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1.
JAMA Intern Med ; 2020 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-32667668

RESUMO

Importance: The US is currently an epicenter of the coronavirus disease 2019 (COVID-19) pandemic, yet few national data are available on patient characteristics, treatment, and outcomes of critical illness from COVID-19. Objectives: To assess factors associated with death and to examine interhospital variation in treatment and outcomes for patients with COVID-19. Design, Setting, and Participants: This multicenter cohort study assessed 2215 adults with laboratory-confirmed COVID-19 who were admitted to intensive care units (ICUs) at 65 hospitals across the US from March 4 to April 4, 2020. Exposures: Patient-level data, including demographics, comorbidities, and organ dysfunction, and hospital characteristics, including number of ICU beds. Main Outcomes and Measures: The primary outcome was 28-day in-hospital mortality. Multilevel logistic regression was used to evaluate factors associated with death and to examine interhospital variation in treatment and outcomes. Results: A total of 2215 patients (mean [SD] age, 60.5 [14.5] years; 1436 [64.8%] male; 1738 [78.5%] with at least 1 chronic comorbidity) were included in the study. At 28 days after ICU admission, 784 patients (35.4%) had died, 824 (37.2%) were discharged, and 607 (27.4%) remained hospitalized. At the end of study follow-up (median, 16 days; interquartile range, 8-28 days), 875 patients (39.5%) had died, 1203 (54.3%) were discharged, and 137 (6.2%) remained hospitalized. Factors independently associated with death included older age (≥80 vs <40 years of age: odds ratio [OR], 11.15; 95% CI, 6.19-20.06), male sex (OR, 1.50; 95% CI, 1.19-1.90), higher body mass index (≥40 vs <25: OR, 1.51; 95% CI, 1.01-2.25), coronary artery disease (OR, 1.47; 95% CI, 1.07-2.02), active cancer (OR, 2.15; 95% CI, 1.35-3.43), and the presence of hypoxemia (Pao2:Fio2<100 vs ≥300 mm Hg: OR, 2.94; 95% CI, 2.11-4.08), liver dysfunction (liver Sequential Organ Failure Assessment score of 2 vs 0: OR, 2.61; 95% CI, 1.30-5.25), and kidney dysfunction (renal Sequential Organ Failure Assessment score of 4 vs 0: OR, 2.43; 95% CI, 1.46-4.05) at ICU admission. Patients admitted to hospitals with fewer ICU beds had a higher risk of death (<50 vs ≥100 ICU beds: OR, 3.28; 95% CI, 2.16-4.99). Hospitals varied considerably in the risk-adjusted proportion of patients who died (range, 6.6%-80.8%) and in the percentage of patients who received hydroxychloroquine, tocilizumab, and other treatments and supportive therapies. Conclusions and Relevance: This study identified demographic, clinical, and hospital-level risk factors that may be associated with death in critically ill patients with COVID-19 and can facilitate the identification of medications and supportive therapies to improve outcomes.

2.
Artigo em Inglês | MEDLINE | ID: mdl-32636199
3.
Am J Kidney Dis ; 2020 Jul 12.
Artigo em Inglês | MEDLINE | ID: mdl-32673736

