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Demirjian S, Chawla L, Davison D, Forni LG, Heung M, Hoste EAJ, Koyner J, Kampf JP, Kwan T, Mcpherson P, Kellum JA. CCL14 Predicts Oliguria and Dialysis Requirement in Patients with Moderate to Severe Acute Kidney Injury. Blood Purif 2024:000538898. [PMID: 38636476 DOI: 10.1159/000538898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
INTRUDUCTION AKI is a frequent complication in critical illness and portends poor outcome. CCL14 has been validated to predict persistent severe AKI in critically ill patients. We examined the association of CCL14 with urine output within 48 hours. METHODS In pooled data from 2 studies of critically ill patients with KDIGO stage 2-3 AKI, CCL14 was measured by NEPHROCLEAR™CCL14 Test on the Astute 140® Meter, and divided to low, intermediate and high categories (1.3 and 13 ng/mL). Average hourly urine output over 48 hours, stage 3 AKI per urine output criterion on day 2, and composite of dialysis or death within 7 days were examined using multivariable mixed, and logistic regression models. RESULTS Of the 497 subjects with median age of 65 [56-74] years, 49% (242/497) were on diuretics. CCL14 concentration was low in 219 (44%), intermediate in 217 (44%), and high in 61 (12%) patients. In mixed regression analysis, urine output trajectory over time was different within each CCL14 risk category based on diuretic use due to significant three-way interaction (p < 0.001). In logistic regression analysis CCL14 risk category was independently associated with low urine output on day 2 (KDIGO stage 3) adjusted for diuretic use and baseline clinical variables and composite of dialysis or death within 7 days (adjusted for urine output within 48 hours of CCL14 measurement). CONCLUSIONS CCL14 measured in patients with moderate to severe AKI is associated with urine output trajectory within 48 hours, oliguria on day 2, and dialysis within 7 days.
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Chuang MH, Tang YS, Chen JY, Pan HC, Liao HW, Chu WK, Cheng CY, Wu VC, Heung M. Abrupt Decline in Estimated Glomerular Filtration Rate after Initiating Sodium-Glucose Cotransporter 2 Inhibitors Predicts Clinical Outcomes: A Systematic Review and Meta-Analysis. Diabetes Metab J 2024; 48:242-252. [PMID: 38273790 PMCID: PMC10995480 DOI: 10.4093/dmj.2023.0201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 09/25/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGRUOUND The initiation of sodium-glucose cotransporter-2 inhibitors (SGLT2i) typically leads to a reversible initial dip in estimated glomerular filtration rate (eGFR). The implications of this phenomenon on clinical outcomes are not well-defined. METHODS We searched MEDLINE, Embase, and Cochrane Library from inception to March 23, 2023 to identify randomized controlled trials and cohort studies comparing kidney and cardiovascular outcomes in patients with and without initial eGFR dip after initiating SGLT2i. Pooled estimates were calculated using random-effect meta-analysis. RESULTS We included seven studies in our analysis, which revealed that an initial eGFR dip following the initiation of SGLT2i was associated with less annual eGFR decline (mean difference, 0.64; 95% confidence interval [CI], 0.437 to 0.843) regardless of baseline eGFR. The risk of major adverse kidney events was similar between the non-dipping and dipping groups but reduced in patients with a ≤10% eGFR dip (hazard ratio [HR], 0.915; 95% CI, 0.865 to 0.967). No significant differences were observed in the composite of hospitalized heart failure and cardiovascular death (HR, 0.824; 95% CI, 0.633 to 1.074), hospitalized heart failure (HR, 1.059; 95% CI, 0.574 to 1.952), or all-cause mortality (HR, 0.83; 95% CI, 0.589 to 1.170). The risk of serious adverse events (AEs), discontinuation of SGLT2i due to AEs, kidney-related AEs, and volume depletion were similar between the two groups. Patients with >10% eGFR dip had increased risk of hyperkalemia compared to the non-dipping group. CONCLUSION Initial eGFR dip after initiating SGLT2i might be associated with less annual eGFR decline. There were no significant disparities in the risks of adverse cardiovascular outcomes between the dipping and non-dipping groups.
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Affiliation(s)
- Min-Hsiang Chuang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Shuo Tang
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Medical University Research Center of Urology and Kidney, Taipei, Taiwan
| | - Jui-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Heng-Chih Pan
- Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Hung-Wei Liao
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wen-Kai Chu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chung-Yi Cheng
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Medical University Research Center of Urology and Kidney, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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Bailoor K, Laventhal N, Heung M, Wright J. Hemodialysis in non-cooperative patients: a structured approach. Nephrol Dial Transplant 2024:gfae017. [PMID: 38253405 DOI: 10.1093/ndt/gfae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Affiliation(s)
- Kunal Bailoor
- Division of Nephrology, University of Michigan Hospitals, Ann Arbor, MI, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Naomi Laventhal
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Pediatric Neonatology, University of Michigan Hospitals, Ann Arbor, MI, USA
| | - Michael Heung
- Division of Nephrology, University of Michigan Hospitals, Ann Arbor, MI, USA
| | - Julie Wright
- Division of Nephrology, University of Michigan Hospitals, Ann Arbor, MI, USA
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Szamosfalvi B, Heung M. Citrate Anticoagulation for CKRT with Liver Failure: Ready for Prime Time? Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00310. [PMID: 38109078 PMCID: PMC10861106 DOI: 10.2215/cjn.0000000000000390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Affiliation(s)
- Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
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Bodmer BS, Breithaupt A, Heung M, Brunetti JE, Henkel C, Müller-Guhl J, Rodríguez E, Wendt L, Winter SL, Vallbracht M, Müller A, Römer S, Chlanda P, Muñoz-Fontela C, Hoenen T, Escudero-Pérez B. In vivo characterization of the novel ebolavirus Bombali virus suggests a low pathogenic potential for humans. Emerg Microbes Infect 2023; 12:2164216. [PMID: 36580440 PMCID: PMC9858441 DOI: 10.1080/22221751.2022.2164216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Ebolaviruses cause outbreaks of haemorrhagic fever in Central and West Africa. Some members of this genus such as Ebola virus (EBOV) are highly pathogenic, with case fatality rates of up to 90%, whereas others such as Reston virus (RESTV) are apathogenic for humans. Bombali virus (BOMV) is a novel ebolavirus for which complete genome sequences were recently found in free-tailed bats, although no infectious virus could be isolated. Its pathogenic potential for humans is unknown. To address this question, we first determined whether proteins encoded by the available BOMV sequence found in Chaerephon pumilus were functional in in vitro assays. The correction of an apparent sequencing error in the glycoprotein based on these data then allowed us to generate infectious BOMV using reverse genetics and characterize its infection of human cells. Furthermore, we used HLA-A2-transgenic, NOD-scid-IL-2γ receptor-knockout (NSG-A2) mice reconstituted with human haematopoiesis as a model to evaluate the pathogenicity of BOMV in vivo in a human-like immune environment. These data demonstrate that not only does BOMV show a slower growth rate than EBOV in vitro, but it also shows low pathogenicity in humanized mice, comparable to previous studies using RESTV. Taken together, these findings suggest a low pathogenic potential of BOMV for humans.
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Affiliation(s)
- B. S. Bodmer
- Institute for Molecular Virology and Cell Biology, Friedrich-Loeffler-Institut, Greifswald – Insel Riems, Germany
| | - A. Breithaupt
- Department of Experimental Animal Facilities and Biorisk Management, Friedrich-Loeffler-Institut, Greifswald – Insel Riems, Germany
| | - M. Heung
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - J. E. Brunetti
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - C. Henkel
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - J. Müller-Guhl
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany,Leibniz Institute of Virology, Hamburg, Germany
| | - E. Rodríguez
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany,German Center for Infection Research (DZIF), Partner Site Hamburg-Luebeck-Borstel, Braunschweig, Germany
| | - L. Wendt
- Institute for Molecular Virology and Cell Biology, Friedrich-Loeffler-Institut, Greifswald – Insel Riems, Germany
| | - S. L. Winter
- Schaller Research Groups, Department of Infectious Diseases, Virology, Heidelberg University Hospital, Heidelberg, Germany
| | - M. Vallbracht
- Schaller Research Groups, Department of Infectious Diseases, Virology, Heidelberg University Hospital, Heidelberg, Germany
| | - A. Müller
- Institute for Molecular Virology and Cell Biology, Friedrich-Loeffler-Institut, Greifswald – Insel Riems, Germany
| | - S. Römer
- Institute for Molecular Virology and Cell Biology, Friedrich-Loeffler-Institut, Greifswald – Insel Riems, Germany
| | - P. Chlanda
- Schaller Research Groups, Department of Infectious Diseases, Virology, Heidelberg University Hospital, Heidelberg, Germany
| | - C. Muñoz-Fontela
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany,German Center for Infection Research (DZIF), Partner Site Hamburg-Luebeck-Borstel, Braunschweig, Germany
| | - T. Hoenen
- Institute for Molecular Virology and Cell Biology, Friedrich-Loeffler-Institut, Greifswald – Insel Riems, Germany, T. Hoenen Institute for Molecular Virology and Cell Biology, Friedrich-Loeffler-Institut, Südufer 10, Greifswald – Insel Riems, 17493Germany
| | - B. Escudero-Pérez
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany,German Center for Infection Research (DZIF), Partner Site Hamburg-Luebeck-Borstel, Braunschweig, Germany
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Paje D, Heath M, Heung M, Horowitz JK, Bernstein SJ, Flanders SA, Chopra V. Midline catheters in patients with advanced chronic kidney disease. J Hosp Med 2023; 18:969-977. [PMID: 37771294 DOI: 10.1002/jhm.13209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 09/01/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Midline catheters (midlines) are increasingly used in patients with advanced chronic kidney disease (CKD). OBJECTIVE This study describes current practice and acute complications associated with midlines in CKD patients. DESIGNS, SETTING, AND PARTICIPANTS Trained abstractors at 66 hospitals from the Michigan Hospital Medicine Safety (HMS) Consortium collected data on a sample of patients who received a midline during hospitalization. Patients were classified as having advanced CKD if their estimated glomerular filtration rate was <45 mL/min/1.73 m2 . MAIN OUTCOME AND MEASURES Midline recipients with advanced CKD were compared to those without advanced CKD by patient, provider, and device characteristics, and by the occurrence of acute complications including major (e.g., upper extremity deep vein thrombosis [UE-DVT] and catheter-related bloodstream infection [CRBSI]) or minor (e.g., catheter occlusion, catheter dislodgement, infiltration, superficial thrombophlebitis, and leaking at insertion site) events. Multivariable mixed effects logistic regression was used to evaluate the association between catheter-related complications and stage of CKD. RESULTS Of 21,415 midline recipients, 5272 (24.6%) had advanced CKD, while 16,143 (75.4%) did not. Most midlines were single lumen (90.5%) and remained in place for a median of 6 days. A major or minor midline complication occurred in 804 (15.3%) patients with and 2239 (14.4%) patients without advanced CKD (adjusted odds ratios = 1.04; 95% confidence interval: 0.94-1.14). Among patients with advanced CKD, CRBSI occurred in 13 patients (0.2%) and UE-DVT occurred in 65 patients (1.2%). The proportion of advanced CKD among midline recipients and the frequency of midline-related complications varied across hospitals (interquartile range [IQR] = 19.2% to 29.8% [median = 25.0%] and IQR = 11.0%-18.9% [median = 15.4%], respectively).
