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1.
J Am Soc Nephrol ; 34(4): 656-667, 2023 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-36735377

RESUMO

SIGNIFICANCE STATEMENT: Pregnancies in women with CKD carry greater risk than pregnancies in the general population. The small number of women in prior studies has limited estimates of this risk, especially among those with advanced CKD. We report the results of a population-based cohort study in Ontario, Canada, that assessed more than 500,000 pregnancies, including 600 with a baseline eGFR < 60 ml/min per 1.73 m 2 . The investigation demonstrates increases in risk of different adverse maternal and fetal outcomes with lower eGFR and further risk elevation with baseline proteinuria. BACKGROUND: CKD is a risk factor for pregnancy complications, but estimates for adverse outcomes come largely from single-center studies with few women with moderate or advanced stage CKD. METHODS: To investigate the association between maternal baseline eGFR and risk of adverse pregnancy outcomes, we conducted a retrospective, population-based cohort study of women (not on dialysis or having had a kidney transplant) in Ontario, Canada, who delivered between 2007 and 2019. The study included 565,907 pregnancies among 462,053 women. Administrative health databases captured hospital births, outpatient laboratory testing, and pregnancy complications. We analyzed pregnancies with serum creatinine measured within 2 years of conception up to 30 days after conception and assessed the impact of urine protein where available. RESULTS: The risk of major maternal morbidity, preterm delivery, and low birthweight increased monotonically across declining eGFR categories, with risk increase most notable as eGFR dropped below 60 ml/min per 1.73 m 2 . A total of 56 (40%) of the 133 pregnancies with an eGFR <45 ml/min per 1.73 m 2 resulted in delivery under 37 weeks, compared with 10% of pregnancies when eGFR exceeded 90 ml/min per 1.73 m 2 . Greater proteinuria significantly increased risk within each eGFR category. Maternal and neonatal deaths were rare regardless of baseline eGFR (<0.3% of all pregnancies). Only 7% of women with an eGFR <45 ml/min per 1.73 m 2 received dialysis during or immediately after pregnancy. CONCLUSIONS: We observed higher rates of adverse pregnancy outcomes in women with low eGFR with concurrent proteinuria. These results can help inform health care policy, preconception counseling, and pregnancy follow-up in women with CKD.


Assuntos
Complicações na Gravidez , Nascimento Prematuro , Insuficiência Renal Crônica , Feminino , Humanos , Recém-Nascido , Gravidez , Estudos de Coortes , Ontário/epidemiologia , Complicações na Gravidez/epidemiologia , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/etiologia , Proteinúria , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/terapia , Estudos Retrospectivos , Taxa de Filtração Glomerular
2.
J Am Soc Nephrol ; 34(7): 1155-1158, 2023 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-37022115

RESUMO

SIGNIFICANCE STATEMENT: Nephrologist staffing models for patients receiving hemodialysis vary widely. Patients may be cared for continuously by a single primary nephrologist or by a group of nephrologists on a rotating basis. It remains unclear whether these differing care models influence clinical outcomes. In this population-based cohort study of more than 14,000 incident patients on maintenance hemodialysis from Ontario, Canada, we found no difference in mortality, kidney transplantation, home dialysis initiation, hospitalizations, or emergency department visits when care was provided by a single primary nephrologist or a rotating group of nephrologists. These results suggest that primary nephrologist models do not necessarily improve objective clinical outcomes, providing reassurance to patients, providers, and administrators that both models are acceptable options.


Assuntos
Falência Renal Crônica , Nefrologistas , Humanos , Falência Renal Crônica/terapia , Estudos de Coortes , Diálise Renal/métodos , Ontário
3.
Am J Kidney Dis ; 81(5): 554-563.e1, 2023 05.
Artigo em Inglês | MEDLINE | ID: mdl-36521779

RESUMO

RATIONALE & OBJECTIVE: To determine whether attendance at an acute kidney injury (AKI) follow-up clinic is associated with reduced major adverse kidney events. STUDY DESIGN: Propensity-matched cohort study. SETTING & PARTICIPANTS: Patients hospitalized with AKI in Ontario, Canada, from February 1, 2013, through September 30, 2017, at a single clinical center, who were not receiving dialysis when discharged. EXPOSURE: Standardized assessment by a nephrologist. OUTCOMES: Time to a major adverse kidney event, defined as death, initiation of maintenance dialysis, or incident/progressive chronic kidney disease. ANALYTICAL APPROACH: Propensity scores were used to match each patient who attended an AKI follow-up clinic to 4 patients who received standard care. Cox proportional hazards models were fit to assess the association between the care within an AKI follow-up clinic and outcomes. To avoid immortal time bias, we randomly assigned index dates to the comparator group. RESULTS: We matched 164 patients from the AKI follow-up clinic to 656 patients who received standard care. During a mean follow-up of 2.2±1.3 (SD) years, care in the AKI follow-up clinic was not associated with a reduction in major adverse kidney events relative to standard care (22.1 vs 24.7 events per 100 patient-years; HR, 0.91 [95% CI, 0.75-1.11]). The AKI follow-up clinic was associated with a lower risk of all-cause mortality (HR, 0.71 [95% CI, 0.55-0.91]). Patients aged at least 66 years who attended the AKI follow-up clinic were more likely to receive ß-blockers (HR, 1.34 [95% CI, 1.02-1.77]) and statins (HR, 1.35 [95% CI, 1.05-1.74]), but not angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (HR, 1.21 [95% CI, 0.94-1.56]). LIMITATIONS: Single-center study and residual confounding. CONCLUSIONS: Specialized postdischarge follow-up for AKI survivors was not associated with a lower risk of major adverse kidney events but was associated with a lower risk of death and increased prescriptions for some cardioprotective medications.


