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Vazquez MA, Oliver G, Amarasingham R, Sundaram V, Chan K, Ahn C, Zhang S, Bickel P, Parikh SM, Wells B, Miller RT, Hedayati S, Hastings J, Jaiyeola A, Nguyen TM, Moran B, Santini N, Barker B, Velasco F, Myers L, Meehan TP, Fox C, Toto RD. Pragmatic Trial of Hospitalization Rate in Chronic Kidney Disease. N Engl J Med 2024; 390:1196-1206. [PMID: 38598574 DOI: 10.1056/nejmoa2311708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND Despite the availability of effective therapies for patients with chronic kidney disease, type 2 diabetes, and hypertension (the kidney-dysfunction triad), the results of large-scale trials examining the implementation of guideline-directed therapy to reduce the risk of death and complications in this population are lacking. METHODS In this open-label, cluster-randomized trial, we assigned 11,182 patients with the kidney-dysfunction triad who were being treated at 141 primary care clinics either to receive an intervention that used a personalized algorithm (based on the patient's electronic health record [EHR]) to identify patients and practice facilitators to assist providers in delivering guideline-based interventions or to receive usual care. The primary outcome was hospitalization for any cause at 1 year. Secondary outcomes included emergency department visits, readmissions, cardiovascular events, dialysis, and death. RESULTS We assigned 71 practices (enrolling 5690 patients) to the intervention group and 70 practices (enrolling 5492 patients) to the usual-care group. The hospitalization rate at 1 year was 20.7% (95% confidence interval [CI], 19.7 to 21.8) in the intervention group and 21.1% (95% CI, 20.1 to 22.2) in the usual-care group (between-group difference, 0.4 percentage points; P = 0.58). The risks of emergency department visits, readmissions, cardiovascular events, dialysis, or death from any cause were similar in the two groups. The risk of adverse events was also similar in the trial groups, except for acute kidney injury, which was observed in more patients in the intervention group (12.7% vs. 11.3%). CONCLUSIONS In this pragmatic trial involving patients with the triad of chronic kidney disease, type 2 diabetes, and hypertension, the use of an EHR-based algorithm and practice facilitators embedded in primary care clinics did not translate into reduced hospitalization at 1 year. (Funded by the National Institutes of Health and others; ICD-Pieces ClinicalTrials.gov number, NCT02587936.).
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Affiliation(s)
- Miguel A Vazquez
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - George Oliver
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Ruben Amarasingham
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Venkatraghavan Sundaram
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Kevin Chan
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Chul Ahn
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Song Zhang
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Perry Bickel
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Samir M Parikh
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Barbara Wells
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - R Tyler Miller
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Susan Hedayati
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Jeffrey Hastings
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Adeola Jaiyeola
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Tuan-Minh Nguyen
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Brett Moran
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Noel Santini
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Blake Barker
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Ferdinand Velasco
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Lynn Myers
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Thomas P Meehan
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Chester Fox
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
| | - Robert D Toto
- From the Department of Internal Medicine (M.A.V., P.B., S.M.P., R.T.M., S.H., B.B., R.D.T.) and the Peter O'Donnell Jr. School of Public Health (C.A., S.Z.), University of Texas Southwestern Medical Center, the Parkland Center for Clinical Innovation (G.O., V.S., A.J., T.-M.N.), Pieces Technologies (R.A.), Veterans Affairs of North Texas Health Care System (R.T.M., S.H., J.H.), Parkland Health (B.M., N.S.), and Texas Health Resources (F.V., L.M.) - all in Dallas; the National Institute of Diabetes and Digestive and Kidney Diseases (K.C.) and the National Heart, Lung, and Blood Institute (B.W.) - both in Bethesda, MD; ProHealth Physicians, Farmington, CT (T.P.M.); and the State University of New York, Buffalo (C.F.)
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Menon R, Otto EA, Barisoni L, Melo Ferreira R, Limonte CP, Godfrey B, Eichinger F, Nair V, Naik AS, Subramanian L, D'Agati V, Henderson JM, Herlitz L, Kiryluk K, Moledina DG, Moeckel GW, Palevsky PM, Parikh CR, Randhawa P, Rosas SE, Rosenberg AZ, Stillman I, Toto R, Torrealba J, Vazquez MA, Waikar SS, Alpers CE, Nelson RG, Eadon MT, Kretzler M, Hodgin JB. Defining the molecular correlate of arteriolar hyalinosis in kidney disease progression by integration of single cell transcriptomic analysis and pathology scoring. medRxiv 2023:2023.06.14.23291150. [PMID: 37398386 PMCID: PMC10312894 DOI: 10.1101/2023.06.14.23291150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Arteriolar hyalinosis in kidneys is an independent predictor of cardiovascular disease, the main cause of mortality in chronic kidney disease (CKD). The underlying molecular mechanisms of protein accumulation in the subendothelial space are not well understood. Using single cell transcriptomic data and whole slide images from kidney biopsies of patients with CKD and acute kidney injury in the Kidney Precision Medicine Project, the molecular signals associated with arteriolar hyalinosis were evaluated. Co-expression network analysis of the endothelial genes yielded three gene set modules as significantly associated with arteriolar hyalinosis. Pathway analysis of these modules showed enrichment of transforming growth factor beta / bone morphogenetic protein (TGFβ / BMP) and vascular endothelial growth factor (VEGF) signaling pathways in the endothelial cell signatures. Ligand-receptor analysis identified multiple integrins and cell adhesion receptors as over-expressed in arteriolar hyalinosis, suggesting a potential role of integrin-mediated TGFβ signaling. Further analysis of arteriolar hyalinosis associated endothelial module genes identified focal segmental glomerular sclerosis as an enriched term. On validation in gene expression profiles from the Nephrotic Syndrome Study Network cohort, one of the three modules was significantly associated with the composite endpoint (> 40% reduction in estimated glomerular filtration rate (eGFR) or kidney failure) independent of age, sex, race, and baseline eGFR, suggesting poor prognosis with elevated expression of genes in this module. Thus, integration of structural and single cell molecular features yielded biologically relevant gene sets, signaling pathways and ligand-receptor interactions, underlying arteriolar hyalinosis and putative targets for therapeutic intervention.
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Galvan A, Damian-Ascencio E, Martínez M, Dominguez Esquivel JM, Vazquez MA. Keggin Heteropolyacid in Auto-Tandem Catalysis: Confinement Effects over Ordered Mesoporous Silica in the Synthesis of 2-Pyridones. NEW J CHEM 2023. [DOI: 10.1039/d3nj00384a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
It is necessary to design and develop simpler, more efficient, and cleaner synthetic methodologies to prepare increasingly complex molecules. One interesting strategy is multicatalysis. The aim of this study was...
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AbdulRahim N, McAdams M, Xu P, Wojciechowski D, La Hoz RM, Lu C, Vazquez MA, Hedayati SS. Association of Inflammatory Biomarkers with Immunosuppression Management and Outcomes in Kidney Transplant Recipients with COVID-19. Transplant Proc 2021; 53:2451-2467. [PMID: 34465422 PMCID: PMC8349691 DOI: 10.1016/j.transproceed.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 07/23/2021] [Accepted: 08/02/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Kidney transplant recipients with coronavirus disease 2019 (COVID-19) are at increased risk for adverse outcomes, such as acute kidney injury (AKI), intensive care unit (ICU) admission, and death. The association of inflammatory biomarkers with outcomes and the impact of changes in immunosuppression on biomarker levels are unknown. METHODS We investigated factors associated with a composite of AKI, ICU admission, or death, and whether immunosuppression changes correlated with changes in inflammatory biomarkers and outcomes in kidney transplant recipients with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction. RESULTS Of 59 patients, 50% had estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Patients who discontinued calcineurin inhibitors (CNIs) had higher peak high-sensitivity C-reactive protein (hs-CRP) than those who maintained the same dose (median, 344; interquartile range [IQR], 145-374 vs median, 41; IQR, 22-116 mg/L, P = .03). Of the patients, 73% were hospitalized, 22% had admissions to the ICU, and 20% died. Of the 56% with AKI, 35% required dialysis. All patients with AKI but without pulmonary manifestations recovered to 10% of baseline creatinine levels. Factors associated with the composite outcome were eGFR <60 mL/min/1.73 m2 (odds ratio [OR], 5.833; 95% confidence interval [CI], 1.880-18.099; P = .002), hs-CRP (OR, 1.011/unit increase; 95% CI, 1.002-1.021; P = .019), white blood cell count (OR, 1.173/unit increase; 95% CI, 1.006-1.368; P = .041), and decreased or discontinued CNI (OR, 4.286; 95% CI, 1.353-13.572; P = .013). eGFR<60 mL/min/1.73 m2 (OR, 11.176; 95% CI, 1.581-79.001; P = .016), and peak hs-CRP (OR, 1.010/unit increase; 95% CI, 1.000-1.020; P = .049) remained associated with the composite in the multivariable model. CONCLUSIONS Kidney transplant recipients with COVID-19 have high rates of ICU admissions, AKI, and death. Those with eGFR<60 mL/min/1.73 m2 are at highest risk. CNI reduction is associated with higher inflammatory biomarkers, correlating with worse outcomes. More studies are needed to determine if this association should drive clinical management.
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Affiliation(s)
- Nashila AbdulRahim
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Hospital and Health System, Dallas, Texas
| | - Meredith McAdams
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Pin Xu
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David Wojciechowski
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ricardo M La Hoz
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher Lu
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Miguel A Vazquez
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Hospital and Health System, Dallas, Texas
| | - S Susan Hedayati
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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5
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Huber TS, Berceli SA, Scali ST, Neal D, Anderson EM, Allon M, Cheung AK, Dember LM, Himmelfarb J, Roy-Chaudhury P, Vazquez MA, Alpers CE, Robbin ML, Imrey PB, Beck GJ, Farber AM, Kaufman JS, Kraiss LW, Vongpatanasin W, Kusek JW, Feldman HI. Arteriovenous Fistula Maturation, Functional Patency, and Intervention Rates. JAMA Surg 2021; 156:1111-1118. [PMID: 34550312 DOI: 10.1001/jamasurg.2021.4527] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance National initiatives have emphasized the use of autogenous arteriovenous fistulas (AVFs) for hemodialysis, but their purported benefits have been questioned. Objective To examine AVF usability, longer-term functional patency, and remedial procedures to facilitate maturation, manage complications, or maintain patency in the Hemodialysis Fistula Maturation (HFM) Study. Design, Setting, and Participants The HFM Study was a multicenter (n = 7) prospective National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases cohort study performed to identify factors associated with AVF maturation. A total of 602 participants were enrolled (dialysis, kidney failure: 380; predialysis, chronic kidney disease [CKD]: 222) with AVF maturation ascertained for 535 (kidney failure, 353; CKD, 182) participants. Interventions All clinical decisions regarding AVF management were deferred to the individual centers, but remedial interventions were discouraged within 6 weeks of creation. Main Outcomes and Measures In this case series analysis, the primary outcome was unassisted maturation. Functional patency, freedom from intervention, and participant survival were summarized using Kaplan-Meier analysis. Results Most participants evaluated (n = 535) were men (372 [69.5%]) and had diabetes (311 [58.1%]); mean (SD) age was 54.6 (13.6) years. Almost two-thirds of the AVFs created (342 of 535 [64%]) were in the upper arm. The AVF maturation rates for the kidney failure vs CKD participants were 29% vs 10% at 3 months, 67% vs 38% at 6 months, and 76% vs 58% at 12 months. Several participants with kidney failure (133 [37.7%]) and CKD (63 [34.6%]) underwent interventions to facilitate maturation or manage complications before maturation. The median time from access creation to maturation was 115 days (interquartile range [IQR], 86-171 days) but differed by initial indication (CKD, 170 days; IQR, 113-269 days; kidney failure, 105 days; IQR, 81-137 days). The functional patency for the AVFs that matured at 1 year was 87% (95% CI, 83.2%-90.2%) and at 2 years, 75% (95% CI, 69.7%-79.7%), and there was no significant difference for those receiving interventions before maturation. Almost half (188 [47.5%]) of the AVFs that matured had further intervention to maintain patency or treat complications. Conclusions and Relevance The findings of this study suggest that AVF remains an accepted hemodialysis access option, although both its maturation and continued use require a moderate number of interventions to maintain patency and treat the associated complications.
