbated during the first year on dialysis, variations in hospitalizations among dialysis facilities across the US contribute to spatial variation. Utilizing national data from the United States Renal Data System (USRDS), we propose a novel multilevel spatiotemporal functional model to study spatiotemporal patterns of hospitalization rates among dialysis facilities. Hospitalization rates of dialysis facilities are considered as spatially nested functional data (FD) with longitudinal hospitalizations nested in dialysis facilities and dialysis facilities nested in geographic regions. A multilevel Karhunen-Loéve expansion is utilized to model the two-level (facility and region) FD, where spatial correlations are induced among region-specific principal component scores accounting for regional variation. A new efficient algorithm based on functional principal component analysis and Markov Chain Monte Carlo is proposed for estimation and inference. We report a novel application using USRDS data to characterize spatiotemporal patterns of hospitalization rates for over 400 health service areas across the US and over the posttransition time on dialysis. Finite sample performance of the proposed method is studied through simulations.
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Affiliation(s)
- Yihao Li
- Department of Biostatistics, University of California, Los Angeles, California
| | - Danh V Nguyen
- Department of Medicine, UC Irvine School of Medicine, Orange, California
| | - Sudipto Banerjee
- Department of Biostatistics, University of California, Los Angeles, California
| | - Connie M Rhee
- Department of Medicine, UC Irvine School of Medicine, Orange, California
| | | | - Esra Kürüm
- Department of Statistics, University of California, Riverside, California
| | - Damla Şentürk
- Department of Biostatistics, University of California, Los Angeles, California
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22
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Narasaki Y, Okuda Y, Moore LW, You AS, Tantisattamo E, Inrig JK, Miyagi T, Nakata T, Kovesdy CP, Nguyen DV, Kalantar-Zadeh K, Rhee CM. Dietary protein intake, kidney function, and survival in a nationally representative cohort. Am J Clin Nutr 2021; 114:303-313. [PMID: 33742197 PMCID: PMC8246621 DOI: 10.1093/ajcn/nqab011] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/08/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND High-protein diets (e.g., Paleo, Atkins, South Beach, ketogenic) have gained popularity as a means to promote weight loss and avoid excess carbohydrate consumption. Yet in chronic kidney disease (CKD) patients, evidence suggests low dietary protein intake (DPI) leads to attenuation of kidney function decline, although concerns remain for risk of protein-energy wasting. OBJECTIVES To examine associations of DPI with mortality in a nationally representative cohort of US adults, stratified by kidney function. METHODS We examined the association between daily DPI scaled to actual body weight (ABW), ascertained by 24-h dietary recall, with all-cause mortality among 27,604 continuous NHANES adult participants (1999-2010), stratified according to impaired versus normal kidney function (estimated glomerular filtration rates <60 compared with ≥60 ml/min/1.72 m2, respectively), using multivariable Cox models. We also examined the relation between high biological value (HBV) protein consumption with mortality. RESULTS In participants with impaired kidney function, a high DPI of ≥1.4 g/kg ABW/day was associated with higher mortality, while lower DPI levels were not associated with mortality (reference, 0.6 to <1.0 g/kg ABW/day): the adjusted HRs (aHRs) were 1.09 (95% CI: 0.90, 1.32), 1.03 (95% CI: 0.82, 1.29), and 1.37 (95% CI: 1.02, 1.85) for DPI <0.6, 1.0 to <1.4, and ≥1.4 g/kg ABW/day, respectively. Yet in participants with normal kidney function, a low DPI of <0.6 g/kg ABW/day was associated with higher mortality, whereas higher DPI levels were not associated with death: the aHRs were 1.18 (95% CI: 1.04, 1.34), 0.92 (95% CI: 0.81, 1.04), and 0.99 (95% CI: 0.85, 1.16) for DPI <0.6, 1.0 to <1.4, and ≥1.4 g/kg ABW/day, respectively. The highest 2 tertiles of HBV consumption were associated with higher mortality in participants with impaired kidney function. CONCLUSIONS Among participants with impaired kidney function, a higher DPI and greater HBV consumption were associated with higher mortality, whereas a lower DPI was associated with higher mortality in those with normal kidney function. Further studies are needed to elucidate the specific pathways between higher DPI and mortality in CKD.
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Affiliation(s)
- Yoko Narasaki
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA,Department of Clinical Nutrition and Food Management, Tokushima University Graduate School of Nutrition and Biosciences, Tokushima, Japan,Japan Society for the Promotion of Science, Tokyo, Japan
| | - Yusuke Okuda
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA,Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Linda W Moore
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Amy S You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Ekamol Tantisattamo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Jula K Inrig
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA,IQVIA, Therapeutic Science and Strategy Unit, San Diego, CA, USA
| | - Tsuyoshi Miyagi
- Department of Cardiovascular Medicine, Nephrology and Neurology, University of the Ryukyus School of Medicine, Okinawa, Japan
| | - Tracy Nakata
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, VA, USA
| | - Danh V Nguyen
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
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Kürüm E, Nguyen DV, Li Y, Rhee CM, Kalantar‐Zadeh K, Şentürk D. Multilevel joint modeling of hospitalization and survival in patients on dialysis. Stat (Int Stat Inst) 2021. [DOI: 10.1002/sta4.356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Esra Kürüm
- Department of Statistics University of California Riverside 92521 California USA
| | - Danh V. Nguyen
- Department of Medicine University of California Irvine Orange 92868 California USA
| | - Yihao Li
- Department of Biostatistics University of California Los Angeles 90095 California USA
| | - Connie M. Rhee
- Department of Medicine University of California Irvine Orange 92868 California USA
- Harold Simmons Center for Chronic Disease Research and Epidemiology University of California Irvine School of Medicine Orange 92868 California USA
| | - Kamyar Kalantar‐Zadeh
- Department of Medicine University of California Irvine Orange 92868 California USA
- Harold Simmons Center for Chronic Disease Research and Epidemiology University of California Irvine School of Medicine Orange 92868 California USA
| | - Damla Şentürk
- Department of Biostatistics University of California Los Angeles 90095 California USA
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Guner YS, Delaplain PT, Schomberg J, Di Nardo M, Yu PT, Lam D, Jancelewicz T, Harting MT, Starr JP, Nguyen DV. Risk Factors for Hemolysis During Extracorporeal Life Support for Congenital Diaphragmatic Hernia. J Surg Res 2021; 263:14-23. [PMID: 33621745 DOI: 10.1016/j.jss.2021.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/08/2021] [Accepted: 01/18/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Neonates receiving extracorporeal life support (ECLS) for congenital diaphragmatic hernia (CDH) require prolonged support compared with neonates with other forms of respiratory failure. Hemolysis is a complication that can be seen during ECLS and can lead to renal failure and potentially to worse outcomes. The purpose of this study was to identify risk factors for the development of hemolysis in CDH patients treated with ECLS. METHODS The Extracorporeal Life Support Organization database was used to identify infants with CDH (2000-2015). The primary outcome was hemolysis (plasma-free hemoglobin >50 mg/dL). Potentially associated variables were identified in the data set. Descriptive statistics and a series of nested multivariable logistic regression models were used to identify associations between hemolysis and demographic, pre-ECLS, and on-ECLS factors. RESULTS There were 4576 infants with a mortality of 52.5%. The overall mean rate of hemolysis was 10.5% during the study period. In earlier years (2000-2005), the hemolysis rates were 6.3% and 52.7% for roller versus centrifugal pumps, whereas in later years (2010-2015), they were 2.9% and 26.5%, respectively. The fully adjusted model demonstrated that the use of centrifugal pumps was a strong predictor of hemolysis (odds ratio: 6.67, 95% confidence interval: 5.14-8.67). In addition, other risk factors for hemolysis included low 5-min Apgar score, on-ECLS complications (renal, metabolic, and cardiovascular), and duration of ECLS. CONCLUSIONS In our cohort of CDH patients receiving ECLS over 15 y, the use of centrifugal pumps increased over time, along with the rate of hemolysis. Patient- and treatment-level risk factors were identified contributing to the development of hemolysis.
