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Thongprayoon C, Pattharanitima P, Kattah AG, Mao MA, Keddis MT, Dillon JJ, Kaewput W, Tangpanithandee S, Krisanapan P, Qureshi F, Cheungpasitporn W. Explainable Preoperative Automated Machine Learning Prediction Model for Cardiac Surgery-Associated Acute Kidney Injury. J Clin Med 2022; 11:6264. [PMID: 36362493 PMCID: PMC9656700 DOI: 10.3390/jcm11216264] [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] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/15/2022] [Accepted: 10/21/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND We aimed to develop and validate an automated machine learning (autoML) prediction model for cardiac surgery-associated acute kidney injury (CSA-AKI). METHODS Using 69 preoperative variables, we developed several models to predict post-operative AKI in adult patients undergoing cardiac surgery. Models included autoML and non-autoML types, including decision tree (DT), random forest (RF), extreme gradient boosting (XGBoost), and artificial neural network (ANN), as well as a logistic regression prediction model. We then compared model performance using area under the receiver operating characteristic curve (AUROC) and assessed model calibration using Brier score on the independent testing dataset. RESULTS The incidence of CSA-AKI was 36%. Stacked ensemble autoML had the highest predictive performance among autoML models, and was chosen for comparison with other non-autoML and multivariable logistic regression models. The autoML had the highest AUROC (0.79), followed by RF (0.78), XGBoost (0.77), multivariable logistic regression (0.77), ANN (0.75), and DT (0.64). The autoML had comparable AUROC with RF and outperformed the other models. The autoML was well-calibrated. The Brier score for autoML, RF, DT, XGBoost, ANN, and multivariable logistic regression was 0.18, 0.18, 0.21, 0.19, 0.19, and 0.18, respectively. We applied SHAP and LIME algorithms to our autoML prediction model to extract an explanation of the variables that drive patient-specific predictions of CSA-AKI. CONCLUSION We were able to present a preoperative autoML prediction model for CSA-AKI that provided high predictive performance that was comparable to RF and superior to other ML and multivariable logistic regression models. The novel approaches of the proposed explainable preoperative autoML prediction model for CSA-AKI may guide clinicians in advancing individualized medicine plans for patients under cardiac surgery.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Pattharawin Pattharanitima
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Andrea G. Kattah
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Michael A. Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Mira T. Keddis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - John J. Dillon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Faculty of Medicine, Chakri Naruebodindra Medical Institute, Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand
| | - Pajaree Krisanapan
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Fawad Qureshi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Thongprayoon C, Kattah AG, Mao MA, Keddis MT, Pattharanitima P, Vallabhajosyula S, Nissaisorakarn V, Erickson SB, Dillon JJ, Garovic VD, Cheungpasitporn W. Distinct phenotypes of hospitalized patients with hyperkalemia by machine learning consensus clustering and associated mortality risks. QJM 2022; 115:442-449. [PMID: 34270780 DOI: 10.1093/qjmed/hcab194] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [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] [Received: 05/27/2021] [Revised: 07/03/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hospitalized patients with hyperkalemia are heterogeneous, and cluster approaches may identify specific homogenous groups. This study aimed to cluster patients with hyperkalemia on admission using unsupervised machine learning (ML) consensus clustering approach, and to compare characteristics and outcomes among these distinct clusters. METHODS Consensus cluster analysis was performed in 5133 hospitalized adult patients with admission hyperkalemia, based on available clinical and laboratory data. The standardized mean difference was used to identify each cluster's key clinical features. The association of hyperkalemia clusters with hospital and 1-year mortality was assessed using logistic and Cox proportional hazard regression. RESULTS Three distinct clusters of hyperkalemia patients were identified using consensus cluster analysis: 1661 (32%) in cluster 1, 2455 (48%) in cluster 2 and 1017 (20%) in cluster 3. Cluster 1 was mainly characterized by older age, higher serum chloride and acute kidney injury (AKI), but lower estimated glomerular filtration rate (eGFR), serum bicarbonate and hemoglobin. Cluster 2 was mainly characterized by higher eGFR, serum bicarbonate and hemoglobin, but lower comorbidity burden, serum potassium and AKI. Cluster 3 was mainly characterized by higher comorbidity burden, particularly diabetes and end-stage kidney disease, AKI, serum potassium, anion gap, but lower eGFR, serum sodium, chloride and bicarbonate. Hospital and 1-year mortality risk was significantly different among the three identified clusters, with highest mortality in cluster 3, followed by cluster 1 and then cluster 2. CONCLUSION In a heterogeneous cohort of hyperkalemia patients, three distinct clusters were identified using unsupervised ML. These three clusters had different clinical characteristics and outcomes.
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Affiliation(s)
- C Thongprayoon
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - A G Kattah
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - M A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - M T Keddis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - P Pattharanitima
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, 10120, Thailand
| | - S Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - V Nissaisorakarn
- Department of Internal Medicine, MetroWest Medical Center, Framingham, MA 01702, USA
| | - S B Erickson
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - J J Dillon
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - V D Garovic
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - W Cheungpasitporn
- From the Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Thongprayoon C, Mao MA, Kattah AG, Keddis MT, Pattharanitima P, Erickson SB, Dillon JJ, Garovic VD, Cheungpasitporn W. Subtyping hospitalized patients with hypokalemia by machine learning consensus clustering and associated mortality risks. Clin Kidney J 2022; 15:253-261. [PMID: 35145640 PMCID: PMC8825225 DOI: 10.1093/ckj/sfab190] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 12/18/2022] Open
Abstract
Background Hospitalized patients with hypokalemia are heterogeneous and cluster analysis, an unsupervised machine learning methodology, may discover more precise and specific homogeneous groups within this population of interest. Our study aimed to cluster patients with hypokalemia at hospital admission using an unsupervised machine learning approach and assess the mortality risk among these distinct clusters. Methods We performed consensus clustering analysis based on demographic information, principal diagnoses, comorbidities and laboratory data among 4763 hospitalized adult patients with admission serum potassium ≤3.5 mEq/L. We calculated the standardized mean difference of each variable and used the cutoff of ±0.3 to identify each cluster's key features. We assessed the association of the hypokalemia cluster with hospital and 1-year mortality. Results Consensus cluster analysis identified three distinct clusters that best represented patients’ baseline characteristics. Cluster 1 had 1150 (32%) patients, cluster 2 had 1344 (28%) patients and cluster 3 had 1909 (40%) patients. Based on the standardized difference, patients in cluster 1 were younger, had less comorbidity burden but higher estimated glomerular filtration rate (eGFR) and higher hemoglobin; patients in cluster 2 were older, more likely to be admitted for cardiovascular disease and had higher serum sodium and chloride levels but lower eGFR, serum bicarbonate, strong ion difference (SID) and hemoglobin, while patients in cluster 3 were older, had a greater comorbidity burden, higher serum bicarbonate and SID but lower serum sodium, chloride and eGFR. Compared with cluster 1, cluster 2 had both higher hospital and 1-year mortality, whereas cluster 3 had higher 1-year mortality but comparable hospital mortality. Conclusion Our study demonstrated the use of consensus clustering analysis in the heterogeneous cohort of hospitalized hypokalemic patients to characterize their patterns of baseline clinical and laboratory data into three clinically distinct clusters with different mortality risks.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Andrea G Kattah
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mira T Keddis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Stephen B Erickson
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - John J Dillon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Tey YS, Aris FA, Jalaluddin MS, Wan Rahimi Shah WF, Ashari A, Kolanthai Velu J, Ganesan KG, Dillon JJ, Kadiman S, Sulong MA, Yahaya SA. Single center experience of transcatheter aortic valve implantation in severe aortic stenosis: study of mid-term clinical outcome. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehab849.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
BACKGROUND
Transcatheter Aortic Valve Implantation (TAVI) had revolutionized the treatment and outcome of symptomatic severe aortic stenosis (AS) since its introduction. In 2009, our center performed the first TAVI in Malaysia and since then it has provided an alternative treatment for severe AS patients. The objective of the study is to evaluate the clinical outcome of severe AS patients who had undergone TAVI in our center.
METHODS
A retrospective observational study was conducted. All TAVIs performed in our center between 01 Jan 2009 and 31 December 2020 were included. Patients’ baseline characteristic, clinical outcomes post procedure at 1-year and 3-year mortality were studied. Data were collected by using case report form and reviewing patient’s case note.
RESULTS
A total of 107 patients had TAVI performed during this period of time. The mean age (±SD) was 77.4 ± 5 (range 61-90 years). 50.5% of the patients were male (n = 54) and 45.8% were Malay ethnicity (n = 49). Majority of the patients had hypertension (86.9%, n = 93), dyslipidaemia (84.1%, n = 90) and ischemic heart disease (60.7%, n = 65). 26.2% of patients (n = 28) had previous coronary artery bypass surgery and 2.8% of patients (n = 3) had previous valvular operation. 85.9% of patient was in NYHA II – IV (n = 92). Mean EuroScore II and STS score were 4.82 and 4.564 respectively. Average hospitalization stay was 5 days. Total of 60 (56.1%) CoreValve were deployed followed by 46 Edwards Sapien (43%) and 1 MyVal (0.9%). 89.7% of procedure was performed via transfemoral access (n = 96) followed by transapical (6.5%, n = 7), transaortic (2.8%, n = 3) and subclavian (0.9%, n = 1). 98.1% (n = 105) procedure was successfully performed. There were 6 in-hospital mortality (5.6%) during indexed TAVI admission, of which 5 out of 6 were TAVI related. Kaplan Meier analysis of predicted survival rate with freedom from all-causes mortality at 1 year was 86.9% and 73.7% at 3 years.
CONCLUSIONS
Untreated severe AS was associated with poor outcome. High success rate of TAVI had provided another option of treatment to severe AS patient who are not the suitable candidate for surgical intervention.
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Affiliation(s)
- Y S Tey
- National Heart Institute, Cardiology, Kuala Lumpur, Malaysia
| | - F A Aris
- National Heart Institute, Cardiology, Kuala Lumpur, Malaysia
| | - M S Jalaluddin
- National Heart Institute, Cardiology, Kuala Lumpur, Malaysia
| | | | - A Ashari
- National Heart Institute, Cardiology, Kuala Lumpur, Malaysia
| | | | - K G Ganesan
- National Heart Institute, Cardiology, Kuala Lumpur, Malaysia
| | - J J Dillon
- National Heart Institute, Cardiothoracic Department, Kuala Lumpur, Malaysia
| | - S Kadiman
- National Heart Institute, Anaesthesiology and Intensive Care Department, Kuala Lumpur, Malaysia
| | - M A Sulong
- National Heart Institute, Clinical Research Department, Kuala Lumpur, Malaysia
| | - S A Yahaya
- National Heart Institute, Cardiology, Kuala Lumpur, Malaysia
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Pattharanitima P, Thongprayoon C, Petnak T, Srivali N, Gembillo G, Kaewput W, Chesdachai S, Vallabhajosyula S, O’Corragain OA, Mao MA, Garovic VD, Qureshi F, Dillon JJ, Cheungpasitporn W. Machine Learning Consensus Clustering Approach for Patients with Lactic Acidosis in Intensive Care Units. J Pers Med 2021; 11:jpm11111132. [PMID: 34834484 PMCID: PMC8623582 DOI: 10.3390/jpm11111132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Received: 09/22/2021] [Revised: 10/28/2021] [Accepted: 10/30/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Lactic acidosis is a heterogeneous condition with multiple underlying causes and associated outcomes. The use of multi-dimensional patient data to subtype lactic acidosis can personalize patient care. Machine learning consensus clustering may identify lactic acidosis subgroups with unique clinical profiles and outcomes. METHODS We used the Medical Information Mart for Intensive Care III database to abstract electronic medical record data from patients admitted to intensive care units (ICU) in a tertiary care hospital in the United States. We included patients who developed lactic acidosis (defined as serum lactate ≥ 4 mmol/L) within 48 h of ICU admission. We performed consensus clustering analysis based on patient characteristics, comorbidities, vital signs, organ supports, and laboratory data to identify clinically distinct lactic acidosis subgroups. We calculated standardized mean differences to show key subgroup features. We compared outcomes among subgroups. RESULTS We identified 1919 patients with lactic acidosis. The algorithm revealed three best unique lactic acidosis subgroups based on patient variables. Cluster 1 (n = 554) was characterized by old age, elective admission to cardiac surgery ICU, vasopressor use, mechanical ventilation use, and higher pH and serum bicarbonate. Cluster 2 (n = 815) was characterized by young age, admission to trauma/surgical ICU with higher blood pressure, lower comorbidity burden, lower severity index, and less vasopressor use. Cluster 3 (n = 550) was characterized by admission to medical ICU, history of liver disease and coagulopathy, acute kidney injury, lower blood pressure, higher comorbidity burden, higher severity index, higher serum lactate, and lower pH and serum bicarbonate. Cluster 3 had the worst outcomes, while cluster 1 had the most favorable outcomes in terms of persistent lactic acidosis and mortality. CONCLUSIONS Consensus clustering analysis synthesized the pattern of clinical and laboratory data to reveal clinically distinct lactic acidosis subgroups with different outcomes.