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Affiliation(s)
- David Paje
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan, USA
| | - Megan Heath
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan, USA
| | - Michael Heung
- Department of Internal Medicine, Division of Nephrology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jennifer K Horowitz
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan, USA
| | - Steven J Bernstein
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan, USA
- Department of Internal Medicine, Division of General Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- The Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, Michigan, USA
- Department of Medicine, University of Colorado Denver, Aurora, Colorado, USA
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Do-Nguyen CC, Sturmer DL, Yang G, Hawkins RB, Engoren M, Wolverton J, Heung M, Zhang M, Likosky DS. Oxygen Delivery Thresholds During Cardiopulmonary Bypass and Risk for Acute Kidney Injury. Ann Thorac Surg 2023; 116:607-613. [PMID: 37271444 DOI: 10.1016/j.athoracsur.2023.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/17/2023] [Accepted: 04/24/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) in cardiac surgery patients is multifactorial and associated with low oxygen delivery (DO2) during cardiopulmonary bypass. METHODS Cardiac surgical patients undergoing full cardiopulmonary bypass between May 1, 2016 and December 31, 2021 were included, whereas those on preoperative dialysis, undergoing circulatory arrest procedures, or lacking minute-to-minute physiologic data were excluded. A 5-minute running average of indexed DO2 (DO2i, mL/min/m2) was calculated ([pump flow] × [hemoglobin] × 1.36 [hemoglobin saturation] + 0.003 [arterial oxygen tension]/body surface area). AKI was defined using established Kidney Disease: Improving Global Outcomes criteria. The threshold of nadir DO2i on the effect of AKI was estimated using risk-adjusted Constrained Broken-Stick models. RESULTS Postoperative AKI occurred among 1155 patients (29.4%), with 276 (7.0%) having stage 2 to 3 AKI. The median nadir DO2i was lower for those with (vs without) AKI (197.9 mL/min/m2 [interquartile range {IQR}, 166.3-233.2] vs 217.2 mL/min/m2 [IQR, 184.5-252.2], P < .001) and stage 2 to 3 AKI relative to stage 1 or none (186.9 mL/min/m2 [IQR, 160.1-220.5] vs 213.8 mL/min/m2 [IQR, 180.4-249.4]). In risk-adjusted analyses the estimated threshold for nadir DO2i was 231.2 mL/min/m2 (95% CI, 173.6-288.8) for any AKI and 103.3 (95% CI, 68.4-138.3) for stage 2 to 3 AKI. CONCLUSIONS Decreasing nadir DO2i was associated with an increased risk of AKI. The identified nadir DO2i thresholds suggest management and treatment of nadir DO2i during cardiopulmonary bypass may decrease a patient's postoperative AKI risk.
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Affiliation(s)
- Chi Chi Do-Nguyen
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - David L Sturmer
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Guangyu Yang
- Institute of Statistics and Big Data, Renmin University of China, Beijing, China
| | - Robert B Hawkins
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Milo Engoren
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jeremy Wolverton
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Michael Heung
- Division of Nephrology, Department of Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Min Zhang
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.
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Wang J, Moy BM, Kaufhold RT, Muzaurieta A, Xia Y, Jiang S, Yim A, Chang Miller J, Zhou S, Lee P, Hou L, Lee J, Heung M. Framework for virtual education of COVID-19 vaccines for Mandarin-speaking learners: an educational intervention module. MedEdPublish (2016) 2023; 13:14. [PMID: 37736237 PMCID: PMC10509786 DOI: 10.12688/mep.19207.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND In the United States, patients with limited English proficiency face significant barriers to comprehending and acting upon health-related information, particularly during the COVID-19 pandemic. The ability of health professionals to communicate COVID-19-related information to Mandarin-speaking patients has proved critical in discussions about vaccine efficacy, side effects, and post-vaccine protection. METHODS The authors created a one-hour educational module to help Mandarin-speaking medical students better convey COVID-19 vaccine information to Mandarin-only speakers. The module is composed of an educational guide, which introduced key terminology and addressed commonly asked questions, and pre- and post-surveys. The authors recruited 59 Mandarin-speaking medical students all of whom had previously completed a medical Mandarin elective. The module and surveys were distributed and completed in August 2021. Data analysis measured the change in aggregate mean for subjective five-point Likert-scale questions and change in percent accuracy for objective knowledge-based questions. RESULTS 86.4% of participants were primary English speakers with variable levels of Mandarin proficiency. The educational module significantly improved participants' subjective comfort level in discussing the COVID-19 vaccine in English and Mandarin. The largest improvement in both English and Mandarin was demonstrated in participants' ability to explain differences between the COVID-19 vaccines, with an aggregate mean improvement of 0.39 for English and 1.48 for Mandarin. Survey respondents also demonstrated increased percent accuracy in knowledge-based objective questions in Mandarin. CONCLUSIONS This module provides Mandarin-learning medical students with skills to deliver reliable information to the general population and acts as a model for the continued development of educational modules for multilingual medical professionals.
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Affiliation(s)
- JiCi Wang
- University of Michigan Medical School, 1301 E. Catherine Street, Ann Arbor, MI, 48109, USA
| | - Benjamin M. Moy
- University of Michigan Medical School, 1301 E. Catherine Street, Ann Arbor, MI, 48109, USA
| | - Ross T. Kaufhold
- University of Michigan Medical School, 1301 E. Catherine Street, Ann Arbor, MI, 48109, USA
| | - Aurelio Muzaurieta
- University of Michigan Medical School, 1301 E. Catherine Street, Ann Arbor, MI, 48109, USA
| | - Yang Xia
- University of Michigan Medical School, 1301 E. Catherine Street, Ann Arbor, MI, 48109, USA
| | - Shannon Jiang
- University of Michigan Medical School, 1301 E. Catherine Street, Ann Arbor, MI, 48109, USA
| | - Angela Yim
- University of Michigan Medical School, 1301 E. Catherine Street, Ann Arbor, MI, 48109, USA
| | - Jane Chang Miller
- Michigan Medicine 3914, Taubman Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Shiwei Zhou
- Michigan Medicine 3914, Taubman Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Pearl Lee
- Michigan Medicine 3914, Taubman Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Lisa Hou
- Asian Center-Southeast Michigan, Southfield, MI, 48075, USA
| | - Janilla Lee
- Asian Center-Southeast Michigan, Southfield, MI, 48075, USA
| | - Michael Heung
- Michigan Medicine 3914, Taubman Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
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Rewa OG, Ortiz-Soriano V, Lambert J, Kabir S, Heung M, House AA, Monga D, Juncos LA, Secic M, Piazza R, Goldstein SL, Bagshaw SM, Neyra JA. Epidemiology and Outcomes of AKI Treated With Continuous Kidney Replacement Therapy: The Multicenter CRRTnet Study. Kidney Med 2023; 5:100641. [PMID: 37274539 PMCID: PMC10238597 DOI: 10.1016/j.xkme.2023.100641] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
Rationale & Objective Continuous kidney replacement therapy (CKRT) is the predominant form of acute kidney replacement therapy used for critically ill adult patients with acute kidney injury (AKI). Given the variability in CKRT practice, a contemporary understanding of its epidemiology is necessary to improve care delivery. Study Design Multicenter, prospective living registry. Setting & Population 1,106 critically ill adults with AKI requiring CKRT from December 2013 to January 2021 across 5 academic centers and 6 intensive care units. Patients with pre-existing kidney failure and those with coronavirus 2 infection were excluded. Exposure CKRT for more than 24 hours. Outcomes Hospital mortality, kidney recovery, and health care resource utilization. Analytical Approach Data were collected according to preselected timepoints at intensive care unit admission and CKRT initiation and analyzed descriptively. Results Patients' characteristics, contributors to AKI, and CKRT indications differed among centers. Mean (standard deviation) age was 59.3 (13.9) years, 39.7% of patients were women, and median [IQR] APACHE-II (acute physiologic assessment and chronic health evaluation) score was 30 [25-34]. Overall, 41.1% of patients survived to hospital discharge. Patients that died were older (mean age 61 vs. 56.8, P < 0.001), had greater comorbidity (median Charlson score 3 [1-4] vs. 2 [1-3], P < 0.001), and higher acuity of illness (median APACHE-II score 30 [25-35] vs. 29 [24-33], P = 0.003). The most common condition predisposing to AKI was sepsis (42.6%), and the most common CKRT indications were oliguria/anuria (56.2%) and fluid overload (53.9%). Standardized mortality ratios were similar among centers. Limitations The generalizability of these results to CKRT practices in nonacademic centers or low-and middle-income countries is limited. Conclusions In this registry, sepsis was the major contributor to AKI and fluid management was collectively the most common CKRT indication. Significant heterogeneity in patient- and CKRT-specific characteristics was found in current practice. These data highlight the need for establishing benchmarks of CKRT delivery, performance, and patient outcomes. Data from this registry could assist with the design of such studies.
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Affiliation(s)
- Oleksa G. Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton Alberta Canada
| | - Victor Ortiz-Soriano
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY
| | - Joshua Lambert
- College of Nursing, University of Cincinnati, Cincinnati, OH
| | - Shaowli Kabir
- Department of Biostatistics, University of Kentucky, Lexington, KY
| | - Michael Heung
- Division of Nephrology, University of Michigan, Ann Arbor, MI
| | - Andrew A. House
- Division of Nephrology, Western University and London Health Sciences Centre, London, Canada
| | - Divya Monga
- Division of Nephrology, University of Mississippi, Jackson, MI
| | - Luis A. Juncos
- Central Arkansas Veterans Healthcare System (CAVHS), Little Rock, Arkansas
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Robin Piazza
- Watermark Research Partners, Inc, Indianapolis, IN
| | - Stuart L. Goldstein
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital and Medical Center, University of Cincinnati, Cincinnati, OH
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton Alberta Canada
| | - Javier A. Neyra
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY
- Department of Internal Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
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10
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Veinot TC, Gillespie B, Argentina M, Bragg-Gresham J, Chatoth D, Collins Damron K, Heung M, Krein S, Wingard R, Zheng K, Saran R. Enhancing the Cardiovascular Safety of Hemodialysis Care Using Multimodal Provider Education and Patient Activation Interventions: Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e46187. [PMID: 37079365 PMCID: PMC10160944 DOI: 10.2196/46187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/19/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND End-stage kidney disease (ESKD) is treated with dialysis or kidney transplantation, with most patients with ESKD receiving in-center hemodialysis treatment. This life-saving treatment can result in cardiovascular and hemodynamic instability, with the most common form being low blood pressure during the dialysis treatment (intradialytic hypotension [IDH]). IDH is a complication of hemodialysis that can involve symptoms such as fatigue, nausea, cramping, and loss of consciousness. IDH increases risks of cardiovascular disease and ultimately hospitalizations and mortality. Provider-level and patient-level decisions influence the occurrence of IDH; thus, IDH may be preventable in routine hemodialysis care. OBJECTIVE This study aims to evaluate the independent and comparative effectiveness of 2 interventions-one directed at hemodialysis providers and another for patients-in reducing the rate of IDH at hemodialysis facilities. In addition, the study will assess the effects of interventions on secondary patient-centered clinical outcomes and examine factors associated with a successful implementation of the interventions. METHODS This study is a pragmatic, cluster randomized trial to be conducted in 20 hemodialysis facilities in the United States. Hemodialysis facilities will be randomized using a 2 × 2 factorial design, such that 5 sites will receive a multimodal provider education intervention, 5 sites will receive a patient activation intervention, 5 sites will receive both interventions, and 5 sites will receive none of the 2 interventions. The multimodal provider education intervention involved theory-informed team training and the use of a digital, tablet-based checklist to heighten attention to patient clinical factors associated with increased IDH risk. The patient activation intervention involves tablet-based, theory-informed patient education and peer mentoring. Patient outcomes will be monitored during a 12-week baseline period, followed by a 24-week intervention period and a 12-week postintervention follow-up period. The primary outcome of the study is the proportion of treatments with IDH, which will be aggregated at the facility level. Secondary outcomes include patient symptoms, fluid adherence, hemodialysis adherence, quality of life, hospitalizations, and mortality. RESULTS This study is funded by the Patient-Centered Outcomes Research Institute and approved by the University of Michigan Medical School's institutional review board. The study began enrolling patients in January 2023. Initial feasibility data will be available in May 2023. Data collection will conclude in November 2024. CONCLUSIONS The effects of provider and patient education on reducing the proportion of sessions with IDH and improving other patient-centered clinical outcomes will be evaluated, and the findings will be used to inform further improvements in patient care. Improving the stability of hemodialysis sessions is a critical concern for clinicians and patients with ESKD; the interventions targeted to providers and patients are predicted to lead to improvements in patient health and quality of life. TRIAL REGISTRATION ClinicalTrials.gov NCT03171545; https://clinicaltrials.gov/ct2/show/NCT03171545. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/46187.
