Outpatient Antibiotic Prescribing Patterns for Adult End-Stage Renal Disease Patients in New York State.

BACKGROUND: Infections are important complications of end-stage renal disease (ESRD) with few studies having investigated oral antibiotic use. Inappropriate antibiotic prescribing can contribute to multidrug-resistant organisms and Clostridioides difficile infections seen in ESRD. This study investigates antibiotic prescribing practices in ESRD across New York State (NYS). METHODS: Retrospective case-control study from 2016 to 2017 of NYS ESRD and non-ESRD patients analyzing Medicare part B billing codes, 7 days before and 3 days after part D claims. Frequencies of each infection, each antibiotic, dosages, and the antibiotics associated with infections were assessed using χ 2 analysis. A NYS small dialysis organization comprising approximately 2200 patients was also analyzed. Outcomes measured were the frequencies of infections and of each antibiotic prescribed. Incidence measures included antibiotics per 1000 and individuals receiving antibiotics per 1000. RESULTS: A total of 48 100 infections were treated in 35 369 ESRD patients and 2 544 443 infections treated in 3 777 314 non-ESRD patients. ESRD patients were younger, male, and African American. ESRD and non-ESRD patients receiving antibiotics was 520.29/1000 and 296.48/1000, respectively (P < .05). The prescription incidence was 1359.95/1000 ESRD vs 673.61/1000 non-ESRD patients. In 36%, trimethoprim-sulfamethoxazole dosage was elevated by current ESRD guidelines. Top infectious categories included nonspecific symptoms, skin, and respiratory for ESRD; and respiratory, nonspecific symptoms, and genitourinary in non-ESRD. CONCLUSIONS: This study identifies issues with appropriate antibiotic usage stressing the importance of antibiotic education to nephrologist and nonnephrologist providers. It provides support for outpatient antibiotic stewardship programs.

Outcomes in Critically Ill Patients With Traumatic Brain Injury: Ethnicity, Documentation, and Insurance Status.

OBJECTIVES: Disparities in traumatic brain injury outcomes for ethnic minorities and the uninsured have previously been demonstrated; however, outcomes in undocumented immigrants have not been examined. We wanted to determine whether ethnicity, insurance, and documentation status served as risk factors for disparities in traumatic brain injury outcomes between undocumented immigrants and documented residents. DESIGN: Retrospective study. SETTING: Patients diagnosed with traumatic brain injury admitted to the surgical/trauma ICU at a level 1 trauma center serving a large immigrant population in New York City from 2009 to 2016. PATIENTS: Four-hundred seventy-one traumatic brain injury patients requiring surgical/trauma ICU admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Undocumented immigrants constituted 29% of the population, were younger (39 vs 57 yr old, respectively; p < 0.0001), Hispanic (83%; p < 0.0001), and uninsured (87%; p < 0.0001). Falls resulted in the majority of traumatic brain injuries in the total population, however, undocumented immigrants were almost twice as likely to be assaulted (p = 0.0032). There was no difference in presence of midline shifts, Injury Severity Score, Glasgow Coma Score, hypotension, hypoxia, and pupillary reactions between undocumented immigrants and documented residents. Undocumented immigrants presented with significantly more effaced basilar cisterns (p = 0.0008). There was no difference in hospital care between undocumented immigrants and documented residents as determined by emergency department to surgical/trauma ICU transfer times (p = 0.967). Undocumented immigrants were more likely to be discharged home (53% vs 33%, respectively; p = 0.0009) and less likely to be sent to rehabilitation (25% vs 32%, respectively; p = 0.0009). After adjusting length of stay and mortality for covariates, undocumented immigrants had shorter length of stay (p < 0.05) and there was no difference in hospital mortality between undocumented immigrants and documented residents. CONCLUSIONS: Undocumented immigrants with traumatic brain injuries were more likely to be younger, have shorter length of stay, and experience similar mortality rates to documented residents. Social economic status may play a role in events prior to hospitalization and likely does in disposition outcomes.

Trauma care in a multiethnic population: effects of being undocumented.

