MO513CLINICAL AND ECONOMIC BURDEN OF FOCAL SEGMENTAL GLOMERULOSCLEROSIS (FSGS) IN THE UNITED STATES: A RETROSPECTIVE, OBSERVATIONAL COHORT STUDY

Background and Aims

The burden of disease associated with FSGS has not been well characterized, especially with regard to health care resource utilization (HCRU) and related costs. The aim of this study was to evaluate all-cause HCRU and estimate associated costs in patients with FSGS compared with a matched non-FSGS cohort; a secondary aim was to evaluate the impact of nephrotic range proteinuria on these outcomes.

Method

Data were from the Optum Clinformatics® Data Mart Database. Patients with ≥ 1 claim (1st claim = index event) for FSGS between April 2016 and December 2018 were identified based on ICD-10-CM codes and matched 1:2 (FSGS:controls) on index date, age, sex, and race to non-FSGS controls; continuous enrollment 6 months pre- and 12 months post-index was required. FSGS nephrotic range (either UPCR >3000 mg/g or ACR >2000 mg/g) and non-nephrotic subpopulations were also identified. Quan-Charlson Comorbidity Index (CCI) and individual comorbidities at baseline, and 12-month post-index all-cause HCRU and associated costs (per patient per year [PPPY]) as well as medication prescriptions related to FSGS treatment were compared between the matched cohorts and between the FSGS subpopulations; t-tests were used for continuous variables and chi-square tests for categorical variables.

Results

844 patients with FSGS were matched with 1688 non-FSGS controls; 57.4% male, 56.9% white, mean (SD) age 54.7 (18.4) years. Mean (SD) CCI was higher in the FSGS cohort relative to matched controls (2.72 [2.12] vs 0.55 [1.29]; P < .0001), with prevalence of most individual comorbidities higher in the FSGS cohort. Only 308 FSGS patients (36.5%) had UPCR or ACR tests with available results during the review period; 112 (36.4%) were in the nephrotic range and 196 were non- nephrotic (63.6%). The FSGS cohort was characterized by higher rates of all-cause HCRU across resource categories (all P < .0001) (Table 1); outpatient visits was the most frequently used category (99.1% vs 69.0%), followed by prescription medications. Among patients who used these resources, units of use were significantly higher in FSGS vs matched controls except for length of stay (Table 1). Readmission rates following 1st post-index hospitalization were higher in the FSGS cohort vs matched controls at 30 days (16.1% vs 6.0%; P < .05) and 365 days (39.1% vs 22.9%; P < .05). Glucocorticoids were the most frequently prescribed FSGS-related medication in both cohorts, with a higher rate in FSGS vs matched controls (50.6% vs 23.3%; P < .0001); other FSGS-related medications were infrequently prescribed (< 14%). Inpatient, outpatient, and prescription costs were higher in the FSGS cohort vs matched controls (all P < .0001) resulting in mean total annual medical costs of $59,753 vs $8,431 PPPY (P < .0001) that were driven by outpatient costs (Fig. 1A). Nephrotic range proteinuria was associated with higher all-cause inpatient, outpatient, and prescription costs vs non-nephrotic patients (all P < .0001; Fig. 1B), resulting in higher total costs ($70,481 vs $36,099 PPPY; P < .0001). A higher proportion of nephrotic range patients were prescribed FSGS-modifying medications (73.2% vs 54.1%; P = 0.001), with glucocorticoids the most frequent medication. However, 26.8% of nephrotic range patients were not prescribed any FSGS-related medications.

Conclusion

FSGS is associated with significant clinical and economic burdens with total annual medical costs > 7-fold higher than matched controls that were driven by outpatient costs. The presence of nephrotic range proteinuria substantially and significantly increased the economic burden. New treatment modalities leading to lower rates of proteinuria may help improve patient outcomes while reducing HCRU and their associated costs.

Compliance with Antibiotic Dosing Guidelines in Critically Ill Patients Receiving Renal Replacement Therapy

Background:

Compliance with antibiotic dosing guidelines and achievement of target serum concentrations in patients with infection who are on renal replacement therapy (RRT) is complex, essential for supportive care, and not well studied.

Objective:

To determine adherence rates to antibiotic dosing guidelines in the setting of RRT in the intensive care unit (ICU).

Methods:

We conducted a retrospective, single-center, cohort study evaluating antibiotic dosing in all patients in the ICU receiving RRT between July 2007 and June 2009. Appropriate dosing was determined by comparing dose administered with established guidelines. Dosing was denoted as accurate if adjustment occurred prior to the third administered dose or, if appropriate dosing is every 12 hours or more, within 24 hours. We compared rates according to modality of RRT (intermittent hemodialysis [IHD] vs continuous veno-venous hemodialysis [CVVHD]), indication for RRT (acute kidney injury [AKI] vs end-stage renal disease [ESRD]), and presence of a clinical pharmacist on rounds.