Assuntos
Injúria Renal Aguda , Assistência ao Convalescente , Humanos , Estudos de Coortes , Seguimentos , Alta do Paciente , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/terapia , Injúria Renal Aguda/complicações , Ontário/epidemiologia , Fatores de Risco
4.
Am J Kidney Dis ; 79(4): 561-569, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34487795

RESUMO

RATIONALE & OBJECTIVE: Even though studies have demonstrated a relationship between hypertensive disorders of pregnancy (HDPs) and chronic kidney disease, there are limited data on the risk of acute kidney injury (AKI) following HDPs. We examined the risk of AKI following the occurrence of HDPs. STUDY DESIGN: Retrospective population-based cohort study. SETTING & PARTICIPANTS: Pregnant women in Ontario, Canada, aged 14-50 years, who delivered at ≥20 weeks' gestation between April 1, 2002, and March 31, 2015. EXPOSURE: Preeclampsia, gestational hypertension, or neither. OUTCOMES: The primary outcome was AKI with receipt of dialysis (AKI-D) ≥90 days after delivery. The main secondary outcome was AKI based on a hospitalization with a diagnostic code for AKI ≥90 days after delivery. ANALYTICAL APPROACH: Time-dependent Cox proportional and cause-specific hazards models were used to evaluate the relationship between HDP and outcomes of interest. Models were adjusted for baseline and time-varying covariates. RESULTS: Our cohort comprised 1,142,656 women and 1,826,235 deliveries, of which 1.7% were associated with gestational hypertension and 4.4% with preeclampsia. After a mean follow-up of 6.7 years, there were 322 episodes of AKI-D (0.41 per 10,000 person-years) and 1,598 episodes of AKI based on diagnostic codes (2.04 per 10,000 person-years). After adjustment, neither preeclampsia nor gestational hypertension was associated with AKI-D. Preeclampsia was associated with AKI (HR, 1.22 [95% CI, 1.03-1.45]), but gestational hypertension was not. LIMITATIONS: Retrospective design and possible unmeasured confounding. Cases of HDPs and AKI may have been undetected. CONCLUSIONS: Preeclampsia was a risk factor for AKI occurring ≥90 days after delivery. Our findings suggest the potential importance of obtaining a pregnancy history as part of a comprehensive risk profile for acute kidney disease and suggest that women with a history of HDP may benefit from monitoring of kidney function.


Assuntos
Injúria Renal Aguda , Hipertensão Induzida pela Gravidez , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Adolescente , Adulto , Estudos de Coortes , Feminino , Humanos , Hipertensão Induzida pela Gravidez/diagnóstico , Hipertensão Induzida pela Gravidez/epidemiologia , Pessoa de Meia-Idade , Ontário/epidemiologia , Gravidez , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
5.
PLoS Med ; 17(5): e1003104, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32427997

