1
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Cooper M, Wiseman AC, Doshi MD, Hall IE, Parsons RF, Pastan S, Reddy KS, Schold JD, Mohan S, Hippen BE. Understanding Delayed Graft Function to Improve Organ Utilization and Patient Outcomes: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2024; 83:360-369. [PMID: 37844725 DOI: 10.1053/j.ajkd.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 10/18/2023]
Abstract
Delayed graft function (DGF) is a common complication after kidney transplant. Despite extensive literature on the topic, the extant definition of DGF has not been conducive to advancing the scientific understanding of the influences and mechanisms contributing to its onset, duration, resolution, or long-term prognostic implications. In 2022, the National Kidney Foundation sponsored a multidisciplinary scientific workshop to comprehensively review the current state of knowledge about the diagnosis, therapy, and management of DGF and conducted a survey of relevant stakeholders on topics of clinical and regulatory interest. In this Special Report, we propose and defend a novel taxonomy for the clinical and research definitions of DGF, address key regulatory and clinical practice issues surrounding DGF, review the current state of therapies to reduce and/or attenuate DGF, offer considerations for clinical practice related to the outpatient management of DGF, and outline a prospective research and policy agenda.
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Affiliation(s)
- Matthew Cooper
- Department of Surgery, Division of Transplantation, Medical College of Wisconsin, Milwaukee, WI.
| | | | - Mona D Doshi
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Isaac E Hall
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah
| | | | - Stephen Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia
| | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jesse D Schold
- Departments of Surgery and Epidemiology, University of Colorado Anschutz Medical College, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Benjamin E Hippen
- Global Medical Office, Fresenius Medical Care, Charlotte, North Carolina
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2
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Subramanian V, Anderson C, Karp S, Pastan S, Gerber D, Locke J, Cohen A, Shah M, Casingal V, Strata R, Singh N, DuBay D, Dhanireddy K. COVID-19 and transplantation-Data censoring. Am J Transplant 2022; 22:1958-1962. [PMID: 35451211 PMCID: PMC9111342 DOI: 10.1111/ajt.17065] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/05/2022] [Accepted: 04/19/2022] [Indexed: 01/25/2023]
Abstract
During the early wave of the COVID-19 pandemic, the Scientific Registry of Transplant Recipients (SRTR) designated a "black out" period between March 12, 2020, and June 12, 2020, for transplant outcomes reporting. We discuss the implications and potential bias it has introduced as it may selectively favor the outcomes for certain regions and harm other regions due to varied effects of different waves of COVID-19 infections across the United States.
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Affiliation(s)
| | | | - Seth Karp
- Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - David Gerber
- University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Jayme Locke
- University of Alabama School of MedicineBirminghamAlabamaUSA
| | - Ari Cohen
- Ochsner Clinic FoundationJeffersonLouisianaUSA
| | - Malay Shah
- University of KentuckyLexingtonKentuckyUSA
| | | | - Robert Strata
- Atrium Health Wake Forest BaptistWinston‐SalemNorth CarolinaUSA
| | - Neeraj Singh
- Willis‐Knighton Medical CenterShreveportLouisianaUSA
| | - Derek DuBay
- Medical University of South CarolinaMt PleasantSouth CarolinaUSA
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3
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Lentine KL, Pastan S, Mohan S, Reese PP, Leichtman A, Delmonico FL, Danovitch GM, Larsen CP, Harshman L, Wiseman A, Kramer HJ, Vassalotti J, Joseph J, Longino K, Cooper M, Axelrod DA. A Roadmap for Innovation to Advance Transplant Access and Outcomes: A Position Statement From the National Kidney Foundation. Am J Kidney Dis 2021; 78:319-332. [PMID: 34330526 DOI: 10.1053/j.ajkd.2021.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/01/2021] [Indexed: 02/07/2023]
Abstract
Over the past 65 years, kidney transplantation has evolved into the optimal treatment for patients with kidney failure, dramatically reducing suffering through improved survival and quality of life. However, access to transplant is still limited by organ supply, opportunities for transplant are inequitably distributed, and lifelong transplant survival remains elusive. To address these persistent needs, the National Kidney Foundation convened an expert panel to define an agenda for future research. The key priorities identified by the panel center on the needs to develop and evaluate strategies to expand living donation, improve waitlist management and transplant readiness, maximize use of available deceased donor organs, and extend allograft longevity. Strategies targeting the critical goal of decreasing organ discard that warrant research investment include educating patients and clinicians about potential benefits of accepting nonstandard organs, use of novel organ assessment technologies and real-time decision support, and approaches to preserve and resuscitate allografts before implantation. The development of personalized strategies to reduce the burden of lifelong immunosuppression and support "one transplant for life" was also identified as a vital priority. The panel noted the specific goal of improving transplant access and graft survival for children with kidney failure. This ambitious agenda will focus research investment to promote greater equity and efficiency in access to transplantation, and help sustain long-term benefits of the gift of life for more patients in need.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St Louis, MO.
| | - Stephen Pastan
- Department of Medicine, Emory Transplant Center, Atlanta, GA
| | - Sumit Mohan
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Alan Leichtman
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | | | | | | | - Lyndsay Harshman
- Department of Pediatrics, University of Iowa Transplant Institute, Iowa City, IA
| | - Alexander Wiseman
- Department of Medicine, Centura Health-Porter Adventist Hospital, Aurora, CO
| | | | - Joseph Vassalotti
- National Kidney Foundation, New York, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Matthew Cooper
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, DC
| | - David A Axelrod
- Department of Surgery, University of Iowa Transplant Institute, Iowa City, IA
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4
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Sherman AC, Lu X, Schneider E, Langston A, Ellis CL, Pastan S, Bhatnagar J, Reagan-Steiner S, Annambhotla P, Lindstrom S, Mehta A, Pouch SM, Sexton ME. Human Adenovirus 11 in 2 Renal Transplant Recipients: Suspected Donor-Derived Infection. Open Forum Infect Dis 2021; 8:ofab092. [PMID: 34386544 PMCID: PMC8355461 DOI: 10.1093/ofid/ofab092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Human adenovirus (HAdV) infections can lead to high mortality in solid organ transplant (SOT) recipients, with rare reports of donor-derived infection. METHODS Two renal transplant recipients with HAdV-11 infection who received kidneys from the same donor are described. Whole-genome sequencing (WGS) was performed. RESULTS WGS showed 100% nucleotide sequence identity for the 2 HAdV-11 isolates. The patients presented with distinct clinical syndromes, and both were treated with brincidofovir. CONCLUSIONS Donor-derived HAdV infection is presumed to be low; however, disseminated HAdV in SOT recipients can be severe, and clinicians should be aware of the clinical course and treatment options.