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Affiliation(s)
- Tiffany Christine Veinot
- School of Information, University of Michigan, Ann Arbor, MI, United States
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, United States
- Department of Learning Health Sciences, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Brenda Gillespie
- Department of Biostatistics, Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI, United States
| | | | - Jennifer Bragg-Gresham
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, United States
| | | | | | - Michael Heung
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
| | - Sarah Krein
- Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, United States
- Veterans Affairs Center for Clinical Management Research, US Department of Veterans Affairs, Ann Arbor, MI, United States
| | | | - Kai Zheng
- School of Information and Computer Sciences, University of California Irvine, Irvine, CA, United States
| | - Rajiv Saran
- Division of Nephrology, School of Medicine, Ann Arbor, MI, United States
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, United States
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11
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Douville NJ, Larach DB, Lewis A, Bastarache L, Pandit A, He J, Heung M, Mathis M, Wanderer JP, Kheterpal S, Surakka I, Kertai MD. Genetic predisposition may not improve prediction of cardiac surgery-associated acute kidney injury. Front Genet 2023; 14:1094908. [PMID: 37124606 PMCID: PMC10133500 DOI: 10.3389/fgene.2023.1094908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/21/2023] [Indexed: 05/02/2023] Open
Abstract
Background: The recent integration of genomic data with electronic health records has enabled large scale genomic studies on a variety of perioperative complications, yet genome-wide association studies on acute kidney injury have been limited in size or confounded by composite outcomes. Genome-wide association studies can be leveraged to create a polygenic risk score which can then be integrated with traditional clinical risk factors to better predict postoperative complications, like acute kidney injury. Methods: Using integrated genetic data from two academic biorepositories, we conduct a genome-wide association study on cardiac surgery-associated acute kidney injury. Next, we develop a polygenic risk score and test the predictive utility within regressions controlling for age, gender, principal components, preoperative serum creatinine, and a range of patient, clinical, and procedural risk factors. Finally, we estimate additive variant heritability using genetic mixed models. Results: Among 1,014 qualifying procedures at Vanderbilt University Medical Center and 478 at Michigan Medicine, 348 (34.3%) and 121 (25.3%) developed AKI, respectively. No variants exceeded genome-wide significance (p < 5 × 10-8) threshold, however, six previously unreported variants exceeded the suggestive threshold (p < 1 × 10-6). Notable variants detected include: 1) rs74637005, located in the exonic region of NFU1 and 2) rs17438465, located between EVX1 and HIBADH. We failed to replicate variants from prior unbiased studies of post-surgical acute kidney injury. Polygenic risk was not significantly associated with post-surgical acute kidney injury in any of the models, however, case duration (aOR = 1.002, 95% CI 1.000-1.003, p = 0.013), diabetes mellitus (aOR = 2.025, 95% CI 1.320-3.103, p = 0.001), and valvular disease (aOR = 0.558, 95% CI 0.372-0.835, p = 0.005) were significant in the full model. Conclusion: Polygenic risk score was not significantly associated with cardiac surgery-associated acute kidney injury and acute kidney injury may have a low heritability in this population. These results suggest that susceptibility is only minimally influenced by baseline genetic predisposition and that clinical risk factors, some of which are modifiable, may play a more influential role in predicting this complication. The overall impact of genetics in overall risk for cardiac surgery-associated acute kidney injury may be small compared to clinical risk factors.
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Affiliation(s)
- Nicholas J. Douville
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, United States
- Center for Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, MI, United States
- Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Daniel B. Larach
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Adam Lewis
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Anita Pandit
- Center for Statistical Genetics and Precision Health Initiative, University of Michigan, Ann Arbor, MI, United States
| | - Jing He
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Michael Mathis
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, United States
- Center for Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, MI, United States
- Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Jonathan P. Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, United States
| | - Ida Surakka
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
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12
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Wang J, Moy BM, Kaufhold RT, Muzaurieta A, Xia Y, Jiang S, Yim A, Chang Miller J, Zhou S, Lee P, Hou L, Lee J, Heung M. Framework for virtual education of COVID-19 vaccines for Mandarin-speaking learners: an educational intervention module. MedEdPublish 2023. [DOI: 10.12688/mep.19207.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Background: In the United States, patients with limited English proficiency face significant barriers to comprehending and acting upon health-related information, particularly during the COVID-19 pandemic. The ability of health professionals to communicate COVID-19-related information to Mandarin-speaking patients has proved critical in discussions about vaccine efficacy, side effects, and post-vaccine protection. Methods: The authors created a one-hour educational module to help Mandarin-speaking medical students better convey COVID-19 vaccine information to Mandarin-only speakers. The module is composed of an educational guide, which introduced key terminology and addressed commonly asked questions, and pre- and post-surveys. The authors recruited 59 Mandarin-speaking medical students all of whom had previously completed a medical Mandarin elective. The module and surveys were distributed and completed in August 2021. Data analysis measured the change in aggregate mean for subjective five-point Likert-scale questions and change in percent accuracy for objective knowledge-based questions. Results: The educational module significantly improved participants' subjective comfort level in discussing the COVID-19 vaccine in English and Mandarin. The largest improvement in both English and Mandarin was demonstrated in the participants ability to explain differences between the COVID-19 vaccines, with an aggregate mean improvement of 0.39 for English and 1.48 for Mandarin. Survey respondents also demonstrated increased percent accuracy in knowledge-based objective questions in Mandarin. Conclusions: This module provides Mandarin-learning medical students with skills to deliver reliable information to the general population and acts as a model for the continued development of educational modules for multilingual medical professionals.
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Liu K, Koyner JL, Heung M, Vijayan A. Care of the Hospitalized Patients with Kidney Failure during COVID-19 Pandemic: Lessons Learned. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00058. [PMID: 36795034 PMCID: PMC10356130 DOI: 10.2215/cjn.0000000000000093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Kathleen Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California at San Francisco, San Francisco, California
| | - Jay L. Koyner
- Section of Nephrology, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Michael Heung
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Anitha Vijayan
- Division of Nephrology, Washington University in St. Louis, St. Louis, Missouri
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14
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Cao J, Zhang X, Shahinian V, Yin H, Steffick D, Saran R, Crowley S, Mathis M, Nadkarni GN, Heung M, Singh K. Generalizability of an acute kidney injury prediction model across health systems. NAT MACH INTELL 2022; 4:1121-1129. [PMID: 38148789 PMCID: PMC10751025 DOI: 10.1038/s42256-022-00563-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/11/2022] [Indexed: 12/03/2022]
Abstract
Delays in the identification of acute kidney injury (AKI) in hospitalized patients are a major barrier to the development of effective interventions to treat AKI. A recent study by Tomasev and colleagues at DeepMind described a model that achieved a state-of-the-art performance in predicting AKI up to 48 hours in advance.1 Because this model was trained in a population of US Veterans that was 94% male, questions have arisen about its reproducibility and generalizability. In this study, we aimed to reproduce key aspects of this model, trained and evaluated it in a similar population of US Veterans, and evaluated its generalizability in a large academic hospital setting. We found that the model performed worse in predicting AKI in females in both populations, with miscalibration in lower stages of AKI and worse discrimination (a lower area under the curve) in higher stages of AKI. We demonstrate that while this discrepancy in performance can be largely corrected in non-Veterans by updating the original model using data from a sex-balanced academic hospital cohort, the worse model performance persists in Veterans. Our study sheds light on the importance of reproducing artificial intelligence studies, and on the complexity of discrepancies in model performance in subgroups that cannot be explained simply on the basis of sample size.
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Affiliation(s)
- Jie Cao
- Department of Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI
| | - Xiaosong Zhang
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Vahakn Shahinian
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Huiying Yin
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Diane Steffick
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arb, MI
| | - Susan Crowley
- Renal Section, VA Connecticut Healthcare System, West Haven, CT
| | - Michael Mathis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI
| | - Girish N. Nadkarni
- Mount Sinai Clinical Intelligence Center, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Data Driven and Digital Medicine (D3M), Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael Heung
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Karandeep Singh
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
- School of Information, University of Michigan, Ann Arbor, MI
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15
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Larach DB, Lewis A, Bastarache L, Pandit A, He J, Sinha A, Douville NJ, Heung M, Mathis MR, Mosley JD, Wanderer JP, Kheterpal S, Zawistowski M, Brummett CM, Siew ED, Robinson-Cohen C, Kertai MD. Limited clinical utility for GWAS or polygenic risk score for postoperative acute kidney injury in non-cardiac surgery in European-ancestry patients. BMC Nephrol 2022; 23:339. [PMID: 36271344 PMCID: PMC9587619 DOI: 10.1186/s12882-022-02964-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/27/2022] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Prior studies support a genetic basis for postoperative acute kidney injury (AKI). We conducted a genome-wide association study (GWAS), assessed the clinical utility of a polygenic risk score (PRS), and estimated the heritable component of AKI in patients who underwent noncardiac surgery. METHODS We performed a retrospective large-scale genome-wide association study followed by a meta-analysis of patients who underwent noncardiac surgery at the Vanderbilt University Medical Center ("Vanderbilt" cohort) or Michigan Medicine, the academic medical center of the University of Michigan ("Michigan" cohort). In the Vanderbilt cohort, the relationship between polygenic risk score for estimated glomerular filtration rate and postoperative AKI was also tested to explore the predictive power of aggregating multiple common genetic variants associated with AKI risk. Similarly, in the Vanderbilt cohort genome-wide complex trait analysis was used to estimate the heritable component of AKI due to common genetic variants. RESULTS The study population included 8248 adults in the Vanderbilt cohort (mean [SD] 58.05 [15.23] years, 50.2% men) and 5998 adults in Michigan cohort (56.24 [14.76] years, 49% men). Incident postoperative AKI events occurred in 959 patients (11.6%) and in 277 patients (4.6%), respectively. No loci met genome-wide significance in the GWAS and meta-analysis. PRS for estimated glomerular filtration rate explained a very small percentage of variance in rates of postoperative AKI and was not significantly associated with AKI (odds ratio 1.050 per 1 SD increase in polygenic risk score [95% CI, 0.971-1.134]). The estimated heritability among common variants for AKI was 4.5% (SE = 4.5%) suggesting low heritability. CONCLUSION The findings of this study indicate that common genetic variation minimally contributes to postoperative AKI after noncardiac surgery, and likely has little clinical utility for identifying high-risk patients.
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Affiliation(s)
- Daniel B Larach
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adam Lewis
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anita Pandit
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Jing He
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anik Sinha
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Nicholas J Douville
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
- Institute of Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan D Mosley
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for AKI (VIP-AKI), Tennessee Valley Health System, Nashville Veterans Affairs Hospital, Nashville, TN, USA
| | - Cassianne Robinson-Cohen
- Vanderbilt O'Brien Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Miklos D Kertai
- Division of Adult Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, Medical Arts Building, Office 526E, Nashville, TN, 37212, USA.
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16
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Sohaney R, Yin H, Shahinian V, Saran R, Burrows NR, Pavkov ME, Banerjee T, Hsu CY, Powe N, Steffick D, Zivin K, Heung M. In-Hospital and 1-Year Mortality Trends in a National Cohort of US Veterans with Acute Kidney Injury. Clin J Am Soc Nephrol 2022; 17:184-193. [PMID: 35131927 PMCID: PMC8823933 DOI: 10.2215/cjn.01730221] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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: 02/03/2021] [Accepted: 12/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES AKI, a frequent complication among hospitalized patients, confers excess short- and long-term mortality. We sought to determine trends in in-hospital and 1-year mortality associated with AKI as defined by Kidney Disease Improving Global Outcomes consensus criteria. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective cohort study used data from the national Veterans Health Administration on all patients hospitalized from October 1, 2008 to September 31, 2017. AKI was defined by Kidney Disease Improving Global Outcomes serum creatinine criteria. In-hospital and 1-year mortality trends were analyzed in patients with and without AKI using Cox regression with year as a continuous variable. RESULTS We identified 1,688,457 patients and 2,689,093 hospitalizations across the study period. Among patients with AKI, 6% died in hospital, and 28% died within 1 year. In contrast, in-hospital and 1-year mortality rates were 0.8% and 14%, respectively, among non-AKI hospitalizations. During the study period, there was a slight decline in crude in-hospital AKI-associated mortality (hazard ratio, 0.98 per year; 95% confidence interval, 0.98 to 0.99) that was attenuated after accounting for patient demographics, comorbid conditions, and acute hospitalization characteristics (adjusted hazard ratio, 0.99 per year; 95% confidence interval, 0.99 to 1.00). This stable temporal trend in mortality persisted at 1 year (adjusted hazard ratio, 1.00 per year; 95% confidence interval, 0.99 to 1.00). CONCLUSIONS AKI associated mortality remains high, as greater than one in four patients with AKI died within 1 year of hospitalization. Over the past decade, there seems to have been no significant progress toward improving in-hospital or long-term AKI survivorship.