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Affiliation(s)
- Yigit S Guner
- Department of Surgery, University of California Irvine Medical Center, Orange, California; Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California.
| | - Patrick T Delaplain
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - John Schomberg
- Department of Nursing and Trauma Research, Children's Hospital of Orange County, Orange, California
| | - Matteo Di Nardo
- Department of Nursing and Trauma Research, Ospedale Pediatrico Bambino Gesu, Rome, Italy
| | - Peter T Yu
- Department of Surgery, University of California Irvine Medical Center, Orange, California; Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
| | - Danny Lam
- Department of Nursing and Trauma Research, Children's Hospital of Orange County, Cardiovacular Intentive Care Unit, Orange, California
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew T Harting
- Department of Pediatric Surgery, Children's Memorial Hermann Hospital, University of Texas McGovern Medical School, Houston, Texas
| | - Joanne P Starr
- Division of Cardiothoracic Surgery, Children's Hospital of Orange County, Orange, California
| | - Danh V Nguyen
- Department of Medicine, Irvine School of Medicine, University of California, Irvine, California
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Tancredi DJ, Harvey DJ, Smiley-Jewell S, Nguyen DV. Requiring post-hoc power of 80% amounts to an unstated lowering of the type-1 error rate. Neurotoxicology 2020; 82:99. [PMID: 33232746 DOI: 10.1016/j.neuro.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/12/2020] [Indexed: 11/19/2022]
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26
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You AS, Kalantar-Zadeh K, Streja E, Park C, Sim JJ, Tantisattamo E, Hsiung JT, Obi Y, Potukuchi PK, Amin AN, Nguyen DV, Kovesdy CP, Rhee CM. Mortality Risk in Chronic Kidney Disease Patients Transitioning to Dialysis: Impact of Opiate and Non-Opiate Use. Am J Nephrol 2020; 51:715-725. [PMID: 32777779 DOI: 10.1159/000509451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/16/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Population-based studies show there is a high prevalence of chronic kidney disease (CKD) patients suffering from chronic pain. While opiates are frequently prescribed in non-dialysis-dependent CKD (NDD-CKD) patients, there may be toxic accumulation of metabolites, particularly among those progressing to end-stage renal disease (ESRD). We examined the association of opiate versus other analgesic use during the pre-ESRD period with post-ESRD mortality among NDD-CKD patients transitioning to dialysis. METHODS We examined a national cohort of US Veterans with NDD-CKD who transitioned to dialysis over 2007-14. Among patients who received ≥1 prescription(s) in the Veterans Affairs (VA) Healthcare System within 1 year of transitioning to dialysis, we examined associations of pre-ESRD analgesic status, defined as opiate, gabapentin/pregabalin, other non-opiate analgesic, versus no analgesic use, with post-ESRD mortality using multivariable Cox models. RESULTS Among 57,764 patients who met eligibility criteria, pre-ESRD opiate and gabapentin/pregabalin use were each associated with higher post-ESRD mortality (ref: no analgesic use), whereas non-opiate analgesic use was not associated with higher mortality in expanded case-mix analyses: HRs (95% CIs) 1.07 (1.05-1.10), 1.07 (1.01-1.13), and 1.00 (0.94-1.06), respectively. In secondary analyses, increasing frequency of opiate prescriptions exceeding 1 opiate prescription in the 1-year pre-ESRD period was associated with incrementally higher post-ESRD mortality (ref: no analgesic use). CONCLUSIONS In NDD-CKD patients transitioning to dialysis, pre-ESRD opiate and gabapentin/pregabalin use were associated with higher post-ESRD mortality, whereas non-opiate analgesic use was not associated with death. There was a graded association between increasing frequency of pre-ESRD opiate use and incrementally higher mortality.
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Affiliation(s)
- Amy S You
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
- University of Washington School of Public Health, Seattle, Washington, USA
| | - John J Sim
- Kaiser Permanente Southern California, Los Angeles, California, USA
| | - Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
| | - Yoshitsugu Obi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Praveen K Potukuchi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Alpesh N Amin
- Department of Medicine, University of California Irvine, Orange, California, USA
| | - Danh V Nguyen
- Division of General Internal Medicine, University of California Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA,
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Zhao RT, Kandil A, Nguyen DV, Campos L, Amin NH, Chang EY. Pain Perception in Taekwondo: Relationship to Injury, Experience, and Time Loss. Sports Med Int Open 2020; 4:E53-E58. [PMID: 32607411 PMCID: PMC7314658 DOI: 10.1055/a-1168-9167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/02/2020] [Indexed: 12/05/2022] Open
Affiliation(s)
- Renee T Zhao
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, United States
| | - Abdullah Kandil
- Department of Physical Medicine and Rehabilitation, University of California Irvine, Irvine, United States
| | - Danh V Nguyen
- Institute for Clinical and Translational Science, University of California Irvine, Irvine, United States.,Department of Medicine, University of California Irvine, Irvine, United States
| | - Luis Campos
- Department of Statistics, Harvard University, Cambridge, United States
| | - Nirav H Amin
- Orthopedic Surgery, Restore Orthopedics & Spine Center, Orange, United States
| | - Eric Y Chang
- Interventional Pain, Sports, Rehabilitation & Regenerative Medicine, Restore Orthopedics & Spine Center, Orange, United States
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Kalantar-Zadeh K, Joshi S, Schlueter R, Cooke J, Brown-Tortorici A, Donnelly M, Schulman S, Lau WL, Rhee CM, Streja E, Tantisattamo E, Ferrey AJ, Hanna R, Chen JL, Malik S, Nguyen DV, Crowley ST, Kovesdy CP. Plant-Dominant Low-Protein Diet for Conservative Management of Chronic Kidney Disease. Nutrients 2020; 12:E1931. [PMID: 32610641 PMCID: PMC7400005 DOI: 10.3390/nu12071931] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/22/2020] [Accepted: 06/22/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic kidney disease (CKD) affects >10% of the adult population. Each year, approximately 120,000 Americans develop end-stage kidney disease and initiate dialysis, which is costly and associated with functional impairments, worse health-related quality of life, and high early-mortality rates, exceeding 20% in the first year. Recent declarations by the World Kidney Day and the U.S. Government Executive Order seek to implement strategies that reduce the burden of kidney failure by slowing CKD progression and controlling uremia without dialysis. Pragmatic dietary interventions may have a role in improving CKD outcomes and preventing or delaying dialysis initiation. Evidence suggests that a patient-centered plant-dominant low-protein diet (PLADO) of 0.6–0.8 g/kg/day composed of >50% plant-based sources, administered by dietitians trained in non-dialysis CKD care, is promising and consistent with the precision nutrition. The scientific premise of the PLADO stems from the observations that high protein diets with high meat intake not only result in higher cardiovascular disease risk but also higher CKD incidence and faster CKD progression due to increased intraglomerular pressure and glomerular hyperfiltration. Meat intake increases production of nitrogenous end-products, worsens uremia, and may increase the risk of constipation with resulting hyperkalemia from the typical low fiber intake. A plant-dominant, fiber-rich, low-protein diet may lead to favorable alterations in the gut microbiome, which can modulate uremic toxin generation and slow CKD progression, along with reducing cardiovascular risk. PLADO is a heart-healthy, safe, flexible, and feasible diet that could be the centerpiece of a conservative and preservative CKD-management strategy that challenges the prevailing dialysis-centered paradigm.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
- Tibor Rubin VA Long Beach Healthcare System, Long Beach, CA 90822, USA;
| | - Shivam Joshi
- Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA;
| | | | - Joanne Cooke
- Kansas City VA Medical Center, Kansas City, MO 64128, USA;
| | - Amanda Brown-Tortorici
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | | | - Sherry Schulman
- UCI Health Susan Samueli Center Integrative Health Institute, Irvine, CA 92626, USA; (S.S.); (S.M.)
| | - Wei-Ling Lau
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Connie M. Rhee
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Elani Streja
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
- Tibor Rubin VA Long Beach Healthcare System, Long Beach, CA 90822, USA;
| | - Ekamol Tantisattamo
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Antoney J. Ferrey
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Ramy Hanna
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Joline L.T. Chen
- Tibor Rubin VA Long Beach Healthcare System, Long Beach, CA 90822, USA;
| | - Shaista Malik
- UCI Health Susan Samueli Center Integrative Health Institute, Irvine, CA 92626, USA; (S.S.); (S.M.)
| | - Danh V. Nguyen
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange, CA 90286, USA; (A.B.-T.); (W.-L.L.); (C.M.R.); (E.S.); (E.T.); (A.J.F.); (R.H.); (D.V.N.)