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Affiliation(s)
- Amy C Sherman
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Xiaoyan Lu
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Eileen Schneider
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Amelia Langston
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carla L Ellis
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Stephen Pastan
- Division of Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Julu Bhatnagar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sarah Reagan-Steiner
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Pallavi Annambhotla
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Stephen Lindstrom
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Aneesh Mehta
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stephanie M Pouch
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marybeth E Sexton
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
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5
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Karadkhele G, Hogan J, Magua W, Zhang W, Badell IR, Mehta A, Lyon M, Pastan S, Pearson TC, Larsen CP. CMV high-risk status and posttransplant outcomes in kidney transplant recipients treated with belatacept. Am J Transplant 2021; 21:208-221. [PMID: 32519434 DOI: 10.1111/ajt.16132] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Cytomegalovirus (CMV) remains associated with poor outcomes after kidney transplantation (kTx). The impact of belatacept on CMV infection remains understudied. In this study, we assessed the impact of belatacept on patient and graft survivals. METHODS CMV seronegative kTx recipients were included. Patient and graft survival were studied using Kaplan-Meier method, log-rank test. Cox models were used to compare outcomes by CMV risk and immunosuppressive regimen. Incidence and persistence of CMV viremia under belatacept vs tacrolimus were compared. RESULTS Among 308 CMV seronegative recipients, 168 CMV high-risk and 203 belatacept-treated patients were included. High-risk CMV status was associated with lower patient survival and graft survival. Among the CMV high-risk group, patients treated with belatacept presented a higher incidence of CMV viremia, a higher rate of first-line treatment failure and a longer time to virus clearance. They had a nonsignificant trend toward a lower graft survival. CONCLUSION Belatacept-based maintenance immunosuppression is associated with an increased risk of CMV primary-infection and a prolonged course of viral replication in CMV high-risk patients. Further studies are needed to confirm the nonsignificant trend towards a lower graft survival in CMV high-risk patients treated with belatacept and whether it is explained by the higher risk of CMV reactivation and infection.
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Affiliation(s)
- Geeta Karadkhele
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia, USA
| | - Julien Hogan
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia, USA
| | - Wairimu Magua
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia, USA
| | - Weiwen Zhang
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia, USA
| | - Idelberto Raul Badell
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia, USA
| | - Aneesh Mehta
- Infectious Diseases Department, Department of Medicine, Emory School of Medicine, Atlanta, Georgia, USA
| | - Marshall Lyon
- Infectious Diseases Department, Department of Medicine, Emory School of Medicine, Atlanta, Georgia, USA
| | - Stephen Pastan
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia, USA
| | - Thomas C Pearson
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia, USA
| | - Christian P Larsen
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia, USA
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6
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Radhakrishnan J, Mohan S, Pastan S, McLean R. Reflections and Next Stages for Kidney International Reports. Kidney Int Rep 2020; 6:1-2. [PMID: 33283078 PMCID: PMC7698824 DOI: 10.1016/j.ekir.2020.11.004] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jai Radhakrishnan
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Sumit Mohan
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Stephen Pastan
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Radha McLean
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
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7
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Husain SA, King KL, Pastan S, Pazter RE, Cohen DJ, Radhakrishnan J, Mohan S. Association Between Declined Offers of Deceased Donor Kidney Allograft and Outcomes in Kidney Transplant Candidates. JAMA Netw Open 2019; 2:e1910312. [PMID: 31469394 PMCID: PMC6724162 DOI: 10.1001/jamanetworkopen.2019.10312] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE In the United States, substantial disparities in access to kidney transplant exist for wait-listed candidates with end-stage renal disease. The implications of transplant centers' willingness to accept kidney offers for access to transplant and mortality outcomes are unknown. OBJECTIVE To determine the outcomes for wait-listed kidney transplant candidates after the transplant center's refusal of a deceased donor kidney offer. DESIGN, SETTING, AND PARTICIPANTS This cohort study obtained data from the United Network for Organ Sharing Potential Transplant Recipient data set on all deceased donor kidney offers in the United States made between January 1, 2008, and December 31, 2015. The final study cohort included adult patients who were wait-listed for kidney transplant and received at least 1 allograft offer during the study period (N = 280 041). Data analysis was conducted from June 1, 2018, to March 30, 2019. EXPOSURE Candidate state of residence. MAIN OUTCOMES AND MEASURES Waiting list outcome event groups included received deceased donor allograft, received living donor allograft, died while on the waiting list, removed from the waiting list without a transplant, or still on the waiting list at the end of follow-up. RESULTS Among the 280 041 kidney transplant candidates included in the study, the mean (SD) age at wait-listing was 51.1 (13.1) years, and male patients were predominant (171 517 [61.2%]). In this cohort, 81 750 candidates (29.2%) received a deceased donor kidney allograft, 30 870 (11.0%) received a living donor allograft, 25 967 (9.3%) died while on the waiting list, and 59 359 (21.2%) were removed from the waiting list. Overall, 10 candidates with at least 1 previous allograft offer died each day during the study period. Time to first offer was similar for candidates who received deceased donor kidney allograft compared with those who died while waiting (median [interquartile range {IQR}] time, 79 [16-426] days vs 78 [17-401] days, respectively). Deceased donor allograft recipients had a median of 17 offers (IQR, 6-44) over 422 days (IQR, 106-909 days), whereas candidates who died while waiting received a median of 16 offers (IQR, 6-41) over 651 days (IQR, 304-1117 days). Most kidneys (84%) were declined on behalf of at least 1 candidate before being accepted for transplant. As reported by centers, organ or donor quality concerns accounted for 8 416 474 (92.6%) of all declined offers, whereas offers were infrequently refused because of patient-related factors (232 193 [2.6%]), logistical limitations (49 492 [0.5%]), or other concerns. The odds of death after an offer and the median number of offers received prior to death varied considerably by state. CONCLUSIONS AND RELEVANCE This study found that transplant candidates appeared to receive a large number of viable deceased donor kidney offers that were refused on their behalf by transplant centers, potentially exacerbating the detrimental consequences of the organ shortage; increased transparency in organ allocation process and decisions may improve patient-centered care and access to kidney transplant.
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Affiliation(s)
- S. Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L. King
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Stephen Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Pazter
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - David J. Cohen
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Jai Radhakrishnan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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8
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Patzer RE, McPherson L, Redmond N, DuBay D, Zayas C, Hartmann E, Mulloy L, Perryman J, Pastan S, Arriola KJ. A Culturally Sensitive Web-based Intervention to Improve Living Donor Kidney Transplant Among African Americans. Kidney Int Rep 2019; 4:1285-1295. [PMID: 31517147 PMCID: PMC6737208 DOI: 10.1016/j.ekir.2019.05.771] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/03/2019] [Accepted: 05/20/2019] [Indexed: 01/23/2023] Open
Abstract
Introduction There are pervasive racial disparities in access to living donor kidney transplantation, which for most patients with end-stage renal disease (ESRD) represents the optimal treatment. We previously developed a theory-driven, culturally sensitive intervention for African American (AA) patients with kidney disease called Living ACTS (About Choices in Transplantation and Sharing) as a DVD and booklet, and found this intervention was effective in increasing living donor transplant knowledge. However, it is unknown whether modifying this intervention for a Web-based environment is effective at increasing access to living donor transplantation. Methods We describe the Web-based Living ACTS study, a multicenter, randomized controlled study designed to test the effectiveness of a revised Living ACTS intervention in 4 transplant centers in the southeastern United States. The intervention consists of a Web site with 5 modules: Introduction, Benefits and Risks, The Kidney Transplant Process, Identifying a Potential Kidney Donor, and ACT Now (which encourages communication with friends and family about transplantation). Results This study will enroll approximately 800 patients from the 4 transplant centers. The primary outcome is the percentage of patients with at least 1 inquiry from a potential living donor among patients who receive Living ACTS as compared with those who receive a control Web site. Conclusion The results from this study are expected to demonstrate the effectiveness of an intervention designed to increase access to living donor transplantation among AA individuals. If successful, the Web-based intervention could be disseminated across the >250 transplant centers in the United States to improve equity in living donor kidney transplantation.
