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1.
CMAJ Open ; 7(4): E706-E712, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31822501

RESUMO

BACKGROUND: End-stage kidney disease is a serious complication of diabetes. We describe the prevalence of chronic kidney disease, prevalence and incidence of end-stage kidney disease and quality of care of early-stage chronic kidney disease for First Nations people with diabetes compared to other Ontarians with diabetes. METHODS: We conducted a retrospective cohort study in Ontario using linked administrative data at ICES. We included adults with incident diabetes between 1994 and 2014, and used laboratory values to identify kidney disease and quality indicators for care for early-stage disease. We compared measures in First Nations people to those in other people in Ontario, and used direct age and sex standardization. We used Cox proportional hazards regression to compare the incidence of end-stage kidney disease between groups. RESULTS: Our study included 21 968 First Nations people with diabetes. The age- and sex-standardized prevalence of chronic kidney disease was higher for First Nations people than for other Ontarians (20.7% v. 18.4%), as was the prevalence of end-stage kidney disease (2.9% v. 1.0%). The incidence of end-stage kidney disease was higher among First Nations people than among other people in Ontario (9.3 v. 4.7 events per 10 000 person-years; age- and sex-adjusted hazard ratio 2.23, 95% confidence interval 1.72-2.89). The 2 groups were similarly likely to receive recommended medications, but First Nations people were less likely to receive laboratory tests for their kidney disease. INTERPRETATION: Despite receiving similar quality of care for early-stage kidney disease, First Nations people with diabetes had higher rates of end-stage kidney disease than other Ontarians. Further research is needed to better understand contributing factors to help inform future interventions.

2.
Can J Kidney Health Dis ; 6: 2054358119861943, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31798925

RESUMO

Background: Clinical practice guidelines recommend arteriovenous fistulas as the preferred form of vascular access for hemodialysis. However, some studies have suggested that older age is associated with poorer fistula outcomes. Objective: We assessed the impact of age on the outcomes of fistula creation and access-related procedures. Design: This was a prospective cohort study using data collected as part of the Dialysis Measurement Analysis and Reporting (DMAR) system. Setting: Participating Canadian dialysis programs, including Southern Alberta Renal Program, Manitoba Renal Program, Sunnybrook Health Sciences Centre (Toronto, Ontario), London Health Sciences Centre (London, Ontario), and The Ottawa Hospital (Ottawa, Ontario). Patients: Incident hemodialysis patients aged 18 years and older who started dialysis between January 1, 2004, and May 31, 2012. Measurements: The primary outcome was the proportion of all first fistula attempts that resulted in catheter-free fistula use, defined as independent use of a fistula for hemodialysis (ie, no catheter in place). Secondary outcomes included the time to catheter-free fistula use among patients with a fistula creation attempt, total number of days of catheter-free fistula use, and the proportion of a patient's hemodialysis career spent with an independently functioning fistula (ie, catheter-free fistula use). Methods: We compared patient characteristics by age group, using t tests or Wilcoxon rank sum tests, and chi-square or Fisher exact tests, as appropriate. Logistic and fractional logistic regression were used to estimate the odds of achieving catheter-free fistula use by age group and the proportion of dialysis time spent catheter-free, respectively. Results: A total of 1091 patients met our inclusion criteria (567 age ≥ 65; 524 age < 65). Only 57% of first fistula attempts resulted in catheter-free fistula use irrespective of age (adjusted odds ratio [OR]≥65vs<65: 1.01; P = .93). The median time from hemodialysis start to catheter-free use of the first fistula did not differ by age when grouped into fistulas attempted pre- and post-dialysis initiation. The adjusted rates of access-related procedures were comparable (incidence rate ratio [IRR]≥65vs<65: 0.95; P = .32). The median percentage of follow-up time spent catheter-free was similar and low in patients who attempted fistulas (<65 years: 19% vs ≥65 years: 21%; P = .85). Limitations: The relatively short follow-up time may have underestimated the benefits of fistula creation and the observational study design precludes inferences about causality. Conclusions: In our study, older patients who underwent a fistula attempt were just as likely as younger patients to achieve catheter-free fistula use, within a similar time frame, and while requiring a similar number of access procedures. However, the minority of dialysis time was spent catheter-free.