Results:

Adherence rates of 546 patients receiving RRT, with 1761 individual antibiotic prescriptions, were analyzed. Dosing errors were more common in the group receiving CVVHD than in the IHD group (58.1% vs 49.5%; p < 0.001). Frequency of dosing errors did not differ significantly between patients receiving RRT for AKI versus those with ESRD (55.4% vs 51.3%; p = 0.24) or in ICUs with or without a pharmacist on rounds (53.0% vs 54.6%; p = 0.67). Underdosing occurred less frequently with a clinical pharmacist on rounds (18.7% vs 31.3%; p < 0.001). However, in-hospital mortality was not significantly different in underdosed individuals compared with the rest of the cohort (52.3% vs 51.6%; p = 0.92).

Conclusions:

Antibiotic underdosing is common. Increased awareness of dose adjustment guidelines for CVVHD and having a clinical pharmacist on rounds may improve rates of underdosing.

Changing attitudes toward influenza vaccination in U.S. Kidney transplant programs over the past decade

BACKGROUND AND OBJECTIVES

Influenza infection in transplant recipients is often associated with significant morbidity. Surveys were conducted in 1999 and 2009 to find out if the influenza vaccination practices in the U.S. transplant programs had changed over the past 10 years.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In 1999, a survey of the 217 United Network for Organ Sharing-certified kidney and kidney-pancreas transplant centers in the U.S. was conducted regarding their influenza vaccination practice patterns. A decade later, a second similar survey of 239 transplant programs was carried out.

RESULTS

The 2009 respondents, compared with 1999, were more likely to recommend vaccination for kidney (94.5% versus 84.4%, P = 0.02) and kidney-pancreas recipients (76.8% versus 48.5%, P < 0.001), family members of transplant recipients (52.5% versus 21.0%, P < 0.001), and medical staff caring for transplant patients (79.6% versus 40.7%, P < 0.001). Physicians and other members of the transplant team were more likely to have been vaccinated in 2009 compared with 1999 (84.2% versus 62.3% of physicians, P < 0.001 and 91.2% versus 50.3% of nonphysicians, P < 0.001).

CONCLUSIONS

Our study suggests a greater adoption of the Centers for Disease Control and Prevention influenza vaccination guidelines by U.S. transplant programs in vaccinating solid-organ transplant recipients, close family contacts, and healthcare workers.

Red cell exchange using cell separator (therapeutic erythrocytapheresis) in two children with acute severe malaria

Red cell exchange using a cell separator (therapeutic erythrocytapheresis) has been used successfully in a large number of clinical conditions including acute severe cases of malaria. We report two children suffering from severe malaria (Plasmodium falciparum) with infestation rates of 75% and 67% respectively. They were treated successfully with erythrocytapheresis in combination with antimalarial treatment.

Feeding in the PICU

Nutrition plays a vital role in maintaining and enhancing the health of an individual. As mortality within intensive care units declines because of increased expertise and better equipment, attention is being focused on better methods of feeding the critically ill child. Feeding the child is one aspect that has been relegated to the back burner of the typically busy PICU. Evidence that feeding enhances immunity, protects the gut and shortens recovery time forces us to learn to feed our patients in more effective and safer ways. This article reviews the importance of feeding, especially that of enteral feeding, in the intensive care setting. The reactions of a stressed metabolism are outlined; separate nutritional components are discussed and requirements in specific conditions are given. Parenteral nutrition remains fraught with practical difficulties in India. Metabolic and infective complications are frequent and constant monitoring coupled with the cost of these solutions raises cost beyond affordable levels. Hence the emphasis on enteral feeding, with it's proven safety, routes of administration and ready availability. The immunity enhancing properties of enteral feeding is another aspect that has gained interest in recent years. Ecoimmunonutrition is a new concept that keeps the ecology of the stressed GI tract intact while providing adequately balanced formulae along with micronutrients and fibre.

A case-control study of laparoscopic versus open sigmoid colectomy for diverticulitis

Laparoscopic sigmoid colectomy (LSC) for diverticular disease accounts for a limited number of laparoscopic colon cases performed nationally because of the technical challenge it presents. Our objective was to determine the feasibility and impact of the laparoscopic approach in elective sigmoid colectomy for diverticular disease and to compare these results with those of the open approach. Twenty elective laparoscopic sigmoid colectomies (LSCs) were performed for diverticulitis between April 1992 and July 1999 at a university-affiliated urban hospital. A case-control study was performed comparing LCS with a matched control group of conventional open sigmoidectomies. Fourteen of 20 sigmoidectomies were successfully completed laparoscopically. The mean operative time for LSC was similar to that for open sigmoid colectomy (251 vs 243 minutes). There was earlier return to oral intake in the LSC group (1 vs 5 days; P < 0.001). The mean length of stay was significantly shorter (P = 0.029) in LSC (4.8 days) versus open sigmoid colectomy (7.8 days). Conversion to open sigmoidectomy extended hospital stay to 8.16 days. The overall complication rate was 10 per cent in both groups. We conclude that LSC can be performed effectively and with a low complication rate for diverticular disease. LSC provides the benefit of quicker return of bowel function and shorter hospitalization.