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Affiliation(s)
- Rachel E Patzer
- Health Services Research Center, Department of Medicine and Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia, USA
- Emory Transplant Center, Atlanta, Georgia, USA
| | - Laura McPherson
- Health Services Research Center, Department of Medicine and Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Derek DuBay
- Department of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Carlos Zayas
- Renal and Pancreas Transplant Program, Augusta University, Augusta, Georgia, USA
| | - Erica Hartmann
- Piedmont Transplant Institute, Piedmont Hospital, Atlanta, Georgia, USA
| | - Laura Mulloy
- Department of Nephrology, Hypertension, and Transplant Medicine, Augusta University, Augusta, Georgia, USA
| | | | - Stephen Pastan
- Emory Transplant Center, Atlanta, Georgia, USA
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kimberly Jacob Arriola
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health of Emory University, Atlanta, Georgia, USA
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9
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Cooper M, Formica R, Friedewald J, Hirose R, O’Connor K, Mohan S, Schold J, Axelrod D, Pastan S. Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards. Clin Transplant 2018; 33:e13419. [DOI: 10.1111/ctr.13419] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 09/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew Cooper
- Medstar Georgetown Transplant Institute; Georgetown University; Washington District of Columbia
| | - Richard Formica
- Department of Medicine, Section of Nephrology; Yale School of Medicine; New Haven Connecticut
| | - John Friedewald
- Northwestern University Comprehensive Transplant Center; Chicago Illinois
| | - Ryutaro Hirose
- Department of Surgery; University of California San Francisco; San Francisco California
| | | | - Sumit Mohan
- Division of Nephrology, Department of Medicine; Vagelos College of Physicians & Surgeons, Columbia University; New York New York
- Department of Epidemiology, Mailman School of Public Health; Columbia University; New York New York
| | - Jesse Schold
- Department of Quantitative Health Sciences; Cleveland Clinic; Cleveland Ohio
| | - David Axelrod
- Department of Surgery; Lahey Hospital and Medical Center; Burlington Massachusetts
| | - Stephen Pastan
- Renal Division, Department of Medicine; Emory University School of Medicine; Atlanta Georgia
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10
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Patzer RE, McPherson L, Basu M, Mohan S, Wolf M, Chiles M, Russell A, Gander JC, Friedewald JJ, Ladner D, Larsen CP, Pearson T, Pastan S. Effect of the iChoose Kidney decision aid in improving knowledge about treatment options among transplant candidates: A randomized controlled trial. Am J Transplant 2018; 18:1954-1965. [PMID: 29446209 PMCID: PMC6510396 DOI: 10.1111/ajt.14693] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 01/05/2018] [Accepted: 02/04/2018] [Indexed: 01/25/2023]
Abstract
We previously developed a mobile- and web-based decision aid (iChoose Kidney) that displays individualized risk estimates of survival and mortality, for the treatment modalities of dialysis versus kidney transplantation. We examined the effect of iChoose Kidney on change in transplant knowledge and access to transplant in a randomized controlled trial among patients presenting for evaluation in three transplant centers. A total of 470 patients were randomized to standard transplantation education (control) or standard education plus iChoose Kidney (intervention). Change in transplant knowledge (primary outcome) among intervention versus control patients was assessed using nine items in pre- and postevaluation surveys. Access to transplant (secondary outcome) was defined as a composite of waitlisting, living donor inquiries, or transplantation. Among 443 patients (n = 226 intervention; n = 216 control), the mean knowledge scores were 5.1 ± 2.1 pre- and 5.8 ± 1.9 postevaluation. Change in knowledge was greater among intervention (1.1 ± 2.0) versus control (0.4 ± 1.8) patients (P < .0001). Access to transplantation was similar among intervention (n = 168; 74.3%) versus control patients (n = 153; 70.5%; P = .37). The iChoose Kidney decision aid improved patient knowledge at evaluation, but did not impact transplant access. Future studies should examine whether combining iChoose Kidney with other interventions can increase transplantation. (Clinicaltrials.gov NCT02235571).
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Affiliation(s)
- Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Laura McPherson
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohua Basu
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Michael Wolf
- Northwestern University Comprehensive Transplant Center, Chicago, IL, USA
| | - Mariana Chiles
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Allison Russell
- Northwestern University Comprehensive Transplant Center, Chicago, IL, USA
| | - Jennifer C. Gander
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - John J. Friedewald
- Northwestern University Comprehensive Transplant Center, Chicago, IL, USA
| | - Daniela Ladner
- Northwestern University Comprehensive Transplant Center, Chicago, IL, USA
| | - Christian P. Larsen
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Thomas Pearson
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephen Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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11
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Patzer RE, Smith K, Basu M, Gander J, Mohan S, Escoffery C, Plantinga L, Melanson T, Kalloo S, Green G, Berlin A, Renville G, Browne T, Turgeon N, Caponi S, Zhang R, Pastan S. The ASCENT (Allocation System Changes for Equity in Kidney Transplantation) Study: a Randomized Effectiveness-Implementation Study to Improve Kidney Transplant Waitlisting and Reduce Racial Disparity. Kidney Int Rep 2017; 2:433-441. [PMID: 28845470 PMCID: PMC5568836 DOI: 10.1016/j.ekir.2017.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION The United Network for Organ Sharing (UNOS) implemented a new Kidney Allocation System (KAS) in December 2014 that is expected to substantially reduce racial disparities in kidney transplantation among waitlisted patients. However, not all dialysis facility clinical providers and end stage renal disease (ESRD) patients are aware of how the policy change could improve access to transplant. METHODS We describe the ASCENT (Allocation System Changes for Equity in KidNey Transplantation) study, a randomized controlled effectiveness-implementation study designed to test the effectiveness of a multicomponent intervention to improve access to the early steps of kidney transplantation among dialysis facilities across the United States. The multicomponent intervention consists of an educational webinar for dialysis medical directors, an educational video for patients and an educational video for dialysis staff, and a dialysis-facility specific transplant performance feedback report. Materials will be developed by a multidisciplinary dissemination advisory board and will undergo formative testing in dialysis facilities across the United States. RESULTS This study is estimated to enroll ~600 U.S. dialysis facilities with low waitlisting in all 18 ESRD Networks. The co-primary outcomes include change in waitlisting, and waitlist disparity at 1 year; secondary outcomes include changes in facility medical director knowledge about KAS, staff training regarding KAS, patient education regarding transplant, and a medical director's intent to refer patients for transplant evaluation. CONCLUSION The results from the ASCENT study will demonstrate the feasibility and effectiveness of a multicomponent intervention designed to increase access to the deceased-donor kidney waitlist and reduce racial disparities in waitlisting.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322.,Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine 1518 Clifton Road Atlanta, GA 30322.,Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University School of Medicine, 1518 Clifton Road, Atlanta, GA 30322