| | - Susan T. Crowley
- VA Connecticut Healthcare System, West Haven, CT 06516, USA;
- Division of Nephrology, Yale University School of Medicine, New Haven, CT 06516, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Sciences Center, Memphis, TN 38163, USA;
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Delaplain PT, Yu PT, Ehwerhemuepha L, Nguyen DV, Jancelewicz T, Stein J, Harting MT, Guner YS. Predictors of long ECMO runs for congenital diaphragmatic hernia. J Pediatr Surg 2020; 55:993-997. [PMID: 32169344 DOI: 10.1016/j.jpedsurg.2020.02.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/20/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although longer ECMO run times for patients with congenital diaphragmatic hernia (CDH) have been associated with worse outcomes, a large study has not been conducted to examine the risk factors for long ECMO runs. METHODS The Extracorporeal Life Support Organization (ELSO) Registry from 2000 to 2015 was used to identify predictors of long ECMO runs in CDH patients. A long run was any duration of ≥14 days. Multivariable logistic regression models were used to examine the association between demographics, pre-ECMO blood gas/ventilator settings, comorbid conditions, and therapies on long ECMO runs. RESULTS There were 4730 CDH-infants examined. The largest association with long ECMO runs was on-ECMO repair (OR: 3.72, 95% CI: 3.013-4.602, p < 0.001) and the use of THAM (OR: 1.463, 95% CI: 1.062-2.016, p = 0.02). Each drop in pH quartile was associated with an increased risk of long ECMO run: pH ≥ 7.3 (reference), pH 7.2-7.9 (OR 1.24, 95% CI: 0.98-1.57, p = 0.07), pH 7.08-7.19 (OR 1.46, 95% CI: 1.17-1.84, p = 0.001), pH ≤ 7.07 (OR 1.64, 95% CI: 1.29-2.07, p < 0.001). CONCLUSIONS We found a correlation between both pre-ECMO demographics/timing of repair and the subsequent risk of long ECMO runs, providing insight for both providers and parents about the risk factors for longer runs. TYPE OF STUDY Treatment Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Patrick T Delaplain
- Children's Hospital Los Angeles, Department of Pediatric Surgery, Los Angeles, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA
| | - Peter T Yu
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA
| | - Louis Ehwerhemuepha
- Children's Hospital of Orange County, Information Systems Department, Orange, CA
| | - Danh V Nguyen
- University of California, Irvine School of Medicine, Department of Medicine, Orange, CA
| | - Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Division of Pediatric Surgery, Memphis, TN
| | - James Stein
- Children's Hospital Los Angeles, Department of Pediatric Surgery, Los Angeles, CA
| | - Matthew T Harting
- University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Department of Pediatric Surgery, Houston, TX
| | - Yigit S Guner
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA.
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Delaplain PT, Ehwerhemuepha L, Nguyen DV, Di Nardo M, Jancelewicz T, Awan S, Yu PT, Guner YS. The development of multiorgan dysfunction in CDH-ECMO neonates is associated with the level of pre-ECMO support. J Pediatr Surg 2020; 55:830-834. [PMID: 32067809 DOI: 10.1016/j.jpedsurg.2020.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/25/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) is the most common indication for neonatal extracorporeal membrane oxygenation (ECMO), but mortality remains at 50%. Multiorgan failure can occur in 25% and has been linked to worse outcomes. We sought to examine the factors that would increase the risk of multiorgan dysfunction (MOD). METHODS The Extracorporeal Life Support Organization (ELSO) database was used to identify infants with CDH (2000-2015). The primary outcome was MOD, which was defined as the presence of organ failure in ≥2 organ systems. We used a multivariable logistic regression to examine the effect of demographics, pre-ECMO respiratory status, comorbidities, and therapies on MOD. RESULTS There were a total of 4374 CDH infants who were treated with ECMO. Overall mortality was 52.4%. The risk models demonstrated that pre-ECMO cardiac arrest (OR 1.458, CI: 1.146-1.861, p = 0.002) and hand-bagging (OR 1.461, CI: 1.094-1.963, p = 0.032) had the strongest association with MOD. In addition, other pre-ECMO indicators of disease severity (pH, HFOV, MAP, 5-min APGAR) and pre-ECMO therapies (bicarb, neuromuscular [NM] blockers) were also associated with MOD. CONCLUSIONS The level of pre-ECMO support has a significant association with the development of MOD, and initiation of ECMO prior to arrest seems to be critical to avoid complications. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Patrick T Delaplain
- University of California Irvine Medical Center, Department of Surgery, Orange, CA.
| | | | - Danh V Nguyen
- University of California, Irvine School of Medicine, Department of Medicine, Orange, CA
| | - Matteo Di Nardo
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Division of Pediatric Surgery, Memphis, TN
| | - Saeed Awan
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Information Systems, Orange, CA
| | - Peter T Yu
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Information Systems, Orange, CA
| | - Yigit S Guner
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Information Systems, Orange, CA
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Estes JP, Chen Y, Şentürk D, Rhee CM, Kürüm E, You AS, Streja E, Kalantar-Zadeh K, Nguyen DV. Profiling dialysis facilities for adverse recurrent events. Stat Med 2020; 39:1374-1389. [PMID: 31997372 PMCID: PMC7125020 DOI: 10.1002/sim.8482] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 08/27/2019] [Accepted: 12/10/2019] [Indexed: 11/08/2022]
Abstract
Profiling analysis aims to evaluate health care providers, such as hospitals, nursing homes, or dialysis facilities, with respect to a patient outcome. Previous profiling methods have considered binary outcomes, such as 30-day hospital readmission or mortality. For the unique population of dialysis patients, regular blood works are required to evaluate effectiveness of treatment and avoid adverse events, including dialysis inadequacy, imbalance mineral levels, and anemia among others. For example, anemic events (when hemoglobin levels exceed normative range) are recurrent and common for patients on dialysis. Thus, we propose high-dimensional Poisson and negative binomial regression models for rate/count outcomes and introduce a standardized event ratio measure to compare the event rate at a specific facility relative to a chosen normative standard, typically defined as an "average" national rate across all facilities. Our proposed estimation and inference procedures overcome the challenge of high-dimensional parameters for thousands of dialysis facilities. Also, we investigate how overdispersion affects inference in the context of profiling analysis. The proposed methods are illustrated with profiling dialysis facilities for recurrent anemia events.
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Affiliation(s)
- Jason P. Estes
- Research, Pratt & Whitney, East Hartford, CT 06042, U.S.A
| | - Yanjun Chen
- Institute for Clinical and Translational Science, University of California, Irvine, CA 92687, U.S.A
| | - Damla Şentürk
- Department of Biostatistics, University of California, Los Angeles, CA 90095, U.S.A
| | - Connie M. Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA 92868, U.S.A
| | - Esra Kürüm
- Department of Statistics, University of California, Riverside, CA 92521, U.S.A
| | - Amy S. You
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA 92868, U.S.A
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA 92868, U.S.A
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA 92868, U.S.A
| | - Danh V. Nguyen
- Department of Medicine, University of California Irvine, Orange, CA 92868, U.S.A
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You AS, Sim JJ, Kovesdy CP, Streja E, Nguyen DV, Brent GA, Kalantar-Zadeh K, Rhee CM. Association of thyroid status prior to transition to end-stage renal disease with early dialysis mortality. Nephrol Dial Transplant 2020; 34:2095-2104. [PMID: 30299498 DOI: 10.1093/ndt/gfy289] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/13/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Advanced chronic kidney disease (CKD) patients, including those receiving dialysis, have a high prevalence of thyroid dysfunction. Although hypothyroidism is associated with higher death risk in end-stage renal disease (ESRD) patients, no studies have examined whether thyroid status in the pre-ESRD period impacts mortality after dialysis initiation. METHODS Among US veterans with CKD identified from the national Veterans Affairs database that transitioned to dialysis over the period from October 2007 to September 2011, we examined the association of pre-ESRD serum thyrotropin (TSH) levels averaged over the 1-year pre-dialysis ('prelude') period with all-cause mortality in the first year following dialysis initiation. RESULTS Among 15 335 patients in the 1-year prelude cohort, TSH levels >5.0 mIU/L were associated with higher mortality in expanded case-mix Cox models (reference: TSH 0.5-5.0 mIU/L): adjusted hazard ratio (aHR) [95% confidence interval (CI) 1.20 (1.07-1.33). Similar findings were observed for TSH >5.0 mIU/L and mortality in the 2- and 5-year cohorts: aHRs (95% CI) 1.11 (1.02-1.21) and 1.15 (1.07-1.24), respectively. Analyses of finer gradations of TSH in the 1-year prelude cohort demonstrated that incrementally higher levels >5.0 mIU/L were associated with increasingly higher mortality in expanded case-mix models (reference: TSH 0.5-3.0 mIU/L): aHRs (95% CI) 1.18 (1.04-1.33) and 1.28 (1.03-1.59) for TSH levels >5.0-10.0 mIU/L and >10.0 mIU/L, respectively. In the 2- and 5-year cohorts, mortality associations persisted most strongly for those with TSH >10.0 mIU/L, particularly after laboratory covariate adjustment. CONCLUSIONS Among new ESRD patients, there is a dose-dependent relationship between higher pre-ESRD TSH levels >5.0 mIU/L and post-ESRD mortality. Further studies are needed to determine the impact of TSH reduction with thyroid hormone supplementation in this population.
