The Seattle Heart Failure Model in Kidney Transplant Recipients.

Cardiovascular disease is the leading cause of mortality following kidney transplantation. Heart failure affects 17-21% of patients with chronic kidney disease and increases along with time receiving dialysis. The Seattle Heart Failure Model (SHFM) is a validated mortality risk model for heart failure patients that incorporates clinical, therapeutic, and laboratory parameters but does not include measures of kidney function. We applied the SHFM to patients with end-stage renal disease (ESRD) who were being evaluated for kidney transplantation to determine if the model was associated with post-transplant mortality. This retrospective single-center study analyzed survival among 360 adult deceased-donor kidney transplant recipients. Cox regression was used to model post-transplant patient survival. Our findings indicated that a 1.0-point increase in the adapted SHFM score was significantly associated with post-transplant mortality (HR 1.76, 95% CI = 1.10-2.83, p = 0.02), independently of the Kidney Donor Profile Index and Estimated Post-Transplant Survival. Individual covariates of the SHFM were evaluated in univariate analyses, and age, sodium, cholesterol, and lymphocyte count were significantly related to mortality. This study provides preliminary evidence that an adapted SHFM score could be a useful tool in evaluating mortality risk post-transplant in patients with ESRD.

Utilization of Cystatin C in the Outpatient Setting.

INTRODUCTION: Serum creatinine is the traditional biomarker for estimating glomerular filtration rate (eGFR). Cystatin C is an alternative biomarker for which estimating equations exist. The use of cystatin C testing, and the interrelationships among the recently revised Chronic Kidney Disease Epidemiology (CKD-EPI) 2021 estimating equations, was evaluated in a national outpatient laboratory dataset. METHODS: Cystatin C results reported on adults between November 2011 and June 2018 by Laboratory Corporation of America Holdings were examined, with classification of ordering providers and diagnostic codes. Updated eGFR results were calculated using the CKD-EPI 2021 equations for each sample with both cystatin C and creatinine values available. The Spearman correlation coefficients were calculated. Reclassification at clinically relevant cut-off values was examined. RESULTS: There were 87,803 serum cystatin C levels among 55,360 patients; mean age 58 ± 17 years; 50% women. Cystatin C usage increased over time and was ordered for many indications. Among 73,367 samples with simultaneous creatinine and cystatin C, r = 0.84 between eGFR-creatinine and eGFR-cystatin. Correlations of eGFR-creatinine, eGFR-cystatin, and the averaged result of the two equations to the new combined equation were r = 0.94, r = 0.97, and r = 0.998, respectively (p < 0.001 for all). Use of combined/averaged equations tended to result in a higher eGFR and upclassification, compared to eGFR-creatinine. CONCLUSION/DISCUSSION: Use of Cystatin C is increasing and has moved beyond the nephrology community and the original indications from the 2012 KDIGO guidelines. Community utilization of cystatin C measurement is likely to expand, and understanding of the relationships between estimating equations will help clinicians optimize their use in the outpatient setting.

Health Disparities in Autosomal Dominant Polycystic Kidney Disease (ADPKD) in the United States.

BACKGROUND AND OBJECTIVES: Autosomal dominant polycystic kidney disease (ADPKD) occurs at conception and is often diagnosed decades prior to kidney failure. Nephrology care and transplantation access should be independent of race and ethnicity. However, institutional racism and barriers to health care may affect patient outcomes in ADPKD. We sought to ascertain the effect of health disparities on outcomes in ADPKD by examining age at onset of kidney failure and access to preemptive transplantation and transplantation after dialysis initiation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Retrospective cohort analyses of adults with ADPKD in the United States Renal Data System from January 2000 to June 2018 were merged to US Census income data and evaluated by self-reported race and ethnicity. Age at kidney failure was analyzed in a linear model, and transplant rates before and after dialysis initiation were analyzed in logistic and proportional hazards models in Black and Hispanic patients with ADPKD compared with White patients with ADPKD. RESULTS: A total of 41,485 patients with ADPKD were followed for a median of 25 (interquartile range, 5-54) months. Mean age was 56±12 years; 46% were women, 13% were Black, and 10% were Hispanic. Mean ages at kidney failure were 55±13, 53±12, and 57±12 years for Black patients, Hispanic patients, and White patients, respectively. Odds ratios for preemptive transplant were 0.33 (95% confidence interval, 0.29 to 0.38) for Black patients and 0.50 (95% confidence interval, 0.44 to 0.56) for Hispanic patients compared with White patients. Transplant after dialysis initiation was 0.61 (95% confidence interval, 0.58 to 0.64) for Black patients and 0.78 (95% confidence interval, 0.74 to 0.83) for Hispanic patients. CONCLUSIONS: Black and Hispanic patients with ADPKD reach kidney failure earlier and are less likely to receive a kidney transplant preemptively and after initiating dialysis compared with White patients with ADPKD.