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Affiliation(s)
- Ryann Sohaney
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan,Division of Nephrology, Department of Internal Medicine, Henry Ford Health System, Detroit, Michigan
| | - Huiying Yin
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Vahakn Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan,Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Nilka Ríos Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Meda E. Pavkov
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tanushree Banerjee
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Chi-yuan Hsu
- Division of Nephrology, School of Medicine, University of California, San Francisco, California
| | - Neil Powe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Diane Steffick
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Kara Zivin
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan,Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
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Heung M, Dickinson T, Wu X, Fitzgerald DC, DeLucia A, Paone G, Chores J, Nieter D, Grix D, Theurer P, Zhang M, Likosky DS. The Role of Race on Acute Kidney Injury Following Cardiac Surgery. Ann Thorac Surg 2021; 114:2188-2194. [PMID: 34838514 DOI: 10.1016/j.athoracsur.2021.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 09/30/2021] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) frequently complicates cardiac surgery and is more common among Black patients. We evaluated determinants of race-based differences in AKI rates. METHODS Serum creatinine-based criteria was used to identify adult cardiac surgical patients developing post-operative AKI in the PERForm registry (7/1/2014-6/30/2019). Patient characteristics, operative details and outcomes were compared by race (Black versus White) after excluding patients with pre-operative dialysis, missing pre- or post-operative creatinine, or other races. A mixed effect model (adjusting for demographics, comorbidities, surgical factors) used hospital as a random effect to predict post-operative stage 2 or 3 AKI. Propensity score analyses were conducted to evaluate robustness of the primary analyses. RESULTS The study cohort included 34,520 patients (8% Black). More Black than White patients were female (43 versus 27%, p<.001), had hypertension (93 versus 87%, p<.001) and diabetes (51 versus 41%, p<.001). AKI >Stage 2 occurred among 1,780 (5%) patients, more often among Black than White patients (8 versus 5%, p<.001). Intra-operatively, Black patients had lower nadir hematocrits (23 versus 26, p<.001), and were more likely to be transfused (22 versus 14%, p<.001). After adjustment, Black (compared to White) race independently predicted odds for post-operative AKI (adjOR 1.50, 95% CI 1.26-1.78). The multivariable findings were similar in propensity score analyses. CONCLUSIONS Despite accounting for differences in risk factors and intra-operative practices, Black patients had a 50% increased odds for developing moderate-severe post-operative AKI compared to White patients. Additional evaluations are warranted to identify potential targets to address racial disparities in AKI outcomes.
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Affiliation(s)
- Michael Heung
- Division of Nephrology, University of Michigan, Ann Arbor, MI.
| | | | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | | | - Alphonse DeLucia
- Department of Cardiac Surgery, Bronson Methodist Hospital, Kalamazoo, MI
| | - Gaetano Paone
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA
| | | | - Donald Nieter
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
| | - David Grix
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
| | - Patricia Theurer
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
| | - Min Zhang
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
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Sohaney R, Shaikhouni S, Ludwig JT, Tilea A, Bitzer M, Yessayan L, Heung M. Continuous Renal Replacement Therapy among Patients with COVID-19 and Acute Kidney Injury. Blood Purif 2021; 51:660-667. [PMID: 34727545 PMCID: PMC8678230 DOI: 10.1159/000518713] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 07/18/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Acute kidney injury (AKI) is a common complication among patients with COVID-19 and acute respiratory distress syndrome. Reports suggest that COVID-19 confers a pro-thrombotic state, which presents challenges in maintaining hemofilter patency and delivering continuous renal replacement therapy (CRRT). We present our initial experience with CRRT in critically ill patients with COVID-19, emphasizing circuit patency and the association between fluid balance during CRRT and respiratory parameters. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS Retrospective chart review of 32 consecutive patients with COVID-19 and AKI managed with continuous venovenous hemodiafiltration with regional citrate anticoagulation (CVVHDF-RCA) according to the University of Michigan protocol. Primary outcome was mean CRRT circuit life per patient during the first 7 days of CRRT. We used simple linear regression to assess the relationship between patient characteristics and filter life. We also explored the relationship between fluid balance on CRRT and respiratory parameters using repeated measures modeling. RESULTS Patients' mean age was 54.8 years and majority were Black (75%). Comorbidities included hypertension (90.6%), obesity (70.9%) diabetes (56.2%), and chronic kidney disease (40.6%). Median CRRT circuit life was 53.5 [interquartile range 39.1-77.6] hours. There was no association between circuit life and inflammatory or pro-thrombotic laboratory values (ferritin p = 0.92, C-reactive protein p = 0.29, D-dimer p = 0.24), or with systemic anticoagulation (p = 0.37). Net daily fluid removal during the first 7 days of CRRT was not associated with daily (closest recorded values to 20:00) PaO2/FIO2 ratio (p = 0.21) or positive end-expiratory pressure requirements (p = 0.47). CONCLUSIONS We achieved adequate CRRT circuit life in COVID-19 patients using an established CVVHDF-RCA protocol. During the first 7 days of CRRT therapy, cumulative fluid balance was not associated with improvements in respiratory parameters, even after accounting for baseline fluid balance.
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Affiliation(s)
- Ryann Sohaney
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA,
| | - Salma Shaikhouni
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - John Travis Ludwig
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Anca Tilea
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Markus Bitzer
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Gharibian KN, Lewis SJ, Heung M, Segal JH, Salama NN, Mueller BA. Telavancin pharmacokinetics in patients with chronic kidney disease receiving haemodialysis. J Antimicrob Chemother 2021; 77:174-180. [PMID: 34613416 DOI: 10.1093/jac/dkab370] [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] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/12/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Telavancin is a lipoglycopeptide antibiotic with limited pharmacokinetic data to guide drug dosing in patients receiving haemodialysis. OBJECTIVES This study characterized telavancin pharmacokinetics in patients receiving haemodialysis. PATIENTS AND METHODS This was a Phase IV, prospective, open-label, single-centre, crossover pharmacokinetic study (ClinicalTrials.gov: NCT02392208). Eight subjects with end-stage kidney disease requiring maintenance haemodialysis (mean ± SD: 47 ± 20 years, 69.5 ± 17.1 kg) received 5 mg/kg telavancin IV 3 h before starting a 3.5 hour haemodialysis treatment with a high-permeability haemodialyser (haemodialysis period). After a 14 day washout period, a second 5 mg/kg dose was administered post-haemodialysis (control period). Telavancin plasma concentrations were measured over a 2 day period after each dose and non-compartmental pharmacokinetic analyses were performed. RESULTS The geometric mean (GM) of telavancin overall clearance was 11.2 mL/h/kg (intrinsic clearance and dialytic clearance) in the haemodialysis period and 5.9 mL/h/kg (off-haemodialysis clearance) in the control period [GM ratio (GMR) = 1.89; 90% CI: 1.70-2.10; P < 0.01]. The GM t½ was 13.1 h when haemodialysis occurred 3 h post-dosing in the haemodialysis period but extended to 20.9 h with post-haemodialysis dosing in the control period (GMR = 0.63; 90% CI: 0.54-0.73; P < 0.01). The GM of telavancin plasma concentrations removed by haemodialysis was 27.7%. The GMR of peak plasma concentration and volume of distribution of the haemodialysis period and the control period were 0.88 (90% CI: 0.79-0.98; P = 0.08) and 1.17 (90% CI: 1.05-1.30; P = 0.048), respectively. CONCLUSIONS Haemodialysis with high-permeability haemodialysers removes telavancin considerably (∼⅓ of body load). Telavancin 5 mg/kg every 48 h post-haemodialysis dosing is recommended, but dose adjustments may be warranted if haemodialysis starts within 3 h of telavancin administration.
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Affiliation(s)
| | - Susan J Lewis
- Department of Pharmacy Practice, University of Findlay College of Pharmacy, Findlay, OH, USA.,Department of Pharmacy, Mercy Health St. Anne Hospital, Toledo, OH, USA
| | - Michael Heung
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Jonathan H Segal
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Noha N Salama
- Department of Pharmaceutics and Industrial Pharmacy, Cairo University Faculty of Pharmacy, Cairo, Egypt.,Department of Pharmaceutical and Administrative Sciences, St. Louis College of Pharmacy at the University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Bruce A Mueller
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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20
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Kapp ME, Fogo AB, Roufouse C, Najafian B, Radhakrishnan J, Mohan S, Miller SE, D’Agati VD, Silberzweig J, Barbar T, Gopalan T, Srivatana V, Mokrzycki MH, Benstein JA, Ng YH, Lentine KL, Aggarwal V, Perl J, Salenger P, Koyner JL, Josephson MA, Heung M, Velez JC, Ikizler A, Vijayan A, William P, Thajudeen B, Slepian MJ. Renal Considerations in COVID-19: Biology, Pathology, and Pathophysiology. ASAIO J 2021; 67:1087-1096. [PMID: 34191753 PMCID: PMC8478105 DOI: 10.1097/mat.0000000000001530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has emerged into a worldwide pandemic of epic proportion. Beyond pulmonary involvement in coronavirus disease 2019 (COVID-19), a significant subset of patients experiences acute kidney injury. Patients who die from severe disease most notably show diffuse acute tubular injury on postmortem examination with a possible contribution of focal macro- and microvascular thrombi. Renal biopsies in patients with proteinuria and hematuria have demonstrated a glomerular dominant pattern of injury, most notably a collapsing glomerulopathy reminiscent of findings seen in human immunodeficiency virus (HIV) in individuals with apolipoprotein L-1 (APOL1) risk allele variants. Although various mechanisms have been proposed for the pathogenesis of acute kidney injury in SARS-CoV-2 infection, direct renal cell infection has not been definitively demonstrated and our understanding of the spectrum of renal involvement remains incomplete. Herein we discuss the biology, pathology, and pathogenesis of SARS-CoV-2 infection and associated renal involvement. We discuss the molecular biology, risk factors, and pathophysiology of renal injury associated with SARS-CoV-2 infection. We highlight the characteristics of specific renal pathologies based on native kidney biopsy and autopsy. Additionally, a brief discussion on ancillary studies and challenges in the diagnosis of SARS-CoV-2 is presented.
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Affiliation(s)
- Meghan E. Kapp
- From the Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Agnes B. Fogo
- From the Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Candice Roufouse
- Department of Immunology and Inflammation, Centre for Inflammatory Diseases, Imperial College, London, UK
| | - Behzad Najafian
- Department of Laboratory Medicine & Pathology, University of Washington Medicine, Seattle, Washington
| | - Jai Radhakrishnan
- Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Sara E. Miller
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina
| | - Vivette D. D’Agati
- Department of Pathology and Cell Biology, Columbia University, New York, New York
| | | | - Tarek Barbar
- Division of Nephrology, Weill Cornell Medical College, New York, New York
| | - Tulasi Gopalan
- Division of Nephrology, Weill Cornell Medical College, New York, New York
| | - Vesh Srivatana
- Division of Nephrology, Weill Cornell Medical College, New York, New York
| | - Michele H. Mokrzycki
- Division of Nephrology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Judith A. Benstein
- Department of Medicine, New York University Tisch Hospital, New York, New York
| | - Yue-Harn Ng
- Division of Nephrology, University of Washington, Seattle, Washington
| | - Krista L. Lentine
- Division of Nephrology (9-FDT), Center for Abdominal Transplantation, St. Louis, Missouri
| | - Vikram Aggarwal
- Division of Nephrology, Northwestern Medicine, Chicago, Illinois
| | - Jeffrey Perl
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | | | - Jay L. Koyner
- Department of Nephrology, University of Chicago, Chicago, Illinois
| | | | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Juan Carlos Velez
- Department of Nephrology, Ochsner Health System, New Orleans, Louisiana
| | - Alp Ikizler
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anitha Vijayan
- Department of Medicine – Nephrology, Washington University School of Medicine in St Louis, St. Louis, Missouri
| | - Preethi William
- Division of Cardiology, Banner University of Arizona, Tucson, Arizona
| | - Bijin Thajudeen
- Division of Nephrology, Banner University of Arizona, Tucson, Arizona
| | - Marvin J. Slepian
- Departments of Medicine and Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, Arizona
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21
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Bernard A, Ortiz SC, Jones E, Heung M, Guetterman TC, Kirst N. The Pandemic Leadership Model: A Study of Medical Student Values During COVID-19. Int J Med Students 2021. [DOI: 10.5195/ijms.2021.1001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Leadership training is of growing importance in medical education. The COVID-19 pandemic provides unique insight into the qualities and characteristics medical students value in leaders. Little standard information exists regarding best practices, competency-based leadership models or frameworks to guide leadership program development in undergraduate medical education. This study aims to determine what students value in leadership during a pandemic and what implicit leadership framework students use in order to inform medical education curricula.