3.
Ann Intern Med ; 2019 Dec 24.
Artigo em Inglês | MEDLINE | ID: mdl-31869834

RESUMO

Background: Preliminary data suggest that preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) may improve risk prediction in patients undergoing noncardiac surgery. Objective: To determine whether preoperative NT-proBNP has additional predictive value beyond a clinical risk score for the composite of vascular death and myocardial injury after noncardiac surgery (MINS) within 30 days after surgery. Design: Prospective cohort study. Setting: 16 hospitals in 9 countries. Patients: 10 402 patients aged 45 years or older having inpatient noncardiac surgery. Measurements: All patients had NT-proBNP levels measured before surgery and troponin T levels measured daily for up to 3 days after surgery. Results: In multivariable analyses, compared with preoperative NT-proBNP values less than 100 pg/mL (the reference group), those of 100 to less than 200 pg/mL, 200 to less than 1500 pg/mL, and 1500 pg/mL or greater were associated with adjusted hazard ratios of 2.27 (95% CI, 1.90 to 2.70), 3.63 (CI, 3.13 to 4.21), and 5.82 (CI, 4.81 to 7.05) and corresponding incidences of the primary outcome of 12.3% (226 of 1843), 20.8% (542 of 2608), and 37.5% (223 of 595), respectively. Adding NT-proBNP thresholds to clinical stratification (that is, the Revised Cardiac Risk Index [RCRI]) resulted in a net absolute reclassification improvement of 258 per 1000 patients. Preoperative NT-proBNP values were also statistically significantly associated with 30-day all-cause mortality (less than 100 pg/mL [incidence, 0.3%], 100 to less than 200 pg/mL [incidence, 0.7%], 200 to less than 1500 pg/mL [incidence, 1.4%], and 1500 pg/mL or greater [incidence, 4.0%]). Limitation: External validation of the identified NT-proBNP thresholds in other cohorts would reinforce our findings. Conclusion: Preoperative NT-proBNP is strongly associated with vascular death and MINS within 30 days after noncardiac surgery and improves cardiac risk prediction in addition to the RCRI. Primary Funding Source: Canadian Institutes of Health Research.

4.
Am J Kidney Dis ; 2019 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-31732233

RESUMO

RATIONALE & OBJECTIVE: Surveillance blood work is routinely performed in maintenance hemodialysis (HD) recipients. Although more frequent blood testing may confer better outcomes, there is little evidence to support any particular monitoring interval. STUDY DESIGN: Retrospective population-based cohort study. SETTING & PARTICIPANTS: All prevalent HD recipients in Ontario, Canada, as of April 1, 2011, and a cohort of incident patients commencing maintenance HD in Ontario, Canada, between April 1, 2011, and March 31, 2016. EXPOSURE: Frequency of surveillance blood work, monthly versus every 6 weeks. OUTCOMES: The primary outcome was all-cause mortality. Secondary outcomes were major adverse cardiovascular events, all-cause hospitalization, and episodes of hyperkalemia. ANALYTICAL APPROACH: Cox proportional hazards with adjustment for demographic and clinical characteristics was used to evaluate the association between blood testing frequency and all-cause mortality. Secondary outcomes were evaluated using the Andersen-Gill extension of the Cox model to allow for potential recurrent events. RESULTS: 7,454 prevalent patients received care at 17 HD programs with monthly blood sampling protocols (n=5,335 patients) and at 8 programs with blood sampling every 6 weeks (n=2,119 patients). More frequent monitoring was not associated with a lower risk for all-cause mortality compared to blood sampling every 6 weeks (adjusted HR, 1.16; 95% CI, 0.99-1.38). Monthly monitoring was not associated with a lower risk for any of the secondary outcomes. Results were consistent among incident HD recipients. LIMITATIONS: Unmeasured confounding; limited data for center practices unrelated to blood sampling frequency; no information on frequency of unscheduled blood work performed outside the prescribed sampling interval. CONCLUSIONS: Monthly routine blood testing in HD recipients was not associated with a lower risk for death, cardiovascular events, or hospitalizations as compared with testing every 6 weeks. Given the health resource implications, the frequency of routine blood sampling in HD recipients deserves careful reassessment.

