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Murillo-Zamora E, Trujillo X, Huerta M, Ríos-Silva M, Guzmán-Esquivel J, Benites-Godínez V, Mendoza-Cano O. Survival in influenza virus-related pneumonia by viral subtype: 2016-2020. Int J Infect Dis 2021; 112:288-293. [PMID: 34547495 DOI: 10.1016/j.ijid.2021.09.037] [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: 07/15/2021] [Revised: 09/11/2021] [Accepted: 09/15/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Influenza remains a common cause of morbidity and mortality worldwide, and viral subtype-related differences in disease outcomes have been documented. OBJECTIVE To characterize the survival experience of adult inpatients with influenza virus-associated pneumonia by viral subtype during five consecutive flu seasons. METHOD We performed a retrospective cohort study; data from 4,678 adults were analyzed using the Kaplan-Meier method. A multivariate Cox proportional hazard regression model was fitted. RESULTS The overall in-hospital mortality rate was 25.0 per 1,000 hospital days. The survival probabilities from pneumonia patients went from 93.4% (95% CI 92.6-94.1%) by day three to 43.3% (95% CI 39.2-47.4%) by day 30 from hospital admission. In general, the lowest survival rates were observed in patients with AH1N1 infection. In multiple models, after adjusting for comorbidities and when compared with A non-subtyped virus, pneumonia patients with AH3N2 or B strains had a significantly decreased risk of a non-favorable disease outcome. The association of other strains was not significant. CONCLUSIONS Our findings suggest that the survival of inpatients with influenza virus-associated pneumonia varies according to the pathogenic viral subtype; the lowest survival rates were observed in patients with AH1N1 infection. This effect was independent of the patients' gender, age, and the analyzed underlying health conditions.
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Affiliation(s)
- Efrén Murillo-Zamora
- Departamento de Epidemiología, Unidad de Medicina Familiar No. 19, Instituto Mexicano del Seguro Social, Av. Javier Mina 301, Col. Centro, C.P. 28000, Colima, Colima, México; Facultad de Medicina, Universidad de Colima, Av. Universidad 333, Col. L as Víboras, C.P. 28040, Colima, Colima, México.
| | - Xóchitl Trujillo
- Centro Universitario de Investigaciones Biomédicas, Universidad de Colima, Av. 25 de julio 965, Col. Villas San Sebastián, C.P. 28045 Colima, México.
| | - Miguel Huerta
- Centro Universitario de Investigaciones Biomédicas, Universidad de Colima, Av. 25 de julio 965, Col. Villas San Sebastián, C.P. 28045 Colima, México.
| | - Mónica Ríos-Silva
- Universidad de Colima - CONACyT, Centro Universitario de Investigaciones Biomédicas, Av. 25 de julio 965, Col. Villas San Sebastián, C.P. 28045 Colima, México
| | - José Guzmán-Esquivel
- Facultad de Medicina, Universidad de Colima, Av. Universidad 333, Col. L as Víboras, C.P. 28040, Colima, Colima, México; Unidad de Investigación en Epidemiología Clínica, Instituto Mexicano del Seguro Social, Av. de los Maestros 149, Col. Centro, CP 28000, Colima, México.
| | - Verónica Benites-Godínez
- Coordinación de Educación en Salud, Instituto Mexicano del Seguro Social, Calzada del Ejercito Nacional 14, Col. Fray Junípero Serra, C.P. 63160, Tepic, Nayarit; Unidad Académica de Medicina, Universidad Autónoma de Nayarit, Ciudad de la Cultura Amado Nervo, C.P. 631555, Tepic, Nayarit , México Tel +523112118800.
| | - Oliver Mendoza-Cano
- Facultad de Ingeniería Civil, Universidad de Colima, km. 9 carretera Colima-Coquimatlán, Coquimatlán, C.P. 28400, Colima, México..
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Justesen K, A Hooker S, Sherman MD, Lonergan-Cullum M, Nissly T, Levy R. Predictors of Family Medicine Patient Retention in Opioid Medication-Assisted Treatment. J Am Board Fam Med 2020; 33:848-57. [PMID: 33219064 DOI: 10.3122/jabfm.2020.06.200086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/02/2020] [Accepted: 06/07/2020] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Opioid use disorder is a prevalent and chronic condition that can lead to adverse outcomes if untreated. Medication-assisted treatment (MAT) with buprenorphine in a primary care setting has the potential to increase availability of treatment and reduce harm; however, retention in MAT is key for patient success. This study's purpose was to examine predictors of retention in a MAT program for OUD in a family medicine residency clinic. METHODS A retrospective chart review was conducted for 238 patients diagnosed with OUD and receiving MAT at a family medicine residency clinic between 2015 to 2017, with visit and prescription data collected through December 2018. Cox-proportional hazards models were used to examine the length of time in treatment. RESULTS Over three-fourths of our patients were retained for at least 3 months, 69% for at least 6 months, and 48% retained for at least 1 year. Physician continuity of care and having insurance coverage significantly predicted retention and longer duration of treatment. CONCLUSIONS Continuity of care and having health insurance were key predictors of patient retention in MAT care. Our findings emphasize the clinical significance of maintaining physician continuity of care to improve retention of patients with OUD in MAT programs. Future research could explore what aspects of continuity of care lead to retention in OUD treatment.
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King DE, Xiang J. Glucosamine/Chondroitin and Mortality in a US NHANES Cohort. J Am Board Fam Med 2020; 33:842-7. [PMID: 33219063 DOI: 10.3122/jabfm.2020.06.200110] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Limited previous studies in the United Kingdom or a single US state have demonstrated an association between intake of glucosamine/chondroitin and mortality. This study sought to investigate the association between regular consumption of glucosamine/chondroitin and overall and cardiovascular (CVD) mortality in a national sample of US adults. METHODS Combined data from 16,686 participants in National Health and Nutrition Examination Survey 1999 to 2010, merged with the 2015 Public-use Linked Mortality File. Cox proportional hazards models were conducted for both CVD and all-cause mortality. RESULTS In the study sample, there were 658 (3.94%) participants who had been taking glucosamine/chondroitin for a year or longer. During followup (median, 107 months), there were 3366 total deaths (20.17%); 674 (20.02%) were due to CVD. Respondents taking glucosamine/chondroitin were less likely to have CVD mortality (hazard ratio [HR] = 0.51; 95% CI, 0.28-0.92). After controlling for age, use was associated with a 39% reduction in all-cause (HR = 0.61; 95% CI, 0.49-0.77) and 65% reduction (HR = 0.35; 95% CI, 0.20-0.61) in CVD mortality. Multivariable-adjusted HR showed that the association was maintained after adjustment for age, sex, race, education, smoking status, and physical activity (all-cause mortality, HR = 0.73; 95% CI, 0.57-0.93; CVD mortality, HR = 0.42; 95% CI, 0.23-0.75). CONCLUSIONS Regular intake of glucosamine/chondroitin is associated with lower all-cause and CVD mortality in a national US cohort and the findings are consistent with previous studies in other populations. Prospective studies to confirm the link may be warranted.
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Muzaale AD, Daubresse M, Bae S, Chu NM, Lentine KL, Segev DL, McAdams-DeMarco M. Benzodiazepines, Codispensed Opioids, and Mortality among Patients Initiating Long-Term In-Center Hemodialysis. Clin J Am Soc Nephrol 2020; 15:794-804. [PMID: 32457228 PMCID: PMC7274292 DOI: 10.2215/cjn.13341019] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Mortality from benzodiazepine/opioid interactions is a growing concern in light of the opioid epidemic. Patients on hemodialysis suffer from a high burden of physical/psychiatric conditions, which are treated with benzodiazepines, and they are three times more likely to be prescribed opioids than the general population. Therefore, we studied mortality risk associated with short- and long-acting benzodiazepines and their interaction with opioids among adults initiating hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The cohort of 69,368 adults initiating hemodialysis (January 2013 to December 2014) was assembled by linking US Renal Data System records to Medicare claims. Medicare claims were used to identify dispensed benzodiazepines and opioids. Using adjusted Cox proportional hazards models, we estimated the mortality risk associated with benzodiazepines (time varying) and tested whether the benzodiazepine-related mortality risk differed by opioid codispensing. RESULTS Within 1 year of hemodialysis initiation, 10,854 (16%) patients were dispensed a short-acting benzodiazepine, and 3262 (5%) patients were dispensed a long-acting benzodiazepine. Among those who were dispensed a benzodiazepine during follow-up, codispensing of opioids and short-acting benzodiazepines occurred among 3819 (26%) patients, and codispensing of opioids and long-acting benzodiazepines occurred among 1238 (8%) patients. Patients with an opioid prescription were more likely to be subsequently dispensed a short-acting benzodiazepine (adjusted hazard ratio, 1.66; 95% confidence interval, 1.59 to 1.74) or a long-acting benzodiazepine (adjusted hazard ratio, 1.11; 95% confidence interval, 1.03 to 1.20). Patients dispensed a short-acting benzodiazepine were at a 1.45-fold (95% confidence interval, 1.35 to 1.56) higher mortality risk compared with those without a short-acting benzodiazepine; among those with opioid codispensing, this risk was 1.90-fold (95% confidence interval, 1.65 to 2.18; Pinteraction<0.001). In contrast, long-acting benzodiazepine dispensing was inversely associated with mortality (adjusted hazard ratio, 0.84; 95% confidence interval, 0.72 to 0.99) compared with no dispensing of long-acting benzodiazepine; there was no differential risk by opioid dispensing (Pinteraction=0.72). CONCLUSIONS Codispensing of opioids and short-acting benzodiazepines is common among patients on dialysis, and it is associated with higher risk of death.
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Affiliation(s)
- Abimereki D. Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sunjae Bae
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Krista L. Lentine
- Department of Medicine, St. Louis University School of Medicine, St. Louis, Missouri
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Hayashi T, Maruyama S, Nangaku M, Narita I, Hirakata H, Tanabe K, Morita S, Tsubakihara Y, Imai E, Akizawa T. Darbepoetin Alfa in Patients with Advanced CKD without Diabetes: Randomized, Controlled Trial. Clin J Am Soc Nephrol 2020; 15:608-615. [PMID: 32245781 PMCID: PMC7269223 DOI: 10.2215/cjn.08900719] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 07/30/2019] [Accepted: 03/06/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Large, randomized, controlled trials targeting higher hemoglobin level with erythropoiesis-stimulating agents for Western patients with CKD showed harm. However, the effect of anemia correction using erythropoiesis-stimulating agents may differ between CKD subpopulations. The Prevention of ESKD by Darbepoetin Alfa in CKD Patients with Non-diabetic Kidney Disease study, a multicenter, randomized, open-label, parallel-group study, aimed to examine the effect of targeting hemoglobin levels of 11-13 g/dl using darbepoetin alfa with reference to a low-hemoglobin target of 9-11 g/dl on kidney outcome in patients with advanced CKD without diabetes in Japan. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We enrolled 491 patients with CKD without diabetes, and an eGFR of 8-20 ml/min per 1.73 m2. Of these 491 patients, 239 and 240 were ultimately assigned to the high- and low-hemoglobin groups, respectively (12 patients were excluded). The primary outcome was a kidney composite end point (starting maintenance dialysis, kidney transplantation, eGFR≤6 ml/min per 1.73 m2, and 50% reduction in eGFR). RESULTS Mean hemoglobin levels were 11.2±1.1 and 10.0±0.9 g/dl in the high- and low-hemoglobin groups, respectively, during the mean study period of 73.5±29.7 weeks. The kidney composite end point occurred in 105 (44%) and 116 (48%) patients in the high- and low-hemoglobin groups, respectively (log-rank test; P=0.32). The adjusted Cox proportional hazards model showed that the hazard ratio for the high- versus low-hemoglobin group was 0.78 (95% confidence interval, 0.60 to 1.03; P=0.08). Cardiovascular events occurred in 19 (8%) and 16 (7%) patients in each group, respectively, with no significant between-group difference (log-rank test; P=0.66). CONCLUSIONS Targeting a higher hemoglobin level (11-13 g/dl) with darbepoetin alfa did not improve kidney outcome compared with targeting a lower hemoglobin level (9-11 g/dl) in patients with advanced CKD without diabetes. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Prevention of ESKD by Darbepoetin Alfa in CKD Patients with Non-diabetic Kidney Disease (PREDICT), NCT01581073.
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Affiliation(s)
- Terumasa Hayashi
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, Osaka, Japan
| | | | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University, Niigata, Japan
| | | | - Kenichiro Tanabe
- Division of Health Data Science, Translational Research Center for Medical Innovation, Kobe, Japan
| | - Satoshi Morita
- Biomedical Statistics and Bioinformatics, Kyoto University, Kyoto, Japan
| | | | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tadao Akizawa
- Division of Nephrology, Showa University School of Medicine, Tokyo, Japan
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Mukasa D, Sung J. A prediction model of low back pain risk: a population based cohort study in Korea. Korean J Pain 2020; 33:153-165. [PMID: 32235016 PMCID: PMC7136293 DOI: 10.3344/kjp.2020.33.2.153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 10/28/2019] [Revised: 12/19/2019] [Accepted: 01/01/2020] [Indexed: 12/27/2022] Open
Abstract
Background Well-validated risk prediction models help to identify individuals at high risk of diseases and suggest preventive measures. A recent systematic review reported lack of validated prediction models for low back pain (LBP). We aimed to develop prediction models to estimate the 8-year risk of developing LBP and its recurrence. Methods A population based prospective cohort study using data from 435,968 participants in the National Health Insurance Service–National Sample Cohort enrolled from 2002 to 2010. We used Cox proportional hazards models. Results During median follow-up period of 8.4 years, there were 143,396 (32.9%) first onset LBP cases. The prediction model of first onset consisted of age, sex, income grade, alcohol consumption, physical exercise, body mass index (BMI), total cholesterol, blood pressure, and medical history of diseases. The model of 5-year recurrence risk was comprised of age, sex, income grade, BMI, length of prescription, and medical history of diseases. The Harrell’s C-statistic was 0.812 (95% confidence interval [CI], 0.804-0.820) and 0.916 (95% CI, 0.907-0.924) in validation cohorts of LBP onset and recurrence models, respectively. Age, disc degeneration, and sex conferred the highest risk points for onset, whereas age, spondylolisthesis, and disc degeneration conferred the highest risk for recurrence. Conclusions LBP risk prediction models and simplified risk scores have been developed and validated using data from general medical practice. This study also offers an opportunity for external validation and updating of the models by incorporating other risk predictors in other settings, especially in this era of precision medicine.
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Affiliation(s)
- David Mukasa
- Complex Diseases & Genome Epidemiology Branch, Division of Epidemiology, School of Public Health, Seoul National University, Seoul, Korea
| | - Joohon Sung
- Complex Diseases & Genome Epidemiology Branch, Division of Epidemiology, School of Public Health, Seoul National University, Seoul, Korea.,Department of Epidemiology, School of Public Health and Institute of Health and Environment, Seoul National University, Seoul, Korea
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Liu Q, Smith AR, Mariani LH, Nair V, Zee J. Methods for Assessing Longitudinal Biomarkers of Time-to-Event Outcomes in CKD: A Simulation Study. Clin J Am Soc Nephrol 2019; 14:1315-1323. [PMID: 31416887 PMCID: PMC6730514 DOI: 10.2215/cjn.00450119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 07/03/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Identifying novel biomarkers is critical to advancing diagnosis and treatment of CKD, but relies heavily on the statistical methods used. Inappropriate methods can lead to both false positive and false negative associations between biomarkers and outcomes. This study assessed accuracy of methods using computer simulations and compared biomarker association estimates in the NEPhrotic syndrome sTUdy NEtwork (NEPTUNE), a prospective cohort study of patients with glomerular disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We compared three methods for analyzing repeatedly measured biomarkers in proportional hazards models: (1) time-invariant average, that averages values over all follow-up and uses the average as a baseline covariate, (2) time-varying last observation carried forward (LOCF), that assumes the covariate is unchanged until the next observed value, and (3) time-varying cumulative average, that updates the average using values at or before each measurement. RESULTS Under both true mechanisms of LOCF and cumulative average, simulation results showed the time-invariant average method often gave extremely inaccurate results. When LOCF was the true association mechanism, the cumulative average method often gave overestimated association estimates that were further away from the null. When cumulative average was the true mechanism, LOCF always underestimated the associations, i.e., closer to the null. In NEPTUNE, compared with the LOCF or cumulative average methods, hazard ratios estimated from the time-invariant average method were always higher. CONCLUSIONS Different analytic methods resulted in markedly different results. Using the time-invariant average produces inaccurate association estimates, whereas other methods can estimate additive (cumulative average) or instantaneous (LOCF) associations depending on the hypothesized underlying association mechanism and research question.