Recipient Obesity and Kidney Transplant Outcomes: A Mate-Kidney Analysis.

RATIONALE & OBJECTIVE: The impact of extreme recipient obesity on long-term kidney transplant outcomes has been controversial. This study sought to evaluate the association of various levels of recipient obesity on kidney transplantation outcomes by comparing mate-kidney recipient pairs to address possible confounding effects of donor characteristics on posttransplant outcomes. STUDY DESIGN: Nationwide observational cohort study using mate-kidney models. SETTING & PARTICIPANTS: In analysis based on the Organ Procurement and Transplant Network/United Network of Organ Sharing database, 44,560 adult recipients of first-time deceased-donor kidney transplants from 2001 through 2016 were paired by donor. PREDICTORS: Recipient body mass index (BMI) categorized as 18-25 (n = 12,446), >25-30 (n = 15,477), >30-35 (n = 11,144; obese), and >35 (n = 5,493; extreme obesity) kg/m2. OUTCOMES: Outcomes included patient survival, graft survival, death-censored graft survival, delayed graft function (DGF), and hospital length of stay. ANALYTICAL APPROACH: Conditional logistic regression and stratified proportional hazards models were used to compare outcomes as odds ratios and hazard ratios (HRs), adjusted for recipient and transplant factors, using recipients with a BMI >35 kg/m2 as a reference. RESULTS: At a median follow-up of 3.9 years, adjusted odds ratios for DGF were 0.42 (95% CI, 0.36-0.48), 0.55 (95% CI, 0.48-0.62), and 0.73 (95% CI, 0.64-0.83) for BMI 18-25, >25-30, and >30-35 kg/m2, respectively (P < 0.001 for all). Death-censored graft failure was less frequent for BMI ≤25 and >25-30 kg/m2 (HRs of 0.66 [95% CI, 0.59-0.74] and 0.79 [95% CI, 0.70-0.88], respectively; P < 0.001 for both), but not for BMI >30-35 kg/m2 (HR, 0.91 [95% CI, 0.81-1.02]; P = 0.09). Length of stay and patient survival did not differ by recipient BMI. LIMITATIONS: Observational study with limited detail regarding potential confounders. CONCLUSIONS: Despite an increased risk of DGF likely unrelated to donor organ quality, long-term transplant outcomes among recipients with a BMI >35 kg/m2 are similar to those among recipients with a BMI >30-35 kg/m2, supporting a flexible approach to kidney transplantation candidacy in candidates with extreme obesity.

Chronic disease burdens of incident U.S. dialysis patients, 1996 - 2015
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INTRODUCTION: The United States Renal Data System has collected data on incident hemodialysis (HD) and peritoneal dialysis (PD) patients since 1995, allowing prevalence of chronic diseases over the past 20 years to be measured. MATERIALS AND METHODS: All first-time HD/PD patients 1996 - 2015 were analyzed. Diabetes and cardiovascular diseases were grouped into single variables. Prevalence of each condition was evaluated with logistic regression. Odds ratios (OR) for a 5-year difference in year of dialysis initiation were calculated. Models were adjusted for age, sex, and race, with interactions between modality and year. One- and 5-year mortality were calculated. RESULTS: Age increased among 1,847,212 HD and 156,965 PD patients; PD patients were younger. First-year mortality fell from 24.4 to 21.1% in HD patients and from 17.1 to 8.5% in PD. 5-year mortality fell from 65.9 to 58.6% in HD patients and from 56.3 to 40.4% in PD. Hypertension increased (OR = 1.34 for HD, 1.35 for PD), as did diabetes (OR = 1.16 for HD, 1.06 for PD) and cancer (OR = 1.09 for HD, 1.10 for PD). Cardiovascular disease decreased in PD (OR = 0.87) only. Stroke decreased (OR = 0.98 for HD, 0.90 for PD), as did peripheral vascular disease (OR = 0.91 for HD, 0.82 for PD). Lung disease increased in HD (OR = 1.10) but decreased in PD (OR = 0.97). DISCUSSION: Mortality and cardiovascular disease burden have declined for dialysis patients in the United States despite an aging population that is increasingly hypertensive and diabetic. Comorbid disease burdens among HD and PD patients have diverged over time, with PD patients having fewer comorbid conditions.