5.
JAMA ; 2019 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-31705755

RESUMO

Importance: At least 30 case reports have linked the muscle relaxant baclofen to encephalopathy in patients with chronic kidney disease (CKD). Objective: To compare the 30-day risk of encephalopathy in patients with CKD and newly prescribed baclofen at greater than or equal to 20 mg per day vs less than 20 mg per day. The secondary objective was to compare the risk of encephalopathy in baclofen users vs nonusers. Design, Setting, and Participants: Retrospective population-based cohort study in Ontario, Canada (2007-2018) using linked health care data. Participants comprised 15 942 older adults (aged 66 years or older) with CKD (defined as an estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2 but not receiving dialysis). The primary cohort was restricted to patients who were newly prescribed baclofen; participants in the secondary cohort were new users and nonusers. Exposures: Prescription for oral baclofen greater than or equal to 20 mg per day vs less than 20 mg per day. Main Outcomes and Measures: Hospital admission with encephalopathy, defined as a main diagnosis of delirium, disorientation, transient alteration of awareness, transient cerebral ischemic attack, or unspecified dementia within 30 days of starting baclofen. Inverse probability of treatment weighting on the propensity score was used to balance comparison groups on indicators of baseline health. Weighted risk ratios (RRs) were obtained using modified Poisson regression and weighted risk differences (RDs) using binomial regression. Prespecified subgroup analyses were conducted by eGFR category. Results: The primary cohort comprised 15 942 patients with CKD (9699 [61%] women; median age, 77 years [interquartile range, 71-82]; 9707 [61%] patients started baclofen at ≥20 mg/d and 6235 [39%] at <20 mg/d). The primary outcome, hospitalization with encephalopathy, occurred in 108/9707 (1.11%) patients who started baclofen at greater than or equal to 20 mg per day and in 26/6235 (0.42%) who started baclofen at less than 20 mg per day; weighted RR, 3.54 (95% CI, 2.24 to 5.59); weighted RD, 0.80% (95% CI, 0.55% to 1.04%). In subgroup analysis, the absolute risk increased progressively at lower eGFR (weighted RD eGFR 45-59, 0.42% [95% CI, 0.19%-0.64%]; eGFR 30-44, 1.23% [95% CI, 0.62%-1.84%]; eGFR <30, 2.90% [95% CI, 1.30%-4.49%]; P for interaction, <.001]). In the secondary comparison with 284 263 nonusers, both groups of baclofen users had a higher risk of encephalopathy (<20 mg/d weighted RR, 5.90 [95% CI, 3.59 to 9.70] and ≥20 mg/d weighted RR, 19.8 [95% CI, 14.0 to 28.0]). Conclusions and Relevance: Among older patients with CKD who were newly prescribed baclofen, the 30-day incidence of encephalopathy was increased among those prescribed higher doses compared with lower doses. If verified, these risks should be balanced against the benefits of baclofen use.

6.
Gastroenterology ; 2019 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-31682852

RESUMO

BACKGROUND & AIMS: Physicians' own screening practices might affect screening in their patients. We conducted a population-based study to evaluate whether family physicians who underwent colorectal cancer testing were more likely to have patients who underwent colorectal cancer testing. METHODS: We collected demographic and healthcare information on residents of Ontario, Canada from administrative databases; the sample was restricted to individuals at average risk of colorectal cancer who were 52-74 years old as of April 21, 2016. We obtained a list of all registered physicians in the province; physicians (n=11,434) were matched with non-physicians (n=45,736) on age, sex, and residential location. Uptake of colorectal tests was defined by a record of a fecal occult blood test in the past 2 years, flexible sigmoidoscopy in the past 5 years, or colonoscopy in the past 10 years. Patients were assigned to family physicians based on billing claim frequency, and then the association between colorectal testing in family physicians and their patients was examined using a modified Poisson regression model. RESULTS: Uptake of colorectal tests by physicians and non-physicians (median age 60; 71% men) was 67.9% (95% CI, 67.0%-68.7%) and 66.6% (95% CI, 66.2%-67.1%), respectively. Physicians were less likely than non-physicians to undergo fecal occult blood testing and were more likely to undergo colonoscopy; prevalence ratios were 0.44 (95% CI, 0.42-0.47) and 1.24 (95% CI, 1.22-1.26), respectively. Uptake of colorectal tests by family physicians was associated with greater uptake by their patients (adjusted prevalence ratio, 1.10; 95% CI, 1.08-1.12). CONCLUSIONS: Approximately one third of physicians and non-physicians are overdue for colorectal cancer screening. Patients are more likely to be tested if their family physician has been tested. There is an opportunity for physicians to increase their participation in colorectal cancer screening, which could in turn motivate their patients to undergo screening.