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Affiliation(s)
- Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
| | - Laura H Mariani
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and.,Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Viji Nair
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
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Tran J, Ayers E, Verghese J, Abramowitz MK. Gait Abnormalities and the Risk of Falls in CKD. Clin J Am Soc Nephrol 2019; 14:983-993. [PMID: 31235462 PMCID: PMC6625617 DOI: 10.2215/cjn.13871118] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 05/04/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Older adults with CKD are at high risk of falls and disability. It is not known whether gait abnormalities contribute to this risk. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Quantitative and clinical gait assessments were performed in 330 nondisabled community-dwelling adults aged ≥65 years. CKD was defined as an eGFR <60 ml/min per 1.73 m2. Cox proportional hazards models were created to examine fall risk. RESULTS A total of 41% (n=134) of participants had CKD. In addition to slower gait speed, participants with CKD had gait cycle abnormalities including shorter stride length and greater time in the stance and double-support phases. Among people with CKD, lower eGFR was independently associated with the severity of gait cycle abnormalities (per 10 ml/min per 1.73 m2 lower eGFR: 3.6 cm [95% confidence interval (95% CI), 1.4 to 5.8] shorter stride length; 0.7% [95% CI, 0.3 to 1.0] less time in swing phase; 1.1% [95% CI, 0.5 to 1.7] greater time in double-support phase); these abnormalities mediated the association of lower eGFR with slower gait speed. On clinical gait exam, consistent with the quantitative abnormalities, short steps and marked swaying or loss of balance were more common among participants with CKD, yet most had no identifiable gait phenotype. A gait phenotype defined by any of these abnormal signs was associated with higher risk of falls among participants with CKD: compared with people without CKD and without the gait phenotype, the adjusted hazard ratio was 1.72 (95% CI, 1.06 to 2.81) for those with CKD and the phenotype; in comparison, the adjusted hazard ratio was 0.71 (95% CI, 0.40 to 1.25) for people with CKD but without the phenotype (P value for interaction of CKD status and gait phenotype =0.01). CONCLUSIONS CKD in older adults is associated with quantitative gait abnormalities, which clinically manifest in a gait phenotype that is associated with fall risk.
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Affiliation(s)
| | - Emmeline Ayers
- Neurology, Albert Einstein College of Medicine, Bronx, New York
| | - Joe Verghese
- Departments of Medicine and.,Neurology, Albert Einstein College of Medicine, Bronx, New York
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Molitch ME, Gao X, Bebu I, de Boer IH, Lachin J, Paterson A, Perkins B, Saenger AK, Steffes M, Zinman B. Early Glomerular Hyperfiltration and Long-Term Kidney Outcomes in Type 1 Diabetes: The DCCT/EDIC Experience. Clin J Am Soc Nephrol 2019; 14:854-861. [PMID: 31123181 PMCID: PMC6556717 DOI: 10.2215/cjn.14831218] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/24/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Glomerular hyperfiltration has been considered to be a contributing factor to the development of diabetic kidney disease (DKD). To address this issue, we analyzed GFR follow-up data on participants with type 1 diabetes undergoing 125I-iothalamate clearance on entry into the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications study. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a cohort study of DCCT participants with type 1 diabetes who underwent an 125I-iothalamate clearance (iGFR) at DCCT baseline. Presence of hyperfiltration was defined as iGFR levels ≥140 ml/min per 1.73 m2, with secondary thresholds of 130 or 150 ml/min per 1.73 m2. Cox proportional hazards models assessed the association between the baseline hyperfiltration status and the subsequent risk of reaching an eGFR <60 ml/min per 1.73 m2. RESULTS Of the 446 participants, 106 (24%) had hyperfiltration (iGFR levels ≥140 ml/min per 1.73 m2) at baseline. Over a median follow-up of 28 (interquartile range, 23, 33) years, 53 developed an eGFR <60 ml/min per 1.73 m2. The cumulative incidence of eGFR <60 ml/min per 1.73 m2 at 28 years of follow-up was 11.0% among participants with hyperfiltration at baseline, compared with 12.8% among participants with baseline GFR <140 ml/min per 1.73 m2. Hyperfiltration was not significantly associated with subsequent risk of developing an eGFR <60 ml/min per 1.73 m2 in an unadjusted Cox proportional hazards model (hazard ratio, 0.83; 95% confidence interval, 0.43 to 1.62) nor in an adjusted model (hazard ratio, 0.77; 95% confidence interval, 0.38 to 1.54). Application of alternate thresholds to define hyperfiltration (130 or 150 ml/min per 1.73 m2) showed similar findings. CONCLUSIONS Early hyperfiltration in patients with type 1 diabetes was not associated with a higher long-term risk of decreased GFR. Although glomerular hypertension may be a mechanism of kidney injury in DKD, higher total GFR does not appear to be a risk factor for advanced DKD.
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Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois;
| | - Xiaoyu Gao
- Biostatistics Center, George Washington University, Rockville, Maryland
| | - Ionut Bebu
- Biostatistics Center, George Washington University, Rockville, Maryland
| | - Ian H de Boer
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington
| | - John Lachin
- Biostatistics Center, George Washington University, Rockville, Maryland
| | - Andrew Paterson
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Perkins
- Division of Endocrinology and Metabolism, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Amy K Saenger
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota; and
| | - Michael Steffes
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota; and
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Van Biesen W, Verger C, Heaf J, Vrtovsnik F, Britto ZML, Do JY, Prieto-Velasco M, Martínez JP, Crepaldi C, De Los Ríos T, Gauly A, Ihle K, Ronco C. Evolution Over Time of Volume Status and PD-Related Practice Patterns in an Incident Peritoneal Dialysis Cohort. Clin J Am Soc Nephrol 2019; 14:882-893. [PMID: 31123180 PMCID: PMC6556715 DOI: 10.2215/cjn.11590918] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [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: 09/26/2018] [Accepted: 04/10/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Volume overload is frequent in prevalent patients on kidney replacement therapies and is associated with outcome. This study was devised to follow-up volume status of an incident population on peritoneal dialysis (PD) and to relate this to patient-relevant outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This prospective cohort study was implemented in 135 study centers from 28 countries. Incident participants on PD were enrolled just before the actual PD treatment was started. Volume status was measured using bioimpedance spectroscopy before start of PD and thereafter in 3-month intervals, together with clinical and laboratory parameters, and PD prescription. The association of volume overload with time to death was tested using a competing risk Cox model. RESULTS In this population of 1054 participants incident on PD, volume overload before start of PD amounted to 1.9±2.3 L, and decreased to 1.2±1.8 L during the first year. At all time points, men and participants with diabetes were at higher risk to be volume overloaded. Dropout from PD during 3 years of observation by transfer to hemodialysis or transplantation (23% and 22%) was more prevalent than death (13%). Relative volume overload >17.3% was independently associated with higher risk of death (adjusted hazard ratio, 1.59; 95% confidence interval, 1.08 to 2.33) compared with relative volume overload ≤17.3%. Different practice patterns were observed between regions with respect to proportion of patients on PD versus hemodialysis, selection of PD modality, and prescription of hypertonic solutions. CONCLUSIONS In this large cohort of incident participants on PD, with different treatment practices across centers and regions, we found substantial volume overload already at start of dialysis. Volume overload improved over time, and was associated with survival.
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Affiliation(s)
- Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium;
| | - Christian Verger
- Registre de dialyse péritonéale de langue Française, Pontoise, France
| | - James Heaf
- Department Medicine, Zealand University Hospital, Roskilde, Denmark
| | | | | | - Jun-Young Do
- Department of Internal Medicine, Yeungnam University Hospital, Daegu, Korea
| | | | - Juan Pérez Martínez
- Servicio de Nefrología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Carlo Crepaldi
- Department of Nephrology Dialysis and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy; and
| | - Tatiana De Los Ríos
- Clinical and Epidemiological Research, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Adelheid Gauly
- Clinical and Epidemiological Research, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Katharina Ihle
- Clinical and Epidemiological Research, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Claudio Ronco
- Department of Nephrology Dialysis and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy; and
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11
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Kim H, Caulfield LE, Garcia-Larsen V, Steffen LM, Grams ME, Coresh J, Rebholz CM. Plant-Based Diets and Incident CKD and Kidney Function. Clin J Am Soc Nephrol 2019; 14:682-691. [PMID: 31023928 PMCID: PMC6500948 DOI: 10.2215/cjn.12391018] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/20/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES The association between plant-based diets, incident CKD, and kidney function decline has not been examined in the general population. We prospectively investigated this relationship in a population-based study, and evaluated if risk varied by different types of plant-based diets. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Analyses were conducted in a sample of 14,686 middle-aged adults enrolled in the Atherosclerosis Risk in Communities study. Diets were characterized using four plant-based diet indices. In the overall plant-based diet index, all plant foods were positively scored; in the healthy plant-based diet index, only healthful plant foods were positively scored; in the provegetarian diet, selected plant foods were positively scored. In the less healthy plant-based diet index, only less healthful plant foods were positively scored. All indices negatively scored animal foods. We used Cox proportional hazards models to study the association with incident CKD and linear mixed models to examine decline in eGFR, adjusting for confounders. RESULTS During a median follow-up of 24 years, 4343 incident CKD cases occurred. Higher adherence to a healthy plant-based diet (HR comparing quintile 5 versus quintile 1 [HRQ5 versus Q1], 0.86; 95% confidence interval [95% CI], 0.78 to 0.96; P for trend =0.001) and a provegetarian diet (HRQ5 versus Q1, 0.90; 95% CI, 0.82 to 0.99; P for trend =0.03) were associated with a lower risk of CKD, whereas higher adherence to a less healthy plant-based diet (HRQ5 versus Q1, 1.11; 95% CI, 1.01 to 1.21; P for trend =0.04) was associated with an elevated risk. Higher adherence to an overall plant-based diet and a healthy plant-based diet was associated with slower eGFR decline. The proportion of CKD attributable to lower adherence to healthy plant-based diets was 4.1% (95% CI, 0.6% to 8.3%). CONCLUSIONS Higher adherence to healthy plant-based diets and a vegetarian diet was associated with favorable kidney disease outcomes.
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Affiliation(s)
- Hyunju Kim
- Center for Human Nutrition and
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland; and
| | | | | | - Lyn M. Steffen
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland; and
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland; and
| | - Casey M. Rebholz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland; and
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12
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Ohnishi T, Kimachi M, Fukuma S, Akizawa T, Fukuhara S. Postdialysis Hypokalemia and All-Cause Mortality in Patients Undergoing Maintenance Hemodialysis. Clin J Am Soc Nephrol 2019; 14:873-881. [PMID: 31048327 PMCID: PMC6556735 DOI: 10.2215/cjn.07950718] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 04/01/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Almost half of patients on dialysis demonstrate a postdialysis serum potassium ≤3.5 mEq/L. We aimed to examine the relationship between postdialysis potassium levels and all-cause mortality. DESIGN, SETTING, PATIENTS, & MEASUREMENTS We conducted a cohort study of 3967 participants on maintenance hemodialysis from the Dialysis Outcomes and Practice Patterns Study in Japan (2009-2012 and 2012-2015). Postdialysis serum potassium was measured repeatedly at 4-month intervals and used as a time-varying variable. We estimated the hazard ratio of all-cause mortality rate using Cox hazard regression models, with and without adjusting for time-varying predialysis serum potassium. Models were adjusted for baseline characteristics and time-varying laboratory parameters. We also analyzed associations of combinations of pre- and postdialysis potassium with mortality. RESULTS The age of participants at baseline was 65±12 years (mean±SD), 2552 (64%) were men, and 96% were treated with a dialysate potassium level of 2.0 to <2.5 mEq/L. The median follow-up period was 2.6 (interquartile range, 1.3-2.8) years. During the follow-up period, 562 (14%) of 3967 participants died, and the overall mortality rate was 6.7 per 100 person-years. Compared with postdialysis potassium of 3.0 to <3.5 mEq/L, the hazard ratios of postdialysis hypokalemia (<3.0 mEq/L) were 1.84 (95% confidence interval, 1.44 to 2.34) in the unadjusted model, 1.44 (95% confidence interval, 1.14 to 1.82) in the model without adjusting for predialysis serum potassium, and 1.10 (95% confidence interval, 0.84 to 1.44) in the model adjusted for predialysis serum potassium. The combination of pre- and postdialysis hypokalemia was associated with the highest mortality risk (hazard ratio, 1.72; 95% confidence interval, 1.35 to 2.19, reference; pre- and postdialysis nonhypokalemia). CONCLUSIONS Postdialysis hypokalemia was associated with mortality, but this association was not independent of predialysis potassium.
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Affiliation(s)
- Tsuyoshi Ohnishi
- Department of Healthcare Epidemiology, School of Public Health and.,Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima City, Fukushima, Japan.,Institute for Health Outcomes and Process Evaluation Research (iHope International), Nakagyoku, Kyoto, Japan; and
| | - Miho Kimachi
- Department of Healthcare Epidemiology, School of Public Health and
| | - Shingo Fukuma
- Human Health Sciences, Kyoto University Graduate School of Medicine, Sakyoku, Kyoto, Japan;
| | - Tadao Akizawa
- Division of Nephrology, Showa University School of Medicine, Tokyo, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health and.,Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima City, Fukushima, Japan
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13
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Li X, Cole SR, Kshirsagar AV, Fine JP, Stürmer T, Brookhart MA. Safety of Dynamic Intravenous Iron Administration Strategies in Hemodialysis Patients. Clin J Am Soc Nephrol 2019; 14:728-737. [PMID: 30988164 PMCID: PMC6500950 DOI: 10.2215/cjn.03970318] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/06/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Intravenous iron therapy for chronic anemia management is largely driven by dosing protocols that differ in intensity with respect to dosing approach (i.e., dose, frequency, and duration). Little is known about the safety of these protocols. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using clinical data from a large United States dialysis provider linked to health care utilization data from Medicare, we constructed a cohort of patients with ESKD aged ≥65 years who initiated and continued center-based hemodialysis for ≥90 days between 2009 and 2012, and initiated at least one of the five common intravenous iron administration strategies; ranked by intensity (the amount of iron given at moderate-to-high iron indices), the order of strategies was 3 (least intensive), 2 (less intensive), 1 (reference), 4 (more intensive), and 5 (most intensive). We estimated the effect of continuous exposure to these strategies on cumulative risks of mortality and infection-related events with dynamic Cox marginal structural models. RESULTS Of 13,249 eligible patients, 1320 (10%) died and 1627 (12%) had one or more infection-related events during the 4-month follow-up. The most and least commonly initiated strategy was strategy 2 and 5, respectively. Compared with the reference strategy 1, more intensive strategies (4 and 5) demonstrated a higher risk of all-cause mortality (e.g., most intensive strategy 5: 60-day risk difference: 1.3%; 95% confidence interval [95% CI], 0.8% to 2.1%; 120-day risk difference: 3.1%; 95% CI, 1.0% to 5.6%). Similarly, higher risks were observed for infection-related morbidity and mortality among more intensive strategies (e.g., strategy 5: 60-day risk difference: 1.8%; 95% CI, 1.2% to 2.6%; 120-day risk difference: 4.3%; 95% CI, 2.2% to 6.8%). Less intensive strategies (2 and 3) demonstrated lower risks of all-cause mortality and infection-related events. CONCLUSIONS Among dialysis patients surviving 90 days, subsequent intravenous iron administration strategies promoting more intensive iron treatment at moderate-to-high iron indices levels are associated with higher risks of mortality and infection-related events.