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Affiliation(s)
- Amy S You
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, USA
| | - John J Sim
- Kaiser Permanente Southern California, Department of Nephrology, Los Angeles, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, USA.,Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Danh V Nguyen
- Division of General Internal Medicine, University of California Irvine, Orange, CA, USA
| | - Gregory A Brent
- Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, USA.,Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, USA
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Li Y, Nguyen DV, Kürüm E, Rhee CM, Chen Y, Kalantar-Zadeh K, Şentürk D. A multilevel mixed effects varying coefficient model with multilevel predictors and random effects for modeling hospitalization risk in patients on dialysis. Biometrics 2019; 76:924-938. [PMID: 31856300 DOI: 10.1111/biom.13205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 11/29/2019] [Accepted: 12/04/2019] [Indexed: 11/30/2022]
Abstract
For patients on dialysis, hospitalizations remain a major risk factor for mortality and morbidity. We use data from a large national database, United States Renal Data System, to model time-varying effects of hospitalization risk factors as functions of time since initiation of dialysis. To account for the three-level hierarchical structure in the data where hospitalizations are nested in patients and patients are nested in dialysis facilities, we propose a multilevel mixed effects varying coefficient model (MME-VCM) where multilevel (patient- and facility-level) random effects are used to model the dependence structure of the data. The proposed MME-VCM also includes multilevel covariates, where baseline demographics and comorbidities are among the patient-level factors, and staffing composition and facility size are among the facility-level risk factors. To address the challenge of high-dimensional integrals due to the hierarchical structure of the random effects, we propose a novel two-step approximate EM algorithm based on the fully exponential Laplace approximation. Inference for the varying coefficient functions and variance components is achieved via derivation of the standard errors using score contributions. The finite sample performance of the proposed estimation procedure is studied through simulations.
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Affiliation(s)
- Yihao Li
- Department of Biostatistics, University of California, Los Angeles, California
| | - Danh V Nguyen
- Department of Medicine, University of California, Irvine, California
| | - Esra Kürüm
- Department of Statistics, University of California, Riverside, California
| | - Connie M Rhee
- Department of Medicine, University of California, Irvine, California
| | - Yanjun Chen
- Institute for Clinical and Translational Science, Irvine, California
| | | | - Damla Şentürk
- Department of Biostatistics, University of California, Los Angeles, California
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Kalantar SS, You AS, Norris KC, Nakata T, Novoa A, Juarez K, Nguyen DV, Rhee CM. The Impact of Race and Ethnicity Upon Health-Related Quality of Life and Mortality in Dialysis Patients. Kidney Med 2019; 1:253-262. [PMID: 32734205 PMCID: PMC7380436 DOI: 10.1016/j.xkme.2019.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Rationale & Objective Health-related quality of life (HRQoL) has been recognized as a strong predictor of mortality among hemodialysis patients. However, differences in the association of HRQoL with survival across diverse racial/ethnic groups have not been well studied in this population. Study Design Observational cohort study. Setting & Participants We examined the relationship between HRQoL and mortality in a prospective cohort of racially/ethnically diverse hemodialysis patients recruited from 18 outpatient dialysis units during 2011 to 2016. Exposure Using the 36-Item Short Form Health Survey (SF-36) administered every 6 months, HRQoL was ascertained by 36 questions summarized as 2 Physical and Mental Component and 8 subscale scores. Outcome All-cause mortality. Analytical Approach Associations of time-varying SF-36 scores with mortality were estimated using Cox models in the overall cohort and within racial/ethnic subgroups. Results Among 753 hemodialysis patients who met eligibility criteria, expanded case-mix analyses showed that the lowest quartiles of time-varying Physical and Mental Component scores were associated with higher mortality in the overall cohort (reference: highest quartile): adjusted HRs, 2.30 (95% CI, 1.53-3.47) and 1.54 (95% CI, 1.05-2.25), respectively. In analyses stratified by race/ethnicity, the lowest quartile of Physical Component scores was significantly associated with higher mortality across all groups: adjusted HRs, 2.64 (95% CI, 1.31-5.29), 1.84 (95% CI, 1.01-3.38), and 3.18 (95% CI, 1.13-8.91) for Hispanic, African American, and other race/ethnicity patients, respectively. The lowest quartile of time-varying physical functioning, role limitations due to physical health, role limitations due to emotional problems, social functioning, and pain subscale scores were associated with higher mortality in the overall cohort and particularly in Hispanics and blacks. Limitations Residual confounding cannot be excluded. Conclusions Lower SF-36 Physical Component and subscale scores were associated with higher mortality in hemodialysis patients, including those of minority background. Further studies are needed to determine whether interventions that augment physical health might improve the survival of these diverse populations.
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Affiliation(s)
- Sara S Kalantar
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA.,University of California Berkeley, Berkeley, CA
| | - Amy S You
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Keith C Norris
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Tracy Nakata
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Alejandra Novoa
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Kimberly Juarez
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine School of Medicine, Orange, CA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
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Saran R, Robinson B, Abbott KC, Agodoa LYC, Bhave N, Bragg-Gresham J, Balkrishnan R, Dietrich X, Eckard A, Eggers PW, Gaipov A, Gillen D, Gipson D, Hailpern SM, Hall YN, Han Y, He K, Herman W, Heung M, Hirth RA, Hutton D, Jacobsen SJ, Jin Y, Kalantar-Zadeh K, Kapke A, Kovesdy CP, Lavallee D, Leslie J, McCullough K, Modi Z, Molnar MZ, Montez-Rath M, Moradi H, Morgenstern H, Mukhopadhyay P, Nallamothu B, Nguyen DV, Norris KC, O'Hare AM, Obi Y, Park C, Pearson J, Pisoni R, Potukuchi PK, Rao P, Repeck K, Rhee CM, Schrager J, Schaubel DE, Selewski DT, Shaw SF, Shi JM, Shieu M, Sim JJ, Soohoo M, Steffick D, Streja E, Sumida K, Tamura MK, Tilea A, Tong L, Wang D, Wang M, Woodside KJ, Xin X, Yin M, You AS, Zhou H, Shahinian V. US Renal Data System 2017 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2019; 71:A7. [PMID: 29477157 DOI: 10.1053/j.ajkd.2018.01.002] [Citation(s) in RCA: 483] [Impact Index Per Article: 96.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Delaplain PT, Harting MT, Jancelewicz T, Zhang L, Yu PT, Di Nardo M, Chen Y, Stein JE, Ford HR, Nguyen DV, Guner Y. Potential survival benefit with repair of congenital diaphragmatic hernia (CDH) after extracorporeal membrane oxygenation (ECMO) in select patients: Study by ELSO CDH Interest Group. J Pediatr Surg 2019; 54:1132-1137. [PMID: 30898399 DOI: 10.1016/j.jpedsurg.2019.02.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 02/21/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Studying the timing of repair in CDH is prone to confounding factors, including variability in disease severity and management. We hypothesized that delaying repair until post-ECMO would confer a survival benefit. METHODS Neonates who underwent CDH repair were identified within the ELSO Registry. Patients were then divided into on-ECMO versus post-ECMO repair. Patients were 1:1 matched for severity based on pre-ECMO covariates using the propensity score (PS) for the timing of repair. Outcomes examined included mortality and severe neurologic injury (SNI). RESULTS After matching, 2,224 infants were included. On-ECMO repair was associated with greater than 3-fold higher odds of mortality (OR 3.41, 95% CI: 2.84-4.09, p<0.01). The odds of SNI was also higher for on-ECMO repair (OR 1.49, 95% CI: 1.13-1.96, p<0.01). A sensitivity analysis was performed by including the length of ECMO as an additional matching variable. On-ECMO repair was still associated with higher odds of mortality (OR 2.38, 95% CI: 1.96-2.89, p<0.01). Results for SNI were similar but were no longer statistically significant (OR 1.33, 95% CI: 0.99-1.79, p=0.06). CONCLUSIONS Of the infants who can be liberated from ECMO and undergo CDH repair, there is a potential survival benefit for delaying CDH repair until after decannulation. TYPE OF STUDY Treatment Study LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Patrick T Delaplain
- Children's Hospital Los Angeles, Department of Pediatric Surgery, Los Angeles, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Division of Pediatric Surgery, Memphis, TN
| | - Lishi Zhang
- University of California Irvine Biostatistics, Institute for Clinical and Translational Science, Irvine, CA
| | - Peter T Yu
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA
| | - Matteo Di Nardo
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Yanjun Chen
- University of California Irvine Biostatistics, Institute for Clinical and Translational Science, Irvine, CA
| | - James E Stein
- Children's Hospital Los Angeles, Department of Pediatric Surgery, Los Angeles, CA
| | - Henri R Ford
- Children's Hospital Los Angeles, Department of Pediatric Surgery, Los Angeles, CA; University of Miami, Miller School of Medicine, Miami, FL
| | - Danh V Nguyen
- University of California, Irvine School of Medicine, Department of Medicine, Orange, CA
| | - Yigit Guner
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA.