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Affiliation(s)
- Pattharawin Pattharanitima
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12121, Thailand
- Correspondence: (P.P.); (C.T.); (W.C.)
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (V.D.G.); (F.Q.); (J.J.D.)
- Correspondence: (P.P.); (C.T.); (W.C.)
| | - Tananchai Petnak
- Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
| | - Narat Srivali
- Division of Pulmonary Medicine, St. Agnes Hosipital, Baltimore, MD 21229, USA;
| | - Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy;
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand;
| | - Supavit Chesdachai
- Division of Infectious Disease, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA;
| | - Oisin A. O’Corragain
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA 19140, USA;
| | - Michael A. Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Vesna D. Garovic
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (V.D.G.); (F.Q.); (J.J.D.)
| | - Fawad Qureshi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (V.D.G.); (F.Q.); (J.J.D.)
| | - John J. Dillon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (V.D.G.); (F.Q.); (J.J.D.)
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (V.D.G.); (F.Q.); (J.J.D.)
- Correspondence: (P.P.); (C.T.); (W.C.)
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Thongprayoon C, Dumancas CY, Nissaisorakarn V, Keddis MT, Kattah AG, Pattharanitima P, Petnak T, Vallabhajosyula S, Garovic VD, Mao MA, Dillon JJ, Erickson SB, Cheungpasitporn W. Machine Learning Consensus Clustering Approach for Hospitalized Patients with Phosphate Derangements. J Clin Med 2021; 10:4441. [PMID: 34640457 PMCID: PMC8509302 DOI: 10.3390/jcm10194441] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/18/2021] [Accepted: 09/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The goal of this study was to categorize patients with abnormal serum phosphate upon hospital admission into distinct clusters utilizing an unsupervised machine learning approach, and to assess the mortality risk associated with these clusters. METHODS We utilized the consensus clustering approach on demographic information, comorbidities, principal diagnoses, and laboratory data of hypophosphatemia (serum phosphate ≤ 2.4 mg/dL) and hyperphosphatemia cohorts (serum phosphate ≥ 4.6 mg/dL). The standardized mean difference was applied to determine each cluster's key features. We assessed the association of the clusters with mortality. RESULTS In the hypophosphatemia cohort (n = 3113), the consensus cluster analysis identified two clusters. The key features of patients in Cluster 2, compared with Cluster 1, included: older age; a higher comorbidity burden, particularly hypertension; diabetes mellitus; coronary artery disease; lower eGFR; and more acute kidney injury (AKI) at admission. Cluster 2 had a comparable hospital mortality (3.7% vs. 2.9%; p = 0.17), but a higher one-year mortality (26.8% vs. 14.0%; p < 0.001), and five-year mortality (20.2% vs. 44.3%; p < 0.001), compared to Cluster 1. In the hyperphosphatemia cohort (n = 7252), the analysis identified two clusters. The key features of patients in Cluster 2, compared with Cluster 1, included: older age; more primary admission for kidney disease; more history of hypertension; more end-stage kidney disease; more AKI at admission; and higher admission potassium, magnesium, and phosphate. Cluster 2 had a higher hospital (8.9% vs. 2.4%; p < 0.001) one-year mortality (32.9% vs. 14.8%; p < 0.001), and five-year mortality (24.5% vs. 51.1%; p < 0.001), compared with Cluster 1. CONCLUSION Our cluster analysis classified clinically distinct phenotypes with different mortality risks among hospitalized patients with serum phosphate derangements. Age, comorbidities, and kidney function were the key features that differentiated the phenotypes.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Carissa Y. Dumancas
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Voravech Nissaisorakarn
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA;
| | - Mira T. Keddis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Andrea G. Kattah
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Pattharawin Pattharanitima
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Tananchai Petnak
- Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA;
| | - Vesna D. Garovic
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Michael A. Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - John J. Dillon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Stephen B. Erickson
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
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Galloway CD, Valys AV, Shreibati JB, Treiman DL, Petterson FL, Gundotra VP, Albert DE, Attia ZI, Carter RE, Asirvatham SJ, Ackerman MJ, Noseworthy PA, Dillon JJ, Friedman PA. Development and Validation of a Deep-Learning Model to Screen for Hyperkalemia From the Electrocardiogram. JAMA Cardiol 2020; 4:428-436. [PMID: 30942845 DOI: 10.1001/jamacardio.2019.0640] [Citation(s) in RCA: 147] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance For patients with chronic kidney disease (CKD), hyperkalemia is common, associated with fatal arrhythmias, and often asymptomatic, while guideline-directed monitoring of serum potassium is underused. A deep-learning model that enables noninvasive hyperkalemia screening from the electrocardiogram (ECG) may improve detection of this life-threatening condition. Objective To evaluate the performance of a deep-learning model in detection of hyperkalemia from the ECG in patients with CKD. Design, Setting, and Participants A deep convolutional neural network (DNN) was trained using 1 576 581 ECGs from 449 380 patients seen at Mayo Clinic, Rochester, Minnesota, from 1994 to 2017. The DNN was trained using 2 (leads I and II) or 4 (leads I, II, V3, and V5) ECG leads to detect serum potassium levels of 5.5 mEq/L or less (to convert to millimoles per liter, multiply by 1) and was validated using retrospective data from the Mayo Clinic in Minnesota, Florida, and Arizona. The validation included 61 965 patients with stage 3 or greater CKD. Each patient had a serum potassium count drawn within 4 hours after their ECG was recorded. Data were analyzed between April 12, 2018, and June 25, 2018. Exposures Use of a deep-learning model. Main Outcomes and Measures Area under the receiver operating characteristic curve (AUC) and sensitivity and specificity, with serum potassium level as the reference standard. The model was evaluated at 2 operating points, 1 for equal specificity and sensitivity and another for high (90%) sensitivity. Results Of the total 1 638 546 ECGs, 908 000 (55%) were from men. The prevalence of hyperkalemia in the 3 validation data sets ranged from 2.6% (n = 1282 of 50 099; Minnesota) to 4.8% (n = 287 of 6011; Florida). Using ECG leads I and II, the AUC of the deep-learning model was 0.883 (95% CI, 0.873-0.893) for Minnesota, 0.860 (95% CI, 0.837-0.883) for Florida, and 0.853 (95% CI, 0.830-0.877) for Arizona. Using a 90% sensitivity operating point, the sensitivity was 90.2% (95% CI, 88.4%-91.7%) and specificity was 63.2% (95% CI, 62.7%-63.6%) for Minnesota; the sensitivity was 91.3% (95% CI, 87.4%-94.3%) and specificity was 54.7% (95% CI, 53.4%-56.0%) for Florida; and the sensitivity was 88.9% (95% CI, 84.5%-92.4%) and specificity was 55.0% (95% CI, 53.7%-56.3%) for Arizona. Conclusions and Relevance In this study, using only 2 ECG leads, a deep-learning model detected hyperkalemia in patients with renal disease with an AUC of 0.853 to 0.883. The application of artificial intelligence to the ECG may enable screening for hyperkalemia. Prospective studies are warranted.
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Affiliation(s)
| | | | | | | | | | | | | | - Zachi I Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rickey E Carter
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | | | - Michael J Ackerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - John J Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Shawwa K, Kompotiatis P, Jentzer JC, Wiley BM, Williams AW, Dillon JJ, Albright RC, Kashani KB. Hypotension within one-hour from starting CRRT is associated with in-hospital mortality. J Crit Care 2019; 54:7-13. [PMID: 31319348 DOI: 10.1016/j.jcrc.2019.07.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [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: 04/02/2019] [Revised: 06/05/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE To investigate early hemodynamic instability and its implications on adverse outcomes in patients who require continuous renal replacement therapy (CRRT). MATERIALS AND METHODS A retrospective study of patients admitted to the intensive care unit (ICU) and underwent CRRT at Mayo Clinic, Rochester, Minnesota between December 2006 through November 2015. RESULTS Multivariate logistic regression was performed to identify predictors of in-hospital mortality and major adverse kidney events (MAKE) at 90 days. Hypotension was defined as any of the following criteria occurring during the first hour of CRRT initiation: mean arterial pressure < 60 mmHg, systolic blood pressure (SBP) <90 mmHg or a decline in SBP >40 mmHg from baseline, a positive fluid balance >500 mL or increased vasopressor requirement. The analysis included 1743 patients, 1398 with acute kidney injury (AKI). In-hospital mortality occurred in 884 patients (51%). Early hypotension occurred in 1124 patients (64.6%) and remained independently associated with in-hospital mortality (OR 1.56, 95% CI: 1.25-1.9). CONCLUSION Hypotension occurs frequently in patients receiving CRRT despite having a reputation as the dialysis modality with better hemodynamic tolerance. It is an independent predictor for worse outcomes. Further studies are required to understand this phenomenon.
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Affiliation(s)
- Khaled Shawwa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | | | - Jacob C Jentzer
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brandon M Wiley
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amy W Williams
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - John J Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Robert C Albright
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
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Abudan AA, Isath A, Ryan JD, Henrich MJ, Dugan JL, Attia ZI, Ladewig DJ, Dillon JJ, Friedman PA. Safety and compatibility of smart device heart rhythm monitoring in patients with cardiovascular implantable electronic devices. J Cardiovasc Electrophysiol 2019; 30:1602-1609. [PMID: 31190453 DOI: 10.1111/jce.14024] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Emerging medical technology has allowed for monitoring of heart rhythm abnormalities using smartphone compatible devices. The safety and utility of such devices have not been established in patients with cardiac implantable electronic devices (CIEDs). We sought to assess the safety and compatibility of the Food and Drug Administration-approved AliveCor Kardia device in patients with CIEDs. METHODS AND RESULTS We prospectively recruited patients with CIED for a Kardia recording during their routine device interrogation. A recording was obtained in paced and nonpaced states. Adverse clinical events were noted at the time of recording. Electrograms (EGMs) from the cardiac device were obtained at the time of recording to assess for any electromagnetic interference (EMI) introduced by Kardia. Recordings were analyzed for quality and given a score of 3 (interpretable rhythm, no noise), 2 (interpretable rhythm, significant noise) or 1 (uninterpretable). A total of 251 patients were recruited (59% with a pacemaker and 41% with ICD). There were no adverse clinical events noted at the time of recording and no changes to CIED settings. Review of all EGMs revealed no EMI introduced by Kardia. Recordings were correctly interpreted in 90% of paced recordings (183 had a score of 3, 43 of 2, and 25 of 1) and 94.7% of nonpaced recordings (147 of 3, 15 of 2, and 9 of 1). CONCLUSION The AliveCor Kardia device has an excellent safety profile when used in conjunction with most CIEDs. The quality of recordings was preserved in this population. The device, therefore, can be considered for heart rhythm monitoring in patients with CIEDs.
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Affiliation(s)
- Anas A Abudan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Ameesh Isath
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - James D Ryan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Mark J Henrich
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Jennifer L Dugan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Zachi I Attia
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - John J Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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10
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Chen JCY, Thorsteinsdottir B, Vaughan LE, Feely MA, Albright RC, Onuigbo M, Norby SM, Gossett CL, D’Uscio MM, Williams AW, Dillon JJ, Hickson LJ. End of Life, Withdrawal, and Palliative Care Utilization among Patients Receiving Maintenance Hemodialysis Therapy. Clin J Am Soc Nephrol 2018; 13:1172-1179. [PMID: 30026285 PMCID: PMC6086702 DOI: 10.2215/cjn.00590118] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [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: 01/12/2018] [Accepted: 05/15/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Withdrawal from maintenance hemodialysis before death has become more common because of high disease and treatment burden. The study objective was to identify patient factors and examine the terminal course associated with hemodialysis withdrawal, and assess patterns of palliative care involvement before death among patients on maintenance hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We designed an observational cohort study of adult patients on incident hemodialysis in a midwestern United States tertiary center, from January 2001 to November 2013, with death events through to November 2015. Logistic regression models evaluated associations between patient characteristics and withdrawal status and palliative care service utilization. RESULTS Among 1226 patients, 536 died and 262 (49% of 536) withdrew. A random sample (10%; 52 out of 536) review of Death Notification Forms revealed 73% sensitivity for withdrawal. Risk factors for withdrawal before death included older age, white race, palliative care consultation within 6 months, hospitalization within 30 days, cerebrovascular disease, and no coronary artery disease. Most withdrawal decisions were made by patients (60%) or a family member (33%; surrogates). The majority withdrew either because of acute medical complications (51%) or failure to thrive/frailty (22%). After withdrawal, median time to death was 7 days (interquartile range, 4-11). In-hospital deaths were less common in the withdrawal group (34% versus 46% nonwithdrawal, P=0.003). A third (34%; 90 out of 262) of those that withdrew received palliative care services. Palliative care consultation in the withdrawal group was associated with longer hemodialysis duration (odds ratio, 1.19 per year; 95% confidence interval, 1.10 to 1.3; P<0.001), hospitalization within 30 days of death (odds ratio, 5.78; 95% confidence interval, 2.62 to 12.73; P<0.001), and death in hospital (odds ratio, 1.92; 95% confidence interval, 1.13 to 3.27; P=0.02). CONCLUSIONS In this single-center study, the rate of hemodialysis withdrawals were twice the frequency previously described. Acute medical complications and frailty appeared to be driving factors. However, palliative care services were used in only a minority of patients.