RESUMO

BACKGROUND: The relation between prepregnancy average glucose concentration and a woman's risk of severe maternal morbidity (SMM) is unknown. The current study evaluated whether an elevated preconception hemoglobin A1c (A1c) is associated with SMM or maternal death among women with and without known prepregnancy diabetes mellitus (DM). METHODS AND FINDINGS: A population-based cohort study was completed in Ontario, Canada, where there is universal healthcare. The main cohort included 31,225 women aged 16-50 years with a hospital live birth or stillbirth from 2007 to 2015, and who had an A1c measured within 90 days before conception, including 28,075 women (90%) without known prepregnancy DM. The main outcome was SMM or maternal mortality from 23 weeks' gestation up to 42 days postpartum. Relative risks (RRs) were generated using modified Poisson regression, adjusting for the main covariates of maternal age, multifetal pregnancy, world region of origin, and tobacco/drug dependence. The mean maternal age was 31.1 years. Overall, SMM or death arose among 682 births (2.2%). The RR of SMM or death was 1.16 (95% CI 1.14-1.19; p < 0.001) per 0.5% increase in A1c and 1.16 (95% CI 1.13-1.18; p < 0.001) after adjusting for the main covariates. The adjusted relative risk (aRR) was increased among those with (1.11, 95% CI 1.07-1.14; p < 0.001) and without (1.15, 95% CI 1.02-1.29; p < 0.001) known prepregnancy diabetes, and upon further adjusting for body mass index (BMI) (1.15, 95% CI 1.11-1.20; p < 0.001), or chronic hypertension and prepregnancy serum creatinine (1.11, 95% CI 1.04-1.18; p = 0.002). The aRR of SMM or death was 1.31 (95% CI 1.06-1.62; p = 0.01) in those with a preconception A1c of 5.8%-6.4%, and 2.84 (95% CI 2.31-3.49; p < 0.001) at an A1c > 6.4%, each relative to an A1c < 5.8%. Among those without previously recognized prepregnancy diabetes and whose A1c was >6.4%, the aRR of SMM or death was 3.25 (95% CI 1.76-6.00; p < 0.001). Study limitations include that selection bias may have incorporated less healthy women tested for A1c, and BMI was unknown for many women. CONCLUSIONS: Our findings indicate that women with an elevated A1c preconception may be at higher risk of SMM or death in pregnancy or postpartum, including those without known prepregnancy DM.


Assuntos
Idade Gestacional , Hemoglobinas Glicadas/metabolismo , Mortalidade Materna , Complicações na Gravidez/epidemiologia , Adolescente , Adulto , Estudos de Coortes , Feminino , Humanos , Nascido Vivo/epidemiologia , Masculino , Idade Materna , Pessoa de Meia-Idade , Período Pós-Parto/fisiologia , Gravidez , Fatores de Risco , Adulto Jovem
6.
Am J Kidney Dis ; 75(4): 471-479, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31732233

RESUMO

RATIONALE & OBJECTIVE: Surveillance blood work is routinely performed in maintenance hemodialysis (HD) recipients. Although more frequent blood testing may confer better outcomes, there is little evidence to support any particular monitoring interval. STUDY DESIGN: Retrospective population-based cohort study. SETTING & PARTICIPANTS: All prevalent HD recipients in Ontario, Canada, as of April 1, 2011, and a cohort of incident patients commencing maintenance HD in Ontario, Canada, between April 1, 2011, and March 31, 2016. EXPOSURE: Frequency of surveillance blood work, monthly versus every 6 weeks. OUTCOMES: The primary outcome was all-cause mortality. Secondary outcomes were major adverse cardiovascular events, all-cause hospitalization, and episodes of hyperkalemia. ANALYTICAL APPROACH: Cox proportional hazards with adjustment for demographic and clinical characteristics was used to evaluate the association between blood testing frequency and all-cause mortality. Secondary outcomes were evaluated using the Andersen-Gill extension of the Cox model to allow for potential recurrent events. RESULTS: 7,454 prevalent patients received care at 17 HD programs with monthly blood sampling protocols (n=5,335 patients) and at 8 programs with blood sampling every 6 weeks (n=2,119 patients). More frequent monitoring was not associated with a lower risk for all-cause mortality compared to blood sampling every 6 weeks (adjusted HR, 1.16; 95% CI, 0.99-1.38). Monthly monitoring was not associated with a lower risk for any of the secondary outcomes. Results were consistent among incident HD recipients. LIMITATIONS: Unmeasured confounding; limited data for center practices unrelated to blood sampling frequency; no information on frequency of unscheduled blood work performed outside the prescribed sampling interval. CONCLUSIONS: Monthly routine blood testing in HD recipients was not associated with a lower risk for death, cardiovascular events, or hospitalizations as compared with testing every 6 weeks. Given the health resource implications, the frequency of routine blood sampling in HD recipients deserves careful reassessment.


Assuntos
Coleta de Amostras Sanguíneas/mortalidade , Coleta de Amostras Sanguíneas/tendências , Diálise Renal/mortalidade , Diálise Renal/tendências , Idoso , Idoso de 80 Anos ou mais , Coleta de Amostras Sanguíneas/métodos , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/mortalidade , Estudos de Coortes , Feminino , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Ontário/epidemiologia , Diálise Renal/métodos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
7.
Am J Kidney Dis ; 76(3): 311-320, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32333946

