Association between regional economic status and renal recovery of dialysis-requiring acute kidney injury among critically ill patients.

The association between regional economic status and the probability of renal recovery among patients with dialysis-requiring AKI (AKI-D) is unknown. The nationwide prospective multicenter study enrolled critically ill adult patients with AKI-D in four sampled months (October 2014, along with January, April, and July 2015) in Taiwan. The regional economic status was defined by annual disposable income per capita (ADIPC) of the cities the hospitals located. Among the 1,322 enrolled patients (67.1 ± 15.5 years, 36.2% female), 833 patients (63.1%) died, and 306 (23.1%) experienced renal recovery within 90 days following discharge. We categorized all patients into high (n = 992) and low economic status groups (n = 330) by the best cut-point of ADIPC determined by the generalized additive model plot. By using the Fine and Gray competing risk regression model with mortality as a competing risk factor, we found that the independent association between regional economic status and renal recovery persisted from model 1 (no adjustment), model 2 (adjustment to basic variables), to model 3 (adjustment to basic and clinical variables; subdistribution hazard ratio, 1.422; 95% confidence interval, 1.022-1.977; p = 0.037). In conclusion, high regional economic status was an independent factor for renal recovery among critically ill patients with AKI-D.

Risk of new-onset diabetes mellitus in primary aldosteronism: a population study over 5 years.

OBJECTIVE: Abnormal glucose metabolism due to insulin resistance has been linked to aldosterone overproduction. However, the long-term incidence of new-onset diabetes mellitus (NODM) among patients with primary aldosteronism after targeted treatment has not been well documented. METHODS: The diagnosis of primary aldosteronism and essential hypertension were identified, and then the occurrence of NODM, all-cause mortality among these patients, was ascertained by a validated algorithm from a 23-million population insurance registry. RESULTS: From 1999 to 2007, 2367 primary aldosteronism patients without previously diabetes mellitus were identified and propensity score-matched with 9468 patients with essential hypertension. Among those primary aldosteronism patients, 754 aldosterone-producing adenomas patients were identified and matched with 3016 essential hypertension controls. After a mean 5.2 years of follow-up, primary aldosteronism patients who underwent adrenalectomy had an attenuated NODM incidence (hazard ratio = 0.60, P < 0.01, versus essential hypertension); whereas those treated with mineralocorticoid receptor antagonist had augmented risk of NODM (hazard ratio = 1.16, P < 0.001, versus essential hypertension). Among the aldosterone-producing adenoma patients, adrenalectomy is also protective from developing NODM (hazard ratio = 0.61, P < 0.001, versus essential hypertension), however, mineralocorticoid receptor antagonist treatment did not alter the risk of NODM (P = 0.10, versus essential hypertension). Adjusted hazard ratios for long-term risk of mortality from this analysis revealed that adrenalectomy is protective, but NODM and major cardiovascular disease are deleterious. CONCLUSION: The primary aldosteronism patients who underwent adrenalectomy had reduced risk for incident NODM and all-cause of mortality, compared with matched hypertensive controls. This observation adds more evidence on the association of primary aldosteronism with a higher risk of metabolic syndrome and long-term mortality.

Multidisciplinary care program for advanced chronic kidney disease: reduces renal replacement and medical costs.

BACKGROUND: Multidisciplinary care is advocated as an effective chronic kidney disease treatment program in a few, but not all, studies. Our study aimed to evaluate the effect of multidisciplinary care on renal outcome and patient survival using a larger cohort. METHOD: A total 1382 chronic kidney disease patients, ages 18-80 years, with chronic kidney disease stage 3B-5, in nephrology outpatient clinics were enrolled. Using age, sex, chronic kidney disease stage, and diabetes mellitus as variables, 592 multidisciplinary care program participants were matched with 614 nonmultidisciplinary care patients. The primary outcomes were long-term renal replacement therapy and mortality. Secondary outcomes included changes of biochemical markers and blood pressure, infection hospitalization, cardiovascular events, and emergent start of long-term dialysis. Annual medical costs were compared. RESULTS: There were no between-group differences regarding mortality. In the multivariate competing-risk regression model, the multidisciplinary care group had a better renal survival (hazard ratio 0.640; 95% confidence interval, 0.484-0.847; P = .002). This effect was most prominent in stage 4 (hazard ratio 0.375; 95% confidence interval, 0.219-0.640; P < .001), but not in stage 3B and 5 patients. The multidisciplinary care group showed a slower estimated glomerular filtration rate decline (-2.57 vs -3.74 mL/min/1.73 m(2), P = .021), and a smaller increase in phosphate (+ 0.03 vs + 0.33 mg/dL, P = .013). Cardiovascular and infection events were both decreased in the multidisciplinary care group (P < .001). There was also less requirement of emergent start dialysis (39.6% vs 54.5%, P = .001). The annual cost for the multidisciplinary care group was lower than the nonmultidisciplinary care group (US $2372 vs $3794, P < .001). In addition, considering the reduction of patients requiring renal replacement therapy, the multidisciplinary care program saved a total US $1931 per patient annually. CONCLUSIONS: Our analysis demonstrated that the multidisciplinary care program provided better health care and reduced renal replacement therapy in patients with advanced chronic kidney disease. By decreasing hospitalizations, emergent start, and the need for renal replacement therapy, the multidisciplinary care program was cost-effective.

