Receipt of rheumatology care and lupus-specific labs among young adults with systemic lupus erythematosus: A US Medicare retention in care cohort study.

OBJECTIVE: In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context. METHODS: This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18-35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography. RESULTS: Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6 months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%-60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71). CONCLUSION: Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes.

Age-Stratified 30-day Rehospitalization and Mortality and Predictors of Rehospitalization Among Patients With Systemic Lupus Erythematosus: A Medicare Cohort Study.

OBJECTIVE: Recent studies suggest young adults with systemic lupus erythematosus (SLE) have high 30-day readmission rates, which may necessitate tailored readmission reduction strategies. To aid in risk stratification for future strategies, we measured 30-day rehospitalization and mortality rates among Medicare beneficiaries with SLE and determined rehospitalization predictors by age. METHODS: In a 2014 20% national Medicare sample of hospitalizations, rehospitalization risk and mortality within 30 days of discharge were calculated for young (aged 18-35 yrs), middle-aged (aged 36-64 yrs), and older (aged 65+ yrs) beneficiaries with and without SLE. Multivariable generalized estimating equation models were used to predict rehospitalization rates among patients with SLE by age group using patient, hospital, and geographic factors. RESULTS: Among 1.39 million Medicare hospitalizations, 10,868 involved beneficiaries with SLE. Hospitalized young adult beneficiaries with SLE were more racially diverse, were living in more disadvantaged areas, and had more comorbidities than older beneficiaries with SLE and those without SLE. Thirty-day rehospitalization was 36% among young adult beneficiaries with SLE-40% higher than peers without SLE and 85% higher than older beneficiaries with SLE. Longer length of stay and higher comorbidity risk score increased odds of rehospitalization in all age groups, whereas specific comorbid condition predictors and their effect varied. Our models, which incorporated neighborhood-level socioeconomic disadvantage, had moderate-to-good predictive value (C statistics 0.67-0.77), outperforming administrative data models lacking comprehensive social determinants in other conditions. CONCLUSION: Young adults with SLE on Medicare had very high 30-day rehospitalization at 36%. Considering socioeconomic disadvantage and comorbidities provided good prediction of rehospitalization risk, particularly in young adults. Young beneficiaries with SLE with comorbidities should be a focus of programs aimed at reducing rehospitalizations.

Multidisciplinary Lupus Nephritis Clinic Reduces Time to Renal Biopsy and Improves Care Quality.

OBJECTIVE: Patients with lupus nephritis (LN) have a 26-fold higher mortality rate compared with their peers. Kidney biopsy, the gold standard diagnostic method for LN, may have an average wait time of more than 50 days. Other gaps in quality process measures during LN visits have also been reported. A subspecialty multidisciplinary clinic (MDC) can provide better care and quality in LN; therefore, we aimed to examine how an LN MDC impacted time to biopsy, time to treatment, and other quality measures. METHODS: We included all validated patients with LN who underwent diagnostic kidney biopsies between the 2011 to 2017 pre-MDC period and the 2018 to 2020 post-MDC period. We compared time to biopsy and treatment and quality measures between the two periods and examined factors associated with timely LN diagnosis, defined as a biopsy within 21 days. RESULTS: During the pre- and post-MDC periods, 53 and 21 patients with LN underwent a diagnostic biopsy, respectively. We found a decrease in the median time to biopsy from 26 days to 16 days after starting the LN clinic (P = 0.014). Beyond clinical factors, the presence of social factors, such as being of a non-White race and having food insecurity, were associated with 54% lower odds of timely diagnosis (adjusted Hazards Ratio [aHR] = 0.46; 95% confidence interval: 0.22-0.93; P = 0.031). We found higher odds of quality measure performance during the post- versus pre-MDC period. CONCLUSION: Wait times to diagnose LN decreased by 40% and higher quality measure performance was noted after establishing an LN MDC. Systemic and social barriers predicted delays in diagnosis that may be addressed by MDCs.

The clinical value of donor-derived cell-free DNA measurements in kidney transplantation.

Early diagnosis is critical to minimizing the damage rejection can do to the transplanted kidney. Donor-derived cell-free DNA (dd-cfDNA) represents non-encapsulated fragmented DNA that is continuously shed into the bloodstream from the allograft undergoing injury, with a half-life of about 30 min. This article reviews the available evidence regarding the diagnostic value of dd-cfDNA in kidney transplantation, as a result of which two assays, Allosure and Prospera, have garnered Medicare approval. We provide information on important scenarios and contexts including antibody-mediated rejection, T-cell mediated rejection, pre-test probability of rejection, timing of the test, repeat transplants, and background cell-free DNA levels to help our understanding of the test characteristics and utility of these assays in clinical practice. Data on multimodality assays including gene expression profiles and serial monitoring of dd-cfDNA in high risk situations are emerging.

Outcomes in the highest panel reactive antibody recipients of deceased donor kidneys under the new kidney allocation system.