7.
Perit Dial Int ; 39(6): 553-561, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31582466

RESUMO

Background:How and where to initiate dialysis are policy challenges with enormous economic and health consequences. Initiating with home hemodialysis (HD) or peritoneal dialysis (PD) may reduce costs and improve outcomes but evidence is conflicting.Methods:We conducted a population-based study in patients aged ≥ 18 years who initiated chronic dialysis in the province of Ontario, Canada from 2006 to 2014 (N = 12,691) using linked administrative data. Patients were grouped by initial modality: facility HD, facility short daily or slow nocturnal (SD/SN) HD, PD, home HD. We estimated publicly-paid healthcare costs (2015 Canadian dollars; 1 = 0.947 US dollar) and survival, from dialysis initiation to March 2015.Results:By 5 years after dialysis initiation, mean 30-day costs (as-treated) for patients receiving PD and home HD were 50% and 64% lower, respectively, than for facility HD patients ($11,011). Approximately 50% of costs were unrelated to dialysis, reflecting high comorbidity in these patients. With covariate adjustment, mean 5-year cumulative costs were similar for initiators of home HD and PD ($304,178 and $349,338) and higher for facility HD initiators ($410,981). The highest 5-year unadjusted survival was for home HD patients (80%), followed by PD (52%), SD/SN HD (50%), and facility HD (42%).Conclusions:This study in a large cohort over 9 years provides new population-based evidence suggesting that initiating dialysis at home is cost-effective, with lower costs and better survival, than starting with facility HD. Survival differences persisted after adjustment for baseline characteristics but we could not adjust for functional status or severity of comorbidities.

8.
Transplant Direct ; 5(8): e474, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31576370

RESUMO

Background: Limited data are available regarding clinical implications of lower renal function after living kidney donation. We examined a novel integrated database to study associations between postdonation estimated glomerular filtration rate (eGFR) and use of antihypertensive medication (AHM) treatment after living kidney donation. Methods: Study data were assembled by linking national U.S. transplant registry identifiers, serum creatinine (SCr) values from electronic medical records, and pharmacy fill records for 3222 living donors (1989-2016) without predonation hypertension. Estimated GFR (mL/min per 1.73 m2) was computed from SCr values by the CKD-EPI equation. Repeated measures multivariable mixed effects modeling examined the associations (adjusted odds ratio, 95%LCLaOR95% UCL) between AHM use and postdonation eGFR levels (random effect) with fixed effects for baseline donor factors. Results: The linked database identified an average of 3 postdonation SCr values per donor (range: 1-38). Lower postdonation eGFR (vs ≥75) bore graded associations with higher odds of AHM use (eGFR 30-44: aOR 0.951.472.26; <30: aOR 1.082.525.90). Other independent correlates of postdonation AHM use included older age at donation (aOR per decade: 1.081.231.40), black race (aOR 1.031.512.21), body mass index > 30 kg/m2 (aOR 1.011.452.09), first-degree donor-recipient relationship (aOR 1.071.381.79), "prehypertension" at donation (systolic blood pressure 120-139: aOR 1.101.461.94; diastolic blood pressure 80-89: aOR 1.061.451.99). Conclusions: This novel linkage illustrates the ability to identify postdonation kidney function and associate it with clinically meaningful outcomes; lower eGFR after living kidney donation is a correlate of AHM treatment requirements. Further work should define relationships of postdonation renal function, hypertension, and other morbidity measures.

9.
CMAJ Open ; 7(4): E624-E629, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31641060

RESUMO

BACKGROUND: In 2007, an electronic repository called the Ontario Laboratories Information System (OLIS) was introduced to allow health care providers timely access to laboratory test results. Since not all laboratories began submitting their data to OLIS simultaneously, we sought to create a date-dependent table of geographic regions (forward sortation areas [FSAs]) from which people would likely present to a hospital linked to OLIS. METHODS: In this descriptive study, we used administrative data to capture adults in Ontario who presented to the emergency department for any reason from 2007 to 2017. To assess changes over time, we classified all emergency department visits into fiscal quarters. The primary outcome measure was the proportion of people in a given FSA presenting to an emergency department at an OLIS-linked hospital (v. a hospital not linked to OLIS). To be included in the catchment area, at least 90% of all emergency department visits in a given quarter from a given FSA must have occurred at an OLIS-linked hospital. RESULTS: By Dec. 31, 2017, 323 (61.4%) of 526 Ontario FSAs were in the catchment area (a population of about 8.5 million). There were no differences in selected demographic characteristics or comorbidities between people residing within the catchment area of OLIS-linked hospitals and those residing in the catchment area of unlinked hospitals on Dec. 31, 2017. We used the FSA information to construct a date-dependent table of geographic areas likely to have hospital laboratory data available in OLIS for future studies. INTERPRETATION: We identified relevant Ontario geographic regions from which people would likely present to a hospital linked to OLIS. These geographic regions constitute a catchment area that may be used in future studies to capture adults who present to an OLIS-linked hospital with laboratory-defined conditions such as acute kidney injury, hyperkalemia and hyponatremia.