Maturing arteriovenous accesses in incident haemodialysis patients and first-year outcomes.

INTRODUCTION: Nephrologists have increased arteriovenous access placement in patients with chronic kidney disease. Not yet usable 'maturing' arteriovenous fistulas and grafts are nearly as common as mature arteriovenous fistulas or grafts. Little has been reported about patients initiating haemodialysis with unready arteriovenous fistulas or grafts. METHODS: The United States Renal Data System records for all adult patients initiating haemodialysis with central venous catheters between July 2010 and December 2011. Patients were categorized by whether a maturing arteriovenous fistula or graft was present. Transition to working arteriovenous fistula or graft was determined from linked Medicare claims. Modality changes and survival were ascertained. A logistic model for one-year survival and a subdistribution hazards model for transition to working arteriovenous fistula or graft, accounting for the competing risk of death, were constructed. RESULTS: Compared to central venous catheter-only, maturing arteriovenous fistula or graft was associated with access conversion (hazard ratio = 2.23 (2.17-2.30) and 3.25 (2.97-3.56), respectively, p < 0.001 for both). Median time to conversion, among those who transitioned, was 95 days (interquartile range = 56-139) for patients with a maturing arteriovenous graft and 135 days (98-198) with a maturing arteriovenous fistula, versus 193 days (138-256) with central venous catheter-only. Pre-dialysis nephrology care, male sex and non-Caucasian race were associated with access conversion. Patients without a maturing arteriovenous fistula or graft had decreased odds of one-year survival (odds ratio = 0.61 (0.58-0.66), p < 0.001), which attenuated with adjustment for access conversion (adjusted odds ratio = 1.06 (0.98-1.13), p = 0.2). CONCLUSION: Maturing arteriovenous fistulas or grafts were associated with enhanced first-year survival and increased opportunity for working arteriovenous fistulas or grafts, which may reflect pre-dialysis decision-making, quality of care and comorbid diseases. Central venous catheter exposure was substantial, even among patients with maturing access. Contributory factors prolonging conversion to arteriovenous access need to be identified and addressed.

The Epidemiologic Burden of Tacrolimus Variability among Kidney Transplant Recipients in the United States.

BACKGROUND: Within-patient tacrolimus level variability >30% has been shown to be a risk factor for de novo donor-specific antibody formation and death-censored graft failure among kidney transplant recipients. The burden of tacrolimus variability and the correlation between variability and subtherapeutic tacrolimus levels were examined in a large national data set. METHODS: All tacrolimus levels drawn at LabCorp® facilities in the United States with a diagnosis code for kidney transplant between November 2011 and September 2017 were examined, excluding values that could represent new allografts. Tacrolimus variability was calculated if at least 3 levels were available. The percentage of subtherapeutic (<4.0 ng/dL) tacrolimus levels (%subT) was also calculated. Interdependence between %subT and tacrolimus variability was assessed with correlation analysis and linear regression. RESULTS: There were 410,257 tacrolimus levels among 27,375 patients, who had 11 (interquartile range [IQR] 6-20) tacrolimus levels over a median follow-up of 26.5 (IQR 12.8-46.1) months. Median tacrolimus variability was 30.6%, and 51.6% of patients exceeded 30% variability. Median %subT was 11.1% (IQR 0-30.8%), and 34.3% of patients had no subtherapeutic levels. The correlation coefficient between tacrolimus variability and %subT was 0.253 (p< 0.001). In linear regression, tacrolimus variability increased 1.86% for each 10% increase in %subT (p < 0.001), but R-squared for this model was only 0.06. CONCLUSION: More than half of established kidney transplant patients from a large national sample exhibited levels of tacrolimus variability that have been associated with inferior transplant outcomes. Tacrolimus variability has a weak association with subtherapeutic levels, but represents a more complicated constellation of clinical factors.