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Affiliation(s)
| | | | | | - Molly A. Feely
- Department of Medicine and
- Center of Palliative Medicine, and
| | | | | | | | | | | | | | | | - LaTonya J. Hickson
- Divisions of Nephrology and Hypertension, and
- Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, Minnesota; and
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11
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Friedman PA, Scott CG, Bailey K, Baumann NA, Albert D, Attia ZI, Ladewig DJ, Yasin O, Dillon JJ, Singh B. Errors of Classification With Potassium Blood Testing: The Variability and Repeatability of Critical Clinical Tests. Mayo Clin Proc 2018; 93:566-572. [PMID: 29728199 DOI: 10.1016/j.mayocp.2018.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Received: 12/12/2017] [Revised: 03/08/2018] [Accepted: 03/16/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To understand the performance of a currently used clinical blood test with regard to the frequency and size of variation of the results. PATIENTS AND METHODS From November 29, 2012, through November 29, 2013, patients were recruited at 65 sites as part of a previously reported clinical trial (ClinicalTrials.gov Identifier: NCT01737697). Eligible outpatients who had been fasting for at least 8 hours underwent venous phlebotomy at baseline, 30 minutes, and 60 minutes to measure plasma potassium levels in whole blood using a point-of-care device (i-STAT, Abbott Laboratories). We analyzed the results to assess their variability and frequency of pseudohyperkalemia and pseudonormokalemia. RESULTS A total of 1170 patients were included in this study. Absolute differences between pairs of measurements from different time points ranged from 0 to 2.5 mmol/L, with a mean difference of 0.26 mmol/L. The mean percentage differences were approximately 5% with an SD of 5%. Approximately 12% of differences between repeated fasting potassium blood test results were above 0.5 mmol/L (33% of the normal range), and 20% of patients (234) had at least one difference greater than 0.5 mmol/L. In 44.0% of the patients with a hyperkalemic average value (true hyperkalemia) (302 of 686), at least one blood test result was in the normal range (pseudonormokalemia), and in 30.2% of the patients with a normal average value (146 of 484), at least one blood test result was elevated (pseudohyperkalemia). CONCLUSION Expected variability and errors exist with potassium blood tests, even when conditions are optimized. Pseudohyperkalemia and pseudonormokalemia are common, indicating a need for thoughtful clinical interpretation of unexpected test results.
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Affiliation(s)
- Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Kent Bailey
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Nikola A Baumann
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Zachi I Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Omar Yasin
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - John J Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Bhupinder Singh
- ZS Pharma, Inc, San Mateo, CA; University of California, Irvine, School of Medicine, Irvine, CA
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12
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Galloway CD, Valys AV, Petterson FL, Gundotra VP, Treiman DL, Albert DE, Dillon JJ, Attia ZI, Friedman PA. NON-INVASIVE DETECTION OF HYPERKALEMIA WITH A SMARTPHONE ELECTROCARDIOGRAM AND ARTIFICIAL INTELLIGENCE. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)30813-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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13
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Haffar S, Bazerbachi F, Leise MD, Dillon JJ, Albright RC, Murad MH, Kamath PS, Watt KD. Systematic review with meta-analysis: the association between hepatitis E seroprevalence and haemodialysis. Aliment Pharmacol Ther 2017; 46:790-799. [PMID: 28869287 DOI: 10.1111/apt.14285] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/10/2017] [Accepted: 08/13/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hepatitis E virus (HEV) infection appears to be more common than previously thought. HEV seroprevalence in patients on maintenance haemodialysis (HD) is unclear with a range from 0% to 44%. In addition, risk factors of transmission of HEV in patients on haemodialysis are unknown. AIM To perform a systematic review and meta-analysis of HEV seroprevalence in HD patients compared with controls. METHODS A systematic search of several databases identified all observational studies with comparative arms. Two reviewers extracted data and assessed the methodological quality. A random-effects model was used for pooled odds ratio (OR) and 95% confidence interval (CI) of positive anti-HEV IgG in both groups. Heterogeneity and publication bias were assessed with appropriate tests. RESULTS We identified 31 studies from 17 countries between 1994 and 2016. Sixteen studies were judged to have adequate quality and 15 to have moderate limitations. HEV infection was more prevalent in patients on haemodialysis compared with controls (OR 2.47, 95% CI 1.79-3.40, I2 = 75.2%, P < .01). We conducted several subgroup analyses without difference in results. Egger regression test did not suggest publication bias (P = .83). Specific risk factors of HEV transmission in patients on haemodialysis were not clearly identified. CONCLUSIONS Hepatitis E virus infection is more prevalent in patients on haemodialysis compared with non-haemodialysis control groups. Further studies are needed to determine risk factors of acquisition, impact on health, and risk for chronic HEV especially among those patients going to receive organ transplantation.
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Affiliation(s)
- S Haffar
- Digestive Center for Diagnosis & Treatment, Damascus, Syrian Arab Republic
| | - F Bazerbachi
- Digestive Center for Diagnosis & Treatment, Damascus, Syrian Arab Republic
| | - M D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - J J Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - R C Albright
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - M H Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, MN, USA
| | - P S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - K D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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14
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Yasin OZ, Attia Z, Dillon JJ, DeSimone CV, Sapir Y, Dugan J, Somers VK, Ackerman MJ, Asirvatham SJ, Scott CG, Bennet KE, Ladewig DJ, Sadot D, Geva AB, Friedman PA. Noninvasive blood potassium measurement using signal-processed, single-lead ecg acquired from a handheld smartphone. J Electrocardiol 2017. [PMID: 28641860 DOI: 10.1016/j.jelectrocard.2017.06.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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: 12/17/2022]
Abstract
OBJECTIVE We have previously used a 12-lead, signal-processed ECG to calculate blood potassium levels. We now assess the feasibility of doing so with a smartphone-enabled single lead, to permit remote monitoring. PATIENTS AND METHODS Twenty-one hemodialysis patients held a smartphone equipped with inexpensive FDA-approved electrodes for three 2min intervals during hemodialysis. Individualized potassium estimation models were generated for each patient. ECG-calculated potassium values were compared to blood potassium results at subsequent visits to evaluate the accuracy of the potassium estimation models. RESULTS The mean absolute error between the estimated potassium and blood potassium 0.38±0.32 mEq/L (9% of average potassium level) decreasing to 0.6 mEq/L using predictors of poor signal. CONCLUSIONS A single-lead ECG acquired using electrodes attached to a smartphone device can be processed to calculate the serum potassium with an error of 9% in patients undergoing hemodialysis. SUMMARY A single-lead ECG acquired using electrodes attached to a smartphone can be processed to calculate the serum potassium in patients undergoing hemodialysis remotely.
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Affiliation(s)
- Omar Z Yasin
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA; Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Zachi Attia
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA; Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA; Electrical and Computer Engineering, Ben-Gurion University of the Negev, P.O. Box 653, Beer Sheva, Israel
| | - John J Dillon
- Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Yehu Sapir
- Electrical and Computer Engineering, Ben-Gurion University of the Negev, P.O. Box 653, Beer Sheva, Israel
| | - Jennifer Dugan
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA; Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Virend K Somers
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA; Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Michael J Ackerman
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA; Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Samuel J Asirvatham
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA; Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Christopher G Scott
- Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Kevin E Bennet
- Division of Engineering, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | | | - Dan Sadot
- Electrical and Computer Engineering, Ben-Gurion University of the Negev, P.O. Box 653, Beer Sheva, Israel
| | - Amir B Geva
- Electrical and Computer Engineering, Ben-Gurion University of the Negev, P.O. Box 653, Beer Sheva, Israel
| | - Paul A Friedman
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA; Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
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15
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New AM, Nystrom EM, Frazee E, Dillon JJ, Kashani KB, Miles JM. Continuous renal replacement therapy: a potential source of calories in the critically ill. Am J Clin Nutr 2017; 105:1559-1563. [PMID: 28468893 PMCID: PMC6546225 DOI: 10.3945/ajcn.116.139014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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: 06/14/2016] [Accepted: 03/29/2017] [Indexed: 01/04/2023] Open
Abstract
Background: Overfeeding can lead to multiple metabolic and clinical complications and has been associated with increased mortality in the critically ill. Continuous venovenous hemofiltration (CVVH) represents a potential source of calories that is poorly recognized and may contribute to overfeeding complications.Objective: We aimed to quantify the systemic caloric contribution of acid-citrate-dextrose regional anticoagulation and dextrose-containing replacement fluids in the CVVH circuit.Design: This was a prospective study in 10 critically ill adult patients who received CVVH from April 2014 to June 2014. Serial pre- and postfilter blood samples (n = 4 each) were drawn and analyzed for glucose and citrate concentrations on each of 2 consecutive days.Results: Participants included 5 men and 5 women with a mean ± SEM age of 61 ± 4 y (range: 42-84 y) and body mass index (in kg/m2) of 28 ± 2 (range: 18.3-36.2). There was generally good agreement between data on the 2 study days (CV: 7-11%). Mean ± SEM pre- and postfilter venous plasma glucose concentrations in the aggregate group were 152 ± 10 and 178 ± 9 mg/dL, respectively. Net glucose uptake from the CVVH circuit was 54 ± 5 mg/min and provided 295 ± 28 kcal/d. Prefilter plasma glucose concentrations were higher in patients with diabetes (n = 5) than in those without diabetes (168 ± 12 compared with 140 ± 14 mg/dL; P < 0.05); however, net glucose uptake was similar (46 ± 8 compared with 61 ± 6 mg/min; P = 0.15). Mean ± SEM pre- and postfilter venous plasma citrate concentrations were 1 ± 0.1 and 3.1 ± 0.2 mmol/L, respectively. Net citrate uptake from the CVVH circuit was 60 ± 2 mg/min and provided 218 ± 8 kcal/d.Conclusions: During CVVH there was a substantial net uptake of both glucose and citrate that delivered exogenous energy and provided ∼512 kcal/d. Failure to account for this source of calories in critically ill patients receiving nutrition on CVVH may result in overfeeding.
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Affiliation(s)
| | | | | | | | | | - John M Miles
- Endocrine Research Unit, Mayo Clinic, Rochester, MN
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16
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Safadi S, Albright RC, Dillon JJ, Williams AW, Alahdab F, Brown JK, Severson AL, Kremers WK, Ryan MA, Hogan MC. Prospective Study of Routine Heparin Avoidance Hemodialysis in a Tertiary Acute Care Inpatient Practice. Kidney Int Rep 2017; 2:695-704. [PMID: 29142987 PMCID: PMC5678923 DOI: 10.1016/j.ekir.2017.03.003] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 02/28/2017] [Accepted: 03/08/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Extracorporeal circuit (EC) anticoagulation with heparin is a key advance in hemodialysis (HD), but anticoagulation is problematic in inpatients at risk of bleeding. We prospectively evaluated a heparin-avoidance HD protocol, clotting of the EC circuit (CEC), impact on dialysis efficiency, and associated risk factors in our acute care inpatients who required HD (January 17, 2014 to May 31, 2015). Methods HD sessions without routine EC heparin were performed using airless dialysis tubing. Patients received systemic anticoagulation therapy and/or antiplatelets for non-HD indications. We observed patients for indications of CEC (interrupted HD session, circuit loss, or inability to return blood). The primary outcome was CEC. Logistic regression with generalized estimating equations assessed associations between CEC and other variables. Results HD sessions (n = 1200) were performed in 338 patients (204 with end-stage renal disease; 134 with acute kidney injury); a median session was 211 minutes (interquartile range [IQR]: 183−240 minutes); delivered dialysis dose measured by Kt/V was 1.4 (IQR: 1.2 Kt/V 1.7). Heparin in the EC was prescribed in only 4.5% of sessions; EC clotting rate was 5.2%. Determinants for CEC were temporary catheters (odds ratio [OR]: 2.8; P < 0.01), transfusions (OR: 2.4; P = 0.04), therapeutic systemic anticoagulation (OR: 0.2; P < 0.01), and antiplatelets (OR: 0.4; P < 0.01). CEC was associated with a lower delivered Kt/V (difference: 0.39; P < 0.01). Most CEC events during transfusions (71%) occurred with administration of blood products through the HD circuit. Discussion We successfully adopted heparin avoidance using airless HD tubing as our standard inpatient protocol. This protocol is feasible and safe in acute care inpatient HD. CEC rates were low and were associated with temporary HD catheters and transfusions. Antiplatelet agents and systemic anticoagulation were protective. ClinicalTrials.gov Identifier:NCT02086682.