BACKGROUND: Epidemiologic studies have shown that undocumented immigrants (UIs) display characteristics of having a low socioeconomic status and are primarily of ethnic minorities. These social determinants of health are known to be associated with diminished health care access and poor clinical outcomes. We therefore investigated the impact of documentation status on the clinical outcomes of patients with traumatic injuries. MATERIALS AND METHODS: We conducted a retrospective review of the trauma registry at our safety net institution for all adult patients who were admitted from 2010 to 2014. UIs were identified by the absence of a valid social security number within their medical records. Multivariate regression analysis was used to determine the impact of documentation status on in-hospital mortality, length of stay (LOS), and the odds of rehab placement. RESULTS: 4924 trauma patients met the study criteria, of which 1050 (21.3%) were UIs. There was no significant difference in mortality rates between the two populations. Multivariate regression analyses revealed a longer average LOS and a decreased likelihood for placement in an in-patient rehabilitation facility following hospitalization for UIs, even after accounting for insurance, age, injury severity, and other possible confounders known to affect these outcomes. CONCLUSIONS: There was no association between in-hospital mortality and documentation status; however, UIs had a longer average LOS and were less likely to be placed into rehab following their hospitalization. A longer LOS and a decreased likelihood for rehabilitation placement suggest that disparities in trauma care exist for UIs, putting them at risk for worse clinical and functional outcomes.

A double-hit: End-stage renal disease patients suffer worse outcomes in intracerebral hemorrhage.

BACKGROUND: Intracerebral hemorrhage (ICH) carries significant morbidity and mortality. Previous single-center retrospective analysis suggests that end-stage renal disease (ESRD) is a risk factor for severe ICH and worse outcomes. This investigation aims to examine the impact of ESRD on ICH severity, complications, and outcomes using a multicenter national database. METHODS: The International Classification of Disease, Ninth and Tenth Revision Clinical Modification codes were used to query the National Inpatient Sample for patients with ICH and ESRD between 2010 and 2019. Primary endpoints were the functional outcome, length of stay (LOS), and in-hospital mortality. Multivariate variable regression models and a propensity-score matched analysis were established to analyze patient outcomes associated with baseline patient characteristics. RESULTS: We identified 211,266 patients with ICH, and among them, 7,864 (3.77%) patients had a concurrent diagnosis of ESRD. Patients with ESRD were younger (60.85 vs. 67.64, P < 0.01) and demonstrated increased ICH severity (0.78 vs. 0.77, P < 0.01). ESRD patients experienced higher rates of sepsis (15.9% vs. 6.15%, P < 0.01), acute myocardial infarction (8.05% vs. 3.65%, P < 0.01), and cardiac arrest (5.94% vs. 2.4%, P < 0.01). In addition, ESRD predicted poor discharge disposition (odds ratio [OR]: 2.385, 95% confidence interval [CI]: 2.227-2.555, P < 0.01), longer hospital LOS (OR: 1.629, 95% CI: 1.553-1.709, P < 0.01), and in-hospital mortality (OR: 2.786, 95% CI: 2.647-2.932, P < 0.01). CONCLUSIONS: This study utilizes a multicenter database to analyze the effect of ESRD on ICH outcomes. ESRD is a significant predictor of poor functional outcomes, in-hospital mortality, and prolonged stay in the ICH population.

Aneurysmal Subarachnoid Hemorrhage and Cardiac Related Fatality: Who Dies and Why?

Medical complications are a notable source of in-hospital death following aneurysmal subarachnoid hemorrhage (aSAH). However, there is a paucity of literature examining medical complications on a national scale. This study uses a national dataset to analyze the incidence rates, case fatality rates, and risk factors for in-hospital complications and mortality following aSAH. We found that the most common complications in aSAH patients (N = 170, 869) were hydrocephalus (29.3%) and hyponatremia (17.3%). Cardiac arrest was the most common cardiac complication (3.2%) and was associated with the highest case fatality rate overall (82%). Patients with cardiac arrest also had the highest odds of in-hospital mortality [odds ratio (OR), 22.92; 95% confidence interval (CI), 19.24-27.30; P < 0.0001], followed by patients with cardiogenic shock (OR, 2.96; 95% CI, 2.146-4.07; P < 0.0001). Advanced age and National Inpatient Sample-SAH Severity Score were found to be associated with an increased risk of in-hospital mortality (OR, 1.03; 95% CI, 1.03-1.03; P < 0.0001 and OR, 1.70; 95% CI, 1.65-1.75; P < 0.0001, respectively). Renal and cardiac complications are significant factors to consider in aSAH management, with cardiac arrest being the strongest indicator of case fatality and in-hospital mortality. Further research is needed to characterize factors that have contributed to the decreasing trend in case fatality rates identified for certain complications.

Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?