Administrative data on diagnosis and mineralocorticoid receptor antagonist prescription identified patients with primary aldosteronism in Taiwan.

OBJECTIVES: To develop algorithms of locating patients with primary aldosteronism (PA) using insurance reimbursement data and to validate the algorithms using medical charts. STUDY DESIGN AND SETTING: We extracted National Health Insurance (NHI) reimbursement data and medical charts in seven enrolled hospitals and analyzed diagnosis-related information for 1999-2010. The NHI codes PA as 255.1x, using the International Classification of Diseases, Ninth Revision, Clinical Modification. Confirmation of PA was based on suppression tests. RESULTS: We reviewed medical charts for 1,094 cases with at least one PA diagnosis. PA was confirmed for 563 cases. Compared with patients with essential hypertension, PA patients had higher systolic blood pressure, higher aldosterone, lower renin activity, and lower potassium level (all P-values <0.05). An algorithm based on PA diagnosis reported in at least one hospital stay or three outpatient visits had modest performance (sensitivity = 0.94 and specificity = 0.20). The best additional condition for the algorithm was use of mineralocorticoid receptor antagonist (MRA; sensitivity = 0.89 and specificity = 0.88). CONCLUSION: Using information on PA diagnosis and MRA prescription reported in insurance claims data can precisely locate PA patients in high-risk groups. This algorithm can construct a reliable PA sample for conducting research in various fields, including epidemiology and clinical practice.

Lifetime costs for peritoneal dialysis and hemodialysis in patients in Taiwan.

BACKGROUND: This study compared the lifetime costs for peritoneal dialysis (PD) and hemodialysis (HD) patients in Taiwan. METHODS: Using the National Health Insurance (NHI) database of all end-stage renal disease patients on maintenance dialysis registered from July 1997 to December 2005, we matched eligible PD patients with eligible HD patients on age, sex, and diabetes status. The matched patients were followed until 31 December 2006. Patients were excluded if they were less than 18 years of age, had been diagnosed with cancer before dialysis, or had been dialyzed at centers or clinics other than hospitals. Outcomes-including life expectancy, total lifetime costs, and costs per life-year paid by the NHI-were estimated and compared. RESULTS: The 3136 pairs of matched PD and HD patients had a mean age of 53.2 ± 15.4 years. The total lifetime cost for PD patients (US$139 360 ± US$8 336) was significantly lower than that for HD patients (US$185 235 ± US$9 623, p < 0.001). Except for patients with diabetes (who had a short life expectancy), the total lifetime cost was significantly lower for PD patients than for HD patients regardless of sex and age (p < 0.01). CONCLUSION: In Taiwan, the total lifetime costs paid by the NHI were lower for PD than for HD patients.

Microalbuminuria screening for detecting chronic kidney disease in the general population: a systematic review.

BACKGROUND: Microalbuminuria screening is widely used in high-risk populations but seldom used in the general population for detecting chronic kidney disease (CKD). Systematic reviews focused on screening for CKD are rare, and the issues about microalbuminuria screening in the general population have never been reviewed. We systematically reviewed studies regarding microalbuminuria screening and evaluated the benefits and harms of this screening method in the general population. METHODS: We systematically searched MEDLINE, PubMed, and the Cochrane Library for English articles published from January 1970 to 13 December 2011. Quality assessments were performed using the QUADAS tool or the Drummond's 10-point checklist. Due to the high heterogeneity of the study designs, meta-analysis for the study results was not possible. Therefore, we performed a narrative synthesis. RESULTS: Six articles from four studies made up our final study population, with four articles evaluating different screening methodologies and two reporting cost-effectiveness analyses. The qualities of the included articles ranged from fair to high. Spot urine albumin concentration and spot urine albumin:creatinine ratio had a similar diagnostic performance for microalbuminuria screening in the general population. Screening for microalbuminuria in high-risk populations, such as patients with diabetes, hypertension, or old age, was cost-effective. However, there was no consensus regarding the cost-effectiveness for microalbuminuria screening in the general population. CONCLUSIONS: Microalbuminuria screening in high-risk populations is cost-effective. However, the cost-effectiveness of screening for microalbuminuria in the general population deserves further study. To keep costs low, spot urine albumin concentration may be preferable than the albumin:creatinine ratio.