Methods: We developed a survey instrument aimed to uncover student perceptions of effective and ineffective leadership qualities and examples, both during the current COVID-19 pandemic and during crises in general.
Results: Students identified the overarching themes of Communication, Other-Orientation, Personal Characteristics, Decisive Action, and Use of Information. These five themes were then built into the model of Pandemic Leadership within the context of complexity leadership theory and collective leadership theory.
Conclusion: This study is unique in its focus on student perceptions of leadership qualities both in general, and during a time of challenge that can serve as a real-world laboratory for leadership. We hope that this information, along with the pandemic leadership model, can serve as the first step to useful and relevant leadership training programs in undergraduate medical education.
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22
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Yessayan L, Sohaney R, Puri V, Wagner B, Riddle A, Dickinson S, Napolitano L, Heung M, Humes D, Szamosfalvi B. Regional citrate anticoagulation "non-shock" protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance. BMC Nephrol 2021; 22:244. [PMID: 34215201 PMCID: PMC8249839 DOI: 10.1186/s12882-021-02443-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) for the prevention of clotting of the extracorporeal blood circuit during continuous kidney replacement therapy (CKRT) has been employed in limited fashion because of the complexity and complications associated with certain protocols. Hypertonic citrate infusion to achieve circuit anticoagulation results in variable systemic citrate- and sodium load and increases the risk of citrate accumulation and hypernatremia. The practice of "single starting calcium infusion rate for all patients" puts patients at risk for clinically significant hypocalcemia if filter effluent calcium losses exceed replacement. A fixed citrate to blood flow ratio, personalized effluent and pre-calculated calcium infusion dosing based on tables derived through kinetic analysis enable providers to use continuous veno-venous hemo-diafiltration (CVVHDF)-RCA in patients with liver citrate clearance of at least 6 L/h. METHODS This was a single-center prospective observational study conducted in intensive care unit patients triaged to be treated with the novel pre-calculated CVVHDF-RCA "Non-shock" protocol. RCA efficacy outcomes were time to first hemofilter loss and circuit ionized calcium (iCa) levels. Safety outcomes were surrogate of citrate accumulation (TCa/iCa ratio) and the incidence of acid-base and electrolyte complications. RESULTS Of 53 patients included in the study, 31 (59%) had acute kidney injury and 12 (22.6%) had the diagnosis of cirrhosis at the start of CVVHDF-RCA. The median first hemofilter life censored for causes other than clotting exceeded 70 h. The cumulative incidence of hypernatremia (Na > 148 mM), metabolic alkalosis (HCO3- > 30 mM), hypocalcemia (iCa < 0.9 mM) and hypercalcemia (iCa > 1.5 mM) were 1/47 (1%), 0/50 (0%), 1/53 (2%), 1/53 (2%) respectively and were not clinically significant. The median (25th-75th percentile) of the highest TCa/iCa ratio for every 24-h interval on CKRT was 1.99 (1.91-2.13). CONCLUSIONS The fixed citrate to blood flow ratio, as opposed to a titration approach, achieves adequate circuit iCa (< 0.4 mm/L) for any hematocrit level and plasma flow. The personalized dosing approach for calcium supplementation based on pre-calculated effluent calcium losses as opposed to the practice of "one starting dose for all" reduces the risk of clinically significant hypocalcemia. The fixed flow settings achieve clinically desirable steady state systemic electrolyte levels.
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Affiliation(s)
- Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA.
| | - Ryann Sohaney
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Vidhit Puri
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Benjamin Wagner
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Amy Riddle
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Sharon Dickinson
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lena Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - David Humes
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA.
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23
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Zhao X, Zhang C, Zhu L, Wu B, Han Y, Heung M, Zuo L. Severe secondary hyperkalemia and arrhythmia from drug interactions between calcium-channel blocker and voriconazole: a case presentation. BMC Nephrol 2021; 22:172. [PMID: 33971831 PMCID: PMC8108408 DOI: 10.1186/s12882-021-02370-6] [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: 09/25/2020] [Accepted: 04/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background Patients with kidney disease may have concurrent hypertension and infection. Dihydropyridine calcium-channel blockers (CCB) are the most popular class of antihypertensive drugs used in clinical settings and can be metabolized by cytochrome P450 isoenzyme 3A4 (CYP3A4). Voriconazole is a commonly used antifungal treatment and a CYP3A4-inhibitor. Insufficient attention to drug interactions from the concomitant use of CCB and voriconazole may result in serious adverse reactions. Case presentation Here, we report a patient with acute kidney injury on stable anti-neutrophil cytoplasm antibody associated vasculitis who developed hyperkalemia resulting in sinus arrest with junctional escape rhythm attributed to drug interactions of CCB with voriconazole. This is a very rarely reported case and may be an under-recognized complication. After continuous renal replacement therapy and changing the anti-hypertensive drugs, symptoms, and laboratory abnormalities of the patient fully recovered. Conclusions This case warns us of severe consequences of drug interactions. Co-prescription of CYP3A4-inhibitors with calcium-channel blockers increases the risk of hypotension and acute kidney injury, which may further induce hyperkalemia and arrhythmia.
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Affiliation(s)
- Xinju Zhao
- Department of Nephrology, Peking University People's Hospital, Beijing, China.
| | - Chunyan Zhang
- Department of pharmacy, Peking University People's Hospital, Beijing, China
| | - Li Zhu
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Bei Wu
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Yun Han
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
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24
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Santos M, Yin H, Steffick D, Saran R, Heung M. Predictors of kidney function recovery among incident ESRD patients. BMC Nephrol 2021; 22:142. [PMID: 33879082 PMCID: PMC8059163 DOI: 10.1186/s12882-021-02345-7] [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: 10/16/2020] [Accepted: 04/07/2021] [Indexed: 11/30/2022] Open
Abstract
Background ESRD is considered an irreversible loss of renal function, yet some patients will recover kidney function sufficiently to come off dialysis. Potentially modifiable predictors of kidney recovery, such as dialysis prescription, have not been fully examined. Methods Retrospective cohort study using United States Renal Data System (USRDS) data to identify incident hemodialysis (HD) patients between 2012 and 2016, the first 4 years for which dialysis treatment data is available. The primary outcome was kidney recovery within 1 year of ESRD and HD initiation, defined by a specific recovery code and survival off dialysis for at least 30 days. Patient and treatment characteristics were compared between those that recovered versus those that remained dialysis-dependent. A time-dependent survival model was used to identify independent predictors of kidney recovery. Results During the study period, there were 372,387 incident HD patients with available data, among whom 16,930 (4.5%) recovered to dialysis-independence. Compared to non-recovery, a higher proportion of patients with kidney recovery were of white race, and non-Hispanic ethnicity. Both groups had a similar age distribution. Patients with an acute kidney injury diagnosis as primary cause of ESRD were most likely to recover, but the most common ESRD diagnosis among recovering patients was type 2 diabetes (29.8% of recovery cases). Higher eGFR and lower albumin at ESRD initiation were associated with increased likelihood of recovery. When examining HD ultrafiltration rate (UFR), each quintile above the first quintile was associated with a progressively lower likelihood of recovery (HR 0.45, 95% CI 0.43–0.48 for highest versus lowest quintile, p < 0.001). Conclusions We identified non-modifiable and potentially modifiable factors associated with kidney recovery which may assist clinicians in counseling and monitoring incident ESRD patients with a greater chance to gain dialysis-independence. Clinical trials are warranted to examine the impact of dialysis prescription on subsequent kidney function recovery.
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Affiliation(s)
- Maria Santos
- University of Michigan Medical School, 1500 E. Medical Center Drive, SPC 5364, Ann Arbor, MI, 48109-5364, USA
| | - Huiying Yin
- University of Michigan Kidney Epidemiology and Cost Center, Ann Arbor, USA
| | - Diane Steffick
- University of Michigan Kidney Epidemiology and Cost Center, Ann Arbor, USA
| | - Rajiv Saran
- University of Michigan Medical School, 1500 E. Medical Center Drive, SPC 5364, Ann Arbor, MI, 48109-5364, USA.,University of Michigan Kidney Epidemiology and Cost Center, Ann Arbor, USA.,Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, USA
| | - Michael Heung
- University of Michigan Medical School, 1500 E. Medical Center Drive, SPC 5364, Ann Arbor, MI, 48109-5364, USA. .,University of Michigan Kidney Epidemiology and Cost Center, Ann Arbor, USA. .,Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, USA.
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25
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Sohaney R, Yin H, Shahinian V, Saran R, Steffick D, Nallamothu BK, Heung M. Trends in the Incidence of Acute Kidney Injury in a National Cohort of US Veterans. Am J Kidney Dis 2021; 77:300-302. [DOI: 10.1053/j.ajkd.2020.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/12/2020] [Indexed: 11/11/2022]
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26
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Szamosfalvi B, Yessayan LT, Heung M. Citrate Anticoagulation for Continuous Kidney Replacement Therapy: An Embarrassment of RICH-es. Am J Kidney Dis 2021; 78:146-150. [PMID: 33493585 DOI: 10.1053/j.ajkd.2021.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/04/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Lenar T Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI.
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27
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Bragg-Gresham J, Zhang X, Le D, Heung M, Shahinian V, Morgenstern H, Saran R. Prevalence of Chronic Kidney Disease Among Black Individuals in the US After Removal of the Black Race Coefficient From a Glomerular Filtration Rate Estimating Equation. JAMA Netw Open 2021; 4:e2035636. [PMID: 33512516 PMCID: PMC7846942 DOI: 10.1001/jamanetworkopen.2020.35636] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cross-sectional study examines whether removal of the Black race coefficient from a glomerular filtration rate (GFR) estimating equation is associated with a change in the estimated prevalence of chronic kidney disease (CKD) in the general Black population and among Black veterans in the US.
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Affiliation(s)
- Jennifer Bragg-Gresham
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Xiaosong Zhang
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Dao Le
- Morsani College of Medicine, University of South Florida, Tampa
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Vahakn Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
- Department of Urology, University of Michigan, Ann Arbor
| | - Hal Morgenstern
- Department of Urology, University of Michigan, Ann Arbor
- Department of Epidemiology, University of Michigan, Ann Arbor
- Department of Environmental Health Sciences, University of Michigan, Ann Arbor
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
- Department of Epidemiology, University of Michigan, Ann Arbor
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28
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Sohaney R, Heung M. Care of the Survivor of Critical Illness and Acute Kidney Injury: A Multidisciplinary Approach. Adv Chronic Kidney Dis 2021; 28:105-113. [PMID: 34389131 DOI: 10.1053/j.ackd.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/19/2020] [Accepted: 01/04/2021] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) is a common complication of critical illness and is associated with adverse short- and long-term health consequences. Survivors of critical illness and AKI experience poor kidney, cardiovascular and quality of life outcomes, along with increased mortality. Yet, many patients surviving AKI are unaware that there is a problem with their kidney health, and post-AKI nephrology follow-up occurs at very low rates. Although there is a paucity of evidence-based studies to guide post-AKI care, attention to risk factors such as hypertension and albuminuria are requisite. There are several ongoing or planned studies which are expected to help inform specific management in the future. Until then, a multidisciplinary approach is warranted to address areas such as quality of life, physical rehabilitation, dietary modifications, and medication reconciliation.
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Szamosfalvi B, Heung M, Yessayan L. Technology Innovations in Continuous Kidney Replacement Therapy: The Clinician's Perspective. Adv Chronic Kidney Dis 2021; 28:3-12. [PMID: 34389135 DOI: 10.1053/j.ackd.2021.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/25/2021] [Accepted: 03/27/2021] [Indexed: 11/11/2022]
Abstract
Continuous kidney replacement therapy (CKRT) has improved remarkably since its first implementation as continuous arteriovenous hemofiltration in the 1970s. However, when looking at the latest generation of CKRT machines, one could argue that clinical deployment of breakthrough innovations by device manufacturers has slowed in the last decade. Simultaneously, there has been a steady accumulation of clinical knowledge using CKRT as well as a multitude of therapeutic and diagnostic innovations in the dialysis and broader intensive care unit technology fields adaptable to CKRT. These include multiple different anticlotting measures; cloud-computing for optimized treatment prescribing and delivered therapy data collection and analysis; novel blood purification techniques aimed at improving the severe multiorgan dysfunction syndrome; and real-time sensing of blood and/or filter effluent composition. The authors present a view of how CKRT devices and programs could be reimagined incorporating these innovations to achieve specific measurable clinical outcomes with personalized care and improved simplicity, safety, and efficacy of CKRT therapy.