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Delaplain PT, Jancelewicz T, Di Nardo M, Zhang L, Yu PT, Cleary JP, Morini F, Harting MT, Nguyen DV, Guner YS. Management preferences in ECMO mode for congenital diaphragmatic hernia. J Pediatr Surg 2019; 54:903-908. [PMID: 30786989 DOI: 10.1016/j.jpedsurg.2019.01.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 01/27/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE The purpose of this study was to identify management preferences that may exist in the care of infants with CDH receiving ECMO with emphasis on VV-ECMO. METHODS A survey was created to measure treatment preferences regarding ECMO use in CDH. The survey was distributed to all APSA and ELSO/Euro-ELSO members via e-mail. Survey results were summarized using descriptive statistics. RESULTS The survey had 230 respondents. The survey participants were surgeons (75%), neonatologists/intensivists (23%), and "other" (2%). The mean annual center volume was 11.6(±9.6) CDH cases, and the average number treated with ECMO was 4.5 (±6.4) cases/yr. The most agreed upon criteria for ECMO initiation were preductal O2 saturation <80% refractory to ventilator manipulation and medical therapy (89%), oxygenation index >40 (80%), severe air-leak (79%), and mixed acidosis (75%). Over 60% of respondents agreed the VV-ECMO would be optimum for average risk neonates. However, this preference diminished as the pre-ECMO level of cardiac support increased. When asked about why each respondent would choose VA-ECMO over VV-ECMO, the responses varied significantly between surgeons and non-surgeons. CONCLUSION While there seem to be areas of consensus among practitioners, such as criteria for initiation of ECMO, this survey revealed substantial variation in individual practice patterns regarding the use of ECMO for CDH. TYPE OF STUDY Qualitative, Survey. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Patrick T Delaplain
- Children's Hospital Los Angeles, Department of Pediatric Surgery, Los Angeles, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA.
| | - Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Division of Pediatric Surgery, Memphis, TN
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Lishi Zhang
- University of California Irvine Biostatistics, Institute for Clinical and Translational Science, Irvine, CA
| | - Peter T Yu
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA
| | - John P Cleary
- Children's Hospital of Orange County, Division of Neonatology, Orange, CA
| | - Francesco Morini
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Danh V Nguyen
- University of California, Irvine School of Medicine, Department of Medicine, Orange, CA
| | - Yigit S Guner
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA
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Hessl D, Schweitzer JB, Nguyen DV, McLennan YA, Johnston C, Shickman R, Chen Y. Cognitive training for children and adolescents with fragile X syndrome: a randomized controlled trial of Cogmed. J Neurodev Disord 2019; 11:4. [PMID: 30982467 PMCID: PMC6463634 DOI: 10.1186/s11689-019-9264-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 03/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals with fragile X syndrome (FXS) typically demonstrate profound executive function (EF) deficits that interfere with learning, socialization, and emotion regulation. We completed the first large, non-pharmacological controlled trial for FXS, designed to evaluate the efficacy of Cogmed, a computer/tablet-based working memory (WM) training program. METHODS The study was a randomized, blinded, parallel two-arm controlled trial in 100 children and adolescents with FXS (63 male, 37 female; 15.28 ± 3.36 yrs.). Participants were randomized equally to adaptive (difficulty level adjusted to performance) or non-adaptive (control) Cogmed training. Participants were assessed at home using objective measures of WM (primary outcome) and EF at baseline, following 20-25 caregiver-supported sessions over 5-6 weeks, and at follow-up 3 months after cessation of training. Parents and teachers provided ratings of WM, attention, and EF. RESULTS The WM composite and selective domains of EF (distractibility, cognitive flexibility), as well as parent- and teacher-reported attention and EF, significantly improved across the full study sample, with many changes maintained at follow-up. However, comparisons of improvement between adaptive and non-adaptive control conditions did not differ, showing that progressively challenging the WM system by expanding span length did not provide added benefit overall. CONCLUSIONS Further experimental comparisons are needed before Cogmed working memory training can be considered empirically validated for children with FXS, forming the basis of treatment recommendation. However, given that prior studies show no significant changes on these measures in FXS without treatment, that improvements were maintained for 3 months, and that blinded teachers reported improvements in the classroom, the modest benefits seen in both adaptive and non-adaptive groups overall are unlikely to be attributable to placebo or practice effects alone. Future analyses examining inter-individual differences (e.g., baseline capacity, training efficiency, co-morbidity, training environment, characteristics of training aide) may help to link this intervention to outcomes and potential transfer effects. TRIAL REGISTRATION US National Institutes of Health (ClinicalTrials.gov), NCT02747394 .
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Affiliation(s)
- David Hessl
- MIND Institute, University of California Davis Medical Center, 2825 50th St, Sacramento, CA 95817 USA
- Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, 2230 Stockton Blvd, Sacramento, CA 95817 USA
- Translational Psychophysiology and Assessment Laboratory (T-PAL), MIND Institute, UC Davis Medical Center, 2825 50th Street, Sacramento, CA 95817 USA
| | - Julie B. Schweitzer
- MIND Institute, University of California Davis Medical Center, 2825 50th St, Sacramento, CA 95817 USA
- Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, 2230 Stockton Blvd, Sacramento, CA 95817 USA
| | - Danh V. Nguyen
- Department of Medicine, University of California Irvine, 333 City Blvd. West, Orange, CA 92868 USA
| | - Yingratana A. McLennan
- MIND Institute, University of California Davis Medical Center, 2825 50th St, Sacramento, CA 95817 USA
- Department of Pediatrics, University of California Davis School of Medicine, 2516 Stockton Blvd, Sacramento, CA 95817 USA
| | - Cindy Johnston
- MIND Institute, University of California Davis Medical Center, 2825 50th St, Sacramento, CA 95817 USA
- Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, 2230 Stockton Blvd, Sacramento, CA 95817 USA
| | - Ryan Shickman
- MIND Institute, University of California Davis Medical Center, 2825 50th St, Sacramento, CA 95817 USA
- Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, 2230 Stockton Blvd, Sacramento, CA 95817 USA
| | - Yanjun Chen
- Institute for Clinical and Translational Science, Irvine, CA 92697 USA
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Chen Y, Şentürk D, Estes JP, Campos LF, Rhee CM, Dalrymple LS, Kalantar-Zadeh K, Nguyen DV. Performance Characteristics of Profiling Methods and the Impact of Inadequate Case-mix Adjustment. COMMUN STAT-SIMUL C 2019; 2019. [PMID: 33311840 DOI: 10.1080/03610918.2019.1595649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Profiling or evaluation of health care providers involves the application of statistical models to compare each provider's performance with respect to a patient outcome, such as unplanned 30-day hospital readmission, adjusted for patient case-mix characteristics. The nationally adopted method is based on random effects (RE) hierarchical logistic regression models. Although RE models are sensible for modeling hierarchical data, novel high dimensional fixed effects (FE) models have been proposed which may be well-suited for the objective of identifying sub-standard performance. However, there are limited comparative studies. Thus, we examine their relative performance, including the impact of inadequate case-mix adjustment.