| | - Kayla Smith
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Mohua Basu
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Jennifer Gander
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, College of Physicians & Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, 622 West 169th Street, New York, NY 10032
| | - Cam Escoffery
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine 1518 Clifton Road Atlanta, GA 30322
| | - Laura Plantinga
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Taylor Melanson
- Department of Health Policy Management, Rollins School of Public Health, Emory School of Medicine, 1518 Clifton Road, Atlanta, GA 30322
| | - Sean Kalloo
- Department of Medicine, Division of Nephrology, College of Physicians & Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, 622 West 169th Street, New York, NY 10032
| | - Gary Green
- American Association of Kidney Patients, 2701 N. Rocky Point Drive, Suite 150, Tampa, FL 33607
| | - Alex Berlin
- Southeastern Kidney Transplant Coalition, Atlanta, GA 30322
| | - Gary Renville
- National Kidney Foundation, 270 Peachtree St NE #1040, Atlanta, GA 30303
| | - Teri Browne
- University of South Carolina, College of Social Work, 902 Sumter Street, Columbia, SC 29208
| | - Nicole Turgeon
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Susan Caponi
- US ESRD Network 2, 1979 Marcus Ave, Lake Success, NY 11042
| | - Rebecca Zhang
- Department of Biostatistics, Rollins School of Public Health, Emory University School of Medicine, 1518 Clifton Road, Atlanta, GA 30322
| | - Stephen Pastan
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
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Patzer RE, Basu M, Mohan S, Smith KD, Wolf M, Ladner D, Friedewald JJ, Chiles M, Russell A, McPherson L, Gander J, Pastan S. A Randomized Controlled Trial of a Mobile Clinical Decision Aid to Improve Access to Kidney Transplantation: iChoose Kidney. Kidney Int Rep 2016; 1:34-42. [PMID: 27610423 PMCID: PMC5012277 DOI: 10.1016/j.ekir.2016.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction Kidney transplantation is the preferred treatment for patients with end-stage renal disease, as it substantially increases a patient’s survival and is cost-saving compared to a lifetime of dialysis. However, transplantation is not universally chosen by patients with renal failure, and limited knowledge about the survival benefit of transplantation versus dialysis may play a role. We created a mobile application clinical decision aid called iChoose Kidney to improve access to individualized prognosis information comparing dialysis and transplantation outcomes. Methods We describe the iChoose Kidney study, a randomized controlled trial designed to test the clinical efficacy of a mobile health decision aid among end-stage renal disease patients referred for kidney transplantation at 3 large, diverse transplant centers across the United States. Approximately 450 patients will be randomized to receive either (i) standard of care or “usual” transplantation education, or (ii) standard of care plus iChoose Kidney. Results The primary outcome is change in knowledge about the survival benefit of kidney transplantation versus dialysis from baseline to immediate follow-up; secondary outcomes include change in treatment preferences, improved decisional conflict, and increased access to kidney transplantation. Analyses are also planned to examine effectiveness across subgroups of race, socioeconomic status, health literacy, and health numeracy. Discussion Engaging patients in health care choices can increase patient empowerment and improve knowledge and understanding of treatment choices. If the effectiveness of iChoose Kidney has a greater impact on patients with low health literacy, lower socioeconomic status, and minority race, this decision aid could help reduce disparities in access to kidney transplantation.
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Affiliation(s)
- Rachel E Patzer
- Emory Transplant Center, 1365 Clifton Road Northeast, Building B, 6th Floor, Atlanta, GA 30322
| | - Mohua Basu
- Emory Transplant Center, 1365 Clifton Road Northeast, Building B, 6th Floor, Atlanta, GA 30322
| | - Sumit Mohan
- Renal and Pancreatic Transplant Program: Columbia University Medical Center, 622 West 169th Street, New York, NY 10032
| | - Kayla D Smith
- Emory Transplant Center, 1365 Clifton Road Northeast, Building B, 6th Floor, Atlanta, GA 30322
| | - Michael Wolf
- Northwestern University Comprehensive Transplant Center, 676 St. Clair Street #1900, Chicago, IL 60611
| | - Daniela Ladner
- Northwestern University Comprehensive Transplant Center, 676 St. Clair Street #1900, Chicago, IL 60611
| | - John J Friedewald
- Northwestern University Comprehensive Transplant Center, 676 St. Clair Street #1900, Chicago, IL 60611
| | - Mariana Chiles
- Renal and Pancreatic Transplant Program: Columbia University Medical Center, 622 West 169th Street, New York, NY 10032
| | - Allison Russell
- Northwestern University Comprehensive Transplant Center, 676 St. Clair Street #1900, Chicago, IL 60611
| | - Laura McPherson
- Emory Transplant Center, 1365 Clifton Road Northeast, Building B, 6th Floor, Atlanta, GA 30322
| | - Jennifer Gander
- Emory Transplant Center, 1365 Clifton Road Northeast, Building B, 6th Floor, Atlanta, GA 30322
| | - Stephen Pastan
- Emory Transplant Center, 1365 Clifton Road Northeast, Building B, 6th Floor, Atlanta, GA 30322
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13
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Plantinga L, Lim SS, Patzer R, McClellan W, Kramer M, Klein M, Pastan S, Gordon C, Helmick C, Drenkard C. Incidence of End-Stage Renal Disease Among Newly Diagnosed Systemic Lupus Erythematosus Patients: The Georgia Lupus Registry. Arthritis Care Res (Hoboken) 2016; 68:357-65. [PMID: 26239749 DOI: 10.1002/acr.22685] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/24/2015] [Accepted: 07/28/2015] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To estimate and identify factors associated with the incidence of all-cause end-stage renal disease (ESRD) among newly diagnosed systemic lupus erythematosus (SLE) patients. METHODS Data from a national registry of treated ESRD were linked to data from a lupus registry of SLE patients who were newly diagnosed and living in Atlanta, Georgia, 2002-2004 (median followup 7.8 years). Cumulative incidence and incidence rates (ESRD treatment initiations per 1,000 patient-years) were calculated, and age- and race-adjusted Poisson models were used to calculate incidence rate ratios (IRRs). RESULTS Among 344 newly diagnosed SLE patients, 29 initiated ESRD treatment over 2,603.8 years of followup. Incidence rates were 13.8 (95% confidence interval [95% CI] 9.4-20.3) among black patients and 3.3 (95% CI 0.8-13.0) among white patients, per 1,000 patient-years; corresponding 5-year cumulative incidence was 6.4% and 2.5% among black and white patients, respectively. Lupus nephritis documented prior to 2005, which occurred in 80% of those who progressed to ESRD, was the strongest risk factor for incident ESRD (IRR 6.7 [95% CI 2.7-16.8]; incidence rate 27.6 per 1,000 patient-years). Results suggested that patients who were black versus white (IRR 3.9 [95% CI 0.9-16.4]) or <18 years old (versus ≥30 years old) at diagnosis (IRR 2.1 [95% CI 0.9-5.3]) may be more likely to progress to ESRD, but incidence did not differ by sex or other characteristics. CONCLUSION The incidence of all-cause ESRD among patients with a recent diagnosis of SLE is high in Georgia. Interventions to decrease ESRD incidence among newly diagnosed SLE patients should target young and black patients, as well as patients with lupus nephritis.