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Neyra JA, Heung M. Nephrology Critical Care: A Darwinian Evolution. Adv Chronic Kidney Dis 2021; 28:1-2. [PMID: 34389130 DOI: 10.1053/j.ackd.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Szamosfalvi B, Puri V, Sohaney R, Wagner B, Riddle A, Dickinson S, Napolitano L, Heung M, Humes D, Yessayan L. Regional Citrate Anticoagulation Protocol for Patients with Presumed Absent Citrate Metabolism. Kidney360 2020; 2:192-204. [PMID: 35373034 PMCID: PMC8740983 DOI: 10.34067/kid.0005342020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/18/2020] [Indexed: 02/04/2023]
Abstract
Background Regional citrate anticoagulation (RCA) is not recommended in patients with shock or severe liver failure. We designed a protocol with personalized precalculated flow settings for patients with absent citrate metabolism that abrogates risk of citrate toxicity, and maintains neutral continuous KRT (CKRT) circuit calcium mass balance and normal systemic ionized calcium levels. Methods A single-center prospective cohort study of patients in five adult intensive care units triaged to the CVVHDF-RCA "Shock" protocol. Results Of 31 patients included in the study, 30 (97%) had AKI, 16 (52%) had acute liver failure, and five (16%) had cirrhosis at the start of CKRT. The median lactate was 5 mmol/L (interquartile range [IQR], 3.2-10.7), AST 822 U/L (IQR, 122-2950), ALT 352 U/L (IQR, 41-2238), total bilirubin 2.7 mg/dl (IQR, 1.0-5.1), and INR two (IQR, 1.5-2.6). The median first hemofilter life censored for causes other than clotting exceeded 70 hours. The cumulative incidence of hypernatremia (Na >148 mM), metabolic alkalosis (HCO3- >30 mM), and hypophosphatemia (P<2 mg/dl) were one out of 26 (4%), zero out of 30 (0%), and one out of 30 (3%), respectively, and were not clinically significant. Mild hypocalcemia occurred in the first 4 hours in two out of 31 patients, and corrected by hour 6 with no additional Ca supplementation beyond the per-protocol administered Ca infusion. The maximum systemic total Ca (tCa; mM)/ionized Ca (iCa; mM) ratio never exceeded 2.5. Conclusions The Shock protocol can be used without contraindications and is effective in maintaining circuit patency with a high, fixed ACDA infusion rate to blood flow ratio. Keeping single-pass citrate extraction on the dialyzer >0.75 minimizes the risk of citrate toxicity even in patients with absent citrate metabolism. Precalculated, personalized dosing of the initial Ca-infusion rate from a table on the basis of the patient's albumin level and the filter effluent flow rate maintains neutral CKRT circuit calcium mass balance and a normal systemic iCa level.
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Affiliation(s)
- Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Vidhit Puri
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ryann Sohaney
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Wagner
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Amy Riddle
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sharon Dickinson
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lena Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - David Humes
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
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Yessayan LT, Heung M, Girard FA, Shaikhouni S, Szamosfalvi B. Deployment of a New CRRT/PIRRT Device during the COVID-19 Pandemic Emergency: Organizational Challenges and Implementation Results. Blood Purif 2020; 50:390-398. [PMID: 33171460 DOI: 10.1159/000511726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/19/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The coronavirus disease 2019 (COVID-19) pandemic led to increased demand nationwide for dialysis equipment, including supplies and machines. To meet the demand in our institution, our surge plan included rapid mobilization of a novel continuous renal replacement treatment (CRRT) machine named SAMI. The SAMI is a push-pull filtration enhanced dialysis machine that can conjugate extremely high single-pass solute removal efficiency with very precise fluid balance control. MATERIAL AND METHODS Machine assembly was conducted on-site by local biomedical engineers with remote assistance by the vendor. One 3-h virtual training session of 3 dialysis nurses was conducted before SAMI deployment. The SAMI was deployed in prolonged intermittent replacement therapy (PIRRT) mode to maximize patients covered per machine per day. Live on-demand vendor support was provided to troubleshoot any issues for the first few cases. After 4 weeks of the SAMI implementation, data on treatments with the SAMI were collected, and a questionnaire was provided to the nurse trainees to assess device usability. RESULTS On-site installation of the SAMI was accomplished with remote assistance. Delivery of remote training was successfully achieved. 23 PIRRT treatments were conducted in 10 patients. 7/10 of patients had CO-VID-19. The median PIRRT dose was 50 mL/kg/h (IQR [interquartile range] 44 - 62 mL/kg/h), and duration of the treatment was 8 h (IQR 6.3 - 8 h). Solute control was adequate. The user response was favorable to the set of usability questions involving user interface, on-screen instructions, machine setup, troubleshooting, and the ease of moving the machine. CONCLUSION Assembly of the SAMI and training of nurses remotely are possible when access to vendor employees is restricted during states of emergency. The successful deployment of the SAMI in our institution during the pandemic with only 3-h virtual training supports that operating the SAMI is simple and safe.
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Affiliation(s)
- Lenar T Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA,
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Francine A Girard
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Salma Shaikhouni
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Sohaney R, Yessayan LT, Heung M. Towards Consensus in Timing of Kidney Replacement Therapy for Acute Kidney Injury? Am J Kidney Dis 2020; 77:542-545. [PMID: 32920155 DOI: 10.1053/j.ajkd.2020.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Ryann Sohaney
- Division of Nephrology, University of Michigan, Ann Arbor, MI
| | | | - Michael Heung
- Division of Nephrology, University of Michigan, Ann Arbor, MI.
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Saran R, Pearson A, Tilea A, Shahinian V, Bragg-Gresham J, Heung M, Hutton DW, Steffick D, Zheng K, Morgenstern H, Gillespie BW, Leichtman A, Young E, O'Hare AM, Fischer M, Hotchkiss J, Siew E, Hynes D, Fried L, Balkovetz D, Sovern K, Liu CF, Crowley S. Burden and Cost of Caring for US Veterans With CKD: Initial Findings From the VA Renal Information System (VA-REINS). Am J Kidney Dis 2020; 77:397-405. [PMID: 32890592 DOI: 10.1053/j.ajkd.2020.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 07/20/2020] [Indexed: 12/15/2022]
Abstract
Kidney disease is a common, complex, costly, and life-limiting condition. Most kidney disease registries or information systems have been limited to single institutions or regions. A national US Department of Veterans Affairs (VA) Renal Information System (VA-REINS) was recently developed. We describe its creation and present key initial findings related to chronic kidney disease (CKD) without kidney replacement therapy (KRT). Data from the VA's Corporate Data Warehouse were processed and linked with national Medicare data for patients with CKD receiving KRT. Operational definitions for VA user, CKD, acute kidney injury, and kidney failure were developed. Among 7 million VA users in fiscal year 2014, CKD was identified using either a strict or liberal operational definition in 1.1 million (16.4%) and 2.5 million (36.3%) veterans, respectively. Most were identified using an estimated glomerular filtration rate laboratory phenotype, some through proteinuria assessment, and very few through International Classification of Diseases, Ninth Revision coding. The VA spent ∼$18 billion for the care of patients with CKD without KRT, most of which was for CKD stage 3, with higher per-patient costs by CKD stage. VA-REINS can be leveraged for disease surveillance, population health management, and improving the quality and value of care, thereby enhancing VA's capacity as a patient-centered learning health system for US veterans.
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Affiliation(s)
- Rajiv Saran
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI.
| | - Aaron Pearson
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Anca Tilea
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Vahakn Shahinian
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI
| | - Jennifer Bragg-Gresham
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI
| | - Michael Heung
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI
| | - David W Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Diane Steffick
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI
| | - Kai Zheng
- Department of Informatics, University of California - Irvine, Irvine, CA
| | - Hal Morgenstern
- Department of Epidemiology and Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI; Department of Urology, Medical School, University of Michigan, Ann Arbor, MI
| | - Brenda W Gillespie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Alan Leichtman
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI
| | - Eric Young
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Ann M O'Hare
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Medicine - Nephrology, VA Puget Sound Health Care System, Seattle, WA
| | - Michael Fischer
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL
| | - John Hotchkiss
- Department of Critical Care Medicine, Pittsburgh VA Medical Center, Pittsburgh, PA
| | - Eddie Siew
- Division of Nephrology and Hypertension, Nashville VA Medical Center, Nashville, TN
| | | | - Linda Fried
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | | | - Karen Sovern
- Department of Veterans Affairs, Center Office of Analytics and Business Intelligence
| | | | - Susan Crowley
- Section of Nephrology, VA Connecticut Healthcare System, West Haven, CT; Yale University School of Medicine, New Haven, CT
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Kokaly AN, Kurlander JE, Pais K, Lee C, Schaefer JK, Heung M, Vordenberg SE. Identification of undocumented over-the-counter medications in an academic nephrology clinic. J Am Pharm Assoc (2003) 2020; 60:e236-e245. [PMID: 32855072 DOI: 10.1016/j.japh.2020.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/15/2020] [Accepted: 08/01/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To explore how accurately over-the-counter (OTC) medications were documented in an academic nephrology clinic and the benefits of using a novel short questionnaire as part of medication reconciliation (MR). METHODS We developed a 3-item tailored questionnaire with questions about use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitors (PPIs), which clinical leadership identified as medications of interest. Over the course of 20 days, medical assistants administered the questionnaire to clinic patients immediately after the standard MR. We summarized the rate of inaccurate medication documentation by individual drug and drug class, comparing the standard MR process with the questionnaire. We also calculated diagnostic performance characteristics of the questionnaire. We evaluated the severity of drug-drug interactions between OTC medications discovered using the OTC medication questionnaire and patients' other prescription medications. RESULTS Nearly 30% (n = 133 of 450) of the participants had at least 1 inaccurately documented OTC medication after the standard MR. The sensitivity and specificity of the standard MR were 79.2% and 93.5%, respectively, for aspirin; 14.5% and 99.5% for NSAIDs; and 80.4% and 97.3% for PPIs. Medication omissions were resolved in the electronic health record approximately two-thirds of the time using the questionnaire. At least 1 drug-drug interaction (DDI) involving active use of an OTC medication was identified in 9.6% of the patients. Of the DDIs, the most common portended effects were increased nephrotoxicity (52.9%), increased bleeding risk (22.9%), and enhanced antiplatelet activity (7.1%). CONCLUSION Despite the standard MR process, inaccurate documentation of commonly used OTC medications occurred in nearly one-third of outpatients in a nephrology clinic. A brief OTC medication questionnaire may be a scalable and effective strategy to address this problem.
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Chen Z, McCulloch CE, Powe NR, Heung M, Saran R, Pavkov ME, Burrows NR, Hsu RK, Hsu CY. Exploring reasons for state-level variation in incidence of dialysis-requiring acute kidney injury (AKI-D) in the United States. BMC Nephrol 2020; 21:336. [PMID: 32778062 PMCID: PMC7418406 DOI: 10.1186/s12882-020-02000-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 07/31/2020] [Indexed: 02/04/2023] Open
Abstract
Background There is considerable state-level variation in the incidence of dialysis-requiring acute kidney injury (AKI-D). However, little is known about reasons for this geographic variation. Methods National cross-sectional state-level ecological study based on State Inpatient Databases (SID) and the Behavioral Risk Factor Surveillance System (BRFSS) in 2011. We analyzed 18 states and six chronic health conditions (diabetes mellitus [diabetes], hypertension, chronic kidney disease [CKD], arteriosclerotic heart disease [ASHD], cancer (excluding skin cancer), and chronic obstructive pulmonary disease [COPD]). Associations between each of the chronic health conditions and AKI-D incidence was assessed using Pearson correlation and multiple regression adjusting for mean age, the proportion of males, and the proportion of non-Hispanic whites in each state. Results The state-level AKI-D incidence ranged from 190 to 1139 per million population. State-level differences in rates of hospitalization with chronic health conditions (mostly < 3-fold difference in range) were larger than the state-level differences in prevalence for each chronic health condition (mostly < 2.5-fold difference in range). A significant correlation was shown between AKI-D incidence and prevalence of diabetes, ASHD, and COPD, as well as between AKI-D incidence and rate of hospitalization with hypertension. In regression models, after adjusting for age, sex, and race, AKI-D incidence was associated with prevalence of and rates of hospitalization with five chronic health conditions--diabetes, hypertension, CKD, ASHD and COPD--and rates of hospitalization with cancer. Conclusions Results from this ecological analysis suggest that state-level variation in AKI-D incidence may be influenced by state-level variations in prevalence of and rates of hospitalization with several chronic health conditions. For most of the explored chronic conditions, AKI-D correlated stronger with rates of hospitalizations with the health conditions rather than with their prevalences, suggesting that better disease management strategies that prevent hospitalizations may translate into lower incidence of AKI-D.