Outcomes After Percutaneous Angioplasty of Arteriovenous Fistulas and Grafts in African American Patients.

PURPOSE: Arteriovenous fistulas and grafts, necessary for hemodialysis, may develop stenoses due to neointimal hyperplasia, which often require percutaneous transluminal angioplasty. Patient and lesion characteristics were evaluated prior to angioplasty and were correlated with 1- and 6-month outcomes. MATERIALS AND METHODS: This was an observational study of African American hemodialysis patients who presented for angioplasty of a dysfunctional fistula or graft. Clinical outcomes were ascertained from dialysis facilities 1 month and 6 months after angioplasty. One-month clinical success was defined as dialyzer blood flows of 450 mL/min without complications or interval shunt thrombosis, interventions, or loss of access, which was rarely achieved at 6 months. Logistic regression models were used to evaluate associations of clinical variables with outcomes. RESULTS: There were 150 stenoses treated during 99 procedures performed on 82 patients. The clinical success rate at one month was 67% with no complications as a result of the percutaneous transluminal angioplasty. Success at 1 month was positively associated with use of aspirin (P = .005) and with referral for high venous pressures (P = .004). Six-month data were available for 81 procedures, with 45.7% requiring repeat angioplasty and 12.3% suffering major complications (thrombectomy, revision surgery, or access abandonment). Major complications were seen predominantly in patients who were not receiving aspirin. CONCLUSIONS: Aspirin use and high venous pressure were associated with 1-month clinical success and fewer major complications at 6 months. Future work should investigate biologic mechanisms of action of aspirin and long-term effects of use to maintain vascular access.

Transfers to Hemodialysis Among US Patients Initiating Renal Replacement Therapy With Peritoneal Dialysis.

RATIONALE & OBJECTIVE: Identifying patients who are likely to transfer from peritoneal dialysis (PD) to hemodialysis (HD) before transition could improve their subsequent care. This study developed a prediction tool for transition from PD to HD. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Adults initiating PD between January 2008 and December 2011, followed up through June 2015, for whom data were available in the US Renal Data System (USRDS). PREDICTORS: Clinical characteristics at PD initiation and peritonitis claims. OUTCOMES: Transfer to HD, with the competing outcomes of death and kidney transplantation. ANALYTICAL APPROACH: Outcomes were ascertained from USRDS treatment history files. Subdistribution hazards (competing-risk) models were fit using clinical characteristics at PD initiation. A nomogram was developed to classify patient risk at 1, 2, 3, and 4 years. These data were used to generate quartiles of HD transfer risk; this quartile score was incorporated into a cause-specific hazards model that additionally included a time-dependent variable for peritonitis. RESULTS: 29,573 incident PD patients were followed up for a median of 21.6 (interquartile range, 9.0-42.3) months, during which 41.2% transferred to HD, 25.9% died, 17.1% underwent kidney transplantation, and the rest were followed up to the study end in June 2015. Claims for peritonitis were present in 11,733 (40.2%) patients. The proportion of patients still receiving PD decreased to <50% at 22.6 months and 14.2% at 5 years. Peritonitis was associated with a higher rate of HD transfer (HR, 1.82; 95% CI, 1.76-1.89; P < 0.001), as were higher quartile scores of HD transfer risk (HRs of 1.31 [95% CI, 1.25-1.37), 1.51 [95% CI, 1.45-1.58], and 1.78 [95% CI, 1.71-1.86] for quartiles 2, 3, and 4 compared to quartile 1 [P < 0.001 for all]). LIMITATIONS: Observational data, reliant on the Medical Evidence Report and Medicare claims. CONCLUSIONS: A large majority of the patients who initiated renal replacement therapy with PD discontinued this modality within 5 years. Transfer to HD was the most common outcome. Patient characteristics and comorbid diseases influenced the probability of HD transfer, death, and transplantation, as did episodes of peritonitis.