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Affiliation(s)
- Sami Safadi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert C Albright
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John J Dillon
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy W Williams
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Fares Alahdab
- Division of Preventive, Occupational, and Aerospace Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie K Brown
- Nursing Practice Resources Division, Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Amanda L Severson
- Medical Nephrology Division, Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Walter K Kremers
- Division and Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary Ann Ryan
- Medical Nephrology Division, Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Marie C Hogan
- Division of Preventive, Occupational, and Aerospace Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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17
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Cheungpasitporn W, Hui J, Kashani KB, Wittwer ED, Albright RC, Dillon JJ. High-dose hydroxocobalamin for vasoplegic syndrome causing false blood leak alarm. Clin Kidney J 2017; 10:357-362. [PMID: 28616214 PMCID: PMC5466086 DOI: 10.1093/ckj/sfx004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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] [Received: 10/20/2016] [Accepted: 01/17/2017] [Indexed: 12/20/2022] Open
Abstract
Blood leak alarms are important safety features in a hemodialysis machine to protect patients from loss of blood through a rupture in the dialyzer membrane (true alarms). A false blood leak alarm can be triggered by air bubbles or detector malfunction (such as deposits of grease or scale). Hydroxocobalamin is an injectable form of vitamin B12 approved by the US Food and Drug Administration for the treatment of confirmed or suspected cyanide toxicity. Due to observations of an increase in arterial pressure after high-dose hydroxocobalamin infusion for the treatment of acute cyanide poisoning, it has recently been reported as an off-label rescue treatment for post–cardiopulmonary bypass vasoplegic syndrome. We report an 83-year-old man who received hydroxocobalamin following cardiac surgery for treatment of vasoplegic syndrome. The patient developed severe acute kidney injury with volume overload. Hydroxocobalamin interference with the blood leak detector compromised his dialysis treatment. We describe the use of continuous renal replacement therapy to overcome the hydroxocobalamin-related interference with hemodialysis. As the utility of hydroxocobalamin potentially expands, physicians must be aware of its inadvertent effect on renal replacement therapy.
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Affiliation(s)
- Wisit Cheungpasitporn
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - John Hui
- Department of Anesthesiology, Division of Critical Care Medicine and Cardiothoracic Anesthesiology, Mayo Clinic, Rochester, MN, USA.,Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Erica D Wittwer
- Department of Anesthesiology, Division of Critical Care Medicine and Cardiothoracic Anesthesiology, Mayo Clinic, Rochester, MN, USA.,Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert C Albright
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - John J Dillon
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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18
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McCarthy JT, El-Azhary RA, Patzelt MT, Weaver AL, Albright RC, Bridges AD, Claus PL, Davis MDP, Dillon JJ, El-Zoghby ZM, Hickson LJ, Kumar R, McBane RD, McCarthy-Fruin KAM, McEvoy MT, Pittelkow MR, Wetter DA, Williams AW. Survival, Risk Factors, and Effect of Treatment in 101 Patients With Calciphylaxis. Mayo Clin Proc 2016; 91:1384-1394. [PMID: 27712637 DOI: 10.1016/j.mayocp.2016.06.025] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [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] [Received: 03/28/2016] [Revised: 06/18/2016] [Accepted: 06/21/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To report on the survival and the associations of treatments upon survival of patients with calciphylaxis seen at a single center. PATIENTS AND METHODS Using the International Classification of Diseases, Ninth Revision diagnosis code of 275.49 and the keyword "calciphylaxis" in the dismissal narrative, we retrospectively identified 101 patients with calciphylaxis seen at our institution between January 1, 1999, through September 20, 2014, using a predefined, consensus-developed classification scheme. RESULTS The average age of patients was 60 years: 81 (80.2%) were women; 68 (68.0%) were obese; 19 (18.8%) had stage 0 to 2 chronic kidney disease (CKD), 19 (18.9%) had stage 3 or 4 CKD; 63 (62.4%) had stage 5 or 5D (dialysis) CKD. Seventy-five patients died during follow-up. Six-month survival was 57%. Lack of surgical debridement was associated with insignificantly lower 6-month survival (hazard ratio [HR]=1.99; 95% CI, 0.96-4.15; P=.07) and significantly poorer survival for the entire duration of follow-up (HR=1.98; 95% CI, 1.15-3.41; P=.01), which was most pronounced in stage 5 or 5D CKD (HR=1.91; 95% CI, 1.03-3.56; P=.04). Among patients with stage 5/5D CKD, subtotal parathyroidectomy (performed only in patients with hyperparathyroidism) was associated with better 6-month (HR=0.12; 95% CI, 0.02-0.90; P=.04) and overall survival (HR= 0.37; 95% CI, 0.15-0.87; P=.02). CONCLUSION Calciphylaxis is associated with a high mortality rate. Significantly effective treatments included surgical debridement and subtotal parathyroidectomy in patients with stage 5/5D CKD with hyperparathyroidism. Treatments with tissue-plasminogen activator, sodium thiosulfate, and hyperbaric oxygen therapy were not associated with higher mortality.
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Affiliation(s)
- James T McCarthy
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| | | | - Michelle T Patzelt
- Mayo Medical School, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, MN
| | - Amy L Weaver
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Robert C Albright
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Paul L Claus
- Department of Medicine, Division of Hyperbaric Medicine in Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | | | - John J Dillon
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Ziad M El-Zoghby
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - LaTonya J Hickson
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Rajiv Kumar
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Robert D McBane
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Amy W Williams
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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El-Azhary RA, Patzelt MT, McBane RD, Weaver AL, Albright RC, Bridges AD, Claus PL, Davis MDP, Dillon JJ, El-Zoghby ZM, Hickson LJ, Kumar R, McCarthy-Fruin KAM, McEvoy MT, Pittelkow MR, Wetter DA, Williams AW, McCarthy JT. Calciphylaxis: A Disease of Pannicular Thrombosis. Mayo Clin Proc 2016; 91:1395-1402. [PMID: 27712638 DOI: 10.1016/j.mayocp.2016.06.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [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] [Received: 03/28/2016] [Revised: 06/18/2016] [Accepted: 06/21/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To identify coagulation risk factors in patients with calciphylaxis and the relationship between anticoagulation use and overall survival. PATIENTS AND METHODS Study subjects were 101 patients with calciphylaxis seen at Mayo Clinic from 1999 to September 2014. Data including thrombophilia profiles were extracted from the medical records of each patient. Survival status was determined using patient registration data and the Social Security Death Index. Survival was estimated using the Kaplan-Meier method, and associations were evaluated using Cox proportional hazards models. RESULTS Sixty-four of the 101 patients underwent thrombophilia testing. Of these, a complete test panel was performed in 55 and a partial panel in 9. Severe thrombophilias observed in 60% (33 of 55) of the patients included antiphospholipid antibody syndrome protein C, protein S, or antithrombin deficiencies or combined thrombophilias. Of the 55 patients, severe thrombophilia (85%, 23 of 27) was noted in patients who were not on warfarin at the time of testing (27). Nonsevere thrombophilias included heterozygous factor V Leiden (n=2) and plasminogen deficiency (n=1). For the comparison of survival, patients were divided into 3 treatment categories: Warfarin (n=63), other anticoagulants (n=20), and no anticoagulants (n=18). There was no statistically significant survival difference between treatment groups. CONCLUSION Laboratory testing reveals a strikingly high prevalence of severe thrombophilias in patients with calciphylaxis, underscoring the importance of congenital and acquired thrombotic propensity potentially contributing to the pathogenesis of this disease. These findings may have therapeutic implications; however, to date, survival differences did not vary by therapeutic choice.
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Affiliation(s)
| | - Michelle T Patzelt
- Mayo Medical School, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, MN
| | - Robert D McBane
- Department of Medicine, Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | - Amy L Weaver
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Robert C Albright
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Paul L Claus
- Department of Medicine, Division of Hyperbaric Medicine in Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | | | - John J Dillon
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Ziad M El-Zoghby
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - LaTonya J Hickson
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Rajiv Kumar
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Amy W Williams
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - James T McCarthy
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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Hickson LJ, Negrotto SM, Onuigbo M, Scott CG, Rule AD, Norby SM, Albright RC, Casey ET, Dillon JJ, Pellikka PA, Pislaru SV, Best PJM, Villarraga HR, Lin G, Williams AW, Nkomo VT. Echocardiography Criteria for Structural Heart Disease in Patients With End-Stage Renal Disease Initiating Hemodialysis. J Am Coll Cardiol 2016; 67:1173-1182. [PMID: 26965538 DOI: 10.1016/j.jacc.2015.12.052] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [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: 10/14/2015] [Revised: 12/07/2015] [Accepted: 12/14/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cardiovascular disease among hemodialysis (HD) patients is linked to poor outcomes. The Acute Dialysis Quality Initiative Workgroup proposed echocardiographic (ECHO) criteria for structural heart disease (SHD) in dialysis patients. The association of SHD with important patient outcomes is not well defined. OBJECTIVES This study sought to determine prevalence of ECHO-determined SHD and its association with survival among incident HD patients. METHODS We analyzed patients who began chronic HD from 2001 to 2013 who underwent ECHO ≤1 month prior to or ≤3 months following initiation of HD (n = 654). RESULTS Mean patient age was 66 ± 16 years, and 60% of patients were male. ECHO findings that met 1 or more and ≥3 of the new criteria were discovered in 87% and 54% of patients, respectively. Over a median of 2.4 years, 415 patients died: 108 (26%) died within 6 months. Five-year mortality was 62%. Age- and sex-adjusted structural heart disease variables associated with death were left ventricular ejection fraction (LVEF) ≤45% (hazard ratio [HR]: 1.48; confidence interval [CI]: 1.20 to 1.83) and right ventricular (RV) systolic dysfunction (HR: 1.68; CI: 1.35 to 2.07). An additive of higher death risk included LVEF ≤45% and RV systolic dysfunction rather than neither (HR: 2.04; CI: 1.57 to 2.67; p = 0.53 for test for interaction). Following adjustment for age, sex, race, diabetic kidney disease, and dialysis access, RV dysfunction was independently associated with death (HR: 1.66; CI 1.34 to 2.06; p < 0.001). CONCLUSIONS SHD was common in our HD study population, and RV systolic dysfunction independently predicted mortality.
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Affiliation(s)
- LaTonya J Hickson
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.
| | | | - Macaulay Onuigbo
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Suzanne M Norby
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Robert C Albright
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Edward T Casey
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - John J Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | | | - Sorin V Pislaru
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Patricia J M Best
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Grace Lin
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Amy W Williams
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Albright RC, Dillon JJ, Hocum CL, Stubbs JR, Johnson PM, Hickson LJ, Williams AW, Dingli D, McCarthy JT. Total Red Blood Cell Transfusions for Chronic Hemodialysis Patients in a Single Center, 2009-2013. Nephron Clin Pract 2016; 133:23-34. [PMID: 27081860 DOI: 10.1159/000445447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 03/12/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Anemia management in chronic hemodialysis (HD) has been affected by the implementation of the prospective payment system (PPS) and changes in clinical guidelines. These factors could impact red blood cell (RBC) transfusion in HD patients. Our distinctive care system contains complete records for all RBC transfusions among our HD patients. AIMS To determine RBC transfusions in patients with prevalent chronic HD, site of administration (inpatient or outpatient), and ordering physician specialty for inpatients; compare pre- and post-PPS RBC transfusions; and compare RBC transfusions during changes in desired outpatient hemoglobin (Hb) range for patients with chronic HD. METHODS Retrospective analysis of medical and blood bank records for patients with prevalent chronic HD July 2009 through June 2013. RESULTS In total, 310-356 patients were studied. Mean (SD) units of RBCs per 100 patients per month for the study's 48 months were outpatient, 2.6 (1.5), and inpatient, 9.4 (4.6). Outpatient pre-PPS RBC units transfused were 2.1 (0.6) vs. post-PPS of 2.6 (1.5; p = 0.22, t test); for inpatients pre-PPS, 7.9 (4.5) RBC units per month vs. post-PPS, 11.5 (5.1; p = 0.11, t test). Inpatient RBC transfusions accounted for 75.2% (14.2%) of all RBC transfusions; 67.3% (16.3%) of inpatient transfusions were ordered by nonnephrologists. Changes in desired Hb range for outpatient HD patients did not lead to changes in RBC transfusions. CONCLUSIONS No changes in RBC transfusions occurred among our patients with chronic HD with PPS implementation and in desired Hb range during the study period. Most transfusions were given in inpatient settings by nonnephrologists.