RESUMO

RATIONALE AND OBJECTIVE: Community racial composition has been shown to be associated with mortality in patients with ESKD. It is unclear whether living in communities with predominantly black residents is also associated with risk for hospitalization among patients receiving hemodialysis. STUDY DESIGN: Retrospective analysis of prospectively collected data from a cohort of patients on hemodialysis. SETTING AND PARTICIPANTS: 4567 patients treated in 154 dialysis facilities located in 127 unique zip codes and enrolled in United States Dialysis Outcomes and Practice Patterns Study (US-DOPPS), phases 4-5 (2010-2015). EXPOSURE: Tertile of percent black residents within patients' dialysis facility's zip code defined through a link to the American Community Survey. OUTCOME: Rate of hospitalizations during the study period. ANALYTIC APPROACH: The associations of patient-, facility- and community-level variables with percent black residents were assessed using ANOVA, Kruskal Wallis or Chi-square/Fisher exact tests. Negative binomial regression was used to estimate the incidence rate ratio (IRR) for hospitalizations between these communities, with and without adjustment for potential confounding variables. RESULTS: The mean age of study patients was 62.7 years. Fifty three percent were white, 27% were black and 45% were female. Patients receiving dialysis in facility zip codes with a higher (Tertile 3: ≥14.4%; median 34.2%) versus lower (Tertile 1: ≤1.8%; median 1%) percentage of black residents were more likely to be younger, black, live in urban communities with lower socio-economic status, have a catheter as a vascular access, and have fewer comorbidities. Patients dialyzing in communities with the highest tertile of black residents experienced a higher adjusted rate of hospitalization (adjusted incident rate ratio 1.32, 95% Confidence Interval (1.12-1.56), compared to communities within the lowest tertile. LIMITATIONS: Potential residual confounding CONCLUSIONS: The risk of hospitalization for patients with ESKD is higher among those treated in communities with a higher percentage of black residents after adjustment for dialysis care as well as patient demographics and comorbidities. Understanding the cause of this association should be a priority of future investigation.

4.
Clin J Am Soc Nephrol ; 15(6): 755-765, 2020 Jun 08.
Artigo em Inglês | MEDLINE | ID: mdl-32467307

RESUMO

BACKGROUND AND OBJECTIVES: Studies of adults have demonstrated an association between metabolic acidosis, as measured by low serum bicarbonate levels, and CKD progression. We evaluated this relationship in children using data from the Chronic Kidney Disease in Children study. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The relationship between serum bicarbonate and a composite end point, defined as 50% decline in eGFR or KRT, was described using parametric and semiparametric survival methods. Analyses were stratified by underlying nonglomerular and glomerular diagnoses, and adjusted for demographic characteristics, eGFR, proteinuria, anemia, phosphate, hypertension, and alkali therapy. RESULTS: Six hundred and three participants with nonglomerular disease contributed 2673 person-years of follow-up, and 255 with a glomerular diagnosis contributed 808 person-years of follow-up. At baseline, 39% (237 of 603) of participants with nonglomerular disease had a bicarbonate level of ≤22 meq/L and 36% (85 of 237) of those participants reported alkali therapy treatment. In participants with glomerular disease, 31% (79 of 255) had a bicarbonate of ≤22 meq/L, 18% (14 of 79) of those participants reported alkali therapy treatment. In adjusted longitudinal analyses, compared with participants with a bicarbonate level >22 meq/L, hazard ratios associated with a bicarbonate level of <18 meq/L and 19-22 meq/L were 1.28 [95% confidence interval (95% CI), 0.84 to 1.94] and 0.91 (95% CI, 0.65 to 1.26), respectively, in children with nonglomerular disease. In children with glomerular disease, adjusted hazard ratios associated with bicarbonate level ≤18 meq/L and bicarbonate 19-22 meq/L were 2.16 (95% CI, 1.05 to 4.44) and 1.74 (95% CI, 1.07 to 2.85), respectively. Resolution of low bicarbonate was associated with a lower risk of CKD progression compared with persistently low bicarbonate (≤22 meq/L). CONCLUSIONS: In children with glomerular disease, low bicarbonate was linked to a higher risk of CKD progression. Resolution of low bicarbonate was associated with a lower risk of CKD progression. Fewer than one half of all children with low bicarbonate reported treatment with alkali therapy. Long-term studies of alkali therapy's effect in patients with pediatric CKD are needed.

5.
Curr Opin Nephrol Hypertens ; 29(2): 243-247, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31996592

RESUMO

PURPOSE OF REVIEW: Vitamin D deficiency is common in patients with kidney disease and many patients receive vitamin D supplementation. Several large, well-designed clinical trials have been published in the last few years evaluating the effects of vitamin D supplementation on important outcomes for patients with kidney disease including effects on cardiovascular disease, secondary hyperparathyroidism, and kidney disease progression. RECENT FINDINGS: Several negative trials have been published showing no effect of cholecalciferol supplementation on cardiovascular events, kidney disease progression, and albuminuria. Long-term supplementation does not appear to be associated with kidney stone disease. Vitamin D supplementation decreases parathyroid hormone (PTH) levels and high levels of 25-hydroxyvitamin D may be required for maximal suppression. SUMMARY: There appear to be no effects of vitamin D supplementation on noncalcemic outcomes including progression of kidney disease, albuminuria, or cardiovascular disease. The primary reason to use vitamin D in kidney disease remains to lower PTH levels.