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Affiliation(s)
- Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Erik M Anderson
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham
| | - Alfred K Cheung
- Nephrology and Hypertension Division, University of Utah School of Medicine, Salt Lake City
| | - Laura M Dember
- Renal, Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle
| | | | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern, Dallas
| | | | | | - Peter B Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Alik M Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, Massachusetts
| | - James S Kaufman
- Renal Section, Veterans Affairs New York Harbor Healthcare System, New York
| | - Larry W Kraiss
- Division of Vascular Surgery, University of Utah, Salt Lake City
| | | | - 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
| | - Harold I Feldman
- Renal, Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia
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6
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de Boer IH, Alpers CE, Azeloglu EU, Balis UGJ, Barasch JM, Barisoni L, Blank KN, Bomback AS, Brown K, Dagher PC, Dighe AL, Eadon MT, El-Achkar TM, Gaut JP, Hacohen N, He Y, Hodgin JB, Jain S, Kellum JA, Kiryluk K, Knight R, Laszik ZG, Lienczewski C, Mariani LH, McClelland RL, Menez S, Moledina DG, Mooney SD, O'Toole JF, Palevsky PM, Parikh CR, Poggio ED, Rosas SE, Rosengart MR, Sarwal MM, Schaub JA, Sedor JR, Sharma K, Steck B, Toto RD, Troyanskaya OG, Tuttle KR, Vazquez MA, Waikar SS, Williams K, Wilson FP, Zhang K, Iyengar R, Kretzler M, Himmelfarb J. Rationale and design of the Kidney Precision Medicine Project. Kidney Int 2021; 99:498-510. [PMID: 33637194 PMCID: PMC8330551 DOI: 10.1016/j.kint.2020.08.039] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [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: 06/22/2020] [Revised: 08/08/2020] [Accepted: 08/14/2020] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease (CKD) and acute kidney injury (AKI) are common, heterogeneous, and morbid diseases. Mechanistic characterization of CKD and AKI in patients may facilitate a precision-medicine approach to prevention, diagnosis, and treatment. The Kidney Precision Medicine Project aims to ethically and safely obtain kidney biopsies from participants with CKD or AKI, create a reference kidney atlas, and characterize disease subgroups to stratify patients based on molecular features of disease, clinical characteristics, and associated outcomes. An additional aim is to identify critical cells, pathways, and targets for novel therapies and preventive strategies. This project is a multicenter prospective cohort study of adults with CKD or AKI who undergo a protocol kidney biopsy for research purposes. This investigation focuses on kidney diseases that are most prevalent and therefore substantially burden the public health, including CKD attributed to diabetes or hypertension and AKI attributed to ischemic and toxic injuries. Reference kidney tissues (for example, living-donor kidney biopsies) will also be evaluated. Traditional and digital pathology will be combined with transcriptomic, proteomic, and metabolomic analysis of the kidney tissue as well as deep clinical phenotyping for supervised and unsupervised subgroup analysis and systems biology analysis. Participants will be followed prospectively for 10 years to ascertain clinical outcomes. Cell types, locations, and functions will be characterized in health and disease in an open, searchable, online kidney tissue atlas. All data from the Kidney Precision Medicine Project will be made readily available for broad use by scientists, clinicians, and patients.
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Affiliation(s)
- Ian H de Boer
- Department of Medicine, University of Washington, Seattle, Washington, USA.
| | - Charles E Alpers
- Department of Pathology, University of Washington, Seattle, Washington, USA
| | - Evren U Azeloglu
- Department of Medicine, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Ulysses G J Balis
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Laura Barisoni
- Department of Pathology, Duke University, Durham, North Carolina, USA
| | - Kristina N Blank
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Andrew S Bomback
- Department of Medicine, Columbia University, New York, New York, USA
| | - Keith Brown
- Patient Representative, Kidney Precision Medicine Project Steering Committee Member
| | - Pierre C Dagher
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Ashveena L Dighe
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Michael T Eadon
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Tarek M El-Achkar
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Joseph P Gaut
- Department of Pathology, Washington University School of Medicine, St. Louis, St. Louis, Missouri, USA
| | - Nir Hacohen
- Broad Institute, Cambridge, Massachusetts, USA
| | - Yongqun He
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeffrey B Hodgin
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sanjay Jain
- Department of Medicine, Washington University School of Medicine, St. Louis, St. Louis, Missouri, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Krzysztof Kiryluk
- Department of Medicine, Columbia University, New York, New York, USA
| | - Richard Knight
- American Association of Kidney Patients, Kidney Precision Medicine Project Patient Partner
| | - Zoltan G Laszik
- Department of Pathology, University of California, San Francisco, San Francisco, California, USA
| | - Chrysta Lienczewski
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Laura H Mariani
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Robyn L McClelland
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Steven Menez
- Department of Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Dennis G Moledina
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sean D Mooney
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - John F O'Toole
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul M Palevsky
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Renal Section, Veterans Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Chirag R Parikh
- Department of Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Emilio D Poggio
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Matthew R Rosengart
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Minnie M Sarwal
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer A Schaub
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - John R Sedor
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kumar Sharma
- Department of Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - Becky Steck
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert D Toto
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Olga G Troyanskaya
- Department of Computer Science, Princeton University, Princeton, New Jersey, USA
| | - Katherine R Tuttle
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Miguel A Vazquez
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Sushrut S Waikar
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts, USA
| | - Kayleen Williams
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Francis Perry Wilson
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kun Zhang
- Institute for Genomic Sciences, University of California, San Diego, California, USA
| | - Ravi Iyengar
- Mount Sinai Institute for Systems Biomedicine, Mount Sinai, New York, New York, USA
| | - Matthias Kretzler
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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7
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García S, Mercado-Sánchez I, Bahena L, Alcaraz Y, García-Revilla MA, Robles J, Santos-Martínez N, Ordaz-Rosado D, García-Becerra R, Vazquez MA. Design of Fluorescent Coumarin-Hydroxamic Acid Derivatives as Inhibitors of HDACs: Synthesis, Anti-Proliferative Evaluation and Docking Studies. Molecules 2020; 25:molecules25215134. [PMID: 33158250 PMCID: PMC7662212 DOI: 10.3390/molecules25215134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 10/20/2020] [Accepted: 10/28/2020] [Indexed: 01/02/2023] Open
Abstract
Coumarin-hydroxamic acid derivatives 7a-k were herein designed with a dual purpose: as antiproliferative agents and fluorescent probes. The compounds were synthesized in moderate yields (30-87%) through a simple methodology, biological evaluation was carried out on prostate (PC3) and breast cancer (BT-474 and MDA-MB-231) cell lines to determine the effects on cell proliferation and gene expression. For compounds 7c, 7e, 7f, 7i and 7j the inhibition of cancer cell proliferation was similar to that found with the reference compound at a comparable concentration (10 μM), in addition, their molecular docking studies performed on histone deacetylases 1, 6 and 8 showed strong binding to the respective active sites. In most cases, antiproliferative activity was accompanied by greater levels of cyclin-dependent kinase inhibitor p21, downregulation of the p53 tumor suppressor gene, and regulation of cyclin D1 gene expression. We conclude that compounds 7c, 7e, 7f, 7i and 7j may be considered as potential anticancer agents, considering their antiproliferative properties, their effect on the regulation of the genes, as well as their capacity to dock to the active sites. The fluorescent properties of compound 7j and 7k suggest that they can provide further insight into the mechanism of action.
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Affiliation(s)
- Santiago García
- Departamento de Química, Universidad de Guanajuato, Guanajuato, Gto. 36050, Mexico; (S.G.); (I.M.-S.); (L.B.); (M.A.G.-R.)
| | - Itzel Mercado-Sánchez
- Departamento de Química, Universidad de Guanajuato, Guanajuato, Gto. 36050, Mexico; (S.G.); (I.M.-S.); (L.B.); (M.A.G.-R.)
| | - Luis Bahena
- Departamento de Química, Universidad de Guanajuato, Guanajuato, Gto. 36050, Mexico; (S.G.); (I.M.-S.); (L.B.); (M.A.G.-R.)
| | - Yolanda Alcaraz
- Departamento de Farmacia, Universidad de Guanajuato, Guanajuato, Gto. 36050, Mexico; (Y.A.); (J.R.)
| | - Marco A. García-Revilla
- Departamento de Química, Universidad de Guanajuato, Guanajuato, Gto. 36050, Mexico; (S.G.); (I.M.-S.); (L.B.); (M.A.G.-R.)
| | - Juvencio Robles
- Departamento de Farmacia, Universidad de Guanajuato, Guanajuato, Gto. 36050, Mexico; (Y.A.); (J.R.)
| | - Nancy Santos-Martínez
- Departamento de Biología de la Reproducción Dr. Carlos Gual Castro, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México 14080, Mexico; (N.S.-M.); (D.O.-R.)
| | - David Ordaz-Rosado
- Departamento de Biología de la Reproducción Dr. Carlos Gual Castro, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México 14080, Mexico; (N.S.-M.); (D.O.-R.)
| | - Rocío García-Becerra
- Departamento de Biología Molecular y Biotecnología, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Ciudad de México 04510, Mexico;
| | - Miguel A. Vazquez
- Departamento de Química, Universidad de Guanajuato, Guanajuato, Gto. 36050, Mexico; (S.G.); (I.M.-S.); (L.B.); (M.A.G.-R.)
- Correspondence: ; Tel.: +52-473-732-0006 (ext. 1419)
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8
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Poggio ED, McClelland RL, Blank KN, Hansen S, Bansal S, Bomback AS, Canetta PA, Khairallah P, Kiryluk K, Lecker SH, McMahon GM, Palevsky PM, Parikh S, Rosas SE, Tuttle K, Vazquez MA, Vijayan A, Rovin BH. Systematic Review and Meta-Analysis of Native Kidney Biopsy Complications. Clin J Am Soc Nephrol 2020; 15:1595-1602. [PMID: 33060160 PMCID: PMC7646247 DOI: 10.2215/cjn.04710420] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [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: 04/09/2020] [Accepted: 07/21/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Native kidney biopsies are commonly performed in the diagnosis of acute kidney diseases and CKD. Because of the invasive nature of the procedure, bleeding-related complications are not uncommon. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases-sponsored Kidney Precision Medicine Project requires that all participants undergo a kidney biopsy; therefore, the objective of this analysis was to study complication rates of native kidney biopsies performed using automated devices under kidney imaging. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This is a systematic review and meta-analysis of the literature published from January 1983 to March 2018. The initial PubMed search yielded 1139 manuscripts. Using predetermined selection criteria, 87 manuscripts were included in the final analysis. A random effects meta-analysis for proportions was used to obtain combined estimates of complication rates. Freeman-Tukey double-arcsine transformations were used to stabilize variance as complications were rare. RESULTS A total of 118,064 biopsies were included in this study. Patient age ranged from 30 to 79 years, and 45% of patients were women. On the basis of our meta-analysis, pain at the site of biopsy is estimated to occur in 4.3% of biopsied patients, hematomas are estimated to occur in 11%, macroscopic hematuria is estimated to occur in 3.5%, bleeding requiring blood transfusions is estimated to occur in 1.6%, and interventions to stop bleeding are estimated to occur in only 0.3%. Death attributed to native kidney biopsy was a rare event, occurring only in an estimated 0.06% of all biopsies but only 0.03% of outpatient biopsies. Complication rates were higher in hospitalized patients and in those with acute kidney disease. The reported complications varied on the basis of study type and geographic location. CONCLUSIONS Although the native kidney biopsy is an invasive diagnostic procedure, the rates of bleeding complications are low. Albeit rare, death can occur postbiopsy. Complications are more frequently seen after kidney biopsies of hospitalized patients with AKI.
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Affiliation(s)
- Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robyn L McClelland
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Kristina N Blank
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Spencer Hansen
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Shweta Bansal
- Division of Nephrology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York
| | - Pietro A Canetta
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York
| | - Pascale Khairallah
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York
| | - Krzysztof Kiryluk
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York
| | - Stewart H Lecker
- Division of Nephrology and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Gearoid M McMahon
- Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul M Palevsky
- Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Samir Parikh
- Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sylvia E Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Boston, Massachusetts.,Nephrology Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Katherine Tuttle
- Division of Nephrology, Providence Medical Research Center, Sacred Heart Medical Center, Spokane, Washington
| | - Miguel A Vazquez
- Division of Nephrology, UT Southwestern Medical Center, Dallas, Texas
| | - Anitha Vijayan
- Division of Nephrology, Washington University in St. Louis, St. Louis, Missouri
| | - Brad H Rovin
- Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, Ohio
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9
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Affiliation(s)
- Joseph R Berger
- Medicine-Nephrology Division, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Henry Quinones
- Medicine-Nephrology Division, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Miguel A Vazquez
- Medicine-Nephrology Division, University of Texas Southwestern Medical Center, Dallas, Texas
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10
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Curtis LH, Dember LM, Vazquez MA, Murray D, DeBar L, Staman KL, Septimus E, Mor V, Volandes A, Wells BL, Huang SS, Green BB, Coronado G, Meyers CM, Tuzzio L, Hernandez AF, Sugarman J. Addressing guideline and policy changes during pragmatic clinical trials. Clin Trials 2019; 16:431-437. [PMID: 31084378 DOI: 10.1177/1740774519845682] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
While conducting a set of large-scale multi-site pragmatic clinical trials involving high-impact public health issues such as end-stage renal disease, opioid use, and colorectal cancer, there were substantial changes to both policies and guidelines relevant to the trials. These external changes gave rise to unexpected challenges for the trials, including decisions regarding how to respond to new clinical practice guidelines, increased difficulty in implementing trial interventions, achieving separation between treatment groups, and differential responses across sites. In this article, we describe these challenges and the approaches used to address them. When deliberating appropriate action in the face of external changes during a pragmatic clinical trial, we recommend considering the well-being of the participants, clinical equipoise, and the strength and quality of the evidence associated with the change; involving those charged with data and safety monitoring; and where possible, planning for potential external changes as the trial is being designed. Any solution must balance the primary obligation to protect the well-being of participants with the secondary obligation to protect the integrity of the trial in order to gain meaningful answers to important public health questions.