BACKGROUND: In most US states, taxpayers are paying, either directly or indirectly, for years of dialysis therapy for undocumented immigrants with end-stage renal disease who lack resources to pay for care themselves. Living donor transplant is a less expensive long-term alternative, but it is unknown what percentage of these patients have potential living donors. METHODS: We conducted a cross-sectional survey of undocumented immigrant patients receiving dialysis at our outpatient center between March and May 2010. Forty-five patients completed the survey. The survey focused on the availability of potential living donors, perceived health status of those donors, and potential recipients' outlook on remaining on dialysis therapy versus receiving a kidney transplant. We gathered demographic and health status data for the survey participants and the 82 documented resident patients receiving care in the same dialysis unit. RESULTS: The average age of our undocumented immigrant patients was 44 years. The undocumented patients were healthier than their legal resident counterparts, with a lower incidence of coronary artery disease (7% vs 33%; P < 0.005) and diabetes mellitus (40% vs 68%; P < 0.005). Approximately half the undocumented immigrants were working when they were surveyed. Of the half who had stopped working, 82% said they would seek work if they had a kidney transplant. 60% had at least one potential kidney donor. Most donors were reported to reside in the United States or Canada. CONCLUSIONS: Undocumented immigrants treated with dialysis in the United States are relatively young and healthy, and many have at least one potential living kidney donor. Given the societal cost-savings associated with transplant, we suggest that policy makers should consider extending coverage to pay for living donor transplant for undocumented immigrants with end-stage renal disease.

Point-of-care ultrasound for assessing arteriovenous fistula maturity in outpatient hemodialysis.

BACKGROUND: Point-of-care ultrasound in end-stage renal disease is on the rise. Presently the decision to cannulate an arteriovenous fistula is based on its duration since surgery and physical exam. This study examines the effects of point-of-care ultrasound on decreasing the time to arteriovenous fistula cannulation, time spent with a central venous catheter, and the complications and infections that arise. METHODS: Prospective point-of-care ultrasound patients were recruited between January 2015 and January 2018, while retrospective data (non-point-of-care ultrasound) were collected via chart review from patients who had fistula creation between November 2011 and May 2014. Patients had point-of-care ultrasound within 3 weeks after arteriovenous fistula creation and were followed for 1 year. Arteriovenous fistula cannulation was initiated when the following parameters were met: diameter > 6 mm (with no depreciable narrowing of more than 20% throughout), depth < 6 mm, and length > 6 cm. Demographic data, as well as time to cannulation and central venous catheter removal, number of infections, complications, and interventions were compared between point-of-care ultrasound and non-point-of-care ultrasound groups using unpaired t-test, chi-square, and Fisher exact test statistical analysis. RESULTS: A total of 37 patients with new arteriovenous fistulas were followed by point-of-care ultrasound compared to 29 non-point-of-care ultrasound patients. Point-of-care ultrasound patients had earlier cannulations (35.5 vs 63.3 days, p < 0.05), shorter central venous catheter duration (68.2 vs 98.3 days, p < 0.05), and less infections (12 vs 19) without differences in complication compared to the non-point-of-care ultrasound. CONCLUSION: Point-of-care ultrasound facilitates early and safe arteriovenous fistula cannulation leading to a reduction in central venous catheter time and risk of infection. Point-of-care ultrasound may also aid in earlier identification of complications and difficult cannulations.

Propofol infusion syndrome: a case of increasing morbidity with traumatic brain injury.

A previously healthy 16-year-old boy with a closed, severe traumatic brain injury was admitted to a surgical and trauma intensive care unit. He was given a continuous infusion of propofol for sedation and to control intracranial pressure. About 3 days after the propofol infusion was started, metabolic acidosis and rhabdomyolysis developed. Acute renal failure ensued as a result of the rhabdomyolysis. Tachycardia with wide QRS complexes developed without hyperkalemia. The patient died of refractory cardiac dysrhythmia and circulatory collapse approximately 36 hours after the first signs of propofol infusion syndrome appeared. Propofol infusion syndrome is a rare but frequently fatal complication in critically ill children who are given prolonged high-dose infusions of the drug. The syndrome is characterized by severe metabolic acidosis, rhabdomyolysis, acute renal failure, refractory myocardial failure, and hyperlipidemia. Despite several publications on the subject in the past decade, most cases still seem to remain undetectable.

Hypertonic saline infusion in traumatic brain injury increases the incidence of pulmonary infection.