Assuntos
Hormônio Paratireóideo/sangue , Insuficiência Renal Crônica/prevenção & controle , Vitamina D/administração & dosagem , Albuminúria/prevenção & controle , Suplementos Nutricionais , Humanos , Vitamina D/análogos & derivados , Vitamina D/sangue
6.
Am J Kidney Dis ; 75(2): 225-234, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31699517

RESUMO

RATIONALE & OBJECTIVE: Metabolic acidosis associated with chronic kidney disease (CKD) may contribute to muscle dysfunction and bone disease. We aimed to test whether treatment with sodium bicarbonate improves muscle and bone outcomes. STUDY DESIGN: Multicenter, randomized, placebo-controlled, clinical trial. SETTING & PARTICIPANTS: 149 patients with CKD stages 3 and 4 between July 2011 and April 2016 at 3 centers in Cleveland, OH, and the Bronx, NY. INTERVENTION: Sodium bicarbonate (0.4 mEq per kg of ideal body weight per day) (n=74) or identical-appearing placebo (n=75). OUTCOMES: Dual primary outcomes were muscle function assessed using sit-to-stand test and bone mineral density. Muscle biopsies were performed at baseline and 2 months. Participants were seen at baseline and 2, 6, 12, and 24 months. RESULTS: Mean baseline serum bicarbonate level was 24.0±2.2 (SD) mEq/L and mean baseline estimated glomerular filtration rate was 36.3±11.2mL/min/1.73m2. Baseline characteristics did not differ between groups. Mean serum bicarbonate levels in the intervention arm during follow-up were 26.4±2.2, 25.5±2.3, 25.6±2.6, and 24.4±2.8 mEq/L (at 2, 6, 12, and 24 months). These were significantly higher than in the placebo group (P<0.001). Compared to the placebo group, participants randomly assigned to sodium bicarbonate treatment had no significant differences in sit-to-stand time (5 repetitions: P=0.1; and 10 repetitions P=0.07) or bone mineral density (P=0.3). Sodium bicarbonate treatment caused a decrease in serum potassium levels that was of borderline statistical significance (P=0.05). There were no significant differences in estimated glomerular filtration rates, blood pressure, weight, serious adverse events, or levels of muscle gene expression between the randomly assigned groups. LIMITATIONS: Initial mean serum bicarbonate level was in the normal range. CONCLUSIONS: Sodium bicarbonate therapy in patients with CKD stages 3 and 4 significantly increases serum bicarbonate and decreases potassium levels. No differences were found in muscle function or bone mineral density between the randomly assigned groups. Larger trials are required to evaluate effects on kidney function. FUNDING: National Institutes of Health grant. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT01452412.


Assuntos
Taxa de Filtração Glomerular/fisiologia , Insuficiência Renal Crônica/tratamento farmacológico , Bicarbonato de Sódio/administração & dosagem , Bicarbonatos/sangue , Biomarcadores/sangue , Progressão da Doença , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Potássio/sangue , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/fisiopatologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
7.
J Urol ; 203(2): 379-384, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31518201