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Affiliation(s)
| | | | | | | | | | | | - Stephen Pastan
- Emory University and Emory Transplant Center, Emory Healthcare, Atlanta, Georgia
| | - Caroline Gordon
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Charles Helmick
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Browne T, Patzer RE, Gander J, Amamoo MA, Krisher J, Sauls L, Pastan S. Kidney transplant referral practices in southeastern dialysis units. Clin Transplant 2016; 30:365-71. [PMID: 26782140 DOI: 10.1111/ctr.12693] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND The Southeastern Kidney Transplant Coalition was created in 2010 to improve kidney transplant (KTx) rates in Georgia, North Carolina, and South Carolina. To identify dialysis staff-reported barriers to transplant, the Coalition developed a survey of dialysis providers in the region. METHODS All dialysis units in the ESRD Network (n = 586) were sent a survey to be completed by the professional responsible for helping patients get transplants. RESULTS One staff member at almost all (n = 546) of the dialysis units in Network 6 completed the survey (93% response rate). Almost all respondents reported being very comfortable (51.47%) or comfortable (46.89%) discussing the KTx process with patients. Just over half (56%) of facilities reported discussing KTx as a treatment option with patients on an annual basis. Fewer than one quarter of respondents (19%) perceived that more than 50% of their patients were interested in kidney transplant, and most of the staff surveyed (68%) reported that <25% of their dialysis patients completed the evaluation process and been wait-listed for a kidney transplant. CONCLUSION The survey results provide insight into KTx referral practices in southeastern dialysis units that may be contributing to low KTx rates in this region.
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Affiliation(s)
- Teri Browne
- University of South Carolina, Columbia, SC, USA
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15
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Ilori TO, Enofe N, Oommen A, Odewole O, Ojo A, Plantinga L, Pastan S, Echouffo-Tcheugui JB, McClellan W. Factors affecting willingness to receive a kidney transplant among minority patients at an urban safety-net hospital: a cross-sectional survey. BMC Nephrol 2015; 16:191. [PMID: 26588895 PMCID: PMC4654893 DOI: 10.1186/s12882-015-0186-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 11/09/2015] [Indexed: 11/21/2022] Open
Abstract
Background In the US, African Americans (AAs) are four times more likely to develop end stage renal disease (ESRD) but half as likely to receive a kidney transplant as whites. Patient interest in kidney transplantation is a fundamental step in the kidney transplant referral process. Our aim was to determine the factors associated with the willingness to receive a kidney transplant among chronic kidney disease (CKD) patients in a predominantly minority population. Methods CKD patients from an outpatient nephrology clinic at a safety-net hospital (n = 213) participated in a cross-sectional survey from April to June, 2013 to examine the factors associated with willingness to receive a kidney transplant among a predominantly minority population. The study questionnaire was developed from previously published literature. Multivariable logistic regression analysis was used to determine factors associated with willingness to undergo a kidney transplant. Results Respondents were primarily AAs (91.0 %), mostly female (57.6 %) and middle aged (51.6 %). Overall, 53.9 % of participants were willing to undergo a kidney transplant. Willingness to undergo a kidney transplant was associated with a positive perception towards living kidney donation (OR 7.31, 95 % CI: 1.31–40.88), willingness to attend a class about kidney transplant (OR = 7.15, CI: 1.76–29.05), perception that a kidney transplant will improve quality of life compared to dialysis (OR = 5.40, 95 % CI: 1.97–14.81), and obtaining information on kidney transplant from other sources vs. participant’s physician (OR =3.30, 95 % CI: 1.13–9.67), when compared with their reference groups. Conclusion It is essential that the quality of life benefits of kidney transplantation be known to individuals with CKD to increase their willingness to undergo kidney transplantation. Availability of multiple sources of information and classes on kidney transplantation may also contribute to willingness to undergo kidney transplantation, especially among AAs. Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0186-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Titilayo O Ilori
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA. .,Renal Division, Emory University School of Medicine, 1639 Pierce Drive, Atlanta GA. Clifton Road, Atlanta, Georgia, 30322, USA.
| | - Nosayaba Enofe
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Anju Oommen
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Oluwaseun Odewole
- Department of Radiology and Imaging Science, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Akinlolu Ojo
- Department of Medicine, Renal Division, University of Michigan, Ann Arbor, Michigan, USA.
| | - Laura Plantinga
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Stephen Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA. .,Emory Transplant Center, Emory Healthcare, Atlanta, Georgia, USA.
| | - Justin B Echouffo-Tcheugui
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA. .,MedStar Health, Baltimore, Maryland, USA.
| | - William McClellan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA. .,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
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16
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Plantinga LC, Drenkard C, Patzer RE, Klein M, Kramer MR, Pastan S, Lim SS, McClellan WM. Sociodemographic and geographic predictors of quality of care in United States patients with end-stage renal disease due to lupus nephritis. Arthritis Rheumatol 2015; 67:761-72. [PMID: 25692867 DOI: 10.1002/art.38983] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 12/02/2014] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To describe end-stage renal disease (ESRD) quality of care (receipt of pre-ESRD nephrology care, access to kidney transplantation, and placement of permanent vascular access for dialysis) in US patients with ESRD due to lupus nephritis (LN-ESRD) and to examine whether quality measures differ by patient sociodemographic characteristics or US region. METHODS National surveillance data on patients in the US in whom treatment for LN-ESRD was initiated between July 2005 and September 2011 (n = 6,594) were analyzed. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) were determined for each quality measure, according to sociodemographic factors and US region. RESULTS Overall, 71% of the patients received nephrology care prior to ESRD. Black and Hispanic patients were less likely than white patients to receive pre-ESRD care (OR 0.73 [95% CI 0.63-0.85] and OR 0.73 [95% CI 0.60-0.88], respectively) and to be placed on the kidney transplant waitlist within the first year after the start of ESRD (HR 0.78 [95% CI 0.68-0.91] and HR 0.82 [95% CI 0.68-0.98], respectively). Those with Medicaid (HR 0.51 [95% CI 0.44-0.58]) or no insurance (HR 0.36 [95% CI 0.29-0.44]) were less likely than those with private insurance to be placed on the waitlist. Only 24% had a permanent vascular access, and placement was even less likely among the uninsured (OR 0.62 [95% CI 0.49-0.79]). ESRD quality-of-care measures varied 2-3-fold across regions of the US, with patients in the Northeast and Northwest generally having higher probabilities of adequate care. CONCLUSION LN-ESRD patients have suboptimal ESRD care, particularly with regard to placement of dialysis vascular access. Minority race/ethnicity and lack of private insurance are associated with inadequate ESRD care. Further studies are warranted to examine multilevel barriers to, and develop targeted interventions to improve delivery of, care among patients with LN-ESRD.