10.
BMJ Open ; 9(9): e033150, 2019 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-31551393

RESUMO

INTRODUCTION: Inflammation, dehydration, hypotension and bleeding may all contribute to the development of acute kidney injury (AKI). Accelerated surgery after a hip fracture can decrease the exposure time to such contributors and may reduce the risk of AKI. METHODS AND ANALYSIS: Hip fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) is a multicentre, international, parallel-group randomised controlled trial (RCT). Patients who suffer a hip fracture are randomly allocated to either accelerated medical assessment and surgical repair with a goal of surgery within 6 hours of diagnosis or standard care where a repair typically occurs 24 to 48 hours after diagnosis. The primary outcome of this substudy is the development of AKI within 7 days of randomisation. We anticipate at least 1998 patients will participate in this substudy. ETHICS AND DISSEMINATION: We obtained ethics approval for additional serum creatinine recordings in consecutive patients enrolled at 70 participating centres. All patients provide consent before randomisation. We anticipate reporting substudy results by 2021. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.

11.
Can J Kidney Health Dis ; 6: 2054358119875459, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31555456

RESUMO

Background: As part of their living kidney donor assessment, all living donor candidates complete a computed tomography (CT) angiogram, but some also receive a nuclear renogram for split renal function (SRF%). Objective: We considered whether split renal volume (SRV%) assessed by CT can predict SRF%. Design: Systematic review and meta-analysis. Setting: Living donor candidates undergoing evaluation as potential living kidney donors. Patients: Living donor candidates who received both a nuclear renogram for split function and CT for SRV as part of their living donor work-up. Measurements: Split renal volume from CT scans and SRF from nuclear renography. Methods: We performed a systematic review and meta-analysis of the literature, abstracting data and digitizing plots where possible. We searched Medline, EMBASE, and the Cochrane Library. We added data from donor candidates assessed in London, Ontario from 2013 to 2016. We used fixed and random-effects models to pool Fisher's z-transformed Pearson's correlation coefficient (r). We conducted random-effects meta-regression on digitized and aggregate data. Studies were restricted to living kidney donors or living donor candidates. Results: After pooling 19 studies (n = 1479), we obtained a pooled correlation of r = 0.74 (95% confidence interval [CI] = 0.61-0.82). By linear regression using individual-level data, we observed a 0.76% (95% CI = 0.71-0.81) increase in SRF% for every 1% increase in SRV%. Split renal volume had a specificity of 88% for discriminating SRF at a threshold that could influence the decision of which kidney is to be removed (between-kidney difference ≥10%). Predonation SRV and SRF both moderately predicted kidney function 6 to 12 months after donation: r = 0.75 for SRV and r = 0.73 for SRF; Δr = 0.05 (-0.02, 0.13). Limitations: Most studies were retrospective and measured SRV and SRF only on selected living donor candidates. Efficiency gains in removing the SRF from the evaluation will depend on the transplant program. Conclusion: Split renal volume has the potential to replace SRF for some candidates. However, it is uncertain whether it can do so reliably and routinely across different transplant centers. The impact on clinical decision-making needs to be assessed in well-designed prospective studies. Trial registration: The digitized data are registered with Mendeley Data (doi10.17632/dyn2bfgxxj.2).

12.
Artigo em Inglês | MEDLINE | ID: mdl-31495887

RESUMO

BACKGROUND: Whether the survival benefit of ß-blockers in congestive heart failure (CHF) from randomized trials extends to patients with advanced chronic kidney disease (CKD) [estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 but not receiving dialysis] is uncertain. METHODS: This was a retrospective cohort study using administrative datasets. Older adults from Ontario, Canada, with incident CHF (median age 79 years) from April 2002 to March 2014 were included. We matched new users of ß-blockers to nonusers on age, sex, eGFR categories (>60, 30-60, <30), CHF diagnosis date and a high-dimensional propensity score. Using Cox proportional hazards models, we examined the association of ß-blocker use versus nonuse with all-cause mortality. RESULTS: We matched 5862 incident ß-blocker users (eGFR >60, n = 3136; eGFR 30-60, n = 2368; eGFR <30, n = 358). There were 2361 mortality events during follow-up. ß-Blocker use was associated with reduced all-cause mortality [adjusted hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.54-0.64]. This result was consistent across all eGFR categories (>60: adjusted HR 0.55, 95% CI 0.49-0.62; 30-60: adjusted HR 0.63, 95% CI 0.55-0.71; <30: adjusted HR 0.55, 95% CI 0.41-0.73; interaction term, P = 0.30). The results were consistent in an intention-to-treat analysis and with ß-blocker use treated as a time-varying exposure. CONCLUSIONS: ß-Blocker use is associated with reduced all-cause mortality in elderly patients with CHF and CKD, including those with an eGFR <30. Randomized trials that examine ß-blockers in patients with CHF and advanced CKD are needed.