RESUMO

PURPOSE: Urge urinary incontinence significantly impacts quality of life. We investigated the association between urge urinary incontinence and socioeconomic status in a nationally representative adult population. MATERIALS AND METHODS: We analyzed the 2005 to 2016 NHANES (National Health and Nutrition Examination Survey), a United States population based, cross-sectional study. Urge urinary incontinence was determined by self-report of leaking urine before reaching the toilet. Socioeconomic status was represented by the poverty income ratio, which reflects the family income relative to poverty thresholds specific to that year and household size. Survey weighted logistic regression models were used to analyze the relationship between socioeconomic status and the poverty income ratio. Multiplicative terms were applied to test for interaction in prespecified subgroups of interest. RESULTS: A total of 25,553 participants were included in the final analysis, representing 180 million people in the United States. Of the participants 19.4% reported any urge urinary incontinence, 4.2% reported weekly urge urinary incontinence and 1.6% reported daily urge urinary incontinence. In the fully adjusted multivariable models those with a poverty income ratio less than 2.00 showed significantly higher odds of any urge urinary incontinence compared to the group with a poverty income ratio of 2.00 or greater (OR 1.17, 95% CI 1.05-1.30, p=0.003). There was increasing strength of association for weekly and daily urge urinary incontinence (OR 1.31, 95% CI 1.12-1.55, p <0.001, and OR 1.60, 95% CI 1.23-2.09, p=0.001, respectively). Individual interaction analyses revealed no significant effect of female gender, age greater than 50 years, body mass index 30 kg/m2 or greater, or less than a high school education on the association of urge urinary incontinence with the poverty income ratio. CONCLUSIONS: This study revealed a significant association between urge urinary incontinence and socioeconomic status after meaningful adjustment for covariates. Health care interventions targeting low socioeconomic status individuals with urge urinary incontinence are needed to address this disparity.


Assuntos
Incontinência Urinária de Urgência/epidemiologia , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos Nutricionais , Classe Social , Fatores de Tempo , Estados Unidos/epidemiologia
8.
Eur Urol Focus ; 6(2): 354-360, 2020 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-30097392

RESUMO

BACKGROUND: The prevalence of urinary stone disease (USD) and asthma is rising and has recently been associated in a pediatric population. OBJECTIVE: To investigate the association between asthma and USD in a nationally representative adult population. DESIGN, SETTING, AND PARTICIPANTS: We analyzed the National Health and Nutrition Examination Survey 2007-2014, a US population-based cross-sectional study. A history of asthma and USD was obtained by self-report to questionnaires. USD severity was represented by graded stratification into non-stone formers, single stone formers, and recurrent stone formers (>2 stones). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Odds ratios (ORs) for asthma were calculated for respondents with USD and separately for the graded USD groups. Survey-weighted logistic regression models included adjustments for demographics (model A), medical information (model B), and for relevant medications (model C). RESULTS AND LIMITATIONS: A total of 20 906 participants aged ≥20 yr were included in the analysis. Of these, 9.2% reported of having a history of kidney stones. Logistic regression analysis adjusted for demographics, medical conditions, and medications showed that stone formers had significantly increased odds of asthma (odds ratio=1.23; 95% confidence interval: 1.03-1.47; p=0.023). Separate logistic regression analysis demonstrated a graded association between single and recurrent stone formers and the odds of having asthma (p=0.01), which remained significant in the 20-50-yr-old population and the diabetic population, especially for recurrent stone formers. Causal relationships were limited by cross-sectional nature of the study. CONCLUSIONS: Increasing severity of USD is associated with an increase in odds for asthma among American adults, providing impetus for future studies into the mechanisms explaining this phenomenon. PATIENT SUMMARY: In this report, we looked at self-reported histories of asthma and urinary stone disease (USD) using information from a large US population. We found that asthma was associated with USD; however, further studies are needed to elucidate this relationship.

10.
Nutrients ; 11(9)2019 Sep 17.
Artigo em Inglês | MEDLINE | ID: mdl-31533272

RESUMO

The incidence of type 2 diabetes mellitus (DM) has increased in the US over the last several years. The consumption of low-fat dairy foods has been linked with decreasing the risk of DM but studies have yet to show a clear correlation. We conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) evaluating the effects of dairy intake on homeostatic model assessment of insulin resistance (HOMA-IR), waist circumference, and body weight. In MEDLINE and Embase, we identified and reviewed 49 relevant RCTs: 30 had appropriate data format for inclusion in the meta-analysis. Using the Review Manager 5 software, we calculated the pooled standardized mean differences comparing dairy dietary interventions to control for our outcomes of interest. For HOMA-IR (794 individuals), we found a mean difference of -1.21 (95% CI -1.74 to -0.67; p-value < 0.00001; I2 = 92%). For waist circumference (1348 individuals), the mean difference was -1.09 cm (95% CI 1.68 to -0.58; p-value < 0.00001; I2 = 94%). For body weight (2362 individuals), the dairy intake intervention group weighed 0.42 kg less than control (p-value < 0.00001; I2 = 92%). Our findings suggest that dairy intake, especially low-fat dairy products, has a beneficial effect on HOMA-IR, waist circumference, and body weight. This could impact dietary recommendations to reduce DM risk.