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Plantinga L, Pastan S, Kramer M, McClellan A, Krisher J, Patzer RE. Association of U.S. Dialysis facility neighborhood characteristics with facility-level kidney transplantation. Am J Nephrol 2014; 40:164-73. [PMID: 25196018 DOI: 10.1159/000365596] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [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: 05/16/2014] [Accepted: 06/29/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Improving access to optimal healthcare may depend on the attributes of neighborhoods where patients receive healthcare services. We investigated whether the characteristics of dialysis facility neighborhoods--where most patients with end-stage renal disease are treated--were associated with facility-level kidney transplantation. METHODS We examined the association between census tract (neighborhood)-level sociodemographic factors and facility-level kidney transplantation rate in 3,983 U.S. dialysis facilities where kidney transplantation rates were high. Number of kidney transplants and total person-years contributed at the facility level in 2007-2010 were obtained from the Dialysis Facility Report and linked to the census tract data on sociodemographic characteristics from the American Community Survey 2006-2010 by dialysis facility location. We used multivariable Poisson models with generalized estimating equations to estimate the link between the neighborhood characteristics and transplant incidence. RESULTS Dialysis facilities in the United States were located in neighborhoods with substantially greater proportions of black and poor residents, relative to the national average. Most facility neighborhood characteristics were associated with transplant, with incidence rate ratios (95% CI) for standardized increments (in percentage) of neighborhood exposures of: living in poverty, 0.88 (0.84-0.92), black race, 0.83 (0.78-0.89); high school graduates, 1.22 (1.17-1.26); and unemployed, 0.90 (0.85-0.95). CONCLUSION Dialysis facility neighborhood characteristics may be modestly associated with facility rates of kidney transplantation. The success of dialysis facility interventions to improve access to kidney transplantation may partially depend on reducing neighborhood-level barriers.
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Affiliation(s)
- Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Atlanta, Ga., USA
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18
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Flueckiger P, Pastan S, Goyal A, McClellan WW, Patzer RE. Associations of ECG interval prolongations with mortality among ESRD patients evaluated for renal transplantation. Ann Transplant 2014; 19:257-68. [PMID: 24878746 DOI: 10.12659/aot.889927] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND It is unknown whether prolongation of electrocardiogram (ECG) intervals is associated with mortality in end-stage renal disease (ESRD) patients evaluated for renal transplantation. MATERIAL AND METHODS We examined the relationship between 12-lead ECG interval measurements (PR >200 ms, QRS >110 ms, or QTC >450 ms) and the presence of none, 1, and 2 or more ECG interval prolongations with all-cause mortality in 930 adult ESRD patients evaluated for renal transplantation from August 2006 to October 2008 and followed through November 2010. RESULTS A total of 108 (11.6%) patients died after a median follow-up of 3.1 years. A stepwise increase in all-cause mortality occurred among adult ESRD patients with prolongation of 1, and 2 or more ECG intervals. In adjusted analyses, the rate of death in patients with at least 1 ECG interval prolongation was 69% higher than that of patients with no ECG prolongations (HR=1.69; 95% CI: 1.05-2.73). Patients with 2 or more ECG interval prolongations had a 2.5-fold increased likelihood of dying vs. patients with no ECG interval prolongations (HR 2.53, 95% CI 1.38-4.82). CONCLUSIONS ECG interval prolongations are associated with higher mortality in patients evaluated for renal transplantation. The ECG is a potentially important evaluative tool for risk assessment in this population.
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Affiliation(s)
| | | | - Abinav Goyal
- Department of Medicine, Emory University, Atlanta, USA
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19
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Patzer RE, Perryman JP, Pastan S, Amaral S, Gazmararian JA, Klein M, Kutner N, McClellan WM. Impact of a patient education program on disparities in kidney transplant evaluation. Clin J Am Soc Nephrol 2012; 7:648-55. [PMID: 22344515 DOI: 10.2215/cjn.10071011] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In 2007, the Emory Transplant Center (ETC) kidney transplant program implemented a required educational session for ESRD patients referred for renal transplant evaluation to increase patient awareness and decrease loss to follow-up. The purpose of this study was to evaluate the association of the ETC education program on completion of the transplant evaluation process. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Incident, adult ESRD patients referred from 2005 to 2008 were included. Patient data were abstracted from medical records and linked with data from the United States Renal Data System. Evaluation completion was compared by pre- and posteducational intervention groups in binomial regression models accounting for temporal confounding. RESULTS A total of 1126 adult ESRD patients were examined in two transplant evaluation eras (75% pre- and 25% postintervention). One-year evaluation completion was higher in the post- versus preintervention group (80.4% versus 44.7%, P<0.0001). In adjusted analyses controlling for time trends, the adjusted probability of evaluation completion at 1 year was higher among the intervention versus nonintervention group (risk ratio=1.38, 95% confidence interval=1.12-1.71). The effect of the intervention was stronger among black patients and those patients living in poor neighborhoods (likelihood ratio test for interaction, P<0.05). CONCLUSIONS Standardizing transplant education may help reduce some of the racial and socioeconomic disparities observed in kidney transplantation.
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Affiliation(s)
- Rachel E Patzer
- Emory Transplant Center, Emory University, Atlanta, Georgia 30322, USA.
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Patzer RE, Perryman JP, Schrager JD, Pastan S, Amaral S, Gazmararian JA, Klein M, Kutner N, McClellan WM. The role of race and poverty on steps to kidney transplantation in the Southeastern United States. Am J Transplant 2012; 12:358-68. [PMID: 22233181 PMCID: PMC3950902 DOI: 10.1111/j.1600-6143.2011.03927.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [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: 01/25/2023]
Abstract
Racial disparities in access to renal transplantation exist, but the effects of race and socioeconomic status (SES) on early steps of renal transplantation have not been well explored. Adult patients referred for renal transplant evaluation at a single transplant center in the Southeastern United States from 2005 to 2007, followed through May 2010, were examined. Demographic and clinical data were obtained from patient's medical records and then linked with United States Renal Data System and American Community Survey Census data. Cox models examined the effect of race on referral, evaluation, waitlisting and organ receipt. Of 2291 patients, 64.9% were black, the mean age was 49.4 years and 33.6% lived in poor neighborhoods. Racial disparities were observed in access to referral, transplant evaluation, waitlisting and organ receipt. SES explained almost one-third of the lower rate of transplant among black versus white patients, but even after adjustment for demographic, clinical and SES factors, blacks had a 59% lower rate of transplant than whites (hazard ratio = 0.41; 95% confidence interval: 0.28-0.58). Results suggest that improving access to healthcare may reduce some, but not all, of the racial disparities in access to kidney transplantation.