13.
Clin J Am Soc Nephrol ; 14(10): 1450-1457, 2019 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-31501090

RESUMO

BACKGROUND AND OBJECTIVES: Survival after surgical repair for congenital heart disease has markedly improved; however, there are limited data on long-term ESKD and mortality during childhood. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted an observational, population-based cohort study of children who had their first surgery for congenital heart disease within 10 years of birth. The study was conducted in Ontario, Canada, where residents have universal access to health care services. Each child who underwent surgical repair was matched to ten children from the general population who were similar in age, sex, index date, rurality, and neighborhood income. Primary outcomes of all-cause mortality and ESKD were reported until March 2015. RESULTS: We followed 3600 children with congenital heart disease for a median of 5.9 (interquartile range, 2.9-9.0) years after their surgical repair. Median age at first surgery was 150 (interquartile range, 40-252) days and 22% were low birth weight (<2500 g). During follow-up, 140 (4%) children who had surgery for congenital heart disease died and 52 (1%) reached ESKD. The cumulative incidence of death and ESKD at 1, 5, and 10 years was higher in children with surgical repair of congenital heart disease (death: 3%, 4%, and 5%, respectively; ESKD: 1%, 2%, and 2%, respectively) compared with the matched control population without any congenital heart disease (death: 0.06%, 0.10%, and 0.13%, respectively; ESKD: 0.00%, 0.02%, and 0.02%, respectively). The risk of ESKD and death increased with severity of congenital heart disease, with the highest risk in children with hypoplastic left heart syndrome and increased in children who had surgical repair of congenital heart disease compared with those without surgical repair. CONCLUSIONS: The risk of mortality and ESKD is high in children who undergo surgical repair for congenital heart disease compared to the general population.

14.
CMAJ ; 191(37): E1018-E1024, 2019 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-31527187

RESUMO

BACKGROUND: Donepezil, rivastigmine and galantamine are popular cholinesterase inhibitors used to manage the symptoms of Alzheimer disease and other dementias; regulatory agencies in several countries warn about a possible risk of rhabdomyolysis with donepezil, based on information from case reports. Our goal was to investigate the 30-day risk of admission to hospital with rhabdomyolysis associated with initiating donepezil versus other cholinesterase inhibitors. METHODS: We conducted a retrospective cohort study in Ontario, Canada, from 2002 to 2017. Participants were adults aged 66 years or older with a newly dispensed prescription for donepezil compared with rivastigmine or galantamine. The primary outcome was hospital admission with rhabdomyolysis (assessed using hospital diagnostic codes) within 30 days of a new prescription of a cholinesterase inhibitor. Odds ratios were estimated using logistic regression, with inverse probability of treatment weights calculated from propensity scores. RESULTS: The average age in our 2 groups was 81.1 years, and 61.4% of our population was female. Donepezil was associated with a higher risk of hospital admission with rhabdomyolysis compared with rivastigmine or galantamine (88 events in 152 300 patients [0.06%] v. 16 events in 68 053 patients [0.02%]; weighted odds ratio of 2.21, 95% confidence interval [CI] 1.52-3.22). Most hospital admissions with rhabdomyolysis after donepezil use were not severe, and no patient was treated with acute dialysis or mechanical ventilation. INTERPRETATION: Initiating donepezil is associated with a higher 30-day risk of admission to hospital with rhabdomyolysis compared with initiating rivastigmine or galantamine. The proportion of patients who develop severe rhabdomyolysis within 30 days of initiating donepezil is very low.