Assuntos
Glicemia/metabolismo , Laticínios , Diabetes Mellitus Tipo 2/prevenção & controle , Dieta com Restrição de Gorduras , Gorduras na Dieta/administração & dosagem , Resistência à Insulina , Insulina/sangue , Valor Nutritivo , Adulto , Idoso , Biomarcadores/sangue , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/fisiopatologia , Gorduras na Dieta/metabolismo , Ingestão de Energia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Recomendações Nutricionais , Circunferência da Cintura , Perda de Peso , Adulto Jovem
11.
BMC Nephrol ; 20(1): 343, 2019 09 02.
Artigo em Inglês | MEDLINE | ID: mdl-31477043

RESUMO

BACKGROUND: Neighborhood racial mix is associated with dialysis facility performance metrics and mortality outcomes in patients on hemodialysis. We explored the association of neighborhood racial mix with emergency department (ED) visits in patients receiving hemodialysis. METHODS: Using Looking Glass (Montefiore's clinical database) we identified a cohort of patients on hemodialysis with an index ED visit at any of 4 Montefiore Hospital locations, between January 2013 and December 2017 and followed it for number of ED visits through December of 2017 or dropout due to death. The racial mix data for the Bronx block group of each subject's residence was derived from the Census Bureau. We then used negative binomial regression to test the association of quintile of percent of Black residents per residential block group with ED visits in unadjusted and adjusted models. To adjust further for quality offered by local dialysis facilities, with the facility zip code as the locus, we used data from the "Dialysis Compare" website. RESULTS: Three thousand nine-hundred and eighteen subjects were identified and the median number of ED visits was 3 (interquartile range (IQR) 1-7) during the study period. Subjects living in the highest quintile of percent Black residents were older, more commonly female and had lower poverty rates and higher rates of high school diplomas. Unadjusted models showed a significant association between the highest quintiles of Black neighborhood residence and count of ED visits. Fully adjusted, stratified models revealed that among males, and Hispanic and White subjects, living in neighborhoods with the highest quintiles of Black residents was associated with significantly more ED visits (p-trend =0.001, 0.02, 0.01 respectively). No association was found between dialysis facility locations' quintile of Black residents and quality metrics. CONCLUSIONS: Living in a neighborhood with a higher percentage of Black residents is associated with a higher number of ED visits in males and non-Black patients on hemodialysis.

12.
Artigo em Inglês | MEDLINE | ID: mdl-31298287

RESUMO

BACKGROUND: In animal studies, zinc supplementation inhibited phosphate-induced arterial calcification. We tested the hypothesis that higher intake of dietary zinc was associated with lower abdominal aortic calcification (AAC) among adults in the USA. We also explored the associations of AAC with supplemental zinc intake, total zinc intake and serum zinc level. METHODS: We performed cross-sectional analyses of 2535 participants from the National Health and Nutrition Examination Survey 2013-14. Dietary and supplemental zinc intakes were obtained from two 24-h dietary recall interviews. Total zinc intake was the sum of dietary and supplemental zinc. AAC was measured using dual-energy X-ray absorptiometry in adults ≥40 years of age and quantified using the Kauppila score system. AAC scores were categorized into three groups: no AAC (AAC = 0, reference group), mild-moderate (AAC >0-≤6) and severe AAC (AAC >6). RESULTS: Dietary zinc intake (mean ± SE) was 10.5 ± 0.1 mg/day; 28% had AAC (20% mild-moderate and 8% severe), 17% had diabetes mellitus and 51% had hypertension. Higher intake of dietary zinc was associated with lower odds of having severe AAC. Per 1 mg/day higher intake of dietary zinc, the odds of having severe AAC were 8% lower [adjusted odds ratio 0.92 (95% confidence interval 0.86-0.98), P = 0.01] compared with those without AAC, after adjusting for demographics, comorbidities and laboratory measurements. Supplemental zinc intake, total zinc intake and serum zinc level were not associated with AAC. CONCLUSIONS: Higher intake of dietary zinc was independently associated with lower odds of having severe AAC among noninstitutionalized US adults.