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Affiliation(s)
- Robert C Albright
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minn., USA
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22
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Hamadah AM, Beaulieu LM, Wilson JW, Aksamit TR, Gregoire JR, Williams AW, Dillon JJ, Albright RC, Onuigbo M, Iyer VK, Hickson LJ. Tolerability and Healthcare Utilization in Maintenance Hemodialysis Patients Undergoing Treatment for Tuberculosis-Related Conditions. Nephron Clin Pract 2016; 132:198-206. [PMID: 26859893 DOI: 10.1159/000444148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/19/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The incidence of tuberculosis (TB) in end-stage renal disease is significantly higher than that in the general population. Among those with kidney dysfunction, anti-TB treatment is associated with increased side effects, but the effect on healthcare utilization is unknown. Methods/Aim: To assess patient-reported symptoms, adverse effects and describe changes in healthcare utilization patterns during treatment for TB, we conducted a case series (n = 12) of patients receiving maintenance hemodialysis (HD) from Mayo Clinic Dialysis Services and concurrent drug therapy for TB from January 2002 through May 2014. Healthcare utilization (hospitalizations and emergency department (ED) visits independent of hospital admission) was compared before and during treatment. RESULTS Patients were treated for latent (n = 7) or active (n = 5) TB. The majority of patients with latent disease were treated with isoniazid (n = 5, 71%), while active-disease patients received a 4-drug regimen. Adverse effects were reported in 83% of patients. Compared to measurements prior to drug initiation, serum albumin and dialysis weights were similar at 3 months. Commonly reported anti-TB drug toxicities were described. More than half (58%) of the patients were hospitalized at least once. No ED or hospital admissions occurred in the period prior to drug therapy, but healthcare utilization increased during treatment in the latent disease group (hospitalization rate per person-month: pre 0 vs. post 1). CONCLUSIONS Among HD patients, anti-TB therapy is associated with frequently reported symptoms and increased healthcare utilization. Among this subset, patients receiving treatment for latent disease may be those with greatest increase in healthcare use. Careful monitoring and early complication detection may help optimize medication adherence and minimize hospitalizations.
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Affiliation(s)
- Abdurrahman M Hamadah
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minn., USA
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Attia ZI, DeSimone CV, Dillon JJ, Sapir Y, Somers VK, Dugan JL, Bruce CJ, Ackerman MJ, Asirvatham SJ, Striemer BL, Bukartyk J, Scott CG, Bennet KE, Ladewig DJ, Gilles EJ, Sadot D, Geva AB, Friedman PA. Novel Bloodless Potassium Determination Using a Signal-Processed Single-Lead ECG. J Am Heart Assoc 2016; 5:JAHA.115.002746. [PMID: 26811164 PMCID: PMC4859394 DOI: 10.1161/jaha.115.002746] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [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] [Indexed: 01/01/2023]
Abstract
Background Hyper‐ and hypokalemia are clinically silent, common in patients with renal or cardiac disease, and are life threatening. A noninvasive, unobtrusive, blood‐free method for tracking potassium would be an important clinical advance. Methods and Results Two groups of hemodialysis patients (development group, n=26; validation group, n=19) underwent high‐resolution digital ECG recordings and had 2 to 3 blood tests during dialysis. Using advanced signal processing, we developed a personalized regression model for each patient to noninvasively calculate potassium values during the second and third dialysis sessions using only the processed single‐channel ECG. In addition, by analyzing the entire development group's first‐visit data, we created a global model for all patients that was validated against subsequent sessions in the development group and in a separate validation group. This global model sought to predict potassium, based on the T wave characteristics, with no blood tests required. For the personalized model, we successfully calculated potassium values with an absolute error of 0.36±0.34 mmol/L (or 10% of the measured blood potassium). For the global model, potassium prediction was also accurate, with an absolute error of 0.44±0.47 mmol/L for the training group (or 11% of the measured blood potassium) and 0.5±0.42 for the validation set (or 12% of the measured blood potassium). Conclusions The signal‐processed ECG derived from a single lead can be used to calculate potassium values with clinically meaningful resolution using a strategy that requires no blood tests. This enables a cost‐effective, noninvasive, unobtrusive strategy for potassium assessment that can be used during remote monitoring.
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Affiliation(s)
- Zachi I Attia
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (Z.I.A., C.V.D.S., V.K.S., J.L.D., C.J.B., M.J.A., S.J.A., J.B., P.A.F.) Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Z.I.A., Y.S., D.S., A.B.G.)
| | - Christopher V DeSimone
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (Z.I.A., C.V.D.S., V.K.S., J.L.D., C.J.B., M.J.A., S.J.A., J.B., P.A.F.)
| | - John J Dillon
- Nephrology and Hypertension, Mayo Clinic, Rochester, MN (J.J.D.)
| | - Yehu Sapir
- Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Z.I.A., Y.S., D.S., A.B.G.)
| | - Virend K Somers
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (Z.I.A., C.V.D.S., V.K.S., J.L.D., C.J.B., M.J.A., S.J.A., J.B., P.A.F.)
| | - Jennifer L Dugan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (Z.I.A., C.V.D.S., V.K.S., J.L.D., C.J.B., M.J.A., S.J.A., J.B., P.A.F.)
| | - Charles J Bruce
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (Z.I.A., C.V.D.S., V.K.S., J.L.D., C.J.B., M.J.A., S.J.A., J.B., P.A.F.)
| | - Michael J Ackerman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (Z.I.A., C.V.D.S., V.K.S., J.L.D., C.J.B., M.J.A., S.J.A., J.B., P.A.F.)
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (Z.I.A., C.V.D.S., V.K.S., J.L.D., C.J.B., M.J.A., S.J.A., J.B., P.A.F.)
| | - Bryan L Striemer
- Center for Advanced Imaging, Mayo Clinic, Rochester, MN (B.L.S.)
| | - Jan Bukartyk
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (Z.I.A., C.V.D.S., V.K.S., J.L.D., C.J.B., M.J.A., S.J.A., J.B., P.A.F.)
| | | | - Kevin E Bennet
- Department of Engineering, Mayo Clinic, Rochester, MN (K.E.B.)
| | | | - Emily J Gilles
- Mayo Clinic Ventures, Mayo Clinic, Rochester, MN (D.J.L., E.J.G.)
| | - Dan Sadot
- Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Z.I.A., Y.S., D.S., A.B.G.)
| | - Amir B Geva
- Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Z.I.A., Y.S., D.S., A.B.G.)
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (Z.I.A., C.V.D.S., V.K.S., J.L.D., C.J.B., M.J.A., S.J.A., J.B., P.A.F.)
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Thongprayoon C, Cheungpasitporn W, Shah IK, Kashyap R, Park SJ, Kashani K, Dillon JJ. Long-term Outcomes and Prognostic Factors for Patients Requiring Renal Replacement Therapy After Cardiac Surgery. Mayo Clin Proc 2015; 90:857-64. [PMID: 26141328 DOI: 10.1016/j.mayocp.2015.03.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [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] [Received: 11/19/2014] [Revised: 03/16/2015] [Accepted: 03/31/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine long-term outcomes, including all-cause mortality, and the likelihood and timing of renal recovery among patients requiring renal replacement therapy (RRT) for acute kidney injury after cardiac surgery. PATIENTS AND METHODS This is a single-center, historical, matched cohort study of post-cardiac surgery patients who required RRT from January 1, 2007, through December 31, 2012. We matched each case with 2 controls, each of whom did not require RRT after cardiac surgery, for age, sex, and type of surgery. The patients were followed up for 1 year after the start of RRT. The main outcomes were all-cause mortality in all patients and rate of renal function recovery in patients who required RRT. RESULTS A total of 202 patients met the inclusion criteria. The unadjusted all-cause mortality among patients requiring RRT was 64% at 1 year vs 8% for matched controls. In multivariate analysis, the hazard ratio for all-cause mortality was 12.59 (95% CI, 8.24-19.68) for cases vs controls. Increased 1-year all-cause mortality was independently associated with increased age, a history of congestive heart failure, lower preoperative creatinine level, longer interval between surgery and starting RRT, and the need for mechanical ventilation or an intra-aortic balloon pump at the time of RRT. Renal recovery occurred in 34% of cases by 90 days and in 39% by 1 year. Of those who recovered renal function, 87% were within 90 days. Only 8 (4%) of the 186 patients were alive and continued to receive RRT at 1 year. CONCLUSIONS The need for RRT after cardiac surgery is an independent risk factor for mortality. In the case of survival, the chance of renal recovery is reasonable.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Ishan K Shah
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Rahul Kashyap
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Soon J Park
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - John J Dillon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
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Cheungpasitporn W, Zand L, Dillon JJ, Qian Q, Leung N. Lactate clearance and metabolic aspects of continuous high-volume hemofiltration. Clin Kidney J 2015; 8:374-7. [PMID: 26251702 PMCID: PMC4515900 DOI: 10.1093/ckj/sfv045] [Citation(s) in RCA: 18] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 11/12/2022] Open
Abstract
Lactic acidosis is associated with high morbidity and mortality in hospitalized patients. Treatment of lactic acidosis is targeted on correcting the underlying causes and optimizing adequate oxygen delivery to the tissues. Even though evidence is lacking, continuous renal replacement therapy (CRRT) and dialysis have been advocated as treatments for lactic acidosis. We report a 28-year-old Caucasian male with a history of hemophagocytic lymphohistiocytosis who presented with septic shock, severe lactic acidosis and multiple organ failure. Metabolic acidosis was corrected after bicarbonate therapy and CRRT with a hemofiltration rate of 7 L/h (58 mL/kg/h). Lactate clearance was calculated to be 79 mL/min. Compared with reported rates of lactate overproduction in septic shock, the rate of lactate clearance is quite small. Our case suggests that CRRT with high-volume hemofiltration is not effective for severe lactic acidosis. Lactic acidosis alone should not be considered as a nonrenal indication for CRRT.
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Affiliation(s)
| | - Ladan Zand
- Division of Nephrology and Hypertension , Mayo Clinic , Rochester, MN , USA
| | - John J Dillon
- Division of Nephrology and Hypertension , Mayo Clinic , Rochester, MN , USA
| | - Qi Qian
- Division of Nephrology and Hypertension , Mayo Clinic , Rochester, MN , USA
| | - Nelson Leung
- Division of Nephrology and Hypertension , Mayo Clinic , Rochester, MN , USA ; Division of Hematology , Mayo Clinic , Rochester, MN , USA
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Fervenza FC, Canetta PA, Barbour SJ, Lafayette RA, Rovin BH, Aslam N, Hladunewich MA, Irazabal MV, Sethi S, Gipson DS, Reich HN, Brenchley P, Kretzler M, Radhakrishnan J, Hebert LA, Gipson PE, Thomas LF, McCarthy ET, Appel GB, Jefferson JA, Eirin A, Lieske JC, Hogan MC, Greene EL, Dillon JJ, Leung N, Sedor JR, Rizk DV, Blumenthal SS, Lasic LB, Juncos LA, Green DF, Simon J, Sussman AN, Philibert D, Cattran DC. A Multicenter Randomized Controlled Trial of Rituximab versus Cyclosporine in the Treatment of Idiopathic Membranous Nephropathy (MENTOR). Nephron Clin Pract 2015; 130:159-68. [PMID: 26087670 DOI: 10.1159/000430849] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 04/17/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Idiopathic membranous nephropathy remains the leading cause of nephrotic syndrome in Caucasian adults. Immunosuppressive therapy with cyclosporine (CSA) is often successful in reducing proteinuria, but its use is associated with a high relapse rate. Rituximab, a monoclonal antibody that specifically targets CD20 on the surface of B-cells, is effective in achieving a complete remission of proteinuria in patients with idiopathic membranous nephropathy. However, whether rituximab is as effective as CSA in inducing and maintaining complete or partial remission of proteinuria in these patients is unknown. The membranous nephropathy trial of rituximab (MENTOR) hypothesizes that B-cell targeting with rituximab is non-inferior to CSA in inducing long-term remission of proteinuria. METHODS AND DESIGN Patients with idiopathic membranous nephropathy, proteinuria ≥5 g/24 h, and a minimum of 3 months of Angiotensin-II blockade will be randomized into a 12-month treatment period with i.v. rituximab, 1,000 mg (2 infusions, 14 days apart; repeated at 6 months if a substantial reduction in proteinuria (equal to or >25%) is seen at 6 months) or oral CSA 3.5-5 mg/kg/day for 6 months (continued for another 6 months if a substantial reduction in proteinuria (equal to or >25%) is seen at 6 months). The efficacy of treatment will be assessed by the remission status (based on changes in proteinuria) at 24 months from randomization. Patient safety will be assessed via collection of adverse event data and evaluation of pre- and posttreatment laboratory data. At the 6-month post-randomization visit, patients who have been randomized to either CSA or rituximab but who do not have a reduction in proteinuria ≥25% (confirmed on repeat measurements within 2 weeks) will be considered treatment failures and exit the study. DISCUSSION This study will test for the first time whether treatment with rituximab is non-inferior to CSA in inducing long-term remission (complete or partial) of proteinuria in patients with idiopathic membranous nephropathy.