RESUMO

RATIONALE & OBJECTIVE: Evidence for the efficacy of direct oral anticoagulants (DOACs) to prevent cardiovascular (CV) events and mortality in older individuals with a low estimated glomerular filtration rate (eGFR) is lacking. We sought to characterize the association of oral anticoagulant use with CV morbidity in elderly patients with or without reductions in eGFRs, comparing DOACs with vitamin K antagonists (VKAs). STUDY DESIGN: Population-based retrospective cohort study. SETTINGS & PARTICIPANTS: All individuals 66 years or older with an initial prescription for oral anticoagulants dispensed in Ontario, Canada, from 2009 to 2016. EXPOSURE: DOACs (apixaban, dabigatran, and rivaroxaban) compared with VKAs by eGFR group (≥60, 30-59, and<30mL/min/1.73m2). OUTCOMES: The primary outcome was a composite of a CV event (myocardial infarction, revascularization, or ischemic stroke) or mortality. Secondary outcomes were CV events alone, mortality, and hemorrhage requiring hospitalization. ANALYTICAL APPROACH: High-dimensional propensity score matching of DOAC to VKA users and Cox proportional hazards regression. RESULTS: 27,552 new DOAC users were matched to 27,552 new VKA users (median age, 78 years; 49% women). There was significantly lower risk for CV events or mortality among DOAC users compared with VKA users (event rates of 79.78 vs 99.77 per 1,000 person-years, respectively; HR, 0.82 [95% CI, 0.75-0.90]) and lower risk for hemorrhage (event rates of 10.35 vs 16.77 per 1,000 person-years, respectively; HR, 0.73 [95% CI, 0.58-0.91]). There was an interaction between eGFR and the association of anticoagulant class with the primary composite outcome (P<0.02): HRs of 1.01 [95% CI, 0.92-1.12], 0.83 [95% CI, 0.75-0.93], and 0.75 [95% CI, 0.51-1.10] for eGFRs of≥60, 30 to 59, and<30mL/min/1.73m2. No interaction was detected for the outcome of hemorrhage. LIMITATIONS: Retrospective observational study design limits causal inference; dosages of DOACs and international normalized ratio values were not available; low event rates in some subgroups limited statistical power. CONCLUSIONS: DOACs compared with VKAs were associated with lower risk for the composite of CV events or mortality, an association for which the strength was most apparent among those with reduced eGFRs. The therapeutic implications of these findings await further study.


Assuntos
Antitrombinas/uso terapêutico , Isquemia Encefálica/epidemiologia , Dabigatrana/uso terapêutico , Mortalidade , Infarto do Miocárdio/epidemiologia , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Insuficiência Renal Crônica/complicações , Rivaroxabana/uso terapêutico , Trombofilia/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Antitrombinas/efeitos adversos , Isquemia Encefálica/prevenção & controle , Causas de Morte , Comorbidade , Dabigatrana/efeitos adversos , Feminino , Taxa de Filtração Glomerular , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Masculino , Infarto do Miocárdio/prevenção & controle , Revascularização Miocárdica , Ontário/epidemiologia , Utilização de Procedimentos e Técnicas , Pontuação de Propensão , Modelos de Riscos Proporcionais , Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Insuficiência Renal Crônica/fisiopatologia , Estudos Retrospectivos , Rivaroxabana/efeitos adversos , Trombofilia/complicações , Vitamina K/antagonistas & inibidores
8.
CMAJ ; 192(30): E851-E857, 2020 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-32719020

RESUMO

BACKGROUND: Prepregnancy kidney dysfunction has been associated with preterm birth, which is the leading cause of neonatal morbidity and mortality; however, the relation is not well understood. We determined the risk of preterm birth in women with prepregnancy kidney dysfunction, defined using pregnancy-specific serum creatinine cut points. METHODS: This population-based cohort study in the province of Ontario, Canada, involved women aged 16 to 50 years who had a singleton birth between 2006 and 2016 and measurement of serum creatinine within 10 weeks preceding their estimated conception date. The exposure was abnormally elevated prepregnancy serum creatinine, defined as greater than the 95th percentile (> 77 µmol/L), a value derived from a population-based sample of women without known kidney disease who became pregnant soon after the measurement was obtained. The main outcome was any preterm birth from 23 to 36 weeks' gestation. Secondary outcomes included provider-initiated preterm birth before 37 weeks' gestation and spontaneous preterm birth before 37 weeks. RESULTS: Among 55 946 pregnancies, preterm birth before 37 weeks' gestation occurred in 3956 women (7.1%). The risk of preterm birth before 37 weeks was higher among women with prepregnancy creatinine above the 95th percentile, relative to those with prepregnancy creatinine at or below the 95th percentile (9.1% v. 7.0%; adjusted relative risk [RR] 1.23, 95% confidence interval [CI] 1.09 to 1.38). The effect was significant for provider-initiated preterm birth (adjusted RR 1.30, 95% CI 1.11 to 1.52) but not for spontaneous preterm birth (adjusted RR 1.12, 95% CI 0.91 to 1.37). INTERPRETATION: Given that prepregnancy kidney dysfunction conferred an increased risk of preterm birth, measurement of serum creatinine (a relatively inexpensive blood test) may form part of the assessment of risk for preterm birth among those planning pregnancy.