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Affiliation(s)
- Xiaojuan Li
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Stephen R Cole
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Abhijit V Kshirsagar
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jason P Fine
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - M Alan Brookhart
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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14
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Xu H, Matsushita K, Su G, Trevisan M, Ärnlöv J, Barany P, Lindholm B, Elinder CG, Lambe M, Carrero JJ. Estimated Glomerular Filtration Rate and the Risk of Cancer. Clin J Am Soc Nephrol 2019; 14:530-539. [PMID: 30872279 PMCID: PMC6450356 DOI: 10.2215/cjn.10820918] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/05/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Community-based reports regarding eGFR and the risk of cancer are conflicting. We here explore plausible links between kidney function and cancer incidence in a large Scandinavian population-based cohort. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In the Stockholm Creatinine Measurements project, we quantified the associations of baseline eGFR with the incidence of cancer among 719,033 Swedes ages ≥40 years old with no prior history of cancer. Study outcomes were any type and site-specific cancer incidence rates on the basis of International Classification of Diseases-10 codes over a median follow-up of 5 years. To explore the possibility of detection bias and reverse causation, we divided the follow-up time into different time periods (≤12 and >12 months) and estimated risks for each of these intervals. RESULTS In total, 64,319 cases of cancer (affecting 9% of participants) were detected throughout 3,338,226 person-years. The relationship between eGFR and cancer incidence was U shaped. Compared with eGFR of 90-104 ml/min, lower eGFR strata associated with higher cancer risk (adjusted hazard ratio, 1.08; 95% confidence interval, 1.05 to 1.11 for eGFR=30-59 ml/min and adjusted hazard ratio, 1.24; 95% confidence interval, 1.15 to 1.35 for eGFR<30 ml/min). Lower eGFR strata were significantly associated with higher risk of skin, urogenital, prostate, and hematologic cancers. Any cancer risk as well as skin (nonmelanoma) and urogenital cancer risks were significantly elevated throughout follow-up time, but they were higher in the first 12 months postregistration. Associations with hematologic and prostate cancers abrogated after the first 12 months of observation, suggesting the presence of detection bias and/or reverse causation. CONCLUSIONS There is a modestly higher cancer risk in individuals with mild to severe CKD driven primarily by skin and urogenital cancers, and this is only partially explained by bias.
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Affiliation(s)
- Hong Xu
- Departments of Medical Epidemiology and Biostatistics and
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, and
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Guobin Su
- Public Health Sciences
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou City, China
| | - Marco Trevisan
- Departments of Medical Epidemiology and Biostatistics and
| | - Johan Ärnlöv
- School of Health and Social Studies, Dalarna University, Falun, Sweden; and
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Peter Barany
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Carl-Gustaf Elinder
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Mats Lambe
- Departments of Medical Epidemiology and Biostatistics and
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15
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Gupta A, Montgomery RN, Bedros V, Lesko J, Mahnken JD, Chakraborty S, Drew D, Klein JA, Thomas TS, Ilahe A, Budhiraja P, Brooks WM, Schmitt TM, Sarnak MJ, Burns JM, Cibrik DM. Subclinical Cognitive Impairment and Listing for Kidney Transplantation. Clin J Am Soc Nephrol 2019; 14:567-575. [PMID: 30890576 PMCID: PMC6450345 DOI: 10.2215/cjn.11010918] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 01/17/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Cognitive impairment is common in patients with kidney disease and can affect physicians' perception and/or patients' ability to complete the pretransplant evaluation. We examined whether cognitive impairment influences the likelihood for transplant listing and whether patients with cognitive impairment take longer to be listed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a single-center longitudinal cohort study. Patients presenting for their index kidney transplant evaluation were screened for cognitive impairment using the Montreal Cognitive Assessment. A score <26 indicated cognitive impairment. The transplant selection committee was blinded to the scores. Kaplan-Meier analysis assessed time to active listing by level of cognition. A Cox proportional hazards model that included age, sex, race/ethnicity, smoking, coronary artery disease, and diabetes was constructed to evaluate the association between Montreal Cognitive Assessment score and listing for transplant. RESULTS In total, 349 patients who underwent Montreal Cognitive Assessment testing at their initial visit were included in the analysis. Patients with cognitive impairment were more likely to be older, black, and smokers. The time to listing in patients with cognitive impairment was longer than the time to listing in those with no cognitive impairment (median time, 10.6 versus 6.3 months; log rank test P=0.01). Cognitive impairment was independently associated with a lower likelihood of being listed for transplant (hazard ratio, 0.93 per unit lower Montreal Cognitive Assessment score; 95% confidence interval, 0.88 to 0.99; P=0.02). A lower proportion of patients with cognitive impairment were listed compared with patients without cognitive impairment at 1 month (2% versus 11%), 6 months (17% versus 37%), and 1 year (23% versus 41%), (P<0.001 for all). CONCLUSIONS Cognitive impairment is associated with a lower likelihood of being listed for kidney transplant, and is associated with longer time to transplant listing.
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Affiliation(s)
| | | | - Victor Bedros
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - John Lesko
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | | | - Shweta Chakraborty
- Transplant Administration, University of Kansas Health System, Kansas City, Kansas; and
| | - David Drew
- Department of Internal Medicine, Tufts Medical Center, Boston, Massachusetts
| | | | | | | | | | | | | | - Mark J Sarnak
- Department of Internal Medicine, Tufts Medical Center, Boston, Massachusetts
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16
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Kim HW, Park JT, Yoo TH, Lee J, Chung W, Lee KB, Chae DW, Ahn C, Kang SW, Choi KH, Han SH. Urinary Potassium Excretion and Progression of CKD. Clin J Am Soc Nephrol 2019; 14:330-340. [PMID: 30765533 PMCID: PMC6419276 DOI: 10.2215/cjn.07820618] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/12/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Data on whether low or high urinary potassium excretion is associated with poor kidney outcome have been conflicting. The aim of this study was to clarify the association between urinary potassium excretion and CKD progression. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We investigated the relationship between lower urinary potassium excretion and CKD progression and compared three urinary potassium indices among 1821 patients from the Korean Cohort Study for Outcome in Patients with CKD. Urinary potassium excretion was determined using spot urinary potassium-to-creatinine ratio, spot urinary potassium concentration, and 24-hour urinary potassium excretion. Patients were categorized into four groups according to quartiles of each urinary potassium excretion metric. The study end point was a composite of a ≥50% decrease in eGFR from baseline values and ESKD. RESULTS During 5326 person-years of follow-up, the primary outcome occurred in 392 (22%) patients. In a multivariable cause-specific hazard model, lower urinary potassium-to-creatinine ratio was associated with higher risk of CKD progression (adjusted hazard ratio, 1.47; 95% confidence interval, 1.01 to 2.12) comparing the lowest quartile with the highest quartile. Sensitivity analyses with other potassium metrics also showed consistent results in 855 patients who completed 24-hour urinary collections: adjusted hazard ratios comparing the lowest quartile with the highest quartile were 3.05 (95% confidence interval, 1.54 to 6.04) for 24-hour urinary potassium excretion, 1.95 (95% confidence interval, 1.05 to 3.62) for spot urinary potassium-to-creatinine ratio, and 3.79 (95% confidence interval, 1.51 to 9.51) for spot urinary potassium concentration. CONCLUSIONS Low urinary potassium excretion is associated with progression of CKD.
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Affiliation(s)
- Hyung Woo Kim
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Jung Tak Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Joongyub Lee
- Department of Prevention and Management, School of Medicine, Inha University, Incheon, Korea
| | - Wookyung Chung
- Department of Internal Medicine, Gachon University, Gil Hospital, Incheon, Korea
| | - Kyu-Beck Lee
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea; and
| | - Dong-Wan Chae
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Kyu Hun Choi
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - on behalf of the KNOW-CKD Study Investigators
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
- Department of Prevention and Management, School of Medicine, Inha University, Incheon, Korea
- Department of Internal Medicine, Gachon University, Gil Hospital, Incheon, Korea
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea; and
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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17
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Adwaney A, Lim C, Blakey S, Duncan N, Ashby DR. Central Venous Stenosis, Access Outcome and Survival in Patients undergoing Maintenance Hemodialysis. Clin J Am Soc Nephrol 2019; 14:378-384. [PMID: 30765534 PMCID: PMC6419278 DOI: 10.2215/cjn.07010618] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 01/03/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Central venous catheters have traditionally provided access for urgent hemodialysis, but are also sometimes advocated as an option for older or more comorbid patients. Adverse effects of this type of dialysis access include central venous stenosis, for which the risk factors and consequences are incompletely understood. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted two studies within the same population cohort, comprising all patients starting hemodialysis in a single center from January 2006 to December 2013. First, patients were retrospectively analyzed for the presence of central venous stenosis; their access outcomes are described and survival compared with matched controls drawn from the same population. Second, a subset of patients with a history of catheter access within this cohort was analyzed to determine risk factors for central venous stenosis. RESULTS Among 2811 patients, central venous stenosis was diagnosed in 120 (4.3%), at a median dialysis vintage of 2.9 (interquartile range, 1.8-4.6) years. Compared with matched controls, patients with central venous stenosis had similar survival (median 5.1 versus 5.2 years; P=0.54). Among a subset of 500 patients, all with a history of catheter use, 34 (6.8%) developed central venous stenosis, at a rate of 2.2 per 100 patient-years. The incidence of central venous stenosis was higher with larger number of previous catheters (relative risk [RR], 2.2; 95% confidence interval [95% CI]. 1.6 to 2.9), pacemaker insertion (RR, 3.9; 95% CI, 1.7 to 8.9), and was lower with older age (RR, 0.7 per decade; 95% CI, 0.6 to 0.8). In a Cox proportional hazards model, the catheter number, pacemaker, and younger age at dialysis initiation were all significant independent risk factors for central venous stenosis. CONCLUSIONS Central venous stenosis occurred in a minority of patients on hemodialysis, and was associated with compromised future access, but unchanged survival. Among patients with a history of catheter use, risk related to both the number of catheters and the total catheter duration, although nondialysis factors such as pacemakers were also important. Central venous stenosis risk was lower in older patients, supporting the selective use of tunneled catheters in this group.
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Affiliation(s)
- Anamika Adwaney
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust, London, UK
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18
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Saglimbene VM, Wong G, Ruospo M, Palmer SC, Garcia-Larsen V, Natale P, Teixeira-Pinto A, Campbell KL, Carrero JJ, Stenvinkel P, Gargano L, Murgo AM, Johnson DW, Tonelli M, Gelfman R, Celia E, Ecder T, Bernat AG, Del Castillo D, Timofte D, Török M, Bednarek-Skublewska A, Duława J, Stroumza P, Hoischen S, Hansis M, Fabricius E, Felaco P, Wollheim C, Hegbrant J, Craig JC, Strippoli GFM. Fruit and Vegetable Intake and Mortality in Adults undergoing Maintenance Hemodialysis. Clin J Am Soc Nephrol 2019; 14:250-260. [PMID: 31738182 PMCID: PMC6390927 DOI: 10.2215/cjn.08580718] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/23/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Higher fruit and vegetable intake is associated with lower cardiovascular and all-cause mortality in the general population. It is unclear whether this association occurs in patients on hemodialysis, in whom high fruit and vegetable intake is generally discouraged because of a potential risk of hyperkalemia. We aimed to evaluate the association between fruit and vegetable intake and mortality in hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Fruit and vegetable intake was ascertained by the Global Allergy and Asthma European Network food frequency questionnaire within the Dietary Intake, Death and Hospitalization in Adults with ESKD Treated with Hemodialysis study, a multinational cohort study of 9757 adults on hemodialysis, of whom 8078 (83%) had analyzable dietary data. Adjusted Cox regression analyses clustered by country were conducted to evaluate the association between tertiles of fruit and vegetable intake with all-cause, cardiovascular, and noncardiovascular mortality. Estimates were calculated as hazard ratios with 95% confidence intervals (95% CIs). RESULTS During a median follow up of 2.7 years (18,586 person-years), there were 2082 deaths (954 cardiovascular). The median (interquartile range) number of servings of fruit and vegetables was 8 (4-14) per week; only 4% of the study population consumed at least four servings per day as recommended in the general population. Compared with the lowest tertile of servings per week (0-5.5, median 2), the adjusted hazard ratios for the middle (5.6-10, median 8) and highest (>10, median 17) tertiles were 0.90 (95% CI, 0.81 to 1.00) and 0.80 (95% CI, 0.71 to 0.91) for all-cause mortality, 0.88 (95% CI, 0.76 to 1.02) and 0.77 (95% CI, 0.66 to 0.91) for noncardiovascular mortality and 0.95 (95% CI, 0.81 to 1.11) and 0.84 (95% CI, 0.70 to 1.00) for cardiovascular mortality, respectively. CONCLUSIONS Fruit and vegetable intake in the hemodialysis population is low and a higher consumption is associated with lower all-cause and noncardiovascular death.
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Affiliation(s)
- Valeria M Saglimbene
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia; .,Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden
| | - Germaine Wong
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Westmead, Australia.,Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | | | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Vanessa Garcia-Larsen
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Patrizia Natale
- Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden.,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Armando Teixeira-Pinto
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Westmead, Australia
| | | | | | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | | | - Angelo M Murgo
- Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden
| | - David W Johnson
- Division of Medicine, Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Woolloongabba, Australia.,Translational Research Institute, University of Queensland, Woolloongabba, Australia
| | - Marcello Tonelli
- Health Sciences Centre, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rubén Gelfman
- Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden
| | - Eduardo Celia
- Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden
| | - Tevfik Ecder
- Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden
| | | | | | - Delia Timofte
- Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden
| | - Marietta Török
- Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden
| | - Anna Bednarek-Skublewska
- Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden.,Medical University of Lublin, Lublin, Poland
| | - Jan Duława
- Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden.,Department of Internal Medicine and Metabolic Diseases, Medical University of Silesia, Katowice, Poland
| | - Paul Stroumza
- Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden
| | | | - Martin Hansis
- Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden
| | | | - Paolo Felaco
- Nephrology and Dialysis Unit, Hospital of the Penne Presidium, Unita' Sanitaria Locale, Pescara, Italy
| | | | | | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia; and
| | - Giovanni F M Strippoli
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia.,Diaverum Medical-Scientific Office, Diaverum, Lund, Sweden.,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.,Diaverum Academy, Diaverum, Bari, Italy
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19
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Yamamoto R, Shinzawa M, Isaka Y, Yamakoshi E, Imai E, Ohashi Y, Hishida A. Sleep Quality and Sleep Duration with CKD are Associated with Progression to ESKD. Clin J Am Soc Nephrol 2018; 13:1825-1832. [PMID: 30442866 PMCID: PMC6302324 DOI: 10.2215/cjn.01340118] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 08/23/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Shorter or longer sleep duration and poor sleep quality are risk factors for numerous cardio-metabolic diseases, cardiovascular disease, and mortality in subjects with normal kidney function. The association of sleep duration and sleep quality with health outcomes in patients with CKD remains uncertain. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A 4-year prospective cohort study in 17 nephrology centers in Japan, the CKD Japan Cohort (CKD-JAC) Study, assessed an association of self-reported sleep duration and sleep quality, on the basis of the Pittsburgh Sleep Quality Index (PSQI) questionnaire, with incidence of ESKD in 1601 patients with eGFR 10-59 ml/min per 1.73 m2 using multivariable-adjusted Cox proportional hazards models. RESULTS Baseline sleep duration and PSQI global score for the 1601 patients were mean±SD 7.0±1.3 hours and median 4 (interquartile range, 3-7), respectively. Poor sleep quality (PSQI global score ≥6) was common (n=588 [37%]). During a median of 4.0 (2.6-4.3) years of the follow-up period, 282 (18%) patients progressed to ESKD. After adjusting for age, sex, eGFR, urinary albumin excretion, smoking status, body mass index, history of diabetes and cardiovascular disease, systolic BP, blockade of the renin-angiotensin system, use of hypnotics, and Beck depression inventory score, both shorter (≤5 hour) and longer (>8 hour) sleep duration were associated with ESKD (adjusted hazard ratios [95% confidence intervals] for ≤5.0, 5.1-6.0, 6.1-7.0, 7.1-8.0, and ≥8.0 hours were 2.05 [1.31 to3.21], 0.98 [0.67 to 1.44], 1.00 [reference], 1.22 [0.89 to 1.66], and 1.48 [1.01 to 2.16]), suggesting a U-shaped relationship between sleep duration and ESKD. PSQI global score ≥6 was also associated with incidence of ESKD (adjusted hazard ratios [95% confidence intervals] for PSQI global score ≤5 and ≥6 were 1.00 [reference] and 1.33 [1.03 to 1.71]). CONCLUSIONS Shorter (≤5 hour) and longer (>8 hour) sleep duration and poor sleep quality (PSQI global score ≥6) were associated with ESKD in patients with CKD.