Hemodynamic effects of hemodialyzer pump speed on arteriovenous fistulas
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AIM: Arteriovenous fistulas (AVF) are the optimal vascular access for hemodialysis although many fistulas fail. The impetus to increase hemodialyzer blood flow (QB) in order to maximize solute clearances may be counterbalanced if AVF suffer adverse hemodynamic effects from accelerated pump flows. The optimal QB to maintain adequate hemodialysis without potentially contributing to AVF dysfunction is unknown. The aim of this study was to measure the hemodynamic effects of increased QB on AVF. MATERIALS AND METHODS: A prospective cohort of 14 patients with primary brachiocephalic AVF underwent venous Doppler measurements prior to cannulation (QB0) and during hemodialysis with QB of 350 mL/min at a standardized anatomical location over 3 - 16 consecutive months. Measurements included vein diameter, blood flow velocity, and volumetric flow. RESULTS: 163 paired Doppler measurements (QB0 and QB350) were made in 14 subjects. There were no significant differences in venous diameter, but significant increases in blood flow velocity and volumetric flow (p < 0.001). Mean blood flow velocity increased from 86.6 ± 35.0 cm/s at QB0 to 105.7 ± 35.0 cm/s at QB350. Mean volumetric flow increased from 849 mL/min at QB0 to 1,059 mL/min at QB350. Vein diameters increased linearly over time, with no significant changes in blood velocity or volumetric flow, suggesting AVF maturation may improve tolerance of pumped blood flow. CONCLUSION: Blood flow velocity and volumetric flow increased when hemodialyzer blood pump was applied to an AVF, creating a situation in which increased turbulence and shear stress might be plausible. Further study is needed to determine if increased QB affects clinical outcomes of AVF.
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Perforated appendicitis in patients with schizophrenia: a retrospective cohort study.

OBJECTIVE: Altered pain sensitivity may affect the outcome of appendicitis in patients with schizophrenia. We aimed to compare the prevalence of perforation in appendicitis between patients with and without schizophrenia. DESIGN: Retrospective cohort study with random matching. SETTING: A single tertiary medical centre in Japan. PARTICIPANTS: From 1985 to 2013, 1821 cases of appendicitis requiring appendectomy were collected. Patients with schizophrenia and a cohort of randomly selected control subjects without schizophrenia who underwent appendectomy were identified. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the rate of perforated appendicitis in patients with and without schizophrenia. Secondary outcome was the odds of perforated appendicitis by different clinical factors. RESULTS: 62 patients with schizophrenia and randomly sampled 200 non-schizophrenic patients were compared. The prevalence of perforation was 53% in patients with schizophrenia versus 17% in controls (p<0.0001). The adjusted OR for perforation were 4.87 (95% CI: 2.33 to 10.2) for schizophrenia, 3.35 (95% CI 1.51 to 7.45) for age >55 years and 2.18 (95% CI: 1.12 to 4.27) for delayed presentation. CONCLUSION: Appendiceal perforation was more frequent in patients with schizophrenia than controls, which may be partly attributable to delayed presentation and altered responses to pain.

Potential contribution of lifestyle and socioeconomic factors to healthy user bias in antihypertensives and lipid-lowering drugs.

OBJECTIVES: Healthy user bias arises when users of preventive medications such as lipid-lowering drugs (LLDs), hormone replacement therapy and antihypertensive (AH) medications are healthier than non-users due to factors other than medication effects, making the medications appear more beneficial in observational studies of effectiveness and safety. The purpose of the study is to examine factors contributing to healthy user effect in patients taking AHs or LLDs. METHODS: Among patients with hypertension or hyperlipidaemia in a population-based sample from the National Health and Nutrition Examination Survey (1999-2010), we assessed the association between socioeconomic and lifestyle factors and the use of AHs/LLDs by logistic regression with adjustment for demographics and comorbidities in a cross-sectional study. RESULTS: When 9715 AH/LLD users were compared with 3725 non-users, AH/LLD users were more likely to be: highly educated (OR 1.2, 95% CI 1.2 to 1.3), non-impoverished (OR 1.3, 95% CI 1.2 to 1.4), current non-smokers (OR 1.2, 95% CI 1.1 to 1.4), physically active (OR 1.1, 95% CI 1.0 to 1.2) and consume more calcium (OR 1.1, 95% CI 1.0 to 1.3) but less likely to have normal body mass index (OR 0.6, 95% CI 0.6 to 0.7) or to meet dietary sodium recommendations (OR 0.8, 95% CI 0.7 to 0.9). CONCLUSIONS: We identified several salutary lifestyle factors associated with AH/LLD use in a representative US population. Healthy user effect may be partly explained by better socioeconomic profiles and lifestyles in AH/LLD users compared with non-users.