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Affiliation(s)
- Zijin Chen
- Department of Nephrology, Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China. .,Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Neil R Powe
- UCSF Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco, California, USA.,Department of Medicine, San Francisco General Hospital, San Francisco, California, USA
| | - Michael Heung
- Division of Nephrology, Department of Medicine and Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA.,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, USA
| | - Rajiv Saran
- Division of Nephrology, Department of Medicine and Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA.,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, USA
| | - Meda E Pavkov
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nilka Rios Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Raymond K Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Liu KD, Forni LG, Heung M, Wu VC, Kellum JA, Mehta RL, Ronco C, Kashani K, Rosner MH, Haase M, Koyner JL. Quality of Care for Acute Kidney Disease: Current Knowledge Gaps and Future Directions. Kidney Int Rep 2020; 5:1634-1642. [PMID: 33102955 PMCID: PMC7569680 DOI: 10.1016/j.ekir.2020.07.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/07/2020] [Accepted: 07/28/2020] [Indexed: 12/18/2022] Open
Abstract
Acute kidney injury (AKI) and acute kidney disease (AKD) are common complications in hospitalized patients and are associated with adverse outcomes. Although consensus guidelines have improved the care of patients with AKI and AKD, guidance regarding quality metrics in the care of patients after an episode of AKI or AKD is limited. For example, few patients receive follow-up laboratory testing of kidney function or post-AKI or AKD care through nephrology or other providers. Recently, the Acute Disease Quality Initiative developed a consensus statement regarding quality improvement goals for patients with AKI or AKD specifically highlighting efforts regarding quality and safety of care after hospital discharge after an episode of AKI or AKD. The goal is to use these measures to identify opportunities for improvement that will positively affect outcomes. We recommend that health care systems quantitate the proportion of patients who need and actually receive follow-up care after the index AKI or AKD hospitalization. The intensity and appropriateness of follow-up care should depend on patient characteristics, severity, duration, and course of AKI of AKD, and should evolve as evidence-based guidelines emerge. Quality indicators for discharged patients with dialysis requiring AKI or AKD should be distinct from end-stage renal disease measures. Besides, there should be specific quality indicators for those still requiring dialysis in the outpatient setting after AKI or AKD. Given the limited preexisting data guiding the care of patients after an episode of AKI or AKD, there is ample opportunity to establish quality measures and potentially improve patient care and outcomes. This review will provide specific evidence-based and expert opinion–based guidance for the care of patients with AKI or AKD after hospital discharge.
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Affiliation(s)
- Kathleen D Liu
- Division of Nephrology, Departments of Medicine and Anesthesia, University of California, San Francisco, California, USA
- Division of Critical Care Medicine, Departments of Medicine and Anesthesia, University of California, San Francisco, California, USA
| | - Lui G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ravindra L Mehta
- Division of Nephrology, Department of Medicine, University of California, San Diego Medical Center, San Diego, San Diego, California, USA
| | - Claudio Ronco
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Department of Nephrology, Dialysis and Transplantation, and International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mitchell H Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michael Haase
- Medical Faculty, Otto-von-Guericke University Magdeburg and Diaverum MVZ, Potsdam, Germany
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
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Pai AB, McGuire MD, Davidge KN, Dean MC, Costello GM, Souza E, Mukherjee S, Heung M, Yevzlin AS, Yessayan LT. Lipoteichoic Acid as a Potential Noninvasive Biomarker of Biofilm in Dialysis Access. ASAIO J 2020; 66:960-965. [PMID: 32740359 DOI: 10.1097/mat.0000000000001091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Tunneled central venous catheters (TCVCs) are colonized by Gram-positive organisms and form biofilm. Lipoteichoic acid (LTA) is a Gram-positive cell wall component that can be measured in serum. The purpose of this pilot study was to characterize LTA concentrations in hemodialysis (HD) patients with TCVCs compared to other access types and to evaluate biofilm morphology and microbiology in TCVCs removed by clinical decision. The study enrolled patients with TCVCs (18), grafts (19), and fistulas (18). Blood samples were collected before HD, at 30 minutes, 2 hours, and end of HD. Catheters removed by clinical decision were evaluated by scanning electron microscopy (SEM) for biofilm morphology, and portions of the catheter were cultured. LTA was detectable in all samples and concentrations increased significantly in all access types during HD (p < 0.05 for all comparisons). Patients with TCVCs that had a >30% increase in LTA concentration from baseline also had the greatest rate of increase (slope) compared to grafts and fistulas (p = 0.03 and p = 0.04, respectively). Catheters removed by clinical decision (n = 7) and examined by SEM had deposition of fibrin. Cultures revealed polymicrobial colonization. TCVCs had the highest rate of increase of LTA during HD. Further studies to determine the source of LTA in patients with AVG and AVF are warranted.
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Affiliation(s)
- Amy Barton Pai
- From the University of Michigan, College of Pharmacy, Ann Arbor, Michigan
| | | | - Karen N Davidge
- From the University of Michigan, College of Pharmacy, Ann Arbor, Michigan
| | - Michael C Dean
- From the University of Michigan, College of Pharmacy, Ann Arbor, Michigan
| | | | - Ernane Souza
- From the University of Michigan, College of Pharmacy, Ann Arbor, Michigan
| | | | - Michael Heung
- University of Michigan, Division of Nephrology, Ann Arbor, Michigan
| | | | - Lenar T Yessayan
- University of Michigan, Division of Nephrology, Ann Arbor, Michigan
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Zeidman AD, Heung M, Connor M, Tolwani A, Yessayan L. The Workforce in Critical Care Nephrology: Challenges and Opportunities. Adv Chronic Kidney Dis 2020; 27:328-335.e1. [PMID: 33131646 DOI: 10.1053/j.ackd.2020.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 11/11/2022]
Abstract
The substantial burden of acute kidney injury and end-stage kidney disease among patients with critical illness highlights the importance and need for a specialized nephrologist in the intensive care unit. The last decade has seen a growing interest in a career focused on critical care nephrology. However, the scope of practice and job satisfaction of those who completed dual training in nephrology and critical care are largely unknown. This article discusses the current practice landscape of critical care nephrology and describes the educational tracks available to pursue this pathway and considerations to enhance the future of this field.
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Wilkinson DA, Heung M, Deol A, Chaudhary N, Gemmete JJ, Thompson BG, Pandey AS. Cerebral Aneurysms in Autosomal Dominant Polycystic Kidney Disease: A Comparison of Management Approaches. Neurosurgery 2020; 84:E352-E361. [PMID: 30060240 DOI: 10.1093/neuros/nyy336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 01/04/2018] [Accepted: 06/23/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Autosomal dominant polycystic kidney disease (ADPKD) is a risk factor for formation of intracranial aneurysms (IAs), though the ideal screening and treatment strategies in this population are unclear. OBJECTIVE To report outcomes of observation, open surgical, or endovascular management of ruptured and unruptured aneurysms in patients with ADPKD. METHODS We performed a retrospective analysis of all patients with ADPKD and IAs at a single center from 2000 to 2016. RESULTS Forty-five patients with ADPKD harboring 71 aneurysms were identified, including 11 patients with subarachnoid hemorrhage (SAH). Of 22 aneurysms managed with observation, none ruptured in 136 yr of clinical follow-up. Thirty-five aneurysms were treated with open surgery and 14 with an endovascular approach. Among treated aneurysms, poor neurologic outcome (modified Rankin scale >2) was seen only in patients presenting with SAH (17% SAH vs 0% elective, P = .06). Acute kidney injury (AKI) was also significantly associated with SAH presentation (22% SAH vs 0% elective, P = .05). Neither procedural complications nor AKI were associated with treatment modality. Among 175 yr of radiographic follow-up in patients with known IAs, 8 de novo aneurysms were found, including 3 that were treated. Of 11 patients with SAH, 7 ruptured in the setting of previously known ADPKD, including 2 with prior angiographic screening and 5 without screening. CONCLUSION Poor outcomes occurred only with ruptured presentation but were equivalent between treatment modalities. Screening is performed only selectively, and 64% (7 of 11) of patients presenting with SAH had previously known ADPKD.
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Affiliation(s)
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Amrit Deol
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | | | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Kuo PY, Saran R, Argentina M, Heung M, Bragg-Gresham J, Krein S, Gillespie BW, Zheng K, Veinot TC. Cramping, crashing, cannulating, and clotting: a qualitative study of patients' definitions of a "bad run" on hemodialysis. BMC Nephrol 2020; 21:67. [PMID: 32103726 PMCID: PMC7045425 DOI: 10.1186/s12882-020-01726-8] [Citation(s) in RCA: 8] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 02/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemodialysis sessions frequently become unstable from complications such as intradialytic hypotension and untoward symptoms. Previous patient safety initiatives promote prevention of treatment complications; yet, they have placed little specific focus on avoidable session instability. A patient-centered definition of session instability grounded in patient experiences, and an understanding of patient perceptions of causes and solutions to instability, may enable such efforts. METHODS Twenty-five participants participated in three focus groups and/or a survey. They were purposively sampled for variation in region of residence, and sensitivity to patient well-being. Focus group recordings were analyzed using descriptive coding, in vivo coding, and thematic analysis. RESULTS Patients define unstable sessions ("bad runs") as those in which they experience severe discomfort or unanticipated events that interfere with their ability to receive therapy. Bad runs were characterized primarily by cramping, low blood pressure ("crashing"), cannulation-related difficulties ("bad sticks"), and clotting of the dialysis circuit or vascular access. Patients believed that cramping and crashing could be explained by both patient and clinician behavior: patient fluid consumption and providers' fluid removal goals. Patients felt that the responsibility for cannulation-related problems lay with dialysis staff, and they asked for different staff or self-cannulated as solutions. Clotting was viewed as an idiosyncratic issue with one's body, and perceived solutions were clinician-driven. Patients expressed concern about "bad runs" on their ability to achieve fluid balance. CONCLUSIONS Findings point to novel priorities for efforts to enhance hemodialysis session stability, and areas in which patients can be supported to become involved in such efforts.
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Affiliation(s)
- Pei-Yi Kuo
- School of information, University of Michigan, 4314 North Quad, 105 S. State St, Ann Arbor, MI, 48109-1285, USA.,Institute of Service Science, National Tsing Hua University, HsinChu, Taiwan
| | - Rajiv Saran
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA.,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, USA
| | | | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer Bragg-Gresham
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA.,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, USA
| | - Sarah Krein
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Health Services Research & Development Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Brenda W Gillespie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Kai Zheng
- School of Information and Computer Sciences, University of California, Irvine, CA, USA
| | - Tiffany C Veinot
- School of information, University of Michigan, 4314 North Quad, 105 S. State St, Ann Arbor, MI, 48109-1285, USA. .,School of Public Health, University of Michigan, 4314 North Quad, 105 S. State St, Ann Arbor, MI, 48109-1285, USA.