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Affiliation(s)
- Ryohei Yamamoto
- Health Care Division, Health and Counseling Center, Osaka University, Toyonaka, Osaka, Japan
| | - Maki Shinzawa
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | | | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Hyogo, Japan
| | | | | | - for the CKD-JAC Investigators
- Health Care Division, Health and Counseling Center, Osaka University, Toyonaka, Osaka, Japan
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Statcom Company Limited, Bunkyo-Ku, Tokyo, Japan
- Nakayamadera Imai Clinic, Takarazuka, Hyogo, Japan
- Chuo University Bunkyo-ku, Tokyo, Japan; and
- Yaizu City Hospital, Yaizu, Shizuoka, Japan
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20
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Cedillo-Couvert EA, Hsu JY, Ricardo AC, Fischer MJ, Gerber BS, Horwitz EJ, Kusek JW, Lustigova E, Renteria A, Rosas SE, Saunders M, Sha D, Slaven A, Lash JP. Patient Experience with Primary Care Physician and Risk for Hospitalization in Hispanics with CKD. Clin J Am Soc Nephrol 2018; 13:1659-1667. [PMID: 30337326 PMCID: PMC6237062 DOI: 10.2215/cjn.03170318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 08/14/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In the general population, the quality of the patient experience with their primary care physician may influence health outcomes but this has not been evaluated in CKD. This is relevant for the growing Hispanic CKD population, which potentially faces challenges to the quality of the patient experience related to language or cultural factors. We evaluated the association between the patient experience with their primary care physician and outcomes in Hispanics with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This prospective observational study included 252 English- and Spanish-speaking Hispanics with entry eGFR of 20-70 ml/min per 1.73 m2, enrolled in the Hispanic Chronic Renal Insufficiency Cohort study between 2005 and 2008. Patient experience with their primary care physician was assessed by the Ambulatory Care Experiences Survey subscales: communication quality, whole-person orientation, health promotion, interpersonal treatment, and trust. Poisson and proportional hazards models were used to assess the association between the patient experience and outcomes, which included hospitalization, ESKD, and all-cause death. RESULTS Participants had a mean age of 56 years, 38% were women, 80% were primary Spanish speakers, and had a mean eGFR of 38 ml/min per 1.73 m2. Over 4.8 years (median) follow-up, there were 619 hospitalizations, 103 ESKD events, and 56 deaths. As compared with higher subscale scores, lower scores on four of the five subscales were associated with a higher adjusted rate ratio (RR) for all-cause hospitalization (communication quality: RR, 1.54; 95% confidence interval [95% CI], 1.25 to 1.90; health promotion: RR, 1.31; 95% CI, 1.05 to 1.62; interpersonal treatment: RR, 1.50; 95% CI, 1.22 to 1.85; and trust: RR, 1.57; 95% CI, 1.27 to 1.93). There was no significant association of subscales with incident ESKD or all-cause death. CONCLUSIONS Lower perceived quality of the patient experience with their primary care physician was associated with a higher risk of hospitalization.
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Affiliation(s)
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Michael J. Fischer
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
| | - Ben S. Gerber
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | | | - John W. Kusek
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Eva Lustigova
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | - Amada Renteria
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Sylvia E. Rosas
- Joslin Diabetes Center and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Milda Saunders
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Daohang Sha
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne Slaven
- Department of Medicine, MetroHealth, Cleveland, Ohio
| | - James P. Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - on behalf of the CRIC Study Investigators
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
- Department of Medicine, MetroHealth, Cleveland, Ohio
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
- Joslin Diabetes Center and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
- Department of Medicine, University of Chicago, Chicago, Illinois
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21
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Kattah AG, Smith CY, Gazzuola Rocca L, Grossardt BR, Garovic VD, Rocca WA. CKD in Patients with Bilateral Oophorectomy. Clin J Am Soc Nephrol 2018; 13:1649-1658. [PMID: 30232136 PMCID: PMC6237067 DOI: 10.2215/cjn.03990318] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/20/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Premenopausal women who undergo bilateral oophorectomy are at a higher risk of morbidity and mortality. Given the potential benefits of estrogen on kidney function, we hypothesized that women who undergo bilateral oophorectomy are at higher risk of CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a population-based cohort study of 1653 women residing in Olmsted County, Minnesota who underwent bilateral oophorectomy before age 50 years old and before the onset of menopause from 1988 to 2007. These women were matched by age (±1 year) to 1653 referent women who did not undergo oophorectomy. Women were followed over a median of 14 years to assess the incidence of CKD. CKD was primarily defined using eGFR (eGFR<60 ml/min per 1.73 m2 on two occasions >90 days apart). Hazard ratios were derived using Cox proportional hazards models, and absolute risk increases were derived using Kaplan-Meier curves at 20 years. All analyses were adjusted for 17 chronic conditions present at index date, race, education, body mass index, smoking, age, and calendar year. RESULTS Women who underwent bilateral oophorectomy had a higher risk of eGFR-based CKD (211 events for oophorectomy and 131 for referent women; adjusted hazard ratio, 1.42; 95% confidence interval, 1.14 to 1.77; absolute risk increase, 6.6%). The risk was higher in women who underwent oophorectomy at age ≤45 years old (110 events for oophorectomy and 60 for referent women; adjusted hazard ratio, 1.59; 95% confidence interval, 1.15 to 2.19; absolute risk increase, 7.5%). CONCLUSIONS Premenopausal women who undergo bilateral oophorectomy, particularly those ≤45 years old, are at higher risk of developing CKD, even after adjusting for multiple chronic conditions and other possible confounders present at index date. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_10_11_CJASNPodcast_18_1.
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Affiliation(s)
- Andrea G. Kattah
- Division of Nephrology and Hypertension, Department of Internal Medicine
| | | | | | | | - Vesna D. Garovic
- Division of Nephrology and Hypertension, Department of Internal Medicine
| | - Walter A. Rocca
- Epidemiology, Department of Health Sciences Research, and
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
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22
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Ellis RJ, Edey DP, Del Vecchio SJ, McStea M, Campbell SB, Hawley CM, Johnson DW, Morais C, Jordan SJ, Francis RS, Wood ST, Gobe GC. End-Stage Kidney Disease following Surgical Management of Kidney Cancer. Clin J Am Soc Nephrol 2018; 13:1641-1648. [PMID: 30266837 PMCID: PMC6237064 DOI: 10.2215/cjn.06560518] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/20/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVES We investigated the incidence of ESKD after surgical management of kidney cancer in the Australian state of Queensland, and described patterns in the initiation of kidney replacement therapy resulting from kidney cancer across Australia. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All newly diagnosed cases of kidney cancer in the Australian state of Queensland between January of 2009 and December of 2014 were ascertained through the Queensland Cancer Registry. There were 2739 patients included in our analysis. Patients who developed ESKD were identified using international classification of disease-10-coded hospital administrative data. Incidence rate and 3-year cumulative incidence were calculated, and multivariable Cox proportional hazards models were used to identify factors associated with ESKD. Additional descriptive analysis was undertaken of Australian population data. RESULTS The incidence rate of ESKD in all patients was 4.9 (95% confidence interval [95% CI], 3.9 to 6.2) per 1000 patient-years. The 3-year cumulative incidence was 1.7%, 1.9%, and 1.0% for all patients, and patients managed with radical or partial nephrectomy, respectively. Apart from preoperative kidney disease, exposures associated with increased ESKD risk were age≥65 years (adjusted hazard ratio [aHR], 2.0; 95% CI, 1.2 to 3.2), male sex (aHR, 2.3; 95% CI, 1.3 to 4.3), preoperative diabetes (aHR, 1.8; 95% CI, 1.0 to 3.3), American Society of Anesthesiologists classification ≥3 (aHR, 4.0; 95% CI, 2.2 to 7.4), socioeconomic disadvantage (aHR, 1.6; 95% CI, 0.9 to 2.7), and postoperative length of hospitalization ≥6 days (aHR, 2.1; 95% CI, 1.4 to 3.0). Australia-wide trends indicate that the rate of kidney replacement therapy after oncologic nephrectomy doubled between 1995 and 2015, from 0.3 to 0.6 per 100,000 per year. CONCLUSIONS In Queensland between 2009 and 2014, one in 53 patients managed with radical nephrectomy and one in 100 patients managed with partial nephrectomy developed ESKD within 3 years of surgery. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_09_28_CJASNPodcast_18_1_.mp3.
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Affiliation(s)
- Robert J. Ellis
- Departments of Nephrology and
- Centre for Kidney Disease Research, Faculty of Medicine
- Kidney Disease Research Collaborative, Translational Research Institute, Brisbane, Australia
- Cancer Causes and Care Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; and
| | - Daniel P. Edey
- Centre for Kidney Disease Research, Faculty of Medicine
- Kidney Disease Research Collaborative, Translational Research Institute, Brisbane, Australia
| | - Sharon J. Del Vecchio
- Urology, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Kidney Disease Research, Faculty of Medicine
- Kidney Disease Research Collaborative, Translational Research Institute, Brisbane, Australia
| | - Megan McStea
- Australasian Kidney Trials Network
- Kidney Disease Research Collaborative, Translational Research Institute, Brisbane, Australia
| | | | - Carmel M. Hawley
- Departments of Nephrology and
- Centre for Kidney Disease Research, Faculty of Medicine
- Australasian Kidney Trials Network
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
| | - David W. Johnson
- Departments of Nephrology and
- Centre for Kidney Disease Research, Faculty of Medicine
- Australasian Kidney Trials Network
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
| | - Christudas Morais
- Urology, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Kidney Disease Research, Faculty of Medicine
- Kidney Disease Research Collaborative, Translational Research Institute, Brisbane, Australia
| | - Susan J. Jordan
- Schools of Public Health and
- Cancer Causes and Care Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; and
| | - Ross S. Francis
- Departments of Nephrology and
- Centre for Kidney Disease Research, Faculty of Medicine
- Australasian Kidney Trials Network
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
| | - Simon T. Wood
- Urology, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Kidney Disease Research, Faculty of Medicine
- Kidney Disease Research Collaborative, Translational Research Institute, Brisbane, Australia
| | - Glenda C. Gobe
- Centre for Kidney Disease Research, Faculty of Medicine
- Biomedical Sciences, and
- NHMRC Chronic Kidney Disease Centre for Research Excellence, University of Queensland, Brisbane, Australia
- Kidney Disease Research Collaborative, Translational Research Institute, Brisbane, Australia
| | - Cancer Alliance Queensland
- Departments of Nephrology and
- Urology, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Kidney Disease Research, Faculty of Medicine
- Australasian Kidney Trials Network
- Schools of Public Health and
- Biomedical Sciences, and
- NHMRC Chronic Kidney Disease Centre for Research Excellence, University of Queensland, Brisbane, Australia
- Kidney Disease Research Collaborative, Translational Research Institute, Brisbane, Australia
- Cancer Causes and Care Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; and
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
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23
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Tartof SY, Hsu JW, Wei R, Rubenstein KB, Hu H, Arduino JM, Horberg M, Derose SF, Qian L, Rodriguez CV. Kidney Function Decline in Patients with CKD and Untreated Hepatitis C Infection. Clin J Am Soc Nephrol 2018; 13:1471-1478. [PMID: 30242027 PMCID: PMC6218821 DOI: 10.2215/cjn.01530218] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 07/27/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Studies evaluating the role of hepatitis C viral (HCV) infection on the progression of CKD are few and conflicting. Therefore, we evaluated the association of untreated HCV on kidney function decline in patients with stage 3-5 CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective cohort study included members of Kaiser Permanente Southern California and Kaiser Permanente Mid-Atlantic States aged ≥18 years, with incident HCV and CKD diagnoses from January 1, 2004 to December 31, 2014. We used generalized estimating equations to compare the rate of change in eGFR between those with HCV and CKD versus CKD alone, adjusting for covariates. Cox proportional hazards models compared the risk of 25% decrease in eGFR and ESKD (defined as progression to eGFR<15 ml/min per 1.73 m2 on two or more occasions, at least 90 days apart) in those with HCV and CKD versus CKD alone, adjusting for covariates. RESULTS We identified 151,974 patients with CKD only and 1603 patients with HCV and CKD who met the study criteria. The adjusted annual decline of eGFR among patients with HCV and CKD was greater by 0.58 (95% confidence interval [95% CI], 0.31 to 0.84) ml/min per 1.73 m2, compared with that in the CKD-only population (HCV and CKD, -1.61; 95% CI, -1.87 to -1.35 ml/min; CKD only, -1.04; 95% CI, -1.06 to -1.01 ml/min). Adjusted for covariates, the hazard for a 25% decline in eGFR and for ESKD were 1.87 (95% CI, 1.75 to 2.00) and 1.93 (95% CI, 1.64 to 2.27) times higher among those with HCV and CKD, respectively, compared with those with CKD only. CONCLUSIONS Untreated HCV infection was associated with greater kidney function decline in patients with stage 3-5 CKD.
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Affiliation(s)
- Sara Yee Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Jin-Wen Hsu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Rong Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Kevin B Rubenstein
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland; and
| | - Haihong Hu
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland; and
| | - Jean Marie Arduino
- Jean Marie Arduino, Center for Observational and Real-world Evidence, Merck Research Laboratories, Merck & Co., Inc., Kenilworth, New Jersey
| | - Michael Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland; and
| | - Stephen F Derose
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Carla V Rodriguez
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland; and
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24
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Bonthuis M, Harambat J, Bérard E, Cransberg K, Duzova A, Garneata L, Herthelius M, Lungu AC, Jahnukainen T, Kaltenegger L, Ariceta G, Maurer E, Palsson R, Sinha MD, Testa S, Groothoff JW, Jager KJ. Recovery of Kidney Function in Children Treated with Maintenance Dialysis. Clin J Am Soc Nephrol 2018; 13:1510-1516. [PMID: 30237216 PMCID: PMC6218837 DOI: 10.2215/cjn.01500218] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 07/17/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Data on recovery of kidney function in pediatric patients with presumed ESKD are scarce. We examined the occurrence of recovery of kidney function and its determinants in a large cohort of pediatric patients on maintenance dialysis in Europe. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data for 6574 patients from 36 European countries commencing dialysis at an age below 15 years, between 1990 and 2014 were extracted from the European Society for Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry. Recovery of kidney function was defined as discontinuation of dialysis for at least 30 days. Time to recovery was studied using a cumulative incidence competing risk approach and adjusted Cox proportional hazard models. RESULTS Two years after dialysis initiation, 130 patients (2%) experienced recovery of their kidney function after a median of 5.0 (interquartile range, 2.0-9.6) months on dialysis. Compared with patients with congenital anomalies of the kidney and urinary tract, recovery more often occurred in patients with vasculitis (11% at 2 years; adjusted hazard ratio [HR], 20.4; 95% confidence interval [95% CI], 9.7 to 42.8), ischemic kidney failure (12%; adjusted HR, 11.4; 95% CI, 5.6 to 23.1), and hemolytic uremic syndrome (13%; adjusted HR, 15.6; 95% CI, 8.9 to 27.3). Younger age and initiation on hemodialysis instead of peritoneal dialysis were also associated with recovery. For 42 patients (32%), recovery was transient as they returned to kidney replacement therapy after a median recovery period of 19.7 (interquartile range, 9.0-41.3) months. CONCLUSIONS We demonstrate a recovery rate of 2% within 2 years after dialysis initiation in a large cohort of pediatric patients on maintenance dialysis. There is a clinically important chance of recovery in patients on dialysis with vasculitis, ischemic kidney failure, and hemolytic uremic syndrome, which should be considered when planning kidney transplantation in these children.