Sex, race, and hemodialysis vascular access processes.

PURPOSE: Hemodialysis (HD) patients who are female or black receive fewer arteriovenous fistulas (AVF) and more grafts (AVG). We evaluated race- and sex-based differences for three process exposures: access surgery, peripherally-inserted central catheters (PICCs), and vascular imaging. METHODS: US Renal Data System with linked Medicare claims for patients initiating HD between April 2010 - December 2011 were used to identify PICC placement, imaging, AVF and AVG surgeries, and the vascular accesses in use at individual HD treatments. Poisson, logistic, and Cox regression models adjusted for clinical and demographic variables were used to evaluate relationships between process exposures, vascular access outcomes, and sex. RESULTS: Among 18,883 individuals initiating HD with catheters with at least one surgical claim for AVF or AVG, women had 16% more PICC and 5% more imaging (p = 0.002), were 43% less likely to have AVF surgery and 68% more likely to have AVG surgery (p<0.001). The odds of AVF surgery producing a working AVF were 18% lower and of AVG surgery producing a working AVG 38% higher (p<0.001). Black patients had 24% more PICCs and 12% more imaging, were 48% less likely to have AVF surgery and 84% more likely to have AVG surgery (p<0.001). The odds of achieving a working AVF were 8% lower and of a working AVG were 38% higher. The hazard of future catheter use after AVF creation was 25% higher for women (p<0.001), but did not differ by race. CONCLUSIONS: Divergences in vascular access by race and sex were partly related to differential process exposures. Black and female patients had more AVG and less AVF surgery, and more PICC and imaging. Success rates were lower for AVF surgery and higher for AVG surgery. Further work is needed to determine whether choices of process exposures arise from differential ability to detect veins on physical examination.

Dialysate Composition for Hemodialysis: Changes and Changing Risk.

Dialysate composition is a critical aspect of the hemodialysis prescription. Despite this, trial data are almost entirely lacking to help guide the optimal dialysate composition. Often, the concentrations of key components are chosen intuitively, and dialysate composition may be determined by default based on dialysate manufacturer specifications or hemodialysis facility practices. In this review, we examine the current epidemiological evidence guiding selection of dialysate bicarbonate, calcium, magnesium, and potassium, and identify unresolved issues for which pragmatic clinical trials are needed.

Vascular imaging for hemodialysis vascular access planning.

INTRODUCTION: Central venous catheters (CVC) increase risks associated with hemodialysis (HD), but may be necessary until an arteriovenous fistula (AVF) or graft (AVG) is achieved. The impact of vascular imaging on achievement of working AVF and AVG has not been firmly established. METHODS: Retrospective cohort of patients initiating HD with CVC in 2010-2011, classified by exposure to venography or Doppler vein mapping, and followed through December 31, 2012. Standard and time-dependent Cox models were used to determine hazard ratios (HRs) of death, working AVF, and any AVF or AVG. Logistic regression was used to assess the association of preoperative imaging with successful AVF or AVG among 18,883 individuals who had surgery. Models were adjusted for clinical and demographic factors. FINDINGS: Among 33,918 patients followed for a median of 404 days, 39.1% had imaging and 55.7% had surgery. Working AVF or AVG were achieved in 40.6%; 46.2% died. Compared to nonimaged patients, imaged patients were more likely to achieve working AVF (HR = 1.45 [95% confidence interval [CI] 1.36, 1.55], P < 0.001]), any AVF or AVG (HR = 1.63 [1.58, 1.69], P > 0.001), and less likely to die (HR = 0.88 [0.83-0.94], P < 0.001). Among patients who had surgery, the odds ratio for any successful AVF or AVG was 1.09 (1.02-1.16, P = 0.008). DISCUSSION: Fewer than half of patients who initiated HD with a CVC had vascular imaging. Imaged patients were more likely to have vascular surgery and had increased achievement of working AV fistulas and grafts. Outcomes of surgery were similar in patients who did and did not have imaging.