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42
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Hoste E, Bihorac A, Al-Khafaji A, Ortega LM, Ostermann M, Haase M, Zacharowski K, Wunderink R, Heung M, Lissauer M, Self WH, Koyner JL, Honore PM, Prowle JR, Joannidis M, Forni LG, Kampf JP, McPherson P, Kellum JA, Chawla LS. Identification and validation of biomarkers of persistent acute kidney injury: the RUBY study. Intensive Care Med 2020; 46:943-953. [PMID: 32025755 PMCID: PMC7210248 DOI: 10.1007/s00134-019-05919-0] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [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: 08/29/2019] [Accepted: 12/26/2019] [Indexed: 12/16/2022]
Abstract
Purpose The aim of the RUBY study was to evaluate novel candidate biomarkers to enable prediction of persistence of renal dysfunction as well as further understand potential mechanisms of kidney tissue damage and repair in acute kidney injury (AKI). Methods The RUBY study was a multi-center international prospective observational study to identify biomarkers of the persistence of stage 3 AKI as defined by the KDIGO criteria. Patients in the intensive care unit (ICU) with moderate or severe AKI (KDIGO stage 2 or 3) were enrolled. Patients were to be enrolled within 36 h of meeting KDIGO stage 2 criteria. The primary study endpoint was the development of persistent severe AKI (KDIGO stage 3) lasting for 72 h or more (NCT01868724). Results 364 patients were enrolled of whom 331 (91%) were available for the primary analysis. One hundred ten (33%) of the analysis cohort met the primary endpoint of persistent stage 3 AKI. Of the biomarkers tested in this study, urinary C–C motif chemokine ligand 14 (CCL14) was the most predictive of persistent stage 3 AKI with an area under the receiver operating characteristic curve (AUC) (95% CI) of 0.83 (0.78–0.87). This AUC was significantly greater than values for other biomarkers associated with AKI including urinary KIM-1, plasma cystatin C, and urinary NGAL, none of which achieved an AUC > 0.75. Conclusion Elevated urinary CCL14 predicts persistent AKI in a large heterogeneous cohort of critically ill patients with severe AKI. The discovery of CCL14 as a predictor of persistent AKI and thus, renal non-recovery, is novel and could help identify new therapeutic approaches to AKI. Electronic supplementary material The online version of this article (10.1007/s00134-019-05919-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eric Hoste
- Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | - Michael Haase
- MVZ Diaverum Am Neuen Garten, Potsdam, Germany.,Medizinische Fakultät, Otto-Von-Guericke Universität Magdeburg, Magdeburg, Germany
| | - Kai Zacharowski
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Richard Wunderink
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Matthew Lissauer
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, 08901, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - John R Prowle
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Lui G Forni
- Department of Clinical & Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK
| | | | | | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA.
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Engoren M, Maile MD, Heung M, Blum JM, Blank R, Napolitano LM, Park PK, Raghavendran K, Jewell ES, Meldrum C. The effect of timing of initiation of renal replacement therapy on mortality: A retrospective case-control study. J Intensive Care Soc 2019; 22:8-16. [PMID: 33643427 DOI: 10.1177/1751143719892792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose To determine if earlier initiation of renal replacement therapy (RRT) is associated with improved survival in patients with severe acute kidney injury. Methods We performed a retrospective case-control study of propensity-matched groups with multivariable logistic regression using Akaike Information Criteria to adjust for non-matched variables in a surgical ICU in a tertiary care hospital. Results We matched 169 of 205 (82%) patients with new initiation of RRT (EARLY group) to 169 similar patients who did not initiate RRT on that day (DEFERRED group). Eighteen (11%) of DEFERRED eventually received RRT before discharge. By univariate analysis, ICU mortality was higher in EARLY (n = 60 (36%) vs. n = 23 (14%), p < 0.001) as was hospital mortality (n = 73 (43%) vs. n = 44 (26%), p = 0.001). Of the 18 RRT patients in DEFERRED, 12 (67%) died in ICU and 13 (72%) in hospital. After propensity matching and logistic regression, we found that EARLY initiation of RRT was associated with a more than doubling of ICU mortality (aOR = 2.310, 95% confidence interval = 1.254-4.257, p = 0.007). However, after similar adjustment, there was no difference in hospital mortality (aOR = 1.283, 95% CI = 0.753-2.186, p = 0.360). Conclusions While ICU mortality was increased in the EARLY group, there was no difference in hospital mortality between EARLY and DEFERRED groups.
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Affiliation(s)
- Milo Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael D Maile
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael Heung
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - James M Blum
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | - Ross Blank
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Pauline K Park
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Elizabeth S Jewell
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Craig Meldrum
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Oliverio AL, Bragg-Gresham JL, Admon LK, Wright Nunes JA, Saran R, Heung M. Obstetric Deliveries in US Women With ESKD: 2002-2015. Am J Kidney Dis 2019; 75:762-771. [PMID: 31785826 DOI: 10.1053/j.ajkd.2019.08.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 12/12/2018] [Accepted: 08/30/2019] [Indexed: 12/31/2022]
Abstract
RATIONALE & OBJECTIVE Women with end-stage kidney disease (ESKD) have decreased fertility and are at increased risk for pregnancy complications. This study examined secular trends and outcomes of obstetric deliveries in a US cohort of women with ESKD. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Women aged 18 to 44 years with ESKD and registered in the US Renal Data System from 2002 to 2015. EXPOSURE ESKD modality (hemodialysis [HD], peritoneal dialysis, transplantation). OUTCOMES Infant delivery, preterm delivery, cesarean delivery. ANALYTICAL APPROACH Unadjusted delivery rates were expressed as number of delivering women per 1,000 patient-years among women aged 18 to 44 years within each year during the study period, stratified by ESKD modality. Logistic regression models were used to evaluate associations of delivery, preterm delivery, and cesarean delivery with patient characteristics. RESULTS The delivery rate in women undergoing HD and women with a kidney transplant increased from 2.1 to 3.6 and 3.1 to 4.6 per 1,000 patient-years, respectively (P<0.001 for each). The delivery rate in patients undergoing peritoneal dialysis was lower and did not increase significantly (P=0.9). Women with a transplant were less likely to deliver preterm compared with women undergoing HD (OR, 0.92; 95% CI, 0.84-1.00), though more likely have a cesarean delivery (OR, 1.18; 95% CI, 1.06-1.31). For deliveries occurring in the 2012 to 2015 period, 75% of women treated with HD were prescribed 4 or fewer outpatient HD treatments per week and 25% were prescribed 5-plus treatments per week in the 30 days before delivery. LIMITATIONS Ascertainment of outcomes and comorbid conditions using administrative claims data. CONCLUSIONS The delivery rate in women of reproductive age with ESKD increased from 2002 to 2015 among those treated with transplantation or HD. Women with a functioning transplant were less likely to deliver preterm, but more likely to have a cesarean delivery. Prescriptions for outpatient intensified HD for pregnant women with ESKD were infrequent in 2012 to 2015.
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Affiliation(s)
- Andrea L Oliverio
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
| | | | - Lindsay K Admon
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Julie A Wright Nunes
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Abstract
This article was migrated. The article was marked as recommended. Background:Chinese Americans are one of the fastest growing populations in the United States. However, 41% of Chinese Americans are not English proficient. Methods:In 2014, Medicine in Mandarin was established by the University of Michigan Medical School (UMMS) as a pre-clinical elective taught by a nationally certified healthcare Mandarin interpreter. A 32-hour curriculum was developed, including both didactics and interactive elements. Assessments included quizzes, standardized patient interviews, and a final exam. An evaluation was administered upon course completion, and a post-course survey was administered to graduates at least six months after course completion. Results:Between 2014 and 2017, the elective graduated 25 students, of whom 23 completed the course evaluation and 22 completed the post-course survey. Prior to the course, 9% of students felt comfortable practicing medicine in Mandarin. This increased to 78% of students post-course. When asked about subsequent clinical experiences, 82% of students reported having applied medical Mandarin skills. Overall, 96% rated the course as very good or excellent. Conclusion:A Medicine in Mandarin elective was well-received by students and improved their comfort in providing medical care in Mandarin. Additional study is warranted to examine the potential clinical impact of this course.
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Saran R, Robinson B, Abbott KC, Agodoa LYC, Bhave N, Bragg-Gresham J, Balkrishnan R, Dietrich X, Eckard A, Eggers PW, Gaipov A, Gillen D, Gipson D, Hailpern SM, Hall YN, Han Y, He K, Herman W, Heung M, Hirth RA, Hutton D, Jacobsen SJ, Jin Y, Kalantar-Zadeh K, Kapke A, Kovesdy CP, Lavallee D, Leslie J, McCullough K, Modi Z, Molnar MZ, Montez-Rath M, Moradi H, Morgenstern H, Mukhopadhyay P, Nallamothu B, Nguyen DV, Norris KC, O'Hare AM, Obi Y, Park C, Pearson J, Pisoni R, Potukuchi PK, Rao P, Repeck K, Rhee CM, Schrager J, Schaubel DE, Selewski DT, Shaw SF, Shi JM, Shieu M, Sim JJ, Soohoo M, Steffick D, Streja E, Sumida K, Tamura MK, Tilea A, Tong L, Wang D, Wang M, Woodside KJ, Xin X, Yin M, You AS, Zhou H, Shahinian V. US Renal Data System 2017 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2019; 71:A7. [PMID: 29477157 DOI: 10.1053/j.ajkd.2018.01.002] [Citation(s) in RCA: 479] [Impact Index Per Article: 95.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Chen Z, Lee BJ, McCulloch CE, Burrows NR, Heung M, Hsu RK, Pavkov ME, Powe NR, Saran R, Shahinian V, Hsu CY. The relation between dialysis-requiring acute kidney injury and recovery from end-stage renal disease: a national study. BMC Nephrol 2019; 20:342. [PMID: 31477040 PMCID: PMC6720077 DOI: 10.1186/s12882-019-1483-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/22/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Approximately 4-6% of incident end stage renal disease (ESRD) patients in the U.S. recover enough kidney function to discontinue dialysis but there is considerable geographic variation. We undertook this study to investigate whether state-level variations in renal recovery among incident ESRD patients correlated with state-level variations in incidence of acute kidney injury requiring dialysis (AKI-D). METHODS We conducted a national cross-sectional ecological study at the state-level using data from State Inpatient Databases and U.S. Renal Data System. All hospital admissions and all ESRD patients in 18 US states (AZ, AR, CA, FL, IA, KY, MA, MD, MI, NJ, NM, NY, NV, OR, RI, SC, VT, and WA) were included. Correlation between AKI-D incidence and rate of renal recovery across states was determined using Pearson's r (overall and in subgroups). We also calculated partial correlations adjusted for sex and age. RESULTS AKI-D incidence ranged from 99.0 per million population (pmp) in Vermont to 490.4 pmp in Nevada. Rate of renal recovery among incident ESRD patients ranged from 8.8 pmp in Massachusetts to 29.3 pmp in Florida. A positive correlation between AKI-D incidence and rate of renal recovery among incident ESRD patients at state level was found overall (unadjusted r = 0.67; p = 0.002) and in age, sex, and race subgroups. The overall correlation persisted after adjusting for age (adjusted r = 0.62; p < 0.001) and sex (adjusted r = 0.65; p < 0.001). CONCLUSION Our findings suggest that AKI-D incidence is an important driver of renal recovery rates among incident ESRD patients.
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Affiliation(s)
- Zijin Chen
- Division of Nephrology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
- Division of Nephrology, Department of Medicine, University of California, San Francisco, 533 Parnassus Ave, U404, Box 0532, San Francisco, CA, 94143-0532, USA
| | - Benjamin J Lee
- Division of Nephrology, Department of Medicine, University of California, San Francisco, 533 Parnassus Ave, U404, Box 0532, San Francisco, CA, 94143-0532, USA
- Houston Kidney Consultants, Houston, TX, USA
- Houston Methodist Institute for Academic Medicine, Houston, TX, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Nilka Ríos Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Raymond K Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, 533 Parnassus Ave, U404, Box 0532, San Francisco, CA, 94143-0532, USA
| | - Meda E Pavkov
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Neil R Powe
- UCSF Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco, CA, USA
- Department of Medicine, San Francisco General Hospital, San Francisco, CA, USA
| | - Rajiv Saran
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, USA
| | - Vahakn Shahinian
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, USA
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, 533 Parnassus Ave, U404, Box 0532, San Francisco, CA, 94143-0532, USA.
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Heung M. Albuminuria: A Novel Marker for Functional Impairment in Older Adults? Am J Nephrol 2019; 45:170-171. [PMID: 28110340 DOI: 10.1159/000455392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Michael Heung
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
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49
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Affiliation(s)
| | - Michael Heung
- 1 Division of Nephrology University of Michigan Ann Arbor, Michigan
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50
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Yessayan L, Heung M. Recognizing Downstream Consequences of Acute Kidney Injury. Am J Nephrol 2019; 47:424-426. [PMID: 29879715 DOI: 10.1159/000489950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/19/2022]
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