16.
Can J Kidney Health Dis ; 6: 2054358119857718, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31367455

RESUMO

Background: While living kidney donation is considered safe in healthy individuals, perioperative complications can occur due to several factors. Objective: We explored associations between the incidence of perioperative complications and donor characteristics, surgical technique, and surgeon's experience in a large contemporary cohort of living kidney donors. Design: Living kidney donors enrolled prospectively in a multicenter cohort study with some data collected retrospectively after enrollment was complete (eg, surgeon characteristics). Setting: Living kidney donor centers in Canada (n = 12) and Australia (n = 5). Patients: Living kidney donors who donated between 2004 and 2014 and the surgeons who performed the living kidney donor nephrectomies. Measurements: Operative and hospital discharge medical notes were collected prospectively, with data on perioperative (intraoperative and postoperative) information abstracted from notes after enrollment was complete. Complications were graded using the Clavien-Dindo system and further classified into minor and major. In 2016, surgeons who performed the nephrectomies were invited to fill an online survey on their training and experience. Methods: Multivariable logistic regression models with generalized estimating equations were used to compare perioperative complication rates between different groups of donors. The effect of surgeon characteristics on the complication rate was explored using a similar approach. Poisson regression was used to test rates of overall perioperative complications between high- and low-volume centers. Results: Of the 1421 living kidney donor candidates, 1042 individuals proceeded with donation, where 134 (13% [95% confidence interval (CI): 11%-15%]) experienced 142 perioperative complications (55 intraoperative; 87 postoperative). The most common intraoperative complication was organ injury and the most common postoperative complication was ileus. No donors died in the perioperative period. Most complications were minor (90% of 142 complications [95% CI: 86%-96%]); however, 12 donors (1% of 1042 [95% CI: 1%-2%]) experienced a major complication. No statistically significant differences were observed between donor groups and the rate of complications. A total of 43 of 48 eligible surgeons (90%) completed the online survey. Perioperative complication rates did not vary significantly by surgeon characteristics or by high- versus low-volume centers. Limitations: Operative and discharge reporting is not standardized and varies among surgeons. It is possible that some complications were missed. The online survey for surgeons was completed retrospectively, was based on self-report, and has not been validated. We had adequate statistical power only to detect large effects for factors associated with a higher risk of perioperative complications. Conclusions: This study confirms the safety of living kidney donation as evidenced by the low rate of major perioperative complications. We did not identify any donor or surgeon characteristics associated with a higher risk of perioperative complications. Trial registrations: NCT00319579: A Prospective Study of Living Kidney Donation (https://clinicaltrials.gov/ct2/show/NCT00319579)NCT00936078: Living Kidney Donor Study (https://clinicaltrials.gov/ct2/show/NCT00936078).

17.
Clin Transplant ; 33(10): e13696, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31421057

RESUMO

We examined a novel linkage of national US donor registry data with records from a pharmacy claims warehouse (2007-2016) to examine associations (adjusted hazard ratio, LCL aHRUCL ) of post-donation fills of antidiabetic medications (ADM, insulin or non-insulin agents) with body mass index (BMI) at donation and other demographic and clinical factors. In 28 515 living kidney donors (LKDs), incidence of ADM use at 9 years rose in a graded manner with higher baseline BMI: underweight, 0.9%; normal weight, 2.1%; overweight, 3.5%; obese, 8.5%. Obesity was associated with higher risk of ADM use compared with normal BMI (aHR, 3.36 4.596.27 ). Metformin was the most commonly used ADM and was filled more often by obese than by normal weight donors (9-year incidence, 6.87% vs 1.85%, aHR, 3.55 5.007.04 ). Insulin use was uncommon and did not differ significantly by BMI. Among a subgroup with BMI data at the 1-year post-donation anniversary (n = 19 528), compared with stable BMI, BMI increase >0.5 kg/m2 by year 1 was associated with increased risk of subsequent ADM use (aHR, 1.03 1.482.14, P = .04). While this study did not assess the impact of donation on the development of obesity, these data support that among LKD, obesity is a strong correlate of ADM use.

18.
Clin J Am Soc Nephrol ; 14(9): 1288-1296, 2019 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-31444174

RESUMO

BACKGROUND AND OBJECTIVES: There is a limited appreciation of the epidemiology of dialysis-receiving AKI in children. The primary objective of the study was to evaluate changes in the incidence of dialysis-receiving AKI among children over a period of 20 years in Ontario, Canada. The secondary objectives were to assess temporal trends in the utilization of various dialysis modalities and 30-day mortality among children with dialysis-receiving AKI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: All children (29 days to 18 years) who received their first dialysis for AKI between 1996 and 2015 were identified from healthcare administrative databases. Those who received dialysis for ESKD, inborn errors of metabolism, and poisonings were excluded. The incidence rates of dialysis-receiving AKI were reported annually. The Cochran-Armitage test was used to assess trends in the incidence and short-term mortality after dialysis-receiving AKI. RESULTS: We identified 1394 children treated with dialysis for AKI during a hospital stay. There was a significant increase in the incidence of dialysis-receiving AKI among hospitalized children from 1996 (0.58 per 1000 person-years) to 2015 (0.65 per 1000 person-years) (P=0.01). The use of continuous kidney replacement therapy and intermittent hemodialysis increased whereas the relative use of peritoneal dialysis declined over time. Thirty-day mortality rates after dialysis-receiving AKI increased from 14% to 25% between 1996 and 2009 and reduced to 19% in the more recent years (P=0.03). CONCLUSIONS: In Ontario, the incidence of dialysis-receiving AKI among children has increased between 1996 and 2015. The use of peritoneal dialysis for AKI has declined and the short-term mortality after dialysis-receiving AKI has increased.