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Affiliation(s)
- Marjolein Bonthuis
- European Society for Pediatric Nephrology/ European Renal Association-European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| | - Etienne Bérard
- Department of Pediatric Nephrology, Centre Hospitalier Universitaire de Nice-Hôpital Archet2, Nice, France
| | - Karlien Cransberg
- Department of Pediatric Nephrology, Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Ali Duzova
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Liliana Garneata
- Department of Internal Medicine and Nephrology, Carol Davila University of Medicine and Pharmacy, Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
| | - Maria Herthelius
- Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Adrian C. Lungu
- Department of Pediatric Nephrology, Fundeni Clinical Institute, Bucharest, Romania and Carol Davila University of Medicine, Pediatrics, Bucharest, Romania
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Lukas Kaltenegger
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Gema Ariceta
- Pediatric Nephrology Department, Hospital Universitari Vall d’Hébron, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Elisabeth Maurer
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Runolfur Palsson
- Division of Nephrology, Landspitali–The National University Hospital of Iceland, Reykjavik, Iceland and Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Manish D. Sinha
- Department of Pediatric Nephrology, Evelina London Children’s Hospital, Guys and St Thomas’ National Health Service Foundation Trust, London, United Kingdom
| | - Sara Testa
- Pediatric Nephrology and Dialysis Unit, Fondazione Instituto di Ricovero e cura a Carattere Scientifico, Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy; and
| | - Jaap W. Groothoff
- Department of Pediatric Nephrology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Kitty J. Jager
- European Society for Pediatric Nephrology/ European Renal Association-European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - on behalf of the ESPN/ERA-EDTA Registry
- European Society for Pediatric Nephrology/ European Renal Association-European Dialysis and Transplant Association Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
- Department of Pediatric Nephrology, Centre Hospitalier Universitaire de Nice-Hôpital Archet2, Nice, France
- Department of Pediatric Nephrology, Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, The Netherlands
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
- Department of Internal Medicine and Nephrology, Carol Davila University of Medicine and Pharmacy, Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
- Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Department of Pediatric Nephrology, Fundeni Clinical Institute, Bucharest, Romania and Carol Davila University of Medicine, Pediatrics, Bucharest, Romania
- Department of Pediatric Nephrology and Transplantation, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Pediatric Nephrology Department, Hospital Universitari Vall d’Hébron, Universitat Autónoma de Barcelona, Barcelona, Spain
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Division of Nephrology, Landspitali–The National University Hospital of Iceland, Reykjavik, Iceland and Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Department of Pediatric Nephrology, Evelina London Children’s Hospital, Guys and St Thomas’ National Health Service Foundation Trust, London, United Kingdom
- Pediatric Nephrology and Dialysis Unit, Fondazione Instituto di Ricovero e cura a Carattere Scientifico, Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy; and
- Department of Pediatric Nephrology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands
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McAdams-DeMarco MA, Daubresse M, Bae S, Gross AL, Carlson MC, Segev DL. Dementia, Alzheimer's Disease, and Mortality after Hemodialysis Initiation. Clin J Am Soc Nephrol 2018; 13:1339-1347. [PMID: 30093374 PMCID: PMC6140560 DOI: 10.2215/cjn.10150917] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 06/04/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Older patients with ESKD experience rapid declines in executive function after initiating hemodialysis; these impairments might lead to high rates of dementia and Alzheimer's disease in this population. We estimated incidence, risk factors, and sequelae of diagnosis with dementia and Alzheimer's disease among older patients with ESKD initiating hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied 356,668 older (age ≥66 years old) patients on hemodialysis (January 1, 2001 to December 31, 2013) from national registry data (US Renal Data System) linked to Medicare. We estimated the risk (cumulative incidence) of diagnosis of dementia and Alzheimer's disease and studied factors associated with these disorders using competing risks models to account for death, change in dialysis modality, and kidney transplant. We estimated the risk of subsequent mortality using Cox proportional hazards models. RESULTS The 1- and 5-year risks of diagnosed dementia accounting for competing risks were 4.6% and 16% for women, respectively, and 3.7% and 13% for men, respectively. The corresponding Alzheimer's disease diagnosis risks were 0.6% and 2.6% for women, respectively, and 0.4% and 2.0% for men, respectively. The strongest independent risk factors for diagnosis of dementia and Alzheimer's disease were age ≥86 years old (dementia: hazard ratio, 2.11; 95% confidence interval, 2.04 to 2.18; Alzheimer's disease: hazard ratio, 2.11; 95% confidence interval, 1.97 to 2.25), black race (dementia: hazard ratio, 1.70; 95% confidence interval, 1.67 to 1.73; Alzheimer's disease: hazard ratio, 1.78; 95% confidence interval, 1.71 to 1.85), women (dementia: hazard ratio, 1.10; 95% confidence interval, 1.08 to 1.12; Alzheimer's disease: hazard ratio, 1.12; 95% confidence interval, 1.08 to 1.16), and institutionalization (dementia: hazard ratio, 1.36; 95% confidence interval, 1.33 to 1.39; Alzheimer's disease: hazard ratio, 1.10; 95% confidence interval, 1.05 to 1.15). Older patients on hemodialysis with a diagnosis of dementia were at 2.14-fold (95% confidence interval, 2.07 to 2.22) higher risk of subsequent mortality; those with a diagnosis of Alzheimer's disease were at 2.01-fold (95% confidence interval, 1.89 to 2.15) higher mortality risk. CONCLUSIONS Older patients on hemodialysis are at substantial risk of diagnosis with dementia and Alzheimer's disease, and carrying these diagnoses is associated with a twofold higher mortality.
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Affiliation(s)
- Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Epidemiology and
| | | | - Sunjae Bae
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alden L. Gross
- Departments of Epidemiology and
- Johns Hopkins University Center on Aging and Health, Baltimore, Maryland
| | - Michelle C. Carlson
- Mental Health, Bloomberg School of Public Health, Baltimore, Maryland; and
- Johns Hopkins University Center on Aging and Health, Baltimore, Maryland
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Epidemiology and
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Liu P, Quinn RR, Oliver MJ, Ronksley PE, Hemmelgarn BR, Quan H, Hiremath S, Bello AK, Blake PG, Garg AX, Johnson J, Verrelli M, Zacharias JM, Abd ElHafeez S, Tonelli M, Ravani P. Association between Duration of Predialysis Care and Mortality after Dialysis Start. Clin J Am Soc Nephrol 2018; 13:893-899. [PMID: 29507006 PMCID: PMC5989670 DOI: 10.2215/cjn.11951017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/27/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Early nephrology referral is recommended for people with CKD on the basis of observational studies showing that longer nephrology care before dialysis start (predialysis care) is associated with lower mortality after dialysis start. This association may be observed because predialysis care truly reduces mortality or because healthier people with an uncomplicated course of disease will have both longer predialysis care and lower risk for death. We examined whether the survival benefit of longer predialysis care exists after accounting for the potential confounding effect of disease course that may also be affected by predialysis care. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a retrospective cohort study and used data from 3152 adults with end stage kidney failure starting dialysis between 2004 and 2014 in five Canadian dialysis programs. We obtained duration of predialysis care from the earliest nephrology outpatient visit to dialysis start; markers of disease course, including inpatient or outpatient dialysis start and residual kidney function around dialysis start; and all-cause mortality after dialysis start. RESULTS The percentages of participants with 0, 1-119, 120-364, and ≥365 days of predialysis care were 23%, 8%, 10%, and 59%, respectively. When we ignored markers of disease course as in previous studies, longer predialysis care was associated with lower mortality (hazard ratio120-364 versus 0-119 days, 0.60; 95% confidence interval, 0.46 to 0.78]; hazard ratio≥365 versus 0-119 days, 0.60; 95% confidence interval, 0.51 to 0.71; standard Cox model adjusted for demographics and laboratory and clinical characteristics). When we additionally accounted for markers of disease course using the inverse probability of treatment weighted Cox model, this association was weaker and no longer significant (hazard ratio120-364 versus 0-119 days, 0.84; 95% confidence interval, 0.60 to 1.18; hazard ratio≥365 versus 0-119 days, 0.88; 95% confidence interval, 0.69 to 1.13). CONCLUSIONS The association between longer predialysis care and lower mortality after dialysis start is weaker and imprecise after accounting for patients' course of disease.
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Affiliation(s)
- Ping Liu
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Robert R. Quinn
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Matthew J. Oliver
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul E. Ronksley
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Hude Quan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Swapnil Hiremath
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Aminu K. Bello
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Peter G. Blake
- Division of Nephrology, Western University, London, Ontario, Canada
| | - Amit X. Garg
- Departments of Medicine, Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - John Johnson
- London Health Sciences Centre, London, Ontario, Canada
| | - Mauro Verrelli
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James M. Zacharias
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Samar Abd ElHafeez
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Epidemiology Department, High Institute of Public Health, Alexandria University, Egypt
| | - Marcello Tonelli
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Hingorani S, Pao E, Stevenson P, Schoch G, Laskin BL, Gooley T, McDonald GB. Changes in Glomerular Filtration Rate and Impact on Long-Term Survival among Adults after Hematopoietic Cell Transplantation: A Prospective Cohort Study. Clin J Am Soc Nephrol 2018; 13:866-873. [PMID: 29669818 PMCID: PMC5989688 DOI: 10.2215/cjn.10630917] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 03/18/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVES Kidney injury is a significant complication for patients undergoing hematopoietic cell transplantation (HCT), but few studies have prospectively examined changes in GFR in long-term survivors of HCT. We described the association between changes in GFR and all-cause mortality in patients up to 10 years after HCT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a prospective, observational cohort study of adult patients undergoing HCT at the Fred Hutchinson Cancer Center in Seattle, Washington from 2003 to 2015. Patients were followed from baseline, before conditioning therapy, until a maximum of 10 years after transplant. We used Cox proportional hazard models to examine the association between creatinine eGFR and all-cause mortality. We used time-dependent generalized estimating equations to examine risk factors for decreases in eGFR. RESULTS A total of 434 patients (median age, 52 years; range, 18-76 years; 64% were men; 87% were white) were followed for a median 5.3 years after HCT. The largest decreases in eGFR occurred within the first year post-transplant, with the eGFR decreasing from a median of 98 ml/min per 1.73 m2 at baseline to 78 ml/min per 1.73 m2 by 1 year post-HCT. Two thirds of patients had an eGFR<90 ml/min per 1.73 m2 at 1 year after transplant. When modeled as a continuous variable, as eGFR declined from approximately 60 ml/min per 1.73 m2, the hazard of mortality progressively increased relative to a normal eGFR of 90 ml/min per 1.73 m2 (P<0.001). For example, when compared with an eGFR of 90 ml/min per 1.73 m2, the hazard ratios for eGFR of 60, 50, and 40 ml/min per 1.73 m2 are 1.15 (95% confidence interval, 0.87 to 1.53), 1.68 (95% confidence interval, 1.26 to 2.24), and 2.67 (95% confidence interval, 1.99 to 3.60), respectively. Diabetes, hypertension, acute graft versus host disease, and cytomegalovirus infection were independently associated with a decline in GFR, whereas calcineurin inhibitor levels, chronic graft versus host disease, and albuminuria were not. CONCLUSIONS Adult HCT recipients have a high risk of decreased eGFR by 1 year after HCT. Although eGFR remains fairly stable thereafter, a decreased eGFR is significantly associated with higher risk of mortality, with a progressively increased risk as eGFR declines.
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Affiliation(s)
- Sangeeta Hingorani
- Division of Pediatrics and Medicine, University of Washington, Clinical Research Division
- Fred Hutchinson Cancer Research Center and
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington; and
| | - Emily Pao
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington; and
| | | | | | - Benjamin L. Laskin
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ted Gooley
- Fred Hutchinson Cancer Research Center and
| | - George B. McDonald
- Division of Pediatrics and Medicine, University of Washington, Clinical Research Division
- Fred Hutchinson Cancer Research Center and
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Schroeder EB, Chonchol M, Shetterly SM, Powers JD, Adams JL, Schmittdiel JA, Nichols GA, O’Connor PJ, Steiner JF. Add-On Antihypertensive Medications to Angiotensin-Aldosterone System Blockers in Diabetes: A Comparative Effectiveness Study. Clin J Am Soc Nephrol 2018; 13:727-734. [PMID: 29572286 PMCID: PMC5969476 DOI: 10.2215/cjn.09510817] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 02/02/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES In individuals with diabetes, the comparative effectiveness of add-on antihypertensive medications added to an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker on the risk of significant kidney events is unknown. DESIGN, SETTING PARTICIPANTS, & MEASUREMENTS We used an observational, multicenter cohort of 21,897 individuals with diabetes to compare individuals who added β-blockers, dihydropyridine calcium channel blockers, loop diuretics, or thiazide diuretics to angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. We examined the hazard of significant kidney events, cardiovascular events, and death using Cox proportional hazard models with propensity score weighting. The composite significant kidney event end point was defined as the first occurrence of a ≥30% decline in eGFR to an eGFR<60 ml/min per 1.73 m2, initiation of dialysis, or kidney transplant. The composite cardiovascular event end point was defined as the first occurrence of hospitalization for acute myocardial infarction, acute coronary syndrome, stroke, or congestive heart failure; coronary artery bypass grafting; or percutaneous coronary intervention, and it was only examined in those free of cardiovascular disease at baseline. RESULTS Over a maximum of 5 years, there were 4707 significant kidney events, 1498 deaths, and 818 cardiovascular events. Compared with thiazide diuretics, hazard ratios for significant kidney events for β-blockers, calcium channel blockers, and loop diuretics were 0.81 (95% confidence interval, 0.74 to 0.89), 0.67 (95% confidence interval, 0.58 to 0.78), and 1.19 (95% confidence interval, 1.00 to 1.41), respectively. Compared with thiazide diuretics, hazard ratios of mortality for β-blockers, calcium channel blockers, and loop diuretics were 1.19 (95% confidence interval, 0.97 to 1.44), 0.73 (95% confidence interval, 0.52 to 1.03), and 1.67 (95% confidence interval, 1.31 to 2.13), respectively. Compared with thiazide diuretics, hazard ratios of cardiovascular events for β-blockers, calcium channel blockers, and loop diuretics compared with thiazide diuretics were 1.65 (95% confidence interval, 1.39 to 1.96), 1.05 (95% confidence interval, 0.80 to 1.39), and 1.55 (95% confidence interval, 1.05 to 2.27), respectively. CONCLUSIONS Compared with thiazide diuretics, calcium channel blockers were associated with a lower risk of significant kidney events and a similar risk of cardiovascular events.
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Affiliation(s)
- Emily B. Schroeder
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
- Divisions of Endocrinology, Metabolism and Diabetes and
| | - Michel Chonchol
- Renal Diseases and Hypertension, University of Colorado Denver, Aurora, Colorado
| | - Susan M. Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - J. David Powers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - John L. Adams
- Center for Effectiveness and Safety Research, Kaiser Permanente, Pasadena, California
| | - Julie A. Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Gregory A. Nichols
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon; and
| | - Patrick J. O’Connor
- HealthPartners Institute and HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
| | - John F. Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
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Wu CL, Chang CC, Kor CT, Yang TH, Chiu PF, Tarng DC, Hsu CC. Hydroxychloroquine Use and Risk of CKD in Patients with Rheumatoid Arthritis. Clin J Am Soc Nephrol 2018; 13:702-709. [PMID: 29661770 PMCID: PMC5969483 DOI: 10.2215/cjn.11781017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 01/30/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Hydroxychloroquine is widely used in patients with rheumatoid arthritis. However, large-scale studies examining the long-term effects of hydroxychloroquine on the development of kidney disease in patients with rheumatoid arthritis are lacking. We aimed to assess the long-term association of hydroxychloroquine use with the risk of developing CKD in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted an observational cohort study for patients with newly diagnosed rheumatoid arthritis who were enrolled prospectively in Taiwan's National Health Insurance Research Database between January 1, 2000 and December 31, 2013. We used multivariable Cox proportional hazard regression to analyze the association of hydroxychloroquine use with incident CKD. RESULTS A total of 2619 patients, including 1212 hydroxychloroquine users and 1407 hydroxychloroquine nonusers, were analyzed. Incident CKD was reported in 48 of 1212 hydroxychloroquine users and 121 of 1407 hydroxychloroquine nonusers. The incidence rate of CKD was lower in hydroxychloroquine users than in hydroxychloroquine nonusers (10.3 versus 13.8 per 1000 person-years). After multivariable adjustment, hydroxychloroquine users still had a lower risk of incident CKD (adjusted hazard ratio, 0.64; 95% confidence interval, 0.45 to 0.90; P=0.01) than hydroxychloroquine nonusers. The lower risk of subsequent CKD development was dose dependent and consistent across subgroup analyses. CONCLUSIONS Hydroxychloroquine use in patients with newly diagnosed rheumatoid arthritis is associated with a significantly lower risk of incident CKD compared with in nonusers.
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Affiliation(s)
- Chia-Lin Wu
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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30
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Rahman M, Hsu JY, Desai N, Hsu CY, Anderson AH, Appel LJ, Chen J, Cohen DL, Drawz PE, He J, Qiang P, Ricardo AC, Steigerwalt S, Weir MR, Wright JT, Zhang X, Townsend RR. Central Blood Pressure and Cardiovascular Outcomes in Chronic Kidney Disease. Clin J Am Soc Nephrol 2018; 13:585-595. [PMID: 29475992 PMCID: PMC5969462 DOI: 10.2215/cjn.08620817] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 01/03/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Central BP measurements provide noninvasive measurement of aortic BP; our objectives were to examine the association of central and brachial BP measurements with risk of cardiovascular outcomes and mortality in patients with CKD and to determine the role of central BP measurement in conjunction with brachial BP in estimating cardiovascular risk. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a prospective, longitudinal study (the Chronic Renal Insufficiency Cohort), central BP was measured in participants with CKD using the SphygmoCorPVx System. Cox proportional hazards models were used for analyses. RESULTS Mean age of the participants (n=2875) was 60 years old. After a median follow-up of 5.5 years, participants in the highest quartile of brachial systolic BP (≥138 mm Hg) were at higher risk for the composite cardiovascular outcome (hazard ratio, 1.59; 95% confidence interval, 1.17 to 2.17; c statistic, 0.76) but not all-cause mortality (hazard ratio, 1.28; 95% confidence interval, 0.90 to 1.80) compared with those in the lowest quartile. Participants in the highest quartile of central systolic BP were also at higher risk for the composite cardiovascular outcome (hazard ratio, 1.69; 95% confidence interval, 1.24 to 2.31; c statistic, 0.76) compared with participants in the lowest quartile. CONCLUSIONS We show that elevated brachial and central BP measurements are both associated with higher risk of cardiovascular disease outcomes in patients with CKD. Measurement of central BP does not improve the ability to predict cardiovascular disease outcomes or mortality in patients with CKD compared with brachial BP measurement.
