Disaster preparation in kidney transplant recipients: a questionnaire-based cohort study from a large United States transplant center
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BACKGROUND: Few quantitative assessments have assessed disaster preparation in kidney transplant patients. This is a survey-based assessment of disaster preparedness of 200 patients at the University of California San Francisco, USA. MATERIALS AND METHODS: Patients answered questionnaires assessing their level of preparedness as well as barriers to preparation. Preparedness was scored based on response to 7 questions. Univariate analyses compared participant characteristics extracted from the medical chart against three tertiles of preparedness: low (scores 0 - 2), medium (scores 3 - 4), and high (scores 5 - 7). California counties were coded and mapped by average preparedness scores. RESULTS: Only 30% of patients were highly prepared for disasters. Participants were prepared with available medication for 2 weeks (78.5%) and least prepared in having a medical ID bracelet (13%). Significant minorities of patients (40% of patients or more) were unprepared with lists of medications, important phone numbers and disaster kits. Preparedness was not associated with demographic and clinical characteristics. Monterey County was the most prepared of the 31 California counties sampled (score of 4.25 out of 7). CONCLUSION: All patients should be educated regarding disaster preparation. County and medical services should collaborate to address specialized populations in general preparedness planning.
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A mixed-methods investigation of incident Hemodialysis access in a safety-net population.

BACKGROUND: Despite improved health outcomes associated with arteriovenous fistulas, 80% of Americans initiate hemodialysis using a catheter, influenced by low socioeconomic status among other factors. Risk factors for incident catheter use in safety-net populations are unknown. Our objective was to identify factors associated with incident catheter use among hemodialysis patients at one safety-net hospital, with a goal of informing fistula placement initiatives targeted at safety-net populations more generally. METHODS: We performed a retrospective review of all incident hemodialysis patients at a single urban safety-net hospital from January 1, 2010 - December 31, 2015 (n = 241), as well as semi-structured interviews with a multi-lingual convenience sample of patients (n = 10) from this cohort. The primary outcome was incident vascular access modality. Multivariable logistic regression was used to identify factors associated with incident catheter use. Interview transcripts were coded using a directed content analysis framework based on a model describing barriers to healthcare access. RESULTS: Subjects were 61.8% male, racially/ethnically diverse (19.5% white, 29.5% black, 28.6% Hispanic, 17.4% Asian), with a mean age of 52.4 years. Eighty-eight percent initiated hemodialysis using a catheter. In multivariable analysis, longer duration of nephrology care was associated with decreased catheter use (>12 months vs. 0-6 months: adjusted Odds Ratio [aOR] 0.07, 95% CI 0.02-0.23, p < 0.001), whereas uninsured status increased odds of catheter use (aOR 3.96, 1.23-12.76, p = 0.02). There was a decrease in catheter use after vascular surgery services became available in-hospital (OR 0.40, 95% CI 0.16-0.98, p = 0.04), however this association was not significant in multivariable analysis (aOR 0.48, 0.17-1.36, p = 0.17). During interviews, patients cited emotional responses to disease, lack of social and financial resources, and limited health knowledge as barriers to obtaining fistula surgery. CONCLUSIONS: The rate of catheter use in this urban safety-net population is above the national average. Access to health insurance, early referrals to nephrology, and provision of in-hospital vascular surgery should be prioritized in the safety-net. Additionally, services that support patients' emotional and learning needs may decrease delays in fistula placement.

Recurrent focal segmental glomerulosclerosis in renal allograft recipients: role of human leukocyte antigen mismatching and other clinical variables.

Recurrence of focal segmental glomerulosclerosis (FSGS) after renal transplantation impacts long-term graft survival and limits access to transplantation. We hypothesized that HLA donor/recipient matching could be used as a surrogate marker of recurrence. In a retrospective study of 42 pediatric and 77 adult subjects with primary FSGS, transplanted from 1990 to 2007 at a single center, we analyzed the degree of donor/recipient HLA compatibility and other clinical variables associated with FSGS recurrence. There were total of 131 allografts for primary FSGS (11 subjects were transplanted twice, and 1 had a third allograft) with 20 cases of FSGS recurrence (17 children) in the primary allograft, and two children who had FSGS recurrence in the second allograft. Fifty-two subjects (40%) were African American, and 66 (50%) Caucasians. Recurrent FSGS and controls were not different for age at transplant, gender, donor source, acute/chronic rejection episodes, and HLA matches. Recurrent FSGS was not associated with HLA mismatches; power equals 83%. Immunosuppressive regimen had no effect on recurrence of FSGS, P = .75. Recurrent FSGS is not associated with HLA mismatching, acute cellular or vascular rejection, and occurs primarily in the pediatric population.

Vitamin D levels and food and environmental allergies in the United States: results from the National Health and Nutrition Examination Survey 2005-2006.

BACKGROUND: Previous research supports a possible link between low vitamin D levels and atopic disease. However, the association between low vitamin D levels and total and allergen-specific IgE levels has not been studied. OBJECTIVE: We sought to test the association between serum 25-hydroxyvitamin D (25[OH]D) deficiency (<15 ng/mL) and insufficiency (15-29 ng/mL) and allergic sensitization measured by serum IgE levels in a US nationally representative sample of 3136 children and adolescents and 3454 adults in the National Health and Nutrition Examination Survey 2005-2006. METHODS: The association of 25(OH)D deficiency with 17 different allergens was assessed after adjustment for potential confounders, including age; sex; race/ethnicity; obesity, low socioeconomic status; frequency of milk intake; daily hours spent watching television, playing videogames, or using a computer; serum cotinine levels; and vitamin D supplement use. RESULTS: In children and adolescents allergic sensitization to 11 of 17 allergens was more common in those with 25(OH)D deficiency. Compared with sufficient vitamin D levels of greater than 30 ng/mL, after multivariate adjustment, 25(OH)D levels of less than 15 ng/mL were associated with peanut (odds ratio [OR], 2.39; 95% CI, 1.29-4.45), ragweed (OR, 1.83; 95% CI, 1.20-2.80), and oak (OR, 4.75; 95% CI, 1.53-4.94) allergies (P < .01 for all). Eight other allergens were associated with 25(OH)D deficiency, with P values of less than .05 but greater than .01. There were no consistent associations seen between 25(OH)D levels and allergic sensitization in adults. CONCLUSION: Vitamin D deficiency is associated with higher levels of IgE sensitization in children and adolescents. Further research is needed to confirm these findings.