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Affiliation(s)
| | - Laura M Dember
- 2 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Miguel A Vazquez
- 3 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Murray
- 4 National Institutes of Health, Bethesda, MD, USA
| | - Lynn DeBar
- 5 Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Edward Septimus
- 7 Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Vincent Mor
- 8 Department of Health Services, Policy, and Practice, School of Public Health, Brown University and Providence Veterans Administration Medical Center, Providence, RI, USA
| | | | - Barbara L Wells
- 10 Division of Cardiovascular Sciences, NHLBI, National Institutes of Health, Bethesda, MD, USA
| | - Susan S Huang
- 11 Irvine School of Medicine, University of California, Irvine, CA, USA
| | - Beverly B Green
- 5 Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Gloria Coronado
- 12 Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Catherine M Meyers
- 13 Office of Clinical and Regulatory Affairs, National Center for Complementary and Integrative Health (NCCIH), Bethesda, MD, USA
| | - Leah Tuzzio
- 5 Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Jeremy Sugarman
- 14 Johns Hopkins Berman Institute of Bioethics and Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
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11
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Kubiak RW, Zelnick LR, Hoofnagle AN, Alpers CE, Terry CM, Shiu YT, Cheung AK, de Boer IH, Robinson-Cohen C, Allon M, Dember LM, Feldman HI, Himmelfarb J, Huber TS, Roy-Chaudhury P, Vazquez MA, Kusek JW, Beck GJ, Imrey PB, Kestenbaum B. Mineral Metabolism Disturbances and Arteriovenous Fistula Maturation. Eur J Vasc Endovasc Surg 2019; 57:719-728. [PMID: 31000459 PMCID: PMC7259372 DOI: 10.1016/j.ejvs.2019.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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] [Received: 12/20/2017] [Accepted: 01/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The arteriovenous fistula (AVF) is central to haemodialysis treatment, but up to half of surgically created AVF fail to mature. Chronic kidney disease often leads to mineral metabolism disturbances that may interfere with AVF maturation through adverse vascular effects. This study tested associations between mineral metabolism markers and vein histology at AVF creation and unassisted and overall clinical AVF maturation. METHODS Concentrations of fibroblast growth factor 23, parathyroid hormone, calcium, phosphate, and vitamin D metabolites: 1,25(OH)2D, 24,25(OH)2D, 25(OH)D, and bioavailable 25(OH)D were measured in pre-operative serum samples from 562 of 602 participants in the Haemodialysis Fistula Maturation Study, a multicentre, prospective cohort study of patients undergoing surgical creation of an autologous upper extremity AVF. Unassisted and overall AVF maturation were ascertained for 540 and 527 participants, respectively, within nine months of surgery or four weeks of dialysis initiation. Study personnel obtained vein segments adjacent to the portion of the vein used for anastomosis, which were processed, embedded, and stained for measurement of neointimal hyperplasia, calcification, and collagen deposition in the medial wall. RESULTS Participants in this substudy were 71% male, 43% black, and had a mean age of 55 years. Failure to achieve AVF maturation without assistance occurred in 288 (53%) participants for whom this outcome was determined. In demographic and further adjusted models, mineral metabolism markers were not significantly associated with vein histology characteristics, unassisted AVF maturation failure, or overall maturation failure, other than a biologically unexplained association of higher 24,25(OH)2D with overall failure. This exception aside, associations were non-significant for continuous and categorical analyses and relevant subgroups. CONCLUSIONS Serum concentrations of measured mineral metabolites were not substantially associated with major histological characteristics of veins in patients undergoing AVF creation surgery, or with AVF maturation failure, suggesting that efforts to improve AVF maturation rates should increase attention to other processes such as vein mechanics, anatomy, and cellular metabolism among end stage renal disease patients.
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Affiliation(s)
- Rachel W Kubiak
- Kidney Research Institute, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Leila R Zelnick
- Kidney Research Institute, University of Washington, Seattle, WA, USA
| | - Andy N Hoofnagle
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Charles E Alpers
- Department of Pathology, University of Washington, Seattle, WA, USA
| | - Christi M Terry
- Division of Nephrology & Hypertension, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Yan-Ting Shiu
- Division of Nephrology & Hypertension, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Ian H de Boer
- Kidney Research Institute, University of Washington, Seattle, WA, USA
| | | | - Michael Allon
- Department of Vascular Surgery, University of Alabama, Birmingham, AL, USA
| | - Laura M Dember
- Renal, Electrolyte & Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Harold I Feldman
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Prabir Roy-Chaudhury
- Division of Nephrology and the University of Arizona Kidney Disease Program, University of Arizona, Tucson, AZ, USA
| | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern, Dallas, TX, USA
| | - John W Kusek
- National Institutes of Diabetes and Digestive and Kidney Diseases, Division of Kidney, Urologic & Hematologic Diseases, Bethesda, MD, USA
| | - Gerald J Beck
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Peter B Imrey
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Bryan Kestenbaum
- Kidney Research Institute, University of Washington, Seattle, WA, USA
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12
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Vazquez MA, GARCIA SANTIAGO, ARMENDARIZ KARLA, VILLASEÑOR-GRANADOS TAYDE, PONCE-NOYOLA PATRICIA, FLORES ALBERTO, MARTINEZ-ALVAREZ JOSEASCENCION, GARCIA-REVILLA MARCOA, ROBLES JUVENCIO, ALCARAZ YOLANDA. Synthesis, biological evaluation and docking study of possible antifungal compounds with a coumarin-containing triazole side chain. J MEX CHEM SOC 2019. [DOI: 10.29356/jmcs.v63i2.751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract. Due to increasing drug resistance by Candida species, especially in hospitals, the search for new antifungal agents has intensified. The incorporation of the coumarin scaffold into several nitrogen-containing heterocyclic moieties reportedly increases antimicrobial efficiency. The aim of this study was to design and synthesize a series of simple coumarin-linked triazole derivatives and test their possible antifungal activity against four Candida species. Docking simulations were conducted to explore the binding properties of the test compounds and compare them to reported data on fluconazole, the reference drug. Starting from 3-acetylcoumarins, coumarins 2a-d, 3a-c and 4a-d were obtained in high yields. The concentration of each compound needed to inhibit the Candida species was determined by serial dilution. An inhibition of 62% of C. albicans was produced by 2b (300 µg/ml), 87% of C. tropicalis by 3a (100 µg/ml), 89% of C. parapsilosis by 3a (500 µg/ml), and 87% of C. glabrata by 4a (300 µg/ml). The values of antifungal activity were similar for the coumarin derivatives and fluconazole, the latter of which induced 90% inhibition of the four yeasts at 500 µg/ml. According to the docking simulations, the interactions at the active site of the lanosterol 1,4-demethylase enzyme (CYP51) are similar for the test compounds and fluconazole. The subcellular location of the derivatives was identified as the mitochondrion. These coumarins are characterized by structural simplicity, with the simplest structures showing better antifungal activity than fluconazole. Further research is needed to isolate CYP51 and directly test its inhibition by coumarin derivatives.
Resumen. Una serie de moléculas de cumarina-triazol se sintetizaron y evaluaron contra diferentes especies de Candida. Las cumarinas 2a-d, 3a-c y 4a-d se obtuvieron utilizando como material de partida las 3-acetilcumarinas en altos rendimientos. La concentración necesaria de las moléculas para mostrar actividad antifúngica contra las cuatro especies de Candida se determinó mediante un método de diluciones seriadas. Se reporta un 62% de inhibición de C. albicans usando 2b (300 µg/ml), 87% de inhibición contra C. parapsilosis por 3a (500 µg/ml), y un 87% de inhibición a C. glabrata por 4a (300 µg/ml). El efecto de las cumarinas es comparado con el fármaco de referencia fluconazol, que induce un 90% de inhibición en todas las cepas usando 500 µg/ml. Los resultados del estudio Docking muestran que las interacciones de todas las moléculas en el sitio activo de la enzima CYP51 son similares a las interacciones presentadas por el fluconazol. Finalmente, tomando ventaja de las propiedades fluorescentes de las cumarinas, la localización subcelular y penetración de los compuestos, fue localizada en las mitocondrias. Las cumarinas reportadas, además de presentar sencillez estructural, también presentan valores de inhibición de las cepas comparables, y en los casos mencionados, mejores que el fármaco de referencia.
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13
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Nguyen OK, Vazquez MA, Charles L, Berger JR, Quiñones H, Fuquay R, Sanders JM, Kapinos KA, Halm EA, Makam AN. Association of Scheduled vs Emergency-Only Dialysis With Health Outcomes and Costs in Undocumented Immigrants With End-stage Renal Disease. JAMA Intern Med 2019; 179:175-183. [PMID: 30575859 PMCID: PMC6439652 DOI: 10.1001/jamainternmed.2018.5866] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In 40 of 50 US states, scheduled dialysis is withheld from undocumented immigrants with end-stage renal disease (ESRD); instead, they receive intermittent emergency-only dialysis to treat life-threatening manifestations of ESRD. However, the comparative effectiveness of scheduled dialysis vs emergency-only dialysis and the influence of treatment on health outcomes, utilization, and costs is uncertain. OBJECTIVE To compare the effectiveness of scheduled vs emergency-only dialysis with regard to health outcomes, utilization, and costs in undocumented immigrants with ESRD. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of 181 eligible adults with ESRD receiving emergency-only dialysis in Dallas, Texas, who became newly eligible and applied for private commercial health insurance in February 2015; 105 received coverage and were enrolled in scheduled dialysis; 76 were not enrolled in insurance for nonclinical reasons (eg, lack of capacity at a participating outpatient dialysis center) and remained uninsured, receiving emergency-only dialysis. We examined data on eligible persons during a 6-month period prior to enrollment (baseline period, August 1, 2014-January 31, 2015) until 12 months after enrollment (follow-up period, March 1, 2015-February 29, 2016), with an intervening 1-month washout period (February 2015). All participants were undocumented immigrants; self-reported data on immigration status was collected from Parkland Hospital electronic health records. EXPOSURES Enrollment in private health insurance coverage and scheduled dialysis. MAIN OUTCOMES AND MEASURES We used enrollment in health insurance and scheduled dialysis to estimate the influence of scheduled dialysis on 1-year mortality, utilization, and health care costs, using a propensity score-adjusted, intention-to-treat approach, including time-to-event analyses for mortality, difference-in-differences (DiD) negative binomial regression analyses for utilization, and DiD gamma generalized linear regression for health care costs. RESULTS Of 181 eligible adults with ESRD, 105 (65 men, 40 women; mean age, 45 years) received scheduled dialysis and 76 (38 men, 38 women; mean age, 52 years) received emergency-only dialysis. Compared with emergency-only dialysis, scheduled dialysis was significantly associated with reduced mortality (3% vs 17%, P = .001; absolute risk reduction, 14%; number needed to treat, 7; adjusted hazard ratio, 4.6; 95% CI, 1.2-18.2; P = .03), adjusted emergency department visits (-5.2 vs +1.1 visits/mo; DiD, -6.2; P < .001), adjusted hospitalizations (-2.1 vs -0.5 hospitalizations/6 months; DiD, -1.6; P < .001), adjusted hospital days (-9.2 vs +0.8 days/6 months; DiD, -9.9; P = .007), and adjusted costs (-$4316 vs +$1452 per person per month; DiD, -$5768; P < .001). CONCLUSIONS AND RELEVANCE In this study, scheduled dialysis was significantly associated with reduced 1-year mortality, health care utilization, and costs compared with emergency-only dialysis. Scheduled dialysis should be the universal standard of care for all individuals with ESRD in the United States.