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Affiliation(s)
- R. E. Patzer
- Emory Transplant Center, Emory University, Atlanta, GA,Emory Healthcare, Emory Transplant Center, Atlanta, GA,Corresponding author: Rachel E. Patzer,
| | | | | | - S. Pastan
- Emory Transplant Center, Emory University, Atlanta, GA,Emory University School of Medicine, Division of Nephrology, Atlanta, GA
| | - S. Amaral
- Children's Hospital of Philadelphia, Division of Nephrology, Philadelphia, PA
| | | | - M. Klein
- Emory Healthcare, Emory Transplant Center, Atlanta, GA
| | - N. Kutner
- Emory University, USRDS Rehabilitation/QoL Special Studies Center, Atlanta, GA
| | - W. M. McClellan
- Emory Healthcare, Emory Transplant Center, Atlanta, GA,Emory University School of Medicine, Division of Nephrology, Atlanta, GA
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Pastan S. Primer on Transplantation edited by Donald Hricik. Am J Transplant 2011. [DOI: 10.1111/j.1600-6143.2011.03577.x] [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: 11/30/2022]
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Pinnaka J, Manocha P, Pastan S. 247 De Novo Al Amyloidosis Presenting in a Renal Allograft: A Report of Two Cases. Am J Kidney Dis 2011. [DOI: 10.1053/j.ajkd.2011.02.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Kutner N, Bowles T, Zhang R, Huang Y, Pastan S. Dialysis facility characteristics and variation in employment rates: a national study. Clin J Am Soc Nephrol 2008; 3:111-6. [PMID: 18178781 DOI: 10.2215/cjn.02990707] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Investigation of factors associated with variation in dialysis patient employment has focused primarily on patient-level factors. Little is known about facility-level factors that may be associated with patient employment. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS The ESRD Facility Survey (CMS-2744A) began in 2004 to collect counts of employed patients aged 18 to 54, in addition to dialysis unit census, types and timing of treatments offered, and staffing. Using the 2004 ESRD Facility Survey File, we investigated dialysis unit characteristics and facility employment rate of patients aged 18 to 54 in a logistic regression analysis that included hospital-based chronic renal care facilities, nonhospital renal disease treatment centers, independent special purpose renal dialysis facilities, and renal disease treatment centers. RESULTS Across all facilities, 18.9% of prevalent patients aged 18 to 54 were employed, but facility employment rates ranged from 0 to 100%. Facility employment rate was positively associated independently with availability of a 5 p.m. or later dialysis shift (odds ratio (OR) 1.54, 95% confidence interval (CI) 1.42 to 1.68), availability of peritoneal dialysis or home hemodialysis (HD) training (OR 1.19, 95% CI 1.11 to 1.28), and provision of frequent HD (OR 1.26, 95% CI 1.07 to 1.49), after adjusting for patient/social worker ratio, rurality of unit location, and unit size. In addition, patient receipt of Vocational Rehabilitation (VR) services was more often reported in facilities with higher employment rates. CONCLUSIONS Promoting gainful employment among ESRD patients continues to be a quality improvement need. A dataset that allows adjustment for patient-level variables would facilitate increased understanding of the contribution of dialysis facility variables to patient employment.
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Affiliation(s)
- Nancy Kutner
- Rehabilitation/Quality of Life Special Studies Center, United States Renal Data System, Emory University, Atlanta, Georgia, USA.
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Charytan D, MacDonald B, Sugimoto H, Pastan S, Staton G, Hennigar R, Kalluri R. An unusual case of pulmonary-renal syndrome associated with defects in type IV collagen composition and anti-glomerular basement membrane autoantibodies. Am J Kidney Dis 2005; 45:743-8. [PMID: 15806477 DOI: 10.1053/j.ajkd.2004.12.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [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: 11/11/2022]
Abstract
Commercial serological assays for the presence of anti-glomerular basement membrane (GBM) antibodies are thought to be indicative of Goodpasture's syndrome. We report a case in which commercial tests inaccurately suggested that a patient with a pulmonary-renal syndrome had Goodpasture's disease. Additional laboratory testing using recombinant type IV collagen NC1 domain proteins showed that the autoantibodies in question were not directed against the Goodpasture antigen (the alpha3NC1 domain), but against the alpha2NC1 domain of type IV collagen. Our findings represent the first known case of human autoantibodies to the alpha2NC1 domain. Further investigation showed that this patient has decreased alpha3 and alpha5 chain expression in the GBM and defects in type IV collagen, resembling abnormalities in patients with Alport's syndrome.
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Affiliation(s)
- David Charytan
- Department of Medicine, Center for Matrix Biology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA 02215, USA
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McClellan WM, Hodgin E, Pastan S, McAdams L, Soucie M. A Randomized Evaluation of Two Health Care Quality Improvement Program (HCQIP) Interventions to Improve the Adequacy of Hemodialysis Care of ESRD Patients: Feedback Alone versus Intensive Intervention. J Am Soc Nephrol 2004; 15:754-60. [PMID: 14978178 DOI: 10.1097/01.asn.0000115701.51613.d7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
End-stage renal disease (ESRD) Networks are quality improvement organizations that collect, analyze, and report information to clinicians and allied health providers about discrepancies between observed patterns of care of ESRD patients and what has been recommended by clinical practice guidelines. The Networks facilitate response to this information by assisting ESRD treatment centers to develop quality improvement programs to redress inadequate care. The authors evaluated this process of quality improvement by selecting 42 treatment centers in a single ESRD Network with the lowest facility-specific mean urea reduction ratio (URR). The treatment centers were randomly assigned to two intervention strategies: (1) feedback alone; (2) an intensive intervention that included feedback, workshops, distribution of educational materials and clinical practice guidelines, technical assistance with the development of quality improvement plans, and continued monitoring. The intensive intervention had greater improvement in the increased proportions of patients dialyzed with prescribed blood flow (P = 0.02) and documented review of prescription (P = 0.01). Furthermore, the mean center URR increased nearly 3% among intensive intervention centers (from 68.1 to 70.9) but only 0.09% among the feedback centers (68.2 to 69.1) (P = 0.002). Similarly, time on dialysis increased 7.5 min on average among patients in intervention centers but decreased 2 min for patients in comparison centers (P = 0.03). These results demonstrate that Network feedback, coupled with the intensive intervention, resulted in improvement in care that would otherwise not have occurred.