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Akhoundi A, Singh B, Vela M, Chaudhary S, Monaghan M, Wilson GA, Dillon JJ, Cartin-Ceba R, Lieske JC, Gajic O, Kashani K. Incidence of Adverse Events during Continuous Renal Replacement Therapy. Blood Purif 2015; 39:333-9. [DOI: 10.1159/000380903] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 02/12/2015] [Indexed: 11/19/2022]
Abstract
Background/Aims: The incidence of adverse events (AEs) in adults who receive continuous renal replacement therapy (CRRT) is unknown. We report the incidence of mechanical, metabolic, and hemodynamic CRRT AEs. Methods: This is a retrospective study of all consecutive adult patients (≥18 years) who underwent CRRT from January 1, 2007 to December 31, 2009. Results: Out of 595 patients who underwent CRRT, 366 (62%) were male and 500 (84%) were Caucasian. Regional citrate anticoagulation was used in 98.6% of all patients. The most common clinically significant electrolyte derangements were ionized hypocalcemia (22%), ionized hypercalcemia (23%), and hyperphosphatemia (44%). Almost all (97%) patients had at least one additional AE including new onset hypotension (within the first hour after CRRT initiation) (43%), hypothermia (44%), new onset arrhythmias (29%), new onset anemia (31%) and thrombocytopenia (40%). Conclusions: ICU patients who require CRRT have a high incidence of AEs. Although the extent to which these complications are attributable to CRRT is not known, clinicians need to be cautious and aware of their high prevalence in this patient population.
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Hickson LJ, Chaudhary S, Williams AW, Dillon JJ, Norby SM, Gregoire JR, Albright RC, McCarthy JT, Thorsteinsdottir B, Rule AD. Predictors of outpatient kidney function recovery among patients who initiate hemodialysis in the hospital. Am J Kidney Dis 2015; 65:592-602. [PMID: 25500361 PMCID: PMC4630340 DOI: 10.1053/j.ajkd.2014.10.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [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: 03/24/2014] [Accepted: 10/05/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Recent policy clarifications by the Centers for Medicare & Medicaid Services have changed access to outpatient dialysis care at end-stage renal disease (ESRD) facilities for individuals with acute kidney injury in the United States. Tools to predict "ESRD" and "acute" status in terms of kidney function recovery among patients who previously initiated dialysis therapy in the hospital could help inform patient management decisions. STUDY DESIGN Historical cohort study. SETTING & PARTICIPANTS Incident hemodialysis patients in the Mayo Clinic Health System who initiated in-hospital renal replacement therapy (RRT) and continued outpatient dialysis following hospital dismissal (2006 through 2009). PREDICTOR Baseline estimated glomerular filtration rate (eGFR), acute tubular necrosis from sepsis or surgery, heart failure, intensive care unit, and dialysis access. OUTCOMES Kidney function recovery defined as sufficient kidney function for outpatient hemodialysis therapy discontinuation. RESULTS Cohort consisted of 281 patients with a mean age of 64 years, 63% men, 45% with heart failure, and baseline eGFR≥30mL/min/1.73m(2) in 46%. During a median of 8 months, 52 (19%) recovered, most (94%) within 6 months. Higher baseline eGFR (HR per 10-mL/min/1.73m(2) increase eGFR, 1.27; 95% CI, 1.16-1.39; P<0.001), acute tubular necrosis from sepsis or surgery (HR, 3.34; 95% CI, 1.83-6.24; P<0.001), and heart failure (HR, 0.40; 95% CI, 0.19-0.78, P=0.007) were independent predictors of recovery within 6 months, whereas first RRT in the intensive care unit and catheter dialysis access were not. There was a positive interaction between absence of heart failure and eGFR≥30mL/min/1.73m(2) for predicting kidney function recovery (P<0.001). LIMITATIONS Sample size. CONCLUSIONS Kidney function recovery in the outpatient hemodialysis unit following in-hospital RRT initiation is not rare. As expected, higher baseline eGFR is an important determinant of recovery. However, patients with heart failure are less likely to recover even with a higher baseline eGFR. Consideration of these factors at hospital discharge informs decisions on ESRD status designation and long-term hemodialysis care.
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Affiliation(s)
- LaTonya J. Hickson
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Sanjay Chaudhary
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Amy W. Williams
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - John J. Dillon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Suzanne M. Norby
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - James R. Gregoire
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Robert C. Albright
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - James T. McCarthy
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Bjoerg Thorsteinsdottir
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
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Lim JY, Deo SV, Jung SH, Altarabsheh SE, Erwin PJ, Dillon JJ, Park SJ. Does off-pump coronary artery bypass confer any advantage in patients with end-stage renal failure? A systematic review and meta-analysis. Heart Lung Circ 2015; 24:55-61. [PMID: 25153358 DOI: 10.1016/j.hlc.2014.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 03/11/2014] [Accepted: 06/04/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Patients with end-stage renal disease (ESRD) are often excluded from trials comparing off and on-pump coronary artery bypass grafting (CABG). Thus data in this cohort is limited to small retrospective studies. Hence we compared the adverse clinical events and outcome in patients with ESRD undergoing off (OPCABG) and on-pump surgery (ONCABG). METHODS Pubmed, Scopus and Web of Science were searched (inception - June 2013) to identify studies comparing clinical results of OPCABG and ONCABG in dialysis dependent patients. A random effect inverse variance weighted meta-analysis was conducted. Results are presented as risk ratios (RR) with 95% confidence intervals; p<0.05 is significant. RESULT Ten retrospective studies (2762 OPCABG and 11310 ONCABG) fulfilled criteria and were pooled. Patients undergoing off-pump surgery were less than 100 in most of the articles. Early mortality [OPCABG (8.4%); ONCABG (10.4%)] was comparable [RR 0.80(0.51-1.17); p=0.35; I(2)=30%]. Re-exploration for bleeding [RR 0.81(0.47-1.39); p=0.44] and blood transfusion [RR 0.79(0.57-1.08); p=0.14] were also comparable. While patients undergoing off-pump surgery were extubated earlier (p<0.01), other post-operative events like stroke (p=0.34) and atrial fibrillation (p=0.10) were similar. Mid-term survival (three to five years) was also comparable. CONCLUSION Patients with end-stage renal disease undergoing coronary artery bypass grafting demonstrate comparable results irrespective of method. While available data is limited to retrospective studies, we failed to demonstrate any significant advantage for performing OPCABG in this group of patients.
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Affiliation(s)
| | - Salil V Deo
- Adventist Wockhardt Heart Institute, Surat Gujarat, India; Case Medical Center, Case Western Reserve University, Cleveland, OH USA.
| | | | | | | | - John J Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN USA
| | - Soon J Park
- Case Medical Center, Case Western Reserve University, Cleveland, OH USA
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Sethi S, Smith RJH, Dillon JJ, Fervenza FC. C3 glomerulonephritis associated with complement factor B mutation. Am J Kidney Dis 2014; 65:520-1. [PMID: 25532781 DOI: 10.1053/j.ajkd.2014.10.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 10/16/2014] [Indexed: 02/06/2023]
Affiliation(s)
- Sanjeev Sethi
- Mayo Clinic College of Medicine, Rochester, Minnesota.
| | | | - John J Dillon
- Mayo Clinic College of Medicine, Rochester, Minnesota
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Schoonover KL, Hickson LJ, Norby SM, Hogan MC, Chaudhary S, Albright RC, Dillon JJ, McCarthy JT, Williams AW. Risk factors for hospitalization among older, incident haemodialysis patients. Nephrology (Carlton) 2014; 18:712-7. [PMID: 23848358 DOI: 10.1111/nep.12129] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2013] [Indexed: 01/10/2023]
Abstract
AIMS The number of elderly persons with end-stage renal disease is increasing with many requiring hospitalizations. This study examines the causes and predictors of hospitalization in older haemodialysis patients. METHODS We reviewed hospitalizations of older (≥65 years) incident chronic haemodialysis patients initiating therapy between 1 January 2007 and 31 December 2009 under the care of a single Midwestern United States dialysis provider. RESULTS Of 125 patients, the mean age was 76 ± 7 years and 72% were male. At first dialysis, 68% used a central venous catheter (CVC) and 51% were in the hospital. Mean follow-up was 1.8 ± 1.0 years. At least one hospitalization occurred in 89 (71%) patients and half of all patients were hospitalized once within the first 223 days. Total hospital admission rate was 1.48 per patient year with hospital days totalling 8.54 days per patient year. The three most common reasons for first admission were cardiac (33%), infection (18%) and gastrointestinal (12%). Predictors of future hospitalization included the first dialysis occurring in hospital (hazard ratios (HR) 2.1, 95% CI 1.4-3.3, P = 0.0005) and the use of a CVC at first haemodialysis (HR 2.6, CI 1.6-4.4, P < 0.0001). CONCLUSION Hospitalizations are common in older incident haemodialysis patients. Access preparation and overall burden of illness leading to the initial hospitalization appear to play a role. Identification of additional factors associated with hospitalization will allow for focused interventions to reduce hospitalization rates and increase the value of care.
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Affiliation(s)
- Kimberly L Schoonover
- Department of Medicine, Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Dillon JJ, DeSimone CV, Sapir Y, Somers VK, Dugan JL, Bruce CJ, Ackerman MJ, Asirvatham SJ, Striemer BL, Bukartyk J, Scott CG, Bennet KE, Mikell SB, Ladewig DJ, Gilles EJ, Geva A, Sadot D, Friedman PA. Noninvasive potassium determination using a mathematically processed ECG: proof of concept for a novel "blood-less, blood test". J Electrocardiol 2014; 48:12-8. [PMID: 25453193 DOI: 10.1016/j.jelectrocard.2014.10.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [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: 07/31/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine if ECG repolarization measures can be used to detect small changes in serum potassium levels in hemodialysis patients. PATIENTS AND METHODS Signal-averaged ECGs were obtained from standard ECG leads in 12 patients before, during, and after dialysis. Based on physiological considerations, five repolarization-related ECG measures were chosen and automatically extracted for analysis: the slope of the T wave downstroke (T right slope), the amplitude of the T wave (T amplitude), the center of gravity (COG) of the T wave (T COG), the ratio of the amplitude of the T wave to amplitude of the R wave (T/R amplitude), and the center of gravity of the last 25% of the area under the T wave curve (T4 COG) (Fig. 1). RESULTS The correlations with potassium were statistically significant for T right slope (P<0.0001), T COG (P=0.007), T amplitude (P=0.0006) and T/R amplitude (P=0.03), but not T4 COG (P=0.13). Potassium changes as small as 0.2mmol/L were detectable. CONCLUSION Small changes in blood potassium concentrations, within the normal range, resulted in quantifiable changes in the processed, signal-averaged ECG. This indicates that non-invasive, ECG-based potassium measurement is feasible and suggests that continuous or remote monitoring systems could be developed to detect early potassium deviations among high-risk patients, such as those with cardiovascular and renal diseases. The results of this feasibility study will need to be further confirmed in a larger cohort of patients.
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Affiliation(s)
- John J Dillon
- Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | | | - Yehu Sapir
- Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Virend K Somers
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L Dugan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Charles J Bruce
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Jan Bukartyk
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Kevin E Bennet
- Division of Engineering, Mayo Clinic, Rochester, MN, USA
| | - Susan B Mikell
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | | | - Amir Geva
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Dan Sadot
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Paul A Friedman
- Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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Patel K, Dillon JJ, Leung N, Bomback AS, Appel GB, D'Agati V, Canetta PA. Use of bortezomib in heavy-chain deposition disease: a report of 3 cases. Am J Kidney Dis 2014; 64:123-7. [PMID: 24613055 DOI: 10.1053/j.ajkd.2014.01.425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [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: 07/17/2013] [Accepted: 01/06/2014] [Indexed: 11/11/2022]
Abstract
Heavy-chain deposition disease (HCDD) is a rare complication of plasma cell dyscrasia in which monoclonal heavy chains deposit in glomerular and tubular basement membranes of the kidney. Clinical and pathologic features of HCDD have been well described in case reports and series, but evidence supporting specific therapies is sparse. Historically, the disease has had a poor prognosis, intensifying the need to clarify optimal treatments. We describe 3 cases of HCDD with biopsy-proven glomerular involvement, severe nephrotic syndrome, and decline in kidney function that were treated successfully with bortezomib, a proteasome inhibitor. None of these patients had multiple myeloma. In all cases, bortezomib-based therapy resulted in sustained resolution of nephrotic syndrome and improvement in kidney function. All 3 patients developed peripheral neuropathy; otherwise, treatment was well tolerated. To our knowledge, this is the first description of the clinical effectiveness of bortezomib against HCDD.