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Affiliation(s)
- Mahboob Rahman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Basu M, Petgrave-Nelson L, Smith KD, Perryman JP, Clark K, Pastan SO, Pearson TC, Larsen CP, Paul S, Patzer RE. Transplant Center Patient Navigator and Access to Transplantation among High-Risk Population: A Randomized, Controlled Trial. Clin J Am Soc Nephrol 2018; 13:620-627. [PMID: 29581107 PMCID: PMC5968906 DOI: 10.2215/cjn.08600817] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/18/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Barriers exist in access to kidney transplantation, where minority and patients with low socioeconomic status are less likely to complete transplant evaluation. The purpose of this study was to examine the effectiveness of a transplant center-based patient navigator in helping patients at high risk of dropping out of the transplant evaluation process access the kidney transplant waiting list. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS We conducted a randomized, controlled trial of 401 patients (n=196 intervention and n=205 control) referred for kidney transplant evaluation (January 2013 to August 2014; followed through May 2016) at a single center. A trained navigator assisted intervention participants from referral to waitlisting decision to increase waitlisting (primary outcome) and decrease time from referral to waitlisting (secondary outcome). Time-dependent Cox proportional hazards models were used to determine differences in waitlisting between intervention and control patients. RESULTS At study end, waitlisting was not significantly different among intervention (32%) versus control (26%) patients overall (P=0.17), and time from referral to waitlisting was 126 days longer for intervention patients. However, the effectiveness of the navigator varied from early (<500 days from referral) to late (≥500 days) follow-up. Although no difference in waitlisting was observed among intervention (50%) versus control (50%) patients in the early period (hazard ratio, 1.03; 95% confidence interval, 0.69 to 1.53), intervention patients were 3.3 times more likely to be waitlisted after 500 days (75% versus 25%; hazard ratio, 3.31; 95% confidence interval, 1.20 to 9.12). There were no significant differences in intervention versus control patients who started evaluation (85% versus 79%; P=0.11) or completed evaluation (58% versus 51%; P=0.14); however, intervention patients had more living donor inquiries (18% versus 10%; P=0.03). CONCLUSIONS A transplant center-based navigator targeting disadvantaged patients improved waitlisting but not until after 500 days of follow-up. However, the absolute effect was relatively small.
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Affiliation(s)
- Mohua Basu
- Division of Transplantation, Department of Surgery and
| | | | - Kayla D. Smith
- Division of Transplantation, Department of Surgery and
- Emory Transplant Center, Atlanta, Georgia; and
| | | | - Kevin Clark
- Emory Transplant Center, Atlanta, Georgia; and
| | - Stephen O. Pastan
- Renal Division, Emory University School of Medicine, Atlanta, Georgia
- Emory Transplant Center, Atlanta, Georgia; and
| | - Thomas C. Pearson
- Division of Transplantation, Department of Surgery and
- Emory Transplant Center, Atlanta, Georgia; and
| | - Christian P. Larsen
- Division of Transplantation, Department of Surgery and
- Emory Transplant Center, Atlanta, Georgia; and
| | - Sudeshna Paul
- Office of Nursing Research, Nell Hodgson Woodruff School of Nursing and
| | - Rachel E. Patzer
- Division of Transplantation, Department of Surgery and
- Emory Transplant Center, Atlanta, Georgia; and
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Plantinga LC, Lynch RJ, Patzer RE, Pastan SO, Bowling CB. Association of Serious Fall Injuries among United States End Stage Kidney Disease Patients with Access to Kidney Transplantation. Clin J Am Soc Nephrol 2018; 13:628-637. [PMID: 29511059 PMCID: PMC5969463 DOI: 10.2215/cjn.10330917] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 12/18/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Serious fall injuries in the setting of ESKD may be associated with poor access to kidney transplant. We explored the burden of serious fall injuries among patients on dialysis and patients on the deceased donor waitlist and the associations of these fall injuries with waitlisting and transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our analytic cohorts for the outcomes of (1) waitlisting and (2) transplantation included United States adults ages 18-80 years old who (1) initiated dialysis (n=183,047) and (2) were waitlisted for the first time (n=37,752) in 2010-2013. Serious fall injuries were determined by diagnostic codes for falls plus injury (fracture, joint dislocation, or head trauma) in inpatient and emergency department claims; the first serious fall injury after cohort entry was included as a time-varying exposure. Follow-up ended at the specified outcome, death, or the last date of follow-up (September 30, 2014). We used multivariable Cox proportional hazards models to determine the independent associations between serious fall injury and waitlisting or transplantation. RESULTS Overall, 2-year cumulative incidence of serious fall injury was 6% among patients on incident dialysis; with adjustment, patients who had serious fall injuries were 61% less likely to be waitlisted than patients who did not (hazard ratio, 0.39; 95% confidence interval, 0.35 to 0.44). Among incident waitlisted patients (4% 2-year cumulative incidence), those with serious fall injuries were 29% less likely than their counterparts to be subsequently transplanted (hazard ratio, 0.71; 95% confidence interval, 0.63 to 0.80). CONCLUSIONS Serious fall injuries among United States patients on dialysis are associated with substantially lower likelihood of waitlisting for and receipt of a kidney transplant.
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Affiliation(s)
| | | | | | | | - C. Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina; and
- Department of Medicine, Duke University, Durham, North Carolina
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Troost JP, Trachtman H, Nachman PH, Kretzler M, Spino C, Komers R, Tuller S, Perumal K, Massengill SF, Kamil ES, Oh G, Selewski DT, Gipson P, Gipson DS. An Outcomes-Based Definition of Proteinuria Remission in Focal Segmental Glomerulosclerosis. Clin J Am Soc Nephrol 2018; 13:414-421. [PMID: 29167190 PMCID: PMC5967666 DOI: 10.2215/cjn.04780517] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 10/18/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Proteinuria is used as an indicator of FSGS disease activity, but its use as a clinical trial end point is not universally accepted. The goal of this study was to refine proteinuria definitions associated with long-term kidney survival. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data on 466 patients with primary FSGS with proteinuria (urine protein-to-creatinine ratio >1 g/g) were analyzed from five independent cohorts. Proteinuria by months 1, 4, and 8 after study baseline was categorized by conventional definitions of complete (<0.3 g/g) and partial remission (<3.5 g/g and 50% reduction in proteinuria). Novel remission definitions were explored using receiver operating curves. Kaplan-Meier methods were used to estimate the associations of proteinuria with progression to ESRD or a 50% loss in kidney function. Propensity score-adjusted Cox proportional hazards models were used to adjust for baseline proteinuria, eGFR, and therapy. RESULTS In the initial derivation cohort, conventional partial remission was not associated with kidney survival. A novel definition of partial remission (40% proteinuria reduction and proteinuria<1.5 g/g) on the basis of receiver operating curve analyses of 89 patients was identified (Sensitivity=0.70; Specificity=0.77). In the validation cohort analyses, complete remission was associated with better prognosis (6 out of 41 patients progressed to kidney failure; 6.6 per 100 patient-years) as was the novel partial remission (13 out of 71 progressed; 8.5 per 100 patient-years), compared with those with no response (51 out of 116 progressed; 20.1 per 100 patient-years). Conventional partial remission at month 8, but not month 4, was also associated with better response (19 out of 85 patients progressed; risk=10.4 per 100 patient-years). Propensity score-adjusted analyses showed the novel partial remission was associated with less progression at months 4 and 8 (month 4: hazard ratio, 0.50; P=0.01; month 8: hazard ratio, 0.30; P=0.002). CONCLUSIONS Reaching either a complete or partial remission using a novel or conventional definition was associated with better long-term outcomes in patients with FSGS. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_02_20_CJASNPodcast_18_3_T.mp3.
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Affiliation(s)
- Jonathan P Troost
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Hougen I, Collister D, Bourrier M, Ferguson T, Hochheim L, Komenda P, Rigatto C, Tangri N. Safety of Intravenous Iron in Dialysis: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol 2018; 13:457-467. [PMID: 29463597 PMCID: PMC5967668 DOI: 10.2215/cjn.05390517] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 11/22/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES The safety of intravenous iron dosing in dialysis is uncertain. Higher-dose intravenous iron may be associated with a higher risk of infections, cardiovascular events, hospitalizations, and mortality. This systematic review aimed to determine the safety of higher-dose versus lower-dose intravenous iron, oral iron, or no iron supplementation in adult patients treated with dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched Medline, EMBASE, Cochrane library, and CINAHL from inception to January 6, 2017 for randomized, controlled trials and observational studies comparing higher-dose intravenous iron with lower-dose intravenous iron, oral iron, or no iron in patients treated with dialysis that had all-cause mortality, infection, cardiovascular events, or hospitalizations as outcomes. RESULTS Of the 2231 eligible studies, seven randomized, controlled trials and 15 observational studies met inclusion criteria. The randomized, controlled trials showed no association between higher-dose intravenous iron (>400 mg/mo for most studies) and mortality (six studies; n=970; pooled relative risk, 0.93; 95% confidence interval, 0.47 to 1.84; follow-up ranging from 35 days to 26 months) or infection (four studies; n=743; relative risk, 1.02; 95% confidence interval, 0.74 to 1.41). The observational studies showed no association between higher-dose intravenous iron (>200 mg/mo for most studies) and mortality (eight studies; n=241,408; hazard ratio, 1.09; 95% confidence interval, 0.98 to 1.21; follow-up ranging from 3 to 24 months), infection (eight studies; n=135,532; pooled hazard ratio, 1.13; 95% confidence interval, 0.99 to 1.28), cardiovascular events (seven studies; n=135,675; hazard ratio, 1.18; 95% confidence interval, 0.90 to 1.56), or hospitalizations (five studies; n=134,324; hazard ratio, 1.08; 95% confidence interval, 0.97 to 1.19). CONCLUSIONS Higher-dose intravenous iron does not seem to be associated with higher risk of mortality, infection, cardiovascular events, or hospitalizations in adult patients on dialysis. Strength of this finding is limited by small numbers of participants and events in the randomized, controlled trials and statistical heterogeneity in observational studies.
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Affiliation(s)
- Ingrid Hougen
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
| | - David Collister
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mathieu Bourrier
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
| | - Thomas Ferguson
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Laura Hochheim
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
| | - Paul Komenda
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Claudio Rigatto
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Paul S, Plantinga LC, Pastan SO, Gander JC, Mohan S, Patzer RE. Standardized Transplantation Referral Ratio to Assess Performance of Transplant Referral among Dialysis Facilities. Clin J Am Soc Nephrol 2018; 13:282-289. [PMID: 29371341 PMCID: PMC5967424 DOI: 10.2215/cjn.04690417] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 10/24/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES For patients with ESRD, referral from a dialysis facility to a transplant center for evaluation is an important step toward kidney transplantation. However, a standardized measure for assessing clinical performance of dialysis facilities transplant access is lacking. We describe methodology for a new dialysis facility measure: the Standardized Transplantation Referral Ratio. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Transplant referral data from 8308 patients with incident ESRD within 249 dialysis facilities in the United States state of Georgia were linked with US Renal Data System data from January of 2008 to December of 2011, with follow-up through December of 2012. Facility-level expected referrals were computed from a two-stage Cox proportional hazards model after patient case mix risk adjustment including demographics and comorbidities. The Standardized Transplantation Referral Ratio (95% confidence interval) was calculated as a ratio of observed to expected referrals. Measure validity and reliability were assessed. RESULTS Over 2008-2011, facility Standardized Transplantation Referral Ratios in Georgia ranged from 0 to 4.87 (mean =1.16, SD=0.76). Most (77%) facilities had observed referrals as expected, whereas 11% and 12% had Standardized Transplantation Referral Ratios significantly greater than and less than expected, respectively. Age, race, sex, and comorbid conditions were significantly associated with the likelihood of referral, and they were included in risk adjustment for Standardized Transplantation Referral Ratio calculations. The Standardized Transplantation Referral Ratios were positively associated with evaluation, waitlisting, and transplantation (r=0.46, 0.35, and 0.20, respectively; P<0.01). On average, approximately 33% of the variability in Standardized Transplantation Referral Ratios was attributed to between-facility variation, and 67% of the variability in Standardized Transplantation Referral Ratios was attributed to within-facility variation. CONCLUSIONS The majority of observed variation in dialysis facility referral performance was due to characteristics within a dialysis facility rather than patient factors included in risk adjustment models. Our study shows a method for computing a facility-level standardized measure for transplant referral on the basis of a pilot sample of Georgia dialysis facilities that could be used to monitor transplant referral performance of dialysis facilities.
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Affiliation(s)
- Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Laura C. Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Renal Division, Department of Medicine and
| | - Stephen O. Pastan
- Renal Division, Department of Medicine and
- Emory Transplant Center, Atlanta, Georgia
| | - Jennifer C. Gander
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Sumit Mohan
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; and
- Department of Epidemiology, Mailman School of Public Health, New York, New York
| | - Rachel E. Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory Transplant Center, Atlanta, Georgia
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Allegretti AS, Parada XV, Eneanya ND, Gilligan H, Xu D, Zhao S, Dienstag JL, Chung RT, Thadhani RI. Prognosis of Patients with Cirrhosis and AKI Who Initiate RRT. Clin J Am Soc Nephrol 2018; 13:16-25. [PMID: 29122911 PMCID: PMC5753306 DOI: 10.2215/cjn.03610417] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 10/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Literature on the prognosis of patients with cirrhosis who require RRT for AKI is sparse and is confounded by liver transplant eligibility. An update on outcomes in the nonlisted subgroup is needed. Our objective was to compare outcomes in this group between those diagnosed with hepatorenal syndrome and acute tubular necrosis, stratifying by liver transplant listing status. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Retrospective cohort study of patients with cirrhosis acutely initiated on hemodialysis or continuous RRT at five hospitals, including one liver transplant center. Multivariable regression and survival analysis were performed. RESULTS Four hundred seventy-two subjects were analyzed (341 not listed and 131 listed for liver transplant). Among nonlisted subjects, 15% (51 of 341) were alive at 6 months after initiating RRT. Median survival was 21 (interquartile range [IQR], 8, 70) days for those diagnosed with hepatorenal syndrome and 12 (IQR, 3, 43) days for those diagnosed with acute tubular necrosis (P=0.25). Among listed subjects, 48% (63 of 131) received a liver transplant. Median transplant-free survival was 15 (IQR, 5, 37) days for those diagnosed with hepatorenal syndrome and 14 (IQR, 4, 31) days for those diagnosed with acute tubular necrosis (P=0.60). When stratified by transplant listing, with adjusted Cox models we did not detect a difference in the risk of death between hepatorenal syndrome and acute tubular necrosis (hazard ratio [HR], 0.81; 95% confidence interval [95% CI], 0.59 to 1.11, among those not listed; HR, 0.73; 95% CI, 0.44 to 1.19, among those listed). CONCLUSIONS Cause of AKI was not significantly associated with mortality in patients with cirrhosis who required RRT. Among those not listed for liver transplant, mortality rates were extremely high in patients both with hepatorenal syndrome and acute tubular necrosis. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_11_09_CJASNPodcast_18_1_A.mp3.