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Affiliation(s)
- Yanjun Chen
- Institute for Clinical and Translational Science, University of California, Irvine, CA 92687, U.S.A
| | - Damla Şentürk
- Department of Biostatistics, University of California, Los Angeles, CA 90095, U.S.A
| | - Jason P Estes
- Research, Pratt & Whitney, East Hartford, CT 06118, U.S.A
| | - Luis F Campos
- Department of Statistics, Harvard University, Cambridge, MA 02138, U.S.A
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA 92868, U.S.A
| | - Lorien S Dalrymple
- Epidemiology and Research, Fresenius Medical Care, Waltham, MA 02451, U.S.A
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA 92868, U.S.A
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine, Orange, CA 92868, U.S.A
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Rhee CM, Kovesdy CP, Ravel VA, Streja E, Sim JJ, You AS, Gatwood J, Amin AN, Molnar MZ, Nguyen DV, Kalantar-Zadeh K. Glycemic Status and Mortality in Chronic Kidney Disease According to Transition Versus Nontransition to Dialysis. J Ren Nutr 2019; 29:82-90. [DOI: 10.1053/j.jrn.2018.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 07/28/2018] [Indexed: 02/07/2023] Open
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Saran R, Robinson B, Abbott KC, Agodoa LYC, Bragg-Gresham J, Balkrishnan R, Bhave N, Dietrich X, Ding Z, Eggers PW, Gaipov A, Gillen D, Gipson D, Gu H, Guro P, Haggerty D, Han Y, He K, Herman W, Heung M, Hirth RA, Hsiung JT, Hutton D, Inoue A, Jacobsen SJ, Jin Y, Kalantar-Zadeh K, Kapke A, Kleine CE, Kovesdy CP, Krueter W, Kurtz V, Li Y, Liu S, Marroquin MV, McCullough K, Molnar MZ, Modi Z, Montez-Rath M, Moradi H, Morgenstern H, Mukhopadhyay P, Nallamothu B, Nguyen DV, Norris KC, O'Hare AM, Obi Y, Park C, Pearson J, Pisoni R, Potukuchi PK, Repeck K, Rhee CM, Schaubel DE, Schrager J, Selewski DT, Shamraj R, Shaw SF, Shi JM, Shieu M, Sim JJ, Soohoo M, Steffick D, Streja E, Sumida K, Kurella Tamura M, Tilea A, Turf M, Wang D, Weng W, Woodside KJ, Wyncott A, Xiang J, Xin X, Yin M, You AS, Zhang X, Zhou H, Shahinian V. US Renal Data System 2018 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2019; 73:A7-A8. [PMID: 30798791 DOI: 10.1053/j.ajkd.2019.01.001] [Citation(s) in RCA: 597] [Impact Index Per Article: 119.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Potter LA, Scholze DA, Biag HMB, Schneider A, Chen Y, Nguyen DV, Rajaratnam A, Rivera SM, Dwyer PS, Tassone F, Al Olaby RR, Choudhary NS, Salcedo-Arellano MJ, Hagerman RJ. A Randomized Controlled Trial of Sertraline in Young Children With Autism Spectrum Disorder. Front Psychiatry 2019; 10:810. [PMID: 31780970 PMCID: PMC6851992 DOI: 10.3389/fpsyt.2019.00810] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 10/14/2019] [Indexed: 12/17/2022] Open
Abstract
Objective: Selective serotonin reuptake inhibitors like sertraline have been shown in observational studies and anecdotal reports to improve language development in young children with fragile X syndrome (FXS). A previous controlled trial of sertraline in young children with FXS found significant improvement in expressive language development as measured by the Mullen Scales of Early Learning (MSEL) among those with comorbid autism spectrum disorder (ASD) in post hoc analysis, prompting the authors to probe whether sertraline is also indicated in nonsyndromic ASD. Methods: The authors evaluated the efficacy of 6 months of treatment with low-dose sertraline in a randomized, double-blind, placebo-controlled trial in 58 children with ASD aged 24 to 72 months. Results: 179 subjects were screened for eligibility, and 58 were randomized to sertraline (32) or placebo (26). Eight subjects from the sertraline arm and five from the placebo arm discontinued. Intent-to-treat analysis showed no significant difference from placebo on the primary outcomes (MSEL expressive language raw score and age equivalent combined score) or secondary outcomes. Sertraline was well tolerated, with no difference in side effects between sertraline and placebo groups. No serious adverse events possibly related to study treatment occurred. Conclusion: This randomized controlled trial of sertraline treatment showed no benefit with respect to primary or secondary outcome measures. For the 6-month period, treatment in young children with ASD appears safe, although the long-term side effects of low-dose sertraline in early childhood are unknown. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02385799.
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Affiliation(s)
- Laura A Potter
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis Health, Sacramento, CA, United States
| | - Danielle A Scholze
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Hazel Maridith B Biag
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis Health, Sacramento, CA, United States
| | - Andrea Schneider
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis Health, Sacramento, CA, United States.,Department of Pediatrics, UC Davis Health, Sacramento, CA, United States.,College of Psychology, California Northstate University, Elk Grove, CA, United States
| | - Yanjun Chen
- Institute for Clinical and Translational Science, University of California, Irvine, Irvine, CA, United States
| | - Danh V Nguyen
- Department of Medicine, University of California, Irvine School of Medicine, Orange, CA, United States
| | - Akash Rajaratnam
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Susan M Rivera
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis Health, Sacramento, CA, United States.,Department of Psychiatry and Behavioral Sciences, UC Davis Health, Sacramento, CA, United States
| | - Patrick S Dwyer
- Department of Psychology, University of California, Davis, Davis, CA, United States
| | - Flora Tassone
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis Health, Sacramento, CA, United States.,Department of Biochemistry and Molecular Medicine, UC Davis Health, Sacramento, CA, United States
| | - Reem R Al Olaby
- College of Health Sciences, California Northstate University, Rancho Cordova, CA, United States
| | - Nimrah S Choudhary
- Department of Biochemistry and Molecular Medicine, UC Davis Health, Sacramento, CA, United States
| | - Maria J Salcedo-Arellano
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis Health, Sacramento, CA, United States
| | - Randi J Hagerman
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis Health, Sacramento, CA, United States.,Department of Pediatrics, UC Davis Health, Sacramento, CA, United States
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Li Y, Nguyen DV, Chen Y, Rhee CM, Kalantar-Zadeh K, Şentürk D. Modeling time-varying effects of multilevel risk factors of hospitalizations in patients on dialysis. Stat Med 2018; 37:4707-4720. [PMID: 30252153 PMCID: PMC6296494 DOI: 10.1002/sim.7950] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 07/25/2018] [Accepted: 07/27/2018] [Indexed: 11/08/2022]
Abstract
For chronic dialysis patients, a unique population requiring continuous medical care, methodologies to monitor patient outcomes, such as hospitalizations, over time, after initiation of dialysis, are of particular interest. Contributing to patient hospitalizations is a number of multilevel covariates such as demographics and comorbidities at the patient level and staffing composition at the dialysis facility level. We propose a varying coefficient model for multilevel risk factors (VCM-MR) to study the time-varying effects of covariates on patient hospitalization risk as a function of time on dialysis. The proposed VCM-MR also includes subject-specific random effects to account for within-subject correlation and dialysis facility-specific fixed effect varying coefficient functions to allow for the modeling of flexible time-varying facility-specific risk trajectories. An approximate EM algorithm and an iterative Newton-Raphson approach are proposed to address the challenge of estimation of high-dimensional parameters (varying coefficient functions) for thousands of dialysis facilities in the United States. The proposed modeling allows for comparisons between time-varying effects of multilevel risk factors as well as testing of facility-specific fixed effects. The method is applied to model hospitalization risk using the rich hierarchical data available on dialysis patients initiating dialysis between January 1, 2006 and December 31, 2008 from the United States Renal Data System, a large national database, where 331 443 hospitalizations over time are nested within patients, and 89 889 patients are nested within 2201 dialysis facilities. Patients are followed-up until December 31, 2013, where the follow-up time is truncated five years after the initiation of dialysis. Finite sample properties are studied through extensive simulations.