Since the institution of the new kidney allocation system in December 2014, kidney transplant candidates with the highest calculated panel reactive antibodies (cPRA) of 99-100 have been transplanted at much higher rates. However, concerns have been raised that outcomes in these patients might be impaired due to higher immunological risk and longer cold ischemia times resulting from long-distance sharing of kidneys. Here, we compare outcomes at the University of Wisconsin between study patients with cPRA 99-100 and all other recipients of deceased donor kidneys transplanted between 12/04/2014 and 12/31/2015. All patients had at least 6 months post-transplant follow-up. The mean follow-up was 13.9±3 months in cPRA ≥99% and 12.3±3.5 months in cPRA ≤98%. There was a total of 152 transplants, 25 study patients, and 127 controls. No statistically significant differences were found between the two groups in delayed graft function, rejection, kidney function, graft and patient survival, or infections. We conclude that transplanting the most highly sensitized patients with kidneys shared outside their local donation service areas is associated with excellent short-term outcomes that are comparable to controls.

Multinational Assessment of Accuracy of Equations for Predicting Risk of Kidney Failure: A Meta-analysis.

IMPORTANCE: Identifying patients at risk of chronic kidney disease (CKD) progression may facilitate more optimal nephrology care. Kidney failure risk equations, including such factors as age, sex, estimated glomerular filtration rate, and calcium and phosphate concentrations, were previously developed and validated in 2 Canadian cohorts. Validation in other regions and in CKD populations not under the care of a nephrologist is needed. OBJECTIVE: To evaluate the accuracy of the risk equations across different geographic regions and patient populations through individual participant data meta-analysis. DATA SOURCES: Thirty-one cohorts, including 721,357 participants with CKD stages 3 to 5 in more than 30 countries spanning 4 continents, were studied. These cohorts collected data from 1982 through 2014. STUDY SELECTION: Cohorts participating in the CKD Prognosis Consortium with data on end-stage renal disease. DATA EXTRACTION AND SYNTHESIS: Data were obtained and statistical analyses were performed between July 2012 and June 2015. Using the risk factors from the original risk equations, cohort-specific hazard ratios were estimated and combined using random-effects meta-analysis to form new pooled kidney failure risk equations. Original and pooled kidney failure risk equation performance was compared, and the need for regional calibration factors was assessed. MAIN OUTCOMES AND MEASURES: Kidney failure (treatment by dialysis or kidney transplant). RESULTS: During a median follow-up of 4 years of 721,357 participants with CKD, 23,829 cases kidney failure were observed. The original risk equations achieved excellent discrimination (ability to differentiate those who developed kidney failure from those who did not) across all cohorts (overall C statistic, 0.90; 95% CI, 0.89-0.92 at 2 years; C statistic at 5 years, 0.88; 95% CI, 0.86-0.90); discrimination in subgroups by age, race, and diabetes status was similar. There was no improvement with the pooled equations. Calibration (the difference between observed and predicted risk) was adequate in North American cohorts, but the original risk equations overestimated risk in some non-North American cohorts. Addition of a calibration factor that lowered the baseline risk by 32.9% at 2 years and 16.5% at 5 years improved the calibration in 12 of 15 and 10 of 13 non-North American cohorts at 2 and 5 years, respectively (P = .04 and P = .02). CONCLUSIONS AND RELEVANCE: Kidney failure risk equations developed in a Canadian population showed high discrimination and adequate calibration when validated in 31 multinational cohorts. However, in some regions the addition of a calibration factor may be necessary.

Percutaneous versus surgical insertion of PD catheters in dialysis patients: a meta-analysis.

PURPOSE: Several small studies have suggested that the percutaneous method of peritoneal dialysis (PD) catheter insertion is effective and has a lower complication rate than surgical techniques (open, laparoscopic or peritoneoscopic), although no randomized, controlled study has compared these methods. Our objective was to compare percutaneous PD catheter insertion vs surgical placement in terms of 1-year catheter survival, catheter dysfunction, fluid leak and incidence of peritonitis. METHODS: We searched Medline for English-language literature from 1966 through June 2014, along with national conference proceedings and reference lists of all included publications to identify relevant studies. Inclusion criteria were having a measure of catheter survival at 1 year, catheter dysfunction, peritonitis rate per patient-month or fluid leak as outcomes. Studies were excluded if they were not in English or if they included pediatric patients. Random effects models were used to derive the pooled risk ratios, differences in patency and their variations. RESULTS: Thirteen studies with a total of 2,681 subjects met the inclusion criteria. There was no significant difference in 1-year catheter survival in percutaneous vs surgical PD catheter placement (relative risk [RR] = 0.81; 95% confidence interval [CI]: 0.59-1.11, p = 0.19). Catheter dysfunction also did not differ significantly between the groups (pooled odds ratio [OR] = 0.86; 95% CI: 0.57-1.29, p = 0.46). The prevalence of peritoneal fluid leak also was similar for percutaneous and surgical groups (OR = 1.10; 95% CI: 0.58-2.09, p = 0.77). However, there was a significant lower incidence of peritonitis among those with percutaneous placement (incidence rate ratio [IRR] = 0.77; 95% CI: 0.62-0.96, p = 0.02). Significant heterogeneity was detected across studies (I2 = 78.4%, p<0.0001). CONCLUSIONS: Our results suggest that there is no significant difference in catheter survival between percutaneous and surgical placement of PD catheters. Whether there are significant benefits from percutaneous placement in terms of peritonitis rates requires further robust studies. These findings have significant implications for future design of clinical trials in the placement of PD catheters and the delivery of dialysis-related services.