We aimed to investigate the incidence of electrolyte abnormalities, acute kidney injury (AKI), deep venous thrombosis (DVT) and infections in patients with traumatic brain injury (TBI) treated with hypertonic saline (HTS) as osmolar therapy. We retrospectively studied 205 TBI patients, 96 with HTS and 109 without, admitted to the surgical/trauma intensive care unit between 2006 and 2012. Hemodynamics, electrolytes, length of stay (LOS), acute physiological assessment and chronic health evaluation II (APACHE II), injury severity scores (ISS) and mortality were tabulated. Infection, mechanical ventilation, DVT and AKI incidence were reviewed. HTS was associated with increased LOS and all infections (p=0.0001). After correction for the Glasgow coma scale (GCS) and ventilator need, pulmonary infections (p=0.001) and LOS remained higher with HTS (p=0.0048). HTS did not result in increased blood pressure, DVT, AKI or neurological benefits. HTS significantly increased the odds for all infections, most specifically pulmonary infections, in patients with GCS<8. Due to these findings, HTS in TBI should be administered with caution regardless of acuity.

The initiation of dialysis in undocumented aliens: the impact on a public hospital system.

BACKGROUND: Health and dialysis care of undocumented aliens often falls on public hospitals because the majority of these patients are uninsured and cannot afford private medical care. With an estimate of greater than 5 million undocumented aliens, the rate of such patients with end-stage renal disease (ESRD) approaches 1,000 patients/y. Although much attention has been focused on the financial and political impact of this group, little has been published on health care issues. METHODS: Records of 55 undocumented alien patients initiating dialysis therapy from 2 public hospitals in the New York City metropolitan area were reviewed and compared with those of 223 American citizens. We interviewed patients in their native language to assess what predialysis care they had received. RESULTS: Undocumented aliens were primarily Hispanic (58%), poorly educated, and in the United States for 5.11 +/- 0.62 years before dialysis therapy. Four percent were aware of their renal disease before immigration, and fewer than one third had any pre-ESRD care. Undocumented aliens had greater creatinine levels and blood pressures and lower calculated glomerular filtration rates compared with Americans. Their admission lengths of stay and total costs for their first dialysis treatments were greater than those of American patients. Undocumented aliens were twice as likely to be employed. CONCLUSION: Undocumented aliens do not appear to migrate here for medical reasons, suggested by their greater employment rate. They are less inclined to seek pre-ESRD care and present relatively late for dialysis therapy. This study highlights the paucity of pre-ESRD care in these patients and in lower income communities in general. Providing early health care to undocumented aliens would avoid more expensive medical care later on.

Anemia management trends in hospital-based dialysis centers (HBDCs), 2010 to 2013.

BACKGROUND: Few data have been reported on anemia management practices in hospital-based dialysis centers (HBDCs), which are uniquely different from other freestanding dialysis centers. Examining data from HBDCs would help determine if HBDCs and the general US dialysis population have similar trends related to how anemia is managed in dialysis patients. OBJECTIVE: Given recent changes in the prescribing information of erythropoiesis-stimulating agents (ESAs) and in end-stage renal disease-related health policy and reimbursement, this study describes trends in anemia management practices in HBDCs from January 2010 through March 2013. METHODS: Electronic medical records of 5404 adult hemodialysis patients in 50 US-based HBDCs were analyzed retrospectively. Patients included in the study cohort were aged ≥18 years and had at least 1 hemoglobin (Hb) measurement and 1 dose of an ESA between January 2010 and March 2013. End points included Hb concentration, darbepoetin alfa dosing, epoetin alfa dosing, and iron biomarkers (transferrin saturation and ferritin) and dosing. RESULTS: From 2010 to 2013, mean monthly Hb levels declined from 11.4 to 10.7 g/dL; the percentage of patients with mean monthly Hb levels <10 g/dL increased from 11.3% to 24.4%; and the percentage of patients with mean monthly Hb levels >12 g/dL declined from 30.1% to 11.2%. The median darbepoetin alfa cumulative 4-week dose also declined 38.8%, and the weekly epoetin alfa dose declined 24%. From January 2010 to March 2013, the percentage of patients with transferrin saturation >30% increased from 35.8% to 43.6%, the percentage of patients with ferritin levels >500 ng/mL increased from 62.0% to 77.9%, the percentage of patients with ferritin levels ≥800 ng/mL increased from 28.9% to 47.3%, and the median cumulative 4-week intravenous iron dose increased 50%. CONCLUSIONS: These study results support growing evidence that meaningful changes have occurred over the last 3 years in how anemia is clinically managed in US hemodialysis patients. Study limitations include that changes in patient clinical/demographic characteristics over time were not controlled for and that study findings may not be applicable to HBDCs that have different patient populations and/or do not use an electronic medical record system. Continuing to evaluate anemia management practices in HBDCs would provide additional information on the risks and benefits of anemia care. Consistent with national data, the findings from this study indicate that from 2010 to 2013, HBDCs modified anemia management practices for dialysis patients, as evidenced by reductions in mean monthly Hb levels and ESA dosing and by increases in iron biomarkers and dosing.