Assuntos
Nefropatias/diagnóstico , Nefropatias/epidemiologia , Nascimento Prematuro/epidemiologia , Adolescente , Adulto , Estudos de Coortes , Creatinina/sangue , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Pessoa de Meia-Idade , Trabalho de Parto Prematuro/epidemiologia , Ontário , Gravidez , Fatores de Risco , Adulto Jovem
9.
CMAJ ; 192(14): E351-E360, 2020 04 06.
Artigo em Inglês | MEDLINE | ID: mdl-32392523

RESUMO

BACKGROUND: Regulatory agencies warn about the risk of acute kidney injury (AKI) after the initiation of sodium-glucose cotransporter-2 (SGLT2) inhibitors. Our objective was to quantify the 90-day risk of AKI in older adults after initiation of SGLT2 inhibitors in routine clinical practice. METHODS: We conducted a population-based retrospective cohort study in Ontario, Canada, involving adults with diabetes who were aged 66 years or older and who were newly dispensed either an SGLT2 inhibitor or a dipeptidyl peptidase-4 (DPP4) inhibitor in an outpatient setting between 2015 and 2017. We used inverse probability of treatment weighting based on a propensity score to balance the 2 groups on measured baseline characteristics. The primary outcome was 90-day risk of a hospital encounter (i.e., visit to the emergency department or admission to hospital) with AKI, which we defined by a 50% or greater increase in the concentration of serum creatinine from the baseline value or an absolute increase of at least 27 µmol/L after an SGLT2 or DDP4 inhibitor was dispensed. We obtained weighted risk ratios using modified Poisson regression and weighted risk differences using binomial regression. RESULTS: We included 39 094 patients with a median age of 70 (interquartile range 68-74) years in the study. Relative to new use of a DPP4 inhibitor, initiation of a SGLT2 inhibitor was associated with a lower 90-day risk of a hospital encounter with AKI: 216 events in 19 611 patients (1.10%) versus 388 events in 19 483 patients (1.99%); weighted risk ratio 0.79 (95% confidence interval 0.64-0.98). INTERPRETATION: In routine care of older adults, new use of SGLT2 inhibitors compared with use of DPP4 inhibitors was associated with a lower risk of AKI. Together with previous evidence, our findings suggest that regulatory warnings about AKI risk with SGLT2 inhibitors are unwarranted.


Assuntos
Injúria Renal Aguda/induzido quimicamente , Diabetes Mellitus Tipo 2/tratamento farmacológico , Inibidores da Dipeptidil Peptidase IV/efeitos adversos , Hipoglicemiantes/efeitos adversos , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos , Idoso , Estudos de Coortes , Diabetes Mellitus Tipo 2/complicações , Inibidores da Dipeptidil Peptidase IV/uso terapêutico , Humanos , Hipoglicemiantes/uso terapêutico , Ontário , Estudos Retrospectivos , Risco , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico
12.
Nephrology (Carlton) ; 24(5): 557-563, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-29785733

RESUMO

AIM: Intensified haemodialysis is associated with regression of left ventricular (LV) mass. Compared to LV ejection fraction, LV strain allows more direct assessment of LV function. We sought to assess the impact of in-centre nocturnal haemodialysis (INHD) on global LV strain (radial, circumferential, and longitudinal) and torsion by cardiac MRI (CMR). METHODS: In this prospective, two-centre cohort study, 37 participants on conventional haemodialysis (CHD, 3-4 h/session for three sessions/week) converted to INHD (7-8 h/session for three sessions/week) and 30 participants continued CHD. Participants underwent CMR using a standardized protocol and had biomarker measurements at baseline and 52 weeks. RESULTS: Among the 55 participants (mean age 55; 40% women) with complete CMR data, those who converted to INHD had a significant improvement in their global circumferential strain (GCS, P = 0.025), while those continuing CHD did not have any significant changes in LV strain. When the two groups were compared, there was significant improvement in torsion. LV strains were significantly correlated with each other, but not with troponin I, C-reactive protein, or brain natriuretic protein (NT-proBNP), except for global longitudinal strain (GLS) with troponin I (P = 0.001) and NT-proBNP (P = 0.038). CONCLUSION: Conversion to INHD was associated with significant improvement in GCS over one year of study, although comparisons with the CHD group were not significant. There was also a significant decrease in torsion in the INHD group compared with CHD. Improvement in LV regional function would support the notion that INHD has favourable effects on both LV structure and function.