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Affiliation(s)
- Yihao Li
- Department of Biostatistics, University of California, Los Angeles, California
| | - Danh V Nguyen
- Department of Medicine, UC Irvine School of Medicine, Orange, California
| | - Yanjun Chen
- Institute for Clinical and Translational Science, University of California, Irvine, California
| | - Connie M Rhee
- Department of Medicine, UC Irvine School of Medicine, Orange, California
| | | | - Damla Şentürk
- Department of Biostatistics, University of California, Los Angeles, California
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Estes JP, Nguyen DV, Chen Y, Dalrymple LS, Rhee CM, Kalantar-Zadeh K, Şentürk D. Rejoinder: Time-dynamic profiling with application to hospital readmission among patients on dialysis. Biometrics 2018; 74:1404-1406. [PMID: 29870066 PMCID: PMC6296889 DOI: 10.1111/biom.12905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Jason P Estes
- Research, Pratt & Whitney, East Hartford, Connecticut 06118, U.S.A
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine, Orange, Connecticut 92868, U.S.A
| | - Yanjun Chen
- Institute for Clinical and Translational Science, Irvine, Connecticut 92697, U.S.A
| | - Lorien S Dalrymple
- Fresenius Medical Care North America, Waltham, Massachusetts 02451, U.S.A
| | - Connie M Rhee
- Department of Medicine, University of California Irvine, Orange, Connecticut 92868, U.S.A
| | - Kamyar Kalantar-Zadeh
- Department of Medicine, University of California Irvine, Orange, Connecticut 92868, U.S.A
| | - Damla Şentürk
- Department of Biostatistics, University of California, Los Angeles, Connecticut 90095, U.S.A
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Chou JA, Streja E, Nguyen DV, Rhee CM, Obi Y, Inrig JK, Amin A, Kovesdy CP, Sim JJ, Kalantar-Zadeh K. Intradialytic hypotension, blood pressure changes and mortality risk in incident hemodialysis patients. Nephrol Dial Transplant 2018; 33:149-159. [PMID: 28444336 DOI: 10.1093/ndt/gfx037] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 02/06/2017] [Indexed: 12/15/2022] Open
Abstract
Background Intradialytic hypotension (IDH) occurs frequently in maintenance hemodialysis (HD) patients and may be associated with higher mortality. We hypothesize that nadir intradialytic systolic blood pressure (niSBP) is inversely related to death risk while iSBP change (Δ) and IDH frequency are incrementally associated with all-cause mortality. Methods In a US-based cohort of 112 013 incident HD patients over a 5-year period (2007-11), using niSBP, ΔiSBP (pre-HD SBP minus niSBP) and IDH frequency (proportion of HD treatments with niSBP <90 mmHg) within the first 91 days of HD, we examined mortality-predictability at 1, 2 and 5 years using Cox models and restricted cubic splines adjusted for case-mix, comorbidities and laboratory covariates. Results We observed that niSBP of <90 and ≥140 mmHg had a 5-year mortality hazard ratio (HR) (95% confidence interval) of 1.57 (1.47-1.67) and 1.25 (1.18-1.33), respectively, compared with niSBP 110 to <120 mmHg. ΔiSBP of <15 and ≥50 compared with 21-30 mmHg had mortality HR of 1.31 (1.26-1.37) and 1.32 (1.24-1.39), respectively. Among patients with >40% IDH frequency, we observed a mortality HR of 1.49 (1.42-1.57) compared with 0% IDH frequency in fully adjusted models. These associations were robust at 1 and 2 years of follow-up. Conclusion In conclusion, we observed a U-shaped association between niSBP and ΔiSBP and mortality and a direct linear relationship between IDH frequency and mortality. Our findings lend some prognostic insight of HD blood pressure and hemodynamics, and have the potential to guide blood pressure management strategies among the HD population.
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Affiliation(s)
- Jason A Chou
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Danh V Nguyen
- Department of Medicine, University of California, Irvine, School of Medicine, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Jula K Inrig
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA.,Quintiles Therapeutic Science and Strategy Unit, San Diego, California
| | - Alpesh Amin
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Medical Center, Los Angeles, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA.,Fielding School of Public Health at UCLA, Los Angeles, CA, USA.,Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA
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Saran R, Robinson B, Abbott KC, Agodoa LYC, Albertus P, Ayanian J, Balkrishnan R, Bragg-Gresham J, Cao J, Chen JLT, Cope E, Dharmarajan S, Dietrich X, Eckard A, Eggers PW, Gaber C, Gillen D, Gipson D, Gu H, Hailpern SM, Hall YN, Han Y, He K, Hebert P, Helmuth M, Herman W, Heung M, Hutton D, Jacobsen SJ, Ji N, Jin Y, Kalantar-Zadeh K, Kapke A, Katz R, Kovesdy CP, Kurtz V, Lavalee D, Li Y, Lu Y, McCullough K, Molnar MZ, Montez-Rath M, Morgenstern H, Mu Q, Mukhopadhyay P, Nallamothu B, Nguyen DV, Norris KC, O'Hare AM, Obi Y, Pearson J, Pisoni R, Plattner B, Port FK, Potukuchi P, Rao P, Ratkowiak K, Ravel V, Ray D, Rhee CM, Schaubel DE, Selewski DT, Shaw S, Shi J, Shieu M, Sim JJ, Song P, Soohoo M, Steffick D, Streja E, Tamura MK, Tentori F, Tilea A, Tong L, Turf M, Wang D, Wang M, Woodside K, Wyncott A, Xin X, Zang W, Zepel L, Zhang S, Zho H, Hirth RA, Shahinian V. US Renal Data System 2016 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2018; 69:A7-A8. [PMID: 28236831 DOI: 10.1053/j.ajkd.2016.12.004] [Citation(s) in RCA: 550] [Impact Index Per Article: 91.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Şentürk D, Chen Y, Estes JP, Campos LF, Rhee CM, Kalantar-Zadeh K, Nguyen DV. Impact of Case-Mix Measurement Error on Estimation and Inference in Profiling of Health Care Providers. COMMUN STAT-SIMUL C 2018; 49:2206-2224. [PMID: 33311842 PMCID: PMC7731965 DOI: 10.1080/03610918.2018.1515360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 07/25/2018] [Accepted: 08/04/2018] [Indexed: 10/27/2022]
Abstract
Profiling analysis aims to evaluate health care providers by modeling each provider's performance with respect to a patient outcome, such as unplanned hospital readmission. High-dimensional regression models are used in profiling to risk-adjust for patient case-mix covariates. Case-mix covariates typically ascertained from administrative databases are inherently error-prone. We examine the impact of case-mix measurement error (ME) on profiling models. The results show that even though the models' coefficient estimates are biased, this does not affect the estimation of standardized readmission ratio (SRR). However, ME leads to increased variation in SRR estimates and degrades the ability to identify under-performing providers.
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Affiliation(s)
- Damla Şentürk
- Department of Biostatistics, University of California, Los Angeles, CA 90095, U.S.A
| | - Yanjun Chen
- Institute for Clinical and Translational Science, University of California, Irvine, CA 92687, U.S.A
| | - Jason P. Estes
- Research, Pratt & Whitney, East Hartford, CT 06118, U.S.A
| | - Luis F. Campos
- Department of Statistics, Harvard University, Cambridge, MA 02138, U.S.A
| | - Connie M. Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA 92868, U.S.A
- Department of Medicine, University of California Irvine, Orange, CA 92868, U.S.A
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA 92868, U.S.A
- Department of Medicine, University of California Irvine, Orange, CA 92868, U.S.A
| | - Danh V. Nguyen
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA 92868, U.S.A
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Guner YS, Harting MT, Fairbairn K, Delaplain PT, Zhang L, Chen Y, Kabeer MH, Yu P, Cleary JP, Stein JE, Stolar C, Nguyen DV. Outcomes of infants with congenital diaphragmatic hernia treated with venovenous versus venoarterial extracorporeal membrane oxygenation: A propensity score approach. J Pediatr Surg 2018; 53:2092-2099. [PMID: 30318280 PMCID: PMC6192269 DOI: 10.1016/j.jpedsurg.2018.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 04/18/2018] [Accepted: 06/03/2018] [Indexed: 11/22/2022]
Abstract
PURPOSE Previous studies comparing extracorporeal membrane oxygenation (ECMO) modality for congenital diaphragmatic hernia (CDH) have not accounted for confounding by indication. We therefore hypothesized that using a propensity score (PS) approach to account for selection bias may identify outcome differences based on ECMO modality for infants with CDH. METHODS We utilized ELSO Registry data (2000-2016). Patients with CDH were divided to either venoarterial (VA) or venovenous (VV) ECMO. Patients were matched by PS to control for nonrandom treatment assignment. Subgroup analyses were conducted based on timing of CDH repair relative to ECMO. Primary analysis was the "intent-to-treat" cohort based on the initial ECMO mode. Mortality was the primary outcome, and severe neurologic injury (SNI) was a secondary outcome. RESULTS PS matching (3:1) identified 3304 infants (VA = 2470, VV = 834). In the main group, mortality was not different between VA and VV ECMO (OR = 1.01, 95% CI: 0.86-1.18) and there was no difference in SNI between VA and VV (OR = 0.80; 95% CI: 0.63-1.01). For the pre-ECMO CDH repair subgroup, 175 VA cases were matched to 70 VV. In these neonates, mortality was higher for VV compared to VA (OR = 2.10, 95% CI: 1.19-3.69), without any difference in SNI (OR = 1.48; 95% CI: 0.59-3.71). For the subgroup that did not have pre-ECMO CDH repair, 2030 VA cases were matched to 683 VV cases. In this subgroup, VV was associated with 27% lower risk of SNI relative to VA (OR = 0.73, 95% CI: 0.56-0.95) without any difference in mortality (OR = 0.94, 95% CI: 0.79-1.11). CONCLUSION This study revalidates that ECMO mode does not significantly affect mortality or SNI in infants with CDH. In the subset of infants who require pre-ECMO CDH repair, VA favors survival, whereas, in the subgroup of infants that did not have pre-ECMO CDH repair, VV favors lower rates of SNI. We conclude that neither mode appears consistently superior across all situations, and clinical judgment should remain a multifactorial decision. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yigit S Guner
- Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA.