13.
Kidney Int Rep ; 4(6): 806-813, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31194171

RESUMO

Introduction: Magnesium (Mg) may protect against arterial calcification. We tested the hypotheses that a higher serum Mg concentration is associated with less arterial calcification and stiffness in patients on hemodialysis (HD) and that these associations are modified by diabetes mellitus. Methods: We performed cross-sectional analyses of 367 incident HD patients from the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease (PACE) cohort. Measures of arterial calcification and stiffness included coronary arterial calcification (CAC) and thoracic aortic calcification (TAC) scores, ankle brachial index (ABI; high ABI: >1.4 or incompressible vessels), pulse wave velocity (PWV), and pulse pressure. Results: Mean Mg was 1.8 ± 0.2 mEq/l and 58% had diabetes. Among nondiabetic individuals, per 0.1 mEq/l higher Mg, non-zero CAC score was lower (% difference: -15.4%; 95% confidence interval [CI]: -28% to -0.55%; P = 0.03), the odds of having TAC score >0 and the odds of having high ABI were lower (odds ratio [OR]: 0.66; 95% CI 0.47-0.93; P = 0.02, and 0.23; 95% CI: 0.06-0.83, P = 0.03, respectively) while adjusting for demographics, comorbidities, markers of mineral metabolism, and dialysis clearance. Among diabetic individuals, per 0.1 mEq/l higher Mg, the odds of having TAC score >0 was higher (OR: 1.57; 95% CI: 1.09-2.26; P = 0.02). Mg was not associated with CAC or high ABI among diabetic individuals. Mg was not associated with PWV or pulse pressure regardless of diabetes status. Conclusion: Diabetes modified the associations of serum Mg with arterial calcification and stiffness in incident HD patients. Higher Mg was associated with less arterial calcification and less peripheral arterial stiffness among nondiabetic individuals, but Mg was only associated with TAC among diabetic individuals with higher Mg being associated with higher likelihood of having TAC score >0.

14.
Am J Kidney Dis ; 73(4): 476-485, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30704880

RESUMO

RATIONALE & OBJECTIVE: Recent studies suggest that metabolic acidosis is associated with mortality and graft failure in kidney transplant recipients. However, it is unknown whether serum bicarbonate (measured as total carbon dioxide [tCO2] in serum) levels predict cardiovascular events (CVEs) following kidney transplantation. STUDY DESIGN: Observational cohort study. SETTINGS & PARTICIPANTS: Single-center study of 2,128 kidney transplant recipients free of CVEs during the first 13.5 months following transplantation. PREDICTOR: tCO2 level at 1 year posttransplantation. OUTCOMES: Ischemic, arrhythmic, and heart failure CVEs and death from any cause. ANALYTICAL APPROACH: Independent associations were assessed using multivariable proportional hazards regression models. Restricted cubic spline Poisson models were used to explore nonlinear associations. Linear spline proportional hazards models were used to assess associations at different tCO2 levels. RESULTS: The prevalence of metabolic acidosis defined as tCO2 level < 24 mEq/L was 38.8% (n=826). There were 384 recipients with a CVE and 610 deaths during a median follow-up of 4.0 years. CVEs included 241 ischemic, 137 arrhythmic, and 150 heart failure events. tCO2 level < 20 mEq/L was associated with increased risk for CVEs (adjusted HR [aHR], 2.00; 95% CI, 1.29-3.10) compared to the reference category of tCO2 level of 24.0 to 25.9 mEq/L. This association was primarily due to ischemic CVEs (aHR, 2.28; 95% CI, 1.34-3.90). For every 1 mEq/L lower tCO2 level for those with tCO2 < 24 mEq/L, risks for all CVEs and ischemic events were 17% and 15% higher, respectively (aHR for all CVEs of 0.83 [95% CI, 0.74-0.94] and aHR for ischemic CVEs of 0.85 [95% CI, 0.74-0.99]). Notably, tCO2 level < 20 mEq/L, compared to tCO2 level of 24.0 to 25.9 mEq/L, was independently associated with all-cause mortality (aHR, 1.43; 95% CI, 1.02-2.02). For every 1-mEq/L lower tCO2 level for those with tCO2 < 24 mEq/L, there was 17% higher risk for death (aHR, 0.83; 95% CI, 0.75-0.92). LIMITATIONS: Single-center observational study. CONCLUSIONS: Metabolic acidosis is an independent risk factor for ischemic CVEs after kidney transplantation. It is unknown whether correction of acidosis improves outcomes in these patients.