Assuntos
Ventrículos do Coração/diagnóstico por imagem , Falência Renal Crônica/terapia , Imageamento por Ressonância Magnética , Contração Miocárdica , Diálise Renal/métodos , Disfunção Ventricular Esquerda/diagnóstico por imagem , Função Ventricular Esquerda , Adulto , Idoso , Fenômenos Biomecânicos , Colúmbia Britânica , Feminino , Ventrículos do Coração/fisiopatologia , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/fisiopatologia , Masculino , Pessoa de Meia-Idade , Ontário , Valor Preditivo dos Testes , Estudos Prospectivos , Recuperação de Função Fisiológica , Fatores de Tempo , Torção Mecânica , Resultado do Tratamento , Disfunção Ventricular Esquerda/fisiopatologia
13.
J Am Soc Nephrol ; 29(7): 1948-1959, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29720548

RESUMO

Background The epidemiology of ESRD requiring maintenance dialysis (ESRD-D) in large, diverse immigrant populations is unclear.Methods We estimated ESRD-D prevalence and incidence among immigrants in Ontario, Canada. Adults residing in Ontario in 2014 were categorized as long-term Canadian residents or immigrants according to administrative health and immigration datasets. We determined ESRD-D prevalence among these adults and calculated age-adjusted prevalence ratios (PRs) comparing immigrants to long-term residents. Among those who immigrated to Ontario between 1991 and 2012, age-adjusted ESRD-D incidence was calculated by world region and country of birth, with immigrants from Western nations as the referent group.Results Among 1,902,394 immigrants and 8,860,283 long-term residents, 1700 (0.09%) and 8909 (0.10%), respectively, presented with ESRD-D. Age-adjusted ESRD-D prevalence was higher among immigrants from sub-Saharan Africa (PR, 2.17; 95% confidence interval [95% CI], 1.84 to 2.57), Latin America and the Caribbean (PR, 2.11; 95% CI, 1.90 to 2.34), South Asia (PR, 1.45; 95% CI, 1.32 to 1.59), and East Asia and the Pacific (PR, 1.34; 95% CI, 1.22 to 1.46). Immigrants from Somalia (PR, 4.18; 95% CI, 3.11 to 5.61), Trinidad and Tobago (PR, 2.88; 95% CI, 2.23 to 3.73), Jamaica (PR, 2.88; 95% CI, 2.40 to 3.44), Sudan (PR, 2.84; 95% CI, 1.53 to 5.27), and Guyana (PR, 2.69; 95% CI, 2.19 to 3.29) had the highest age-adjusted ESRD-D PRs relative to long-term residents. Immigrants from these countries also exhibited higher age-adjusted ESKD-D incidence relative to Western Nations immigrants.Conclusions Among immigrants in Canada, those from sub-Saharan Africa and the Caribbean have the highest ESRD-D risk. Tailored kidney-protective interventions should be developed for these susceptible populations.


Assuntos
Emigrantes e Imigrantes/estatística & dados numéricos , Falência Renal Crônica/etnologia , Falência Renal Crônica/terapia , Diálise Renal/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Ásia/etnologia , Feminino , Guiana/etnologia , Humanos , Incidência , Jamaica/etnologia , Falência Renal Crônica/epidemiologia , América Latina/etnologia , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Prevalência , Somália/etnologia , Sudão/etnologia , Trinidad e Tobago/etnologia , Adulto Jovem
14.
J Am Soc Nephrol ; 29(3): 1001-1010, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29242248

RESUMO

Mortality after AKI is high, but the causes of death are not well described. To better understand causes of death in patients after a hospitalization with AKI and to determine patient and hospital factors associated with mortality, we conducted a population-based study of residents in Ontario, Canada, who survived a hospitalization with AKI from 2003 to 2013. Using linked administrative databases, we categorized cause of death in the year after hospital discharge as cardiovascular, cancer, infection-related, or other. We calculated standardized mortality ratios to compare the causes of death in survivors of AKI with those in the general adult population and used Cox proportional hazards modeling to estimate determinants of death. Of the 156,690 patients included, 43,422 (28%) died in the subsequent year. The most common causes of death were cardiovascular disease (28%) and cancer (28%), with respective standardized mortality ratios nearly six-fold (5.81; 95% confidence interval [95% CI], 5.70 to 5.92) and eight-fold (7.87; 95% CI, 7.72 to 8.02) higher than those in the general population. The highest standardized mortality ratios were for bladder cancer (18.24; 95% CI, 17.10 to 19.41), gynecologic cancer (16.83; 95% CI, 15.63 to 18.07), and leukemia (14.99; 95% CI, 14.16 to 15.85). Along with older age and nursing home residence, cancer and chemotherapy strongly associated with 1-year mortality. In conclusion, cancer-related death was as common as cardiovascular death in these patients; moreover, cancer-related deaths occurred at substantially higher rates than in the general population. Strategies are needed to care for and counsel patients with cancer who experience AKI.