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Kelly Fairbairn
- Community Memorial Hospital, Department of Surgery, Ventura, CA
| | - Patrick T Delaplain
- University of California Irvine Medical Center, Department of Surgery, Orange, CA; Children's Hospital Los Angeles, Department of Pediatric Surgery
| | - Lishi Zhang
- University of California Irvine Biostatistics, Institute for Clinical and Translational Science Irvine, CA
| | - Yanjun Chen
- University of California Irvine Biostatistics, Institute for Clinical and Translational Science Irvine, CA
| | - Mustafa H Kabeer
- Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA
| | - Peter Yu
- Children's Hospital of Orange County, Division of Pediatric Surgery, Orange, CA; University of California Irvine Medical Center, Department of Surgery, Orange, CA
| | - John P Cleary
- Children's Hospital of Orange County, Division of Neonatalogy, Orange, CA
| | - James E Stein
- Children's Hospital Los Angeles, Department of Pediatric Surgery
| | - Charles Stolar
- Columbia University College of Physicians and Surgeons, New York City, New York; California Pediatric Surgical Group, Santa Barbara
| | - Danh V Nguyen
- University of California, Irvine School of Medicine, Department of Medicine, Orange, CA
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Delaplain PT, Zhang L, Nguyen DV, Ashrafi AH, Yu PT, Di Nardo M, Chen Y, Starr J, Ford HR, Guner YS. Effect of pump type on outcomes in neonates with congenital diaphragmatic hernia requiring ECMO. Perfusion 2018; 33:71-79. [PMID: 29788843 DOI: 10.1177/0267659118766729] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE With the exception of neonatal respiratory failure, most centers are now using centrifugal over roller-type pumps for the delivery of extracorporeal membrane oxygenation (ECMO). Evidence supporting the use of centrifugal pumps specifically in infants with congenital diaphragmatic hernia (CDH) remains lacking. We hypothesized that the use of centrifugal pumps in infants with CDH would not affect mortality or rates of severe neurologic injury (SNI). METHODS Infants with CDH were identified within the ELSO registry (2000-2016). Patients were then divided into those undergoing ECMO with rollertype pumps or centrifugal pumps. Patients were matched based on propensity score (PS) for the ECMO pump type based on pre-ECMO covariates. This was done for all infants and separately for each ECMO mode, venovenous (VV) and venoarterial (VA) ECMO. RESULTS We identified 4,367 infants who were treated with either roller or centrifugal pumps from 2000-2016. There was no difference in mortality or SNI between the two pump types in any of the groups (all infants, VA-ECMO infants, VV-ECMO infants). However, there was at least a six-fold increase in the odds of hemolysis for centrifugal pumps in all groups: all infants (odds ratio [OR] 6.99, p<0.001), VA-ECMO infants (OR 8.11, p<0.001 and VV-ECMO infants (OR 9.66, p<0.001). CONCLUSION For neonates with CDH requiring ECMO, there is no survival advantage or difference in severe neurologic injury between those receiving roller or centrifugal pump ECMO. However, there is a significant increase in red blood cell hemolysis associated with centrifugal ECMO support.
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Affiliation(s)
- Patrick T Delaplain
- 1 Department of Surgery, University of California, Irvine Medical Center, Irvine, CA, USA.,2 Department of Pediatric Surgery, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Lishi Zhang
- 3 Biostatistics, Institute for Clinical and Translational Science, University of California, Irvine, CA, USA
| | - Danh V Nguyen
- 4 Department of Medicine, Institute for Clinical and Translational Science, University of California, Irvine, CA, USA
| | - Amir H Ashrafi
- 5 Division of Neonatology, Children's Hospital of Orange County, Orange, CA, USA
| | - Peter T Yu
- 1 Department of Surgery, University of California, Irvine Medical Center, Irvine, CA, USA.,6 Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Matteo Di Nardo
- 7 Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Yanjun Chen
- 3 Biostatistics, Institute for Clinical and Translational Science, University of California, Irvine, CA, USA
| | - Joanne Starr
- 8 Division of Cardiothoracic Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Henri R Ford
- 2 Department of Pediatric Surgery, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Yigit S Guner
- 1 Department of Surgery, University of California, Irvine Medical Center, Irvine, CA, USA.,6 Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, USA
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Obi Y, Nguyen DV, Zhou H, Soohoo M, Zhang L, Chen Y, Streja E, Sim JJ, Molnar MZ, Rhee CM, Abbott KC, Jacobsen SJ, Kovesdy CP, Kalantar-Zadeh K. Development and Validation of Prediction Scores for Early Mortality at Transition to Dialysis. Mayo Clin Proc 2018; 93:1224-1235. [PMID: 30104041 DOI: 10.1016/j.mayocp.2018.04.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 03/10/2018] [Accepted: 04/13/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To develop and validate a risk prediction model that would help individualize treatment and improve the shared decision-making process between clinicians and patients. PATIENTS AND METHODS We developed a risk prediction tool for mortality during the first year of dialysis based on pre-end-stage renal disease characteristics in a cohort of 35,878 US veterans with incident end-stage renal disease who transitioned to dialysis treatment between October 1, 2007, and March 31, 2014 and then externally validated this tool among 4284 patients in the Kaiser Permanente Southern California (KPSC) health care system who transitioned to dialysis treatment between January 1, 2007, and September 30, 2015. RESULTS To ensure model goodness of fit, 2 separate models were selected for patients whose last estimated glomerular filtration rate (eGFR) before dialysis initiation was less than 15 mL/min per 1.73 m2 or 15 mL/min per 1.73 m2 or higher. Model discrimination in the internal validation cohort of veterans resulted in C statistics of 0.71 (95% CI, 0.70-0.72) and 0.66 (95% CI, 0.65-0.67) among patients with eGFR lower than 15 mL/min per 1.73 m2 and 15 mL/min per 1.73 m2 or higher, respectively. In the KPSC external validation cohort, the developed risk score exhibited C statistics of 0.77 (95% CI, 0.74-0.79) in men and 0.74 (95% CI, 0.71-0.76) in women with eGFR lower than 15 mL/min per 1.73 m2 and 0.71 (95% CI, 0.67-0.74) in men and 0.67 (95% CI, 0.62-0.72) in women with eGFR of 15 mL/min per 1.73 m2 or higher. CONCLUSION A new risk prediction tool for mortality during the first year after transition to dialysis (available at www.DialysisScore.com) was developed in the large national Veterans Affairs cohort and validated with good performance in the racially, ethnically, and gender diverse KPSC cohort. This risk prediction tool will help identify high-risk populations and guide management strategies at the transition to dialysis.
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Affiliation(s)
- Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine Medical Center, Orange, CA
| | - Danh V Nguyen
- Division of General Internal Medicine and Primary Care, University of California, Irvine Medical Center, Orange, CA
| | - Hui Zhou
- Kaiser Permanente Southern California, Pasadena, CA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine Medical Center, Orange, CA
| | - Lishi Zhang
- Institute for Clinical and Translational Science, University of California, Irvine, CA
| | - Yanjun Chen
- Institute for Clinical and Translational Science, University of California, Irvine, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine Medical Center, Orange, CA; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - John J Sim
- Kaiser Permanente Southern California, Pasadena, CA
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN; Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN; Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine Medical Center, Orange, CA
| | - Kevin C Abbott
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | | | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine Medical Center, Orange, CA; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA; Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA.
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