Women on hemodialysis have lower self-reported health-related quality of life scores but better survival than men.

BACKGROUND: Hemodialysis patients suffer from poor quality of life and survival. A retrospective cohort study was performed to examine the sex differences in self-reported quality of life and mortality in a Taiwanese hemodialysis cohort. METHODS: A total of 816 stable hemodialysis patients were included. Patients completed two questionnaires: the 36-item Short Form Health Survey Questionnaire (SF-36, Taiwan Standard Version 1.0) to assess health-related quality of life (HRQoL) and the Beck Depression Inventory (BDI, Chinese Version) to assess depressive mood. Mortality outcomes were recorded for a seven-year follow-up period. RESULTS: After adjustment for confounding factors, women had significantly higher BDI scores (P=.003), lower physical functioning (P<.001), bodily pain (P<.001), mental health (P=0007), and physical component scale (PCS) scores (P<.001). There were 284 deaths recorded. In the Cox-proportional hazard model, women had significantly lower mortality than men (P<.001). CONCLUSIONS: Women on hemodialysis had more depression-related symptoms and poor self-reported HRQoL, but better survival than men. The sex difference in psychological and HRQoL issues deserves greater concern because this relates to clinical care and further study.

Impact of timing of renal replacement therapy initiation on outcome of septic acute kidney injury.

INTRODUCTION: Sepsis is the leading cause of acute kidney injury (AKI) in critical patients. The optimal timing of initiating renal replacement therapy (RRT) in septic AKI patients remains controversial. The objective of this study is to determine the impact of early or late initiation of RRT, as defined using the simplified RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal failure) classification (sRIFLE), on hospital mortality among septic AKI patients. METHODS: Patient with sepsis and AKI requiring RRT in surgical intensive care units were enrolled between January 2002 and October 2009. The patients were divided into early (sRIFLE-0 or -Risk) or late (sRIFLE-Injury or -Failure) initiation of RRT by sRIFLE criteria. Cox proportional hazard ratios for in hospital mortality were determined to assess the impact of timing of RRT. RESULTS: Among the 370 patients, 192 (51.9%) underwent early RRT and 259 (70.0%) died during hospitalization. The mortality rate in early and late RRT groups were 70.8% and 69.7% respectively (P > 0.05). Early dialysis did not relate to hospital mortality by Cox proportional hazard model (P > 0.05). Patients with heart failure, male gender, higher admission creatinine, and operation were more likely to be in the late RRT group. Cox proportional hazard model, after adjustment with propensity score including all patients based on the probability of late RRT, showed early dialysis was not related to hospital mortality. Further model matched patients by 1:1 fashion according to each patient's propensity to late RRT showed no differences in hospital mortality according to head-to-head comparison of demographic data (P > 0.05). CONCLUSIONS: Use of sRIFLE classification as a marker poorly predicted the benefits of early or late RRT in the context of septic AKI. In the future, more physiologically meaningful markers with which to determine the optimal timing of RRT initiation should be identified.

A modified sequential organ failure assessment score to predict hospital mortality of postoperative acute renal failure patients requiring renal replacement therapy.

BACKGROUND: A predictive model for hospital mortality in postoperative acute renal failure (ARF) patients requiring renal replacement therapy (RRT) may aid clinicians' therapeutic decision-making and research design. METHODS: A prospective observational study of 398 postoperative ARF patients requiring RRT was conducted in four hospitals. The derivation cohort consisted of 334 patients recruited between January 2002 and December 2005. The validation cohort consisted of 64 patients recruited between January 2006 and December 2006. RESULTS: The hospital mortality rates for the derivation and validation cohorts were 65.6 and 62.5%, respectively. A modified Sequential Organ Failure Assessment (SOFA) score was constructed at the commencement of RRT by a formula of serum lactate level (mM) + 2 x (generic SOFA score) + 3 x (age per decade) + 8 (if mechanical circulatory support required) + 10 (if total parenteral nutrition required) + 11 (if status postcardiopulmonary resuscitation) + 13 (if positive sepsis sign). The area under the receiver operating characteristic curve of the model for the derivation and validation cohorts was 0.804 and 0.839, respectively. CONCLUSION: This validated score at dialysis commencement might assist clinicians in estimating hospital mortality, planning future clinical trials, and providing quantitative guidance for decision making in postoperative ARF patients requiring RRT.