19.
Hypertension ; 74(3): 645-651, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31327266

RESUMO

Alpha-blockers (ABs) are commonly prescribed as part of a multidrug regimen in the management of hypertension. We set out to assess the risk of hypotension and related adverse events with AB use compared with other blood pressure (BP) lowering drugs using a population-based, retrospective cohort study of women (≥66 years) between 1995 and 2015 in Ontario, Canada. Cox proportional hazards examined the association of AB use and hypotension and related events (syncope, fall, and fracture) compared with other BP lowering drugs matched via a high dimensional propensity score. The primary outcome was a composite of hospitalizations for hypotension and related events (syncope, fractures, and falls) within 1 year. From 734 907 eligible women, 14 106 were dispensed an AB (mean age, 75.7; standard deviation 6.9 years, median follow-up 1 year) and matched to 14 106 dispensed other BP lowering agents. The crude incidence rate of hypotension and related events was 95.7 (95% CI [confidence interval], 90.4-101.1, events 1214 [8.6%]) with AB and 79.8 (95% CI, 74.9-84.7 per 1000 person-years, events 1025 [7.3%]) with other BP lowering medications (incident rate ratio, 1.20; 95% CI, 1.10-1.30). The risk was higher for hypotension (hazard ratio, 1.71; 95% CI, 1.33-2.20) and syncope (hazard ratio, 1.44; 95% CI, 1.18-1.75) with no difference in falls, fractures, adverse cardiac events, or all-cause mortality. Treatment of hypertension in women with ABs is associated with a higher risk of hypotension and hypotension-related events compared with other BP lowering agents. Our findings suggest that ABs should be used with caution, even as add on therapy for hypertension.


Assuntos
Antagonistas Adrenérgicos alfa/efeitos adversos , Hipertensão/tratamento farmacológico , Hipotensão/induzido quimicamente , Hipotensão/epidemiologia , Acidentes por Quedas/estatística & dados numéricos , Antagonistas Adrenérgicos alfa/uso terapêutico , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/uso terapêutico , Canadá , Estudos de Coortes , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Fraturas Ósseas/diagnóstico , Fraturas Ósseas/epidemiologia , Avaliação Geriátrica/métodos , Humanos , Hipertensão/diagnóstico , Hipotensão/fisiopatologia , Incidência , Prognóstico , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Síncope/diagnóstico , Síncope/epidemiologia , Resultado do Tratamento
20.
Nephrol Dial Transplant ; 34(7): 1145-1154, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31264694

RESUMO

BACKGROUND: Clinical guidelines caution against nonsteroidal anti-inflammatory drug (NSAID) use in older adults. The study objective was to quantify the 30-day risk of acute kidney injury (AKI) and hyperkalemia in older adults after NSAID initiation and to develop a model to predict these outcomes. METHODS: We conducted a population-based retrospective cohort study in Ontario, Canada from 2007 to 2015 of patients ≥66 years. We matched 46 107 new NSAID users with 46 107 nonusers with similar baseline health. The primary outcome was 30-day risk of AKI and secondary outcomes were hyperkalemia and all-cause mortality. RESULTS: NSAID use versus nonuse was associated with a higher 30-day risk of AKI {380 [0.82%] versus 272 [0.59%]; odds ratio (OR) 1.41 [95% confidence interval (CI) 1.20-1.65]} and hyperkalemia [184 (0.40%) versus 123 (0.27%); OR 1.50 (95% CI 1.20-1.89); risk difference 0.23% (95% CI 0.13-0.34)]. There was no association between NSAID use and all-cause mortality. A prediction model incorporated six predictors of AKI or hyperkalemia: older age, male gender, lower baseline estimated glomerular filtration rate, higher baseline serum potassium, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use or diuretic use. This model had moderate discrimination [C-statistic 0.72 (95% CI 0.70-0.74)] and good calibration. CONCLUSIONS: In older adults, new NSAID use compared with nonuse was associated with a higher 30-day risk of AKI and hyperkalemia but not all-cause mortality. Prescription NSAID use among many older adults may be safe, but providers should use caution and assess individual risk.

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