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Miguel A Vazquez
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | | | - Joseph R Berger
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Henry Quiñones
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | | | - Joanne M Sanders
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | | | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Anil N Makam
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
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14
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Robbin ML, Greene T, Allon M, Dember LM, Imrey PB, Cheung AK, Himmelfarb J, Huber TS, Kaufman JS, Radeva MK, Roy-Chaudhury P, Shiu YT, Vazquez MA, Umphrey HR, Alexander L, Abts C, Beck GJ, Kusek JW, Feldman HI. Prediction of Arteriovenous Fistula Clinical Maturation from Postoperative Ultrasound Measurements: Findings from the Hemodialysis Fistula Maturation Study. J Am Soc Nephrol 2018; 29:2735-2744. [PMID: 30309898 DOI: 10.1681/asn.2017111225] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [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: 11/25/2017] [Accepted: 09/06/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The utility of early postoperative ultrasound measurements in predicting arteriovenous fistula (AVF) clinical maturation is uncertain. METHODS We investigated the relationships of ultrasound parameters with AVF clinical maturation in newly created AVF, measured at 1 day and 2 and 6 weeks, in 602 participants of a multicenter, observational cohort study. A backward elimination algorithm identified ultrasound measurements that independently predicted unassisted and overall AVF maturation. Candidate variables included AVF blood flow, diameter, and depth, upper arm arterial diameter, presence of stenosis, presence of accessory veins, seven case-mix factors (age, sex, black race, AVF location, diabetes, dialysis status, and body mass index), and clinical center. We evaluated the accuracy of the resulting models for clinical prediction. RESULTS At each ultrasound measurement time, AVF blood flow, diameter, and depth each predicted in a statistically significant manner both unassisted and overall clinical maturation. Moreover, neither the remaining ultrasound parameters nor case-mix factors were associated with clinical AVF maturation after accounting for blood flow, diameter, and depth, although maturation probabilities differed among clinical centers before and after accounting for these parameters. The crossvalidated area under the receiver operating characteristic curve for models constructed using these three ultrasound parameters was 0.69, 0.74, and 0.79 at 1 day and 2 and 6 weeks, respectively, for unassisted AVF clinical maturation and 0.69, 0.71, and 0.76, respectively, for overall AVF maturation. CONCLUSIONS AVF blood flow, diameter, and depth moderately predicted unassisted and overall AVF clinical maturation. The other factors considered did not further improve AVF maturation prediction.
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Affiliation(s)
| | - Tom Greene
- Departments of Population Health Sciences and.,Internal Medicine and
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Laura M Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, and Center for Clinical Epidemiology and Biostatistics, and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter B Imrey
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Alfred K Cheung
- Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah.,Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah.,Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Jonathan Himmelfarb
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, Washington
| | - Thomas S Huber
- Division of Vascular Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - James S Kaufman
- Renal Section, Veterans Affairs New York Harbor Healthcare System, New York, New York.,Division of Nephrology, New York University School and Medicine, New York, New York
| | - Milena K Radeva
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Prabir Roy-Chaudhury
- Division of Nephrology, University of Arizona College of Medicine, Tucson, Arizona
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | - Miguel A Vazquez
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | - Gerald J Beck
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - John W Kusek
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Harold I Feldman
- Department of Biostatistics and Epidemiology, Department of Medicine, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Wang K, Zelnick LR, Imrey PB, deBoer IH, Himmelfarb J, Allon MD, Cheung AK, Dember LM, Roy-Chaudhury P, Vazquez MA, Kusek JW, Feldman HI, Beck GJ, Kestenbaum B. Effect of Anti-Hypertensive Medication History on Arteriovenous Fistula Maturation Outcomes. Am J Nephrol 2018; 48:56-64. [PMID: 30071516 DOI: 10.1159/000491828] [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: 04/30/2018] [Accepted: 06/29/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND The arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis. However, approximately half of AVFs fail to mature. The use of angiotensin converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) exerts favorable endothelial effects and may promote AVF maturation. We tested associations of ACE-I and ARBs, CCBs, beta-blockers, and diuretics with the maturation of newly created AVFs. METHODS We evaluated 602 participants from the Hemodialysis Fistula Maturation Study, a multi-center, prospective cohort study of AVF maturation. We ascertained the use of each medication class within 45 days of AVF creation surgery. We defined maturation outcomes by clinical use within 9 months of surgery or 4 weeks of initiating hemodialysis. RESULTS Unassisted AVF maturation failure without intervention occurred in 54.0% of participants, and overall AVF maturation failure (with or without intervention) occurred in 30.1%. After covariate adjustment, CCB use was associated with a 25% lower risk of overall AVF maturation failure (95% CI 3%-41% lower) but a non-significant 10% lower risk of unassisted maturation failure (95% CI 23% lower to 5% higher). ACE-I/ARB, beta-blocker, and diuretic use was not significantly associated with AVF maturation outcomes. None of the antihypertensive medication classes were associated with changes in AVF diameter or blood flow over 6 weeks following surgery. CONCLUSIONS CCB use may be associated with a lower risk of overall AVF maturation failure. Further studies are needed to determine whether CCBs might play a causal role in improving AVF maturation outcomes.
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Affiliation(s)
- Ke Wang
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Leila R Zelnick
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Peter B Imrey
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Ian H deBoer
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Jonathan Himmelfarb
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Michael D Allon
- Division of Nephrology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, Salt Lake City, Utah, USA
- Department of Bioengineering, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Renal Section, Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Laura M Dember
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Prabir Roy-Chaudhury
- Division of Nephrology, University of Arizona Health Sciences and Banner University Medical Center, Tucson, Arizona, USA
- Medical Service, Southern Arizona Veterans Affairs Healthcare System, Tucson, Arizona, USA
| | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - John W Kusek
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Harold I Feldman
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Bryan Kestenbaum
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington, USA
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16
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Allon M, Imrey PB, Cheung AK, Radeva M, Alpers CE, Beck GJ, Dember LM, Farber A, Greene T, Himmelfarb J, Huber TS, Kaufman JS, Kusek JW, Roy-Chaudhury P, Robbin ML, Vazquez MA, Feldman HI. Relationships Between Clinical Processes and Arteriovenous Fistula Cannulation and Maturation: A Multicenter Prospective Cohort Study. Am J Kidney Dis 2018; 71:677-689. [PMID: 29398178 PMCID: PMC5916528 DOI: 10.1053/j.ajkd.2017.10.027] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [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: 06/02/2017] [Accepted: 10/31/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Half of surgically created arteriovenous fistulas (AVFs) require additional intervention to effectively support hemodialysis. Postoperative care and complications may affect clinical maturation. STUDY DESIGN Hemodialysis Fistula Maturation (HFM) Study, a 7-center prospective cohort study. SETTING & PARTICIPANTS 491 patients with single-stage AVFs who had neither thrombosis nor AVF intervention before a 6-week postoperative ultrasonographic examination and who required maintenance hemodialysis. PREDICTORS Postoperative care processes and complications. OUTCOMES Attempted cannulation, successful cannulation, and unassisted and overall clinical maturation as defined by the HFM Study criteria. RESULTS AVF cannulation was attempted in 443 of 491 (90.2%) participants and was eventually successful in 430 of these 443 (97.1%) participants. 263 of these 430 (61.2%) reached unassisted and 118 (27.4%) reached assisted AVF maturation (overall maturation, 381/430 [88.6%]). Attempted cannulation was less likely in patients of surgeons with policies for routine 2-week versus later-than-2-week first postoperative visits (OR, 0.21; 95% CI, 0.06-0.70), routine second postoperative follow-up visits (OR, 0.39; 95% CI, 0.15-0.97), and a routine clinical postoperative ultrasound (OR, 0.28; 95% CI, 0.14-0.55). Attempted cannulation was also less likely among patients undergoing procedures to assist maturation (OR, 0.51; 95% CI, 0.27-0.98). Unassisted maturation was more likely for patients treated in facilities with access coordinators (OR, 1.91; 95% CI, 1.17-3.12), but less likely after precannulation nonstudy ultrasounds (OR per ultrasound, 0.42 [95% CI, 0.26-0.68]) and initial unsuccessful cannulation attempts (OR per each additional attempt, 0.90 [95% CI, 0.83-0.98]). Overall maturation was less likely with infiltration before successful cannulation (OR, 0.44; 95% CI, 0.22-0.89). Among participants receiving maintenance hemodialysis before AVF surgery, unassisted and overall maturation were less likely with longer intervals from surgery to initial cannulation (ORs for each additional month of 0.81 [95% CI, 0.76-0.88] and 0.93 [95% CI, 0.89-0.98], respectively) and from initial to successful cannulation (ORs for each additional week of 0.87 [95% CI, 0.81-0.94] and 0.88 [95% CI, 0.83-0.94], respectively). LIMITATIONS Surgeons' management policies were assessed only by questionnaire at study onset. Most participants received upper-arm AVFs, planned 2-stage AVFs were excluded, and maturation time windows were imposed. Some care processes may have been missed and the observational design limits causal attribution. CONCLUSIONS Multiple processes of care and complications are associated with AVF maturation outcomes.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL.
| | - Peter B Imrey
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT; Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Milena Radeva
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Charles E Alpers
- Department of Pathology, University of Washington Medical Center, Seattle, WA
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Laura M Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA
| | - Tom Greene
- Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Jonathan Himmelfarb
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA
| | - Thomas S Huber
- Division of Vascular Surgery, University of Florida College of Medicine, Gainesville, FL
| | - James S Kaufman
- VA New York Harbor Healthcare System and New York University School of Medicine, New York, NY
| | - John W Kusek
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Michelle L Robbin
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern, Dallas, TX
| | - Harold I Feldman
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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17
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Simon GE, Coronado G, DeBar LL, Dember LM, Green BB, Huang SS, Jarvik JG, Mor V, Ramsberg J, Septimus EJ, Staman KL, Vazquez MA, Vollmer WM, Zatzick D, Hernandez AF, Platt R. Data Sharing and Embedded Research. Ann Intern Med 2017; 167:668-670. [PMID: 28973353 PMCID: PMC5811187 DOI: 10.7326/m17-0863] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Gregory E Simon
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Gloria Coronado
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Lynn L DeBar
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Laura M Dember
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Beverly B Green
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Susan S Huang
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Jeffrey G Jarvik
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Vincent Mor
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Joakim Ramsberg
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Edward J Septimus
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Karen L Staman
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Miguel A Vazquez
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - William M Vollmer
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Douglas Zatzick
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Adrian F Hernandez
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Richard Platt
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
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18
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Cheung AK, Imrey PB, Alpers CE, Robbin ML, Radeva M, Larive B, Shiu YT, Allon M, Dember LM, Greene T, Himmelfarb J, Roy-Chaudhury P, Terry CM, Vazquez MA, Kusek JW, Feldman HI. Intimal Hyperplasia, Stenosis, and Arteriovenous Fistula Maturation Failure in the Hemodialysis Fistula Maturation Study. J Am Soc Nephrol 2017; 28:3005-3013. [PMID: 28710091 PMCID: PMC5619966 DOI: 10.1681/asn.2016121355] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/13/2017] [Indexed: 12/30/2022] Open
Abstract
Intimal hyperplasia and stenosis are often cited as causes of arteriovenous fistula maturation failure, but definitive evidence is lacking. We examined the associations among preexisting venous intimal hyperplasia, fistula venous stenosis after creation, and clinical maturation failure. The Hemodialysis Fistula Maturation Study prospectively observed 602 men and women through arteriovenous fistula creation surgery and their postoperative course. A segment of the vein used to create the fistula was collected intraoperatively for histomorphometric examination. On ultrasounds performed 1 day and 2 and 6 weeks after fistula creation, we assessed fistula venous stenosis using pre-specified criteria on the basis of ratios of luminal diameters and peak blood flow velocities at certain locations along the vessel. We determined fistula clinical maturation using criteria for usability during dialysis. Preexisting venous intimal hyperplasia, expressed per 10% increase in a hyperplasia index (range of 0%-100%), modestly associated with lower fistula blood flow rate (relative change, -2.5%; 95% confidence interval [95% CI], -4.6% to -0.4%; P=0.02) at 6 weeks but did not significantly associate with stenosis (odds ratio [OR], 1.07; 95% CI, 1.00 to 1.16; P=0.07) at 6 weeks or failure to mature clinically without procedural assistance (OR, 1.07; 95% CI, 0.99 to 1.15; P=0.07). Fistula venous stenosis at 6 weeks associated with maturation failure (OR, 1.98; 95% CI, 1.25 to 3.12; P=0.004) after controlling for case mix factors, dialysis status, and fistula location. These findings suggest that postoperative fistula venous stenosis associates with fistula maturation failure. Preoperative venous hyperplasia may associate with maturation failure but if so, only modestly.