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Abstract
BACKGROUND Hemodialysis with a venous catheter increases the risk of infection. The extent to which venous catheters are associated with an increased risk of death among hemodialysis patients has not been extensively studied. METHODS We conducted a retrospective cohort study of 7497 prevalent hemodialysis patients to assess the association between dialysis with a venous catheter and risk of death due to all causes and to infection. RESULTS A tunneled cuffed catheter was used for access in 12% of the patients and non-cuffed, not tunneled catheter in 2%. Younger age (P = 0.0005), black race (P = 0.0022), female gender (P = 0.0004), short duration since starting dialysis (P = 0.0003) and impaired functional status (P = 0.0001) were independently associated with increased use of catheter access. The proportion of patients who died was higher among those who were dialyzed with a non-cuffed (16.8%) or cuffed (15.2%) catheter compared to those dialyzed with either a graft (9.1%) or a fistula (7.3%; P < 0.001). The proportion of deaths due to infection was higher among patients dialyzed with a catheter (3.4%) compared to those dialyzed with either a graft (1.2%) or a fistula (0.8%; P < 0.001). The adjusted odds ratio (95% CI) for all-cause and infection-related death among patients dialyzed with a catheter was 1.4 (1.1, 1.9) and 3.0 (1.4, 6.6), respectively, compared to those with an arteriovenous (AV) fistula. CONCLUSION Venous catheters are associated with an increased risk of all-cause and infection-related mortality among hemodialysis patients.
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Affiliation(s)
- Stephen Pastan
- Renal Division, Department of Medicine, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, USA
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Affiliation(s)
- S Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, GA, USA.
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Abstract
The 18 End Stage Renal Disease (ESRD) Networks were established by Congress to oversee the care of Medicare beneficiaries with ESRD, serving as HCFA's primary quality improvement (QI) agents. The Networks play a critical role in the ESRD surveillance system by collecting, analyzing and disseminating data from dialysis clinics regarding the occurrence of ESRD, and the processes of care and outcomes of ESRD patients. In addition, under the direction of volunteer Medical Review Boards, the Networks propose, design and implement regional QI activities targeting specific areas in the delivery of ESRD care, and provide technical assistance to foster QI at the facility level. In this article, we discuss the ESRD Network system and review the scope of QI activities through which the Networks accomplish their mission.
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Affiliation(s)
- J Krisher
- Southeastern Kidney Council/ESRD Network 6, and the Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, GA, USA
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Abstract
BACKGROUND The purpose of this study was to evaluate the relationship between dialysis dose, patient characteristics, and medical comorbidities on mortality in chronic peritoneal dialysis patients. METHODS This work comprised a study cohort of 1446 patients obtained from a random sample of chronic peritoneal dialysis patients from each dialysis center in three southeastern states. Data collected on a standardized form were used to calculate weekly Kt/V urea and creatinine clearance. Data were linked to Network files containing data on patient demographic and medical comorbidities. RESULTS Both weekly Kt/V urea and creatinine clearance were measured at least once in only 60.5% of continuous ambulatory peritoneal dialysis (CAPD) patients and 63.7% of cycler patients. Among the 873 patients who had at least one calculable adequacy measure, the mean (+/-SD) weekly Kt/V urea was 2.13 +/- 0.55, and the normalized mean weekly creatinine clearance was 62.9 +/- 20.4 L/week/m2. During the seven month period of follow-up, there were 140 deaths. In separate logistic regression models that included all of the studied risk factors, using separate variables for the urinary and peritoneal components of dialysis adequacy, each 10 L/week/1.73 m2 increase in the urinary component of weekly creatinine clearance was associated with a 40% decreased risk of death, and each 0.1 unit increase in the urinary component of weekly Kt/V urea was associated with a 12% decreased risk of death. In contrast, the dialysate components of neither weekly creatinine clearance nor weekly Kt/V urea were predictive of death. Other factors that were associated with an increased risk of death included increasing age, diabetes mellitus as the cause of end-stage renal disease (ESRD), and a history of myocardial infarction. CONCLUSIONS Residual renal function, as expressed by weekly creatinine clearance or Kt/V urea, is an important predictor of death in chronic peritoneal dialysis patients. The nonsignificant findings regarding peritoneal clearances and mortality may possibly be secondary to the narrow range of peritoneal clearances in this study cohort.
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Affiliation(s)
- M Rocco
- Division of Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1053, USA.
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Affiliation(s)
- S Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, GA 30308, USA
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Affiliation(s)
- Stephen Pastan
- Dept of the Medicine, Emory University School of Medicine, 30308, Atlanta, GA, USA
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Abstract
Bioelectrical impedance (BEI) measurements have been used to measure total body water volume (VBEI). The VBEI were measured after hemodialysis in 14 patients, as was dialyzer blood water urea clearance (KBW) and dialysate urea clearance (KD). Urea clearance based on the mass transfer coefficient, KoA, was determined (KKoA). Residual renal function was measured, and three point variable volume single pool urea kinetic modeling (UKM) was done. Urea distribution volumes were calculated using the measured urea clearance values from blood water (VBW), dialysate (VD), and KoA (VKoA) as inputs. Direct dialysate quantitation was calculated based on total dialysate collections to measure urea clearance (KDDQ) and urea distribution volume (VDDQ). Total body water estimates were made using the Hume and Watson anthropometric formulas (VHUME and VWATSON). It was found that average VBEI (34.76 L) was larger than VBW (27.50 L) and VD (26.69 L), but it was not different from VKoA (32.15 L), VHUME (35.15 L), or VWATSON (34.53 L). Linear regression revealed a good correlation between VBEI and both VBW and VD (R = 0.873 and 0.882, respectively). The BEI measurements provide a simple method for measuring total body water in dialysis patients that correlated well with UKM volumes.
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Affiliation(s)
- S Pastan
- Department of Medicine, University School of Medicine, Indianapolis, Indiana
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Pastan S, Gassensmith C, Manatunga AK, Copley JB, Smith EJ, Hamburger RJ. Prospective comparison of peritoneoscopic and surgical implantation of CAPD catheters. ASAIO Trans 1991; 37:M154-6. [PMID: 1836333] [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] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Prospectively collected data were analyzed comparing surgically and peritoneoscopically placed peritoneal dialysis catheters in 88 patients. Peritoneoscopically placed catheters were found to survive longer than surgically placed ones. Rates of exit site infection and pericatheter leaks were found to be similar with both techniques.
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Affiliation(s)
- S Pastan
- Department of Medicine, Indiana University School of Medicine, Indianapolis
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Abstract
Concern exists that increasingly high-efficiency dialysis will result in large urea gradients between intracellular and extracellular compartments (VI, VE) leading to large amounts of extracellular volume depletion (delta VE) and hemodynamic instability induced by rapid water flow from VE to VI. The authors investigated this question with a two-compartment model that provided estimates of VI, VE, and osmotically active intracellular and extracellular urea and nonurea concentrations during hemodialysis. The authors found that the urea gradient-induced transcellular water shift is only a very small fraction of VE, even with high urea clearance and short hemodialysis time. The net water shift was small because the urea and nonurea transcellular osmolar gradients were of similar magnitudes but in offsetting directions.
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Affiliation(s)
- S Pastan
- Department of Medicine, Indiana University School of Medicine, Indianapolis
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