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Affiliation(s)
| | | | | | | | | | | | - Jules L. Dienstag
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Raymond T. Chung
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Breeden M, Brieler J, Salas J, Scherrer JF. Antidepressants and Incident Hypertension in Primary Care Patients. J Am Board Fam Med 2018; 31:22-8. [PMID: 29330236 DOI: 10.3122/jabfm.2018.01.170234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Many ADMs can alter blood pressure (BP), but the research on the effect of antidepressant medication (ADMs) on incident hypertension is mixed. We investigated whether the use of ADMs was associated with the subsequent development of hypertension. METHODS A retrospective cohort study was conducted using electronic medical record data from 6224 patients with primary care visits from 2008 to 2015. Prescription orders were used to identify ADM use, and hypertension was defined by medical record diagnosis. Using package insert warnings, a 3-level ADM exposure variable was created: ADMs that increase BP (ADM BP+), ADMs that do not increase BP, and no ADM. Unadjusted and adjusted Cox proportional hazard models were computed to estimate the association between the ADM exposure and incident hypertension. RESULTS Unadjusted results revealed that ADM BP+ use compared with the no ADM group was significantly associated with incident hypertension (hazard ratio, 1.30; 95% confidence interval, 1.08-1.57). After adjusting for covariates, ADM BP+ use was no longer significantly associated with incident hypertension (hazard ratio, 1.20; 95% confidence interval, 0.97-1.49). CONCLUSIONS Commonly used ADMs were not associated with incident hypertension after controlling for other factors associated with ADM use and hypertension. Research on potential dose and duration effects is warranted.
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Sumida K, Molnar MZ, Potukuchi PK, George K, Thomas F, Lu JL, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Changes in Albuminuria and Subsequent Risk of Incident Kidney Disease. Clin J Am Soc Nephrol 2017; 12:1941-1949. [PMID: 28893924 PMCID: PMC5718265 DOI: 10.2215/cjn.02720317] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 08/02/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Albuminuria is a robust predictor of CKD progression. However, little is known about the associations of changes in albuminuria with the risk of kidney events outside the settings of clinical trials. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a nationwide cohort of 56,946 United States veterans with an eGFR≥60 ml/min per 1.73 m2, we examined the associations of 1-year fold changes in albuminuria with subsequent incident CKD (>25% decrease in eGFR reaching <60 ml/min per 1.73 m2) and rapid eGFR decline (eGFR slope <-5 ml/min per 1.73 m2 per year) assessed using Cox models and logistic regression, respectively, with adjustment for confounders. RESULTS The mean age was 64 (SD, 10) years old; 97% were men, and 91% were diabetic. There was a nearly linear association between 1-year fold changes in albuminuria and incident CKD. The multivariable-adjusted hazard ratios (95% confidence intervals) of incident CKD associated with more than twofold decrease, 1.25- to twofold decrease, 1.25- to twofold increase, and more than twofold increase (versus <1.25-fold decrease to <1.25-fold increase) in albuminuria were 0.82 (95% confidence interval, 0.77 to 0.89), 0.93 (95% confidence interval, 0.86 to 1.00), 1.12 (95% confidence interval, 1.05 to 1.20), and 1.29 (95% confidence interval, 1.21 to 1.38), respectively. Qualitatively similar associations were present for rapid eGFR decline (adjusted odds ratios; 95% confidence intervals for corresponding albuminuria changes: adjusted odds ratio, 0.86; 95% confidence interval, 0.78 to 0.94; adjusted odds ratio, 0.98; 95% confidence interval, 0.89 to 1.07; adjusted odds ratio, 1.18; 95% confidence interval, 1.08 to 1.29; and adjusted odds ratio, 1.67; 95% confidence interval, 1.54 and 1.81, respectively). CONCLUSIONS Relative changes in albuminuria over a 1-year interval were linearly associated with subsequent risk of kidney outcomes. Additional studies are warranted to elucidate the underlying mechanisms of the observed associations and test whether active interventions to lower elevated albuminuria can improve kidney outcomes.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine and
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z. Molnar
- Division of Nephrology, Department of Medicine and
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | | | - Koshy George
- Division of Nephrology, Department of Medicine and
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine and
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California; and
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine and
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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Xie D, Yang W, Jepson C, Roy J, Hsu JY, Shou H, Anderson AH, Landis JR, Feldman HI. Statistical Methods for Modeling Time-Updated Exposures in Cohort Studies of Chronic Kidney Disease. Clin J Am Soc Nephrol 2017; 12:1892-1899. [PMID: 28818846 PMCID: PMC5672960 DOI: 10.2215/cjn.00650117] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
When estimating the effect of an exposure on a time-to-event type of outcome, one can focus on the baseline exposure or the time-updated exposures. Cox regression models can be used in both situations. When time-dependent confounding exists, the Cox model with time-updated covariates may produce biased effect estimates. Marginal structural models, estimated through inverse-probability weighting, were developed to appropriately adjust for time-dependent confounding. We review the concept of time-dependent confounding and illustrate the process of inverse-probability weighting. We fit a marginal structural model to estimate the effect of time-updated systolic BP on the time to renal events such as ESRD in the Chronic Renal Insufficiency Cohort. We compare the Cox regression model and the marginal structural model on several attributes (effects estimated, result interpretation, and assumptions) and give recommendations for when to use each method.
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Affiliation(s)
- Dawei Xie
- Department of Biostatistics, Epidemiology and Informatics, and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- Department of Biostatistics, Epidemiology and Informatics, and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher Jepson
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason Roy
- Department of Biostatistics, Epidemiology and Informatics, and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesse Y. Hsu
- Department of Biostatistics, Epidemiology and Informatics, and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Haochang Shou
- Department of Biostatistics, Epidemiology and Informatics, and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda H. Anderson
- Department of Biostatistics, Epidemiology and Informatics, and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J. Richard Landis
- Department of Biostatistics, Epidemiology and Informatics, and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harold I. Feldman
- Department of Biostatistics, Epidemiology and Informatics, and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Chen TK, Tin A, Peralta CA, Appel LJ, Choi MJ, Lipkowitz MS, Winkler CA, Estrella MM. APOL1 Risk Variants, Incident Proteinuria, and Subsequent eGFR Decline in Blacks with Hypertension-Attributed CKD. Clin J Am Soc Nephrol 2017; 12:1771-1777. [PMID: 29051146 PMCID: PMC5672963 DOI: 10.2215/cjn.01180117] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 06/30/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES The natural history of kidney disease among blacks who carry the APOL1 high-risk variants varies, with only a subgroup progressing to ESRD. We aimed to determine whether the APOL1 risk variants are associated with incident proteinuria in the context of hypertension-attributed CKD, and whether subsequent kidney function decline after the onset of proteinuria differs by APOL1 risk status. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using Cox models, we studied the association between APOL1 risk status and incident proteinuria (defined as a doubling of urine protein-to-creatinine ratio to a level ≥0.22 g/g creatinine) among African-American Study of Kidney Disease and Hypertension (AASK) trial participants with APOL1 genotyping and without proteinuria at baseline. RESULTS Of the 480 participants in our study, 82 (17%) had the high-risk genotypes (2 alleles), and 254 (53%) developed proteinuria over a median follow-up of 6.8 years. At baseline, mean eGFR was lower in the APOL1 high-risk group compared with the low-risk group (0 or 1 allele; 49.6 versus 53.2 ml/min per 1.73 m2, respectively; P=0.02), but median proteinuria was similar (0.04 g/g creatinine for both groups; P=0.43). Individuals with the high-risk genotypes were 1.72-fold more likely to develop incident proteinuria compared with those with the low-risk genotypes (95% confidence interval, 1.27 to 2.32), independent of age, sex, ancestry, baseline eGFR, baseline systolic BP, and randomized treatment groups. Although eGFR declined faster after the onset of proteinuria, this rate did not differ significantly by APOL1 risk status. CONCLUSIONS Among blacks with established moderate CKD, the APOL1 high-risk variants are associated with greater risk of incident proteinuria. After proteinuria onset, kidney function declines more rapidly but does not differ by APOL1 risk status. This suggests that factors that lead to proteinuria, beyond APOL1, may additionally drive CKD progression.
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Affiliation(s)
- Teresa K Chen
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Molnar MZ, Streja E, Sumida K, Soohoo M, Ravel VA, Gaipov A, Potukuchi PK, Thomas F, Rhee CM, Lu JL, Kalantar-Zadeh K, Kovesdy CP. Pre-ESRD Depression and Post-ESRD Mortality in Patients with Advanced CKD Transitioning to Dialysis. Clin J Am Soc Nephrol 2017; 12:1428-1437. [PMID: 28679562 PMCID: PMC5586564 DOI: 10.2215/cjn.00570117] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 05/26/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVES Depression in patients with nondialysis-dependent CKD is often undiagnosed, empirically overlooked, and associated with higher risk of death, progression to ESRD, and hospitalization. However, there is a paucity of evidence on the association between the presence of depression in patients with advanced nondialysis-dependent CKD and post-ESRD mortality, particularly among those in the transition period from late-stage nondialysis-dependent CKD to maintenance dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS From a nation-wide cohort of 45,076 United States veterans who transitioned to ESRD over 4 contemporary years (November of 2007 to September of 2011), we identified 10,454 (23%) patients with a depression diagnosis during the predialysis period. We examined the association of pre-ESRD depression with all-cause mortality after transition to dialysis using Cox proportional hazards models adjusted for sociodemographics, comorbidities, and medications. RESULTS Patients were 72±11 years old (mean±SD) and included 95% men, 66% patients with diabetes, and 23% blacks. The crude mortality rate was similar in patients with depression (289/1000 patient-years; 95% confidence interval, 282 to 297) versus patients without depression (286/1000 patient-years; 95% confidence interval, 282 to 290). Compared with patients without depression, patients with depression had a 6% higher all-cause mortality risk in the adjusted model (hazard ratio, 1.06; 95% confidence interval, 1.03 to 1.09). Similar results were found across all selected subgroups as well as in sensitivity analyses using alternate definitions of depression. CONCLUSION Pre-ESRD depression has a weak association with post-ESRD mortality in veterans transitioning to dialysis.
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Affiliation(s)
- Miklos Z. Molnar
- Division of Nephrology, Department of Medicine and
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | | | - Melissa Soohoo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Vanessa A. Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Abduzhappar Gaipov
- Division of Nephrology, Department of Medicine and
- Department of Extracorporeal Hemocorrection, National Scientific Medical Research Center, Astana, Kazakhstan; and
| | | | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Connie M. Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine and
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine and
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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Chonchol M, Gitomer B, Isakova T, Cai X, Salusky I, Pereira R, Abebe K, Torres V, Steinman TI, Grantham JJ, Chapman AB, Schrier RW, Wolf M. Fibroblast Growth Factor 23 and Kidney Disease Progression in Autosomal Dominant Polycystic Kidney Disease. Clin J Am Soc Nephrol 2017; 12:1461-1469. [PMID: 28705885 PMCID: PMC5586583 DOI: 10.2215/cjn.12821216] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/26/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Increases in fibroblast growth factor 23 precede kidney function decline in autosomal dominant polycystic kidney disease; however, the role of fibroblast growth factor 23 in autosomal dominant polycystic kidney disease has not been well characterized. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS We measured intact fibroblast growth factor 23 levels in baseline serum samples from 1002 participants in the HALT-PKD Study A (n=540; mean eGFR =91±17 ml/min per 1.73 m2) and B (n=462; mean eGFR =48±12 ml/min per 1.73 m2). We used linear mixed and Cox proportional hazards models to test associations between fibroblast growth factor 23 and eGFR decline, percentage change in height-adjusted total kidney volume, and composite of time to 50% reduction in eGFR, onset of ESRD, or death. RESULTS Median (interquartile range) intact fibroblast growth factor 23 was 44 (33-56) pg/ml in HALT-PKD Study A and 69 (50-93) pg/ml in Study B. In adjusted models, annualized eGFR decline was significantly faster in the upper fibroblast growth factor 23 quartile (Study A: quartile 4, -3.62; 95% confidence interval, -4.12 to -3.12 versus quartile 1, -2.51; 95% confidence interval, -2.71 to -2.30 ml/min per 1.73 m2; P for trend <0.001; Study B: quartile 4, -3.74; 95% confidence interval, -4.14 to -3.34 versus quartile 1, -2.78; 95% confidence interval, -2.92 to -2.63 ml/min per 1.73 m2; P for trend <0.001). In Study A, higher fibroblast growth factor 23 quartiles were associated with greater longitudinal percentage increase in height-adjusted total kidney volume in adjusted models (quartile 4, 6.76; 95% confidence interval, 5.57 to 7.96 versus quartile 1, 6.04; 95% confidence interval, 5.55 to 6.54; P for trend =0.03). In Study B, compared with the lowest quartile, the highest fibroblast growth factor 23 quartile was associated with elevated risk for the composite outcome (hazard ratio, 3.11; 95% confidence interval, 1.84 to 5.25). Addition of fibroblast growth factor 23 to a model of annualized decline in eGFR≥3.0 ml/min per 1.73 m2 did not improve risk prediction. CONCLUSIONS Higher serum fibroblast growth factor 23 concentration was associated with kidney function decline, height-adjusted total kidney volume percentage increase, and death in patients with autosomal dominant polycystic kidney disease. However, fibroblast growth factor 23 did not substantially improve prediction of rapid kidney function decline.
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Affiliation(s)
- Michel Chonchol
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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van Londen M, Aarts BM, Deetman PE, van der Weijden J, Eisenga MF, Navis G, Bakker SJL, de Borst MH. Post-Transplant Hypophosphatemia and the Risk of Death-Censored Graft Failure and Mortality after Kidney Transplantation. Clin J Am Soc Nephrol 2017; 12:1301-1310. [PMID: 28546442 PMCID: PMC5544514 DOI: 10.2215/cjn.10270916] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 04/25/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Hypophosphatemia is common in the first year after kidney transplantation, but its clinical implications are unclear. We investigated the relationship between the severity of post-transplant hypophosphatemia and mortality or death-censored graft failure in a large cohort of renal transplant recipients with long-term follow-up. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a longitudinal cohort study in 957 renal transplant recipients who were transplanted between 1993 and 2008 at a single center. We used a large real-life dataset containing 28,178 phosphate measurements (median of 27; first to third quartiles, 23-34) serial measurements per patient) and selected the lowest intraindividual phosphate level during the first year after transplantation. The primary outcomes were all-cause mortality, cardiovascular mortality, and death-censored graft failure. RESULTS The median (interquartile range) intraindividual lowest phosphate level was 1.58 (1.30-1.95) mg/dl, and it was reached at 33 (21-51) days post-transplant. eGFR was the main correlate of the lowest serum phosphate level (model R2 =0.32). During 9 (5-12) years of follow-up, 181 (19%) patients developed graft failure, and 295 (35%) patients died, of which 94 (32%) deaths were due to cardiovascular disease. In multivariable Cox regression analysis, more severe hypophosphatemia was associated with a lower risk of death-censored graft failure (fully adjusted hazard ratio, 0.61; 95% confidence interval, 0.43 to 0.88 per 1 mg/dl lower serum phosphate) and cardiovascular mortality (fully adjusted hazard ratio, 0.37; 95% confidence interval, 0.22 to 0.62) but not noncardiovascular mortality (fully adjusted hazard ratio, 1.33; 95% confidence interval, 0.9 to 1.96) or all-cause mortality (fully adjusted hazard ratio, 1.15; 95% confidence interval, 0.81 to 1.61). CONCLUSIONS Post-transplant hypophosphatemia develops early after transplantation. These data connect post-transplant hypophosphatemia with favorable long-term graft and patient outcomes.
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Affiliation(s)
- Marco van Londen
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen and University of Groningen, Groningen, The Netherlands
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Prochaska M, Taylor E, Vaidya A, Curhan G. Low Bone Density and Bisphosphonate Use and the Risk of Kidney Stones. Clin J Am Soc Nephrol 2017; 12:1284-1290. [PMID: 28576907 PMCID: PMC5544505 DOI: 10.2215/cjn.01420217] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/05/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Previous studies have demonstrated lower bone density in patients with kidney stones, but no longitudinal studies have evaluated kidney stone risk in individuals with low bone density. Small studies with short follow-up reported reduced 24-hour urine calcium excretion with bisphosphonate use. We examined history of low bone density and bisphosphonate use and the risk of incident kidney stone as well as the association with 24-hour calcium excretion. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a prospective analysis of 96,092 women in the Nurses' Health Study II. We used Cox proportional hazards models to adjust for age, body mass index, thiazide use, fluid intake, supplemental calcium use, and dietary factors. We also conducted a cross-sectional analysis of 2294 participants using multivariable linear regression to compare 24-hour urinary calcium excretion between participants with and without a history of low bone density, and among 458 participants with low bone density, with and without bisphosphonate use. RESULTS We identified 2564 incident stones during 1,179,860 person-years of follow-up. The multivariable adjusted relative risk for an incident kidney stone for participants with history of low bone density compared with participants without was 1.39 (95% confidence interval [95% CI], 1.20 to 1.62). Among participants with low bone density, the multivariable adjusted relative risk for an incident kidney stone for bisphosphonate users was 0.68 (95% CI, 0.48 to 0.98). In the cross-sectional analysis of 24-hour urine calcium excretion, the multivariable adjusted mean difference in 24-hour calcium was 10 mg/d (95% CI, 1 to 19) higher for participants with history of low bone density. However, among participants with history of low bone density, there was no association between bisphosphonate use and 24-hour calcium with multivariable adjusted mean difference in 24-hour calcium of -2 mg/d (95% CI, -25 to 20). CONCLUSIONS Low bone density is an independent risk factor for incident kidney stone and is associated with higher 24-hour urine calcium excretion. Among participants with low bone density, bisphosphonate use was associated with lower risk of incident kidney stone but was not independently associated with 24-hour urine calcium excretion.