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Affiliation(s)
- Alfred K Cheung
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah;
- Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Peter B Imrey
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Charles E Alpers
- Department of Pathology, University of Washington Medical Center, Seattle, Washington
| | | | - Milena Radeva
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Brett Larive
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Laura M Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine
- Center for Clinical Epidemiology and Biostatistics, and
- Departments of Biostatistics and Epidemiology and
| | - Tom Greene
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jonathan Himmelfarb
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington
| | - Prabir Roy-Chaudhury
- Division of Nephrology, University of Arizona Health Sciences and Banner University Medical Center, Tucson, Arizona
- Medical Service, Southern Arizona Veterans Affairs Healthcare System, Tucson, Arizona
| | - Christi M Terry
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - John W Kusek
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Harold I Feldman
- Renal-Electrolyte and Hypertension Division, Department of Medicine
- Center for Clinical Epidemiology and Biostatistics, and
- Departments of Biostatistics and Epidemiology and
- Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Tanriover B, Jaikaransingh V, MacConmara MP, Parekh JR, Levea SL, Ariyamuthu VK, Zhang S, Gao A, Ayvaci MU, Sandikci B, Rajora N, Ahmed V, Lu CY, Mohan S, Vazquez MA. Acute Rejection Rates and Graft Outcomes According to Induction Regimen among Recipients of Kidneys from Deceased Donors Treated with Tacrolimus and Mycophenolate. Clin J Am Soc Nephrol 2016; 11:1650-1661. [PMID: 27364616 PMCID: PMC5012491 DOI: 10.2215/cjn.13171215] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [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: 12/12/2015] [Accepted: 05/30/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES IL-2 receptor antagonist (IL2-RA) is recommended as a first-line agent for induction therapy in renal transplantation. However, this remains controversial in deceased donor renal transplantation (DDRT) maintained on tacrolimus (TAC)/mycophenolic acid (MPA) with or without steroids. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied the United Network for Organ Sharing Registry for patients receiving DDRT from 2000 to 2012 maintained on TAC/MPA at transplantation hospital discharge (n=74,627) to compare outcomes of IL2-RA and other induction agents. We initially divided the cohort into two groups on the basis of steroid use at the time of discharge: steroid (n=59,010) versus no steroid (n=15,617). Each group was stratified into induction categories: IL2-RA, rabbit antithymocyte globulin (r-ATG), alemtuzumab, and no induction. The main outcomes were incidence of acute rejection within the first year and overall graft failure (defined as graft failure and/or death) post-transplantation. Propensity score (PS), specifically inverse probability of treatment weight, analysis was used to minimize selection bias caused by nonrandom assignment of induction therapies. RESULTS Median (25th, 75th percentiles) follow-up times were 3.9 (1.1, 5.9) and 3.2 (1.1, 4.9) years for steroid and no steroid groups, respectively. Acute rejection within the first year and overall graft failure within 5 years of transplantation were more common in the no induction category (13.3%; P<0.001 and 28%; P=0.01, respectively) in the steroid group and the IL2-RA category (11.1%; P=0.16 and 27.4%; P<0.001, respectively) in the no steroid group. Compared with IL2-RA, PS-weighted and covariate-adjusted multivariable logistic and Cox analyses showed that outcomes in the steroid group were similar among induction categories, except that acute rejection was significantly lower with r-ATG (odds ratio [OR], 0.68; 95% confidence interval [95% CI], 0.62 to 0.74). In the no steroid group, compared with IL2-RA, odds of acute rejection with r-ATG (OR, 0.80; 95% CI, 0.60 to 1.00) and alemtuzumab (OR, 0.68; 95% CI, 0.53 to 0.88) were lower, and r-ATG was associated with better graft survival (hazard ratio, 0.86; 95% CI, 0.75 to 0.99). CONCLUSIONS In DDRT, compared with IL2-RA induction, no induction was associated with similar outcomes when TAC/MPA/steroids were used. r-ATG seems to offer better graft survival over IL2-RA in steroid avoidance protocols.
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Affiliation(s)
| | | | | | | | | | | | - Song Zhang
- Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ang Gao
- Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mehmet U.S. Ayvaci
- Information Systems, Naveen Jindal School of Management, University of Texas at Dallas, Dallas, Texas
| | | | | | - Vaqar Ahmed
- Division of Nephrology, Texas Tech University Health Sciences Center, Lubbock, Texas; and
| | | | - Sumit Mohan
- Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York
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20
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Torlak F, Ayvaci MUS, Ahsen ME, Arce C, Vazquez MA, Tanriover B. Estimating Waiting Time for Deceased Donor Renal Transplantion in the Era of New Kidney Allocation System. Transplant Proc 2016; 48:1916-9. [PMID: 27569922 DOI: 10.1016/j.transproceed.2016.03.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/30/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND On December 4, 2014, a new deceased donor kidney allocation system (KAS) was implemented. The KAS was designed to improve organ equity and graft-recipient longevity matching. However, estimated wait-time to deceased donor transplantation is difficult to predict post-KAS. METHODS Using the Kidney-Pancreas Simulated Allocation Model software (KPSAM), a program that the Organ Procurement and Transplant Network uses to assess policy proposals, we compared the kidney allocations of both the new (post-KAS) and old policies (pre-KAS) (10 iterations for each group; total N = 204,148) and estimated wait-time based on blood type, duration of dialysis exposure, and calculated panel-reactive antibody (CPRA). RESULTS The simulations revealed that estimated median (25(th) and 75(th) percentile) waiting time in transplanted recipients decreased from 2.3 (1.2, 3.8) years in the old allocation to 1.8 (0.8, 3.4) years in the new allocation system. The rate of transplantations performed within the first year of wait-listing increased from 20.7% to 31.3%. The KPSAM resulted in more transplantations in recipients with more than 5 years of dialysis exposure (26.5% to 37.4%), longevity matching (12.2% to 17.5%), blood group B (12.6% to 17.2%), and high CPRA ≥98% (1.9% to 4.3%) in post-KAS compared with pre-KAS simulations. CONCLUSIONS Based on the KPSAM results, it was projected that post-KAS wait-time in transplanted recipients might decrease approximately 6 months (22%) across all CPRA categories. It might be related to the KAS awarding waiting time points for prelisting dialysis time and priority points awarded based on CPRA (bolus effect).
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Affiliation(s)
- F Torlak
- Neurobiology Department, University of Texas at Dallas, Dallas, Texas, USA
| | - M U S Ayvaci
- Information Systems and Operations Management, University of Texas at Dallas, Dallas, Texas, USA
| | - M E Ahsen
- IBM Research, Yorktown Heights, New York, USA
| | - C Arce
- Division of Nephrology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - M A Vazquez
- Division of Nephrology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - B Tanriover
- Division of Nephrology, UT Southwestern Medical Center, Dallas, Texas, USA.
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21
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Villaseñor-Granados T, García S, Vazquez MA, Robles J. Molecular docking-based screening of newly designed coumarin derivatives with potential antifungal activity against lanosterol 14 α-demethylase. Theor Chem Acc 2016. [DOI: 10.1007/s00214-016-1965-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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22
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Tanriover B, MacConmara MP, Parekh J, Arce C, Zhang S, Gao A, Mufti A, Levea SL, Sandikci B, Ayvaci MUS, Ariyamuthu VK, Hwang C, Mohan S, Mete M, Vazquez MA, Marrero JA. SIMULTANEOUS LIVER KIDNEY TRANSPLANTATION IN LIVER TRANSPLANT CANDIDATES WITH RENAL DYSFUNCTION: IMPORTANCE OF CREATININE LEVELS, DIALYSIS, AND ORGAN QUALITY IN SURVIVAL. Kidney Int Rep 2016; 1:221-229. [PMID: 27942610 PMCID: PMC5138564 DOI: 10.1016/j.ekir.2016.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction The survival benefit from simultaneous liver-kidney transplantation (SLK) over liver transplant alone (LTA) in recipients with moderate renal dysfunction is not well understood. Moreover, the impact of deceased donor organ quality in SLK survival has not been well described in the literature. Methods The Scientific Registry of Transplant Recipients was studied for adult recipients receiving LTA (N = 2700) or SLK (N = 1361) with moderate renal insufficiency between 2003 and 2013. The study cohort was stratified into 4 groups based on serum creatinine (<2 mg/dl versus ≥2 mg/dl) and dialysis status at listing and transplant. The patients with end-stage renal disease and requiring acute dialysis more than 3 months before transplantation were excluded. A propensity score matching was performed in each stratified group to factor out imbalances between the SLK and LTA regarding covariate distribution and to reduce measured confounding. Donor quality was assessed with liver donor risk index. The primary outcome of interest was posttransplant mortality. Results In multivariable propensity score-matched Cox proportional hazard models, SLK led to decrease in posttransplant mortality compared with LTA across all 4 groups, but only reached statistical significance (hazard ratio 0.77; 95% confidence interval, 0.62–0.96) in the recipients not exposed to dialysis and serum creatinine ≥ 2 mg/dl at transplant (mortality incidence rate per patient-year 5.7% in SLK vs. 7.6% in LTA, P = 0.005). The decrease in mortality was observed among SLK recipients with better quality donors (liver donor risk index < 1.5). Discussion Exposure to pretransplantation dialysis and donor quality affected overall survival among SLK recipients.
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Affiliation(s)
- Bekir Tanriover
- Division of Nephrology, UT Southwestern Medical Center, Dallas, TX
| | | | - Justin Parekh
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Cristina Arce
- Division of Nephrology, UT Southwestern Medical Center, Dallas, TX
| | - Song Zhang
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Ang Gao
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Arjmand Mufti
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Swee-Ling Levea
- Division of Nephrology, UT Southwestern Medical Center, Dallas, TX
| | | | | | | | - Christine Hwang
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Sumit Mohan
- Division of Nephrology, Columbia University, College of Physicians & Surgeons, New York, NY
| | - Mutlu Mete
- Department of Computer Science, Texas A&M, Commerce, TX
| | - Miguel A Vazquez
- Division of Nephrology, UT Southwestern Medical Center, Dallas, TX
| | - Jorge A Marrero
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
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23
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Dember LM, Imrey PB, Duess MA, Hamburg NM, Larive B, Radeva M, Himmelfarb J, Kraiss LW, Kusek JW, Roy-Chaudhury P, Terry CM, Vazquez MA, Vongpatanasin W, Beck GJ, Vita JA. Vascular Function at Baseline in the Hemodialysis Fistula Maturation Study. J Am Heart Assoc 2016; 5:JAHA.116.003227. [PMID: 27451463 PMCID: PMC5015367 DOI: 10.1161/jaha.116.003227] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background End‐stage renal disease is accompanied by functional and structural vascular abnormalities. The objective of this study was to characterize vascular function in a large cohort of patients with end‐stage renal disease, using noninvasive physiological measurements, and to correlate function with demographic and clinical factors. Methods and Results We analyzed cross‐sectional baseline data from the Hemodialysis Fistula Maturation Study, a multicenter prospective observational cohort study of 602 patients with end‐stage renal disease from 7 centers. Brachial artery flow‐ and nitroglycerin‐mediated dilation, carotid‐femoral and ‐radial pulse wave velocity, and venous occlusion plethysmography were performed prior to arteriovenous fistula creation. Relationships of these vascular function measures with demographic, clinical, and laboratory factors were evaluated using linear mixed‐effects models. Arterial function, as assessed by flow‐ and nitroglycerin‐mediated dilation and carotid‐femoral pulse wave velocity, worsened with increasing age and diabetes mellitus. Venous capacitance decreased with diabetes mellitus but not with age. Flow‐mediated dilation was higher among patients undergoing maintenance dialysis than for those at predialysis, and a U‐shaped relationship between serum phosphorus concentration and flow‐mediated dilation was evident. Partial correlations among different measures of vascular function, adjusting for demographic factors, diabetes mellitus, and clinical center, were modest or essentially nonexistent. Conclusions Multiple demographic and clinical factors were associated with the functions of vessels of different sizes and types in this large cohort of patients with end‐stage renal disease. Low correlations between the different measures, controlling for demographic factors, diabetes mellitus, and center, indicated that these different types of vascular function otherwise vary heterogeneously across patients.
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Affiliation(s)
- Laura M Dember
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Peter B Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | | | | | - Brett Larive
- Department of Quantitative Health Sciences, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Milena Radeva
- Department of Quantitative Health Sciences, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | | | | | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | | | | | | | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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24
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de Boer IH, Kovesdy CP, Navaneethan SD, Peralta CA, Tuot DS, Vazquez MA, Crews DC. Pragmatic Clinical Trials in CKD: Opportunities and Challenges. J Am Soc Nephrol 2016; 27:2948-2954. [PMID: 27283497 DOI: 10.1681/asn.2015111264] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Randomized controlled trials in CKD lag in number behind those of other chronic diseases, despite the high morbidity and mortality experienced by patients with kidney disease and the exorbitant costs of their health care. Observational studies of CKD frequently yield seemingly paradoxic associations of traditional risk factors with outcomes, making it difficult to extrapolate the results of trials conducted in people with normal kidney function to patients with CKD. However, many completed trials in CKD have been limited by intermediate outcomes of unclear clinical significance or narrow eligibility criteria that limit external validity, and implementation of proven therapies remains a challenge. It is therefore imperative that the nephrology community capitalize on recent interest in novel approaches to trial design, such as pragmatic clinical trials. These trials are meant to promote research within real world settings to yield clinically relevant results with greater applicability than those of traditional trials, while maintaining many advantages, such as controlling for potential sources of bias. We provide a description of pragmatic clinical trials and a discussion of advantages, disadvantages, and practical challenges inherent to this study design, in the context of specific scientific questions relevant to patients with CKD.