Peripherally Inserted Central Catheters and Hemodialysis Outcomes.

BACKGROUND AND OBJECTIVES: Use of peripherally inserted central catheters has expanded rapidly, but the consequences for patients who eventually require hemodialysis are undefined. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Our national, population-based analysis included 33,918 adult Medicare beneficiaries from the US Renal Data System who initiated hemodialysis with central venous catheters as their sole vascular access in 2010 and 2011. We used linked Medicare claims to identify peripherally inserted central catheter exposures and evaluate the associations of peripherally inserted central catheter placement with transition to working arteriovenous fistulas or grafts and patient survival using a Cox model with time-dependent variables. RESULTS: Among 33,918 individuals initiating hemodialysis with a catheter as sole access, 12.6% had received at least one peripherally inserted central catheter. Median follow-up was 404 days (interquartile range, 103-680 days). Among 6487 peripherally inserted central catheters placed, 3435 (53%) were placed within the 2 years before hemodialysis initiation, and 3052 (47%) were placed afterward. Multiple peripherally inserted central catheters were placed in 30% of patients exposed to peripherally inserted central catheters. Recipients of peripherally inserted central catheters were more likely to be women and have comorbid diagnoses and less likely to have received predialysis nephrology care. After adjustment for clinical and demographic factors, peripherally inserted central catheters placed before or after hemodialysis initiation were independently associated with lower likelihoods of transition to any working fistula or graft (hazard ratio for prehemodialysis peripherally inserted central catheter, 0.85; 95% confidence interval, 0.79 to 0.91; hazard ratio for posthemodialysis peripherally inserted central catheter, 0.81; 95% confidence interval, 0.73 to 0.89). CONCLUSIONS: Peripherally inserted central catheter placement was common and associated with adverse vascular access outcomes. Recognition of potential long-term adverse consequences of peripherally inserted central catheters is essential for clinicians caring for patients with CKD.

Inpatient venous access practices: PICC culture and the kidney patient.

PURPOSE: Depleted venous access is frequently cited as a reason for low fistula achievement. These quality assurance studies were designed to clarify the interactions between kidney disease, acuity of care and vascular access practices, and define the impact of nephrology intervention. METHODS: The inpatient population at an urban teaching hospital was surveyed three times between May 2010 and May 2012. Data were collected on limb protection and vascular access practices, as well as level of kidney function and level of care. RESULTS: Peripherally inserted central catheter (PICC) insertion consistently exceeded 30% in patients with chronic kidney disease; reasons for insertion were often poorly defined. More than 50% of patients had devices in the nondominant arm; use of limb protection bracelets was rare. An educational intervention designed to increase nephrologist awareness increased limb protection slightly, but did not affect the distribution of vascular access devices. CONCLUSIONS: PICC placement and invasion of the nondominant arm are both frequent in patients with abnormal kidney function, in spite of guidelines discouraging their use. The rate of PICC is higher than that of patients with normal kidney function. Current vascular access practices have substantial potential to affect future fistula rates. Effective vein protection may require participation of the entire medical community.

Anti-glomerular basement membrane disease treated with mycophenolate mofetil, corticosteroids, and plasmapheresis.

An 18-year-old woman presented with anemia, pulmonary hemorrhage, and necrotizing glomerulonephritis, and was diagnosed with anti-glomerular basement membrane (anti-GBM) disease. Treatment was undertaken with plasma exchange, mycophenolate mofetil and corticosteroids, due to patient refusal of cyclophosphamide. Clinical remission was successfully induced with this fertility-sparing regimen. A relapse due to therapy non-adherence was successfully treated with a second course of plasmapheresis, mycophenolate, and steroids. Thereafter, 6 months of directly observed therapy resulted in a favorable outcome with well-preserved pulmonary and renal function. This case suggests the possibility that mycophenolate may have a role in the treatment of anti-GBM disease.