Assuntos
Acidose/complicações , Doenças Cardiovasculares/epidemiologia , Falência Renal Crônica/terapia , Transplante de Rim/efeitos adversos , Medição de Risco/métodos , Acidose/epidemiologia , Adulto , Doenças Cardiovasculares/etiologia , Causas de Morte/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Diálise Renal , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Wisconsin/epidemiologia
15.
Transplantation ; 103(8): 1683-1688, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30801528

RESUMO

BACKGROUND: Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality in kidney transplant recipients. Vitamin D has an integral role in proper immune function, and deficiency is common among kidney transplant recipients. It remains unclear whether 25-hydroxyvitamin D [25(OH)D] level is associated with CMV infection in kidney transplant recipients. METHODS: We examined the relationship between 25(OH)D levels, measured at least 6 months posttransplant, and subsequent CMV infection in 1976 recipients free of prior CMV infection. RESULTS: Of 1976 recipients, 251 (12.7%) were vitamin D deficient [25(OH)D <20 ng/mL] and 548 (27.7%) were insufficient (20-29 ng/mL) at the time of the first 25(OH)D measurement. A total of 107 recipients had a CMV infection within 1 year of a 25(OH)D measurement. Vitamin D deficiency was associated with a 1.81-fold higher risk (relative hazard = 1.81; 95% confidence interval [CI], 1.06-3.09) than vitamin D sufficiency after adjustment for baseline characteristics and concurrent graft function and blood calcineurin inhibitor concentration. Each 1 ng/mL lower 25(OH)D was associated with a 2% higher risk of infection (95% CI, 0%-4%) in continuous analyses after adjustment. CONCLUSIONS: Low 25(OH)D is common in kidney transplant recipients and associated with late CMV infection. These results highlight the need for interventional trials to assess the potential for vitamin D supplementation to reduce infectious complications in kidney transplant recipients.

16.
Am J Kidney Dis ; 72(6): 834-845, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30297082

RESUMO

Deficiency of 25-hydroxyvitamin D (25[OH]D) is common in patients with chronic kidney disease stages 3 and 4 and is associated with poor outcomes. However, the evaluation and management of vitamin D deficiency in nephrology remains controversial. This article reports on the proceedings from a "controversies conference" on vitamin D in chronic kidney disease that was sponsored by the National Kidney Foundation. The report outlines the deliberations of the 3 work groups that participated in the conference. Until newer measurement methods are widely used, the panel agreed that clinicians should classify 25(OH)D "adequacy" as concentrations > 20ng/mL without evidence of counter-regulatory hormone activity (ie, elevated parathyroid hormone). The panel also agreed that 25(OH)D concentrations < 15ng/mL should be treated irrespective of parathyroid hormone level. Patients with 25(OH)D concentrations between 15 and 20ng/mL may not require treatment if there is no evidence of counter-regulatory hormone activity. The panel agreed that nutritional vitamin D (cholecalciferol, ergocalciferol, or calcifediol) should be supplemented before giving activated vitamin D compounds. The compounds need further study evaluating important outcomes that observational studies have linked to low 25(OH)D levels, such as progression to end-stage kidney disease, infections, fracture rates, hospitalizations, and all-cause mortality. We urge further research funding in this field.