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Affiliation(s)
- Ian H de Boer
- Division of Nephrology and Department of Medicine, Kidney Research Institute, University of Washington, Seattle, WA;
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis VA Medical center, Memphis, TN
| | - Sankar D Navaneethan
- Section of Nephrology, Department of Medicine, Selzman Institute for Kidney Health, Baylor College of Medicine; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Carmen A Peralta
- Kidney Health Research Collaborative and Division of Nephrology, University of California San Francisco, San Francisco, CA
| | - Delphine S Tuot
- Division of Nephrology, University of California San Francisco, San Francisco, CA
| | - Miguel A Vazquez
- Division of Nephrology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine; and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
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25
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Affiliation(s)
- Seth Toomay
- Division of Interventional Radiology; Department of Radiology; University of Texas Southwestern Medical Center; Dallas Texas
| | - John Rectenwald
- Division of Vascular Surgery; Department of Surgery; University of Texas Southwestern Medical Center; Dallas Texas
| | - Miguel A. Vazquez
- Division of Nephrology; Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas Texas
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26
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Janis JE, MacKenzie KD, Wright SE, Pomahac B, Lu C, Susa J, Wada S, Vazquez MA, Chong T, Tullius SG. Management of steroid-resistant late acute cellular rejection following face transplantation: a case report. Transplant Proc 2015; 47:223-5. [PMID: 25645808 DOI: 10.1016/j.transproceed.2014.09.152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/23/2014] [Indexed: 11/27/2022]
Abstract
Face transplants have been clinically established, and early acute rejections have been reported. Late acute rejections have been less common. Immediate and accurate diagnosis along with successful treatment is critical to prevent graft damage. This case report describes the successful treatment of a severe, steroid-resistant rejection 2 years after a full face transplant.
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Affiliation(s)
- J E Janis
- Department of Plastic Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - K D MacKenzie
- Department of Transplant, University of Texas Southwestern Medical Center, Dallas, Texas
| | - S E Wright
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, Texas
| | - B Pomahac
- Department of Plastic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - C Lu
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - J Susa
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - S Wada
- Department of Infectious Disease, University of Texas Southwestern Medical Center, Dallas, Texas
| | - M A Vazquez
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - T Chong
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - S G Tullius
- Division of Transplant Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Finkelstein JA, Brickman AL, Capron A, Ford DE, Gombosev A, Greene SM, Iafrate RP, Kolaczkowski L, Pallin SC, Pletcher MJ, Staman KL, Vazquez MA, Sugarman J. Oversight on the borderline: Quality improvement and pragmatic research. Clin Trials 2015; 12:457-66. [PMID: 26374685 DOI: 10.1177/1740774515597682] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pragmatic research that compares interventions to improve the organization and delivery of health care may overlap, in both goals and methods, with quality improvement activities. When activities have attributes of both research and quality improvement, confusion often arises about what ethical oversight is, or should be, required. For routine quality improvement, in which the delivery of health care is modified in minor ways that create only minimal risks, oversight by local clinical or administrative leaders utilizing institutional policies may be sufficient. However, additional consideration should be given to activities that go beyond routine, local quality improvement to first determine whether such non-routine activities constitute research or quality improvement and, in either case, to ensure that independent oversight will occur. This should promote rigor, transparency, and protection of patients' and clinicians' rights, well-being, and privacy in all such activities. Specifically, we recommend that (1) health care organizations should have systematic policies and processes for designating activities as routine quality improvement, non-routine quality improvement, or quality improvement research and determining what oversight each will receive. (2) Health care organizations should have formal and explicit oversight processes for non-routine quality improvement activities that may include input from institutional quality improvement experts, health services researchers, administrators, clinicians, patient representatives, and those experienced in the ethics review of health care activities. (3) Quality improvement research requires review by an institutional review board; for such review to be effective, institutional review boards should develop particular expertise in assessing quality improvement research. (4) Stakeholders should be included in the review of non-routine quality improvement and quality improvement-related research proposals. Only by doing so will we optimally leverage both pragmatic research on health care delivery and local implementation through quality improvement as complementary activities for improving health.
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Affiliation(s)
- Jonathan A Finkelstein
- Division of General Pediatrics, Boston Children's Hospital, Departments of Pediatrics and Population Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Alexander Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Daniel E Ford
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Adrijana Gombosev
- School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Sarah M Greene
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
| | | | - Laura Kolaczkowski
- Multiple Sclerosis Patient-Powered Research Network, University of Dayton, Dayton, OH, USA
| | | | | | | | - Miguel A Vazquez
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeremy Sugarman
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
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Rodriguez Z, Leavitt KM, Martin J, Romaguera J, Negron I, Vazquez MA. The Prevalence of Sexually Transmitted Infections on Teen Pregnancies and Their Association With Adverse Pregnancy Outcomes [100]. Obstet Gynecol 2015. [DOI: 10.1097/01.aog.0000463072.36677.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tujios SR, Hynan LS, Vazquez MA, Larson AM, Seremba E, Sanders CM, Lee WM. Risk factors and outcomes of acute kidney injury in patients with acute liver failure. Clin Gastroenterol Hepatol 2015; 13:352-9. [PMID: 25019700 PMCID: PMC4937794 DOI: 10.1016/j.cgh.2014.07.011] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 07/01/2014] [Accepted: 07/02/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with acute liver failure (ALF) frequently develop renal dysfunction, yet its overall incidence and outcomes have not been fully assessed. We investigated the incidence of acute kidney injury (AKI) among patients with ALF, using defined criteria to identify risk factors and to evaluate its effect on overall outcomes. METHODS We performed a retrospective review of data from 1604 patients enrolled in the Acute Liver Failure Study Group, from 1998 through 2010. Patients were classified by the Acute Kidney Injury Network criteria, as well as for etiology of liver failure (acetaminophen-based, ischemic, and all others). RESULTS Seventy percent of patients with ALF developed AKI, and 30% received renal replacement therapy (RRT). Patients with severe AKI had higher international normalized ratio values than those without renal dysfunction (P < .001), and a higher proportion had advanced-grade coma (coma grades 3 or 4; P < .001) or presented with hypotension requiring vasopressor therapy (P < .001). A greater proportion of patients with acetaminophen-induced ALF had severe kidney injury than of patients with other etiologies of ALF; 34% required RRT, compared with 25% of patients with ALF not associated with acetaminophen or ischemia (P < .002). Of the patients with ALF who were alive at 3 weeks after study entry, significantly fewer with AKI survived for 1 year. Although AKI reduced the overall survival time, more than 50% of patients with acetaminophen-associated or ischemic ALF survived without liver transplantation (even with RRT), compared with 19% of patients with ALF attribute to other causes (P < .001). Only 4% of patients requiring RRT became dependent on dialysis. CONCLUSIONS Based on a retrospective analysis of data from more than 1600 patients, AKI is common in patients with ALF and affects short- and long-term outcomes, but rarely results in chronic kidney disease. Acetaminophen-induced kidney injury is frequent, but patients have better outcomes than those with other forms of ALF.
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Affiliation(s)
- Shannan R. Tujios
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Linda S. Hynan
- Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Miguel A. Vazquez
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Corron M. Sanders
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - William M. Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas,Division of Gastroenterology, Hepatology and Nutrition, The Wexner Medical Center, The Ohio State University, Columbus, Ohio
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Sapisochin G, Rodríguez de Lope C, Gastaca M, Ortiz de Urbina J, Suarez MA, Santoyo J, Castroagudín JF, Varo E, López-Andujar R, Palacios F, Sanchez Antolín G, Perez B, Guiberteau A, Blanco G, González-Diéguez ML, Rodriguez M, Varona MA, Barrera MA, Fundora Y, Ferron JA, Ramos E, Fabregat J, Ciria R, Rufian S, Otero A, Vazquez MA, Pons JA, Parrilla P, Zozaya G, Herrero JI, Charco R, Bruix J. "Very early" intrahepatic cholangiocarcinoma in cirrhotic patients: should liver transplantation be reconsidered in these patients? Am J Transplant 2014; 14:660-7. [PMID: 24410861 DOI: 10.1111/ajt.12591] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [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: 09/09/2013] [Accepted: 11/12/2013] [Indexed: 01/25/2023]
Abstract
A retrospective cohort multicenter study was conducted to analyze the risk factors for tumor recurrence after liver transplantation (LT) in cirrhotic patients found to have an intrahepatic cholangiocarcinoma (iCCA) on pathology examination. We also aimed to ascertain whether there existed a subgroup of patients with single tumors ≤2 cm ("very early") in which results after LT can be acceptable. Twenty-nine patients comprised the study group, eight of whom had a "very early" iCCA (four of them incidentals). The risk of tumor recurrence was significantly associated with larger tumor size as well as larger tumor volume, microscopic vascular invasion and poor degree of differentiation. None of the patients in the "very early" iCCA subgroup presented tumor recurrence compared to 36.4% of those with single tumors >2 cm or multinodular tumors, p = 0.02. The 1-, 3- and 5-year actuarial survival of those in the "very early" iCCA subgroup was 100%, 73% and 73%, respectively. The present is the first multicenter attempt to ascertain the risk factors for tumor recurrence in cirrhotic patients found to have an iCCA on pathology examination. Cirrhotic patients with iCCA ≤2 cm achieved excellent 5-year survival, and validation of these findings by other groups may change the current exclusion of such patients from transplant programs.
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Affiliation(s)
- G Sapisochin
- Department of HBP Surgery and Transplantation, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
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Dember LM, Imrey PB, Beck GJ, Cheung AK, Himmelfarb J, Huber TS, Kusek JW, Roy-Chaudhury P, Vazquez MA, Alpers CE, Robbin ML, Vita JA, Greene T, Gassman JJ, Feldman HI. Objectives and design of the hemodialysis fistula maturation study. Am J Kidney Dis 2013; 63:104-12. [PMID: 23992885 DOI: 10.1053/j.ajkd.2013.06.024] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [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: 01/03/2013] [Accepted: 06/28/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND A large proportion of newly created arteriovenous fistulas cannot be used for dialysis because they fail to mature adequately to support the hemodialysis blood circuit. The Hemodialysis Fistula Maturation (HFM) Study was designed to elucidate clinical and biological factors associated with fistula maturation outcomes. STUDY DESIGN Multicenter prospective cohort study. SETTING & PARTICIPANTS Approximately 600 patients undergoing creation of a new hemodialysis fistula will be enrolled at 7 centers in the United States and followed up for as long as 4 years. PREDICTORS Clinical, anatomical, biological, and process-of-care attributes identified pre-, intra-, or postoperatively. OUTCOMES The primary outcome is unassisted clinical maturation, defined as successful use of the fistula for dialysis for 4 weeks without maturation-enhancing procedures. Secondary outcomes include assisted clinical maturation, ultrasound-based anatomical maturation, fistula procedures, fistula abandonment, and central venous catheter use. MEASUREMENTS Preoperative ultrasound arterial and venous mapping, flow-mediated and nitroglycerin-mediated brachial artery dilation, arterial pulse wave velocity, and venous distensibility; intraoperative vein tissue collection for histopathologic and molecular analyses; postoperative ultrasounds at 1 day, 2 weeks, 6 weeks, and prior to fistula intervention and initial cannulation. RESULTS Assuming complete data, no covariate adjustment, and unassisted clinical maturation of 50%, there will be 80% power to detect ORs of 1.83 and 1.61 for dichotomous predictor variables with exposure prevalences of 20% and 50%, respectively. LIMITATIONS Exclusion of 2-stage transposition fistulas limits generalizability. The requirement for study visits may result in a cohort that is healthier than the overall population of patients undergoing fistula creation. CONCLUSIONS The HFM Study will be of sufficient size and scope to: (1) evaluate a broad range of mechanistic hypotheses, (2) identify clinical practices associated with maturation outcomes, (3) assess the predictive utility of early indicators of fistula outcome, and (4) establish targets for novel therapeutic interventions to improve fistula maturation.
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Affiliation(s)
- Laura M Dember
- Renal, Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Peter B Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Alfred K Cheung
- Nephrology and Hypertension Division, University of Utah School of Medicine, Salt Lake City, UT
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, WA
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL
| | - John W Kusek
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Prabir Roy-Chaudhury
- Division of Nephrology and Hypertension, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Miguel A Vazquez
- Division of Nephrology, University of Texas Southwestern, Dallas, TX
| | | | - Michelle L Robbin
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Joseph A Vita
- Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA
| | - Tom Greene
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Jennifer J Gassman
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Harold I Feldman
- Renal, Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Nica A, Lok CE, Harris J, Lee TC, Mokrzycki MH, Maya ID, Vazquez MA, Xi W, Moist LM. Understanding Surgical Preference and Practice in Hemodialysis Vascular Access Creation. Semin Dial 2013; 26:520-6. [DOI: 10.1111/sdi.12046] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lok CE, Moist L, Hemmelgarn BR, Tonelli M, Vazquez MA, Dorval M, Oliver M, Donnelly S, Allon M, Stanley K. Effect of fish oil supplementation on graft patency and cardiovascular events among patients with new synthetic arteriovenous hemodialysis grafts: a randomized controlled trial. JAMA 2012; 307:1809-16. [PMID: 22550196 PMCID: PMC4046844 DOI: 10.1001/jama.2012.3473] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CONTEXT Synthetic arteriovenous grafts, an important option for hemodialysis vascular access, are prone to recurrent stenosis and thrombosis. Supplementation with fish oils has theoretical appeal for preventing these outcomes. OBJECTIVE To determine the effect of fish oil on synthetic hemodialysis graft patency and cardiovascular events. DESIGN, SETTING, AND PARTICIPANTS The Fish Oil Inhibition of Stenosis in Hemodialysis Grafts (FISH) study, a randomized, double-blind, controlled clinical trial conducted at 15 North American dialysis centers from November 2003 through December 2010 and enrolling 201 adults with stage 5 chronic kidney disease (50% women, 63% white, 53% with diabetes), with follow-up for 12 months after graft creation. INTERVENTIONS Participants were randomly allocated to receive fish oil capsules (four 1-g capsules/d) or matching placebo on day 7 after graft creation. MAIN OUTCOME MEASURE Proportion of participants experiencing graft thrombosis or radiological or surgical intervention during 12 months' follow-up. RESULTS The risk of the primary outcome did not differ between fish oil and placebo recipients (48/99 [48%] vs 60/97 [62%], respectively; relative risk, 0.78 [95% CI, 0.60 to 1.03; P = .06]). However, the rate of graft failure was lower in the fish oil group (3.43 vs 5.95 per 1000 access-days; incidence rate ratio [IRR], 0.58 [95% CI, 0.44 to 0.75; P < .001]). In the fish oil group, there were half as many thromboses (1.71 vs 3.41 per 1000 access-days; IRR, 0.50 [95% CI, 0.35 to 0.72; P < .001]); fewer corrective interventions (2.89 vs 4.92 per 1000 access-days; IRR, 0.59 [95% CI, 0.44 to 0.78; P < .001]); improved cardiovascular event-free survival (hazard ratio, 0.43 [95% CI, 0.19 to 0.96; P = .04]); and lower mean systolic blood pressure (-3.61 vs 4.49 mm Hg; difference, -8.10 [95% CI, -15.4 to -0.85]; P = .01). CONCLUSIONS Among patients with new hemodialysis grafts, daily fish oil ingestion did not decrease the proportion of grafts with loss of native patency within 12 months. Although fish oil improved some relevant secondary outcomes such as graft patency, rates of thrombosis, and interventions, other potential benefits on cardiovascular events require confirmation in future studies. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN15838383.