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Affiliation(s)
- Kinjal Patel
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - John J Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN
| | - Andrew S Bomback
- Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Gerald B Appel
- Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Vivette D'Agati
- Department of Cell Biology and Pathology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Pietro A Canetta
- Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY.
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Deo SV, Shah IK, Dunlay SM, Lim JY, Erwin PJ, Dillon JJ, Park SJ. Coronary Artery Bypass Grafting Versus Drug-Eluting Stents in Patients with End-Stage Renal Disease. J Card Surg 2014; 29:163-9. [DOI: 10.1111/jocs.12296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Salil V. Deo
- Department of Cardiovascular Surgery; Adventist Wockhardt Heart Institute; Surat, Gujarat India
| | - Ishan K. Shah
- Department of Surgery; University of Minnesota; Minneapolis Minnesota
| | - Shannon M. Dunlay
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota
| | - Ju Yong Lim
- Division of Cardiovascular Surgery; Mayo Clinic; Rochester Minnesota
| | | | - John J. Dillon
- Division of Nephrology and Hypertension; Mayo Clinic; Rochester Minnesota
| | - Soon J. Park
- Division of Cardiovascular Surgery; University Hospitals; Case Western Reserve University; Cleveland Ohio
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Irazabal MV, Eirin A, Lieske J, Beck LH, Sethi S, Borland TM, Dillon JJ, Nachman PH, Nasr SH, Cornell LD, Leung N, Cattran DC, Fervenza FC. Low- and high-molecular-weight urinary proteins as predictors of response to rituximab in patients with membranous nephropathy: a prospective study. Nephrol Dial Transplant 2012; 28:137-46. [PMID: 22987142 DOI: 10.1093/ndt/gfs379] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Selective urinary biomarkers have been considered superior to total proteinuria in predicting response to treatment and outcome in patients with membranous nephropathy (MN). METHODS We prospectively tested whether urinary (U) excretion of retinol-binding protein (RBP), α1-microglobulin (α1M), albumin, immunoglobulin IgG and IgM and/or anti-phospholipase 2 receptor (PLA(2)R) levels could predict response to rituximab (RTX) therapy better than standard measures in MN. We also correlated changes in antibodies to PLA(2)R with these urinary biomarkers. RESULTS Twenty patients with MN and proteinuria (P) >5 g/24 h received RTX (375 mg/m(2) × 4) and at 12 months, 1 patient was in complete remission (CR), 9 were in partial remission (PR), 5 had a limited response (LR) and 4 were non-responders (NR). At 24 months, CR occurred in 4, PR in 12, LR in 1, NR in 2 and 1 patient relapsed. By simple linear regression analysis, UIgG at baseline (mg/24 h) was a significant predictor of change in proteinuria at 12 months (Δ urinary protein) (P = 0.04). In addition, fractional excretion (FE) of IgG, urinary alpha 1 microglobulin (Uα1M) (mg/24 h) and URBP (μg/24 h) were also predictors of response (P = 0.05, 0.04, and 0.03, respectively). On the other hand, UIgM, FEIgM, albumin and FE albumin did not predict response (P = 0.10, 0.27, 0.22 and 0.20, respectively). However, when results were analyzed in relation to proteinuria at 24 months, none of the U markers that predicted response at 12 m could predict response at 24 m (P = 0.55, 0.42, 0.29 and 0.20). Decline in anti-PLA(2)R levels was associated with and often preceded urinary biomarker response but positivity at baseline was not a predictor of proteinuria response. CONCLUSIONS The results suggest that in patients with MN, quantification of low-, medium- and high-molecular-weight urinary proteins may be associated with rate of response to RTX, but do not correlate with longer term outcomes.
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Affiliation(s)
- Maria V Irazabal
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, MN, USA
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Schinstock CA, Albright RC, Williams AW, Dillon JJ, Bergstralh EJ, Jenson BM, McCarthy JT, Nath KA. Outcomes of arteriovenous fistula creation after the Fistula First Initiative. Clin J Am Soc Nephrol 2011; 6:1996-2002. [PMID: 21737851 DOI: 10.2215/cjn.11251210] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The arteriovenous fistula (AVF) is the preferred hemodialysis access, but AVF-failure rate is high, and complications from AVF placement are rarely reported. There is no clear consensus on predictors of AVF patency. This study determined AVF outcomes and patency predictors at Mayo Clinic Rochester following the Fistula First Initiative. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective cohort study of AVFs placed at Mayo Clinic from January 2006 through December 2008 was performed. The AVF placement-associated primary and secondary failure rates, complications, interventions, and hospitalizations were examined. Kaplan-Meier survival curves and Cox proportional hazard models were used to determine primary and secondary patency and associated predictors. RESULTS During this time frame, 317 AVFs were placed in 293 individual patients. The primary failure rate was 37.1% after excluding patients not initiated on hemodialysis during follow-up (n = 38) or those with indeterminate outcome (37 lost to follow-up; six died; two transplanted). Of usable AVFs, 11.4% later failed. AVF creation incurred complications and hospitalization in 21.2% and 12.3% of patients, respectively. The risk for reduced primary patency was increased by diabetes (HR, 1.54; 95% CI, 1.14 to 2.07); the risk for reduced primary and secondary patency was decreased with larger arteries (HR, 0.83; 95% CI, 0.73 to 0.94; and HR, 0.69; 95% CI, 0.56 to 0.84, respectively). CONCLUSIONS Primary failure remains a major issue in the post-Fistula First era. Complications from AVF placement must be considered when planning AVF placement. Our data demonstrate that artery size is the main predictor of AVF patency.
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Fervenza FC, Abraham RS, Erickson SB, Irazabal MV, Eirin A, Specks U, Nachman PH, Bergstralh EJ, Leung N, Cosio FG, Hogan MC, Dillon JJ, Hickson LJ, Li X, Cattran DC. Rituximab therapy in idiopathic membranous nephropathy: a 2-year study. Clin J Am Soc Nephrol 2010; 5:2188-98. [PMID: 20705965 DOI: 10.2215/cjn.05080610] [Citation(s) in RCA: 198] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES It was postulated that in patients with membranous nephropathy (MN), four weekly doses of Rituximab (RTX) would result in more effective B cell depletion, a higher remission rate, and maintaining the same safety profile compared with patients treated with RTX dosed at 1 g every 2 weeks. This hypothesis was supported by previous pharmacokinetic (PK) analysis showing that RTX levels in the two-dose regimen were 50% lower compared with nonproteinuric patients, which could potentially result in undertreatment. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Twenty patients with MN and proteinuria >5 g/24 h received RTX (375 mg/m(2) × 4), with re-treatment at 6 months regardless of proteinuria response. PK analysis was conducted simultaneously with immunological analyses of T and B cells to ascertain the effect of RTX on lymphocyte subpopulations. RESULTS Baseline proteinuria of 11.9 g/24 h decreased to 4.2 and 2.0 g/24 h at 12 and 24 months, respectively, whereas creatinine clearance increased from 72.4 ml/min per 1.73 m(2) at baseline to 88.4 ml/min per 1.73 m(2) at 24 months. Of 18 patients who completed 24-month follow-up, 4 are in complete remission, 12 are in partial remission, 1 has a limited response, and 1 patient relapsed. Serum RTX levels were similar to those obtained with two doses of RTX. CONCLUSIONS Four doses of RTX resulted in more effective B cell depletion, but proteinuria reduction was similar to RTX at 1 g every 2 weeks. Baseline quantification of lymphocyte subpopulations did not predict response to RTX therapy.
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Affiliation(s)
- Fernando C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, MN 55901, USA.
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Lorenz EC, Vrtiska TJ, Lieske JC, Dillon JJ, Stegall MD, Li X, Bergstralh EJ, Rule AD. Prevalence of renal artery and kidney abnormalities by computed tomography among healthy adults. Clin J Am Soc Nephrol 2010; 5:431-8. [PMID: 20089492 DOI: 10.2215/cjn.07641009] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Management of incidental renal artery and kidney abnormalities in patients undergoing computed tomography scans is a clinical challenge because their frequency in healthy subjects has not been precisely estimated. Therefore, the prevalence and management of these abnormalities were determined among a large cohort of potential kidney donors undergoing protocol evaluations. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All patients at the Mayo Clinic who underwent computed tomographic angiography and urography as part of their kidney donor evaluation between 2000 and 2008 were identified. Radiographic reports were abstracted for abnormalities of the renal arteries and kidneys. The prevalence of radiographic abnormalities was stratified by age and gender, and the effect on approval for kidney donation was determined. RESULTS Among 1957 potential kidney donors, the mean +/- SD age was 43 +/- 12 years, and 58% were women. The most common abnormalities were kidney stones (11%), focal scarring (3.6%), fibromuscular dysplasia (2.8%), and other renal artery narrowing or atherosclerosis (5.3%). Fibromuscular dysplasia, focal scarring, parenchymal atrophy, and upper tract dilation were more common in women. Renal artery narrowing, focal scarring, and indeterminate masses increased with age. Overall, 25% of potential donors had at least one abnormality. However, these incidental radiographic abnormalities contributed to exclusion from donation in only 6.7% of potential donors. CONCLUSIONS Incidental radiographic abnormalities of the renal arteries and kidneys are common. The majority of imaging findings are not perceived to be harmful enough to prevent kidney donation, but future studies are needed to determine their clinical relevance.
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Abstract
PURPOSE We tested the hypothesis that the cationic phosphate binder sevelamer hydrochloride could reduce hyperoxaluria and calcium oxalate supersaturation in patients with enteric hyperoxaluria by binding fatty acids, binding phosphate and rendering calcium free to bind oxalate, and/or directly binding oxalate. A secondary objective was to assess changes in the urinary excretion of other substances associated with nephrolithiasis. MATERIALS AND METHODS Ten patients with enteric hyperoxaluria were enrolled in a nonrandomized, open label trial of sevelamer hydrochloride (3,200 mg 3 times daily for 7 days). RESULTS With treatment mean urinary oxalate decreased 17% (0.84 to 0.70 mmol per day) and the urinary oxalate-to-creatinine ratio decreased 11% (0.055 to 0.049 mmol/mmol, p not significant for both). Urinary calcium increased 25% (p not significant). Urinary citrate decreased 23% (p = 0.01) and urinary phosphorus decreased 44% (p = 0.0001). Mean supersaturation of calcium oxalate, brushite, hydroxyapatite, uric acid and sodium urate did not change significantly. However, the decrease in brushite supersaturation approached statistical significance (p = 0.07). Mean serum phosphorus was 3.6 mg/dl at baseline and 3.3 mg/dl with therapy (p not significant). Hypophosphatemia did not develop in any patients. One patient dropped out of study due to abdominal pain. CONCLUSIONS Sevelamer hydrochloride dramatically decreased urinary phosphorus excretion with a lesser effect on urinary oxalate. Supersaturation of calcium oxalate did not decrease due to countervailing effects on other constituents including an increase in urinary calcium and a decrease in urinary citrate. Although sevelamer hydrochloride may not be an ideal agent for correcting hyperoxaluria, its potential to reduce calcium phosphate supersaturation merits further investigation.
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Affiliation(s)
- John C Lieske
- Mayo Clinic Division of Nephrology and Hypertension and Mayo Hyperoxaluria Center, Rochester, Minnesota 55905, USA.
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Fervenza FC, Cosio FG, Erickson SB, Specks U, Herzenberg AM, Dillon JJ, Leung N, Cohen IM, Wochos DN, Bergstralh E, Hladunewich M, Cattran DC. Rituximab treatment of idiopathic membranous nephropathy. Kidney Int 2008; 73:117-25. [PMID: 17943078 DOI: 10.1038/sj.ki.5002628] [Citation(s) in RCA: 186] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Idiopathic membranous nephropathy is a common cause of nephrotic syndrome whose pathogenesis may involve B-cell functions. Rituximab is a monoclonal antibody that binds to the CD20 antigen on B cells thereby deleting them. We conducted an open-label pilot trial of rituximab treatment in 15 severely nephrotic patients with proteinuria refractory to angiotensin-converting enzyme inhibition and/or receptor blockade but with adequately controlled blood pressure. Rituximab was given 2 weeks apart and, at 6 months, patients who remained proteinuric but had recovered B-cell counts were given a second course of treatment. Proteinuria was significantly decreased by about half at 12 months. Of the 14 patients who completed follow-up, full remission was achieved in two and partial remission in six patients based upon the degree of proteinuria. Side effects were minor; however, we found no relationship between the response and number of B cells in the blood, CD20 cells in the kidney biopsy, degree of tubulointerstitial fibrosis, starting proteinuria or creatinine values. Rituximab appears effective in reducing proteinuria in some patients with idiopathic membranous nephropathy but prospective identification of responsive patients was not possible.