Assuntos
Falência Renal Crônica/prevenção & controle , Hormônio Paratireóideo/sangue , Insuficiência Renal Crônica/complicações , Deficiência de Vitamina D/tratamento farmacológico , Deficiência de Vitamina D/etiologia , Vitamina D/análogos & derivados , Suplementos Nutricionais , Progressão da Doença , Educação , Feminino , Humanos , Falência Renal Crônica/mortalidade , Masculino , Prognóstico , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/fisiopatologia , Medição de Risco , Sociedades Médicas , Vitamina D/administração & dosagem
18.
Transpl Int ; 31(3): 293-301, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28871657

RESUMO

Mortality in the general population and in patients on chronic hemodialysis is significantly higher in winter than summer. It is unknown whether such a seasonal difference exists for mortality or graft failure among kidney transplant recipients. We analyzed United Network for Organ Sharing (UNOS) data to assess whether the annual distribution of deaths and graft failures differed significantly from expected. There was significant annual variation in both deaths (n = 52 523) and graft failures (n = 50 301; both P < 0.001). The number of observed deaths exceeded the number expected by 8.9% in winter (P < 0.001), whereas the number of deaths was 4.8% lower than expected in summer (P < 0.01). The pattern was strongest for deaths attributable to cardiovascular disease (n = 11 509; 21.9%). Similarly, there was an excess of graft failures in winter (3.6%; P < 0.01) and a deficit in other seasons (all P ≤ 0.02). This pattern was observed for graft failures due to chronic rejection (P < 0.001) and other causes (P < 0.001), but not for acute rejection (P = 0.28) or recurrent disease (P = 0.27). Potential explanations for this variation include changes in physiologic parameters, changes in medication adherence and other behaviors, or changes in insurance coverage or clinical care. Further studies are necessary to identify specific mechanisms.


Assuntos
Rejeição de Enxerto/epidemiologia , Transplante de Rim/mortalidade , Complicações Pós-Operatórias/epidemiologia , Insuficiência Renal/epidemiologia , Estações do Ano , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/imunologia , Insuficiência Renal/imunologia , Estudos Retrospectivos , Estados Unidos/epidemiologia
20.
BMC Nephrol ; 18(1): 352, 2017 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-29202796

RESUMO

BACKGROUND: End stage renal disease (ESRD) patients on maintenance hemodialysis, are high utilizers of inpatient services. Because of data showing improved outcomes in medical patients admitted to hospitalist-run, non-teaching services, we hypothesized that discharge from a hospitalist-run, non-teaching service is associated with lower risk of 30-day re-hospitalization in a cohort of patients on hemodialysis. METHODS: One thousand and 84 consecutive patients with ESRD on maintenance hemodialysis who were admitted to Montefiore, a tertiary care center, in 2014 were analyzed using the electronic medical records. We evaluated factors associated with 30-day readmission in multivariable regression models. We then tested the association of care by a hospitalist-run, non-teaching service with 30-day readmission in a propensity score matched analysis. RESULTS: Patients cared for on the hospitalist-run, non-teaching service had lower socio-economic scores (SES) and had longer lengths of stay (LOS), as compared to a standard teaching service, but otherwise the populations were similar. In multivariable testing, severity of illness, (OR 2.40, (95%CI: 1.43-4.03) for highest quartile) number of previous hospitalizations (OR 1.22 (95%CI:1.16-1.28) for each admission), and discharge to a skilled nursing facility (SNF)(OR 1.56 (95%CI:1.01-2.43) were significantly associated with 30-day re-admissions. Care by the non-teaching service was associated with a lower risk of 30-day readmission, even after adjusting for clinical factors and matching based on propensity score (OR 0.65(95%CI:0.46-0.91) and 0.71(95%CI:0.66-0.77) respectively). CONCLUSIONS: Patients with ESRD on hemodialysis discharged from a hospitalist-run, non-teaching medicine service had lower odds of readmission as compared to those patients discharged from a standard teaching service.


Assuntos
Falência Renal Crônica/terapia , Alta do Paciente/tendências , Readmissão do Paciente/tendências , Diálise Renal/tendências , Idoso , Estudos de Coortes , Feminino , Humanos , Falência Renal Crônica/epidemiologia , Masculino , Pessoa de Meia-Idade , Alta do Paciente/normas , Readmissão do Paciente/normas , Diálise Renal/normas , Estudos Retrospectivos , Fatores de Tempo
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