Assuntos
Injúria Renal Aguda/epidemiologia , Doenças Cardiovasculares/mortalidade , Causas de Morte , Infecções/mortalidade , Neoplasias/mortalidade , Sobreviventes/estatística & dados numéricos , Injúria Renal Aguda/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Comorbidade , Bases de Dados Factuais , Diabetes Mellitus/epidemiologia , Feminino , Hospitalização , Humanos , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Neoplasias/tratamento farmacológico , Neoplasias/epidemiologia , Casas de Saúde , Ontário/epidemiologia , Modelos de Riscos Proporcionais , Fatores de Risco
15.
Kidney Int ; 91(4): 928-936, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28017326

RESUMO

The utility of anticoagulants for ischemic stroke prophylaxis in elderly patients with chronic kidney disease (CKD) and atrial fibrillation remains uncertain. In this population-based retrospective cohort study, we determined the association of anticoagulant use with ischemic stroke or hemorrhage in elderly patients (66 years and older) with advanced chronic kidney disease (eGFR under 45 ml/min/1.73m2) and atrial fibrillation. We followed 6,544 patients with CKD and new onset atrial fibrillation, of whom 1,475 filled a prescription for an anticoagulant. We used propensity-score matched Cox proportional hazards and competing risk models to determine the time to first event of ischemic stroke, hemorrhage or mortality. After matching to examine exposure to anticoagulants, 1,417 matched pairs were identified. The crude rate of ischemic stroke and hemorrhage were 41.3 and 61.3 with anticoagulants and 34.4 and 34.3 without anticoagulants per 100 person-years, respectively. The hazard ratios of ischemic stroke, hemorrhage, and mortality for receipt of an anticoagulation prescription were 1.10 (95% confidence interval, 0.78-1.56), 1.42 (1.04-1.93), and 0.74 (0.62-0.88) as compared to non-receipt of anticoagulation. After accounting for the competing risk of death, the hazard ratios for ischemic stroke and hemorrhage were 1.12 (0.90-1.39) and 1.60 (1.31-1.97), respectively. The findings were consistent in a sensitivity analysis accounting for time varying anticoagulant exposure. Thus, in older patients with CKD and atrial fibrillation, receipt of an anticoagulant was not associated with a lower risk of ischemic stroke, but a higher risk of hemorrhage and a lower risk of mortality.


Assuntos
Anticoagulantes/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Coagulação Sanguínea , Isquemia Encefálica/prevenção & controle , Hemorragia/induzido quimicamente , Insuficiência Renal Crônica/complicações , Acidente Vascular Cerebral/prevenção & controle , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/sangue , Fibrilação Atrial/complicações , Fibrilação Atrial/mortalidade , Isquemia Encefálica/sangue , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Prescrições de Medicamentos , Feminino , Hemorragia/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Pontuação de Propensão , Modelos de Riscos Proporcionais , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
16.
Am J Kidney Dis ; 70(1): 11-20, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28069285

RESUMO

BACKGROUND: Readmissions following hospital discharge among maintenance dialysis patients are common, potentially modifiable, and costly. Compared with patients receiving in-center hemodialysis (HD), patients receiving peritoneal dialysis (PD) have fewer routine dialysis clinic encounters and as a result may be more susceptible to a hospital readmission following discharge. STUDY DESIGN: Population-based retrospective-cohort observational study. SETTINGS & PARTICIPANTS: Patients treated with maintenance dialysis who were discharged following an acute-care hospitalization during January 1, 2003, to December 31, 2013, across 164 acute-care hospitals in Ontario, Canada. For those with multiple hospitalizations, we randomly selected a single hospitalization as the index hospitalization. PREDICTOR: Dialysis modality PD or in-center HD. Propensity scores were used to match each patient on PD therapy to 2 patients on in-center HD therapy to ensure that baseline indicators of health were similar between the 2 groups. OUTCOME: All-cause 30-day readmission following the index hospital discharge. RESULTS: 28,026 dialysis patients were included in the study. 4,013 PD patients were matched to 8,026 in-center HD patients. Among the matched cohort, 30-day readmission rates were 7.1 (95% CI, 6.6-7.6) per 1,000 person-days for patients on PD therapy and 6.0 (95% CI, 5.7-6.3) per 1,000 person-days for patients on in-center HD therapy. The risk for a 30-day readmission among patients on PD therapy was higher compared with those on in-center HD therapy (adjusted HR, 1.19; 95% CI, 1.08-1.31). The primary results were consistent across several key prespecified subgroups. LIMITATIONS: Lack of information for the frequency of nephrology physician encounters following discharge from the hospital in both the PD and in-center HD cohorts. Limited validation of International Classification of Diseases, Tenth Revision codes. CONCLUSIONS: The risk for 30-day readmission is higher for patients on home-based PD compared to in-center HD therapy. Interventions to improve transitions in care between the inpatient and outpatient settings are needed, particularly for patients on PD therapy.