The role of the primary care physician in managing early stages of chronic kidney disease.

Recent increases in obesity, diabetes, and hypertension, along with the aging of the US population, are driving a dramatic rise in the prevalence of chronic kidney disease (CKD). Despite this increase, the majority of Americans with early-stage CKD remain unaware of their disease. Primary care physicians are at the forefront of efforts for early recognition of CKD and management to control its progression. Patients with CKD should be referred to nephrologists no later than the point at which their estimated glomerular filtration rate reaches 30 mL/min. Nephrology evaluation at this point is essential to facilitate timely preparation for care of end-stage renal disease through preemptive transplantation or planned transition to dialysis. In addition to stringent control of underlying hypertension and/or diabetes, mineral metabolic parameters (serum parathyroid hormone, phosphorus, calcium, and bicarbonate) in patients with advancing CKD should be managed closely to avoid adverse effects on the cardiovascular and skeletal systems.

Does timing of dialysis in patients with ESRD and acute myocardial infarcts affect morbidity or mortality?

BACKGROUND AND OBJECTIVES: Patients with ESRD have an increased incidence of coronary events with a relatively higher risk for mortality after acute myocardial infarction (AMI). We evaluated whether it is safer to delay dialysis in AMI or if delay poses separate risks. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a retrospective review of 131 long-term hemodialysis patients who had AMI and were admitted between 1997 and 2005 at three New York City municipal hospitals. Patients were separated into three groups on the basis of time between cardiac symptoms and first dialysis (<24 h, 24 to 48 h, and >48 h). RESULTS: A total of 17 (13%) patients died, 10 (59%) of whom had either hypotension or an arrhythmia during their first cardiac care unit dialysis. Although these groups were comparable in acuity and cardiac status, there were no findings of increased morbidity (26, 36, and 20%, respectively) or mortality (11, 18, and 13%, respectively), despite differences in the timing of each group's dialysis. We found that previous cardiac disease, predialysis K+, DeltaK+ after dialysis, and APACHE scores were significantly higher in patients with peridialysis morbidity. CONCLUSIONS: We conclude that there is no increased morbidity with early dialysis in AMI, but rather close attention needs to be paid to the rate of decrease in serum potassium in patients with ESRD and their level of acuity when undergoing dialysis.

Nucleosome effects on mesangial cell matrix and proliferation: a possible role in early lupus nephritis.

BACKGROUND: Oligonucleosomes (ON) have been demonstrated in the circulation and biopsies of lupus nephritis patients. Their presence as immune complexes is an early and persistent finding in lupus nephritis as are changes in mesangial matrix. Since ON competitively bind to glomerular mesangial cells (MC) in a receptor-like fashion, the purpose of our study was to investigate what effects ON have on MC matrix and proliferation. METHODS: Rat and mouse MCs grown with ON or DNA for 1 week were dissociated from their matrices with Triton-X and their proteins were determined. MC collagen production, using collagenase sensitive 3H-proline incorporation, was measured after 48-hour incubation with ON and DNA. Similar experiments using 10-fold excess DNA were done to assess its blocking effect on ON induced collagen synthesis. ON interaction with matrix was evaluated by incubated 125I-ON with MC matrix grown with ON or media alone for 1 week. RESULTS: MCs stimulated by ON but not DNA significantly increased total matrix protein, total collagen and specifically, collagen type I synthesis. DNA inhibited ON-stimulated collagen synthesis. MC matrix incubated with ON binds 3 times more 125I-ON than matrix generated in media alone. Histone, a major component of nucleosomes, significantly increased 3H-thymidine incorporation. CONCLUSIONS: Oligonucleosomes, both qualitatively and quantitatively, influence mesangial cell function. These findings for the first time suggest ON to be pathogenic independent of their IC construct. DNA inhibition of ON induced mesangial matrix changes suggests participation of the ON/DNA receptor. Increased production of collagen type I may contribute to glomerulosclerosis.