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Affiliation(s)
- Charmaine E Lok
- University of Toronto, and Division of Nephrology, Department of Medicine, Toronto General Hospital, 8NU-844, 200 Elizabeth St, Toronto, ON M5G 2C4, Canada.
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Dixon BS, Beck GJ, Dember LM, Vazquez MA, Greenberg A, Delmez JA, Allon M, Himmelfarb J, Hu B, Greene T, Radeva MK, Davidson IJ, Ikizler TA, Braden GL, Lawson JH, Cotton JR, Kusek JW, Feldman HI. Use of aspirin associates with longer primary patency of hemodialysis grafts. J Am Soc Nephrol 2011; 22:773-81. [PMID: 21415156 DOI: 10.1681/asn.2010060582] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Extended-release dipyridamole plus low-dose aspirin (ERDP/ASA) prolongs primary unassisted graft patency of newly created hemodialysis arteriovenous grafts, but the individual contributions of each component are unknown. Here, we analyzed whether use of aspirin at baseline associated with primary unassisted graft patency among participants in a randomized trial that compared ERDP/ASA and placebo in newly created grafts. We used Cox proportional hazards regression, adjusting for prespecified baseline comorbidities and covariates. Of all participants, 43% reported use of aspirin at baseline; of these, 82% remained on nonstudy aspirin (i.e., excluding ERDP/ASA) at 1 year. After 1 year of follow-up, the incidence of primary unassisted patency among participants using aspirin at baseline was 30% (95% CI: 24 to 35%) and among those not using aspirin was 23% (95% CI: 18 to 27%). Use of aspirin at baseline associated with a dose-dependent prolongation of primary unassisted graft patency that approached statistical significance (adjusted HR, 0.83; 95% CI: 0.68 to 1.01; P=0.06). Use of aspirin at baseline did not associate with prolongation of cumulative graft patency or participant survival. In conclusion, use of aspirin associates with a trend toward longer primary unassisted patency of newly placed hemodialysis grafts similar to that observed for ERDP/ASA.
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Affiliation(s)
- Bradley S Dixon
- Division of Nephrology, University of Iowa College of Medicine, E-300D GH, 200 Hawkins Drive, Iowa City, IA 52242-1081, USA.
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Vazquez MA. Patients Could Consider PD More Often. J Vasc Access 2009. [DOI: 10.1177/112972980901000427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Vazquez MA. The Best AVF and AVG Patency Data you Never Saw: Surprising Outcomes from the Dialysis access Consortium. J Vasc Access 2009. [DOI: 10.1177/112972980901000412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Dixon BS, Beck GJ, Vazquez MA, Greenberg A, Delmez JA, Allon M, Dember LM, Himmelfarb J, Gassman JJ, Greene T, Radeva MK, Davidson IJ, Ikizler TA, Braden GL, Fenves AZ, Kaufman JS, Cotton JR, Martin KJ, McNeil JW, Rahman A, Lawson JH, Whiting JF, Hu B, Meyers CM, Kusek JW, Feldman HI. Effect of dipyridamole plus aspirin on hemodialysis graft patency. N Engl J Med 2009; 360:2191-201. [PMID: 19458364 PMCID: PMC3929400 DOI: 10.1056/nejmoa0805840] [Citation(s) in RCA: 215] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Arteriovenous graft stenosis leading to thrombosis is a major cause of complications in patients undergoing hemodialysis. Procedural interventions may restore patency but are costly. Although there is no proven pharmacologic therapy, dipyridamole may be promising because of its known vascular antiproliferative activity. METHODS We conducted a randomized, double-blind, placebo-controlled trial of extended-release dipyridamole, at a dose of 200 mg, and aspirin, at a dose of 25 mg, given twice daily after the placement of a new arteriovenous graft until the primary outcome, loss of primary unassisted patency (i.e., patency without thrombosis or requirement for intervention), was reached. Secondary outcomes were cumulative graft failure and death. Primary and secondary outcomes were analyzed with the use of a Cox proportional-hazards regression with adjustment for prespecified covariates. RESULTS At 13 centers in the United States, 649 patients were randomly assigned to receive dipyridamole plus aspirin (321 patients) or placebo (328 patients) over a period of 4.5 years, with 6 additional months of follow-up. The incidence of primary unassisted patency at 1 year was 23% (95% confidence interval [CI], 18 to 28) in the placebo group and 28% (95% CI, 23 to 34) in the dipyridamole-aspirin group, an absolute difference of 5 percentage points. Treatment with dipyridamole plus aspirin significantly prolonged the duration of primary unassisted patency (hazard ratio, 0.82; 95% CI, 0.68 to 0.98; P=0.03) and inhibited stenosis. The incidences of cumulative graft failure, death, the composite of graft failure or death, and serious adverse events (including bleeding) did not differ significantly between study groups. CONCLUSIONS Treatment with dipyridamole plus aspirin had a significant but modest effect in reducing the risk of stenosis and improving the duration of primary unassisted patency of newly created grafts. (ClinicalTrials.gov number, NCT00067119.)
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Affiliation(s)
- Bradley S Dixon
- University of Iowa College of Medicine and the Veterans Affairs Medical Center, Iowa City, IA 52242-1081, USA.
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Dember LM, Beck GJ, Allon M, Delmez JA, Dixon BS, Greenberg A, Himmelfarb J, Vazquez MA, Gassman JJ, Greene T, Radeva MK, Braden GL, Ikizler TA, Rocco MV, Davidson IJ, Kaufman JS, Meyers CM, Kusek JW, Feldman HI. Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis: a randomized controlled trial. JAMA 2008; 299:2164-71. [PMID: 18477783 PMCID: PMC4943222 DOI: 10.1001/jama.299.18.2164] [Citation(s) in RCA: 572] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
CONTEXT The arteriovenous fistula is the preferred type of vascular access for hemodialysis because of lower thrombosis and infection rates and lower health care expenditures compared with synthetic grafts or central venous catheters. Early failure of fistulas due to thrombosis or inadequate maturation is a barrier to increasing the prevalence of fistulas among patients treated with hemodialysis. Small, inconclusive trials have suggested that antiplatelet agents may reduce thrombosis of new fistulas. OBJECTIVE To determine whether clopidogrel reduces early failure of hemodialysis fistulas. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, placebo-controlled trial conducted at 9 US centers composed of academic and community nephrology practices in 2003-2007. Eight hundred seventy-seven participants with end-stage renal disease or advanced chronic kidney disease were followed up until 150 to 180 days after fistula creation or 30 days after initiation of dialysis, whichever occurred later. INTERVENTION Participants were randomly assigned to receive clopidogrel (300-mg loading dose followed by daily dose of 75 mg; n = 441) or placebo (n = 436) for 6 weeks starting within 1 day after fistula creation. MAIN OUTCOME MEASURES The primary outcome was fistula thrombosis, determined by physical examination at 6 weeks. The secondary outcome was failure of the fistula to become suitable for dialysis. Suitability was defined as use of the fistula at a dialysis machine blood pump rate of 300 mL/min or more during 8 of 12 dialysis sessions. RESULTS Enrollment was stopped after 877 participants were randomized based on a stopping rule for intervention efficacy. Fistula thrombosis occurred in 53 (12.2%) participants assigned to clopidogrel compared with 84 (19.5%) participants assigned to placebo (relative risk, 0.63; 95% confidence interval, 0.46-0.97; P = .018). Failure to attain suitability for dialysis did not differ between the clopidogrel and placebo groups (61.8% vs 59.5%, respectively; relative risk, 1.05; 95% confidence interval, 0.94-1.17; P = .40). CONCLUSION Clopidogrel reduces the frequency of early thrombosis of new arteriovenous fistulas but does not increase the proportion of fistulas that become suitable for dialysis. Trial Registration clinicaltrials.gov Identifier: NCT00067119.
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Affiliation(s)
- Laura M Dember
- Boston University, School of Medicine, Renal Section, EBRC 504, 650 Albany St, Boston, Massachusetts 02118, USA.
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Richer E, Lewis MA, Odvina CV, Vazquez MA, Smith BJ, Peterson RD, Poindexter JR, Antich PP, Pak CYC. Reduction in normalized bone elasticity following long-term bisphosphonate treatment as measured by ultrasound critical angle reflectometry. Osteoporos Int 2005; 16:1384-92. [PMID: 15726294 DOI: 10.1007/s00198-005-1848-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2004] [Accepted: 12/28/2004] [Indexed: 10/25/2022]
Abstract
Using an improved version of ultrasound critical angle reflectometry, the bone quality of cortical and trabecular bone was assessed in vivo by measuring elastic moduli (normalized for bone density) at both principal axes, referred to as the minimum and maximum normalized elasticities. The measurements were made in 30 normal premenopausal women, 30 normal postmenopausal women, 22 untreated postmenopausal women with osteoporosis, 74 postmenopausal women with osteoporosis or osteopenia on bisphosphonate treatment, and 32 patients with renal transplantation (16 women and 16 men) taking steroids. Cortical elasticity was higher than trabecular elasticity; both declined slightly and non-significantly with age in normal women. Among untreated postmenopausal women with osteoporosis, cortical maximum normalized elasticity (E(cmax)) remained within 95% prediction intervals of normal women. Among patients on bisphosphonate, E(cmax) was low in the majority of patients. E(cmax) was significantly more depressed among those taking the drug > or =3 years than <3 years (22.1% below normal premenopausal women versus 17.2%, P =0.001), and among those with incident non-spinal fractures than without (75.9 vs. 81.5%, P =0.008). E(cmax) was independent of bone mineral density at the calcaneus. Most patients with renal transplantation had low E(cmax), with a mean 20.8% below the normal premenopausal mean. Qualitatively similar findings were found with cortical minimum elasticity and with trabecular minimum and maximum elasticities. Thus, the material bone quality of cortical and trabecular bone may be impaired following bisphosphonate treatment, as in renal transplantation on steroids.
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Affiliation(s)
- Edmond Richer
- Advanced Radiological Sciences Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Vazquez MA, Donoso J, Muñoz F, Blanco FG, del Vado MAG, Echevarria G. Kinetic and thermodynamic parameters forSchiff-rase formation between 5′-deoxypyridoxal and hexylamine. Helv Chim Acta 2004. [DOI: 10.1002/hlca.19900730723] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kasiske BL, Cangro CB, Hariharan S, Hricik DE, Kerman RH, Roth D, Rush DN, Vazquez MA, Weir MR. The evaluation of renal transplantation candidates: clinical practice guidelines. Am J Transplant 2002; 1 Suppl 2:3-95. [PMID: 12108435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Bertram L Kasiske
- Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis
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Kasiske BL, Vazquez MA, Harmon WE, Brown RS, Danovitch GM, Gaston RS, Roth D, Scandling JD, Singer GG. Recommendations for the outpatient surveillance of renal transplant recipients. American Society of Transplantation. J Am Soc Nephrol 2001. [PMID: 11044969 DOI: 10.1681/asn.v11suppl_1s1] [Citation(s) in RCA: 392] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Many complications after renal transplantation can be prevented if they are detected early. Guidelines have been developed for the prevention of diseases in the general population, but there are no comprehensive guidelines for the prevention of diseases and complications after renal transplantation. Therefore, the Clinical Practice Guidelines Committee of the American Society of Transplantation developed these guidelines to help physicians and other health care workers provide optimal care for renal transplant recipients. The guidelines are also intended to indirectly help patients receive the access to care that they need to ensure long-term allograft survival, by attempting to systematically define what that care encompasses. The guidelines are applicable to all adult and pediatric renal transplant recipients, and they cover the outpatient screening for and prevention of diseases and complications that commonly occur after renal transplantation. They do not cover the diagnosis and treatment of diseases and complications after they become manifest, and they do not cover the pretransplant evaluation of renal transplant candidates. The guidelines are comprehensive, but they do not pretend to cover every aspect of care. As much as possible, the guidelines are evidence-based, and each recommendation has been given a subjective grade to indicate the strength of evidence that supports the recommendation. It is hoped that these guidelines will provide a framework for additional discussion and research that will improve the care of renal transplant recipients.