Assuntos
Readmissão do Paciente/estatística & dados numéricos , Diálise Renal , Idoso , Instituições de Assistência Ambulatorial , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Diálise Peritoneal , Diálise Renal/métodos , Estudos Retrospectivos , Medição de Risco
17.
Am J Kidney Dis ; 70(6): 826-833, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28823585

RESUMO

BACKGROUND: The risk for venous thromboembolism (VTE) is elevated with albuminuria or a low estimated glomerular filtration rate (eGFR). However, the VTE risk due to the combined effects of eGFR and albuminuria are unknown. STUDY DESIGN: Population-based cohort study. SETTINGS & PARTICIPANTS: 694,956 adults in Ontario, Canada, from 2002 to 2012. FACTORS: eGFR and albumin-creatinine ratio (ACR). OUTCOME: VTE. RESULTS: 15,180 (2.2%) VTE events occurred during the study period. Both albuminuria and eGFR were independently associated with VTE. The association of albuminuria and VTE differed by level of eGFR (P for ACR × eGFR interaction < 0.001). After considering the competing risk for death, there was a 61% higher rate of VTE in patients with normal eGFRs (eGFRs>90mL/min/1.73m2) and heavy albuminuria (ACR>300mg/g) compared with those with normal eGFRs and no albuminuria (subdistribution HR, 1.61; 95% CI, 1.38-1.89). Among those with reduced kidney function (eGFR, 15-29mL/min/1.73m2), the risk for VTE was only minimally increased, irrespective of albuminuria (subdistribution HRs of 1.23 [95% CI, 1-1.5] and 1.09 [95% CI, 0.82-1.45] for ACR<30 and >300mg/g, respectively). LIMITATIONS: Only single determinations of ACR and eGFR were used. Diagnostic/International Classification of Diseases codes were used to define VTE. CONCLUSIONS: Albuminuria increases the risk for VTE markedly in patients with normal eGFRs compared with those with lower eGFRs.


Assuntos
Albuminúria/epidemiologia , Taxa de Filtração Glomerular , Insuficiência Renal Crônica/epidemiologia , Tromboembolia Venosa/epidemiologia , Idoso , Albuminúria/urina , Estudos de Coortes , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Insuficiência Renal Crônica/metabolismo , Estudos Retrospectivos , Risco
18.
J Am Soc Nephrol ; 27(9): 2825-32, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-26823554

RESUMO

New staging systems for CKD account for both reduced eGFR and albuminuria; whether each measure associates with greater risk of hemorrhage is unclear. In this retrospective cohort study (2002-2010), we grouped 516,197 adults ≥40 years old by eGFR (≥90, 60 to <90, 45 to <60, 30 to <45, 15 to <30, or <15 ml/min per 1.73 m(2)) and urine albumin-to-creatinine ratio (ACR; >300, 30-300, or <30 mg/g) to examine incidence of hemorrhage. The 3-year cumulative incidence of hemorrhage increased 20-fold across declining eGFR and increasing urine ACR groupings (highest eGFR/lowest ACR: 0.5%; lowest eGFR/highest ACR: 10.1%). Urine ACR altered the association of eGFR with hemorrhage (P<0.001). In adjusted models using the highest eGFR/lowest ACR grouping as the referent, patients with eGFR=15 to <30 ml/min per 1.73 m(2) had adjusted relative risks of hemorrhage of 1.9 (95% confidence interval [95% CI], 1.5 to 2.4) with the lowest ACR and 3.7 (95% CI, 3.0 to 4.5) with the highest ACR. Patients with the highest eGFR/highest ACR had an adjusted relative risk of hemorrhage of 2.3 (95% CI, 1.8 to 2.9), comparable with the risk for patients with the lowest eGFR/lowest ACR. The associations attenuated but remained significant after adjustment for anticoagulant and antiplatelet use in patients ≥66 years old. The risk of hemorrhage differed by urine ACR in high risk subgroups. Our data show that declining eGFR and increasing albuminuria each independently increase hemorrhage risk. Strategies to reduce hemorrhage events among patients with CKD are warranted.


Assuntos
Hemorragia/epidemiologia , Hemorragia/etiologia , Falência Renal Crônica/complicações , Albuminúria/etiologia , Estudos de Coortes , Feminino , Taxa de Filtração Glomerular , Humanos , Incidência , Falência Renal Crônica/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença
19.
JAMA ; 2022 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-36355384

RESUMO

A 62-year-old woman undergoing peritoneal dialysis (PD) presented to the clinic with severe abdominal pain and cloudy PD fluid. Seven days prior, she inadvertently broke aseptic technique when tightening a leaking connection of her PD catheter tubing. Cloudy fluid that was drained from her PD catheter was sent for laboratory analysis. What would you do next?

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