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Affiliation(s)
- Megan Prochaska
- Divisions of Renal Medicine and
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Eric Taylor
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
- Division of Nephrology and Transplantation, Maine Medical Center, Portland, Maine
| | | | - Gary Curhan
- Divisions of Renal Medicine and
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
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Drechsler C, Hayek SS, Wei C, Sever S, Genser B, Krane V, Meinitzer A, März W, Wanner C, Reiser J. Soluble Urokinase Plasminogen Activator Receptor and Outcomes in Patients with Diabetes on Hemodialysis. Clin J Am Soc Nephrol 2017; 12:1265-1273. [PMID: 28495863 PMCID: PMC5544516 DOI: 10.2215/cjn.10881016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 04/10/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Soluble urokinase plasminogen activator receptor is a novel biomarker strongly predictive of cardiovascular outcomes implicated in the pathogenesis of kidney disease. Soluble urokinase plasminogen activator receptor levels, however, correlate with declining kidney function. It is unclear whether soluble urokinase plasminogen activator receptor levels remain associated with outcomes in patients with ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We measured plasma soluble urokinase plasminogen activator receptor levels in 1175 patients (mean age =66±8 years old, 54% men) with type 2 diabetes mellitus on hemodialysis participating in the German Diabetes and Dialysis Study followed for a median of 4 years for outcomes including all-cause death, cardiovascular events, and infection-related mortality. Survival analysis was performed using stepwise Cox proportional hazards models adjusted for potential confounders. Also, adjustments were made for inflammatory markers (C-reactive protein and leukocyte count) and the oxidative stress marker asymmetric dimethyl arginine to investigate potential mediators of the relationship between soluble urokinase plasminogen activator receptor and outcomes. RESULTS Median soluble urokinase plasminogen activator receptor levels were 10,521 pg/ml (interquartile range, 9105-12,543 pg/ml). When stratified by tertiles, patients with soluble urokinase plasminogen activator receptor >11,633 pg/ml (third tertile) had adjusted 1.6-fold higher mortality (hazard ratio, 1.60; 95% confidence interval, 1.27 to 2.03) compared with those with low soluble urokinase plasminogen activator receptor <9599 pg/ml (first tertile). Risks of sudden death and stroke were higher (adjusted hazard ratio, 1.98; 95% confidence interval, 1.27 to 3.09 and adjusted hazard ratio, 1.74; 95% confidence interval, 1.05 to 2.90, respectively), together accounting for higher incidence of cardiovascular events (adjusted hazard ratio, 1.48; 95% confidence interval, 1.15 to 1.89). Associations with outcomes persisted after adjusting for C-reactive protein, leukocyte count, and asymmetric dimethyl arginine. Addition of soluble urokinase plasminogen activator receptor to a risk factor model modestly improved risk discrimination for all-cause death (ΔC statistic, 0.02; 95% confidence interval, 0.00 to 0.03) and cardiovascular events (ΔC statistic, 0.02; 95% confidence interval, 0.00 to 0.05). CONCLUSIONS The association of soluble urokinase plasminogen activator receptor levels with outcomes persists in patients on hemodialysis. Additional study is warranted to characterize the underlying pathways of that association, which may yield opportunities to develop new therapeutic strategies.
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Affiliation(s)
- Christiane Drechsler
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Perl J, Na Y, Tennankore KK, Chan CT. Temporal Trends and Factors Associated with Home Hemodialysis Technique Survival in Canada. Clin J Am Soc Nephrol 2017; 12:1248-1258. [PMID: 28739576 PMCID: PMC5544522 DOI: 10.2215/cjn.13271216] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 05/04/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES The last 15 years has seen growth in home hemodialysis (HD) utilization in Canada owing to reports of improved outcomes relative to patients on conventional in-center HD. What effect growth has had on home HD technique and patient survival during this period is not known. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS We compared the risk of home HD technique failure, mortality, and the composite outcome among three incident cohorts of patients on home HD in Canada: 1996-2002, 2003-2007, and 2008-2012. A multivariable piece-wise exponential model was used to evaluate all outcomes using inverse probability of treatment and censoring weights. RESULTS A total of 1869 incident patients on home HD were identified from the Canadian Organ Replacement Register. Relative to those treated between 2003 and 2007 (n=568), the risk of home HD technique failure was similar between patients treated between 1996 and 2002 (n=233; adjusted hazard ratio [AHR], 1.39; 95% confidence interval [95% CI], 0.78 to 2.46) but higher among incident patients on home HD treated between 2008 and 2012 (n=1068; AHR, 1.51; 95% CI, 1.06 to 2.15). Relative to patients treated between 2003 and 2007, adjusted mortality was similar among those treated between 2008 and 2012 (AHR, 0.83; 95% CI, 0.58 to 1.19) and those treated between 1996 and 2002 (AHR, 0.67; 95% CI, 0.38 to 1.21). The risk of the composite outcome of death and technique failure was similar across cohorts, as was the risk of receiving a kidney transplant. Increasing age, diabetes as a comorbidity, and smoking status were associated with an increased risk of death as well as the composite outcome. Medium-sized facilities had a lower risk of death, technique failure, and the composite outcome compared with larger facilities. CONCLUSIONS A higher risk of technique failure was seen in the most contemporary era. Further characterization of the risk factors for, and causes of technique failure is needed to develop strategies to improve patient retention on home HD.
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Affiliation(s)
- Jeffrey Perl
- Division of Nephrology and
- The Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Ontario, Canada
| | | | - Karthik K. Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; and
| | - Christopher T. Chan
- Division of Nephrology, Department of Medicine, University of Toronto, University Health Network, Ontario, Canada
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Eriguchi R, Obi Y, Streja E, Tortorici AR, Rhee CM, Soohoo M, Kim T, Kovesdy CP, Kalantar-Zadeh K. Longitudinal Associations among Renal Urea Clearance-Corrected Normalized Protein Catabolic Rate, Serum Albumin, and Mortality in Patients on Hemodialysis. Clin J Am Soc Nephrol 2017; 12:1109-1117. [PMID: 28490436 PMCID: PMC5498364 DOI: 10.2215/cjn.13141216] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/29/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES There are inconsistent reports on the association of dietary protein intake with serum albumin and outcomes among patients on hemodialysis. Using a new normalized protein catabolic rate (nPCR) variable accounting for residual renal urea clearance, we hypothesized that higher baseline nPCR and rise in nPCR would be associated with higher serum albumin and better survival among incident hemodialysis patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Among 36,757 incident hemodialysis patients in a large United States dialysis organization, we examined baseline and change in renal urea clearance-corrected nPCR as a protein intake surrogate and modeled their associations with serum albumin and mortality over 5 years (1/2007-12/2011). RESULTS Median nPCRs with and without accounting for renal urea clearance at baseline were 0.94 and 0.78 g/kg per day, respectively (median within-patient difference, 0.14 [interquartile range, 0.07-0.23] g/kg per day). During a median follow-up period of 1.4 years, 8481 deaths were observed. Baseline renal urea clearance-corrected nPCR was associated with higher serum albumin and lower mortality in the fully adjusted model (Ptrend<0.001). Among 13,895 patients with available data, greater rise in renal urea clearance-corrected nPCR during the first 6 months was also associated with attaining high serum albumin (≥3.8 g/dl) and lower mortality (Ptrend<0.001); compared with the reference group (a change of 0.1-0.2 g/kg per day), odds and hazard ratios were 0.53 (95% confidence interval, 0.44 to 0.63) and 1.32 (95% confidence interval, 1.14 to 1.54), respectively, among patients with a change of <-0.2 g/kg per day and 1.62 (95% confidence interval, 1.35 to 1.96) and 0.76 (95% confidence interval, 0.64 to 0.90), respectively, among those with a change of ≥0.5 g/kg per day. Within a given category of nPCR without accounting for renal urea clearance, higher levels of renal urea clearance-corrected nPCR consistently showed lower mortality risk. CONCLUSIONS Among incident hemodialysis patients, higher dietary protein intake represented by nPCR and its changes over time appear to be associated with increased serum albumin levels and greater survival. nPCR may be underestimated when not accounting for renal urea clearance. Compared with the conventional nPCR, renal urea clearance-corrected nPCR may be a better marker of mortality.
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Affiliation(s)
- Rieko Eriguchi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
| | - Amanda R. Tortorici
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
| | - Taehee Kim
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
- Division of Nephrology, Department of Medicine, Inje University, Busan, South Korea
| | - Csaba P. Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee; and
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, Orange, California
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
- Department Epidemiology, University of California, Los Angeles Fielding School of Public Health, University of California, Los Angeles, California
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Wang M, Obi Y, Streja E, Rhee CM, Lau WL, Chen J, Hao C, Hamano T, Kovesdy CP, Kalantar-Zadeh K. Association of Parameters of Mineral Bone Disorder with Mortality in Patients on Hemodialysis according to Level of Residual Kidney Function. Clin J Am Soc Nephrol 2017; 12:1118-1127. [PMID: 28487345 PMCID: PMC5498357 DOI: 10.2215/cjn.11931116] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 04/04/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The relationship between mineral and bone disorders and survival according to residual kidney function status has not been previously studied in patients on hemodialysis. We hypothesized that residual kidney function, defined by renal urea clearance, modifies the association between mineral and bone disorder parameters and mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The associations of serum phosphorus, albumin-corrected calcium, intact parathyroid hormone, and alkaline phosphatase with all-cause mortality were examined across three strata (<1.5, 1.5 to <3.0, and ≥3.0 ml/min per 1.73 m2) of baseline residual renal urea clearance using Cox models adjusted for clinical characteristics and laboratory measurements in 35,114 incident hemodialysis patients from a large United States dialysis organization over the period of 2007-2011. RESULTS A total of 8102 (23%) patients died during the median follow-up of 1.3 years (interquartile range, 0.6-2.3 years). There was an incremental mortality risk across higher serum phosphorus concentrations, which was pronounced among patients with higher residual renal urea clearance (Pinteraction=0.001). Lower concentrations of serum intact parathyroid hormone were associated with higher mortality among patients with low residual renal urea clearance (i.e., <1.5 ml/min per 1.73 m2), whereas higher concentrations showed a higher mortality risk among patients with greater residual renal urea clearance (i.e., ≥1.5 ml/min per 1.73 m2; Pinteraction<0.001). Higher serum corrected total calcium and higher alkaline phosphatase concentrations consistently showed higher mortality risk (Ptrend<0.001 for both) irrespective of residual renal urea clearance strata (Pinteraction=0.34 and Pinteraction=0.53, respectively). CONCLUSIONS Residual kidney function modified the mortality risk associated with serum phosphorus and intact parathyroid hormone among incident hemodialysis patients. Future studies are needed to examine whether taking account for residual kidney function into the assessment of mortality risk associated with serum phosphorus and intact parathyroid hormone improves patient management and clinical outcomes in the hemodialysis population.
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Affiliation(s)
- Mengjing Wang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Wei Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Jing Chen
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chuanming Hao
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Takayuki Hamano
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Department of Epidemiology, Fielding School of Public Health at University of California, Los Angeles, Los Angeles, California; and
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
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Ashby VB, Leichtman AB, Rees MA, Song PXK, Bray M, Wang W, Kalbfleisch JD. A Kidney Graft Survival Calculator that Accounts for Mismatches in Age, Sex, HLA, and Body Size. Clin J Am Soc Nephrol 2017; 12:1148-1160. [PMID: 28596416 PMCID: PMC5498352 DOI: 10.2215/cjn.09330916] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 03/27/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Outcomes for transplants from living unrelated donors are of particular interest in kidney paired donation (KPD) programs where exchanges can be arranged between incompatible donor-recipient pairs or chains created from nondirected/altruistic donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using Scientific Registry of Transplant Recipients data, we analyzed 232,705 recipients of kidney-alone transplants from 1998 to 2012. Graft failure rates were estimated using Cox models for recipients of kidney transplants from living unrelated, living related, and deceased donors. Models were adjusted for year of transplant and donor and recipient characteristics, with particular attention to mismatches in age, sex, human leukocyte antigens (HLA), body size, and weight. RESULTS The dependence of graft failure on increasing donor age was less pronounced for living-donor than for deceased-donor transplants. Male donor-to-male recipient transplants had lower graft failure, particularly better than female to male (5%-13% lower risk). HLA mismatch was important in all donor types. Obesity of both the recipient (8%-18% higher risk) and donor (5%-11% higher risk) was associated with higher graft loss, as were donor-recipient weight ratios of <75%, compared with transplants where both parties were of similar weight (9%-12% higher risk). These models are used to create a calculator of estimated graft survival for living donors. CONCLUSIONS This calculator provides useful information to donors, candidates, and physicians of estimated outcomes and potentially in allowing candidates to choose among several living donors. It may also help inform candidates with compatible donors on the advisability of joining a KPD program.
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Affiliation(s)
- Valarie B. Ashby
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Alan B. Leichtman
- Arbor Research Collaborative for Health, Division of Nephrology, University of Michigan, Ann Arbor, Michigan; and
| | - Michael A. Rees
- Departments of Urology and Pathology, University of Toledo Medical Center, Toledo, Ohio
| | - Peter X.-K. Song
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Mathieu Bray
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Wen Wang
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
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Hsu JY, Roy JA, Xie D, Yang W, Shou H, Anderson AH, Landis JR, Jepson C, Wolf M, Isakova T, Rahman M, Feldman HI. Statistical Methods for Cohort Studies of CKD: Survival Analysis in the Setting of Competing Risks. Clin J Am Soc Nephrol 2017; 12:1181-1189. [PMID: 28242844 PMCID: PMC5498354 DOI: 10.2215/cjn.10301016] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Survival analysis is commonly used to evaluate factors associated with time to an event of interest (e.g., ESRD, cardiovascular disease, and mortality) among CKD populations. Time to the event of interest is typically observed only for some participants. Other participants have their event time censored because of the end of the study, death, withdrawal from the study, or some other competing event. Classic survival analysis methods, such as Cox proportional hazards regression, rely on the assumption that any censoring is independent of the event of interest. However, in most clinical settings, such as in CKD populations, this assumption is unlikely to be true. For example, participants whose follow-up time is censored because of health-related death likely would have had a shorter time to ESRD, had they not died. These types of competing events that cause dependent censoring are referred to as competing risks. Here, we first describe common circumstances in clinical renal research where competing risks operate and then review statistical approaches for dealing with competing risks. We compare two of the most popular analytical methods used in settings of competing risks: cause-specific hazards models and the Fine and Gray approach (subdistribution hazards models). We also discuss practical recommendations for analysis and interpretation of survival data that incorporate competing risks. To demonstrate each of the analytical tools, we use a study of fibroblast growth factor 23 and risks of mortality and ESRD in participants with CKD from the Chronic Renal Insufficiency Cohort Study.
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Affiliation(s)
- Jesse Yenchih Hsu
- Department of Biostatistics and Epidemiology and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason A Roy
- Department of Biostatistics and Epidemiology and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dawei Xie
- Department of Biostatistics and Epidemiology and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- Department of Biostatistics and Epidemiology and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Haochang Shou
- Department of Biostatistics and Epidemiology and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda Hyre Anderson
- Department of Biostatistics and Epidemiology and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Richard Landis
- Department of Biostatistics and Epidemiology and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher Jepson
- Department of Biostatistics and Epidemiology and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Myles Wolf
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University, Chicago, Illinois
- Center for Translational Metabolism and Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, Case Western Reserve University, Cleveland, Ohio
- University Hospitals Cleveland Medical Center, Cleveland, Ohio; and
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
| | - Harold I Feldman
- Department of Biostatistics and Epidemiology and
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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