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Affiliation(s)
- B L Kasiske
- Division of Nephrology, Hennepin County Medical Center, University of Minnesota, Minneapolis 55415, USA.
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Vazquez MA, Jeyarajah DR, Kielar ML, Lu CY. Long-term outcomes of renal transplantation: a result of the original endowment of the donor kidney and the inflammatory response to both alloantigens and injury. Curr Opin Nephrol Hypertens 2000; 9:643-8. [PMID: 11128427 DOI: 10.1097/00041552-200011000-00009] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Recent data suggest that long-term allograft survival might be affected by two factors. The first is the endowment of the allograft, which consists of two elements: the nephron mass and the ability of these nephrons to repair injuries sustained during the transplant process. The second factor is renal inflammation. Although inflammation is traditionally ascribed to alloreactivity, recent data have shown that there is also a renal inflammatory response to early injury after transplantation, to brain death in the donor, and as part of the maladaptive response to nephron loss. These two factors contribute to the detrimental effects of delayed graft function or acute rejection on the long-term survival seen in most studies, and the beneficial effects of anti-inflammatory agents on the maladaptive response to nephron loss.
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Affiliation(s)
- M A Vazquez
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas 75390-8856, USA
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Burkey SH, Vazquez MA, Valentine RJ. De novo renal artery aneurysm presenting 6 years after transplantation: a complication of recurrent arterial stenosis? J Vasc Surg 2000; 32:388-91. [PMID: 10918000 DOI: 10.1067/mva.2000.106943] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pseudoaneurysms represent a well-recognized vascular complication of renal transplantation, but true aneurysms involving the donor renal artery have not been described. We report a patient who had a de novo aneurysm of the donor renal artery 6 years after receiving a cadaveric renal transplant from a child. The aneurysm was repaired successfully, and allograft function was preserved. Histologic evidence confirmed that the lesion was a true aneurysm. Given the potential for graft loss associated with complications of unrepaired aneurysms, we believe that the presence of a true aneurysm in a donor renal artery represents an indication for repair.
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Affiliation(s)
- S H Burkey
- Division of Vascular Surgery, Department of Surgery, and the Renal Transplant Unit, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Vazquez MA. Chronic rejection of renal transplants: new clinical insights. Am J Med Sci 2000; 320:43-58. [PMID: 10910373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Chronic rejection is the most important cause for returning to dialysis after failure of a renal transplant. The term chronic allograft nephropathy refers to the progressive decline of renal function seen in some renal transplant recipients in association with alloantigen-dependent and alloantigen-independent factors. This review examines the role of factors related to allorecognition, injury, nephron dosing, and donor and recipient characteristics in the development of chronic allograft nephropathy. The clinical associations to chronic allograft nephropathy are presented in the context of pathogenetic mechanisms of renal damage and disease progression. As there is no therapy available at this time for established chronic allograft nephropathy, possible areas of intervention for the prevention of chronic rejection are discussed.
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Affiliation(s)
- M A Vazquez
- University of Texas Southwestern Medical Center, Dallas 75235-8856, USA.
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Gisbert JP, Vazquez MA, Jimenez I, Cruzado AI, Carpio D, Del Castillo E, Martin MJ, Morales A, Pajares R, Rodriguez A, Pajares JM. 13C-urea breath test for the diagnosis of Helicobacter pylori infection before treatment: is citric acid necessary? Dig Liver Dis 2000; 32:20-4. [PMID: 10975750 DOI: 10.1016/s1590-8658(00)80039-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM 13C-urea breath test is one of the best methods for the diagnosis of Helicobacter pylori infection. Although a citric acid solution is generally used prior to urea intake, the superiority of this strategy has not been sufficiently demonstrated. Thus, our aim was to compare 13C-urea breath test with and without citric acid solution, to evaluate whether 13C-urea breath test can also achieve favourable results when the test meal is omitted. METHODS 13C-urea breath test with and without citric acid were compared prospectively in 53 subjects without prior Helicobacter pylori eradication therapy prescription. Basal samples and at 15', 30', and 45' after taking 100 mg of 13C-urea were obtained. The gold standard for Helicobacter pylori diagnosis was the 13C-urea breath test result with citric acid at 30', and "Delta Over Baseline" values >5 at that time were considered positive. RESULTS The prevalence of Helicobacter pylori infection was 68%. Mean Delta Over Baseline values with citric acid at 15', 30' and 45' were: 29.6+/-39, 30.8+/-37 and 24.6+/-27; whereas respective values without citric acid were lower: 14.9+/-22, 12.2+/-17 and 10D+/-13 (p<O. 001 for all comparisons, Wilcoxon test for paired data). Thus, the area under the curve (constructed with Delta Over Baseline values at different times) with citric acid was 85+/- 102, and 37+/-50 without citric acid [p<0.001). Correlation coefficient between Delta Over Baseline values with and without citric acid at 30' was 0.73 (p<0.0001). The percentage of subjects achieving the highest Delta Over Baseline value at 15', 30' and 45' with citric acid was 51%, 30% and 19%, whereas without citric acid it was 51%, 26% and 23% (non-significant differences). The area under receiver operating characteristic curve for 13C-urea breath test without citric acid was: 0.98 at 15', 1 at 30' and 0.97 at 45'. The best cut-off point for 13C-urea breath test without citric acid at 30' was anywhere between 3. 3 and 3.9 (that is, a lower value than that usually considered with citric acid), with 100% (95% confidence interval, 90-100%) sensitivity and 100% [82-100%) specificity CONCLUSIONS 13C-urea breath test values with citric acid are higher than those obtained without citric acid, although this difference does not imply a diagnostic superiority in untreated patients when considering 13C-urea breath test without citric acid at 30'. Therefore, for the diagnosis of Helicobacter pylori infection in untreated patients, citric acid solution in 13C-urea breath test protocol can be omitted.
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Affiliation(s)
- J P Gisbert
- Department of Gastroenterology, University Hospital of La Princesa, Madrid, Spain.
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Lu CY, Penfield JG, Kielar ML, Vazquez MA, Jeyarajah DR. Hypothesis: is renal allograft rejection initiated by the response to injury sustained during the transplant process? Kidney Int 1999; 55:2157-68. [PMID: 10354265 DOI: 10.1046/j.1523-1755.1999.00491.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Allograft rejection can be caused by numerous factors such as damage to the donor kidney during surgical removal or implantation, injury sustained during the transport process between the donor and recipient, and suboptimal allograft perfusion during the intra- and post-operative period. In cadaveric allografts, damage can occur during cold storage, during the transit stage between donor and recipient, and hemodynamic instability due to the initial damage that caused its removal from the donor (such as brain death or trauma). We hypothesize that rejection requires recognition of this injury in addition to recognition of alloantigens. If indeed injury proves to be one factor in acute rejection episodes, then therapeutic efforts can be made to reduce injury during the transplantation process.
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Affiliation(s)
- C Y Lu
- Division of Nephrology, Department of Internal Medicine, Dallas, Texas, USA.
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Lu CY, Penfield JG, Khair-el-Din TA, Sicher SC, Kielar ML, Vazquez MA, Che L. Docosahexaenoic acid, a constituent of fetal and neonatal serum, inhibits nitric oxide production by murine macrophages stimulated by IFN gamma plus LPS, or by IFN gamma plus Listeria monocytogenes. J Reprod Immunol 1998; 38:31-53. [PMID: 9616876 DOI: 10.1016/s0165-0378(98)00005-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Murine macrophage activation is deficient in the fetus and the neonate, and in areas of the placenta perfused by the fetal circulation. Fetal and neonatal serum concentrations of docosahexaenoic acid (DHA) are 150 microM, or approximately 50-fold higher than in the adult. We previously showed that DHA inhibits activation of the gene for inducible nitric oxide synthase (iNOS) in murine macrophages stimulated in vitro with interferon gamma (IFN gamma) plus lipopolysaccharide (LPS). We have now pursued these observations in greater depth. An assay system was developed which separated the stimulation of macrophages by IFN gamma plus LPS, and the actual production of nitric oxide (NO). It was found that macrophages do not produce NO until they have been stimulated by IFN gamma plus LPS for a period of 10 h. NO is produced during the subsequent 10 h, even though IFN gamma plus LPS are not longer present. DHA, if present, inhibited only during the initial 10 h stimulation; DHA did not inhibit the production of NO by macrophages which had previously been stimulated by IFN gamma plus LPS, and were already producing NO. It was also found that DHA was less inhibitory if given prior to the IFN gamma plus LPS stimulation. In a dose-responsive manner, DHA inhibited the increased abundance of iNOS mRNA by macrophages stimulated by IFN gamma plus LPS. NO contributes to the host defense against Listeria monocytogenes and other intracellular pathogens. We therefore investigated the ability of DHA to inhibit NO production by macrophages stimulated by IFN gamma plus Listeria monocytogenes in vitro; DHA inhibited transcription of the iNOS gene and also the listeriocidal activity of activated macrophages. Inhibition of NO production by DHA may contribute to the increased susceptibility of the fetoplacental unit and neonate to intracellular infections.
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Affiliation(s)
- C Y Lu
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas 75235-8856, USA.
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Vazquez JA, Dembry LM, Sanchez V, Vazquez MA, Sobel JD, Dmuchowski C, Zervos MJ. Nosocomial Candida glabrata colonization: an epidemiologic study. J Clin Microbiol 1998; 36:421-6. [PMID: 9466752 PMCID: PMC104553 DOI: 10.1128/jcm.36.2.421-426.1998] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Candida glabrata has emerged as an important nosocomial pathogen, yet little is known about its epidemiology. We prospectively followed 98 patients admitted to a medical intensive care unit and the bone marrow transplant unit of a university hospital. Samples from environmental surfaces and the hands of hospital personnel were also cultured. Patients with newly acquired C. glabrata strains were compared to controls who were culture negative for C. glabrata. C. glabrata was recovered from multiple sites from 24 patients and three environmental surfaces. Sixteen patients (17%) acquired C. glabrata after admission to the study units. Significant risk factors for the nosocomial acquisition of C. glabrata were prolonged duration of hospitalization in the unit and prior antimicrobial use. Strain delineation by restriction enzyme analysis revealed 28 different strains of C. glabrata; three strain types were common to nine patients. The environmental isolates were of the same strain type and common to five patients (four patients with newly acquired strains). These results suggest the possibility of exogenous nosocomial acquisition of C. glabrata, including the possible acquisition from the hospital environment. Transmission may be by indirect contact since identical strains of C. glabrata were recovered from patients who were geographically and temporally associated.
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Affiliation(s)
- J A Vazquez
- Department of Internal Medicine, Wayne State University School of Medicine, and Veterans Administration Medical Center, Detroit, Michigan 48201, USA.
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Pascual J, Argente J, Lopez MB, Muñoz M, Martinez G, Vazquez MA, Jodar E, Perez-Cano R, Hawkins F. Bone mineral density in children and adolescents with diabetes mellitus type 1 of recent onset. Calcif Tissue Int 1998; 62:31-5. [PMID: 9405730 DOI: 10.1007/s002239900390] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
There is still controversy over the impact of diabetes control and duration on bone mass and growth parameters in children and adolescents with insulin-dependent diabetes mellitus (IDDM). The aim of this study was to assess bone mineral density (BMD) at axial and appendicular sites, in children with noncomplicated IDDM of recent onset, and its relation to metabolic control and auxological parameters (weight, height, and puberal stage). Fifty-five young Spanish IDDM, otherwise healthy patients (26 males, aged (SD 9.7 +/- 4.3 years) and 29 females, aged (SD 11.2 +/- 3.8 years) were studied. Duration of diabetes was 1-13.8 years. Two hundred eighty-two age-matched, healthy, Spanish children served as controls. HbA1 was assayed by high pressure liquid chromatography (HPLC) and BMD was measured using dual X-ray absorptiometry (DXA) densitometry at the spine and forearm. Results showed a Gaussian BMD distribution of patients according to sex and age, without sexual-stage differences. There was no correlation between BMD and glycated hemoglobin (average life disease or last HbA1 values) or duration of the disease; moreover, no differences in bone mass were found between <3 and >/=3 years of disease duration. Diabetes impact index (mean HbA1 x duration of disease in months) showed no significant influence of diabetes control on BMD. We could not demonstrate any impact of diabetes on BMD and growth parameters in children with IDDM of short duration.
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Affiliation(s)
- J Pascual
- Service of Endocrinology, University Hospital 12 Octubre, Madrid, Spain
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