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Affiliation(s)
- F C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA.
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Abstract
The lengthy course of IgA nephropathy and the possibility of good outcomes without therapy suggest nontoxic therapies such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs.) Among patients with IgA nephropathy, both ACE inhibitors and ARBs reduce the transglomerular passage of large, but not small, molecules, reducing proteinuria. The antiproteinuric effects of ACE inhibitors and ARBs are probably equivalent. Dual ACE inhibitor-ARB therapy reduces proteinuria by 54% to 73% and is more effective than either agent alone. To determine whether ACE inhibitors or ARBs preserve renal function long-term, one must rely on trials studying nondiabetic, proteinuric renal diseases rather than on trials specific to IgA nephropathy. Among this group of patients, several randomized, controlled trials, including the AIPRI trial, the REIN trial, and a metaanalysis of 11 randomized, controlled trials, have established clearly that the ACE inhibitors preserve renal function. There is no reason to believe that this information is not applicable to IgA nephropathy. The COOPERATE trial, in which 50% of the subjects had IgA nephropathy, established that ACE inhibitors and ARBs preserve renal function equally, and that dual ACE inhibitor-ARB therapy preserves renal function more effectively than either therapy alone. These data suggest that most individuals with proteinuric renal diseases, including IgA nephropathy, should be treated with ACE inhibitors and ARBs, ideally in combination. Polymorphisms of the angiotensinogen gene, the ACE gene, and the angiotensin II type I receptor gene have, so far, failed to predict either susceptibility to or progression of IgA nephropathy. However, the D allele of the ID polymorphism, particularly the DD genotype, could predict a favorable response to renin-angiotensin blockade.
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Affiliation(s)
- John J Dillon
- Division of Nephrology, Mayo Clinic and Foundation, 200 1st Street, NW, Rochester, MN 55905, USA.
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Pratt DW, Dillon JJ, Lloyd RV, Wood DE. Electron paramagnetic resonance spectra of pyrrolidino and pyrrolino free radicals. Structure of dialkylamino radicals. ACTA ACUST UNITED AC 2002. [DOI: 10.1021/j100691a012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hartman AR, Fleming GF, Dillon JJ. Meta-analysis of adjuvant cyclophosphamide/methotrexate/5-fluorouracil chemotherapy in postmenopausal women with estrogen receptor-positive, node-positive breast cancer. Clin Breast Cancer 2001; 2:138-43; discussion 144. [PMID: 11899785 DOI: 10.3816/cbc.2001.n.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [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: 11/20/2022]
Abstract
Conflicting results have been published regarding the efficacy of adjuvant cyclophosphamide/methotrexate/5-fluorouracil (CMF)-type chemotherapy in postmenopausal, estrogen receptor (ER)-positive women. The Oxford overview suggests real but limited benefit of any chemotherapy in this group of patients but avoids analyzing smaller subsets. We wished to better quantitate the benefit of adding CMF to tamoxifen in postmenopausal ER-positive women with tumor involvement of axillary lymph nodes. Six randomized studies comparing CMF plus tamoxifen to tomoxifen alone in postmenopausal, ER-positive, node-positive women have been published since 1992. They include 2368 patients. We performed a meta-analysis of 6 endpoints: survival, disease-free survival, locoregional recurrence, distant recurrence, contralateral breast recurrence, and thromboembolic complications. There was a statistically significant increase in disease-free survival from the addition of CMF-type chemotherapy to tamoxifen in this population; the absolute risk of relapse was reduced by 5.5% at 5 years. Effects of locoregional recurrence were greater than those on overall recurrence. No significant survival benefit was observed.
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Affiliation(s)
- A R Hartman
- Department of Oncology, Stanford University Medical Center, Palo Alto, CA, USA
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Affiliation(s)
- John J Dillon
- Section of Nephrology, The University of Chicago, Chicago, Illinois
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Dillon JJ. Continuous renal replacement therapy or hemodialysis for acute renal failure? Int J Artif Organs 1999; 22:125-7. [PMID: 10357238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Hartman AR, Williams SF, Dillon JJ. Survival, disease-free survival and adverse effects of conditioning for allogeneic bone marrow transplantation with busulfan/cyclophosphamide vs total body irradiation: a meta-analysis. Bone Marrow Transplant 1998. [PMID: 9733266 DOI: 10.1038/sj.bmt.1701334]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Randomized, prospective studies comparing BUCY to TBI conditioning regimens for allogeneic bone marrow transplantation have yielded conflicting results. We investigated the overall survival, the disease-free survival and the toxicities of BUCY vs TBI-based regimens by conducting a meta-analysis of all published, randomized, prospective trials comparing these regimens. Five studies were analyzed. We evaluated six endpoints: survival, disease-free survival, veno-occlusive disease (VOD) of the liver, acute GVHD, chronic GVHD, and interstitial pneumonitis. We combined individual study results using a random effects model. Survival and disease-free survival were better with TBI-based regimens than with BUCY, but these differences were not statistically significant (survival odds ratio 1.4, 95% confidence interval 0.9-2.2, P = 0.09; disease-free survival odds ratio 1.2, 95% confidence interval 0.7-2.1, P = 0.44). A power analysis indicated that BUCY was unlikely to have a clinically relevant survival or disease-free survival advantage. The power analysis could not exclude the possibility of such an advantage for TBI-based regimens. A significantly greater incidence of VOD occurred with BUCY (odds ratio 2.5, 95% confidence interval 1.2-5.2, P = 0.02). For the other side-effects, there were no significant differences. We concluded that TBI-based regimens cause less VOD than BUCY and are at least as good for survival and disease-free survival.
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Affiliation(s)
- A R Hartman
- Department of Medicine, The University of Chicago, IL, USA
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Hartman AR, Williams SF, Dillon JJ. Survival, disease-free survival and adverse effects of conditioning for allogeneic bone marrow transplantation with busulfan/cyclophosphamide vs total body irradiation: a meta-analysis. Bone Marrow Transplant 1998; 22:439-43. [PMID: 9733266 DOI: 10.1038/sj.bmt.1701334] [Citation(s) in RCA: 125] [Impact Index Per Article: 4.8] [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: 11/08/2022]
Abstract
Randomized, prospective studies comparing BUCY to TBI conditioning regimens for allogeneic bone marrow transplantation have yielded conflicting results. We investigated the overall survival, the disease-free survival and the toxicities of BUCY vs TBI-based regimens by conducting a meta-analysis of all published, randomized, prospective trials comparing these regimens. Five studies were analyzed. We evaluated six endpoints: survival, disease-free survival, veno-occlusive disease (VOD) of the liver, acute GVHD, chronic GVHD, and interstitial pneumonitis. We combined individual study results using a random effects model. Survival and disease-free survival were better with TBI-based regimens than with BUCY, but these differences were not statistically significant (survival odds ratio 1.4, 95% confidence interval 0.9-2.2, P = 0.09; disease-free survival odds ratio 1.2, 95% confidence interval 0.7-2.1, P = 0.44). A power analysis indicated that BUCY was unlikely to have a clinically relevant survival or disease-free survival advantage. The power analysis could not exclude the possibility of such an advantage for TBI-based regimens. A significantly greater incidence of VOD occurred with BUCY (odds ratio 2.5, 95% confidence interval 1.2-5.2, P = 0.02). For the other side-effects, there were no significant differences. We concluded that TBI-based regimens cause less VOD than BUCY and are at least as good for survival and disease-free survival.
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Affiliation(s)
- A R Hartman
- Department of Medicine, The University of Chicago, IL, USA
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Arnow PM, Garcia-Houchins S, Neagle MB, Bova JL, Dillon JJ, Chou T. An outbreak of bloodstream infections arising from hemodialysis equipment. J Infect Dis 1998; 178:783-91. [PMID: 9728548 DOI: 10.1086/515363] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [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: 11/04/2022] Open
Abstract
An outbreak of 29 cases of bloodstream infection by 16 pathogens occurred during 8 months at two chronic hemodialysis centers. Consequences included 21 hospital admissions and removal of 23 dialysis catheters. An epidemiologic investigation comparing case-patients with uninfected controls showed that risk was significantly (P < .05) associated with having a catheter for vascular access; receiving treatment on a Monday, Wednesday, Friday schedule; and receiving treatment on one heavily contaminated dialysis machine. Culture studies and mock trials showed that bloodstream pathogens were present in a recently installed, commercially marketed attachment for disposal of spent priming saline and could enter blood line tubing directly or indirectly during dialyzer priming and tubing assembly. The outbreak was halted by measures directed at the attachment. Investigation of this problem demonstrated that microbial overgrowth in the attachment caused bloodstream infections and underscores the importance of microbiologic considerations in the design and use of hemodialysis equipment.
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Affiliation(s)
- P M Arnow
- Department of Medicine and Pritzker School of Medicine, University of Chicago, University of Chicago Hospital, Illinois, USA.
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Newell KA, Millis JM, Bruce DS, Woodle ES, Cronin DC, Loss G, Grewal H, Alonso EM, Dillon JJ, Whitington PF, Thistlethwaite JR. An analysis of hepatic retransplantation in children. Transplantation 1998; 65:1172-8. [PMID: 9603163 DOI: 10.1097/00007890-199805150-00005] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [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: 02/07/2023]
Abstract
BACKGROUND The limited supply of organ donors has led some groups to reconsider the role of retransplantation. Historically, except for children with malignancies, extrahepatic sources of sepsis, or severe irreversible neurologic injuries, our institution has offered all children with failing liver grafts the option of retransplantation regardless of their current severity of illness. The purpose of this study was to examine the outcome of hepatic retransplantation in children in an attempt to identify factors predictive of outcome and to assess the results of our approach to retransplantation. METHODS Between October 1984 and December 1995, 314 children less than 15 years of age underwent a total of 441 liver transplants. Data were obtained retrospectively by review of hospital records. RESULTS With a mean follow-up period of 5.3+/-2.7 years, the overall patient survival rates at 1 and 5 years were 77.1% and 67.1%, respectively. Primary allograft survival rates were 65.6% and 56.5%, respectively. Of the 137 patients who developed failure of their primary allograft, 92 underwent retransplantation (29.3% of all primary transplants). Both patient and allograft survival rates were significantly decreased after retransplantation (P<0.0001 versus primary transplants). Univariate and multivariate analysis of retransplanted patients revealed only two factors that were statistically related to patient and graft survival: age at the time of retransplantation (P<0.02 univariate and P<0.05 multivariate) and retransplantation with a reduced-size allograft (P<0.005 univariate and P<0.05 multivariate). In this series, the effect on patient survival of differences in medical condition as reflected by United Network for Organ Sharing (UNOS) status approached, but did not achieve, significance (P=0.08 for UNOS 1 versus UNOS 2 and 3). UNOS status did not affect graft survival. Neither the cause of primary allograft loss or the timing of retransplantation relative to the first transplant were related to outcome. CONCLUSIONS These data demonstrate that the failure of primary hepatic allografts remains a major problem in pediatric liver transplantation and that the overall results of retransplantation were significantly worse than those associated with primary transplants. We have identified a group of children who experienced a significantly worse outcome after retransplantation. This group consisted of children less than 3 years of age retransplanted using reduced-size grafts. Based on this finding, we now attempt to avoid retransplanting young children with reduced-size grafts. By using this approach, we hope to be able to offer children the option of retransplantation with improved results and simultaneously minimize the negative impact on patients awaiting primary transplants.
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Affiliation(s)
- K A Newell
- Section of Transplantation, University of Chicago, Illinois 60637, USA
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Abstract
Published reports examining the efficacy of fish oil for preserving renal function in immunoglobulin A (IgA) nephropathy have yielded conflicting results. This investigation was a meta-analysis conducted to determine whether the medical literature supports this therapy. In addition, the sources of variability among published findings were examined. Studies were combined using a random effects model. Five controlled studies were identified, two with positive results and three with negative results. Forty-four percent of the between-study variance could be attributed to differences in follow-up times and, less significantly, the number of renal function measurements; a weighting procedure was developed, eliminating this variance from the combined result. When all studies were combined, the mean effect, +0.25 +/- 0.23 SD (positive effects indicate that treatment was superior to control), was not statistically significant; however, the probability of at least a minor beneficial effect was 75%. Mixed-effects regression suggested that this therapy may be more effective among individuals with more proteinuria. The medical literature, therefore, does not prove the efficacy of fish oil therapy in IgA nephropathy, but suggests that an additional placebo-controlled trial is warranted. A sample-size calculation indicated that such a trial should be larger than those to date or should attempt to increase the treatment effect, perhaps by treating for more than 2 yr or enrolling more severely proteinuric individuals.
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Affiliation(s)
- J J Dillon
- Section of Nephrology, University of Chicago, Illinois, USA
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